Browse publications by year: 2023

  1. Jamaluddin FN, Ibrahim F, Ahmad SA
    J Healthc Eng, 2023;2023:1951165.
    PMID: 36756137 DOI: 10.1155/2023/1951165
    In sports, fatigue management is vital as adequate rest builds strength and enhances performance, whereas inadequate rest exposes the body to prolonged fatigue (PF) or also known as overtraining. This paper presents PF identification and classification based on surface electromyography (EMG) signals. An experiment was performed on twenty participants to investigate the behaviour of surface EMG during the inception of PF. PF symptoms were induced in accord with a five-day Bruce Protocol treadmill test on four lower extremity muscles: the biceps femoris (BF), rectus femoris (RF), vastus medialis (VM), and vastus lateralis (VL). The results demonstrate that the experiment successfully induces soreness, unexplained lethargy, and performance decrement and also indicate that the progression of PF can be observed based on changes in frequency features (ΔF med and ΔF mean) and time features (ΔRMS and ΔMAV) of surface EMG. This study also demonstrates the ability of wavelet index features in PF identification. Using a naïve Bayes (NB) classifier exhibits the highest accuracy based on time and frequency features with 98% in distinguishing PF on RF, 94% on BF, 9% on VL, and 97% on VM. Thus, this study has positively indicated that surface EMG can be used in identifying the inception of PF. The implication of the findings is significant in sports to prevent a greater risk of PF.
    MeSH terms: Bayes Theorem; Electromyography/methods; Fatigue; Humans; Muscle, Skeletal; Muscle Fatigue*; Quadriceps Muscle*
  2. Shoaib MA, Chuah JH, Ali R, Hasikin K, Khalil A, Hum YC, et al.
    Comput Intell Neurosci, 2023;2023:4208231.
    PMID: 36756163 DOI: 10.1155/2023/4208231
    Cardiac health diseases are one of the key causes of death around the globe. The number of heart patients has considerably increased during the pandemic. Therefore, it is crucial to assess and analyze the medical and cardiac images. Deep learning architectures, specifically convolutional neural networks have profoundly become the primary choice for the assessment of cardiac medical images. The left ventricle is a vital part of the cardiovascular system where the boundary and size perform a significant role in the evaluation of cardiac function. Due to automatic segmentation and good promising results, the left ventricle segmentation using deep learning has attracted a lot of attention. This article presents a critical review of deep learning methods used for the left ventricle segmentation from frequently used imaging modalities including magnetic resonance images, ultrasound, and computer tomography. This study also demonstrates the details of the network architecture, software, and hardware used for training along with publicly available cardiac image datasets and self-prepared dataset details incorporated. The summary of the evaluation matrices with results used by different researchers is also presented in this study. Finally, all this information is summarized and comprehended in order to assist the readers to understand the motivation and methodology of various deep learning models, as well as exploring potential solutions to future challenges in LV segmentation.
    MeSH terms: Heart; Heart Diseases*; Humans; Image Processing, Computer-Assisted/methods; Magnetic Resonance Imaging; Neural Networks (Computer)
  3. Raharjo Y, Ismail AF, Dzarfan Othman MH, Fahmi MZ, Saiful, Santoso D, et al.
    RSC Adv, 2023 Jan 18;13(5):2972-2983.
    PMID: 36756405 DOI: 10.1039/d2ra07557a
    The adequacy in uremic toxin removal upon hemodialysis treatment is essential in patients with kidney failure diseases as poor removal leads to heart failure, hypertension, and stroke. The combination of adsorption and diffusion processes has become very advantageous for hemodialysis membranes. By this mechanism, water-soluble uremic toxins (WSUTs) and protein-bounded uremic toxins (PBUTs) could be removed at one time. Therefore, this study aimed to develop a novel imprinted zeolite by p-cresol (IZC) and then incorporated it into polyethersulfone (PES) and poly(vinyl pyrrolidone) (PVP) to produce hollow fiber mixed matrix membrane (HF-MMM). The IZC proved to be sensitive in attracting the adsorbate, classifying it as having a strong adsorption behavior. Accordingly, IZC is very promising to be applied as an adsorbent in the hemodialysis treatment. In this study, IZC as p-cresol's adsorbent was incorporated into a PES-based polymeric membrane with a small addition of PVP to produce HF-MMM using a dry/wet spinning process. The effect of air gap distance between the spinneret and coagulant bath and percentage loading for PES, PVP, and IZC were studied and optimized to obtain the best performance of HF-MMM. The 40 cm of air gap distance, 16 wt% of PES, 2 wt% of PVP, and 1 wt% of IZC loading were able to produce a superior hemodialysis membrane. These optimized parameters showed sufficient uremic toxin removal, i.e., 60.74% of urea, 52.35% of p-cresol in the phosphate buffer saline solution, and 66.29% of p-cresol in bovine serum albumin solution for 4 h permeation using the dialysis system. These HF-MMMs also achieved pure water flux of 67.57 L m-2 h-1 bar-1 and bovine serum albumin rejection of 95.05%. Therefore, this membrane has proven to be able to clean up WSUT and PBUT through a one-step process. Moreover, as compared to the neat PES membrane, MMM was able to remove p-cresol at 186.22 times higher capability.
