ObjectiveTo observe the clinical efficacy and safety of Zhinao capsules in the treatment of mild and moderate sleep disorders in Alzheimer's disease patients with the syndrome of spleen-kidney deficiency and combined phlegm and stasis. MethodsA randomized， double-blind， placebo， controlled clinical trial design was adopted， and 60 Alzheimer's disease patients aged 50-85 years with mild and moderate sleep disorders due to spleen-kidney deficiency and combined phlegm and stasis were included. According to the randomized numble table method， the patients were assigned into a treatment group and a control group （30 in each group， with 29 patients in the treatment group and 28 patients in the control group finally completing the trial）. The treatment group was treated with donepezil hydrochloride tablets combined with Zhinao capsules， and the control group was treated with donepezil hydrochloride tablets combined with the simulant of Zhinao capsules for 12 weeks. The Pittsburgh sleep quality index （PSQI）， smart bracelet sleep monitoring， epworth sleeping scale （ESS）， Mini-Mental State Examination （MMSE）， Activities of Daily Living （ADL）， and traditional Chinese medicine symptoms were scored. Furthermore， the brain-derived neurotrophic factor （BDNF） and gamma-aminobutyric acid （GABA） levels were measured. ResultsAfter 12 weeks of treatment， the total response rate of clinical efficacy assessment in the treatment group reached 89.7%， which was significantly higher than that （21.4%） in the control group （Z=-5.14， P<0.01）. After treatment， the TCM symptom scores declined in both groups （P<0.01）， and the scores in the treatment group were lower than those in the control group （P<0.01）. After treatment， the treatment group showed decreased total score and seven component scores of the PSQI scale （P<0.05， P<0.01）， and the scores in the treatment group were lower than those in the control group （P<0.05， P<0.01）. After treatment， the treatment group showed increases in the duration of deep sleep， light sleep， rapid eye movement sleep， and total sleep at night and decreases in the time to fall asleep， the number of awakenings from sleep at night， and the time for sporadic daytime naps （P<0.01）. The control group did not show significant changes in the duration of light sleep， time to fall asleep， and number of awakenings from sleep at night. Moreover， the treatment group outperformed the control group in terms of the indicators above （P<0.05， P<0.01）. After treatment， the treatment group showed decreased scores of ESS， ADL and its subscales physical self-maintenance scale （PSMS）， and Instrumental Activities of daily living scale （IADLs） and increased score of MMSE and levels of BDNF and GABA （P<0.05， P<0.01）. There was no significant difference in PSMS between the two groups， and the treatment group was significantly better than the control group in terms of the rest of the above indicators （P<0.05， P<0.01）. Patients in neither groups complained of uncomfortable symptoms. ConclusionZhinao capsules have significant clinical efficacy in treating patients with mild and moderate sleep disorders in Alzheimer's disease patients with the syndrome of spleen-kidney deficiency and combined phlegm and stasis. Zhinao capsules can significantly reduce PSQI， ESS， and ADL scores， increase the MMSE score and the expression of BDNF and GABA， effectively optimize the structure of sleep， improve the intelligence， and enhance the ability of daily life， without causing uncomfortable symptoms. The mechanism may be related to the increase in the expression of sleep/wake-related neurotransmitters.

