The Management of Pediatric Otitic Hydrocephalus: Case Report.

Otitic Hydrocephalus (OH) is one of the most significant life-threatening complications of otological infections. Given their low prevalence and non-specific ear symptoms, this complication requires a high index of suspicion for diagnosis. In this case report, we aim to provide an analysis of OH and describe common clinical signs and symptoms, treatment options, morbidity and mortality.

Publications poorly report the essential RadiOmics ParametERs (PROPER): A meta-research on quality of reporting.

PURPOSE: To investigate the quality of reporting in radiomics research, with a focus on the most basic technical parameters. METHODS: A PubMed literature search was conducted to identify original studies on radiomics (last search: January 2, 2023). Following a sample size calculation with an a priori power analysis, a random sample of the radiomic literature was collected. In addition to baseline characteristics, the key aspects of radiomic software, resampling, and discretization were evaluated. Agreement between raters was analyzed. Disagreements were resolved through consensus. RESULTS: A sample of 87 publications was evaluated. Most publications (89%; 77/87) were retrospective. They were conducted predominantly with private data (87%; 76/87) at a single institution (77%; 67/87) without external validation (90%; 78/87). 69% (60/87) of the papers reported the radiomic software used (p < 0.001), with nearly half (43%; 26/60) omitting the version. 37% (32/87) reported the resampling size (p = 0.018), while 22% (7/32) did not report using iso-voxel resampling. 34% (30/87) reported the discretization parameters (p < 0.01), but more than three-quarters (77%; 23/30) did not experiment with different discretization parameters. A wide range of discretization parameter values were reported. Most papers (79%; 69/87) failed to report all three essential items simultaneously (p < 0.001). CONCLUSION: Even the essential radiomic parameters that are usually displayed on the user interface of radiomic software tools were poorly reported in radiomics-related publications. This issue of transparency may require additional action from researchers, editors, and reviewers in the form of adopting more stringent reporting standards (e.g., checklists, guidelines).

REliability of consensus-based segMentatIoN in raDiomic feature reproducibility (REMIND): A word of caution.

OBJECTIVE: To evaluate the reliability of consensus-based segmentation in terms of reproducibility of radiomic features. METHODS: In this retrospective study, three tumor data sets were investigated: breast cancer (n = 30), renal cell carcinoma (n = 30), and pituitary macroadenoma (n = 30). MRI was utilized for breast and pituitary data sets, while CT was used for renal data set. 12 readers participated in the segmentation process. Consensus segmentation was created by making corrections on a previous region or volume of interest. Four experiments were designed to evaluate the reproducibility of radiomic features. Reliability was assessed with intraclass correlation coefficient (ICC) with two cut-off values: 0.75 and 0.9. RESULTS: Considering the lower bound of the 95% confidence interval and the ICC threshold of 0.90, at least 61% of the radiomic features were not reproducible in the inter-consensus analysis. In the susceptibility experiment, at least half (54%) became non-reproducible when the first reader is replaced with a different reader. In the intra-consensus analysis, at least about one-third (32%) were non-reproducible when the same second reader segmented the image over the same first reader two weeks later. Compared to inter-reader analysis based on independent single readers, the inter-consensus analysis did not statistically significantly improve the rates of reproducible features in all data sets and analyses. CONCLUSIONS: Despite the positive connotation of the word "consensus", it is essential to REMIND that consensus-based segmentation has significant reproducibility issues. Therefore, the usage of consensus-based segmentation alone should be avoided unless a reliability analysis is performed, even if it is not practical in clinical settings.

Investigation of fathers' metaphors regarding child sexual abuse in Turkey: A metaphor study.

