• Title/Summary/Keyword: Model System

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Potentiation of Antitumor Effect of Radiotherapy by Recombinant Tumor Necrosis Factor-$\alpha$ (방사선의 항암작용에 대한 재조합 TNF-$\alpha$의 효과)

  • Seong Jinsil;Shin Hang Chul;Kim Gwi Eon;Suh Chang Ok
    • Radiation Oncology Journal
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    • v.16 no.3
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    • pp.225-231
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    • 1998
  • Purpose : To determine whether TNF-$\alpha$ increases the antitumor effect of radiotherapy in murine syngeneic tumor system. Materials and Methods : Syngeneic murine tumors of MCa-K or MCa-4 (mammary carcinoma), OCa-I (ovarian carcinoma), or HCa-I(hepatocarcinoma were grown in hind legs of C3Hf/HeJ mice. When tumors were grown to 6 mm in mean diameter mice were treated with TNF-$\alpha$, radiation, or combination of the both. Gamma-radiation was given as a single dose of 30 Gy for HCa-I and 15 Gy for other tumors using Cobalt-60 teletherapy unit. A novel TNF-$\alpha$ mutein developed in Korea, was intraperitoneally administered daily at a dose of 10 ug per mouse for 7 days. In combination of radiation and TNF-$\alpha$, the drug was started 1 hour after radiation. Tumor growth delay assay was used to measure the tumor response to the treatment. Results : Among 4 tested tumors, TNF-$\alpha$ alone showed significant antitumor activity in MCa-K and OCa-I tumors, which showed absolute growth delay (AGD) of 5.0 days and 6.5 days, respectively. In combination with radiation, TNF-$\alpha$ showed significant delay of AGD (41.1 days) in OCA-I compared to AGDs of TNF-$\alpha$ alone and radiation, i.e., 6.5 days and 26.9 days, respectively(p<0.05). Enhancement factor was 1.29 in OCa-I, which showed supraadditive effect. TNF-$\alpha$ did not show significant delay of AGDs in the remaining 3 tumors compared to AGDs of TNF-$\alpha$ alone and radiation. Conclusions: TNF-$\alpha$ alone showed antitumor effects in MCa-K and OCa-I. In combination with radiation, TNF-$\alpha$ acted in supraadditive way in OCa-I only. The results of this study imply that the combination of TNF-$\alpha$ and radiation has different therapeutic potential depending on tumor model and further study is advocated.

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Prognostic Factors for Local Control in Early Glottic Cancer Treated with Radiation Therapy (방사선치료를 받은 조기 성문암 환자의 국소 종양 제어에 관한 예후 인자)

  • Chung Woong-Ki;Ahn Sung Ja;Nam Taek Keun;Nah Byung Sik;Cho Jae-Shik;Lim Sang-Chull
    • Radiation Oncology Journal
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    • v.18 no.4
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    • pp.226-232
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    • 2000
  • Purpose :This study was performed to find out the prognostic factors affecting local control in early glottic cancer treated with radiation therapy alone. Materials and Methods :We analysed 37 patients of histologically confirmed early glottic cancer treated at Chonnam National University Hospital between July Im and December 1995, retrospectively. Age of patients ranged from 30 to 73 years (median; 59 years). Thirty-five (95$\%$) patients were male. Histological type was all squamous cell carcinoma. According to the staging system of 1997 American Joint Committee on Cancer, 37 patients were restaged as follows: Tla; U (73$\%$), Tlb; 3 (8$\%$), 72: 7 (19$\%$). Radiation therapy was done using 6 MV X-ray of linear accelerator The range of total radiation dose delivered to the glottic lesion was between 5,040 cGy and 7,020 cGy (median; 6,600 cGy). Median follow-up period was U months. local control rates were calculated by Kaplan-Meier method. Generalized Wilcoxon test was used to evaluate the difference of control rates between comparable groups. Multivariate analysis using Cox proportional hazard model was done to find out prognostic factors affecting local control. Results:5 year survival rate of 37 patients was 89$\%$. Local control rate of 37 patients was 74$\%$ in 5 years. We included age, 7-stage, anterior commissure involvement, fraction size, total radiation dose, treatment time of radiotherapy as potential prognostic factors in univariate and multivariate analysis. As a result, treatment time had statistical significance in local control rate in both univariate (p=0.026) and multivariate (p=0.017) analysis. Complication was not recorded except one patient with hypothyroidism. Conclusion :This study revealed that overall treatment time of radiation was a significant factor affecting local control rate.

