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Due to the nature of RME, which sees mathematics as a human activity, there is never a fixed and complete theory for mathematics education. Therefore, it is seen as an approach that still needs to be developed. The aim of this research is to analyze the RME (Realistic Mathematics Education) activities prepared by the pre-service primary school teachers who were educated with a constructivist approach. Participants were 137 student teachers who have been trained with a constructivist approach for about 15 years and will teach with this approach. It was determined that the activities prepared by the pre-service primary school teachers were generally at a medium-level in terms of compliance with RME. The results of the research show that no matter how much education they had, the effects of constructivist education could not overcome some traditional patterns in pre-service teachers. In addition, the training they had about RME was not enough to break these patterns. It has been observed that pre-service teachers are insufficient in preparing activities for the basic principles of constructivism with RME. This shows that the disruption in the education system started at the undergraduate level. With this beginning, an endless cycle is formed. In order to avoid the basic patterns brought by traditional education, learning approaches such as the RME approach in addition to the constructivist approach should also be employed at lower grade levels.

This study aimed to examine the diagrammatic representation skills and problem-solving performances of students according to their problem-solving representations. A cross-sectional survey design using quantitative methods was used in this study. The sample consisted of 31 second-grade and 41 third-grade students from a public primary school in Turkey. The Diagrammatic Representation Test and Mathematical Operations Test were used in this study. The data were analyzed with descriptive statistical analysis, the chi-square test, the independent samples t-test, discriminant analysis and logistic regression analysis. The findings indicated that while the preferred types of representations for solving verbal problems and problem-solving performance did not vary significantly based on grade level, scores obtained from the diagrammatic representation test exhibited significant differences. It was observed that students' problem-solving performance and diagrammatic skills could predict their preferred types of representations for solving verbal problems. Consequently, students who possess knowledge regarding effective representation preferences, as well as the ability to construct and utilize them, are more likely to generate appropriate and high-quality representations, leading to accurate problem-solving outcomes. This, in turn, enhances their performance in diagrammatic representation tasks.

The purpose of the current study is to determine the number sense performances and metacognitive awareness of primary school fourth grade students and the status of metacognitive awareness in predicting number sense. To this end, the study employed the relational survey model, one of the quantitative research methods. In the study, it was revealed that the number sense performances of the primary school fourth grade students were at a medium level and did not vary depending on gender. In addition, it was determined that the students' metacognitive awareness was at a high level and that metacognitive awareness did not vary significantly depending on gender. It was found that there is a positive correlation between the number sense performances and metacognitive awareness of the primary school fourth grade students. The students' metacognitive awareness was found to predict their number sense performances at a low level.

Abstract Background Type 2 Diabetes mellitus (T2DM) and periodontitis share common risk factors and influence one another. However, primary care and oral health care continue to operate separate from each other and fail to synchronize care for patients with T2DM and periodontitis. The purpose of this practice-based trial is to evaluate the implementation of a new integrated care pathway for patients with T2DM and periodontitis. The new approach integrates a screening for T2DM risk in dental care settings in patients with periodontitis, a screening for periodontitis risk in primary care settings in patients with T2DM, and mutual referrals between dentists and primary care physicians. Methods Two practice-based studies will be carried out in parallel: (i) In dental care settings: a practice-based, multi-centric, cluster-randomized, controlled trial with a control and an intervention group; (ii) in primary care settings: a practice-based, multi-centric, non-randomized, controlled trial with a synthetic control group calculated from claims data. Following a two-step recruitment approach, 166 dentists and 248 general practitioners will be recruited, who themselves will recruit a total of 3808 patients in their practices. Patient data will be collected at baseline, 12 months, and 24 months after study enrollment. The evaluation comprises: (i) impact evaluation, using a hierarchical linear mixed model; (ii) process evaluation, based on surveys alongside the trials; (iii) economic evaluation. In addition, a Discrete-Choice-Experiment will identify provider’s payment preferences for the new care approach. Discussion Upon successful implementation, the intervention will enable health care providers to detect a risk for T2DM and periodontitis in patients at an early stage, thus providing patients an opportunity for timely diagnosis and therapy. Ultimately, this can lead to increased quality of life and reduced health care expenditures. On a methodologic level, the project provides novel insights into a complex intervention on the intersection of general practice and dental care. Trial registration The study was prospectively registered at the German Clinical Trials Register ( https://drks.de/search/de/trial/DRKS00030587 ) on 3. July 2023 under ID “DRKS00030587“.

