Toward Complete Transformation of Sodium Polysulfides by Regulating the Second-Shell Coordinating Environment of Atomically Dispersed Fe.

Room temperature sodium-sulfur (RT Na-S) batteries are highly competitive as potential energy storage devices. Nevertheless, their actually achieved reversible capacities are far below the theoretical value due to incomplete transformation of polysulfides. Herein, atomically dispersed Fe-N/S active center by regulating the second-shell coordinating environment of Fe single atom is proposed. The Fe-N4 S2 coordination structure with enhanced local electronic concentration around the Fermi level is revealed via synchrotron radiation X-ray absorption spectroscopy (XAS) and theoretical calculations, which can not only significantly promote the transformation kinetics of polysulfides, but induce uniform Na deposition for dendrite-free Na anode. As a result, the obtained S cathode delivers a high initial reversible capacity of 1590 mAh g-1 , nearly the theoretical value. This work opens up a new avenue to facilitate the complete transformation of polysulfides for RT Na-S batteries.

Diphtheria Toxin-Induced Cell Death Triggers Wnt-Dependent Hair Cell Regeneration in Neonatal Mice.

UNLABELLED: Cochlear hair cells (HCs), the sensory cells that respond to sound, do not regenerate after damage in adult mammals, and their loss is a major cause of deafness. Here we show that HC regeneration in newborn mouse ears occurred spontaneously when the original cells were ablated by treatment with diphtheria toxin (DT) in ears that had been engineered to overexpress the DT receptor, but was not detectable when HCs were ablated in vivo by the aminoglycoside antibiotic neomycin. A variety of Wnts (Wnt1, Wnt2, Wnt2b, Wnt4, Wnt5a, Wnt7b, Wnt9a, Wnt9b, and Wnt11) and Wnt pathway component Krm2 were upregulated after DT damage. Nuclear ß-catenin was upregulated in HCs and supporting cells of the DT-damaged cochlea. Pharmacological inhibition of Wnt decreased spontaneous regeneration, confirming a role of Wnt signaling in HC regeneration. Inhibition of Notch signaling further potentiated supporting cell proliferation and HC differentiation that occurred spontaneously. The absence of new HCs in the neomycin ears was correlated to less robust Wnt pathway activation, but the ears subjected to neomycin treatment nonetheless showed increased cell division and HC differentiation after subsequent forced upregulation of ß-catenin. These studies suggest, first, that Wnt signaling plays a key role in regeneration, and, second, that the outcome of a regenerative response to damage in the newborn cochlea is determined by reaching a threshold level of Wnt signaling rather than its complete absence or presence. SIGNIFICANCE STATEMENT: Sensory HCs of the inner ear do not regenerate in the adult, and their loss is a major cause of deafness. We found that HCs regenerated spontaneously in the newborn mouse after diphtheria toxin (DT)-induced, but not neomycin-induced, HC death. Regeneration depended on activation of Wnt signaling, and regeneration in DT-treated ears correlated to a higher level of Wnt activation than occurred in nonregenerating neomycin-treated ears. This is significant because insufficient regeneration caused by a failure to reach a threshold level of signaling, if true in the adult, has the potential to be exploited for development of clinical approaches for the treatment of deafness caused by HC loss.

Generation of hair cells in neonatal mice by ß-catenin overexpression in Lgr5-positive cochlear progenitors.

Mammalian hair cells do not regenerate, and their loss is a major cause of deafness. We recently identified leucine-rich repeat containing, G-protein-coupled receptor 5 (Lgr5)-expressing cochlear supporting cells with the capacity for self-renewal and hair cell differentiation in vitro. We found that these cells, a subset of cochlear supporting cells, were responsive to Wnt signaling. Here we asked whether these Lgr5-positive cells, despite their lack of contribution to hair cell replacement after degenerative loss, could be driven by forced expression of ß-catenin to act as hair cell progenitors in vivo. We showed that forced stabilization of ß-catenin in supporting cells in neonatal animals resulted in proliferation of supporting cells and generation of hair cells. Although ß-catenin expression was increased by genetic means in all supporting cells, entry to the cell cycle and differentiation to hair cells of the normally postmitotic cells was restricted to the Lgr5-positive population. Our finding suggests that Wnt/ß-catenin can drive Lgr5-positive cells to act as hair cell progenitors, even after their exit from the cell cycle and apparent establishment of cell fate.

