Traditional Chinese Medicine Clinics Research Articles

Research Progress on the Antitumor Mechanism of Compound Kushen Injection

Compound Kushen Injection (CKI), as a clinical traditional Chinese medicine preparation, has prominent antitumor effect but with several side effects. A large number of studies have shown that CKI plays an antitumor role by regulating tumor cell proliferation, inducing tumor cell differentiation and apoptosis, inhibiting tumor cell invasion and metastasis, reducing tumor angiogenesis, regulating the immunity, and so on. Clinically, CKI is widely used to treat various tumors, where it is often combined with surgery, chemotherapy, radiotherapy, targeted therapy, and other antitumor treatments. This article reviews the antitumor mechanism of CKI and the progress of its clinical application in order to provide a theoretical basis for further clinical application.

Randomized double-blind trial comparing low dose and conventional dose of a modified traditional herbal formula Guizhi Fuling Wan in women with symptomatic uterine fibroids

Ethnopharmacological relevanceThe herbal formula Guizhi Fuling Wan is one common remedy for treating uterine fibroids (UFs) and the relevant symptoms in Traditional Chinese Medicine (TCM). Previous systematic reviews showed that Guizhi Fuling Formula appeared to have additional benefit based on mifepristone treatment in reducing volume of fibroids. Aim of studyTo study the efficacy and safety of the conventional dose of a modified herbal formula Guizhi Fuling Wan in patients with symptomatic uterine fibroids in comparison with a sub-effective dose control. Materials and methodsThis randomized double-blind, dosage-controlled trial was carried out in an outpatient clinic of traditional Chinese medicine in Hong Kong. Women with symptomatic uterine fibroids diagnosed according to the WHO International Classification of Diseases (ICD-10) were recruited and randomly assigned to one of two groups that received modified Guizhi Fuling Wan at either a low dose or the conventional dose on a daily basis for 16 weeks. This study was quality controlled by a data safety monitoring board. The primary outcome was the symptom severity as measured with the Uterine Fibroid Symptom–Quality of Life questionnaire. The secondary outcomes included quality of life, menstrual bleeding (measured on a pictorial blood loss assessment chart), pain severity (measured on the 6-point behavioral rating scale), change in Chinese medicine syndrome score, fibroid volume (measured by magnetic resonance imaging), hemoglobin level, and hormone levels. ResultsSeventy-eight women were recruited for this study. Between-groups comparison showed no significant difference at the endpoint for all outcomes except for the Chinese medicine syndrome score; however, at the endpoint, within-group comparison showed significant improvement in both groups relative to baseline in symptom severity, functional influence of pelvic pain, Chinese medicine syndrome score, and fibroid volume and uterus condition on magnetic resonance imaging (p < 0.05).The low-dose group yielded greater endpoint improvement in the Chinese medicine syndrome score than the conventional-dose group (p=0.024). No serious adverse events related to the intervention were noted. ConclusionBoth low-dose and conventional-dose preparations significantly ameliorated uterine fibroid–related symptoms and fibroid volume, although no significant difference was found between the low-dose and conventional-dose groups. The herbal formula GuizhiFuling Wan is safe in women with uterine fibroids.

Study on Traditional Chinese Medicine Clinical Nursing of Patients with Cervical Spondylosis by Using Meridian and Scraping According to Syndrome Differentiation

Study on Traditional Chinese Medicine Clinical Nursing of Patients with Cervical Spondylosis by Using Meridian and Scraping According to Syndrome Differentiation

Review of Latest Traditional Chinese Medicine Clinical Studies on Pediatric Tic Disorder with Tuina Treatment

Objectives: The purpose of this review is to investigate the latest traditional Chinese medicine clinical studies on pediatric tic disorder with Tuina treatment and propose the directions of future studies and clinical applications. Methods: To obtain data from CNKI, set the field by ‘中醫學’, ‘中藥’, ‘中西醫結合’ and used keywords ‘抽动障碍’, ‘抽動 穢語綜合’, ‘小兒抽动’, ‘兒童抽动’ and ‘推拿’, ‘導引’, ‘按摩’, ‘Tuina’, ‘massage’ in cross combination way. Results: 12 clinical studies were selected. These studies were analyzed by author &amp; year, subjects, diagnostic criterion, evaluation criterion, syndrome differentiation, treatment period, methods&amp; results, frequent acupoints and assessment of the quality of studies. All of reports achieved effective therapeutic results on the pediatric tic disorder with Tuina treatment. Conclusion: Tuina treatment has a positive effect and are easily accepted by children who have fear and rejection to traditional Korean Medicine such as acupuncture and Herbal remedy. It is also safe and simple to operate. So the Tuina treatment is worthy to disseminate potential for further development in the treatment of pediatric tic disorders.