BACKGROUND AND PURPOSE: This study was designed to determine the perceptions of fathers about child sexual abuse in Turkey using metaphors to facilitate understanding of child sexual abuse. METHODS: The study was conducted as a qualitative study based on metaphor analysis. The data were collected from 164 Turkish fathers in Turkey between August 2022 and September 2022 using a descriptive information form for fathers and a semi-structured interview form exploring fathers' perceptions of child sexual abuse. The semi-structured interview form included metaphor statements like "Child sexual abuse is like....... because .......", and "Child sexual abuse reminds me of the color....... because .......". The data were analyzed using the content analysis technique. The study was reported based on Standards for Reporting Qualitative Research (SRQR). RESULTS: According to the results, 77.4% of the fathers had knowledge about protecting their children from sexual abuse, 40.9% got this information from the internet, and only 11.1% educated their children about sexual abuse. Seventy three percent of the fathers were afraid of confusing their children while educating them. The fathers involved in the study used 20 metaphors related to "child sexual abuse" and "the color evoked by child sexual abuse". The metaphors created by the fathers were analyzed under six categories: "emotions, feeling inadequate, punishment method, abuser, child concept, and uncertainty". CONCLUSION: Based on the results of the study, fathers had common feelings and emphasize the same concepts about child sexual abuse. PRACTICE IMPLICATIONS: Metaphors provide a unique approach to identifying fathers' conceptual images of child sexual abuse.

A case report of reversible intracranial lesions after long-term Azathioprine therapy in an autoimmune hepatitis patient.

This study is written to report a case of 67-year-old female with known autoimmune hepatitis (AIH) who developed balance and walking difficulties. Clinical and imaging investigations were more suggestive of AIH suffering from lymphoproliferative disease. To identify the underlying suspected lymphoproliferative disease, series of brain scans were performed, which showed multiple brain lesions. This is a report on a striking case of multiple contrast enhanced brain lesions discovered in an AIH patient that was resolved upon withdrawal of azathioprine. Many side effects of azathioprine are acknowledged around the world; however, to the very best of our knowledge, an article on azathioprine inducing suspected malignancy was never reported.

NEgatiVE results in Radiomics research (NEVER): A meta-research study of publication bias in leading radiology journals.

PURPOSE: The purpose of this study was to conduct a meta-research of radiomics-related articles for the publication of negative results, with a focus on the leading clinical radiology journals due to their purportedly high editorial standards. METHODS: A literature search was performed in PubMed to identify original research studies on radiomics (last search date: August 16th, 2022). The search was restricted to studies published in Q1 clinical radiology journals indexed by Scopus and Web of Science. Following an a priori power analysis based on our null hypothesis, a random sampling of the published literature was conducted. Besides the six baseline study characteristics, a total of three items about publication bias were evaluated. Agreement between raters was analyzed. Disagreements were resolved through consensus. Statistical synthesis of the qualitative evaluations was presented. RESULTS: Following a priori power analysis, we included a random sample of 149 publications in this study. Most of the publications were retrospective (95%; 142/149), based on private data (91%; 136/149), centered on a single institution (75%; 111/149), and lacked external validation (81%; 121/149). Slightly fewer than half (44%; 66/149) made no comparison to non-radiomic approaches. Overall, only one study (1%; 1/149) reported negative results for radiomics, yielding a statistically significant binomial test (p < 0.0001). CONCLUSION: The top clinical radiology journals almost never publish negative results, having a strong bias toward publishing positive results. Almost half of the publications did not even compare their approach with a non-radiomic method.

Preparation, characterization, and evaluation of antibacterial and cytotoxic activity of chitosan-polyethylene glycol nanoparticles loaded with amoxicillin as a novel drug delivery system.

In this study, nanoparticles of amoxicillin (AMX) were prepared using chitosan (CHI) and polyethylene glycol (PEG). The physicochemical properties of the particles were investigated by FT-IR, DSC, SEM, and zeta potential analyses. The nanoparticles showed a spherical shape, and the average size of formulations was within the range of 696.20 ± 24.86 - 359.53 ± 7.41 nm. Zeta potential data demonstrated that the formulations had positive surface charges with a zeta potential range of 21.38 ± 2.28 - 7.73 ± 1.66 mV. FTIR analysis showed that the drug was successfully entrapped in the nanoparticles. DSC results suggested that the drug was present in amorphous form in the polymer matrix. In vitro release studies demonstrated that the release pattern consisted of two phases, with an initial burst release followed by a controlled and sustained release. The MTT assay results on mouse fibroblast cell line indicated that the prepared formulations did not affect the viability of the cells. In the in vitro antibacterial activity test, it was found that the drug-loaded nanoparticles have AMX-equivalent antibacterial activity against E. coli, and S. aureus. These findings revealed that the obtained nanoparticles might be a promising and safe nanocarrier system for efficient delivery of AMX.

