High fat diet, prostate cancer prone
Diets high in saturated fat increase the risk of prostate cancer. As per a report from University of Texas M. D. Anderson Cancer Center in Houston published in the International Journal of Cancer:
Take home messages
- Men who consume high saturated animal fat diet are two times more likely to experience disease progression after prostate cancer surgery than men with lower saturated fat intake.
- There is also shorter "disease–free" survival time among obese men who eat high saturated fat diet compared with non–obese men consuming diets low in saturated fat.
- Men with a high saturated fat intake had the shortest survival time free of prostate cancer (19 months)
- Non–obese men with low fat intake survived the longest time free of the disease (46 months).
- Non–obese men with high intake and obese men with low intake had "disease–free" survival of 29 and 42 months, respectively.
- High saturated fat diet has been linked to cancer of the prostate
- Reducing saturated fat in the diet after prostate cancer surgery can help reduce cancer progression.
- Cancer prostate has the same risk factors as that of heart blockages and both are linked to high saturated fat intake.
- With an increase in number of heart patients, a corresponding increase in prostate cancer patients is also seen in the society.
213th Meeting of the Central Working Committee of Indian Medical Association at Hotel Radisson Blu, New Delhi.
- Review of data from two Women's Health Initiative clinical trials reveals the varying effects of menopausal hormone therapy on the incidence of breast cancer over time. Researchers noted that while combined hormone therapy was associated with increased breast cancer risk, the use of estrogen alone was not. The results are published in the journal JAMA Oncology.
- Breathing problems during sleep, such as heavy snoring and sleep apnea, may be associated with earlier decline in memory and thinking skills, suggests a new study published in the journal Neurology.
- New research suggests that the presence of ultrasound (US)-detected bone erosions is not specific for rheumatoid arthritis (RA), but erosions of RA are generally more extensive than for other diseases.
- Glucose tolerance is lower in the evening than in the morning, and the body's internal clock and misalignment of that clock with behavior can affect the level of tolerance, suggests a new study published in Proceedings of the National Academy of Sciences of the United States of America.
- A study from UK has identified six types of obese people: young males who were heavy drinkers, middle aged individuals who were unhappy and anxious, older people who despite living with physical health conditions were happy, younger healthy females, older affluent healthy adults and individuals with very poor health. According to the study, those who have a BMI of 30 or over fit into one of the six groups and treatment approaches should be tailored according to which group they fall into.
Dr KK Spiritual Blog
Why do we never eat a breakfast of onion?
Anything which cannot be taken as a full meal is not good for health and either should not be taken or taken in a small amount. For example, we never eat a breakfast of onion or garlic or radish. These are food items, which either should not be taken or eaten only in small quantity only as an accompaniment to the main meal. Onion is good for health. It has anti–cholesterol and blood thinning properties, yet it is consumed only in small quantity. In Vedic language, onion has both rajasik and tamasik promoting properties, which make a person more aggressive and dull.
- Cholesterol targets stay, according to new, more comprehensive American Association of Clinical Endocrinologists (AACE) guidelines for type 2 diabetes management that address both glycemic control and risk factors. The group did not endorse the American Heart Association/American College of Cardiology (AHA/ACC)'s lipid and obesity guidelines in 2013 that eliminated LDL goals and had called for its members to use AACE guidelines instead.
- Results of a study on the use of dabigatran (Pradaxa, Boehringer Ingelheim) in patients with atrial fibrillation within a large US healthcare system reveal considerable site-level variation in adherence to the novel oral anticoagulant (NOAC). The study is published in the April 14, 2015 issue of the Journal of the American Medical Association.
- Using disposable diapers instead of cloth diapers in neonatal intensive care units (NICUs) may reduce hospital-acquired infections and costs in developing countries, suggests new research from India published in the Journal of Tropical Pediatrics.
- A new report from the Centers for Disease Control and Prevention (CDC) and the FDA's Center for Tobacco Products revealed that the use of electronic cigarettes tripled among middle and high school students between 2013 and 2014. The report is published online in Morbidity and Mortality Weekly Report.
Situation: A patient developed high altitude cerebral edema while traveling to Leh.
Reaction: Oh my God! Why was acetazolamide not started before the journey?
Lesson: Make sure all high–risk patients are given acetazolamide before they go to mountains.
