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Gender and racial disparities exist after left ventricular assist device (LVAD) implantation. Compared with older devices, the HeartMate 3 (HM3) (Abbott Cardiovascular) has demonstrated improved survival. Whether HM3 differentially improves outcomes by gender or race and ethnic groups is unknown.

IMPORTANCE: Advance care planning (ACP) remains low among patients with advanced cancer. Multilevel interventions compared with clinician-level interventions may be more effective in improving ACP. OBJECTIVE: To evaluate whether a multilevel intervention could improve clinician-documented ACP compared with a clinician-level intervention alone. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial, performed from September 12, 2019, through May 12, 2021, included adults with advanced genitourinary cancers at an academic, tertiary hospital. Data analysis was performed by intention to treat from May 1 to August 10, 2023. INTERVENTION: Participants were randomized 1:1 to a 6-month patient-level lay health worker structured ACP education along with a clinician-level intervention composed of 3-hour ACP training and integration of a structured electronic health record documentation template (intervention group) or to the clinician-level intervention alone (control group). MAIN OUTCOME AND MEASURES: The primary outcome was ACP documentation in the electronic health record by the oncology clinician within 12 months after randomization. Secondary, exploratory outcomes included shared decision-making, palliative care use, hospice use, emergency department visits, and hospitalizations within 12 months after randomization. RESULTS: Among 402 participants enrolled in the study, median age was 71 years (range, 21-102 years); 361 (89.8%) identified as male. More intervention group participants had oncology clinician–documented ACP than control group participants (82 [37.8%] vs 40 [21.6%]; odds ratio [OR], 2.29; 95% CI, 1.44-3.64). At 12-month follow-up, more intervention than control group participants had palliative care (72 [33.2%] vs 25 [13.5%]; OR, 3.18; 95% CI, 1.91-5.28) and hospice use (49 [22.6%] vs 19 [10.3%]; OR, 2.54; 95% CI, 1.44-4.51). There were no differences in the proportion of participants between groups with an emergency department visit (65 [30.0%] vs 61 [33.0%]; OR, 0.87; 95% CI, 0.57-1.33) or hospitalization (89 [41.0%] vs 85 [46.0%]; OR, 0.82; 95% CI, 0.55-1.22). Intervention group participants had fewer hospitalizations than control group participants (mean [SD] number of hospitalizations per year, 0.87 [1.60] vs 1.04 [1.77]) and a lower risk of hospitalization (incidence rate ratio, 0.80; 95% CI, 0.65-0.98). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, a multilevel intervention improved oncology clinician–documented ACP compared with a clinician-level intervention alone for patients with genitourinary cancer. The intervention is one approach to effectively increase ACP among patients with cancer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03856463

The Information Centric Networking (ICN) is a future internet architecture to support efficient content distribution in a vehicular environment. In-network caching in ICN provides a realistic solution for vehicular communication due to storage of content replicas inside network vehicles. However, the challenge still exists while caching content replicas in resource constraint vehicles (such as limited power and cache capacity) to minimize the communication latency. To address the above mentioned challenge, this paper proposes EPC - an ICN based Energy efficient Placement of Content chunk that fits well in a vehicular environment. The proposed resource management strategy mainly aims to reduce the content fetching delay by caching content replicas towards the network edge router. The EPC strategy decides on placement of content chunks on each vehicle by jointly considering residual power of current vehicle, local popularity of content, and caching gain. The EPC supports efficient utilization of network available resources by allowing only vehicles with their residual power greater than threshold to perform chunk caching and hence, further offers reduced content duplication in the whole network. The effectiveness of the proposed scheme is evaluated in Icarus- an ICN simulator for analyzing the performance of ICN caching and routing strategies. The EPC outperforms various state of the art caching strategies approximately by 30% when gets evaluated in terms of offered cache hit ratio, content retrieval delay, and the average number of hops utilized for fetching the requested content.

