Nomograms for Predicting Prognosis of Primary Mediastinal Seminoma: A Population-Based Study

Objectives. Primary mediastinal seminoma (PMS) was an uncommon carcinoma, and the appropriate treatment remained controversial due to the low incidence. We aimed to investigate the demographics and tumor biological characteristics to determine the potential effective treatment and predict the prognosis. Methods. Patients diagnosed with PMS were selected between 1975 and 2016 from Surveillance, Epidemiology, and End Results (SEER) database. Kaplan–Meier analysis and Cox proportional hazard model were conducted to determine the prognostic factors, and nomograms were employed to visually predict the prognosis. Concordance index (C-index), calibration curve, and receiver operating characteristic (ROC) curve were conducted to validate the prediction model. Results. A total of 476 patients were included with a median age of 31 years (range, 2–76 years), and a median size of the tumor was 11.6 cm (range, 0.2–24.0 cm). The 5- and 10-year overall survival (OS) rates were 70.4% and 68.4%, respectively. Age, the extent of the primary site, metastatic status, and surgery performance were independent prognostic factors. Not received surgery was considered a poor prognostic factor for OS (HR, 1.86; 95% CI, 1.13–3.03; P = 0.013 ). The C-index was 0.733 (95% CI, 0.685–0.781) and 0.819 (95% CI, 0.737–0.901) for internal and external validation for predicting OS, respectively. The area under the ROC curve (AUC) was 0.743 (95% CI, 0.681–0.804) for predicting OS (sensitivity, 0.532; specificity, 0.887) in the training cohort. Conclusions. The nomogram could efficiently predict the survival of patients with PMS. Surgery was the potential effective treatment, and chemotherapy was strongly recommended for patients over 40 years.

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Nomogram for predicting the overall survival and cancer-specific survival of patients with extremity liposarcoma: a population-based study

BMC Cancer ◽

10.1186/s12885-020-07396-x ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Lin Ye ◽

Chuan Hu ◽

Cailin Wang ◽

Weiyang Yu ◽

Feijun Liu ◽

...

Keyword(s):

Overall Survival ◽

Prognostic Factors ◽

Area Under The Curve ◽

Risk Groups ◽

Population Based ◽

Cancer Specific Survival ◽

Kaplan Meier ◽

Extremity Soft Tissue Sarcoma ◽

Individual Survival ◽

Size Grade

Abstract Background Extremity liposarcoma represents 25% of extremity soft tissue sarcoma and has a better prognosis than liposarcoma occurring in other anatomic sites. The purpose of this study was to develop two nomograms for predicting the overall survival (OS) and cancer-specific survival (CSS) of patients with extremity liposarcoma. Methods A total of 2170 patients diagnosed with primary extremity liposarcoma between 2004 and 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox analyses were performed to explore the independent prognostic factors and establish two nomograms. The area under the curve (AUC), C-index, calibration curve, decision curve analysis (DCA), Kaplan-Meier analysis, and subgroup analyses were used to evaluate the nomograms. Results Six variables were identified as independent prognostic factors for both OS and CSS. In the training cohort, the AUCs of the OS nomogram were 0.842, 0.841, and 0.823 for predicting 3-, 5-, and 8-year OS, respectively, while the AUCs of the CSS nomogram were 0.889, 0.884, and 0.859 for predicting 3-, 5-, and 8-year CSS, respectively. Calibration plots and DCA revealed that the nomogram had a satisfactory ability to predict OS and CSS. The above results were also observed in the validation cohort. In addition, the C-indices of both nomograms were significantly higher than those of all independent prognostic factors in both the training and validation cohorts. Stratification of the patients into high- and low-risk groups highlighted the differences in prognosis between the two groups in the training and validation cohorts. Conclusion Age, sex, tumor size, grade, M stage, and surgery status were confirmed as independent prognostic variables for both OS and CSS in extremity liposarcoma patients. Two nomograms based on the above variables were established to provide more accurate individual survival predictions for extremity liposarcoma patients and to help physicians make appropriate clinical decisions.

