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Hyperhidrosis (HH) is a pathological condition of excessive secretion of the eccrine sweat glands in amounts greater than that required for physiological needs. Herein, we describe a patient who was treated with autologous blood pleurodesis for ductus thoracicus injury after endoscopic thoracic sympathectomy. A 23-year-old woman was admitted to our clinic with a complaint of bilateral pronounced axillary HH, minimal sweating of the hands, and bruising. She underwent bilateral thoracic sympathectomy at levels T3 and T4. A milky fluid was observed in the left chest tube and was diagnosed as chylothorax. No similar case of postoperative chylothorax treated with autologous blood pleurodesis has been found in the English literature. According to anatomical variations, the ductus thoracicus is susceptible to injury even in the hands of an experienced surgeon. In case an injury has occurred shortly after thoracic sympathectomy, autologous blood pleurodesis is an effective treatment for chylothorax. This procedure is safe and cheap and can be easily performed at the bedside.

Collision sports, such as Rugby Union (“Rugby”) have a particularly high risk of injury. Of all injuries common to collision sports, concussions have received the most attention due to the potentially negative cognitive effects in the short- and long-term. Despite non-professional Rugby players comprising the majority of the world’s playing population, there is relatively little research in this population. Stellenbosch Rugby Football Club (“Maties”), the official rugby club of Stellenbosch University, represents one of the world’s largest non-professional Rugby clubs, making this an ideal cohort for community-level injury surveillance. The aim of this study was to describe the incidence and events associated with concussion in this cohort. Baseline demographics were obtained on the 807 male student Rugby non-professional players who registered for the 10-week long 2018 season, which comprised 101 matches and 2,915 of exposure hours. All match-related injuries were captured by the medical staff of Stellenbosch Campus Health Service on an electronic form developed from the consensus statement for injury recording in Rugby. The mean age, height and weight of this cohort were 20 ± 2 years, 182 ± 7 cm and 88 ± 14 kg, respectively. Overall, there were 89 time-loss injuries, which equated to an injury rate of 30.6 per 1,000 match hours [95% confidence intervals (CIs): 24.2–36.9], or about one injury per match. The most common injury diagnosis was “concussion” (n = 27 out of 90 injuries, 30%), at a rate of 9.3 per 1,000 match hours (95% CIs: 5.8–12.8). The three most common mechanisms of concussion in the present study were performing a tackle (33%), accidental collision (30%) and being tackled (11%). Concussion was the most common injury in this population, at a rate that was six times higher than the most comparable study from the UK, which had far more exposure time over six seasons and wider range of player ability, from recreational to semi-professional. This might be explained by the training and vigilance of the club’s first aiders observing all matches for concussion. Future studies should try to explain this high rate and subsequently reduce these concussions. The addition of video surveillance data would assist in identifying the etiology of these concussions injuries in order to develop specific targeted interventions.

Introduction Worldwide, 2 million patients aged 18–50 years suffer a stroke each year, and this number is increasing. Knowledge about global distribution of risk factors and aetiologies, and information about prognosis and optimal secondary prevention in young stroke patients are limited. This limits evidence-based treatment and hampers the provision of appropriate information regarding the causes of stroke, risk factors and prognosis of young stroke patients.Methods and analysis The Global Outcome Assessment Life-long after stroke in young adults (GOAL) initiative aims to perform a global individual patient data meta-analysis with existing data from young stroke cohorts worldwide. All patients aged 18–50 years with ischaemic stroke or intracerebral haemorrhage will be included. Outcomes will be the distribution of stroke aetiology and (vascular) risk factors, functional outcome after stroke, risk of recurrent vascular events and death and finally the use of secondary prevention. Subgroup analyses will be made based on age, gender, aetiology, ethnicity and climate of residence.Ethics and dissemination Ethical approval for the GOAL study has already been obtained from the Medical Review Ethics Committee region Arnhem-Nijmegen. Additionally and when necessary, approval will also be obtained from national or local institutional review boards in the participating centres. When needed, a standardised data transfer agreement will be provided for participating centres. We plan dissemination of our results in peer-reviewed international scientific journals and through conference presentations. We expect that the results of this unique study will lead to better understanding of worldwide differences in risk factors, causes and outcome of young stroke patients.

Introduction Services are being encouraged to provide postdiagnostic treatment to those with dementia but the availability of evidence-based interventions following diagnosis has not kept pace with increase in demand. To address this need, the Journeying through Dementia (JtD) intervention was created. A randomised controlled trial (RCT), based on a pilot study, is in progress.Methods and analysis The RCT is a pragmatic, two-arm, parallel group trial designed to test the clinical and cost-effectiveness of JtD compared with usual care. Recruitment will be through NHS services, third sector organisations and Join Dementia Research. The sample size is 486 randomised (243 to usual care and 243 to the intervention usual care). Participants can choose to ask a friend or relative (supporter) to become involved in the study. The primary outcome measure for participants is Dementia-Related Quality of Life (DEMQOL), collected at baseline and at 8 months’ postrandomisation. Secondary outcome measures will be collected from participants and supporters at those visits. Participants will also be followed up at 12 months’ postrandomisation with a reduced set of measures. A process evaluation will be conducted through qualitative and fidelity substudies. Analyses will compare the two arms of the trial on an intention to treat as allocated basis. The primary analyses will compare the mean DEMQOL scores of the participants at 8 months between the two study arms. A cost-effectiveness analysis will consider the incremental cost per Quality Adjusted Life Years of the intervention compared with usual care. Qualitative and fidelity substudies will be analysed through framework analysis and fidelity assessment tools respectively.Ethics and dissemination REC and HRA approval were obtained. A Data Monitoring and Ethics Committee has been constituted. Dissemination will be via publications, conferences and social media. Intervention materials will be made open access.Trial registration number ISRCTN17993825.

