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In a recent floristic field survey of overall vegetation to some border areas of Maharashtra and Madhya Pradesh, we have collected the numerous grasses. After critical laboratory observation of grass species and literature survey has revealed the addition of two new grass species for the Madhya Pradesh state. Their vegetative and reproductive morphology was studied in detail and differences with their allied species are mentioned here.

The work in this paper deals with reconstructing and optimizing the wing geometry of an Unmanned Combat Aerial Vehicle for improved performance and reviewing the impact of the modification on flight parameters in a steady flight. The behavior of airfoils at planned flight conditions under I.S.A. is checked in XFLR5 software. Following up by 2-D CFD and boundary layer analysis of former and new airfoil, dimensions of the wing are re-developed, keeping the fuselage and tail structure same. The existing wing and the optimized wing design is analyzed by Vortex Lattice Method and Triangular Panel Method, with an objective to make the shape of the wing aerodynamically suitable for an increased Lift to Drag ratio and thereby minimizing drag coefficients.

Leaves are most important part of the plant and can be used for the identification of a taxon. An appropriate understanding of leaf development in terms of shape and responsible abiotic factors is necessary for improvement in plant. Leaf shape variation could be evaluated successfully, and the symmetrical and asymmetrical elements of the overall shape variation could be detected. The aim of the present study was to establish a quantitative analysis method of leaf shape by elliptic Fourier descriptors and principal component analysis (EF-PCA). EF-PCA describes an overall shape mathematically by transforming coordinate information concerning its contours into elliptic Fourier descriptors (EFDs) and summarizing the EFDs by principal component analysis. We can be able to extract six variables by using leaf specimen images from field and herbarium specimens. In the present study, total leaf area with respect to notch area is more variable within species. Within a species the major source of the symmetrical elements may be governed by genotypic features and the asymmetrical elements are strongly affected by the environment. We could discuss the value of morphometrics to detect subtle morphological variation which may be undetectable by human eye.

The aim of the present study is to do the balancing between the science and cultural practices in an increasingly complex developing society and policy on the traditional knowledge landscape. Various quantitative indices are proposed to determine the cultural importance of socio-religious and ethnobotanically valuable plants as a tool for the evaluation of cultural heritage. These indices were applied to an ethnobotanical, sociocultural survey of plants and plant parts traditionally used and consumed in the selected study area. Selected plants were grouped into seven use categories for further analysis. The cultural value index (CV), use value index (UV), the relative frequency of citation (RFC), relative importance (RI), and cultural importance index (CI) were calculated for different plant species cited by 45 informants in different traditional societies from the studied states. The calculated values of the cultural importance of plants through diverse indices generated interesting variations from three regions of India. There were eight common species through all the three states. Among these eight species Butea monosperma shows the highest values from Rajasthan and Ziziphus jujube shows the lowest values from Gujarat region. While Nelumbo nucifera, Vigna mungo, and Nymphaea lotus were also portrayed high calculated values in the CI, RI, and CVs. The combined use of these indices makes it possible to quantify the role which has given to a particular plant within a specific culture in one or many festivals in general or religious rituals.

Background: The present study was carried out to describe the Histopathological features of various neoplasms in the urinary bladder biopsies and to categorize the neoplastic lesions according to W.H.O (2016)/ISUP classification of urinary bladder tumors. Materials and Methods: A total of 37 cases, 28 urinary bladder biopsies (TURBT) and 9 cystectomy specimens of urinary bladder neoplasia [histologically proved] of patients were studied retrospectively over the period from June 2016- Oct 2018 in Pathology department of Smt. N.H.L. medical college. All cases of urothelial carcinomas were graded histologically according to WHO (2016)/ISUP classification. Results: Maximum numbers of patients are in age group 60-69 years. Males (78.37%) are more frequently affected as compared to female. The most frequent Neoplastic findings in Urinary bladder is Invasive Papillary Urothelial carcinoma (81.06%); Low grade (37.8%) being more common than High grade (35.14%). A large percentage (80%) of high grade invasive urothelial cell carcinomas presented with muscle invasion. Conslusion: Invasion to the muscle propria layer correlates with high grade tumor. In 18.5% cases detrusor muscle was absent, hence the importance of including detrusor muscle in the biopsy specimens needs to be emphasized. We must accept the fact that grading is highly subjective and that in future various molecular and immunohistochemical studies will provide better reproducibility. Keywords: Invasive papillary urothelial carcinoma, Muscle invasion, Urinary bladder neoplasms.

Background and Objectives: Antibiotic misuse contributes to antibiotic resistance and is a growing public health threat in the United States and globally. Professional medical societies promote antibiotic stewardship education for medical students, ideally before inappropriate practice habits form. To our knowledge, no tools exist to assess medical student competency in antibiotic stewardship and the communication skills necessary to engage patients in this endeavor. The aim of this study was to develop a novel instrument to measure medical students’ communication skills and competency in antibiotic stewardship and patient counseling. Methods: We created and pilot tested a novel instrument to assess student competencies in contextual knowledge and communication skills about antibiotic stewardship with standardized patients (SP). Students from two institutions (N=178; Albert Einstein College of Medicine and Warren Alpert Medical School of Brown University) participated in an observed, structured clinical encounter during which SPs trained in the use of the instrument assessed student performance using the novel instrument. Results: In ranking examinee instrument scores, Cronbach α was 0.64 (95% CI: 0.53 to 0.74) at Einstein and 0.71 (95% CI: 0.60 to 0.79) at Brown, both within a commonly accepted range for estimating reliability. Global ratings and instrument scores were positively correlated (r=0.52, F [3, 174]=30.71, P