ObjectiveTo observe the clinical efficacy and safety of Zhinao capsules in the treatment of mild and moderate sleep disorders in Alzheimer's disease patients with the syndrome of spleen-kidney deficiency and combined phlegm and stasis. MethodsA randomized， double-blind， placebo， controlled clinical trial design was adopted， and 60 Alzheimer's disease patients aged 50-85 years with mild and moderate sleep disorders due to spleen-kidney deficiency and combined phlegm and stasis were included. According to the randomized numble table method， the patients were assigned into a treatment group and a control group （30 in each group， with 29 patients in the treatment group and 28 patients in the control group finally completing the trial）. The treatment group was treated with donepezil hydrochloride tablets combined with Zhinao capsules， and the control group was treated with donepezil hydrochloride tablets combined with the simulant of Zhinao capsules for 12 weeks. The Pittsburgh sleep quality index （PSQI）， smart bracelet sleep monitoring， epworth sleeping scale （ESS）， Mini-Mental State Examination （MMSE）， Activities of Daily Living （ADL）， and traditional Chinese medicine symptoms were scored. Furthermore， the brain-derived neurotrophic factor （BDNF） and gamma-aminobutyric acid （GABA） levels were measured. ResultsAfter 12 weeks of treatment， the total response rate of clinical efficacy assessment in the treatment group reached 89.7%， which was significantly higher than that （21.4%） in the control group （Z=-5.14， P<0.01）. After treatment， the TCM symptom scores declined in both groups （P<0.01）， and the scores in the treatment group were lower than those in the control group （P<0.01）. After treatment， the treatment group showed decreased total score and seven component scores of the PSQI scale （P<0.05， P<0.01）， and the scores in the treatment group were lower than those in the control group （P<0.05， P<0.01）. After treatment， the treatment group showed increases in the duration of deep sleep， light sleep， rapid eye movement sleep， and total sleep at night and decreases in the time to fall asleep， the number of awakenings from sleep at night， and the time for sporadic daytime naps （P<0.01）. The control group did not show significant changes in the duration of light sleep， time to fall asleep， and number of awakenings from sleep at night. Moreover， the treatment group outperformed the control group in terms of the indicators above （P<0.05， P<0.01）. After treatment， the treatment group showed decreased scores of ESS， ADL and its subscales physical self-maintenance scale （PSMS）， and Instrumental Activities of daily living scale （IADLs） and increased score of MMSE and levels of BDNF and GABA （P<0.05， P<0.01）. There was no significant difference in PSMS between the two groups， and the treatment group was significantly better than the control group in terms of the rest of the above indicators （P<0.05， P<0.01）. Patients in neither groups complained of uncomfortable symptoms. ConclusionZhinao capsules have significant clinical efficacy in treating patients with mild and moderate sleep disorders in Alzheimer's disease patients with the syndrome of spleen-kidney deficiency and combined phlegm and stasis. Zhinao capsules can significantly reduce PSQI， ESS， and ADL scores， increase the MMSE score and the expression of BDNF and GABA， effectively optimize the structure of sleep， improve the intelligence， and enhance the ability of daily life， without causing uncomfortable symptoms. The mechanism may be related to the increase in the expression of sleep/wake-related neurotransmitters.

Objective:To envaluate the effect of public cardiopulmonary resuscitation (CPR) training in Ningnan Mountain area.Methods:Using the method of convenient sampling, 775 people in Ningnan Mountain area were investigated about CPR and first aid knowledge by questionnaire from January to December 2019. The awareness rate of CPR, operation score, and operation qualification rate of the public before and after CPR training in the primary trauma treatment (PTC) mode were observed.Results:After PTC training, the public's CPR knowledge score, operation score and operation qualification rate, in terms of first aid telephone, consciousness judgment method, identification of respiratory arrest, artificial respiration implementation method, effective CPR indication and extrathoracic cardiac compression position were significantly improved [first aid telephone score: 82.68±8.54 vs. 60.25±10.38, consciousness judgment method score: 79.46±10.82 vs. 58.35±9.26, identification of respiratory arrest score: 80.85±9.64 vs. 59.26±11.45, artificial respiration implementation method score: 81.54±9.48 vs. 56.47±10.54, extrathoracic cardiac compression site score: 80.35±10.48 vs. 59.56±9.85, effective indication of CPR score: 81.02±9.45 vs. 58.21±8.69, operation assessment score: 60.25±10.45 vs. 50.38±9.68, operation assessment qualified rate: 60.39% (468/775) vs. 12.13% (94/775), all P < 0.05]. Conclusion:PTC mode is helpful to improve the effect of public CPR training, which is worthy of clinical promotion.

