ABSTRACT
p38 MAPK has been implicated in the pathogenesis of asthma as well as pro-allergic Th2 cytokines, orosomucoid-like protein isoform 3 (ORMDL3), regulation of sphingolipid biosynthesis, and regulatory T cell-derived IL-35. To elucidate the role of p38 MAPK in the pathogenesis of asthma, we examined the effect of NJK14047, an inhibitor of p38 MAPK, against ovalbumin (OVA)-induced allergic asthma; we administrated NJK14047 before OVA sensitization or challenge in BALB/c mice. As ORMDL3 regulation of sphingolipid biosynthesis has been implicated in childhood asthma, ORMDL3 expression and sphingolipids contents were also analyzed. NJK14047 inhibited antigen-induced degranulation of RBL-2H3 mast cells. NJK14047 administration both before OVA sensitization and challenge strongly inhibited the increase in eosinophil and lymphocyte counts in the bronchoalveolar lavage fluid. In addition, NJK14047 administration inhibited the increase in the levels of Th2 cytokines. Moreover, NJK14047 reduced the inflammatory score and the number of periodic acid-Schiff-stained cells in the lungs. Further, OVA-induced increase in the levels of C16:0 and C24:1 ceramides was not altered by NJK14047. These results suggest that p38 MAPK plays crucial roles in activation of dendritic and mast cells during sensitization and challenge periods, but not in ORMDL3 and sphingolipid biosynthesis.
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In vertebrates, the entire central nervous system is derived from the neural tube, which is formed through a conserved early developmental morphogenetic process called neurulation. Although the perturbations in neurulation caused by genetic or environmental factors lead to neural tube defects (NTDs), the most common congenital malformation and the precise molecular pathological cascades mediating NTDs are not well understood. Recently, we have developed human spinal cord organoids (hSCOs) that recapitulate some aspects of human neurulation and observed that valproic acid (VPA) could cause neurulation defects in an organoid model. In this study, we identified and verified the significant changes in cell–cell junctional genes/proteins in VPA-treated organoids using transcriptomic and immunostaining analysis. Furthermore, VPA-treated mouse embryos exhibited impaired gene expression and NTD phenotypes, similar to those observed in the hSCO model. Collectively, our data demonstrate that hSCOs provide a valuable biological resource for dissecting the molecular pathways underlying the currently unknown human neurulation process using destructive biological analysis tools.
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Background@#The incidence of venous thromboembolism (VTE) has gradually increased in the Korean population. This study aimed to evaluate the annual age- and sex-adjusted incidence rates (ASR) of VTE and anticoagulation trends between 2014 and 2018. @*Methods@#Using the Korean Health Insurance Review and Assessment Service database, we retrospectively identified VTE patients between 2014 and 2018 using both diagnostic and medication anticoagulant codes assigned within 6 months of the initial index event. Anticoagulant patterns were classified as follows: direct oral anticoagulants (DOAC), panticoagulants, warfarin, and mixed anticoagulation regimens. @*Results@#We identified 95,205 patients with VTE (female, 56.8%). The ASR for VTE per 100,000 person-years increased from 32.8 in 2014 to 53.7 cases in 2018 (relative risk of 1.63; 95% confidence interval, 1.6–1.67). The VTE incidence rates were 25 times higher in the ≥ 80 group than in the 30s group. VTE occurred 1.29 times more often in women than in men. The proportion of DOAC prescriptions increased from 40.5% to 72.8%, whereas warfarin prescriptions decreased from 27% to 5.6% in 2014 and 2018. @*Conclusion@#In Korea, the ASRs of VTE continued to increase since 2014, but the rate of increase slowed in 2018. The VTE occurred more often in the elderly and in women. Five years after the introduction of DOACs in 2013, they accounted for 73% of all anticoagulants used to treat VTE.
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Neuromesodermal progenitors (NMPs) constitute a bipotent cell population that generates a wide variety of trunk cell and tissue types during embryonic development. Derivatives of NMPs include both mesodermal lineage cells such as muscles and vertebral bones, and neural lineage cells such as neural crests and central nervous system neurons. Such diverse lineage potential combined with a limited capacity for self-renewal, which persists during axial elongation, demonstrates that NMPs are a major source of trunk tissues. This review describes the identification and characterization of NMPs across multiple species. We also discuss key cellular and molecular steps for generating neural and mesodermal cells for building up the elongating trunk tissue.
