Application of multidisciplinary team-based integrated traditional Chinese medicine and Western medicine in rotator cuff injury patients undergoing arthroscopic surgery

BACKGROUND Arthroscopic rotator cuff repair is a common surgical treatment for rotator cuff injuries(RCIs).Although this procedure has certain clinical advantages,it requires rehabilitation management interventions to ensure therapeutic efficacy.AIM To investigate the effect of integrated traditional Chinese medicine and Western medicine(TCM-WM)under the multidisciplinary team(MDT)model on the postoperative recovery of patients undergoing arthroscopic surgery for RCIs.METHODS This study enrolled 100 patients who underwent arthroscopic rotator cuff repair for RCIs at the Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine between June 2021 and May 2024.They were divided into a control group(n=48)that received routine rehabilitation treatment and an experimental group(n=52)that received TCM-WM under the MDT model(e.g.,acupuncture,TCM traumatology and orthopedics,and rehabilitation).The results of the Constant–Murley Shoulder Score(CMS),Visual Analogue Scale(VAS),Shoulder Pain and Disability Index(SPADI),muscular strength evaluation,and shoulder range of motion(ROM)assessments were analyzed.RESULTS After treatment,the experimental group showed significantly higher CMS scores in terms of pain,functional activity,shoulder joint mobility,and muscular strength than the baseline and those of the control group.The experimental group also exhibited significantly lower VAS and SPADI scores than the baseline and those of the control group.In addition,the experimental group showed significantly enhanced muscular strength(forward flexor and external and internal rotator muscles)and shoulder ROM(forward flexion,abduction,and lateral abduction)after treatment compared with the control group.CONCLUSION TCM-WM under the MDT model improved shoulder joint function,relieved postoperative pain,promoted postoperative functional recovery,and facilitated the recovery of muscular strength and shoulder ROM in patients with RCIs who underwent arthroscopic rotator cuff repair.

Quality of life and survival analyses of breast cancer cases treated with integrated traditional Chinese and Western medicine

BACKGROUND Breast cancer(BC)is the second leading cause of tumor-related mortality after lung cancer.Chemotherapy resistance remains a major challenge to progress in BC treatment,warranting further exploration of feasible and effective alternative therapies.AIM To analyzed the quality of life(QoL)and survival of patients with BC treated with integrated traditional Chinese and Western medicine(TCM-WM).METHODS This study included 226 patients with BC admitted to the First Affiliated Hospital of Guangxi University of Traditional Chinese Medicine between February 2018 and February 2023,including 100 who received conventional Western medicine treatment(control group)and 126 who received TCM-WM treatment(research group).The total effective rate,side effects(alopecia,nausea and vomiting,hepatorenal toxicity,and myelosuppression),QoL assessed using the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire(EORTC QLQ-C30),1-year overall survival(OS),recurrence and metastasis rates,and serum inflammatory factors[interleukin(IL)-6,IL-10,and tumor necrosis factor alpha]were comparatively analyzed.RESULTS The research group showed statistically better overall efficacy,EORTC QoL-C30 scores,and 1-year OS than the control group,with markedly lower side effects and 1-year recurrence and metastasis rates.Moreover,the posttreatment levels of serum inflammatory in the research group were significantly lower than the baseline and those in the control group.CONCLUSION Overall,TCM-WM demonstrated significantly improved therapeutic efficacy while ensuring drug safety in BC,which not only improved patients’QoL and prolonged survival,but also significantly inhibited the inflammatory response.

Expert consensus on diagnosis and treatment of ulcerative colitis with integrated traditional Chinese and Western medicine:A nursing perspective

Ulcerative colitis(UC)is a chronic nonspecific intestinal inflammatory disease of unclear etiology,characterized by continuous and diffuse inflammatory changes of colorectal mucosa.In recent years,the incidence rate of UC in China has increased year by year,but there is no effective cure method in Western medicine.Traditional Chinese medicine treatment based on syndrome differentiation has the unique advantages of simplicity,convenience,effectiveness,and low cost.Therefore,integration of Chinese and Western medicine has become an important strategy for UC diagnosis and treatment,and has made significant progress in UC.On the basis of learning from a number of consensuses at home and abroad,combined with Chinese research results and the actual clinical situation of traditional Chinese and Western medicine,the UC group of the Chinese Association of Integrative Medicine has formulated the expert consensus on the diagnosis and treatment of UC with integrated traditional Chinese and Western medicine.In this consensus,the pathogenesis,etiology and pathogenesis,diagnosis,integrated traditional Chinese and Western medicine treatment,and chronic disease management with integrated traditional Chinese and Western medicine for UC were recommended by experts.This article interprets the consensus from the perspective of nursing in order to provide reference basis for clinical nursing workers.

