• Title/Summary/Keyword: CM at Risk

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The Effect of Nasal BiPAP Ventilation in Acute Exacerbation of Chronic Obstructive Airway Disease (만성 기도폐쇄환자에서 급성 호흡 부전시 BiPAP 환기법의 치료 효과)

  • Cho, Young-Bok;Kim, Ki-Beom;Lee, Hak-Jun;Chung, Jin-Hong;Lee, Kwan-Ho;Lee, Hyun-Woo
    • Tuberculosis and Respiratory Diseases
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    • v.43 no.2
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    • pp.190-200
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    • 1996
  • Background : Mechanical ventilation constitutes the last therapeutic method for acute respiratory failure when oxygen therapy and medical treatment fail to improve the respiratory status of the patient. This invasive ventilation, classically administered by endotracheal intubation or by tracheostomy, is associated with significant mortality and morbidity. Consequently, any less invasive method able to avoid the use of endotracheal ventilation would appear to be useful in high risk patient. Over recent years, the efficacy of nasal mask ventilation has been demonstrated in the treatment of chronic restrictive respiratory failure, particularly in patients with neuromuscular diseases. More recently, this method has been successfully used in the treatment of acute respiratory failure due to parenchymal disease. Method : We assessed the efficacy of Bilevel positive airway pressure(BiPAP) in the treatment of acute exacerbation of chronic obstructive pulmonary disease(COPD). This study prospectively evaluated the clinical effectiveness of a treatment schedule with positive pressure ventilation via nasal mask(Respironics BiPAP device) in 22 patients with acute exacerbations of COPD. Eleven patients with acute exacerbations of COPD were treated with nasal pressure support ventilation delivered via a nasal ventilatory support system plus standard treatment for 3 consecutive days. An additional 11 control patients were treated only with standard treatment. The standard treatment consisted of medical and oxygen therapy. The nasal BiPAP was delivered by a pressure support ventilator in spontaneous timed mode and at an inspiratory positive airway pressure $6-8cmH_2O$ and an expiratory positive airway pressure $3-4cmH_2O$. Patients were evaluated with physical examination(respiratory rate), modified Borg scale and arterial blood gas before and after the acute therapeutic intervention. Results : Pretreatment and after 3 days of treatment, mean $PaO_2$ was 56.3mmHg and 79.1mmHg (p<0.05) in BiPAP group and 56.9mmHg and 70.2mmHg (p<0.05) in conventional treatment (CT) group and $PaCO_2$ was 63.9mmHg and 56.9mmHg (p<0.05) in BiPAP group and 53mmHg and 52.8mmHg in CT group respectively. pH was 7.36 and 7.41 (p<0.05) in BiPAP group and 7.37 and 7.38 in cr group respectively. Pretreatment and after treatment, mean respiratory rate was 28 and 23 beats/min in BiPAP group and 25 and 20 beats/min in CT group respectively. Borg scale was 7.6 and 4.7 in BiPAP group and 6.4 and 3.8 in CT group respectively. There were significant differences between the two groups in changes of mean $PaO_2$, $PaCO_2$ and pH respectively. Conclusion: We conclude that short-term nasal pressure-support ventilation delivered via nasal BiPAP in the treatment of acute exacerbation of COPD, is an efficient mode of assisted ventilation for improving blood gas values and dyspnea sensation and may reduce the need for endotracheal intubation with mechanical ventilation.

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The Effect of Elastic Band Exercise Training and Detraining on Body Composition and Fitness in the Elder (탄력밴드 운동이 노인의 신체조성과 체력에 미치는 지속적 효과)