Objective:To evaluate the short-term efficacy of modified laparoscopic extralevator abdominoperineal excision (L-ELAPE) for ultralow rectal cancer.Methods:The retrospective cohort study was conducted.The clinicopathological data of 60 patients with ultralow rectal cancer who underwent L-ELAPE in the Tangdu Hospital Affiliated to the Air Force Medical University from January 2014 to July 2018 were collected. There were 32 males and 28 females, aged (58±12)years, with a range from 38 to 75 years. Of the 60 patients, 30 patients undergoing modified L-ELAPE were allocated into modified group and 30 patients undergoing traditional L-ELAPE were allocated into control group. For patients in the modified group, the abdominal procedure is the same as the traditional L-ELAPE. The improvements were as follows: (1) when tumor was located in the anterior rectal wall, the patient was plased into the jackknife position before starting the perineal procedure. (2) In order to prevent the small intestine from falling into the presacral space after surgery, the pelvic floor peritoneum was closed under laparoscopy and the biological patch was placed if necessary. For patients in the control group, the whole procedure was performed in the lithotomy position and the biological patch was sutured at the levator ani muscle. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Follow-up was conducted by outpatient examinations and pelvic computed tomography (CT) examination at 3 months after surgery to assess the small intestine falling into the presacral space up to January 2019. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the t test. Count data were described as absolute numbers, and comparison between groups was analyzed using the chi-square test or Fisher′s exact probability. Results:(1) Surgical situations: patients in the two groups completed surgeries successfully, without tranversion to laparostomy or death within 1 month after operation. The operation time, volume of intraoperative blood loss, the number of lymph node harvested, quality score of the whole group specimens, quality score of anterior wall tumor specimens were (359±105)minutes, (192±99)mL, 17±6, 4.1±0.8, 4.7±0.5 for the modified group, respectively, versus (268±37)minutes, (136±61)mL, 15±5, 3.5±0.7, 3.9±0.7 for the control group, respectively. There were significant differences in the operation time, the quality score of the whole group specimens and the quality score of anterior wall tumor specimens between the two groups ( t=2.613, 2.130, 2.871, P<0.05). There was no significant difference in the volume of intraoperative blood loss or the number of lymph node harvested between the two groups ( t=1.521, 0.864, P>0.05). (2) Postoperative situations: the time to first liquid food intake, time to urinary catheter removal, the level of C-reactive protein at the first postoperative day, duration of postoperative hospital stay and cases with perineal complications were (3.3±1.1)days, (8.7±4.8)days, (85±27)mg/L, (8.5±4.5)days and 4 for the modified group, respectively, versus (2.7±1.4)days, (7.7±2.8)days, (79±25)mg/L, (7.7±2.2)days and 5 for the control group. There was no significant difference in the time to first liquid food intake, time to urinary catheter removal, the level of C-reactive protein at the first postoperative day, duration of postoperative hospital stay between the two groups ( t=1.311, 1.520, 0.521, 0.509, P>0.05). There was no significant difference in the perineal complications between the two groups ( P>0.05). All patients with perineal complications were cured after drainage, wound management, nutritional support and extention of hospital stay. (3) Follow-up: all patients were followed up after surgery. The modified group and the control group had 2 cases and 19 cases of small intestine falling into the presacral space showed by the pelvic CT examination at the postoperative 3 months, respectively, showing a significant difference between the two groups ( χ2=21.172, P<0.05). Conclusions:Modified L-ELAPE is safe and feasible for the ultralow rectal cancer, which can provide a better exposure and specimen quality for the tumor located at anterior rectal wall and reduce the incidence of small intestine falling into the presacral space. However, it has longer operation time.

OBJECTIVETo investigate the application value of the Overlap method in digestive tract reconstruction of totally laparoscopic left colectomy(TLLC) and its potential advantage.

METHODSThe retrospective cohort study was adopted. Clinicopathological data of 16 patients with left colon cancer who underwent TLLC and Overlap anastomosis between August 2016 and August 2017 at Tangdu Hospital were retrospectively collected as Overlap group. Twenty-one patients who underwent laparoscopic assisted left colectomy (LALC) between January 2015 and July 2016 at Tangdu Hospital were used as control (traditional group). The intraoperative and postoperative data were compared between the two groups. During digestive tract reconstruction in the Overlap group, the proximal colon and distal colon were lined up side by side; a side-to-side anastomosis was conducted on colic band with a 60 mm linear stapler; and the common entry hole was closed using running suture. While in traditional group, the bowel was pulled out of abdominal wall through the assisted incision; the sample was resected and a proximal and distal end-to-end anastomosis was performed.