Amoxicillin has been encapsulated in PEG-CHI nanoparticles.The structure of nanoparticles was investigated by SEM, FTIR, and DSC studies.The nanoparticles showed an initial fast release followed by a slow release.PEG-CHI nanoparticles displayed equivalent antibacterial activity to amoxicillin, and a non-cytotoxic profile in healthy cells.

Transparency in Artificial Intelligence Research: a Systematic Review of Availability Items Related to Open Science in Radiology and Nuclear Medicine.

RATIONALE AND OBJECTIVES: Reproducibility of artificial intelligence (AI) research has become a growing concern. One of the fundamental reasons is the lack of transparency in data, code, and model. In this work, we aimed to systematically review the radiology and nuclear medicine papers on AI in terms of transparency and open science. MATERIALS AND METHODS: A systematic literature search was performed in PubMed to identify original research studies on AI. The search was restricted to studies published in Q1 and Q2 journals that are also indexed on the Web of Science. A random sampling of the literature was performed. Besides six baseline study characteristics, a total of five availability items were evaluated. Two groups of independent readers including eight readers participated in the study. Inter-rater agreement was analyzed. Disagreements were resolved with consensus. RESULTS: Following eligibility criteria, we included a final set of 194 papers. The raw data was available in about one-fifth of the papers (34/194; 18%). However, the authors made their private data available only in one paper (1/161; 1%). About one-tenth of the papers made their pre-modeling (25/194; 13%), modeling (28/194; 14%), or post-modeling files (15/194; 8%) available. Most of the papers (189/194; 97%) did not attempt to create a ready-to-use system for real-world usage. Data origin, use of deep learning, and external validation had statistically significantly different distributions. The use of private data alone was negatively associated with the availability of at least one item (p<0.001). CONCLUSION: Overall rates of availability for items were poor, leaving room for substantial improvement.

Attitudes of parents in the role of a father in Turkey toward child sex education and their sexual communication with their children.

BACKGROUND AND PURPOSE: The study aimed to evaluate the attitudes of parents in the role of a father in Turkey toward child sex education and their sexual communication with their children. METHODS: This descriptive and cross-sectional study was conducted with the fathers of children in the pediatric outpatient clinic at a state hospital between December 30, 2021, and April 15, 2022. The study was reported based on STROBE. The data were collected from 297 fathers using the Descriptive Information Form, the Attitudes Scale Toward Sex education (ASTSE), and the Sexual Communication Scale for Parents(SCSP). RESULTS: Sample statistics demonstrate that 67.7% of the participants did not receive sex education in their childhood, and 57.4% stated that their children received sex education only from their mothers. Higher attitudes toward sexual education were found in the fathers with a university or higher education degree (χ2 = 15.396; p < 0.01), and those giving sex education to their children (χ2 = 18.388;p < 0.001). Higher total scores were obtained on the sexual communication scale by fathers with university and higher education degrees (χ2 = 12.898;p < 0.01) and those who received sex education in their childhood (t = 2.330;p = 0.021). There is a highly significant positive correlation between the mean scores of the role of a parent subscale of the ASTSE and the mean total score of the SCSP (r = 0.81;p < 0.001). CONCLUSIONS: There is a positive correlation between fathers' parental role attitudes toward sex education and their sexual communication with their children. PRACTICE IMPLICATIONS: Supporting fathers' sexual communication with their children can positively affect fathers' attitudes and communication toward sex education.

Increased ocular wall thickness and decreased globe volume in children with mucopolysaccharidosis type VI.

PURPOSE lthough clinical ophthalmologic findings have been reported, no study documented magnetic resonance imaging (MRI) findings in mucopolysaccharidosis (MPS) type VI. The aim of this study was to determine the ophthalmologic imaging findings of MPS type VI in the pediatric age group retrospectively. METHODS Brain MRIs of 10 patients with MPS type VI and 49 healthy children were evaluated independently by two pediatric radiologists for the following characteristics: globe volume, ocular wall thickness, and optic nerve sheath diameter for each orbit. The means of the measurement of each group were compared by using an independent t-test. Agreement and bias between reviewers were assessed by intra-class correlation coefficients (ICC). RESULTS A total of 59 children [32 girls (54.23%), 27 boys (45.77%); age range, 4-16 years; mean age, 10.37 ± 3.73 years] were included in the study. Statistical analysis revealed smaller eyeballs and thicker ocular walls of patients with MPS type VI (P < .001 and P < .001, respectively). However, there was no statistically significant difference in terms of optic nerve sheath diameter between the two groups (P=.648). CONCLUSION Patients with MPS type VI displayed reduced globe volumes and increased ocular wall thicknesses compared to the healthy children. Therefore, we recommend that ophthalmologic imaging findings might prove to be an auxiliary tool in the diagnosis of MPS patients.

