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Bacteria has been known to grow in pipes of water distribution systems and bottled drinking water. Its growth in reusable drinking water bottles is not clear even though they have become more popular and used by children and adults daily everywhere. This study found that there is an extremely high level of bacteria content and a rapid microbial growth in reusable drinking water bottles. The bacteria content tested by heterotrophic plate count (HPC) is in a range of 0-2.4x105 CFU/mL with an average of about 34,000 bacteria counts/ml for bottles used by children and 75,000 bacteria counts/ml for bottles used by adults. Bacteria number can quickly increases to 1-2 million counts/ml in the bottles one day later. Considering the high level of HPC bacteria content in the reusable drinking water bottles, it may be necessary to have some control measures to reduce the bacteria level and to minimize the associated likely health risk of the disease spreading since many people use reusable water bottles every day. 

The paper presents and develops the issue of Cumulative Effect Assessment (CEA) in the Environmental Impact Assessment (EIA) screening procedure established by the State and Regional regulations In Italy. In the period 2001-15 in the territory of the Venice province (north east Italy, Veneto region) n. 328 projects (and the related environmental preliminary/definitive studies) were applied to competent Authorities (6% to the State, 39% to the Region and 55% to the Province). All the Environmental Impact Studies (EISs) and Environmental Preliminary Studies (EPSs) referring to the this territory officially applied to competent Authorities in the period 2001-2010, have been analysed with focus on the identification and assessment of cumulative effects (CEs); the projects considered and analysed for this purpose comprise a total of n. 181 EIA screening and ordinary procedures; the remaining 147 projects in the period 2011-15 (for a total of 328) are here considered only for statistical reason to an update assessment of project typologies in the same territory. The methodology applied for the analysis of the sample of environmental studies in the period 2001-10 refers to that presented by Cooper and Sheate (2002) with modifications. The investigation has been developed looking for the way in which the topic is performed by practitioners in the environmental studies as from qualitative as well as quantitative point of view. Specific attention has been paid to waste management plants which are always subject to EIA screening procedure since 2008 according to Directive 97/11/EEC and in case to the whole EIA procedure. The approach proposed by Lombardia Region (North Italy; 2010) for EIA screening procedure of waste management plants has been applied to identify CEs and modified according to the characteristics of the considered territory; it allows the performance of the project-based approach and must be completed with a regional-based approach (Dubè, 2003). The proposed approach can be useful in case of waste management and IPPC (Integrated Pollution Prevention and Control, Directive 96/61/EEC, amended with Directives 2008/1/EC and 2010/75/EU) plants to define the financial warranties required for the authorization of operative activity of the plants to cover potential environmental damages produced in cases of accidents and other conditions as required in Europe (art. 14 Directive 2004/35/EC on environmental liability). Several project categories were chosen and their EISs analysed as an exemplificative case according to the potential generation of cumulative impacts and the characteristics of the territory. With reference to the completed procedures where the competent Authority presented a final judgement, it has been observed that the CEA has been seldom developed due to not compulsory legal requirements as already observed by Burris and Canter (1997). Moreover, when it is considered, the methodology is limited and not systemized. Indices of impact have been identified according to emission for the main environmental components focussed with the analysis of the pressure factors of the plants. The study points out the need to analyse and evaluate the cumulative effects (CEs) at a strategic level (within the Strategic Environmental Assessment-SEA- procedure) with a view to preparing the study for EIA/EPS framework procedure for the projects derived from the corresponding plan/program. A sound knowledge of the considered territory and in particular of its pressure sources is of main importance for CEA assessment and impacts’ prevention. Geographic Information Sytesm (GIS) application is strongly needed for pressure sources’ census and control data storing

This study investigated the effect of Portland cement on stabilization of heavy metal contaminated clayey soils that may give range of geo environemntal benefits. The absolute concentration of heavy metals: Lead (Pb), Zinc (Zn), Chromium (Cr), Cadmium (Cd) and Copper (Cu) were measured using an inductively coupled plasma atomic emission spectroscopy (ICP-AES). A series of laboratory scale experiments such as unconfined compression test (UCT), pH test and synthetic precipitation leaching procedure (SPLP) were performed to study the effects of curing time and cement content on the unconfined compressive strength (UCS) and leaching characteristics of heavy metals. According to results, excessive concentration of heavy metals are present in the topsoil of Shanghai Jiao Tong University (SJTU) among which Pb, Zn and Cd were most prominent. Other test results showed that the dry density of both C4 and C8 soil samples increases with curing time. Similarly the compressive strength (qu)of C4 and C8 samples at 21 d of curing increases by 40% (113 kPa-288 kPa) and 15% (745kPa-864 kPa) respectively, as compared to the 7 d of curing. Besides, the test results showed a prominent decrease in the leached concentration of heavy metals with increasing curing time.

