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Objective@#To investigate the reliability and validity of the Korean version of Children’s Depression Inventory 2 Short Version (CDI 2:S) in comparison with its full-length version (CDI 2) as a screening tool for depressive youth. @*Methods@#A total of 714 children from the community and 62 psychiatric patients were enrolled in this study. The Korean version of the Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version (K-SADS-PL-K) served as the reference standard for computing receiver operating characteristic (ROC) curves. To evaluate the ability of the CDI 2 and CDI 2:S to discriminate major depressive disorders, areas under the curves (AUCs) were compared. To investigate psychometric properties of the CDI 2:S, internal consistency was calculated and confirmatory factor analysis was conducted. @*Results@#For the CDI 2, the cutoff at 20 yielded the best balance between sensitivity (83%) and specificity (91%). For the CDI 2:S, the cutoff point of 10 resulted in high sensitivity (82%) and high specificity (93%). The short form was proven to be as sensitive and specific as the CDI 2. Further analyses confirmed that the CDI 2:S also had good reliability and validity. @*Conclusion@#The CDI 2:S, a sensitive and brief form of the CDI 2, may serve as a better option in time-constrained psychiatric settings.
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Protective ventilation is a prevailing ventilatory strategy these days and is comprised of small tidal volume, limited inspiratory pressure, and application of positive end-expiratory pressure (PEEP). However, several retrospective studies recently suggested that tidal volume, inspiratory pressure, and PEEP are not related to patient outcomes, or only related when they influence the driving pressure. Therefore, this review introduces the concept of driving pressure and looks into the possibility of driving pressure-guided ventilation as a new ventilatory strategy, especially in thoracic surgery where postoperative pulmonary complications are common, and thus, lung protection is of utmost importance.
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Objectives@#This study examined the results of the restandardization of the Korean Personality Assessment Inventory (PAI). The Korean PAI was first standardized in 2001 and then restandardized in 2019 to establish new normative data. On the other hand, differences may exist in the results of the restandardized version considering the time interval, which may include cultural and social differences. Thus, differences between the results of the Korean PAI administered in 2001 and 2019 must be examined to confirm its new normative data followed by restandardization. @*Methods@#Data from 2212 adults who administered the original Korean PAI in 2001 and 1263 adults who administered the Korean PAI in 2019 were collected. The study compared the reliability and mean scores. In addition, the mean scores of the Korean PAI administered in 2019 were converted to T-scores adapted to the normative data of 2001. The collected data was analyzed using a t-test and comparing the T-scores. @*Results@#The internal consistency reliability showed a similar pattern in both versions, but the differences among the mean scores and T-scores appeared to be significant. @*Conclusion@#The significant differences between the scores of the Korean PAI administered in 2001 and 2019 reflect the result of the restandardization. Therefore, the restandardized version of the Korean PAI may bring more precise information that can be adapted to the contemporary era.
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BACKGROUND@#Considering the functional role of red blood cells (RBC) in maintaining oxygen supply to tissues, RBC transfusion can be a life-saving intervention in situations of severe bleeding or anemia. RBC transfusion is often inevitable to address intraoperative massive bleeding; it is a key component in safe perioperative patient management. Unlike general medical resources, packed RBCs (pRBCs) have limited availability because their supply relies entirely on voluntary donations. Additionally, excessive utilization of pRBCs may aggravate prognosis or increase the risk of developing infectious diseases. Appropriate perioperative RBC transfusion is, therefore, crucial for the management of patient safety and medical resource conservation. These concerns motivated us to develop the present clinical practice guideline for evidence-based efficient and safe perioperative RBC transfusion management considering the current clinical landscape.@*METHODS@#This guideline was obtained after the revision and refinement of exemplary clinical practice guidelines developed in advanced countries. This was followed by rigorous evidence-based reassessment considering the healthcare environment of the country.@*RESULTS@#This guideline covers all important aspects of perioperative RBC transfusion, such as preoperative anemia management, appropriate RBC storage period, and leukoreduction (removal of white blood cells using filters), reversal of perioperative bleeding tendency, strategies for perioperative RBC transfusion, appropriate blood management protocols, efforts to reduce blood transfusion requirements, and patient monitoring during a perioperative transfusion.@*CONCLUSIONS@#This guideline will aid decisions related to RBC transfusion in healthcare settings and minimize patient risk associated with unnecessary pRBC transfusion.
