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PubMed2000

Radiofrequency application to the posteroseptal region alters retrograde accessory pathway activation.

INTRODUCTION: Radiofrequency applications to the posteroseptal region can ablate the atrioventricular accessory pathway residing in this area. In conjunction with the adjacent anatomic structures, however, ablative lesions which do not effectively ablate the accessory pathway could markedly alter retrograde atrial activation sequence and confound interpretation of further mapping of an accessory pathway. METHODS AND RESULTS: Electrophysiologic studies, endocardial activation mapping and radiofrequency catheter ablation were undertaken in three patients with recurrent supraventricular tachycardia. Patients were initially thought to have a single posteroseptal accessory pathway; earliest ventrioatrial activation during tachycardias and during ventricular pacing was at the coronary sinus ostium, but initial radiofrequency applications were unsuccessful to ablate the pathway. After initial radiofrequency applications to the posteroseptal region, the earliest retrograde atrial activation changed to the right atrial free wall in two patients. Additional radiofrequency application to the posteroseptal area was able to ablate the single posteroseptal accessory pathway in one patient. Radiofrequency application to the right atrial free wall was required to stop tachycardia initiation in other patient. The third patient was suspected of having a slow-slow atrioventricular nodal reentry tachycardia. Radiofrequency application to the posteroseptal area changed the earliest retrograde atrial activation to the distal coronary sinus recording site, mimicking an accessory pathway at the left atrial free wall. Radiofrequency application to the anteroseptum was able to ablate the concealed accessory pathway. CONCLUSION: Radiofrequency applications to the posteroseptal region can markedly alter retrograde atrial activation, thereby confounding further mapping of the accessory pathway.

Adolescent↗

PubMed2003

Effect of urea fertilizer application on soluble protein and free amino acid content of cotton petioles in relation to silverleaf whitefly (Bemisia argentifolii) populations.

The impact of urea nitrogen fertilization on silverleaf whitefly, Bemisia argentifolii Bellows & Perring, population dynamics was examined in field-grown cotton (Gossypium hirsutum L.). Five urea nitrogen treatments were tested, consisting of soil applications of 0, 112, 168, and 224 kg nitrogen per hectare, and acombined soil-foliar application of 112:17 kg nitrogen per hectare. A positive response was observed between N application rates and the measured levels of nitrate N in petioles from mature cotton leaves. Similarly, a positive response was observed between N application rates and the numbers of adult and immature whiteflies appearing during population peaks. To determine whether these positive responses were related, we measured the levels of dietary N compounds (proteins and free amino acids) that would be available for insect nutrition in cotton petioles at the different N application rates. Sampling dates and N application treatments affected levels of soluble proteins in cotton petioles, and interactions between sampling dates and treatments were significant. Across all sampling dates, the relationship between N application rates and levels of soluble proteins was linear. Sampling dates also affected levels of total and individual free amino acids. Fertilizer treatments only affected levels of total amino acids, aspartate, asparagine, and arginine plus threonine. Levels of aspartate or asparagine and the N application rates were linearly correlated. No significant correlations were observed between levels of dietary N compounds in cotton petioles and numbers of whiteflies, either adults or immatures, on the cotton plants.

Amino Acids↗

PubMed2002

Complexities in ETS-domain transcription factor function and regulation: lessons from the TCF (ternary complex factor) subfamily. The Colworth Medal Lecture.

The ETS-domain transcription factor family can be divided into a series of subfamilies. Elk-1 represents the founding member of the ternary complex factor (TCF) subfamily. By focusing on the TCF subfamily, we can demonstrate the complexities that exist in the function and regulation of ETS-domain transcription factors. This article focuses on Elk-1 in detail and summarizes the functions of other TCFs. The key themes covered include the domain structure of the TCFs, the mechanisms of complex formation with serum response factor, regulation of TCFs by mitogen-activated protein kinase cascades, and transcriptional regulatory properties of the TCFs. Finally, the emerging role of the TCFs in vivo is discussed. A picture is developing indicating that, while these proteins exhibit significant sequence and functional conservation, key differences in their structure and regulation are being identified which may relate to unique functions of these proteins in vivo.

Amino Acid Sequence↗

PubMed1975

Fluoride application procedures in orthodontic practice, current concepts.

