Evaluation of two different enzyme-linked immunosorbent assay for severe fever with thrombocytopenia syndrome virus diagnosis

To develop the large scale serological assay for severe fever with thrombocytopenia syndrome virus (SFTSV) infection, we evaluated two different enzyme-linked immunosorbent assay (ELISA) methods using nucleocapsid protein (NP) and Gn proteins of CB1 (genotype B) SFTSV strains. The NP-based ELISA tests showed more sensitive with broad cross-reactivity between two different genotype A and B strains compared with those of Gn-based ELISA tests. However, Gn-based ELISA showed more genotype specificity and specificity. These result suggested that NP-based ELISA test could be applicable for general sero-prevalence studies of SFTSV infections, while Gn-based ELISA could be applicable for a certain specific genotype sero-prevalence study.

Disparity in Health Screening and Health Utilization according to Economic Status / 가정의학회지

BACKGROUND: Cardiovascular disease (CVD) has become the most common cause of mortality and morbidity worldwide. Health screening is associated with higher outpatient visits for detection and treatment of CVD-related diseases (diabetes mellitus, hypertension, and dyslipidemia). We examined the association between health screening, health utilization, and economic status. METHODS: A sampled cohort database from the National Health Insurance Corporation was used. We included 306,206 participants, aged over 40 years, without CVD (myocardial infarction, stroke, and cerebral hemorrhage), CVD-related disease, cancer, and chronic renal disease. The follow-up period was from January 1, 2003 through December 31, 2005. RESULTS: Totally, 104,584 participants received at least one health screening in 2003–2004. The odds ratio of the health screening attendance rate for the five economic status categories was 1.27 (95% confidence interval [CI], 1.24 to 1.31), 1.05 (95% CI, 1.02 to 1.08), 1, 1.16 (95% CI, 1.13 to 1.19) and 1.50 (95% CI, 1.46 to 1.53), respectively. For economic status 1, 3, and 5, respectively, the diagnostic rate after health screening was as follows: diabetes mellitus: 5.94%, 5.36%, and 3.77%; hypertension: 32.75%, 30.16%, and 25.23%; and dyslipidemia: 13.43%, 12.69%, and 12.20%. The outpatient visit rate for attendees diagnosed with CVD-related disease was as follows for economic status 1, 3, and 5, respectively: diabetes mellitus: 37.69%, 37.30%, and 43.70%; hypertension: 34.44%, 30.09%, and 32.31%; and dyslipidemia: 18.83%, 20.35%, and 23.48%. CONCLUSION: Thus, higher or lower economic status groups had a higher health screening attendance rate than the middle economic status group. The lower economic status group showed lower outpatient visits after screening, although it had a higher rate of CVD diagnosis.

Association between Weight Changes after Smoking Cessation and Cardiovascular Disease among the Korean Population / 가정의학회지

BACKGROUND: Cigarette smoking is a risk factor for cardiovascular disease (CVD) and has both beneficial and harmful effects in CVD. We hypothesized that weight gain following smoking cessation does not attenuate the CVD mortality of smoking cessation in the general Korean population. METHODS: Study subjects comprised 2.2% randomly selected patients from the Korean National Health Insurance Corporation, between 2002 and 2013. We identified 61,055 subjects who were classified as current smokers in 2003–2004. After excluding 21,956 subjects for missing data, we studied 30,004 subjects. We divided the 9,095 ex-smokers into two groups: those who gained over 2 kg (2,714), and those who did not gain over 2 kg (6,381, including weight loss), after smoking cessation. Cox proportional hazards regression models were used to estimate the association between weight gain following smoking cessation and CVD mortality. RESULTS: In the primary analysis, the hazard ratios of all-cause deaths and CVD deaths were assessed in the three groups. The CVD risk factors and Charlson comorbidity index adjusted hazard ratios (aHRs) for CVD deaths were 0.80 (95% confidence interval [CI], 0.37 to 1.75) for ex-smokers with weight gain and 0.80 (95% CI, 0.50 to 1.27) for ex-smokers with no weight gain, compared to one for sustained smokers. The associations were stronger for events other than mortality. The aHRs for CVD events were 0.69 (95% CI, 0.54 to 0.88) and 0.81 (95% CI, 0.70 to 0.94) for the ex-smokers with and without weight gain, respectively. CONCLUSION: Although smoking cessation leads to weight gain, it does not increase the risk of CVD death.

