• Title/Summary/Keyword: susceptibility effect

Search Result 665, Processing Time 0.034 seconds

The Adjuvant Effect of Subcutaneous Interferon-gamma in the Treatment of Refractory Multidrug-resistant Pulmonary Tuberculosis (난치성 다제내성 폐결핵에서 피하주사 Interferon-gamma 치료의 효과: 예비연구)

  • Kim, Eun Kyung;Shim, Tae Sun;Lee, Jung Yeon;Oh, Yeon-Mok;Lim, Chae-Man;Lee, Sang Do;Koh, Younsuck;Kim, Dong Soon;Kim, Won Dong;Kim, Woo Sung
    • Tuberculosis and Respiratory Diseases
    • /
    • v.57 no.3
    • /
    • pp.226-233
    • /
    • 2004
  • Background : Interferon-gamma (IFN-${\gamma}$) is a critical cytokine in the defense against a Mycobacterium tuberculosis infection. Even though IFN-${\gamma}$ has occasionally been used in the treatment of refractory multidrug-resistant tuberculosis (MDR-TB) with some promising results, there is still some controversy regarding the therapeutic efficacy of IFN-${\gamma}$. This study was performed to examine the effect of subcutaneous IFN-${\gamma}$ in the treatment of MDR-TB patients. Methods : Six patients with refractory MDR-TB were enrolled in this study. Two million IU of IFN-${\gamma}$ was administered subcutaneously three times a week with the concomitant administration of antituberculous drugs for at least for 28 weeks. During the IFN-${\gamma}$ therapy, the sputum smear and culture, radiological and clinical evaluations were performed every 4 weeks throughout the study period. Results : The mean age of the 6 patients was 37 years (ranges, 15-61 years). The drug susceptibility test to standard antituberculous drugs revealed resistance to an average of 6.8 (${\pm}1.2$) agents including isoniazid and rifampicin. An average of 10.8 (${\pm}1.3$) antituberculous drugs were prescribed before IFN-${\gamma}$ therapy. The culture became negative in 2 patients (33%) after initiating IFN-${\gamma}$ therapy; one at 8 weeks, and the other at 24 weeks. Finally, after stopping the IFN-${\gamma}$ therapy after 28 weeks, the culture became positive again in the two patients who were culture-negative. The other 4 patients who failed in the culture conversion are still on antituberculous treatment except for one who died of tuberculosis. Conclusion : Even though 28 weeks of subcutaneous IFN-${\gamma}$ therapy in combination with antituberculous drugs was successful in inducing the culture-negative conversion in some patients with refractory MDR-TB, the culture became positive again after stopping the IFN-${\gamma}$ therapy. This suggests that subcutaneous IFN-${\gamma}$ therapy may have suppressive effect on tuberculosis only during the IFN-${\gamma}$ therapy period in some patients. Further studies will be needed to determine the optimum dose, the administration route, the duration of therapy, and the predicting factors of the response to adjuvant IFN-${\gamma}$ therapy.

Follow-Up Study of 6-Month Short Course Chemotherapy for Pulmonary Tuberculosis with 2SKHRZ/4HRZ (폐결핵에서 6개월 단기 항결핵 화학요법의 추구검사)

