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Over the years, we have seen the International Medical Graduates (IMGs) struggling to match into the United States Medical Residency system. Many of them pass the United States Medical Licensing Exam (USMLE) and match without research publications; however, many IMGs are left behind and do not match because they did not improve their chances of matching by improving their curriculum vitae (CV) enough. They could not add research publications on their CV, or they could not add enough US clinical experience to show and impress the residency program directors and justify their selection.

The association of nervous system with skin is well documented. Many common psychiatric disorders can involve skin either directly or indirectly. We found an association of 13 primary psychiatric disorders leading to dermatological diseases, with association of 2 of 13 considered to be idiopathic. Association of the mind and body has long been studied. Several skin problems lead to psychological and psychiatric symptoms, however not all skin problems lead to psychiatric symptoms. On the contrary, many primary psychiatric illnesses appear to have associated skin disorders. RESUMEN La asociación del sistema nervioso con la piel está bien documentada. Muchos trastornos psiquiátricos comunes pueden implicar a la piel directa o indirectamente. Se encontró asociación de 13 trastornos psiquiátricos primarios que llevan a enfermedades dermatológicas, y de las 13, asociación de 2 consideradas idiopáticas. La asociación entre la mente y el cuerpo se ha estudiado durante mucho tiempo. Varios problemas de la piel conducen a los síntomas psicológicos y psiquiátricos, pero no todos los problemas llevan a síntomas psiquiátricos de la piel. Por el contrario, parece que muchas enfermedades psiquiátricas primarias se asocian con trastornos de la piel.

The California Institute of Behavioral Neurosciences and Psychology also known as CiBNP was founded in 2016 by Dr. Hassaan Tohid and Dr. Syeda Sidra Tohid with an aim of teaching online and make quality education possible for everyone around the world. The institute started with just one student few years ago now serves thousands of international medical graduates (IMGs) and scientists from all over the world and helps them with the knowledge of research, research methodology, research writing, publishing, statistical data analysis, and many other research-related courses. The CiBNP’s “Be a Published Author Program” is one of the most popular programs among the IMGs, where the students learn to write, publish, and eventually become published authors in just a matter of few months. The institute faced challenges in the beginning years unlike majority of businesses because it was started with no finances, no investor’s support, and no prior experience of running a business. The founders started the organization with a mission to serve students across the globe without needing to travel to a campus and the mission continues. The courses currently offered by CiBNP as mentioned on the website include research writing and publishing, statistical data analysis, research methodology, research proposal writing, and many more. CiBNP strives to work harder to become one of the finest online training institutes in the upcoming years.

The mission of United States medical licensing examination (USMLE) /Scholar-RX is simple and straightforward: serve and help medical students around the globe. Scholar-RX, the organization, was founded by the co-author of the book First Aid (one of the most famous books for USMLE preparation). The Scholar-RX provides Online Question Bank for the USMLE preparation and continues to serve the international medical graduates (IMGs) and American medical graduates (AMGs). In this chapter, the readers will also read an interview of the founder and CEO of USMLE/Scholar-RX Dr. Tao Le, who is also one of the first authors/editors of the popular book First Aid USMLE STEP 1, and will also learn how the First Aid/USMLE Scholar-Rx has been helping IMGs over the years, and how the book First Aid made an impact and became one of the most read books related to USMLE Step 1 preparation. We the editors believed that this book should highlight the success story of First Aid, USMLE/Scholar-RX, and Dr. Tao Le as a useful resource for the readers of this book.

