Plaque removal efficacy of oscillating-rotating power toothbrushes: review of six comparative clinical trials

PURPOSE

This review of six clinical trials provides a comprehensive overview of the results of statistical analyses to explore between-brush differences, specifically in the lingual, gingival marginal, and approximal ("hard-to-clean") areas, in post-brushing plaque removal of oscillating-rotating (O-R) power toothbrushes compared to either a marketed sonic power toothbrush or a manual toothbrush control.

METHODS

All studies were single-center, randomized and controlled, and examiner-blind. Four trials were four-period crossover design with replicate single-use brushing, while two studies were parallel group investigations (4 or 12 weeks) with multiple brushings and assessments at each visit. Generally healthy subjects were enrolled. Plaque evaluations were via the Turesky Modification of the Quigley-Hein Plaque Index (TMQHPI) or the Rustogi Modification of the Navy Plaque Index (RMNPI). At each evaluation visit, subjects brushed with either the randomly assigned O-R power brush [Oral-B Professional Care Series 4000 (Triumph) or Oral-B Vitality with Floss Action or Precision Clean brush head] or a control brush [Sonicare FlexCare with ProResults brush head (three trials) or an American Dental Association (ADA) reference manual toothbrush (three trials)]. ANCOVA and ANOVA analyses subsequently evaluated specifically the 'hard-to-clean' tooth surfaces for between-brush differences.

RESULTS

In total, 462 subjects completed the trials and were evaluable. While all toothbrushes provided significant post-brushing versus baseline plaque removal efficacy, the magnitude of the reduction was consistently superior for the O-R brush compared to either the sonic power or manual brush control in all the 'hard-to-clean" region-specific analyses. Adjusted mean RMNPI or TMQHPI benefits favoring the O-R brush relative to the sonic brush control were collectively 18% to 34% greater on lingual surfaces (P < or = 0.044), 32% to 49% greater on lingual approximal surfaces (P < 0.001), and 32% and 31% greater in lingual mandibular and lingual mandibular anterior regions, respectively (P < or = 0.005). Post-brushing whole mouth adjusted mean reduction RMNPI or TMQHPI benefits favoring the O-R brush compared to the manual brush control were collectively 31% to 206% greater on lingual surfaces (P < or = 0.001), 29% to 217% greater on lingual approximal surfaces (P < or = 0.001), and 67% to 526% greater in lingual gingival margin regions, respectively (P < or = 0.001). All study toothbrushes were well-tolerated.

A novel power toothbrush with multi-directional, triple zone cleaning technology

PURPOSE

Numerous laboratory and clinical studies have proven that certain power toothbrush technologies are more effective in removal of dental plaque and reduction of gingivitis than regular manual toothbrushes. Regardless of this evidence, there is still a large group of individuals who prefer the experience of a manual-like toothbrush. Recently a novel multi-directional power brush has been developed as an alternative for those people who favor the traditional size and shape of a manual toothbrush and prefer the manual brushing technique, but would benefit from the greater cleaning efficiency of the power brush.

METHODS

This unique multi-directional power toothbrush with triple-zone cleaning technology has been tested in multiple clinical trials. This special issue introduces the technical features of the brush and presents four clinical investigations conducted with this power toothbrush versus manual and sonic controls.

RESULTS

The studies described in this issue demonstrate the superior efficacy of the multi-directional brush in plaque and gingivitis reduction relative to control brushes, even in the hard-to-reach interdental spaces and marginal areas.

Clinicians' attitudes to depression in Europe: a pooled analysis of Depression Attitude Questionnaire findings

BACKGROUND

Depression in primary care is common but under-recognized and suboptimally managed. Health professionals' attitudes are likely to play an important part in their recognition and management of depression.

OBJECTIVES

To pool findings from studies using the Depression Attitude Questionnaire (DAQ) to provide greater detail of clinicians' attitudes and the measure's psychometric properties.

METHODS

Electronic databases and grey literature were searched for relevant studies. Data from eligible studies were requested and pooled analysis conducted.

