Development of a digital star-shot analysis system for comparing radiation and imaging isocenters of proton treatment machine.

PURPOSE: To directly compare the radiation and imaging isocenters of a proton treatment machine, we developed and evaluated a real-time radiation isocenter verification system. METHODS: The system consists of a plastic scintillator (PI-200, Mitsubishi Chemical Corporation, Tokyo, Japan), an acrylic phantom, a steel ball on the detachable plate, Raspberry Pi 4 (Raspberry Pi Foundation, London, UK) with camera module, and analysis software implemented through a Python-based graphical user interface (GUI). After kV imaging alignment of the steel ball, the imaging isocenter defined as the position of the steel ball was extracted from the optical image. The proton star-shot was obtained by optical camera because the scintillator converted proton beam into visible light. Then the software computed both the minimum circle radius and the radiation isocenter position from the star-shot. And the deviation between the imaging isocenter and radiation isocenter was calculated. We compared our results with measurements obtained by Gafchromic EBT3 film (Ashland, NJ, USA). RESULTS: The minimum circle radii were averaged 0.29 and 0.41 mm while the position deviations from the radiation isocenter to the laser marker were averaged 0.99 and 1.07 mm, for our system and EBT3 film, respectively. Furthermore, the average position difference between the radiation isocenter and imaging isocenter was 0.27 mm for our system. Our system reduced analysis time by 10 min. CONCLUSIONS: Our system provided automated star-shot analysis with sufficient accuracy, and it is cost-effective alternative to conventional film-based method for radiation isocenter verification.

Comparative Efficacy of Rosuvastatin Monotherapy and Rosuvastatin/Ezetimibe Combination Therapy on Insulin Sensitivity and Vascular Inflammatory Response in Patients with Type 2 Diabetes Mellitus.

BACKGRUOUND: Type 2 diabetes mellitus (T2DM) induces endothelial dysfunction and inflammation, which are the main factors for atherosclerosis and cardiovascular disease. The present study aimed to compare the effects of rosuvastatin monotherapy and rosuvastatin/ezetimibe combination therapy on lipid profile, insulin sensitivity, and vascular inflammatory response in patients with T2DM. METHODS: A total of 101 patients with T2DM and dyslipidemia were randomized to either rosuvastatin monotherapy (5 mg/day, n=47) or rosuvastatin/ezetimibe combination therapy (5 mg/10 mg/day, n=45) and treated for 12 weeks. Serum lipids, glucose, insulin, soluble intercellular adhesion molecule-1 (sICAM-1), and peroxiredoxin 4 (PRDX4) levels were determined before and after 12 weeks of treatment. RESULTS: The reduction in low density lipoprotein cholesterol (LDL-C) by more than 50% from baseline after treatment was more in the combination therapy group. The serum sICAM-1 levels increased significantly in both groups, but there was no difference between the two groups. The significant changes in homeostasis model assessment of insulin resistance (HOMA-IR) and PRDX4 were confirmed only in the subgroup in which LDL-C was reduced by 50% or more in the combination therapy group. However, after adjusting for diabetes mellitus duration and hypertension, the changes in HOMA-IR and PRDX4 were not significant between the two groups. CONCLUSION: Although rosuvastatin/ezetimibe combination therapy had a greater LDL-C reduction effect than rosuvastatin monotherapy, it had no additional effects on insulin sensitivity and vascular inflammatory response. Further studies are needed on the effect of long-term treatment with ezetimibe on insulin sensitivity and vascular inflammatory response.

Effects of Fermented Polygonum cuspidatum on the Skeletal Muscle Functions.

Plant extract fermentation is widely employed to enhance the nutritional and pharmaceutical value of functional foods. Polygonum cuspidatum (Pc) contains flavonoids, anthraquinones, and stilbenes, imparting protective effects against inflammatory diseases, cancer, diabetes, and cardiovascular diseases. However, the effects of fermented Pc on skeletal muscle strength remain unexplored. In this study, we generated fermented Pc using a complex of microorganisms containing Lactobacillus spp. (McPc) and assessed its effects on muscle strength and motor function in mice. Compared to unfermented Pc water extract, elevated levels of emodin and resveratrol were noted in McPc. This was identified and quantified using UPLC-QTOF/MS and HPLC techniques. Gene expression profiling through RNA-seq and quantitative RT-PCR revealed that McPc administration upregulated the expression of genes associated with antioxidants, glycolysis, oxidative phosphorylation, fatty acid oxidation, and mitochondrial biogenesis in cultured C2C12 myotubes and the gastrocnemius muscle in mice. McPc significantly improved skeletal muscle strength, motor coordination, and traction force in mice subjected to sciatic neurectomy and high-fat diet (HFD). McPc administration exhibited more pronounced improvement of obesity, hyperglycemia, fatty liver, and hyperlipidemia in HFD mice compared to control group. These findings support the notion that emodin and resveratrol-enriched McPc may offer health benefits for addressing skeletal muscle weakness.

