Treatment preferences for medication or surgery in patients with deep endometriosis and bowel involvement - a discrete choice experiment.

OBJECTIVE: To study the preferences of women with deep endometriosis (DE) with bowel involvement when they have to choose between conservative (medication) or surgical treatment. DESIGN: Labelled discrete choice experiment (DCE). SETTING: Dutch academic and non-academic hospitals and online recruitment. POPULATION OR SAMPLE: A total of 169 women diagnosed with DE of the bowel. METHODS: Baseline characteristics and the fear of surgery were collected. Women were asked to rank attributes and choose between hypothetical conservative or surgical treatment in different choice sets (scenarios). Each choice set offered different levels of all treatment attributes. Data were analysed by using multinomial logistic regression. MAIN OUTCOME MEASURES: The following attributes - effect on/risk of pain, fatigue, pregnancy, endometriosis lesions, mood swings, osteoporosis, temporary stoma and permanent intestinal symptoms - were used in this DCE. RESULTS: In the ranking, osteoporosis was ranked with low importance, whereas in the DCE, a lower chance of osteoporosis was one of the most important drivers when choosing a conservative treatment. Women with previous surgery showed less fear of surgery compared with women without surgery. Low anterior resection syndrome was almost equally important for patients as the chance of pain reduction. Pain reduction had higher importance than improving fertility chances, even in women with desire for a future child. CONCLUSIONS: The risk of developing low anterior resection syndrome as a result of treatment is almost equally important as the reduction of pain symptoms. Women with previous surgery experience less fear of surgery compared with women without a surgical history. TWEETABLE ABSTRACT: First discrete choice experiment in patients with deep endometriosis.

Paediatric orbital conjunctival epithelial cyst with positive asialotransferrin.

Conjunctival orbital cysts are rare; they are typically either conjunctival dermoid or conjunctival epithelial cysts - congenital or acquired (inclusion). We describe the case of a 15-month-old girl presenting with strabismus and proptosis who had a retrobulbar intraconal cystic lesion displacing the optic nerve, with an adjacent middle cranial fossa anomaly. Aspiration of the orbital cyst tested positive for asialotransferrin, raising the suspicion of a direct communication with cerebrospinal fluid (CSF). Subsequent fine cut CT scanning disproved any connection with the intracranial space, and the cyst was excised complete and intact. Histopathology showed a conjunctival epithelial cyst. To our knowledge, this is the first case report in the literature of an asialotransferrin positive pediatric orbital conjunctival epithelial cyst. It is of clinical relevance as it explores the possibility of either a false positive asialotransferrin or potentially a prior developmental communication with the subarachnoid space. These two diagnostic possibilities are discussed.

Limited Added Value of Magnetic Resonance Imaging After Dynamic Transvaginal Ultrasound for Preoperative Staging of Endometriosis in Daily Practice: A Prospective Cohort Study.

OBJECTIVES: To assess the added value of magnetic resonance imaging (MRI) after dynamic transvaginal ultrasound (TVUS) in the diagnostic pathway for preoperative staging of pelvic endometriosis. METHODS: A prospective observational study was conducted between April 22, 2014, and May 1, 2015. During that period, 363 patients with a clinical suspicion of endometriosis were included. All patients underwent a history, clinical examination, and dynamic TVUS examination. Most of the patients (n = 274) underwent conservative treatment according to the European Society of Human Reproduction and Embryology guidelines. Eighty-nine patients were selected for surgery, of whom 72 patients underwent the complete diagnostic pathway: ie, history, clinical examination, dynamic TVUS, and MRI. All data were analyzed by the nonparametric McNemar test for comparing each step in the diagnostic algorithm. RESULTS: The sensitivity and specificity for the history, pelvic examination, and dynamic TVUS were 93.7% and 55.6% (P < .001), respectively; when MRI findings were included, the sensitivity and specificity were 85.9% and 62.5%. Adding MRI routinely to the diagnostic procedure of endometriosis did not significantly improve the sensitivity or specificity. CONCLUSIONS: There is no significant added value of routine MRI after dynamic TVUS for the preoperative staging of endometriosis.

Phytophthora Species Detected in Two Ozark Forests with Unusual Patterns of White Oak Mortality.