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BACKGROUND: Considering the functional role of red blood cells (RBC) in maintaining oxygen supply to tissues, RBC transfusion can be a life-saving intervention in situations of severe bleeding or anemia. RBC transfusion is often inevitable to address intraoperative massive bleeding; it is a key component in safe perioperative patient management. Unlike general medical resources, packed RBCs (pRBCs) have limited availability because their supply relies entirely on voluntary donations. Additionally, excessive utilization of pRBCs may aggravate prognosis or increase the risk of developing infectious diseases. Appropriate perioperative RBC transfusion is, therefore, crucial for the management of patient safety and medical resource conservation. These concerns motivated us to develop the present clinical practice guideline for evidence-based efficient and safe perioperative RBC transfusion management considering the current clinical landscape. METHODS: This guideline was obtained after the revision and refinement of exemplary clinical practice guidelines developed in advanced countries. This was followed by rigorous evidence-based reassessment considering the healthcare environment of the country. RESULTS: This guideline covers all important aspects of perioperative RBC transfusion, such as preoperative anemia management, appropriate RBC storage period, and leukoreduction (removal of white blood cells using filters), reversal of perioperative bleeding tendency, strategies for perioperative RBC transfusion, appropriate blood management protocols, efforts to reduce blood transfusion requirements, and patient monitoring during a perioperative transfusion. CONCLUSIONS: This guideline will aid decisions related to RBC transfusion in healthcare settings and minimize patient risk associated with unnecessary pRBC transfusion.
Sujets)
Humains , Anémie , Transfusion sanguine , Maladies transmissibles , Prestations des soins de santé , Transfusion d'érythrocytes , Érythrocytes , Hémorragie , Leucocytes , Monitorage physiologique , Oxygène , Sécurité des patients , PronosticRésumé
OBJECTIVE: The Beck Depression Inventory-II (BDI-II) is one of the most popular scales for evaluating the severity of depression in adolescents as well as adults. The prevalence of depression increases during adolescence, and it has shown a rapid increase with occurrence at an earlier age and a tendency to continue into adulthood. Data from an adolescent nonclinical sample provides us more information related to depressive symptoms as potential risk factors. The current study was designed to two objectives: 1) to analyze the reliability and validity the BDI-II among Korean adolescents and 2) to evaluate the factorial structure in a Korean nonclinical adolescent sample. METHODS: The participants included 1072 adolescent boys and girls. We assessed the internal consistency, corrected item-total correlation, and the convergent validity of the BDI-II. We also performed confirmatory factor analyses to determine the internal structure of the BDI-II for Korean adolescents using Mplus 6.1. RESULTS: The Cronbach's alpha for the BDI-II total score was 0.89. The correlation between the BDI-II and the PHQ-9 was strong (r=0.75), and anxiety-related measures were 0.68 and 0.71, which were also in the high range. Among the five different factor structures, the modified three-factor model demonstrated the best overall fit. CONCLUSION: The BDI-II is a reliable tool for measuring the severity of depressive symptoms in Korean adolescents. Therefore, the findings can provide basic information for examining the prevalence rate, intervention strategies for depression in adolescents.
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Adolescent , Adulte , Femelle , Humains , Dépression , Trouble dépressif , Diagnostic , Prévalence , Psychométrie , Reproductibilité des résultats , Facteurs de risque , Poids et mesuresRésumé
PURPOSE: Today's clinical nurses deal with complex problems that need accurate evidence for practice and decision making. In this study the effectiveness of an EBP education program was examined. METHODS: A pre-posttest design was used for this study and participants were 46 nurses working at a tertiary hospital located in Suwon, Korea. Date collection was done before and after the education program, from July 27 to October 2, 2015. Data were analyzed using paired t-test and ANCOVA with SPSS 21.0. RESULTS: There were significant differences in scores before and after the EBP education program for EBP readiness: belief (t=-5.65, p<.001), implementation(t=-2.89, p=.006), competence (t=-4.21, p<.001), and for evidence-based decision making (t=-16.25, p<.001) by the nurses. CONCLUSION: The findings indicate that the EBP education program has positive effects on EBP belief, implementation, competence and evidence-based decision making. In the future, it is necessary to reinforce the content of the program in the clinical workplace and to provide continuous education for clinical nurses.