Dr Good Dr Bad
Situation: A hypertensive patient had cough that was not responding to treatment.
Dr. Bad: Take an X–ray.
Dr. Good: Stop ACE inhibitors.
Lesson: The commonest cause of cough in a patient with high blood pressure is the intake of ACE inhibitors.
A Touching Story from a Father
My wife called, ‘How long will you be with that newspaper? Will you come here and make your darling daughter eat her food?’
I tossed the paper away and rushed to the scene. My only daughter Sindu looked frightened.
Tears were welling up in her eyes. In front of her was a bowl filled to its brim with Curd Rice. Sindu is a nice child, quite intelligent for her age. She has just turned eight. She particularly detested Curd Rice. My mother and my wife are orthodox, and believe firmly in the ‘cooling effects’ of Curd Rice! I cleared my throat, and picked up the bowl.
‘Sindu, darling, why don’t you take a few mouthful of this Curd Rice? Just for Dad’s sake, dear.’
Sindu softened a bit, and wiped her tears with the back of her hands.
‘OK, Dad. I will eat – not just a few mouthfuls, but the whole lot of this.’
But, you should…’ Sindu hesitated. ‘Dad, if I eat this entire curd Rice, will you give me whatever I ask for?’
Oh sure, darling’… ‘Promise? ‘Promise’.
I covered the pink soft hand extended by my daughter with mine, and clinched the deal.
‘Ask Mom also to give a similar promise’, my daughter insisted.
My wife put her hand on Sindu’s, muttering ‘Promise’. Now I became a bit anxious.
‘Sindu dear, you shouldn’t insist on getting a computer or any such expensive items. Dad does not have that kind of money right now. OK?–
‘No, Dad. I do not want anything expensive’.
Slowly and painfully, she finished eating the whole quantity.
I was silently angry with my wife and my mother for forcing my child to eat something that she detested. After the ordeal was through, Sindu came to me with her eyes wide with expectation. All our attention was on her.
‘Dad, I want to have my head shaved off, this Sunday!’ was her demand.
‘Atrocious!’ shouted my wife, ‘A girl child having her head shaved off? Impossible!’ ‘Never in our family!’ my mother rasped. ‘She has been watching too much of television. Our culture is getting totally spoiled with these TV programs!’
‘Sindu darling, why don’t you ask for something else? We will be sad seeing you with a clean–shaven head.’
‘No, Dad. I do not want anything else’, Sindu said with finality.
‘Please, Sindu, why don’t you try to understand our feelings?’
I tried to plead with her.
‘Dad, you saw how difficult it was for me to eat that Curd Rice’. Sindu was in tears. ‘And you promised to grant me whatever I ask for.
Now, you are going back on your words. Was it not you who told me the story of King Harishchandra, and its moral that we should honor our promises no matter what?’
It was time for me to call the shots.
‘Our promise must be kept.’
‘Are you out your mind?’ chorused my mother and wife.
‘No. If we go back on our promises, she will never learn to honor her own. Sindu, your wish will be fulfilled.’
With her head clean–shaven, Sindu had a round-face, and her eyes looked big and beautiful.
On Monday morning, I dropped her at her school. It was a sight to watch my hairless Sindu walking towards her classroom. She turned around and waved. I waved back with a smile. Just then, a boy alighted from a car, and shouted, ‘Sinduja, please wait for me!’
What struck me was the hairless head of that boy.
‘May be, that is the in–stuff’, I thought. ‘Sir, your daughter Sinduja is great indeed!’ Without introducing herself, a lady got out of the car, and continued, ‘that boy who is walking along with your daughter is my son Harish. He is suffering from… … leukemia.’ She paused to muffle her sobs.
‘Harish could not attend the school for the whole of the last month. He lost all his hair due to the side effects of the chemotherapy. He refused to come back to school fearing the unintentional but cruel teasing of the schoolmates.
Sinduja visited him last week, and promised him that she will take care of the teasing issue. But, I never imagined she would sacrifice her lovely hair for the sake of my son! Sir, you and your wife are blessed to have such a noble soul as your daughter.’
I stood transfixed. And then, I wept. ‘My little Angel, you are teaching me how selfless real love is!’
The happiest people on this planet are not those who live on their own terms but are those who change their terms for the ones whom they love.