Feasibility of Virtual Reality-Based Auditory Localization Training With Binaurally Recorded Auditory Stimuli for Patients With Single-Sided Deafness.

OBJECTIVES: To train participants to localize sound using virtual reality (VR) technology, appropriate auditory stimuli that contain accurate spatial cues are essential. The generic head-related transfer function that grounds the programmed spatial audio in VR does not reflect individual variation in monaural spatial cues, which is critical for auditory spatial perception in patients with single-sided deafness (SSD). As binaural difference cues are unavailable, auditory spatial perception is a typical problem in the SSD population and warrants intervention. This study assessed the applicability of binaurally recorded auditory stimuli in VR-based training for sound localization in SSD patients. METHODS: Sixteen subjects with SSD and 38 normal-hearing (NH) controls underwent VR-based training for sound localization and were assessed 3 weeks after completing training. The VR program incorporated prerecorded auditory stimuli created individually in the SSD group and over an anthropometric model in the NH group. RESULTS: Sound localization performance revealed significant improvements in both groups after training, with retained benefits lasting for an additional 3 weeks. Subjective improvements in spatial hearing were confirmed in the SSD group. CONCLUSION: By examining individuals with SSD and NH, VR-based training for sound localization that used binaurally recorded stimuli, measured individually, was found to be effective and beneficial. Furthermore, VR-based training does not require sophisticated instruments or setups. These. RESULTS: suggest that this technique represents a new therapeutic treatment for impaired sound localization.

The effect of noise on the cortical activity patterns of speech processing in adults with single-sided deafness.

The most common complaint in people with single-sided deafness (SSD) is difficulty in understanding speech in a noisy environment. Moreover, the neural mechanism of speech-in-noise (SiN) perception in SSD individuals is still poorly understood. In this study, we measured the cortical activity in SSD participants during a SiN task to compare with a speech-in-quiet (SiQ) task. Dipole source analysis revealed left hemispheric dominance in both left- and right-sided SSD group. Contrary to SiN listening, this hemispheric difference was not found during SiQ listening in either group. In addition, cortical activation in the right-sided SSD individuals was independent of the location of sound whereas activation sites in the left-sided SSD group were altered by the sound location. Examining the neural-behavioral relationship revealed that N1 activation is associated with the duration of deafness and the SiN perception ability of individuals with SSD. Our findings indicate that SiN listening is processed differently in the brains of left and right SSD individuals.

Solitalea lacus sp. nov., isolated from pond sediment.

A Gram-stain-negative, strictly aerobic, oxidase-positive, catalase-negative, motile by gliding, creamy white-pigmented bacterium, designated strain S2-8T, isolated from a sediment sample from a Wiyang pond in the Republic of Korea, was subjected to polyphasic taxonomic analysis. Growth was observed at 10-40 °C (optimum: 30 °C), pH 7-8 and 0-0.5% NaCl. Phylogenetic analyses based on 16S rRNA gene sequences revealed that strain S2-8T belonged to the family Sphingobacteriaceae in the phylum Bacteroidota and was closely related to Solitalea longa HR-AVT, Solitalea canadensis DSM 3403T and Solitalea koreensis R2A36-4T with 97.2, 96.7 and 93.7 % 16S rRNA gene sequence similarities, respectively. Average nucleotide identity and digital DNA-DNA hybridization values for these type strains were 72.0-75.2% and 21.2-21.9 %, respectively. The major respiratory quinone is menaquinone-7. The major fatty acids were iso-C15 : 0, iso-C17 : 0 3-OH and summed feature 3 (comprising C16 : 1 ω7c and/or C16 : 1 ω6c). The major polar lipids were phosphatidylethanolamine, two unidentified amino acids and four unidentified lipids. The G+C content of genomic DNA was 37.9 mol%. Based on polyphasic taxonomic analysis, it was observed that strain S2-8T is a novel species belonging to the genus Solitalea, for which the name Solitalea lacus sp. nov. is proposed. The type strain is S2-8T (= KACC 22266T= JCM 34533T).