Leaves are most important part of the plant and can be used for the identification of a taxon. An appropriate understanding of leaf development in terms of shape and responsible abiotic factors is necessary for improvement in plant. Leaf shape variation could be evaluated successfully, and the symmetrical and asymmetrical elements of the overall shape variation could be detected. The aim of the present study was to establish a quantitative analysis method of leaf shape by elliptic Fourier descriptors and principal component analysis (EF-PCA). EF-PCA describes an overall shape mathematically by transforming coordinate information concerning its contours into elliptic Fourier descriptors (EFDs) and summarizing the EFDs by principal component analysis. We can be able to extract six variables by using leaf specimen images from field and herbarium specimens. In the present study, total leaf area with respect to notch area is more variable within species. Within a species the major source of the symmetrical elements may be governed by genotypic features and the asymmetrical elements are strongly affected by the environment. We could discuss the value of morphometrics to detect subtle morphological variation which may be undetectable by human eye.

OBJECTIVES The objectives of this prospective, cross-sectional study were to compare self-perception and communication-success ratings of adolescents with cochlear implant (AWCI) and their caregivers (C-AWCI) and to explore associations with age at CI, implant age, and chronological age. METHOD Fourteen CI centers across India participated. The Think About it Quiz (TAIQ), Self Assessment of Communication-Adolescent (SAC-A), and Significant Other Assessment of Communication-Adolescent (SOAC-A) were translated into five languages. Data were collected from 173 AWCI aged 10;0-19;6 years and an associated caregiver for each participant. RESULTS On the TAIQ, self-ratings by AWCI were significantly lower than the ratings by C-AWCI. Peer acceptance correlated with athletic competence for both groups. For the SAC-A versus SOAC-A, there was no significant difference between AWCI and C-AWCI ratings. Except for a negative correlation between peer-acceptance and chronological age for caregiver ratings, no other associations were found between any other ratings and age at CI, implant age, and chronological age. CONCLUSIONS Caregiver judgments of their adolescents with CI were not in equal agreement with self-ratings by the adolescents across various aspects of performance. Caregivers appeared to underestimate the self-perception issues faced by adolescents with CI but had excellent agreement with their adolescents' self-rating of communication success. The inclusion of activities to improve children's participation in sports could possibly improve peer acceptance.

Objectives Clinical reasoning skills are essential for sound medical decision-making. Though many have suggested that clinical reasoning instruction should begin in pre-clerkship curricula, neither pre-clerkship clinical skills director perspectives nor extent of instruction is known. This survey study serves as part of a needs assessment for United States medical school pre-clerkship clinical reasoning curricula. Methods United States medical school pre-clerkship clinical skills course directors were surveyed about perceived importance of formal instruction on clinical reasoning concepts, inclusion of these concepts in the curricula, barriers to instruction, and familiarity with clerkship curricula. Results were analyzed using descriptive and analytic statistics. Narrative comments were analyzed qualitatively for themes. Results Of 148 directors surveyed, 102 (69%) participated and 89 (60%) completed all closed-ended items. Each clinical reasoning concept was identified as somewhat to extremely important to include in pre-clerkship curricula by 90–99% of respondents. Pre-clerkship curricula included variable degrees of formal instruction for concepts, though most respondents rated their inclusion as moderate or extensive. Perceived importance of teaching most concepts moderately correlated with the degree of inclusion in the curriculum (Spearman’s rho 0.39–0.44). Curricular time constraints and lack of faculty with skills to teach these concepts were the most frequently cited barriers to instruction. Respondents indicated being somewhat 57% (n=54) to extremely 29% (n=27) familiar with clerkship curricula at their institutions. Conclusions This study is the first to examine pre-clerkship clinical skills course director perspectives about clinical reasoning instruction and extent of its inclusion in their curricula.

Introduction The head-to-toe approach to teaching the physical examination (PE) focuses on technique and performing a comprehensive PE whereas core + clusters and hypothesis-driven PE (HDPE) approaches integrate clinical reasoning into performing a focused PE. These approaches can be implemented in a developmental sequence. We report the implementation and evaluation of an HDPE educational session. Methods We designed a 3-hour HDPE session as part of a transition to clerkship program. For each of five clinical vignettes, rising third-year students worked in pairs and then in small groups to generate a differential diagnosis and determine relevant PE maneuvers. Students next performed these maneuvers on peers with facilitator observation and feedback. Students completed postsession surveys on their retrospective pre- and postsession knowledge and confidence, as well as their satisfaction with the session. We completed quantitative and qualitative analyses on survey data. Results One hundred ninety-two students participated, and 140 (73%) completed the survey. Students were significantly more likely to report feeling confident generating a differential diagnosis and using it to select PE maneuvers for common complaints postsession. Over 80% of respondents felt the session improved critical thinking about patient presentations and would help them in clerkships. Discussion Our session increased student confidence in the progression to performing an HDPE just prior to the start of clerkships. The session is feasible and straightforward to implement. It requires a large number of faculty to facilitate, but the breadth of cases used allows inclusion of faculty from all fields.

A Gesture Vocalizer is a small scale or a large scale system that provides a way for dumb and mute people to communicate easily. The research paper defines a technique, Finger Gesture Vocalizer which includes sensors attached to the gloves above the fingers of the person who wants to communicate. The sensors are arranged in such a way on the gloves, that they can capture the movements of the fingers and based on the change in resistance of the sensors, it can be identified what the person wants to say. The message is displayed on the LCD and is also converted to audio using the APR33A3 audio processing unit. Standard sign languages such as that of American Sign Language which is used by dumb and mute people to communicate can be employed while wearing these gloves.

