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ImportanceTherapy for advanced melanoma has transformed during the past decade, but early detection and prognostic assessment of cutaneous melanoma (CM) remain paramount goals. Best practices for screening and use of pigmented lesion evaluation tools and gene expression profile (GEP) testing in CM remain to be defined.ObjectiveTo provide consensus recommendations on optimal screening practices and prebiopsy diagnostic, postbiopsy diagnostic, and prognostic assessment of CM.Evidence reviewCase scenarios were interrogated using a modified Delphi consensus method. Melanoma panelists (n = 60) were invited to vote on hypothetical scenarios via an emailed survey (n = 42), which was followed by a consensus conference (n = 51) that reviewed the literature and the rationale for survey answers. Panelists participated in a follow-up survey for final recommendations on the scenarios (n = 45).FindingsThe panelists reached consensus (≥70% agreement) in supporting a risk-stratified approach to melanoma screening in clinical settings and public screening events, screening personnel recommendations (self/partner, primary care provider, general dermatologist, and pigmented lesion expert), screening intervals, and acceptable appointment wait times. Participants also reached consensus that visual and dermoscopic examination are sufficient for evaluation and follow-up of melanocytic skin lesions deemed innocuous. The panelists reached consensus on interpreting reflectance confocal microscopy and some but not all results from epidermal tape stripping, but they did not reach consensus on use of certain pigmented lesion evaluation tools, such as electrical impedance spectroscopy. Regarding GEP scores, the panelists reached consensus that a low-risk prognostic GEP score should not outweigh concerning histologic features when selecting patients to undergo sentinel lymph node biopsy but did not reach consensus on imaging recommendations in the setting of a high-risk prognostic GEP score and low-risk histology and/or negative nodal status.Conclusions and relevanceFor this consensus statement, panelists reached consensus on aspects of a risk-stratified approach to melanoma screening and follow-up as well as use of visual examination and dermoscopy. These findings support a practical approach to diagnosing and evaluating CM. Panelists did not reach consensus on a clearly defined role for GEP testing in clinical decision-making, citing the need for additional studies to establish the clinical use of existing GEP assays.

Abstract Introduction Optimizing uptake of pre‐exposure prophylaxis (PrEP) for individuals at risk of HIV acquisition has been challenging despite clear scientific evidence and normative guidelines, particularly for key populations (KPs) such as men who have sex with men (MSM), female sex workers (FSWs), transgender (TG) people and persons who inject drugs (PWID). Applying an iterative Programme Science cycle, building on the effective programme coverage framework, we describe the approach used by the Centre for Infectious Disease Research in Zambia (CIDRZ) to scale up PrEP delivery and address inequities in PrEP access for KP in Lusaka, Zambia. Methods In 2019, CIDRZ partnered with 10 local KP civil society organizations (CSOs) and the Ministry of Health (MOH) to offer HIV services within KP‐designated community safe spaces. KP CSO partners led KP mobilization, managed safe spaces and delivered peer support; MOH organized clinicians and clinical commodities; and CIDRZ provided technical oversight. In December 2021, we introduced a community‐based intervention focused on PrEP delivery in venues where KP socialize. We collected routine programme data from September 2019 to June 2023 using programme‐specific tools and the national electronic health record. We estimated the before‐after effects of our intervention on PrEP uptake, continuation and equity for KP using descriptive statistics and interrupted time series regression, and used mixed‐effects regression to estimate marginal probabilities of PrEP continuity. Results Most (25,658) of the 38,307 (67.0%) Key Population Investment Fund beneficiaries were reached with HIV prevention services at community‐based venues. In total, 23,527 (61.4%) received HIV testing services, with 15,508 (65.9%) testing HIV negative and found PrEP eligible, and 15,241 (98.3%) initiating PrEP. Across all programme quarters and KP types, PrEP uptake was >90%. After introducing venue‐based PrEP delivery, PrEP uptake (98.7% after vs. 96.5% before, p

A challenge with large undergraduate classes is the provision of opportunities for students to construct educational documents and to obtain individualized feedback pertaining to their work. Being able to work as part of a group, to clearly express information both orally and in writing, and to self-reflect while providing constructive feedback are soft skills that are valued by employers in the healthcare professions. We describe a two-part assignment in which students first worked in small groups to construct an informative newsletter pertaining to either the gut microbiome or one of four assigned fad diets and then evaluated a newsletter created by a group of their peers. Survey data revealed that most students found the assignments valuable learning exercises and that the opportunity to evaluate a newsletter created by their peers was welcomed. These assignments provide a way for students studying anatomy and physiology to reflect on what they have learned in class and, through self-directed research, apply their new knowledge in a way that will serve them well once out in the workplace.

