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Burnout is a syndrome of emotional exhaustion, loss of meaning at work, feeling of ineffectiveness, and a tendency to view people as objects rather than as a human being. Physician burnout leads to dissatisfaction at work and suboptimal patient care. Various causes of burnout at the individual, work environment, and health system levels have been identified. In this review, we initially focus on the burden of burnout. Subsequently, we describe the determinants of this problem in India and the West, while drawing on relevant literature. Finally, we provide evidence based practical suggestions to deal with physician burnout. Strategies suggested to deal with burnout need to be implemented based on locally available resources. Repeated assessment of burnout constructs using validated questionnaires can evaluate the effectiveness of an intervention. Hospitals, educational institutions, and physician societies need to collaborate with practicing physicians to address burnout and invest in physician well-being to continue providing high-quality medical care in the future.

The 2019 COVID-19 pandemic has thrown the global health-care system into a chaotic flux. Consolidating and reviewing all available knowledge will be crucial to combating the spread of this novel coronavirus. Prevention is paramount, but health care workers are at increased risk, and protective supplies are being limited and being rationed. Common symptoms include fever, cough, and shortness of breath. Hospitalizations are estimated to occur in about 20% of cases and are mostly due to pneumonia.[1] While multiple promising treatments are being reported in the medical literature; there is limited, reliable clinical data are available. To minimize exposure of medical staff to contagious patients and to provide rapid escalation of care to these patients, a telehealth strategy could be leveraged. Such a strategy would entail the use of both telemedicine visits for communication and digital health platforms for monitoring.

Background Patients from various countries may have unique patterns of using complementary and alternative medicine (CAM) and unique reasons for using it. Objective Our objective was to assess the use of CAM among patients from the Gulf region attending the Executive and International Health Program of the Department of General Internal Medicine at Mayo Clinic in Rochester, Minnesota. Methods This cross-sectional survey was administered to all patients who were from the Gulf region and were undergoing outpatient evaluation in the Executive and International Health Program. After their initial medical evaluation by a physician, the patients were invited to anonymously complete the modified International Complementary and Alternative Medicine Questionnaire. Results The survey was completed by 69 patients (41 women, 27 men; mean age, 45.4 years). The most frequently seen providers for CAM treatments were physicians (71.0% of patients), spiritual healers (29.0%), and chiropractors (20.3%). CAM treatments most frequently received from a physician were massage therapy (51.0%), hijama (38.8%), spiritual healing (24.5%), and acupuncture or herbs (16.3%). The most frequently used dietary supplements were ginger (42.0%), bee products (30.4%), and garlic (27.5%). The most common self-help therapies were prayers for health (68.1%), meditation (15.9%), and relaxation techniques (11.6%). CAM therapy, including visits to CAM providers, was used by 92.8% of patients. CAM was mainly used to improve well-being and long-term health conditions rather than for acute illnesses. Conclusion The use of CAM was high among our patients from the Gulf region, and the CAM therapies used by this population differed from the ones used by US patients. Physicians providing care to patients from the Gulf region should be aware of how the use of CAM may affect the care needs of these patients.

Annona reticulata Linn, has been shown to possess antipyretic, antihelmintic, hypoglycemic, antiulcer and wound healing properties. However, its immunomodulatory role is yet to be explored.In the present study, we intended to investigate the effects of A. reticulata leaf ethanol extract on various components of the immune system.The effects of A. reticulata leaf extract on human peripheral blood mononuclear cells, monocyte (THP1), and human macrophage (U937) cell lines were investigated. An animal study was conducted to observe the effect of the extract on humoral as well as cell mediated immunity.The extract stimulated proliferation of human PBMC, monocytes (THP1), and macrophages (U937) significantly in a dose dependent manner; expression of transforming growth factor-beta (TGF-β) increased in western blot analysis. Additionally, the extract treated macrophages exhibited features of activation under the microscope with a significant hike in the NO production. Flow cytometry of extract treated human PBMC revealed increased proliferation of lymphocytes (CD4, CD8B-cells) along with enhanced intracellular expression of IL-2, IL-6. Animal study data indicate a significant rise in the antibody titer as well as a strong delayed type hypersensitivity response in the extract (150 mg/kg and 300 mg/kg) treated mice; furthermore, the expression of IL-2 and IL-6 in mice PBMC was augmented.The collective data evince the immunomodulatory potential of A. reticulata L. leaf.

Newborn oil massage is a widespread practice. Vigorous massage with potentially harmful products and forced removal of vernix may disrupt skin barrier integrity. Hospitalized, very-preterm infants treated with sunflower seed oil (SSO) have demonstrated improved growth but community-based data on growth and health outcomes are lacking.We aimed to test whether SSO therapy enhances neonatal growth and reduces morbidity at the population level.We conducted an open-label, controlled trial in rural Uttar Pradesh, India, randomly allocating 276 village clusters equally to comparison (usual care) and intervention comprised of promotion of improved massage practices exclusively with SSO, using intention-to-treat and per-protocol mixed-effects regression analysis.We enrolled 13,478 and 13,109 newborn infants in demographically similar intervention and comparison arms, respectively. Adherence to exclusive SSO increased from 22.6% of intervention infants enrolled in the first study quartile to 37.2% in the last quartile. Intervention infants gained significantly more weight, by 0.94 g · kg-1 · d-1 (95% CI: 0.07, 1.82 g · kg-1 · d-1, P = 0.03), than comparison infants by intention-to-treat analysis. Restricted cubic spline regression revealed the largest benefits in weight gain (2-4 g · kg-1 · d-1) occurred in infants weighing2000 g at birth. Weight gain in intervention infants was higher by 1.31 g · kg-1 · d-1 (95% CI: 0.17, 2.46 g · kg-1 · d-1; P = 0.02) by per-protocol analysis. Morbidities were similar by intention-to-treat analysis but in per-protocol analysis rates of hospitalization and of any illness were reduced by 36% (OR: 0.64; 95% CI: 0.44, 0.94; P = 0.02) and 44% (OR: 0.56; 95% CI: 0.40, 0.77; P0.001), respectively, in treated infants.SSO therapy improved neonatal growth, and reduced morbidities when applied exclusively, across the facility-community continuum of care at the population level. Further research is needed to improve demand for recommended therapy inside hospital as well as in community settings, and to confirm these results in other settings.This trial was registered at www.isrctn.com as ISRCTN38965585 and http://ctri.nic.in as CTRI/2014/12/005282.

