[Comparison of misoprostol and ricinus oil meal for cervical ripening and labor induction]

OBJECTIVE

To compare the safety and efficacy of intravaginal prostaglandin E1, misoprostol with ricinus oil meal for labor induction.

METHODS

Sixty patients with an indication for induction of labor were randomly assigned to two groups (30 cases each) induction with misoprotol, 50 micrograms intra-vaginally every 3 hours until active labor, or with that ricinus oil meal was taken.

RESULTS

The time from start of induction to vaginal delivery was significantly shorter in the misoprostol group (12.2 vs 18.1, P < 0.05), and fewer patients in the misoprostol group required oxytocin augmentation (10.0% vs 40.0%, P < 0.05). The mean change in the Bishop score was significantly higher in those receiving misoprostol (5.5 vs 3.1, P < 0.05). Uterine tachysystole occurred more frequently in patients in the misoprostol group (16.7%) than in the ricinus oil meal group (3.0%). No significant differences were noted in the mode of delivery and patients of successful labor induction.

CONCLUSIONS

Vaginally administered misoprostol is an effective agent for the cervical ripening and induction of labor.

Hypercholesterolemia exacerbates transplant arteriosclerosis via increased neointimal smooth muscle cell accumulation: studies in apolipoprotein E knockout mice

BACKGROUND

Hypercholesterolemia is thought to be a significant risk factor for coronary vasculopathy in cardiac transplant recipients.

METHODS AND RESULTS

We examined the development of arteriosclerosis in mouse carotid artery loops allografted from B.10A(2R) (H-2h2) donors to normocholesterolemic C57BL/6J (H-2h) recipients and hypercholesterolemic C57BL/6J recipients in which the apolipoprotein (apo) E gene had been knocked out. Luminal occlusion and cross-sectional neointimal area were greater in arteries allografted into hypercholesterolemic recipients at 15 and 30 days after transplantation. We also measured cellular and extracellular matrix components of the neointima by computerized planimetry of the fractional areas subtended by smooth muscle cells (anti-alpha-actin stain), collagen (Masson's trichrome), lipid (oil red O), and leukocytes (anti-CD45). The neointimal area stained for smooth muscle cells was significantly greater in hypercholesterolemic recipients than in normocholesterolemic recipients at 15 and 30 days after allografting. Lipid contributed to neointimal area to a lesser degree, and there was no significant increase in the contribution of collagen or leukocytes.

CONCLUSIONS

Smooth muscle cell accumulation appears to be the principal contributor to the increase in neointimal area observed in arteries allografted into hypercholesterolemic mice.

[Content determination of baicalin and baicalein in shuanghuanglian powdery injection by the method of HPLC-ECD]

The contents of baicalin and baicalein in Shuanghuanglian Powdery Injection have been determined by the method of HPLC-ECD under following conditions: column-ERC-ODS-1161, 6 mm x 100 mm; temperature-55 degrees C; mobile phase-0.1 mol/L KH2PO4, acetic acid and tetrahydrofuran (1000:100:190); flow rate-0.8 ml/min; detector voltage-+650 mV. The result shows the limit of detection for baicalin and baicalein to be 25 ng and 50 ng respectively, with an average recovery of 100.1% and 99.7% respectively. Highly reproducible, rapid, simple, convenient and accurate, this method is good for the content determination of baicalin and baicalein in Chinese medicinal herbs and preparations.

[Study on conversion degree of double bonds of dental composites by Fourier transform infrared spectroscope]

Conversion degrees (CDs) of double bonds of 8 dental composites were measured by Fourier transform infrared spectroscope. Also, effects of disc-sampling method and film-sampling method on CD were compared. The results showed that CDs of 8 composites ranged from 45% to 75%. CDs of visible-light-cured (VLC) composites were higher than those of chemically-cured (CC) ones. In VLC composites, those with hybrid fillers had higher CDs than those with superfine fillers. In VLC composites, CDs obtained by disc-sampling method were higher than by film-sampling method; in CC composites, there were no differences between CDs obtained by both sampling methods.

[Clinical significance of expression of multidrug resistance gene in breast cancer tissue]

OBJECTIVES

To investigate the role of expression of multidrug resistance gene (mdr-1 gene) in chemotherapeutic resistance of breast cancer and to determine if expression of mdr-1 gene may act as an index for predicting chemotherapy response and prognosis.