There is no surprise that both early education and medical education systems vary widely between countries. The education system of the United States is complex and often seen as the system of extreme differences. The primary and secondary education are often seen as inadequate and poorly organized compared to most of the other wealthy countries, while at the same time American universities are seen as some of the most prestigious in the world. Students generally have to spend at least 12 years at school, although nowadays higher education is becoming increasingly popular. The system is decentralized, and individual states set the curricula for most of the early education. The role of the federal government is limited. University admissions are competitive, and admission committees value application aspects beyond just academics. This is especially prominent among the elite universities. College students are required to fulfill pre-medical requirements to gain admission to medical school. Medical school admissions are based on college performance, Medical College Admission Test (MCAT) exam score, and interview performances. Medical students take the medical licensing exams called the United States Medical Licensing Examination (USMLE) in order to graduate and gain licensure. Graduate medical education is compulsory and lasts for 3 or more years after medical school. The application process for residency programs is mostly centralized. Licensure requirements depend on the individual states and whether the physician is a graduate of an American medical school or an international medical graduate. As would be expected, the Canadian system is similar to the American system, and both countries tend to recognize the qualifications obtained in the other. British system may be the most influential in the world due to historic ties Britain has with a number of countries around the world. Secondary education differs from that in the United States. Medicine is usually an undergraduate course that lasts 5 or 6 years, but the specialty training tends to be longer. The German system allows children who do not wish to pursue higher education to start their vocational training earlier than most countries. Their early education system also focuses on personal development beyond just the academics. The French and Italian systems are more traditional. Medical schools in all three countries last 6 years, which are then followed by periods of specialization. The admission criteria and processes vary between countries although ultimately all the countries within the European Union recognize the degrees from any other member state. In Latin America, Mexico and Argentina generally provide medical education through public universities; more than half of Brazilian medical students attend private institutions. The governmental involvement in early education is significant in all three countries. As is the case with most aspects of life in Latin America, there are stark differences between the opportunities provided to those who live in more urban and those who live in rural areas. Similar conclusions can be drawn about the systems in India, Pakistan, and countries in the Middle East and Africa. While the oversight may often be lacking, those countries are able to educate many excellent physicians that western healthcare systems depend on. We have also looked at Australia, Japan, and China since Australia can be perceived as a country in a lot of ways similar to the United States, Japan is widely seen as a powerhouse of science and technology, and China is often seen as a country with highest-performing high school students in the world. A lot of that holds true when it comes to their educational systems as well. Interestingly, Japanese medical education system has a lot of similarities with the US system. China and Australia have historically followed more traditional medical curricula, the likes of which are seen in the European Union and the United Kingdom. Australia, meanwhile, appears to be slowly moving away from the British approach to medical education and toward the American and Canadian approach.

Thousands of international medical graduates (IMGs) each year attempt to get into the US healthcare system by applying for US clinical residency. A huge number of these students do not match. Those who do may struggle with cultural, language, system, and ethical issues. Successful integration into the US healthcare system means that IMGs must learn about the ethics of medical practice and the way medical ethics work in the United States. IMGs come from many different countries with different backgrounds and are often accustomed to doing things in a way that reflects the culture of their training. IMGs need to know (1) common definitions and ethical terminologies and (2) how things are different in the United States. Anticipating how the United States is different will help them avoid any mistakes during their professional practice and facilitate a smoother cultural transition. In this chapter, we will outline some of the most important medical ethics issues and provide illustrations to contrast differences between medical practice in the United States and other parts of the world.

To be more competitive for the United States (US) residency match, the international medical graduates (IMGs) need to work hard and improve their curriculum vitae (CV); however, a proper direction and clarity is needed about what to focus on mainly. It is a well-known fact that IMGs must have some sort of clinical experience in the United States and should have some research publications along with the licensing exam. These three things are the Big Three of residency that I call as “The Triangle of Residency.” This triangle is the United States Medical Licensing Exam (USMLE), the US clinical experience, and the research experience of some kind that ends up in a publication. It is obvious that the students need to pass USMLEs, and they are not eligible to apply for residency without it; however, not having US clinical experience and not having any research publications can severely hamper their chances of matching into the clinical residency. If a student has stupendous USMLE scores like 270+, then of course that student is one of the rarest candidates and will still be able to get some interview calls, but the majority of IMGs do not get those once in a blue moon unusually high score. A score of somewhere between 230 and 240 is considered a reasonably good score, and a score of 250 plus is still considered as a huge achievement. Yet, there is a huge percentage of students get these kinds of scores and such scores are not too uncommon; a lot of candidates have these kinds of scores; therefore, to be different from the crowd, the students must add more things to their CV, and US clinical experience and research publications will make them distinct. Thus, the IMGs must strive to find these additional opportunities and become more competitive for residency match.

Thousands of international medical graduates (IMGs) apply for the United States (US) medical residency program each year. Many do succeed, but a huge percentage of students do not match. This causes frustration, anxiety, grief, depression, and many other issues among the IMGs. Surprisingly, these signs are not just confined to those candidates who do not match but are also found in the vast majority of candidates applying for a match. In a nutshell, these signs are found pre- and post-match in various foreign medical graduates.