RESULTS

Twenty studies were eligible and data were obtained from 12 of these involving GPs (n = 1543) and nurses (n = 984). Responses showed strong disagreement that depression is due to ageing or weakness. European GPs were more positive about depression treatments than UK GPs; nurses were more favourable about psychotherapy than GPs. UK GPs especially strongly opposed notions that depression is best managed by psychiatrists. Trends over time indicated increasing acknowledgement of psychological therapies and the nurse's role in depression management. Factor analysis indicated that many DAQ items fitted weakly within an overall model. The most parsimonious solution involved two factors: a positive view of depression and its treatment response and professional confidence in depression management.

CONCLUSIONS

Individual DAQ items appear to measure key aspects of clinicians' attitudes to depression, and item responses indicate important differences between professions and geographical settings as well as changes over time. There are problems with the DAQ as a scale: its internal consistency is weak, and several items appear specific to particular professions or service structures, indicating that this questionnaire should be revised.

Pharmaceutical care: cultural, practice and professional perspectives

Focal points

Pharmaceutical care for older people: recording and review of medication following admission to hospital

Focal points

Event-by-event fluctuations of azimuthal particle anisotropy in Au+Au collisions at square root(sNN) = 200 GeV

This Letter presents the first measurement of event-by-event fluctuations of the elliptic flow parameter v(2) in Au+Au collisions at square root(s(NN))=200 GeV as a function of collision centrality. The relative nonstatistical fluctuations of the v(2) parameter are found to be approximately 40%. The results, including contributions from event-by-event elliptic flow fluctuations and from azimuthal correlations that are unrelated to the reaction plane (nonflow correlations), establish an upper limit on the magnitude of underlying elliptic flow fluctuations. This limit is consistent with predictions based on spatial fluctuations of the participating nucleons in the initial nuclear overlap region. These results provide important constraints on models of the initial state and hydrodynamic evolution of relativistic heavy ion collisions.

Benefit of the power component of sonic and rotation-oscillation modes of action for plaque removal using power toothbrushes

PURPOSE

To assess the benefit of the power component of two power toothbrushes, with sonic and rotation-oscillation mechanisms, on plaque removal efficacy.

METHODS

Two independent studies with identical designs were used to assess the benefit of the power component of two power toothbrushes, with sonic and rotation-oscillation mechanisms, on plaque removal efficacy. Each brush was tested with the power 'On' relative to a control of the same brush with the power 'Off' used like a manual toothbrush. The studies were carried out independently at different sites, and each employed a replicate use, single brushing, two-treatment, four-period, examiner-blind, randomized, crossover design for assessing plaque removal. Study 1 compared rotation-oscillation action (Oral-B Triumph with FlossAction brush head), and Study 2 compared sonic action (Sonicare FlexCare with ProResults standard brush head) with power on versus off. The two treatments in each study consisted of (1) brushing teeth per manufacturer's instructions of the power toothbrush and (2) brushing without power by using the power toothbrush like a manual toothbrush. Prior to the treatment phase of each study, subjects exclusively used the assigned study toothbrush for 2 minutes twice per day according to the manufacturer's instructions (power on) during an acclimation period. Plaque was scored at prebrushing (baseline) and post-brushing on Visits 2, 3, 4 and 5 using the Turesky Modified Quigley-Hein Plaque Index (TMQHPI). A 2-day washout period separated each treatment period.

RESULTS

32 subjects were enrolled in each study; 28 subjects provided complete data for Study 1 and 32 subjects provided complete data for Study 2. The adjusted mean TMQHPI plaque removal scores for Study 1 were 0.793 for the rotation-oscillation 'On' regimen and 0.675 for the rotation-oscillation 'Off' regimen. This represents a statistically significantly (P<0.0001) greater plaque score reduction for the rotation-oscillation 'On' versus rotation-oscillation 'Off' treatment. The adjusted mean TMQHPI plaque removal scores for Study 2 were 1.042 for the sonic 'On' regimen and 1.007 for the sonic 'Off' regimen. This represents a nonsignificant (P=0.426) greater plaque score reduction for the difference between sonic 'On' versus sonic 'Off' regimen.