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The evaluation of lens absorbed dose according to the Optimold for whole brain radiation therapy (전뇌 방사선치료 시 Optimold에 따른 수정체의 흡수선량 평가)

  • Yang, Yong Mo;Park, Byoung Suk;Ahn, Jong Ho;Song, Ki Won
    • The Journal of Korean Society for Radiation Therapy
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    • v.26 no.1
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    • pp.77-81
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    • 2014
  • Purpose : In the current whole brain Radiation Therapy, Optimold was used to immobilize the head. However, skin dose was increased about 22% due to the scattering radiation by the Optimold. Since the minimum dose causing cataracts was 2 Gy, it could be seen that the effects were large especially on the lens. Therefore, in the whole brain Radiation Therapy, it was to compare and to evaluate the lens absorbed dose according to the presence of Optimold in the eyeball part. Materials and Methods : In order to compare and to evaluate the lens absorbed dose according to the presence of Optimold in the eyeball part, the Optimold mask was made ??up to 5mm bolus on the part of the eye lens in the human model phantom (Anderson Rando Phantom, USA). In the practice treatment, to measure the lens dose, the simulation therapy was processed by placing the GafChromic EBT3 film under bolus, and after the treatment plan was set up through the treatment planning system (Pinnacle, PHILIPS, USA), the treatments were measured repeatedly three times in the same way. After removing the Optimold mask in the eyeball part, it was measured in the same way as above. After scanning the film and measuring the dose by using the Digital Flatbed Scanner (Expression 10000XL, EPSON, USA), the doses were compared and evaluated according to the presence of Optimold mask in the eyeball part. Results : When there was the Optimold mask in the eyeball part, it was measured at $10.2cGy{\pm}1.5$ in the simulation therapy, and at $24.8cGy{\pm}2.7$ in the treatment, and when the Optimold mask was removed in the eye part, it was measured at $12.9cGy{\pm}2.2$ in the simulation therapy, and at $17.6cGy{\pm}1.5$ in the treatment. Conclusion : In case of removing the Optimold mask in the eyeball part, the dose was increased approximately 3 cGy in the simulation therapy and was reduced approximately 7 cGy in the treatment in comparison to the case that the Optimold mask was not removed. During the whole treatment, since the lens absorbed dose was reduced about 27%, the chance to cause cataracts and side effects was considered to be reduced due to decrease of the absorbed dose to the eye lens which had the high sensitivity on the radiation.

Numerical and Experimental Study on the Coal Reaction in an Entrained Flow Gasifier (습식분류층 석탄가스화기 수치해석 및 실험적 연구)

  • Kim, Hey-Suk;Choi, Seung-Hee;Hwang, Min-Jung;Song, Woo-Young;Shin, Mi-Soo;Jang, Dong-Soon;Yun, Sang-June;Choi, Young-Chan;Lee, Gae-Goo
    • Journal of Korean Society of Environmental Engineers
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    • v.32 no.2
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    • pp.165-174
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    • 2010
  • The numerical modeling of a coal gasification reaction occurring in an entrained flow coal gasifier is presented in this study. The purposes of this study are to develop a reliable evaluation method of coal gasifier not only for the basic design but also further system operation optimization using a CFD(Computational Fluid Dynamics) method. The coal gasification reaction consists of a series of reaction processes such as water evaporation, coal devolatilization, heterogeneous char reactions, and coal-off gaseous reaction in two-phase, turbulent and radiation participating media. Both numerical and experimental studies are made for the 1.0 ton/day entrained flow coal gasifier installed in the Korea Institute of Energy Research (KIER). The comprehensive computer program in this study is made basically using commercial CFD program by implementing several subroutines necessary for gasification process, which include Eddy-Breakup model together with the harmonic mean approach for turbulent reaction. Further Lagrangian approach in particle trajectory is adopted with the consideration of turbulent effect caused by the non-linearity of drag force, etc. The program developed is successfully evaluated against experimental data such as profiles of temperature and gaseous species concentration together with the cold gas efficiency. Further intensive investigation has been made in terms of the size distribution of pulverized coal particle, the slurry concentration, and the design parameters of gasifier. These parameters considered in this study are compared and evaluated each other through the calculated syngas production rate and cold gas efficiency, appearing to directly affect gasification performance. Considering the complexity of entrained coal gasification, even if the results of this study looks physically reasonable and consistent in parametric study, more efforts of elaborating modeling together with the systematic evaluation against experimental data are necessary for the development of an reliable design tool using CFD method.