A survey is given of present knowledge of different methods of fluoride administration with emphasis on practical measures of proved value for orthodontic patients. The review covers different F administration procedures by dental personnel and self-application and includes the use of prophylaxis pastes, topical solutions, gels, mouth rinses, dentifrices, tablets, cements, coatings, varnishes, etc. Some recommendations are given as to optimal programs in orthodontic practice based upon evaluations of clinical effectiveness, safety and ease of application. Some caries reduction has been obtained from professional application of F prophylaxis pastes, but F pastes cannot replace topical F application. Treatment with F gels or solutions preceded by thorough cleaning and drying of the teeth is advocated before the placement of appliances and at recementations. Because F solutions are tedious to apply, and not more effective than F gels, the latter are preferable. APF gel application is suited in conjunction with impression taking. Daily self-application of SnF2 gels undoubtedly is effective in reducing caries in orthodontic patients. However, daily NaF or APF mouth rinses may have the dual effect of caries inhibition and stimulating hygiene interest and are more thoroughly tested. In addition to the other forms of F administration, a F dentifrice should be used regularly. Daily F application is appropriate also for orthodontic patients in fluoridated areas. In vitro studies with F cements indicate a great F uptake by the enamel, but controlled, long-term clinical studies are lacking. Also the final judgment of a number of new coating techniques and F varnishes must await further clinical testing, although a beneficial effect of F sealing in orthodontic patients is substantiated. In conclusion, APF gel application before insertion of appliances and at regular recementations plus daily rinsing with dilute NaF or APF solutions throughout the periods of treatment and retention plus the regular use of a F dentifrice is recommended as a routine procedure for all orthodontic patients.

Child↗

PubMed2003

Formaldehyde application for haemorrhagic radiation-induced proctitis: a clinical and histological study.

OBJECTIVES: Haemorrhagic radiation-induced proctitis is a serious complication of radiotherapy of pelvic organs. In severe cases, massive haemorrhage may necessitate hospitalization and repeated transfusions. Application of formaldehyde under direct vision is one of the most efficient treatments. The aim of this study was to evaluate the results of this treatment as well as the histological changes induced by formaldehyde on the rectal mucosa. MATERIAL AND METHODS: From January 1991 to September 2001, 13 patients who presented a haemorrhagic radiation-induced proctitis have been treated in our outpatient clinic with 4% formaldehyde cotton soaked applications. They were followed up to one year after the treatment. Endoscopic biopsies were performed before, immediately after the application, 1 month later, as well as at the one-year follow-up. RESULTS: In eight cases bleeding stopped after the first application. In two patients a second application was necessary to control the haemorrhage and in two other patients bleeding ceased definitively after the fourth application. Follow-up evaluation at 12 months showed no sign of acute proctitis or rebleeding. One asymptomatic patient had a mild stenosis of the rectum. Baseline biopsies showed signs of acute inflammation. Those performed after the application of formaldehyde showed fresh thromboses of the vessels of the mucosa. Biopsies at 1 month and 1 year showed only chronic changes secondary to the radiotherapy. CONCLUSION: Local application of 4% formaldehyde for the treatment of haemorrhagic radiation-induced proctitis gives good results, is well tolerated and easy to perform. Formaldehyde applied selectively causes thromboses of the bleeding vessels, without deep lesions or extended necrosis.

Aged↗

PubMed2002

The importance of accurate dosage of topical agents: a method of estimating involved area and application to calcipotriol treatment failures.