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Scaphoid Nonunion With Poor Prognostic Factors

Hand ◽

10.1177/1558944716661994 ◽

2016 ◽

Vol 12 (2) ◽

pp. 135-139 ◽

Cited By ~ 10

Author(s):

Tahseen Chaudhry ◽

Lauren Uppal ◽

Dominic Power ◽

Michael Craigen ◽

Simon Tan

Keyword(s):

Prognostic Factors ◽

Bone Graft ◽

Femoral Condyle ◽

Donor Site ◽

Donor Site Morbidity ◽

Vascularized Bone Graft ◽

Union Rate ◽

Poor Prognostic Factor ◽

Low Incidence ◽

Vascularized Bone

Background: To report on the results of free medial femoral condyle (MFC) vascularized bone graft for scaphoid nonunions with 1 or more poor prognostic factors. Methods: We have used the free MFC vascularized bone graft for scaphoid nonunions that have 1 or more factors associated with a poor prognosis. These were, a delay in presentation of over 5 years, a proximal pole nonunion, the presence of avascular necrosis (AVN), or previous nonunion surgery. We used this technique on 20 patients over a 4.5-year period. Results: Our overall union rate was 88.5% (17 of 19 patients), with 1 patient failing to attend for follow-up. Our mean union time was 7 months (2-18). All patients had at least 1 poor prognostic factor and over half had 2 or more. Of those with AVN with or without other factors, the union rate was 85% (11 of 13). There were 2 donor site complications that required a further procedure and 2 patients with residual wrist pain that required a scapho-trapezio-trapezoid joint fusion and a radial styloidectomy, respectively. Both nonunions were offered further surgery, and 1 elected to undergo successful revision surgery. Conclusions: Overall, this technique showed good results, in a subgroup of patients that typically have poorer outcomes, with a low incidence of donor site morbidity. Our union rate compares favorably with other techniques for this difficult subset of patients with 1 or more poor prognostic factors, although results are clearly not as good as those of studies using the MFC graft for all scaphoid nonunions. We continue to reserve this technique for nonunions with 1 or more poor prognostic factors, and we believe that this technique should at least be considered in these patients.

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Development and External Validation of a Nomogram for Predicting Overall Survival in Stomach Cancer: A Population-Based Study

Journal of Healthcare Engineering ◽

10.1155/2021/8605869 ◽

2021 ◽

Vol 2021 ◽

pp. 1-13

Author(s):

Haonan Ji ◽

Huita Wu ◽

Yu Du ◽

Li Xiao ◽

Yiqin Zhang ◽

...

Keyword(s):

Overall Survival ◽

Prognostic Factors ◽

Stomach Cancer ◽

External Validation ◽

Model Development ◽

Training Group ◽

Population Based ◽

Survival Prediction ◽

Kolmogorov Smirnov ◽

Testing Group

Objective. The study was to develop and externally validate a prognostic nomogram to effectively predict the overall survival of patients with stomach cancer. Methods. Demographic and clinical variables of patients with stomach cancer in the Surveillance, Epidemiology, and End Results (SEER) database from 2007–2016 were retrospectively collected. Patients were then divided into the Training Group (n = 4,456) for model development and the Testing Group (n = 4,541) for external validation. Univariate and multivariate Cox regressions were used to explore prognostic factors. The concordance index (C-index) and the Kolmogorov–Smirnov (KS) value were used to measure the discrimination, and the calibration curve was used to assess the calibration of the nomogram. Results. Prognostic factors including age, race, marital status, TNM stage, surgery, chemotherapy, grade, and the number of regional nodes positive were used to construct a nomogram. The C-index was 0.790 and the KS value was 0.45 for the Training Group, and the C-index was 0.789 for the Testing Group, all suggesting the good performance of the nomogram. Conclusion. We have developed an effective nomogram with ten easily acquired prognostic factors. The nomogram could accurately predict the overall survival of patients with stomach cancer and performed well on external validation, which would help improve the individualized survival prediction and decision-making, thereby improving the outcome and survival of stomach cancer.

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A New Predictive Model for Breast Cancer Survival in New Zealand: Development, Internal and External Validation, and Comparison With the Nottingham Prognostic Index

Journal of Global Oncology ◽

10.1200/jgo.18.91800 ◽

2018 ◽

Vol 4 (Supplement 2) ◽

pp. 227s-227s

Author(s):

M. Elwood ◽

S. Tin Tin ◽

E. Tawfiq ◽

R.J. Marshall ◽

T.M. Phung ◽

...