Sujets)
Prise de décision , Éducation , Pratique factuelle , Corée , Capacité mentale , Centres de soins tertiairesRésumé
Acute kidney injury is a common and serious complication after major cardiovascular surgery and is independently associated with poor short- and long-term outcomes. The pathogenesis of cardiac surgery-associated acute kidney injury is complex and involves multiple pathways including hemodynamic, inflammatory, metabolic and nephrotoxic factors. Three definitions of acute kidney injury based on serum creatinine and urine output (RIFLE, AKIN, and KDIGO criteria) have been proposed and validated. Several novel biomarkers of acute kidney injury have been developed to facilitate the subclinical diagnosis of acute kidney injury, as well as the better risk stratification of patients. Despite the high-quality research conducted in this field to date, there is very little evidence supporting specific interventions to treat acute kidney injury in patients undergoing cardiovascular surgery. Thus, early identification of high-risk patients and preventing cardiac surgery-associated acute kidney injury by mitigating risk factors or avoiding renal insults remains the mainstay of management. Although some strategies have shown promising results in renoprotection, further large randomized trials are needed to confirm the benefit of such approaches.
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Humains , Atteinte rénale aigüe , Marqueurs biologiques , Créatinine , Diagnostic , Hémodynamique , Facteurs de risque , Chirurgie thoraciqueRésumé
BACKGROUND: The early detection of coagulopathy helps guide decisions regarding optimal transfusion management during cardiac surgery. This study aimed to determine whether rotational thromboelastometry (ROTEM) analysis during cardiopulmonary bypass (CPB) could predict thrombocytopenia and hypofibrinogenemia after CPB. METHODS: We analyzed 138 cardiac surgical patients for whom ROTEM tests and conventional laboratory tests were performed simultaneously both during and after CPB. An extrinsically activated ROTEM test (EXTEM), a fibrin-specific ROTEM test (FIBTEM) and PLTEM calculated by subtracting FIBTEM from EXTEM were evaluated. Correlations between clot amplitude at 10 min (A10), maximal clot firmness, platelet count, and fibrinogen concentrations at each time point were calculated. A receiver operating characteristic analysis with area under the curve (AUC) was used to assess the thresholds of EXTEM, PLTEM and FIBTEM parameters during CPB and for predicting thrombocytopenia and hypofibrinogenemia after weaning of CPB. RESULTS: The A10 on EXTEM, PLTEM, and FIBTEM during CPB showed a good correlation with platelet counts (r = 0.622 on EXTEM and r = 0.637 on PLTEM; P < 0.0001 for each value) and fibrinogen levels (r = 0.780; P < 0.0001) after CPB. A10 on a FIBTEM threshold of 8 mm during the CPB predicted a fibrinogen concentration < 150 mg/dl (AUC = 0.853) after CPB. Additionally, the threshold level of A10 on EXTEM during CPB for predicting platelet counts < 100,000 /microl after CPB was 42 mm (AUC = 0.768). CONCLUSIONS: EXTEM, PLTEM, and FIBTEM parameters during CPB may be useful for predicting thrombocytopenia and hypofibrinogenemia after weaning of CPB.
Sujets)
Humains , Pontage cardiopulmonaire , Fibrinogène , Numération des plaquettes , Courbe ROC , Chirurgie thoracique , Thromboélastographie , Thrombopénie , SevrageRésumé
An elevated serum concentration of uric acid may be associated with an increased risk of acute kidney injury (AKI). The aim of this study was to investigate the impact of preoperative uric acid concentration on the risk of AKI after coronary artery bypass surgery (CABG). Perioperative data were evaluated from patients who underwent CABG. AKI was defined by the AKI Network criteria based on serum creatinine changes within the first 48 hr after CABG. Multivariate logistic regression was utilized to evaluate the association between preoperative uric acid and postoperative AKI. We evaluated changes in C statistic, the net reclassification improvement, and the integrated discrimination improvement to determine whether the addition of preoperative uric acid improved prediction of AKI. Of the 2,185 patients, 787 (36.0%) developed AKI. Preoperative uric acid was significantly associated with postoperative AKI (odds ratio, 1.18; 95% confidence interval, 1.10-1.26; P<0.001). Adding uric acid levels improved the C statistic and had significant impact on risk reclassification and integrated discrimination for AKI. Preoperative uric acid is related to postoperative AKI and improves the predictive ability of AKI. This finding suggests that preoperative measurement of uric acid may help stratify risks for AKI in in patients undergoing CABG.
