• Title/Summary/Keyword: Dae-Yong Hong

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The Relationship between the Causative Allergens of Allergic Diseases and Environments in Korea Over a 8-Year-Period: Based on Skin Prick Test from 2006 to 2015

  • Park, Chan-Soon;Kim, Boo-Young;Kim, Soo Whan;Lee, Joo Hyung;Koo, Soo Kweon;Kim, Kyung-Su;Kim, Seon Tae;Kim, Yong-Dae;Kim, Jeong Hong;Kim, Jin Kook;Kim, Chang Hoon;Kim, Hyun Jun;Kim, Hyo Yeol;Rha, Ki-Sang;Roh, Hwan-Jung;Park, Dong-Joon;Shin, Seung-Heon;Lim, Sang-Chul;Lee, Jae-Hoon;Lee, Heung Man;Lee, Heung Gu;Kim, Young Ha;Cho, Jin Hee
    • Journal of Rhinology
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    • v.25 no.2
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    • pp.91-98
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    • 2018
  • Background and Objectives: The present study evaluated the results of skin prick test using 55 allergens at 20 centers in the Republic of Korea in 2006, 2010, and 2014-2015. The aim was to assess changes in the positive rate of allergens according to temporal, regional, and environmental factors. Materials and Method: In total, 20 hospitals were selected based on the population distribution in the Republic of Korea. A skin prick test panel comprising 55 aeroallergens was distributed to 18 hospitals for this prospective study. The 2006 and 2010 skin prick test results were collected and analyzed retrospectively from 20 hospitals, while the 2014/2015 skin prick test results (from June 2014 to May 2015) were collected prospectively from 18 hospitals. Results: A total of 14,897 SPT test results were analyzed: 4,319 in 2006, 7,431 in 2010, and 1,852 in 2014/2015. The overall rate of skin prick test positivity to more than two allergens was significantly higher in males than females. The positive rates of alder pollens and birch, oak and ragweed pollen positivity were increased in older patients. Several positive rates were increased according to the temperature in spring. The positive rates for beech pollen, birch pollen, hazel pollen, oak pollen, Tyrophagus putrescentiae, mugwort, cat, Acarus siro, Lepidoglyphus destructor and Tyrophagus putrescentiae were significantly increased, while those of Cult rye pollen and dandelion were significantly decreased over the three test periods. The overall positive rate for allergens in Jeju province varied significantly from Seoul and other cities. Conclusion: Change in the positive rate of multiple aeroallergens was evaluated in the Republic of Korea over time. Our findings can be used to recommend aeroallergens suitable for inclusion in skin prick test panels in the Republic of Korea and will facilitate further investigation of changes in the patterns of allergic diseases.

Interpretation of Cultural Landscape at the Geumsidang(今是堂) sibigyung(12 Landscapes) in Miryang, Gyungnam (밀양 금시당(今是堂) 12경의 문화경관 해석)

  • Eom, Tae-Geon;Kim, Soo-Jin;Park, Jung-Lim;Kang, Han-Min;Sim, Woo-Kyung
    • Journal of the Korean Institute of Traditional Landscape Architecture
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    • v.29 no.2
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    • pp.1-18
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    • 2011
  • This study has been examined characteristics of Yeoju Lee family, rich group at Miryang in the middle of the Joseon Dynasty, around Geumsidang(今是堂) Lee Gwang-jin remains as a cultural landscape appeared in pictures, poetry, and a strange story. Geumsidang Lee Gwang-jin returned to his old home abandoned the middle government post after the death of Moonjeong queen in socially confused stage and tried to manage an annex to a Geumsidang located in Baekgok of Eungchun riverside, and Geumsidang he managed was affected by his teacher and uncle Wolyoun Lee Tae of a view of nature, filial behavior, and nature management etc. Also, 'Painting of 12 landscapes to Geumsidang' is landscape painting with the actual view not like the '8 landscapes of So-Sang' or '8 landscapes of Sa-Si' which is abstract landscape and Lee Gyeong-hong drew 12 landscapes of Geumsidang that includes Angbong(鶯峰: nightingale peak), Yongdu mountain(龍頭山), Mubong Buddhist temple(舞鳳寺), Maam mountain(馬巖山), Wolyeon-dae(月淵臺), Saindang village(舍人堂村), Youngnam-ru(嶺南樓), Miryang eubseong(密陽邑城), Eyeonso(梨淵沼: pear tree deep water), Yullim(栗林: chestnut tree forest), Miryang river(密陽江), Sammundong fields(沙門野), land and government office owned by Yeoju Lee family as landscape objects. 'Poems of 12 landscapes to Geumsidang' by Lee Yong-gu 11th sons of Lee Gwang-jin was written based on 'Painting of 12 landscapes to Geumsidang', and sang for time, season, and changes of the weather. All 12 poems are all a quatrain with seven Chinese characters in each line consisted of all 28 words, but does not match completely with shown elements in pictures because it is not a simple description of pictures but it is recreated by writer's personality. Therefore these painting shows not only th meaning of filial behavior but also village owned by Yeoju Lee family rich group in Miryang, and these poem recreated the pictures by changing as certain scenic spot with the object of enforcing territory of Yeoju Lee family.