  4. Phey Phey ML, Tuan Abdullah TA, Md Ali UF, Mohamud MY, Ikram M, Nabgan W
    RSC Adv, 2023 Jan 18;13(5):3039-3055.
    PMID: 36756434 DOI: 10.1039/d2ra07617a
    The catalytic conversion of CO2 via the Reverse Water Gas Shift (RWGS) reaction for CO production is a promising environment-friendly approach. The greenhouse gas emissions from burning fossil fuels can be used to produce valuable fuels or chemicals through CO2 hydrogenation. Therefore, this project was to study the CO2 conversion via RWGS over various Cu/ZnO catalysts supported by regenerated spent bleaching earth (RSBE) prepared by wet impregnation technique with different Cu : Zn ratios (0.5, 1.0, 1.5, 2.0, 3.0). The causes of environmental pollution from the disposal of spent bleaching earth (SBE) from an edible oil refinery can be eliminated by using it as catalyst support after the regeneration process. The synthesized catalysts were characterized by thermogravimetric analysis (TGA), X-ray diffraction (XRD), temperature-programmed reduction of hydrogen (TPR-H2), pyridine-adsorbed Fourier transform infrared (FTIR-pyridine), temperature programmed desorption of carbon dioxide (TPD-CO2), N2 physisorption, and Fourier transform infrared (FTIR) analysis. The RWGS reaction was carried out in a slurry reactor at 200 °C, with a pressure of 3 MPa, a residence time of 4 h, and catalyst loading of 1.0 g with an H2/CO2 ratio of 3. According to experimental data, the Cu/Zn ratio significantly impacts the catalytic structure and performance. The catalytic activity increased until the Cu : Zn ratio reached the maximum value of 1.5, while a further increase in Cu/Zn ratio inhibited the catalytic performance. The CZR3 catalyst (Cu/Zn ratio of 1.5) with a higher catalytic reducibility, high copper dispersion with small crystalline size, lower total pore volume as well as higher basicity showed superior catalytic performance in terms of CO2 conversion (40.67%) and CO yield (39.91%). Findings on the effect of reaction conditions revealed that higher temperature (>240 °C), higher pressure (>3 MPa), higher reaction time (>4 h) and higher catalyst loading (>1.25 g) could improve CO2 conversion to CO yield. A maximum CO2 conversion of 45.8% and multiple recycling stability of the catalyst were achieved, showing no significant decrease in CO2 conversion.
  5. Nam HY, Draman Yusof MR, Kamarul T
    Stem Cells Int, 2023;2023:4907230.
    PMID: 36756494 DOI: 10.1155/2023/4907230
    The present study was conducted to determine whether adipose derived mesenchymal stromal cells (AD-MSCs) or bone marrow derived-MSCs (BM-MSCs) would provide superior tenogenic expressions when subjected to cyclical tensile loading. The results for this would indicate the best choice of MSCs source to be used for cell-based tendon repair strategies. Both AD-MSCs and BM-MSCs were obtained from ten adult donors (N = 10) and cultured in vitro. At passaged-2, cells from both groups were subjected to cyclical stretching at 1 Hz and 8% of strain. Cellular morphology, orientation, proliferation rate, protein, and gene expression levels were compared at 0, 24, and 48 hours of stretching. In both groups, mechanical stretching results in similar morphological changes, and the redirection of cell alignment is perpendicular to the direction of stretching. Loading at 8% strain did not significantly increase proliferation rates but caused an increase in total collagen expression and tenogenic gene expression levels. In both groups, these levels demonstrated no significant differences suggesting that in a similar loading environment, both cell types possess similar tenogenic potential. In conclusion, AD-MSCs and BM-MSCs both demonstrate similar tenogenic phenotypic and gene expression levels when subjected to cyclic tensile loading at 1 Hz and 8% strain, thus, suggesting that the use of either cell source may be suitable for tendon repair.
  6. Zulkifli N'A, Zahir NH, Abdullah Ripain AH, Said SM, Zakaria R
    Nanoscale Adv, 2023 Jan 31;5(3):879-892.
    PMID: 36756501 DOI: 10.1039/d2na00756h
