Roles of serum uric acid on the association between arsenic exposure and incident metabolic syndrome in an older Chinese population.

Growing evidences showed that heavy metals exposure may be associated with metabolic diseases. Nevertheless, the mechanism underlying arsenic (As) exposure and metabolic syndrome (MetS) risk has not been fully elucidated. So we aimed to prospectively investigate the role of serum uric acid (SUA) on the association between blood As exposure and incident MetS. A sample of 1045 older participants in a community in China was analyzed. We determined As at baseline and SUA concentration at follow-up in the Yiwu Elderly Cohort. MetS events were defined according to the criteria of the International Diabetes Federation (IDF). Generalized linear model with log-binominal regression model was applied to estimate the association of As with incident MetS. To investigate the role of SUA in the association between As and MetS, a mediation analysis was conducted. In the fully adjusted log-binominal model, per interquartile range increment of As, the risk of MetS increased 1.25-fold. Compared with the lowest quartile of As, the adjusted relative risk (RR) of MetS in the highest quartile was 1.42 (95% confidence interval, CI: 1.03, 2.00). Additionally, blood As was positively associated with SUA, while SUA had significant association with MetS risk. Further mediation analysis demonstrated that the association of As and MetS risk was mediated by SUA, with the proportion of 15.7%. Our study found higher As was remarkably associated with the elevated risk of MetS in the Chinese older adults population. Mediation analysis indicated that SUA might be a mediator in the association between As exposure and MetS.

The association of isocarbophos and isofenphos with different types of glucose metabolism: The role of inflammatory cells.

To investigate the associations between isocarbophos and isofenphos with impaired fasting glucose (IFG) and type 2 diabetes mellitus (T2DM), and to assess the mediation roles of inflammation cells. There were 2701 participants in the case-control study, including 896 patients with T2DM, 900 patients with IFG, 905 subjects with NGT. Plasma isocarbophos and isofenphos concentrations were measured using gas chromatography and triple quadrupole tandem mass spectrometry. Generalized linear models were used to calculate the relationships between plasma isofenphos and isocarbophos levels with inflammatory factor levels and T2DM. Inflammatory cell was used as mediators to estimate the mediating effects on the above associations. Isocarbophos and isofenphos were positively related with T2DM after adjusting for other factors. The odds ratio (95% confidence interval) (OR (95%CI)) for T2DM was 1.041 (1.015, 1.068) and for IFG was 1.066 (1.009, 1.127) per unit rise in ln-isocarbophos. The prevalence of T2DM increased by 6.4% for every 1 unit more of ln-isofenphos (OR (95% CI): 1.064 (1.041, 1.087)). Additionally, a 100% rise in ln-isocarbophos was linked to 3.3% higher ln-HOMA2IR and a 0.029 mmol/L higher glycosylated hemoglobin (HbA1c) (95% CI: 0.007, 0.051). While a 100% rise in ln-isofenphos was linked to increase in ln-HOMA2 and ln-HOMA2IR of 5.8% and 3.4%, respectively. Furthermore, white blood cell (WBC) and neutrophilic (NE) were found to be mediators in the relationship between isocarbophos and T2DM, and the corresponding proportions were 17.12% and 17.67%, respectively. Isofenphos and isocarbophos are associated with IFG and T2DM in the rural Chinese population, WBC and NE have a significant role in this relationship.

Characteristics of catalytic destruction of dichloromethane and ethyl acetate mixture over HxPO4-RuOx/CeO2 catalyst.

Catalytic destruction is an ascendant technology for the abatement of volatile organic compounds (VOCs) originating from solvent-based industrial processes. The varied composition tends to influence each VOC's catalytic behavior in the reaction mixture. We investigated the catalytic destruction of multi-component VOCs including dichloromethane (DCM) and ethyl acetate (EA), as representatives from pharmaceutical waste gases, over co-supported HxPO4-RuOx/CeO2 catalyst. A mutual inhibitory effect relating to concentrations because of competitive adsorption was verified in the binary VOCs oxidation and EA posed a more negative effect on DCM oxidation owing to EA's superior adsorption capacity. Preferential adsorption of EA on acidic sites (HxPO4/CeO2) promoted DCM activation on basic sites (O2-) and the dominating EA oxidation blocked DCM's access to oxidation centers (RuOx/CeO2), resulting in boosted monochloromethane yield and increased chlorine deposition for DCM oxidation. The impaired redox ability of Ru species owing to chlorine deposition in turn jeopardized deep oxidation of EA and its by-products, leading to increased gaseous by-products such as acetic acid originating from EA pyrolysis. Notably, DCM at low concentration slightly promoted EA conversion at low temperatures with or without water, consistent with the enhanced EA adsorption in co-adsorption analyses. This was mainly due to that DCM impeded the shielding effect of hydrolysate deposition from rapid EA hydrolysis depending on the decreased acidity. Moreover, water benefited EA hydrolysis but decreased CO2 selectivity while the generated water derived from EA was likely to affect DCM transformation. This work may provide theoretical guidance for the promotion of applied catalysts toward industrial applications.