Life is short, the vanities of world are transient but they alone live who live for others; the rest are more dead than alive.
Heart disease starts in youth
Autopsy studies of young people who died in accidents have shown that by the late teens, the heart blockages, the kind of lesions that cause heart attacks and strokes are in the process of developing. The best opportunity to prevent heart disease is to look at children and adolescents and start the preventive process early. More than a third of children and adolescents are overweight or obese.
The first signs that men are at higher risk of heart disease than women appear during the adolescent years despite the fact that boys lose fat and gain muscle in adolescence, while girls add body fat.
Between the ages of 11 and 19, levels of triglycerides, a type of blood fat associated with cardiovascular disease, increases in the boys and drops in the girls. Levels of HDL cholesterol, the "good" kind that helps keep arteries clear, go down in boys but rise in girls.
Blood pressure increases in both, but significantly more in boys. Insulin resistance, a marker of cardiovascular risk, which is lower in boys at age 11, rises until the age of 19 years.
Any protection that the young women have for cardiovascular protection can be wiped out by obesity and hence obesity in girls at any cost should be handled on priority.
What It Means
Five year old Becky answered the door when the Census taker came by.
She told the Census taker that her daddy was a doctor and wasn’t home, because he was performing an appendectomy.
"My," said the census taker, "that sure is a big word for such a little girl. Do you know what it means?"
"Sure! Fifteen hundred bucks and that doesn’t even include the anesthesiologist!"
All of the following statement regarding management of side effects of hormonal therapy are correct except
1. Vaginal bleeding is a warning sign for possible endometrial cancer or pathology in postmenopausal women on tamoxifen.
2. Fluoxetine is the "selective serotonin reuptake inhibitors (SSRI)" of choice for the management of hot flushes in women taking tamoxifen.
3. Estrogen replacement therapy is contraindicated in women with ER/PR positive breast cancer for managing hot flushes and bone loss.
4. Gabapentin is an active agent for the management of tamoxifen related hot flushes.
Yesterday’s Mind Teaser: Which of the following statements regarding tamoxifen is correct?
1. Compared with AIs, tamoxifen has been associated with a decreased risk of venous thromboembolic events.
2. Similar to AIs in post menopausal women, tamoxifen increases the risk of bone loss and osteoporosis.
3. In post menopausal women, tamoxifen has shown better efficacy than inhibitors.
4. Tamoxifen may be associated with an increased risk of ischemic cereborvascular complications.
Answer for yesterday’s Mind Teaser: 1. Unlike tamoxifen, AIs are associated with an increased risk of endometrial cancer.
Correct Answers received from: Dr G Madhusudhan, Dr Shangarpawar, Vasanti Thote, Dr K Raju.
Answer for 17th April Mind Teaser: 1. Unlike tamoxifen, AIs are associated with an increased risk of endometrial cancer.
Correct Answers received: Dr Shangarpawar, Vasanti Thote, Tukaram Pagad.
Dear Sir, Thanks for providing the useful information. Regards: Dr Priti
Rabies News (Dr A K Gupta)
What is the incubation period in animals?
The incubation period in dogs and cats is 10 days to 6 months; most cases become apparent between 2 weeks and 3 months. In cattle, an incubation period from 25 days to more than 5 months has been reported (in vampire bat–transmitted rabies).
IJCP Book of Medical Records
Total CPR since 1st November 2012 – 101090 trained
Video of the Day
Sameer Malik Heart Care Foundation Fund
Conference Update - Diabetes India 2015
Type 2 diabetes: Insulin resistance or calorie resistance
Prof Philip Home, Newcastle upon Tyne
Why are sulfonylurea drugs different from other hypoglycemic drugs?
- Classically type 2 diabetes is described as being due to insulin resistance secondary to obesity and inactivity, with a failure of compensatory insulin secretion. However, after decades of research there has been a failure to understand the biochemical pathways of these two defects.
- Insulin resistance may however just be an artefact of measurement. Of rather it is a concept because we can measure the poor response of the tissues to insulin. Poor responses to insulin may not be due to defects in the insulin signaling pathway, but rather to defects or adaptations of cellular metabolism within the effector cell.
- In that regard we know the key organ in type diabetes is the liver. We also know that with low calorie diets it is possible to nearly normalize glucose output within 7 days, at a time when fatty liver is not corrected, and of course the person with diabetes is still obese. So type 2 diabetes is probably a disease of calorie excess, with co-causation for obesity.