METHODS

Using reverse transcription-polymerase chain reaction (RT-PCR) technique, we determined the levels of mdr-1 mRNA in 82 breast cancer samples.

RESULTS

Positive expressions of mdr-1 gene were 34.3% in 35 cases of untreated primary breast cancer and 59.0% in 47 cases of relapsed metastatic breast cancer, separately, and the difference was statistically significant (P < 0.05). In 28 cases of relapsed metastatic breast cancer of mdr-1 gene positive expression, 22(78.6%) were ever treated with MDR related drugs. Levels of mdr-1 gene expression of all 7 cases were higher after chemotherapy than before chemotherapy. Positive expressions were 16.7% and high grade positive expressions were 5.6% in 18 sensitive cases. Positive expressions were 71.4% and high grade positive expressions were 50.0% in 14 resistant cases. The difference was statistically significant (P < 0.01). There were no relations between expression of mdr-1 gene and ages, menopause status, lymphnode involvements, clinical stages, and estrogen receptor levels.

CONCLUSION

The results indicated that retreated metastatic breast cancer is more extensively resistant than untreated primary breast cancer and acquired drug resistance is an important reason. Expression of mdr-1 gene seems to be a reference index for predicting response of chemotherapy.

[The development of light-curing soft denture liner]

In this study, a visible light-curing soft denture liner was developed, and 6 methacrylate polyurethane elastomer and a diluent were synthesised, their effect on tensile strength, compression set, Shore A hardness, absorption and solubility were also investigated. The results showed that the elastomer made of polyethylene adipate or polybutylene ether glycol possessed the highest tensile strength and hardness, the elastomer made of polypropylene ether glycol showed low tensile strength and low shore A hardness, the elastomer made of hydroxyl-terminated liquid polybutadiene rubber had a moderate tensile strength and hardness.

[Determination of calcium, magnesium and potassium in nurtured cell by AAS with quick-pulsed nebulization technique and NaOH base digestion]

The sample is digested with 6% NaOH solution and an amount of 50 microl is used for protein content analysis by the method of Comassie Brilliant Blue G250, the residual is diluted with equal 0.4% Lathanurm-EDTA solution. Its Calcium magensium and potassium content are determined by AAS. With quick-pulsed nebulization technique. When a self-made micro-sampling device is used, 20microl of sample volume is needed and it is only the 1/10 approximately 1/20 of the sample volume required for conventional determination. Sensitivity, precision and rate of recovery agree well with those using regular wet ashing method.

[Criteria of measuring mdr-1 gene expression level in breast cancer by RT-PCR]

OBJECTIVE

To formulate criteria of judjing multidrug resistance gene(mdr-1 gene) expression level and to provide basis for predicting chemotherapy response and prognosis.

METHODS

Using reverse transcription-polymerase chain reaction (RT-PCR) assay, the expression of mdr-1 gene in 82 breast cancer samples was detected. The data were treated by statistic analysis system (SAS)-singlevariate analysis.

RESULTS

The level of mdr-1 gene expression clearly deviated from normal to right distribution (P < 0.0001), and thus might be divided by quantiles P50(mdr-1/beta 2-MG = 0.2) and P75 (mdr-1/beta 2-MG = 0.6), which were taken as the criteria for comparing 56 patients' chemosensitivity to ADM, VDS, VCR in vitro and 32 relapsed metastatic patients' chemotherapy response in vivo, seperately. When mdr-1/beta 2-MG < 0.2, the ratio of coincidence was lower between expression of mdr-1 and drug resistance in vitro and in vivo; When mdr-1/beta 2-MG > or = 0.2-< 0.6, the ratio of coincidence elevated slightly, but in 30%-50% of the cases drug resistance in vitro and in vivo did not correlate. When mdr-1/beta 2-MG > or = 0.6, the ratio of coincidence elevated significantly. According to the above-mentioned results, criteria of evaluating mdr-1 gene expression level was formulated: the mdr-1/beta 2-MG ratio < 0.2(P50) was considered as negative expression, the ratio > or = 0.2-< 0.6(P75) was weakly positive expression, > or = 0.6 was strongly positive expression.

CONCLUSIONS

The criteria of mdr-1 gene expression may reflect objectively drug resistance in vitro and chemotherapy response in vivo. The method may also be applicable to other tumours.

