Research on the development methodology for clinical practice guidelines for organic integration of traditional Chinese medicine and Western medicine

Integrated traditional Chinese medicine(TCM)and Western medicine(WM)is a new medical science grounded in the knowledge bases of both TCM and WM,which then forms a unique modern medical system in China.Integrated TCM and WM has a long history in China,and has made important achievements in the process of clinical diagnosis and treatment.However,the methodological defects in currently published clinical practice guidelines(CPGs)limit its development.The organic integration of TCM and WM is a deeper integration of TCM and WM.To realize the progression of"integration"to"organic integration",a targeted and standardized guideline development methodology is needed.Therefore,the purpose of this study is to establish a standardized development procedure for clinical practice guidelines for the organic integration of TCM and WM to promote the systematic integration of TCM and WM research results into clinical practice guidelines in order to achieve optimal results as the whole is greater than the sum of the parts.

Quality of life and survival analyses of breast cancer cases treated with integrated traditional Chinese and Western medicine

BACKGROUND Breast cancer(BC)is the second leading cause of tumor-related mortality after lung cancer.Chemotherapy resistance remains a major challenge to progress in BC treatment,warranting further exploration of feasible and effective alternative therapies.AIM To analyzed the quality of life(QoL)and survival of patients with BC treated with integrated traditional Chinese and Western medicine(TCM-WM).METHODS This study included 226 patients with BC admitted to the First Affiliated Hospital of Guangxi University of Traditional Chinese Medicine between February 2018 and February 2023,including 100 who received conventional Western medicine treatment(control group)and 126 who received TCM-WM treatment(research group).The total effective rate,side effects(alopecia,nausea and vomiting,hepatorenal toxicity,and myelosuppression),QoL assessed using the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire(EORTC QLQ-C30),1-year overall survival(OS),recurrence and metastasis rates,and serum inflammatory factors[interleukin(IL)-6,IL-10,and tumor necrosis factor alpha]were comparatively analyzed.RESULTS The research group showed statistically better overall efficacy,EORTC QoL-C30 scores,and 1-year OS than the control group,with markedly lower side effects and 1-year recurrence and metastasis rates.Moreover,the posttreatment levels of serum inflammatory in the research group were significantly lower than the baseline and those in the control group.CONCLUSION Overall,TCM-WM demonstrated significantly improved therapeutic efficacy while ensuring drug safety in BC,which not only improved patients’QoL and prolonged survival,but also significantly inhibited the inflammatory response.

Application of multidisciplinary team-based integrated traditional Chinese medicine and Western medicine in rotator cuff injury patients undergoing arthroscopic surgery

BACKGROUND Arthroscopic rotator cuff repair is a common surgical treatment for rotator cuff injuries(RCIs).Although this procedure has certain clinical advantages,it requires rehabilitation management interventions to ensure therapeutic efficacy.AIM To investigate the effect of integrated traditional Chinese medicine and Western medicine(TCM-WM)under the multidisciplinary team(MDT)model on the postoperative recovery of patients undergoing arthroscopic surgery for RCIs.METHODS This study enrolled 100 patients who underwent arthroscopic rotator cuff repair for RCIs at the Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine between June 2021 and May 2024.They were divided into a control group(n=48)that received routine rehabilitation treatment and an experimental group(n=52)that received TCM-WM under the MDT model(e.g.,acupuncture,TCM traumatology and orthopedics,and rehabilitation).The results of the Constant–Murley Shoulder Score(CMS),Visual Analogue Scale(VAS),Shoulder Pain and Disability Index(SPADI),muscular strength evaluation,and shoulder range of motion(ROM)assessments were analyzed.RESULTS After treatment,the experimental group showed significantly higher CMS scores in terms of pain,functional activity,shoulder joint mobility,and muscular strength than the baseline and those of the control group.The experimental group also exhibited significantly lower VAS and SPADI scores than the baseline and those of the control group.In addition,the experimental group showed significantly enhanced muscular strength(forward flexor and external and internal rotator muscles)and shoulder ROM(forward flexion,abduction,and lateral abduction)after treatment compared with the control group.CONCLUSION TCM-WM under the MDT model improved shoulder joint function,relieved postoperative pain,promoted postoperative functional recovery,and facilitated the recovery of muscular strength and shoulder ROM in patients with RCIs who underwent arthroscopic rotator cuff repair.