Clearance of intracellular pathogens, such as Leishmania (L.) major, depends on an immune response with well-regulated cytokine signaling. Here we describe a pathogen-mediated mechanism of evading CXCL10, a chemokine with diverse antimicrobial functions, including T cell recruitment. Infection with L. major in a human monocyte cell line induced robust CXCL10 transcription without increasing extracellular CXCL10 protein concentrations. We found that this transcriptionally independent suppression of CXCL10 is mediated by the virulence factor and protease, glycoprotein-63 (gp63). Specifically, GP63 cleaves CXCL10 after amino acid A81 at the base of a C-terminal alpha-helix. Cytokine cleavage by GP63 demonstrated specificity, as GP63 cleaved CXCL10 and its homologs, which all bind the CXCR3 receptor, but not distantly related chemokines, such as CXCL8 and CCL22. Further characterization demonstrated that CXCL10 cleavage activity by GP63 was produced by both extracellular promastigotes and intracellular amastigotes. Crucially, CXCL10 cleavage impaired T cell chemotaxis in vitro, indicating that cleaved CXCL10 cannot signal through CXCR3. Ultimately, we propose CXCL10 suppression is a convergent mechanism of immune evasion, as Salmonella enterica and Chlamydia trachomatis also suppress CXCL10. This commonality suggests that counteracting CXCL10 suppression may provide a generalizable therapeutic strategy against intracellular pathogens.ImportanceLeishmaniasis, an infectious disease that annually affects over one million people, is caused by intracellular parasites that have evolved to evade the host's attempts to eliminate the parasite. Cutaneous leishmaniasis results in disfiguring skin lesions if the host immune system does not appropriately respond to infection. A family of molecules called chemokines coordinate recruitment of the immune cells required to eliminate infection. Here, we demonstrate a novel mechanism that Leishmania (L.) spp. employ to suppress host chemokines: a Leishmania-encoded protease cleaves chemokines known to recruit T cells that fight off infection. We observe that other common human intracellular pathogens, including Chlamydia trachomatis and Salmonella enterica, reduce levels of the same chemokines, suggesting a strong selective pressure to avoid this component of the immune response. Our study provides new insights into how intracellular pathogens interact with the host immune response to enhance pathogen survival.

Infections are leading causes of morbidity and mortality in the advanced aged. Various factors including immunosenescens, comorbid chronic diseases, and alterations in normal physiological organ functions may modify the frequency and severity of infections in elderly patients. Normal body reactions to ensuing infection, such as increased body temperature, may be blunted in those patients causing difficulties in differential diagnosis between infection and other diseases. In severe infections the respiratory and urinary tracts are the most frequently involved systems which may be accompanied by severe sepsis. Bacteremia and sepsis are also associated with indwelling vascular catheters in the elderly who are admitted to the intensive care unit (ICU). Older patients are more vulnerable to the Clostridioides difficile infection, as well. Although the general management of infections in severely ill elderly patients is not different than in younger patients, meticulous care in fluid management and careful individualized optimization in antibiotic therapy, along with the other principals of antimicrobial stewardship are warranted in order to prevent increased mortality caused by infection. Organized team management when treating critically ill elderly patients in the ICU is essential and will reduce the morbidity and mortality due to infection in such patients.

In the light of the European Union's interest in creativity and innovation, this paper, drawing on data from the EU project Creative Little Scientists (2011-2014), explores the teaching and learning of science and creativity in Early Years education. The project's conceptual framework, developed from detailed analysis of relevant literatures, highlighted the potential existence of a number of pedagogical synergies between inquiry-based science and creativity-based approaches in Early Years education. The science and creativity literature reviews were thus re-examined to identify synergistic features of teaching and learning in the Early Years. These were seen to include: play and exploration, motivation and affect, dialogue and collaboration, problem-solving and agency, questioning and curiosity, reflection and reasoning, and teacher scaffolding and involvement. Field work undertaken over a 4-month-period in 48 sites across the 9 partner countries provided the opportunity to examine the existence of these synergies in Early Years settings and primary classrooms with learners aged 3-8 years. Qualitative in nature, the fieldwork was framed by a case study strategy encompassing multiple methods of data collection: sequential digital images capturing interactions; observations supplemented by audio recording; timelines; and interviews with teachers and groups of children. The data set comprised 71 cases in early science (and mathematics), with 3 episodes of activity per case encapsulating creativity in these domains, resulting in 218 episodes for analysis. A deductive-inductive analytical approach was undertaken in two phases with cross-case analysis both within and between countries. The paper exemplifies the pedagogical synergies innovatively identified in the conceptual framework and documented in the fieldwork, and highlights the potential for creativity in exploratory science contexts. Additionally, it highlights differences between practice observed in preschool and primary settings and advances a new conceptual definition of creativity within Early Years science education.

The purpose of this study is to investigate student- and school-level factors that help to explain the difference in the nature of science (NOS) views. Overall, the design of this study is correlational. The sample consisted of 3062 students enrolled in the sixth, seventh, and eighth grades of elementary schools in Turkey. A hierarchical linear modelling was selected as a modelling technique. This study has established the importance of the student's socioeconomic background, learning approaches undertaken, self-efficacy, and motivational goals in the formation of their NOS views. The findings reveal that quality of both the physical infrastructure of schools and the educational resources in schools, parent educational levels, student achievement, self-efficacy, experience of meaningful learning, and learning goal orientation are positively related to different dimensions of student NOS views. Additionally, performance goal orientation and rote learning approaches have a negative relationship with different dimensions of student NOS views.