  • Koh, Hyung Ki;Kang, Yun Jung;Lim, Seong Yong;Shin, Jong Wook;Choi, Jae Sun;Yoo, Ji Hoon;Park, In Won;Choi, Byoung Whui;Hue, Sung Ho;Seo, Seung Chun
    • Tuberculosis and Respiratory Diseases
    • /
    • v.43 no.6
    • /
    • pp.852-861
    • /
    • 1996
  • Background : Many clinicians have experienced the difficulty of decision on termination of antituberculosis chemotherapy after the 6th month due to relapse of disease. There is still controversy in the effect of 2S(K)HRZ/4HRZ 6-month short course chemotherapy including pyrazinamide for 6 months in patiems with pulmonary tuberculosis. And there is no long term follow-up study of 6-month short course chemotherapy for pulmonary tuberculosis in korea. So we had performed the study to find the result of 6-month antituberculosis chemotherapy for 4 years. Method : We studied prospectively the effect of 2S(K)HRZ/4HRZ in one hundred-fifty patients with pulmonary tuberculosis and followed up fifty-nine patients for more than 1 year to 4 years after the completion of 6-month short course therapy. Results : 1) Out of one hundred-fifty patients, seventy-two patients(48%) completed the prescribed 6-month chemotherapy. Sixty-eight patients(45.3%) have experienced premature discontinuation and the most common cause of premature discontinuation was drop-out against advice(thirty-six patients, 24%). Ten patients(6.7%) were treated beyond the 6 months mainly due to irregular treatment. 2) Fifty-nine patients(81.9%) among seventy-two patients with completed treatment have been followed up for more than 1 year and 32 patients(44.4%) for more than 4 years. There was three relapse patients of whom two patients have experienced relapse of pulmonary tuberculosis within 1 year after the termination of chemotherapy. 3) Among one hundred-thirty-four patients who have been assessible for more than two months of chemotherapy, including the patients who experienced within 2 months, there were eighty-two patients(61.2%) who have experienced adverse reactions and the treatment regimen was changed only in thirteen patients(9.7%). The most frequent cause of adverse reactions was arthralgia and/or hyperuricemia, which had occurred in 33 patients(24.6%). Conclusion : In a university hospital in Korea, 6-month shot course chemotherapy of 2S(K)HRZ/4HRZ had unnegligible relapses and premature discontinuation. Therefore, change of the regimen might be carefully considered by drug susceptibility results. Close monitoring of patients, retrial of sputum exam and radiologic evaluation during treatment might be required in the endemic area of drug resistant strains like in Korea. Further study about the effect of 6-month short course chemotherapy including pyrazinamide for 6-month might be needed.

  • PDF

The Effect of Youth's Experience of School Violence on Cyber Violence -Focus on the Multiple Mediating Effects of Human Rights Sensitivity and Peer Conformity- (청소년의 학교폭력 경험이 사이버폭력에 미치는 영향 - 인권감수성과 또래동조성의 다중매개효과를 중심으로 -)

  • Kim, Jung-Ae
    • The Journal of the Korea Contents Association
    • /
    • v.21 no.5
    • /
    • pp.446-464
    • /
    • 2021
  • The purpose of this study is to verify the multi-mediated effects of human rights sensitivity and peer-coordination in the relationship between teenagers' school violence experience and cyberbullying in order to find alternatives to prevent cyberbullying as teenagers increase their use of smartphones. In order to achieve this research goal, four middle schools were selected by the education office located in downtown Busan and analyzed on 908 middle school students. The results of the study are as follows. First, school violence experiences have been shown to affect cyberbullying. Second, the experience of abuse and neglect during school violence affected human rights sensitivity, but the experience of damage did not affect human rights sensitivity. Third, among school violence experiences, the experience of damage and abuse influenced peer co-operation, but the experience of sitting on the sidelines did not affect peer co-operation. Fourth, human rights sensitivity affected cyberbullying. Fifth, peer groupings affected cyberbullying. Sixth, human rights sensitivity influenced peer-reaction. Seventh, among human rights sensitivities, bystander experience and cyberbullying were found to be mediating bystander experience and cyberbullying, but the damage experience and abuse experience did not have a mediating effect in human rights sensitization and cyberbullying. Eighth, peer cooperation was found to be mediating cyberbullying, but there was no mediating effect between on-the- sidelines experience and cyberbullying. Ninth, human rights sensitivity and peer creation are shown to mediate the relationship between on-the- sidelines experience and cyberbullying sequentially. However, human rights sensitivity and peer creation did not mediate cyberbullying sequentially between the experience of damage and the experience of perpetration. The implications of this study were to verify the effects of teenagers' school violence damage experience, abuse experience, and bystander experience on cyberbullying, and multiple interventions of human rights sensitivity and peer group.