RESULTSIn Overlap group, 10 cases were male and 6 cases were female, with a mean age of (66.4±4.8) years and a BMI of (23.6±2.3) kg/m; the tumor located in distal transverse colon in 1 case, in splenic flexure in 2 cases, in descending colon in 4 cases, in upper sigmoid colon in 9 cases. TLLC was successfully completed in all the cases without conversion to laparotomy. In traditional group, 12 cases were male and 9 cases were female, with mean age of (65.9±5.8) years and BMI of (22.7±2.8) kg/m; the tumor located in the distal transverse colon in 1 case, in the splenic flexure in 3 cases, in the descending colon in 6 cases, in the upper sigmoid colon in 11 cases. No statistically significant differences in baseline data were found between the two groups (all P>0.05). Compared to the traditional group, the total operation time was shorter [(143.4±11.1) minutes vs. (166.4±16.5) minutes, t=4.792, P=0.000], the anastomosis time was prolonged [(44.3±3.3) minutes vs. (22.4±3.0) minutes, t=-20.948, P=0.000], the amount of bleeding was reduced [(46.6±13.6) ml vs. (70.5±20.0) ml, t=4.106, P=0.000], and the incision length was shorter [(3.9±0.9) cm vs. (6.7±1.3) cm, t=7.056, P=0.000] in the Overlap group. There were no significant differences in lymph nodes harvested (17.3±2.9 vs. 15.5±3.0), time to flatus [(2.8±1.3) days vs. (2.6±1.0)days], postoperative complications [6.2%(1/16) vs. 9.5%(2/21)] and postoperative hospitalization [(4.6±1.4) days vs.(4.7±1.2) days] between the two groups (all P>0.05).

CONCLUSIONThe Overlap reconstruction method in totally laparoscopic left colectomy is a safe and feasible procedure, and provides less injury and better cosmetic outcome of abdominal wall.

Aged ; Colectomy ; Colonic Neoplasms ; surgery ; Female ; Humans ; Laparoscopy ; Laparotomy ; Male ; Middle Aged ; Reconstructive Surgical Procedures ; Retrospective Studies ; Treatment Outcome

OBJECTIVETo investigate the application value of the clearance of No.253 lymph nodes with priority to fascial space and preserving left colic artery (LCA) in patients undergoing laparoscopic radical proctectomy.

METHODSFrom August 2015 to August 2016, 97 consecutive middle-low rectal cancer patients underwent laparoscopic radical proctectomy using the clearance of No.253 lymph nodes with priority to fascial space and preserving LCA at Department of General Surgery, Tangdu Hospital. Among 97 patients, 45 were females , 52 were males, mean age was (64.3±5.5) years and mean BMI was (22.4±1.8) kg/m. Brief steps of this clearance: traditional medial approach was the commencement of the dissection at the membrane bridge line in front of iliac vascular bifurcation, then entering into the Toldt's space; superior rectal artery served as the top of the tent and the Toldt's space was extended as far as possible; blunt separation was developed caudally (reaching 2 cm below the sacral promontory), cephalad (reaching the lower part of the pancreas), left laterally (reaching Toldt's line), dextrally (reaching abdominal aorta); after giving priority to fascias space, from the root of inferior mesenteric artery, LCA was exposed and No.253 lymph nodes were dissected. This regimen was suitable for the rectal adenocarcinoma patients without distant metastasis.

RESULTSThere was no tension in the intestine and mesenteria after anastomosis in all the 97 patients. One patient received LCA ligation during the clearance, because of thinner LCA resulting in bleeding. The other 96 cases completed the clearance and operation successfully. The mean No.253 lymphadenectomy time was 11-27(17.1±5.3) minutes. The mean number of harvested No.253 lymph node was 0-6(4±2). The No.253 lymph nodes of 6 patients were positive. No.253 regional mesentery was complete in 95 patients. The total harvested number of lymph node was 11-26(17.3±5.3). Six patients with positive lymph nodes aged from 68 to 72 years old and all of them underwent TME operation 6-8 weeks after neoadjuvant chemoradiotherapy. The mean operative time was 89-189(125±35) minutes. The mean estimated blood loss was 10.5-38.6(22.4±10.5) ml. The first exhaust time was 3.0-6.0(5.6±2.1) days. The mean time to extracting the drainage tube was 3.0-5.0(4.5±2.5) days. Anastomotic fistula appeared in 1 case and hemorrhage appeared in 1 case, and these 2 cases were cured by conservative treatment. No perioperative death occurred. The mean postoperative hospital stay was 3.0-10.0(3.6±2.6) days.