Development of Novel Musical Stimuli to Investigate the Perception of Musical Emotions in Individuals With Hearing Loss.

BACKGROUND: Many studies have examined the perception of musical emotion using excerpts from familiar music that includes highly expressed emotions to classify emotional choices. However, using familiar music to study musical emotions in people with acquired hearing loss could produce ambiguous results as to whether the emotional perception is due to previous experiences or listening to the current musical stimuli. To overcome this limitation, we developed new musical stimuli to study emotional perception without the effects of episodic memory. METHODS: A musician was instructed to compose five melodies with evenly distributed pitches around 1 kHz. The melodies were created to express the emotions of happy, sad, angry, tender, and neutral. To evaluate whether these melodies expressed the intended emotions, two methods were applied. First, we classified the expressed emotions of melodies with selected musical features from 60 features using genetic algorithm-based k-nearest neighbors. Second, forty-four people with normal hearing participated in an online survey regarding the emotional perception of music based on dimensional and discrete approaches to evaluate the musical stimuli set. RESULTS: Twenty-four selected musical features produced classification for intended emotions with an accuracy of 76%. The results of the online survey in the normal hearing (NH) group showed that the intended emotions were selected significantly more often than the others. K-means clustering analysis revealed that melodies with arousal and valence ratings corresponded to representative quadrants of interest. Additionally, the applicability of the stimuli was tested in 4 individuals with high-frequency hearing loss. CONCLUSION: By applying the individuals with NH, the musical stimuli were shown to classify emotions with high accuracy, as expressed. These results confirm that the set of musical stimuli can be used to study the perceived emotion in music, demonstrating the validity of the musical stimuli, independent of innate musical bias such as due to episodic memory. Furthermore, musical stimuli could be helpful for further studying perceived musical emotion in people with hearing loss because of the controlled pitch for each emotion.

Flavobacterium humidisoli sp. nov., isolated from riverside soil.

A novel Gram-stain-negative, yellow-pigmented, non-motile and rod-shaped bacterial strain designated MMS21-Er5T was isolated and subjected to polyphasic taxonomic characterization. MMS21- Er5T could grow at 4-34 °C (optimum, 30 °C), at pH 6-8 (optimum, pH 7) and in the presence of 0-2% NaCl (optimum, 1 %). The results of phylogenetic analysis based on 16S rRNA gene sequences indicated that MMS21- Er5T showed low levels of sequence similarities with other species, as the highest similarity of 97.83 % was observed with Flavobacterium tyrosinilyticum THG DN8.8T, then 97.68 % with 'Flavobacterium ginsengiterrae' DCY 55 and 97.63 % with Flavobacterium banpakuense 15F3T, which were well below the suggested cutoff for species distinction. The whole genome sequence of MMS21-Er5T consisted of a single contig of 5.63 Mbp, and the DNA G+C content was 34.06 mol%. The in-silico DNA-DNA hybridization and orthologous average nucleotide identity values were highest with Flavobacterium tyrosinilyticum KCTC 42726T (45.7 and 91.92% respectively). The predominant respiratory quinone for the strain was menaquinone-6 (MK-6), the major cellular fatty acid was iso-C15 : 0, and the diagnostic polar lipids were phosphatidylethanolamine and phosphatidyldiethanolamine. The combination of physiological and biochemical tests clearly distinguished the strain from related species of the genus Flavobacterium. On the basis of these results, strain MMS21-Er5T evidently represents a novel species of the genus Flavobacterium, for which the name Flavobacterium humidisoli sp. nov. is proposed (type strain=MMS21-Er5T=KCTC 92256T =LMG 32524T).

Attentional modulation of auditory cortical activity in individuals with single-sided deafness.