Comparative toxicity of some pesticides on reproduction of Korean native freshwater Cladocerans, Moina macrocopa and Daphnia sp. (한국산 물벼룩 Moina macrocopa와 Daphnia sp.에 대한 수종 농약의 번식독성 비교)

  • Kim, Byung-Seok;Park, Yoen-Ki;Park, Kyung-Hun;Jeong, Mi-Hye;You, Are-Sun;Yang, Yu-Jung;Shin, Jin-Sup;Kim, Jin-Hwa;Yoon, Seong-Myeong;Ahn, Young-Joon
    • The Korean Journal of Pesticide Science
    • /
    • v.11 no.4
    • /
    • pp.246-253
    • /
    • 2007
  • The reproduction toxicity of several pesticides on two Korean water flea was investigated to develop a new standard species used for ecological risk assessment of pesticide. Moina macrocopa and Daphnia sp. were exposed to 4 different types of pesticides over 10 and 21 days, respectively. No-ohserved effect concentration (NOEC) for synthetic pyrethroid, fenpropathrin on Moina macrocopa and Daphnia sp. were 0.17 and $0.06\;{\mu}g\;L^{-1}$, respectively. Diazinon, carbofuran and myclobutanil were in the order of their reproduction toxicity to cladocerans tested. There were large differences between Moina macrocopa and Daphnia sp. in their susceptibility to fenpropathrin, diazinon and carbofuran except myclobutanil. Daphnia sp. is more sensitive than M. macrocopa to pesticides tested. Therefore Daphnia sp. may be a good surrogate species to assess the reproduction effect of pesticides on aquatic invertebrates. M. macrocopa also be a good surrogate species because it is one of the most abundant cladocera in agricultural environment, especially rice paddy in Korea. In addition to it's ecological importance of wide spread distribution, it has also economical importance to make possible to shorten period for reproduction test using M. macrocopa due to it's short life cycle.

Role of Catecholamines in Ventricular Fibrillation (Catecholamines에 관(關)하여 -제4편(第四編) : 심실전동발생(心室顫動發生)에 있어서의 catecholamines의 의의(意義)-)

  • Lee, Woo-Choo
    • The Korean Journal of Pharmacology
    • /
    • v.19 no.1
    • /
    • pp.15-35
    • /
    • 1983
  • Although it has been well known that ventricular fibrillation is the most important complication during hypothermia, much investigation has failed to show the exact nature of the etiology of ventricular fibrillation. Recently, there has been considerable research on the relationship between sympathetic activity and ventricular fibrillation under hypothermia. Cardiac muscle normally contains a certain amount of norepinephrine and the dramatic effect of this catecholamines on the cardiac muscle is well documented. It is, therefore, conceivable that cardiac catecholamines might exert an influence on the susceptibility of heart muscle to tachycardia, ventricular fibrillation and arrhythmia, under hypothermia. Hypothermia itself is stress enough to increase tonus of sympatheticoadrenal system. The normal heart is supplied by an autonomic innervation and is subjected to action of circulating catecholamines which may be released from the heart. If the reaction of the heart associated with a variable amount of cardiac catecholamines is. permitted to occur in the induction of hypothermia, the action of this agent on the heart has not to be differentiated from the direct effects of cooling. The studies presented in this paper were designed to provide further information about the cardio-physiological effects of reduced body temperature, with special reference to the role of catecholamines in ventricular fibrillation. Healthy cats, weighing about 3 kg, were anesthetized with pentobarbital(30 mg/kg) intraperitoneally. The trachea was intubated and the endotracheal tube was connected to a C.F. Palmer type A.C. respirator. Hypothermia was induced by immersing the cat into a ice water tub and the rate of body temperature lowering was $1^{\circ}C$ per 5 to 8 min. Esophageal temperature and ECG (Lead II) were simultaneously monitored. In some cases the blood pH and serum sodium and potassium were estimated before the experiment. After the experiment the animals were killed and the hearts were excised. The catecholamines content of the cardiac muscle was measured by the method of Shore and Olin (1958). The results obtained are summarized as follows. 1) In control animal the heart rate was slowed as the temperature fell and the average pulse rates of eight animals were read 94/min at $31^{\circ}C$, 70/min at $27^{\circ}C$ and 43/min at $23^{\circ}C$ if esophageal temperature. Ventricular fibrillation was occurred with no exception at a mean temperature of $20.3^{\circ}C(21-l9^{\circ}C)$. The electrocardiogram revealed abnormal P waves in each progressive cooling of the heart. there was, ultimately, a marked delay in the P-R interval, QRS complex and Q-T interval. Inversion of the T waves was characteristic of all animals. The catecholamines content of the heart muscle excised immediately after the occurrence of ventricular fibrillation was about thirty percent lower than that of the pre-hypothermic heart, that is, $1.0\;{\mu}g/g$ wet weight compared to the prehypothermic value of $1.41\;{\mu}g/g$ wet weight. The changes of blood pH, serum sodium and potassium concentration were not remarkable. 2) By the adrenergic receptor blocking agent, DCI(2-3 mg/kg), given intramuscularly thirty minutes before hypothermia, ventricular fibrillation did not occur in one of five animals when their body temperature was reduced even to $16^{\circ}C$. These animals succumbed at that low temperature, and the changes of heart rate and loss of myocardial catecholamines after hypothermia were similar to those of normal animals. The actual effect of DCI preventing the ventricular fibrillation is not predictable. 3) Administration of reserpine(1 mg/kg, i.m.) 24 hours Prior to hypothermia disclosed reduced incidence of ventricular fibrillation, that is, six of the nine animals went into fibrillation at an average temperature of $19.6^{\circ}C$. By reserpine myocardial catecholamines content dropped to $0.045\;{\mu}g/g$ wet weight. 4) Bretylium pretreatment(20 mg/kg, i.m.), which blocks the release of catecholamines, Prevented the ventricular fibrillation under hypothermia in four of the eight cats. The pulse rate, however, was approximately the same as control and in some cases was rather slower. 5) Six cats treated with norepinephrine(2 mg/kg, i.m.) or DOPA(50 mg/kg) and tranylcypromine(10 mg/kg), which tab teen proved to cause significant increase in the catecholamines content of the heart muscle, showed ventricular fibrillation in all animals under hypothermia at average temperature of $21.6^{\circ}C$ and the pulse rate increased remarkably as compared with that of normal. Catecholamines content of cardiac muscle of these animals markedly decreased after hypothermia but higher than control animals. 6) The functional refractory periods of isolated rabbit atria, determined by the paired stimulus technique, was markedly shortened by administration of epinephrine, norepinephrine and isoproterenol. 7) Adrenergic beta-blocking agents, such as pronethalol, propranolol and sotalol(MJ-1999), inhibited completely the shortening of refractory period induced by norepinephrine. 8) Pretreatment with either phenoxftenbamine or phentolamine, an adrenergic alphatlocking agent, did not modify the decrease in refractory period induced by norepinephrine. From the above experiment it is possible to conclude that catecholamines play an important role in producing ventricular fibrillation under hypothermia. The shortening of the refractorf period of cardiac muscle induced by catecholamines mar be considered as a partial factor in producing ventriculr fibrillaton and to be mediated by beta-adrenergic receptor.