Experience of Dementia-related Anxiety in Middle-aged Female Caregivers for Family Members with Dementia: A Phenomenological Study

PURPOSE: In Korea, most elderly with dementia receive care from family members, yet little research is available on the experience of dementia-related anxiety in middle-aged female caregivers for a family member with dementia. The purpose of this study was to describe the lived experience of dementia-related anxiety in middle-aged female caregivers for family members with dementia. METHODS: A descriptive phenomenological study was conducted. A purposive sampling strategy was used to recruit participants. Twelve middle-aged women (40-59 years, mean age = 51.90 years) who were family caregivers were interviewed from February 2014 to August 2014. Data were collected through semistructured interviews and analyzed using Giorgi's method. RESULTS: The essential structure of the phenomenon was a fear of losing self-identity. The main essence was represented by six components: keenly feeling the effects of aging because of memory deficit, continuous comparison of the family member's behavior with that of the participant's, Finding it painful to see a family member with dementia as he/she does not know how this will end, not knowing the conclusion of the disease process, reducing the risk of dementia, and trying to change one's lifestyle from what it used to be in the past. CONCLUSIONS: The study provides the essential structure of the experience on dementia-related anxiety that caregivers of a family member with dementia have. The findings could help healthcare providers and researchers have better understanding of dementia-related anxiety and give more attention to the caregivers to relieve their anxiety

Effect of resin thickness on the microhardness and optical properties of bulk-fill resin composites

OBJECTIVES: This study evaluated the effects of the resin thickness on the microhardness and optical properties of bulk-fill resin composites. METHODS: Four bulk-fill (Venus Bulk Fill, Heraeus Kulzer; SDR, Dentsply Caulk; Tetric N-Ceram Bulk Fill, Ivoclar vivadent; SonicFill, Kerr) and two regular resin composites (Charisma flow, Heraeus Kulzer; Tetric N-Ceram, Ivoclar vivadent) were used. Sixty acrylic cylindrical molds were prepared for each thickness (2, 3 and 4 mm). The molds were divided into six groups for resin composites. The microhardness was measured on the top and bottom surfaces, and the colors were measured using Commission Internationale d'Eclairage (CIE) L*a*b* system. Color differences according to the thickness and translucency parameters and the correlations between the microhardness and translucency parameter were analyzed. The microhardness and color differences were analyzed by ANOVA and Scheffe's post hoc test, and a student t-test, respectively. The level of significance was set to alpha = 0.05. RESULTS: The microhardness decreased with increasing resin thickness. The bulk-fill resin composites showed a bottom/top hardness ratio of almost 80% or more in 4 mm thick specimens. The highest translucency parameter was observed in Venus Bulk Fill. All resin composites used in this study except for Venus Bulk Fill showed linear correlations between the microhardness and translucency parameter according to the thickness. CONCLUSIONS: Within the limitations of this study, the bulk-fill resin composites used in this study can be placed and cured properly in the 4 mm bulk.

Effect of resin thickness on the microhardness and optical properties of bulk-fill resin composites

OBJECTIVES: This study evaluated the effects of the resin thickness on the microhardness and optical properties of bulk-fill resin composites. METHODS: Four bulk-fill (Venus Bulk Fill, Heraeus Kulzer; SDR, Dentsply Caulk; Tetric N-Ceram Bulk Fill, Ivoclar vivadent; SonicFill, Kerr) and two regular resin composites (Charisma flow, Heraeus Kulzer; Tetric N-Ceram, Ivoclar vivadent) were used. Sixty acrylic cylindrical molds were prepared for each thickness (2, 3 and 4 mm). The molds were divided into six groups for resin composites. The microhardness was measured on the top and bottom surfaces, and the colors were measured using Commission Internationale d'Eclairage (CIE) L*a*b* system. Color differences according to the thickness and translucency parameters and the correlations between the microhardness and translucency parameter were analyzed. The microhardness and color differences were analyzed by ANOVA and Scheffe's post hoc test, and a student t-test, respectively. The level of significance was set to alpha = 0.05. RESULTS: The microhardness decreased with increasing resin thickness. The bulk-fill resin composites showed a bottom/top hardness ratio of almost 80% or more in 4 mm thick specimens. The highest translucency parameter was observed in Venus Bulk Fill. All resin composites used in this study except for Venus Bulk Fill showed linear correlations between the microhardness and translucency parameter according to the thickness. CONCLUSIONS: Within the limitations of this study, the bulk-fill resin composites used in this study can be placed and cured properly in the 4 mm bulk.