Ki Ho School of Neo-Confucianism on Yi Xue Qi Meng in Later Chosun Period (조선후기 기호성리학파의 역학계몽 이해)

  • Yi, Suhn Gyohng
    • The Journal of Korean Philosophical History
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    • no.35
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    • pp.275-308
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    • 2012
  • This article aims to investigate the studies of Yi Xue Qi Meng(易學啓蒙) performed by the researchers of Neo-Confucianism in Ki Ho region in later Chosun period. Philologically speaking, these studies were mainly performed by Han Won Jin and his colleagues. While the study of Yi Hwang(李滉)'s Qi Meng Zhuan Yi(啓蒙傳疑) performed by the researchers of Toegye(退溪) School lasts from the end of the sixteenth century to the nineteen's century, the Ki Ho(畿湖) scholars' study of Yi Xue Qi Meng are centered in the eighteenth century and hardly any significant work on this text is found before and after this century. In order to single out the distinctive features of Ki Ho School of Neo-Confucianism, this article examines three subjects the Ki Ho scholars delved into: (i) their theory of Tai Ji(太極), (ii) their theory of He-Tu(河圖) and the formation of eight trigrams, and (iii) the so-called Wu Wei Xiang De Shuo(五位相得說) discussed in one of the sections in Yi Xue Qi Meng titled the Source of He-Tu and Luo Shu[本圖書]. The Ki Ho scholars are remarkable in interpreting Tai Ji in Yi Xue Qi Meng in the context of the theory of Li-Qi and the theory of human nature. There are differences in opinion among the Ki-Ho scholars with regard to the relation between He-Tu and the formation of eight trigrams. Eventually, they withhold Zhu Xi(朱熹) and Hu Fang Ping(胡方平)'s attempt to synthesize He-Tu, the rectangular diagram of Fu Xi(伏羲)'s eight trigrams, and the circular diagram of Fu Xi's eight trigrams into one single principle. Han Won Jin tries to explain the relation between He-tu and the formation of eight trigrams in terms of the relation between He-Tu and the circular diagram, and his attempt is widely supported by his colleagues. This theory runs counter to traditional model of explaining truth. My conjecture is that such academic trend is further developed by the defenders of Practical Learning such as Hong Dae Yong(洪大容), who vigorously reject traditional system of truth and science, and that it partly explains why the study of Yi Xue Qi Meng ceases in the nineteenth century.

Spatio-Temporal Variation Characteristics of Primary Productivity and Environmental Factors of Shellfish Mariculture in Jaran Bay, Korea (자란만 패류양식어장의 기초생산력 및 환경인자 변동 특성)