Keyword(s):

Breast Cancer ◽

New Zealand ◽

External Validity ◽

External Validation ◽

Prognostic Index ◽

Population Based ◽

Nottingham Prognostic Index ◽

Data Set ◽

Kaplan Meier ◽

Internal And External Validity

Background: Women diagnosed with breast cancer, their doctors, and their families, would find a valid estimate of her prognosis helpful in planning treatment and support. Assessing prognosis is complex as many factors influence it. Several predictive models have been produced, but none has been developed or tested on patients in New Zealand (NZ). Aim: We aimed to develop and validate a NZ predictive model (NZPM) for breast cancer, and compare its performance to a widely used UK-developed model, the Nottingham Prognostic Index (NPI). Methods: We developed a model to predict 10-year breast cancer-specific survival, using data collected prospectively in the largest population-based breast cancer registry in NZ (Auckland, 9182 patients), and assessed its performance in this data set (internal validation) and in an independent NZ population-based series of 2625 patients in Waikato (external validation). The data included all women with primary invasive breast cancer diagnosed from 1 June 2000 to 30 June 2014, with follow-up to death or to 31 December 2014. We used multivariate Cox proportional hazards regression to assess predictors and to estimate the probability of breast cancer mortality within 10 years, and therefore 10-year survival, for each patient. We assessed observed survival by the Kaplan-Meier method. We assessed discrimination by the C-statistic, and calibration by comparing predicted and observed survival rates for patients in 10 groups ordered by predicted 10-year survival. We compared this NZPM with the NPI in the validation data set. Results: The final NZPM used continuous variables of age, tumor size, and number of positive lymph nodes, and categorical variables of ethnicity, tumor stage, tumor grade, ER and PR receptors, HER2 status, and histologic type of tumor. Discrimination was good: C-statistics were 0.84 for internal validity and 0.83 for independent external validity. For calibration, for both internal and external validity, the predicted 10-year survival probabilities in 10 groups of patients, ordered by predicted survival, were all within the 95% confidence intervals (CI) of the observed Kaplan-Meier survival probabilities. The NZPM showed good discrimination even within the prognostic groups defined by the NPI. Conclusion: These results for the NZPM show good internal and external validity, transportability, potential clinical value, and its clear superiority over the NPI. Further research will assess other potential predictors, other outcomes, performance in specific subgroups of patients, and compare the NZPM to other models, which have been developed in other countries and have not yet been tested in NZ.

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Comparing the Characteristics and Predicting the Survival of Head and Neck Melanoma versus Body Melanoma: A Population-based Study

10.21203/rs.3.rs-154802/v1 ◽

2021 ◽

Author(s):

Yuxin Ding ◽

Runyi Jiang ◽

Yuhong Chen ◽

Jing Jing ◽

Xiaoshuang Yang ◽

...

Keyword(s):

Prognostic Factors ◽

Head And Neck ◽

Proportional Hazards ◽

Population Based ◽

Cox Proportional Hazards ◽

Kaplan Meier ◽

Cox Proportional Hazards Models ◽

Great Consistency ◽

Lentigo Maligna Melanoma ◽

Head And Neck Melanoma

Abstract Background Previous studies have reported poorer survival in head and neck melanoma (HNM) than in body melanoma (BM). Individualized tools to predict the prognosis for patients with HNM or BM remain insufficient. Objectives To compare the characteristics of HNM and BM, and to establish and validate the nomograms for predicting the 3-, 5- and 10-year survival of patients with HNM or BM. Methods We studied patients with HNM or BM from 2004 to 2015 in the Surveillance, Epidemiology, and End Results (SEER) database. The HNM group and BM group were randomly divided into training and validation cohorts. We performed the Kaplan-Meier method for survival analysis, and used multivariate Cox proportional hazards models to identify independent prognostic factors. Nomograms for HNM patients or BM patients were developed via the rms package, and were measured by the concordance index (C-index), the area under the receiver operator characteristic (ROC) curve (AUC) and calibration plots. Results Of 70605 patients acquired, 21% (n = 15071) had HNM and 79% (n = 55534) had BM. The HNM group contained more older patients, male patients, and lentigo maligna melanoma, and more frequently had thicker tumors and metastases than the BM group. The 5-year CSS and OS rates were 88.1 ± 0.3% and 74.4 ± 0.4% in the HNM group and 92.5 ± 0.1% and 85.8 ± 0.2% in the BM group, respectively. Eight independent prognostic factors (age, sex, histology, thickness, ulceration, stage, metastases, and surgery) were identified to construct nomograms for HNM patients or BM patients. The performance of the nomograms were excellent: the C-index of the CSS prediction for HNM patients and BM patients in the training cohort were 0.839 and 0.895, respectively; in the validation cohort, they were 0.848 and 0.888, respectively; the AUCs for the 3-, 5- and 10-year CSS rates of HNM were 0.871, 0.865 and 0.854 (training), and 0.881, 0.879 and 0.861 (validation), respectively; of BM, the AUCs were 0.924, 0.918 and 0.901 (training) and 0.916, 0.908 and 0.893 (validation), respectively; and the calibration plots showed great consistency. Conclusions The characteristics of HNM and BM are heterogeneous, and we constructed and validated specific nomograms as practical prognostic tools for patients with HNM or BM.