    Molybdenum disulfide (MoS2) has been attracting considerable attention due to its excellent electrical and optical properties. We successfully grew high-quality, large-area and uniform few-layer (FL)-MoS2 on p-doped gallium nitride (p-GaN) using a simplified sulfurization technique by the single-zone CVD of a Mo seed layer via E-beam evaporation. Tuning the sulfurization parameters, namely temperature and duration, has been discovered to be an effective strategy for improving MoS2 orientation (horizontally aligned and vertically aligned) and quality, which affects photodetector (PD) performance. The increase in the sulfurization temperature to 850 °C results in improved structural quality and crystallite size. However, a prolonged sulfurization duration of 60 minutes caused the degradation of the film quality. The close lattice match between p-GaN and MoS2 contributes to the excellent quality growth of deposited MoS2. Following this, an n-MoS2/p-GaN heterostructure PD was successfully built by a MoS2 position-selectivity method. We report a highly sensitive and self-powered GaN/MoS2 p-n heterojunction PD with a relatively high responsivity of 14.3 A W-1, a high specific detectivity of 1.12 × 1013 Jones, and a fast response speed of 8.3/13.4 μs (20 kHz) under a UV light of 355 nm at zero-bias voltage. Our PD exhibits superior performance to that of the previously reported MoS2/GaN p-n PD. Our findings suggest a more efficient and straightforward approach to building high-performance self-powered UV PDs.
  7. Matsui R, Yamaguchi K, Lee JJV, Ting I, Khairilisani D, Chang J, et al.
    Ther Innov Regul Sci, 2023 Mar;57(2):261.
    PMID: 36315399 DOI: 10.1007/s43441-022-00476-z
  8. Naguib AM, Apparoo Y, Xiong C, Phan CW
    Int J Med Mushrooms, 2023;25(2):11-22.
    PMID: 36749053 DOI: 10.1615/IntJMedMushrooms.2022046849
    Neurodegeneration is one of the most common manifestations in an aging population. The occurrence of oxidative stress and neuroinflammation are the main contributors to the phenomenon. Neurologic conditions such as Alzheimer's disease (AD) and Parkinson's disease (PD) are challenging to treat due to their irreversible manner as well as the lack of effective treatment. Grifola frondosa (Dicks.: Fr.) S.F. Gray, or maitake mushroom, is believed to be a potential choice as a therapeutic agent for neurodegenerative diseases. G. frondosa is known to be a functional food that has a wide variety of medicinal purposes. Thus, this review emphasizes the neuroprotective effects and the chemical composition of G. frondosa. Various studies have described that G. frondosa can protect and proliferate neuronal cells through neurogenesis, antioxidative, anti-inflammatory, and anti-β-amyloid activities. The mechanism of action behind these therapeutic findings in various in vitro and in vivo models has also been intensively studied. In this mini review, we also summarized the chemical composition of G. frondosa to provide a better understanding of the presence of nutritional compounds in G. frondosa.
    MeSH terms: Adjuvants, Immunologic; Agaricales*; Antioxidants
  9. Singh S, Meher N, Mohammed A, Razab MKAA, Bhaskar LVKS, Nawi NM
    Medicine (Baltimore), 2023 Feb 03;102(5):e30284.
    PMID: 36749239 DOI: 10.1097/MD.0000000000030284
    The primary target of severe acute respiratory syndrome coronavirus 2 is the respiratory system including the nose and lungs, however, it can also damage the kidneys, cardiovascular system and gastrointestinal system. Many recent reports suggested that severe acute respiratory syndrome coronavirus 2 infections can also affect the central nervous system as well as peripheral nervous system that lead to the several neurological complications. The virus can break the blood brain barrier and enters the brain via haematological route or directly by the angiotensin-converting enzyme 2 receptors present on endothelial cells of many cerebral tissues. The neurological complications are manifested by headache, dizziness, encephalopathy, encephalitis, cerebrovascular disease, anosmia, hypogeusia, muscle damage, etc. This review article described the possible routes and mechanism of nervous system infection and the range of neurological complications of COVID-19 that may help the medical practitioners and researchers to improve the clinical treatment and reduce the mortality rate among patients with viral diseases.
    MeSH terms: Brain; Communicable Diseases*; Humans; Endothelial Cells
  10. Koczwara B, Chan A, Jefford M, Lam WWT, Taylor C, Wakefield CE, et al.
    JCO Glob Oncol, 2023 Jan;9:e2200305.
    PMID: 36749908 DOI: 10.1200/GO.22.00305
    MeSH terms: Humans; Neoplasms*
  11. Yeap TB, Ab Mukmin L, Ang SY, Ghani AR
    BMJ Case Rep, 2023 Feb 07;16(2).
    PMID: 36750294 DOI: 10.1136/bcr-2022-252692
    Patients with medically refractory epilepsy (MRE) are indicated for vagus nerve stimulation (VNS) placement. Anaesthesia for VNS placement is extremely challenging and requires several considerations. We present a man in his 20s with MRE who successfully underwent VNS placement. We review the mechanism of action of VNS, anaesthetic challenges and measures to prevent seizures.
    MeSH terms: Drug Resistant Epilepsy*; Anesthesia*; Anesthesiology*; Humans; Male; Seizures; Treatment Outcome; Vagus Nerve Stimulation*
  12. Dewi IP, Wahyuni FS, Aldi Y, Ismail NH, Dachriyanus
    J Complement Integr Med, 2023 Jun 01;20(2):365-371.
    PMID: 36750417 DOI: 10.1515/jcim-2022-0419
    OBJECTIVES: The objective of this study is to determine the activity of Garcinia cowa Roxb. n-hexane, ethyl acetate, and butanol fractions as an immunomodulator in vitro and obtain the fraction that has the potential as an immunomodulator.