Fibrous dysplasia: A rare cause of optic neuropathy.

Fibrous dysplasia (FD) is a progressive and benign osteodystrophic disease where cranial bones are most commonly affected. In this case report, we present a 27-year-old patient with previous diagnosis of FD who was referred to our clinic with sudden loss of visual acuity and color discrimination. Examination of the right eye was normal, whereas visual acuity on the left eye was 6/9 and color vision (CV) with Ishihara test plates was 9/12. The visual field (VF) demonstrated a peripheral concentric defect on the left eye. As visual acuity in the left eye decreased to 6/30 and computed tomography imaging of the brain and orbit showed optic nerve compression by immature bony structures, optic nerve decompression was recommended with the diagnosis of compressive optic neuropathy. Endoscopic transnasal orbital and optic canal decompression was performed. At the postoperative course, visual acuity on the left eye turned to 6/6, CV was 12/12, and VF improved markedly. In subjects with craniofacial FD, a multidisciplinary approach is important. If there is evidence of compressive optic neuropathy, surgery should be performed.

Pediatric head and neck rhabdomyosarcoma; the role of MRI in differentiation from other common pediatric malignant head and neck tumors.

BACKGROUND: The tumor localization/extent and imaging characteristics of rhabdomyosarcomas (RMSs) especially parameningeal type, could overlap with the common tumors of the head and neck (H&N) such as lymphoma and nasopharyngeal carcinoma (NPC). Our goal was to investigate magnetic resonance imaging (MRI) features that could favor the diagnosis of RMS over lymphoma and NPC in H&N region. METHODS: Pretreatment MRI of 42 pediatric patients (mean: 9.7±5.1 years, min-max: 2-18 years) with a recent diagnosis of RMS (n=12), lymphoma (n=14) and NPC (n=16) were retrospectively studied. Tumor localization, extension and spread were evaluated. Signal and enhancement characteristics of the tumors and the presence of necrosis were noted. ADC values were measured by using both the small sample and single slice methods. For comparison of three groups, the Kruskal Wallis test and Pairwise comparisons were used. The intra-class correlation coefficient (ICC) was calculated for the assessment of inter-observer agreement. RESULTS: Nasopharynx ±parapharyngeal space involvement was detected in 58.3% of RMSs. Rhabdomyosarcoma was more heterogeneous in T2 images compared to lymphoma (p=0.014). Rhabdomyosarcoma showed significantly higher frequency of heterogeneous enhancement (p < 0.001) and necrosis (p < 0.001) among these tumors. The mean ADC values of lymphoma were significantly lower than the values of RMS (p < 0.001) and NPC (p < 0.01) for both observers. The mean ADC values were higher in RMSs than NPCs (p > 0.05). Intra-class correlation in ADC measurements was higher for the single slice method (ICC=0.997) than the small sample method (ICC=0.989). CONCLUSIONS: Rhabdomyosarcoma tends to have higher ADC values than lymphoma and has a higher frequency of heterogeneous enhancement and necrotic parts than both lymphoma and nasopharyngeal carcinoma. These features could help radiologists to differentiate RMS from the above-mentioned mimickers.

The emotional neglect potentials of nurses working in the COVID-19 service towards their children: A qualitative study.