Sujets)
Femelle , Humains , Mâle , Adulte d'âge moyen , Atteinte rénale aigüe/étiologie , Pontage aortocoronarien/effets indésirables , Créatinine/sang , Hyperuricémie/sang , Tests de la fonction rénale , Complications postopératoires/étiologie , Période postopératoire , Période préopératoire , Études rétrospectives , Acide urique/sangRésumé
OBJECTIVES: The Beck Hopelessness Scale (BHS) is a 20-item scale for measuring the extent of negative attitudes about the future. Previous studies repeatedly demonstrated clinical utility of BHS, particularly for predicting suicide. The aim of this study is to examine the reliability and validity of the Korean version of the Beck Hopelessness Scale (K-BHS), which is commonly used for measuring hopelessness. METHODS: The study sample consisted of 1022 community-dwelling general adults from 4 regional areas (i.e., Seoul, Gyeonggi, Cheongju, and Jinju) across South Korea. They completed the K-BHS, Patient Health Questionnaire-9, Spielberger State-Trait Anxiety Inventory, and Adult ADHD Self-Report Scale. RESULTS: The Cronbach's alpha value for the K-BHS was 0.85. Test-retest reliability at average 7.2 days was 0.86. Discriminant validity was determined. Confirmatory factor analysis supported a three factor model. CONCLUSION: The K-BHS demonstrated satisfactory reliability and validity and therefore may be useful in measuring the construct of hopelessness and in clinical suicide risk assessments. Further studies are needed in order to explore the psychometric features and correlates of this scale among clinical populations.
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Adulte , Humains , Anxiété , Dépression , Corée , Psychométrie , Reproductibilité des résultats , Appréciation des risques , Séoul , SuicideRésumé
A 57-year-old female patient with suspicious interstitial lung disease underwent aortic valvular replacement for aortic stenosis. She complained of severe dyspnea, and her preoperative chest X-ray and computed tomography findings showed multiple ground glass opacity causing interstitial lung disease. After aortic valvular replacement, and as part of the weaning process after cardiopulmonary bypass, she was placed on a ventilator. Nonetheless, the peak airway pressure was higher than 40 mmHg with a less than 50 ml tidal volume, and there was no visible end-tidal CO2 curve. Repeated suction, expansion, and intravenous corticosteroid injection with aminophylline loading were performed to improve the patient's condition. Extracorporeal membrane oxygenation began after cardiopulmonary bypass and was sustained for 5 days. This case demonstrated the fragility of lungs with interstitial disease, and the need to exercise more precaution against acute respiratory failure after cardiopulmonary bypass.
Sujets)
Femelle , Humains , Adulte d'âge moyen , Aminophylline , Sténose aortique , Valve aortique , Pontage cardiopulmonaire , Dyspnée , Oxygénation extracorporelle sur oxygénateur à membrane , Verre , Poumon , Pneumopathies interstitielles , Insuffisance respiratoire , Aspiration (technique) , Thorax , Volume courant , Respirateurs artificiels , SevrageRésumé
BACKGROUND: Several studies have shown in animal models that remote ischemic preconditioning (rIPC) has a neuroprotective effect. However, a randomized controlled trial in human subjects to investigate the neuroprotective effect of rIPC after cardiac surgery has not yet been reported. Therefore, we performed this pilot study to determine whether rIPC reduced the occurrence of postoperative cognitive dysfunction in patients who underwent off-pump coronary artery bypass graft (OPCAB) surgery. METHODS: Seventy patients who underwent OPCAB surgery were assigned to either the control or the rIPC group using a computer-generated randomization table. The application of rIPC consisted of four cycles of 5 min ischemia and 5 min reperfusion on an upper limb using a blood pressure cuff inflating 200 mmHg before coronary artery anastomosis. The cognitive function tests were performed one day before surgery and again on postoperative day 7. We defined postoperative cognitive dysfunction as decreased postoperative test values more than 20% of the baseline values in more than two of the six cognitive function tests that were performed. RESULTS: In the cognitive function tests, there were no significant differences in the results obtained during the preoperative and postoperative periods for all tests and there were no mean differences observed in the preoperative and postoperative scores. The incidences of postoperative cognitive dysfunction in the control and rIPC groups were 28.6% (10 patients) and 31.4% (11 patients), respectively. CONCLUSIONS: rIPC did not reduce the incidence of postoperative cognitive dysfunction after OPCAB surgery during the immediate postoperative period.