From Becoming Home: Diaspora and the Anglophone Transnational edited by Jude V. Nixon and Maria Concetta Constantini. © 2022 by Vernon Press. Used by permission of the publisher. Publisher website: https://vernonpress.com/book/1365

Health sciences students need strong communication skills so that they can engage patients, explain concepts and justify medical procedures. For 3% of their final mark, 547 students studying the anatomy and physiology of the immune system were assigned the creation of a one-page brochure to help parents understand the importance and mechanism of childhood vaccination. Students were provided with a list of possible topics (e.g. how vaccines promote active immunity, why childhood vaccination is important, the link between herd immunity and community protection) and asked to explain the physiological bases of those concepts in layman's terms. Student participation approached 100% and assignment scores averaged 85.0 - 87.6%. Feedback provided to students addressed information quality and accuracy as well as the use of colour, illustrations, and appropriate text to engage readers and convey ideas. Timely provision of feedback to large classes was facilitated by the assignment function of the course learning management system.

Multiple steps from HIV diagnosis to treatment initiation and confirmed engagement with the health system are required for people living with HIV to establish full linkage to care in the modern treat all era. We undertook a qualitative study to gain an in-depth understanding of the impeding and enabling factors at each step of this linkage pathway. In-depth interviews were conducted with fifty-eight people living with HIV recruited from ten routine HIV care settings supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) in Lusaka, Zambia. Using a semi-structured interview guide informed by an established conceptual framework for linkage to care, questions explored the reasons behind late, missed, and early linkage into HIV treatment, as well as factors influencing the decision to silently transfer to a different clinic after an HIV diagnosis. We identified previously established and intersecting barriers of internal and external HIV-related stigma, concerns about ART side effects, substance use, uncertainties for the future, and a perceived lack of partner and social support that impeded linkage to care at every step of the linkage pathway. However, we also uncovered newer themes specific to the current test and treat era related to the rapidity of ART initiation and insufficient patient-centered post-test counseling that appeared to exacerbate these well-known barriers, including callous health workers and limited time to process a new HIV diagnosis before treatment. Long travel distance to the clinic where they were diagnosed was the most common reason for silently transferring to another clinic for treatment. On the other hand, individual resilience, quality counseling, patient-centered health workers, and a supportive and empathetic social network mitigated these barriers. These findings highlight potential areas for strengthening linkage to care and addressing early treatment interruption and silent transfer in the test and treat era in Zambia.

SARS-CoV-2 serosurveys help estimate the extent of transmission and guide the allocation of COVID-19 vaccines. We measured SARS-CoV-2 seroprevalence among women attending ANC clinics to assess exposure trends over time in Zambia. We conducted repeated cross-sectional SARS-CoV-2 seroprevalence surveys among pregnant women aged 15-49 years attending their first ANC visits in four districts of Zambia (two urban and two rural) during September 2021-September 2022. Serologic testing was done using a multiplex bead assay which detects IgG antibodies to the nucleocapsid protein and the spike protein receptor-binding domain (RBD). We calculated monthly SARS-CoV-2 seroprevalence by district. We also categorized seropositive results as infection alone, infection and vaccination, or vaccination alone based on anti-RBD and anti-nucleocapsid test results and self-reported COVID-19 vaccination status (vaccinated was having received ≥1 dose). Among 8,304 participants, 5,296 (63.8%) were cumulatively seropositive for SARS-CoV-2 antibodies from September 2021 through September 2022. SARS-CoV-2 seroprevalence primarily increased from September 2021 to September 2022 in three districts (Lusaka: 61.8-100.0%, Chongwe: 39.6-94.7%, Chipata: 56.5-95.0%), but in Chadiza, seroprevalence increased from 27.8% in September 2021 to 77.2% in April 2022 before gradually dropping to 56.6% in July 2022. Among 5,906 participants with a valid COVID-19 vaccination status, infection alone accounted for antibody responses in 77.7% (4,590) of participants. Most women attending ANC had evidence of prior SARS-CoV-2 infection and most SARS-CoV-2 seropositivity was infection-induced. Capturing COVID-19 vaccination status and using a multiplex bead assay with anti-nucleocapsid and anti-RBD targets facilitated distinguishing infection-induced versus vaccine-induced antibody responses during a period of increasing COVID-19 vaccine coverage in Zambia. Declining seroprevalence in Chadiza may indicate waning antibodies and a need for booster vaccines. ANC clinics have a potential role in ongoing SARS-CoV-2 serosurveillance and can continue to provide insights into SARS-CoV-2 antibody dynamics to inform near real-time public health responses.