The purpose of this study was to analyze the performances of students in solving problems presented in different forms including equations, verbal equations, stories, and stories supported by diagrams in problem-solving. A descriptive survey model was employed in the study. The study group consisted of 14 fourth-grade students. Data were collected from the students by using four different types of worksheets (equation, verbal equation, story, and story + diagram). Each worksheet consisted of 10 similar problems that require the same mathematical operations but differ in presentation. To prevent the similarity in the problems by the students, the worksheets were applied to the students face-to-face by the classroom teachers during the course hours, at two-week intervals. The obtained data were analyzed through descriptive statistics. According to the findings of the study, the students solved the equation problems more accurately than the verbal and story problems. Furthermore, it was determined that students solved diagram-supported story problems more accurately than the other problem types.

Place value concept that learns especially in primary school ages is also the basis of many issues students will encounter throughout their learning lives. This research aims to developmentally determine understanding of the place value concept in early childhood. The model of research is a case study from qualitative research methods. The study group consists of 171 children (84 at the age of 7 and 87 at the age of 8) who study in three different public schools in January, in the 2020-2021 academic year in Ankara, Turkey, selected by criteria sampling from purposeful sampling methods. As a data collection tool, "place value worksheets" consisting of 25 questions developed by researchers were used. Data was collected online by classroom teachers through "EBA". The content analysis method was used in the analysis of the data. Looking at the research results, it was observed that children gave meaning to the place value concept in seven categories. It was seen that seven years olds reached the lowest correct answer rate in the code "the ability to express the number whose resolution is given in terms of ones" in the category of "the ability to resolve". It was concluded that "the ability to write numbers between two numbers" code in "the ability to compare" category has the lowest correct response rate for eight years old children. Lower levels of seven years old student's understanding of the place value concept suggest that students' readiness levels are not sufficient at this age.

Abstract Concept cartoons, in relationship with Realistic Mathematics Education (RME), not only serve as a dynamic platform for problem-solving but also intricately weave mathematical concepts into the fabric of real-world scenarios, creating a harmonious fusion of theory and practical application. By using relatable characters and presenting ideas through engaging narratives, students are encouraged to tackle problems within the given context. The aim of this study was to investigate the measurement estimation strategies used by students when exposed to concept cartoons specifically designed for RME. A qualitative research methodology was followed, involving 46 fourth-grade students from a primary school. The data collection instrument utilized was “RME-Supported Concept Cartoons.” Descriptive analysis was employed to analyze the collected data. The concept cartoon activities incorporated measurement estimation strategies such as prior knowledge, unit iteration/separation, segmentation/chunking, and comparison, which students could potentially prefer. However, it was observed that students predominantly utilized division into unit iteration/separation and segmentation/chunking strategies over other estimation strategies. Furthermore, the frequency of strategy use did not exhibit significant variations based on gender. When examining the strategies developed by the students, it is noteworthy that the presence of “another solution-oriented option” and “irrelevant answers” was prominent.

Self-efficacy and spatial anxiety towards geometry are stated to be effective to improve teachers' attitudes towards geometry. Therefore, it is necessary to determine the effect of geometry self-efficacy and spatial anxiety on attitude towards geometry. This determines the extent to which the pre-service primary school teachers' geometry self-efficacy and spatial anxiety predict their attitudes towards geometry. The study used the cross-sectional survey model and the sample was determined with the convenience sampling method. The sample consists of 165 pre-service primary school teachers attending a state university. To collect the data, the geometry self-efficacy scale, the spatial anxiety scale, and the geometry attitude scale were used. Multiple regression analysis was conducted in the data analysis to explain the predictors of the attitude towards geometry. It was found that the pre-service teachers' geometry self-efficacy beliefs and spatial anxiety were high while their geometry attitude was medium. Their geometry self-efficacy positively and significantly correlated with the attitude towards geometry and negatively and significantly correlated with spatial anxiety. While the sub-dimensions of geometry self-efficacy; positive self-efficacy beliefs, use of geometry knowledge, and negative self-efficacy beliefs had positive effects on the attitude towards geometry, spatial anxiety had a negative effect on the attitude towards geometry.