Electrosynthesis-Induced Pt Skin Effect in Mesoporous Ni-Rich Ni-Pt Thin Films for Hydrogen Evolution Reaction.

A Pt skin effect, i.e., an enrichment of Pt within the first 1-2 nm from the surface, is observed in as-prepared electrodeposited Ni-rich Ni-Pt thin films. This effect, revealed by Rutherford backscattering (RBS), is present for both dense thin films and mesoporous thin films synthesized by micelle-assisted electrodeposition from a chloride-based electrolyte. Due to the Pt skin effect, the Ni-rich thin films show excellent stability at the hydrogen evolution reaction (HER) in acidic media, during which a gradient in the Pt/Ni ratio is established along the thickness of the thin films, while the activity at the HER remains unaffected by this structural change. Further characterization by elastic recoil detection with He ions analysis shows that hydrogen profiles are similar to those of Pt: a surface hydrogen peak coincides with the Pt skin, and a gradient in hydrogen concentration is established during HER in acidic media, together with a considerable uptake in hydrogen. A comparative study shows that in alkaline media, hydrogen evolution has little to no effect on the structural properties of the thin films, even for much longer times of exposure. The mesoporous thin films, in addition to their higher efficiency at HER compared to dense thin films, also show lower internal stress, as determined by Rietveld refinement of grazing incidence X-ray diffraction patterns. The latter also reveal a fully single-phase and nanocrystalline structure for all thin films with varying Ni contents.

Hepatoprotective activity of Mentha rotundifolia aqueous extract against hepatocellular damage induced by CCL4 in rats.

This study aims to assess hepatoprotective properties of M. rotundifolia. Decoction was used to prepare the aqueous extract. The preliminary cytotoxicity evaluated against Caco 2 and RAW 264 cells demonstrate no cytotoxic effect. The preventive impact of the extract against liver damage was evaluated by examining blood levels of AST, ALT, ALP, total proteins, and histological alterations in liver tissues. Thirty albino rats were separated into five groups: the first served as normal group, the second was injected by olive oil (3 ml/kg), and the third was injected by CCL4 (3 ml/kg). However, groups IV and V received daily doses of 250 and 500 mg extract/kg bw, respectively before CCL4 injection. The results showed that the administration of the extract led to a marked improvement in plasma biochemical markers and a reduction in symptoms of CCL4-induced liver damage. The extract exhibits hepatoprotective activity, which may be attributed to its phytochemical components.

Solution State-Like Reactivity of a Flexible Crystalline Werner-Type Metal Complex.

Flexible crystalline solids exhibit unique properties in response to external stimuli like heat and light. However, challenges exist in developing crystalline solids that have similar degrees of flexibility as in solution. Herein, we report the preparation of the new flexible crystalline metal complex [Cd(CF3SO3)2(4-spy)4] (4-spy=4-styrylpyridine), which contains photoreactive 4-spy ligand. Unlike traditional solids, this metal complex displays solution state-like [2+2] photocycloaddition reactivity. Specifically, UV irradiation of the crystalline material leads to formation of the same diverse array of dimers and cis isomer that are generated by photoreaction in the solution state. In addition, the photoresponsive flexibility of the solid leads to a photosalient effect and photo-induced formation of pores. The origin of the solution state-like photoreactivity of the solid is related to properties of the Cd(II) cation and fluorinated CF3SO3 anion, and the multi-orientational arrangement of the 4-spy ligands.

A Versatile Redox-Active Electrolyte for Solid Fixation of Polyiodide and Dendrite-Free Operation in Sustainable Aqueous Zinc-Iodine Batteries.