Gradual onset injuries (GOIs) in recreational cyclists are common but not well described. The aim of this study is to describe the clinical characteristics of GOIs (main anatomical regions, specific anatomical sites, specific GOIs, tissue type, severity of GOIs, and treatment modalities) of GOIs among entrants participating in a community-based mass participation-cycling event over 5 years. During the 2016–2020 Cape Town Cycle Tour, 62,758 consenting race entrants completed an online pre-race medical screening questionnaire. 1879 reported GOIs in the previous 12 months. In this descriptive epidemiological study, we report frequency (% entrants) of GOIs by anatomical region/sites, specific GOI, tissue type, GOI severity, and treatment modalities used. The main anatomical regions affected by GOIs were lower limb (47.4%), upper limb (20.1%), hip/groin/pelvis (10.0%), and lower back (7.8%). Specifically, GOI were common in the knee (32.1%), shoulder (10.6%), lower back (7.8%) and the hip/buttock muscles (5.2%). The most common specific GOI was anterior knee pain (17.2%). 57.0% of GOIs were in soft tissue. Almost half (43.9%) of cyclists with a GOI reported symptom duration >12 months, and 40.3% of GOIs were severe enough to reduce/prevent cycling. Main treatment modalities used for GOIs were rest (45.9%), physiotherapy (43.0%), stretches (33.2%), and strength exercises (33.1%). In recreational cyclists, >50% of GOIs affect the knees, shoulders, hip/buttock muscles and lower back, and 40% are severe enough to reduce/prevent cycling. Almost 45% of cyclists with GOIs in the lower back; or hip/groin/pelvis; or lower limbs; or upper limb reported a symptom duration of >12 months. Risk factors associated with GOIs need to be determined and preventative programs for GOIs need to be designed, implemented, and evaluated. [ABSTRACT FROM AUTHOR]

Amaç: Pulmoner sekestrasyon anormal sistemik arter damarlanmasına sahip kistik, fonksiyone olmayan embiryonik akciğer dokusuyla karakterize konjenital bir malformasyondur. Klinik olarak bronşektazi, pnömoni, akciğer absesi ya da kaviter akciğer hastalıklarını taklit edebilen, tedavisinde cerrahi rezeksiyon gerektiren konjenital bir patolojidir. Olgu: Burada sol akciğerin alt lob bazal segmentinde lokalize intralober sekestrasyon olan 11 yaşında kız çocuğu olgusunu rapor ettik. Radyolojik incelemede sol alt lobta akciğer absesi ile uyumlu görünüm mevcut idi. Akciğer absesi tanısıyla bazal segmentektomi uygulandı ancak intralobar sekestrasyon olduğu tesbit edildi. Sonuç: Burada radyolojik olarak nekrotizan pnömoni ve akciğer absesiyle karışan pulmoner sekestrasyon olgusu sunuldu ve literatür eşliğinde tartışıldı.

The purposes of this study were to develop and validate an instrument for assessing elementary students' nature of science (NOS) views and to explain the elementary school students' NOS views, in terms of varying grade levels and gender. The sample included 782 students enrolled in sixth, seventh, and eighth grades. Exploratory factor analysis factor structures and confirmatory factor analysis fit indices confirmed the existence of the hypothesised four dimensions in the structure of the nature of science instrument (NOSI). These dimensions and associated Cronbach a reliabilities of scores were observation and inferences (0.74), tentative NOS (0.76), imagination and creativity (0.80), and empirical NOS (0.63). Descriptive analyses revealed that the most favourable NOS views were obtained for the empirical nature of scientific knowledge. The students were uncertain about NOS views related to tentative NOS and imagination and creativity. The least favourable NOS views were obtained for observation and inferences.

Aim To find out the frequency of smoking in subgroups of ischemic stroke and to search for relation between smoking and asymptomatic ischemic lesions (AILs) in cranial magnetic resonance imaging (MRI), recurrence of ischemic stroke, hemorrhagic transformation, seizure, pneumonia, pulmonary embolism, myocardial infarction and deep vein thrombosis. Methods The stroke database of the Neurology Clinic in Istanbul Faculty of Medicine were retrospectively screened and patients with ischemic stroke admitted between 1995-2014 were included in this study. Results There were 3615 patients. The lowest frequency of smoking was found in patients with cardioembolism (348/1160, 30%) (p

Introduction: Unplanned pregnancy is a community health concern. Research with South African women revealed the complexities surrounding pregnancy planning. Categorising pregnancies as either planned or unplanned is insufficient, as reducing a multidimensional concept to a dichotomous variable oversimplifies a complex matter. Methods: Pregnant females, 18 years and older with a primary DSM-IV-TR (APA 2000) diagnosis of psychiatric illness, are qualified for inclusion in this quantitative descriptive study. Participants completed a structured psychiatric assessment, including the London Measure of Unplanned Pregnancy (LMUP) during care as usual visits at two Maternal Mental Health Clinics. Results: Although 37.1% termed their pregnancy unplanned when asked dichotomously, the LMUP scores revealed that 50.6% of the 170 participants fell outside the ‘planned’ category. Worryingly, 73.3% of the women with unplanned or ambivalent pregnancies did not use contraception. Neither the women’s intention to fall pregnant nor their perception of the right timing for being pregnant could be predicted by the group (unplanned, ambivalent or planned) in which they fell; 82.6% of the unplanned group, 57.1% of the ambivalent group and 6.0% of the planned group indicated not wanting the baby. All the women in the ‘planned’ group agreed with their partner to have a baby. This holds true for 24.4% of the women in the other two groups. Conclusion: Results revealed similar findings as other studies in terms of contraception use, pregnancy timing, pregnancy intent, desire to have a baby, partner involvement and health-promoting behaviours during pregnancy. The large size of the ambivalent category emphasises that pregnancy planning cannot be viewed in terms of two dichotomous points, but should rather be thought of as a scale or continuum.

In this study, to explore the illness perceptions of adolescents with well-controlled type 1 diabetes mellitus in South Africa, semi-structured interviews were conducted with nine, purposively selected adolescents (mean = 13.9 years; median = 12). Themes that emerged from the thematic analysis include the following: accepting diabetes and the diabetes care plan as part of their lives; viewing diabetes as manageable and as their responsibility; and the important role of gaining information on diabetes and diabetes management. These perceptions contributed to adherence to diabetes care plans and should be explored and developed among adolescents with type 1 diabetes mellitus to improve their diabetes management.