In this study, the visual estimation skills of fourth grade elementary school students based on their mathematical thinking processes were investigated. The research questions focus on understanding how students' mathematical thinking processes influence their visual estimation skills. A total of 445 students participated in the study. The relational scanning model was used to determine the relationship between students' visual estimation skills and their mathematical thinking processes. The Mathematical Process Instrument and the Visual Estimation Skills test were used as data-gathering tools. The data obtained were analyzed using different statistical methods, including the chi-squared test, t-test, and single-factor analysis of variance. The findings contribute to our understanding of the complex relationship between mathematical thinking processes and visual estimation skills in students, addressing the research questions raised in the study. These results can inform educators and instructional designers when developing effective teaching materials and strategies that cater to students' diverse thinking processes.

BackgroundThe increasing number of requests for help for acutely ill patients and their management is a major problem in the health systems of many countries, but especially in Germany. Rescue coordination centers and ambulances in Germany are increasingly overloaded. As a result, rides as a part of rescue operations have been increasing in length for years, yet a relevant proportion of these operations represent low-acuity calls (LACs). The basic objective of this pilot study is the quantitative analysis of the potential misuse of requests to the rescue control center. Indications for alternative treatment options and how to handle these treatment options in nonacute, non–life-threatening health conditions, such as minor injuries or minor infectious diseases, will be assessed. The identification of these LACs is vital in order to prevent health care resources in emergency medical care becoming inadequate. ObjectiveThe overarching goal of this study is to determine the percentage of unnecessary rescue missions on site and subsequently to obtain an impression of the paramedics’ assessment of alternative treatment options or alternative methods of rescue transportation. MethodsThis will be an exploratory, noninterventional, cross-sectional study with a quantitative approach. The study is multicentric, with 21 ambulances in 12 different locations. The data for this study were collected via a questionnaire, newly developed for this study, for rescue personnel. Additionally, secondary data from the responsible control center will be linked and processed in an initial descriptive analysis. This descriptive analysis will form the basis for a subsequent variance analysis. ResultsData collection started as projected on September 18, 2023, and was ongoing until end of November 2023. We expect the documentation of several thousand rescue operations. We expect the following study results: (1) many unnecessary rescue operations, (2) immediate on-site assessment of correct care and treatment, and (3) patients’ reasons for calling a rescue coordination center. ConclusionsTo our knowledge, this is the first observational study in which acute rescue operations are recorded on site. The focus of this study is on the trained paramedics’ assessment of whether rescue operations are necessary or not. Additionally, alternative treatments, such as out-of-hours care service or primary care service, are shown for each individual case. The study also intends to cover the question of which factors are relevant and statistically significantly connected to the misuse of ambulances. Trial RegistrationGerman Register for Clinical Studies (Deutsches Register für Klinische Studien) DRKS00032510; https://drks.de/search/en/trial/DRKS00032510 International Registered Report Identifier (IRRID)DERR1-10.2196/54002

Abstract Background Calculation of individual risk is the cornerstone of effective cardiovascular prevention. arriba is a software to estimate the individual risk to suffer a cardiovascular event in 10 years. Prognosis and the absolute effects of pharmacological and lifestyle interventions help the patient make a well-informed decision. The risk calculation algorithm currently used in arriba is based on the Framingham risk algorithm calibrated to the German setting. The objective of this study is to evaluate and adapt the algorithm for the target population in primary care in Germany. Methods/design arriba-pro will be conducted within the primary care scheme provided by a large health care insurer in Baden-Württemberg, Germany. Patients who are counseled with arriba by their general practitioners (GPs) will be included in the arriba-pro cohort. Exposure data from the consultation with arriba such as demographic data and risk factors will be recorded automatically by the practice software and transferred to the study centre. Information on relevant prescription drugs (effect modifiers) and cardiovascular events (outcomes) will be derived from administrative sources. Discussion The study is unique in simulating a therapy naïve cohort, matching exactly research and application setting, using a robust administrative data base, and, finally, including patients with known cardiovascular disease who have been excluded from previous studies. Trial registration The study is registered with Deutsches Register Klinischer Studien (DRKS00004633).