Research progress of integrated traditional Chinese and Western medicine in the treatment of advanced gastric cancer

Gastric cancer(GC)is a malignant tumor originating from the gastric epithelium,and its incidence and mortality rates rank third among all malignant tumors worldwide.It is also one of the most common cancers in China and is treated predominantly by Western medicine in clinical practice.However,with the advancements in medical technology and informatics,the values of traditional Chinese medicine(TCM)in preventing and treating GC and improving prognosis have increasingly been recognized.According to TCM,clinical manifestations of GC can be divided into Yege(dysphagia),regurgitation,stomach pain,and Zhengxia(abdominal mass).Due to the unbalanced distribution of health care resources in China,most GC patients already have progressive or advanced-stage disease at the first diagnosis.As a result,most GC patients have poor physical function,and surgery or chemotherapy alone will aggravate the impairment to the immune function and seriously affect the quality of life.In contrast,TCM therapies have shown promising efficacy in the management of these patients.Here we review the role of the integrated TCM and Western medicine in treating advanced GC.

A Clinical Study of Integrated Traditional Chinese and Western Medicine in the Treatment of Liver-Stomach Disharmony Functional Dyspepsia

Objective:To explore the clinical effect of integrated traditional Chinese and Western medicine in the treatment of liver-stomach disharmony functional dyspepsia.Methods:Sixty patients with functional dyspepsia of liver-stomach disharmony type admitted to our hospital from January to August 2022 were selected as research subjects and randomly divided into two groups,a study group and a control group,with 30 cases in each group.The main observations were stomachache or pain over bilateral flanks,emotionally depressed,belching,fullness and discomfort over the abdomen and flanks,acid regurgitation,loss of appetite,frequent sighing,noisy epigastric,and the treatment effect.Results:According to the classification of symptom severity on the traditional Chinese medicine(TCM)symptom score table,statistics were made on the corresponding severity of the main symptoms and secondary symptoms of the two groups of patients,and the data of the two groups were compared by Wilcoxon test.The results showed that there was no significant difference in the distribution of TCM symptoms between the two groups;the study group’s total effective rate of pain relief(recovery+markedly effective+effective)was 96.67%,and Fisher’s χ^(2) test indicated a significant difference in the total effective rate of pain relief between the two groups(P=0.027<0.05).Conclusion:The use of integrated traditional Chinese and western medicine is clearly better than the simple application of western medicine.It is safe and has no side effects.It can be used as a treatment for patients with functional dyspepsia.

Application of integrated traditional Chinese and Western medicine in the treatment of juvenile localized scleroderma with skin ulcer: a case report

Background:Juvenile Localized Scleroderma(JLS)is a rare pediatric rheumatic disease characterized by inflammation and skin sclerosis.The side effect of consensus-recommended medications and the risk of disability posed challenges to the JLS treatment.We intend to demonstrate the potential of traditional Chinese medicine in treating JLS with skin ulcers and reducing the dose of glucocorticoid.Method:Here we report a case of a 13-year-old male with JLS who took oral methotrexate tablets of 10 mg/week and methylprednisolone of 6 mg/day for over six months without significant effect and suffered from skin ulcers on the dorsal feet one month after drug cessation.Subsequently,the patient was treated with integrated traditional Chinese and Western medicine of low-dose glucocorticosteroid,adjusted Shenqi Huoxue formula and Jinshe Xiaoyan formula,etc.Results:After integrated treatment,the patient’s dorsal feet ulcers healed and the skin sclerosis and hyperpigmentation improved significantly.Conclusions:This case report suggests that integrated traditional Chinese and Western medicine can be used as an effective treatment for JLS.