Factors associated with chronic obstructive pulmonary disease (COPD) among never-smokers have received little research attention. One potential risk factor for COPD is obesity, which is of particular importance in light of the global obesity epidemic. The objective of this study was to investigate the association between COPD and levels of obesity in a nationally representative sample of non-Hispanic white never-smokers. Data were drawn from the 2012 Center for Disease Control’s Behavioral Risk Factor Surveillance System (BRFSS). Pearson’s chi-square tests and logistic regression analyses were conducted in a large nationally representative sample of non-Hispanic white respondents aged 50 and over (76,004 women; 37,618 men) who reported that they had never smoked. A dose-response relationship was observed for both men and women: the prevalence of COPD increased from 2.5% in men and 3.5% in women who were of a healthy weight (BMI < 25) to 7.6% in men and 13.4% in women who had a BMI of 40 or higher. Even after adjusting for 7 potential confounds (e.g., age, education, and income), the odds of COPD were 3.21 higher for men (95% CI = 2.46, 4.20) and 4.00 higher for women with class III obesity (95% CI = 3.52, 4.55) in comparison with those of healthy weight. Regular screening for COPD is warranted in never-smoking obese patients who are aged 50 and over. Future research is needed to investigate plausible mechanisms for this association, including (1) the role of chronic inflammation associated with obesity and (2) the impact of central obesity on respiratory system mechanics.

This study focuses on two main issues concerning changes in student attitudes toward science study and their perceptions of its usefulness in their lives. Information has been gathered concerning how student attitudes toward science have changed for teachers and schools not involved with any funded professional development project. Pretesting and posttesting were administered with such "control” groups at the same intervals corresponding with the data collected from students with teachers enrolled in five funded Professional Development projects over the 1981-2008 interim. The grade levels used by the National Assessment of Education Progress in their 1977 assessment of science were used; it focused on students in grades 3, 7, and 11. The results indicate a steady decline in student positive attitudes concerning their science study as grade levels increase. Conversely, the student perceptions of the usefulness of their science study as related to daily living, further science study, and for potential careers remained much the same over the 30-year interim is a second focus. Generally, results indicate that traditional teaching and major use of textbooks cause increasingly negative student attitudes about science while not producing major changes in their perceptions of its usefulness in their lives. (Contains 3 tables and 1 figure.)

The purpose of this grounded theory study was to provide a framework for understanding the contemporary experience of First Nations grandparents. Fifteen respondents (N = 15) were selected from two demographically different Canadian cities. Seven of the grandparents lived with their child and a grandchild or grandchildren at the time of the interview; an additional four had lived with their grandchildren at some point prior to this investigation. Results revealed that First Nations grandparents had leveraged their own experiences of cultural disruption to reinvest in the cultural health and well-being of their grandchildren. One grandfather described this role as "walking the red road" which entailed a responsibility "to provide wisdom and . . . protection." Identified benefits of rejuvenating traditions and grandparent involvement included cultural healing and joy. (Contains 1 figure and 3 footnotes.)

• Mild to moderate stage Alzheimer's Disease patients are more prone to falls. • Both clinical balance test scores and posturograhic balance measures are lower in mild to moderate Alzheimer's Disease patients than healthy peers. • Early screening for balance and falls in mild to moderate Alzheimer's Disease patients is crucial. The aim of the study was to compare balance performance in mild-moderate stage Alzheimer's disease (AD) patients and healthy peers using clinical balance tests and computerized posturography. We recruited 95 patients and divided them into two groups; 51 patients (62 % (n=32) female) in AD group and 44 patients in healthy controls group (50 % (n=22) female). Berg Balance Scale (BBS) and Timed Up & Go (TUG) test were performed. Computerized posturography was performed. The mean age was 77.2±5.5 years in the AD group and 73.8±4.4 years in the control group (p<0.001). Sensory organization test composite equilibrium score (60[30-81], p<0.001), step quick turn-sway velocity (69.2 [38.2-95.8], p<0.001) and step quick turn-time (3.8 [1.6-8.4], p<0.001) were significantly impaired in mild-moderate stage AD patients. Berg Balance Scale (50 [32-56], p<0.001) and TUG test (13.0 [7.0-25.7], p<0.001) results were worse in AD. Computerized posturography measures were impaired in mild-moderate AD patients. The results highlight importance of early screening for balance and fall risk in AD patients. The study provides multi-dimensional and holistic assessment of balance performance in early-stage AD patients. Alzheimer's disease patients at earlier stages are prone to fall risk and should be evaluated accordingly. [ABSTRACT FROM AUTHOR]

