1.Effect of Astragali Radix on Gut Microbiota and GLP-1 in Newly Diagnosed Type 2 Diabetes Patients with Qi Deficiency Type
Keke HOU ; Lin CHEN ; Zhidan ZHANG ; Yunyi YANG ; Fangli ZHANG ; Yuanying XU ; Hongping YIN ; Lan DING ; Tao LEI ; Wenjun SHA
Chinese Journal of Experimental Traditional Medical Formulae 2026;32(6):161-170
ObjectiveTo investigate the therapeutic effect of Astragali Radix-mediated changes in gut microbiota on treating type 2 diabetes (T2DM). MethodsA 12-week randomized, placebo-controlled clinical trial enrolled eighty patients with newly diagnosed type 2 diabetes and poor glycemic control in the Qi deficiency type. All patients received insulin therapy. The observation group (40 cases) was administered with Astragali Radix Granules, while the control group (40 cases) received a placebo. Both treamtents were taken orally twice daily. Changes in gut microbiota were assessed by 16s rDNA sequencing. Serum glucagon-like peptide-1 (GLP-1) levels were measured using enzyme-linked immunosorbent assay (ELISA). Glucose metabolism indicators including fasting blood glucose (FPG), 2-hour postprandial blood glucose (2 h PG),glycated albumin(GA), and glycated hemoglobin (HbA1c) were evaluated. Pancreatic function was evaluated using fasting C-peptide (FCP), 2-hour postprandial C-peptide (2 h CP), and C-peptide area under the curve (AUCcp). Traditional Chinese medicine (TCM) syndrome scores, clinical efficacy, and safety indicators were also observed. ResultsIn terms of glucose metabolism indicators, compared with the baseline, both groups exhibited significantly lower FPG, 2 h PG, GA and HbA1C (P<0.01),while FCP, 2 h CP and AUCcp were significantly higher (P<0.01). Compared with the control group after the treatment, the observation group showed significantly lower FPG, 2 h PG, GA and HbA1C(P<0.05, P<0.01),and significantly higher FCP, 2 h CP and AUCcp (P<0.05, P<0.01), indicating that Astragali Radix can improve glucose metabolism. In terms of the diversity of gut microbiota, no significant differences were detected in the Chao1, Shannon and Simpson indexes of the two groups compared with their respective baselines. However, compared with the post-treatment control group, the observation group demonstrated significant increases in the Chao1, Shannon and Simpson indexes (P<0.05, P<0.01). The β-diversity analysis showed significant separation in gut microbiota composition before and after treatment in both groups, indicating that Astragali Radix can significantly alter the structure and improve the diversity of gut microbiota. At the phylum level, compared with the baseline, both groups showed a significant increase in the relative abundance of Bacteroidota(P<0.01). The relative abundance of the potentially harmful phylum Proteobacteria was significantly lower in the observation Group after treatment (P<0.01). Compared with the post-treatment control group, the observation group had a significantly higher relative abundance of Bacteroidota(P<0.01). No significant difference was found in Firmicutes/Bacteroidota (F/B) ratio between the two groups after treatment, and other phyla showed no significant differences. At the genus level, compared with the baseline, the observation group exhibited a significant increase in Bacteroides (P<0.01) and a significant decrease in Escherichia-Shigella (P<0.01), whereas no significant difference was seen in the control group . Compared with the control group after treatment, the observation group after treatment had a significantly higher relative abundance of Bacteroides (P<0.01). No significant differences were seen in other genera. Linear discriminant analysis (LDA) identified potential characteristics taxa: in the observation group, Bacteroidota at the phylum level and Bacteroides and Dubosiella at the genus level, in the control group, Proteobacteria at the phylum level as well as Barnesiella and Staphylococcus at the genus level. Correlation analysis based on a heatmap revealed that GLP-1 levels were positively correlated with Firmicutes, F/B ratio and Fusobacterium, and negatively correlated with Bacteroidota, Proteobacteria, Bacteroides and Escherichia-Shigella. In terms of clinical efficacy, compared with the control group, the total effective rate of the observation group was significantly higher (P<0.05). Compared with the baseline, the scores for shortness of breath, fatigue, weakness, spontaneous sweating and reluctance to speak significantly decreased in both groups (P<0.01). Compared with the control group after treatment, the score for weakness was significantly lower in the observation group (P<0.01),indicating that Astragali Radix could improve clinical symptoms and alleviate weakness symptoms. In terms of safety, compared with the baseline, alanine aminotransferase (ALT) levels significantly decreased in both groups (P<0.05,P<0.01),indicating that Astragali Radix did not induce any significant abnormalities in liver and kidney functions. ConclusionAstragali Radix demonstrates the potential to significantly improve the gut microbiota environment in patients of newly diagnosed type 2 diabetes with Qi deficiency. The therapeutic effect may contribute to glycemic control, possibly mediated by an elevation in GLP-1 level. These findings may support its further clinical investigations and potential applications.