Therapeutic Effect of Integrated Traditional Chinese and Western Medicine on Anal Pruritus After Anorectal Surgery

Objective:To explore the therapeutic effect of integrated traditional Chinese and western medicine on anal pruritus after anorectal surgery.Methods:Ninety-eight patients with anal pruritus after anorectal surgery in our hospital were selected as the research subjects.They were divided into two groups,the control group(50 cases)and the study group(48 cases),according to the treatment plan.The control group was under a simple western medicine treatment plan,while the study group was under an integrated traditional Chinese and western medicine treatment plan.The overall efficacy,severity of anal pruritus,time to eliminate clinical symptoms,and anxiety and depression scores of the two groups of patients under different treatment plans were compared.Results:After two weeks of treatment,the total effective rate of the study group was 95.83%,which was significantly higher than that of the control group(82.00%,P<0.05).After 7 and 14 days of treatment,the anal pruritus scores improved significantly in both the groups,but the study group was superior to the control group,with statistical difference(P<0.01).The time of disappearance of skin itching and skin damage in the study group was shorter than that in the control group.After 14 days of treatment,the anxiety and depression scores of both groups were lower than those after 7 days of treatment;however,there was statistical difference between the two groups(P<0.01).Conclusion:In the clinical treatment of anorectal postoperative diseases,such as anal pruritus,the combination of traditional Chinese and western medicine can significantly improve the symptoms of pruritus,shorten the time of disappearance of clinical symptoms,improve depression and anxiety,and create a positive clinical application value in promoting the rehabilitation of patients and improving their quality of life.

Expert consensus on diagnosis and treatment of ulcerative colitis with integrated traditional Chinese and Western medicine:A nursing perspective

Ulcerative colitis(UC)is a chronic nonspecific intestinal inflammatory disease of unclear etiology,characterized by continuous and diffuse inflammatory changes of colorectal mucosa.In recent years,the incidence rate of UC in China has increased year by year,but there is no effective cure method in Western medicine.Traditional Chinese medicine treatment based on syndrome differentiation has the unique advantages of simplicity,convenience,effectiveness,and low cost.Therefore,integration of Chinese and Western medicine has become an important strategy for UC diagnosis and treatment,and has made significant progress in UC.On the basis of learning from a number of consensuses at home and abroad,combined with Chinese research results and the actual clinical situation of traditional Chinese and Western medicine,the UC group of the Chinese Association of Integrative Medicine has formulated the expert consensus on the diagnosis and treatment of UC with integrated traditional Chinese and Western medicine.In this consensus,the pathogenesis,etiology and pathogenesis,diagnosis,integrated traditional Chinese and Western medicine treatment,and chronic disease management with integrated traditional Chinese and Western medicine for UC were recommended by experts.This article interprets the consensus from the perspective of nursing in order to provide reference basis for clinical nursing workers.

Treatment of postpartum depression with integrated traditional Chinese and Western medicine nursing and electrical stimulation

BACKGROUND Postpartum depression(PPD)is a common psychological disease among puerperal women,and postpartum pelvic floor dysfunction is a common disease among pregnant women.The occurrence of postpartum pelvic floor dysfunction will increase the incidence of PPD.AIM To explore the therapeutic effect of integrated traditional Chinese and Western medicine nursing combined with electrical stimulation of pelvic floor muscles and the rectus abdominis on PPD.METHODS From April 2020 to January 2022,100 parturients with a rectus abdominis muscle separation distance>2.0 cm who underwent reexamination 6 wk after delivery at our hospital were selected as the research subjects.According to the random number table method,the patients were divided into either an observation group(n=50)or a control group(n=50).There was no significant difference in the general data between the two groups(P>0.05).Both groups were treated by electrical stimulation.The observation group was additionally treated by integrated traditional Chinese and Western medicine nursing.A self-designed Depression Knowledge Questionnaire was used to evaluate the awareness of knowledge on depression in all patients 3 wk after intervention.The Hamilton Depression Scale(HAMD)was used to evaluate the depression before intervention and 1 wk and 3 wk after intervention,and the Morisky Medication Adherence Scale(MMAS-8)was used to evaluate the medication compliance.SPSS19.0 was used for statistical analyses.RESULTS The rate of awareness of knowledge on depression in the observation group was significantly higher than that of the control group(P<0.05).The scores of MMAS-8 were comparable between the two groups before intervention(P>0.05),but were significantly higher in the observation group than in the control group at 1 wk and 3 wk after intervention(P<0.05).The HAMD scores were comparable between the two groups before intervention(P>0.05),but were significantly lower in the observation group than in the control group at 1 wk and 3 wk after intervention(P<0.05).CONCLUSION Integrated traditional Chinese and Western medicine nursing combined with electrical stimulation of pelvic floor muscles and the rectus abdominis is effective in the treatment of postpartum depression and worthy of clinical promotion.