  • Lee, Dae In;Choi, Yong-Hyeon;Hong, SokJin;Kim, Hyung Chul;Lee, Won-Chan
    • Journal of the Korean Society of Marine Environment & Safety
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    • v.28 no.5
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    • pp.721-734
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    • 2022
  • This study analyzed the spatio-temporal variation characteristics of major environmental factors such as primary productivity (PP), chlorophyll a, nutrients, sinking particle matters, and organic contamination and biochemical composition of surface sediment on a monthly basis for approximately 2 years around shellfish mariculture in Jaran Bay, Korea. In addition, PP in Jaran Bay was compared with that in other coastal areas and related policy plans were proposed. The average PP of the study area was high in summer and autumn with 6.43~115.43 mgC m-2 hr-1 range. This was lower than that in Gamak Bay and Masan Bay, whereas higher than that in Garorim Bay and the West Sea. The PP in coastal waters, where many aquaculture farms were distributed, significantly fluctuated. The different size compositions of phytoplanktons constituting chlorophyll a slightly varied by month, and little restriction existed on the productivity of phytoplanktons owing to the depletion of nutrients. Typically, the Redfield ratio was less than 16, indicating that nitrogen was the limiting factor for the growth of phytoplanktons. The biochemical composition of particulate organic matters in the water column showed the highest carbohydrates, but lipids and protein contents were high in surface sediments. The concentration of TOC and AVS of the surface sediments was high at inside of bay, and sometimes, exceeded the environmental criteria of fishing grounds. The organic C:N ratio of sediments ranged from 8.1 to 10.4 on average. PP had the highest correlation with chlorophyll a, nitrogen and protein of particle organic materials. Recently, chlorophyll a, DIN, and DIP of water column trends tended to decrease, however, the contamination of sediments increased. Considering the annual PP of 125.9 gC m-2 yr-1 and mariculture area (oyster) of 4.97 km2, the annual carbon production from phytoplanktons was estimated to be about 625 tons, and the annual total wet weight of shellfish (oyster) was estimated to be about 6,250 tons.

Single-Center Real-World Experience with Primary Central Nervous System Lymphoma in the 21st Century (원발 중추신경계림프종의 단일 기관 현실 세계 21세기 경험)

  • Hyungwoo Cho;Jung Yong Hong;Dae Ho Lee;Shin Kim;Kyoungmin Lee;Eun Hee Kang;Sunjong Lee;Jung Sun Park;Jeong Hoon Kim;Jin Sook Ryu;Jooryung Huh;Cheolwon Suh
    • The Korean Journal of Medicine
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    • v.99 no.1
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    • pp.37-49
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    • 2024
  • Background/Aims: In Korea, the incidence of primary diffuse large B-cell lymphoma of the central nervous system (PCNSL) is increasing and autologous stem cell transplantation (ASCT) has improved the survival of younger patients. We explored our real-world experience with PCNSL at Asan Medical Center (AMC). Methods: We used the AMC lymphoma registry to collect patient data prospectively. We analyzed 279 patients diagnosed from 2002 until August 2019. Results: The PCNSL incidence at AMC increased progressively and comprised 7.4-8.9% of new non-Hodgkin lymphoma patients annually during the most recent 4 years. The median age was 60 years (range, 17-85) and males comprised 55%. Patients under 65 years of age (n = 183) had no significant differences in characteristics compared to those aged 65 years or over, with the exception of less occipital lobe involvement and lower beta-2 microglobulin levels. Rituximab, methotrexate, procarbazine, and vincristine (R-MPV) combination induction had the best overall response, of 95%. The median overall survival was 3.8 years with 5- and 10-year survival rates of 41.5% and 30.2%, respectively. Survival was better in younger patients and those treated with ASCT. Thiotepa, busulfan, and cytoxan (TBC) conditioning chemotherapy had better survival than other combinations. The International Extranodal Lymphoma Study Group and Memorial Sloan Kettering Cancer Center prognostic score systems were valid in this cohort. Age and performance status were independent prognostic factors. Exclusive extra-central nervous system failure occurred in six patients (5.6%) among 107 failures. Conclusions: The incidence of PCNSL is rising. R-MPV induction therapy followed by ASCT with TBC has improved the survival of young, fit PCNSL patients.

Evaluation of Xerostomia Following Intensity Modulated Radiotherapy (IMRT) for Head and Neck Cancer Patients (세기조절방사선치료를 시행받은 두경부암 환자군에서 구강건조증지표 분석)