Persons with single-sided deafness (SSD) typically complain about the impaired ability to locate sounds and to understand speech within background noise. However, the findings from previous studies suggest that paying attention to sounds could mitigate the degraded spatial and speech-in-noise perception. In the present study, we characterize the pattern of cortical activation depending on the side of deafness, and attentional modulation of neural responses to determine if it can assist better sound processing in people with SSD. For the active listening condition, adult subjects with SSD performed sound localization tasks. On the other hand, they watched movies without attending to speech stimuli during passive listening. The sensor-level global field power of N1 and source-level N1 activation were computed to compare the active- and passive-listening conditions and left- and right-sided deafness. The results show that attentional modulation differs depending on the side of deafness: active listening increased the cortical activity in individuals with left-sided deafness but not in those with right-sided deafness. At the source level, the attentional gain was more apparent in left-sided deafness in that paying attention enhanced brain activation in both hemispheres. In addition, SSD participants with larger cortical activities in the right primary auditory cortex had shorter durations of deafness. Our results indicate that the side of deafness can change top-down attentional processing in the auditory cortical pathway in SSD patients.

Hyaluronic Acid Nanoparticles as a Topical Agent for Treating Psoriasis.

Although conventional topical approaches for treating psoriasis have been offered as an alternative, there are still unmet medical needs such as low skin-penetrating efficacy and off-target adverse effects. A hyaluronic acid nanoparticle (HA-NP) formed by self-assembly of HA-hydrophobic moiety conjugates has been broadly studied as a nanocarrier for long-term and target-specific delivery of drugs, owing to their excellent physicochemical and biological characteristics. Here, we identify HA-NPs as topical therapeutics for treating psoriasis using in vivo skin penetration studies and psoriasis animal models. Transcutaneously administered HA-NPs were found to be accumulated and associated with pro-inflammatory macrophages in the inflamed dermis of a psoriasis mouse model. Importantly, HA-NP exerted potent therapeutic efficacy against psoriasis-like skin dermatitis in a size-dependent manner by suppressing innate immune responses and restoring skin barrier function without overt toxicity signs. The therapeutic efficacy of HA-NPs on psoriasis-like skin dermatitis was due to the outermost hydrophilic HA shell layer of HA-NPs, independent of the molecular weight of HA and hydrophobic moiety, and comparable with that of other conventional psoriasis therapeutics widely used in the clinical settings. Overall, HA-NPs have the potential as a topical nanomedicine for treating psoriasis effectively and safely.

Rapid production method with increased yield of high-purity extracellular vesicles obtained using extended mitochondrial targeting domain peptide.

Extracellular vesicles (EVs) are nano-sized membranous structures involved in intercellular communication and various physiological and pathological processes. Here, we present a novel method for rapid (within 15 min), large-scale production of high-purity EVs using eMTDΔ4, a peptide derived from Noxa. The treatment of mesenchymal stem cells derived from human Wharton's jelly after trypsinization and subsequent eMTDΔ4 stimulation in a chemically defined sucrose buffer with orbital shaking led to a substantial increase (approximately 30-fold) in EV production with markedly high purity (approximately 45-fold). These EVs (TS-eEVs) showed higher regenerative and immunomodulatory potential than natural EVs obtained from the culture media after 48 h. The calcium chelator BAPTA-AM and calpain inhibitor ALLM, but not the natural EV biogenesis inhibitor GW4869, blocked the TS-eEV production induced by eMTDΔ4, indicating that the eMTDΔ4-mediated regulation of intracellular calcium levels and calpain activity are closely associated with the rapid, mass production of TS-eEVs. The present study may lead to considerable advances in EV-based drug development and production of stem cell-derived EVs for cell therapy.

Detection of 94 PDE-5is and Their Analogs Including N-Desmethylthiosildenafil in Various Formulations of Dietary Supplements and Food Samples Using HPLC and LC-Q-TOF/MS.