Objective: To highlight the inflammatory and immunological mechanisms involved in depression and psoriasis. Methods: A comprehensive literature search was performed in various databases, in total 145 studies were selected. Results: Depression and psoriasis have an association. Immune mechanisms -the actions of tumor necrosis factor-a, interleukin 1 (IL-1), IL-2, IL-10, IL-22, IL-17, interferon-7, IL-1ß, prostaglandin E2, C-reactive protein, IL-6, and IL-8 etc.-, and some genetic changes are involved. Conclusions: A possible bidirectional relationship of psoriasis and major depression exists; i.e. the depression leads to psoriasis, and psoriasis leads to depression. We recommend more studies in the future to get a deeper and better understanding about this relationship. RESUMEN Objetivo: Poner de relieve los mecanismos inflamatorios e inmunológicos involucrados en la depresión y la psoriasis. Métodos: Se realizó en varias bases de datos una búsqueda bibliográfica completa; en total se incluyeron 145 estudios. Resultados: Hay asociación entre depresión y psoriasis y están involucrados mecanismos inmunitarios -las acciones del factor de necrosis tumoral alfa, las interleucinas (IL) 1, 2, 10, 22 y 17, el interferón gamma, la IL-1ß, la prostaglandina E2, la proteína C reactiva, la IL-6 y la IL-8, etc. - y algunos cambios genéticos. Conclusiones: Hay una posible relación bidireccional entre psoriasis y depresión, es decir, la depresión lleva a psoriasis y la psoriasis lleva a depresión. Se recomiendan más estudios en el futuro para obtener una comprensión más profunda y mejor sobre esta relación.

Introduction: The world renowned comedian and four-time Oscar nominated actor Robin Williams died on August 11, 2014. From the outset, the news indicated that his death was believed to be a suicide and this was later confirmed to be true by the autopsy reports. Williams had been suffering from severe depression, which is believed to be the leading contributor to his suicide. In this case study, I will highlight the event of the actor's suicide and the main risk factors along with depression leading to his tragic death. As of the end of 2015, no other case study seemed to have addressed or explored the links between the cause (or causes) and events leading to Robin Williams' suicide. Case description: Robin Williams was suffering from relationship problems, financial problems, drug addiction, and major depression. All of these factors led to his suicide. Comments: The chances of committing suicide drastically increase in the presence of any of the key risk factors. Unfortunately, the actor Robin Williams was dealing with four of the major risk factors all together, which put him at a high risk of committing suicide and eventually led to his tragic death.

Understanding social cognition has become a hallmark in deciphering autism spectrum disorder. Neurobiological theories are taking precedence in causation studies as researchers look to abnormalities in brain development as the cause of deficits in social behavior, cognitive processes, and language. Following their discovery in the 1990s, mirror neurons have become a dominant theory for that the mirror neuron system may play a critical role in the pathophysiology of various symptoms of autism. Over the decades, the theory has evolved from the suggestion of a broken mirror neuron system to impairments in mirror neuron circuitry. The mirror neuron system has not gained total support due to inconsistent findings; a comprehensive analysis of the growing body of research could shed light on the benefits, or the disadvantage of continuing to study mirror neurons and their connection to autism.

A rare kind of antibody, known as anti-glutamic acid decarboxylase (GAD) autoantibody, is found in some patients. The antibody works against the GAD enzyme, which is essential in the formation of gamma aminobutyric acid (GABA), an inhibitory neurotransmitter found in the brain. Patients found with this antibody present with motor and cognitive problems due to low levels or lack of GABA, because in the absence or low levels of GABA patients exhibit motor and cognitive symptoms. The anti-GAD antibody is found in some neurological syndromes, including stiff-person syndrome, paraneoplastic stiff-person syndrome, Miller Fisher syndrome (MFS), limbic encephalopathy, cerebellar ataxia, eye movement disorders, and epilepsy. Previously, excluding MFS, these conditions were called ‘hyperexcitability disorders’. However, collectively, these syndromes should be known as “anti-GAD positive neurological syndromes.” An important limitation of this study is that the literature is lacking on the subject, and why patients with the above mentioned neurological problems present with different symptoms has not been studied in detail. Therefore, it is recommended that more research is conducted on this subject to obtain a better and deeper understanding of these anti-GAD antibody induced neurological syndromes.