Nursing perspective of expert consensus for diagnosis and treatment of gastric cancer with integrated traditional Chinese and Western medicine

Gastric cancer is a common and highly malignant tumor of the digestive system,which seriously threatens human health.The benefit of surgical treatment is limited.The effect of radiotherapy and chemotherapy is not significant,and the toxic and side effects are large.Although the diagnosis and treatment modes of molecular targeting and multidisciplinary cooperation have also been further developed and applied,a relatively unified comprehensive treatment standard scheme has not been formed.Traditional Chinese medicine(TCM),as complementary and alternative medicine,has unique advantages in the development of diagnosis and treatment of diseases in China.Therefore,the Chinese Association of Integrative Medicine formed“Expert Consensus for Diagnosis and Treatment of Gastric Cancer with Integrated Traditional Chinese and Western Medicine”on the basis of clinical practice and experience.In this article,the consensus is interpreted from the perspective of nursing,focusing on the pathogenesis,high‑risk factors,characteristic therapies of TCM,and nursing of integrated traditional Chinese and Western medicine for gastric cancer,to provide a reference for front‑line medical personnel in the roots in the future nursing care of gastric cancer.

Treatment of postpartum depression with integrated traditional Chinese and Western medicine nursing and electrical stimulation

BACKGROUND Postpartum depression(PPD)is a common psychological disease among puerperal women,and postpartum pelvic floor dysfunction is a common disease among pregnant women.The occurrence of postpartum pelvic floor dysfunction will increase the incidence of PPD.AIM To explore the therapeutic effect of integrated traditional Chinese and Western medicine nursing combined with electrical stimulation of pelvic floor muscles and the rectus abdominis on PPD.METHODS From April 2020 to January 2022,100 parturients with a rectus abdominis muscle separation distance>2.0 cm who underwent reexamination 6 wk after delivery at our hospital were selected as the research subjects.According to the random number table method,the patients were divided into either an observation group(n=50)or a control group(n=50).There was no significant difference in the general data between the two groups(P>0.05).Both groups were treated by electrical stimulation.The observation group was additionally treated by integrated traditional Chinese and Western medicine nursing.A self-designed Depression Knowledge Questionnaire was used to evaluate the awareness of knowledge on depression in all patients 3 wk after intervention.The Hamilton Depression Scale(HAMD)was used to evaluate the depression before intervention and 1 wk and 3 wk after intervention,and the Morisky Medication Adherence Scale(MMAS-8)was used to evaluate the medication compliance.SPSS19.0 was used for statistical analyses.RESULTS The rate of awareness of knowledge on depression in the observation group was significantly higher than that of the control group(P<0.05).The scores of MMAS-8 were comparable between the two groups before intervention(P>0.05),but were significantly higher in the observation group than in the control group at 1 wk and 3 wk after intervention(P<0.05).The HAMD scores were comparable between the two groups before intervention(P>0.05),but were significantly lower in the observation group than in the control group at 1 wk and 3 wk after intervention(P<0.05).CONCLUSION Integrated traditional Chinese and Western medicine nursing combined with electrical stimulation of pelvic floor muscles and the rectus abdominis is effective in the treatment of postpartum depression and worthy of clinical promotion.

Research progress of integrated traditional Chinese and Western medicine in the treatment of advanced gastric cancer

Gastric cancer(GC)is a malignant tumor originating from the gastric epithelium,and its incidence and mortality rates rank third among all malignant tumors worldwide.It is also one of the most common cancers in China and is treated predominantly by Western medicine in clinical practice.However,with the advancements in medical technology and informatics,the values of traditional Chinese medicine(TCM)in preventing and treating GC and improving prognosis have increasingly been recognized.According to TCM,clinical manifestations of GC can be divided into Yege(dysphagia),regurgitation,stomach pain,and Zhengxia(abdominal mass).Due to the unbalanced distribution of health care resources in China,most GC patients already have progressive or advanced-stage disease at the first diagnosis.As a result,most GC patients have poor physical function,and surgery or chemotherapy alone will aggravate the impairment to the immune function and seriously affect the quality of life.In contrast,TCM therapies have shown promising efficacy in the management of these patients.Here we review the role of the integrated TCM and Western medicine in treating advanced GC.