Annually the list of pesticides is replenished by new ones. One of the main criteria for their registration is toxicological and hygienic assessment and its impact on the environment. In order to register the new soy herbicide Damu - Safen, EC (fomesafen, 250 g/l) it was necessary to assess its toxicological and hygienic impact on the environment and humans. Therefore, for the first time we conducted studies of the environmental objects under the influence of Damu-Safen, EC (fomesafen, 250 g/l) and the risk assessment of the active substance fomesafen and pesticide Damu - Safen, EC on the workers. According to the results of the assessment of working conditions for the workers of the tanker and the tractor operator, an acceptable risk was obtained that meets regulatory and hygienic requirements. Residual amounts of fomesafen not exceeding the normative levels were found during conducted studies on environmental objects. Consequently, the results of the risk assessment in the application of pesticide Damu-Safen, EC (fomesafen, 250 g/l) and its impact on the working people and environmental objects indicate the possibility of its application in compliance with optimal environmental conditions and compliance with regulations for appliances and personal protective equipment.

Background: Early and effective identification of childhood neurodevelopmental disorders remains a critical task of all pediatric healthcare professionals, which is critical to the well-being of children and their families. Methods: A retrospective review of medical records of all preschool children referred to a Child Development Centre (CDC) in North-West England, over a six-month period between Sept 2014 and Feb 2015 was conducted. The local multi-professional approach to the clinical assessment and management of preschool children was described and the published literature on this topic was reviewed. Results: Twenty four different categories of professionals spanning the whole range of primary, secondary, and tertiary healthcare, social care and educational services were involved in the management of the patients. The largest group of professionals was the primary healthcare specialists. The ten different primary care professionals managed an average of 42% of the patients. The secondary healthcare providers were involved in the care of an average of 17%, tertiary care providers 10%, educational specialists 25% and social care professionals were involved with 5% of all the patients. The commonest diagnostic disorders were Speech/Language delay (56%), Global developmental delay (33%), Behavior difficulties (26%), Social communication concerns (21%) and Autistic spectrum disorder (19%). Conclusion: The high number and specialties of various healthcare professionals at all levels of care indicates the high social and economic investment required in managing the affected preschool children in the region. Childhood neurodevelopmental disorders in the preschool age represents a high level of public health significance.

For over twenty years, following the creation of space stations, MIR first and then the ISS (International Space Station) men (3 to 6) live and succeed each other continuously about 300 - 400 km of altitude to make scientific experiments. For this reason sending men into space has become an activity “almost banal or regular “but this remains potentially a very dangerous environment for the adapted manon Earth and thus requires medical monitoring to ensure the health of astronauts and the persistence of their ability during their mission. In general, the medical benefits on Earth of space conquest go far beyond envy and the need for man to discover the cosmos but to develop many tools medicines to also offer solutions for all living beings on Earth!

Aims and objectives: By reporting the use of therapeutic nursing interventions to facilitate the process of change in a depressive elderly caregiver, this paper seeks to underline the importance of fitting interventions to individual clients. Background: In assisting families of chronic illness sufferers, it must be remembered that the perceptions and functions of both clients and families are determined by family members, and that changes, if any, are made by those clients and families, rather than by nurses. However, nurses do play an important role in facilitating the process of change. Design: This is a case report. Methods: A case study of a depressive elderly caregiver is used to examine the use of therapeutic nursing interventions to facilitate the process of change with problem analysis, case conceptualisation and specific skills employed documented. Results: The change from one therapeutic approach (Cognitive-behavioural therapy) to another (Narrative Therapy) facilitates enlisting the caregiver’s unique strengths, resources and competence to overcome the difficulties and challenges identified during the process of change. In dealing with depression in family caregivers, nurses should not only be flexible but also remain sceptical in using different approaches, with heightened awareness of the client’s circumstances.