CONCLUSIONThe clearance of No.253 lymph nodes with priority to fascial space and preserving LCA in laparoscopic radical proctectomy is safe and feasible.

Aged ; Digestive System Surgical Procedures ; methods ; Female ; Humans ; Laparoscopy ; Lymph Node Excision ; Lymph Nodes ; Male ; Mesenteric Artery, Inferior ; surgery ; Middle Aged ; Rectal Neoplasms ; surgery

Objective To investigate the application value of the modified Overlap method in digestive tract reconstruction of totally laparoscopic total gastrectomy (TLTG).Methods The retrospective cohort study was conducted.The clinicopathological data of 50 patients with gastric cancer who underwent TLTG with Overlap anastomosis between January 2016 and December 2016 in the Tangdu Hospital of the Fourth Military Medical University were collected.Twenty-six patients using classic Overlap method and 24 patients using modified Overlap method were respectively allocated into the classic Overlap group and modified Overlap group.All the patients underwent D2 lymph node dissection.Patients in the classic Overlap group underwent totally laparoscopic catastalsis side-to-side esophagojejunostomy.During digestive tract reconstruction in the modified Overlap group,there was no esophageal transection before anastomosis,and gastric fundus traction fully exposed to the lower esophagus.Esophagus was spun anticlockwise,and a hole was opened at the left posterior esophageal wall.Transection of jejunum was 25 cm away from Treitz ligment,and opening a hole at mesenteric margin was 6 cm away from distal jejunum to transected end of jejunum.Esophagus-distal jejunum side-to-side anastomosis was done using 60 mm linear stapler,and then laterally closing openings and transecting esophagus.Observation indicators:(1) intra-and post-operative recovery:total operation time,time of esophagus-jejunum anastomosis,volume of intraoperative blood loss,number of lymph node dissected,time to anal exsufflation,cases with complications and duration of postoperative hospital stay;(2) follow-up and survival.Follow-up using outpatient examination and telephone interview was performed to detect the postoperative tumor-free survival and tumor recurrence or metastasis up to March 2017.Measurement data with normal distribution were represented as (x)±s and comparison between groups was analyzed using the independent-sample t test.Comparison of count data was analyzed using the chi-square test or Fisher exact probability.Results (1) Intra-and post-operative recovery:all the 50 patients underwent successful TLTG using Overlap method,without conversion to open surgery.Total operation time and time of esophagus-jejunum anastomosis were respectively (278.6± 14.9) minutes,(46.5 ± 4.4) minutes in the classic Overlap group and (253.3 ± 12.8) minutes,(20.4 ± 2.3) minutes in the modified Overlap group,with statistically significant differences between the 2 groups (t =5.459,22.482,P＜0.05).Volume of intraoperative blood loss,number of lymph node dissected,time to anal exsufflation,cases with complications and duration of postoperative hospital stay were respectively (73±25) mL,34±6,(2.7± 1.0) days,2,(9.7± 1.6) days in the classic Overlap group and (71 ± 22) mL,35± 5,(2.6± 1.3) days,2,(9.8± 1.5) days in the modified Overlap group,with no statistically significant difference between the 2 groups (t =0.175,-0.616,0.293,-0.217,P＞ 0.05).Two patients in the classic Overlap group were respectively complicated with esophagus-jejunum anastomotic fistula and pancreatic leakage,2 patients in the modified Overlap group were respectively complicated with pulmonary infection and subcutaneous emphysema,and they were improved by symptomatic treatment.(2) Follow-up and survival:41 of 50 patients were followed up for 3-15 months,with a median time of 7 months,including 20 in the classic Overlap group and 21 in the modified Overlap group.During follow-up,patients had tumor-free survival,without tumor recurrence and metastasis.Conclusion Compared with classic Overlap method,the modified Overlap method can simplify the anastomotic procedures,shorten operation time and achieve similar efficacy,and it is also a simple and effective method for digestive tract reconstruction after TLTG.

