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Abstract Background Trust in the healthcare system may impact adherence to recommended healthcare practices, including willingness to test for and vaccinate against COVID-19. This study examined racial/ethnic differences in the associations between trust in the U.S. healthcare system and willingness to test for and vaccinate against COVID-19 during the first year of the pandemic. Methods This cross-sectional study used data from the REACH-US study, a nationally representative online survey conducted among a diverse sample of U.S. adults from January 26, 2021-March 3, 2021 (N = 5,121). Multivariable logistic regression estimated the associations between trust in the U.S. healthcare system (measured as “Always”, “Most of the time”, “Sometimes/Almost Never”, and “Never”) and willingness to test for COVID-19, and willingness to receive the COVID-19 vaccine. Racial/ethnic differences in these associations were examined using interaction terms and multigroup analyses. Results Always trusting the U.S. healthcare system was highest among Hispanic/Latino Spanish Language Preference (24.9%) and Asian (16.7%) adults and lowest among Multiracial (8.7%) and Black/African American (10.7%) adults. Always trusting the U.S. healthcare system, compared to never, was associated with greater willingness to test for COVID-19 (AOR: 3.20, 95% CI: 2.38–4.30) and greater willingness to receive the COVID-19 vaccine (AOR: 2.68, 95% CI: 1.97–3.65). Conclusions Trust in the U.S. healthcare system was associated with greater willingness to test for COVID-19 and receive the COVID-19 vaccine, however, trust in the U.S. healthcare system was lower among most marginalized racial/ethnic groups. Efforts to establish a more equitable healthcare system that increases trust may encourage COVID-19 preventive behaviors.

Abstract The past decade has seen an increase in the prevalence of sequence type (ST) 45 methicillin-resistant Staphylococcus aureus (MRSA), yet the underlying drivers for its emergence and spread remain unclear. To better understand the worldwide dissemination of ST45 S. aureus, we performed phylogenetic analyses of Australian isolates, supplemented with a global population of ST45 S. aureus genomes. Our analyses revealed a distinct lineage of multidrug-resistant ST45 MRSA harbouring qacA, predominantly found in Australia and Singapore. Bayesian inference predicted that the acquisition of qacA occurred in the late 1990s. qacA was integrated into a structurally variable region of the chromosome containing Tn552 (carrying blaZ) and Tn4001 (carrying aac(6’)-aph(2”)) transposable elements. Using mutagenesis and in vitro assays, we provide phenotypic evidence that qacA confers tolerance to chlorhexidine. These findings collectively suggest both antimicrobial resistance and the carriage of qacA may play a role in the successful establishment of ST45 MRSA.

Understanding the response of coastal barriers to future changes in rates of sea level rise, sediment availability, and storm intensity/frequency is essential for coastal planning, including socioeconomic and ecological management. Identifying drivers of past changes in barrier morphology, as well as barrier sensitivity to these forces, is necessary to accomplish this. Using remote sensing, field, and laboratory analyses, we reconstruct the mesoscale (decades–centuries) evolution of central Fire Island, a portion of a 50 km barrier island fronting Long Island, New York, USA. We find that the configuration of the modern beach and foredune at Fire Island is radically different from the system's relict morphostratigraphy. Central Fire Island is comprised of at least three formerly inlet-divided rotational barriers with distinct subaerial beach and dune–ridge systems that were active prior to the mid-19th century. Varying morphologic states reflected in the relict barriers (e.g., progradational and transgressive) contrast with the modern barrier, which is dominated by a tall and nearly continuous foredune and is relatively static, except for erosion and drowning of its fringing marsh. We suggest that this state shift indicates a transition from a regime dominated by inlet-mediated gradients in alongshore sediment availability to one where human impacts exerted greater influence on island evolution from the late 19th century onward. The retention of some geomorphic capital in Fire Island's relict subaerial features combined with its static nature renders the barrier increasingly susceptible to narrowing and passive submergence. This may lead to an abrupt geomorphic state shift in the future, a veiled vulnerability that may also exist in other stabilized barriers.