Nursing perspective of expert consensus for diagnosis and treatment of gastric cancer with integrated traditional Chinese and Western medicine

Gastric cancer is a common and highly malignant tumor of the digestive system,which seriously threatens human health.The benefit of surgical treatment is limited.The effect of radiotherapy and chemotherapy is not significant,and the toxic and side effects are large.Although the diagnosis and treatment modes of molecular targeting and multidisciplinary cooperation have also been further developed and applied,a relatively unified comprehensive treatment standard scheme has not been formed.Traditional Chinese medicine(TCM),as complementary and alternative medicine,has unique advantages in the development of diagnosis and treatment of diseases in China.Therefore,the Chinese Association of Integrative Medicine formed“Expert Consensus for Diagnosis and Treatment of Gastric Cancer with Integrated Traditional Chinese and Western Medicine”on the basis of clinical practice and experience.In this article,the consensus is interpreted from the perspective of nursing,focusing on the pathogenesis,high‑risk factors,characteristic therapies of TCM,and nursing of integrated traditional Chinese and Western medicine for gastric cancer,to provide a reference for front‑line medical personnel in the roots in the future nursing care of gastric cancer.

Evidence-based optimization of integrated traditional Chinese and Western medicine therapies for prevention and treatment of coronary heart disease： design and implementation

As a chronic disease that seriously endangers public health, the number of coronary heart disease （CHD） patients in China has increased in recent years. There is great potentiality to integrate traditional Chinese and Western medicine therapies to prevent and treat CHD in clinical practice. However, most of the current integrated therapies still lack sufficient high-quality evidence, and the key links in how to apply are unclear. It is urgent to optimize them through evidence-based research to further improve the effectiveness. Therefore, we propose strategies to conduct evidence-based optimization of integrated traditional Chinese and Western medicine therapies in prevention and treatment of progressive cardiovascular diseases. These are integrated clinical trial design, attention to the key links of taking effect, combination of clinical and basic research. Based on the strategies, we started the national key research and development project ＂Evidence-based optimization research of TCM therapies in prevention and treatment of CHD （angina pectoris - myocardial infarction - heart failure）＂, which is expected to be a new paradigm in the field.

Clinical Experience in the Treatment of Vulvovaginal Candida Disease with Integrated Traditional Chinese and Western Medicine

Summarizing two cases of vaginal candidiasis,cured by integrated traditional Chinese and western medicine in clinical work,it is found that the combination of traditional Chinese and western medicine has a significant effect on the treatment of this disease.The curative effect is outstanding,and the recurrence rate is significantly reduced,which can be used as a reference for gynecological medical workers.

Professor YANG Yu-fei’s Experience on the Integrated Chinese and Western Medicine Treatment Strategy for Advanced Colorectal Cancer

Colorectal cancer is one of the common malignant tumors in China.It poses a serious threat to the national health of China.For advanced colorectal cancer, the main goal of treatment is to prolong survival and improve quality of life.It complements other advantages, showing good therapeutic results.However, how to grasp the timing of integrated Chinese and Western Medicine for the treatment of advanced colorectal cancer and use the integrated Chinese and Western Medicine treatment methods flexibly contains profound therapeutic art.Prof.YANG Yu-fei is an authoritative expert in the field of integrated Chinese and Western medicine for colorectal cancer.She is good at accurately grasping the timing of treatment of integrated Chinese and Western Medicine, and flexibly adjusts the treatment strategy according to the specific conditions.In this paper, we shared Professor YANG Yu-fei's strategy for treating advanced colorectal cancer with emphasis on integrated Chinese and Western Medicine and attached a typical case, with a view to provide reference for the treatment of advanced colorectal cancer with integrated Chinese and Western Medicine.

Progress on Therapy of Infertility by Integrated Traditional Chinese and Western Medicine

Infertility is one of the difficult complicated diseases. Many couples suffer from it. The pathogenesis is very complicated. The imbalance or lesson of any link of the reproductive system can cause infertility. This paper summarizes the treatment of female infertility by integrated Traditional Chinese Medicine (TCM) and Western Medicine (WM) which can not only improve the ovulation rate and pregnancy rate, but also decrease the complications. The effects are better than that by TCM or WM only. Therefore, the coupling method is worth to be used widely in clinical practice.