Effects of Service Leadership on Job Satisfaction in Family Restaurant (외식산업에 있어서 서비스 리더십이 직무만족에 미치는 영향 - 패밀리레스토랑을 중심으로 -)

  • Jung, Hyun-Young;Yang, Il-Sun;Kim, Hyun-Ah
    • Journal of the Korean Society of Food Science and Nutrition
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    • v.34 no.5
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    • pp.667-673
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    • 2005
  • The purposes of this study were 1) to analyze the preference of leadership style among ${\lceil}$Transformational leadership$\rfloor$ and ${\lceil}$Service leadership$\rfloor$, 2) to examine the differences of the job satisfaction between the high level of service leadership group and low level of the service leadership group and 3) to testify the hypothesis that the service leadership and its 4 elements (belief, attitude, ability, insight) affect the job satisfaction. The questionnaires were developed to measure the service leadership, the preference of leadership style (transfer-mational leadership and service leadership) and Job satisfaction. The surveys were distributed to 120 managers and employees in the family restaurant in Korea, and 104 questionnaires were responded (response rate: $86.7\%$). The SPSS 12.0 package program was used to conduct the descriptive analysis, correlation analysis, t-test and multiple regression analysis. The result of leadership style preference showed the followers preferred the service leadership $(75.0\%)$ to the transformational leadership $(25.0\%)$. Comparing the job satisfaction of high level of service leadership group and that of low level of service leadership group, the job satisfaction of high level of service leadership group was significantly (p<0.001) higher than that of low level of service leadership group (high level of service leadership group: 4.03, low service leadership group: 3.27, measured on a 5-point likert scale). All three factors of job satisfaction (human factor, service system and company image) in high level of leadership group were significantly (p<0.001) higher than those of lower level of service leadership group. The result of multiple regression analysis presented that the service leadership and it's 4 elements (concept, mind, skill, insight) have significant (p=0.000) effects on the job satisfaction. As a conclusion, we examined theoretical framework of service leadership model and testified the applicability in the field of family restaurants. But the service leadership was the new conceptual theory, so there should be the more empirical studies on managers and employees in the service industry.

cDNA microarray gene expression profiling of melittin and mast cell degranulation peptide in human mast cell strain (봉독의 주요성분인 Melittin과 MCDP이 비만세포주에서 유전자 발현에 미치는 영향에 대한 microarray 분석)

  • So, Jae-jin;Woo, Hyun-su;Kim, Chang-hwan
    • Journal of Acupuncture Research
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    • v.22 no.3
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    • pp.37-51
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    • 2005
  • Mast cell is a cell that functions mainly in our body with a respect to inflammation and allergic response. Bee venom has been progressed in a study as a model related to mechanism in alleviation of pain until now, but it is being progressed in a study relevant to immunocyte in anti-inflammation or anti-allergic response. The present study is aimed to present the basis related to a future study of gene, by researching the influence of melittin and MCD Peptide, which are major ingredients in Bee venom, upon the expression of gene in the mast cell strain. In this study, it dealt with melittin and MCD Peptide respectively, in the effective concentration after passing though the experiment of cytotoxicity by using human mast cell strain. Also, with the respect in the aspect of expression in gene that changes at this time, information was obtained through the technique of analyzing microarray. Through experimental statistics, when regarding a case that global M is significant in more than 1 or -1, in melittin, all 7 genes were accelerated, and 8 inhibited. In MCDP, 7 genes were accelerated and 17 genes inhibited. The function in the body to which these genes are related, was associated with the protein binding within a cell, the activation in the function of lymphocyte, the acceptor related to macrophage antigen. In cell nucleus, substance related to GABA A receptor, protein associated with cAMP reactive element, substance related to complement system No.8 and to B-cell, protein substance related to polycystic kidney disease, substance related to inflammation, and the protein substance of influencing coagulation of blood. Through these results of analysis, it could obtain more useful materials in clarifying the mechanism of action in melittin and MCD peptide, which are in charge of mainly medical action in the abdomen. Also, it is thought that an in-depth study on the influence of main ingredients in Bee venom, the wholly honey bee venom aqua upon anti-allergic response or anti-inflammation are further required.