Background Effective communication is essential for interprofessional collaborative practice; however, a conceptual framework of interprofessional collaborative communication (ICC) has not been proposed. Purpose Develop and apply a conceptual framework of ICC. Methods Literature on interprofessional collaboration and interprofessional communication informed framework development; we then applied it to analyze medical student communication with a standardized nurse (SN). We identified prototypical ways that students engaged in two of the ICC framework constructs. Nurses provided feedback on our framework. Discussion The ICC conceptual framework consisted of four constructs. Higher rated students engaged in more bidirectional information exchange and solicited the SN's input into the care plan. Prototypes ranged from less collaborative (i.e. closed-ended) to more collaborative exchanges inviting the SN to share knowledge and suggestions. Six nurses endorsed the framework. Conclusions Bidirectional information exchange and soliciting input into decision-making may be particularly important for ICC. This novel ICC framework can inform curriculum development and learner assessment.

Background While leadership training is increasingly incorporated into residency education, existing assessment tools to provide feedback on leadership skills are only applicable in limited contexts. Objective We developed an instrument, the Leadership Observation and Feedback Tool (LOFT), for assessing clinical leadership. Methods We used an iterative process to develop the tool, beginning with adapting the Leadership Practices Inventory to create an open-ended survey for identification of clinical leadership behaviors. We presented these to leadership experts who defined essential behaviors through a modified Delphi approach. In May 2014 we tested the resulting 29-item tool among residents in the internal medicine and pediatrics departments at 2 academic medical centers. We analyzed instrument performance using Cronbach's alpha, interrater reliability using intraclass correlation coefficients (ICCs), and item performance using linear-by-linear test comparisons of responses by postgraduate year, site, and specialty. Results A total of 377 (of 526, 72%) team members completed the LOFT for 95 (of 519, 18%) residents. Overall ratings were high—only 14% scored at the novice level. Cronbach's alpha was 0.79, and the ICC ranged from 0.20 to 0.79. Linear-by-linear test comparisons revealed significant differences between postgraduate year groups for some items, but no significant differences by site or specialty. Acceptability and usefulness ratings by respondents were high. Conclusions Despite a rigorous approach to instrument design, we were unable to collect convincing validity evidence for our instrument. The tool may still have some usefulness for providing formative feedback to residents on their clinical leadership skills.

To understand how third-year medical student interprofessional collaborative practice (IPCP) is affected by self-efficacy and interprofessional experiences (extracurricular experiences and formal curricula).The authors measured learner IPCP using an objective structured clinical examination (OSCE) with a standardized nurse (SN) and standardized patient (SP) during a statewide clinical performance examination. At four California medical schools from April to August 2012, SPs and SNs rated learner IPCP (10 items, range 0-100) and patient-centered communication (10 items, range 0-100). Post-OSCE, students reported their interprofessional self-efficacy (16 items, 2 factors, range 1-10) and prior extracurricular interprofessional experiences (3 items). School representatives shared their interprofessional curricula during guided interviews.Four hundred sixty-four of 530 eligible medical students (88%) participated. Mean IPCP performance was 79.6 ± 14.1 and mean self-efficacy scores were 7.9 (interprofessional teamwork) and 7.1 (interprofessional feedback and evaluation). Seventy percent of students reported prior extracurricular interprofessional experiences; all schools offered formal interprofessional curricula. IPCP was associated with self-efficacy for interprofessional teamwork (β = 1.6, 95% CI [0.1, 3.1], p = 0.04) and patient-centered communication (β = 12.5, 95% CI [2.7, 22.3], p = 0.01).Medical student IPCP performance was associated with self-efficacy for interprofessional teamwork and patient-centered communication. Increasing interprofessional opportunities that influence medical students' self-efficacy may increase engagement in IPCP.

Power Transformers with more than one secondary winding are not uncommon in industrial applications. But new classes of applications where very large number of independent secondaries are used are becoming popular in controlled converters for medium and high voltage applications. Cascade H-bridge medium voltage drives and Pulse Step Modulation (PSM) based high voltage power supplies are such applications. Regulated high voltage power supplies (Fig.1) with 35-100 kV, 5-10 MW output range with very fast dynamics (μS order) uses such transformers. Such power supplies are widely used in fusion research. Here, series connection of isolated voltage sources with conventional switching semiconductor devices is achieved by large number of separate transformers or by single unit of multi-secondary transformer. Naturally, a transformer having numbers of secondary windings (~40) on single core is the preferred solution due to space and cost considerations. For design and simulation analysis of such a power supply, the model of a multi-secondary transformer poses special problem to any circuit analysis software as many simulation softwares provide transformer models with limited number (3-6) of secondary windings. This article discusses a more detailed representation of flux coupled magnetic model with saturable core properties to simulate actual transformers very close to its observed parameters in test and actual usage.

Delay tolerant networks (DTN) are wireless networks where disconnections arise often due to the mobility of nodes, failures of energy, the low density of nodes, or when the network extends over long distances. In these situations, traditional routing protocols that have been developed for mobile ad hoc networks prove to be unsuccessful to the scope of transmitting messages between nodes. The Spray and Wait routing may achieve low routing and energy efficiency due to the blindness in the spray phase. To deal with this situation, we propose an opportunistic routing with enclosed message copies, called the Vibrant Energy aware Spray and Wait (VESW), which utilizes the information about vibrancy of node and remaining energy to allocate the number of copies between the corresponding pair nodes in the spray phase.