Abstract Myelinated axons form long-range connections that enable rapid communication between distant brain regions, but how genetics governs the strength and organization of these connections remains unclear. We perform genome-wide association studies of 206 structural connectivity measures derived from diffusion magnetic resonance imaging tractography of 26,333 UK Biobank participants, each representing the density of myelinated connections within or between a pair of cortical networks, subcortical structures or cortical hemispheres. We identify 30 independent genome-wide significant variants after Bonferroni correction for the number of measures studied (126 variants at nominal genome-wide significance) implicating genes involved in myelination (SEMA3A), neurite elongation and guidance (NUAK1, STRN, DPYSL2, EPHA3, SEMA3A, HGF, SHTN1), neural cell proliferation and differentiation (GMNC, CELF4, HGF), neuronal migration (CCDC88C), cytoskeletal organization (CTTNBP2, MAPT, DAAM1, MYO16, PLEC), and brain metal transport (SLC39A8). These variants have four broad patterns of spatial association with structural connectivity: some have disproportionately strong associations with corticothalamic connectivity, interhemispheric connectivity, or both, while others are more spatially diffuse. Structural connectivity measures are highly polygenic, with a median of 9.1 percent of common variants estimated to have non-zero effects on each measure, and exhibited signatures of negative selection. Structural connectivity measures have significant genetic correlations with a variety of neuropsychiatric and cognitive traits, indicating that connectivity-altering variants tend to influence brain health and cognitive function. Heritability is enriched in regions with increased chromatin accessibility in adult oligodendrocytes (as well as microglia, inhibitory neurons and astrocytes) and multiple fetal cell types, suggesting that genetic control of structural connectivity is partially mediated by effects on myelination and early brain development. Our results indicate pervasive, pleiotropic, and spatially structured genetic control of white-matter structural connectivity via diverse neurodevelopmental pathways, and support the relevance of this genetic control to healthy brain function.

Background: Prostate bed (PB) motion may lead to geographical miss of the target volume in post-prostatectomy radiotherapy (RT). Optimal clinical target volume (CTV) to planning target volume (PTV) margins prevent geographical miss and unnecessary irradiation of normal tissue. There is little data available informing appropriate CTV to PTV margins in the post-prostatectomy setting. The purpose of this review was to quantify the inter-fraction and intra-fraction motion of the PB and draw a conclusion regarding the use of anisotropic CTV to PTV margins for post-prostatectomy RT treatment. Methodology: A search of PubMed and EMBASE databases was carried out using keywords (prostate bed [Title/Abstract]) AND (motion [Title/Abstract]). All study types assessing inter-fraction and/or intra-fraction motion of the PB based on imaging of soft tissue anatomy were included. Data on patient preparation, immobilisation, and image guidance was abstracted from the included studies. Magnitude of PB motion along with the estimated CTV to PTV margins calculated was also tabulated. Quality of studies was assessed using the MINORS tool. Results: Seventeen studies were included in the analysis. The largest magnitude of inter-fraction PB motion occurs in the anterior-posterior direction. This motion is attributed to the influence of the bladder and rectal volume on the PB. The PB moves independently of bone and the magnitude of motion varies between the superior and inferior portions of the prostate bed. Conclusion: Anisotropic CTV to PTV margins are appropriate for use in the post-prostatectomy setting and their implementation for treatment planning purposes are warranted based on the evidence reviewed.

Current theory suggests that heterogeneous metapopulation structures can help foster the diffusion of innovations to solve pressing issues including climate change adaptation and promoting public health. In this paper, we develop an agent-based model of the spread of adaptations in simulated populations with minority-majority metapopulation structure, where subpopulations have different preferences for social interactions (i.e., homophily) and, consequently, learn deferentially from their own group. In our simulations, minority-majority-structured populations with moderate degrees of in-group preference better spread and maintained an adaptation compared to populations with more equal-sized groups and weak homophily. Minority groups act as incubators for novel adaptations, while majority groups act as reservoirs for the adaptation once it has spread widely. This suggests that population structure with in-group preference could promote the maintenance of novel adaptations.

This is the protocol for a Campbell systematic review. The proposed systematic review question is: What is the effectiveness of arts interventions for at-risk and offending children and young people (8-25 years)? There are three objectives: (1) To evaluate evidence on the effectiveness and impact of arts interventions on keeping children safe from involvement in violence and crime; (2) To synthesise evidence on factors impacting the implementation of arts interventions, and barriers and facilitators to participation and achievement of intended outcomes; (3) To develop a theory-of-change approach to ensure the development of an evidence-led framework of the processes by which arts interventions might work in preventing offending behaviours.