High transverse momentum triggered correlations over a large pseudorapidity acceptance in Au + Au collisions at square root(s(NN)) = 200 GeV

A measurement of two-particle correlations with a high transverse momentum trigger particle (p(T)(trig) > 2.5 GeV/c) is presented for Au+Au collisions at square root(s(NN)) = 200 GeV over the uniquely broad longitudinal acceptance of the PHOBOS detector (-4 < Delta eta < 2). A broadening of the away-side azimuthal correlation compared to elementary collisions is observed at all Delta eta. As in p+p collisions, the near side is characterized by a peak of correlated partners at small angle relative to the trigger particle. However, in central Au+Au collisions an additional correlation extended in Delta eta and known as the "ridge" is found to reach at least |Delta eta| approximately = 4. The ridge yield is largely independent of Delta eta over the measured range, and it decreases towards more peripheral collisions. For the chosen (p(T)(trig) cut, the ridge yield is consistent with zero for events with less than roughly 100 participating nucleons.

Comparison of rotation/oscillation and sonic power toothbrushes on plaque and gingivitis for 10 weeks

PURPOSE

Although power toothbrushes provide valuable tools toward improving oral health, contrasting results are discerned in their efficiency. This 10-week study was conducted to compare the safety and efficacy of rotation/oscillation and sonic power toothbrushes in the reduction of plaque and gingivitis.

METHODS

This two-treatment, parallel group, examiner-blind, randomized study had the subjects brush twice daily at home with their assigned rotation/oscillation or sonic toothbrush following manufacturer's instructions with center visits at baseline, and at 4 and 10 weeks following the baseline visit, for assessment of oral safety (all visits), plaque (baseline, Weeks 4 and 10), and gingivitis (baseline and Week 10). Gingivitis and number of bleeding sites were measured using the Löe-Silness Gingivitis Index, and plaque was measured using the Turesky Modification of the Quigley-Hein Plaque Index.

RESULTS

At Week 10, 171 subjects were evaluable for plaque assessment (85 in Sonic group, 86 in rotation/oscillation group) and 165 subjects were evaluable for gingivitis and bleeding sites assessment (84 in sonic group, 81 in rotation/oscillation group). The rotation/oscillation group had statistically significantly lower gingivitis scores (by 3.5%) and statistically significantly fewer bleeding sites than the sonic group (by 16.1%) with P = 0.038 and 0.028, respectively, at Week 10. Compared to baseline, only the rotation/oscillation group showed a statistically significant improvement in gingivitis (P = 0.003) and bleeding (P < 0.001) at Week 10. At both Weeks 4 and 10, the rotation/oscillation group had directionally lower plaque scores than the sonic group (by approximately 3%), but treatment group differences were not statistically significant (P > 0.1) at either time point. Both groups showed statistically significantly lower plaque scores at Weeks 4 and 10 relative to baseline.

Replicate single-use comparative study of plaque removal with two contemporary manual toothbrushes

PURPOSE

To compare the plaque removing efficacy of Oral-B Advantage 123 and Colgate 360 degrees manual toothbrushes on a single brushing after a 24-hour void in oral hygiene.

METHODS

This study had a two-treatment (Advantage 123 versus Colgate 360 degrees), examiner-blind, randomized, four-period (visit) crossover design. At the first (baseline) visit, subjects received a plaque examination using the Rustogi Modified Navy Plaque Index (RMNPI) after which they were instructed to brush for 1 minute in their normal manner with their assigned toothbrush and a marketed dentifrice and unaided by access to a mirror. Post-brushing plaque was then assessed. At three further visits, each separated by a period of 3-8 days, brushes were assigned to subjects according to their treatment sequence and the same brushing and plaque grading procedure as at baseline was followed.

RESULTS

50 subjects were enrolled in the replicate single-use study; all were included in the analysis. Oral-B Advantage 123 was significantly better than Colgate 360 degrees at reducing whole mouth (P = 0.006), gingival margin (P = 0.010) and approximal (P = 0.040) plaque scores.

System size, energy, and centrality dependence of pseudorapidity distributions of charged particles in relativistic heavy-ion collisions

We present the first measurements of the pseudorapidity distribution of primary charged particles in Cu+Cu collisions as a function of collision centrality and energy, sqrt[s_{NN}]=22.4, 62.4, and 200 GeV, over a wide range of pseudorapidity, using the PHOBOS detector. A comparison of Cu+Cu and Au+Au results shows that the total number of produced charged particles and the rough shape (height and width) of the pseudorapidity distributions are determined by the number of nucleon participants. More detailed studies reveal that a more precise matching of the shape of the Cu+Cu and Au+Au pseudorapidity distributions over the full range of pseudorapidity occurs for the same N{part}/2A rather than the same N_{part}. In other words, it is the collision geometry rather than just the number of nucleon participants that drives the detailed shape of the pseudorapidity distribution and its centrality dependence at RHIC energies.