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Free fatty acid receptor 2 (FFA2, also known as GPR43), a G-protein-coupled receptor, has been known to recognize short-chain fatty acids and regulate inflammatory responses. FFA2 gene deficiency exacerbated disease states in several models of inflammatory conditions including asthma. However, in vivo efficacy of FFA2 agonists has not been tested in allergic asthma. Thus, we investigated effect of 4-chloro-α-(1-methylethyl)-N-2-thiazoylylbenzeneacetanilide (4-CMTB), a FFA2 agonist, on antigen-induced degranulation in RBL-2H3 cells and ovalbumin-induced allergic asthma in BALB/c mice. Treatment of 4-CMTB inhibited the antigen-induced degranulation concentration-dependently. Administration of 4-CMTB decreased the immune cell numbers in the bronchoalveolar lavage fluid and suppressed the expression of inflammatory Th2 cytokines (IL-4, IL-5, and IL-13) in the lung tissues. Histological studies revealed that 4-CMTB suppressed mucin production and inflammation in the lungs. Thus, results proved that FFA2 functions to suppress allergic asthma, suggesting 4-CMTB activation of FFA2 as a therapeutic tool for allergic asthma.
ABSTRACT
Neuromesodermal progenitors (NMPs) constitute a bipotent cell population that generates a wide variety of trunk cell and tissue types during embryonic development. Derivatives of NMPs include both mesodermal lineage cells such as muscles and vertebral bones, and neural lineage cells such as neural crests and central nervous system neurons. Such diverse lineage potential combined with a limited capacity for self-renewal, which persists during axial elongation, demonstrates that NMPs are a major source of trunk tissues. This review describes the identification and characterization of NMPs across multiple species. We also discuss key cellular and molecular steps for generating neural and mesodermal cells for building up the elongating trunk tissue.
ABSTRACT
Free fatty acid receptor 2 (FFA2, also known as GPR43), a G-protein-coupled receptor, has been known to recognize short-chain fatty acids and regulate inflammatory responses. FFA2 gene deficiency exacerbated disease states in several models of inflammatory conditions including asthma. However, in vivo efficacy of FFA2 agonists has not been tested in allergic asthma. Thus, we investigated effect of 4-chloro-α-(1-methylethyl)-N-2-thiazoylylbenzeneacetanilide (4-CMTB), a FFA2 agonist, on antigen-induced degranulation in RBL-2H3 cells and ovalbumin-induced allergic asthma in BALB/c mice. Treatment of 4-CMTB inhibited the antigen-induced degranulation concentration-dependently. Administration of 4-CMTB decreased the immune cell numbers in the bronchoalveolar lavage fluid and suppressed the expression of inflammatory Th2 cytokines (IL-4, IL-5, and IL-13) in the lung tissues. Histological studies revealed that 4-CMTB suppressed mucin production and inflammation in the lungs. Thus, results proved that FFA2 functions to suppress allergic asthma, suggesting 4-CMTB activation of FFA2 as a therapeutic tool for allergic asthma.
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Background/Aims@#Seasonal variation is an environmental factor proposed to affect the incidence of venous thromboembolism (VTE). However, VTE seasonal variation is not well studied in Asian populations, which have different genetic determinants of VTE compared to Westerners. The present study aimed at investigating seasonal variation of VTE occurrence and the effect of various demographic factors (i.e., age, sex, and co-morbidities) on variation. @*Methods@#VTE seasonal variation was evaluated in 59,626 index cases (from January 2009 to December 2013) in the Korean Health Insurance Review and Assessment Service database. We quantified and compared VTE occurrence across four seasons, and additionally assessed monthly through a chronobiological analysis. @*Results@#VTE incidence varied both seasonally and monthly, with new cases peaking in the winter (January and February) and the lowest incidence in the summer (August and September). After adjusting for sex, age, type of VTE, and combined cancer diagnosis, winter remained a significant independent factor driving VTE incidence. Additionally, seasonal variation was prominent in patients aged 60 years or older and in patients with pulmonary embolism, but not so prominent in patients of aged less than 60 years and patients with deep vein thrombosis. @*Conclusions@#Seasonal variation was a weak but independent contributor to VTE incidence in a Korean population diagnosed from 2009 to 2013, especially in those individuals with old age or suffering from a pulmonary embolism.