Group B Streptococcus (GBS) is a major human and animal pathogen that threatens public health and food security. Spill-over and spill-back between host species is possible due to adaptation and amplification of GBS in new niches but the evolutionary and functional mechanisms underpinning those phenomena are poorly known. Based on analysis of 1,254 curated genomes from all major GBS host species and six continents, we found that the global GBS population comprises host-generalist, host-adapted and host-restricted sublineages, which are found across host groups, preferentially within one host group, or exclusively within one host group, respectively, and show distinct levels of recombination. Strikingly, the association of GBS genomes with the three major host groups (humans, cattle, fish) is driven by a single accessory gene cluster per host, regardless of sublineage or the breadth of host spectrum. Moreover, those gene clusters are shared with other streptococcal species occupying the same niche and are functionally relevant for host tropism. Our findings demonstrate (1) the heterogeneity of genome plasticity within a bacterial species of public health importance, enabling the identification of high-risk clones; (2) the contribution of inter-species gene transmission to the evolution of GBS; and (3) the importance of considering the role of animal hosts, and the accessory gene pool associated with their microbiota, in the evolution of multi-host bacterial pathogens. Collectively, these phenomena may explain the adaptation and clonal expansion of GBS in animal reservoirs and the risk of spill-over and spill-back between animals and humans.

Abstract Plant resistance and predators can influence density‐dependent survivorship and growth of herbivores, and their damage to plants. Although the independent effects of plant resistance and predators on herbivores and herbivory are well known, little is known about their interactive and density‐dependent effects on herbivores and the amount and distribution of damage on plants. These relationships are important for understanding how herbivore and plant populations influence each other. We used a laboratory density‐manipulation experiment to determine how plant resistance (three treatments: jasmonate‐insensitive, unmanipulated wild type, and jasmonate‐sprayed wild‐type plants) and predation (two treatments: predator or no predator) affect the survivorship and growth of an herbivore, as well as per capita damage and the distribution of damage on plants. We found evidence that the density dependence of herbivore survivorship was influenced by predators and an interactive effect of plant resistance and predation. Herbivore growth was reduced by higher plant resistance but was not density‐dependent nor affected by predation. Per capita plant damage was reduced by plant resistance, predation, and herbivore density. The within‐plant distribution of damage became more even with increasing herbivore density but was not affected by predation or the independent effect of plant resistance. The distribution of damage was also affected by an interaction between plant resistance and herbivore density; damage became less aggregated with density across all plant resistance treatments, but the decrease was strongest for the jasmonate‐insensitive plants. These results show that predators influence herbivore density dependence, and that plant resistance can affect the impact of predators on herbivores. Though plant resistance, predation, and herbivore density all reduced per capita herbivore damage to plants, only herbivore density and plant resistance affected the distribution of damage. Distributions of herbivory can influence plant success; documenting patterns of herbivory is an under‐appreciated avenue for integrating effects of plant resistance, predators, and herbivore density on plant–herbivore interactions.

Processed foods have been part of the American diet for decades, with key roles in providing a safe, available, affordable, and nutritious food supply. The USDA Food Guides beginning in 1916 and the US Dietary Guidelines for Americans (DGA) since 1980 have included various types of commonly consumed processed foods (e.g., heated, fermented, dried) as part of their recommendations. However, there are multiple classification systems based on “level” of food processing, and additional evidence is needed to establish the specific properties of foods classified as “highly” or “ultra”-processed (HPF/UPFs). Importantly, many foods are captured under HPF/UPF definitions, ranging from ready-to-eat fortified whole grain breakfast cereals to sugar-sweetened beverages and baked goods. The consequences of implementing dietary guidance to limit all intake of foods currently classified as HPF/UPF may require additional scrutiny to evaluate the impact on consumers’ ability to meet daily nutrient recommendations and to access affordable food, and ultimately, on health outcomes. Based on a meeting held by the Institute for the Advancement of Food and Nutrition Sciences in May 2023, this paper provides perspectives on the broad array of foods classified as HPF/UPFs based on processing and formulation, including contributions to nutrient intake and dietary patterns, food acceptability, and cost. Characteristics of foods classified as UPF/HPFs are considered, including the roles and safety approval of food additives and the effect of food processing on the food matrix. Finally, this paper identifies information gaps and research needs to better understand how the processing of food affects nutrition and health outcomes.