2.The construction and evaluation of heart preservation model for empty beating donor heart based on extracorporeal membrane oxygenation technology
Shijie YIN ; Xiao YUE ; Chunhua WANG ; Wei WU ; Guanbin QIN ; Lan LUO ; Qiangxin HUANG ; Guixin HE
Chinese Journal of Clinical Thoracic and Cardiovascular Surgery 2026;33(05):791-798
Objective To explore the construction of heart preservation model of empty beating donor based on extracorporeal membrane oxygenation (ECMO). Methods From January 2022 to August 2023, 20 Guangxi Bama miniature pigs weighing 25-30 kg were selected, half male and half female. Under general anesthesia and heparinization, a midline thoracotomy was performed. The pericardium was cut after freeing the anterior and posterior vena cavae, and a perfusion needle was inserted near the brachiocephalic artery in the ascending aorta, connected to a blood collection bag to collect 500-600 mL of blood. The anterior and posterior vena cavae were ligated, the aorta was blocked and perfused with HTK solution to stop the heart beating. The superior and inferior vena cavae were cut off, the right pulmonary vein was decompressed, the aorta and left and right pulmonary arteries and veins were cut off, and the whole heart was removed. An ECMO device was used to continuously perfuse a cardioprotective solution mainly composed of oxygenated warm blood, maintaining the isolated pig heart beating for 8 hours, monitoring (once/hour) ECMO perfusion parameters, blood gas indicators, perfusate electrolytes, inflammatory factors, myocardial enzymes, myoglobin, and troponin levels. Myocardial tissue was taken for hematoxylin-eosin (HE) staining to observe myocardial cell damage and evaluate the quality of heart preservation. Results Among the 20 isolated beating pig hearts, 17 successfully resumed beating, 3 experienced ventricular fibrillation, resuscitated after intracardiac electrical defibrillation, and all 20 pig hearts successfully beat for 8 hours. There was no statistical difference in ECMO perfusion parameters, blood gas indicators, perfusate electrolytes, and inflammatory factors at each time point (P>0.05). There were statistical increases in myocardial enzymes, myoglobin, and troponin levels (P<0.05). HE staining results suggested that there was no severe myocardial damage. Conclusion ECMO technology can be used for pig heart preservation with good results, and this study provides experimental evidence for improving heart preservation research in clinical heart transplantation.
3.The Impact of Pcdh15 Deficiency on Cellular Energy Metabolism and Oxidative Stress, and Its Role and Mechanism in Hearing Loss
Ying LAN ; Yang WU ; Shijie ZHAO ; Jun TANG ; Xingming LIANG ; Tao HOU ; Lu PENG ; Yongpeng LI ; Xinxing ZHAO ; Shihua YIN
Clinical and Experimental Otorhinolaryngology 2026;19(2):129-144
Objectives:
. This study aimed to explore the role of the Pcdh15 gene in hearing maintenance and to examine the effects of its deficiency on cochlear structure, cochlear function, and hearing loss in mice.
Methods:
. CRISPR/Cas9 technology was used to generate Pcdh15 knockout (KO) mice. Auditory function was evaluated using hearing tests, while histological approaches were employed to assess morphological changes in cochlear hair cells and spiral ganglion neurons (SGNs). RNA sequencing (RNA-seq) was performed on cochlear tissue from postnatal day 18 (P18) wild-type (WT) and Pcdh15 KO mice to identify differentially expressed genes (DEGs). These DEGs were subjected to functional annotation and pathway analysis, with particular emphasis on oxidative phosphorylation (OXPHOS). Reactive oxygen species (ROS) levels were quantified using flow cytometry and DCFH-DA assays.