  • PDF

Effect of Exogenous Application of Salicylic Acid or Nitric Oxide on Chilling Tolerance and Disease Resistant in Pepper Seedlings (외생 살리실산과 일산화질소 처리가 고추묘의 저온 내성 및 병 저항성에 미치는 영향)

  • Park, Song-Yi;Kim, Heung-Tae;Oh, Myung-Min
    • Journal of Bio-Environment Control
    • /
    • v.23 no.4
    • /
    • pp.329-336
    • /
    • 2014
  • As an abiotic stress, chilling stress is one of the major factors limiting plant growth and increasing susceptibility to pathogens. Therefore, enhancing stress tolerance in plants is an important strategy for their survival under unfavorable environmental conditions. The objective of this study was to determine the effects of the exogenous application of salicylic acid (SA) or nitric oxide (NO) on chilling tolerance in pepper seedlings. Pepper (Capsicum annuum L. 'kidaemanbal') seedlings were grown under normal growing conditions ($20/25^{\circ}C$, 15 hours photoperiod, $145{\pm}5{\mu}mol{\cdot}m^{-2}{\cdot}s^{-1}$, fluorescence lamps) for 23 days after transplanting. The solution (3 mL) of 1 mM SA and 0.3 mM NO with surfactant triton 0.1% were sprayed two times a week, respectively. Right after the completion of chemical application, seedlings were subjected to chilling condition at $4^{\circ}C$ for 6 hours under dark condition and then the seedlings were recovered at the normal growing conditions for 2 days. In order to assess plant tolerance against chilling stress, growth characteristics, chlorophyll fluorescence (Fv/Fm), and membrane permeability were determined after chilling stress imposition. Total phenolic concentration and antioxidant capacity were measured during the whole experimental period. Disease incidence for pepper bacterial spot and wilt was also analyzed. Pepper seedlings treated with SA or NO were maintained similar dry mass ratio, while the value in control increased caused by chilling stress suggesting relatively more water loss in control plants. Electrolyte leakage of pepper seedlings treated with SA or NO was lower than that of control 2 days after chilling treatment. Fv/Fm rapidly decreased after chilling stress in control while the value of SA or NO was maintained about 0.8. SA increased higher total phenolic concentration and antioxidant capacity than NO and control during chemical treatment. In addition, increase in total phenolic concentration was observed after chilling stress in control and NO treatment. SA had an effect on the reduction of bacterial wilt in pepper seedlings. The results from this study revealed that pre-treatment with SA or NO using foliar spray was effective in chilling tolerance and the reduction of disease incidence in pepper seedlings.