A randomized 12-week study to compare the gingivitis and plaque reduction benefits of a rotation-oscillation power toothbrush and a sonic power toothbrush

OBJECTIVE

Sonic and rotation-oscillation power toothbrushes are popular and effective, but have been shown to differ in relative benefits. The objective of this 12-week investigation was to compare the efficacy of a rotation-oscillation powered toothbrush and a newly introduced sonic toothbrush in the reduction of gingivitis and dental plaque.

METHODS

This was a randomized, controlled, examiner-blind, two-treatment, parallel-group study to assess gingivitis reduction and plaque reductions after twice-daily brushing with either the rotation-oscillation brush or the sonic toothbrush over 12 weeks. The Modified Gingival Index (MGI) and Gingival Bleeding Index (GBI) were used to determine gingivitis benefits at Week 6 and Week 12, and plaque was scored at these visits before and after supervised brushing using the Rustogi Modified Navy Plaque Index (RMNPI).

RESULTS

In 171 evaluable subjects, gingivitis reduction benefits were significantly greater for the rotation-oscillation brush group than for those using the sonic toothbrush, with relative mean benefits favoring the rotation-oscillation brush of 29.4% for GBI and 8.2% for MGI at 12 weeks (p < or = 0.01). The rotation-oscillation brush produced significantly lower RMNPI plaque by 33.3% compared to the sonic toothbrush (p < 0.001) at Week 12.

CONCLUSION

The rotation-oscillation power toothbrush was significantly more efficacious than the sonic toothbrush in removing plaque, in reducing gingivitis, and lowering the number of bleeding sites after 12 weeks of twice-daily brushing.

A study comparing the plaque removal efficacy of an advanced rotation-oscillation power toothbrush to a new sonic toothbrush

OBJECTIVE

Recently, a new sonic power toothbrush has been marketed. The purpose of this study was to compare the plaque removal efficacy of a control rotation-oscillation power toothbrush (Oral-B Triumph) to this new sonic-powered toothbrush (Sonicare FlexCare) following a single brushing.

METHODS

This study was a randomized, controlled, examiner-blind, two-treatment, four-period crossover design, which examined plaque removal with the two toothbrushes following replicate single uses in 48 subjects. Plaque was scored before and after brushing using the Turesky Modification of the Quigley-Hein Plaque Index (TMQHPI).

RESULTS

Baseline plaque scores were 2.87 for the sonic toothbrush and 2.85 for the rotation-oscillation toothbrush treatment groups. With respect to all surfaces examined, the sonic toothbrush delivered an adjusted (via Analysis of Covariance) mean difference between baseline and post-brushing plaque scores of 0.95, while the rotation-oscillation toothbrush delivered an adjusted mean difference of 1.06. The difference between treatment groups was statistically significant (p = 0.003).

CONCLUSION

The rotation-oscillation toothbrush delivered superior plaque removal by reducing plaque scores, on average, 12.1% more than the new sonic toothbrush.

System size, energy, pseudorapidity, and centrality dependence of elliptic flow

This Letter presents measurements of the elliptic flow of charged particles as a function of pseudorapidity and centrality from Cu-Cu collisions at 62.4 and 200 GeV using the PHOBOS detector at the Relativistic Heavy Ion Collider. The elliptic flow in Cu-Cu collisions is found to be significant even for the most central events. For comparison with the Au-Au results, it is found that the detailed way in which the collision geometry (eccentricity) is estimated is of critical importance when scaling out system-size effects. A new form of eccentricity, called the participant eccentricity, is introduced which yields a scaled elliptic flow in the Cu-Cu system that has the same relative magnitude and qualitative features as that in the Au-Au system.

System size and centrality dependence of charged hadron transverse momentum spectra in Au + Au and Cu + Cu collisions at square root of SNN = 62.4 and 200 GeV

We present transverse momentum distributions of charged hadrons produced in Cu + Cu collisions at square root of SNN = 62.4 and 200 GeV. The spectra are measured for transverse momenta of 0.25 < pT < 5.0 GeV/c at square root of SNN = 62.4 GeV and 0.25 < pT < 7.0 GeV/c at square root of SNN = 200 GeV, in a pseudorapidity range of 0.2 < eta < 1.4. The nuclear modification factor R(AA) is calculated relative to p + p data at both collision energies as a function of collision centrality. At a given collision energy and fractional cross section, R(AA) is observed to be systematically larger in Cu + Cu collisions compared to Au + Au. However, for the same number of participating nucleons, R(AA) is essentially the same in both systems over the measured range of pT, in spite of the significantly different geometries of the Cu + Cu and Au + Au systems.