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Incidence and Outcome of Myelodysplastic Syndromes in Province of Modena.

Blood ◽

10.1182/blood.v110.11.4610.4610 ◽

2007 ◽

Vol 110 (11) ◽

pp. 4610-4610 ◽

Cited By ~ 1

Author(s):

Alessia Bari ◽

Raffaella Marcheselli ◽

Ivan Rashid ◽

Goretta Bonacorsi ◽

Roberto Marasca ◽

...

Keyword(s):

Overall Survival ◽

Relative Survival ◽

Epidemiological Data ◽

Cancer Registries ◽

Population Based ◽

Refractory Anemia ◽

Pathology Report ◽

Kaplan Meier ◽

Appropriate Treatment ◽

Standard Population

Abstract Background As in the past Myelodisplastic Syndromes (MDS) were considered preneoplastic conditions, rarely data on these diseases were collected by cancer registries. Thus, there are few well documented population-based studies on the incidence and outcome of MDS. The aim of this study was to collect epidemiological data and clinical characteristics of MDS by studying all cases identified by the Modena Cancer Registry (MCR). Materials and methods We examined all cases of MDS diagnosed in the Province of Modena (population 633.993 at 2001 Census). MDS from 1997 to 2005 were identified using the MCR database and the archival files of the centralized hemolymphopathological laboratory at Modena Cancer Centre according to ICD-O-3 codes 9980,9982–87,9989. Death certificate, cytology and histology report, both local and national reports of Hospital admission, ICD-9 code reported in medical records were used as sources for identifying new MDS cases and their outcome. After collection, all cases were checked and validated by a hematologist (A.B.) and a pathologist (G.B.) by a review of the original pathology report. The large majority of bone marrow aspirate and biopsy were examined by the same pathologist (G.B.) making diagnostic criteria uniform. Clinical and follow-up data were retrieved by active search of discharge letters, review of hospital records, and interview of general practitioners. Information on vital status was achieved from official population registries. Age standardized rates (ASR) were calculated according to the World Standard population (Doll et al, 1966). The dates of diagnosis and death or the closing date of study (December 2006) were used to estimate survival. Observed survival and relative survival were calculated according to Kaplan-Meier method and the Hakulinen approach, respectively. Results A total of 205 cases of MDS were identified. The ASR of MDS was 1.2/100,000 varying slightly (from 0.9 to 1.5/100,000; p > 0.05) during the study period, and the crude incidence rate was 3.6/100,000. Median age at diagnosis was 75 years for men and 78 for women. Overall, 58% of patients aged more than 75 years, while only 1% were less than 45 years old. According to French, American and British (FAB) classification there were 35 cases (17% of all MDS) of Refractory Anemia (RA), 51 (25%) of RA with ringed sideroblasts, 73 cases (36%) of RA with excess of blasts (RAEB), 11 (5%) of RAEB in transformation, 31 (15%) of MDS not otherwise specified and 4 (2%) of other MDS. Overall the prognosis of MDS was poor, although we found statistically significant differences by clinical subtypes. In our MDS population the relative survival was 68%, 36% and 26% at 1, 3 and 5 years, respectively. Conclusions To our knowledge, this study is the first in Italy providing information on the incidence and outcome of MDS using population-based data. Our results confirm that the risk of developing MDS increases with age for both men and women. The incidence of MDS was substantially stable during the study period. Overall survival was poor reflecting the aggressiveness of these diseases and the advanced age of patients at time of diagnosis. As expected, we observed important differences in overall survival by FAB subtypes. In the last few years, innovative treatments for MDS are emerging and we believe that the availability of precise epidemiological data could help clinicians in choosing the most appropriate treatment.