Comparison of the Inhibitory Effects of Nematicides on Nematode Populations in a Regional Vinyl Plastic House (지역별 시설재배지에서 식물기생선충의 살선충제에 대한 밀도억제 효과 비교)

  • Kim, Sae-Hee;Park, Sang-Eun;Ko, Na-Yeon;Ryu, Tae-Hee;Shin, Heo-Seob;Kwon, Hye-Ri;Seo, Mi-Ja;Yu, Yong-Man;Youn, Young-Nam
    • Korean journal of applied entomology
    • /
    • v.52 no.3
    • /
    • pp.215-225
    • /
    • 2013
  • To assess the efficacy of nematicides for the control of plant-parasitic nematodes in fruit and vegetables fields, soil samples were collected from a cucumber field at Gongju; from strawberry fields at Buyeo, Nonsan, and Jinju; and from a melon field at Gocksung in Jeonnam Province, Korea. Plant-parasitic nematodes were separated from each soil sample and identified. The susceptibilities of the nematodes to abamectin 1.68% SC, cadusafos 3% GR, dazomet 98% GR, fosthiazate 30% SL and BA12011 SL were examined under laboratory and field conditions. The average population density of plant-parasitic nematodes was generally reduced after the treatment with nematicides; however, there was increase in the population of Pratylenchus spp. in soil after treatment with fosthiazate at Buyeo and Gocksung. Furthermore, there were increased populations following treatment with abamectin, cadusafos, and dazomet at Gocksung. The control effects of BA12011 treatment on plant-parasitic nematodes were confirmed to be similar to those of the other 4 nematicides evaluated, although its control effect was higher than that of fosthiazate in cucumber-growing soil at Gongju. The effects of nematicide treatment on egg mass formation in each of the collected soils differed according to the region of soil origin. Abamectin was effective in reducing the degree of egg mass formation in Buyeo and Jinju soil, whereas BA12011 was effective in Nonsan and Gocksung soil. Dazomet was found to inhibit egg mass formation in Gongju soil. To evaluate the effect of the newly developed nematicide, BA12011, experiments were conducted in a cucumber-growing greenhouse. The average population densities of Meloidogyne spp., Pratylenchus spp., and Helicotylenchus spp. after the first treatment were reduced to a greater extent than after the second treatment. It is thus suggested that early nematicide treatment is important for effective control of plant-parasitic nematodes.

Regulation of Gb3 Expression on Dendritic Cells (수지상세포에 있어서 베로독소 수용체의 발현조절)

  • Lim, Suk-Hwan;Kim, Gi-Young;Kim, Hyung-Chun;Kim, Young-Hee;Son, Yong-Hae;Oh, Yang-Hyo;Park, Yeong-Min
    • Journal of Life Science
    • /
    • v.17 no.4 s.84
    • /
    • pp.482-492
    • /
    • 2007
  • Infection with Shiga-like toxin (SLT)-producing Escherichia coli causes a spectrum of illnesses with high morbidity and mortality. Host mediators play an important role in the pathogenesis of SLT-I toxicity. We here investigated the effect of SLT-I on tumor necrosis $factor-{\alpha}\;(TNF-{\alpha})$ production, effect of $TNF-{\alpha}$ on glycolipid globotriaosyleramide (Gb3) expression, and relationship between Gb3 level and differential susceptibility of cells to SLT-I. In this study, we observed that detectable levels of $TNF-{\alpha}$ are produced 6 hrs after induction and continued to increase during 48 hrs by SLT-I. It was also found that Vero cells and dendritic cells expressed high levels of Gb3, 83% and 68%, respectively, and that macrophages had a low level of Gb3 (29%) and showed refractory to cytotoxicity against SLT-I. Vero cells and dendritic cells expressing high levels of Gb3 were highly susceptible to SLT-I. furthermore, macrophages showed a resistance to SLT-I cytotoxicity, despite the fact that Gb3 expression was enhanced. These results suggest that the expression of Gb3 is necessary, but not sufficient to confer sensitivity of macrophages to SLT-I and further underpin the important role of SLT-I and its receptor, Gb3, in the pathogenesis of E. coli O157 infection.