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Sphingosine-1-phosphate (S1P) and its receptors have been implicated in atopic dermatitis. S1P2 was found to function as a proallergic receptor, while its antagonist JTE-013 was found to suppress allergic asthma in mice. Topical application of JTE-013 has not been investigated in an in vivo model of atopic dermatitis. Therefore, the therapeutic potential of JTE-013 topical application was evaluated by the use of a 2,4-dinitrochlorobenzene (DNCB)-induced atopic dermatitis mouse model. DNCB-induced inflammation and mast cell accumulation in skin tissues were significantly suppressed by topical JTE-013 treatment in BALB/c mice. DNCB-induced increase of lymph nodes sizes and elevated inflammatory cytokines (IL-4, IL-13, IL-17, and IFN-γ) in lymph nodes were also significantly reduced by the JTE-013 treatment. Elevated serum levels of IgE were significantly suppressed by the topical treatment of JTE-013. In summary, the topical treatment of JTE-013 S1P2antagonist suppressed DNCB-induced atopic dermatitis symptoms and immune responses. These results suggested JTE-013 as a potential therapeutic agent for atopic dermatitis.
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PURPOSE: Though regular surveillance of hepatocellular carcinoma (HCC) for high-risk patients is widely recommended, its rate and effectiveness are not clear. The aim of this study is to investigate the actual rate of HCC surveillance and its related factors and to clarify its impact on survival in a Korean HCC cohort. MATERIALS AND METHODS: From 2012 to 2015, 319 newly diagnosed HCC patients were prospectively enrolled at a tertiary hospital. Patient interviews based on a structured questionnaire survey were conducted. Surveillance was defined as liver imaging test ≥ 2 times with at least 3-month interval within 2 years prior to HCC diagnosis. RESULTS: Surveillance rate was 39.8%. Of the HCC patients with high-risk factors, only 182 (57.1%) had knowledge for the need for regular surveillance, and 141 (44.2%) had the accurate information about the method (ultrasound-based study). Surveillance group showed a higher proportion of early HCC (p < 0.001) and a longer overall survival (p < 0.001) compared to non-surveillance group. The multivariable Cox regression analysis indicated Child-Pugh class A, history of anti-viral therapy, low serum α-fetoprotein level, non-advanced Barcelona Clinic Liver Cancer stage as independent predictors of overall survival, while regular surveillance was not (p=0.436). CONCLUSION: Less than half of the newly diagnosed Korean HCC patients were under surveillance and the accurate perception for the need of HCC surveillance was insufficient. Of those under surveillance, most patients were diagnosed with early stage HCC, which led to the improved survival. Comprehensive efforts to optimize the surveillance program for the target population are warranted.
Subject(s)
Humans , Carcinoma, Hepatocellular , Cohort Studies , Diagnosis , Health Services Needs and Demand , Korea , Liver , Liver Cirrhosis , Liver Neoplasms , Mass Screening , Methods , Prospective Studies , Tertiary Care CentersABSTRACT
Hepatic hemangioma represents the most common benign primary hepatic neoplasm. Although most such tumors are small and asymptomatic, giant hepatic hemangioma is frequently symptomatic, and requires intervention. Moreover, diffuse multiple hepatic hemangiomatosis occupying almost the entire liver is extremely rare in adults, and the optimal management for this condition is unclear. We report a case of a rapidly growing, symptomatic giant hepatic hemangioma with diffuse hepatic hemangiomatosis in a 50-year-old female patient who was treated by living-donor liver transplantation. This case shows malignant behavior of a benign hemangioma that required liver transplantation. Although this case could not meet the criteria for transplantation according to the MELD (model for end-stage liver disease) score system, it should be considered as an exceptional indication for deceased-donor liver allocation. Further studies of the mechanism underlying hemangioma growth are warranted.