PURPOSE: This study aims to examine in depth the potential child emotional neglect behaviors of nurses working in the COVID-19 service, and their feelings, thoughts, and experiences regarding the causes and effects on their children. DESIGN AND METHODS: The study was designed as a qualitative study based on a descriptive phenomenological approach. A purposeful sample of service providers (N = 22) in the COVID-19 clinics of the region's largest hospital in northeast Turkey in terms of education and patient care were recruited for the study. The data were collected through semi-structured interviews using the individual in-depth face-to-face interview method. The interviews were audio-recorded, transcribed verbatim, and analyzed with Braun and Clarke's thematic analysis method. The research was reported by following Consolidated criteria for reporting qualitative research-COREQ. RESULTS: The findings enabled the identification of four unique themes expressed by the participants: parent-child interaction, social impact, physiological impact, and psychological impact. The first theme consists of adversely affected time nurses spent with their children, decreased physical contact, and communication problems; the second theme includes nurses' and their children's social isolation and social stigma; the third theme includes a change in eating habits and daily activities; the fourth theme includes fear of losing parents and emotional change. CONCLUSIONS AND PRACTICE IMPLICATIONS: To prevent the increased emotional neglect potential due to the COVID-19 pandemic, it is necessary to regulate the working conditions of parents who are nursing professionals and support the parent/child emotionally and psychologically.

The concept of pain inventory for children: The reliability and validity study of the Turkish version.

BACKGROUND AND PURPOSE: Pain experiences in childhood are very likely to be reflected in adulthood. The early evaluation of the concept of pain in children may eventually lead to. better patient outcomes in the future. Therefore, we aimed to culturally and developmentally adapt the Concept of Pain Inventory for Children (COPI) for Turkish children. METHODS: This descriptive, correlational study was conducted with 239 post-operative children aged 8-12 years between June and December 2021. The research adhered to COSMIN guidelines. The data were collected using a descriptive information form and the COPI. Factor analysis, Cronbach's alpha, and item-total score analysis were used for the data analysis. RESULTS: The resulting unidimensional scale consists of 12 items in Turkish. The scale explained 65% of the total variance. The exploratory factor analysis showed that the factor loadings of items ranged from 0.64 to 0.91. The confirmatory factor analysis showed that the factor loadings of items ranged from 0.66 to 0.92. Goodness of fit indexes were found to be as follows: Normed Fit Index >0.90; Incremental Fit Index >0.90; Comparative Fit Index >0.90; and the Root Mean Square Error of Approximation <0.08. The total Cronbach's alpha coefficient of the scale was 0.78 (reliable). CONCLUSIONS: The 12-item Turkish translation of the COPI was deemed valid and reliable in 8-12-year-old children in a post-operative setting. PRACTICE IMPLICATIONS: Evaluation of children's pain concepts during childhood may contribute to the identification of conceptual gaps for pain science education.

New Ketene Dithioacetals Generated from 2-Nitroperchlorobutadiene and Investigation of Their Antibacterial, Antifungal, Anticonvulsant and Antidepressant Activities.

The ketene dithioacetal 3 generated from 2-nitroperchlorobutadiene 1 reacted with various heterocyclic amines and aliphatic, aromatic and heterocyclic thiols to produce functionalized new ketene-N,S,S-acetals and S,S,S-acetals 4a-f, 5a-h as heterocyclic dithiolanes. They were separated/purified by chromatographic methods and their exact structure characterization were made clear by spectroscopic methods. These compounds synthesized could act as effective drugs for versatile activity. Evaluation of the antimicrobial effect of the obtained substances determined derivatives 4e and 5h, which have MIC=15.6 µg/mL for the test culture of Mycobacterium luteum bacteria closing to the control drug Vancomycin. The obtained compounds can be proposed as a promising synthetic objects for future molecular design to enhance the antimicrobial action. Ketene dithioacetals 3, 4a, 4b, 4e, 5g (50 mg/kg) exhibited antiseizure effect comparable with reference drug (valproic acid) on the model of pentylenetetrazole-induced convulsions after single oral administration both at 3 h and 24 h. Furthermore, tested dithioacetals possessed prolonged antidepressant activity in forced swim test (FST) considerable decreasing the duration of immobility time compared to reference drug amitriptyline. This is the first study of the investigation of anticonvulsant and antidepressant activities of ketene dithioacetals.

A rare case of two Stafne bone cavities in the ipsilateral mandible with bicortical bone perforation.

Stafne bone cavity (SBC) is a bone defect which appears unilaterally round or oval shaped radiolucent area with well-defined border. The most common location of the defect is the mandibular molar area at the lingual side of the mandible, below the mandibular canal. Additionally other rarer variants of SBC, anterior lingual, buccal aspect of ascending ramus, and lingual aspect of ascending ramus are also reported. In this paper, a rare case of posterior and anterior variant of double SBCs with buccal cortical bone perforation was presented. An 83-year-old male patient was referred to our clinic for a routine dental examination. Panoramic examination presented two well-defined radiolucent areas. One was located at the right posterior region of the mandible, below the inferior alveolar canal and the second in the region of right canine-premolar area, anterior of the mental foramen. Cone beam computed tomography also confirmed the defects. Magnetic resonance imaging of patient showed that posterior variant was filled with part of submandibular gland and anterior variant was filled with part of sublingual gland. The diagnosis was made as double SBCs and the patient was informed about the lesions.