ß-Catenin is required for hair-cell differentiation in the cochlea.

The development of hair cells in the auditory system can be separated into steps; first, the establishment of progenitors for the sensory epithelium, and second, the differentiation of hair cells. Although the differentiation of hair cells is known to require the expression of basic helix-loop-helix transcription factor, Atoh1, the control of cell proliferation in the region of the developing cochlea that will ultimately become the sensory epithelium and the cues that initiate Atoh1 expression remain obscure. We assessed the role of Wnt/ß-catenin in both steps in gain- and loss-of-function models in mice. The canonical Wnt pathway mediator, ß-catenin, controls the expression of Atoh1. Knock-out of ß-catenin inhibited hair-cell, as well as pillar-cell, differentiation from sensory progenitors but was not required to maintain a hair-cell fate once specified. Constitutive activation of ß-catenin expanded sensory progenitors by inducing additional cell division and resulted in the differentiation of extra hair cells. Our data demonstrate that ß-catenin plays a role in cell division and differentiation in the cochlear sensory epithelium.

A dominant mutation in the stereocilia-expressing gene TBC1D24 is a probable cause for nonsyndromic hearing impairment.

Mutations in TBC1D24 have been linked to a variety of epileptic syndromes and recently to syndromic hearing impairment DOORS syndrome and nonsyndromic hearing impairment DFNB86. All TBC1D24 mutations reported so far were inherited in the recessive mode. In a dominant family segregated with late-onset, progressive, nonsyndromic hearing impairment, linkage analysis revealed a 2.07 Mb candidate region on chromosome 16p13.3 that contains TBC1D24. Whole-exome sequencing identified a heterozygous p.Ser178Leu variant of TBC1D24 as the only candidate mutation segregating with the hearing loss within the family. In perinatal mouse cochlea, we detected a restricted expression of Tbc1d24 in the stereocilia of the hair cells as well as in the spiral ganglion neurons. Our study suggested that the p.Ser178Leu mutation of TBC1D24 is a probable cause for dominant, nonsyndromic hearing impairment. Identification of TBC1D24 as the stereocilia-expressing gene may shed new light on its specific function in the inner ear.

Treatment of congenital middle ear cholesteatoma in children using endoscopic and microscopic ear surgeries: a case series.

Introduction: Surgical removal is widely employed in children with congenital middle ear cholesteatoma (CMEC). Here, we report the surgical outcomes of CMEC removal via endoscopic ear surgery (EES) and microscopic ear surgery (MES) in children. Methods: Children with CMEC who underwent preoperative medical history inquiry, hearing test, endoscopic evaluation, and radiology imaging before receiving EES or MES were included. Postoperative audiological outcomes and recurrence rates were collected. Results: Seventeen children (20 ears) with stage II-IV CMEC were included. Of those, 11 ears (55.0%) underwent EES, and 9 ears (45.0%) underwent MES. The follow-up time was 35 ± 13.5 months. One child in the EES group with stage III CMEC had a recurrence during the follow-up period. In the EES group, the average minimum diameter of the external auditory canal on the affected side was 5.8 mm (4.3-8.0 mm). No linear association was found between age and the minimum diameter of the external auditory canal. Discussion: EES is a promising treatment option for children with early-stage CMEC because of its low recurrence rate and minimally invasive nature. The minimum diameter of the external auditory canal on the affected side should be meticulously examined when performing EES in children.

A Reconfigurable All-Optical-Controlled Synaptic Device for Neuromorphic Computing Applications.

Retina-inspired visual sensors play a crucial role in the realization of neuromorphic visual systems. Nevertheless, significant obstacles persist in the pursuit of achieving bidirectional synaptic behavior and attaining high performance in the context of photostimulation. In this study, we propose a reconfigurable all-optical controlled synaptic device based on the IGZO/SnO/SnS heterostructure, which integrates sensing, storage and processing functions. Relying on the simple heterojunction stack structure and the role of energy band engineering, synaptic excitatory and inhibitory behaviors can be observed under the light stimulation of ultraviolet (266 nm) and visible light (405, 520 and 658 nm) without additional voltage modulation. In particular, junction field-effect transistors based on the IGZO/SnO/SnS heterostructure were fabricated to elucidate the underlying bidirectional photoresponse mechanism. In addition to optical signal processing, an artificial neural network simulator based on the optoelectrical synapse was trained and recognized handwritten numerals with a recognition rate of 91%. Furthermore, we prepared an 8 × 8 optoelectrical synaptic array and successfully demonstrated the process of perception and memory for image recognition in the human brain, as well as simulated the situation of damage to the retina by ultraviolet light. This work provides an effective strategy for the development of high-performance all-optical controlled optoelectronic synapses and a practical approach to the design of multifunctional artificial neural vision systems.