Abstract Background This study investigates the efficacy of a complex multifaceted intervention aiming at increasing the quality of care of GPs for patients with multimorbidity. In its core, the intervention aims at enhancing the doctor-patient-dialogue and identifying the patient’s agenda and needs. Also, a medication check is embedded. Our primary hypothesis is that a more patient-centred communication will reduce the number of active pharmaceuticals taken without impairing the patients’ quality of life. Secondary hypotheses include a better knowledge of GPs about their patients’ medication, a higher patient satisfaction and a more effective and/or efficient health care utilization. Methods/design Multi-center, parallel group, cluster randomized controlled clinical trial in GP surgeries. Inclusion criteria: Patients aged 65–84 years with at least 3 chronic conditions. Intervention: GPs allocated to this group will receive a multifaceted educational intervention on performing a narrative doctor-patient dialogue reflecting treatment targets and priorities of the patient and on performing a narrative patient-centred medication review. During the one year intervention GPs will have a total of three conversations à 30 minutes with the enrolled patients. Control: Care as usual. Follow-up per patient: 14 months after baseline interview. Primary efficacy endpoints: Differences in medication intake and health related quality of life between baseline and follow-up in the intervention compared to the control group. Randomization: Computer-generated by an independent institute. It will be performed successively when patient recruitment in the respective surgery is finished. Blinding: Participants (GPs and patients) will not be blinded to their assignment but will be unaware of the study hypotheses or outcome measures. Discussion There is growing evidence that the phenomenon of polypharmacy and low quality of drug use is substantially due to mis-communication (or non-communication) in the doctor patient interaction. We assume that the number of pharmaceutical agents taken can be reduced by a communicational intervention and that this will not impair the patients’ health-related quality of life. Improving communication is a core issue of future interventions, especially for patients with multimorbidity. Trial registration Current Controlled Trials ISRCTN46272088.

Abstract Background With an average prescription rate of 50%, in German primary care antibiotics are still too frequently prescribed for respiratory tract infections. The over-prescription of antibiotics is often explained by perceived patient pressure and fears of a complicated disease progression. The CHANGE-2 trial will test the effectiveness of two interventions to reduce the rate of inappropriate antibiotic prescriptions for adults and children suffering from respiratory tract infections in German primary care. Methods/Design The study is a three-arm cluster-randomized controlled trial that measures antibiotic prescription rates over three successive winter periods and reverts to administrative data of the German statutory health insurance company AOK. More than 30,000 patients in two regions of Germany, who visit their general practitioner or pediatrician for respiratory tract infections will be included. Interventions are: A) communication training for general practitioners and pediatricians and B) intervention A plus point-of-care testing. Both interventions are tested against usual care. Outcome measure is the physicians’ antibiotic prescription rate for respiratory tract infections derived from data of the health insurance company AOK. Secondary outcomes include reconsultation rate, complications, and hospital admissions. Discussion Major aim of the study is to improve the process of decision-making and to ensure that patients who are likely to benefit from antibiotics are treated accordingly. Our approach is simple to implement and might be used rapidly among general practitioners and pediatricians. We expect the results of this trial to have major impact on antibiotic prescription strategies and practices in Germany, both among general practitioners and pediatricians. Trial registration The study is registered at the Current Controlled Trials Ltd (ISRCTN01559032)