The Ophthalmology-centered medical industry in Suzhou in the Ming and the Qing Dynasties - from the Painting Album of Cityscapes and Business

The Painting Album of Cityscapes and Business was finished in the early Qing Dynasty with realism. This painting album described the prosperity in business and everyday life in Suzhou during the late Ming and the early Qing Dynasties. They were drawn and painted retrospectively, ie, the content of the pictures was based on existing paintings handed down. In the painting album, more than ten medical-related elements were specifically depicted, such as traditional Chinese medicine clinics and pharmacies and seven ophthalmology-related elements including one clinic specialized in ophthalmology, two spectacle shops, two people wearing eyeglasses and three blind people. Up to now, no specialized ophthalmology clinics and spectacle shops have been found in earlier literature and paintings. It can be speculated that the Painting Album of Cityscapes and Business is the earliest album of paintings depicting clinics specialized in ophthalmology and spectacle shops in China. This painting album provides important information for the study of the medical industry in Suzhou in the late Ming and the early Qing Dynasties, particularly, in terms of ophthalmology-related diagnosis and treatment.

An interview with YU Ying-ao-a scholar in clinical literature

Professor Ying-ao YU came from a family with medical background and studied under the guidance of Bo-wei QIN. He graduated from Shanghai Second Medical College. He also was a graduate of the first session of the Integrated Medicine in China. After that, he was assigned to the editorial office of the Academy of Chinese Medicine, engaging in the study of clinical literature of traditional Chinese medicine(TCM). With National Medical Master Zhi-zheng LU, he went to Baotou Steel Staff Hospital in Inner Mongolia to implement TCM training. He has devoted himself to research of TCM clinical literature and his clinical practice for more than 60 years. Based on this work, he developed his own clinical diagnosis and treatment model entitled Differentiation of Diseases, Differentiation of Symptoms and Signs-General Therapy-Treatment through Prescription-Treatment through Clinical Symptoms and Signs. This model makes an outstanding contribution to clinical TCM and clinical literature research. The author interviewed Professor YU systematically in terms of his experiences in TCM clinically and his cultural heritage in TCM clinical philology to share with readers.

Comparative study on the pharmacodynamic difference of oral administration of Xiaojin Pills accompanied with Chinese Baijiu and water

Ethnopharmacological relevanceXiaojin Pills is a classic prescription for the treatment of mammary glands hyperplasia with a history of nearly 300 years, and is also the first choice of Chinese patent medicine for the clinical treatment of mammary glands hyperplasia in contemporary traditional Chinese medicine clinic. Clinical and animal studies have shown that Xiaojin Pills has the effects of anti-mammary glands hyperplasia, promoting blood circulation, anti-inflammation and analgesia. However, its initial administration method was “taking orally after soaked with Chinese Baijiu”, the modern method was changed to “taking orally with water” in recent 20 years. Whether there is any difference in the efficacy of the two administration methods is still unknown. Aim of the studyTo reveal the difference in efficacy and metabolic mechanism of anti-mammary gland hyperplasia between the oral administration of Xiaojin Pills accompanied with Chinese Baijiu (XJP&B) and water (XJP&W). Materials and methodsCOX-2 inhibition rate test and anti-platelet aggregation activity test were used to investigate the efficacy difference between the 40 vol% Chinese Baijiu and water extracts of Xiaojin Pills on anti-inflammatory and blood-activating in vitro. Kunming male mice (20 ± 5 g) and SD female rats (200–220 g) were orally treated with XJP&B and XJP&W, respectively. Then the difference in anti-inflammatory and analgesic effects between XJP&B and XJP&W were evaluated via xylene-induced ear swelling test, formaldehyde-induced pain test, and acetic acid-induced writhing test in mice. Determination of nipple diameter, pathological examination of mammary gland tissue, determination of serum E2, P and FSH content and hemorheological parameters of rats with mammary gland hyperplasia were performed to explore the efficacy difference in anti-mammary gland hyperplasia between XJP&B and XJP&W. Metabolomics was used to study the difference of anti-mammary gland hyperplasia mechanism between XJP&B and XJP&W. ResultsThe results showed that the effect of XJP&B was superior to that of XJP&W in anti-platelet aggregation, inhibition of inflammation and pain, and anti-mammary gland hyperplasia. Interestingly, the advantages were more significant under low-dose condition. In addition, the mechanism of the two combinations against mammary gland hyperplasia was indeed different. Their common metabolic pathways include tryptophan metabolism and alanine, aspartic acid and glutamic acid metabolism. However, Chinese Baijiu and XJP&B also have additional regulatory effects on linoleic acid metabolic pathway. ConclusionIn brief, this research demonstrated that the efficacy of XJP&B was better than that of XJP&W in activating the blood, anti-inflammation, analgesia and anti-mammary gland hyperplasia, which means that XJP&B has synergistic and superior effects. The special dose-effect relationship under the condition of XJP&B was also found, laying the foundation for clinical treatment to reduce the dosage and shorten the medication cycle, which is beneficial to reduce the economic burden of patients.

