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In this study, we compared a wide range of cell-based bioassays to the use of chemical analysis followed by exposure-activity ratio (EAR) and Toxicological Prioritization index (ToxPi) for prioritizing chemicals, sites, and hazard concerns in water samples. Surface water samples were collected from nine sites in three Central Pennsylvania streams and analyzed for a forty-six contaminants of emerging concern (CECs), including pesticides, personal care products, and pharmaceuticals. Cell-based reporter assays evaluated human and zebrafish molecular initiating events (MIEs) in endocrine and metabolic disruption, altered lipid metabolism, and oxidative stress. Bioassays showed that 12 out of 40 assays had at least one site with activity over the effect-based trigger (EBT) values. The receptors that exhibited the highest number of samples above the EBT that would be expected to cause toxicity were Aryl hydrocarbon receptor (AhR, human and zebrafish), Pregnane X Receptor (PXR), Estrogen Receptor-beta (ERB), and Androgen Receptor (AR). Characterizing the collection sites by their bioactivity aligned closely with the stream in which samples were collected. The sum of all EARs for each chemical indicated that the pharmaceutical Carbamazepine and the pesticides Carbaryl and Atrazine posed the greatest concern. However, predicted activity and site prioritization based on individual chemical analysis and calculated EAR were different than those measured by bioassay, indicating that biologically active chemicals are present in the samples that were not included in the targeted analytes. Taken together, these data show that chemical analysis and EAR analysis are beneficial for prioritization of chemicals, whereas mechanism-based bioassays are more inclusive of known as well as unknown chemical contaminants and thus of more use for overall water quality analysis and site prioritization., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: John P. Vanden Heuvel reports financial support was provided by INDIGO Biosciences Inc. J.P. Vanden Heuvel is a Founder and Chief Scientific Officer of INDIGO Biosciences, Inc. For other authors there are no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The human hand has constant contact with the environment, hence requires regular hand hygiene. Hand hygiene has gained recognition because of the COVID-19 pandemic and is a largely effective, affordable preventive measure against infectious diseases. This study used both national and sub-national analyses to evaluate the effect of COVID-19 handwashing guidelines on instances of diarrhea in Ghana., Methods: Data on diarrhea cases spanning February 2018 and March 2022 were retrieved from the District Health Information Management System (DHIMS 2) using a data extraction guide. The data were summarized using descriptive statistics. The difference in diarrhea cases between the pre-COVID-19 and COVID-19 periods was measured using a two-sample t-test across Ghana's 16 administrative areas. Causal Impact package in R statistical software was employed to determine the impact of the introduction of COVID-19 hand hygiene protocols on diarrheal disease., Results: A total of 5,645,533 diarrheal cases reported between February 2018 and March 2022 through the routine MIS (DHIMS2) were examined. Fifty-three percent of the cases occurred before the introduction of the hand hygiene protocol. Descriptive statistics indicated a statistically significant decrease in average diarrheal cases during the hand hygiene implementation era (13,463 cases reduction, p<0.001). Sub-national analyses revealed significant reductions in various regions: Greater Accra, Ashanti, Ahafo, Central, Eastern, Northern, Upper East, Upper West, and Volta (p<0.05). Causal impact analysis confirmed 11.0% nationwide reduction in diarrheal cases attributed to the COVID-19 hand hygiene protocols (p<0.001)., Conclusion: This study underscores the effectiveness of COVID-19 hand hygiene protocols in reducing diarrheal morbidity in Ghana, with varying regional impacts. These findings advocate for the sustenance of investments and commitments made at the COVID hand hygiene protocols, particularly in this era where the pandemic appears controlled., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Adu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The COVID-19 pandemic has caused increased anxiety among medical students due to the uncertainty of the long-term effects on the future of medical education. There are currently insufficient studies aimed at investigating the changes in the mental health and studying habits of medical students during public health emergencies such as this pandemic, as well as methods that can be incorporated to appropriately manage anxiety effectively. To investigate the psychological impact and associated factors on medical students during the pandemic. This retrospective, cross-sectional study consisted of 291 medical students of the faculty of medical sciences at the university of the West Indies, St. Augustine campus, Trinidad and Tobago. The mental health and study habits of said students were assessed with the use of questionnaires via an online survey platform. Data of our study showed that 56% of the students were experiencing increased stress and anxiety. Students of 82.8% experienced irregular sleeping habits and 76.3% of participants experienced a change in eating habits brought on by the pandemic. Participants of 67.4% studied less than 4 hrs. a day, 61.5% were less productive, 62.2% showed an inability to focus and avoid distractions in their study environment during the COVID-19 pandemic. There is a need for proper supportive strategies to assist students in effectively managing anxiety and depression during public health emergencies such as COVID-19. It is suggested that all universities, colleges and education bodies alike implement a pandemic preparedness course as well as an accessible online support forum.