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Population-Based Survival Analysis of Patients With Limb Rhabdomyosarcoma and Metastasis at Diagnosis

Frontiers in Surgery ◽

10.3389/fsurg.2021.738771 ◽

2021 ◽

Vol 8 ◽

Author(s):

Chunying Yang ◽

Haiqing Wang ◽

Feng Niu ◽

Lufeng Yao

Keyword(s):

Poor Prognosis ◽

Population Based ◽

Tumor Subtype ◽

Male Predominance ◽

Cox Proportional Hazard ◽

Kaplan Meier ◽

Appropriate Treatment ◽

Younger Age ◽

Relative Rarity ◽

Cox Proportional Hazard Regression

Purpose: Given the poor prognosis and the relative rarity of patients diagnosed with limb rhabdomyosarcoma (LRMS) and metastasis at diagnosis, we performed this study to reveal distinctive clinical features and evaluated prognostic factors of this special population in order to provide appropriate treatment.Patients and Methods: We carried out retrospective research of patients diagnosed with LRMS and metastasis from 1975 to 2016 using the Surveillance, Epidemiology, and End Results (SEER) program database. Survival curves were generated by applying the Kaplan–Meier method. In terms of evaluating and determining independent predictors of survival, we conducted univariate and multivariate survival analyses using the Cox proportional hazard regression model.Results: This retrospective analysis contained a series of 245 patients with metastatic LRMS, with male predominance (male vs. female, 1.6:1). Nearly half of the patients were diagnosed with alveolar rhabdomyosarcoma (44.9%). According to the results of the univariate and multivariate analyses, younger age, tumor subtype, and radiotherapy were found to be significantly associated with improved overall survival (OS) and cause-specific survival (CSS).Conclusions: Patients with LRMS and metastasis at diagnosis experienced a quite poor prognosis. Age at diagnosis, tumor subtype, and radiotherapy can help clinicians to better estimate the prognosis. This study indicated that local radiotherapy can provide a survival benefit.

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Survival outcomes and prognostic factors for ascending nasopharyngeal carcinoma (T4N0-1) receiving radiation therapy combined with chemotherapy: a population-based study from SEER database.

10.21203/rs.3.rs-22999/v1 ◽

2020 ◽

Author(s):

Fangzheng Wang ◽

Jiang Chuner ◽

Piao Yongfeng ◽

Wang Lei ◽

Yan Fengqin ◽

...

Keyword(s):

Radiation Therapy ◽

Prognostic Factors ◽

Nasopharyngeal Carcinoma ◽

Univariate Analysis ◽

Population Based ◽

Rank Test ◽

Survival Outcomes ◽

Cancer Specific Survival ◽

Kaplan Meier ◽

Cox Proportional Hazard Models

Abstract Purpose This study aims to investigate survival outcomes and prognostic factors for upward nasopharyngeal carcinoma (NPC) patients receiving radiation therapy (RT) combined with chemotherapy (CT). Methods A total of 421 previously untreated, newly diagnosed T4N0-1 NPC patients, who were identified within the Surveillance, Epidemiology, and End Results (SEER) registry (years 2004–2015), were collected and retrospectively reviewed. All patients received treatment of RT and CT. Kaplan-Meier analysis was used to evaluate overall survival (OS) and cancer-specific survival (CSS). The differences in OS and CSS were compared using Log-rank test. The independent prognostic factors were established by using univariate and multivariate Cox proportional hazard models. Results With a median follow-up duration of 37 months (range: 3-154 months), the 5-year estimate OS and CSS rates were 59.3% and 63.7%, respectively. N0 and ≥ 65 years were poor prognostic factors for OS and CSS. Moreover, histology and race were associated with OS and CSS. Univariate analysis indicated that ≥ 65 years, N0, NHB and grade III were unfavorable independent prognosticators of OS and CSS. Multivariate analysis demonstrated that ≥ 65 years, N0 and NHB were correlated with poor OS and CSS. Conclusion Patients with stage T4N0-1 NPC receiving RT plus CT had favorable OS and CSS. Moreover, age, N stage and race were independent prognostic factors of OS and CSS.