  • So, Wi-Young;Song, Misoon;Cho, Be-Long;Park, Yeon-Hwan;Kim, Yeon-Soo;Lim, Jae-Young;Kim, Seon-Ho;Song, Wook
    • 한국노년학
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    • v.29 no.4
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    • pp.1247-1259
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    • 2009
  • Muscle mass is reduced by aging. There seems to be no direct relationship between sarcopenia(muscle loss) and medical cost in the elderly, but lowering muscle mass results in increase risk of fall and decrease of strength, fitness, physical activity, and independent life. This is coupled with physical trouble and chronic degenerative disease such as diabetes, obesity, hyperlipidemia, and hypertension. Thus, sarcopenia is potential risk factor increasing mortality. The purpose of this study was to investigate the effects of elastic band exercise and detraining on sarcopenia prevention related variables, body composition and fitness. The subject of this study was 60~70 aged 14 seniors who participated in exercise program in J-welfare senior center at J-gu in S-city. Elastic band exercise was performed twice per week for 12 weeks. The body composition and fitness variables were measured before 12 weeks of control, after control(before exercise), after 12 weeks of exercise(before detraining), and after 12 weeks of detraining. There was no significant difference in body composition and fitness variables before and after 12 weeks of control, but elastic band exercise before and after 12 weeks has effect on body composition variables such as weight (t=2.978, p=0.001), body mass index (t=3.502, p=0.004), percent body fat (t=2.216, p=0.045), muscle mass (t=-3.837, p=0.002), visceral fat area (t=5.186, p<0.001), and waist-hip ratio (t=3.045, p=0.009) and on fitness variables such as 2-minutes step (t=-6.891 p<0.001), arm curl (t=-4.702, p<0.001), chair stand (t=-4.860, p<0.001), chair sit and reach (t=-5.910, p<0.001), back scratch (t=-3.835, p=0.002), and 8-ft up and go (t=7.560, p<0.001). This exercise effect was continued after 12 weeks of detraining on body composition variables such as weight (t=2.323, p=0.037), body mass index (t=2.503, p=0.026), muscle mass (t=-3.137, p=0.008) and on fitness variables such as 2-minutes step (t=-6.489 p<0.001), chair stand (t=-4.694, p<0.001), chair sit and reach (t=-3.690, p=0.003), and 8-ft up and go (t=7.539, p<0.001). It was found that the elastic band exercise has positive effect on body composition and fitness in the elderly and the effect was maintained over 12 weeks of detraining.

Radiation Therapy and Chemotherapy after Breast Conserving Surgery for Invasive Breast Cancer: An Intermediate Result (침윤성 유방암에서 유방보존수술 후 방사선치료 및 항암화학 병용치료의 성적 및 위험인자 분석)

  • Lee, Seok-Ho;Choi, Jin-Ho;Lee, Young-Don;Park, Heoung-Kyu;Kim, Hyun-Young;Park, Se-Hoon;Lee, Kyu-Chan
    • Radiation Oncology Journal
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    • v.25 no.1
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    • pp.16-25
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    • 2007
  • [ $\underline{Purpose}$ ]: Breast conserving surgery (BCS) followed by chemotherapy (CTx.) and radiation therapy (RT) is widely performed for the treatment of early breast cancer. This retrospective study was undertaken to evaluate our interim results in terms of failure patterns, survival and relative risk factors. $\underline{Materials\;and\;Methods}$: From January 1999 through December 2003, 129 patients diagnosed with invasive breast cancer and treated with BCS followed by RT were subject to retrospective review. The median age of the patients was 45 years (age distribution, $27{\sim}76$ years). The proportions of patients according to their tumor, nodes, and metastases (TNM) stage were 65 (50.4%) in stage I, 41 (31.7%) in stage IIa, 13 (10.1%) in stage IIb, 9 (7.0%) in stage III, and 1 patient (0.8%) in stage IIIc. For 32 patients (24.8%), axillary node metastasis was found after dissection. BCS consisted of quadrantectomy in 115 patients (89.1%) and lumpectomy in 14 patients (10.6%). Axillary node dissection at axillary level I and II was performed for 120 patients (93%). For 7 patients (5.4%), only sentinel node dissection was performed with BCS. For 2 patients (1.6%) axillary dissection of any type was not performed. Postoperative RT was given with 6 MV X-rays. A tumor dose of 50.4 Gy was delivered to the entire breast area using a tangential field with a wedge compensator. An aditional dose of $9{\sim}16\;Gy$ was given to the primary tumor bed areas with electron beams. In 30 patients (23.3%), RT was delivered to the supraclavicular node. Most patients had adjuvant CTx. with $4{\sim}6$ cycles of CMF (cyclophosphamide, methotrexate, 5-fluorouracil) regimens. The median follow-up period was 50 months (range: $17{\sim}93$ months). $\underline{Results}$: The actuarial 5 year survival rate (5Y-OSR) was 96.9%, and the 5 year disease free survival rate (5Y-DFSR) was 93.7%. Local recurrences were noted in 2 patients (true: 2, regional node: 1) as the first sign of recurrence at a mean time of 29.3 months after surgery. Five patients developed distant metastases as the first sign of recurrence at $6{\sim}33$ months (mean 21 months). Sites of distant metastatic sites were bone in 3 patients, liver in 1 patient and systemic lesions in 1 patient. Among the patients with distant metastatic sites, two patients died at 17 and 25 months during the follow-up period. According to stage, the 5Y-OSR was 95.5%, 100%, 84.6%, and 100% for stage I, IIa, IIb, and III respectively. The 5Y-DFSR was 96.8%, 92.7%, 76.9%, and 100% for stage I, IIa, IIb, and III respectively. Stage was the only risk factor for local recurrence based on univariate analysis. Ten stage III patients included in this analysis had a primary tumor size of less than 3 cm and had more than 4 axillary lymph node metastases. The 10 stage III patients received not only breast RT but also received posterior axillary boost RT to the supraclavicular node. During the median 53.3 months follow-up period, no any local or distant failure was found. Complications were asymptomatic radiation pneumonitis in 10 patients, symptomatic pneumonitis in 1 patient and lymphedema in 8 patients. $\underline{Conclusion}$: Although our follow up period is short, we had excellent local control and survival results and reaffirmed that BCS followed by RT and CTx. appears to be an adequate treatment method. These results also provide evidence that distant failure occurs earlier and more frequent as compared with local failure. Further studies and a longer follow-up period are needed to assess the effectiveness of BCS followed by RT for the patients with less than a 3 cm primary tumor and more than 4 axillary node metastases.