Background and aim The leaves of AnnonareticulataLinn (牛心果niú x ınguǒ; Bullock’s heart), a member of Annonaceae family, have been used extensively in folk medicine; however, its wound healing potential is yet to be explored. Our aim was to investigate the wound healing ability of A. reticulataleaf extract in vitro and in streptozotocin induced diabetic mice model. Material and methods We observed the plant extract induced proliferation and migration of primary human dermal fibroblast (HDF), human skin fibroblast cell line (GM00637) and human keratinocyte cell line (HACAT). The expression of transforming growth factor beta (TGF-β), connective tissue growth factor (CTGF), vascular endothelial growth factor (VEGF), alpha smooth muscle actin (α-SMA), matrix metalloproteinases (MMP-2, MMP-9), collagen-1, collagen-3, focal adhesion kinase (FAK) were evaluated by Western blot and gelatin zymography. Excisional diabetic wound model was used for in vivo wound healing assay. Furthermore, we processed wound tissue for histological and immunohistochemical study. Result A. reticulata L. leaf extract stimulates proliferation and migration of HDF, skin fibroblast and keratinocyte significantly in a dose dependent manner; expression of TGF-β, CTGF, VEGF, α-SMA, MMP-2, MMP-9, collagen-1, collagen-3, FAK increased. Additionally, an enhanced expression of phospho-SMAD2, phospho-SMAD3 in the treated cells indicated the activation of TGF-β signal transduction pathway, similarly increased expression of phospho-AkT suggested activation of PI3/AkT pathway. Expression of CTGF and α-SMA was also increased significantly in wound tissue. Mass spectrometric analysis revealed that mainly two compounds to be present in the extract: quercetin and β-sitosterol. Conclusion Collective data suggest that A.reticulata leaf extract may have a stimulatory effect in diabetic wound healing., Graphical abstract Image 1, Highlights • While the leaf extract from other species of the Annonaceae family have been studied extensively for wound healing activity, Annona reticulata leaf has not been explored for the same. • The present study showed significantly increased proliferation and migration of both fibroblasts and keratinocytes in the treated group with enhanced expression of various growth factors critical to wound healing.Topical application accelerated wound closure in diabetic mice model compared to the positive control group. • Annona reticulata Linn leaf extract have stimulatory effect in diabetic wound healing.

Several medications have been used perioperatively in patients undergoing noncardiac surgery in an attempt to improve outcomes. Antiplatelet therapy for primary prevention of cardiovascular events should generally be discontinued seven to 10 days before surgery to avoid increasing the risk of bleeding, unless the risk of a major adverse cardiac event exceeds the risk of bleeding. Antiplatelet therapy for secondary prevention should be continued perioperatively, except before procedures with very high bleeding risk, such as intracranial procedures. Antiplatelet drugs should be continued and surgery delayed, if possible, for at least 14 days after percutaneous coronary intervention without stent placement, 30 days after percutaneous coronary intervention with bare-metal stent placement, and six to 12 months after percutaneous coronary intervention with drug-eluting stent placement. Perioperative beta blockers are recommended for patients already receiving these agents, and it is reasonable to consider starting therapy in patients with known or strongly suspected coronary artery disease or who are at high risk of perioperative cardiac events and are undergoing procedures with a high risk of cardiovascular complications. Long-term statin therapy should be continued perioperatively or started in patients with clinical indications who are not already receiving statins. Clonidine should not be started perioperatively, but long-term clonidine regimens may be continued. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers generally can be continued perioperatively if patients are hemodynamically stable and have good renal function and normal electrolyte levels.

Maintenance of professional competence remains an exercise of permament learning and an essential requirement for evidence –based medical practice. Physicians attend continuing professional development (CPD) programs to acquire new knowledge. Often CPD programs remain the main source for updates of information. CPD organizers have a considerable responsibility in determining appropriate curriculum for their conferences. Organizing an effective CPD activity often requires understanding of the principles of adult education. Prior to deciding on the curriculum for a CPD, course organizers should conduct needs assessment of physicians. CPD planners should create activities that would consistently improve physician competence. CPD sessions that are interactive, using multiple methods of instructions for small groups of physicians from a single specialty are more likely to change physician knowledge and behavior. The effectiveness of a CPD program should be evaluated at a level beyond measuring physician satisfaction. CPD planners should incorporate methods to determine the course attendees’ improvement of knowledge, skills and attitudes during the CPD activities. Pre and post conference evaluations of physicians using multiple choice questions may form a useful method of assessment.

In this work the effect of multi-pass friction stir processing (FSP) followed by warm pressing on an as-extruded ZK60 Mg plate was investigated. The microstructure, texture and resulting mechanical properties are reported here. Multi-pass FSP to partial depths on the top and bottom plate surfaces produced a novel, layered structure with three distinct microstructural zones associated with stirred, transition and core regions. In the stirred zone, FSP, followed by pressing at 200 °C, created a 0.8 μm ultrafine grain size which accounts for ∼55 vol.% of the material. The transition region (∼10 vol.%), showed extensively sheared coarse grains distributed in a matrix of finer grains. However, the core region (∼35 vol.%) showed extensive twinning inside coarse grains in an overall bimodal microstructure reminiscent of extrusion. The processed Mg with a strong basal texture exhibited high yield strength (>300 MPa) and retention of adequate tensile ductility (>10%). The enhancement in mechanical properties of processed Mg is found to be highly influenced by the layered microstructure: UFG grained stirred zone, finer precipitates and strong basal texture.