The Effectiveness of Traditional Chinese Medicine (TCM) as an Adjunct Treatment on Stable COPD Patients: A Systematic Review and Meta-Analysis.

Background Traditional Chinese medicine (TCM), including Chinese herbal medicine (CHM) and acupuncture, exhibits beneficial effects on stable chronic obstructive pulmonary disease (COPD) such as improving lung function and reducing exacerbation. Previous research studies have examined either CHM or acupuncture alone, which are not the usual practice in TCM clinic setting. We conduct a systematic review for evaluating the clinical effectiveness and safety of TCM by combining CHM and acupuncture. Methods Databases are searched from inception to November 2019. Randomized controlled trials examining either acupuncture or CHM on stable COPD are included. Primary outcomes include lung functions, exacerbations, and COPD assessment test. Secondary outcomes include quality of life, TCM syndrome score and effective rate, and 6-minute walk distance. Two independent reviewers extract data and assess the quality of evidence and generate meta-analysis and risk of bias by STATA. This protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. Results 100 randomized controlled trials (8291 participants) were included to compare add-on Chinese medicine treatment with conventional treatment (CT). Combining CHM with CT improves FEV1 (MD: 0.18, 95% CI: 0.08, 0.28), exacerbation rate (MD: −0.29, 95% CI: −0.61, 0.03), COPD assessment test (MD: −2.16, 95% CI: −3.44, -0.88), TCM syndrome score (MD: −3.96, 95% CI: −5.41, −2.51) and effective rate (RR: 0.89, 95% CI: 0.80, 0.93), and 6-minute walk test (MD: 37.81, 95% CI: 20.90, 54.73). No serious adverse events were reported. Risk of bias: low to unclear. Conclusions This review identifies sufficient moderate-to-low-quality evidence to suggest TCM as an adjunct treatment for stable COPD patients. Though heterogeneity was low among studies, the results were limited and the quality of evidence was low or very low based on small sample sizes and risk of bias. Future studies with larger sample sizes are warranted. The trial is registered with CRD42019161324.

Understanding Radix Angelica sinensis Blood Replenishing mechanisms on Blood Deficiency Rats Based on a UPLC-Q/TOF-MS Metabolomics and Network Pharmacology