Introduction: Major inequities exist in levels of health and wellbeing, availability, and access to healthcare services between seniors of Indigenous and non-Indigenous background in Ontario. First Nations elders are 45-55% more frail than the average senior in Ontario. Additionally, needed rehabilitation services are not easily accessible or available in the first language of most First Nations elders within their home communities. A literature review demonstrated community-based rehabilitation assistant models had been successfully developed and implemented in regions facing similar equity and access challenges. Building on these findings, a needs assessment was conducted to capture unique needs and requirements in Northwestern Ontario relating to rehabilitation among First Nations elders. Methods: The needs assessment resulted in four First Nations, three Indigenous health organizations, three rehabilitation health organizations, and two academic institutions iteratively developing and evaluating curriculum for a Community Rehabilitation Worker (CRW) program in treaty territories 5, 9, and Robinson-Superior. The goal of the program is to train local CRWs, familiar with local languages and cultures, to provide rehabilitative services that support ageing in place, health, wellbeing, and quality of life for First Nations elders. The study employed a community participatory action research approach aligning with the OCAP® (Ownership, Control, Access, and Possession) framework for working with Indigenous populations. Seventeen community partners were active participants in the program development, evaluation, and adaptation of the CRW curriculum. Feedback was received through advisory committee meetings, surveys, and individual and group interviews. Results: All 101 participants agreed, across all curriculum modules, that (1) the time allotment was realistic; (2) instructional materials, activities, and resources were appropriate and easy to understand; (3) evaluation activities accurately measured learning; and (4) participants identifying as Indigenous felt that Indigenous culture was adequately reflected. The qualitative findings highlighted the importance of incorporating culture, spirituality, traditions, local language use, and reintegration of First Nations elders into traditional activities and community activities for both the CRW curriculum and rehabilitation efforts. The need for locally available First Nations, elder-focused mental health support, transportation options, and gathering spaces such as those commonly seen in urban areas was also highlighted. Conclusion: The process of iteratively developing and evaluating a CRW program resulted in a Northwestern Ontario college welcoming the first cohort of students to the CRW program in March 2022. The program is co-facilitated with a First Nations Elder and includes components of local culture, language, and the reintegration of First Nations elders into community as part of the rehabilitation efforts. In addition, to appropriately support the quality of life, health, and wellbeing of First Nations elders, the project team called upon provincial and federal governments to work with First Nations to make available dedicated funding to address inequities in resources available to First Nations elders in Northwestern Ontario urban and First Nations remote communities. This included elder-focused transportation options, mental health services, and gathering places. The program implementation will be evaluated with the first cohort of CRWs for further adaptations considering potential scale and spread. As such, the project and findings may also represent a resource for others wishing to pursue similar development using participatory approaches in rural and remote communities both nationally and internationally. [ABSTRACT FROM AUTHOR]

Objective: To explore the role of biomarkers (hsCRP, sRANKL, PRDX1 and EPO) in arterial stiffness and in predicting further vascular events. Methods: Patients from the ongoing ASIST study each attended a laboratory visit within fourteen days of their diagnosed TIA or lacunar stroke. Arterial stiffness was calculated using cfPWV (carotid-femoral pulse wave velocity) measured with Complior ®Artech, France, and with the CAVI ®Fukuda, Japan (cardio-ankle vascular index) method. Blood samples were taken for ELISA assays. Analysis was completed with SPSS software Results: Forty patients were evaluated in this preliminary project (29 male/11 female, mean age 70.7±11.99), with four experiencing a further event during the six month follow up (10%). All biomarkers and both measurements for arterial stiffness had a higher mean value in patients with a further event (hsCRP 3.89 vs 1.42, P = 0.08; EPO 9.06 vs 9.01, P = 0.85; sRANKL 0.05 vs 0.03, P = 0.31; PRDX1 6.27 vs 6.21, P = 0.95; CAVI 11.13 vs 9.69, P = 0.15; cfPWV 10.82 vs 10.2, P = 0.55), however none were statistically significant. Levels of PRDX1 were elevated acutely post-event before falling significantly (R = −0.475, P = 0.002), while hsCRP and EPO continued to be elevated at >10 days post- event. In addition, CAVI correlated closely with hsCRP (R = 0.28, P = 0.09) and EPO (R = 0.29, P = 0.08), but cfPWV was not closely related to any of the biomarkers. Conclusions: This preliminary data suggests that biomarkers, particularly EPO and hsCRP, are more closely related to CAVI than cfPWV. hsCRP was the most relevant as an independent predictive factor for further vascular events.

Two important parent groups are solo grandfathers and single fathers raising children alone. The health of male caregivers raising children has received little attention by scholars. Investigating the health of single male caregivers raises awareness about their physical vulnerability. This study uses the 2012 Behavioral Risk Factor Surveillance System to compare health characteristics of 82 solo grandfathers with 396 single fathers aged 50 years and older. The findings suggest that grandfathers exhibited a high prevalence for various health conditions, including diabetes (44%), heart attack (27%), chronic obstructive pulmonary disease (23%), and stroke (6%). Almost half of grandfathers rated their health as fair/poor (47%), and nearly two in five had functional limitations (38%). Although older single fathers had better health characteristics than grandfathers, their health profile was poorer than population norms. Logistic regression analysis suggests that solo grandfathers are more at risk for poor health outcomes than older single fathers. Practice interventions to minimize health risks are discussed.

Background: Dementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB. Objectives: To study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers. Review methods: Cochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies. Design: ResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants. Settings: ResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England. Participants: ResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews. Intervention: An online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools. Main outcome measures: ResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications. Results: ResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings. Limitations: Functionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals. Conclusions: A Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care. Future work: There is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts. Trial registration: Current Controlled Trials ISRCTN02553381 (the ResCare trial) and ISRCTN58876649 (the FamCare study). Funding: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 5, No. 15. See the NIHR Journals Library website for further project information.