Novel copolymers of trisubstituted ethylene monomers, ring-substituted 2-phenyl-1,1-dicyanoethylenes, RC6H4CH = C(CN)2 (where R is 2-F, 2-CN, 3-CN, 4-CN, 3-C6H5O, 4-C6H5O, 2-C6H5CH2O, 3-C6H5CH2O, 4-C6H5CH2O, 4-CH3CO2, 4-CH3CONH, 4-(CH3)2N) and styrene were prepared by solution copolymerization in the presence of a radical initiator (ABCN) at 70°C. The composition of the copolymers was calculated from nitrogen analysis, and the structures were analyzed by IR, 1H and 13C-NMR. The order of relative reactivity (1/r 1) for the monomers is 4-(CH3)2N (3.35) > 4-C6H5CH2O (3.1) > 2-C6H5CH2O (1.77) > 3-C6H5CH2O (1.72) > 4-C6H5O (1.70) > 4-CH3CO2 (1.58) > 2-F (1.11) > 3-C6H5O (0.90) > 3-CN (0.88) > 2-CN (0.86) > 4-CH3CONH (0.84) > 4-CN (0.76). Relatively high Tg of the copolymers in comparison with that of polystyrene indicates a decrease in chain mobility of the copolymer due to the high dipolar character of the trisubstituted ethylene monomer unit. Decomposition of the copolymers in nitrogen occurred in two steps,...

A novel series of transition metal complexes have been synthesized from the reaction of 5-((3-(methylthio)-5-(pyridin-4-yl)-4 H -1,2,4-triazol-4-ylamino)methyl)quinolin-8-ol with transition metal salts. The structures of these compounds have been elucidated by elemental and spectral analysis. Furthermore, compounds were screened for in vitro antimicrobial activity against the representative panel of two Gram-positive and two Gram-negative bacteria and two strains of fungus. The various compounds show potent inhibitory action against test organisms.

New ligands 5-((4-(3-(pyridine-4-yl)-7H-[1,2,4]triazolo[3,4-b] [1, 3,4]thiadiazine-6-yl)phenylamino)methyl)quinolin-8-ol (L1) and 5-((3-(pyridine-4-yl)-7H-[1,2,4]triazolo[3,4-b][1,3,4]thiadiazine-6- ylamino)methyl)quinolin-8-ol (L2) have been synthesized. The obtained ligands were characterized by 1H NMR, 13C NMR, and IR spectroscopic techniques, and reacted with transition metal salts to afford metal containing heterochelates. The structures of the synthesized heterochelates were characterized using elemental analyses, infrared spectra, electronic spectra, magnetic measurements, FAB mass spectrum, and thermo gravimetric analyses. The kinetic parameters, such as order of reaction (n) and the energy of activation (Ea), are reported using the Freeman–Carroll method. Ligands and heterochelates were also screened for their in vitro antibacterial activity.

A new ligand, 5-{[5-(pyridine-4-yl)-1,3,4-oxadiazole-2-ylthio]methyl}quinoline-8-ol (K), was synthesized by base-catalysed reaction of 5-chloromethyl-8-hydroxy quinoline (CMQ) and 5-(pyridine-4-yl)-1,3,4-oxadiazole-2-thiol. The obtained ligand K was characterized by 1H NMR, 13C NMR and IR spectroscopic techniques and reacted with transition metal salts to afford metal-containing heterochelates. The structures of the synthesized heterochelates were characterized using elemental analyses, infrared spectra, electronic spectra, magnetic measurements, FAB mass spectrum and thermogravimetric analyses. The kinetic parameters such as order of reaction (n) and the energy of activation (Ea) are reported using the Freeman–Carroll method. The pre-exponential factor (A), the activation entropy (ΔS#), the activation enthalpy (ΔH#) and the free energy of activation (ΔG#) were calculated. Heterochelates were also screened for their in vitro antibacterial activity against a range of Gram-positive (Bacillus substilis, Staphylococcus aureus) and Gram-negative (Escherichia coli, Serratiamarcescens) organisms. Copyright © 2010 John Wiley & Sons, Ltd.

Twelve coordinate lanthanide (III) complexes with the general composition [Ln L3Xn(H2O)n] where Ln = Pr(III), Sm(III), Eu (III), Gd (III), Tb (III), Dy (III), X = Cl−1, NO3 −2, n = 2–7, and L is 1-(4-chlorophenyl)-3-(4-fluoro/hydroxyphenyl)prop-2-en-1- thiosemicarbazone have been prepared. The lanthanide complexes (5) were derived from the reaction between 1-(4-chlorophenyl)-3-(4-fluoro/hydroxyphenyl)prop-2-en-1-thiosemicarbazone (4) with an aqueous solution of lanthanide salt. Chalcone thiosemicarbazone ligand (4) was prepared by the reaction of [1-(4-chlorophenyl)-3-(4-fluoro/hydroxyphenyl)]prop-2-enone (chalcone) (3) with thiosemicarbazide in the presence of hot ethanol. All the lanthanide-ligand 1:3 complexes have been isolated in the solid state, are stable in air, and characterized on the basis of their elemental and spectral data. Thiosemicarbazone ligands behave as bidentate ligands by coordinating through the sulfur of the isocyanide group and nitrogen of the cyanide residue. The probable structu...

5-Chloromethyl-8-quinolinol was condensed stoichiometrically with benzotriazole in presence of potassium carbonate. The resulting 5-[1(H)-benzo triazole methylene]-8-quinolinol (BTMQ) was characterized by elemental analysis and spectral studies. The transition metal chelatesviz. Cu2+, Ni2+, Co3+, Mn2+and Zn2+of BTMQ were prepared and characterized by metal-ligand (M:L) ratio, IR and reflectance spectral studies and magnetic properties. The antifungal activity of BTMQ and its metal chelates was screened against various fungi. The results show that all these samples are good antifungal agents.