Little attention is given to accurate dosage of topical medication which is a potential source of side-effects and treatment failure. There are studies on the dosage for 'sparing' application relevant to topical steroids but not for 'liberal' application. Though calcipotriol is a first line topical treatment for psoriasis, approximately one-third of patients do not respond adequately. The aims of the present study were to define liberal dosage, to develop a method of calculation of area of involved skin and to evaluate the efficacy of calcipotriol in optimized liberal dosages, based on preliminary studies, in calcipotriol treatment failures. Weight/unit area of ointment and cream base, constituting liberal application, was determined in six normal volunteers. The area of psoriatic involvement in 24 calcipotriol non-responders was estimated by a 'fill-up' method and a modified 'hand' method. The results of the two methods were similar (Pearson correlation coefficient 0.68, P < 0.0001) but the 'hand' method proved easier in use and was the preferred method for the rest of the study. The patients applied calcipotriol at their accustomed rates for at least 2 weeks and then at the calculated liberal rates, using cream in the morning and ointment at night, for 4 weeks. The efficacy measures were Psoriasis Area and Severity Index (PASI) (primary measure), a four-point efficacy score and a visual analogue scale. As a result of the preliminary study and the actual amounts used by the patients in the psoriasis treatment study reported below, liberal application has been defined as 50 g/m2 per application for ointment base and 40 g/m2 per application for cream. At this dosage, an average individual would use approximately 100 g of medication/week to treat 10% of the body surface. During the 4-week treatment study, the psoriasis patients used an average of 39 g (SD 17 g)/m2 per application of cream and 52 g (SD 13 g)/m2 per application of ointment. All efficacy measures showed marked improvement (P < 0.0001). The frequency distribution of the PASI reduction defined responsive (70% of patients) and poorly responsive groups (30%), with mean PASI reduction of 60% and 17%, respectively.

Administration, Topical↗

PubMed2003

[Laser-induced thermotherapy (LITT) of lung metastases: description of a miniaturized applicator, optimization, and initial treatment of patients].

PURPOSE: A thin-caliber applicator system was developed for introducing a laser fiber under CT guidance into lung metastases with only minimal complications. MATERIALS AND METHODS: A space-saving 5.5 French Teflon cannula with a titanium trocar and connectors for a laser light guide (2 or 3 cm Dornier Diffusor-Tip H-6111-T2 or H-6111-T3 coupled to a Dornier Medilas Fibertom 5100 laser, wavelength of 1064 nm) and a perfusion line for physiologic saline solution were developed. After puncture the laser Diffusor-Tip remains in the cannula and is cooled during its tissue passage by slowly flowing saline solution. The miniaturized applicator system (Monocath) was calibrated in nonperfused bovine liver for maximum energy supply and necessary flow of the cooling saline solution in reference to a commercially available 9 French laser catheter with an 11.5 French inducer sheath (Power-Applicator). The new applicator system was used for treating lung metastases in 10 patients over a period of 21 months. RESULTS: The size of heat coagulation in bovine liver was 24 +/- 2 ml using the miniaturized system with application of 15 W for 20 min and a saline flow of 0.75 ml/min, in comparison to a size of 29 +/- 7 ml for the commercial applicator (30 W, 20 min, 60 ml/min). All metastases could be safely approached with the miniaturized applicator, except for two metastatic lesions at the lung base in two patients. A minor pneumothorax developed in three patients and intrapulmonary bleeding in two. Contrast-enhanced CT demonstrated necrosis of the treated metastatic areas in 6 patients. Follow-up of three patients after 5, 6, and 8 months showed complete tumor regression with minimal scarring in one patient. CONCLUSION: The miniaturized applicator system enables the introduction of a laser fiber into pulmonary metastases with only minor complications. Complete ablation seems to be achievable in suitable patients with the applied laser energy and a slow cooling fluid flow rate.

Adult↗

PubMedDate not supplied

Mortality among aerial pesticide applicators and flight instructors: a reprint.

A cohort mortality study was conducted of male aerial pesticide applicators and flight instructors identified from computerized Federal Aviation Administration medical examination records from 1965-1979. Vital status of 9,677 applicators and 9,727 instructors was determined through January 1, 1980, and standardized mortality ratios (SMRs) were calculated. The overall SMR was 127 for applicators (699 deaths) and 93 for instructors (454 deaths). Fatalities from nonmotor vehicle accidents, mostly aircraft crashes, were in notable excess (SMR = 1,168 among applicators, 630 among instructors), whereas deaths from most chronic diseases, including all cancer, was below expectation (e.g., for arteriosclerotic heart disease, SMR = 52 among applicators and 50 among instructors). The ability of the study to assess cancer risk among applicators was limited by a relatively brief follow-up period. However, 8 applicators (SMR = 171), but only 1 flight instructor (SMR = 24), died of leukemia, and small, nonsignificant risk elevations for some other cancer sites among applicators were observed and warrant continued follow-up.

Accidents, Aviation↗

PubMed2003

Male reproductive hormones and thyroid function in pesticide applicators in the Red River Valley of Minnesota.