The relationship of the occipital lobe of the brain with schizophrenia is not commonly studied; however, this topic is considered an essential subject matter among clinicians and scientists. We conducted this systematic review to elaborate the relationship in depth. We found that most schizophrenic patients show normal occipital anatomy and physiology, a minority showed dwindled values, and some demonstrated augmented function and structure. The findings are laborious to incorporate within single disease models that present the involvement of the occipital lobe in schizophrenia. Schizophrenia progresses clinically in the mid-twenties and thirties and its prognosis is inadequate. Changes in the volume, the gray matter, and the white matter in the occipital lobe are quite evident; however, the mechanism behind this involvement is not yet fully understood. Therefore, we recommend further research to explore the occipital lobe functions and volumes across the different stages of schizophrenia.

Stiff-person syndrome (SPS) is a rare disorder that affects the central nervous system and is characterized by progressive muscle stiffness, rigidity, and spasm of axial and limb muscles. The syndrome is caused by a lack of gamma aminobutyric acid (GABA), which occurs because of antibodies against glutamic acid decarboxylase (GAD), an essential enzyme for GABA synthesis. Hence, the patients present with increased muscular activity. In this article, we will discuss two case studies of stiff-person syndrome.

Objectives Earthquakes are unpredictable and devastating natural disasters. They can cause massive destruction and loss of life and survivors may suffer psychological symptoms of severe intensity. Our goal in this article is to review studies published in the last 20 years to compile what is known about posttraumatic stress disorder (PTSD) occurring after earthquakes. The review also describes other psychiatric complications that can be associated with earthquakes, to provide readers with better overall understanding, and discusses several sociodemographic factors that can be associated with post-earthquake PTSD Method A search for literature was conducted on major databases such as MEDLINE, PubMed, EMBASE, and PsycINFO and in neurology and psychiatry journals, and many other medical journals. Terms used for electronic searches included, but were not limited to, posttraumatic stress disorder (PTSD), posttraumatic symptoms, anxiety, depression, major depressive disorder, earthquake, and natural disaster. The relevant information was then utilized to determine the relationships between earthquakes and posttraumatic stress symptoms. Results It was found that PTSD is the most commonly occurring mental health condition among earthquake survivors. Major depressive disorder, generalized anxiety disorder, obsessive compulsive disorder, social phobia, and specific phobias were also listed. Conclusion The PTSD prevalence rate varied widely. It was dependent on multiple risk factors in target populations and also on the interval of time that had elapsed between the exposure to the deadly incident and measurement. Females seemed to be the most widely-affected group, while elderly people and young children exhibit considerable psychosocial impact. Resumo Objetivos Terremotos são desastres naturais imprevisíveis e devastadores. Eles podem causar destruição em massa e morte, e os sobreviventes podem apresentar sintomas psicológicos severos. O objetivo deste estudo foi revisar estudos publicados nos últimos 20 anos pra compilar o conhecimento disponível acerca da ocorrência de transtorno do estresse pós-traumático (TEPT) após terremotos. A revisão também descreve outras complicações psiquiátricas que podem estar associadas a terremotos, oferecendo aos leitores um melhor entendimento geral sobre o assunto, e discute vários fatores sociodemográficos que podem estar associados com TEPT pós-terremoto. Métodos Foi realizada uma busca de literatura nas principais bases de dados, como MEDLINE, PubMed, EMBASE e PsycINFO, e também em revistas de neurologia e psiquiatria, e vários outros periódicos médicos. Os termos usados nas buscas eletrônicas incluíram, mas não se limitaram a, posttraumatic stress disorder (PTSD), posttraumatic symptoms, anxiety, depression, major depressive disorder, earthquake e natural disaster. As informações relevantes foram então utilizadas para determinar as relações entre terremotos e sintomas de estresse pós-traumático. Resultados A revisão revelou que o TEPT é a condição de saúde mental mais comum em sobreviventes de terremoto. Depressão maior, transtorno de ansiedade generalizada, transtorno obsessivo-compulsivo, fobia social e fobias específicas foram outras condições encontrados. Conclusão A prevalência de TEPT variou bastante. O transtorno foi dependente de múltiplos fatores de risco em populações-alvo e também do intervalo de tempo decorrido entre a exposição ao incidente fatal e a avaliação. As mulheres pareceram ser o grupo mais amplamente afetado, ao passo que idosos e crianças demonstração considerável impacto psicossocial.

