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Distortion of the Dose Profile in a Three-dimensional Moving Phantom to Simulate Tumor Motion during Image-guided Radiosurgery (방사선수술에서 종양 움직임을 재현시킨 움직이는 팬텀을 이용하여 선량 분포의 왜곡에 대한 연구)

  • Kim, Mi-Sook;Ha, Seong-Hwan;Lee, Dong-Han;Ji, Young-Hoon;Yoo, Seong-Yul;Cho, Chul-Koo;Yang, Kwang-Mo;Yoo, Hyung-Jun;Seo, Young-Seok;Park, Chan-Il;Kim, Il-Han;Ye, Seong-Jun;Park, Jae-Hong;Kim, Kum-Bae
    • Radiation Oncology Journal
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    • v.25 no.4
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    • pp.268-277
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    • 2007
  • Purpose: Respiratory motion is a considerable inhibiting factor for precise treatment with stereotactic radiosurgery using the CyberKnife (CK). In this study, we developed a moving phantom to simulate three-dimensional breathing movement and investigated the distortion of dose profiles between the use of a moving phantom and a static phantom. Materials and Methods: The phantom consisted of four pieces of polyethylene; two sheets of Gafchromic film were inserted for dosimetry. Treatment was planned to deliver 30 Gy to virtual tumors of 20, 30, 40, and 50 mm diameters using 104 beams and a single center mode. A specially designed robot produced three-dimensional motion in the right-left, anterior-posterior, and craniocaudal directions of 5, 10 and 20 mm, respectively. Using the optical density of the films as a function of dose, the dose profiles of both static and moving phantoms were measured. Results: The prescribed isodose to cover the virtual tumors on the static phantom were 80% for 20 mm, 84% for 30 mm, 83% for 40 mm and 80% for 50 mm tumors. However, to compensate for the respiratory motion, the minimum isodose levels to cover the moving target were 70% for the $30{\sim}50$ mm diameter tumors and 60% for a 20 mm tumor. For the 20 mm tumor, the gaps between the isodose curves for the static and moving phantoms were 3.2, 3.3, 3.5 and 1.1 mm for the cranial, caudal, right, and left direction, respectively. In the case of the 30 mm tumor, the gaps were 3.9, 4.2, 2.8, 0 mm, respectively. In the case of the 40 mm tumor, the gaps were 4.0, 4.8, 1.1, and 0 mm, respectively. In the case of the 50 mm diameter tumor, the gaps were 3.9, 3.9, 0 and 0 mm, respectively. Conclusion: For a tumor of a 20 mm diameter, the 80% isodose curve can be planned to cover the tumor; a 60% isodose curve will have to be chosen due to the tumor motion. The gap between these 80% and 60% curves is 5 mm. In tumors with diameters of 30, 40 and 50 mm, the whole tumor will be covered if an isodose curve of about 70% is selected, equivalent of placing a respiratory margin of below 5 mm. It was confirmed that during CK treatment for a moving tumor, the range of distortion produced by motion was less than the range of motion itself.

Effect of Eddy on the Cycle of 210Po and 234 in the central Region of Korean East Sea (동해 중부해역에서 210Po과 234Th의 순환에 대한 소용돌이의 영향)