Nuclear hormone receptor-responsive element binding specificity has been reported to reside predominantly in the proximal box (P-box), three amino acids located in a DNA-recognition alpha-helix situated on the C-terminal side of the first zinc finger. To further define the residues in the vitamin D receptor (VDR) DNA binding domain (DBD) that mediate its interaction as a retinoid X receptor (RXR) heterodimer with the rat osteocalcin vitamin D-responsive element (VDRE), chimeric receptors were created in which the core DBD of VDR was replaced with that of the homodimerizing glucocorticoid receptor (GR). Systematic alteration of GR DBD amino acids in these chimeras to VDR DBD residues identified arg-49 and lys-53, just C-terminal of the P-box within the base recognition alpha-helix of human VDR (hVDR), as the only two amino acids among 36 differences required to convert the GR core zinc finger domain to that of the VDR. Gel mobility shift and 1,25-dihydroxyvitamin D3-stimulated transcription assays verified that an hVDR-GR DBD chimera is functional on the rat osteocalcin VDRE with only the conservative change of lys-49 to arg, and of the negatively charged glu-53 to a basic amino acid (lys or arg). Thus, for RXR heterodimerizing receptors like VDR, the P-box requires redefinition and expansion to include a DNA specificity element corresponding to arg-49 and lys-53 of hVDR. Examination of DNA specificity element amino acids in other nuclear receptors in terms of conservation and base contact in cocrystal structures supports the conclusion that these residues are crucial for selective DNA recognition.

Bis(1,3‐diketonato)palladium(II) complexes were synthesized by three routes. In route one, sodium hexachlorodipalladate in methanol was treated with the appropriately substituted diaryl‐1,3‐diketones using sodium carbonate, while in route two substituted diaryl‐1,3‐diketones were treated with palladium chloride in acetone to afford the desired bis(1,3‐diketonato)palladium(II). In route three 1,3‐bis(substituted aryl)prop‐2‐enones were treated with palladium chloride and sodium hydrogen carbonate in THF to provide the oxygen insertion product, bis(1,3‐diketonato)palladium(II) complexes. All synthesized compounds were characterized on the basis of spectral and analytical data.

ObjectiveTo explore experiences during childhood and adolescence that influenced reproductive and sexual health among women who had entered the sex industry in adolescence.MethodsA qualitative study was conducted using information provided by 25 female sex workers (FSWs) from Tijuana, Mexico, who reported entering the sex industry when younger than 18 years. In-depth, semi-structured interviews were conducted with all participants between January 31, 2011, and July 8, 2011.ResultsFour interrelated themes that shaped health experiences-early sexual abuse, early illicit drug use, ongoing violence, and limited access to reproductive and sexual health care-were identified. Participants reporting these experiences were at risk of unintended teenaged pregnancy, spontaneous abortion or stillbirth, and untreated sexually transmitted infections.ConclusionPrograms and policies that address social, structural, and individual vulnerabilities during adolescence and adulthood are required to promote reproductive and sexual health among FSWs in Tijuana, Mexico.

Context Clinical supervisors oversee trainees’ performance while granting them increasing opportunities to work independently. Although the factors contributing to supervisors’ trust in their trainees to conduct clinical work have been identified, how the development of trust is shaped by these factors remains less clear. Objectives This study was designed to determine how supervisors develop and experience trust in resident (postgraduate years 2 and 3) trainees in the clinical workplace. Methods Internal medicine in-patient supervisors at two institutions were interviewed about the meaning and experience of developing trust in resident trainees. Transcribed data were coded and analysed using a phenomenographic approach. Results Forty-three supervisors participated. Supervisors characterised the meaning of trust from the perspectives of trainee competence and leadership or from their own perspective of needing to provide more or less supervision. Supervisors initially considered trust to be usually independent of prior knowledge of the resident, and then used sources of information about trust to develop their judgements of trust. Sources, which incorporated inference, included supervisors’ comparisons with a standard, direct observation of the trainee as a team leader or care provider, and stakeholder input from team members, patients and families. Barriers against and accelerators to trust formation related to the resident, supervisor, resident–supervisor relationship, context and task. Trust formation had implications for supervisors’ roles, residents’ increasingly independent provision of care, and team functioning. Conclusions From a general starting point, supervisors develop trust in residents informed by observation, inference and information gathered from the team and patients. Judgements of trust yield outcomes defined by supervisors’ changing roles, the increasingly independent provision of care by residents, and team functioning. The implications of these findings for graded resident autonomy aligned with learning needs can inform the design of training environments to enable readiness for unsupervised practice.

Some 1-fluoroaryl-1,3-diketones were prepared by treatment of methyl 1-fluoroaryl ketone with ethyl acetate, ethyl fluoroacetate or ethyl pentafluoropropionate in the presence of sodamide which were characterized in the form of their copper chelates. 1-Substituted-aryl-1,3-diketones (1a-h) in turn on treatment with uranyl acetate afforded corresponding bis(1,3-diketonato) dioxouranium(VI) (3a-f). Bis(1,3-diketonato)dioxouranium(VI) (3a-f) when subjected to electrophilic bromination or nitration reactions yielded bis(2-bromo-1,3-diketonato)dioxouranium(VI) (4a-e) and bis(2-nitro-1,3-diketonato)dioxouranium(VI) (5a-e), respectively. The bonding mode of the ligands to the uranium ion has also been determined from IR and 1H NMR spectral studies.