Background: There is currently no disease-modifying treatment available to halt or delay the progression of the disease pathology in dementia. An agreed core set of the best-available and most appropriate outcomes for disease modification would facilitate the design of trials and ensure consistency across disease modification trials, as well as making results comparable and meta-analysable in future trials. Objectives: To agree a set of core outcomes for disease modification trials for mild to moderate dementia with the UK dementia research community and patient and public involvement (PPI). Data sources: We included disease modification trials with quantitative outcomes of efficacy from (1) references from related systematic reviews in workstream 1; (2) searches of the Cochrane Dementia and Cognitive Improvement Group study register, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Latin American and Caribbean Health Sciences Literature and PsycINFO on 11 December 2015, and clinical trial registries [International Standard Randomised Controlled Trial Number (ISRCTN) and clinicaltrials.gov] on 22 and 29 January 2016; and (3) hand-searches of reference lists of relevant systematic reviews from database searches. Review methods: The project consisted of four workstreams. (1) We obtained related core outcome sets and work from co-applicants. (2) We systematically reviewed published and ongoing disease modification trials to identify the outcomes used in different domains. We extracted outcomes used in each trial, recording how many used each outcome and with how many participants. We divided outcomes into the domains measured and searched for validation data. (3) We consulted with PPI participants about recommended outcomes. (4) We presented all the synthesised information at a conference attended by the wider body of National Institute for Health Research (NIHR) dementia researchers to reach consensus on a core set of outcomes. Results: We included 149 papers from the 22,918 papers screened, referring to 125 individual trials. Eighty-one outcomes were used across trials, including 72 scales [31 cognitive, 12 activities of daily living (ADLs), 10 global, 16 neuropsychiatric and three quality of life] and nine biological techniques. We consulted with 18 people for PPI. The conference decided that only cognition and biological markers are core measures of disease modification. Cognition should be measured by the Mini Mental State Examination (MMSE) or the Alzheimer’s Disease Assessment Scale – Cognitive subscale (ADAS-Cog), and brain changes through structural magnetic resonance imaging (MRI) in a subset of participants. All other domains are important but not core. We recommend using the Neuropsychiatric Inventory for neuropsychiatric symptoms: the Disability Assessment for Dementia for ADLs, the Dementia Quality of Life Measure for quality of life and the Clinical Dementia Rating scale to measure dementia globally. Limitations: Most of the trials included participants with Alzheimer’s disease, so recommendations may not apply to other types of dementia. We did not conduct economic analyses. The PPI consultation was limited to members of the Alzheimer’s Society Research Network. Conclusions: Cognitive outcomes and biological markers form the core outcome set for future disease modification trials, measured by the MMSE or ADAS-Cog, and structural MRI in a subset of participants. Future work: We envisage that the core set may be superseded in the future, particularly for other types of dementia. There is a need to develop an algorithm to compare scores on the MMSE and ADAS-Cog. Study registration: The project was registered with Core Outcome Measures in Effectiveness Trials [www.comet-initiative.org/studies/details/819?result=true (accessed 7 April 2016)]. The systematic review protocol is registered as PROSPERO CRD42015027346. Funding: The National Institute for Health Research Health Technology Assessment programme.

Background: Dementia is a national priority and this research addresses the Prime Minister’s commitment to dementia research as demonstrated by his 2020 challenge and the new UK Dementia Research Institute. In the UK > 800,000 older people have dementia. It has a major impact on the lives of people with dementia themselves, on the lives of their family carers and on services, and costs the nation £26B per year. Pharmacological cures for dementias such as Alzheimer’s disease are not expected before 2025. If no cure can be found, the ageing demographic will result in 2 million people living with dementia by 2050. People with dementia lose much more than just their memory and their daily living skills; they can also lose their independence, their dignity and status, their confidence and morale, and their roles both within the family and beyond. They can be seen as a burden by society, by their families and even by themselves, and may feel unable to contribute to society. This programme of research aims to find useful interventions to improve the quality of life of people with dementia and their carers, and to better understand how people with dementia can be supported at home and avoid being admitted to hospital. Objectives: (1) To develop and evaluate the maintenance cognitive stimulation therapy (MCST) for people with dementia; (2) to develop the Carer Supporter Programme (CSP), and to evaluate the CSP and Remembering Yesterday, Caring Today (RYCT) for people with dementia both separately and together in comparison with usual care; and (3) to develop a home treatment package (HTP) for dementia, to field test the HTP in practice and to conduct an exploratory trial. Methods: (1) The MCST programme was developed for people with dementia based on evidence and qualitative work. A randomised controlled trial (RCT) [with a pilot study of MCST plus acetylcholinesterase inhibitors (AChEIs)] compared MCST with cognitive stimulation therapy (CST) only. The MCST implementation study conducted a trial of outreach compared with usual care, and assessed implementation in practice. (2) The CSP was developed based on existing evidence and the engagement of carers of people with dementia. The RCT (with internal pilot) compared the CSP and reminiscence (RYCT), both separately and in combination, with usual care. (3) A HTP for dementia, including the most promising interventions and components, was developed by systematically reviewing the literature and qualitative studies including consensus approaches. The HTP for dementia was evaluated in practice by conducting in-depth field testing. Results: (1) Continuing MCST improved quality of life and improved cognition for those taking AChEIs. It was also cost-effective. The CST implementation studies indicated that many staff will run CST groups following a 1-day training course, but that outreach support helps staff go on to run maintenance groups and may also improve staff sense of competence in dementia care. The study of CST in practice found no change in cognition or quality of life at 8-month follow-up. (2) The CSP/RYCT study found no benefits for family carers but improved quality of life for people with dementia. RYCT appeared beneficial for the quality of life of people with dementia but at an excessively high cost. (3) Case management for people with dementia reduces admissions to long-term care and reduces behavioural problems. In terms of managing crises, staff suggested more costly interventions, carers liked education and support, and people with dementia wanted family support, home adaptations and technology. The easy-to-use home treatment manual was feasible in practice to help staff working in crisis teams to prevent hospital admissions for people with dementia. Limitations: Given constraints on time and funding, we were unable to compete the exploratory trial of the HTP package or to conduct an economic evaluation. Future research: To improve the care of people with dementia experiencing crises, a large-scale clinical trial of the home treatment manual is needed. Conclusion: There is an urgent need for effective psychosocial interventions for dementia. MCST improved quality of life and was cost-effective, with benefits to cognition for those on AChEIs. MCST was feasible in practice. Both CSP and RYCT improved the quality of life of people with dementia, but the overall costs may be too high. The HTP was useful in practice but requires evaluation in a full trial. Dementia care research may improve the lives of millions of people across the world. Trial registrations: Current Controlled Trials ISRCTN26286067 (MCST), ISRCTN28793457 (MCST implementation) and ISRCTN37956201 (CSP/RYCT). Funding: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 5, No. 5. See the NIHR Journals Library website for further project information.