In the present effort, 144 pesticide applicators and 49 urban control subjects who reported no chronic disease were studied. Applicators provided records of the season's pesticides used by product, volumes, dates, and methods of application. Blood specimens for examination of hormone levels were obtained in summer and fall. In the herbicide-only applicator group, significant increases in testosterone levels in fall compared to summer and also elevated levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in the fall were noted. With respect to fungicide use, in an earlier cross-sectional epidemiologic study, data demonstrated that historic fungicide use was associated with a significant alteration of the sex ratio of children borne to applicators. As before, among current study subjects it was noted that historic fungicide use was associated with increased numbers of girls being born. Lower mean total testosterone concentrations by quartile were also correlated with increased numbers of live-born female infants. A downward summer to fall seasonal shift in thyroid-stimulating hormone (TSH) concentrations occurred among applicators but not among controls. Farmers who had aerial application of fungicides to their land in the current season showed a significant shift in TSH values (from 1.75 to 1.11 mU/L). Subclinical hypothyroidism was noted in 5/144 applicators (TSH values >4.5 mU/L), but not in urban control subjects. Based on current and past studies, it was concluded that, in addition to pesticide exposure, individual susceptibility and perhaps economic factors may play a supporting role in the reported results.

Adult↗

PubMed1983

A new coaxial TEM radiofrequency/microwave applicator for non-invasive deep-body hyperthermia.

At the moment great efforts are being made to develop non-invasive heating systems which produce controlled local or regional deep-body hyperthermia. Electromagnetic interference techniques (10-80 MHz) with several separated applicators or with multiple applicators can produce deep-body heating. In our institute a coaxial frequency-independent TEM radiofrequency/microwave applicator has been designed. This applicator can produce a theoretically optimal interference maximum in the centre of the body. The applicator is very simple to construct and inexpensive. To test the design with the equipment available, a scaled prototype of the TEM applicator has been developed. The prototype has a diameter of 20 cm and operates at 434 MHz. The applicator has been tested on several phantom materials. The measured absorbed power distributions are in good agreement with the calculated theoretical distributions. The theoretical calculations of the absorbed power distributions of a 10-80 MHz TEM deep-body applicator are very encouraging.

Diathermy↗

PubMed2003

Dissipation and mobility of permethrin in the field with repeated applications under tropical conditions.

Studies on persistence, mobility and the effect of repeated application of permethrin on its half-life were carried out under field conditions. The half-life of permethrin in the top 20 cm of the soil increased from 11.5 to 23.6 days as the application rates increased from 35 to 140 g ha(-1). Induced by heavier rainfall, more residues moved downward in trial 2 than in trial 1. Repeated applications enhanced degradation rates and mobility of permethrin in the soil. The residue level in the 0-5-cm layer was reduced at day 28 after 17 consecutive applications to a level lower than after 5 applications. The half-life of permethrin was reduced from 15.9 days to 11.2 days after 5 and 17 applications, respectively. The residue reached the 15-20 cm layer much earlier (approximately 3 days after treatment) in soil that received 17 applications as compared to those with two applications.

Chromatography, High Pressure Liquid↗

PubMed1999

Temperature measurement errors with thermocouples inside 27 MHz current source interstitial hyperthermia applicators.

The multielectrode current source (MECS) interstitial hyperthermia (IHT) system uses thermocouple thermometry. To obtain a homogeneous temperature distribution and to limit the number of traumas due to the implanted catheters, most catheters are used for both heating and thermometry. Implications of temperature measurement inside applicators are discussed. In particular, the impact of self-heating of both the applicator and the afterloading catheter were investigated. A one-dimensional cylindrical model was used to compute the difference between the temperature rise inside the applicators (deltaTin) and in the tissue just outside the afterloading catheter (deltaTout) as a function of power absorption in the afterloading catheter, self-heating of the applicator and the effective thermal conductivity of the surrounding tissue. Furthermore, the relative artefact (ERR), i.e. (deltaTin - deltaTout)/deltaTin, was measured in a muscle equivalent agar phantom at different positions in a dual-electrode applicator and for different catheter materials. A method to estimate the tissue temperature by power-off temperature decay measurement inside the applicator was investigated. Using clinical dual-electrode applicators in standard brachytherapy catheters in a muscle-equivalent phantom, deltaTin is typically twice as high as deltaTout. The main reason for this difference is self-heating of the thin feeder wires in the centre of the applicator. The measurement error caused by energy absorption in the afterloading catheter is small, i.e. even for materials with a high dielectric loss factor it is less than 5%. About 5 s after power has been switched off, Tin in the electrodes represents the maximum tissue temperature just before power-off. This delay time (t(delay)) and ERR are independent of Tin. However, they do depend on the thermal properties of the tissue. Therefore, ERR and t(delay) and their stability in perfused tissues have to be investigated to enable a reliable estimation of the tissue temperatures around electrodes in clinical practice.