Antecedents: Les carcinomes sebaces sont des tumeurs cutanees relativement rares; moins de 600 cas ont ete rapportes. Ils se forment presque toujours a l'interieur des glandes de Meibomius; moins de 150 de ces carcinomes etaient extraoculaires. Leur incidence de recidive locale et de metastases regionales est elevee. Par ailleurs, le rapport entre les tumeurs sebacees et les tumeurs malignes viscerales a ete bien etabli dans la litterature. Objectif: Decrire le cas d'une femme de 44 ans de race blanche atteinte de sclerose en plaques chronique chez qui sont apparus de multiples adenomes sebaces au niveau du cuir chevelu ainsi qu'un carcinome sebace solitaire. Conclusion: Les carcinomes sebaces extraoculaires sont des tumeurs peu frequentes ayant une incidence elevee de recidive locale et de metastases regionales. La chirurgie par excision large des tumeurs constitue le traitement usuel. Nous rapportons ici le premier cas de multiples tumeurs sebacees chez une patiente atteinte de sclerose en plaques. La presence de ces tumeurs justifie la recherche d'une tumeur maligne interne. Les resultats des etudes sur les tumeurs sebacees et leur rapport avec les tumeurs malignes viscerales et les affections immunologiques sont presentes dans cet article de meme que les resultats des etudes sur le carcinome sebace et plus particulierement le carcinome extraoculaire.

The functional significance of two unlinked human vitamin D receptor (hVDR) gene polymorphisms was evaluated in twenty human fibroblast cell lines. Genotypes at both a Fok I restriction site (F/f) in exon II and a singlet (A) repeat in exon IX (L/S) were determined, and relative transcription activities of endogenous hVDR proteins were measured using a transfected, 1,25-dihydroxyvitamin D(3)-responsive reporter gene. Observed activities ranged from 2--100-fold induction by hormone, with higher activity being displayed by the F and the L biallelic forms. Only when genotypes at both sites were considered simultaneously did statistically significant differences emerge. Moreover, the correlation between hVDR activity and genotype segregated further into clearly defined high and low activity groups with similar genotypic distributions. These results not only demonstrate functional relevance for both the F/f and L/S common polymorphisms in hVDR, but also provide novel evidence for a third genetic variable impacting receptor potency.

Background: Muir-Torre syndrome is a rare autosomal dominant genodermatosis, first described in 1967, characterized by the presence of sebaceous tumors and an internal malignancy in the absence of other predisposing factors. Objective: Our purpose was to review and update published literature on Muir-Torre syndrome. Methods: We describe a 66-year-old white man with a history of sebaceous tumors and newly diagnosed transitional cell cancer of the right ureter and adenocarcinoma of the jejunum. The literature on Muir-Torre syndrome is reviewed by means of MEDLINE search and available published reports and updated. Results: Only 205 cases of Muir-Torre syndrome with 399 internal malignancies have been reported. The common presentation is the presence of sebaceous tumors along with a low-grade visceral malignancy. Sebaceous tumors appeared before the internal malignancy in 45 cases (22%), concurrently in 12 (6%), and after the internal malignancy in 114 (56%). In 33 (16%) of 205 patients, a temporal relationship was not reported. The total number of sebaceous gland carcinomas reported is 44; 17 of 44 were neoplasms of the meibomian gland. Keratoacanthomas have been noted in 48 (23%) of 205 patients. Gastrointestinal cancers are the most common internal malignancies (61%), followed by genitourinary (22%). Conclusion: The presence of sebaceous tumors warrants a search for an internal malignancy. In patients with Muir-Torre syndrome, regular follow-up and search for new malignancy is mandatory. Evaluation and monitoring of the family members of patients are also necessary. Patients and their families should be counseled for genetic testing. Genetic analysis of the primary tumor and skin lesions should be arranged as an added research tool if possible to better understand the disease. (J Am Acad Dermatol 1999;41:681-6.)

Treatment of 1H-4,5-dihydro-3-aryl-5-(2-hydroxyaryl)pyrazole with o-dibromoxylene under liquid-liquid phase transfer catalytic conditions using tetra-n-butylammonium hydrogen sulphate or [18]-crown-6 as PT catalyst, benzene/chloroform as organic phase and 50% aqueous potassium hydroxide as second phase, afforded novel 2,5,9,10-tetrahydro [7,8-g] benzo-8-arylpyrazolo[4,5-e] [1,5-b] benzoxazonines.

Treatment of 1H-4,5-dihydro-3-aryl-5-(2-hydroxyaryl)pyrazole with o-dibromoxylene under liquid-liquid phase transfer catalytic conditions using tetra-n-butylammonium hydrogen sulphate or [18]-crown-6 as PT catalyst, benzene/chloroform as organic phase and 50% aqueous potassium hydroxide as second phase, afforded novel 2,5,9,10-tetrahydro [7,8-g] benzo-8-arylpyrazolo[4,5-e] [1,5-b] benzoxazonines.

The Gerbich (Ge) antigens are a collection of high-incidence antigens carried on the red blood cell membrane glycoproteins, glycophorins C and D. Antibodies against these antigens are uncommon, and there have been only rare case reports of hemolytic disease of the fetus and newborn due to anti-Ge. In this case report, we present a neonate with severe anemia and hyperbilirubinemia due to anti-Ge3. Routine and special laboratory studies undertaken in this case suggested two mechanisms for the patient's hemolysis and persistent anemia. Antibody-dependent hemolysis was associated with early-onset hyperbilirubinemia, anemia, and a mild reticulocytosis, and inhibition of erythroid progenitor cell growth was associated with late anemia and normal bilirubin and reticulocyte values. Though rare, anti-Ge3 can be a dangerous antibody in pregnancy. Affected neonates may require intensive initial therapy and close follow-up for at least several weeks after delivery.