Competing Interests: Conflicts of interest the authors declare they have no conflicts of interest.

Background: Environmental contamination with antimicrobial agents is one of the leading drivers of antimicrobial resistance (AMR) worldwide. However, scarce data exists concerning the factors fueling unsafe disposal of medicines globally. This study aimed to assess for the knowledge, practices, and barriers concerning safe disposal of unwanted medicines among health professions students (HPS) at Makerere University, Uganda., Methods: We conducted a cross-sectional study using an online assessment tool sent through WhatsApp groups and E-mail addresses of undergraduate HPS at the College of Health Sciences Makerere University, Uganda between 1 st February and 16 th March 2022.Good knowledge was defined as a score of 80% of the knowledge domain questions on a standardized questionnaire., Results: We enrolled 205 participants, 135 (65.9%) were male, with a median age of 23 (range: 19 -43) years. Overall, 157 (76%) participants had good Knowledge. The mean knowledge score was 63%. About half (n=102, 49.8%) of the participants had unused medicines kept at their respective residential places, mainly antibiotics (27%, ×/102) and analgesics (21 %, ×/102). The most common method of medicine disposal was dumping into household garbage (n=103, 50.2%). Only 37 (18%) of participants had ever used the take-back method of medicine disposal. The most reported barriers for safe disposal were inadequate knowledge and insufficient advice from the dispensers concerning safe disposal practices. Year of study was the only factor significantly associated with knowledge about safe disposal of medicines, (adjusted Odds Ratio: 9.7, 95%CI 2.3 - 40.5, p= 0.002), with participants in higher academic years having more knowledge than those in lower years., Conclusion: Despite a good knowledge level among the participants, the practice of safe disposal of unused medicines remains suboptimal in this population. Strategies aimed at enhancing safe disposal practices such as giving proper instructions to medicine buyers by dispensers regarding disposal practices are recommended to abate the growing burden of AMR., Competing Interests: Competing interest The authors declare that they have no competing conflicts.

Anaemia in pregnancy remains a critical public health concern in many countries including Ghana and it poses severe consequences in the short to long-term for women and their unborn babies. Although antenatal care (ANC) is largely provided for pregnant women, the extent its utilisation protects against anaemia in pregnancy remains largely understudied. The study assessed the adequacy of ANC services utilisation and its effect on anaemia among pregnant women in the Wa Municipality of Ghana. A facility-based cross-sectional survey was conducted. Probability proportionate to size sampling and systematic random sampling were used to select the facilities and 353 respondents. While 80⋅2 % of the pregnant women reported having received a sufficient number of ANC services provided, the prevalence of the overall ANC adequacy was only 44⋅2 %. After adjusting for potential confounders, pregnant women who could not achieve adequate ANC attendance were 2⋅3 times more likely to be anaemic in the third trimester of gestation AOR = 2⋅26 (95 % CI 1⋅05, 4⋅89), compared to their counterparts who maintained adequate ANC attendance. Adequate ANC attendance was a consistent and significant predictor of anaemia in pregnancy in the third trimester. Health and nutrition education on the need for early initiation of ANC attendance and support for the consumption of diversified diets are two possible interventions that can help contain anaemia in pregnancy., (© The Author(s) 2022.)