Prior research on information literacy instruction in engineering graduate programs rarely considers course instructor perspectives, and instead only uses student feedback to evaluate the efficacy of information literacy instruction. This study documents the authors' efforts to evolve the library curriculum to motivate student learning and meet the course needs. Data collected from the student survey and course instructor questionnaire found that most students reported that the instruction was engaging and satisfying, but evaluations of the usefulness of the instruction were mixed. The course instructor was satisfied with the students' overall work in information gathering though found their project reports unsatisfactory in terms of report writing and critical thinking. The findings shed light on student needs and faculty expectations of engineering project-based graduate courses.

Introduction In sub-Saharan Africa, HIV/AIDS remains a leading cause of death. The UNAIDS established the ‘95-95-95’ targets to improve HIV care continuum outcomes. Using geospatial data from the Zambia Population-based HIV Impact Assessment (ZAMPHIA), this study aims to investigate geospatial patterns in the ‘95-95-95’ indicators and individual-level determinants that impede HIV care continuum in vulnerable communities, providing insights into the factors associated with gaps.Methods This study used data from the 2016 ZAMPHIA to investigate the geospatial distribution and individual-level determinants of engagement across the HIV care continuum in Zambia. Gaussian kernel interpolation and optimised hotspot analysis were used to identify geospatial patterns in the HIV care continuum, while geospatial k-means clustering was used to partition areas into clusters. The study also assessed healthcare availability, access and social determinants of healthcare utilisation. Multiple logistic regression models were used to examine the association between selected sociodemographic and behavioural covariates and the three main outcomes of study.Results Varied progress towards the ‘95-95-95’ targets were observed in different regions of Zambia. Each ‘95’ displayed a unique geographical pattern, independent of HIV prevalence, resulting in four distinct geographical clusters. Factors associated with gaps in the ‘95s’ include younger age, male sex, and low wealth, with younger individuals having higher odds of not being on antiretroviral therapy and having detectable viral loads.Conclusions Our study revealed significant spatial heterogeneity in the HIV care continuum in Zambia, with different regions exhibiting unique geographical patterns and levels of performance in the ‘95-95-95’ targets, highlighting the need for geospatial tailored interventions to address the specific needs of different subnational regions. These findings underscore the importance of addressing differential regional gaps in HIV diagnosis, enhancing community-level factors and developing innovative strategies to improve local HIV care continuum outcomes.