Unilateral Facial Paralysis and Ophthalmoplegia Caused by Lower Lip Carcinoma: A Case Report.

We discuss a case of lower lip carcinoma which presented with atypical symptoms; facial paralysis, conductive type hearing loss, and ophthalmoplegia. Due to an earlier resection, no mass was evident on the primary examination. Diagnostic imaging revealed a mass originating from the lower lip, the perineural spread of the tumor along the left inferior alveolar nerve to the left infratemporal fossa and the left foramen ovale. Through a retrograde course from the foramen ovale, the tumor extended the ipsilateral cavernous sinus, Meckel's cave, and cisternal portion of the CN V. This atypical spread pattern of the tumor caused symptoms that may be attributed to a diagnosis related to the ear. The biopsy confirmed squamous cell carcinoma, and the patient was referred for chemotherapy and radiotherapy.

Psychological distress in middle eastern immigrants to the United States: A challenge to the healthy migrant model?

RATIONALE AND OBJECTIVE: Research has documented a robust mental health advantage among Asian and Latino immigrants to the United States relative to the native-born. The current investigation extended this line of research, asking whether Middle Eastern immigrants to the United States enjoy a similar mental health advantage. METHODS: Drawing on pooled cross-sections from the 2007-2018 National Health Interview Surveys, we used OLS regression to examine psychological distress in Middle Eastern immigrants relative to both native-born Whites and immigrants from other global regions. We used statistical interactions to assess whether gender and period differences are contingent on region of birth. RESULTS: Findings reveal that the average level of psychological distress is higher among Middle Eastern immigrants than among both U.S.-born Whites and immigrants from other regions. Despite changing circumstances of migration for Middle Easterners and implementation in the United States of anti-immigrant policies, we see no evidence that distress increased more among immigrants compared to native-born Whites. Results point to greater psychological distress among Middle Eastern women than their native-born White counterparts and women from other immigrant groups, as well as Middle Eastern men. In contrast, psychological distress levels for Middle Eastern and native-born White men were indistinguishable, suggesting that the Middle Eastern mental health disadvantage in the United States is borne solely by women. CONCLUSIONS: Results show that the mental health advantage enjoyed by some immigrant groups does not extend to Middle Eastern women, contradicting the healthy migrant model and challenging the assumption of a uniform mental health advantage across immigrant groups.

Adenoid Cystic Carcinoma of Lacrimal Gland with Bone Remodeling.

Adenoid cystic carcinoma is the most common type of malignancy seen in the lacrimal glands and is generally characterized by invasive malignant appearance with irregular margins and associated bone erosion or destruction. The authors report an unusual patient with a large expansile, well-circumscribed lacrimal adenoid cystic carcinoma with adjacent bone remodeling, radiologically mimicking a benign lesion.

Spinal and cerebral hematoma in systemic lupus erythematosus and antiphospholipid syndrome: is drug interaction the culprit?

OBJECTIVES: Thrombotic events are common in systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). Warfarin is the most commonly used anticoagulant drug for thrombosis treatment, but it is can interact with many drugs, foods, or medicinal herbs. Herein, we presented a case with SLE and APS who was complicated by spinal and cerebral hematoma as a result of warfarin interaction. CASE PRESENTATION: Spinal subdural hematoma and frontal intraparenchymal hematoma were occurred in our patient, who was in remission for 2 years with rituximab, hydroxychloroquine and warfarin. We learned that she had been using some herbal products (shepherd's purse and horsetail) and phenyramidol for a few days. Spinal and cerebral hematomas caused by the interaction of phenyramidol and warfarin were treated with fresh frozen plasma and vitamin K without the need for surgery. CONCLUSIONS: The drug interactions with warfarin can cause fatal hemorrhagic or thrombotic events. Especially, the patients with SLE and/or APS using warfarin should be warned not to use different medications or herbal agents.