Nursing outcomes of traditional Chinese medicine adjunctive therapy on osteofascial compartment syndrome:a review

The rate of disability due to acute osteofascial compartment syndrome(OCS)is high,and the therapeutic effect of decompressive fasciotomy is not ideal.This paper retrospectively reviews the modern treatment of OCS,including Western medicine and Traditional Chinese medicine(TCM),mainly in the context of the advantages of TCM in the treatment process of decompressive fasciotomy or conservative treatment to the patients who are suffering from OCS.It was found that TCM treatment reduced the levels of serum creatine kinase(CK),lactate dehydrogenase(LDH),and aspartate aminotransferase(AST);it is beneficial to the elimination of swelling and pain.TCM adjunctive therapy promotes patients’postoperative functional recovery and decreases the occurrence of fasciotomy in patients;TCM can relieve tissue hypoxia of compartments and prevent necrosis of muscle and nerve tissue.TCM treatment improves the quality of medical service and ensures the safety of OCS patients.This paper aims to summarize the function of TCM in the treatment of OCS,provide reference for the clinical treatment of OCS,and improve the nursing/medical outcomes of OCS.

Application of integrated traditional Chinese and Western medicine in the treatment of juvenile localized scleroderma with skin ulcer: a case report

Background:Juvenile Localized Scleroderma(JLS)is a rare pediatric rheumatic disease characterized by inflammation and skin sclerosis.The side effect of consensus-recommended medications and the risk of disability posed challenges to the JLS treatment.We intend to demonstrate the potential of traditional Chinese medicine in treating JLS with skin ulcers and reducing the dose of glucocorticoid.Method:Here we report a case of a 13-year-old male with JLS who took oral methotrexate tablets of 10 mg/week and methylprednisolone of 6 mg/day for over six months without significant effect and suffered from skin ulcers on the dorsal feet one month after drug cessation.Subsequently,the patient was treated with integrated traditional Chinese and Western medicine of low-dose glucocorticosteroid,adjusted Shenqi Huoxue formula and Jinshe Xiaoyan formula,etc.Results:After integrated treatment,the patient’s dorsal feet ulcers healed and the skin sclerosis and hyperpigmentation improved significantly.Conclusions:This case report suggests that integrated traditional Chinese and Western medicine can be used as an effective treatment for JLS.

Research on the Reform of“Traditional Chinese Medicine Nursing”Teaching Based on the Concept of Outcome-Based Education

Continuously evolving teaching concepts and the adoption of diverse teaching methods have led to outcome-oriented education becoming a fundamental focus of teaching reform in colleges and universities.In this article,the“Traditional Chinese Medicine Nursing”course is used as an example to discuss the reform of education based on the concept of outcome-based education,with the purpose of improving students'learning outcomes and practical skills.

Teaching Reform of “Nursing of Traditional Chinese Medicine” Course Based on OBE Concept

Traditional Chinese medicine(TCM)nursing is one of the important disciplines in TCM.It is based on TCM theory and combined with modern nursing theory and technology,aiming to provide comprehensive and individualized nursing services.With the changes in the medical environment and the continuous improvement of people’s health needs,the teaching of TCM nursing is facing new challenges and opportunities.This paper aims to discuss the teaching reform of TCM nursing course based on the concept of outcome-based education(OBE)or student-centered teaching.The significance of this study is to provide theoretical basis and practical guidance for the teaching reform of TCM nursing course,and to promote the development and progress of TCM nursing education.Through the teaching reform based on OBE concept,we can better cultivate TCM nursing talents with innovative spirit and practical skills,and contribute to the development of TCM.