The influence of microstructure evolution on the low-temperature superplasticity of ultrafine alpha/beta titanium alloys was established. For this purpose, the static and dynamic coarsening response and plastic flow behavior of Ti-6Al-4V with a submicrocrystalline microstructure were determined via a series of heat treatments and uniaxaial compression tests at temperatures of 650 °C, 775 °C, and 815 °C. At all test temperatures, static coarsening exhibited diffusion-controlled (r 3 vs time) kinetics and followed a dependence on phase composition and volume fraction qualitatively similar to previous observations at 850 °C to 950 °C. Dynamic coarsening at 775 °C and 815 °C and strain rates of 10−4 and 10−3 s−1 were similar to prior higher-temperature observations as well in that the kinetics were approximately one order of magnitude faster than the corresponding static behaviors. The increase in coarsening rate with superimposed deformation was attributed to the enhancement of diffusion by dislocations generated in the softer beta phase. With respect to deformation response, plastic flow was superplastic with m values of ∼0.6 at 650 °C, 775 °C, and 815 °C and strain rates of 10−4 and 10−3 s−1. Dynamic coarsening resulted in flow hardening at both temperatures and strain rates for a short preheat time (15 minutes) but was noticeably reduced when a longer preheat time (1 hour) was used prior to testing at 10−3 s−1. The latter behavior was largely attributed to noticeable static coarsening during preheating. A generalized constitutive relation based on a single stress exponent and the instantaneous alpha particle size was shown to describe the superplastic flow of ultrafine Ti-6Al-4V at low and high temperatures.

In recent literature related to mechanical testing of small-volume metal specimens, plastic strain bursts during apparent elastic loading have been reported for materials commonly known to exhibit smooth yielding. Interpretation of the observed plastic yielding effects in these tests have ignored a significant part of the actual experimental findings, and produced conclusions regarding dislocation structure that these tests do not unequivocally support. It is pointed out that the heterogeneity of dislocation debris left in the microstructure does not clearly represent deformation resistance, nor give a clear indication of strain within the specimen. The measured high rate of strain hardening and stability of plastic flow in the small-volume specimens are dependent on stress-state, and are shown to be not correlated with dislocation debris or dislocation-starvation concepts; rather the reason for the observed strengthening is related to the resistance to slip propagation through the specimen surface to form surface steps, viewed as an atomic-scale shear fracture process, elaborated in a companion paper. In a compression test the surface is closed under high compressive stress, thus repeatedly blocking the process, but in a tension test the surface separates more easily, causing loss of plastic stability.

The results of an analysis of creep deformation in hexagonal and circular honeycomb structures using an elastic–plastic finite element method are reported here. Representative unit cells of transverse sections of the honeycomb structures were subjected to compression loading, with the wall material assumed to undergo creep following a power law of the form e ˙ = K σ n . It is shown that, in spite of using a steady-state law, the honeycomb shows primary and tertiary creep stages, arising from inhomogeneous deformation and geometrical effects, respectively. When the creep law is modified to include work-hardening of the wall material, the onset of the tertiary-like stage is delayed. It is also found that a circular honeycomb is stronger than a hexagonal honeycomb of similar relative density due to constraints within the structure. External constraints, such as those which may arise from friction with external surfaces, are also shown to lead to strengthening by producing triaxial compressive stresses within the cell walls.

This paper reports a novel technique to fabricate hexagonal honeycomb structures. Here, a low-melting coating on stacked circular tubes is used to form liquid bridges at the tube junctions upon heating. The surface tension in these bridges then pulls the curved tube elements continuously to create planar walls, thereby replacing the circular core structures with ones of hexagonal geometry. An analysis of this process explains the rate of evolution of the tube radius based on the flow law of the tube material, the latter being influenced by the penetration of liquid phase along the boundaries of the nickel grains in the tubes.

Eight new metal-organic hybrid materials of Cu(ll) have been synthesized by using flexible glutarate/adipate as a bridging ligand, 2,2'-bipyridine/1,10-phenanthroline as a chelating ligand, and BF 4 -/Cl0 4 -/Cl- as a counteranion. These materials are characterized by single-crystal X-ray diffraction analyses and variable temperature magnetic measurements. Out of them, complexes 1, 3, 5, and 8 crystallize in the triclinic system with space group P1. Complexes 2, 4, 6, and 7 crystallize in the monoclinic system with space group P2 1 /n (2, 4), F2 1 /c (6), and C2 (7). The structural analysis reveals that bridging glutarate gives rise to dinuclear and tetranuclear species, whereas the adipate dianion leads to octanuclear, one-dimensional and two-dimensional polymeric complexes, although they have been prepared under similar conditions. Supramolecular architectures of higher dimensionality have been achieved through H-bonding and π-π interaction. In all the complexes, the bridging and/or counteranions as well as chelating ligand have a vital role in directing the solid-state structure. A variable temperature (2-300 K) magnetic susceptibility study discloses the antiferromagnetic coupling for all of the complexes.