Hazard Analysis for the Application of Good Agricultural Practices(GAP) on Paprika During Cultivation (파프리카의 농산물우수관리제도(GAP)적용을 위한 재배단계의 위해요소 분석)

  • Nam, Min-Ji;Chung, Do-Yeong;Shim, Won-Bo;Chung, Duck-Hwa
    • Journal of Food Hygiene and Safety
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    • v.26 no.3
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    • pp.273-282
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    • 2011
  • This study established hazards which may cause risk to human at farm during cultivation stage of paprika. Samples of plants (paprika, leaf, stem), cultivation environments (water, soil), personal hygiene (hand, glove, clothes), work utensils (carpet, basket, box) and airborne bacteria were collected from three paprika farms (A, B, C) located in Western Gyeongnam, Korea. The collected samples were assessed for biological (sanitary indications and major foodborne pathogens), chemical (heavy metals, pesticide residues) and physical hazards. In biological hazards, total bacteria and coliform were detected at the levels of 1.9~6.6 and 0.0~4.610g CFU/g, leaf, mL, hand or 100 $cm^2$, while Escherichia coli was not detected in all samples. In major pathogens, only Bacillus cereus were detected at levels of ${\leq}$ 1.5 log CFU/g, mL, hand or 100 $cm^2$, while Staphylococuus aureus, Listeria monocytogenes, E. coli O157 and Salmonella spp. were not detected in all samples. Heavy metal and pesticide residue as chemical hazards were detected at levels below the regulation limit, physical hazard factors, such as insects, pieces of metal and glasses, were also found in paprika farms. Proper management is needed to prevent biological hazards due to cross-contamination while physical and chemical hazards were appropriate GAP criteria.

Wind Stability of Commercially Important Tree Species and Silvicultural Implications, Daegwallyeong Korea (대관령 지역 경제림에 대한 내풍 안정성 분석 및 임업적 적용)