Objectives To estimate potential silent transfer using baseline viral load measures among individuals presenting as new to HIV care in routine HIV clinical settings in Lusaka, Zambia.Design Cross-sectional study.Setting Two large, urban government-operated health facilities supported by the Centre for Infectious Disease Research in Zambia.Participants A total of 248 participants with an incident positive HIV rapid test.Outcome measures The primary outcome measure was HIV viral suppression at baseline (i.e., potential silent transfer), defined as having a viral load ≤1000 RNA copies(c)/mL at the time of initiating HIV care. We also examined viral suppression at ≤60 c/mL.Methods We surveyed and measured baseline HIV viral load as part of the national recent infection testing algorithm among people living with HIV (PLWH) presenting as new to care. Using mixed effects Poisson regression, we identified characteristics among PLWH associated with potential silent transfer.Results Among the 248 PLWH included, 63% were women with median age of 30, and 66 (27% (66/248)) had viral suppression at ≤1000 c/mL and 53 (21% (53/248)) at ≤60 c/mL thresholds, respectively. Participants aged 40+ years had a significantly higher adjusted prevalence of potential silent transfer (adjusted prevalence ratio (aPR): 2.10; 95% CI: 2.08, 2.13) compared with participants aged 18–24 years. Participants reporting no formal education had a significantly higher adjusted prevalence of potential silent transfer (aPR: 1.63; 95% CI: 1.52, 1.75) compared with those completing primary education. Among 57 potential silent transfers who completed a survey, 44 (77%) indicated having tested positive previously at ≥1 of 38 clinics in Zambia.Conclusions The high proportion of PLWH with potential silent transfer points to clinic shopping and/or co-enrolment at multiple care sites simultaneously, suggesting an opportunity to improve care continuity at the time of HIV care entry.

Reading in a foreign language has value for learners as a potentially rich source of input as well as enjoyment. It requires persistence, however. Within models of self-regulated learning, persistence relates to learners' self-efficacy and use of strategies to aid task completion and regulation of engagement. Yet the relationship between self-efficacy and self-regulatory strategies is underexplored for second language (L2) reading, despite some intervention studies finding that instruction aimed at improving strategy use positively influences self-efficacy. The current study investigated the relationship between what we call text engagement regulatory reading strategies (TERRS) and reading self-efficacy among 529 beginner learners of French. It also explored whether different learner profiles exist with respect to that relationship, and how far learners of different profiles benefited in respect of reading self-efficacy from 3 instructional approaches: phonics instruction plus the use of challenging texts; strategy-based instruction using the same texts; and no explicit phonics or strategy instruction using the texts only. The use of TERRS was an important predictor of reading self-efficacy and central to 3 distinct learner profile clusters. Increases in reading self-efficacy were significantly greater for learners of certain profiles who received strategy-based instruction, with implications for theories of self-regulated language learning and classroom practice.

We present a novel methodology for optimizing fiber optic network performance by determining the ideal values for attenuation, nonlinearity, and dispersion parameters in terms of achieved signal-to-noise ratio (SNR) gain from digital backpropagation (DBP). Our approach uses Gaussian process regression, a probabilistic machine learning technique, to create a computationally efficient model for mapping these parameters to the resulting SNR after applying DBP. We then use simplicial homology global optimization to find the parameter values that yield maximum SNR for the Gaussian process model within a set of a priori bounds. This approach optimizes the parameters in terms of the DBP gain at the receiver. We demonstrate the effectiveness of our method through simulation and experimental testing, achieving optimal estimates of the dispersion, nonlinearity, and attenuation parameters. Our approach also highlights the limitations of traditional one-at-a-time grid search methods and emphasizes the interpretability of the technique. This methodology has broad applications in engineering and can be used to optimize performance in various systems beyond optical networks.

BackgroundDifferentiated service delivery (DSD) for human immunodeficiency virus (HIV)-infected persons who are clinically stable on antiretroviral therapy (ART) has been embraced as a solution to decrease access barriers and improve quality of care. However, successful DSD implementation is dependent on understanding the prevalence, incidence, and durability of clinical stability.MethodsWe evaluated visit data in a cohort of HIV-infected adults who made at least 1 visit between 1 March 2013 and 28 February 2015 at 56 clinics in Zambia. We described visit frequency and appointment intervals using conventional stability criteria and used a mixed-effects linear regression model to identify predictors of appointment interval. We developed a multistate model to characterize patient stability over time and calculated incidence rates for transition between states.ResultsOverall, 167819 patients made 3418018 post-ART initiation visits between 2004 and 2015. Fifty-four percent of visits were pharmacy refill-only visits, and 24% occurred among patients on ART for >6 months and whose current CD4 was >500 cells/mm3. Median appointment interval at clinician visits was 59 days, and time on ART and current CD4 were not strong predictors of appointment interval. Cumulative incidence of clinical stability was 66.2% at 2 years after enrollment, but transition to instability (31 events per 100 person-years) and lapses in care (41 events per100 person-years) were common.ConclusionsCurrent facility-based care was characterized by high visit burden due to pharmacy refills and among treatment-experienced patients. Differentiated service delivery models targeted toward stable patients need to be adaptive given that clinical stability was highly transient and lapses in care were common.