Therapeutic Effect of Integrated Traditional Chinese and Western Medicine on Anal Pruritus After Anorectal Surgery

Objective:To explore the therapeutic effect of integrated traditional Chinese and western medicine on anal pruritus after anorectal surgery.Methods:Ninety-eight patients with anal pruritus after anorectal surgery in our hospital were selected as the research subjects.They were divided into two groups,the control group(50 cases)and the study group(48 cases),according to the treatment plan.The control group was under a simple western medicine treatment plan,while the study group was under an integrated traditional Chinese and western medicine treatment plan.The overall efficacy,severity of anal pruritus,time to eliminate clinical symptoms,and anxiety and depression scores of the two groups of patients under different treatment plans were compared.Results:After two weeks of treatment,the total effective rate of the study group was 95.83%,which was significantly higher than that of the control group(82.00%,P<0.05).After 7 and 14 days of treatment,the anal pruritus scores improved significantly in both the groups,but the study group was superior to the control group,with statistical difference(P<0.01).The time of disappearance of skin itching and skin damage in the study group was shorter than that in the control group.After 14 days of treatment,the anxiety and depression scores of both groups were lower than those after 7 days of treatment;however,there was statistical difference between the two groups(P<0.01).Conclusion:In the clinical treatment of anorectal postoperative diseases,such as anal pruritus,the combination of traditional Chinese and western medicine can significantly improve the symptoms of pruritus,shorten the time of disappearance of clinical symptoms,improve depression and anxiety,and create a positive clinical application value in promoting the rehabilitation of patients and improving their quality of life.

A Clinical Study of Integrated Traditional Chinese and Western Medicine in the Treatment of Liver-Stomach Disharmony Functional Dyspepsia

Objective:To explore the clinical effect of integrated traditional Chinese and Western medicine in the treatment of liver-stomach disharmony functional dyspepsia.Methods:Sixty patients with functional dyspepsia of liver-stomach disharmony type admitted to our hospital from January to August 2022 were selected as research subjects and randomly divided into two groups,a study group and a control group,with 30 cases in each group.The main observations were stomachache or pain over bilateral flanks,emotionally depressed,belching,fullness and discomfort over the abdomen and flanks,acid regurgitation,loss of appetite,frequent sighing,noisy epigastric,and the treatment effect.Results:According to the classification of symptom severity on the traditional Chinese medicine(TCM)symptom score table,statistics were made on the corresponding severity of the main symptoms and secondary symptoms of the two groups of patients,and the data of the two groups were compared by Wilcoxon test.The results showed that there was no significant difference in the distribution of TCM symptoms between the two groups;the study group’s total effective rate of pain relief(recovery+markedly effective+effective)was 96.67%,and Fisher’s χ^(2) test indicated a significant difference in the total effective rate of pain relief between the two groups(P=0.027<0.05).Conclusion:The use of integrated traditional Chinese and western medicine is clearly better than the simple application of western medicine.It is safe and has no side effects.It can be used as a treatment for patients with functional dyspepsia.

Nursing perspective of Guidelines for Diagnosis and Treatment of Gout with Integrated Traditional Chinese and Western Medicine

Gout is a common rheumatism and its long-term recurrent attacks can cause joint destruction and deformity,even disability,which seriously affects the quality of life of patients.Chinese medicine plays a unique advantage in the treatment and rehabilitation of gout.To further standardize the diagnosis and treatment of gout with integrated traditional Chinese and Western medicine,the Chinese Association of Integrative Medicine issued the Guidelines for Diagnosis and Treatment of Gout with Integrated Traditional Chinese and Western Medicine in August 2021.Expert recommendations were made on the etiology and pathogenesis;diagnosis and classification standards;patient health management;and integrated traditional Chinese and Western medicine treatment,prevention,and nursing of gout.This article interprets the guidelines from the nursing point of view,focusing on the detailed explanation of diet care,functional exercise,and appropriate techniques of traditional Chinese medicine for gout,in order to provide better clinical reference for high-quality nursing services for gout patients.

Nursing perspective of expert consensus on the diagnosis and treatment of cerebral infarction with integrated traditional Chinese and Western medicine

Cerebral infarction(CI)is also known as ischemic stroke.It is one of the most common cerebrovascular diseases,with high mortality and disability rate,which has seriously threatened human health.To better apply the diagnosis and treatment plan of integrated traditional Chinese and Western medicine to the treatment of patients with CI,the Chinese Association of Integrative Medicine issued the Expert Consensus on the Diagnosis and Treatment of Cerebral Infarction with the Integrated Traditional Chinese and Western Medicine in 2021.It involves etiology and pathogenesis of CI,diagnosis and treatment standards of Traditional Chinese Medicine(TCM)and Western Medicine,syndrome elements of TCM,as well as rehabilitation nursing of CI with integrated traditional Chinese and Western medicine during acute period and recovery period.This study interprets the consensus from routine nursing,dietary nursing,emotional nursing,complication nursing,rehabilitation nursing,and continuous nursing,aiming to provide evidence-based support for clinical TCM nursing practice.