Hyperthermia, Induced↗

PubMed2004

Cancer incidence among pesticide applicators exposed to alachlor in the Agricultural Health Study.

The authors evaluated the incidence of cancer among pesticide applicators with exposure to alachlor in the Agricultural Health Study, a prospective cohort study of licensed pesticide applicators in Iowa and North Carolina. A total of 49,980 pesticide applicators are included in this analysis; 26,510 applicators (53%) reported use of alachlor on the enrollment questionnaire. Detailed pesticide exposure and other information were obtained from a self-administered questionnaire completed at the time of enrollment (1993-1997). Poisson regression analysis was used to evaluate the exposure-response relations between alachlor and cancer incidence controlled for the effects of potential confounding factors. A total of 1,466 incident malignant neoplasms were diagnosed during the study period, 1993-2000. Among alachlor-exposed applicators, the authors found a significant increasing trend for incidence of all lymphohematopoietic cancers associated with lifetime exposure-days (p for trend = 0.02) and intensity-weighted exposure-days (p for trend = 0.03) to alachlor. The risks of leukemia (rate ratio = 2.83, 95% confidence interval: 0.74, 10.9) and multiple myeloma (rate ratio = 5.66, 95% confidence interval: 0.70, 45.7) were increased among applicators in the highest alachlor exposure category. Our findings suggest a possible association between alachlor application and incidence of lymphohematopoietic cancers among applicators in the Agricultural Health Study.

Acetamides↗

PubMed1992

Serum 2,3,7,8-tetrachlorodibenzo-p-dioxin levels of New Zealand pesticide applicators and their implication for cancer hypotheses.

BACKGROUND: The phenoxyherbicide 2,4,5-trichlorophenoxyacetic acid (2,4,5-T) has been widely used by professional pesticide applicators in New Zealand since before 1950. Epidemiologic studies of the risk of cancer and birth defects have been conducted in this group of workers, but little is known about the extent of their exposure to the 2,4,5-T contaminant 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), a potent carcinogen in animals. PURPOSE: The objective of this study was to determine whether the blood serum levels of TCDD in a group of professional 2,4,5-T applicators in New Zealand were greater than those of a matched control group not involved in 2,4,5-T spraying. METHODS: Of 548 men employed as professional pesticide applicators in New Zealand from 1979 through 1982, nine were selected who had sprayed pesticides, although not necessarily 2,4,5-T, for at least 180 months. These applicators had sprayed 2,4,5-T for a range of 83-372 months. We measured the blood serum levels of polychlorinated dibenzo-p-dioxins and dibenzofurans, which were substituted with chlorine at the 2,3,7,8 position, in the nine pesticide applicators and in a matched group of nine control subjects. RESULTS: The average serum level of TCDD for applicators was almost 10 times that for the matched control subjects, while the average levels of all other congeners and isomers measured in the two groups did not differ substantially. TCDD levels in eight of the nine applicators were higher than those in the control subjects (mean difference, 47.7 parts per trilion). The variation in TCDD levels among the applicators was related to their duration of work exposure to 2,4,5-T. CONCLUSIONS: On the basis of our findings in these subjects in New Zealand, we conclude that increased risks of cancer from brief exposure to phenoxyherbicides reported in other countries are probably not attributable to the TCDD that contaminates 2,4,5-T. We cannot determine from these results, however, whether TCDD exposure from prolonged use of 2,4,5-T poses significant health risks.

Humans↗

PubMed1998

Broiler skin color as affected by organic acids: influence of concentration and method of application.