Radix Angelica sinensis (RAS) is a famous Chinese medicine with hematinic effects and has been applied for the treatment of blood deficiency syndrome for many years. Previous studies have indicated that RAS has beneficial effects in the treatment of hemolytic anemia. The hemolytic anemia/blood deficiency syndrome is a common syndrome that is often presented in most traditional Chinese medicine (TCM) clinics. Based on routine blood indicators, metabolomics analysis was conducted to investigate the mechanism of RAS in the treatment of hemolytic anemia. Multivariate and univariate statistical analysis were used to identify potential biomarkers in the serum. On administering RAS to the haemololitic anaemic rat, the levels of WBC, RBC, HGB, and PLT in AG tended to shift toward that of the control group. Additionally, all the 26 metabolites such as cholic acid, succinic acid and orotate which are regulated by blood deficiency appeared normal through the five metabolic pathways, such as linoleic acid metabolism, alanine, aspartic acid and glutamate metabolism, pyrimidine metabolism, arginine and proline metabolism. Thus, three metabolic pathways predicted by the network pharmacology were consistent with the metabolism pathway of Angelica sinensis: linoleic acid metabolism, arginine and proline metabolism, tryptophan metabolism. The integrated metabolomics and network pharmacology comprehensively improved the understanding of the physiological and metabolic state of an organism. The possible hematopoietic effects and underlying mechanism of action on hemolytic anemia rats after lavage with RAS water extracts, could potentially be elucidated by combining pharmacology with untargeted metabolomics. These pointed out the significance of metabolomics as a valuable tool for studying the essence of Chinese medicine’s syndrome theory and the mechanism of RAS under anti-blood deficiency syndrome.

Chinese Medicine Formula Kai-Xin-San Ameliorates Neuronal Inflammation of CUMS-Induced Depression-like Mice and Reduces the Expressions of Inflammatory Factors via Inhibiting TLR4/IKK/NF-κB Pathways on BV2 Cells.

Kai-Xin-San (KXS) is a traditional Chinese medicinal formula composed of Ginseng Radix et Rhizoma, Polygalae Radix, Acori Tatarinowii Rhizoma, and Poria for relieving major depressive disorder and Alzheimer’s disease in traditional Chinese medicine (TCM) clinics. Previous studies on the antidepressant mechanism of KXS mainly focused on neurotransmitter and neurotrophic factor regulation, but few reports exist on neuronal inflammation regulation. In the current study, we found that KXS exerted antidepressant effects in chronic unpredictable mild stress-induced depression-like mice according to the results of behavioral tests. Meanwhile, KXS also inhibited the activation of microglia and significantly reduced the expression of pro-inflammatory cytokines such as IL-1β, IL−2, and TNF-α in the hippocampus of mice. In mice BV2 microglia cell lines, KXS extract reduced the expression of inflammatory factors in BV2 cells induced by lipopolysaccharide via inhibiting TLR4/IKK/NF-κB pathways, which was also validated by the treatment of signaling pathway inhibitors such as TAK-242 and JSH-23. T0hese data implied that the regulation of pro-inflammatory cytokines in microglia might account for the antidepressant effect of KXS, thereby providing more scientific information for the development of KXS as an alternative therapy for major depressive disorder.

Therapeutic effect of Jianpi Liqi Fang combined with transcatheter arterial chemoembolization in patients with hepatocellular carcinoma and spleen deficiency syndrome.

To investigate the therapeutic effect of the Jianpi Liqi Fang ( ，JPLQF) combined with transcatheter arterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) and spleen deficiency syndrome (SDS) and identify a potential indicator of efficacy. Ninety-nine patients with HCC who were diagnosed with SDS, non-spleen deficiency syndrome (NSDS), or no syndrome (NS) were treated with JPLQF combined with TACE for three periods. Therapeutic efficacy was compared among the groups. Plasma proteins were screened using label-free discovery analysis and verified via enzyme-linked immunosorbent assay (ELISA). Furthermore, receiver operating characteristic (ROC) curves were analyzed to evaluate therapeutic indicators. After treatment, the Karnofsky Performance Status was significantly improved in the SDS group and significantly better than that in the NS group. The Traditional Chinese Medicine (TCM) syndrome scores were lower in the SDS group after treatment and lower than those in the NSDS group. However, alanine aminotransferase, carbohydrate antigen 19-9, alpha-fetoprotein, and carcinoembryonic antigen levels and white blood cell and platelet counts did not differ among the groups. Serum aspartate aminotransferase levels in the SDS group were significantly lower after treatment than before treatment, and total bilirubin levels were significantly lower in the SDS group than in the NSDS group. Label-free analysis identified 24 differentially expressed proteins (DEPs) between the SDS and NS groups, including 17 and 7 upregulated and downregulated proteins, respectively. Fibulin-5 (FBLN5) displayed the largest difference in expression between the groups. ELISA confirmed that FBLN5 levels were significantly lower in the NSDS and NS groups than in the SDS group. Following treatment with JPLQF and TACE, FBLN5 expression was upregulated only in the SDS group. Furthermore, ROC curve analysis indicated that FBLN5 may serve as a potential indicator of the efficacy of JPLQF combined with TACE in patients with HCC and SDS. JPLQF combined with TACE improved quality of life, clinical TCM symptoms, and liver function in patients with HCC and SDS. FBLN5 expression was significantly altered by treatment with JPLQF and TACE in patients with HCC and SDS.