Consumption of foods and dietary supplements (DS) adulterated with unprescribed or non-permitted phosphodiesterase-5 inhibitors (PDE-5i) and their analogs can cause serious risk to human health. This study aims to analyze 93 PDE-5i and their analogs present in adulterated foods and DS using an established and validated method involving high-performance liquid chromatography (HPLC). The method was validated in solid and liquid samples, resulting in a limit of detection and quantitation of 0.03-0.5 and 0.08-1.6 µg/mL, respectively. Using the validated method, a total of 404 samples were screened. It was found that 32% of 404 samples were illegally adulterated with PDE-5i and their analogs; moreover, 16.9% of the adulterated samples were found to contain more than three compounds. HPLC-quadrupole-time-of-flight (TOF)/mass spectrometry (MS) analysis was conducted on all the samples to confirm the detected compounds accurately based on fragmentation ion patterns. In addition, sildenafil and tadalafil were detected from the capsule shells of DS unusually. Subsequently, the detected compounds were identified and quantified using HPLC at concentrations ranging from 0.007 to 370.0 mg/g. NMR analysis was carried out to confirm the accurate chemical structure of a compound found during the TOF/MS analysis, which did not match with the 93 reference standards.; it was identified to be N-desmethylthiosildenafil. In this study, various PDE-5i compounds and their analogs were detected from low to high concentrations in a sample. Therefore, the study sheds light on the misuse of PDE-5i and their analogs in consumable products, which pose a severe threat to public health.

Development of a method for simultaneous screening of four natural-derived steroids and their analogues used as dietary supplements via liquid chromatography-quadrupole-time of flight mass spectrometry and liquid chromatography-tandem mass spectrometry.

Natural-derived steroids and their analogues are present in various plants and insects. To minimize the chance of missing a positive doping test and avoiding potentially serious health problems, adequate screening methods are necessary for the detection of a wide range of natural-derived steroids and their analogues in dietary supplements. In this study, an accurate and simple liquid-chromatography-tandem mass spectrometry (LC-MS/MS) method was developed and validated to determine and quantify the natural-derived steroids and their analogues according to the International Conference on Harmonization of technical Requirements for Registration of Pharmaceuticals for Human Use guidelines. The validation results indicating excellent extraction efficiency and low matrix effects show that the LC-MS/MS method is reliable for the detection of natural-derived steroids and their analogues. In addition, we established the ion fragmentation of turkesterone and ion fragmentation of four natural-derived steroids and their analogues. The validated method was applied to 60 dietary supplements purchased online and in person from international vendors in 2020. Ecdysterone and 5α-hydroxylaxogenin were detected respectively in 3 and 14 of 60 dietary supplements. Especially, a high amount of 5α-hydroxylaxogenin, an FDA-unapproved ingredient, was detected in two of dietary supplements (44.4 and 32.3 mg/g). This component should be controlled since it may cause unexpected side effects if administered excessively. Thus, this method will be helpful for the continuous control and supervision of unlicensed dietary supplements containing natural-derived steroids and their analogues.

Novel Small-Molecule Inhibitor of NLRP3 Inflammasome Reverses Cognitive Impairment in an Alzheimer's Disease Model.

Aberrant activation of the Nod-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome plays an essential role in multiple diseases, including Alzheimer's disease (AD) and psoriasis. We report a novel small-molecule inhibitor, NLRP3-inhibitory compound 7 (NIC7), and its derivative, which inhibit NLRP3-mediated activation of caspase 1 along with the secretion of interleukin (IL)-1ß, IL-18, and lactate dehydrogenase. We examined the therapeutic potential of NIC7 in a disease model of AD by analyzing its effect on cognitive impairment as well as the expression of dopamine receptors and neuronal markers. NIC7 significantly reversed the associated disease symptoms in the mice model. On the other hand, NIC7 did not reverse the disease symptoms in the imiquimod (IMQ)-induced disease model of psoriasis. This indicates that IMQ-based psoriasis is independent of NLRP3. Overall, NIC7 and its derivative have therapeutic prospects to treat AD or NLRP3-mediated diseases.

25-Hydroxycholesterol suppress IFN-γ-induced inflammation in microglia by disrupting lipid raft formation and caveolin-mediated signaling endosomes.