- The mechanisms by which excess substrate (calorie) load on the liver can result in excess glucose out are becoming clearer. They probably work through fundamental pathways related to those that have always enabled adaptation to different food sources. A possibility is that a need for intra-cellular phosphate homeostasis regulates the system.
- This has consequences for medication design, and our understanding of how some of our current medications work, and why they are of limited efficacy.
Prof Zeljko Metelko, Croatia
- Sulfonylureas (SUs) are the strongest hypoglycemics in non insulin medication group.
- Approach to SU treatment has to be more similar to the insulin treatment than other oral drugs.
- Scientific and EBM data about SUs are known, but individual patient reactivity is unknown.
- Because of hypoglycemic action of SU, BG self control should be very similar to self control with insulin treatment
- Better distribution of SU medication during the day, based on BG self-control: Can reduce the number of hypoglycemics, can reduce body weight increase, prolong beta cell life
It is estimated that 2 million deaths occur every year from contaminated food or drinking water.
World Medical Association
Request for Comments on WMA Declaration on Ethical Considerations regarding Health Databases and Biobanks (Draft)
The World Medical Association’s Declaration of Helsinki provides guidelines for medical research on human beings. It aims to promote the ethical conduct of research and to protect human subjects from associated risks.
The Declaration of Helsinki was the first international research guideline that required research participants to provide informed consent. This concept was not invented by WMA, but it was the WMA that successfully promoted it for the first time in a global policy. Informed consent, although not perfect, is the strongest instrument for protecting personal autonomy, and with it self-determination and dignity. It is the primary means for all potential research subjects to express their will and/or preferences. We consider it a crucial instrument for protection and respect.
Research is changing. Large collections of data and human specimens allow for the development of new research strategies and models, as well as new predictive types of research and analysis. The combination of large amounts of data, the possibility of combining large databases and the application of information technology is already changing all aspects of our lives. Research is no exception.
The potential of such databases is vast, but so are the dangers. While there is a strong possibility of finding solutions, cures and remedies for a multitude of medical problems, illnesses and suffering, the challenge lies in the high potential for the abuse and misuse of health databases and biobanks. We are convinced that the answer to this dilemma is to be found in an ethically correct process which takes into account the willingness and trust of those donating and sharing their data (or specimens) as well as acknowledging the obligation to apply high standards of protection.
It is clear that the “one-by-one” approach, which has so far been taken in obtaining informed consent for any physical experiment, must be retained because of the immediate impact upon subjects. However, we also acknowledge that the use of personal health data and specimens can lead to similar or comparable damage and likewise requires the protection of donors. While physical experiments allow and require direct contact with the subject, the use of databases and biobanks allows for the frequent use of data sets. Therefore, if gaining consent from donors of the data or specimens were to be a “conditio sine qua non” for their use it could entail multiple problems or even be prohibitive as it may no longer be possible to contact the donors, or the high frequency of requests for use could become a burden upon them.
One solution could be the use of anonymised, pseudonomised and potentially aggregated data which protects personal integrity and eliminates the risk of harm to the donor. At this point it is helpful to note that, in contrast to physical experimentation scenarios, with databases or biobanks the holder of the data will often be separate from the researcher using the data. This separation allows for stronger protections against the reidentification of individuals than in the classical setting of physical experiments where identification is crucial for protection. However, even anonymisation and pseudonomisation will not always be possible or feasible, and the possibility of consent that accepts the use of data or specimens on more than one occasion should be considered (broad consent).
Furthermore, it must be acknowledged that the potential for harm will often be minimal or even non-existent when using only data or specimens as compared to physical experimentation. Prohibiting research simply out of respect for a non-relevant principle would not be desirable. But giving up the principle would not be an option either. Finally, we know that harm and discomfort can also occur as a consequence of the abuse or the mishandling of health information. This is one of the reasons for patient confidentiality and medical secrecy in general.
A WMA work group chaired by the Icelandic Medical Association has developed a draft guideline in the form of a “DECLARATION ON ETHICAL CONSIDERATIONS REGARDING HEALTH DATABASES AND BIOBANKS”, which advises a balanced approach by requesting broad consent from the donors of data or specimens indicating their preparedness to share or donate their data or material for later use, which at the time of donation or sharing cannot be definitely described. However, this broad consent will be conditional upon a governance process, which can partly substitute individual informed consent or ensure that informed consent will be obtained at a later date if it is deemed necessary by an independent ethics committee.