Optically driven intelligent computing with ZnO memristor.

Artificial vision is crucial for most artificial intelligence applications. Conventional artificial visual systems have been facing challenges in terms of real-time information processing due to the physical separation of sensors, memories, and processors, which results in the production of a large amount of redundant data as well as the data conversion and transfer between these three components consuming most of the time and energy. Emergent optoelectronic memristors with the ability to realize integrated sensing-computing-memory (ISCM) are key candidates for solving such challenges and therefore attract increasing attention. At present, the memristive ISCM devices can only perform primary-level computing with external light signals due to the fact that only monotonic increase of memconductance upon light irradiation is achieved in most of these devices. Here, we propose an all-optically controlled memristive ISCM device based on a simple structure of Au/ZnO/Pt with the ZnO thin film sputtered at pure Ar atmosphere. This device can perform advanced computing tasks such as nonvolatile neuromorphic computing and complete Boolean logic functions only by light irradiation, owing to its ability to reversibly tune the memconductance with light. Moreover, the device shows excellent operation stability ascribed to a purely electronic memconductance tuning mechanism. Hence, this study is an important step towards the next generation of artificial visual systems.

Genetic findings of Sanger and nanopore single-molecule sequencing in patients with X-linked hearing loss and incomplete partition type III.

BACKGROUND: POU3F4 is the causative gene for X-linked deafness-2 (DFNX2), characterized by incomplete partition type III (IP-III) malformation of the inner ear. The purpose of this study was to investigate the clinical characteristics and molecular findings in IP-III patients by Sanger or nanopore single-molecule sequencing. METHODS: Diagnosis of IP-III was mainly based on clinical characteristics including radiological and audiological findings. Sanger sequencing of POU3F4 was carried out for these IP-III patients. For those patients with negative results for POU3F4 Sanger sequencing, nanopore long-read single-molecule sequencing was used to identify the possible pathogenic variants. Hearing intervention outcomes of hearing aids (HAs) fitting and cochlear implantation (CI) were also analyzed. Aided pure tone average (PTA) was further compared between two groups of patients according to their different locations of POU3F4 variants: in the exon region or in the upstream region. RESULTS: In total, 18 male patients from 14 unrelated families were diagnosed with IP-III. 10 variants were identified in POU3F4 by Sanger sequencing and 6 of these were reported for the first time (p.Gln181*, p.Val215Gly, p.Arg282Gln, p.Gln316*, c.903_912 delins TGCCA and p.Arg205del). Four different deletions that varied from 80 to 486 kb were identified 876-1503 kb upstream of POU3F4 by nanopore long-read single-molecule sequencing. De novo genetic mutations occurred in 21.4% (3/14) of patients with POU3F4 mutations. Among these 18 patients, 7 had bilateral HAs and 10 patients received unilateral CI. The mean aided PTA for HAs and CI users were 41.1 ± 5.18 and 40.3 ± 7.59 dB HL respectively. The mean PTAs for patients with the variants located in the exon and upstream regions were 39.6 ± 6.31 versus 43.0 ± 7.10 dB HL, which presented no significant difference (p = 0.342). CONCLUSIONS: Among 14 unrelated IP-III patients, 28.6% (4/14) had no definite mutation in exon region of POU3F4. However, possible pathogenic deletions were identified in upstream region of this gene. De novo genetic mutations occurred in 21.4% (3/14) of patients with POU3F4 mutation. There was no significant difference of hearing intervention outcomes between the IP-III patients with variants located in the exon region and in the upstream region.

[Clinical study on naoxintong capsule for stroke recovery of Qi-deficiency and blood-stasis syndrome].