AbstractThe β-lactam antibiotics are the most effective medicines for treating bacterial infections. Resistance to them, particularly through the production of β-lactamases, which can hydrolyse all kinds of β-lactams, poses a threat to their continued use. The synthesised flavone and coumarin based isoxazole derivatives have the potential to be used as broad-spectrum inhibitors of the mechanistically different serine-(SBL) and metallo-β-lactamases (MBL). The synthesised compounds were discovered as potent β-lactamase inhibitors using molecular docking and in silicopharmacokinetic analysis. We studied the binding of chemically synthesised inhibitors to clinically significant β-lactamases of class A, B, and C using biophysical and biochemical approaches, and computational analyses. These molecules follow Lipinski’s rule of five and have acceptable solubility, permeability, and oral bioavailability. These molecules were found to be non-toxic and non-carcinogenic. MIC results suggest that these molecules restore the antibiotic efficacy against class A, B, and C β-lactamases. Kinetics data showed that these molecules reduce the catalytic efficiency of clinically relevant class A, B, and C β-lactamases. Fluorescence study showed significant interaction between these flavone-/coumarin-based isoxazole derivatives and class A/B/ C β-lactamases. This study showed promising effect of these new generation compounds as broad spectrum β-lactamase inhibitors of both SBLs and MBLs.Communicated by Ramaswamy H. Sarma

Introduction: We evaluated real-world outcomes in patients with advanced ovarian cancer (AOC) based on their cumulative risk profile and maintenance therapy (MT) status following first-line (1L) treatment. Methods: This retrospective observational study of a nationwide electronic health record-derived de-identified database included adult patients diagnosed with stage III/IV OC from January 1, 2011 to February 28, 2021, who received 1L therapy and had ≥ 12 weeks of follow-up after the index date (end of 1L therapy). Patients were grouped according to whether they received MT or active surveillance (AS) following 1L treatment and by the cumulative number of risk factors (RF) present (stage IV disease; no surgery/treated with neoadjuvant therapy and interval debulking surgery; had postoperative visible residual disease; and had BRCAwild-type disease/unknown BRCAstatus). Time to next treatment (TTNT) and overall survival (OS) were assessed with a cloning and inverse probability of censoring (IPC)-weighted Kaplan–Meier method. Results: Among 1920 patients, 22.2% received MT and 77.8% received AS. Median IPC-weighted TTNT and OS were 13.3 months (95% CI 11.7–15.8) and 39.1 months (95% CI 32.5–48.6) in the MT cohort, respectively, and 8.6 months (95% CI 8.0–9.5) and 38.4 months (95% CI 36.4–41.0) in the AS cohort, respectively. Almost all patients had ≥ 1 RF (MT 95.3%; AS 96.7%). Median IPC-weighted TTNT was shorter among patients with more RF in both cohorts (MT: 1 RF, 19.3 months, 95% CI 13.5–37.8; 2 RF, 17.2 months, 95% CI 12.8–20.2; 3 RF, 11.0 months, 95% CI 8.2–13.8; 4 RF, 7.0 months, 95% CI 6.2–8.8; AS: 1 RF, 17.7 months, 95% CI 13.5–22.3; 2 RF, 10.2 months, 95% CI 9.1–11.5; 3 RF, 6.5 months, 95% CI 5.8–7.4; 4 RF, 4.1 months, 95% CI 3.5–4.5). Conclusion: Regardless of RF number, MT was associated with longer TTNT in real-world patients with AOC.

As COVID-19 cases begin to decrease in the USA, learning from the pandemic experience will provide insights regarding disparities of care delivery. We sought to determine if specific populations hospitalized with COVID-19 are equally likely to be enrolled in clinical trials. We examined patients hospitalized with COVID-19 at centers participating in the American Heart Association’s COVID-19 CVD Registry. The primary outcome was odds of enrollment in a clinical trial, according to sex, race, and ethnicity. Among 14,397 adults hospitalized with COVID-19, 9.5% (n= 1,377) were enrolled in a clinical trial. The proportion of enrolled patients was the lowest for Black patients (8%); in multivariable analysis, female and Black patients were less likely to be enrolled in a clinical trial related to COVID-19 compared to men and other racial groups, respectively. Determination of specific reasons for the disparities in trial participation related to COVID-19 in these populations should be further investigated.