Practical utilization of zinc-iodine (Zn-I2) batteries is hindered by significant challenges, primarily stemming from the polyiodide shuttle effect on the cathode and dendrite growth on the anode. Herein, a feasible redox-active electrolyte has been introduced with tetraethylammonium iodide as an additive that simultaneously addresses the above mentioned challenges via polyiodide solidification on the cathode and the electrostatic shielding effect on the anode. The tetraethylammonium (TEA+) captures water-soluble polyiodide intermediates (I3 -, I5 -), forming a solid complex at the cathode, thereby suppressing capacity loss during charge/discharge. Furthermore, the TEA+ mitigates dendrite growth on the Zn anode via the electrostatic shielding effect, promoting uniform and compact Zn deposition at the anode. Consequently, the Zn||Zn symmetric cell demonstrates superior cycling stability during Zn plating/stripping over 4,200 h at 1 mA cm-2 and 1 mAh cm-2. The Zn||NiNC full-cell exhibits a stable capacity retention of 98.4% after 20 000 cycles (>5 months) with near-unity Coulombic efficiency at 1 A g-1. The study provides novel insights for establishing a new direction for low-cost, sustainable, and long-lifespan Zn-I2 batteries.

An idea to explore: A systematic approach for solving plasmid double-digest puzzles.

A common exercise given to students early in a molecular biology course is the creation of a restriction map of a plasmid "digested" by two restriction enzymes (RE). Meanwhile, students have learned from an early age about the properties and analyses of circles in their mathematics courses. But it is rare for students to learn using puzzle-based assignments at the intersection of molecular biology and mathematics. Therefore, we should present students with a puzzle that allows them to combine knowledge and skills from these seemingly disconnected disciplines. Here, we present a method for analyzing RE digests of circular plasmids using basic geometric principles.

A comprehensive evaluation of the frog effect on drivers in mountain highway tunnels - The effect of low-volume intermittent information.

OBJECTIVE: The driver's inability to fully absorb and react to operational cues while driving is like boiling a frog in warm water. With intermittent, low-volume information, drivers can underreact by ignoring these minor but continuous changes. This paper aims to provide an opportunity to test the effects of intermittently occurring low-volume information on drivers. METHODS: A real vehicle test with naturalistic driving was used to collect driving speed data from 40 drivers on a highway tunnel section in Chongqing, China, where nine tunnels are located. Drivers were classified into three categories according to the degree of compliance of their driving speed with the speed limit required by traffic signs, and drivers were analyzed in terms of their sensitivity to traffic signs and their reaction to driving maneuvers. RESULTS: Conservative drivers are the most absorbent of low-volume intermittent information, and the cumulative effect of the frog effect does not exceed 2.00 km; eager drivers tend to ignore this information, and the cumulative effect of the frog effect reaches 2.91 km; and the general type of driver is in the middle of these two types of drivers, and the frog effect gradually penetrates the driving speed in a weakly increasing manner, up to a maximum of 9.8 km. CONCLUSION: At the beginning of a journey, drivers are most sensitive to traffic signs, and low-volume intermittent information can also play a role in guiding driving operations effectively at this time. However, as the driving distance increases, the effect of the frog effect on different types of drivers gradually increases, even exceeding the effect caused by the black-and-white hole effect, especially when driving in tunnel groups. Considering the driving characteristics of different types of drivers to improve the deployment of low-volume intermittent information and reduce the distance of the frog effect can effectively improve driving safety.

Soret-Effect Induced Phase-Change in a Chromium Nitride Semiconductor Film.

Phase-change materials such as Ge-Sb-Te (GST) exhibiting amorphous and crystalline phases can be used for phase-change random-access memory (PCRAM). GST-based PCRAM has been applied as a storage-class memory; however, its relatively low ON/OFF ratio and the large Joule heating energy required for the RESET process (amorphization) significantly limit the storage density. This study proposes a phase-change nitride, CrN, with a much wider programming window (ON/OFF ratio more than 105) and lower RESET energy (one order of magnitude reduction from GST). High-resolution transmission electron microscopy revealed a phase-change from the low-resistance cubic CrN phase into the highly resistive hexagonal CrN2 phase induced by the Soret-effect. The proposed phase-change nitride could greatly expand the scope of conventional phase-change chalcogenides and offer a strategy for the next-generation of PCRAM, enabling a large ON/OFF ratio (∼105), low switching energy (∼100 pJ), and fast operation (∼30 ns).