In analysing the already existing scenarios for the use (and abuse) of health data and biobanks, the work group came to the conclusion that the major risk scenarios do not result from science, but from the commercial, administrative or political use of such data. Limiting our guidelines to research only would have left us blind to the imminent risk of abuse from outside the field of medicine: commercialisation, cost-cutting and potential political abuse.
Therefore, in contrast to the Declaration of Helsinki, this policy aims to address any use of health databases and biobanks and is not restricted to research. As physicians are the primary custodians of confidential health information, they feel an obligation towards their patients and other persons who entrust them with their data and specimens.
How to participate in the open consultation
The WMA kindly invites all experts and stakeholders to submit comments on this draft version via email to the WMA secretariat at email@example.com no later than 5 June 2015. The workgroup will thoroughly review all comments and consider all input; however please note that it may not be possible to take account of all the suggestions received in the draft declaration.
The draft version of the Declaration on Ethical Considerations regarding Health Databases and Biobanks from the work group may be downloaded here. (www.wma.net/en/20activities/10ethics/15hdpublicconsult/2015-Draft-policy-HDB_BB.pdf) Although desirable, due to time considerations it will not be possible to provide documentation or consider comments submitted in languages other than English. The finished version of the document will be translated into Spanish and French by the WMA.
All submissions will be kept on file and may be made available to members of the public upon request to the WMA following completion of the revision process.
Physician Leaders Urge Governments to Protect Health Care
News Release: 20 April 2015: The World Medical Association is urging governments around the world to ensure that several major trade agreements they are negotiating will protect, promote and prioritize public health and the provision of health care. The WMA has also expressed grave reservations about the level of secrecy surrounding discussions on the agreements, which it described as anti-democratic.
At its Council meeting in Oslo over the weekend, WMA leaders approved an emergency resolution which welcomed the aim of trade agreements to produce economic benefits, but demanded firm assurances over four new agreements - the Trans Pacific Partnership, the Trans Atlantic Trade and Investment Partnership, the Trade in Services Agreement and the Comprehensive Economic and Trade Agreement.
The resolution added that a proposed mechanism for investors to bring claims against governments could be used to challenge evidence-based public health laws, including tobacco plain packaging, and could threaten tobacco control, alcohol control, regulation of foods and beverages, access to medicines, health care services, environmental protection and climate change improvements. Such challenges may undermine efforts to improve health, tackle the social determinants of health and ultimately harm patients.
WMA President Dr. Xavier Deau said: ‘We are asking our national medical association members to urge their governments to ensure that these trade agreements do not interfere with governments' ability to regulate health and health care, or to guarantee a right to health for all. We want governments to oppose any provisions and mechanisms which would compromise access to health care services or medicines.
‘The negotiation of these agreements has been one of the best kept secrets of our time. Negotiating documents are withheld from the public and parliaments. While this secrecy continues, the medical profession has every right to be cautious and suspicious.'
Immediate diagnosis is by rapid diagnostic test (Bivalent, Ag-based). RDT may be positive up to 3 weeks after complete treatment and parasitic clearance.
Antriksh Indian Medical Golf Towers: IMA joins hands with Antriksh Group
IMA has entered into a MoU with Antriksh Group. The group is developing a residential society exclusively for the member doctors of the IMA called ‘Antriksh Indian Medical Golf Towers’
, situated at Sector 150, Noida-Greater Noida Expressway, Noida. This residential society and the colony will comply with all health parameters as defined by the IMA making it an environmentally healthy society.
IMA has been able to negotiate the following key items with Antriksh Group for its members:
- IMA members who wish to book apartment(s) in this society will get a discount of 20% on the basic sales price.
- Few additional charges such as Lease Rent, Fire Fighting Charges, Club Membership Charges have been completely waived off for the IMA members.
- In case any member wants to sell off their unit in the open market at any time during the construction, the first transfer fees, which is typically around 2-5% of the cost of the apartment has been completely waived off for the members.
- If at the end of 1 year, any member feels that the project is not worth investing, they can apply for cancellation and will get 100% refund, without any deduction.