    METHODS: Raw 264.7 macrophages were used to asses G. cowa Roxb. immunomodulatory activity. The MTT assay was chosen to measure cell viability to evaluate the cytotoxic effect on cells. ELISA method was used to measure the concentration of Interleukin-6 (IL-6) and Tumor Necrosis Factor Alpha (TNF-α) secreted by cells after being treated with G. cowa Roxb. fraction. The neutral red uptake assay determined the effect of Garcinia cowa Roxb. on the phagocytic activity.

    RESULTS: After Raw 264.7 macrophages were given the Hexan fraction (Hex) at concentrations of 12.5 and 25 μg/mL, there was a decrease in the concentration of IL-6, TNF-α, and the phagocytosis index of cells. Administration of the Ethyl Acetate fraction (EtOAc) at concentrations of 12.5 and 25 μg/mL on cells caused a decrease in IL-6 and TNF-α levels but did not affect the phagocytosis index. There was an increase in the level of TNF-α and the phagocytosis index after being given the Butanol fraction (BuOH) with concentrations of 12.5 and 25 μg/mL but there was a slight decrease in the level of IL-6.

    CONCLUSIONS: Both Hex and EtOAc fractions could suppress immune responses through decreasing IL-6, TNF-α, and slightly decreased phagocytic activity. BuOH fraction could stimulate immunomodulatory activities through enhanced TNF-α levels and phagocytic index, but less potent in enhancing IL-6 production. The BuOH fraction could be developed as an immunostimulant.