Premise of the studyTo maximize benefits from symbiosis, legumes must limit physiological inputs into ineffective rhizobia that nodulate hosts without fixing nitrogen. The capacity of legumes to decrease the relative fitness of ineffective rhizobia-known as sanctions-has been demonstrated in several legume species, but its mechanisms remain unclear. Sanctions are predicted to work at the whole-nodule level. However, whole-nodule sanctions would make the host vulnerable to mixed-nodule infections, which have been demonstrated in the laboratory and observed in natural settings. Here, we present and test a cell-autonomous model of legume sanctions that can resolve this dilemma.MethodsWe analyzed histological and ultrastructural evidence of sanctions in two legume species, Acmispon strigosus and Lotus japonicus. For the former, we inoculated seedlings with rhizobia that naturally vary in their abilities to fix nitrogen. In the latter, we inoculated seedlings with near-isogenic strains that differ only in the ability to fix nitrogen.Key resultsIn both hosts, plants inoculated with ineffective rhizobia exhibited evidence for a cell autonomous and accelerated program of senescence within nodules. In plants that received mixed inoculations, only the plant cells harboring ineffective rhizobia exhibited features consistent with programmed cell death, including collapsed vacuoles, ruptured symbiosomes, and bacteroids that are released into the cytosol. These features were consistently linked with ultrastructural evidence of reduced survival of ineffective rhizobia in planta.ConclusionsOur data suggest an elegant cell autonomous mechanism by which legumes can detect and defend against ineffective rhizobia even when nodules harbor a mix of effective and ineffective rhizobial genotypes.

Abstract The management of wavelength routed optical mesh networks is complex with many potential light path routes and numerous physical layer impairments to transmission performance. This complexity can be reduced by applying the ideas of abstraction from computer science where different equipment is described in the same basic terms. The noise-to-signal ratio can be used as a metric to describe the quality of transmission performance of a signal propagated through a network element and accumulates additively through a sequence of such elements allowing the estimation of end-to-end performance. This study aims to explore the robustness of the noise-to-signal ratio metric in an installed fibre infrastructure. We show that the abstracted noise-to-signal ratio is independent of the observers and their location. We confirm that the abstracted noise-to-signal ratio can reasonably predict the performance of light-paths subsequently set in our network. Having a robust network element abstraction that can be incorporated into routeing engines allows the network management controller to make decisions on the most effective way to use the network resources in terms of the routeing and data coding format.

A simplified calculation method is proposed for determining the peak dynamic windage yaw angle φ^ of electricity transmission line (TL) tower suspension insulator strings (SISs). According to the rigid-body rule, the geometric stiffness matrix in the calculation of the windage yaw angle φ of SISs is dominated by the average wind loads, while the fluctuating wind loads are the dominant factor in the elastic stiffness. With the average wind state of conductors as the initial calculation condition, the load-response-correlation (LRC) method can be used to determine the fluctuating windage yaw angle φd and the corresponding equivalent static wind loads (ESWLs). Then, the improved rigid straight rod model, which uses the actual length of conductors rather than the projected length, was used to determine the average windage yaw angle φ¯. Through the linear superposition of the horizontal increments of φ¯ and φ^d (the peak value of φd), the formulae to calculate the φ^ of SISs were derived. Additionally, the formulae for the dynamic wind load factor, βc, which is a key factor in designing wind loads for φ, were derived according to the principle of ESWLs, rather than being empirically determined by the Chinese code. Thus, the calculation model regarding the loads and response for the φ of SISs was established, and an actual TL was used to verify the established calculation model. Afterward, the influence of the different engineering design parameters on φ and its βc were analyzed. The parameter analyses show that the wind speed, span, and ground roughness influence the magnitudes of φ^ and βc, however, the height difference between the two suspension points of the conductors, the nominal height, and the sag-to-span ratio may be neglected in the approximate calculation. Our method offers a new solution to TL design when there are large deformations and small strains.