  • Moktan, Mani Ram;Kwon, Jino;Lim, Joo-Hoon;Shin, Moon-Hyun;Park, Chan-Woo;Bae, Sang-Won
    • Korean Journal of Agricultural and Forest Meteorology
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    • v.17 no.1
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    • pp.58-68
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    • 2015
  • This study compares the wind stability of Larix kaempferi (Lamb.) Carr., Pinus koraiensis Sie. & Zucc. and Abies holophylla Maxim. to understand and inform wind risk management of these plantation trees at Daegwallyeong, Korea. Temporary square plots of $20m{\times}20m$ ($400m^2$) were laid out, and DBH (Diameter at Breast Height) and height for trees greater than 10 cm in DBH were measured by species. A total of 15 plots with 5 plots each in L. kaempferi, P. koraiensis and A. holophylla stands were sampled at random. Among the species, A. holophylla and P. koraiensis have comparatively lower h/d (Height/DBH) ratios than L. kaempferi. These results indicate that the former two species are more wind firm than the latter species. About 9% of the L. kaempferi trees have higher h/d ratios than the critical threshold limit 80. These trees are vulnerable to wind damage and should be removed in the next thinning regime. The analysis of variance detected a significant difference (p < 0.05) in the h/d ratios and Gini coefficient indicating species differences and DBH size variation, respectively. Gini coefficient was 16.4% in A. holophylla, 15.9% in P. koraiensis and 14% in L. kaempferi stands indicating limited DBH size variation. Lower h/d ratios are attributed to thinning in these stands and tree morphological differences. To increase wind firmness, low thinning should concentrate to remove trees with the h/d ratio above 80 coinciding at the time of stand distinction phase. Forest managers and practitioners should measure and maintain h/d ratios of trees below the critical threshold limit of 80 through stand density management. Variable density thinning approach should be tested to increase tree DBH sizes of the even-aged stands.

Growth and Yield Responses of Soybean to Planting Density in Late Planting (남부지방 콩 만파 재배 시 재식밀도에 따른 생육 및 수량변이)

  • Park, Hyeon-Jin;Han, Won-Young;Oh, Ki-Won;Ko, Jong-Min;Bae, Jin Woo;Jang, Yun Woo;Baek, In Youl;Kang, Hang-Won
    • KOREAN JOURNAL OF CROP SCIENCE
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    • v.60 no.3
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    • pp.343-348
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    • 2015
  • Soybean is one of the important food crop around the world. Especially in East Asia, it is the main ingredient for traditional food like soy sauce and soy paste. The double cropping system including soybean following onion, Chinese cabbage, and potato is widely adopted in Southern region of Korea. In this system, sowing date of second crop (soybean) can be delayed depending on first crops' growth period and weather condition. When planting date is delayed it is known that soybean yield is declined because of shorter vegetative growth period and earlier flowering induced by warm temperature and changes in photoperiod. The objective of this study was to determine soybean growth and yield responses as plant populations at late planting date. Field experiment was conducted at Department of Functional Crop, National Institute of Crop Science, RDA located in Miryang, Gyeongsangnam-Do for two years ('13-'14) in upland field with mid-late maturity cultivar Daewon. A split-plot block design was used with three replications. Main plots were three sowing dates from June 20 to July 20 with 15 days intervals, and subplots were 4 levels of planting densities. Data of maturity (R8) was recorded, yield components and yield were examined after harvesting. Experimental data were analyzed by using PROC GLM, and DMRT were used for mean comparison. Optimum planting population for maximizing soybean yield in late planting which compared with standard population. In mid-June planting, higher planting density causes increased plant height and decreased diameter which lead to higher risk of lodging, however, reduced growth period due to late planting alleviated this problem. Therefore higher seeding rates can provide protection against low seedling emergence caused by late planting in this region.

Evaluation of Microbiological Hazards of Cooking Utensils and Environment of Mass Catering Establishments (급식장의 조리기구.용기 및 작업환경에 대한 미생물학적 위해분석)

  • 박희경;김경립;신혜원;계승희;유화춘
    • Journal of Food Hygiene and Safety
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    • v.15 no.4
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    • pp.315-323
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    • 2000
  • Serious consequences can arise from lack of hygiene in mass catering. Microbiological testing is of value in determining hazards for developing a HACCP plan, and in demonstrating to food handlers the reality of the microbial risk. This studies was performed to describe the overall hygiene of cooking utensils and equipments, employees, and environment in mass catering establishments. Generally, hygienic conditions of cutting board and sanitized dish cloth were better than those of other cooking utensils such as knife, sieve, and peeler. It was found that the cross-contamination of knife might be caused by the use of contaminated sanitizing solution. It was observed that there was considerable variation (10$^1$~10$^{5}$ CFU) of the number of general bacteria for employee's hands. The number of general bacteria were influenced from establishment, employee, and the period of analysis. The number of Coliform group for employee's hands was in the range of 10$^2$~10$^4$CFU only at the first analysis. Total aerial bacteria in working area of mass catering establishments was below 7 CFU/Plate and aerial Staphylococcus sp. was not detected at all except one spot.