  • Lee, Seok-Ho;Kim, Tae-Hyun;Chie, Eui-Kyu;Im, Hyun-Shun;Im, En-Shil;Ryu, Jun-Sun;Jung, Yoo-Seok;Park, Sung-Yong;Kim, Joo-Young;Pyo, Hong-Ryull;Shin, Kyung-Hwan;Kim, Dae-Yong;Cho, Kwan-Ho
    • Radiation Oncology Journal
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    • v.22 no.2
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    • pp.106-114
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    • 2004
  • Purpose : This study was done to evaluate xerostomia fellowing intensity modulated radiotherapy for patients with head and neck cancer, and to analyze the correlation between the dosimetric parameters and xerostomia parameters. Materials and Methods : From February till October 2003, 13 patients with 3 months of follow-up were evaluated for xerostomia after being treated for head and neck cancer with IMRT. Their median age was 57 years(range: 43$\~$77). Xerostomia were assessed with a 4-question xerostomia questionnaire score (XQS) and a test for salivary flow rates (unstimulated and stimulated). The patients were also given a validated LENT SOMA scale (LSC) questionnaire. The evaluations were completed before radiation therapy (pre-RT) and at 1 and, 3 months after radiation therapy (RT). We evaluated xerostomia at pre-RT, 1 and, 3 months after RT. The association between the xerostomia parameters (XQS and LSC) and salivary flow rates (unstimulated and stimulated: USFR and SSFR) was assessed at 1 and 3 months after RT. Resrlts : All 13 patients showed no significant changes in XQS, LSC and Salivary Flow rates. As a result, we couldn't find out about xerostomia development. Based on the total mean parotid dose, 3,500 cGy, we divided these patients into two groups. The 8 patients (<3,500 cGy) showed no significant changes in XQS, LSC and Salivary Flow rates However, in 5 Patients ($\geq$3,500 cOGy), there was a significant increase in USFR and, SSFR at 3 months after RT, and for the XQS and, LSC at 1 and 3 months after RT. The correlation between XQS and, LSC, and USFR and, SSFR in ail patients (13) was significant at 3 months after RT. The correlation had a tendency to the decrease for USFR and, SSFR in proportion to the increase of XQS and, LSC. Conclusion : Based on the results of this study, IMRT seem to be an effective treatment to significantly decrease the xerostomia. XQS and, LSC seem to be a effective tool for predicting the xerostomia. A total parotid gland mean dose of <3,500 cGy should be a planning goal if substantial sparing of the gland function is desired. Furthermore, patients should be enrolled in a study to define a more accurate threshold dose for the parotid gland.

Community-based Helicobacter pylori Screening and its Effects on Eradication in Patients with Dyspepsia (지역사회에서 소화불량 환자의 Helicobacter pylori 감염에 대한 집단검진 및 치료효과)

  • Kim, Seong-Ho;Hong, Dae-Yong;Lee, Kyeong-Soo;Kim, Seok-Beom;Kim, Sang-Kyu;Suh, Jeong-Ill;Kim, Mee-Kyung;Kang, Pock-Soo
    • Journal of Preventive Medicine and Public Health
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    • v.33 no.3
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    • pp.285-298
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    • 2000
  • Objectives : To investigate the positive rate of Helicobacter pylori in patients with dyspepsia; medical compliance and related factors; the eradication rate a year after screening and related factors; the relationship between the eradication of Helicobacter pylori and the improvement of symptoms; and the estimated cost of three alternative approaches to treat Helicobacter pylori in the community. Methods : A total of 510 subjects with dyspeptic symptoms were selected and given the serological test in March 1998. The subjects were all adults over 30 years of age residing in Kyongju city. Results : Of the 510 selected subjects, 375 (73.5%) subjects proved positive for Helicobacter pylori on serological testing. Of these 304 (81.1%) who consented to an endoscopic examination, underwent a Campylobacter-like organism (CLO) test. Of these 304 subjects, 204 (67.1%), who had positive CLO test results, were given the triple therapy - tripotassium dicitrato bismuthate, amoxicillin, and metronidazole. To determine the eradication rate of Helicobacter pylori, 181 (88.1%) out of the 204 subjects who were given the triple therapy completed a follow-up urea breath test one year later. Of these, the Helicobacter pylori of 87(48.1%) subjects was eradicated. Among the 122 subjects who were medication compliant, the Helicobacter pylori eradication rate was 57.4% (70 subjects), while the eradication rates was only 28.8% (17subjects) in the non-compliant group. The Helicobacter pylori eradication was significantly related to compliance (p<0.01), but not to other characteristics and habits. The symptom improvement rate tended to be higher 62.1%), in the Helicobacter pylori eradicated group than in the non-eradicated group (59.6%). Conclusions : When the advantages and disadvantages of each alternative treatment were considered in the light of cost, antibiotic tolerance and the number of patients to be treated, alternative II was favorable in terms of cost. Alternative III was favorable in terms of the number of patients to be treated, antibiotic tolerance and early detection of gastric cancer. Further long-term research analyzing the cost-benefit and cost-effectiveness of each treatment will be needed as supporting material in creating new policies.