Professional Identity of Elementary School Health Teachers: A Grounded Theory Approach

PURPOSE: This study was conducted to explore the professional identity of elementary school health teachers. METHODS: In-depth interviews with fifteen elementary school health teachers were conducted from July 2010 to August 2012. Qualitative data collected by the researcher including transcription and field notes were analyzed through an adapted methodology based on the Grounded Theory of Strauss and Corbin. RESULTS: Fifteen categories, 35 sub-categories and 120 concepts were obtained. The key category that was consistently maintained in identity formation was 'keeping themselves being a teacher providing nursing' which has three styles, 'focusing on health education', 'combining nursing and education' and 'focusing on providing nursing care'. CONCLUSION: Results of this study will provide basic information for preparing manuals regarding the range of activities in school health teachers' jobs, improving promotion and merit payment systems for school health teachers, creating support programs for them, and contributing to the formation and establishment of their professional identity.

Comparison of the effect of different media on the clinical outcomes of the density-gradient centrifugation/swim-up and swim-up methods / 대한생식의학회지

OBJECTIVE: Sperm must be properly prepared in in vitro fertilization (IVF)-embryo transfer (ET) programs in order to control the fertilization rate and ensure that embryos are of high quality and have appropriate developmental abilities. The objective of this study was to determine the most optimal sperm preparation method for IVF. METHODS: Patients less than 40 years of age who participated in a fresh IVF-ET cycle from November 2012 to March 2013 were included in this study. Poor responders with less than three mature oocytes were excluded. Ham's F-10 medium or sperm-washing medium (SWM) was used in combination with the density-gradient centrifugation/swim-up (DGC-SUP) or SUP methods for sperm preparation. A total of 429 fresh IVF-ET cycles were grouped according to the media and methods used for sperm preparation and retrospectively analyzed (DGC-SUP/Ham's F-10, n=82; DGC-SUP/SWM, n=43; SUP/Ham's F-10, n=181; SUP/SWM, n=123). RESULTS: There were no significant differences among these four groups with respect to the mean age of the female partners, duration of infertility, number of previous IVF cycles, and retrieved oocytes. We determined that both the DGC-SUP and SUP methods for sperm preparation from whole semen, using either Ham's F-10 or SWM media, result in comparable clinical outcomes, including fertilization and pregnancy rates. CONCLUSION: We suggest that both media and both methods for sperm preparation can be used for selecting high-quality sperm for assistive reproductive technology programs.

Assessment of mOMV adjuvant efficacy in the pathogenic H1N1 influenza virus vaccine

PURPOSE: Since the pandemic (H1N1) 2009 virus has been a seasonal flu which still poses great human health concerns worldwide, vaccination would be considered as the most effective strategy to control the influenza virus spreading. Here, we assessed adjuvant efficacy of modified outer membrane vesicle (mOMV) towards the pandemic H1N1 split antigen. MATERIALS AND METHODS: For this study, mice were vaccinated twice with various amount of antigen (0.05, 0.1, and 0.5 microg/dose hemagglutinin [HA]) that were mixed with mOMV, aluminum hydroxide (alum), and MF59, as well as the combined adjuvant comprising the mOMV plus alum. RESULTS: We found that all the adjuvanted vaccines of A/California/04/09 (CA04, H1N1) containing HA antigen more than 0.1 microg/dose protected effectively from lethal challenge (maCA04, H1N1) virus, compared to the antigen only group. Furthermore, vaccinated mice received as low as 0.05 microg/dose of the split vaccine containing the combined adjuvant (10 microg of mOMV plus alum) showed a full protection against lethal challenge with H1N1 virus. Taken together, these results suggest that mOMV can exert not only the self-adjuvanticity but also a synergy effect for the vaccine efficacy when combined with alum. CONCLUSION: Our results indicate that mOMV could be a promising vaccine adjuvant by itself and it could be used as a vaccine platform for development of various vaccine formulations to prepare future influenza pandemic.