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유리화 동결법에 의한 난자의 동결 중 항동해제에 Cytoskeleton Stabilizer, Taxol의 처리 후 배발달율의 개선에 관한 연구

  • 정형민;박성은;임정묵;고정재;정미경;차광렬
    • Proceedings of the KSAR Conference
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    • 2001.03a
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    • pp.74-74
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    • 2001
  • 난자 동결방법의 선별은 보다 효과적인 난자은행의 개발에 필수 불가결한 중요한 요소이다. 이전의 연구에서 마우스의 난자를 ethylene glycol과 electron microscope grid를 이용한 유리화 동결법으로 동결 융해한 결과 기존의 slow freezing 방법에서보다 높은 생존율과 배발달율이 나타남을 관찰하였다. 그러나 동결융해후의 난자는 방추사와 염색체의 이상성이 대조군에 비해 높은 빈도로 나타나 융해후의 배발달율을 감소시키는 것으로 보고되었다. 이에 본 연구에서는 유리화동결법동안 항동해제에 Cytoskeleton system을 안정화시키는 cytoskeleton stabilizer인 taxol을 첨가시킨후 동결시켰을때 생존율과 발달율을 개선시킬 수 있는지 알아보고자 본 실험을 시행하였다. ICR mouse의 성숙란을 채취하여 연구목적에 따라 taxol을 첨가시키지 않은 대조군과 첨가시킨 실험군으로 분류하였다. 동결방법은 난자를 1.5 M ethylene glycol (EG)에 2분 30초간 노출시킨후 5.5 M EG와 1 M sucrose가 첨가된 동결액에 20초간 노출시킨 후 Grid에 난자를 부착시킨후 직접 액체질소에 침지하여 동결하였다. 동결후 난자는 5단계로 융해를 실시한 후 정자와 체외수정을 시킨 후 수정된 난자는 modified P1 배약액에 124 h까지 발달율을 관찰하였고, 배양 후 발달된 배반포는 대조군과 실험군, 각각 4마리의 발정동기화된 recipient에 이식을 시행하였다. 배발달율은 대조군에 비해 실험군에서 4세포기 (48 vs. 84.4%), 8세포기 (34% vs. 70.6%), 상실배 (26% vs. 58.6%) 그리고 배반포 발달율은 (24% vs. 58.6%)로 높게 관찰되었다. 배아이식후 대조군과 실험군에서 각각 2 마리가 임신이되어 정상적인 산자를 분만하였다. 따라서 항동해제에 taxol의 첨가는 동결 융해후의 난자의 배발달율을 증진시킬 수 있었다..8%로 나타나 난할율 및 배반포 발생율에 있어서 융합조건에 따라 큰 차이는 없었으나 1.9㎸/cm, 30$\mu\textrm{s}$ 2회의 조건이 다른 조건들에 비하여 유의적으로 낮았다. 따라서, 체세포와 수핵란 세포질간의 융합율과 배반포 발생에 미치는 영향은 전압보다는 시간에 더 크게 받음을 알 수 있었으며, 이와 같은 결과에서 융합시 시간을 오래 주는 것보다 전압을 높이는 것이 수핵난자의 세포질에 상해를 줄이고 이후 배반포 발생에 유리할 것으로 사료되었다.면에서도 더욱 더 활발할 것으로 기대된다. 배란후 72시간째에 초음파진단기를 이용하여 난소의 난포발달을 조사한 결과 , 대조구와 bFF처리구에 비해 AI처리구에서 발달난포가 유의적으로 많은 것을 확인하였다. 이상과 같은 결과로, Anti-inhibin serum은 한우 자체에서 분비하는 Inhibin을 특이하게 억제하여 Inhibin에 의해 억제되는 FSH분비가 촉진됨으로써 난포발달과 estrogen의 농도가 촉진되는 것으로 사료되어 anti-inhibin serum이 한우의 과배란유기 효과가 있는 것으로 사료된다.정량 분석한 결과이다. 시편의 조성은 33.6 at% U, 66.4 at% O의 결과를 얻었다. 산화물 핵연료의 표면 관찰 및 정량 분석 시험시 시편 표면을 전도성 물질로 증착시키지 않고, Silver Paint 에 시편을 접착하는 방법으로도 만족한 시험 결과를 얻을 수 있었다.째, 회복기 중에 일어나는 입자들의 유입은 자기폭풍의 지속시간을 연장시키는 경향을 보이며 큰 자기폭풍일수록 현저했다. 주상에서 관측된 이러한 특성은 서브스톰 확장기 활동이 자기폭풍의 발달과 밀접한 관계가 있음을 시사한다.se that were all low in two aspects, named "the Nonsignificant group". And the issues were high risk perception in general setting and

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Lower Incidence but More Aggressive Behavior of Right Sided Breast Cancer in Pakistani Women: Does Right Deserve More Respect?