Lemongrass is a culinary herb with a lemony aroma.it is mostly cultivated in Southeast Asia, Sri Lanka, Indonesia and India. It is conventionally used for relieving anxiety, stress and pain. Because of the presence of limonene and citral, lemongrass extracts exhibits antimicrobial, antidandruff and anti-inflammatory effects. However Tea tree extracts are mostly employed in the treatment of dermal, inflammatory and microbial infections.

The discipline of Hassidic Philosophy, which emanates from a particular movement in Orthodox Judaism called Hassidism, begins with the premise that all of creation is a dichotomous world of opposites with both sides in a perpetual conflict with one another. The human construct is therefore a dichotomous spiritual entity manifested in the physical world through a mind-body. One side of this soul is the Godly intellect giving rise to the human identity or self-awareness and the other side is the animal soul whose purpose is to galvanize the body. Having learned that this discipline provides its followers with tools for behavioral transformation through inner conflict resolution, I find that it offers a clearer understanding of the spiritual component of holistic health and nursing theory as well as a tool for behavioral transformation that has practical application in nursing practice. Therefore, the purpose of this paper is to present the basic constructs of Hassidism as it pertains to human behavior, demonstrate its compatibility with existing nursing theory and offer a new methodology for advanced practice nurses (APN’s) to assist their clients in achieving behavioral transformation through inner conflict resolution.

Aim: With the continuing trend in the incidence of diabetic ulcer, the current researches on wound care and healing will bring best and effective practices on wound care and healing among patients suffering from diabetes mellitus. Methods: This study utilized a systematic review of literatures in light of wound care through Pub Med database with the key words “Diabetes Mellitus,” “wound practices,” “wound healing,” and “systematic review.” The searched literatures were of case reports, interventional studies, and review papers whose main texts were in English. Results: There were 7,988 published articles yielded from the keywords used and 16 were included in this study. The practiced management and techniques in these literatures focused on comfortable and cost efficient means of wound care and healing with the involvement of group participation than individual plan of care. Conclusions: There are meager evidences of feasible wound and healing options that needs further studies in resolving wound issues among patients with Diabetes Mellitus. This systematic review establishes the insufficiency of high level of evidence based studies on wound healing in DM patients and brings a track for continuity of rigid studies concerning this topic.

The main purpose of this investigation is to inspect the innovative conception of the magneto hydrodynamic (MHD) nanoparticles of single wall carbon nanotubes base on the fluids (water, engine oil, and ethylene, glycol and kerosene oil) between two rotating parallel plates. Carbon nanotubes (CNTs) parade sole assets due to their rare structure. Such structure has significant optical and electronics features, wonderful strength and elasticity, and high thermal and chemical permanence. The heat exchange phenomena is deliberated subject to thermal radiation. Kerosene oil is taken as based nano fluids because of its unique attention due to their advanced thermal conductivities, exclusive features, and applications. The fluid flow is presumed in steady state. With the help of suitable resemblance variables, the fundamental leading equations have been converted to a set of differential equations. To obtain the solution of the modeled problem, the homotopic approach has been used. The influence of imbedded physical variables upon the velocities and temperature profiles are defined and deliberated through graphs. Moreover, for the several values of relevant variables, the skin fraction coefficient and local Nusselt number are tabulated. Plots have been presented in order to examine how the velocities and temperature profile get affected by various flow parameters.