Nursing perspective of expert consensus on the diagnosis and treatment of cerebral infarction with integrated traditional Chinese and Western medicine

Cerebral infarction(CI)is also known as ischemic stroke.It is one of the most common cerebrovascular diseases,with high mortality and disability rate,which has seriously threatened human health.To better apply the diagnosis and treatment plan of integrated traditional Chinese and Western medicine to the treatment of patients with CI,the Chinese Association of Integrative Medicine issued the Expert Consensus on the Diagnosis and Treatment of Cerebral Infarction with the Integrated Traditional Chinese and Western Medicine in 2021.It involves etiology and pathogenesis of CI,diagnosis and treatment standards of Traditional Chinese Medicine(TCM)and Western Medicine,syndrome elements of TCM,as well as rehabilitation nursing of CI with integrated traditional Chinese and Western medicine during acute period and recovery period.This study interprets the consensus from routine nursing,dietary nursing,emotional nursing,complication nursing,rehabilitation nursing,and continuous nursing,aiming to provide evidence-based support for clinical TCM nursing practice.

Nursing perspective of the expert consensus on diagnosis and treatment of integrated Chinese and Western medicine in lung cancer

Lung cancer is a malignant tumor with the highest incidence and mortality in China,which seriously affects the quality of life of patients.Traditional Chinese medicine(TCM)plays a unique advantage in the treatment and rehabilitation of lung cancer.In order to standardize TCM diagnosis and treatment and disease management of clinical medical workers,the Chinese Association of Integrative Medicine issued the“Expert Consensus on the Diagnosis and Treatment of Lung Cancer by Integrated Traditional Chinese and Western Medicine”in August 2021.Experts’recommendations were made on the clinical staging and syndrome differentiation and classification of lung cancer,characteristic TCM therapies,and nursing care of integrated traditional Chinese and Western medicine.This article interpreted the Consensus on the above aspects from a nursing perspective,hoping to provide references for clinical medical workers in the treatment and nursing care of lung cancer.

The prognosis and survival of integrated traditional Chinese and western medicine on glioma: a meta-analysis

Objective:To systematically access the effects of integrated traditional Chinese and western medicine treatment versus western medicine treatment alone in glioma.Methods:Published randomized controlled trials were included from electronic databases(Cochrane Library,Pubmed,Embase,Chinese National Knowledge Infrastructure,Wanfang database,Chinese Scientific Journal Database,Chinese Biomedical Literature Database.Deadline on January 30,2020).The Cochrane handbook was referred to evaluate the methodological quality.Curative efficacy,gastrointestinal side effects,bone marrow suppression,survival time and quality of life(Karnofsky)were compared between the two groups.Meta-analysis was conducted using Reveman 5.3 and Stata 14.0 software.Results:Twelve randomized controlled trials involved 886 cases were selected,including 446 cases in the trial group and 440 cases in the control group.The meta-analysis indicated that the overall efficacy of integrated traditional Chinese and western medicine showed significant improvement compared with western medicine alone.The effects included reduced tumor size(RR=1.32,95%CI(1.18,1.49),P<0.05),gastrointestinal adverse reactions(RR=0.42,95%CI(0.30,0.60),P<0.05),bone marrow suppression(RR=0.437,95%CI(0.282,0.677),P<0.05),and improved KPS score(SMD=0.632,95%CI(0.312,0.952),P<0.05).Conclusion:For patients with glioma,integrated traditional Chinese and western medicine treatment can be one of the options for a better treatment.

Integrated Chinese and Western Medicine for the Treatment of Acne Associated Blepharokeratoconjunctivitis Case 1

This article reported a case of acne associated blepharokeratoconjunctivitis(BKC)in a young woman.During her pregnancy,to reduce the systemic use of drugs due to its side effect,localized eye drop,oral administration of Chinese medicine,and fumigation treatment were adopted.In integrated Chinese and Western medicine treatments,localized treatment simultaneously with the intrinsic conditioning of the patient’s physique could treat both the symptoms and root causes of disease.It can effectively improve clinical efficacy,shorten the course of the disease,and reduce patient suffering and recurrence.