Introduction: Up to 20% of EGFR-mutated NSCLC cases harbor uncommon EGFR mutations, including atypical exon 19 and compound mutations. Relatively little is known about the efficacy of osimertinib in these cases. Methods: Patients treated with first-line osimertinib for NSCLC with rare EGFR exon 19 (non E746_A750del) or compound mutations were included. Response assessment and time to progression were determined using Response Evaluation Criteria in Solid Tumors version 1.1 criteria. Kaplan-Meier analyses were used to estimate progression-free survival (PFS), time to treatment discontinuation (TTD), and overall survival (OS). Results: Thirty-seven patients with NSCLC harboring an atypical EGFR exon 19 mutation or compound mutation were treated with first-line osimertinib at Johns Hopkins from 2016 to 2021. Overall response rate (ORR) was 76% and median PFS, TTD, and OS were 13 months (95% confidence interval [CI]: 10–15), 22 months (95% CI: 17–32) and 36 months (95% CI, 29–48), respectively. Among atypical exon 19 mutations (n = 25), ORR was 80%, median PFS was 12 months (95% CI: 10–15), median TTD was 19 months (95% CI: 17–38), and median OS was 48 months (95% CI: 25–not reached). Compound mutations (n = 12) had an ORR of 67%, median PFS of 14 months (95% CI: 5–22), median TTD of 26 months (95% CI: 5–36), and median OS of 36 months (95% CI: 20–46). Twelve patients (32%) continued first-line osimertinib after local therapy for oligoprogression. Conclusions: Osimertinib exhibited favorable outcomes for rare EGFR exon 19 and compound mutations. The heterogeneity in outcomes among these groups of tumors with similar mutations underscores the need for continued reporting and further study of outcomes among rare variants to optimize management for each patient.

Abstract Antibiotic resistance is a significant global public health concern. Uropathogenic Escherichia coli sequence type (ST)131, a widely prevalent multidrug-resistant clone, is frequently associated with bacteraemia. This study investigates third-generation cephalosporin resistance in bloodstream infections caused by E. coli ST131. From 2013-2014 blood culture surveillance in Wales, 142 E. coli ST131 genomes were studied alongside global data. All three major ST131 clades were represented across Wales, with clade C/H30 predominant (n = 102/142, 71.8%). Consistent with global findings, Welsh strains of clade C/H30 contain β-lactamase genes from the bla CTX-M-1 group (n = 65/102, 63.7%), which confer resistance to third-generation cephalosporins. Most Welsh clade C/H30 genomes belonged to sub-clade C2/H30Rx (58.3%). A Wales-specific sub-lineage, named GB-WLS.C2, diverged around 1996-2000. An introduction to North Wales around 2002 led to a localised cluster by 2009, depicting limited genomic diversity within North Wales. This investigation emphasises the value of genomic epidemiology, allowing the detection of genetically similar strains in local areas, enabling targeted and timely public health interventions.

Abstract The ability of Mycobacterium tuberculosis (Mtb) to persist in the host complicates and prolongs tuberculosis (TB) patient chemotherapy. Here we demonstrate that a neglected two-component system (TCS) of Mtb, TcrXY, is an autoregulated acid-sensing TCS that controls a functionally diverse 70-gene regulon required for bacterial persistence. Characterisation of two representatives of this regulon, Rv3706c and Rv3705A, implicate these genes as key determinants for the survival of Mtb in vivo by serving as important effectors to mitigate redox stress at acidic pH. We show that genetic silencing of the response regulator tcrX using CRISPR interference attenuates the persistence of Mtb during chronic mouse infection and improves treatment with the two front-line anti-TB drugs, rifampicin and isoniazid. We propose that targeting TcrXY signal transduction blocks the ability of Mtb to sense and respond to acid stress, resulting in a disordered program of persistence to render the organism vulnerable to existing TB chemotherapy.

Abstract Inspired by biology, great progress has been made in creating artificial molecular motors. However, the dream of harnessing proteins – the building blocks selected by nature – to design autonomous motors has so far remained elusive. Here we report the synthesis and characterization of the Lawnmower, an autonomous, protein-based artificial molecular motor comprised of a spherical hub decorated with proteases. Its “burnt-bridge” motion is directed by cleavage of a peptide lawn, promoting motion towards unvisited substrate. We find that Lawnmowers exhibit directional motion with average speeds of up to 80 nm/s, comparable to biological motors. By selectively patterning the peptide lawn on microfabricated tracks, we furthermore show that the Lawnmower is capable of track-guided motion. Our work opens an avenue towards nanotechnology applications of artificial protein motors.