Background: NSU is generally caused by right cerebral hemisphere lesions with a preeminent localization on the frontoparietal lobe. Aim: To assess the correlation between the typology and the brain lesion site and the consensual consent modality of body image modification after an integrated rehabilitative and neuropsychological treatment. Setting: A rehabilitation institute for the treatment of neurological gait disorders and neuropsichological failures. methods: Patients recruited were divided according to the brain lesion site into 3 groups (IG = ischemic group = 5 patients; HG = hemorrhagic group = 4 patients; IG + HG = ischemic + hemorrhagic group = 3 patients) based on CT brain performed in the post-acute phase. At time T0, the patients recruited underwent a systematic review of their current neuroradiological profile (location delineation and type of brain injury) compared with a consensual framing of the neuromotor and neuropsychological profile acquired at the time of taking charge in the ward. At time T1 and after the drafting and implementation of the rehabilitation treatment plan foreseen in the study (1 to 4 months after T0), the patients in our sample underwent a re-evaluation of their neuromotor and neuropsychological profile with controls of the same outcome parameters considered at time T0. Results: A parametrically but not statistically significant modification of the results obtained was observed by measuring the MI ULl, MI LLl and TCT scales in the group with hemorrhagic brain injury; the analysis of variance did not show any statistical significance in the relationship between the type of stroke (ischemic, hemorrhagic or both) and the motor impairment passing from time T0 to time T1. The analysis of variance did not reveal a statistically or parametrically significant relationship between the type (ischemic, hemorrhagic and ischemic + hemorrhagic) of cerebral stroke and the variations of the neuropsychological profile. The T-Student test showed statistically significant changes in the importance of the lesion site in defining the degree of motor disability. In particular, we observed, about the presence of frontal lobe lesions, a statistically significant variation passing from the T0 time to the T1 time for the following motor scales in 9 of 12 recruited patients: MI LLl (26.4 vs. 62, with p < 0.05), TCT (43.6 vs. 80.6, with p < 0.01 for equal variance assumed and p < 0.05 for equal variance not assumed), FAC (0.8 vs. 2.3 with p < 0,01 for equal variance assumed and p < 0.05 for equal variance not assumed). Conclusion: We have confirmed the importance of the anatomical-dysfunctional correlation as a key concept from which to start in any neurorehabilitative treatment approach. Our work has highlighted the basic role of the right frontal lobe in the programming and execution of the gesture and its kinesthetic control as regards the left lower limb and the trunk.

Graphical abstract Biodegradation of implanted gold in human tissue. TEM images reveal markedly biodegradation of implanted gold and re-crystallization of dissolved gold as nanoparticle of different size, shape and crystallinity. Highly crystalline icosahedral Au nanoparticle and the corresponding power spectrum are shown on top. Background: Despite the importance of biodegradation for the durability of metal prosthesis and the widely use of gold implants, there exist a lack of knowledge regarding the stability of pure gold in tissue. Methods: We studied biodegradation of grids of pure gold, nickel, and copper as well as middle ear prosthesis of gold, platinum or titanium. Metals were implanted into rat skin and humans. Dissolution and re-crystallization process of the metals was analysed using SEM, TEM, power spectra as well as elemental analysis by EDX and EELS/ESI. Results: Biodegradation of gold was detected, presumably by solving and re-precipitation of gold around implants. Gold cluster, nanoparticles, and mesostructures were detected, formed by dissolution and re-crystallization process. This process results into a migration of gold into the farer off tissue. Cellular filaments as biomolecular templates facilitate the formation of mesostructures. Loss of function of middle ear prosthesis by biodegradation is caused by chronic inflammation and fibrosis. Indeed, similar processes were detected with platinum, but in a very lower level. Conclusion: Noble metal implants undergo biodegradation in oxidative environment in tissue. The dissolution – recrystallization process can be explained by enzyme catalysed redox processes comprising reactive oxygen species and reduction agents as ascorbic acid present in cells and body tissue. Enymes like myeloperoxidase inside lysosomes of inflammatory cells produce hypochloride ions and H2O2 which can dissolve the gold. General significance: The crucial role of the specific chemical environments of gold implants in tissue for their chemical stability and durability of function has been demonstrated. Due to widely use and importance of gold implants, this finding is of general interes.

Background: In health care systems nursing care documentation is a vital and powerful tool that ensures continuity of care and communication between health personnel for better patient outcomes. Knowledge, attitude and practice of nurses’ towards nursing care documentation affect the quality and coordination of patients’ care. Hence, this study aimed to assess knowledge, attitude, practice and associated factors towards nursing care documentation among nurses in West Gojjam Zone public hospitals, Amhara Ethiopia. Method: Institutional based cross sectional study was conducted among 246 nurses in West Gojjam Zone public hospitals from February to March 8, 2018. The study participants were selected by simple random sampling technique. Data were collected by using pre-tested and validated self-administered structured questionnaire with internal reliability of Cronbach’s Alpha values 0.912, 0.784 and 0.713 for knowledge, attitude and practice questions respectively. Epi data version 3.1 and SPSS version 20 was used for data entry and analysis respectively. Descriptive statistics and binary logistic regression model were used. Result: The overall response rate was 97.56%. Among 240 respondents 54.6% of them had good knowledge, 50% of study participants had favorable attitude and 47.5% of study participants had good nursing care documentation practice. Sex and monthly salary were found to be statistically significant with knowledge of nurses. Work setting, work experiences and knowledge of nurses had significant association with nurses’ attitude towards nursing care documentation. Availability of operational standards, knowledge and attitude of nurses had significant association with nursing care documentation practice. Conclusions and Recommendation: Results of this study showed that knowledge, attitude and practice of West Gojjam zone public hospital nurses on nursing care documentation were poor. Therefore; in order to solve this problem each hospital should recruit nurses until hospitals are saturated enough. It is recommended to avail nursing care documentation standards/guidelines in each hospital and to give training about it and also it is recommended to conduct multisite studies especially qualitative type to increase its quality.