Nursing perspective of expert consensus for diagnosis and treatment of colorectal cancer with integrated traditional Chinese and Western medicine

As one of the most common malignant tumors in the world,colorectal cancer(CRC)is accompanied by a variety of symptoms in the process of disease development and treatment,which seriously affect the functional state and quality of life of patients.In China,comprehensive intervention measures of traditional Chinese medicine(TCM)play an indispensable role in the treatment and rehabilitation of CRC.In order to further standardize and improve the treatment and management of CRC by medical staff,the Chinese Association of Integrative Medicine issued the“Expert Consensus for Diagnosis and Treatment of Colorectal Cancer with Integrated Traditional Chinese and Western Medicine”in August 2021.This paper interprets this consensus in detail from the perspective of nursing,focusing on the common understanding of the pathogenesis of CRC,TCM diagnosis and syndrome differentiation,integrated traditional Chinese and Western medicine nursing,TCM characteristic therapies,etc.,with a view to deepening the understanding and practical application of the consensus among clinical doctors and nurses and improving the level of diagnosis,treatment,and nursing of CRC.

Construction of nursing standard of integrated traditional Chinese and Western medicine for patients with COVID‑19 (mild and common) in Beijing based on Delphi method

Objective:The objective of this study is to establish a nursing standard of integrated traditional Chinese and Western medicine for patients with COVID‑19(mild and common)in Beijing,to provide reference for clinical nursing of patients with COVID‑19(mild and common).Methods:Through online communication meeting with nurses who are in the frontline of anti‑epidemic,clinical investigation,literature research,and expert demonstration meeting are carried out to prepare the draft of the standard,and the Delphi method is applied to determine the standard of integrated traditional Chinese and Western medicine care for patients with COVID‑19(mild and common)in Beijing.Results:The nursing standard of integrated traditional Chinese and Western medicine for patients with COVID‑19(mild and common)was established,which included 5 first‑level indicators,14 second-level indicators and 60 third‑level indicators.After two rounds of Delphi method,the positive coefficients of experts were 96%and 83%,the authoritative coefficients of experts were 0.89 and 0.91,and the Kendall’s coefficient of concordance(W)of experts were 0.12,0.09,0.10,0.13(P<0.05)and 0.44,0.43,0.37,0.39(P<0.05).Conclusion:The standard of integrated traditional Chinese and Western medicine nursing for patients with COVID‑19(mild and common)in Beijing constructed by the Delphi method is scientific and practical,which provides a reference for clinical application of integrated traditional Chinese and Western medicine nursing to fight against COVID‑19 infection.

Discussion on reprogramming of tumor energy metabolism and intervention of traditional Chinese medicine based on the theory of“collateral Q i stagnation”

The theory of stagnation of collateral Qi(Chinese medicine refers to the most fundamental and subtle substances thatconstitute the human body and maintain life activities,and also has the meaning of physiological functions)originates from the theory of collateral disease,which refers to the deficiency of Qi in the body’s collaterals,the loss of Qi and blood,and the failure of stagnation of collateral Qi,which leads to the loss of Qi,blood and body fluid,and the formation of pathological products such as deficiency,depression,phlegm,blood stasis in the local area,and ultimately damage the pathological process of collaterals.Based on the in-depth study of the pathogenesis of collateral Qi stagnation and the previous study of meridian channels,we believe that the key pathogenesis of the formation,evolution and spread of malignant tumors is“collateral Qi deficiency stagnation,collateral Qi stagnation and collateral Qi decay”.As an important energy resonance channel of the body,meridians play a key role in the process of material transformation and energy metabolism.It is believed that the small focus caused by the pathogenesis of stagnation is the cause of malignant transformation of tumor,the reprogramming of energy metabolism induced by the lesion of collateral Qi is the basis of the progress of tumor pathogenesis,and the formation of tumor microenvironment regulated by the tumor toxin vena is the root of alienation of tumor development.Guided by this theory,focusing on the correlation between collateral Qi and tumor energy metabolism,using Professor Hua Baojin's treatment method of“Regulating Qi and detoxifying”to prescribe drugs can adjust collateral Qi function,achieve the relative balance of internal environment,and then inhibit the progress of tumor.Based on the above understanding,this study tries to enlighten new diagnosis and treatment ideas under the guidance of“stagnation of collateral Qi”in traditional Chinese medicine,in order to provide some theoretical support for the intervention of traditional Chinese medicine in the process of tumor development.