Abstract Background Autism spectrum disorder (henceforth autism) is a complex neurodevelopmental condition associated with differences in gray matter (GM) volume covariations, as reported in our previous study of the Longitudinal European Autism Project (LEAP) data. To make progress on the identification of potential neural markers and to validate the robustness of our previous findings, we aimed to replicate our results using data from the Enhancing Neuroimaging Genetics Through Meta-Analysis (ENIGMA) autism working group. Methods We studied 781 autistic and 927 non-autistic individuals (6–30 years, IQ ≥ 50), across 37 sites. Voxel-based morphometry was used to quantify GM volume as before. Subsequently, we used spatial maps of the two autism-related independent components (ICs) previously identified in the LEAP sample as templates for regression analyses to separately estimate the ENIGMA-participant loadings to each of these two ICs. Between-group differences in participants’ loadings on each component were examined, and we additionally investigated the relation between participant loadings and autistic behaviors within the autism group. Results The two components of interest, previously identified in the LEAP dataset, showed significant between-group differences upon regressions into the ENIGMA cohort. The associated brain patterns were consistent with those found in the initial identification study. The first IC was primarily associated with increased volumes of bilateral insula, inferior frontal gyrus, orbitofrontal cortex, and caudate in the autism group relative to the control group (β = 0.129, p = 0.013). The second IC was related to increased volumes of the bilateral amygdala, hippocampus, and parahippocampal gyrus in the autism group relative to non-autistic individuals (β = 0.116, p = 0.024). However, when accounting for the site-by-group interaction effect, no significant main effect of the group can be identified (p > 0.590). We did not find significant univariate association between the brain measures and behavior in autism (p > 0.085). Limitations The distributions of age, IQ, and sex between LEAP and ENIGMA are statistically different from each other. Owing to limited access to the behavioral data of the autism group, we were unable to further our understanding of the neural basis of behavioral dimensions of the sample. Conclusions The current study is unable to fully replicate the autism-related brain patterns from LEAP in the ENIGMA cohort. The diverse group effects across ENIGMA sites demonstrate the challenges of generalizing the average findings of the GM covariation patterns to a large-scale cohort integrated retrospectively from multiple studies. Further analyses need to be conducted to gain additional insights into the generalizability of these two GM covariation patterns.

Abstract Feeding on plant-derived sugars is an essential component of mosquito biology, affecting key aspects of their lives such as survival, metabolism, and reproduction. Among mosquitoes, Aedes aegypti and Aedes albopictus are two invasive mosquito species in the US, and are vectors of diseases such as dengue fever, chikungunya, and Zika. These species live in heavily populated, urban areas, where they have high accessibility to human hosts as well as to plants in backyards and public landscapes. However, the range of plants that are suitable sugar hosts for these species remains to be described, despite the importance of understanding what plants may attract or repel mosquitoes to inform citizens and municipal authorities accordingly. Here, we tested whether Ae. aegypti and Ae. albopictus would sugar-feed on eleven commonly planted ornamental plant species. We confirmed feeding activity using the anthrone method and identified the volatile composition of plant headspace using gas-chromatography mass-spectroscopy. These chemical analyses revealed that a broad range of olfactory cues are associated with plants that mosquitoes feed on. This prompted us to use plant DNA barcoding to identify plants that field-caught mosquitoes feed on. Altogether, results show that native and invasive mosquito species can exploit a broader range of plants than originally suspected, including wild and ornamental plants from different phyla throughout the Spring, Summer and Fall seasons.

OnabotulinumtoxinA (onabotA) is approved in the US for 12 therapeutic indications. Real-world data on onabotA multi-indication use are limited, often leading to delayed or reduced treatment. This study provides real-world evidence on the safety of onabotA when treating multiple indications concomitantly. SYNCHRONIZE was a multicenter, retrospective, chart-review study evaluating onabotA’s safety for adults treated for ≥2 therapeutic indications within a 3-month period. The primary outcome was treatment-emergent adverse events (TEAEs) within 6 months post-treatment. A total of 279 patients were included. The most common concomitant indications treated were cervical dystonia and chronic migraine (43.4%). The average 3-month cumulative dose for multiple indications was 282.2 U. The treatment interval for multiple indications was ≤24 h for most patients (62.4%). Overall, 28.7% of patients reported ≥1 TEAE with no apparent trends in TEAEs and dose interval or cumulative dose. Reported TEAEs included UTI (5.7%), neck pain (5.0%), and headache (4.3%). No patient had a lack of effect according to clinical objective measurements. SYNCHRONIZE described the real-world safety of onabotA for patients treated concomitantly for ≥2 indications within a 3-month period. TEAEs were generally consistent with the known safety profiles of individual indications. No new safety signals were identified).