Sujets)
Humains , Pression sanguine , Pontage coronarien à coeur battant , Vaisseaux coronaires , Incidence , Ischémie , Préconditionnement ischémique , Modèles animaux , Neuroprotecteurs , Projets pilotes , Période postopératoire , Répartition aléatoire , Reperfusion , Chirurgie thoracique , Transplants , Membre supérieurRésumé
OBJECTIVE: A self-report scale of adult attention-deficit/hyperactivity disorder, the World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS) was developed and demonstrated good psychometric properties. The purpose of the present study is to investigate the psychometric properties of the ASRS in Korean samples. METHODS: The ASRS includes 18 questions regarding the frequency of recent DSM-IV Criterion A symptoms of adult ADHD. We examined the factor structure, internal consistency, and convergent validity of the ASRS in Korean samples. RESULTS: The ASRS demonstrated good internal consistency and test-retest reliability. Correlations between the ASRS and other adult ADHD measures were high, providing evidence of convergent validity. A subsequent exploratory factor analysis indicated that a two-factor solution provided the best fit. CONCLUSION: It is expected that this scale would be helpful in clinical settings and research in Korea.
Sujets)
Adulte , Humains , Diagnostic and stastistical manual of mental disorders (USA) , Corée , Psychométrie , Reproductibilité des résultats , Organisation mondiale de la santéRésumé
BACKGROUND: We investigated the protective effects of propofol in the HK-2 cell line of human kidney proximal tubular cells against hydrogen peroxide (H2O2)-induced oxidative stress. METHODS: After pretreatment with different concentrations of propofol (0 microM, 10 microM, 25 microM and 50 microM) for 30 minutes, HK-2 cells were exposed to 8 mM H2O2 for 4 hours. Cell death was assessed by measuring the percentage of lactate dehydrogenase (LDH) release and by counting viable cells. The nature of cell death was assessed by doubles-taining cells with fluorescein isothiocyanate-labeled Annexin V and propidium iodide, and then analyzing the cells using flow cytometry. RESULTS: After exposure to 8 mM H2O2 for 4 hours, the percentage of LDH release was 45.1 +/- 4.2% and the number of viable HK-2 cells was 5.2 +/- 6.0%. Pretreatment with propofol suppressed H2O2-induced LDH release in a concentration-dependent manner, reducing the percentage of LDH release to 38.1 +/- 5.6%, 33.5 +/- 6.3%, and 26.2 +/- 3.8% of the controls at 10 microM, 25 microM and 50 microM propofol, respectively. Numbers of viable cells increased following propofol pretreatment, with 11.4 +/- 10.9%, 19.5 +/- 16.1%, and 32.4 +/- 23.3% cell survival rates after pretreatment with 10 microM, 25 microM and 50 microM propofol, respectively. Analyses of flow cytometry showed that the propofol pretreatment decreased the percentage of necrotic and late apoptotic cells. CONCLUSIONS: Propofol protects HK-2 human kidney proximal tubular cells against H2O2-induced oxidative stress.