As a first step in the cloning of the DNA repair gene uvsF of Aspergillus nidulans, uvsF pyrG double mutant strains were transformed with a genomic library which carried the complementing Neurospora pyr-4 gene in the vector. Rare pyr+ uvs+ cotransformants were obtained on media lacking pyrimidines, overlayed with MMS (methyl-methane sulfonate) to which uvsF is hypersensitive. Among MMS-resistant transformants, Southerns revealed two types which showed single bands of different sizes when BglII-digested genomic DNA was probed with the vector. Both types produced uvsF- recombinants without vector sequences in homozygous crosses, but only those with the larger band also produced haploid uvs+ progeny. Using BglII-digested genomic DNA to transform Escherichia coli, plasmids of the corresponding two sizes could be rescued. Their inserts had a short internal region in common, giving evidence of rearrangement(s). In secondary transformation of uvsF mutants, only the plasmids with the larger insert showed complementation and these were used to screen Aspergillus libraries. Three types of genomic and two overlapping cDNA clones were identified. The cDNAs hybridized not only to each other, but also to the common region of the rescued plasmids. Therefore, cDNA subclones were used to map the putative uvsF sequences to a short segment in one genomic clone. In Northerns, the complementing large plasmid hybridized to three mRNAs, while the cDNA subclone identified one of these as the probable uvsF message.

Two cases are reported in which depression was associated with the use of calcium channel blocker, nifedipine. In one instance, a patient became unresponsive to treatment with nortriptyline when nifedipine was introduced. In both cases, the depression resolved following discontinuation of nifedipine.

Benazepril hydrochloride, a new non-sulfhydryl ACE inhibitor (ACEI) was studied in a titrated dose of 10 mg-20 mg once a day for 6 weeks in 42 mild to moderate adult hypertensive patients with sitting diastolic blood pressure (SDBP) 95-114 mm Hg. The pre-drug SDBP(mean +/- SE) of 102.5 +/- 0.8 mm Hg showed a significant reduction to 87.5 +/- 0.93 mm Hg at the end of treatment. BP was controlled (SDBPor = 90 mm Hg) in 34 (81%) patients and a drop of at least 10 mm Hg from the pre-treatment SDBP value was noted in 34 (81%) patients. Common adverse reaction was cough in 8(19%) patients. Clinically significant changes in laboratory evaluations were not seen in any patient. Study showed that benazepril in a dose range of 10 to 20 mg per day is an effective agent for treatment of mild to moderate hypertension.

Background: Merkel cell carcinoma (MCC) is a rare primary neuroendocrine skin tumor that usually arises in the head and neck or the extremities of elderly patients. Because of the limitation of retrospective data, optimal treatment is not well defined. Objective: Our purpose was to present the clinical course and treatment of 10 patients with MCC and review the published literature on MCC. Method: We conducted a retrospective analysis and obtained detailed clinical information for all 10 patients treated for MCC at our institution from 1986 through 1998. The medical literature was also reviewed for natural history and treatment recommendations using MEDLINE search. Results: Five men and 5 women received their treatment between 1986 and 1998 for MCC (5 had stage IA disease, 4 stage IB, 1 stage II). The mean age was 70.3 years (range, 47-86 years). Seven tumors were located on the head and neck and 3 on extremities. Five of 10 patients had a relapse (mean time before recurrence, 5.7 months) (range, 2 weeks-20 months); one patient had local recurrence, one had regional lymph node recurrence, and 3 had both local and regional lymph node recurrence. In 4 patients systemic metastases developed. Long survival is also noted (6 to > 164 months); 4 patients died of MCC. After initial surgery, 9 patients received radiotherapy at some point and 3 patients also received chemotherapy. Five of 10 patients had 13 previously treated or coexisting malignant neoplasms. In one patient MCC developed in a previously irradiated field. Review of 875 cases showed a male/female ratio of 1.5:1; location of tumors was as follows: head and neck, 47%; extremities, 40%; trunk, 8%; unknown primary site, 5%. Local recurrence was observed in 25%, regional lymph node involvement in 52%, distant metastasis in 34%, and MCC was a cause of death in 34%. Conclusion: MCC has a high incidence of locoregional recurrence with distant metastases that is more common with higher stage lesions. Early local management of smaller lesions results in good long-term survival. It is not known whether prophylactic lymph node dissection and/or radiation and adjuvant radiation increases survival. Long survival can be achieved after treating locoregional recurrence. The role of chemotherapy is still controversial and should be considered in patients with advanced disease and those not thought to be candidates for surgery. (J Am Acad Dermatol 2000;43:755-67.).

The vitamin D receptor (VDR) binds 1,25-dihydroxyvitamin D(3) and mediates its actions on gene transcription by heterodimerizing with retinoid X receptors (RXRs) on direct repeat (DR+3) vitamin D responsive elements (VDREs) located in target genes. The VDRE binding function of VDR has been primarily ascribed to the zinc finger region (residues 24-87). To define the minimal VDRE binding domain for human VDR (hVDR), a series of C-terminally truncated hVDR mutants (Delta134, Delta113, Delta102, Delta90, Delta84, Delta80, and Delta60) was generated and expressed in bacteria. Only the Delta134 and Delta113 mutants bound the VDRE (predominantly as monomers), suggesting that, in addition to the conserved zinc finger region of hVDR, as many as 25 amino acids in a C-terminal extension (CTE) participate in DNA binding. Site-directed mutagenesis of conserved charged residues in full-length hVDR was then performed to dissect the functional significance of the CTE (residues 88-112) in the context of the complete hVDR-RXR-VDRE interaction. Functional assays revealed that E98K/E99K, R102A/K103A/R104A, and K109A/R110A/K111A mutant hVDRs possessed dramatically reduced DNA binding and transcriptional activities, whereas distinct point mutants, such as K103A, bound to DNA normally but lacked transcriptional activity. Therefore, the boundary for the minimal DNA-binding domain in hVDR extends C-terminal of the zinc fingers to Lys-111, with clusters of highly conserved charged amino acids playing a crucial role in binding to the DR+3 element. Further, individual residues in this region (e.g., Lys-103) may lie on the opposing face of a DNA-binding alpha-helix, where they could contact transcriptional coactivators or basal transcription factors.