Tidal variations of phytoplankton were studied at two stations i.e., Station 1 (Science Centre) and Station 2 (Junglighat Bay) during the period of December 2010 to February 2011 in the coastal waters of South Andaman Islands, India. Phytoplankton biomass (Chlorophyll-a) was observed low (avg. 0.02- 0.1 mg m(-3)) at the stations during the sampling period. Low values of dissolved oxygen and biochemical oxygen demand were recorded during low tide. In all 114 species belonging to 42 genera of diatoms, 16 genera of dinoflagellates and 4 genera of cyanobacteria were identified. Phytoplankton population density ranged from 827cells I(-1) to 11,790 cells l(-1) and was high during high tide in comparison to low tide. Diatoms were dominant (70.86-88.0%) and contributed more towards phytoplankton biomass followed by dinoflagellates (10.8-19.53%) and cyanobacteria (0.73-9.4%). Dinoflagellates were visualised more in the samples when diatom population had declined. Diversity indices such as species diversity (H') ranged from 0.68-3.1; species richness (d) varied from 2.18-6.54 and Pielou's evenness (J') ranged from 0.24-0.94. H' was more during high tide than at low tide at Station 2. On the other hand, low diversity and equitability in phytoplankton population were observed at Station 1 during the month of January, 2011. It may be due to dominance of mono specific cells of Rhizosolenia sp. The study indicates low production of phytoplankton in coastal waters. Variation of tides may leave implications on sampling, because it has an influence on species diversity and proportion of specific micro algal groups at different times.

Due to the increased domination of industrial sales channels by distributors, suppliers must develop strong relationships with industrial distributors in order to succeed in new markets. Initiating partnering relationships with distributors in new markets, however, entails significant risks and commitments with the prospect of substantial long‐term rewards. To help suppliers assess and select distributor partners, this study focuses on the starting‐point of the relationship by exploring industrial distributors' expectations of benefits. A nationwide survey of US industrial distributors showed that distributors expect financial and competitive differentiation benefits with greater differentiation benefits inferred to lead to fewer financial benefits. Several observable distributor characteristics can be used by suppliers to conduct preliminary assessments of distributor expectations and thereby prepare for a healthy future relationship.

BACKGROUND: Learner feedback is the primary method for evaluating clinical faculty, despite few existing standards for measuring learner assessments. OBJECTIVE: To review the published literature on instruments for evaluating clinical teachers and to summarize themes that will aid in developing universally appealing tools. DESIGN: Searching 5 electronic databases revealed over 330 articles. Excluded were reviews, editorials, and qualitative studies. Twenty-one articles describing instruments designed for evaluating clinical faculty by learners were found. Three investigators studied these papers and tabulated characteristics of the learning environments and validation methods. Salient themes among the evaluation studies were determined. MAIN RESULTS: Many studies combined evaluations from both outpatient and inpatient settings and some authors combined evaluations from different learner levels. Wide ranges in numbers of teachers, evaluators, evaluations, and scale items were observed. The most frequently encountered statistical methods were factor analysis and determining internal consistency reliability with Cronbach’s α. Less common methods were the use of test-retest reliability, interrater reliability, and convergent validity between validated instruments. Fourteen domains of teaching were identified and the most frequently studied domains were interpersonal and clinical-teaching skills. CONCLUSIONS: Characteristics of teacher evaluations vary between educational settings and between different learner levels, indicating that future studies should utilize more narrowly defined study populations. A variety of validation methods including temporal stability, interrater reliability, and convergent validity should be considered. Finally, existing data support the validation of instruments comprised solely of interpersonal and clinical-teaching domains.

Biaxial forming behavior is investigated for three aluminum sheet alloys (Al 5182 containing 1% Mn (5182+Mn), Al 5754, and 6111-T4) using a heated die and punch in the warm forming temperature range of 200–350 °C. It is found that, while all three alloys exhibit significant improvement in their formability compared with that at room temperature, the non-heat-treatable alloys 5182 + Mn and 5754 give higher part depths than that of heat-treatable 6111-T4. The formability generally increases with decreasing BHP (BHP), but increasing the forming temperature and/or BHP minimizes the wrinkling tendency and improves the forming performance. The stretchability of the sheet alloys increase with increasing temperature and increasing BHP. For the alloys and forming conditions involved in the current study, the formability, measured in terms of part depth, comes mainly from the drawing of metal into the die cavity, although stretching effects do influence the overall forming behavior. The optimum formability is achieved by setting the die temperature 50 °C higher than the punch temperature to enhance the drawing component. Setting the die temperature higher than the punch temperature also improves the strain distribution in a part in such a manner that postpones necking and fracture by altering the location of greatest thinning.

Reactions of MCl(3).3H(2)O (M = Rh and Ru) with the ligand 2-[(2-N-arylamino)phenylazo]pyridine [HL(1); NH(4)C(5)N=NC(6)H(4)N(H)C(6)H(4)(H) (HL(1a)), NH(4)C(5)N=NC(6)H(4)N(H)C(6)H(4)(CH(3)) (HL(1b)), and NH(4)C(5)N=NC(6)H(4)N(H)C(5)H(4)N (HL(1c))] in the presence of dilute NEt(3) afforded multiple products. In the case of rhodium, two green compounds, viz. [Rh(L(1))(2)](+) ([2](+)) and [RhCl(pap)(L(1))](+) ([3](+)), where L(1) and pap stand for the conjugate base of [HL(1)] and 2-(phenylazo)pyridine, respectively, were separated on a preparative thin layer chromatographic plate. The reaction of RuCl(3).3H(2)O, on the other hand, produced two brown compounds, viz. [RuCl(HL(1))(L(1))] (4) and [RuCl(pap)(L(1))] (5), respectively, as the major products. The X-ray structures of the representative complexes are reported. Except for complex 2, and 4, the products are formed due to the cleavage of an otherwise unreactive C(phenyl)-N(amino) bond. In complex 4, one of the tridentate ligands (HL(1)) does not use its maximum denticity and coordinates as a neutral bidentate donor. Plausible reasons for the differences in their modes of coordination of the ligands as in 2 and 4 have been discussed. The ligand pap in the cationic mixed ligand complex [3](+) reacts instantaneously with ArNH(2) to produce an ink-blue compound, [RhCl(HL(2))(L(1))](+) ([6](+)) in a high yield. The ligand HL(2) is formed due to regioselective fusion of ArNH(2) residue at the para carbon of the phenyl ring (with respect to the azo fragment) of pap in [3](+). The above complexes are generally intensely colored and show strong absorptions in the visible region, which are assigned to intraligand charge transfer transitions. These complexes undergo multiple and successive one-electron-transfer processes at the cathodic potentials. Electrogenerated cationic complexes of ruthenium(III), [4](+) and [5](+), showed rhombic EPR spectra at 77 K.