Analysis on the therapeutic effects of integrated traditional Chinese and Western medicine on ulcerative colitis and its effects on coagulation function and inflammatory factors

Objective:To analyze the therapeutic effects of Integrated Traditional Chinese and Western Medicine on ulcerative colitis (UC) and its effects on coagulation function and inflammatory factors.Methods: 220 cases of patients with UC were selected as the research subjects and randomly divided into the observation group and the control group, 110 cases were included into each group. The patients in the control group were treated with single western medicine, while the patients in the observation group were treated with enema treatment of traditional Chinese Medicine. The clinical therapeutic effects of the two groups were evaluated and compared. The blood coagulation indexes of the activated partial thromboplastin time (APTT), prothrombin time (PT), the plasma fibrinogen (Fib), the D dimer (D-D) of two groups patients who in the treatment were detected and compared. The serum tumor necrosis factor (TNF-α), interleukin-6 (IL-6), interleukin-8 (IL-8) levels of the patients in the two groups were measured and compared.Results: The clinical efficiencies of the observation group and the control group were 97% and 75%, the clinical efficiencies and the therapeutic effects of the observation group were better than those in the control group, there were statistically significant differences between the two groups. The plasma Fib levels and the plasma D-D levels after the treatment of the patients in the two groups were significantly lower than those before the treatment, the difference was statistically significant. The plasma Fib levels and the plasma D-D levels after the treatment of the patients in the observation group were lower than those in the control group, the difference was statistically significant. The serum inflammatory factors levels after the treatment of the patients in the two groups were significantly lower than those before the treatment, the difference was statistically significant. The serum inflammatory factors levels after the treatment of the patients in the observation group were lower than those in the control group, the difference is powerful and have statistically significant.Conclusion: The application of Integrated Traditional Chinese and Western Medicine in the treatment of UC can improve the therapeutic effect significantly, correct imbalance of the patients' coagulation dissolution function, reduce the degree of inflammatory reaction, which benefits to promote of the patients' rehabilitation, reduce the incidence of complications and improve the prognosis of patients.

Clinical efficacy and significance of serum fibroblast growth factor-21 and ghrelin in the treatment of type 2 diabetes complicated with coronary heart disease with integrated traditional Chinese and western medicine

Objective: To treat the patients with type 2 diabetes mellitus complicated with coronary heart disease, to explore the clinical efficacy and mechanism of conventional western medicine combined with Yiqi Yangyin Huoxue herbs, and to detect the level of serum fibroblast growth factor-21 (FGF-21) and Ghrelin. Changes and significance. Methods: A randomized control method was used to collect 100 patients with type 2 diabetes mellitus complicated with coronary heart disease who were diagnosed and treated in our hospital from March 2015 to March 2018.They were randomly divided into two groups according to the random number table method: 50 patients separately. The patients in the control group were treated with conventional western medicine and basic treatment;the observation group was treated with the addition and subtraction of traditional Chinese medicine formulas on the basis of the control group;the clinical curative effect was evaluated after two months of treatment, and the treatment efficiency and scores of traditional Chinese medicine symptoms were observed in the two groups. Basic laboratory indicators were improved, and serum levels of FGF-21 and Ghrelin in patients were measured and the difference between the results of the tests was compared with the condition and efficacy. Results: After treatment, the total effective rate of the observation group (86.0%) was significantly higher than that of the control group (68.0%) (P<0.05), suggesting that the combination of Chinese and Western medicine treatment can significantly improve the clinical efficacy;before treatment,there is no difference between the two groups of Chinese medicine symptom scores (P>0.05). After treatment, the symptom scores of the two groups were significantly improved after treatment (P<0.05). The observation group was better among the two groups (P<0.05).After treatment, the basic biochemical indicators were improved. The observation group was better than the control group (P<0.05);Serum FGF-21 levels were significantly lower in both groups after treatment (P<0.05), and Ghrelin levels were significantly increased. There was a statistically significant difference between the two groups (P<0.05). Conclusion: The use of conventional western medicine in combination with Yiqi Yangyin Huoxue Chinese medicine for the treatment of type 2 diabetes mellitus patients with coronary heart disease can significantly improve the clinical efficacy, effectively promote the improvement of symptoms, and can be used in clinical work through serum FGF-21, Ghrelin levels combined detection of the value of Abnormal changes to predict the severity of type 2 diabetes mellitus with coronary heart disease severity and treatment effect should be widely used in clinical diagnosis and treatment.