Abstract Background In Germany, clinical trials and comparative effectiveness studies in primary care are still very rare, while their usefulness has been recognised in many other countries. A network of researchers from German academic general practice has explored the reasons for this discrepancy. Methods Based on a comprehensive literature review and expert group discussions, problem analyses as well as structural and procedural prerequisites for a better implementation of clinical trials in German primary care are presented. Results In Germany, basic biomedical science and technology is more reputed than clinical or health services research. Clinical trials are funded by industry or a single national programme, which is highly competitive, specialist-dominated, exclusive of pilot studies, and usually favours innovation rather than comparative effectiveness studies. Academic general practice is still not fully implemented, and existing departments are small. Most general practitioners (GPs) work in a market-based, competitive setting of small private practices, with a high case load. They have no protected time or funding for research, and mostly no research training or experience. Good Clinical Practice (GCP) training is compulsory for participation in clinical trials. The group defined three work packages to be addressed regarding clinical trials in German general practice: (1) problem analysis, and definition of (2) structural prerequisites and (3) procedural prerequisites. Structural prerequisites comprise specific support facilities for general practice-based research networks that could provide practices with a point of contact. Procedural prerequisites consist, for example, of a summary of specific relevant key measures, for example on a web platform. The platform should contain standard operating procedures (SOPs), templates, checklists and other supporting materials for researchers. Conclusion All in all, our problem analyses revealed that a substantial number of barriers contribute to the low implementation of clinical research in German general practice. Some issues are deeply rooted in Germany’s market-based healthcare and academic systems and traditions. However, new developments may facilitate change: recent developments in the German research landscape are encouraging.

Abstract Background Comparatively few studies address the problems related to multimorbidity. This is surprising, since multimorbidity is a particular challenge for both general practitioners and patients. This study focuses on the latter, analyzing the way patients aged 65–85 cope with multimorbidity. Methods 19 narrative in-depth interviews with multimorbid patients were conducted. The data was analysed using grounded theory. Of the 19 interviewed patients 13 were female and 6 male. Mean age was 75 years. Participating patients showed a relatively homogeneous socio-economic status. Patients were recruited from the German city of Hamburg and the state of North Rhine-Westphalia. Results Despite suffering from multimorbidity, interviewees held positive attitudes towards life: At the social level, patients tried to preserve their autonomy to the most possible extent. At the emotional level, interviewees oscillated between anxiety and strength - having, however, a positive approach to life. At the practical level, patients aimed at keeping their diseases under control. The patients tended to be critical in regards to medication. Conclusions These findings might have implications for the treatment of multimorbid patients in primary care and further research: The generally presumed passivity of older individuals towards medical treatment, which can be found in literature, is not evident among our sample of older patients. In future, treatment of these patients might take their potential for pro-active cooperation more strongly into account than it is currently the case.

Abstract Background Multimorbidity is a phenomenon with high burden and high prevalence in the elderly. Our previous research has shown that multimorbidity can be divided into the multimorbidity patterns of 1) anxiety, depression, somatoform disorders (ADS) and pain, and 2) cardiovascular and metabolic disorders. However, it is not yet known, how these patterns are influenced by patient characteristics. The objective of this paper is to analyze the association of socio-demographic variables, and especially socio-economic status with multimorbidity in general and with each multimorbidity pattern. Methods The MultiCare Cohort Study is a multicentre, prospective, observational cohort study of 3.189 multimorbid patients aged 65+ randomly selected from 158 GP practices. Data were collected in GP interviews and comprehensive patient interviews. Missing values have been imputed by hot deck imputation based on Gower distance in morbidity and other variables. The association of patient characteristics with the number of chronic conditions is analysed by multilevel mixed-effects linear regression analyses. Results Multimorbidity in general is associated with age (+0.07 chronic conditions per year), gender (-0.27 conditions for female), education (-0.26 conditions for medium and -0.29 conditions for high level vs. low level) and income (-0.27 conditions per logarithmic unit). The pattern of cardiovascular and metabolic disorders shows comparable associations with a higher coefficient for gender (-1.29 conditions for female), while multimorbidity within the pattern of ADS and pain correlates with gender (+0.79 conditions for female), but not with age or socioeconomic status. Conclusions Our study confirms that the morbidity load of multimorbid patients is associated with age, gender and the socioeconomic status of the patients, but there were no effects of living arrangements and marital status. We could also show that the influence of patient characteristics is dependent on the multimorbidity pattern concerned, i.e. there seem to be at least two types of elderly multimorbid patients. First, there are patients with mainly cardiovascular and metabolic disorders, who are more often male, have an older age and a lower socio-economic status. Second, there are patients mainly with ADS and pain-related morbidity, who are more often female and equally distributed across age and socio-economic groups. Trial registration ISRCTN89818205