Digestive proteinases of the larger black flour beetle, Cynaeus angustus (Coleoptera: Tenebrionidae)

Digestion in the larger black flour beetle, Cynaeus angustus (LeConte), was studied to identify new control methods for this pest of stored grains and grain products. The physiological pH of the larval gut, as measured with extracts in water, was approximately 6.1, and the pH for optimal hydrolysis of casein by gut extracts was 6.2 when buffers were reducing. However, under non-reducing conditions, hydrolysis of casein and synthetic serine proteinase substrates was optimal in alkaline buffer. Three major proteinase activities were observed in zymograms using casein or gelatin. Caseinolytic activity of C. angustus gut extracts was inhibited by inhibitors that target aspartic and serine proteinase classes, with minor inhibition by a cysteine proteinase inhibitor. In particular, soybean trypsin and trypsin/chymotrypsin inhibitors were most effective in reducing the in vitro caseinolytic activity of gut extracts. Based on these data, further studies are suggested on the effects of dietary soybean inhibitors of serine proteinases, singly and in combination with aspartic and cysteine proteinase inhibitors, on C. angustus larvae. Results from these studies can be used to develop new control strategies to prevent damage to grains and stored products by C. angustus and similar coleopteran pests.

Behavioral and histological outcomes following graded spinal cord contusion injury in the C57Bl/6 mouse

A computer-controlled electromagnetic spinal cord injury device (ESCID) has been adapted to develop a mouse model of spinal cord contusion injury. In the present study, we have extended this model in C57Bl/6 mice with behavioral and histopathological outcome assessment. Three groups of mice received a laminectomy at the T(9) vertebral level followed by a contusion injury from a predetermined starting load of 1500 dynes. Contusion was produced by rapid displacement of the spinal cord to a peak distance of 0.3, 0.5, or 0.8 mm, with the entire injury and retraction procedure completed over a 23-ms epoch. Control groups received laminectomy alone or complete transection. Functional recovery was examined for 9 weeks after injury using the BBB locomotor rating scale, grid walking, and footprint analysis. Distinct patterns of locomotor recovery were evident across the five groups. Measurements of spared white matter at the epicenter, lesion length, and cross-sectional area of fibronectin-immunopositive scar tissue were also significantly different between injury groups. The severity of injury corresponded with the biomechanical measures recorded at the time of impact as well as with behavioral and histological parameters. The results demonstrate that graded contusion injuries can be produced reliably in mice using the ESCID. The data provide a thorough and quantitative analysis of the effects of contusion injury on long-term behavioral and histological outcome measures in this strain and species.

Autologous skin banking

Small amounts of excess autograft are commonly harvested during burn procedures, and typically these are discarded. However, the resources of a local skin bank may be used to preserve this tissue for a later autologous use. This has been a routine practice in our institution and we feel that it has impacted favorably on patient care. In this paper we report 42 consecutive applications of autologous frozen skin and illustrate the technique with a case report.

Do you know what a dietetic technician can do? A focus on clinical technicians and their expanded roles and responsibilities

Dietetic technicians, registered, play a key role in providing quality, cost-effective client care and foodservice management and are guided by the mission statement of the American Dietetic Association to promote optimal nutrition, health, and well-being. Many organizations use dietetic technicians to complete the screening and/or basic level assessments. The dietetic technician also can assist with patient monitoring and complete such tasks as calculating and documenting calorie counts, providing basic diet instruction, monitoring diet consumption and compliance, and determining tolerance of nutritional supplements. Since the last role delineation study was conducted, dietetic technicians have expanded into many different work settings, and practice roles have changed accordingly.