Emotional relief for patients and nurses in Traditional Chinese Medicine clinics

Emotional relief for patients and nurses in Traditional Chinese Medicine clinics

Effective Dose of Rhizoma Coptidis Extract Granules for Type 2 Diabetes Treatment: A Hospital-Based Retrospective Cohort Study.

Rhizoma Coptidis is a popular phytomedicine for the treatment of type 2 diabetes in Asia, but its effective dose for diabetes treatment remains confused because of diverse origins. This study aimed to investigate the dose-response effects of Rhizoma Coptidis extract granules (RCEG), produced with standardized quality control, on hypoglycemic effects in patients with type 2 diabetes. We conducted a retrospective analysis of Chang Gung Research Database from January 01, 2008 to November 30, 2017. Outpatients visiting traditional Chinese medicine clinics and receiving RCEG for type 2 diabetes treatment were included. Plasma glucose, lipid, and other parameters were analyzed from 93 patients with a total of 737 visits within 60 weeks. Scatter plots with the LOESS analysis were used to explore the association between RCEG dose and hypoglycemic effect. The minimal effective dose was chosen to divide the study population into the high-dose and low-dose RCEG groups. Non-parametric tests were used for between-group and within-group comparisons. The multivariate nonlinear mixed-effects model was applied to access the effect of treatment length and groups simultaneously on the change of HbA1c and fasting plasma glucose. The “arule” package in R was used to present the network diagram of RCEG and other co-prescriptions. We first discovered a significant relationship between RCEG dose and HbA1c reduction when the dose reached 0.08 g/kg/day or higher. We thus defined 0.08 g/kg/day of RCEG as the minimum effective dose, and a threshold to separate patients into the high-dose (≥0.08 g/kg/d) and low-dose (<0.08 g/kg/d) RCEG groups. In the high-dose RCEG group, a significant decrease in total cholesterol and a trend toward triglyceride reduction were also noted. Patients more effectively responded to RCEG treatment if they had a higher initial HbA1c level, higher heart rates, better liver function tests, and better tolerance to the higher dose and treatment duration of RCEG. In addition, digestive/tonic/dampness draining formulas and blood regulation recipes were two of the most frequent co-prescriptions with RCEG. This study concluded that RCEG at a dose exceeding 0.08 g/kg/d had beneficial effects on glycemic and lipid control, without showing nephro- or hepatotoxicity, in patients with type 2 diabetes.

A Survey of Clinical Evidence Evaluation Systems for Traditional Chinese Medicine

Objectives. We investigated the cognition and application of the “Evaluation System of Traditional Chinese Medicine Clinical Evidence” among populations with disparate backgrounds. Methods. We performed an online survey using a self-designed questionnaire. Results. Of 307 returned questionnaires, 284 were noted to be valid, and the effective recovery rate was 92.5%. Our analyses showed that the respondents demonstrated a better understanding of clinical evidence-based evaluation systems and that they used these occasionally. For both the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and the traditional Chinese medicine (TCM) evidence evaluation systems, the respondents generally showed poor overall understanding, rendering the systems impractical. Among the respondents who were exposed to the existing evidence evaluation system for TCM. More than 70% of the respondents remarked that it was difficult to obtain high-quality evidence using any existing methods to evaluate TCM clinical evidence, that there was a lack of clear evaluation criteria, and that it was difficult to grasp the evaluation process. Conclusions. The evaluation systems of TCM clinical evidence have gained a certain degree of recognition among practitioners, who show a great willingness to use it, but practical applications are limited. In addition, it is also expected that an evaluation system would be more in line with the clinical characteristics of TCM.