Surgical site infections are one of the most important factors that increase morbidity and length of stay, especially after abdominal surgical procedures. With the COVID-19 pandemic, serious isolation and contact measures have been taken in hospital clinics in Turkey and all over the world. The aim of this study is to compare the rate of surgical site infection in patients who underwent abdominal surgery between March 15, 2020 and May 31, 2020 in Gazi University Faculty of Medicine, General Surgery Clinic, and patients who underwent abdominal surgery between the same dates a year ago. The features were examined with the SSI between the two periods. A statistically significant difference was found between the patients who were operated on before and during the pandemic in terms of smoking status (p=0.020), urgency of surgery (p=0.001) and chemotherapy receiving status (p=0.002). A statistically significant difference was not recorded between patients with and without surgical site infection in terms of the season in which the operation was performed, the surgery over the previous incision, the type of operation, the urgency of the operation and the presence of a drain. The precautions taken due to the COVID-19 pandemic do not change the risk of developing SSI after abdominal surgery. In preventing the risk of SSI, the factors related to the wound and the patient, which have been defined before, are at the forefront. [Med-Science 2023; 12(2.000): 442-7]

Abstract Background Multimorbidity is a highly frequent condition in older people, but well designed longitudinal studies on the impact of multimorbidity on patients and the health care system have been remarkably scarce in numbers until today. Little is known about the long term impact of multimorbidity on the patients' life expectancy, functional status and quality of life as well as health care utilization over time. As a consequence, there is little help for GPs in adjusting care for these patients, even though studies suggest that adhering to present clinical practice guidelines in the care of patients with multimorbidity may have adverse effects. Methods/Design The study is designed as a multicentre prospective, observational cohort study of 3.050 patients aged 65 to 85 at baseline with at least three different diagnoses out of a list of 29 illnesses and syndromes. The patients will be recruited in approx. 120 to 150 GP surgeries in 8 study centres distributed across Germany. Information about the patients' morbidity will be collected mainly in GP interviews and from chart reviews. Functional status, resources/risk factors, health care utilization and additional morbidity data will be assessed in patient interviews, in which a multitude of well established standardized questionnaires and tests will be performed. Discussion The main aim of the cohort study is to monitor the course of the illness process and to analyse for which reasons medical conditions are stable, deteriorating or only temporarily present. First, clusters of combinations of diseases/disorders (multimorbidity patterns) with a comparable impact (e.g. on quality of life and/or functional status) will be identified. Then the development of these clusters over time will be analysed, especially with regard to prognostic variables and the somatic, psychological and social consequences as well as the utilization of health care resources. The results will allow the development of an instrument for prediction of the deterioration of the illness process and point at possibilities of prevention. The practical consequences of the study results for primary care will be analysed in expert focus groups in order to develop strategies for the inclusion of the aspects of multimorbidity in primary care guidelines.

Abstract Background The reduction in the number of unnecessary prescriptions of antibiotics has become one of the most important objectives for primary health care. German GPs report that they are under "pressure to prescribe" antibiotics particularly in consultations with Turkish immigrants. And so a qualitative approach was used to learn more about the socio-medical context of Turkish patients in regard to acute coughs. A German leaflet designed to improve the doctor-patient communication has been positively tested and then adapted for Turkish patients. Methods The original leaflet was first translated into Turkish. Then 57 patients belonging to 8 different GPs were interviewed about the leaflet using a semi-standardised script. The material was audio recorded, fully transcribed, and analysed by three independent researchers. As a first step a comprehensive content analysis was performed. Secondly, elements crucial to any Turkish version of the leaflet were identified. Results The interviews showed that the leaflets' messages were clearly understood by all patients irrespective of age, gender, and educational background. We identified no major problems in the perception of the translated leaflet but identified several minor points which could be improved. We found that patients were starting to reconsider their attitudes after reading the leaflet. Conclusion The leaflet successfully imparted relevant and new information to the target patients. A qualitative approach is a feasible way to prove general acceptance and provides additional information for its adaptation to medico-cultural factors.