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A Retrospective Study of the Radiotherapy Care Patterns for Patients with Laryngeal Cancer and Comparison of Different Korean Hospitals Treated from 1998 through 1999 (한국인 후두암 환자의 방사선치료 과정 및 내용에 관한 분석 (1998~1999년도))

  • Chung, Woong-Ki;Kim, Il-Han;Yoon, Mee-Sun;Ahn, Sung-Ja;Nam, Taek-Keun;Song, Ju-Young;Chung, Jae-Uk;Nah, Byung-Sik;Lee, Joon-Kyoo;Wu, Hong-Gyun;Lee, Chang-Geol;Lee, Sang-Wook;Park, Won;Ahn, Yong-Chan;Kang, Ki-Moon;Kim, Jung-Soo;Oh, Yoon-Kyeong;Cho, Moon-June;Park, Woo-Yoon;Kim, Jin-Hee;Choi, Doo-Ho;Yun, Hyong-Geun;Kim, Woo-Cheol;Yang, Dae-Sik;Sohn, Seung-Chang;Suh, Hyun-Suk;Ahn, Ki-Jung;Chun, Mi-Son;Lee, Kyu-Chan;Choi, Young-Min;Jeung, Tae-Sik;Kang, Jin-Oh
    • Radiation Oncology Journal
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    • v.27 no.4
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    • pp.201-209
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    • 2009
  • Purpose: To investigate the care patterns for radiation therapy and to determine inter-hospital differences for patients with laryngeal carcinoma in Korea. Materials and Methods: A total of 237 cases of laryngeal carcinoma (glottis, 144; supraglottis, 93) assembled from 23 hospitals, who underwent irradiation in the year of 1998 and 1999, were retrospectively analyzed to investigate inter-hospital differences with respect to radiotherapy treatment. We grouped the 23 hospitals based on the number of new patients annually irradiated in 1998; and designated them as group A (${\geq}$900 patients), group B (${\geq}$400 patients and <900 patients), and group C (<400 patients). Results: The median age of the 237 patients was 62 years (range, 25 to 88 years), of which 216 were male and 21 were female. The clinical stages were distributed as follows: for glottis cancer, I; 61.8%, II; 21.5%, III; 4.2%, IVa; 11.1%, IVb; 1.4%, and in supraglottic cancer, I; 4.3%, II; 19.4%, III; 28.0%, IVa; 43.0%, IVb; 5.4%, respectively. Some differences were observed among the 3 groups with respect to the dose calculation method, radiation energy, field arrangement, and use of an immobilization device. No significant difference among 3 hospital groups was observed with respect to treatment modality, irradiation volume, and median total dose delivered to the primary site. Conclusion: This study revealed that radiotherapy process and patterns of care are relatively uniform in laryngeal cancer patients in Korean hospitals, and we hope this nationwide data can be used as a basis for the standardization of radiotherapy for the treatment of laryngeal cancer.

Biodistribution of 3-[$^{131}I$]iodo-O-methyl-L-${\alpha}$-methyltyrosine in Tumor Bearing Rats: A Comparison Study with L-3-[$^{131}I$]iodo-${\alpha}$-methyltyrosine (종양 이식 백서에서 3-[$^{131}I$iodo-O-methyl-L-${\alpha}$-methyltyrosine의 체내 동태 연구: L-3-[$^{131}I$iodo-${\alpha}$-methyltyrosine와 비교)