Plant ATP-binding cassette (ABC) protein family is the largest multifunctional highly conserved protein superfamily that transports diverse substrates across biological membranes by the hydrolysis of ATP and is also the part of the several other biological processes like cellular detoxification, growth and development, stress biology, and signaling processes. In the agriculturally important legume crop Cajanus cajan, a genome-wide identification and characterization of the ABC gene family was carried out. A total of 159 ABC genes were identified that belong to eight canonical classes CcABCA to CcABCG and CcABCI based on the phylogenetic analysis. The number of genes was highest in CcABCG followed by CcABCC and CcABCB class. A total of 85 CcABC genes were found on 11 chromosomes and 74 were found on scaffold. Tandem duplication was the major driver of CcABC gene family expansion. The dN/dS ratio revealed the purifying selection. The phylogenetic analysis revealed class-specific eight superclades which reflect their functional importance. The largest clade was found to be CcABCG which reflects their functional significance. CcABC proteins were mainly basic in nature and found to be localized in the plasma membrane. The secondary structure prediction revealed the dominance of α-helix. The canonical transmembrane and nucleotide binding domain, signature motif LSSGQ, Walker A, Walker B region, and Q loop were also identified. A class-specific exon-intron pattern was also observed. In addition to core elements, different cis-acting regulatory elements like stress, hormone, and cellular responsive were also identified. Expression profiling of CcABC genes at various developmental stages of different anatomical tissues was performed and it was noticed that CcABCF3, CcABCF4, CcABCF5, CcABCG66, and CcABCI3 had the highest expression. The results of the current study endow us with the further functional analysis of Cajanus ABC in the future.

Introduction: While dealing with the COVID-19-related morbidities and mortalities in general, its adverse impact on non-COVID-19 maternal mortalities was completely forgotten so our aim is to study the adverse consequences of the COVID-19 pandemic on non-COVID-19 hospital births and non-COVID-19 maternal mortalities. Methodology: Retrospective observational study was done in the Department of Obstetrics and Gynecology, Swaroop Rani Hospital, Prayagraj, to compare the non-COVID-19 hospital births, referrals, and non-COVID-19 maternal mortalities during 15 months of pre-pandemic period (March 2018 to May 2019) and 15 months of pandemic period (March 2020 to May 2021 period) and to assess their relation to GRSI using chi-square test, pairedTtest and Pearson’s Correlation Coefficient. Result: The total non-COVID-19 hospital births decreased by 4.32% in pandemic period as compared to pre-pandemic period. Monthly hospital births decreased drastically, to 32.7% during the end of the first pandemic wave and to 60.17% during the second wave. 67% increase in the total referral and a significant decrease in the quality of referral leading to significantly higher non-COVID-19 maternal mortality figures (pvalue 0.00003) during the pandemic period. Leading causes of mortalities were uterine rupture (pvalue 0.00001), septic abortion (pvalue 0.0001), primary postpartum hemorrhage (pvalue 0.002) and preeclampsia (pvalue 0.003). Conclusion: While the world is talking only about COVID deaths, increased non-COVID-19 maternal mortalities during the COVID pandemic need equal attention and call for more stringent government guidelines for the care of non-COVID-19 pregnant women as well during the pandemic period.

Glutathione S-transferases are a multifunctional protein superfamily that is involved in diverse plant functions such as defense mechanisms, signaling, stress response, secondary metabolism, and plant growth and development. Although the banana whole-genome sequence is available, the distribution of GST genes on banana chromosomes, their subcellular localization, gene structure, their evolutionary relation with each other, conserved motifs, and their roles in banana are still unknown. A total of 62 full-length GST genes with the canonical thioredoxin fold have been identified belonging to nine GST classes, namely tau, phi, theta, zeta, lambda, DHAR, EF1G, GHR, and TCHQD. The 62 GST genes were distributed into 11 banana chromosomes. All the MaGSTs were majorly localized in the cytoplasm. Gene architecture showed the conservation of exon numbers in individual GST classes. Multiple Em for Motif Elicitation analyses revealed few class-specific motifs and many motifs were found in all the GST classes. Multiple sequence alignment of banana GST amino acid sequences with rice, Arabidopsis, and soybean sequences revealed the Ser and Cys as conserved catalytic residues. Gene duplication analyses showed the tandem duplication as a driving force for GST gene family expansion in banana. Cis-regulatory element analysis showed the dominance of light-responsive element followed by stress- and hormone-responsive elements. Expression profiling analyses were also done by RNA-seq data. It was observed that MaGSTs are involved in various stages of fruit development. MaGSTU1 was highly upregulated. The comprehensive and organized studies of MaGST gene family provide groundwork for further functional analysis of MaGST genes in banana at molecular level and further for plant breeding approaches.