Comparison of Clinical Findings of Gastric Perforation between Preterm and Term Neonates / 대한주산의학회잡지

PURPOSE: The purpose of this study was to compare the clinical findings and mortality of gastric perforation between preterm and term infants. METHODS: The medical records of neonates, admitted to the neonatal intensive care unit of Dongsan Medical Center for gastric perforation between July 1992 and June 2012, were reviewed retrospectively. The admission records of clinical findings and mortality were reviewed and statistically analyzed between preterm and term infants. RESULTS: Nine infants were diagnosed with neonatal gastric perforation. Of the nine infants, the number of term infants was five and the number of male was eight. Of the four infants diagnosed with spontaneous gastric perforation, the number of preterm and term infants was three and one respectively. The anatomical location of perforation was greater curvature in all four preterm infants. However, various sites such as greater curvature (three infants) and antrum (two infants) were observed in five term infants. Mortality rate was tended to be lower in preterm infants compared to term infants, without statistical significance (25.0% vs. 40.0%, P>0.1). There was no mortality in four infants diagnosed with spontaneous gastric perforation. However, two infants diagnosed with necrotizing enterocolitis (NEC) all died. CONCLUSION: There was no significant difference in clinical findings and mortality of gastric perforation between preterm and term infants. The prognosis of spontaneous gastric perforation was good, however, mortality rate was tended to be higher in NEC than other causes (P=0.083).

Clinical Features and Outcomes of Meconium Intestinal Obstruction in Preterm Infants / 대한주산의학회잡지

PURPOSE: This study was undertaken to investigate the clinical features and outcomes of meconium intestinal obstruction (MIO) in preterm infants. METHODS: A retrospective analysis of medical records and radiologic images was conducted in a neonatal intensive care unit over a 3-year period (2009-2011). In addition, birth year- and gestational age-matched babies were selected by random sampling with twice the number as the control group. RESULTS: There were 43 infants with MIO who were appropriate as subjects. In perinatal factors, a maternal history of hypertension and the use of magnesium sulfate were more frequent in patients with MIO, but not significant. Feeding intolerance was more common in the MIO group than the control (86% vs. 24.4%; P<0.001). The frequency of gastrografin enema was once in all but one of the patients, and the microcolon was detected in 7 cases (16.3%. Radiographic change after enema was seen earlier than clinical improvement (P<0.05).The patients with MIO took longer to achieve full enteral feeding, and had a more prolonged hospital stay (P<0.001). CONCLUSION: Feeding intolerance in preterm infants may be an early clinical finding of MIO. Meconium obstruction causes a delay of full enteral feeding and extension of hospital stay.

The Effects of Hand Moxibustion and Hand Press Pellet on Blood Pressure, Blood Lipids and Blood Cell Components in Aged Women with Essential Hypertension

PURPOSE: The purpose of this study was to evaluate the effects of hand moxa and hand press pellet on blood pressure, blood lipids and blood cell components in elderly women. METHODS: This study was conducted as a quasi-experiment with none equivalent control group pre-post test design. The participants were elders who had essential hypertension. There were 18 members in the experimental group and 20 members in the control group. The experimental group received hand moxibustion and hand press pellet 3 times a week for 12 weeks. The results were analyzed using 2 test, t-test, Fisher's exact test and repeated measures ANOVA with the SPSS/WIN program. RESULTS: There were significant decreases in blood pressure in the experimental group compared to the control group. No significant difference was observed in total triglyceride, LDL cholesterol and HDL cholesterol between the two groups. Differences in hemoglobin and hematocrit were not significant either. However, there were significant increases in RBC in the experimental group after the intervention. CONCLUSION: The results suggest that combined hand therapy contributes to the decrease of blood pressure among the elderly with hypertension. Therefore combined hand therapy is recommended as a complementary nursing intervention strategy for the elderly with essential hypertension.

Two Cases of Congenital Vallecular Cyst with Respiratory Distress and Feeding Problems in Young Infant / 대한이비인후과학회지

Congenital vallecular cyst (VC) is a rare cause of stridor and respiratory distress in neonates and infants. Due to the anatomical location of the cyst, an infant with a VC is at risk of life-threatening upper airway obstruction and eventual death. The cyst sits in the vallecular space and can cause significant retroflexion of the epiglottis. It may also present with feeding problems resulting in failure to grow. Endoscopic laryngoscopy is necessary to visualize it and mar-supialization of the cyst is the preferred treatment. We present 2 successfully treated cases of congenital VC in young infants with symptoms of upper respiratory obstruction and feeding problems.