Widespread decline and mortality of white oaks (Quercus alba) occurred in Missouri Ozark forests between 2011 and 2017. Symptoms included rapid crown death with bronzing of leaves, retention of dead leaves, crown dieback and thinning, and loss of large limbs within one year of death. Decline and mortality were associated with hillside drainages and fit descriptions of European oak forests predisposed to decline by pathogenic Phytophthora species. A survey was performed at two locations in 2014 and 2015 to assess the distribution of dead and declining white oaks, and the occurrence and distribution of Phytophthora species. Multiple Phytophthora species were detected, including P. cinnamomi, P. cactorum, P. europaea, and P. pini. P. cinnamomi was the most common and widely distributed species among plots at both locations. The detection of P. cinnamomi at the base of white oaks was not associated with poor crown vigor. However, more quantitative survey techniques are necessary to clearly evaluate this relationship. P. cinnamomi kills fine roots of white and red oaks in North America and has been associated with the decline of white oaks in the United States (Ohio) and other countries. Further studies are needed to determine the importance of P. cinnamomi in oak decline within the Ozark highlands.

The Role of FDG-PET in the Diagnosis and Staging of Ocular Adnexal Lymphoproliferative Disease.

PURPOSE: To further evaluate fluorine 18 fluoro-deoxyglucose positron emission tomography (FDG PET) in the staging of ocular adnexal lymphoproliferative disease (OALD). METHODS: Retrospective and prospective case series with review of clinical and imaging records including computed tomography (CT), FDG PET (± PET/CT) and/or magnetic resonance imaging (MRI). RESULTS: Thirty-four patients had FDG PET and CT scans at initial staging. Eleven were retrospectively reviewed and 23 were prospectively enrolled. Of 34 patients, 17 (50%) had primary disease, 17 (50%) had secondary and of these, 13 patients (38%) had OALD as their initial manifestation. Sixteen patients had active systemic disease in conjunction with their orbital disease. Systemic disease was demonstrated by FDG PET (± CT) in 15 of 16 (94%) patients and 11 of 16 (69%) patients with CT. FDG PET found orbital disease in 27 of 34 patients (79%) versus 33 of 34 patients with orbital CT (97%). Four of 16 patients in which FDG-PET detected systemic disease where CT did not were upstaged and their management changed significantly in 5 cases. CONCLUSIONS: This study reaffirms FDG PET as an important part of initial staging. Our study suggests FDG PET detects systemic disease more reliably than CT alone and results in significant changes in management. Our findings suggest FDG PET detection for local OALD is less sensitive than CT. MRI is helpful in augmenting other imaging modalities in further identifying disease. Given the prevalence of simultaneous systemic presentations of OALD, FDG PET in this regard is especially important and highlights the need for coordinated multidisciplinary care.

Assessment of Dermal and Inhalation Exposure to Permethrin During Field Treatment of Military Uniforms.

INTRODUCTION: Permethrin is a common pesticide spray-applied to civilian clothing and military uniforms for protection against biting arthropods in an effort to reduce risks to arthropod-borne diseases. During mass clothing spray events, exposure is possible through the dermal, inhalation, and ingestion routes. The potentially exposed population during a spray event includes the pesticide applicator(s) and working party (personnel who handle clothing/uniforms by positioning on the ground, flipping, and removing after spraying is complete). Previous investigation is limited regarding permethrin exposure via multiple routes of entry. Additionally, most exposure assessments are limited to pesticide applicators rather than working party that support applicator personnel. The purpose of this investigation was to conduct a multi-route exposure assessment for all personnel normally participating in mass permethrin military uniform treatments. MATERIALS AND METHODS: The protocol and Informed Consent Document were approved by the Uniformed Services University of the Health Sciences (USUHS) Institutional Review Board (IRB) before fieldwork initiation (IRB number: USUHS.2019-032). Sampling occurred during routine spray events performed by 14 U.S. Navy personnel (3 applicators and 11 working party) over 2 days. Personal exposures were measured with dermal sampling, and airborne concentrations were measured with area air sampling. Permethrin area air sampling and analysis were conducted using OSHA Versatile Sampler-2 sampling media (n = 36). Dermal exposure was measured using dosimeter gloves (n = 26) and a dermal patch (n = 26) worn by study participants. RESULTS: All air samples were reported below the 0.4 µg limit of quantification. Glove sample results ranged from 45 to 120,000 µg and patch results ranged from 0.57 to 45 µg. A repeated-measures ANOVA showed non-statistically significant differences in dermal concentrations (P-value = .8340) between the applicators and working party in patches and gloves. CONCLUSIONS: Results suggest dermal contact is the primary route of exposure compared to inhalation when mass spraying clothing with permethrin. Similar dermal exposures between these two occupations may necessitate reconsidering risk assessment procedures, training and personal protective equipment (PPE) requirements for mass spray uniform treatments. Specifically, while PPE requirements for applicators are highly regulated by the Armed Forces Pest Management Board and include items such as Tyvek suits, chemical protective gloves, and air-purifying respirators, PPE was not regulated for working party personnel before this investigation.