Methodological exploration on the construction of a traditional Chinese medicine nursing expert consensus based on evidence--taking stroke as an example

Objective: To explore the methodology of the evidence-based expert consensus formulation process of traditional Chinese medicine(TCM) nursing taking stroke as an example.Methods: First, preliminary and comprehensive presentation of all stroke-related symptoms and corresponding TCM nursing techniques involved were revealed through bibliometric analysis. Then, selection of stroke symptoms and TCM nursing techniques for inclusion in the consensus was performed using an expert consultation method. Next, we determined the search strategy for a precise evidence search;conducted an evaluation of evidence quality and the grade of the evidence;and completed evidence extraction, evidence analysis, and evidence synthesis based on the included symptoms and TCM nursing techniques. The Delphi method was then applied to determine the strength of each recommendation and the choice of nursing care points by referring to the Grading of Recommendations, Assessment, Development, and Evaluations grid. Finally, we conducted an external expert validation of the Delphi results to form an expert consensus guideline.Results: Through the bibliometric analysis, 22 stroke symptoms and 18 TCM nursing techniques were identified in the literature. Then, after expert consultation, 22 symptoms and 111 pairs of symptoms combined with TCM nursing techniques were selected for the evidence search. Evidence integration yielded 10 stroke symptoms corresponding to 29 bodies of evidence;these 10 symptoms were retained through the Delphi consultation, and recommendation strength results for 26 recommendations were obtained. A total of 9 symptoms were further retained for expert external validation to form 24 recommendations, with a recommendation process score range of 7.64-9.99 points and a more scientific and standardized recommendation-formation process.Conclusion: Owing to the current limited conditions of evidence-based resources for TCM nursing, the present consensus-building process represents only a preliminary exploration of an evidence-based expert consensus for TCM nursing to provide a reference for a more scientific and standardized methodology.

Therapeutic Effects of Integrated Traditional Chinese Medicine and Western Medicine in Treating Severe Acute Respiratory Syndrome

Objective: To improve the effects of treatment of severe acute re spiratory syndrome (SARS) and to explore the clinical significance of integrate d traditional Chinese medicine and western medicine (ICWM) in the treatment of S ARS and its influence on the chief indexes in the process of the disease. Methods: The clinical study involving observation of 135 patients of SARS was conducted in the randomized, synchronously controlled and open way. The patients were divided into two groups, 68 in the ICWM group and 67 in the c ontrol group, all of whom were treated with the same basic treatment of western medicine, but to the ICWM group, Chinese drugs for clearing Heat, detoxifying an d removing Dampness were given additionally. The comprehensive effect on relievi ng fever, cell mediated immunity, pulmonary inflammation and secondary infect ion was compared between the two groups. Results: The therapeutic effect in the ICWM group was better than that in the control group in such aspects as steadily lowering body temperature, alleviating general symptoms, accelerating the absorption of pulmonary infiltra tion and easing cellular immunity suppression. Conclusion: The therapeutic effect of ICWM is better in treating SARS than that of western medicine alone.

Construction thoughts and practice of Traditional Chinese Medicine nursing inheritance work

Master-apprentice system is a main mode of talent cultivation for Traditional Chinese medicine(TCM). To vigorously push forward inheritance and innovation of TCM nursing, Beijing Administration of Traditional Chinese Medicine carried out TCM nursing inheritance work in 2016, establishing 3 studios and 1 workstation. In this paper, we summarized constructional methods and achievements in TCM nursing inheritance studios and workstation, raised issues during working, and thought about how to work in the next stage, in hoping to lay a good foundation for carrying out in-depth work about TCM nursing inheritance.