Results:
. Pcdh15 KO mice exhibited progressive sensorineural hearing loss, which worsened to profound deafness by P18. Notably, cochlear hair cells and SGNs showed substantial loss and pronounced morphological abnormalities, particularly within the basal high-frequency region. RNA-seq analysis identified 1,359 DEGs, including 1,024 downregulated and 335 upregulated genes. Pathway analysis indicated that Pcdh15 deficiency was associated with inhibition of the OXPHOS pathway, potentially disrupting mitochondrial respiratory chain complexes I, III, IV, and V and thereby impairing energy production and ATP metabolism. In addition, early-stage cochleae from KO mice demonstrated elevated ROS levels and increased oxidative stress, suggesting that redox imbalance may contribute to hearing damage.
Conclusion
. Pcdh15 plays a critical role in hearing maintenance. Its deficiency is associated with severe hearing loss and marked cochlear abnormalities, which are linked to inhibition of OXPHOS, disruption of energy metabolism, and exacerbation of oxidative stress. Together, these findings provide new insights into the mechanisms underlying hearing loss and suggest potential targets for therapeutic intervention.
4.Comparison of Patient Satisfaction Between Gynecological Teaching Outpatient Clinics and General Clinics and Analysis of Influencing Factors
Xiaochen SONG ; Huiying HU ; Qian ZHOU ; Jie YIN ; Shuo LIANG ; Xiaochuan LI ; Rong CHEN ; Lan ZHU
Medical Journal of Peking Union Medical College Hospital 2026;17(5):1390-1396
To evaluate patient satisfaction levels in a gynecological teaching clinic and to explore its associated influencing factors, so as to provide evidence for optimizing the operational model of teaching clinics. This was a single-center retrospective cross-sectional survey. Patients who attended the gynecological teaching clinic(teaching clinic group) and the general outpatient clinic(general clinic group) at Peking Union Medical College Hospital from May 2023 to July 2025 were enrolled. Satisfaction wasassessed using the Chinese version of the Patient Satisfaction Questionnaire-18, with the 5-level ordinal overall satisfaction as the primary outcome. Ordinal logistic regression was employed to identify independent influencing factors of satisfaction. A total of 1146 patients(578 in the teaching clinic group and 568 in the general clinic group) were enrolled, among whom 985 completed the questionnaire follow-up(496 in the teaching clinic group and 489 in the general clinic group), yielding a response rate of 85.95%. The 5-level ordinal overall satisfaction was higher in the teaching clinic group than in the general clinic group( Patient satisfaction in the gynecological teaching clinic is relatively high, with notable strength in doctor-patient communication; however, there remains room for improvement in technical service quality and humanistic care. Adequate consultation duration and the teaching clinic model are associated with higher patient satisfaction.
5.Study of Reference Materials for Quantitative Analysis of Gene Copy Numbers of Lentiviral Vectors
Yin-Bo HUO ; Jia-Qi YANG ; Qing TAO ; Wen LIANG ; Li XU ; Lan-Ying LI ; Xiao-Lei ZUO ; Juan YAN ; Min DING ; Ai-Wen MA ; Gang LIU
Chinese Journal of Analytical Chemistry 2025;53(9):1555-1565
Lentiviral vectors(LVs)are key gene delivery tools for integrating target genes into the host genome,but they may also pose risks of insertional mutagenesis.The vector copy number(VCN)in cells is critical for determining the safety of gene modification.However,the reliability and accuracy of its quantification process are influenced by multiple factors.Developing cell reference materials with specific vector copy numbers represents a viable approach to enhance the reliability and consistency of measurement results,enabling quality control of the quantification process and traceability of outcomes.However,the preparation of such reference materials faces challenges in cell sample design,preparation protocols,and advanced quantification techniques.In this study,T lymphocyte cell line Jurkat-based reference materials with LV gene copy numbers of 1 and 2 copy/cell were developed.A high-precision duplex digital polymerase chain reaction(dPCR)method was established to quantify the LV gene and endogenous genes simultaneously.Additionally,the results of dPCR were cross-validated through next-generation sequencing and flow cytometric analysis.Ultimately,confocal microscopy characterization results showed that the developed cell reference materials had intact morphology.The quantification result of VCN-1 was(1.07±0.11)copy/cell,and that of VCN-2 was(2.09±0.21)copy/cell.These cell reference materials demonstrated compliance with stability and homogeneity requirements,and could be applied for quality control throughout the VCN measurement workflow and metrological traceability,improving the accuracy,comparability,and validity of copy number measurements.