[This corrects the article DOI: 10.1371/journal.pone.0171742.].

BACKGROUND:Environmental factors during childhood are thought to play a role in the aetiology of Crohn's Disease (CD). In South Africa, recently published work based on an investigation of 14 childhood environmental exposures during 3 age intervals (0-5, 6-10 and 11-18 years) has provided insight into the role of timing of exposure in the future development of CD. The 'overlapping' contribution of the investigated variables however, remains unclear. The aim of this study was to perform a post hoc analysis using this data and investigate the extent to which each variable contributes to the subsequent development of CD relative to each aforementioned age interval, based on a score analysis approach. METHODS:Three methods were used for the score analysis. Two methods employed the subgrouping of one or more (similar) variables (methods A and B), with each subgroup assigned a score value weighting equal to one. For comparison, the third approach (method 0) involved no grouping of the 14 variables. Thus, each variable held a score value of one. RESULTS:Results of the score analysis (Method 0) for the environmental exposures during 3 age intervals (0-5, 6-10 and 11-18 years) revealed no significant difference between the case and control groups. By contrast, results from Method A and Method B revealed a significant difference during all 3 age intervals between the case and control groups, with cases having significantly lower exposure scores (approximately 30% and 40% lower, respectively). CONCLUSION:Results from the score analysis provide insight into the 'compound' effects from multiple environmental exposures in the aetiology of CD.

Objectives: This study examined the relationship between childhood sexual abuse (CSA) and myocardial infarction in men and women, while controlling for social determinants (i.e., socioeconomic status, social support, mental health) and traditional cardiovascular risk factors (i.e., age, race, obesity, smoking, physical inactivity, diabetes mellitus). Methods: Population-based data were obtained from the 2010 Behavioral Risk Factor Surveillance System. Myocardial infarction was ascertained by self-report of a health-professional diagnosis. CSA was defined as forced sex with someone at least 5 years older before the age of 18. The final sample included 5,095 men and 7,768 women. Results: After adjustment for 15 factors, abused males had nearly 3 times the odds of heart attack compared to non-abused males (OR=2.96; 95% CI=1.12, 7.85). Among women, CSA was not associated with heart attack in the age-race adjusted (OR=1.20; 95% CI=0.39, 3.68) or fully-adjusted (OR=0.88; 95% CI=0.28, 2.75) analyses. Conclusions: CSA was associated with heart attack in men, even when controlling for traditional risk factors; however, no association was found among women. Future research is needed to replicate the study's unique findings. (Contains 2 tables.)

A regionally representative Canadian sample was used to investigate the gender-specific relationship between childhood physical abuse and lifetime suicidal ideation. The prevalence of suicidal ideation was about five times higher in abused men and women compared with their nonabused counterparts. After controlling for five clusters of potentially confounding factors (adverse childhood conditions, socioeconomic factors, health behaviors, psychosocial stressors/chronic illnesses, and mental health), childhood physical abuse was significantly associated with suicidal ideation (OR[subscript adjusted] women = 4.48, 95% CI = 3.32-6.04; men = 3.57, 95% CI = 2.08-6.14). These findings suggest childhood physical abuse is independently associated with suicidal ideation and highlight the importance of providing preventative treatment to childhood abuse survivors.

This study investigated childhood physical abuse and ulcers in a regionally representative community sample. Age, race and sex were controlled for in addition to five clusters of potentially confounding factors: adverse childhood conditions, adult socioeconomic status, current health behaviors, current stress and marital status, and history of mood/anxiety disorders. Childhood physical abuse is associated with many negative physical and psychological adult health outcomes. Two recent studies demonstrate a potential link between childhood physical abuse and peptic ulcer disease in adulthood. The authors use regional data for the Canadian provinces of Manitoba and Saskatchewan from the 2005 Canadian Community Health Survey. Of the 13,069 respondents with complete data on abuse and ulcers, 7.3% (n = 1,020) report that they had been physically abused as a child by someone close to them and 3.0% (n = 493) report that they had been diagnosed with peptic ulcers by a health professional. The regional response rate is approximately 84%. Findings show that those reporting abuse had more than twice the prevalence of ulcers than did those not reporting abuse (6.6% vs. 2.7%). The fully adjusted odd ratio of peptic ulcers among those who had reported childhood physical abuse is 1.68 (95% CI = 1.22, 2.32). A significant and stable relationship between childhood physical abuse and peptic ulcers is found, even when taking into account five clusters of potentially confounding factors. Prospective studies that apply the biopsychosocial model are likely to be the most effective for identifying the pathways that connect childhood physical abuse and ulcer disease. (Contains 1 table and 1 figure.)

The purpose of this paper is to assess the impact of a series of brief interventions (BIs) on anti-natal alcohol consumption of women from a disadvantaged and high-risk background attending state health clinics in a rural district, Western Cape Province, South Africa. A pragmatic cluster randomised trial design was followed. All pregnant women, who were less than 20 weeks pregnant and more than 15 years of age, were eligible for the study. The intervention comprised a comprehensive assessment for current and lifetime alcohol use plus information (control group) or comprehensive assessment plus four BI sessions over the pregnancy period (intervention group). The Alcohol Use Disorders Identification Test (AUDIT) was completed pre- and post-intervention. Although both groups demonstrated declines in AUDIT scores, findings showed a statistically significant difference in the total AUDIT scores between the intervention and control groups post-intervention (F = 9.54, p = 0.002). The difference was two units (SE = 0.6). The follow-up rate was 92% (N = 179 of the original 194 eligible women). The impact of BIs is shown to be a powerful tool. Information and an understanding, supportive attitude seem to be crucial agents for behaviour change. (Contains 2 figures and 2 tables.)