Factors related to the Health related Quality of Life among Institutionalized Elders / 성인간호학회지

PURPOSE: This purpose of this study was to identify the factors related to the health related quality of life among institutionalized elders. METHODS: The subjects were 247 elders institutionalized among one of the four nursing homes in Busan. Data were collected through interview with four standardized questionnaires from August to October, 2008. Questionnaires were related to health related quality of life (SmithKline Beecham's Quality of Life scale, SBQoL), quality of sleep(Pittsburgh Sleep Quality index, PSQI), activity of daily living (Katz ADL Index), and depression (Geriatric Depression Scale Short Form Korea, GDSSF-K). Data were analyzed for descriptive analysis, t-test, one-way ANOVA, Pearson's correlation coefficient, and stepwise multiple regression by using SPSS/WIN 17.0 program. RESULTS: The mean HRQoL in the subjects was 6.62 +/- 0.91. Percentage of the respondents reporting sleep disorders were 72.5% and 27.1% reported being vulnerable to depression. The significant predictors of the HRQoL were sleep quality, activity of daily living (ADL), level of education, and depression. The factors accounted for 28.8% of variance in the health related quality of life of institutionalized elders. CONCLUSION: Sleep quality, activity of daily living, and depression need to be considered as the important control factors for improving the health related quality of life in the institutionalized elders.

Perianastomotic ulceration presenting with long-term iron deficiency anemia and growth failure: A case report and review of the literature / 소아과

Perianastomotic ulceration (PAU) rarely occurs after small bowel resection in infancy. Since the understanding of its pathogenesis is incomplete, an effective method of treatment has not yet been discovered. We report the first case in Korea of a 10-year-old girl with chronic iron deficiency anemia (IDA) and growth failure who was diagnosed with PAU at colonoscopy. Seven years were required to identify the cause of IDA. After surgical resection and revision of anastomosis, a close follow-up is being conducted due to the risk of recurrence. Here, we also review reports on 25 pediatric patients with PAU derived from a search of the English-language literature and describe the clinical features of PAU along with the results of treatment.

Left Ventricular Function in Children and Adolescents With Type 1 Diabetes Mellitus

BACKGROUND AND OBJECTIVES: Adult studies have reported that patients with diabetes mellitus (DM) show ultrastructural and functional myocardial deterioration. The aim of this study was to assess whether cardiac functional deterioration can be detected in pediatric patients with type I DM and whether or not a relatively short duration of DM and hyperglycemia influences cardiac function. SUBJECTS AND METHODS: Forty-seven children and adolescents with DM and 38 healthy subjects (control group) were enrolled. Glycosylated hemoglobin (HbA1c), DM-induced complications, and left ventricular (LV) function as assessed using conventional and unconventional echocardiography {tissue Doppler imaging (TDI) and vector velocity imaging (VVI)} were evaluated. RESULTS: The conventional echocardiographic parameters, with the exception of early peak mitral inflow velocity, the findings of pulsed wave TDI at the annular level, and regional ventricular function by VVI, were not significantly different between the two groups. Using the conventional and unconventional indices of systolic and diastolic function, no significant relationship was found between the duration of DM and the echocardiographic parameters. The deceleration time (DT) and E'/A' had an inverse correlation with HbA1c (p=0.042 and p=0.016, respectively). CONCLUSION: Patients with DM in childhood and early adolescence rarely have insight on the significance of DM, and their diet is difficult to control. An alteration of myocardial function induced by DM may begin earlier than generally thought, and these changes are accelerated when glycemic control is poor. We recommend the early institution of close observation of patients with diabetes for alterations in cardiac function, in addition to other diabetic complications.

Phenomenological Research on the Experience of Weight Control Among Nursing Students / 성인간호학회지

PURPOSE: This study was conducted to discover the essence and the structure of the experiences of weight control by nursing students. METHODS: Participants were 12 nursing students who had tried losing weight at C university in Busan, Korea. The data were collected from June 17 to August 6, 2006. For the purpose of this study, focus group discussions and in depth interviews were employed. RESULTS: The collected data were analyzed by using Giorgi's method. As the results of the analysis, the following four components of experience were derived: My appearance looked abnorml; Measures for self-realization; Pursuit of my own way only; Feelings of accomplishment and self confidence. CONCLUSION: It is necessary to develop an effective weight control program with minimized side effects that are harmful to health, based on the components of the nursing students' experiences in weight control that were identified in this study.