  • Choi, Chang-Woon;Yang, Seung-Dae;Woo, Kwang-Sun;Chung, Wee-Sup;Lim, Soo-Jung;Suh, Yong-Sup;Chun, Kwon-Soo;Ahn, Soon-Hyuk;Lee, Jong-Doo;Hong, Sung-Woon;Lim, Sang-Moo
    • The Korean Journal of Nuclear Medicine
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    • v.32 no.3
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    • pp.290-297
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    • 1998
  • Purpose : The aim of this study was to evaluate the feasibility of 3-[$^{131}I$]iodo-O-methyl-L-${\alpha}$-methyltyrosine ([$^{131}I$]OMIMT) as an agent for tumor image. Materials and Methods : After synthesis of 4-O-methyl-L-${\alpha}$-methyltyrosine (OMAMT), OMAMT was labeled with [$^{131}I$] using Iodogen method. In vitro cellular uptake study was performed using 9 L gliosarcoma cells at various time points upto 4 hr. The biodistribution (five rats implanted with the 9 L gliosar-coma cells per group) was evaluated at 30 min, 2 hr, 24 hr after iv injection of 3.7 MBq [$^{131}I$]OMIMT or L-3-[$^{131}I$]iodo-${\alpha}$-methyltyrosine [$^{131}I$]IMT). Gamma camera images were obtained at 30 min, 2 hr and 24 hr. Results: [$^{131}I$]OMIMT uptake was 3.3 times and 2.5 times higher than [$^{131}I$]IMT uptake at 30 min and 60 min, respectively and same after 2 hr in in vitro study using 9L gliosarcoma cells. Maximum accumulation in tumor occurred at 30 min for both [$^{131}I$]OMIMT and [$^{131}I$]IMT in tumor bearing rats. The tumor uptake of [$^{131}I$]OMIMT was significantly higher than that of [$^{131}I$]IMT at early time point studied ($3.74{\pm}0.48$ vs $0.38{\pm}0.17%$ ID/g at 30 min and $2.40{\pm}0.17$ vs $0.24{\pm}0.03%$ ID/g at 2 hr, respectively, p<0.01). However, the tumor uptake of both radiolabels were not significantly different at 24 hr ($0.04{\pm}0.01$ vs $0.05{\pm}0.01%$ ID/g). Tumor was visualized as early as at 30 min in gamma camera images. Conclusion: These data suggested that [$^{131}I$]OMIMT might be a useful tumor imaging agent and has more advantage for the tumor imaging compared to [$^{131}I$]IMT

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Literature Analysis of Radiotherapy in Uterine Cervix Cancer for the Processing of the Patterns of Care Study in Korea (한국에서 자궁경부알 방사선치료의 Patterns of Care Study 진행을 위한 문헌 비교 연구)

  • Choi Doo Ho;Kim Eun Seog;Kim Yong Ho;Kim Jin Hee;Yang Dae Sik;Kang Seung Hee;Wu Hong Gyun;Kim Il Han
    • Radiation Oncology Journal
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    • v.23 no.2
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    • pp.61-70
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    • 2005
  • Purpose: Uterine cervix cancer is one of the most prevalent women cancer in Korea. We analysed published papers in Korea with comparing Patterns of Care Study (PCS) articles of United States and Japan for the purpose of developing and processing Korean PCS. Materials and Methods: We searched PCS related foreign-produced papers in the PCS homepage (212 articles and abstracts) and from the Pub Med to find Structure and Process of the PCS. To compare their study with Korean papers, we used the internet site 'Korean Pub Med' to search 99 articles regarding uterine cervix cancer and radiation therapy. We analysed Korean paper by comparing them with selected PCS papers regarding Structure, Process and Outcome and compared their items between the period of before 1980's and 1990's. Results: Evaluable papers were 28 from United States, 10 from the Japan and 73 from the Korea which treated cervix PCS items. PCS papers for United States and Japan commonly stratified into $3\~4$ categories on the bases of the scales characteristics of the facilities, numbers of the patients, doctors, Researchers restricted eligible patients strictly. For the process of the study, they analysed factors regarding pretreatment staging in chronological order, treatment related factors, factors in addition to FIGO staging and treatment machine. Papers in United States dealt with racial characteristics, socioeconomic characteristics of the patients, tumor size (6), and bilaterality of parametrial or pelvic side wail invasion (5), whereas papers from Japan treated of the tumor markers. The common trend in the process of staging work-up was decreased use of lymphangiogram, barium enema and increased use of CT and MRI over the times. The recent subject from the Korean papers dealt with concurrent chemoradiotherapy (9 papers), treatment duration (4), tumor markers (B) and unconventional fractionation. Conclusion: By comparing papers among 3 nations, we collected items for Korean uterine cervix cancer PCS. By consensus meeting and close communication, survey items for cervix cancer PCS were developed to measure structure, process and outcome of the radiation treatment of the cervix cancer. Subsequent future research will focus on the use of brachytherapy and its impact on outcome including complications. These finding and future PCS studies will direct the development of educational programs aimed at correcting identified deficits in care.