Color of broiler skin was evaluated after exposure to organic acids under various concentrations and simulated potential plant application conditions. Breast skin from chilled broiler carcasses was treated with acetic (AA), citric (CA), lactic (LA), malic (ML), mandelic (MN), propionic (PA), or tartaric (TA) acids at 0.5, 1, 2, 4, and 6% concentrations. Each acid and concentration was applied in simulated dip (23 C for 15 s), scalder (50 C for 2 min), and immersion chiller (1 C for 60 min) conditions. A tap water control was included with each application method. Objective color values of L* (lightness), a* (redness), and b* (yellowness) were measured before and after the treatments to calculate color differentials under a factorial arrangement of organic acids and concentrations. Skin lightness increased (P < 0.01) in simulated chiller as compared to dip and scalder applications. Skin redness was reduced significantly in scalder, and yellowness in dip and scalder applications, respectively. In simulated dip application, with the exception of PA, all acids decreased lightness and increased redness and yellowness values. Propionic acid had little affect on lightness and redness values, but decreased yellowness values. In simulated scalder application, with the exception of PA, all acids decreased lightness with increasing concentration. The redness values changed little in scalder application. However, yellowness values were increased with all acids, except for PA, which decreased yellowness values. In simulated chiller conditions, all acids, except for PA, decreased lightness and redness and increased yellowness values. Propionic acid increased lightness and decreased yellowness values significantly in chiller conditions. Alterations in skin color should be taken into account in the selection and application of organic acids as carcass disinfectants.

Acetic Acid↗

PubMed1977

Study of U.S. medical school applicants, 1975-76.

This annual descriptive study provides statistics on the demographic and background characteristics, academic ability, and career plans of applicants to the 1975--76 first-year class. Comparisons with the preceding year's applicant pool, traditionally the focus of the applicant study series, show a slight decline in the size of the pool, a continued increase in the number of women applicants and acceptees, and a slightly higher acceptance rate for all applicants. The study has been expanded by reinstating data on the socioeconomic background of applicants and by providing general summaries on topics such as career plan preferences of applicants. New to the series is an analysis of "in-phase" applicants, that is, undergraduate college seniors applying to medical school for the first time. The conclusion outlines those activities of the Association of American Medical Colleges over the past year that are related to the medical school admissions process.

Adult↗

PubMed1993

A descriptive analysis of medical school application forms.

A detailed analysis was conducted of the application forms for the 1992-93 and 1993-94 entering classes at all 126 U.S. medical schools, with the expectation that knowledge of the types of information that admission committees and their institutions solicit through these materials would help to illuminate the little-understood nature of the medical school admission process. Although application forms are only one component of the admission process, these documents are key sources of information about the character and/or mission of individual medical schools as well as about prospective students. The analyses began with a detailed inventory of the information requested by the American Medical College Application Service (AMCAS) form. Then each medical school was grouped by the type of application form(s) it used, and an analysis was conducted of the application forms of schools that used their own primary (i.e., non-AMCAS) forms or combinations of the AMCAS form and their own supplemental forms. Finally, some of the additional types of biographical and behavioral information that schools sought through their own forms were examined and clustered. The analyses provided a detailed picture of the various application forms that medical schools use in their application processes and the ways in which those forms are used, either singularly or together, to obtain information from applicants. Another major finding concerned variations among schools in the use of questions requiring in-depth responses.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation Studies as Topic↗

PubMed1995

The decline and rise of the medical school applicant pool.

The authors characterize the demographic changes that transpired with the decline and rise of the medical school applicant pool over the past decade, and describe the variations in academic antecedents, attrition, and graduation rates of students matriculated during that time. Data over the ten-year cycle, derived from the AAMC's Student and Applicant Information Management System (SAIMS), were examined in the context of published education and employment statistics. The contraction and expansion of the applicant pool were related to changes in the number and pattern of undergraduate majors and to changes in the employment conditions for college-educated youth. Furthermore, a significant part of the variations in size of the applicant pool is an artifact of changes in the number of repeat applications. Matriculants' pre-medical grades and MCAT scores dropped slightly during the period of applicant decline, and rebounded as admission committees were able to exercise greater selection when the pool expanded. The attrition of medical students rose and fell during this time, but the changes were small and of little discrete influence on graduation rates during the period. The downturn and rebound in applications over the past decade appear to be more related to cycles in the employment market for college graduates than to applicants' perceptions of unfavorable/favorable conditions in medical education and practice.

College Admission Test↗