[A promoter responsible for over-expression of cholera toxin B subunit in cholera toxin A subunit structure gene]

A promoter sequence, which promotes the transcription of cholera toxin B subunit gene, was found in cholera toxin A subunit structure gene. The transcription starts at the adenine Located at +833, that is 456bp upstream to the A of the initiation codon ATG of cholera toxin B gene. Under the control of the promoter, cholera toxin B subunit was over-expressed as high as 200 mg/L at an optimized culture condition. The chloramphenicol acetyl transferase gene and beta-galactosidase could also be efficiently expressed under the direction of the promoter. This promoter may be responsible for the 6 fold and 7 fold higher expression level of cholera toxin B subunit than cholera toxin A subunit in V. cholerae and Escheria coli respectively. The over-expression of CTB may be useful in preparing vaccine against cholera and facilitating the construction of peptide-bearing immunogenic hybrid proteins.

Rapid-processing procedure for heat polymerization of polymethyl methacrylate in a pressure cooker with automatic controls

This study introduces a new rapid-processing procedure for curing polymethyl methacrylate denture base resin in an automatically controlled pressure cooker. The cooker filled with water was inflated with 6 kgf/cm2 air pressure and heated to 120 degrees C (248 degrees F) and maintained for 10 minutes. No significant differences were found between the new pressure cooker method and the conventional method for surface hardness and porosity (p > 0.05). The pressure cooker significantly shortened polymerization time, and the polymerization is controlled automatically.

[Cloning and screening on tumor-related genes inactivated in rat hepatoma cells. II. Reversion of malignant phenotype of hepatoma cells]

A rat normal expressing cDNA library was established and subsequently its whole DNA was transfected into CBRH-7919 rat hepatoma cell cultures. With neomycin selection and morphological distinction, several reversed colonies were isolated and subcloned. All these colonies showed decreased growth rates, reduced capacity for foci formation on soft agar and tumorigenicity in nude mice compared to CBRH-7919. Analysis of rescued plasmid cDNA from these colonies is under way.

Diagnosis of hepatitis C Virus (HCV) infection by antigen-capturing ELISA

BACKGROUND

Hepatitis C virus (HCV) is a major cause of non-A non-B hepatitis. Detection of circulating antibodies against HCV by enzyme-linked immunosorbent assay (ELISA) has provided the main approach for the diagnosis of HCV infection. Most ELISA kits use a mixture of core, NS3, NS4 and NS5 antigen as capture antigens and enzyme-labeled goat anti-human IgG as conjugate.

OBJECTIVES

To establish an ELISA system based on the antigen-capturing principle, using a recombinant chimeric polyprotein containing four HCV antigenic components as antigen.

STUDY DESIGN

HCV antigens were expressed in Escherichia coli as chimeric polyprotein either in inclusion bodies or in soluble form. Protein expressed in inclusion bodies was used as solid-phase antigen, and the antigen expressed in a soluble form was used as enzyme conjugate after being labeled with horseradish peroxidase (HRP).

RESULTS

Genes coding HCV antigens were cloned and sequenced, chimeric polyproteins containing four immunodominant components (core, NS3, NS4 and NS5) were expressed in E. coli both in soluble and in inclusion body form. These two chimeric proteins retained the antigenicity of HCV antigens. Antibody-capturing ELISA using the chimeric antigens showed a sensitivity of 97% (97/100) and a specificity of 98% (97/99) using the reference panel from the National Institute for the Control of Pharmaceutic and Biological Products of China (NICPBC); the same assay showed a sensitivity of 97.9% (48/49) and a specificity of 100% (43/43) using the self-established reference panel. Antigen-capturing ELISA was set up using the antigen labeled with horseradish peroxidase as conjugate, and was shown to be as sensitive as (97.9%) and more specific than (100%) antibody-capturing ELISA using the reference panel in this work. The antigen-capturing ELISA also showed a high accordance (98.9%) with UBI HCV enzyme immunoassay (EIA) 4.0 kits (United Biomedical Inc. USA).

CONCLUSION

Antigen-capturing ELISA provided a convenient, sensitive and more specific approach for the diagnosis of hepatitis C virus infection.