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Numerical Analysis of Unstable Combustion Flows in Normal Injection Supersonic Combustor with a Cavity (공동이 있는 수직 분사 초음속 연소기 내의 불안정 연소유동 해석)

  • Jeong-Yeol Choi;Vigor Yang
    • Proceedings of the Korean Society of Propulsion Engineers Conference
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    • 2003.05a
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    • pp.91-93
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    • 2003
  • A comprehensive numerical study is carried out to investigate for the understanding of the flow evolution and flame development in a supersonic combustor with normal injection of ncumally injecting hydrogen in airsupersonic flows. The formulation treats the complete conservation equations of mass, momentum, energy, and species concentration for a multi-component chemically reacting system. For the numerical simulation of supersonic combustion, multi-species Navier-Stokes equations and detailed chemistry of H2-Air is considered. It also accommodates a finite-rate chemical kinetics mechanism of hydrogen-air combustion GRI-Mech. 2.11[1], which consists of nine species and twenty-five reaction steps. Turbulence closure is achieved by means of a k-two-equation model (2). The governing equations are spatially discretized using a finite-volume approach, and temporally integrated by means of a second-order accurate implicit scheme (3-5).The supersonic combustor consists of a flat channel of 10 cm height and a fuel-injection slit of 0.1 cm width located at 10 cm downstream of the inlet. A cavity of 5 cm height and 20 cm width is installed at 15 cm downstream of the injection slit. A total of 936160 grids are used for the main-combustor flow passage, and 159161 grids for the cavity. The grids are clustered in the flow direction near the fuel injector and cavity, as well as in the vertical direction near the bottom wall. The no-slip and adiabatic conditions are assumed throughout the entire wall boundary. As a specific example, the inflow Mach number is assumed to be 3, and the temperature and pressure are 600 K and 0.1 MPa, respectively. Gaseous hydrogen at a temperature of 151.5 K is injected normal to the wall from a choked injector.A series of calculations were carried out by varying the fuel injection pressure from 0.5 to 1.5MPa. This amounts to changing the fuel mass flow rate or the overall equivalence ratio for different operating regimes. Figure 1 shows the instantaneous temperature fields in the supersonic combustor at four different conditions. The dark blue region represents the hot burned gases. At the fuel injection pressure of 0.5 MPa, the flame is stably anchored, but the flow field exhibits a high-amplitude oscillation. At the fuel injection pressure of 1.0 MPa, the Mach reflection occurs ahead of the injector. The interaction between the incoming air and the injection flow becomes much more complex, and the fuel/air mixing is strongly enhanced. The Mach reflection oscillates and results in a strong fluctuation in the combustor wall pressure. At the fuel injection pressure of 1.5MPa, the flow inside the combustor becomes nearly choked and the Mach reflection is displaced forward. The leading shock wave moves slowly toward the inlet, and eventually causes the combustor-upstart due to the thermal choking. The cavity appears to play a secondary role in driving the flow unsteadiness, in spite of its influence on the fuel/air mixing and flame evolution. Further investigation is necessary on this issue. The present study features detailed resolution of the flow and flame dynamics in the combustor, which was not typically available in most of the previous works. In particular, the oscillatory flow characteristics are captured at a scale sufficient to identify the underlying physical mechanisms. Much of the flow unsteadiness is not related to the cavity, but rather to the intrinsic unsteadiness in the flowfield, as also shown experimentally by Ben-Yakar et al. [6], The interactions between the unsteady flow and flame evolution may cause a large excursion of flow oscillation. The work appears to be the first of its kind in the numerical study of combustion oscillations in a supersonic combustor, although a similar phenomenon was previously reported experimentally. A more comprehensive discussion will be given in the final paper presented at the colloquium.