Cavitation caused by superplastic straining of a fine-grained Al–Mg–Mn–Cu alloy under uniaxial tension has been quantitatively evaluated. Tensile tests were conducted at constant true strain rate in a range of 10−4s−1 to 10−2s−1 at constant temperatures between 450°C and 550°C. Care was exercised to achieve precision in strain-rate control in these tests since strain-rate and temperature history do affect the extent of cavitation. Measurements of the number and size of cavities were made by using image analysis on tested specimens viewed by optical microscopy and further supported by SEM. With increasing strain, the cavity population density increases, a result seen previously but not studied in detail. Cavity growth was also monitored carefully and found to be due to the plastic deformation of the matrix surrounding the cavity. The total volume fraction of cavities which is the product of the above two components was found to increase exponentially with strain. The dependencies of cavity volume fraction on strain-rate and temperature are not straightforward, however. Based on experimental observations of decohesion between matrix and non-deformable particles, continuous nucleation of new cavities, and data related to plasticity-based growth of cavities, attempts are made to explain these complex effects.

Wilms’ tumor is the most common pediatric primary renal cancer and is highly responsive to surgery and chemotherapy. The role of radiotherapy has evolved in the last three decades from the use of stepwise incremental doses in all patients to the current concept of added radiotherapy in advanced cases or in those with unfavorable pathology. To the authors’ knowledge, this is the first case of a young woman with prior history of Wilms’ tumor and significant weight loss due to radiation arteritis involving the abdominal vasculature. A 31-year-old woman presented with a history of weight loss and severe malnutrition. An angiogram revealed that the aorta was occluded below the renal artery. The celiac artery and the superior mesenteric artery were occluded at the origin, and large intercostal collaterals reconstituted the pelvic circulation. She was initially treated with total parenteral nutrition (TPN) and underwent an infrarenal aortic bypass surgery. Histopathology of the aorta revealed intimal fibrocalcific thickening and changes consistent with radiation-induced arteritis. Later, she was readmitted with progressive hepatic insufficiency. Despite intensive medical therapy, she died of multi-organ failure.

Reaction of [NH4]2[OsIVBr6] with 1,2-diaminobenzene (H2opda) in aerobic conditions afforded [Os(bqdi)3][ClO4]2 (bqdi = 1,2-benzoquinone diimine), a diamagnetic osmium(II) complex containing three redox non-innocent α,α′-diimine ligands. In the crystal structure the relatively long CN distances together with short Os–N distances indicate the existence of considerable metal(dπ)–ligand(pπ) interactions. Cyclic voltammetry of [Os(bqdi)3][ClO4]2 shows one electron redox processes at −0.24, −0.67 and −1.78 V versus Fc–Fc+ (Fc = ferrocene) which are assigned as successive reductions of the coordinated bqdi, and an irreversible OsII–OsIII couple at +0.99 V. The solution electronic spectra of the mixed-valent (ligand) compounds, generated by electrolysis of [Os(bqdi)3]2+ in an optically transparent thin-layer electrode cell at potentials past the first and the second cathodic responses, show near-IR transitions at 1405 and 1164 nm, respectively, assignable to inter-valence charge transfer between the reduced 1,2-diiminosemiquinone monoanion (dsq) and non-reduced (bqdi) ligands. The spectrum of the triply reduced form is more consistent with the formulation [OsIII(dsq)2(opda)]− than with the expected formulation [Os(dsq)3]−, suggesting that an internal redox isomerism has occurred.

Tumor lysis syndrome (TLS) presenting in absence of chemotherapy is a rare occurrence. One of the true oncological emergencies, it can lead to significant morbidity and mortality. TLS is a phenomena usually associated with tumor cell death after treatment. The etiology of the spontaneous TLS is not well understood, which complicates the diagnosis. TLS is well known to oncologists but physicians outside of this specialty have little or no experience with this condition. Early recognition and treatment are the keys to limiting the sequela of the condition. Spontaneous tumor lysis syndrome is rare but presents added risks to the patient because of the potential for delayed diagnosis and no benefit of pretreatment. Diagnosis may be further delayed because this may be the first symptom of underlying malignancy. Therefore, it is imperative that all clinicians are familiar with the syndrome to assure timely recognition.

The mechanical behavior of a superplastic Al–4.7% Mg–0.8% Mn–0.4% Cu alloy has been characterized by a new type of step strain-rate test which preserves the initial microstructure of the alloy (i.e. an isostructural test). Four different grain sizes of the alloy (8–30 μm), prepared by variations in thermomechanical processing practice, were examined. A sigmoidal relationship between log σ and log e is observed for each isostructural condition. The value of maximum m ( = dlog σ/ dlog e ) increased with increasing temperature and with decreasing grain size. The isostructural log σ vs log e data are evaluated using the grain mantle based quantitative model proposed by Ghosh. In the dislocation creep region ( e >10 −1 / s ), the stress exponent is 4.55 and activation energy is close to that for lattice self-diffusion, but the grain size exponent is non-zero (∼0.37). In the grain mantle deformation region ( e −3 / s ), the value of the stress exponent based on effective stress ( σ − σ 0 , where σ 0 is threshold stress) is ∼1.7, and the grain size exponent is 2.3; but interestingly activation energy is the same as that for dislocation creep. Grain mantle creep is now also believed to be controlled by dislocation glide and climb processes, but its rate is enhanced many times due to a high concentration of vacancies near grain boundaries. σ 0 computed based on the model shows that it increases with increasing grain size and with decreasing temperature.