[Detection of expression of multidrug resistance gene in breast cancer by RT-PCR]

Using RT-PCR technique, we established a method for measuring expression of mdr-1 gene in breast cancer and the conditions affecting PCR results. Expression of mdr-1 gene was detected in 74 breast cancer samples. The results showed that 34.3%(12/35) untreated primary lesions and 59.0%(23/39) relapsed metastatic lesions had positive expression of mdr-1 gene (P < 0.05). In 32 patients, the overall correlation of mdr-1 gene expression with clinical drug sensitivity was 78.1%. The results validate that RT-PCR assay is highly sensitive, relatively quantitative and reliable for measuring levels of mdr-1 gene expression in clinical samples.

Immunologic basis of transplant-associated arteriosclerosis

Although immunosuppressive therapy minimizes the risk of graft failure due to acute rejection, transplant-associated arteriosclerosis of the coronary arteries remains a significant obstacle to the long-term survival of heart transplant recipients. The participation of specific inflammatory cell types in the genesis of this lesion was examined in a mouse model in which carotid arteries were transplanted across multiple histocompatibility barriers into seven mutant strains with immunologic defects. An acquired immune response--with the participation of CD4+ (helper) T cells, humoral antibody, and macrophages--was essential to the development of the concentric neointimal proliferation and luminal narrowing characteristic of transplant arteriosclerosis. CD8+ (cytotoxic) T cells and natural killer cells were not involved in the process. Arteries allografted into mice deficient in both T-cell receptors and humoral antibody showed almost no neointimal proliferation, whereas those grafted into mice deficient only in helper T cells, humoral antibody, or macrophages developed small neointimas. These small neointimas and the large neointimas of arteries grafted into control animals contained a similar number of inflammatory cells; however, smooth muscle cell number and collagen deposition were diminished in the small neointimas. Also, the degree of inflammatory reaction in the adventitia did not correlate with the size of the neointima. Thus, the reduction in neointimal size in arteries allografted into mice deficient in helper T cells, humoral antibody, or macrophages may be accounted for by a decrease in smooth muscle cell migration or proliferation.

[An experimental and clinical study on radix Salviae miltiorrhiae in the treatment of hepatocellular Ca2+ overload during hepatic ischemia/reperfusion injury]

In recent years there has been considerable interest concerning the role of hepatocellular Ca2+ overload which probably was a major factor in hepatic ischemia/reperfusion injury. We studied the effect of radix salviae miltiorrhizae (RSM) on cytosolic free calciumion concentration [(Ca2+)i](nM) in isolated hepatocytes in rats and patients with ischemia reperfusion by microflurometry using fluorescent (Ca2+)i indicator Fura-2/AM. Changes of lipid peroxide free radical (ROO.) signal ranges with in the liver tissue by ESR technique and those of hepatocellular ultrastructure by electronmicroscope were also observed. The results showed that RSM reduced levels of (Ca2+)i and ROO. Ymax (mm) ESR signal rangs. RSM had an effect on protecting hepatocytes against ischemia/reperfusion injury as a useful receptor-operated calcium channels (ROC) blocker.

Post-transcriptional stimulation of transforming growth factor beta 1 mRNA by TGF-beta 1 treatment of transformed human osteoblasts

Following exogenous administration of transforming growth factor-beta 1 (TGF-beta 1) polypeptide to the human osteosarcoma cell line TE-85, we observed a 2- to 6-fold stimulation of steady-state TGF-beta 1 mRNA. The stimulation was dose- and time-dependent, as judged from Northern blot hybridization analyses. A 2- to 6-fold increase of the TGF-beta 1 polypeptide was also found in the media of these cells after TGF-beta 1 treatments. The autostimulation of TGF-beta 1 mRNA was nullified by cycloheximide treatment of the cells. The in vitro transcription rates of the TGF-beta 1 gene by isolated nuclei were not altered by TGF-beta 1 treatment. Under conditions of transcriptional inhibition, the stability of TGF-beta 1 mRNA was enhanced nearly two-fold by TGF-beta 1 treatment. Our findings indicate that TGF-beta 1 can stimulate autologous gene expression and subsequent polypeptide translation by a post-transcriptional mechanism requiring protein synthesis in human osteoblast-like cells. The recognized versatility of TGF-beta 1 autostimulation mechanisms (transcriptional and post-transcriptional) in other mesenchymal cells may apply also to skeletal cells, further underscoring the broad and potent activities of this cytokine.