Physicists are generally trained in the Standard Model of Physics (SMP). This implies that they perceive and account for only 3 dimensions of space in a moment in time (3S-1t) (a 4-dimensional [4D] model). However, applying the SMP, more than fifty significant conundrums have arisen that are unexplained or incomplete. Explaining these within the SMP 4D fabric led to hypothesizing a ‘fifth force’, most recently the hypothetical ‘X17 particle’. We propose this hypothetical X17 may better be explained by a 9-dimensional model (9D) with gimmel. Our model, the Neppe-Close Triadic Dimensional Vortical Paradigm (TDVP) has amplified the ‘physics’ from 4 dimensions to 9D, specifically first postulating and then further demonstrating mathematically—starting with derivations of the Cabibbo angle—that 9 dimensions must exist. Moreover, this data is empirically demonstrated because the neutron, proton and electron mass-energy-gimmel equivalence in the Triadic Rotational Units of Equivalence (TRUE) as part of the TDVP model, exactly corresponds with the normalized data for the mass-energy equivalence volumetric data for these particles in the CERN Large Hadron Collider. This data shows definitively that we exist in a 9-dimensional finite, quantized, volumetric, spinning reality. This is, furthermore, embedded in an infinite continuity (9D+). Mathematically, applying this 9D+ model definitively requires an extra third component that is massless and energyless (‘gimmel’). Without gimmel, no particle in the universe would be stable. TDVP unifies nature because the same laws apply across the quantum, macro-world and cosmological reality. Our 4D experience is simply the physical component of 9D+ existence. Summary Amplification: At all levels, there is the consistent application of a 9-Dimensional quantized finite reality embedded within an infinite continuity. The application of gimmel specifically requires applying the 9-dimensional model and is based on necessary mathematical calculations not only at the quantal level (where the fifty plus unsolved, unexplained or contradictory conundrums can be explained somewhat, and there is no longer ‘quantum weirdness’), but at the macroscale level with more gimmel in the life elements (which, additionally, are consistently all cubic multiples of 108 cubed), as well as cosmologically, where the correlations with proportionate Dark Matter and Dark Energy are overwhelming. Moreover, these 9-dimensional plus factors together with Triadic Rotational Units of Equivalence (TRUE) and gimmel, allow numerous solutions that couldn’t otherwise be solved. For example, importantly, applying the simple mathematics of TRUE, we can demonstrate why gluons, while adequate in 4D, are impossible applying 9D. These solutions are simpler because we have markedly adapted George Spencer-Brown’s ‘Laws of Form’ to applying a new method of mathematical calculation, Edward Close’s ‘Calculus of Distinctions’ (COD) which recognizes quantal limits and that the nature of finite reality is quantized and volumetric. The COD includes distinguishing between content, extent, and impact. We emphasize the pioneering works of Wolfgang Pauli with his multidimensional model and his ‘Pauli Exclusion Principle’, Alfred Whitehead with ‘Process Philosophy’ and his ‘Principia Mathematica’ (with Bertrand Russell), Georg Cantor with Set Theory, and Roger Penrose with spinors and twistors. TDVP is a prime example of our broad new specialty of ‘Dimensional Biopsychophysics’ (DBP). DBP extends physics, consciousness, and the biopsychosocial to extra dimensions and applies mathematics empirically. Like Max Tegmark, we recognize the key role of mathematics as fundamental in nature, not just for application in calculation and operations.