Acute microglial activation plays an important role in neuroprotection. However, dysregulated, prolonged microgliosis exacerbates neurodegeneration through excessive release of pro-inflammatory cytokines and cytotoxic factors. Interferon-gamma (IFN-γ), an inflammatory cytokine, exacerbates the detrimental microglial response. Although various anti-inflammatory drugs have been evaluated as interventions for microglia-mediated neuroinflammation, no anti-inflammatories are in clinical use for microgliosis. The present study evaluated the anti-inflammatory mechanisms of oxysterols, blood brain barrier (BBB) penetrable bioactive lipids, revealing that this intervention suppresses neuroinflammation by disrupting membrane lipid raft formation and caveolae-mediated endosomal IFN-γ signaling. We find that 25-hydroxycholesterol (25-HC) rapidly repressed IFN-γ receptor trafficking to lipid rafts in microglia by disrupting raft formation, thereby suppressing microglial inflammatory response. IFN-γ treatment upregulated expression of Cav-1, a major component of caveolae, and IFN-γ signaling was sustained through Cav-1+ signaling endosomes. 25-HC repressed IFN-γ induction of Cav-1 expression in microglia, and subsequently suppressed the chronic inflammatory response. Taken together, these findings demonstrated that 25-HC effectively regulate the inflammatory status of microglia by mediating the formation of rafts and caveolae-dependent signaling endosomes. Given the important roles of IFN-γ and microglia in the pathology of neurodegenerative brain diseases, a novel anti-inflammatory mechanism of 25-HC that is not receptor-dependent, but rather is related to the regulation of membrane rafts and caveolae, suggests a new therapeutic target for inflammatory neurodegenerations.

Transcultural Adaptation and Validation of the Korean Version of the Vocal Tract Discomfort Scale.

OBJECTIVES: The present study translated the Vocal Tract Discomfort Scale (VTDS) into Korean (K-VTDS) and evaluated its reliability and validity. STUDY DESIGN: This was a prospective study. METHODS: The VTDS was first translated into Korean and validated. One hundred and fifty-nine patients with voice disorders were divided into three different diagnostic groups (functional, structural, and neurologic voice disorder) and 131 vocally healthy adults were also included. All participants completed the K-VTDS and the Korean version of the Voice Handicap Index (K-VHI) and Korean versions of the Voice-Related Quality of Life (K-VRQOL). The internal consistency of the K-VTDS was analyzed through Cronbach's α coefficient. The VTDS score differences related to the diagnostic groups were assessed with t test and analysis of variance. We assessed the correlation between the K-VTDS, the K-VHI, and the K-VRQOL using Pearson's correlation analysis. RESULTS: High internal consistency and the test-retest reliability of the K-VTDS were found. The voice disorder group had significantly higher K-VTDS scores for the subscales and total scores than those in the healthy group (P < 0.001). The K-VTDS scores for the subscale of frequency and total scores were highest in the functional voice disorder group. We found a significant difference in frequency and total score of the K-VTDS between the functional voice disorder group and the structural voice disorder group (P < 0.05). We observed a strong positive correlation among the scores for the subscales of frequency and severity, and total scores in the K-VTDS. The K-VTDS showed moderate correlation with the K-VHI and the K-VRQOL. CONCLUSION: The K-VTDS is a reliable and valid instrument for voice assessment for voice disorders in Korean-speaking patients.

Corrigendum: Ear-Specific Hemispheric Asymmetry in Unilateral Deafness Revealed by Auditory Cortical Activity.

[This corrects the article DOI: 10.3389/fnins.2021.698718.].

Screening sexual performance enhancing compounds and their analogues in counterfeit and illicit erectile dysfunction drugs by high-performance liquid chromatography and liquid chromatography-tandem mass spectrometry.

The growth of the counterfeit and illicit drugs market is attributable in part to phosphodiesterase type-5 inhibitor (PDE-5is) medications for erectile dysfunction (ED). PDE-5is and their analogues are being increasingly supplied as counterfeit and illicit drugs marketed to enhance sexual performance. Herein, we screened and confirmed a total of 181 such counterfeit and illicit drugs used to date to enhance sexual performance by high-performance liquid chromatography (HPLC) and liquid chromatography-tandem mass spectrometry (LC-MS/MS). Out of 181 samples, PDE-5is and their analogues were detected in 156 samples, with 49.4% containing two or more components in a single sample. Sildenafil, tadalafil, and miscellaneous group were detected a rates of 64.1%, 34.4%, and 1.5% times and concentrations of 0.04-496 mg/g, 0.02-147 mg/g, and 0.54-16.4 mg/g, respectively with multiple compound groups also detected in single samples. Overdosing on these drugs can lead to adverse effects, the toxicities of combined administrations have not been researched, and administering multiple components in a single sample can be fatal. We recommend that counterfeit and illicit drugs for enhancing sexual performance be continuously controlled and supervised for the protection of public health, and more studies into toxicity and side effects are required.