Subject(s)
Adult , Female , Humans , Middle Aged , Hemangioma , Liver Neoplasms , Liver Transplantation , LiverABSTRACT
OBJECTIVES: This study was conducted to identify the relations between multiple chronic diseases and peridontal diseases in Korean adults. METHODS: A total of 4,142 cases was set for analysis, who aged 35 and over and finished with the third year health survey and oral health check-up of the fifth Korea National Health and Nutrition Examination Survey(2012). Peridontal disease was defined if community periodontal index(CPI) was 3(formation of paradental cyst of more than 4mm) or 4(formation of paradental cyst of more than 6mm). RESULTS: The subjects consisted of 48.5% male and 51.5% female. The prevalence rate of peridontal disease was found to be 30.1% in total. In peridontal disease the more the age increased, and the lower the education level and income level as well as the more where the residential area was rural, the higher the prevalence rate was(p < 0.01). According to the number of multiple chronic conditions the prevalence rate of periodontal disease accounted for 27.8%, 31.9%, 33.1%, and 35.2% when there were 0, 1, 2, and 3 or more chronic diseases respectively. As a result of logistic regression analysis, gender, age, education level, residential area, current smoking, and use of oral hygienic products were found to be significant factors on peridontal disease. CONCLUSIONS: This research revealed the prevalence rate of peridontal disease was 30.1% in Korean adults and health behaviors affecting on periodontal disease were more significant.
Subject(s)
Adult , Female , Humans , Male , Chronic Disease , Education , Health Behavior , Health Surveys , Korea , Logistic Models , Oral Health , Periodontal Diseases , Prevalence , Smoke , SmokingABSTRACT
The molecular mechanism underlying the initiation of somatic cell reprogramming into induced pluripotent stem cells (iPSCs) has not been well described. Thus, we generated single-cell-derived clones by using a combination of drug-inducible vectors encoding transcription factors (Oct4, Sox2, Klf4 and Myc) and a single-cell expansion strategy. This system achieved a high reprogramming efficiency after metabolic and epigenetic remodeling. Functional analyses of the cloned cells revealed that extracellular signal-regulated kinase (ERK) signaling was downregulated at an early stage of reprogramming and that its inhibition was a driving force for iPSC formation. Among the reprogramming factors, Myc predominantly induced ERK suppression. ERK inhibition upregulated the conversion of somatic cells into iPSCs through concomitant suppression of serum response factor (SRF). Conversely, SRF activation suppressed the reprogramming induced by ERK inhibition and negatively regulated embryonic pluripotency by inducing differentiation via upregulation of immediate early genes, such as c-Jun, c-Fos and EGR1. These data reveal that suppression of the ERK-SRF axis is an initial molecular event that facilitates iPSC formation and may be a useful surrogate marker for cellular reprogramming.
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OBJECTIVE: The goal of this study was to describe the psychiatric symptoms in the teachers from Danwon High School who were exposed to the sinking of the Motor Vessel Sewol. METHODS: Data were collected from 32 teachers who underwent psychiatric interventions by 16 volunteer psychiatrists for 3 months after the sinking of the Motor Vessel Sewol. RESULTS: The most commonly diagnosed clinical diagnosis in the teachers were normal reaction, acute stress disorder and adjustment disorder. Psychiatric symptoms including anxiety, depressed mood and sleep disturbances were also observed. CONCLUSION: In the acute aftermath of the Sewol Ferry sinking on April 16, 2014, psychiatrists volunteered to provide professional psychiatric interventions to Danwon High School teachers. These results suggest the importance of crisis intervention focused on the teachers who are exposed to disasters. The implications for future research and interventions are discussed.
Subject(s)
Humans , Adjustment Disorders , Anxiety , Crisis Intervention , Diagnosis , Disasters , Psychiatry , Stress Disorders, Post-Traumatic , Stress Disorders, Traumatic, Acute , VolunteersABSTRACT
PURPOSE: While sleeping problems increase with advancing age, there are inherent differences in sleep between males and females. Previous studies have shown inconsistent results of the relationship between sleep duration and risk of injury from falling. While controlling various sociodemographic and health-related factors, national representative data were used in order to analyze the association between sleep duration and injury from falling among older adults. MATERIALS AND METHODS: The data were obtained from the Korean Community Health Survey of 2011. A total of 55654 individuals aged 65 years and older participated in the study. Multivariable logistic regression analysis was conducted to identify the factors associated with injury from falling. RESULTS: After adjusting for covariates, such as age, sex, marital status, whether or not an individual is a recipient of benefits from the National Basic Livelihood Act, hypertension, diabetes mellitus, dyslipidemia, stress level, and self-rated health status, those who slept five hours or less per day [odds ratio (OR)=1.26; 95% confidence interval (CI)=1.18–1.34; p<0.001] or eight hours or more per day (OR=1.11; 95% CI=1.04–1.17; p=0.001) presented significantly higher ORs for injury from falling. A similar result was found when we conducted stratification by sex. CONCLUSION: The current study supports that there is a relationship between short sleep duration and injury from falling and also identified a marginal risk of long sleep in older adults. Therefore, sleep management in older adults with inadequate sleep duration may be necessary.