OBJECTIVE: To study the efficacy and safety of Naoxintong capsule treatment of stroke recovery with Qi-deficiency and blood-stasis syndrome (cerebral infarction), and to compared the non-inferiority analysis with the positive drug Tongxinluo capsule. METHOD: Taking Tongxinluo capsules as control, randomized, double-blind, controlled, multi-center clinical experiments were studied. The evaluating indexes included the decrease of integral value of stroke patients, changes in traditional Chinese medicine, the improvement of the patient viability status (disability level), Chinese stroke scale (CSS), activities of daily living (DAL) scale and barthel index (BI ) points. RESULT: The total effect of the two groups, Chinese and other symptoms, showed no significant statistical significance. CONCLUSION: Naoxintong capsule stroke recovery, with Qi-deficiency and blood-stasis syndrome (cerebral infarction) has a therapeutic effect, and more secure.

Bimodal Stimulation in Children With Bilateral Profound Sensorineural Hearing Loss: A Suitable Intervention Model for Children at the Early Developmental Stage.

OBJECTIVE: To evaluate the auditory and speech benefit of bimodal stimulation for prelingual deafened cochlear implantation recipients. STUDY DESIGN: Retrospective and comparative study. SETTING: Tertiary referral center. PATIENTS: Fifty-six children with bilateral prelingual profound sensorineural hearing loss were enrolled, including 28 consecutive children with unilateral cochlear implantation (CI group), and 28 consecutive children with bimodal stimulation (BI group) who used an additional hearing aid (HA) in the contralateral ear. MAIN OUTCOME MEASURES: Hearing assessments included the Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS) and Categories of Auditory Performance (CAP). Speech evaluations included the Meaningful Use of Speech Scale (MUSS), and Speech Intelligibility Rating (SIR). These measurements were evaluated at the first mapping of cochlear implants and 0.5, 1, 3, 6, 12, 18, 24 months after. Data were analyzed by repeated measures analysis. RESULTS: The mean ages of BI and CI groups were similar (17.6 ±â€Š6.87 vs 19.0 ±â€Š8.10 months, p = 0.497). The initial scores for hearing and speech assessments showed no differences between the two groups, apart from IT-MAIS (2.46 ±â€Š0.631 in BI group vs 0.50 ±â€Š0.279 in CI group, p = 0.004). The auditory and speech development over time were different in the two groups as seen in IT-MAIS (p < 0.001), CAP (p = 0.029), MUSS (p < 0.001), and SIR (p < 0.001). A continuing but stable difference was observed in CAP, MUSS, and SIR at 3, 18, and 12 months after the first mapping, respectively. In addition, the BI group had better IT-MAIS scores at 3 and 6 months compared with the CI group; however, the difference was not significant after 12 months. CONCLUSION: Bimodal stimulation is beneficial for prelingually deafened CI recipients who have minimal contralateral residual hearing when bilateral CIs are not available. Hearing aid use in the contralateral ear might be recommended for children after unilateral cochlear implantation to facilitate the development of auditory and speech skills.

Increased Type I and Decreased Type II Hair Cells after Deletion of Sox2 in the Developing Mouse Utricle.

The vestibular system of the inner ear contains Type I and Type II hair cells (HCs) generated from sensory progenitor cells; however, little is known about how the HC subtypes are formed. Sox2 (encoding SRY-box 2) is expressed in Type II, but not in Type I, HCs. The present study aimed to investigate the role of SOX2 in cell fate determination in Type I vs. Type II HCs. First, we confirmed that Type I HCs developed from Sox2-expressing cells through lineage tracing of Sox2-positive cells using a CAG-tdTomato reporter mouse crossed with a Sox2-CreER mouse. Then, Sox2 loss of function was induced in HCs, using Sox2flox transgenic mice crossed with a Gfi1-Cre driver mouse. Knockout of Sox2 in HCs increased the number of Type I HCs and decreased the number of Type II HCs, while the total number of HCs and Sox2-positive supporting cells did not change. In addition, the effect of Sox2-knockout persisted into adulthood, resulting in an increased number of Type I HCs. These results demonstrate that SOX2 plays a critical role in the determination of Type II vs. Type I HC fate. The results suggested that Sox2 is a potential target for generating Type I HCs, which may be important for regenerative strategies for balance disorders.

Extended hepatectomy with segments I and VII as resection remnant: a simple model for small-for-size injuries in pigs.