BackgroundPremature infants and their parents experience significant stress related to separation and lifesaving procedures. While evidence suggests that skin-to-skin contact (SSC) is a stress-reducing intervention for both neonates and parents, the mechanisms that underlie its efficacy are not well understood.ObjectivePurpose of this systematic review is to summarize the current state of knowledge on changes in biomarkers (ie, oxytocin [OT], cortisol, hypoxanthine, xanthine, uric acid, and allantoin), associated with SSC in premature infants and parents, that may reflect physiologic responses to stress.MethodsA comprehensive literature search was conducted from 1990 to 2020. Studies were selected using prespecified inclusion and exclusion criteria.ResultsOf the 175 studies identified, only 19 are included in this review. Ten studies evaluated only infants, 2 evaluated only parents, and 7 evaluated for changes in biomarkers in both infants and parents. Cortisol was the most common biomarker evaluated. While changes in infants' cortisol levels were highly variable, in 55% of the parent studies, parent cortisol levels decreased following SSC. In both parents and infants, OT levels decreased following SSC. Only 1 study found that allantoin levels were significantly lower in infants who received SSC.Implications for practice and researchWhile evidence suggests the numerous benefits of SSC, additional research is needed to identify the optimal biomarker to determine the mechanisms that underlie these effects. The use of novel biomarkers (eg, gene expression changes microbiome) may provide new insights into the mechanisms that underlie the efficacy of SSC.Video Abstract available at:https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=48.

Technology education (TE) has the creating, making, and doing aspects of human activity at its foundation. This article presents a comparison of the teaching sense of efficacy (TSE) of practising TE teachers and teacher candidates (TC) during a forced switch to emergency remote teaching (ERT). In phase 1, the switch to ERT had a significantly negative effect on TE teachers (N = 42; r = -0.60). In phase 2, TE TCs (N = 16) were similarly affected (r = -0.53). Results of a two-way mixed ANOVA in phase 3 suggest that ERT had a greater negative impact on practising TE teachers' TSE for student engagement (partial eta squared = 0.11) and classroom management (partial eta squared = 0.19) than it did on TE TCs' TSE. As novice teachers tend to draw more from contextual factors than mastery experiences, this research suggests that experienced teachers were at a greater loss due to the pandemic than TCs.

A source of contestation in higher education curricula is the multiplicity of demands they serve and purposes they seek to fulfil. In this paper, we see this contestation as actively shaping assessment theory and practice, resulting in paradoxes of valorisation and vilification of everyday assessment practices. We address the plethora of contestations in higher education assessment through the disruption of dichotomies in assessment discourse by re-querying assessment "autonomy," "logic" and the "basis" of success. To this end, we apply Legitimation Code Theory to construct a new holistic framework for assessment inquiry, contributing to both extant and developing assessment theory by proposing a single sociological framework to analyse assessment practice cross-discipline, institution and geographical boundaries.

The use of online learning in postgraduate teaching has increased dramatically in recent years. Health-care professionals can benefit from the flexibility afforded by online learning to fulfil their continuing professional development goals. Understanding student expectations, concerns, and experiences of such courses is crucial for the development and successful facilitation of this education modality. The aim of this paper was to examine student perspectives of an online postgraduate certificate in clinical exercise prescription. A set of recommendations based on these findings was also created which may serve to inform those involved in online education. Students expressed their expectations and concerns about taking the course before it began, and completed surveys on their experience after module completion. A multi-method approach using both qualitative content analysis and quantitative survey analysis was used to analyze student responses on the online modules in the virtual learning environment. Students (n = 19) had a combination of academic, personal, and clinical expectations entering the course. Concerns entering the course included ability to reach academic standards set by the course due to personal circumstances or lack of academic ability; the ability to manage time and workload; and the online nature of the course. Students felt supported throughout the course, although some had difficulties keeping up with the workload or managing their time. Results of this study can be used to inform the structure and coordination of online modules, in particular in the postgraduate healthcare setting.