Subject(s)
Adult , Female , Humans , Male , Accidental Falls , Cross-Sectional Studies , Diabetes Mellitus , Dyslipidemias , Health Surveys , Hypertension , Korea , Logistic Models , Marital StatusABSTRACT
The aim of this study was to examine the effects of CYP2C19*2 and *3 genetic polymorphisms on omeprazole pharmacokinetic (PK) and pharmacodynamic (PD) responses. Twenty-four healthy Korean volunteers were enrolled and given 20 mg omeprazole orally once daily for 8 days. The genotypes of CYP2C19 single nucleotide polymorphisms (SNPs) (*2, *3, and *17) were screened. The plasma concentrations of omeprazole, omeprazole sulfone, and 5-hydroxy (5-OH) omeprazole were determined by liquid chromatography with tandem mass spectrometry (LC-MS/MS). The noncompartmental method was used for the determination of PK parameters. Change of mean pH and proportion (%) of time of gastric pH above 4.0 were estimated. The poor metabolizer (PM) group had the lowest metabolic ratio and exhibited the highest area under the curve (AUC) for omeprazole among the CYP2C19 phenotype groups. The PM group showed the greatest change of mean pH and the highest % time of gastric pH above 4.0. The relationship between AUC of omeprazole and % time of gastric pH above 4.0 was confirmed. The study demonstrates that CYP2C19*2 and *3 influence the PKs and PDs of omeprazole in Korean healthy volunteers. Clinical trial registry at the U.S. National Institutes of Health (https://clinicaltrials.gov), number NCT02299687.
Subject(s)
Area Under Curve , Chromatography, Liquid , Cytochrome P-450 CYP2C19 , Genotype , Healthy Volunteers , Hydrogen-Ion Concentration , Methods , Omeprazole , Phenotype , Plasma , Polymorphism, Genetic , Polymorphism, Single Nucleotide , Tandem Mass Spectrometry , VolunteersABSTRACT
OBJECTIVES: The aim of this systematic literature review is to analyze the psychosocial interventions for children and adolescents after disasters. METHODS: We conducted a review of the extant research literature from 1991 to 2015 via a comprehensive search of the MEDLINE, EMBASE, Cochrane CENTRAL, PubMed and PsyclNFO databases. The keywords employed in this research included: ‘child’, ‘adolescent’, ‘youth’, ‘disaster’, ‘posttraumatic’, ‘psychosocial’, ‘therapy’ and ‘intervention’. The researchers followed the PRISMA guidelines. A total of 850 articles were screened for their eligibility and fifty-nine were found to meet the study criteria. The final data analysis was performed based on the disaster type, study design, type of intervention, sample size, age, school grade, number of sessions, setting of intervention delivery, providers, approach and parent involvement. RESULTS: Countries worldwide have experienced various kinds of disasters, including earthquakes, hurricanes, vessel accidents, tornados, tsunamis, volcanic eruptions, war, fire, terrorism, and traffic accidents. The types of psychosocial intervention that were conducted after these disasters included: psychological first aid, psychological debriefing, psychoeducation, trauma focused cognitive behavior therapy, eye movement desensitization reprocessing, prolonged exposure therapy, group play therapy and arts therapy, project interventions, school-based interventions and web-based interventions. CONCLUSION: The findings of the systematic literature review suggest that an appropriate psychosocial intervention could be utilized as evidence-based mental health treatment for children and adolescents after disasters.