    MeSH terms: Immunologic Factors/pharmacology; Tumor Necrosis Factor-alpha; Interleukin-6; Garcinia*
  13. Kaewunruen S, Osman MH
    Sci Rep, 2023 Feb 07;13(1):2141.
    PMID: 36750640 DOI: 10.1038/s41598-023-28866-9
    Unplanned track inspections can be a direct consequence of any disruption to the operation of on-board track geometry monitoring activities. A novel response strategy to enhance the value of the information for supplementary track measurements is thus established to construct a data generation model. In this model, artificial (synthetic) data is assigned on each measurement point along the affected track segment over a short period of time. To effectively generate artificial track measurement data, this study proposes a NARX (nonlinear autoregressive with exogenous variables) model, which incorporates short-range memory dependencies in the dependent variable and integrates interdependent effects from external factors. Nonlinearities in the proposed model have been determined using an artificial neural network that allowed fast computation of a mapping function in line with the needs of effective disruption management. The risk of over fitting the data generation model, which reflected its generalisation ability, has been effectively managed through risk aversion concept. For the model evaluation, the deviation of track longitudinal level has been taken as a case study, predicted using its degradation rate and track alignment and gauge as exogenous variables. Simulation results on two datasets that are statistically different showed that the data generation model for disrupted track measurements is reliable, accurate, and easy-to-use. This novel model is an essential breakthrough in railway track integrity prediction and resilient operation management.
  14. Turkiewicz A, Manko E, Oresegun DR, Nolder D, Spadar A, Sutherland CJ, et al.
    Sci Rep, 2023 Feb 07;13(1):2142.
    PMID: 36750737 DOI: 10.1038/s41598-023-29368-4
    The zoonotic Plasmodium knowlesi parasite is a growing public health concern in Southeast Asia, especially in Malaysia, where elimination of P. falciparum and P. vivax malaria has been the focus of control efforts. Understanding of the genetic diversity of P. knowlesi parasites can provide insights into its evolution, population structure, diagnostics, transmission dynamics, and the emergence of drug resistance. Previous work has revealed that P. knowlesi fall into three main sub-populations distinguished by a combination of geographical location and macaque host (Macaca fascicularis and M. nemestrina). It has been shown that Malaysian Borneo groups display profound heterogeneity with long regions of high or low divergence resulting in mosaic patterns between sub-populations, with some evidence of chromosomal-segment exchanges. However, the genetic structure of non-Borneo sub-populations is less clear. By gathering one of the largest collections of P. knowlesi whole-genome sequencing data, we studied structural genomic changes across sub-populations, with the analysis revealing differences in Borneo clusters linked to mosquito-related stages of the parasite cycle, in contrast to differences in host-related stages for the Peninsular group. Our work identifies new genetic exchange events, including introgressions between Malaysian Peninsular and M. nemestrina-associated clusters on various chromosomes, including in parasite invasion genes (DBP[Formula: see text], NBPX[Formula: see text] and NBPX[Formula: see text]), and important proteins expressed in the vertebrate parasite stages. Recombination events appear to have occurred between the Peninsular and M. fascicularis-associated groups, including in the DBP[Formula: see text] and DBP[Formula: see text] invasion associated genes. Overall, our work finds that genetic exchange events have occurred among the recognised contemporary groups of P. knowlesi parasites during their evolutionary history, leading to apparent mosaicism between these sub-populations. These findings generate new hypotheses relevant to parasite evolutionary biology and P. knowlesi epidemiology, which can inform malaria control approaches to containing the impact of zoonotic malaria on human communities.
    MeSH terms: Animals; Genetics, Population; Humans; Macaca fascicularis/parasitology; Malaysia/epidemiology; Selection, Genetic; Genetic Variation; Malaria, Falciparum*; Malaria, Vivax*
  15. Sornpaisarn B, Limmade Y, Pengpid S, Jayasvasti I, Chhoun P, Somphet V, et al.
    BMC Public Health, 2023 Feb 07;23(1):272.
    PMID: 36750861 DOI: 10.1186/s12889-023-15165-1
    BACKGROUND: To tackle noncommunicable disease (NCD) burden globally, two sets of NCD surveillance indicators were established by the World Health Organization: 25 Global Monitoring Framework (GMF) indicators and 10 Progress Monitoring Indicators (PMI). This study aims to assess the data availability of these two sets of indicators in six ASEAN countries: Cambodia, Lao PDR, Malaysia, Myanmar, Thailand, and Vietnam.