Objectives: Although, the relationship between childhood physical abuse and adult heart disease has been documented, very few studies have controlled for many of the known risk factors for heart disease. The objective of the current study, therefore, was to investigate the association between childhood physical abuse and adult heart disease while controlling for the following established risk factors: (1) childhood stressors; (2) adult health behaviors; (3) adult stressors; (4) depression; and, (5) high pressure. Methods: Data was obtained from the 2005 Canadian Community Health Survey. The sample included 13,093 respondents from the Canadian provinces of Manitoba and Saskatchewan, of whom 7.4% (n = 1025) reported that they had been physically abused as a child by someone close to them and 4.4% (n = 850) reported that they had been diagnosed with heart disease by a health professional. The regional level response rate was 84%. Results: The age-gender-race adjusted odds ratio of heart disease among those who had reported childhood physical abuse was 1.57 (95% CI = 1.12, 2.20). When adjustments were made for all of the established risk factors the odds ratio declined to 1.45 (95% CI = 1.01, 2.08). Conclusions: The relationship between childhood physical abuse and heart disease persists even when controlling for five types of factors previously thought to mediate the relationship. Practice implications: Further research would benefit from a closer analysis of the potential mechanisms linking childhood physical abuse and heart disease. (Contains 2 tables and 1 figure.)

This paper reports findings from a study of young children's views about electric circuits. Twenty-eight children aged 5 and 6 years were interviewed. They were shown examples of circuits and asked to predict whether they would work and explain why. They were then invited to try out some of the circuit examples or make circuits of their own choosing. Children expressed a variety of views about the connections needed in a circuit, offered different kinds of explanation and showed differing levels of competence in circuit making. The range of responses showed similarities to those of older students found in previous research. The relationship between practical competence, prediction, and explanation was not straightforward. For example, children with similar levels of practical competence made different predictions or offered different kinds of explanation. Analysis of the circuits children chose to construct suggested influences of existing competence and knowledge. In particular, some children tested out circuit examples about which they had been unsure during the interview, while others explored circuit connections more generally. Findings underline the importance of drawing on a variety of evidence in assessing young children's understandings of electric circuits. They indicate that young children may offer views about electric circuits not unlike those of older children and adults with similar experience. Finally, there was some suggestion that the interview procedure may have acted as an instructive stimulus in helping children to become more conscious of their own views and reflect on their thinking in the light of further evidence. (Contains 1 figure and 4 tables.)

This study examined the relationships among students' learning approaches, motivational goals, previous science grades, and their science achievement for the concepts related to atomic theory and explored the effects of gender and sociodemographic variables on students' learning approaches, motivational goals, and their science achievement for the concepts related to atomic theory. The sample constituted 416 seventh grade elementary students. A Science Achievement Test (specifically designed for atomic theory), A Learning Approach Questionnaire, and An Achievement Motivation Questionnaire were administered to the students. Results of the correlation analyses revealed positive relationships among meaningful learning, performance orientation, and self efficacy. Students' previous science grades were positively correlated with achievement, meaningful learning, and self-efficacy and negatively correlated with rote learning and performance orientations. ANOVA results revealed that participants' parents' education level had significant effect on their achievement and meaningful learning, rote learning, and approach performance orientations. (Contains 1 figure and 4 tables.)

Purpose: Older adults are less likely than any other age group to use the federal Food Stamp Program. The personal and social costs of elderly diet insufficiency include disease exacerbation, depression, and increased hospitalization. In order to improve targeting and outreach efforts, this study identifies the characteristics of eligible older Americans who are not receiving food stamps and assesses the validity of the Andersen behavioral model for predicting impoverished older adults food stamp use. Design and Methods: We conducted a secondary analysis of the 2003 American Community Survey, which is a nationally representative survey with a response rate of 96.7%. We restricted our study subsample to the 14,724 impoverished American citizens who were aged 65 years and older. We used bivariate and logistic regression analyses to compare the 2,796 food stamp recipients with the 11,928 nonrecipients. Results: One in five impoverished older American citizens had received foods stamps in the preceding year. Female respondents, renters, younger respondents, disabled individuals, and those who received Supplemental Security Income or welfare were more likely to receive food stamps. The pseudo-R-square value indicated that the Andersen Behavioral Model explained 28% of the model's variability. Implications: Improved targeting is needed to enhance older adults' participation rates. Mobile and satellite food stamp offices in lower income neighborhoods and other innovative outreach programs that collaborate with community partners could also improve access. With the vast majority of impoverished older adults not receiving food stamps, strategies such as these are extremely important to rectify this situation among the most vulnerable group of older Americans.

Introduction: Videoconferencing (VC) is becoming a common method for the delivery of continuing education (CE) to clinicians in remote locations. The purpose of this study was to compare the effectiveness, acceptability, and costs of a full-day training workshop (TW) delivered through two different formats: face-to-face (FTF) and VC. The TW was designed to teach administration and scoring guidelines for the Chedoke-McMaster Stroke Assessment, an outcome measure used by rehabilitation professionals. Methods: The TW was delivered simultaneously in FTF and VC formats to a total of five remote communities on two separate occasions. Participants completed a test of scoring competency at the beginning (pretest) and end (posttest) of the TW as well as a feedback questionnaire. A cost comparison was also undertaken. Results: Forty-four physical and occupational therapists participated. No significant between-group differences were found in posttest scoring competency related to delivery format (FTF or VC): (F[subscript 1,38] = 0.6, MSE = 3.6, p greater than 0.4), or for the two workshops: (F[subscript 1,38] = 1.4, MSE = 3.6, p greater than 0.2). Despite technical difficulties, participant experience was rated as "good" to "excellent." The VC method offered considerable cost savings to participants and their organizations, at a minimum of $7,437 (Canadian). Conclusion: Clinicians participating in the TW via VC performed as well as those in the FTF group on the competency test. Videoconferencing improves access to CE, is well received by participants, and provides a cost-effective method of course delivery. Further evaluation of other CE events delivered through VC is indicated. (Contains 1 figure and 4 tables.)