BACKGROUND: Small-for-size (SFS) syndrome is an important clinical problem after living donor liver transplantation, split liver transplantation or extended hepatectomy. The uncertainty of the mechanisms and treatments of SFS syndrome urges surgeons to establish effective models for SFS syndrome. METHODS: A new porcine model for SFS syndrome based on extended hepatectomy was established. Portal pressure gradient was observed before and after the surgery, and venous sampling for estimation of alanine aminotransferase, total bilirubin, and international normalized ratio was continued on a daily basis. RESULTS: Although the external morphology of the porcine liver differs from that of human being, segmental anatomy is remarkably similar in term of its vascularity and biliary tree. Extended hepatectomy with segments I and VII as resection remnant (about 20% of total liver volume) resulted in similar survival rates, blood liver function tests, and elevated portal pressure gradient as clinical SFS syndrome. CONCLUSIONS: The extended hepatectomy based new model can easily be reproduced, with few costs and surgical complications. Clinical SFS syndrome can easily be simulated by this new model, which is a useful tool for studying SFS syndrome-related liver injuries, especially portal overperfusion and hypertension.

Clinical observation on cervical spondylopathy vertebroarterial type treated by electro-acupuncture.

OBJECTIVE: To observe the clinical therapeutic effects of electro-acupuncture in the treatment of cervical spondylopathy of the vertebroarterial type. METHODS: According to the consulting order, the patients were randomly divided into a treatment group (29 cases treated with electro-acupuncture), and a control group (28 cases treated with simple acupuncture). 20 treatments were given to patients in both groups. RESULTS: The markedly effective rate of the treatment group was 75% and that of the control group was 61.54% (P<0.05). CONCLUSION: Electro-acupuncture has a better therapeutic effect than the simple acupuncture in the treatment of cervical spondylopathy of the vertebroarterial type.

Ultrasensitive Memristive Synapses Based on Lightly Oxidized Sulfide Films.

For biological synapses, high sensitivity is crucial for transmitting information quickly and accurately. Compared to biological synapses, memristive ones show a much lower sensitivity to electrical stimuli since much higher voltages are needed to induce synaptic plasticity. Yet, little attention has been paid to enhancing the sensitivity of synaptic devices. Here, electrochemical metallization memory cells based on lightly oxidized ZnS films are found to show highly controllable memristive switching with an ultralow SET voltage of several millivolts, which likely originates from a two-layer structure of ZnS films, i.e., the lightly oxidized and unoxidized layers, where the filament rupture/rejuvenation is confined to the two-layer interface region several nanometers in thickness due to different ion transport rates in these two layers. Based on such devices, an ultrasensitive memristive synapse is realized where the synaptic functions of both short-term plasticity and long-term potentiation are emulated by applying electrical stimuli several millivolts in amplitude, whose sensitivity greatly surpasses that of biological synapses. The dynamic processes of memorizing and forgetting are mimicked through a 5 × 5 memristive synapse array. In addition, the ultralow operating voltage provides another effective solution to the relatively high energy consumption of synaptic devices besides reducing the operating current and pulse width.

A multicentral randomized control study on clinical acupuncture treatment of Bell's palsy.

OBJECTIVE: To confirm the clinical therapeutic effects of acupuncture and moxibustion on Bell's palsy. METHODS: 480 cases from 4 hospitals were enrolled for this study, among whom 439 cases completed the whole course of the study. The patients were randomly divided into the following 3 groups, a control group(treated with prednisone, vitamin B1, vitamin B12 and dibazol), an acu-moxibustion group (treated with filiform needle plus moxibustion), and a basic treatment plus acu-moxibustion group (treated with oral medicine like those in the control group plus acupuncture, and with moxibustion like in the acu-moxibustion group). The whole treatment course lasted 4 weeks. The therapeutic effects were evaluated according to the symptoms and signs, House-Brackmann grading scale and facial disability indexes(FDI). RESULTS: All the 4 centers (hospitals) completed this study well, with no statistically significant difference found among the 4 centers in therapeutic effects. The patients with different conditions were well distributed in the 3 groups, thus the basic general data were comparable (P > 0.05). The therapeutic effects of the two treatment groups were better than the control group (respectively P < 0.05 and P < 0.01), and it was the best in the acu-moxibustion group (P < 0.01). CONCLUSION: Acupuncture and moxibustion may exert definite therapeutic effects on Bell's palsy, better than that of the basic treatment group or the basic treatment plus acu-moxibustion group.