The Federal and State governments have declared the presence of an opioid addiction pandemic in the United States claiming the lives of more than 55,000 in 2015 (Rudd RA, Seth P, David F and Scholl L. 2016). The pharmaceutical manufacturers of the numerous FDA-approved opioid drugs are raking in more than $5 billion per year with about 2 million chronic pain sufferers addicted. The irony of this narcotic use and abuse conundrum is the existence of evidence-based technology for drug-free pain management which is not covered for reimbursement among public and private third-party payers. Therefore, this paper is presented to propose a pilot study to demonstrate the efficacy of resolving the chronic inflammation, edema and ischemia that causes non-malignant chronic pain with PEMF therapy, a non-invasive, non-thermal radio transmission of electrical impulses, thereby invalidating the legitimacy of prescribing opioid analgesics in such cases.

Circular Economy, Sustainability, Design for Environment are some of the keywords that identify new formidable challenges to be faced in the next years. Raw materials have a dominant role in reaching that goal. Green energy, electric vehicles, communication, etc. depends on raw materials labeled as critical because of their economic importance coupled with high supply risk. For this reason, mitigating actions need to be used in materials selection and design such as material substitution, improved materials efficiency and recycling. In this technical communication, a method to implement raw materials criticality issues in materials selection is described according to the recent literature. The strategy is based on Ashby’s approach and the definition of the alloy criticality index quantifying the criticality per unit of mass of the material.

Healthcare is realizing the importance of health information technology - its applications and devices in play today. Advancing healthcare best practices will rely on up to date data and analysis to provide the most effective forms of therapy. Healthcare is becoming more reliant on patients who are engaging in their own healthcare. With this we are seeing an increase in available health related apps for these devices. This summary reviews various connected health strategies using proven apps and devices to improving the quality of care, promoting patient engagement, and improving outcomes. Here we discuss several trends and the healthcare delivery implications.

The Uranium extraction and processing plant of INB (Brazilian Nuclear Industries) is in Caetité, a city located in a region hosting the largest Uranium reserve of the country. The degree of Uranium contamination in the Caetité population was investigated before using teeth as bioindicator, where a quite high Uranium concentration was measured in this region, about 160 times higher than the world-wide average. Radiobiological risks are here evaluated from Uranium burdens in organs as skeleton, kidneys, liver, tissues and blood, which were estimated from transfer coefficients and effective internal doses. This was accomplished by means of calculations with the use of the STATFLUX/ICRP approach, plus a set of Uranium transfer rate parameters as function of individual’s age assuming an uninterrupted exposure over a period of 60 years. It was found that U ingestion rates by residents of Caetité are three orders of magnitude higher than worldwide average, indicating that food and water would exhibit high levels of contamination. Calculated effective internal doses range from a minimum of one to a maximum of three orders of magnitude higher than background doses, for blood and bones respectively. The likelihood that this circumstance could lead to serious health problems as e.g. neoplasia is addressed. The methodology presented in this work offers subsidies for further studies on environmental pollution by radionuclides.

Introduction: A patient satisfaction is considered as one of the desire outcomes of health care and it is directly related with utilization of health services. However, its level is falls at the fundamental level in developing countries including Ethiopia. Objective: To assess the level of patients’ satisfaction and its associated factors at Dessie Referral Hospital, Northeast Ethiopia Methods and Materials: An institutional based cross-sectional study design was employed from May 1 to June 1 2019. A total of 374 patients were selected by using systematic sampling technique and interviewer administer structured questionnaire was used to collect data. After data collection, the data were checked for its completeness and entered into Epi data version 3.1. The data were presented in frequency distribution tables and graphs. Both bivariable and multivariable logistic regression were applied to identify factors at a p < 0.05. Result: Among total study participants, 220 (58.8%) patients were satisfied with nursing care service. Patients who had particular nurse for nursing care were more likely satisfied than those who didn’t have particular nurse for nursing care (AOR = 2.01, 95% CI: 1.212 - 3.334). Patients who had other diseases in addition to current health problem were more likely satisfied (AOR = 0.45 & 95% CI: 0.196 - 1.031) compared with patients who had not. Conclusion: In this finding, the level of patients’ satisfaction towards nursing care was low. Having specific or particular nurse and presence of comorbid disease were factors associated with patients’ satisfaction towards nursing care. Health institutions should assign particular nurses for patients to improve their satisfaction and quality of care. In addition, nurses should give great attention to their patients who have co-morbid illnesses.