    METHODS: As data on policy indicators were straightforward and fully available, we focused on studying 25 non-policy indicators: 23 GMFs and 2 PMIs. Gathering data availability of the target indicators was conducted among NCD surveillance experts from the six selected countries during May-June 2020. Our research team found information regarding whether the country had no data at all, was using WHO estimates, was providing 'expert judgement' for the data, or had actual data available for each target indicator. We triangulated their answers with several WHO data sources, including the WHO Health Observatory Database and various WHO Global Reports on health behaviours (tobacco, alcohol, diet, and physical activity) and NCDs. We calculated the percentages of the indicators that need improvement by both indicator category and country.

    RESULTS: For all six studied countries, the health-service indicators, based on responses to the facility survey, are the most lacking in data availability (100% of this category's indicators), followed by the health-service indicators, based on the population survey responses (57%), the mortality and morbidity indicators (50%), the behavioural risk indicators (30%), and the biological risk indicators (7%). The countries that need to improve their NCD surveillance data availability the most are Cambodia (56% of all indicators) and Lao PDR (56%), followed by Malaysia (36%), Vietnam (36%), Myanmar (32%), and Thailand (28%).

    CONCLUSION: Some of the non-policy GMF and PMI indicators lacked data among the six studied countries. To achieve the global NCDs targets, in the long run, the six countries should collect their own data for all indicators and begin to invest in and implement the facility survey and the population survey to track NCDs-related health services improvements once they have implemented the behavioural and biological Health Risks Population Survey in their countries.

    MeSH terms: Humans; Risk Factors; Global Health; World Health Organization
  16. Md Isa Z, Ismail NH, Mohd Tamil A, Jaafar MH, Ismail R, Mohamed Noor Khan NA, et al.
    BMC Nutr, 2023 Feb 07;9(1):27.
    PMID: 36750888 DOI: 10.1186/s40795-023-00687-z
  17. Sanusi SY, Al-Bataynehb OB
    Iran Endod J, 2023;18(1):15-40.
    PMID: 36751408 DOI: 10.22037/iej.v18i1.34931
    Pulp treatment in primary dentition is generally divided into vital and non-vital pulp therapies and assists in the preservation of pulpally involved primary teeth in the dental arch until the affected tooth naturally exfoliates. The success of pulp therapies depends on several factors; e.g. proper case selection, accurate diagnosis and good coronal seal. To date, studies on the success and failure rates of pulp treatments are based on clinical signs and symptoms, radiographic findings and histological analysis. However, the clinical and radiographic evidence may not completely portray the true status of the dental pulp. Histological evidence remains the gold standard in the assessment of pulp condition, whether it is in a healthy or adverse state. The aims of the current research were to summarise the treatment outcomes of pulp therapy in primary dentition based on clinical, radiographic and histological criteria, and to support its relevance in the presence of limited histological evidence to measure authentic treatment success. An electronic database search of dental literature from 1990 to 2022 was carried out using the MEDLINE, i.e. PubMed, database. Current dental literature showed that the success rates of primary tooth pulp therapy are high. The obtained results were based largely on clinical and radiographic studies with narrow histological investigations to assess the treatment outcome(s) of pulp therapy in primary dentition. Despite the scarcity of histological evidence, pulp therapies in primary teeth are still practical due to their statistically empirical success compared to their failure. Consequently, pulp therapy of primary dentition is still relevant, and should continue to be indicated as an important treatment option.
  18. Ramoo V, Kamaruddin A, Wan Nawawi WNF, Che CC, Kavitha R
    Florence Nightingale J Nurs, 2023 Feb;31(1):2-10.
    PMID: 36751711 DOI: 10.5152/FNJN.2022.22061
    AIM: This study aims to assess the perception and satisfaction of nurses toward the electronic medical record system in a teaching hospital.

    METHOD: A cross-sectional study was conducted among 350 nurses in a teaching hospital via a self-administered questionnaire between May to October 2019. Descriptive analysis, independent t-test, analysis of variance, and hierarchical multiple regression were used to analyze the data using Statistical Package for Social Sciences software version 25. In addition, a The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was used as guide in reporting the results of this study.

    RESULTS: Almost all the nurses (98%, n = 343) had a positive perception toward the electronic medical record system, though their perceptions significantly differ across work units, computer or laptop ownership, and daily time spent on the system (all p < .05). Nurses who had received training reported better satisfaction with the system.

    CONCLUSION: Among the issues highlighted by the participants that warrant attention were system development and connectivity. This study, therefore, emphasizes the involvement of nursing personnel in system development to ensure an appropriate approach for nursing care delivery.

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