Sujets)
Humains , Annexine A5 , Mort cellulaire , Lignée cellulaire , Survie cellulaire , Cytométrie en flux , Fluorescéine , Hydrogène , Peroxyde d'hydrogène , Rein , L-Lactate dehydrogenase , Stress oxydatif , Propidium , PropofolRésumé
OBJECTIVES: Differential diagnosis based on descriptive psychopathology between bipolar and unipolar depression in the clinical setting is a still huge challenge. Projective psychological tests might provide additional clues. This study aimed to find distinct Rorschach test characteristics of bipolar depression in comparison with unipolar depression. METHODS: Medical records and raw data of the Rorschach Inkblot test applied using standardized procedure for the Exner Comprehensive System were retrospectively reviewed for patients with bipolar disorder or unipolar depression. Individual variables of the Rorchach test were compared among three groups, i.e., (hypo) mania (n=59), bipolar depression (n=56) and unipolar depression (n=25). RESULTS: Bipolar depression group, in accordance with (hypo) manic group, showed more color reponses (WSumC), more extroverted and intuitive decision-making (EBright), and higher emotional expression (CF+C) and instability (ebright), compared to unipolar deperssion group. On the contrary, the (hypo) mania group displayed more cognitive errors (Sum6, WSum6) compared to both depression groups. CONCLUSION: This study suggests that Rorchach test might provide valuable markers for differential diagnosis between bipolar and unipolar depression, and that some of those markers could be regarded as trait markers of bipolar disorder.
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Humains , Trouble bipolaire , Dépression , Trouble dépressif , Diagnostic différentiel , Dossiers médicaux , Tests psychologiques , Psychopathologie , Études rétrospectives , Test de RorschachRésumé
No abstract available.
Sujets)
Arrêt circulatoire en hypothermie profonde , Chirurgie thoraciqueRésumé
OBJECTIVE: Experiencing traumatic events in childhood is related to various psychiatric problems in adulthood, and a comprehensive tool for measuring childhood trauma is necessary in this field. This study aimed to examine the psychometric properties, and factor structure of the Korean version of the Early Trauma Inventory Self Report-Short Form (ETISR-SF). ETISR-SF measures the childhood trauma, including physical, and emotional sexual abuse, as well as general traumas. METHODS: A clinical and nonclinical samples comprising of 97 subjects from a local community, and 207 patients with the ETISR-SF, were assessed. Other tools, including the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI) were used to assess clinical symptoms. Additional data from 69 college students was used to examine the test-retest reliability. RESULTS: The original four-factor model was supported by the confirmatory factor analysis scale [chi2 (351, n=304)=3374.025, p<0.001, TLI=0.969, CFI=0.972, RMSEA=0.030]. The ETISR-SF was found to be a reliable instrument (Cronbach's alpha=0.869). Comparison of the ETISR-SF scores discriminated the clinical group from that of the control group. The measure showed good convergent and divergent validity, in that the scores were correlated higher with the scores on the CTQ-SF (0.691) than with the scores on the BDI or BAI (0.424, 0.397 respectively). The ETISR-SF was found to be temporally stable, showing the moderate to high correlation (0.844). CONCLUSION: These findings suggest that the Korean version of the ETISR-SF appears to be a reliable and valid instrument for the measurement of reported childhood trauma.
Sujets)
Humains , Anxiété , Dépression , Psychométrie , Infractions sexuellesRésumé
Conventional aortic valve replacement for severe aortic stenosis is associated with a high operative mortality in the elderly patients with significant comorbidities, including severe respiratory dysfunction, renal insufficiency, and compromised cardiac function. Human transcatheter aortic valve implantation was first reported in 2002 and has become a valid alternative in selected high-risk patients in Europe and North America. This article describes the first attempt of transfemoral transcatheter aortic valve implantation in Korea. The procedure was applied in two consecutive patients with severe aortic stenosis. Despite several intra-operative complications during procedure, the post-operative outcomes were good for both patients. At post-operative 30 days there was satisfactory prosthetic valve function and hemodynamic stability.
Sujets)
Sujet âgé , Humains , Anesthésie , Valve aortique , Sténose aortique , Comorbidité , Europe , Hémodynamique , Corée , Amérique du Nord , Insuffisance rénaleRésumé
A 53-year-old woman who had undergone total gastrectomy and received adjuvant chemotherapy two months ago underwent adhesiolysis of the small bowel. She presented with sudden desaturation and dyspnea of unknown etiology at postanesthetic care unit. Following ET intubation, the endotracheal tube suction revealed massive hemoptysis. Bilateral lung infiltrated on her chest radiograph and bronchofibroscopic examination disclosed a diffuse hemorrhage on both lung fields without bleeding focus. These findings were consistent with diffuse alveolar hemorrhage (DAH) syndrome. As per our knowledge and search, this is the first reported case of DAH that occurred during the recovery period immediately after general anesthesia. DAH is known to have a high mortality rate and an early detection followed by adequate treatment is essential.