Validation of the MCMI-III PTSD scale among combat veterans

The new MCMI-III Posttraumatic Stress Disorder (PTSD) scale was validated on 104 combat veterans who were divided into two groups, PTSD Treatment Group and Non-PTSD Treatment Group. PTSD status was carefully determined by clinical interview and therapists' reports. The Combat Exposure Scale, the Mississippi Scale for Combat-related PTSD, and the Impact of Events Scale were also given. Analysis showed that the MCMI-III PTSD scale had a low internal consistency, but that it significantly differentiated the two groups and significantly correlated to those on other PTSD self-report scales. This scale appeared to be influenced by an acquiescent response style. Further validation studies are needed.

A comparison of aural and rectal temperature measurements in children with moderate and severe injuries

OBJECTIVE

The purpose of this study was to compare initial rectal and aural (i.e., ear-based) temperature measurements in children with moderate and severe injuries during their trauma care in the emergency department.

DESIGN

A cross-sectional, prospective design was used to compare aural temperature and rectal temperatures in injured children.

SAMPLE/SETTING

A convenience sample of 40 children who met the study inclusion criteria were enrolled at the level I pediatric regional resource trauma center in western Pennsylvania.

METHODS

Aural temperature was measured by infrared technology (IVAC Corporation, San Diego, Calif.), and rectal temperatures were measured with a thermistor (IVAC Corporation).

RESULTS

The subjects (N = 40) ranged in age from 1 to 14 years (mean 6.9 years; SD = 4.4 years). The mean difference between rectal and aural temperature measurements (mean = -0.3 degree C; SD = 0.76 degree C) was statistically significant when compared with a paired t test (p < 0.05). The Pearson product-moment correlation coefficient between aural and rectal temperature measurements was moderate to high (r = 0.85).

CONCLUSION

The moderate to high correlation between the two methods shows promise for use of aural infrared temperature measurements as a screening measure for children with moderate and severe injuries.

Effectiveness of a Prudhoe Bay crude oil and its aliphatic, aromatic and heterocyclic fractions in inducing mortality and aryl hydrocarbon hydroxylase in chick embryo in ovo

Prudhoe Bay crude oil (PBCO) and its aliphatic, aromatic and heterocyclic fractions were tested on the developing chick embryo for (i) embryotoxicity (ii) their ability to induce hepatic and renal cytochrome P450 levels as well as hepatic, renal and pulmonary aryl hydrocarbon hydroxylase activities. On the basis of its concentration in PBCO, the aromatic fraction was responsible for most of the embryotoxicity as well as for the enzyme inducing ability. The NOS fraction constituted less than 7% (w/v) of PBCO but, on a weight equivalent basis, was roughly as potent as the aromatic fraction in causing embryotoxicity and in inducing cytochrome P450 levels and aryl hydrocarbon hydroxylase. The aliphatic fraction was found to be essentially inactive. The results are consistent with the concept that elevation of aryl hydrocarbon hydroxylase levels by certain components of PBCO may lead to increased embryotoxicity.

Oxygen fields in specific spinal loci of the canine spinal cord

Oxygen tension (PO2) measurements were made in the dog spinal cord with a small recessed-tip oxygen microelectrode. The use of vibration and specific marking techniques has allowed the elimination of tissue compression artifacts and the mapping of regional PO2 in the thoracic spinal cord. A symmetrical distribution of PO2 values can be shown for the lateral white funiculi; the gray matter and dorsal columns have multimodal distributions. Statistical evaluation showed all these areas to have different PO2 profiles; PO2 values (mmHg) were 61.2 +/- 12.4 for the lateral white funiculi, 55.3 +/- 19.0 for the dorsal columns, and 30.0 +/- 13.6 in spinal gray. The relatively normal distribution patterns of these oxygen tensions indicate that traditional statistical methods may be used to compare and evaluate oxygen diffusion fields in the adult spinal cord.

Thromboxane - synthesizing activity in guinea pig lung microsomes

The microsomal fraction of guinea pig lung contains the enzymatic activity that converts arachidonic acid to thromboxane B2. The properties of guinea pig lung enzyme are generally similar to the human platelet enzyme, except the lung enzyme is unstable at 37 degrees C. No difference in total enzymatic activity is observed in the normal and sensitized guinea pig lungs.

Rate of disappearance of endogenous insulin from the circulation after removal of insulinomas

In two patients with insulinomas a rapid rate of disappearance of insulin from the circulation was found after the tumours had been removed. In a third case the rate of disappearance was slower but the insulin was not immunologically identical to normal human insulin standards, as it was in the other two cases.