Threats to the integrity of psychological assessment: The misuse of test raw data and materials.

In the practice of psychological assessment there have been warnings for decades by the American Psychological Association (APA), the National Academy of Neuropsychology (NAN), other associations, and test vendors, against the disclosure of test raw data and test materials. Psychological assessment occurs across several different practice environments, and test raw data is a particularly sensitive aspect of practice considering what it implicitly represents about a client/patient, and this concept is further developed in this paper. Many times, test materials are intellectual property protected by copyrights and user agreements. It follows that improper management of the release of test raw data and test materials threatens the scientific integrity of psychological assessment. Here the matters of test raw data, test materials, and different practice environments are addressed to highlight the challenges involved with improper releases and to offer guidance concerning good-faith efforts to preserve the integrity of psychological assessment and legal agreements. The unique demands of forensic practice are also discussed, including attorneys' needs for cross-examination and discovery, which may place psychologists (and other duly vetted evaluators) in conflict with their commitment to professional ethical codes and legal agreements. To this end, important threats to the proper use of test raw data and test materials include uninformed professionals and compromised evaluators. In this paper, the mishandling of test raw data and materials by both psychologists and other evaluators is reviewed, representative case examples, including those from the literature, are provided, pertinent case law is discussed, and practical stepwise conflict resolutions are offered.

Minimal Rickettsial Infection Rates and Distribution of Ticks in Uganda: An Assessment of the Seasonal Effects and Relevance to Tick-Borne Disease Risk in East Africa.

Tick-borne diseases (TBDs) pose a significant risk to humans and represent one of the major factors influencing readiness within the United States' military worldwide. Additionally, ticks and TBDs constitute major animal health problems leading to economic losses at multiple levels affecting low- and middle-income countries the hardest. Tick control is frequently hampered by issues ranging from acaricide resistance to lack of data on tick distribution and infection rates. We conducted a cross-sectional study to assess tick species distribution, host use, and rickettsial pathogen infection rate of ticks in different areas of the Uganda Cattle Corridor. We identified 4,425 hard ticks (Ixodida: Ixodidae) comprised of seven species by morphological characters with 3,315 ticks collected from four locations during the dry season and 1,110 ticks from one location during the wet season. Rickettsial pathogen prevalence was assessed in ticks collected from two districts to determine the minimum infection rate compared across seasons, village location, and tick species. We found statistically significant differences in the abundance and distribution of tick species among districts in the dry season, host animal species, and the proportion of rickettsial positive pools between villages. Seasonality, village location, and tick species do not affect the minimum infection rate of rickettsial pathogens of ticks in Uganda, but village location affects the proportion of positive tick pools. These results indicate geographical and seasonal differences among pathogen-harboring ticks contributing to our understanding of the current distribution of ticks and TBDs in Uganda.

Vocalization assessed by electrolaryngography is unaffected by topical lidocaine anesthesia: a prospective, crossover, randomized, double-blind placebo-controlled study.

BACKGROUND: Topical anesthesia of the upper airway is often recommended when difficulty in airway management is anticipated. There are published reports, however, of administration of topical anesthesia resulting in complete loss of airway control. Adverse effects are mostly attributed to interference with involuntary protective airway reflexes, while gross motor function itself generally is thought to be preserved. We hypothesized that if motor control is affected, measurable quantitative changes in vocalization should follow the use of topical anesthesia. METHODS: A prospective, crossover, randomized, double-blind study was conducted, in which 24 healthy volunteers each performed 2 vocal exercises, while having their glottic appearance recorded digitally via fiberoptic nasendoscopy. Subjects gargled with 3 test solutions on separate occasions (placebo, 2% lidocaine, and 4% lidocaine) and repeated the vocal exercises and nasendoscopy. The angle between the vocal cords was measured using MB-Ruler®, and the Laryngograph Speech Studio® software was used for vocal parameter analysis. RESULTS: The only significant changes in voice quality occurred between the control and test groups (P = 0.014). No difference could be found between the placebo and lidocaine groups. CONCLUSIONS: Although gargling with local anesthetic affected vocalization, no pharmacological effect attributable to local anesthetic was observed.