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THE EFFECT OF LOW DIETARY CALCIUM AND IRRADIATION ON MANDIBLE IN RATS (저칼슘식이와 방사선조사가 백서 악골에 미치는 영향의 실험적 연구)

  • Lee Sun-Ki;Lee Sang-Rae
    • Journal of Korean Academy of Oral and Maxillofacial Radiology
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    • v.23 no.2
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    • pp.229-250
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    • 1993
  • This study was performed to investigate the morphological and structural changes of bone tissues and the effects of irradiation on the mandibular bodies of rats which were fed low calcium diets. In order to carry out this experiment, 160 seven-week old Sprague-Dawley strain rats weighing about 150 gm were selected and equally divided into one normal diet group of 80 rats and one low calcium diet group with the remainder. These groups were then subdivided into two groups, 40 were assigned rats for each subdivided group, exposed to radiation. The Group 1 was composed of forty non-irradiated rats with normal diet, Group 2 of forty irradiated rats with normal diet, Group 3 forty non-irradiated rats with low calcium diet, and Group 4 forty irradiated rats with low calcium diet. The two irradiation groups received a single dose of 20 Gy on the jaw area only and irradiated with a cobalt-50 teletherapy unit. The rats with normal and low calcium diet groups were serially terminated by ten on the 3rd, the 7th, the 14th, and the 21st day after irradiation. After termination, both sides of the dead rats mandible were removed and fixed with 10% neutral formalin. The bone density of mandibular body was measured by use of bone mineral densitometer(Model DPX -alpha, Lunar Corp., U.SA). Triga Mark ill nuclear reactor in Korea Atomic Research Institute was used for neutron activation and then calcium contents of mandibular body were measured by using a 4096 multichannel analyzer (EG and G ORTEC 919 MCA, U.SA). Also the mandibular body was radiographed with a soft X-ray apparatus(Hitex Co., Ltd., Japan). Thereafter, the obtained microradiograms were observed by a light microscope and were used for the morphometric analysis using a image analyzer(Leco 2001 System, Leco Co., Canada). The morphometric analysis was performed for parameters such as the total area, the bone area, the inner and outer perimeters of the bone. The obtained results were as follows: 1. In the morphometric analysis, total area and outer perimeter of the mandibular bodies of Group 3 were a little smaller than that of Group 1. The mean bone width and bone area were much smaller than that of Group 1 and the inner perimeter of Group 3 was much longer than that of Group 1. The total area and outer perimeter of Group 2 and Group 4 showed little difference. The mean bone width and bone area of Group 4 were smaller than that of Group 2 and the inner perimeter of Group 4 was longer than that of Group 2. 2. The remarkable decreases of the number and thickness of trabeculae and also the resorption of endosteal surface of cortical bone could be seen in the microradiogram of Group 3, Group 4 since the 3rd day of experiment. On the 21st day of experiment, the above findings could be more clearly seen in Group 4 than in Group 3. 3. The bone mineral density of Group 3 was lesser than that of Group 1 and the bone mineral density of Group 4 was lesser than that of Group 2 on the 7th, 14th, 21st days. The irradiation caused the bone mineral density to be decreased regardless of diet. In the case of Groups with low calcium diet, the bone mineral density was much decreased on the 21st day than on the 3rd day of experiment. 4. The calcium content in mandible of Group 3 was smaller than that of Group 1 throughout the experiment. roup 4 showed the least amount of calcium content. The irradiation caused the calcium content to be decreased regardless of diet. In the case of Groups with low calcium diet, the calcium content was much decreased on the 21st day than on the 3rd day of experiment. In conclusion, the present study demonstrated that morphological changs and decrease of bone mass due to resorption of bone by low calcium diet, and that the resorption of bone could be found in the spongeous bone and endosteal surface of cortical bone. So the problem of resorption of bone must be considered when the old and the postmenopausal women are taken radiotherapy because the irradiation seems to be accelerated the resorption of osteoporotic bone.

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The Effects of Modafinil on Clinical Features and Sleep Structure of Narcolepsy Patients and Healthy Controls (모다피닐이 기면병 환자와 대조군의 임상 양상과 수면구조에 구조에 미치는 영향)