Background: Intermittent preventive treatment of malaria in pregnancy with Sulphadoxine-Pyrimethamine (IPTp-SP) tablets is one of the recommended interventions to reduce the burden of malaria on both the pregnant woman and the unborn child. The aim of this study was to assess the prevalence of IPTp-SP uptake and its associated factors in the Atwima Kwanwoma District of Ashanti Region, Ghana., Methods: The study was cross sectional. A structured questionnaire was administered to 394 respondents, comprising pregnant women in their last two months of pregnancy and nursing mothers who delivered within three months prior to the study. Medical records of the respondents were also reviewed. Descriptive statistics such as simple proportions, and averages were computed. Chi-square test and multiple logistic regression analysis were performed to determine factors associated with IPTp-SP uptake., Results: The average age of the respondents was 28.2 (±5.9) years. Almost all of the respondents (98%) had received SP at the time of the study. Fifty percent received their first dose of SP between 16 and 19 weeks of gestation. The multiple logistic regression analysis showed a statistically significant association between IPTp-SP uptake and educational level, time of first ANC visit, number of ANC visits and receiving education on SP prior to the administration of the drug., Conclusion: Education on SP use should be intensified at all levels of the health system. Early initiation of ANC is also recommended for optimal uptake of IPTp-SP. More research is needed to understand factors affecting the uptake of SP during pregnancy in the country., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2022 The Author(s).)

Objectives: Physical and mental health outcomes of autistic individuals deteriorate during transition to adulthood. The study aims to identify opportunities to improve physician knowledge in health-care transitions (HCT) for autistic individuals by understanding perceived versus experienced facilitators and barriers in overall HCT curriculum implementation in graduate medical education., Methods: Medicine-Pediatrics program directors participated in a Health Care Transition Residency Curriculum Collaborative Improvement Network and used an iterative process to develop and improve HCT curricula. Pre- and postcollaborative semistructured interviews were administered to program directors. The study occurred over 9 months (July 2018-February 2019). Recurring interview themes were analyzed utilizing Dedoose qualitative coding software and presented utilizing percentages and proportions., Results: Most program directors developed curricula in response to a gap in their current transition curricula. All program directors partially or completely met their goals during the collaborative. The most common types of curricular delivery were didactic (65%) and clinical experience-based (53%). Some tested unique delivery platforms, like the electronic medical record system (29%) and online modules (24%). Program directors often involved residents in the curricular development process and overwhelmingly (65%) felt this was a major facilitator. Competing priorities of faculty (71%) and of residents (53%) were the most common barriers., Conclusions: Gaps in HCT curricula delivery were primarily attributed to suboptimal health care systems where training occurs, though existing clinical experiences and diverse learning modalities were successfully leveraged. Using a quality improvement framework and actively engaging resident trainees in curriculum development were successful strategies programs used in the development of HCT curricula., Competing Interests: CONFLICT OF INTERST DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: Contact allergy is a major clinical and public health challenge. It is important to identify individuals who are at risk and perform patch testing to identify relevant allergens. Predicting clinical risk on the basis of input parameters is common in clinical medicine and traditionally has been achieved with linear models., Objectives: We hypothesized that the risk of a clinically relevant positive patch test could be predicted according to clinical and demographic parameters., Methods: We compared the predictive accuracy of logistic regression with more sophisticated machine learning approaches such as gradient boosting, in the prediction of patch testing results., Results: We found that both logistic regression and more sophisticated machine learning approaches were able to predict the risk of positive patch tests. For certain predictions, including the overall risk of a clinically relevant positive patch test, gradient boosting approaches can outperform logistic regression., Conclusions: These findings suggest that complex nonlinear interactions between input variables are relevant in risk prediction. While a risk prediction model cannot replace the judgment of an experienced clinician, quantifying the risk of a clinically relevant positive patch test result has the potential to assist in decision making and to inform discussions with patients., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Tramadol has gained popularity among the drugs of the most active population especially the respondents in Ghana abuse especially farmers who nicknamed as "farm and buy cow." It has recently become a public health concern, and stakeholders are worried about tramadol abuse and its implications on health in the Upper West Region. The study sought to measure the prevalence of tramadol/related substance abuse and the associated factors., Methods: A community-based analytic cross-sectional study involving 420 respondents was conducted. The participants were selected using a multistage sampling technique. Semistructured questionnaire was used to generate the data., Results: About 77.6% of the respondents abuse tramadol while 83.9% of the participants take at least one other related substance or drug. Participants with history of any substance abuse were 5 times more likely to abuse tramadol [AOR = 5.15; 95% CI (1.501-17.656); p = 0.009], compared to respondents with no history of any substance abuse. Respondents who take tramadol to enhance sex were 4 times more likely to abuse tramadol [AOR = 3.776; 95% CI (1.352-10.545); p = 0.011]. Formal sector employment was protective against tramadol abuse [AOR = 0.100; 95% CI (0.017-0.595); p = 0.011] compared to self-employment and the unemployed. In addition, use of nonopioid prescription drugs for posttraumatic/pain management reduced the risk of tramadol abuse [AOR = 0.237; 95% CI (0088-0.640); p = 0.004] compared to the posttraumatic/pain management dependence on prescription of only opioid like tramadol., Conclusion: An infantile municipality like Jirapa is challenged with high level of tramadol and related substance which has serious repercussion on the health system in the Jirapa district. It is important that measures are taken by the stakeholders to stop tramadol and related substance and mitigate the impact of drug abuse in the district., Competing Interests: All authors declare that they have no conflict of interests., (Copyright © 2021 Ferguson Saapiire et al.)