  • YANG, HAN SOEB;KIM, SOUNG SOO;LEE, JAE CHUL
    • 한국해양학회지
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    • v.30 no.4
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    • pp.279-287
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    • 1995
  • The vertical profiles of natural 210Pb, 210Po and 234Th activities were measured for the upper 100 m of water column at three stations in the middle region of the Korean East Sea during May 1992. And the distribution of these radionuclides was discussed associated with the formation of warm eddy or water mass. The main thermocline was maintained between the depth of 50 and 100 m at the southern station (Sta. A1), and between the depth of 10 to 50 m at the coastal station of Sockcho (Sta. B10). Contrastingly, a main thermocline at Sta. A10, which locates near the center of warm eddy, was observed below 230 m depth. Between 50 and 220 m depth of Sta. A10 is there a relatively homogeneous water mass of 10.1${\pm}$0.5$^{\circ}C$, which is significantly higher in temperature and lower in nutrient than the other two stations. It seems to be due to sinking of the warm surface water in which nutrients were completely consumed. Both 210Pb and 210Po show the highest concentration at Sta. A1 and the lowest at Sta. B10 among the three stations. Also, the 210Pb activity is generally higher in the upper layer than in the lower layer, while 210Po activity represents the reversed pattern at all three stations. At Sta. A1 and Sta. B10, the activities of 210Po relative to its parent 210Pb were deficient in the water column above the main thermocline, but were excess below the thermocline. However, the station near the center of warm eddy(Sta. A10), shows no excess of 210Po in the depths below 50 m, although its defficiency is found in the upper layer like the other stations. At Sta. A1 and b10. 234Th activities are slightly lower in the surface mixed layer than in the deeper region However, at Sta. A10, 234Th activity in the upper 30 m is higher than below 50 m or in the same depth of the other stations, probably because of the high concentration of particulate matter. The residence time of 210Po in the surface mixed layer at Sta. A10 is 0.4 year, much shorter than at the other two stations(about one year). Above 100 m depth, the residence times of 234Th range from 18 to 30 other two stations(about on year). Above 100 m depth, the residence times of 234Th range from 18 to 30 days at all stations, without significant regional variation. The percentages of recycled 210Po within the thermocline are 39% and 92% at Sta. A1 and Sta. B10, respectively. Much higher value at Sta. B10 may be due to a thin thickness of the mixed layer as well as the slower recycling rate of 210Po in the main thermocline.

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The Outbreak of Red Tides in the Coastal Waters off Kohung, Chonnam, Korea 3. The Temporal and Spatial Variations in the Heterotrophic Dinoflagellates and Ciliates in 1997 (전남 고흥 해역의 유해성 적조의 발생연구 3. 1997년도 종속영향성 와편모류와 섬모류의 시공간적 변화)

  • Jeong, Hae-Jin;Park, Jong-Kyu;Kim, Jae-Seong;Kim, Seong-Taek;Yoon, Joo-Eh;Kim, Su-Kyeong;Park, Yong-Min
    • The Sea:JOURNAL OF THE KOREAN SOCIETY OF OCEANOGRAPHY
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    • v.5 no.1
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    • pp.37-46
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    • 2000
  • We investigated the temporal and spatial variations in heterotrophic dinoflagellates (hereafter HTD) and ciliates from June to September 1997 in the waters off Kohung, Korea where red tides dominated by harmful dinoflagellates had occurred from August to October since 1995. We took water samples five times from 5-7 depths at 3 stations in this study period. A total of 17 HTD species were present and of these species in the genus Protoperidinium were 11. The species number of tintinnids (hereafter TIN) present totalled 15 and several naked ciliate (hereafter NC) species were observed. The species numbers of HTD and TIN rapidly increased between August 1st and 21st and then reached to the maximum numbers of 13 and 10, respectively, on August 27 when red tides dominated by Gyrodinium impudicum were first observed in the study area. However the species numbers drastically decreased on September 22. The maximum densities of HTD, TIN, and NC were 45, 39, 57 cells $ml^{-1}$, respectively. ADAS, calculated by averaging the densities of a certain species in the all samples collected from all depths and stations at a sampling period, most increased between August 1st and 21st and then reached to the maximum density of f cells $ml^{-1}$ on August 27 for HTD, while did between August 21st and 27th and up to 7 cells $ml^{-1}$ for TIN. Unlike ADAS of HTD and TIN, that of NC did not change much with the maximum of 8 cells $ml^{-1}$ on August 27th. The pattern of the temperal variation in the species number and ADAS of HTD was similar to that of diatoms and the distributions of Protoperidinium spp. and diatoms had a strong positive correlation. This evidence suggests that HTD, in particular Protoperidinium spp. be a grazer on diatom. In general, the densities of HTD, TIN, and NC decreased with going to stations located in the outer bay. Therefore, the availability of suitable prey and distance from the coastal line might be responsible for the distribution of HTD, TIN, and NC. The results of the present study provide a basis for further experiments for the feeding by dominant HTD, TIN, and NC on dominant phytoplankton including red tide species and for understanding food webs in the planktonic community before, during, and after the red tide outbreak.