Low-grade, low-stage endometrioid carcinomas (LGLS EC) demonstrate 5-yr survival rates up to 95%. However, a small subset of these tumors recur, and little is known about prognostic markers or established mutation profiles associated with recurrence. The goal of the current study was to identify the molecular profiles of the primary carcinomas and the genomic differences between primary tumors and subsequent recurrences. Four cases of LGLS EC with recurrence and 8 cases without recurrence were evaluated via whole-exome sequencing. Three of the 4 recurrent tumors were evaluated via Oncomine Comprehensive Assay. The resulting molecular profiles of the primary and recurrent tumors were compared. Two of the 3 recurrent cases showed additional mutations in the recurrence. One recurrent tumor included an additional TP53mutation and the other recurrent tumor showed POLEand DDR2kinase gene mutation. The POLEmutation occurred outside the exonuclease domain. PIK3CAmutations were detected in 4 of 4 primary LGLS EC with recurrence and in 3 of 8 disease-free cases. LGLS EC with recurrence showed higher MSIsensor scores compared with LGLS without recurrence. The level of copy number gains in LGLS EC with recurrence was larger than LGLS EC without recurrence. This pilot study showed 1 of 3 recurrent cases gained a mutation associated with genetic instability (TP53) and 1 of them also acquired a mutation in the DDR2 kinase, a potential therapeutic target. We also noted a higher level of copy number gains, MSIsensor scores and PIK3CAmutations in the primary tumors that later recurred.

The pervasive growth in the variety of consumer electronic devices (CEDs), as well as the Internet traffic, has evolved various security risks toward their usage. This article presents the concept of communications without a centralized server to facilitate the fastest communication between end-devices, e.g., user handheld devices, and edge devices. Three communication scenarios are presented to support authentication in the proposed architecture. To understand the concept, this article first describes the growth in the CEDs market. Afterward, the discussion on various challenges faced for incorporating security in such devices is presented along with edge-based security solutions. Finally, the article presents a use-case of the content delivery network to discuss various security solutions based on the edge with the hope that these solutions will work for future security.

IMPORTANCE: The use of sacubitril/valsartan is not endorsed by practice guidelines for use in patients with New York Heart Association class IV heart failure with a reduced ejection fraction because of limited clinical experience in this population. OBJECTIVE: To compare treatment with sacubitril/valsartan treatment with valsartan in patients with advanced heart failure and a reduced ejection fraction and recent New York Heart Association class IV symptoms. DESIGN, SETTING, AND PARTICIPANTS: A double-blind randomized clinical trial was conducted; a total of 335 patients with advanced heart failure were included. The trial began on March 2, 2017, and was stopped early on March 23, 2020, owing to COVID-19 risk. INTERVENTION: Patients were randomized to receive sacubitril/valsartan (target dose, 200 mg twice daily) or valsartan (target dose, 160 mg twice daily) in addition to recommended therapy. MAIN OUTCOMES AND MEASURES: The area under the curve (AUC) for the ratio of N-terminal pro–brain natriuretic peptide (NT-proBNP) compared with baseline measured through 24 weeks of therapy. RESULTS: Of the 335 patients included in the analysis, 245 were men (73%); mean (SD) age was 59.4 (13.5) years. Seventy-two eligible patients (18%) were not able to tolerate sacubitril/valsartan, 100 mg/d, during the short run-in period, and 49 patients (29%) discontinued sacubitril/valsartan during the 24 weeks of the trial. The median NT-proBNP AUC for the valsartan treatment arm (n = 168) was 1.19 (IQR, 0.91-1.64), whereas the AUC for the sacubitril/valsartan treatment arm (n = 167) was 1.08 (IQR, 0.75-1.60). The estimated ratio of change in the NT-proBNP AUC was 0.95 (95% CI 0.84-1.08; P = .45). Compared with valsartan, treatment with sacubitril/valsartan did not improve the clinical composite of number of days alive, out of hospital, and free from heart failure events. Aside from a statistically significant increase in non–life-threatening hyperkalemia in the sacubitril/valsartan arm (28 [17%] vs 15 [9%]; P = .04), there were no observed safety concerns. CONCLUSIONS AND RELEVANCE: The findings of this trial showed that, in patients with chronic advanced heart failure with a reduced ejection fraction, there was no statistically significant difference between sacubitril/valsartan and valsartan with respect to reducing NT-proBNP levels. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02816736