Cellular homeostasis requires adaption to environmental stress. In response to various environmental and genotoxic stresses, all cells produce dinucleoside polyphosphates (Np n Ns), the best studied of which is diadenosine tetraphosphate (Ap 4 A). Despite intensive investigation, the precise biological roles of these molecules have remained elusive. However, recent studies have elucidated distinct and specific signaling mechanisms for these nucleotides in prokaryotes and eukaryotes. This review summarizes these key discoveries and describes the mechanisms of Ap 4 A and Ap 4 N synthesis, the mediators of the cellular responses to increased intracellular levels of these molecules and the hydrolytic mechanisms required to maintain low levels in the absence of stress. The intracellular responses to dinucleotide accumulation are evaluated in the context of the "friend" and "foe" scenarios. The "friend (or alarmone) hypothesis" suggests that Ap n N act as bona fide secondary messengers mediating responses to stress. In contrast, the "foe" hypothesis proposes that Ap n N and other Np n N are produced by non-canonical enzymatic synthesis as a result of physiological and environmental stress in critically damaged cells but do not actively regulate mitigating signaling pathways. In addition, we will discuss potential target proteins, and critically assess new evidence supporting roles for Ap n N in the regulation of gene expression, immune responses, DNA replication and DNA repair. The recent advances in the field have generated great interest as they have for the first time revealed some of the molecular mechanisms that mediate cellular responses to Ap n N. Finally, areas for future research are discussed with possible but unproven roles for intracellular Ap n N to encourage further research into the signaling networks that are regulated by these nucleotides., (Copyright © 2020 Ferguson, McLennan, Urbaniak, Jones and Copeland.)

Global climate change poses a significant threat to natural communities around the world, with many plant species showing signs of climate stress. Grassland ecosystems are not an exception, with climate change compounding contemporary pressures such as habitat loss and fragmentation. In this study, we assess the climate resilience of Themeda triandra, a foundational species and the most widespread plant in Australia, by assessing the relative contributions of spatial, environmental and ploidy factors to contemporary genomic variation. Reduced-representation genome sequencing on 472 samples from 52 locations was used to test how the distribution of genomic variation, including ploidy polymorphism, supports adaptation to hotter and drier climates. We explicitly quantified isolation by distance (IBD) and isolation by environment (IBE) and predicted genomic vulnerability of populations to future climates based on expected deviation from current genomic composition. We found that a majority (54%) of genomic variation could be attributed to IBD, while an additional 22% (27% when including ploidy information) could be explained by two temperature and two precipitation climate variables demonstrating IBE. Ploidy polymorphisms were common within populations (31/52 populations), indicating that ploidy mixing is characteristic of T. triandra populations. Genomic vulnerabilities were found to be heterogeneously distributed throughout the landscape, and our analysis suggested that ploidy polymorphism, along with other factors linked to polyploidy, reduced vulnerability to future climates by 60% (0.25-0.10). Our data suggests that polyploidy may facilitate adaptation to hotter climates and highlight the importance of incorporating ploidy in adaptive management strategies to promote the resilience of this and other foundation species., (© 2020 John Wiley & Sons Ltd.)