LEW-to-F344 carotid artery allografts: analysis of a rat model of posttransplant vascular injury involving cell-mediated and humoral responses

A key manifestation of chronic rejection is an obliterative arteriosclerosis. Myointimal thickening in the vessel is preceded by an endothelialitis involving accumulation of host mononuclear cells in the perivascular and intimal spaces. We report a paratopic LEW-to-F344 rat carotid artery transplantation model developed to study the cells, cytokines, and inflammatory response associated with this early phase of vascular immune injury. Compared with contralateral control arteries and isografts, LEW-to-F344 carotid allografts develop intimal thickening with mononuclear cell infiltration that persists (days 20, 45, 75, 90, and 120). Allografted vessels had dense collections of intimal and adventitial leukocytes (CD45+) consisting of equal numbers of T cells and macrophages. There were small but variable numbers of intimal smooth muscle cells. Intimal cells showed dense staining for tumor necrosis factor-alpha, interleukin-8, platelet-derived growth factor, iNOS, and ICAM and weaker labeling for interleukin-1 beta and interleukin-6. There was also prominent staining for interleukin-4 and interleukin-7 with no detectable interferon-gamma or interleukin-2 staining and high titer labeling for IgG1 (but not IgG2). The predominance of the T cell infiltrate coupled with interleukin-4 and IgG1 expression in carotid allografts is consistent with a TH2 response. This contrasts with balloon-injured rat carotids, which evoke a macrophage-dependent proliferative response. These findings demonstrate that there are distinct as well as common activation pathways in various forms of vascular injury and the LEW-to-F344 carotid model provides the opportunity to gain insight into molecular mechanisms regulating alloimmune injury in the vessel.

[Secretory immunoglobulin A in human milk and infants' feces at 1-4 months after delivery]

OBJECTIVE

To determine the concentration of secretory immunoglobulin A (SIgA) in human milk at 1, 2, 3 and 4 months after delivery and in infants' feces in the same period and find out the effect of milk on the content of SIgA in infants' intestine.

METHODS

20 women and 12 breast feeding infants and 13 formula feeding infants were studied, and milk and infants' feces were collected at 1, 2, 3 and 4 months after delivery, respectively. The concentrations of SIgA in milk and feces were determined by radioimmunoassay.

RESULTS

No apparent changes in the concentration of SIgA were found in human milk and feces from breast feeding and formula feeding infants at 1-4 months after delivery, but the concentration of fecal SIgA in breast feeding infants was significantly higher than that in the formula feeding infants, during the first 4 months after birth.

CONCLUSIONS

Human milk can provide a large amount of SIgA for infants. We conclude from these data that human milk is beneficial in protecting the immunological function of infants digestive tract.

Nucleotide sequence of maize dwarf mosaic virus capsid protein gene and its expression in Escherichia coli

The 3'-terminal 1,279 nucleotide sequence of maize dwarf mosaic virus (MDMV) genome has been determined. This sequence contains an open reading frame of 1,023 nucleotides and a 3'-non-coding region of 256 nucleotides. The open reading frame includes all of the coding regions for the viral capsid protein (CP) and part of the viral nuclear inclusion protein (NIb). The predicted viral CP consists of 313 amino acid residues with a calculated molecular weight of 35,400. The amino acid sequence of the viral CP derived from MDMV cDNA shows about 47%-54% homology to that of 4 other potyviruses. The viral CP gene was constructed in frame with the lacZ gene in pUC19 plasmid and expressed in E. coli cells. The fusion polypeptide positively reacted in Western blot with an antiserum prepared against the native viral CP.

Chinese character operating system of traditional Chinese medicine and pharmacology (TCMP)

With the development in research, teaching and literature work in traditional Chinese medicine and pharmacology (TCMP) by means of computers, it has been found that the existing Chinese character operative systems cannot meet the need of carrying out information processing and software development in this field, since these systems do not include many of the common and special terms in TCMP. This makes it inconvenient to exchange academic thoughts in information processing in this field with our colleagues at home and abroad and greatly affects the sharing of the literature data in TCMP. It is therefore necessary to develop a Chinese character operating system applicable to the use of computers in the research of TCMP. Recently, we have developed jointly a Chinese character operating system of TCMP. This system is based on the original GB2312-80 Chinese character international code, to which are added 1,150 Chinese characters commonly used in TCMP. The five-stroke code, which make input possible according to word forms, are used for the input of expanded words. Besides, the system also provides the codes of a number of common names of Chinese materia medica, acupoint names, common terms in traditional Chinese medicine (TCM), TCM disease names, names of classic TCM works, etc. It also provides a convenient character-creating software. We hope that our work will lead to discussions concerning the difficult problems in computer processing of TCMP literature, i.e. the Chinese character.