Parkinson's disease is a widespread neurological illness. However, its psychiatric links have also been discussed lately by many authors, which has brought more depth to the specialized field of neuropsychiatry. Neuropsychiatric complications are commonly seen in Parkinson's patients, including major depression, anxiety, psychosis and hallucination, and cognitive abnormality. Almost all of these complications have a distinct pathophysiology and treatment. In this article we review the most recent studies about the association of these symptoms with Parkinson's disease and highlight the epidemiology, diagnosis, pathophysiology, and treatment of the neuropsychiatric complications, with more emphasis on the pathophysiology of these complications.

Little has been known about the possible brain changes in the patients suffering from the psychiatric illness called Dissociative Identity Disorder (DID). This review suggests that the patients of DID have structural changes in the limbic system–hippocampus and amygdala -and the cortex. Blood flow is also altered in the orbito-frontal cortex. Another interesting finding of this review is that the glutamate release is found to be the cause of the dissociative symptoms. Furthermore, this review also highlights that in some DID patients the dorsolateral prefrontal and parietal cortex are activated. The limbic system especially the amygdala and the dorsolateral prefrontal and parietal cortex are associated with the short term and working memory, while the hippocampus is associated with long-term memory. All of these regions are somehow affected in the DID patient’s brain. Thus, this explains the symptoms of the multiple personality changes and forgetting about the previous personality. However, the future studies will broaden our knowledge about the complete neuropsychiatry of this unique medical illness.

Objective: To highlight the changes in the frontal lobe of the human brain in people with schizophrenia. Methods: This was a qualitative review of the literature. Results: Many schizophrenic patients exhibit functional, structural, and metabolic abnormalities in the frontal lobe. Some patients have few or no alterations, while some have more functional and structural changes than others. Magnetic resonance imaging (MRI) shows structural and functional changes in volume, gray matter, white matter, and functional activity in the frontal lobe, but the mechanisms underlying these changes are not yet fully understood. Conclusion: When schizophrenia is studied as an essential topic in the field of neuropsychiatry, neuroscientists find that the frontal lobe is the most commonly involved area of the human brain. A clear picture of how this lobe is affected in schizophrenia is still lacking. We therefore recommend that further research be conducted to improve understanding of the pathophysiology of this psychiatric dilemma. Resumo Objetivo: Descrever as alterações no lobo frontal do cérebro humano em indivíduos com esquizofrenia. Métodos: Esta foi uma revisão qualitativa da literatura. Resultados: Muitos pacientes esquizofrênicos exibem anormalidades funcionais, estruturais e metabólicas no lobo frontal. Alguns pacientes apresentam poucas ou nenhuma alteração, ao passo que outros apresentam mais alterações funcionais e estruturais quando comparados com seus pares. A ressonância magnética é capaz de demonstrar alterações estruturais e funcionais em volume, substância cinzenta, substância branca e atividade funcional do lobo frontal, porém os mecanismos subjacentes a essas alterações ainda não são completamente compreendidos. Conclusão: Quando a esquizofrenia é estudada como um tópico central na área da neuropsiquiatria, os neurocientistas observam que o lobo frontal é a área do cérebro humano mais comumente envolvida. Uma imagem clara de como esse lobo é afetado na esquizofrenia permanece inexistente. Portanto, recomendamos que mais pesquisas sejam conduzidas para melhorar nosso entendimento sobre a fisiopatologia desse dilema psiquiátrico.

Objective: The aim of this paper was to highlight the mechanisms involved and the relationship between depression and psoriasis. Method: A comprehensive literature search was performed in various databases, and finally 88 studies were deemed relevant. Results: A significant link was found between depression and psoriasis, primarily through immune mechanisms related but not limited to the actions of inflammatory cytokines such as tumor necrosis factor-α, interleukin 1 (IL-1), IL-2, IL-10, interferon-γ, IL-1β, prostaglandin E2, C-reactive protein, IL-6, and IL-8. Conclusion: Various neuroimmunological studies point towards the notion that depression and psoriasis are associated with each other. Melatonin has also been found to be associated with both conditions. A possibility exists that both conditions can cause each other due to the possible bidirectional relationship of psoriasis and major depression. However, if this is the case, then why all depressed patients fail to develop psoriasis and why all psoriatic patients fail to develop depression remains a question unanswered. We believe that future studies will unmask this mystery.