Efficacy of several statistical methods in differentiating TBI and co-occurring conditions: A replication study.

OBJECTIVES: (1) Cross-validation of neuropsychological test data sets of moderate-severe TBI (N = 30) with test data from moderate-severe (N = 74); somatization (N = 24) and PCS (N = 22) cases in a database, (2) Determine if cognitive test data sets alone differentiated TBI from other groups, and (3) Evaluate the efficacy of measures in comparisons: Kullback-Leibler, Correlation, Patterns, Cohen's d, and MNB. MATERIALS AND METHODS: Meyer's Neuropsychological System; Comparison groups -TBI sample with structural evidence of brain injury (CT/MRI); comparison of 5 statistical measures' efficacy in test data analysis comparing a community sample of moderate TBI (N=30) with a data base containing moderate-severe TBI (N = 74) + co-occurring groups (PCS N = 22) + Somatization (N = 24). Measures utilized: Correlation, Kullbeck-Leibler divergence, Cohen's d, MNB code, Configuration. RESULTS: Combining the five measures most accurately matched the TBI sample (30/30 cases) with MNB comparison groups of similar TBI severity while differentiating those cases from PCS and Somatoform cognitive testdata. Both Kullback Leibler & Cohens' d reduced false positive errors in comparison with the other measures.

Disease Features and Gastrointestinal Microbial Composition in Patients with Systemic Sclerosis from Two Independent Cohorts.

OBJECTIVE: The study objective was to examine alterations in gastrointestinal (GI) microbial composition in patients with systemic sclerosis (SSc) and to investigate the relationship between SSc features and GI microbiota using two independent, international cohorts. METHODS: Prospective patients with SSc from Lund University (LU), Sweden, from the University of California, Los Angeles (UCLA), United States, and control subjects provided stool specimens for 16S ribosomal RNA sequencing. Alpha and beta diversity analyses were performed. Multivariate negative binomial models identified differentially abundant genera between groups. RESULTS: Patients from LU with SSc (n = 106) with recent SSc diagnosis (median disease duration 2.0 years) had lower abundance of commensal genera (eg, Faecalibacterium) and higher abundance of pathobiont genera (eg, Desulfovibrio) than LU-controls (n = 85). Patients from UCLA with SSc (n = 71) had a similar prevalence of females, a similar body mass index, and similar age but an increased disease duration (median 7.1 years) compared with patients from LU with SSc. Factors associated with beta diversity in patients with SSc from both LU and UCLA included disease duration (P = 0.0016), interstitial lung disease (P = 0.003), small intestinal bacterial overgrowth (P = 0.002), and immunosuppression use (P = 0.014). In multivariable analysis, the UCLA-SSc cohort had higher abundance of specific pathobiont genera (eg, Streptococcus) compared with the LU-SSc cohort. CONCLUSION: Enrichments and depletions in certain microbial genera were observed in patients recently diagnosed with SSc, suggesting that dysbiosis is present in early SSc. Specific disease features were independently associated with fecal microbial composition in both cohorts. After controlling for these factors, the abundance of several pathobiont bacteria differed between the cohorts, suggesting that environmental factors, along with disease manifestations, should be considered in future SSc studies.

Case report: Death associated with stroke following intracarotid amobarbital testing.

OBJECTIVE: One previous accidental death during intracarotid amobarbital testing (IAT) associated with cerebral angiography (CA) has been reported in the literature. The objectives of this article are to briefly review morbidity and mortality risks for patients undergoing diagnostic CA and to describe a case with a fatal outcome. METHOD: The case of a 38-year-old man who had a right middle cerebral artery stroke while undergoing IAT is described. The patient was not high risk by Centers for Medicare and Medicaid Services criteria or invasive procedures; neither did he have risk factors for embolic stroke. CONCLUSIONS: A problem noted is that IAT procedures vary from center to center and that IAT may increase the risk for individual patients because of differences between IAT and other CA interventions.