Studies on the Enzyme from Arthrobacter luteus Accelerating the Lysis of Yeast Cell Walls - I. Effects of Various Factors on the Lysis of Yeast Cell Walls by the Preparation of Crude Zymolyase (Arthrobacter luteus가 생산(生産)하는 효모(酵母) 세포벽(細胞壁) 용해(溶解) 촉진(促進) 효소(酵素)에 관(關)한 연구(硏究) - 제(第) 1 보(報) : Zymolyase 조(粗) 효소(酵素)에 의한 효모(酵母) 세포벽(細胞壁) 용해(溶解)에 미치는 제(諸) 인자(因子)의 영향(影響) -)

  • Oh, Hong-Rock;Shimoda, Tadahisa;Funatsu, Masaru
    • Korean Journal of Food Science and Technology
    • /
    • v.11 no.4
    • /
    • pp.242-248
    • /
    • 1979
  • To detect proper lytic assay conditions of the crude zumolyase from Arthrobacter luteus, effets of the various factors involved in the lytic system of Sacchromyces sake cultured with shaking in the malt extracts medium were investigated. The results are summarized as follows : 1. The susceptibilities of viable cells of S. sake from logarithmic growth phase to the lytic enzmye were much greater than those of the cells in lag and stationary phases. The cells cultured for 18 hr were the most susceptible to the enzyme. 2. Lytic activity of the enzyme toward the viable cells of S. sake was very low. It was, however, enhanced 4 folds of more by the pretreatment of the cells with 0.05 M sodium sulfite. 3. Lytic activity of the enzyme toward commercial baker's yeast cells was negligible, and the effect of sodium sulfite on the lysis of the cells also was nothing but a little. 4. The lyophilized cells of the baker's yeast showed more susceptibility to the lytic enzyme than viable cells of the yeast. No definite effect of sodium sulfite on the lysis of the lyophilized cells, however, was observed either baker's yeast of S. sake. 5. It appeared that the relationship between the reaction rate and the enzyme concentration on the lysis of the yeast cell walls followed enzyme kinetic theory, but one between the reaction rate and concentration of the yeast cells as substrates showed different pattern from that in enzyme kinetic theory. 6. After the preparation of crude zymolyase was kept at $7^[\circ}C$ for 10 days in the 0.05 M phosphate buffer, pH 7.5, the remainning lytic activity was about 80 %.

  • PDF

The Effect of Oral Health Behavior by Oral Health Belief of Student in Dental Hygiene Department of College Students in Seoul (서울지역 일부대학 치위생과 학생의 구강건강신념이 구강보건행태에 미치는 영향)

  • Park, Mi-Sook
    • Journal of dental hygiene science
    • /
    • v.11 no.2
    • /
    • pp.107-119
    • /
    • 2011
  • The purpose of this study was to examine the effects of oral health behavior by oral health belief from the students in the dental hygienics department who take charge of oral health office, and therefore to lead a clear oral health care, to complete desirable oral health belief, and finally to utilize them for oral health field. The survey was conducted using structured self-administered questionnaires based on oral health belief model targeting 163 students in the dental hygienics department of one of the college in Seoul, and collected data were statistically analyzed using the SPSS 18.0 program. As a result of analysis to determine that the oral health belief significantly affects on the oral heal behavior, the personal variables such as age, economic status and occupation, and the seriousness for the oral health belief were indicated to be significant variables(p<0.05), and as a result of analysis that effects on the number of the oral health behavior, the susceptibility and the seriousness were indicated to be significant variables for oral health belief(P<0.05). As a conclusion, oral health belief was identified as a factor of salience through understanding that oral health belief of the students in the dental hygienics department effects on oral health behavior based on an oral health belief model, and it can be concluded that the necessity of oral health belief investigation should be discussed as a crucial issue to provide a more effective oral health promotion plan.