Background/aims: We have previously shown that inhibition of the mitochondrial Kv1.3 channel results in an initial mitochondrial hyperpolarization and a release of oxygen radicals that mediate mitochondrial depolarization, cytochrome c release and death. Here, we investigated whether inhibition of Kv1.3 channels can also induce cellular resistance mechanisms that counteract the induction of cell death under certain conditions., Methods: We treated leukemic T cells with the mitochondria-targeted Kv1.3 inhibitor PCARBTP and determined the activity of different kinases associated with cell survival including ZAP70, PI-3-K, AKT, JNK and ERK by measuring the activation-associated phosphorylation of these proteins. Furthermore, we inhibited AKT and JNK and determined the effect of PCARBTP-induced tumor cell death., Results: We demonstrate that treatment of Jurkat T leukemia cells with low doses of the mitochondria-targeted inhibitor of Kv1.3 PCARBTP (0.25 μM or 1 μM) for 10 minutes induced a constitutive phosphorylation/activation of the pro-survival signaling molecules ZAP70, PI-3-K, AKT and JNK, while the phosphorylation/activation of ERK was not affected. Stimulation of Jurkat cells via the TCR/CD3 complex induced an additional activation of a similar pattern of signaling events. Higher doses of the Kv1.3 inhibitor, i.e. 10 μM PCARBTP, reduced the basal phosphorylation/activation of these signaling molecules and also impaired their activation upon stimulation via the TCR/CD3 complex. A low dose of PCARBTP, i.e. 0.25 μM PCARBTP, was almost without any effect on cell death. In contrast, concomitant inhibition of PI-3-K or AKT greatly sensitized Jurkat leukemia cells to the Kv1.3 inhibitor PCARBTP and allowed induction of cell death already at 0.25 μM PCARBTP., Conclusion: These studies indicate that Jurkat leukemia cells respond to low doses of the mitochondria-targeted Kv1.3 inhibitor PCARBTP with an activation of survival signals counteracting cell death. Inhibition of these T cell survival signals sensitizes leukemia cells to death induced by mitochondria-targeted Kv1.3 inhibitors. High doses of the Kv1.3 inhibitor inactivate these signals directly permitting death., Competing Interests: The authors declare to have no conflict of interest., (© Copyright by the Author(s). Published by Cell Physiol Biochem Press.)

Pediatric dental patients who cannot receive dental care in the clinic due to uncooperative behavior are often referred to receive dental care under general anesthesia (GA). At Stony Brook Medicine, dental patients requiring treatment with GA receive dental care in our outpatient facility at the Stony Brook School of Dental Medicine (SDM) or in the Stony Brook University Hospital ambulatory setting (SBUH). This study investigates the time and cost for ambulatory American Society of Anesthesiologists (ASA) Class I pediatric patients receiving full-mouth dental rehabilitation using GA in these 2 locations, along with a descriptive analysis of the patients and dental services provided. In this institutional review board-approved cross-sectional retrospective study, ICD-9 codes for dental caries (521.00) were used to collect patient records between July 2009 and May 2011. Participants were limited to ASA I patients aged 36-60 months. Complete records from 96 patients were reviewed. There were significant differences in cost, total anesthesia time, and recovery room time (P < .001). The average total time (anesthesia end time minus anesthesia start time) to treat a child at SBUH under GA was 222 ± 62.7 minutes, and recovery time (time of discharge minus anesthesia end time) was 157 ± 97.2 minutes; the average total cost was $7,303. At the SDM, the average total time was 175 ± 36.8 minutes, and recovery time was 25 ± 12.7 minutes; the average total cost was $414. After controlling for anesthesia time and procedures, we found that SBUH cost 13.2 times more than SDM. This study provides evidence that ASA I pediatric patients can receive full-mouth dental rehabilitation utilizing GA under the direction of dentist anesthesiologists in an office-based dental setting more quickly and at a lower cost. This is very promising for patients with the least access to care, including patients with special needs and lack of insurance.