6.Construction and research of type Ⅱ endoleak model after endovascular aneurysm repair of abdominal aortic aneurysm
Shaohong YIN ; Boru HUANG ; Ying LAN ; Zhanfeng GAO
International Journal of Surgery 2025;52(7):474-479
Objective:To establish a novel in vivo and in vitro model of type 2 endoleaks (T2EL) after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA).Methods:In vitro model: Using 3Dmax (2022) software, models of AAA and T2EL were created. These models were fabricated using 3D printing technology, with quartz as the material. Fresh pig blood was injected into the models, and a circulation system was established using a peristaltic pump. The direction of blood flow was observed to confirm the establishment of the in vitro T2EL model. In vivo model: Six Bama miniature pigs were selected, each 10 months old and weighing 40-50 kg. After determining whether unilateral iliac artery occlusion could be permanent through experiments, an AAA animal model from the end of the abdominal aorta to the left common iliac artery was created using the patch formation method. EVAR was performed through the right femoral artery, completely occluding the left iliac artery. The T2EL model was established by using the retrograde blood flow from the left iliac artery. The formation of AAA and T2EL models in vivo was confirmed by color Doppler ultrasound, digital subtraction angiography (DSA), and other methods. The measurement data with normal distribution were expressed as mean±standard deviation( ± s), and comparisons between groups were performed using the independent-samples t-test. The comparison between groups of count data was conducted using the chi-square test. Results:The successful establishment of the T2EL model was confirmed by observing the blood flow in the circulating drip flask. The weight of the Bama miniature pigs in the in vivo model was (41.33±2.21) kg, the diameter of the abdominal aorta was (7.45±0.15) mm, and the maximum diameter of the aneurysm was (16.67±0.61) mm. Through experiments, it was determined that the left iliac artery and umbilical artery of the experimental pigs could be isolated. Therefore, after the aneurysm from the end of the abdominal aorta to the left common iliac artery was established, a covered stent was implanted from the abdominal aorta to the right common iliac artery for EVAR treatment. The successful establishment of the AAA model and the T2EL model with the left iliac artery as the main "culprit vessel" was confirmed by color Doppler ultrasound and DSA.Conclusion:The in vitro models established through 3D printing technology and the T2EL animal model with the left iliac artery as the main "culprit vessel" have a high success rate and can serve as a model basis for the mechanism and treatment research of T2EL after EVAR for AAA.
7.Experimental Evaluation of the Clinical Laboratory ELISA Assay Using A Randomization Quality Control Method for Indoor Quality Control
Zhijun GAO ; Jianjun LI ; Yin CAI ; Yana REN ; Mengchen XIE ; Lan ZHENG ; Guoping ZHOU
Journal of Modern Laboratory Medicine 2025;40(3):199-202
Objective To evaluate the application of ELISA randomized quality control,and continuously improve the laboratory testing capacity and quality assurance,in order to gradually improve the application of randomized quality control to the daily testing of ELISA.Methods Collected the quality control data of KEHUA HBsAg,compared the difference between randomized quality control data and immobilized quality control data.Group comparison of randomization quality control between rows and columns.The randomized quality control data were analyzed retrospectively and the quality control chart was established by using the randomized quality control data.Analyzed and compared the lost-control situation of randomized quality control and immobilized quality control.Results Randomized quality control S/CO value(2.831±0.343)and immobilized quality control S/CO value(2.651±0.260)in the same microplate,the difference between two was statistically significant(t=5.970,P<0.05).The differences between randomized quality control and immobilized quality control in columns 2 to 8 were statistically significant(t=2.285~5.536,all P<0.05).There were no statistically significant differences between randomized quality control and immobilized quality control in column 9 to 12(t=0.031~1.605,all P>0.05).There was no statistically significant difference in randomization quality control among all lines(F=0.858,P>0.05).The randomized quality control data was used to establish a quality control chart.Within the time range of the collected data,the randomized quality control was out of control for 6 times,all were greater than+3s,and the loss of control rate was 4.72%(6/127).Fixed position quality control lost control 9 times during the same period,all of which were greater than+3s,with a loss of control rate of 0.61%(9/1 481).Conclusion The randomized quality control has a greater possibility to reflect the factors affecting all the samples on the microporous plate.Random quality control can be used to find possible systematic errors in testing.Randomized quality control can gradually be fully applied to daily indoor quality control,but the loss of control rate and coefficient of variation may increase.