Combinatorially selected peptides for protection of soybean against Phakopsora pachyrhizi.

Phakopsora pachyrhizi, the fungal pathogen that causes Asian soybean rust, has the potential to cause significant losses in soybean yield in many production regions of the United States. Germplasm with durable, single-gene resistance is lacking, and control of rust depends on timely application of fungicides. To assist the development of new modes of soybean resistance, we identified peptides from combinatorial phage-display peptide libraries that inhibit germ tube growth from urediniospores of P. pachyrhizi. Two peptides, Sp2 and Sp39, were identified that inhibit germ tube development when displayed as fusions with the coat protein of M13 phage or as fusions with maize cytokinin oxidase/dehydrogenase (ZmCKX1). In either display format, the inhibitory effect of the peptides on germ tube growth was concentration dependent. In addition, when peptides Sp2 or Sp39 in either format were mixed with urediniospores and inoculated to soybean leaves with an 8-h wetness period, rust lesion development was reduced. Peptides Sp2 and Sp39, displayed on ZmCKX1, were found to interact with a 20-kDa protein derived from germinated urediniospores. Incorporating peptides that inhibit pathogen development and pathogenesis into breeding programs may contribute to the development of soybean cultivars with improved, durable rust tolerance.

Ocular trauma associated with falls in older people: A 10-year review from a state trauma service.

BACKGROUND: Falls are the leading cause of injury-related emergency presentations, hospital admissions and deaths in Victorians over the age of 65. While there is extensive literature analysing traumatic injuries resulting from falls in older patients, there is little data on ocular injuries in this patient group. METHODOLOGY: A retrospective audit of all patients over 65 years referred to the Ophthalmology Department of a tertiary hospital following fall from standing height between January 2009 and December 2018 to determine the demographics, injury setting, ophthalmic injuries, interventions and outcomes of ocular trauma secondary to falls. RESULTS: Two hundred and seventy patients (F = 155, M = 115) were included, with a mean age of 81 years. 180 falls (66.7%) occurred in a residential environment. The most common reason for referral was orbital fracture (n = 155). Severe ocular injuries included globe rupture (n = 23), retro-bulbar haematoma (n = 22), retinal detachment (n = 6) and traumatic optic neuropathy (n = 6). Forty patients (14.8%) presented with a visual acuity (VA) below 6/60 while 34 patients (12.5%) had a non-assessable VA secondary to delirium or intubation. Of these 34, 9 had a significant ocular injury. A total of 28 patients (10.4%) were permanently blinded by their injuries. Twenty-three patients (8.5%) required admission to ICU and 16 patients (5.93%) died during their in-hospital stay. Thirty-six injuries were referred beyond the 24-hour mark, including a globe rupture and a case of traumatic optic neuropathy. With the exception of the missed globe rupture, all other injuries requiring emergency surgery were operated on within 24 h. CONCLUSION: Falls in older people may be associated with sight-threatening ocular injuries which are common and easy to miss in this population demographic. The presence of ocular injuries in this patient group is associated with significant rates of in-hospital mortality and poor functional outcomes. It is therefore essential for trauma practitioners to perform a detailed and systematic assessment in order to identify sight-threatening ocular injuries and allow for expedient sight-saving intervention to be performed.

Total Endovascular Arch Repair Using Needle Fenestration and Extracorporeal Membrane Oxygenation.

There remains a clinical need for endovascular repair of the ascending aorta and the aortic arch in patients who are prohibitively high risk for open surgical repair. Herein we present a case of a total endovascular arch repair by means of a novel technique for graft fenestration using a trans-septal needle with extracorporeal membrane oxygenation support. Although the use of trans-septal needle fenestration use has been described, the use in arch fenestrations has not. We present this case as an example of techniques that may be useful in the expanding landscape of endovascular ascending and arch repair.

Improving the Digestibility of Plant Defensins to Meet Regulatory Requirements for Transgene Products in Crop Protection.