The purpose of this report was to: summarize the care of a child between the ages of 12 to 16 years old born with Noonan-like central giant cell syndrome and unrelated common variable immune deficiency; provide information on the dental management of patients with Noonan's syndrome; and present a brief discussion of the recent associated genetic findings. A review of the common features of Noonan syndrome and Noonan-like central giant cell syndrome is also provided.

Objectives: Psychogenic nonepileptic seizures (PNES) are frequently encountered in epilepsy monitoring units (EMU) and can result in significant long-term disability. We reviewed our experience with veterans undergoing seizure evaluation in the EMU to determine the time delay to diagnosis of PNES, the frequency of PNES, and cumulative antiepileptic drug (AED) treatment. We compared veterans with PNES to civilians with PNES studied in the same EMU., Methods: We reviewed records of all patients admitted to one Veterans Affairs Medical Center (VAMC) EMU over a 10-year interval. These patients included 203 veterans and 726 civilians from the university affiliate. The percentage of patients with PNES was calculated for the veteran and civilian groups. Fifty veterans with only PNES were identified. Each veteran with PNES was matched to the next civilian patient with PNES. The 2 groups were compared for interval from onset of the habitual spells to EMU diagnosis, cumulative AED treatment, and other measures., Results: PNES were identified in 25% of veterans and 26% of civilians admitted to the EMU. The delay from onset of spells to EMU diagnosis averaged 60.5 months for veterans and 12.5 months for civilians (p < 0.001). Cumulative AED treatment was 4 times greater for veterans with PNES as compared to civilians (p < 0.01). Fifty-eight percent of veterans with PNES were thought to have seizures related to traumatic brain injury., Conclusions: The results indicate a substantial delay in the diagnosis of PNES in veterans as compared to civilians. The delay is associated with greater cumulative AED treatment.

This study was undertaken to establish the caries prevalence in Head Start/Early Head Start children among the non-fluoridate community of Suffolk County, Long Island, and to elicit access-to-oral-health-care issues that are present for these children. Three hundred five parents completed questionnaire surveys about access-to-care issues at Suffolk County Head Start centers. Two hundred sixteen Suffolk County Head Start children ages 2 to 5 were screened for this study. The average DMFT (decayed, missing, filled teeth) across all children screened was 2.01. Fifty-four percent of parents reported that their children received dental care in the last two years. Twenty-four percent of children who received dental care reported having access-to-care issues. Of the parents who encountered such issues, the most prevalent one stated was, "We could not find a dentist to accept our insurance." The authors concluded that there is a heightened prevalence of early childhood caries in the Head Start/Early Head Start population of Suffolk County, Long Island. There are high levels of underutilized dental care in this population. The parents in this community have reported there are access-to-care issues present that may result in high levels of dental disease.

Background: Red flags are recognised as indicators of possible serious spinal pathology, and their use is indicated by numerous guidelines. Similar to other countries worldwide, Scotland lacked a national view about the overall quality of the physiotherapy management of low back pain and the use of red flags. Anecdotal evidence suggested that practice varied considerably., Aim: To improve the use and documentation of red flags by physiotherapists during the assessment and management of low back pain., Design: Prospective, multicentred, national data collection and improvement initiative., Setting: National Health Service (NHS) health boards in Scotland (n=14) plus two private provider sites., Participants: One hundred and eighty-six individual NHS provider sites and two private provider sites, with in excess of 360 physiotherapists providing services to low back pain patients., Method: Measurement of documented practice in line with evidence- and consensus-based recommendations from guidelines collected via a web-based tool over two 5-week audit cycles interspersed with an improvement phase over 1 year (2008-2009)., Results: Data from 2147 patients showed improvement in the documentation of all red flags assessed from 33% (n=709) to 65% (n=1396), and improvement in the documentation of cauda equina syndrome from 60% (n=1288) to 84% (n=1804) over the two cycles. Only two regions provided evidence of 100% documentation of all components of cauda equina syndrome, with wide variation across the country., Conclusion: This national initiative resulted in considerable improvement in the documentation of red flags. Despite this, however, one in five patients did not receive optimal management as recommended by guidance. This has significant implications for patient safety and highlights the need for ongoing education of physiotherapists in this area., (Copyright © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)