Change, challenge, and commitment motivate staff at the University of Miami/Jackson Memorial Medical Center in Miami, Florida, to prepare its health care system for the 21st century. Doctors, nurses, environmental workers, pharmacists, cashiers, nursing assistants, laboratory technologists, and many others are participating on a variety of teams to bring about the changes needed for our delivery system to be competitive.

Background Intractable hemorrhage is a dreaded complication after cardiovascular surgery often requiring re-exploration and the administration of large quantities of blood products. In view of problems with aprotinin, a new safer effective agent is needed. Recombinant activated FVII is approved for use in patients with hemophilia A and B who have inhibitors to factors VIII and IX, and has shown promise in off-label use for the management of life-threatening hemorrhage in several clinical scenarios including cardiac surgery. It may help control bleeding, reduce blood product usage, and avoid potential morbidity. Its exact place in the management of bleeding during and after cardiac surgery is not yet fully known. Methods. We performed a retrospective review of patients who were given recombinant factor VIIa (rFVIIa; Novoseven, NovoNordisk, Copenhagen, Denmark) to control bleeding after major cardiovascular surgery requiring cardiopulmonary bypass (CPB) at our institution. The decision to administer rFVIIa was made empirically based on the observation by the surgeons of refractory bleeding that appeared unresponsive to conventional hemostasis agents including the requirement of large volumes of blood components, and was at least severe enough to prevent chest closure. We compared blood loss and blood component usage in patients before and after rFVIIa. We also performed a detailed review of the English literature to determine the role of rFVIIa in the treatment of bleeding after cardiac surgery. Results. Between August 2002 to February 2006, 1295 patients underwent open heart surgery at our institution; of these, 28 were given Novoseven either to control intractable bleeding, or to prevent major bleeding. Table 1 shows the patient characteristics. Satisfactory hemostasis was achieved in all but 3 patients after a single 90 μg/kg intravenous dose of rFVIIa. In all patients, there was a dramatic reduction in the amount of blood components (PRBCs, Platelets and FFP) used after rFVIIa infusion (Table 2). Cryoprecipitate was administered routinely with rFVIIa and its usage did not change significantly (Table 2). No thromboembolic or other complications directly related to rVIIa occurred. Conclusions. We have demonstrated that intravenous rFVIIa is effective, safe, and valuable in the management of intractable bleeding after complicated cardiac surgeries. There are several reports and reviews in the literature which corroborate our experience and indicate that recombinant factor VIIa is a potent pro-hemostatic agent which has a role in the treatment of life-threatening refractory hemorrhage associated with cardiac surgery. Earlier preemptive administration of rFVIIa during or before surgery may be of value in patients at high risk of intractable bleeding in order to limit blood loss, and to avoid potential morbidity from large volume blood component transfusions. Randomized, controlled trials are warranted to assess the efficacy, safety, and cost-benefit of this intervention in cardiac surgical patients. TABLE 1. Characteristics and operative course of the 28 patients Mean age 60 yrs (range 22–85) Male, M 24(85%); F 4(15%) Total number of surgical procedures performed: 34 Aortic valve: 7; Bentall or modified Bentall: 9 (3 emergent) Mitral Valve Replacement: 4; CABG: 10; Redo 2 Left pneumonectomy/resection of L Atrial cuff & pericardium: 1 Removal of Inferior vena cava tumor (Renal cell ca): Re-exploration: 6; Delayed closure: 5; Both re-exploration and delayed closure: Median bypass time: 214 min (65–358) Timing of Novoseven: intra op: 21 including elective use in 2 pts; post op: 7 Dose of Novoseven: 90mcg/kg in 22; 45 mcg/kg 2 patients Responders 25(89%) Outcome: Deaths 11(38%) Autopsies: 2; no evidence of systemic thrombosis Table 2. Details of the blood products administered both before and after rFVIIa infusion. Componen Mean units Before rVIIa Mean units After rVIIa Difference; p value PRBC usage 15.9 5.033333 0.045 Platelet usage 4.448276 1.37931 0.005 FFP Usage 9.931034 5.793103 0.042 Cryoppt 21.71429 12.54167 0.091

Long chain organic poly(ammonium phosphate)s (1a–g and 2) were prepared by a precipitation technique by reaction of poly(lithium phosphate) with organic ammonium salts. Their compositions were established by nitrogen and phosphorus analyses and their polymeric nature was confirmed by molecular weight determinations via end group titrations and by the viscosity method. Studies of conductance at different concentrations indicated their polyelectrolytic behaviour. Paper chromatographic studies supplied additional evidence of a long chain polymeric structure, like Graham's salt and poly(lithium phosphate).

A few novel complex polyphosphate derivatives of the general composition (BHPO3)n (where B is pyridine, substituted methylpyridines, quinoline, morpholine, benzimidazole, and imidazole) have been synthesized by precipitation techniques. Viscosity average molecular weight values indicate their polymeric character which is similar to that of Graham's salt and other linear chain polymers. The viscosity average molecular weights of the precipitated polyphosphates have been found to be dependent on the basicities of the heterocyclic amines. The relation between the Mw and Rg values determined by paper chromatography also confirm their polymeric nature. Conductivity measurements at different dilutions indicate their polyelectrolytic behavior analogous to the Fuoss model.