A Study on Health Behaviors, Health Status and Anxiety about Aging for the Elderly: Focused on the Elderly in Senior Center

PURPOSE: This study is conducted to survey and examine the relationships among anxiety about aging, perceived health status and health promoting behaviors in the elderly, and to provide basic data for health promoting interventions that would improve their successful aging. METHODS: Data in this study was collected from 333 elderly participants living in Busan. Descriptive statistics, t-test or ANOVA with Scheffe's test, Pearson's correlation coefficients and stepwise multiple regression were used for data analysis. RESULTS: The major findings of this study were as follows. 1) The mean score of anxiety about aging was 2.67 +/- 0.30, perceived health status 2.46 +/- 0.37, and health promoting behavior 2.77 +/- 0.21. 2) There was a positive correlation between health promoting behavior and perceived health status (r = 267, p = .000). There was a negative correlation between anxiety about aging and health promoting behavior (r = -.163, p = .003). 3) Health-promoting behavior was significantly associated with perceived health and anxiety about aging, which explained 20.9% of variance in health-promoting behavior. CONCLUSION: In order to promote perceived health status and to decrease anxiety about aging in the elderly, it is necessary to develop supporting interventions to decrease anxiety about aging.

Subcutaneous botulinum toxin type a injection for chronic medial knee pain with ostheoarthritis

BACKGROUND:This study was designed to evaluate the efficacy of subcutaneous Botulinum toxin type A (BoNT-A) injection for treating chronic medial knee pain with osteoarthritis. METHODS:A randomized, double-blind, placebo-controlled clinical trial was conducted at a university hospital in Korea.The subjects suffering from chronic medial knee pain with osteoarthritis were randomly allocated to either the BoNT-A (treatment, n = 23) group or the normal saline (placebo, n = 27) group.Injections were given to 10 points per unilateral knee along the course of the saphenous nerve.A total of 90 units of BoNT-A (60 units at baseline and 30 units after 1 week) was given for treating unilateral knee pain and a total of 180 units of BoNT-A was given for treating bilateral knee pain.The placebo group received the same volume of normal saline. RESULTS:The Visual Analog Scale (VAS) pain score was significantly decreased in both the BoNT-A and normal saline groups 1, 4 and 12 weeks after injection.After adjusting for covariates, BoNT-A had a 0.788 times higher effect to decrease the VAS score than did normal saline, but the effect was marginally significant (P = 0.050). CONCLUSIONS:Subcutaneous injection along the course of the saphenous nerve significantly reduces chronic medial knee pain. The pain reduction effect of BoNT-A is higher than that of placebo, but the effect is marginally significant

Subcutaneous botulinum toxin type a injection for chronic medial knee pain with ostheoarthritis

BACKGROUND:This study was designed to evaluate the efficacy of subcutaneous Botulinum toxin type A (BoNT-A) injection for treating chronic medial knee pain with osteoarthritis. METHODS:A randomized, double-blind, placebo-controlled clinical trial was conducted at a university hospital in Korea.The subjects suffering from chronic medial knee pain with osteoarthritis were randomly allocated to either the BoNT-A (treatment, n = 23) group or the normal saline (placebo, n = 27) group.Injections were given to 10 points per unilateral knee along the course of the saphenous nerve.A total of 90 units of BoNT-A (60 units at baseline and 30 units after 1 week) was given for treating unilateral knee pain and a total of 180 units of BoNT-A was given for treating bilateral knee pain.The placebo group received the same volume of normal saline. RESULTS:The Visual Analog Scale (VAS) pain score was significantly decreased in both the BoNT-A and normal saline groups 1, 4 and 12 weeks after injection.After adjusting for covariates, BoNT-A had a 0.788 times higher effect to decrease the VAS score than did normal saline, but the effect was marginally significant (P = 0.050). CONCLUSIONS:Subcutaneous injection along the course of the saphenous nerve significantly reduces chronic medial knee pain. The pain reduction effect of BoNT-A is higher than that of placebo, but the effect is marginally significant