Background:Inflammation-based indexes have been used to predict survival and recurrence in cancer patients.Systemic immune-inflammation index (SII) was reported to be associated with prognosis in some malignant tumors.In the present study,we aimed to explore the association between SII and the prognosis of patients with gastric cancer.Methods:We retrospectively analyzed data from 444 gastric cancer patients who underwent gastrectomy at the First Affiliated Hospital of Sun Yat-sen University between January 1994 and December 2005.Preoperative SII was calculated.The Chi square test or Fisher's exact test was used to determine the relationship between preoperative SII and clinicopathologic characteristics.Overall survival (OS) rates were estimated using the Kaplan-Meier method,and the effect of SII on OS was analyzed using the Cox proportional hazards model.Receiver operating characteristic (ROC) curves were used to compare the predictive ability of SII,NLR,and PLR.Results:SII equal to or higher than 660 was significantly associated with old age,large tumor size,unfavorable Borrmann classification,advanced tumor invasion,lymph node metastasis,distant metastasis,advanced TNM stage,and high carcino-embryonic antigen level,high neutrophil-lymphocyte ratio,and high platelet-lymphocyte ratio (all P ＜ 0.05).High SII was significantly associated with unfavorable prognosis (P ＜ 0.001) and SII was an independent predictor for OS (P =0.015).Subgroups analysis further showed significant associations between high SII and short OS in stage Ⅰ,Ⅱ,Ⅲ subgroups (all P ＜ 0.05).SII was superior to NLR and PLR for predicting OS in patients with gastric cancer.Conclusion:Preoperative SII level is an independent prognostic factor for OS in patients with gastric cancer.

Objective To investigate the effect of allicin on the development of atherosclerosis in apoE-/-mice and explore its underlying mechanism from the perspective of protein S-nitrosylation.Methods Thirty male apoE-/- mice were randomly divided into 3 groups:control group (saline,ig),low-dose group (allicin,9 mg/kg·d, ig)and high-dose group (allicin,18 mg/kg·d,ig).They were fed with high cholesterol diet for 12 weeks.The levels of plasma lipids,oxidized-LDL (ox-LDL),malondialdehyde,tumor necrosis factor-alpha and nitric oxide (NO)were measured.The atherosclerotic lesions in aortic root were evaluated after hematoxylin and eosin staining and elastica van Gieson and immunohistochemical staining,respectively.Furthermore,in vitro experiments were performed using human umbilical vein endothelial cells (HUVECs).The HUVECs were treated with allicin (10μmol/L or 20 μmol/L)for 24 hours in the presence of ox-LDL (50 μg/mL).The level of NO in supernatant was measured by a nitrate/nitrite assay. The protein S-nitrosylation of the HUVECs was detected through immunofluorescence.Results The histological analysis revealed that allicin treatment not only significantly decreased the areas of the atherosclerotic lesion (all P <0.05)but also suppressed the macrophage accumulation and smooth muscle cell proliferation in the lesion.There was no significant difference in the levels of plasma lipids between control and treated groups.However,allicin exerted obvious anti-oxidative and anti-inflammatory effects. Interestingly,the allicin treatment led to marked increase of the plasma NO level (P <0.05)and aortic protein S-nitrosylation.The experiments in vitro further proved that the allicin up-regulated the levels of NO and protein S-nitrosylation in HUVECs treated with ox-LDL (P < 0.01 ).Conclusion Allicin can inhibit the development of atherosclerosis.The mechanism is associated with the up-regulation of protein S-nitrosylation in endothelial cells, which plays an important role in anti-oxidization and anti-inflammation.

Objective To introduce the laboratory and clinical characteristics of acute lymphoblastic leukemia accompanied by the karyotypic abnormality of 5q-.Methods Report the diagnosis and treatment of one case of acute lymphoblastic leukemia with 5q- and review the relevant literatures.Results The patient came to the hospital because of bellyache and ostalgia.The blood routine showed a high WBC count and reduced platelets.Bone marrow aspirates examination indicated acute leukemia and by peroxidase staining and flow cytometry test,acute pro-T lymphoblastic leukemia was diagnosed.The karyotype and fluorescence in situ hybridization analysis showed 5q-.The hyper-CVAD regimen induced a temporary remission but it did not work anymore after the relapse nor did the MEA regimen.From the literatures ever reported,the kyryotypic abnormality of 5q- was rarely seen in acute lymphoblastic leukemia.In such cases,the minimal deletion region overlaped between marks of D5S410 and D5S436 corresponding to chromosomal location 5q31-33.Conclusion 5q- is rare in acute lymphoblastic leukemia and more features are still to be found about the kind of disorder.