  • Fatima, Nosheen;Zaman, Maseeh Uz;Maqbool, Aamir;Khan, Shaista H.;Riaz, Nazia
    • Asian Pacific Journal of Cancer Prevention
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    • v.14 no.1
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    • pp.43-45
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    • 2013
  • Background: The aim of this epidemiological study was to establish the laterality of breast cancer (BC) and its association with size, receptor status of the primary tumor and bone metastasis (BM) in a local population. Materials and Methods: This retrospective study included cases of BC from Jan-2009 to Dec-2011 who were referred for metastatic work up or follow up survey with Technetium-99m MDP bone scan (BS) to the Nuclear Medicine Department of Karachi Institute of Radiotherapy and Nuclear Medicine (KIRAN). A total of 384 patients out of 521 were included and all reviewed for age, primary tumor size (PTS), laterality, receptor status like estrogen receptor (ER) progesterone receptor (PR) and Her-2-Neu receptor, presence or absence of BM with sites of involvement and time interval between diagnosis of BC and appearance of BM. Results: The left to right sided BC proportion was significantly higher than unity (59%:41%; p<0.001). The right sided BC was observed in younger age group (46:52 years; p<0.0001) and with a smaller PTS than the left sided (3.43:4.15 cm; p<0.0001). The patients with BM had relatively higher negative receptor status with a significant predominance of right sided BC. The overall incidence of BM on BS was 28% and relatively higher in right than left breast (33%:24% p=0.068). The average number of BM sites was also significantly greater for the right side (6:4, P<0.0001). The % cumulative risk of BM in right breast was noted at significantly smaller PTS than left side with log rank value of 5.579; p<0.05. The Kaplan Meier survival plot for event free survival of BM in left sided BC was significantly higher than for the right side (log rank value=4.155, p<0.05), with an earlier appearance of BM in right BC. Conclusions: 1) A left sided predominance of BC was seen in local population; 2) right sided BC had a more aggressive behavior with extensive and earlier appearance of BM at relatively younger age, smaller PTS and receptor (s) negativity.

Surgical Management of Infective Endocarditis Complicated by Embolic Stroke: Early versus Delayed Surgery

  • Kim, Gwan-Sic;Kim, Joon-Bum;Jung, Sung-Ho;Yun, Tae-Jin;Choo, Suk-Jung;Chung, Cheol-Hyun;Lee, Jae-Won
    • Journal of Chest Surgery
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    • v.44 no.5
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    • pp.332-337
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    • 2011
  • Background: The optimal timing of surgery for infective endocarditis complicated by embolic stroke is unclear. We compared early versus delayed surgery in these patients. Materials and Methods: Between 1992 and 2007, 56 consecutive patients underwent open cardiac surgery for the treatment of infective endocarditis complicated by acute septic embolic stroke, 34 within 2 weeks (early group) and 22 more than 2 weeks (delayed group) after the onset of stroke. Results: The mean age at time of surgery was $45.7{\pm}14.8$ years. Stroke was ischemic in 42 patients and hemorrhagic in 14. Patients in the early group were more likely to have highly mobile, large (>1 cm in diameter) vegetation and less likely to have hemorrhagic infarction than those in the delayed group. There were two (3.7%) intraoperative deaths, both in the early group and attributed to neurologic aggravation. Among the 54 survivors, 4 (7.1%), that is, 2 in each group, showed neurologic aggravation. During a median follow-up of 61.7 months (range, 0.4~170.4 months), there were 5 late deaths. Overall 5-year neurologic aggravation-free survival rates were $79.1{\pm}7.0%$ in the early group and $90.9{\pm}6.1%$ in the delayed group (p=0.113). Conclusion: Outcomes of early operation for infective endocarditis in stroke patients were similar to those of the conventional approach. Early surgical intervention may be preferable for patients at high risk of life-threatening septic embolism.