Despite the use of chemical fungicides, fungal diseases have a major impact on the yield and quality of plant produce globally and hence there is a need for new approaches for disease control. Several groups have examined the potential use of antifungal plant defensins for plant protection and have produced transgenic plants expressing plant defensins with enhanced resistance to fungal disease. However, before they can be developed commercially, transgenic plants must pass a series of strict regulations to ensure that they are safe for human and animal consumption as well as the environment. One of the requirements is rapid digestion of the transgene protein in the gastrointestinal tract to minimize the risk of any potential allergic response. Here, we examine the digestibility of two plant defensins, NaD1 from Nicotiana alata and SBI6 from soybean, which have potent antifungal activity against major cereal pathogens. The native defensins were not digestible in simulated gastrointestinal fluid assays. Several modifications to the sequences enhanced the digestibility of the two small proteins without severely impacting their antifungal activity. However, these modified proteins did not accumulate as well as the native proteins when transiently expressed in planta, suggesting that the protease-resistant structure of plant defensins facilitates their stability in planta.

Laboratory-directed protein evolution.

Systematic approaches to directed evolution of proteins have been documented since the 1970s. The ability to recruit new protein functions arises from the considerable substrate ambiguity of many proteins. The substrate ambiguity of a protein can be interpreted as the evolutionary potential that allows a protein to acquire new specificities through mutation or to regain function via mutations that differ from the original protein sequence. All organisms have evolutionarily exploited this substrate ambiguity. When exploited in a laboratory under controlled mutagenesis and selection, it enables a protein to "evolve" in desired directions. One of the most effective strategies in directed protein evolution is to gradually accumulate mutations, either sequentially or by recombination, while applying selective pressure. This is typically achieved by the generation of libraries of mutants followed by efficient screening of these libraries for targeted functions and subsequent repetition of the process using improved mutants from the previous screening. Here we review some of the successful strategies in creating protein diversity and the more recent progress in directed protein evolution in a wide range of scientific disciplines and its impacts in chemical, pharmaceutical, and agricultural sciences.

Subcellular localization and biochemical comparison of cytosolic and secreted cytokinin dehydrogenase enzymes from maize.

Cytokinin dehydrogenase (CKX; EC 1.5.99.12) degrades cytokinin hormones in plants. There are several differently targeted isoforms of CKX in plant cells. While most CKX enzymes appear to be localized in the apoplast or vacuoles, there is generally only one CKX per plant genome that lacks a translocation signal and presumably functions in the cytosol. The only extensively characterized maize CKX is the apoplastic ZmCKX1; a maize gene encoding a non-secreted CKX has not previously been cloned or characterized. Thus, the aim of this work was to characterize the maize non-secreted CKX gene (ZmCKX10), elucidate the subcellular localization of ZmCKX10, and compare its biochemical properties with those of ZmCKX1. Expression profiling of ZmCKX1 and ZmCKX10 was performed in maize tissues to determine their transcript abundance and organ-specific expression. For determination of the subcellular localization, the CKX genes were fused with green fluorescent protein (GFP) and overexpressed in tomato hairy roots. Using confocal microscopy, the ZmCKX1-GFP signal was confirmed to be present in the apoplast, whereas ZmCKX10-GFP was detected in the cytosol. No interactions of ZmCKX1 with the plasma membrane were observed. While roots overexpressing ZmCKX1-GFP formed significantly more mass in comparison with the control, non-secreted CKX overexpression resulted in a small reduction in root mass accumulation. Biochemical characterization of ZmCKX10 was performed using recombinant protein produced in Pichia pastoris. In contrast to the preference for 2,6-dichlorophenolindophenol (DCPIP) as an electron acceptor and trans-zeatin, N(6)-(Delta(2)-isopentenyl)adenine (iP) and N(6)-(Delta(2)-isopentenyl)adenosine (iPR) as substrates for ZmCKX1, the non-secreted ZmCKX10 had a range of suitable electron acceptors, and the enzyme had a higher preference for cis-zeatin and cytokinin N-glucosides as substrates.

The Surgical Simulation and Training Markup Language (SSTML): an XML-based language for medical simulation.

Under contract with the Telemedicine & Advanced Technology Research Center (TATRC), Energid Technologies is developing a new XML-based language for describing surgical training exercises, the Surgical Simulation and Training Markup Language (SSTML). SSTML must represent everything from organ models (including tissue properties) to surgical procedures. SSTML is an open language (i.e., freely downloadable) that defines surgical training data through an XML schema. This article focuses on the data representation of the surgical procedures and organ modeling, as they highlight the need for a standard language and illustrate the features of SSTML. Integration of SSTML with software is also discussed.