The main goal of this study is to investigate the extent to which a computer-based flashcard program, Anki, can help college-level ESL learners improve their vocabulary as well as the learners' perceptions about the program. The vocabulary targeted for the study consisted of Coxhead's (2000) "Academic Word List", including the most common words in university textbooks. An academic vocabulary dictionary which encompasses 210 academic words was designed for the study and thirteen students coming from two ESL classes used the Anki dictionary for ten minutes every day during the three week intervention process. Pretest and posttest scores of students were compared to evaluate the effectiveness of the learning process. Learners` perceptions about the training were investigated by means of surveys, interviews and observations. The results present the benefits that might be gained from the integration of flashcard programs into a language classroom, as well as the perceptions of learners about the process.

English permits certain non-prototypical sentence forms that have focusing or foregrounding effect. Focus structures place certain elements of the basic version of the sentence in different positions in order to make them more prominent. Due to the widespread usage of them, EFL/ESL teachers should be familiar with the grammar of these structures and how they are usually used, the points learners have difficulty with, and the necessary pedagogical implications for teaching these structures. However, the problems that ESL/EFL students have while using English focus structures have not been widely investigated. Thus, this paper firstly looks into the cleft sentences, formed through movement of constituents and other changes, and the sentences with fronting and left-dislocation involving only movement. Then, studies which reveal a clearer picture of learners' problems with these structures are presented. Finally, some activities are designed in order to show how focus structures can be handled in language learning classroom.

Willingness to communicate in a second language has become an important area of research recently. However, different factors which influence learners' willingness to communicate have not been widely investigated in the Turkish classroom context. Motivation is considered as an important factor which has a direct influence on learners' willingness to communicate. Thus, this study will look into the relationship between English as a foreign language (EFL) learners' willingness to communicate (WTC) in Turkish EFL context and their motivation about English learning through the participation of 106 EFL students who were registered in the one-year preparatory school at Usak University, Turkey. Language Learning Orientation Scale and Willingness to Communicate Scale were adopted for the study. Descriptive statistics and simple linear regression analysis were carried out to find out the relationship between WTC and motivation. Findings indicated that participants were somewhat willing to communicate and there was a significant correlation between learners' WTC and motivation. The findings of this study is useful in terms of the pedagogical and theoretical implications which emphasize the role of motivation in encouraging L2 learners' willingness to communicate.

Willingness to communicate in a second language has gained importance recently with the increasing popularity of communicate language teaching. However, different factors which influence learners' willingness to communicate have not been widely investigated in the Turkish classroom context. Thus, this study investigated English as a foreign language (EFL) learners' willingness to communicate (WTC) in Turkish EFL context and its interaction with different factors such as gender, proficiency levels. 711 preparatory school students at a state university in Turkey participated in this study. For data collection, willingness to communicate scale adapted from Peng and Woodrow (2010) was utilized in order to investigate Turkish preparatory students' willingness to communicate in English. Firstly, descriptive analysis of the scale was carried out through Statistical Package for Social Sciences (SPSS). Then, independent samples t-tests and one-way ANOVA were conducted to investigate the effects of gender and language proficiency variables on learners' willingness to communicate. The results of the study indicated that the learners in this study were moderately willing to communicate in English. It was found that learners were more willing to communicate in controlled situations compared to more meaning-focused situations. With regard to the effect of gender on Turkish EFL learners' WTC, it was found that female EFL learners are more willing to communicate in English in the classroom compared to male EFL students. Lastly, learners who have higher language proficiency levels were found to have higher WTC level compared to learners who have lower language proficiency levels.

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (PFAPA) is an autoinflammatory disease that is thought to occur with the contribution of genetic and environmental factors, but its etiology has not been clearly elucidated. It is characterized by recurrent attacks with fever, pharyngitis, oral aphthous lesions, and cervical lymphadenopathy, and an increase in the level of serum acute phase reactants is observed during the attacks. Although PFAPA usually begins in childhood, adult-onset cases are also reported in the literature. In the pathogenesis of PFAPA, an increase in the expression of various inflammatory cytokines, especially interleukin-1β (IL-1β), is observed as a result of the increase in inflammasome activity. Selective IgA deficiency (SIgAD) is the most prevalent primary immunodeficiency. Although most SIgAD cases remain asymptomatic and remain undiagnosed, it is known that the risk of mucosal infection is generally increased in SIgAD cases. In addition, the frequency of autoinflammatory diseases is increased in SIgAD cases compared with the general population. We aim to present a case of adult-onset PFAPA and SIgAD coexistence.