8.Expert Consensus on the Ethical Requirements for Generative AI-Assisted Academic Writing
You-Quan BU ; Yong-Fu CAO ; Zeng-Yi CHANG ; Hong-Yu CHEN ; Xiao-Wei CHEN ; Yuan-Yuan CHEN ; Zhu-Cheng CHEN ; Rui DENG ; Jie DING ; Zhong-Kai FAN ; Guo-Quan GAO ; Xu GAO ; Lan HU ; Xiao-Qing HU ; Hong-Ti JIA ; Ying KONG ; En-Min LI ; Ling LI ; Yu-Hua LI ; Jun-Rong LIU ; Zhi-Qiang LIU ; Ya-Ping LUO ; Xue-Mei LV ; Yan-Xi PEI ; Xiao-Zhong PENG ; Qi-Qun TANG ; You WAN ; Yong WANG ; Ming-Xu WANG ; Xian WANG ; Guang-Kuan XIE ; Jun XIE ; Xiao-Hua YAN ; Mei YIN ; Zhong-Shan YU ; Chun-Yan ZHOU ; Rui-Fang ZHU
Chinese Journal of Biochemistry and Molecular Biology 2025;41(6):826-832
With the rapid development of generative artificial intelligence(GAI)technologies,their widespread application in academic research and writing is continuously expanding the boundaries of sci-entific inquiry.However,this trend has also raised a series of ethical and regulatory challenges,inclu-ding issues related to authorship,content authenticity,citation accuracy,and accountability.In light of the growing involvement of AI in generating academic content,establishing an open,controllable,and trustworthy ethical governance framework has become a key task for safeguarding research integrity and maintaining trust within the academic community.This expert consensus outlines ethical requirements across key stages of AI-assisted academic writing-including topic selection,data management,citation practices,and authorship attribution.It aims to clarify the boundaries and ethical obligations surrounding AI use in academic writing,ensuring that technological tools enhance efficiency without compromising in-tegrity.The goal is to provide guidance and institutional support for building a responsible and sustainable research ecosystem.
9.Characteristics of traditional Chinese medicine syndromes in patients with Chikungunya hemorrhagic fever:a cross-sectional study
Shiying LU ; Danwen ZHENG ; Xintian HONG ; Yuping LIU ; Guangzong LI ; Zhifeng HONG ; Jinghua YANG ; Yan ZHANG ; Banghan DING ; Yuntao LIU ; Yuanyuan WANG ; Xin YIN ; Jingwei SHUI ; Xiaofei FAN ; Hai LAN ; Zhongde ZHANG
Journal of Beijing University of Traditional Chinese Medicine 2025;48(11):1531-1539
Objective To explore the traditional Chinese medicine(TCM)syndrome characteristics of patients with Chikungunya hemorrhagic fever and to provide empirical data to support the application of TCM in diagnosing and treating Chikungunya hemorrhagic fever.Methods A cross-sectional survey was conducted to collect clinical data(sex,age,days since onset,and comorbidity underlying disease conditions)and TCM with four-examination information(symptoms,tongue manifestations,and pulse manifestations)from 255 patients with Chikungunya hemorrhagic fever who visited Lecong Hospital of Shunde,Foshan,the Third People's Hospital of Shunde District of Foshan,Shunde Hospital of Southern Medical University Affiliated Chencun Hospital between July 23 and July 29,2025.Factor and cluster analyses were used to summarize TCM syndrome characteristics and analyze core pathogenesis in conjunction with clinical features.Results Among the 255 patients with Chikungunya hemorrhagic fever,131 were male and 124 were female,with a age of(49.05±17.93)years and a disease duration of(3.26±1.78)days.Among the four types of examination information in TCM,35 items exhibited a frequency exceeding 10%.The most prevalent symptoms were arthralgia(180 patients,70.59%),exanthem(153 patients,60.00%),fatigue(99 patients,38.82%),anhidrosis(98 patients,38.43%),pruritus(96 patients,37.65%),and fever(92 patients,36.08%).Tongue and pulse manifestations were primarily white fur(155 patients,60.78%),pink tongue(111 patients,43.53%),slippery pulse(143 patients,56.08%),and greasy fur(134 