Quantifying HONO Production from Nitrate Photolysis in a Polluted Atmosphere.

The photolysis of particulate nitrate (pNO3-) has been suggested to be an important source of nitrous acid (HONO) in the troposphere. However, determining the photolysis rate constant of pNO3- (jpNO3-) suffers from high uncertainty. Prior laboratory measurements of jpNO3- using aerosol filters have been complicated by the "shadow effect"─a phenomenon of light extinction within aerosol layers that potentially skews these measurements. We developed a method to correct the shadow effect on the photolysis rate constant of pNO3- for HONO production (jpNO3- â†’ HONO) using aerosol filters with identical chemical compositions but different aerosol loadings. We applied the method to quantify jpNO3- â†’ HONO over the North China Plain (NCP) during the winter haze period. After correcting for the shadow effect, the normalized average jpNO3- â†’ HONO at 5 °C increased from 5.89 × 10-6 s-1 to 1.72 × 10-5 s-1. The jpNO3- â†’ HONO decreased with increasing pH and nitrate proportions in PM2.5 and had no correlation with nitrate concentrations. A parametrization for jpNO3- â†’ HONO was developed for model simulation of HONO production in NCP and similar environments.

Nitrite facilitated transformation of halophenols in ice.

This study investigated the expediated transformation of halophenols in the presence of nitrite (NO2-) under slightly acidic conditions in ice, whereas such transformation was negligible in liquid water at 4 °C. We proposed that this phenomenon was attributed to the freeze-concentration effect, incurring a pH drop and the aggregation of NO2- and halophenols within the liquid-like grain boundary layer amid ice crystals. Within this micro-environment, NO2- underwent protonation to generate reactive nitrous acid (HNO2) and nitrosonium ions (NO+) that facilitate the nitration and oxidation of halophenols. When 10 µÐœ halophenol was treated by freezing in the presence of 5 µÐœ NO2-, the total yields of nitrated products reached 2.4 µÐœ and 1.4 µÐœ within 12 h for 2-chlorophenol (2CP) and 2-bromophenol (2BP), respectively. NO+ drove oxidative coupling reactions, generating hydroxyl polyhalogenated diphenyl ethers (OH-PBDEs) and hydroxyl polyhalogenated diphenyls via C-O or C-C coupling. These two pathways were intricately intertwined. The presence of natural organic matter (NOM) mitigated the formation of nitrated products and completely suppressed the coupling products. This study offers valuable insights into the fate of halophenols in ice and suggests potential pathways for the formation of nitrophenolic compounds and OH-PBDEs in natural cold environments. These findings also open up a new avenue in environmental chemistry research.

A customized self-assembled synergistic biocatalyst for plastic depolymerization.

The enzymatic degradation of plastic offers a green, sustainable strategy and scalable circular carbon route for solving polyester waste. Among the earlies discovered plastic-degrading enzymes are PET hydrolase (PETase) and MHET hydrolase (MHETase), which act synergistically. To promote the adsorption of enzymes on PET surfaces, increase their robustness, and enable directly depolymerization, we designed hydrophobin HFBI fused-PETase and MHETase. A customized self-assembled synergistic biocatalyst (MC@CaZn-MOF) was further developed to promote the two-step depolymerization process. The tailored catalysts showed better adhesion to the PET surface and desirable durability, retaining over 70% relative activity after incubation at pH 8.0 and 60 °C for 120 h. Importantly, MC@CaZn-MOF could directly decompose untreated AGf-PET to generate 9.5 mM TPA with weight loss over 90%. The successful implementation of a bifunctional customized catalyst makes the large-scale biocatalytic degradation of PET feasible, contributing to polymer upcycling and environmental sustainability.

An Eu (III)-functionalized covalent organic framework fluorescent probe for specific detection of Flumequine based on pore restriction and antenna effect.