- Many financial schemes have been created to enable the IMA members to choose the best suitable payment mode for them. One of them is EMI subvention scheme in which the buyer member will be required to pay only 10% of the total cost of the apartment. For next three years, until possession of apartments is offered, the developer will pay pre-EMIs to the financing bank. And after one year of booking, if the IMA member is not satisfied with the value of the investment, they can apply for cancellation and get their money back.
- Developers will also help the buyer member with loan arrangement.
- The society once in frame will co-own the management of the Club House called “IMA House” and the Golf Club.
- Relatives of IMA members will also be entitled to book flats in this scheme.
It is expected that once 200 member doctors buy apartments in this project, the market cost of the apartments will increase by minimum around Rs 1000 per sq ft in one year and by a minimum Rs 2000 per sq ft in 2 years’ time frame. This will yield to a buyer who books under the subvention scheme, a profit of 200% and 400% over a period of 1 years and 2 years respectively. Buyers can keep that parameter as a benchmark of gauging the return on their investment.
The apartment buying agreement of the IMA member will be directly with the developer and IMA will not be party to it. IMA has only negotiated special terms for the members.
Members who wish to enquire about the project, visit project site or book may contact the special helpdesk created by Antriksh.
Contact details Phone helpline:
Antriksh Group website:
Snapshot of key features of the project
(as per project Brochure)
- Lowest density sector in Delhi NCR leading to limited number of units and wide open areas
- Project in the centre of a 9 Hole signature Golf Course
- 3BHK and 4 BHK apartments with super area – 2025 sq ft, 2425 sq ft, 2900 sq ft and 3475 sq ft Sector located at the junction of 3 major expressways
- Certified Green Building Concept
- Ultramodern club house with Swimming Pool
- Maximum sports facility including Cricket Academy
- Sr Sec School, Nursing Home, temple, Local market all within the township boundaries
- 24x7 electricity and potable water supply
- 3 tier security system with CCTV monitoring in centralized Hi-tech control room.
Some of the key features of ‘Health Friendly Homes’ concept
created by IMA are as follows:
- Air and Noise Pollution Control
- Water Softening Plant
- Mobile Tower Radiation Free Zone
- Rain Water Harvesting
- Eco friendly Garbage Disposal
- Nursing Home/Healthcare Centre
- First Aid Kits and First Aid Centres
- 24×7 Ambulance Facility
- Potable Water Supply
Quote of the Day
Any man’s life will be filled with constant and unexpected encouragement if he makes up his mind to do his level best each day. Booker T. Washington
IMA in Social Media
https://www.facebook.com/ima.national 28238 likes
https://www.facebook.com/imsaindia 45464 likes
https://www.facebook.com/imayoungdoctorswing 1115 likes
Twitter @IndianMedAssn 877 followers
News on Maps
Do not ignore transient brain dysfunction
TIA or transient ischemic attack or mini paralysis is "a brief episode of neurologic dysfunction caused by lack of blood supply to a specific area of the brain or eye, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction or brain attack", said Padma Shri, Dr. B C Roy National Awardee & DST National Science Communication Awardee, Dr. K K Aggarwal, President Heart Care Foundation of India and Honorary Secretary General IMA
It is a neurological emergency and early recognition can identify patients who may benefit from preventive therapy or from surgery of large vessels such as the carotid artery.
The initial evaluation of suspected TIA and minor non disabling ischemic paralysis includes brain imaging, neurovascular imaging and a cardiac evaluation. Laboratory tests may help to rule out metabolic and hematologic causes of neurologic symptoms.
TIA or minor non disabling ischemic paralysis is associated with a high early risk of recurrent paralysis. The risk of paralysis in the first two days after TIA is approximately 4 to 10 percent. Immediate evaluation and intervention after a TIA or minor ischemic reduces the risk of recurrent stroke.
Risk factor management is appropriate for all patients. Currently viable strategies include blood pressure reduction, statins, antiplatelet therapy and lifestyle modification, including smoking cessation.
For patients with TIA or ischemic stroke of atherothrombotic, lacunar (small vessel occlusive), or cryptogenic type, antiplatelet agents should be given. For patients with atrial fibrillation and a recent ischemic stroke or TIA, the treatment is blood thinners. For patients with carotid blockages surgery is needed.