The dearth of child psychiatrists in Pakistan is becoming one of the major causes of many cases of attention deficit hyperactivity disorder (ADHD) remain undiagnosed. Some important measures must be taken at the private and the governmental levels, so that the ADHD cases do not remain diagnosed in the future.

A literature search was conducted in different databases to study the topic of liver problems and diabetes. The aim of the study was to explore more about an association of diabetes mellitus with the liver. The study shows that diabetes does indeed have an effect on liver. Similarly, liver problems like chronic liver disease lead to diabetes which is known as hepatogenous diabetes. Common liver problems seen in diabetes patients include but not limited to fatty liver, decreased glycogen levels, risk of liver cancer etc. Like any medical problem, any knowledge about any subject is never enough, therefore we recommend more studies in the near future to broaden our understanding about the association of the liver with diabetes.

In this article, we discussed a clinical problem known as cardio renal syndrome (CRS). In CRS, both, the affected cardiovascular system, either low output or high output failure leads to the renal dysfunction or vice versa. As already known, the heart failure is the leading cause of readmission in the US and worldwide. The patients suffering with cardiac failure need extra care, as they may develop various complications. Cardiac output is affected in heart failure and does have an impact on the renal function. High cardiac output and low cardiac output, both can lead to renal dysfunction. In conclusion, we will also highlight some information about the prevention of the renal damage associated with the CVS. However, future research is recommended to understand more about the exact pathophysiology involved in this association.

We present a rare case of visual release hallucinations also referred to as Charles bonnet syndrome. The disorder is rare and no officially recognized mode of treatment has been developed. However, we hope that as the time goes by, and more cases of CBS are found. It will be possible for the scientists and the clinicians to find a permanent and a better cure for this rare mystery.

A large number of patients do not have cauda equina syndrome (CES) on MRI to account for their clinical findings; consequently, the majority of urgent scans requested are normal. We aimed to determine whether any clinical manifestation of CES, as stated in Royal College of Radiology guidelines, could predict the presence of established CES on MRI. We also aimed to support a larger study to develop a more universal assessment tool for acute lower back pain. A retrospective analysis of consecutive patients who warranted urgent MRI was conducted. Seventy-nine patients were eligible for study. The Kendall’s tau test was used for statistical analysis of all data. A p value of less than 0.05 was considered to be significant. MRI was performed in 62 patients out of 79. A total of 32.9% of patients had scans within 24 hours of admission. Nine of these patients were referred to neurosurgery for urgent neurosurgical review. Of these, 6.3% of patients had an established CES on MRI scan. One patient who had an out-patient MRI spine (15 days from hospital presentation) was found to have an established CES, was urgently referred to spinal surgery and underwent primary fenestration excision of the lumbar vertebra. No clinical features that were able to predict the presence of an established CES on MRI were elucidated. Findings included decreased anal tone 7.6% ( p = 0.282), faecal incontinence 3.8% ( p = 0.648), urinary retention 7.6% ( p = 0.510), bladder incontinence 8.9% ( p = 0.474), constipation 2.5% ( p = 0.011) and saddle anaesthesia 8.9% ( p = 0.368). Patients who had an abnormal MRI spine for back pain prior to this presentation showed a correlation with a newly diagnosed CES on MRI ( p = 0.016) with a correlation coefficient of 0.272.

Context: Human/animal shaving biology.Objective: To assess the effect of shaving on percutaneous penetration and skin function.Methods: We screened 500+publications in Pub Med, Scopus, Cochrane Library and pertinent journals out of which only 17 were deemed relevant. Terms for searches included shaving and skin, percutaneous penetration and shaving, skin absorption and shaving, absorption of dyes and shaving, skin penetration, effects of shaving and absorption, shave and dyes, axillary shaving and stratum corneum, shaving and breast cancer, shaving and infections, etc.Result: Shaving appears to have an exaggerated effect on percutaneous absorption; however, some studies do not support this evidence.Conclusion: Shaving enhances percutaneous penetration of some chemicals; however this effect is species and chemical specific. Further investigations of chemicals of varying physio-chemical properties are mandated before a generalized theory can be promulgated.