The overuse of quinolone antibiotics has led to a series of health and environmental issues. Herein, we combine the distinct luminescence properties of Eu3+ with the unique structure of covalent organic frameworks (COFs) to develop a precise and sensitive fluorescent probe for detecting Flumequine (Flu) in water. Eu3+ is thoroughly anchored into the channels of COFs as recognition sites, while the synthesized probe material still maintains its intact framework structure. The unique structure of COFs provides excellent support and protection for Eu3+. Therefore, COF-Eu can rapidly bind with Flu which can transfer the absorbed energy to Eu3+ through an "antenna effect", resulting in red fluorescence. Moreover, there is a good linear relationship between Flu concentration in the range of 0-30 µM, with a detection limit of 41 nM. Simultaneously, the material maintains remarkable reproducibility, with its performance remaining almost unchanged after five cycles of use. Remarkably, the probe demonstrates excellent Flu recovery rates in real samples. This study provides a viable approach for the recognition of flumequine in the environment through a customized fluorescence detection method.

Hypnotic effect of AR-001 through adenosine A1 receptor.

Insomnia is one of the most common sleep disorders, affecting 10-15% of the global population. Because classical remedies used to treat insomnia have various side effects, new therapeutics for insomnia are attracting attention. In the present study, we found that N2-Ethyl-N4-(furan-2-ylmethyl) quinazoline-2,4-diamine (AR-001) has adenosine A1 receptor agonistic activity and exhibits hypnotic efficacy by decreasing sleep onset latency and increasing total sleep time in a pentobarbital-induced sleep model. This hypnotic effect of AR-001 was significantly inhibited by the adenosine A1 receptor antagonist 8-cyclopentyl-1,3-dipropylxanthine (DPCPX). As a result of immunohistochemistry, AR-001 was shown to increase neural activity in the sleep-promoting region, ventrolateral preoptic nucleus (VLPO), and decrease neural activity in the wake-promoting region, basal forebrain (BF), and lateral hypothalamus (LH), and that these effects of AR-001 were significantly inhibited by DPCPX treatment. In addition, AR-001 increased adenosine A1 receptor mRNA levels in the hypothalamus. In conclusion, this study suggests that AR-001 has a hypnotic effect, at least partially, through adenosine A1 receptor and may have therapeutic potential for insomnia.

Comparison of perioperative outcomes between colorectal operations performed on weekends versus those performed on weekdays.

BACKGROUND: Weekend surgical time is an underused asset. Concerns over a possible weekend effect (substandard care) may be a barrier. METHODS: This study examined whether a weekend effect applies to elective colorectal surgery via a single-center retrospective analysis comparing outcomes between patients who underwent elective colorectal surgery on a weekend versus a weekday. Demographics, length of stay, operative and anesthesia time, the rate of reoperation within 30 days, and the rate of major complications were compared between patient groups. RESULTS: Of the 2,008 patients identified, 1,721 (85.7%) underwent surgery on a weekday, and 287 (14.3%) underwent surgery on a weekend. The proportion of operations with an open approach was higher on weekends than weekdays (49.5% vs. 41.8%, p=0.017). Patients who underwent surgery on the weekend tended to have a shorter mean (SE) length of stay (4.2 (0.2) vs. 6.1 (0.2), p<0.001), anesthesia time (233.8 (6.5) vs. 307.6 (3.3) minutes, p<0.001), and operative time (225.4 (6.4) vs. 297.6 (3.3) minutes, p<0.001). On multivariable analysis, patients who had an operation on a weekend had a 38% lower chance of having a prolonged length of stay (>75th percentile of length of stay) compared to those on a weekday (aOR=0.62, 95% CI (0.42, 0.92)). There were no differences in rates of complications or reoperation for patients undergoing surgery on a weekend compared to a weekday. CONCLUSION: At centers with experienced anesthesiologists, appropriately trained nursing staff, and expert surgeons, colorectal surgery performed on a weekend has similar safety outcomes as surgeries performed on a weekday.

An Infrared Nanospectroscopy Technique for the Study of Electric-Field-Induced Molecular Dynamics.

Static electric fields play a considerable role in a variety of molecular nanosystems as diverse as single-molecule junctions, molecules supporting electrostatic catalysis, and biological cell membranes incorporating proteins. External electric fields can be applied to nanoscale samples with a conductive atomic force microscopy (AFM) probe in contact mode, but typically, no structural information is retrieved. Here we combine photothermal expansion infrared (IR) nanospectroscopy with electrostatic AFM probes to measure nanometric volumes where the IR field enhancement and the static electric field overlap spatially. We leverage the vibrational Stark effect in the polymer poly(methyl methacrylate) for calibrating the local electric field strength. In the relevant case of membrane protein bacteriorhodopsin, we observe electric-field-induced changes of the protein backbone conformation and residue protonation state. The proposed technique also has the potential to measure DC currents and IR spectra simultaneously, insofar enabling the monitoring of the possible interplay between charge transport and other effects.