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Mumps- and Rubella-specific IgG Levels in Adolescents (청소년기의 연령증가에 따른 볼거리 및 풍진 항체가 변동)

  • Cheon, Hae Won;Shin, Young Kyoo;Lee, Kang Woo;Choung, Ji Tae;Tockgo, Young Chang
    • Pediatric Infection and Vaccine
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    • v.5 no.1
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    • pp.128-135
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    • 1998
  • Purpose : This study was intended to measure seropositivities and the level of mumps- and rubella-specific IgG of MMR vaccinees from 12 to 17 years of age in Korea. Materials and Methods : From May 1996 to July 1996 we obtained sera from students of 1 middle and 2 high schools in Seoul, who were MMR vaccinees from 12 to 17 years of age and had no evidence of immunodeficiency. These 216 study population include 110 males and 106 females. Mumps- and rubella-specific IgG antibody levels were measured by ELISA. Cut-off values for seropositivity were 20 U(Gamma Unit) in mumps and over 0.17 in rubella. Results : 1) As age increased, seropositivities to mumps increased, being 68.4% in 12 year, 79.3% in 13 year, 72.2% in 14 year, 82.0% in 15 year, 87.5% in 16 year, 87.0% in 17 year, which however has no statistical significance. 2) As age increased, the level of mumps-specific IgG antibody(mean+standard deviation, GU) increased, being $52.0{\pm}49.2$ in 12 year, $65.9{\pm}51.4$ in 13 year, $71.1{\pm}66.0$ in 14 year, $67.8{\pm}53.6$ in 15 year, $82.8{\pm}67.8$ in 16 year, $92.0{\pm}68.9$ in 17 year, which however has no statistical significance. 3) As age increased, seropositivities of rubella-specific IgG increased significantly, being 26.3% in 12 year, 20.7% in 13 year, 50.0% in 14 year, 67.2% in 15 year, 66.7% in 16 year, 65.2% in 17 year(P<0.001). 4) As age increased, rubella-specific IgG increased significantly, being $0.13{\pm}0.145$ in 12 year, $0.087{\pm}0.101$ in 13 year, $0.194{\pm}0.168$ in 14 year, $0.260{\pm}0.187$ in 15 year, $0.305{\pm}0.213$ in 16 year, $0.325{\pm}0.221$ in 17 year(P<0.001). There was positive correlation between age and rubella-specific IgG titer(rubella-specific $IgG=0.0517{\times}age-0.5586$, r=0.3752, P<0.001). Conclusion : In adolescent, seropositivities and the level of mumps-specific IgG remained relatively high, but approximately 20% of study population showed seronegativity. Seropositivities and the level of rubella-specific IgG showed the lowest level at 13 years of age and were increased with age after 14 years of age. Further evaluation may be needed to elucidate the cause of these changes of rubella-specific IgG.

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Young Rabbit Model for Pathophysiologic Study of Acute Lung Injury in Early Childhood (유아기 급성폐손상 병태생리 연구를 위한 어린 토끼 실험모델)