  • Shin, Hong-Beom;Jeong, Do-Un;Kim, Eui-Joong
    • Sleep Medicine and Psychophysiology
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    • v.13 no.2
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    • pp.67-74
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    • 2006
  • Introduction: Excessive daytime sleepiness and cataplexy are key features of narcolepsy. Modafinil is psychostimulant used in the treatment of narcolepsy. In this study, we evaluated effects of modafinil on nocturnal sleep structure and sleep latency in multiple sleep latency test and clinical features. Methods: Twelve narcoleptic patients (7 male, age: $22.9{\pm}2.6\;yrs$) were participated in the study. All of them had done nocturnal polysomnography (nPSG), multiple sleep latency test (MSLT), clinical symptoms scales and have repeated same procedure after taking 200 mg of modafinil. We have done linear mixed model analysis to describe effects of group, medication and nap time on these measures. Results: Modafinil did not affect clinical scales except PSQI which had been reduced after medication. In this study, Modafinil reduced total sleep time, sleep efficiency and increased wake after sleep onset and percent of arousal during sleep in nocturnal polysomnography and prolonged mean sleep latency in multiple sleep latency tests in both group. Discussion: Modafinil has stimulant effect of central nervous system but its effect on night sleep is less than other psychostimulants such as methylphenidate. We ascertained that modafinil affected total sleep time, sleep efficiency and percent of wake during sleep but did not effect on sleep structure. Modafinil was effective in the management of day time sleepiness. Modafinil can enhance alertness of control group without day time sleepiness.

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Appling Nursing Theory to Clinical Practice of Home Health Care (가정간호실무에 적용가능한 이론적틀)

  • Woo, Seon-Hye
    • Journal of Home Health Care Nursing
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    • v.11 no.1
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    • pp.5-13
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    • 2004
  • The home health care industry has grown rapidly and can be expected to continue to grow in the foreseeable future. Home health care refers to the practice of nursing applied to clients with a health condition in the clients place of residence. clients and their designated care givers are the focus at home health nursing practice. The goal of care is to initiate. manage and evaluate the resources needed to promote the clients optimal level of well-being and function. Nursing activities necessary to achieve this goal may warrant preventive maintenance and restorative emphases to prevent potential problems from developing. Many project program were suggested home health care model for Korea's health care system and policy direction for expansion and establishment of home health care .But the aim of this paper is to provide on overview for theoretical frame work in home health care. Theories and conceptual frameworks or models are important nursing because they define and guide the boundaries of professional practice and identify key nurse-patient-caregiver relationships that emerge with caring. Following is the research with an investigation of the literature review in the University of Arizona international medline database, In conclusion, are as followers: First, many nursing theorists have had a tremendous impact on nursing practice. the following highlights those nursing theorists that are particularly helpful in understanding home health care. 1. Florence Nightingale : Our earliest theoretical legacy. Nightingale's believes are reflected in basic infection control practice such as hand washing and infectious waste disposal and are key nursing interventions in home care. 2. Martha Roger's :Science of unitary human beings theory. Rorger's believed that the focus of shared. non invasive healing modelities is the human environmental field rather than direct physical care. These modelities continue to evolve as our awareness (reflecting greater diversity, faster rhythms, motions, and ways of knowing) transcends time and space, allowing individuals to get in touch with their integral nature of unbroken wholeness. On people as ever changing energy fields have special relevance in home care especially with hospice and palliative care applications. 3. Madeline Leininger's; Transcultural nursing theory. Home care nurses move through a variety of communities and often care for patients from different cultural back grounds. Therefore Leininger's work has a good that with home care because home care nursing practice is very culturally focused. 4. Dorothea Orem's : Self care deficit theory. Orem's theory views care as something to be performed by both nurses and patients. The role of the nurse is to provide education and support that help patients acquire the necessary activities to perform self-care. Orem's theory is foundational to have care because it begins to truly acknowledge the role of the patient in managing his or her own health. which is referred to as self-care. 5. Margaret Neuman's; Health as expending consciousness theory. Neuman believes that health compasses disease and reflects an underlying pattern of person-environment interaction. A key application of 'Neuman's work to home care is for nurses to understand that health and illness do not necessarily exist at opposite ends of a continuum. 6. Jean Watson's: Theory of human caring. Watson's theory of human caring in nursing proposes human caring as the moral ideal of nursing. Nurses participate human caring to protect, enhance and preserve humanity by assisting individuals to fing meaning in illness. pain and existence and to help others gain self knowledge. self control. and self healing such thinking lends richness to theory development. as well as clinical practice in home care. Second, Robin Rice : Dynamic self determination for self care. (A theoretical framework for home care) Dynamical self determination for self care can be useful to home care nurses in a variety of ways. As research tool it can be reflected in the interview process when the home visit. The home care nurse's role is that of facilitator of patient self-determination for self care through numerous strategies. including patient education and case management.

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