K-ras mutation in colorectal carcinomas from singapore

54 sporadic colorectal cancers were analyzed for aberrations in the K-ras oncogene. DNA was extracted from frozen tissues obtained from surgical resection and analyzed for mutations in codons 12, 13 and 61 of the K-ras oncogene using single strand conformation polymorphism analysis (SSCP) and direct sequencing. Point mutations in the K-ras oncogene were found in 26/54 (48%) cases, all of which resulted in amino acid substitutions. No other types of mutations (e.g. insertions or deletions) were found. 4 of the mutations were at codon 12, 22 in codon 13 and only 1 was a codon 61 mutant. G-->A transitions were found to be predominant. A remarkable finding was the high preponderance of (13)Gly-(13)Ser mutations (54%). No correlation was observed between K-ras mutations and tumor location, Dukes' stage, differentiation levels, age or sex of the patient.

[Cloning and screening on tumor-related genes inactivated in rat hepatoma cells]

The paper describes an experiment screening tumor-related genes which specifically expressed in rat normal liver cells but inactivated in hepatoma cells with subtractive hybridization technique. During the test, subtracting normal liver cDNA with hepatoma mRNA produces probe-A whereas subtracting hepatoma cDNA by normal liver mRNA gives probe-B. The paper shows six cDNA fragments (TR 1-6) which hybridize probe-A preferentially obtained through dot-blot screening of 2500 colonies with the two probes. Among TR 1-6, special expressions of TR 2 and TR 4 in normal liver cells are further analyzed.

Resistance of human immunodeficiency virus type 1 to acyclic 6-phenylselenenyl- and 6-phenylthiopyrimidines

Acyclic 6-phenylselenenyl- and 6-phenylthiopyrimidine derivatives are potent and specific inhibitors of human immunodeficiency virus type 1 (HIV-1). The development of in vitro resistance to two derivatives, 5-ethyl-1-(ethoxymethyl)-(6-phenylthio)-uracil (E-EPU), was evaluated by serial passage of HIV-1 in increasing concentrations of inhibitor. HIV-1 variants exhibiting > 500-fold resistance to E-EPSeU and E-EPU were isolated after sequential passage in 1, 5, and 10 microM inhibitor. The resistant variants exhibited coresistance to related acyclic 6-substituted pyrimidines and the HIV-1-specific inhibitors (+)-(5S)-4,5,6,7-tetrahydro-5- pyrimidines and the HIV-1-specific inhibitors (+)-(5S)-4,5,6,7-tetrahydro-5- methyl-6-(3-methyl-2-butenyl)imidazo[4,5,1-jk]benzodiazepin-2(1H)- thione (TIBO R82150) and nevirapine, but remained susceptible to 3'-azido-3'-deoxythymidine, 2',3'-dideoxycytidine, 2',3'-dideoxyinosine, and phosphonoformic acid. DNA sequence analysis of reverse transcriptase (RT) derived from E-EPSeU-resistant virus identified a Tyr (TAT)-to-Cys (TGT) mutation at either codon 188 (Cys-188; 9 of 15 clones) or codon 181 (Cys-181; 5 of 15 clones). The same amino acid changes were found in RT from E-EPU-resistant virus, but the Cys-181 mutation was more common (9 of 10 clones) than the Cys-188 mutation (1 of 10 clones). Site-specific mutagenesis and production of mutant recombinant viruses demonstrated that both the Cys-181 and Cys-188 mutations cause resistance to E-EPSeU and E-EPU. Of the two mutations, the Cys-188 substitution produced greater E-EPSeU and E-EPU resistance. The predominance of the Cys-188 mutation in E-EPSeU-resistant variants has not been noted for other classes of HIV-1 specific RT inhibitors. HIV-1 resistance is likely to limit the therapeutic efficacy of acyclic 6-substituted pyrimidines if they are used as monotherapy.