Plastic flow response, microstructure evolution, and defect formation during the primary hot working of conventional alpha/beta titanium alloys and gamma titanium aluminide alloys with two–phase lamellar colony microstructures are reviewed. The effects of initial grain/colony size, deformation rate and temperature on constitutive behaviour and the mechanisms associated with the observed flow softening are discussed. The kinetics of dynamic globularization are summarized and interpreted in terms of measured constitutive response. In addition, the mechanisms underlying failure via shear localization and cavitation during breakdown metalworking operations are described.

A nationwide survey of U.S. industrial distributors showed that expectations of benefits from a relationship with a core supplier and the outcomes of that relationship are important antecedents of distributor satisfaction with a relationship. The underlying outcome dimensions -- tangible and intangible benefits -- affect satisfaction levels. However, among the expectation dimensions, only price benefits influence satisfaction. The impact of expectations and outcomes on relationship satisfaction are moderated by relationship style and distributor size.

Evolution of grain morphology in a fine grained Al-Mg-Mn-Cu alloy during uniaxial superplastic deformation is studied quantitatively. Grains undergo elongation, as well as dynamic grain growth along all directions, the separation and analysis of which is attempted here. Based on such analysis, the computed true grain growth rate along directions transverse to the tensile axis are found to exceed that parallel to the tensile axis. Possible mechanisms for this new observation are suggested. A unique relationship between grain boundary sliding rate and dynamic grain growth rate is found at different applied strain rates; this indicates that grain boundary sliding and grain boundary migration rates are inherently connected through the same mechanism.

Background The InBox messaging system is an internal, electronic program used at Mayo Clinic, Rochester, MN, to facilitate the sending, receiving, and answering of patient-specific messages and alerts. A standardized InBox was implemented in the Division of General Internal Medicine to decrease the time physicians, physician assistants, and nurse practitioners (clinicians) spend on administrative tasks and to increase efficiency. Methods Clinicians completed surveys and a preintervention InBox pilot test to determine inefficiencies related to administrative burdens and defects (message entry errors). Results were analyzed using Pareto diagrams, value stream mapping, and root cause analysis to prioritize administrative-burden inefficiencies to develop a new, standardized InBox. Clinicians and allied health staff were the target of this intervention and received standardized InBox training followed by a postintervention pilot test for clinicians. Results Sixteen of 28 individuals (57%) completed the preintervention survey. Twenty-eight clinicians participated in 2 separate 8-day pilot tests (before and after intervention) for the standardized InBox. The number of InBox defects was substantially reduced from 37 (Pilot 1) to 7 (Pilot 2). Frequent InBox defects decreased from 25% to 10%. More than half of clinicians believed the standardized InBox positively affected their work, and 100% of clinicians reported no negative affect on their work. Conclusions This project demonstrated the successful implementation of the standardized InBox messaging system. Initial assessments show substantial reduction of InBox entry defects and administrative tasks completed by clinicians. The findings of this project suggest increased clinician and allied health staff efficiency, satisfaction, improved clinician work-life balance, and decreased clinician burden caused by administrative tasks.

Superplastic forming characteristics of a fine-grained 5083 aluminum sheet have been investigated by means of gas-pressure forming of a rectangular pan. This part geometry lends itself to a simple representation in terms of nearly one-dimensional sheet stretching and permits reasonably rigorous control of strain rate throughout the forming cycle. This study followed a study of the uniaxial tensile properties carried out on this alloy. A two-stage forming cycle, which comprised a short, rapid prestraining stage followed by a stage of slower rate of superplastic straining, was used because the uniaxial tensile work showed enhancement of superplastic response of this alloy under this condition. The study examined the effect of process parameters such as initial gas pressurization rate, level of hydrostatic pressure, and lubricants on the thinning characteristics of the sheet, especially along the die entry radii. The gas pressure/time cycle was suitably modified to avoid premature sheet failure due to excessive sheet thinning or cavitation. Cavitation under the biaxial forming condition and the effect of hydrostatic pressure on cavitation suppression were evaluated. A defect-free pan with sharp corners was formed.

The deformation behavior of a two phase (y+ a2) lamellar TiAl alloy reinforced with various amounts of AITi~C carbide platelets has been examined by determining Vickers hardness at room temperature and in the temperature range 900-1300 °C. The compression flow behavior of these materials has also been examined in the semi-solid state. The hardness values for all materials dropped from about 4 GPa at room temperature to 120 MPa at 1300 °C. The composites exhibited limited increase in hardness with respect to the base material over most of the temperature range investigated. At 900 °C, however, the 13% A1Ti2C reinforced composite showed an increase in hardness of about 1.2 GPa over that of the base material. The composites exhibited interfacial as well as transgranular cracks induced by indentations, while the matrix material did not exhibit cracking during the hardness tests. Forgeability of semi-solid Ti-48AI reinforced with 13% AITi2C composite was studied by performing compression tests at 1470 °C and strain rates ranging from 0.33 to 2.00 s- 1. Stress-strain curves exhibited a peak stress which is associated with breakdown of the carbide platelets. The size of the carbide platelets decreased and their reorientation took place with increasing strain. At strains higher than 0.9, reagglomeration of the carbide platelets was observed.