Characterization of a knock-in mouse model of the homozygous p.V37I variant in Gjb2.

The homozygous p.V37I variant in GJB2 is prevalent in East and Southeast Asians and may lead to mild-to-moderate hearing loss with reduced penetrance. To investigate the pathogenic mechanism underlying this variant, we generated a knock-in mouse model of homozygous p.V37I by an embryonic stem cell gene targeting method. Auditory brainstem response test showed that the knock-in mice developed progressive, mild-to-moderate hearing loss over the first 4-9 months. Overall no significant developmental and morphological abnormality was observed in the knock-in mouse cochlea, while confocal immunostaining and electron microscopic scanning revealed minor loss of the outer hair cells. Gene expression microarray analysis identified 105 up-regulated and 43 down-regulated genes in P5 knock-in mouse cochleae (P < 0.05 adjusted by the Benjamini &Hochberg method), among which four top candidate genes with the highest fold-changes or implication to deafness Fcer1g, Nnmt and Lars2 and Cuedc1 were verified by quantitative real-time PCR. Our study demonstrated that the homozygous p.V37I knock-in mouse modeled the hearing phenotype of the human patients and can serve as a useful animal model for further studies. The differentially expressed genes identified in this study may shed new insights into the understanding of the pathogenic mechanism and the phenotypic modification of homozygous p.V37I.

Efficacy of acupuncture and moxibustion in treating Bell's palsy: a multicenter randomized controlled trial in China.

BACKGROUND: Bell's palsy involves acute facial paralysis due to inflammation of the facial nerve. Acupuncture and moxibustion (acu-moxi) is beneficial in treating facial palsy. In order to verify the efficacy of acu-moxi on Bell's palsy, a randomized single-blind, multicenter clinical trial was performed. METHODS: A total of 480 patients from four clinical centers were involved in this trial, of whom 439 completed the trial and 41 did not. All patients were randomly assigned to either the control group or to one of two treatment groups. The control group was treated with prednisone, vitamin B1, vitamin B12, and dibazole; the treatment groups were treated either with acu-moxi alone or in combination with prednisone, Vitamin B1, vitamin B12, and dibazole. Symptoms and signs, the House-Brackmann scale, and facial disability index (FDI) scores were assessed and determined both pre- and post-treatment to evaluate the effectiveness of the treatment methods. RESULTS: The characteristics of the control and two treatment groups were comparable without statistically significant differences before treatment. There were significant differences between the control and treatment groups after treatment (chi(2) = 15.265, P = 0.018). According to evaluations based on the House-Brackmann scale and FDI scores, the effectiveness of treatment in the two treatment groups was better than in the control group and was most effective in patients receiving acu-moxi treatment alone (Z = -2.827, P = 0.005). CONCLUSION: The efficacy of acu-moxi treatment for Bell's palsy is verified scientifically.

[Cochlear implants for the patients with cochlear nerve defects].

OBJECTIVE: By watching the effects of cochlear implants in the children with cochlear nerve defects, to evaluate the relationship and efficiency of HRCT AND MRI in diagnostic for cochlear nerve defects. METHOD: The imaging dates and the post-operative effects of the 10 cochlear nerve defect patients were retrospectively analyzed. RESULT: Three patients with bilateral IAC stenosis by HRCT and cochlear nerve defects by MRI but no other abnormal. Seven other patients showed normal IAC by HRCT including 1 showed type IP- I plus vestibular semi circular canal dysplasia. These 7 patients MRI showed 3 bilateral cochlear nerve absent and 4 bilateral cochlear nerve dysplasia. Ten cases of children after 12-32 month follow-up, 3 patients began speaking simple language, whose MAIS scale, CAP and SIR scores improved. One case just began speaking but pronunciation vague. Four cases had reactions to sounds, and can say monosyllabic words. Two cases without effects (1 CI abolished). Compared with other patients with normal cochlear nerve, the effects of the 10 cases were disappointed. CONCLUSION: The effects of cochlear implant for the patients with cochlear nerve defects were poor. The preoperative MRI as sessment including oblique sagittal view for cochlear nerve is necessary. The preoperative communication with the parents telling ineffective result possibility is important.