Emotional relief for patients and nurses in Traditional Chinese Medicine clinics

Emotional relief for patients and nurses in Traditional Chinese Medicine clinics

Study on the Application Strategy of Promoting Blood Circulation and Removing Blood-Stasis in Gynecology Clinic of Traditional Chinese Medicine

Study on the Application Strategy of Promoting Blood Circulation and Removing Blood-Stasis in Gynecology Clinic of Traditional Chinese Medicine

Learnings from observing a Chinese medicine clinic during the initial stages of the COVID-19 pandemic

When the COVID-19 epidemic raged around the world, I had the opportunity to record the experience from a traditional Chinese medicine (TCM) clinic in London’s Chinatown from January to March 2020. The TCM clinic was aware of the risk of the virus long before any announcement from the British government. In the early days, there […]

病证结合的中医临床思维

病证结合的中医临床思维

Effects of Astragalus Mongholicus and Its Fermentation Objects on Anti-oxidation Capability of Hypothyroidism Rats

<i>Objectives</i>: The morbidity rate of hypothyroidism is relatively high, the features of which are delitescent invasion, long course, untypical symptoms, great harm, etc. To intervene and cure hypothyroidism by traditional Chinese medicine could palliate untoward reaction of Western medicine, relieve symptoms of patients and enhance immunity. Astragalus mongholicus is frequently used as clinical traditional Chinese medicine. Reported by some literatures, compositions of Astragalus mongholicus have antioxidative function. Therefore, we studied effects of Astragalus mongholicus and its fermentation objects on anti-oxidation capability of hypothyroidism rats, and then discussed its mechanism of action. <i>Methods</i>: Eighty Wistar rats, half of which are female, were randomly divided into eight groups. They were named normal control group, hypothyroidism model group, high-dose Astragalus mongholicus group, medium-dose Astragalus mongholicus group, low-dose Astragalus mongholicus group, high-dose Astragalus mongholicus fermentation objects group, medium-dose Astragalus mongholicus fermentation objects group, low-dose Astragalus mongholicus fermentation objects group. There were ten rats in each group. We copied hypothyroidism rats samples by chemical induction------0.05% PTU freely drinking water. The rats were treated by different doses of Astragalus mongholicus as well as its, fermentation objects and killed after four weeks. We tested activity of serum superoxide dismutases (SOD), glutathion peroxidase (GSH-Px) nitricoxide synthase (NOS); contents of malondialdehyde (MDA), nitrogen monoxidum (NO) and the function of glandula thyreoidea. <i>Results</i>: After being treated by Astragalus mongholicus as well as its fermentation objects, the hypothyroidism rats’ function of glandula thyreoidea has improved evidently (P<0.05). Secondly, contents of malondialdehyde (MDA) in blood serum degraded remarkably (P<0.05). Thirdly, activity of superoxide dismutases (SOD) and glutathione. Peroxidase (GSH-Px) in blood serum stepped up strikingly (P<0.05). Fourthly, vis vitalis of nitric oxide synthase (NOS) and contents of nitrogen monoxidum (NO) in blood serum stepped down surprisingly (P<0.05). <i>Conclusion</i>: Astragalus mongholicus and its fermentation objects have certain therapeutical effects on thyroid hypofunction, whose mechanism has something to do with increasing anti-oxidation capability of hypothyroidism rats.

Clinical observation of treating Meniere’s syndrome by combining modified Zhenwu decoction and acupuncture at Taichong acupoints

Objective: The aim of the research is to observe the therapeutic effect of combination of modified Zhenwu decoction and acupuncture at Taichong acupoints on Meniere's syndrome. Methods: Eighty-eight patients with Meniere's syndrome admitted in the traditional Chinese medicine (TCM) clinic of the hospital were randomly divided into four groups: a TCM group, an acupuncture group, a combined treatment group, and a western medicine group (n=22 in each group). Modified Zhenwu decoction was administrated in the TCM group; acupuncture at Taichong acupoints in both feet was performed in the acupuncture group; the combined treatment group received treatment applied in both the TCM and acupuncture groups simultaneously; and the western medicine group was treated with a vertigo drug, betahistine mesylate tablets. Before treatment, all patients were examined using the rating scale of severity of vertigo and the vestibular symptom index (VSI), to compare score differences. Conclusions: The four therapies all showed significant therapeutic effects on Meniere's syndrome. The comparison among groups revealed that the combined treatment group has better therapeutic effects than the other three groups, exhibiting a significant superiority (P < 0.05).