Subject(s)
Adolescent , Child , Humans , Accidents, Traffic , Cognitive Behavioral Therapy , Cyclonic Storms , Disasters , Earthquakes , Eye Movement Desensitization Reprocessing , Fires , First Aid , Implosive Therapy , Mental Health , Parents , Play Therapy , Sample Size , Statistics as Topic , Terrorism , Tornadoes , Tsunamis , Volcanic EruptionsABSTRACT
This study aimed to investigate the prevalence and clinical determinants of cataract and cataract surgery in Korean population. The 2008-2012 Korean National Health and Nutrition Examination Survey was analyzed, which included 20,419 participants aged ≥ 40 years. The survey is a multistage, probability-cluster survey, which can produce nationally representative estimates. Prevalence of cataract and cataract surgery was estimated. Clinical determinants for those were investigated using logistic regression analyses (LRAs). The prevalence of cataract was 42.28% (95% confidence interval [CI], 40.67-43.89); 40.82% (95% CI, 38.97-42.66) for men and 43.62% (95% CI, 41.91-45.33) for women (P = 0.606). The prevalence of cataract surgery was 7.75% (95% CI, 7.30-8.20); 6.38% (95% CI, 5.80-6.96) for men and 9.01% (95% CI, 8.41-9.61) for women (P < 0.001). Cataract was associated with older age (P < 0.001), men (P = 0.032), lower household income (P = 0.031), lower education (P < 0.001), hypertension (P < 0.001), and diabetes mellitus (DM) (P < 0.001). Cataract surgery was consistently associated with older age, occupation, DM, asthma, and anemia in two LRAs, which compared participants with cataract surgery to those without cataract surgery and those having a cataract but without any cataract surgery, respectively. Hypertension, arthritis, and dyslipidemia were associated with cataract surgery at least in one of these LRAs. These results suggest that there are 9.4 million individuals with cataract and 1.7 million individuals with cataract surgery in Korea. Further studies are warranted to reveal the causality and its possible mechanism of developing/exacerbating cataract in novel determinants (i.e., anemia, asthma, and arthritic conditions) as well as well-known determinants.
Subject(s)
Adult , Aged , Female , Humans , Male , Middle Aged , Age Factors , Cataract/complications , Cataract Extraction , Diabetes Mellitus, Type 2/complications , Hypertension/complications , Logistic Models , Nutrition Surveys , Prevalence , Republic of Korea/epidemiology , Risk Factors , Socioeconomic FactorsABSTRACT
Nontuberculous mycobacteria (NTM) have been increasingly recognized as an important cause of chronic pulmonary infections. The Mycobacterium avium complex (MAC), which is composed of two species, Mycobacterium avium and Mycobacterium intracelluare, is the most commonly encountered pathogen associated with NTM lung disease. MAC pulmonary infection typically presents in a fibrocavitary form or a nodular bronchiectatic form. However, there have been atypical presentations of MAC pulmonary infections, including solitary pulmonary nodules (SPN). There have been several previous reports of SPN due to MAC infection in the United States, Japan, and Korea. In 2009, Sekine and colleagues reported a case of MAC pulmonary infection presenting with multiple nodules. To date, however, there have been no cases of NTM lung infection with multiple cavitary pulmonary nodules, and neither a fibrotic change nor nodular bronchiectasis. The present case showed a multiple cavitating nodular lung infection due to MAC, which is very rare and different from the typical presentation of MAC pulmonary infections. We also showed that percutaneous transthoracic needle aspiration can be a useful diagnostic tool to evaluate a case of multiple cavitary nodules.
Subject(s)
Bronchiectasis , Japan , Korea , Lung , Lung Diseases , Mycobacterium avium , Mycobacterium avium Complex , Mycobacterium , Needles , Nontuberculous Mycobacteria , Solitary Pulmonary Nodule , United StatesABSTRACT
OBJECTIVES: This study attempted to evaluate the usefulness and direction of development of post-traumatic assessment and interventions based on the opinions of psychiatrics and disaster and trauma-related experts using the Delphi survey technique. METHODS: In-depth individual interviews served as the pre-survey and were followed by Delphi primary and secondary surveys. Specialists in child and adolescent mental health, psychological support professionals specialized in disasters and related practitioners with experience of disasters in Korea completed a set of questionnaires and participated in focus group interviews and in-depth individual interviews on post-traumatic assessment and intervention. RESULTS: We found that the following issues have a significant impact on the interventions after disasters: the proper time of the initial interview in the event of a disaster, assessment notices, aged assessment services, mandatory enforcement measures, scale screening and treatment intervention elements, symptoms degree classification, intervention standardization, the use of a levelled program, care unit environment, and operation plan. CONCLUSION: This study proposed effective mental health intervention measures and has implications for the development of evaluation treatment protocols after disasters.