  • 권영민;최석철;박종원;김양원;이양행;황윤호;조광현
    • Journal of Chest Surgery
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    • v.36 no.8
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    • pp.545-558
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    • 2003
  • Adult respiratory distress syndrome (ARDS) is of particular interest because of its severity of the associated lung injury and its high mortality. However, the pathophysiologies of ARDS in infant and childhood groups are still not well clarified inspite of many previous investigations. To investigate the time course of pathophysiology of ARDS in infant and childhood groups, this study was designed with experimental endotoxin-induced ARDS model using young rabbits (8 week-old). Material and Method: Rabbits were divided into the control group (n=8) and the endotoxin-treated group (n=32). The endotoxin group was subdivided into 4 groups by the sampling times as 3, 6, 12 and 24 hr-groups (G- $E_{3,6,12,24,}$ each n=8). The experimental ARDS was made by a bolus injection of endotoxin (Escherichia coli serotype 055 : B5, 0.50 mg/kg) via rabbit ear vein. For evaluation of the hematologic and inflammatory markers, and superoxide dismutase (SOD) concentrations, the blood samples were taken from the heart. The bronchoalveolar lavage fluid (BALF) were obtained for analysis of the leukocytes and protein concentration. With biopsy of the lung, histopathologic changes of the lung were also evaluated. Result: In the endotoxin groups, significant leukopenia (owing to pancytopenia) occurred in 3 and 6-hr groups, which was followed by significant leukocytosis (owing to neutrophilia) in the 12 and 24-hr groups (p<0.05). Serum levels of tumor necrosis factor-$\alpha$ (TNF-$\alpha$) and interleukin-1 $\beta$ (IL-1 $\beta$) in the endotoxin groups were higher than those of control group (p<0.05). Serum levels of superoxide dismutase (SOD) of G- $E_{3}$ and G- $E_{6}$ were higher than those of control group, whereas those of G- $E_{12}$ were lower than those of control groups (p<0.05). Total leukocyte counts and protein con-centrations in BALF were significantly elevated in the endotoxin groups compared to the control group (p < 0.05). The hemorrhagic pattern of BALF showed occurred in the endotoxin groups. The endotoxin groups (in G- $E_{6}$) had severe infiltration of inflammatory cells (lymphocyte and monocyte) in the pulmonary interstitium and parenchyma, migrations of neutrophil and eosinophil into alveolar spaces and interstitial widening, which are the evidences of acute lung injury. In the endotoxin groups, there were significant positive correlations between the BALF findings and the immunologic markers (TNF-$\alpha$, IL-1$\beta$, SOD) (p<0.05). Conclusion: Severe acute lung injury occurred in all the endotoxin-treated rabbits. The pathophysiologic findings were so progressive until 6-hr by time dependant pattern, and then recovered slowly, Variable hematologic, immuno-logic, and pathologic factors were well correlated in the development and progression of endoxin-induced lung injury. The pathophysiologic responses were sensitive and rapid in young rabbit Young rabbit seemed to be a useful experimental animal model for infant and childhood groups.roups.

Effect of Plant Growth Regulator Treatments on the Growth and Lateral Root Formation in Soybean Sprouts - I. Effect of Plant Growth Regulator Treatments on the Growth in Soybean Sprouts (생장조절물질(生長調節物質) 처리(處理)가 콩나물의 생육(生育) 및 세근발생(細根發生)에 미치는 영향(影響) - I. 생장조절물질(生長調節物質)의 단용(單用) 및 혼용처리(混用處理)가 콩나물의 생육(生育)에 미치는 효과(效果))