In this paper, we describe the deformation schemes inspired by Heine and Tsallis in reference of q-deformed physical systems related to the quantum group structures and the statistical mechanics. We discuss the dynamics of deformed unimodal maps in particular q-logistic map and q-Gaussian map. We show that there exists a set of parameter values with positive measures, for which these deformed maps exhibits stochastically stable chaos. The deformed maps have chaotic behavior for a large space of deformed parameter qthan the canonical maps.

Oxidative injury is concerned with the pathogenesis of several liver injuries, including those from acute liver failure to cirrhosis. This study was designed to explore the antioxidant activity of Bacopa monnieri(BM) on Aflatoxin B1 (AFB1) induced oxidative damage in Wistaralbino rats. Aflatoxin B1 treatment (200 μg/kg/day, p.o.) for 28 days induced oxidative injury by a significant alteration in serum liver function test marker enzymes (AST, ALT, ALP, LDH, albumin and bilirubin), inflammatory cytokines (IL-6, IL-10 and TNF-α), thiobarbituric acid reactive substances (TBARS) along with reduction of antioxidant enzymes (GSH, SOD, CAT), GSH cycle enzymes and drug-metabolizing enzymes (AH and AND). Treatment of rats with B. monnieri(20, 30 and 40 mg/kg for 5 days, p.o.) after 28 days of AFB1 intoxication significantly restored these parameters near control in a dose-dependent way. Histopathological examination disclosed extensive hepatic injuries, characterized by cellular necrosis, infiltration, congestion and sinusoidal dilatation in the AFB1-treated group. Treatment with B. monnierisignificantly reduced these toxic effects resulting from AFB1. B. monnieriper segroup (40 mg/kg) did not show any significant change and proved safe. The cytotoxic activity of B. monnieriwas also evaluated on HepG2 cells and showed a good percentage of cytotoxic activity. This finding suggests that B. monnieriprotects the liver against oxidative damage caused by AFB1, which aids in the evaluation of the traditional usage of this medicinal plant.Graphical Abstract

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The PARADIGM-HF (Prospective Comparison of Angiotensin II Receptor Blocker Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial reported that sacubitril/valsartan (S/V), an angiotensin receptor-neprilysin inhibitor, significantly reduced mortality and heart failure (HF) hospitalization in HF patients with a reduced ejection fraction (HFrEF). However, fewer than 1% of patients in the PARADIGM-HF study had New York Heart Association (NYHA) functional class IV symptoms. Accordingly, data that informed the use of S/V among patients with advanced HF were limited. The LIFE (LCZ696 in Hospitalized Advanced Heart Failure) study was a 24-week prospective, multicenter, double-blinded, double-dummy, active comparator trial that compared the safety, efficacy, and tolerability of S/V with those of valsartan in patients with advanced HFrEF. The trial planned to randomize 400 patients ≥18 years of age with advanced HF, defined as an EF ≤35%, New York Heart Association functional class IV symptoms, elevated natriuretic peptide concentration (B-type natriuretic peptide [BNP] ≥250 pg/ml or N-terminal pro–B-type natriuretic peptide [NT-proBNP] ≥800 pg/ml), and ≥1 objective finding of advanced HF. Following a 3- to 7-day open label run-in period with S/V (24 mg/26 mg twice daily), patients were randomized 1:1 to S/V titrated to 97 mg/103 mg twice daily versus 160 mg of V twice daily. The primary endpoint was the proportional change from baseline in the area under the curve for NT-proBNP levels measured through week 24. Secondary and tertiary endpoints included clinical outcomes and safety and tolerability. Because of the COVID-19 pandemic, enrollment in the LIFE trial was stopped prematurely to ensure patient safety and data integrity. The primary analysis consists of the first 335 randomized patients whose clinical follow-up examination results were not severely impacted by COVID-19. (Entresto [LCZ696] in Advanced Heart Failure [LIFE STUDY] [HFN-LIFE]; NCT02816736)