The tensile fracture strain, stress and fracture mode for a discontinuously reinforced aluminum matrix composite, 2014Al/15vol.%Al 2 O 3 , were determined and compared with those of the unreinforced matrix material, 2014A1, at various temperatures. Tests were conducted under uniaxial tension at elevated temperatures with a strain rate of 0.1 s − . It was found that the tensile fracture strain as well as fracture stress of the composite were lower than those of the matrix material. The tensile fracture mode changed from transgranular fracture to intergranular fracture between 400 °C and 500 °C for both materials. For the composite, at temperatures below 400 °C the growth and coalescence of voids occurred via a dislocation creep process primarily along the AlAl 2 O 3 interface. Above 400 °C voids initiated and grew at the AlAl 2 O 3 interface and grain boundaries via a diffusion creep process. The void growth was found not along the tensile direction but along the AlAl 2 O 3 interface and grain boundaries, and this resulted in a low fracture strain. A method for determining quantitatively the characteristics of the void initiation and growth is discussed.

Recently, a panel of experts, nominated by IUPAC, proposed the following tentative definition for the hydrogen bond: “The hydrogen bond is an attractive interaction between a group X-H and an atom or group of atoms Y in the same or different molecule(s), where there is evidence of bond formation” (Arunan, 2007). The energy of H-bond (~5 Kcal/mole of H-bonds) is intermediate between those of Van der Waals interaction (~0.3 Kcal/mole) and covalent (~100 Kcal/mole) chemical bonds (Stillinger, 1980). Since the energy of H-bond is of the order of a few KTs, thermal energy constantly acts to disrupt H-bonds. One can thus consider the energetics to drive formation of H-bonds, and entropic factors arising from thermal energy to break H-bonds. The result is a time-varying distribution of H-bonds among the different donor-acceptor pairs in the system. Combination of femtosecond 2D IR spectroscopy and molecular dynamics simulations demonstrated that the vast majority of average numbers of H-bonds are part of a H-bonded well of attraction and virtually all molecules return to a H-bonding partner within 200 fs (Eaves et al., 2005). Despite this continuous dynamics, fluctuation in the total number of H-bonds in a system containing a large number of molecules is quite small. Most simulation models suggest that a given H atom in water is H-bonded for 85-90% of the time (Bakker & Skinner, 2010). H-bonds have been a subject of intense research over several decades owing to the enormous role they play on several physico-chemical properties of interest. As quoted by Buckingham et al., “The concept of the H-bond is a century old but youthful because of its vital role in so many branches of science and because of continued advances in experiment, theory and simulation” (Buckingham et al., 2008). The significance of H-bonds can be best understood by comparing the physical state of water and methane, both of similar size; at room temperature, while methane is supercritical, water exists in liquid state, making it possible for life to sustain on earth. The anomalous expansion of water at 4°C makes it possible for marine life to exist. The high dielectric constant of water opens up the entire field of electrochemistry. The internal structure of water is largely responsible for selfassembly of surfactants, leading to a wide array of liquid crystalline phases. H-bonds are largely responsible for preserving the structure/conformation of several life-supporting biological molecules such as DNA, RNA and proteins in aqueous solutions.

The authors decompose repeat buying for frequently purchased nondurables. The results are very similar for two categories each over a different city and time period. A factor analysis of 18 measures of repeat buying obtains four principal factors that explain 79–85% of the variance: Preference, Inertia, Coupon Proneness and Impulse Buying. A cluster analysis of factors on these dimensions yields four segments, with distinct behavioral characteristics.

The mechanical behavior of hot pressed MoSi2-based composites containing M05Si3, SiO2, CaO and TiC as reinforcing second phases was investigated in the temperature regime 1000-1300 °C. The effects of strain rate on the flow stress for M05Si~-, SiO2- and CaO-containing composites are presented. Effects of several processing routes and microstructural modifications on the mechanical behavior of MoSi2-M05Si ~ composites are given. Of these four composite additions, M05Si 3 and CaO produce strengthening of MoSi 2 in the temperature range investigated. SiO 2 greatly reduces the strength, consistent with the formation of a glassy phase at interface and interphase boundaries. TiC reduces the flow stress of MoSi 2 in a manner that suggests dislocation pumping into the MoSi 2 matrix. The strain rate effects indicate that dislocation creep (glide and climb) processes operate over the temperature range investigated, with some contribution from diffusional processes at the higher temperatures and lower strain rates. Erbium is found to be very effective in refining the microstructures and in increasing the hardness and fracture properties of MoSi2-MosSi 3 eutectics prepared by arc melting. Initial results on microstructural modeling of the deformation and fracture of MoSi2-based composites are also reported.

Background The triad of quality, innovation and economic restraint is as important in health care as it is in the business world. There are many proposals for the assessment of quality and of economic restraints in health care but only a few address assessment of innovations. We propose a strategy and new structures to standardize the description of health care innovations and to quantify them. Discussion Strategy and structure are based on the assumption that in the early phase of an innovation only data on the feasibility and possibly on the efficacy or effectiveness of an innovation can be expected. From the patient's perspective, benefit resulting from an innovation can be confirmed only in a later phase of development. Early indicators of patient's benefit will be surrogate parameters which correlate only weakly with the desired endpoints. After the innovation has been in use, there will be more evidence on correlations between surrogate parameters and the desired endpoints to provide evidence of the patient benefit. From an administrative perspective, this evidence can be considered in decisions about public financing. Different criteria are proposed for the assessment of innovations in prevention, diagnosis and therapy. For decisions on public financing a public fund for innovations may be helpful. Depending on the phase of innovation risk sharing models are proposed between manufacturers, private insurers and public funding. Summary Potential for patient benefit is always uncertain during early stages of innovations. This uncertainty decreases with increasing information on the effects of the innovation. Information about an innovation can be quantified, categorized and integrated into rational economic decisions.