  • Kang, C.K.;Lee, J.M.;Saka, H.
    • Korean Journal of Weed Science
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    • v.9 no.1
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    • pp.56-68
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    • 1989
  • aA series of experiments were conducted to investigate the effect of plant growth regulator treatments on the growth and lateral root formation in soybean sprouts in order to establish the effective method of producing root-less or short-rooted soybean sprouts with larger diameter in the hypocotyl. Major results can be summarized as follows. 1. Soybean sprouts showed fairly uniform elongation rate from 3 to g days after imbibition with daily increase of 3.8cm. The speed of elongation of hypocotyl was reduced whereas that of root accelerated 7 days after imbibition. Lateral roots began to emerge fairly evenly from 5 to 9 days after imbibition with a daily increase of 4.4. 2. Auxins(IAA, IBA, NAA, 2,4-D) inhibited hypocotyl elongation and formation of lateral roots and increased hypocotyl diameter without influencing root length and hook diameter at higher concentrations. The dry weight of cotyledon was increased significantly as compared to that of hypocotyl and root. Among the tested auxins, 2, 4-D was the most effective. 3. BA and 4PU-30 significantly reduced elongation of hypocotyl and root and resulted in the biggest diameter of hypocotyl when treated at higher concentrations. The lowest effective concentration of BA to prevent the formation of larval gal roots was 12.5ppm. The formation of lateral roots could be completely prevented by BA and 4PU-30 treatment but kinetin, zeatin, zeatin riboside resulted in many lateral roots and increased thickness of soybean sprouts with little influence. Cotyledon deformation was found in soybean sprouts treated by 4PU-30. 4. 2, 4-D was the most effective for increasing the hypocotyl diameter while 4PU-30 was the most effective for reducing no. of lateral roots. 5. It can be concluded that among the plant growth regulators tested, BA was effective in reducing root length and increasing hypocotyl diameter. BA 12.5 ppm or 15 ppm may thus be the more practical for production of soybean sprouts. 6. ABA showed no significant effect of growth parameter, however ABA 25 ppm inhibited only no of lateral roots with little influence on the growth of seedling. 7. Ethephon inhibited the elongation of hypocotyl and root and increased hypocotyl diameter at higher concentrations. 8. The combined effect of cytokinins and ethephon was very similar to result of BA treatment alone. As the ethephon concentration increased, hypocotyl diameter and dry weight of cotyledon tended to increase.

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Effects of Formaldehyde/Urea Molar Ratio on Bonding Strength of Plywood and Properties of Sliver-PB and Strand-PB (F/U 몰비의 변이가 합판의 접착성과 Sliver-PB, Strand-PB의 물성에 미치는 영향)

  • Park, Heon;You, Young-Sam
    • Journal of the Korean Wood Science and Technology
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    • v.27 no.2
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    • pp.38-45
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    • 1999
  • This study was to figure out proper Formaldehyde/Urea molar ratio of UF resin with satisfactory bonding strength of plywood and properties of particleboard. The six kinds of UF resins were manufactured with F/U molar ratio 1.0, 1.2, 1.4, 1.6, 1.8, and 2.0. The boards were made of three kinds of raw materials : Veneer, Sliver-Particle and Strand-Particle. Manufacturing condition of plywood : amount of mixing resin was 150g/$m^2$. The fourty secs/mm simple-pressing schedule in the pressure 10kgf/$m^2$ was applied for 480mm${\times}$700mm board at the temperature of $110^{\circ}C$ in a hot press. Manufacturing condition of particleboard : Target density was 0.65g/$cm^2$. The stepwise 9 minutes- multi-pressing schedule in the maximum pressure 40kgf/$cm^2$, the minimum pressure 15kgf/$cm^2$ was applied for $480mm{\times}634mm{\times}12mm$ board at the temperature of $150^{\circ}C$ in a hot press. The results are as follows : I. In bonding strength, plywood which was made by F/U molar ratio 1.2 showed the highest value. Other molar ratio resin also gave the satisfied value of KS standard, 7.5kgf/$cm^2$. 2. In internal bond strength of particleboard, Sliver-Particleboard(SLPB) and Strand-Particleboard(STPB) varied respectively from 5.9kgf/$cm^2$ to 4.8kgf/$cm^2$, from 6.7kgf/$cm^2$ to 5.4kgf/$cm^2$. SLPB with F/U=1.2 and STPB with F/U=1.6 had higher IB value. Also, both SLPB and STPB showed lower IB value in F/U molar ratio 2.0 and 1.0. 3. SLPB and STPB with six kinds of UF resin respectively satisfied bending strength of KS standard 150 Type(130kgf/$cm^2$) and 200 Type(180kgf/$cm^2$). Bending strength data for both of SLPB and STPB showed little or no loss from F/U=1.8 to F/U=1.2. Also, STPB was approximately two times higher than that of SLPB. Therefore, the raw material's shape had more effect on bending strength than the FlU molar ratio. 4. F/U=1.6 and 1.4 showed the lower thickness swelling in SLPB and STPB. All of STPBs satisfied thickness swelling of KS standard, under 12%.