Oblique ion beam patterned and structured thin films hold promise as an advanced material for applications to photonics, micro- to nano-electronics, electro-optical and electrochemical devices fabrication. Herein, for the first time, we report the fabrication of patterned and structured SiC thin films over Si(111) by obliquely incident Ar+beam. We show that at a short time scale, carbon clusters possessing nano-dimensional size evolve while ripple structures with direction parallel to the ion beam projection emerge at later time scales. The roughness evolution plot follows exponential and power law scaling at low and high bombarding time (in terms of ion fluence). The underlying mechanism is the altered surface layer composition due to the non-stoichiometric sputtering of silicon and carbon. The optical bands corresponding to silicon carbide (3.27–4.23 eV) & silicon (1.15–1.45 eV) co-exist for lower argon ion fluences while optical bands of silicon (1.15- 1.45 eV) remains and silicon carbide vanishes for higher argon ion fluences. Our experimental findings demonstrated the fabrication of ripple patterns over radiation tolerant, thermally and physically stable SiC by large area irradiation and capability to tailor the temporal characteristics of these evolved structures.

AbstractThe discovery of NDM-1 and its variants has caused the emergence of antibiotic resistance in the community and hospital setting, causing major concern for health care across the globe. New Delhi Metallo-β-lactamase is known to hydrolyse almost all β-lactam antibiotics. Studies have shown the hydrolytic activates of NDM-1 and some of its variants, however a comparative study of these NDM variants has not been explored in detail. Hence, we proposed to check their catalytic activity by performing a comparative study between NDM-1 and its variants. The study was initiated to clone NDM variants (NDM-1, NDM-4, NDM-5, NDM-6 and NDM-7) followed by overexpression of the recombinant proteins to check their hydrolytic properties against β-lactam antibiotics. The minimum inhibitory concentration of carbapenems antibiotics for blaNDM-5clone was found four fold increased, whereas no change was observed in the clones having other variants. The hydrolytic activity of carbapenem with NDM-5 variant was found to be augmented as per the kinetics parameter where Km was decreased and kcat, kcat/Km values increased as compared to the NDM-1. Molecular docking studies were employed to identify the variations in the binding ability among all NDM variants with imipenem or meropenem. Simulation studies at 100 ns showed a good stability of NDM-5 with imipenem and meropenem as compared to NDM-1. CD spectroscopy data revealed significant changes in the secondary structure of NDM variants. We conclude that NDM-5 showed higher hydrolytic activity as compared to other variants. This study provides a comparative analysis of the severity of NDM producing strains.

Heterostructures based on atomically thin two-dimensional layered transition metal dichalcogenides are highly promising for optoelectronic device applications owing to their tunable optical and electronic properties. However, the synthesis of heterostructures with desired materials having proper interfacial contacts has been a challenging task. Here, we develop a colloidal synthetic route for the design of MoSe2–Cu2S nanoheterostructures, where the Cu2S islands grow vertically on top of the defect sites present on the MoSe2surface, thereby forming a vertical p–n junction having plasmonic characteristics. These MoSe2–Cu2S nanoheterostructures are used to fabricate photodetectors with superior photoresponse characteristics. The fabricated device exhibits a broad-band spectral photoresponse over the visible to near-infrared range with a peak responsivity of 410 mA W–1at −2.0 V and over 3000-fold photo-to-dark current ratio. The superior device performance of MoSe2–Cu2S over only MoSe2devices is due to the combined effect of the formation of the p–n junction, pronounced light–matter interactions, and passivation of surface defects. This study would pave the way for designing a new class of nanoheterostructured materials for their potential applications in next-generation photonic devices.

(Abstracted from N Engl J Med2019;381:2391–2402)The standard treatment for newly diagnosed advanced epithelial ovarian cancer involves cytoreductive surgery and platinum-taxane combination chemotherapy. Unfortunately, recurrence occurs in up to 85% of patients after completing this chemotherapy regimen.

AbstractThis paper presents reliability analysis and perceptions of genetically modified organisms (GMOs) using Cronbach’s alpha and the study involved in carrying out pre- and post-survey instrument analysis. The outcome has been validated and found acceptable for internal consistency. Perceptions have been tabulated and changes in them have been observed.