Many patients with chronic kidney disease (CKD) are seen by primary care physicians who may not be aware of indications or benefits of timely nephrologist referral. Late referral to a nephrologist may lead to suboptimal pre-end stage renal disease care and greater mortality. It is not known whether current postgraduate training adequately prepares a future internist in this aspect of CKD management.The authors performed an online questionnaire survey of internal medicine residents in the United States to determine their perceptions of indications for nephrology referral in CKD management.Four hundred seventy-nine residents completed the survey with postgraduate year (PGY) distribution of 166 PGY 1,187 PGY 2 and 126 PGY 3. Few residents chose nephrology referral for proteinuria (45%), uncontrolled hypertension (64%), or hyperkalemia (26%). Twenty-eight percent of the residents considered consulting a nephrologist for anemia of CKD, whereas 45% would do so for bone disorder of CKD. Most of the residents would involve a nephrologist at glomerular filtration rate (GFR)30 ml/min/1.73 m(2) (90%) and for rapid decline in GFR (79%). Many residents would refer a patient for dialysis setup at GFR 15 to 30 ml/min/1.73 m(2) (59%); however, 18% would do so at GFR15 ml/min/1.73 m(2). Presence of CKD clinic experience or an in-house nephrology fellowship program did not considerably change these perceptions.Results show that internal medicine residents have widely differing perceptions of indications for nephrology referral. Educational efforts during residency training to raise awareness and benefits of early referral may improve CKD management by facilitating better collaboration between internist and nephrologist.

BACKGROUND We sought to determine the associations between journal country of origin and language and journal impact factor of general medicine journals. METHODS For each "Medicine, General and Internal" journal listed in the Institute for Scientific Information (ISI) Journal Citation Reports (JCR), the 2003 impact factor, language (ie, English, multiple languages [including English], or non-English), and country of origin (ie, US or non-US) were determined. The mean log impact factors of the journals by language, country of origin, and a combination of country of origin and language were compared. RESULTS Of the 102 "Medicine, General and Internal" journals listed in the ISI JCR, 41 (40%) were published in the US and 83 (81%) were published in English. English-language journals had a significantly greater 2003 mean log impact factor than non-English journals and journals originating in the US had a significantly greater impact factor than journals originating elsewhere. However, the mean log impact factor of English-language journals originating in the US did not differ significantly from that of English-language journals originating elsewhere. CONCLUSION Journal impact factor is more associated with journal language (ie, English versus non-English), rather than journal country of origin.

Two new polymeric azido-bridged manganese complexes of formulas [Mn(N3)2 (bpee)]n (1) and {[Mn(N3)(dpyo)Cl(H2O)2](H2O)}n (2) [bpee, trans-1,2-bis(4-pyridyl)ethylene; dpyo, 4,4'-dipyridyl N,N'-dioxide] have been synthesized and characterized by single-crystal X-ray diffraction analysis and low-temperature magnetic study. Both the complexes 1 and 2 crystallize in the triclinic system, space group P1, with a = 8.877(3) A, b = 11.036(3) A, c = 11.584(4) A, alpha = 72.62(2) degrees, beta = 71.06(2) degrees, gamma = 87.98(3) degrees, and Z = 1 and a = 7.060(3) A, b = 10.345(3) A, c = 11.697(4) A, alpha = 106.86(2) degrees, beta = 113.33(2) degrees, gamma = 96.39(3) degrees, and Z = 2, respectively. Complex 1 exhibits a 2D structure of [-Mn(N3)2-]n chains, connected by bpee ligands, whose pyridine rings undergo pi-pi and C-H...pi interactions. This facilitates the rare arrangement of doubly bridged azide ligands with one end-on and two end-to-end (EO-EE-EE) sequence. Complex 2 is a neutral 1D polymer built up by [Mn(N3)(dpyo)Cl(H2O)2] units and lattice water molecules. The metals are connected by single EE azide ligands, which are arranged in a cis position to the Mn(II) center. The 1D zipped chains are linked by H-bonds involving lattice water molecules and show pi-pi stacking of dpyo pyridine rings to form a supramolecular 2D layered structure. The magnetic studies were performed in 2-300 K temperature range, and the data were fitted by considering an alternating chain of exchange interactions with S = 5/2 (considered as classical spin) with the spin Hamiltonians H = -Ji sigma(S(3i)S(3i+1) + S(3i+1)S(3i+2)) - J2 sigmaS(3i-1)S(3i) and H = -Ji sigmaS(2i)S(2i+1) - J2 sigmaS(2i+1)S(2i+2) for complexes 1 and 2, respectively. Complex 2 exhibits small antiferromagnetic coupling between the metal centers, whereas 1 exhibits a new case of topological ferromagnetism, which is very unusual.

Uncertainty in diagnosis is frequently encountered in medical practice and causes stress in patients and physicians. Factors contributing to uncertainty include biological variability of patients, patient and physician bias, error in test interpretation, differing values and opinions of patients and physicians, and uncertainty surrounding decision-making. Physicians differ in their ability to tolerate uncertainty, and this varying tolerance has been linked with choice of specialty, increased test ordering, personal anxiety, increased cost of providing medical care, and decreased comfort with geriatric patients and patients with psychological problems. We review the current evidence for and effects of physician uncertainty in medical practice. Although uncertainty in practice cannot be completely eliminated, numerous strategies can be adopted to decrease uncertainty and enhance patients' trust. These include applying the best-available evidence-based information along with observance of core clinical practices, including meticulous history taking, excluding worrisome diagnoses, and involvement in shared decision-making.

Background Maternal and newborn deaths are unacceptably common in Ethiopia, North-Eastern Nigeria, and the state of Uttar Pradesh in India. Governments are working to strengthen health systems to improve maternal and newborn health but need access to accurate evidence on which to base decisions. This panel session will include both policy-makers and researchers and include examples of how they can work together to translate evidence into policy and practice. Three brief examples are given below. The discussion will draw from these and others, building on a framework from our recent qualitative study of what helps and hinders the scale-up of health innovations in within the health systems in these settings. The session will be interactive, with active participation of audience members.