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Radioiodine Therapy of Liver Cancer Cell Following Tissue Specific Sodium Iodide Symporter Gene Transfer and Assessment of Therapeutic Efficacy with Optical Imaging (조직 특이 발현 Sodium Iodide Symporter 유전자 이입에 의한 방사성옥소 간암세포 치료와 광학영상을 이용한 치료효과 평가)

  • Jang, Byoung-Kuk;Lee, You-La;Lee, Yong-Jin;Ahn, Sohn-Joo;Ryu, Min-Jung;Yoon, Sun-Mi;Lee, Sang-Woo;Yoo, Jeong-Soo;Cho, Je-Yeol;Lee, Jae-Tae;Ahn, Byeong-Cheol
    • Nuclear Medicine and Molecular Imaging
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    • v.42 no.5
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    • pp.383-393
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    • 2008
  • Purpose: Cancer specific killing can be achieved by therapeutic gene activated by cancer specific promotor. Expression of sodium iodide symporter (NIS) gene causes transportation and concentration of iodide into the cell, therefore radioiodine treatment after NIS gene transfer to cancer cell could be a form of radionuclide gene therapy. luciferase (Luc) gene transfected cancer cell can be monitored by in vivo optical imaging after D-luciferin injection. Aims of the study are to make vector with both therapeutic NIS gene driven by AFP promoter and reporter Luc gene driven by CMV promoter, to perform hepatocellular carcinoma specific radiodiodine gene therapy by the vector, and assessment of the therapy effect by optical imaging using luciferase expression. Materials and Methods: A Vector with AFP promoter driven NIS gene and CMV promoter driven Luc gene (AFP-NIS-CMV-Luc) was constructed. Liver cancer cell (HepG2, Huh-7) and non liver cancer cell (HCT-15) were transfected with the vector using liposome. Expression of the NIS gene at mRNA level was elucidated by RT-PCR. Radioiodide uptake, perchlorate blockade, and washout tests were performed and bioluminescence also measured by luminometer in these cells. In vitro clonogenic assay with 1-131 was performed. In vivo nuclear imaging was obtained with gamma camera after 1-131 intraperitoneal injection. Results: A Vector with AFP-NIS-CMV-Luc was constructed and successfully transfected into HepG2, Huh-7 and HCT-15 cells. HepG2 and Huh-7 cells with AFP-NIS-CMV-Luc gene showed higher iodide uptake than non transfected cells and the higher iodide uptake was totally blocked by addition of perchlorate. HCT-15 cell did not showed any change of iodide uptake by the gene transfection. Transfected cells had higher light output than control cells. In vitro clonogenic assay, transfected HepG2 and Huh-7 cells showed lower colony count than non transfected HepG2 and Huh-7 cells, but transfected HCT-15 cell did not showed any difference than non transfected HCT-15 cell. Number of Huh-7 cells with AFP-NIS-CMV-Luc gene transfection was positively correlated with radioidine accumulation and luciferase activity. In vivo nuclear imaging with 1-131 was successful in AFP-NIS-CMV-Luc gene transfected Huh-7 cell xenograft on nude mouse. Conclusion: A Vector with AFP promoter driven NIS and CMV promoter driven Luc gene was constructed. Transfection of the vector showed liver cancer cell specific enhancement of 1-131 cytotoxicity by AFP promoter, and the effect of the radioiodine therapy can be successfully assessed by non-invasive luminescence measurement.