Generation of citric acid-hyperproducers independent of methanol effect by high-level expression of cexA encoding citrate exporter in Aspergillus tubingensis.

Methanol reportedly stimulates citric acid (CA) production by Aspergillus niger and A. tubingensis; however, the underlying mechanisms remain unclear. Here, we elucidated the molecular functions of the citrate exporter gene cexA in relation to CA production by Aspergillus tubingensis WU-2223L. Methanol addition to the medium containing glucose as a carbon source markedly increased CA production by strain WU-2223L by 3.38-fold, resulting in a maximum yield of 65.5 g/L, with enhanced cexA expression. Conversely, the cexA-complementing strain with the constitutive expression promoter Ptef1 (strain LhC-1) produced 68.3 or 66.7 g/L of CA when cultivated without or with methanol, respectively. Additionally, strain LhC-2 harboring two copies of the cexA expression cassette produced 80.7 g/L of CA without methanol addition. Overall, we showed that cexA is a target gene for methanol in CA hyperproduction by A. tubingensis WU-2223L. Based on these findings, methanol-independent CA-hyperproducing strains, LhC-1 and LhC-2, were successfully generated.

Analysis of dynamic evolution characteristics and driving factors of regional synergistic effect of reducing carbon and saving water: the case of Yangtze River Delta Urban Agglomerations, China.

Carbon emissions and water consumption are both important factors affecting sustainable development. Therefore, it is necessary to put them in the same research framework and investigate the synergy. In this study, the dynamic evolution characteristics of the synergistic effect of reducing carbon and saving water (RCSW) were analyzed. Then, taking the Yangtze River Delta Urban Agglomerations (YRDUA) as the research object, the influencing factors and specific paths of the synergistic effect were clarified. The results showed that the low-carbon emission efficiency (LCEE) had a stable synergy with the intensive utilization efficiency of water resources (IUEWR) in the YRDUA. Government financial expenditure, actual use of foreign capital, and population density were the most significant driving forces for the synergistic effect of RCSW, with q values of 0.561, 0.363, and 0.240, respectively. In addition, most of the interactions of the driving factors were nonlinear enhancement and double-factor enhancement.

The optimal management of large upper ureteral stones (> 1.5 cm) with infection in elderly patients: a comparative analysis of three minimally invasive surgical approaches.

PURPOSE: The aim of this study was to investigate the efficacy and safety of three minimally invasive surgical approaches for treating large upper ureteral stones complicated by infection in elderly (> 60 years) patients. METHODS: Clinical data from 95 elderly patients with large upper ureteral stones and infection, treated at our hospital between January 2018 and April 2023, were retrospectively analyzed. The surgical approaches included FURL (flexible ureteroscopic lithotripsy) 33 cases, mPCNL (minimally percutaneous nephrolithotomy) 29 cases, and RLUL (retroperitoneal laparoscopic ureterolithotomy) 33 cases. Surgical time, intraoperative blood loss, postoperative hospital stay, reoperation rate, incidence of postoperative complications, and hospitalization costs were observed and compared among the three groups. RESULTS: No statistically significant difference was found in stone clearance rates among the three groups (P > 0.05). The FURL group exhibited advantages over the mPCNL and RLUL groups in surgical time, intraoperative blood loss, and postoperative hospital stay (P < 0.05). However, it also had the highest reoperation rate and hospitalization costs (P < 0.05). RLUL demonstrated superiority over the mPCNL and RLUL groups in terms of reoperation rate, incidence of complications, and hospitalization costs (P < 0.05). Notably, mPCNL exhibited the highest complication rate at 37.9% (P < 0.05). CONCLUSION: For elderly patients with large upper ureteral stones complicated by infection, FURL, mPCNL, and RLUL represent effective surgical approaches. Further attention is needed regarding the perioperative safety of mPCNL. RLUL, which offers higher safety, efficacy, and cost-effectiveness, can be considered a primary surgical option for these patients.