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Prognostic Indicators in Base of Tongue Adenocarcinoma: A Population-Based Analysis

Ear Nose & Throat Journal ◽

10.1177/0145561319881241 ◽

2019 ◽

pp. 014556131988124

Author(s):

Kristen Kraimer ◽

Ashwin Ganti ◽

Max A. Plitt ◽

Peter Revenaugh ◽

Kerstin Stenson ◽

...

Keyword(s):

Prognostic Factors ◽

Primary Outcome ◽

Cox Regression ◽

Tumor Grade ◽

Population Based ◽

Prognostic Indicators ◽

Inclusion Criteria ◽

Cox Regression Analysis ◽

Base Of Tongue ◽

Kaplan Meier

Introduction: The objectives of this investigation are to characterize the epidemiology of base of tongue adenocarcinoma utilizing a population-based database and to identify prognostic factors that may affect survival. Methods: A retrospective cohort study was conducted using the Surveillance, Epidemiology, and End Results database. Univariate Kaplan-Meier analysis and multivariate Cox-regression analysis were performed to evaluate the association of suspected prognostic factors with survival. Overall survival (OS) and disease-specific survival (DSS) were the primary outcome measures. Results: A total of 176 cases were eligible based on inclusion criteria. The 5-year OS and DSS were 49% and 66%, respectively. On multivariate analysis, surgical management was associated with improved OS and DSS (OS hazard ratio [HR]: 0.34, 95% confidence interval [CI]: 0.20-0.58, P < .001; DSS HR: 0.20, 95% CI: 0.09-0.48, P < .001), while higher tumor grade was associated with worse OS and DSS (OS HR: 1.58, 95% CI: 1.14-2.19, P = .006; DSS HR: 1.68, 95% CI: 1.01-2.79, P = .045). Administration of chemotherapy or radiation did not have a significant association with OS or DSS. Conclusion: This investigation is the largest to date to analyze the base of tongue adenocarcinoma as its own entity. Surgery remains the mainstay of treatment, and lower tumor grade is associated with improved survival in these patients. Administration of radiation or chemotherapy was not associated with improved survival.

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Survival Nomograms for Patients with Pancreatic Neuroendocrine Tumors: A Population-based Study

10.21203/rs.3.rs-111287/v2 ◽

2020 ◽

Author(s):

Bi Lin ◽

Dinglai Yu ◽

Shengchuan Chen ◽

Daojie Wang ◽

Chaohao Huang

Keyword(s):

Risk Factors ◽

Prognostic Factors ◽

Neuroendocrine Tumors ◽

Cancer Survival ◽

Predictive Accuracy ◽

Population Based ◽

Pancreatic Neuroendocrine Tumors ◽

Discrimination Power ◽

Kaplan Meier ◽

Cox Proportional Hazard Regression

Abstract Background: Although pancreatic neuroendocrine tumors (PNETs) are considered indolent tumors, most patients are diagnosed at an advanced stage. We aimed to establish a nomogram for clinical use to predict the survival of PNET patients using the Surveillance, Epidemiology, and End Results (SEER) database.Methods: Based on the SEER database, 1,103 patients with PNETs were enrolled and randomly divided into training and validation sets. We performed Kaplan-Meier analysis and Cox proportional hazard regression analysis in the training set to evaluate the value of the prognostic factors. A nomogram was then constructed to analyze these independent prognostic factors for predicting the overall survival (OS) and specific cancer survival (CSS). C-index, calibration curve, and decision curve analysis were used to evaluate the predictive accuracy of the nomogram.Results: Age, primary site, TNM stage, grade, and surgery were associated with OS and CSS in the multivariate models. Nomograms were established depending on these risk factors and had a better discrimination power than the TMN stage. The validation techniques showed that the nomograms were able to predict the 3- and 5-year OS and CSS accurately, and also proved to be superior.Conclusions: Nomograms were established depending on these risk factors and had a better discrimination power than the TMN stage. The validation techniques showed that the nomograms were able to predict 3- and 5-year OS and CSS accurately, and also proved to be superior.

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