The study of food habit and degree of depression in nursing home and privite home living elderly (시설노인과 재가노인의 식습관과 정신건강 상태에 관한 실태조사)

  • Han, Myung-Joo;Koo, Sung-Ja;Lee, Young-Soon
    • Journal of the Korean Society of Food Culture
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    • v.13 no.5
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    • pp.475-486
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    • 1998
  • The dietary habit, health condition and the cognition concerning the health food have been surveyed with the help of the 151 old people living in In-Cheon and Seoul. In this study, the old are classified as an institution for the aged and the old in their own home. The preference and mental health condition influenced on dietary habits have been surveyed as wall. Their dietary habits such s three meals a day and a regular meal time have show) that they have generally good eating habits. Psychologically, the old in an institution for the aged think their health condition is not so good in comparison with the old in their own home. The old in their own home have good condition in that they can go up the stairs, exercise often and walk relatively well. Moreover, men's health condition is better than women. The old generally like meats(especially beef) and prefer sesame oil, perilla oil, soy been oil to Western oil. They like sweat flavor the most and hot, salty taste in order. Thier favorite cooking method is a pot stew, soup and season. The difference between dietary habit and mental health based on an academic career, an allowance and a residential condition shows that the old who live alon have relatively terrible eating habit and the more learned, the better. The more pocket money they have, the better dietary habits they have. The old feel glommy in general and the old in an institution are more depressed and it is statistically significant.

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A Comparative Study on the Pattern of Outpatient Department Utilization at a Tertiary Level Hospital before and after Implementation of the Patient Referral System (의료전달체계 실시 전후의 3차 진료기관 외래환자 이용양상 비교)

  • Lee, Kyeong-Soo;Kim, Chang-Yoon;Kang, Pock-Soo
    • Journal of Preventive Medicine and Public Health
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    • v.25 no.1 s.37
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    • pp.88-100
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    • 1992
  • This study was conducted to assess the effects of implementation of the patient referral system started July 1st, 1989. A comparison on the pattern of outpatient services of the Departments of Internal Medicine, General Surgery, and Pediatrics at the Yeungnam University Hospital was conducted for each one year period before and after implementation of the patient referral system. The pre-implementation period was from July 1, 1988 to June 30, 1989 and the post-implementation period was from July 1, 1989 to June 30, 1990. The information used for this study was obtained from official forms, prepared by the Yeungnam University Hospital, and submitted to the Korean Medical Insurance Cooperatives. After implementation of the patient referral system, the number of outpatient cases in the Department of Internal Medicine decreased 36.1% from 9,669 cases to 6,181 cases a year. Cases in the Department of General Surgery decreased 23.7% from 1,864 cases to 1,422 cases a year. The number of cases in the Department of Pediatrics decreased 36.9% from 3,372 cases to 2,128 cases a year. After implementation of the patient referral system, the average age of cases in the Departments of Internal Medicine and General Surgery was 52.5 and 49.7 years old, respectively. This was a significant increase in comparison with the pre-implementation period. After implementation of patient referral system, the proportion of new outpatients in the Department of Internal Medicine decreased from 24.1% to 14.6%, the Department of General Surgery from 36.0% to 23.4%, and the Department of Pediatrics from 15.5% to 8.3%. The number of visits per case decreased significantly in the Department of Internal Medicine(from 1.74 to 1.61), but there was no significant change in the Departments of General Surgery and Pediatrics. The length of treatment per case increased significantly in all three departments(from 16.1 days to 19.3 days in the Department of Internal Medicine, from 12.0 days to 15.2 days in the Department General Surgery, and 8.9 days to 11.2 days in the Department of Pediatrics). The number of clinical tests per case increased significantly in the Department of Internal Medicine (from 2.2 to 2.5), in the Department of Pediatrics(from 0.8 to 1.1) and increased in the Department of General Surgery(from 6.4 to 6.6). The average medical cost per case decreased from 43,900 Won to 42,500 Won in the Department of Internal Medicine, while the cost increased from 75,900 Won to 78,500 Won in the Department of General Surgery and from 12,700 Won to 13,500 Won in the Department of Pediatrics. In case-mix, the chronic degenerative disease(i. e. hypertension, diabetes mellitus, angina pectoris, malignant neoplasm, and pulmonary tuberculosis) ranked higher and acute infectious diseases and simple cases(i. e. gastritis and duodenitis, haemorrhoids, anal fissure, carbuncle, acute URI, and bronchitis) ranked lower after implementation of the patient referral system compared to before implementation.

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