patients,52.53%).Patients with disease onset≤3 d had a higher incidence of arthralgia,fatigue,fever,aversion to cold,generalized muscle pain,aversion to wind,insomnia,headache,sweating,low-grade fever,poor appetite,loose stool,hyperhidrosis,and red tongue than those with disease onset≥4 d(P<0.05).Patients with disease onset≥4 d had a higher incidence of pink tongue and thick fur than those with disease onset≤3 d(P<0.05).The syndrome elements in patients with Chikungunya hemorrhagic fever predominantly manifested on the defensive exterior,with involvement of the sinew-bone joints,skin-muscle,and spleen.Pathogenic factors were primarily characterized by external winds,dampness,and heat.Factor and cluster analysis result indicated three TCM pathogenesis progression patterns:imbalance of the defensive exterior with wind-dampness conflict and heat transformation;dampness-heat flowing into muscles and meridians causing joint obstruction and qi blood stasis;and dampness-heat congelation resulting in qi mechanism obstruction,consumption of body fluids,and infiltration of the skin.Conclusion Patients with Chikungunya hemorrhagic fever primarily present with fever,joint pain,and rashes.In TCM,this condition falls under the category of"dampness-warmth"syndrome.Its etiology is attributed to pathogens,with transmission occurring through mosquito bites.The core pathogenesis of TCM is the invasion of the defensive exterior and dampness-toxic heat accumulation.The therapeutic principles focus on clearing heat pathogens,resolving dampness pathogens,dispersing wind pathogens,and promoting the resolution of rashes.
10.Predictive value of miR-1,BNP and IMA for unstable angina pectoris
Yan MENG ; Xue-feng WANG ; Yin LIU ; Yan-bao SHEN ; Gui-lan KANG
Chinese Journal of cardiovascular Rehabilitation Medicine 2025;34(2):189-193
Objective:To investigate the predictive value of microRNA-1(miR-1),brain natriuretic peptide(BNP)and ischemia-modified albumin(IMA)for unstable angina pectoris(UAP).Methods:We enrolled 237 UAP patients admitted to Xining Second People's Hospital between June 2018 and December 2020 as UAP group.Another 86 healthy subjects undergoing physical examination simultaneously were enrolled as control group.MiR-1 expression,BNP and IMA levels were measured.General data between UAP group and control group,serum miR-1 expression,BNP and IMA levels among different Braunwald class and prognosis were compared.Receiver operat-ing characteristic(ROC)curve was employed to analyze predictive value of miR-1,BNP,IMA and their combina-tion for prognosis in UAP patients.Results:Compared with participants in the control group,those in UAP group had significant higher serum miR-1 expression[(1.80±0.59)vs.(0.93±0.11)],BNP[(107.34±37.46)pg/ml vs.(52.31±10.64)pg/ml]and IMA[(79.76±19.29)g/L vs.(53.16±6.43)g/L](P<0.001 all).As Braun-wald class increased(class Ⅰ~Ⅲ),serum miR-1 expression,BNP and IMA levels elevated(P<0.001 all).Com-pared with patients in favorable outcome group,those in unfavorable outcome group had significant higher serum miR-1 expression[(2.31±0.54)vs.(1.53±0.41)],BNP[(147.03±29.63)pg/ml vs.(85.95±19.46)pg/ml]and IMA[(97.24±15.35)g/L vs.(70.35±13.88)g/L](P<0.001 all).ROC curve indicated that AUC of com-bined detection for predicting unfavorable outcome in UAP patients was 0.925(95%CI 0.884~0.955),which was significantly higher than miR-1(AUC=0.880,95%CI 0.831~0.918),BNP(AUC=0.863,95%CI 0.813~0.904)and IMA(AUC=0.900,95%CI 0.854~0.935)alone(Z=2.884,3.130,2.090,P<0.05 or<0.01).Conclusion:MiR-1 expression,BNP and IMA levels significantly increase in UAP patients,and they are associated with the severity of disease.Combined detection has good predictive value for unfavorable outcome in UAP pa-tients.

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