Children's engagement in physical activity of a vigorous intensity or higher is more effective at promoting cardiorespiratory fitness than moderate physical activity. It remains unclear how higher intensity physical activity varies between days when schoolchildren participate in physical education (PE) and non-PE days. The purpose of this study was to assess how PE contributes to sedentary behaviour and the intensity profile of physical activity accumulated on PE days compared to non-PE days. Fifty-three schoolchildren (36 girls, 11.7 ± 0.3 years) completed five-day minute-by-minute habitual physical activity monitoring using triaxial accelerometers to determine time spent sedentary (<1.5 Metabolic Equivalent of Tasks (METs)) and in light (1.5-2.9 METs), moderate (3-5.9 METs), vigorous (6-8.9 METs), hard (9-11.9 METs) and very hard intensity (=12 METs) physical activity on PE days and non-PE days. Sedentary time was higher on non-PE days than on PE days (mean difference: 62 minutes, p < 0.001). Hard and very hard intensity physical activity was significantly higher on PE days compared with non-PE days (mean total difference: 33 minutes, all significant at p < 0.001). During the PE lesson, boys spent more time in hard (p < 0.01) and very hard (p < 0.01) physical activity compared to girls. Schoolchildren spent significantly more time in higher intensity physical activity and significantly less time sedentary on PE days than on non-PE days. As well as reducing sedentary behaviour, the opportunity to promote such health-promoting higher intensity physical activity in the school setting warrants further investigation.

BackgroundIn the UK, 11.8% of expectant mothers undergo an elective caesarean section (ELCS) representing 92 000 births per annum. It is not known to what extent this procedure has an impact on mental well-being in the longer term.AimsTo determine the prevalence and postpartum progression of anxiety and depression symptoms in women undergoing ELCS in Wales.MethodPrevalence of depression and anxiety were determined in women at University Hospital Wales (2015–16; n = 308) through completion of the Edinburgh Postnatal Depression Scale (EPDS; ≥13) and State-Trait Anxiety Inventory (STAI; ≥40) questionnaires 1 day prior to ELCS, and three postpartum time points for 1 year. Maternal characteristics were determined from questionnaires and, where possible, confirmed from National Health Service maternity records.ResultsUsing these criteria the prevalence of reported depression symptoms was 14.3% (95% CI 10.9–18.3) 1 day prior to ELCS, 8.0% (95% CI 4.2–12.5) within 1 week, 8.7% (95% CI 4.2–13.8) at 10 weeks and 12.4% (95% CI 6.4–18.4) 1 year postpartum. Prevalence of reported anxiety symptoms was 27.3% (95% CI 22.5–32.4), 21.7% (95% CI 15.8–28.0), 25.3% (95% CI 18.5–32.7) and 35.1% (95% CI 26.3–44.2) at these same stages. Prenatal anxiety was not resolved after ELCS more than 1 year after delivery.ConclusionsWomen undergoing ELCS experience prolonged anxiety postpartum that merits focused clinical attention.Declaration of interestNone.

The onset of the 2019 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic necessitated the identification of approved drugs to treat the disease, before the development, approval and widespread administration of suitable vaccines. To identify such a drug, we used a visual analytics workflow where computational tools applied over an AI-enhanced biomedical knowledge graph were combined with human expertise. The workflow comprised rapid augmentation of knowledge graph information from recent literature using machine learning (ML) based extraction, with human-guided iterative queries of the graph. Using this workflow, we identified the rheumatoid arthritis drug baricitinib as both an antiviral and anti-inflammatory therapy. The effectiveness of baricitinib was substantiated by the recent publication of the data from the ACTT-2 randomised Phase 3 trial, followed by emergency approval for use by the FDA, and a report from the CoV-BARRIER trial confirming significant reductions in mortality with baricitinib compared to standard of care. Such methods that iteratively combine computational tools with human expertise hold promise for the identification of treatments for rare and neglected diseases and, beyond drug repurposing, in areas of biological research where relevant data may be lacking or hidden in the mass of available biomedical literature.

Background: Accurate medical image interpretation is an essential proficiency for multiple medical specialties, including dermatologists and primary care providers. A dermatoscope, a ×10-×20 magnifying lens paired with a light source, enables enhanced visualization of skin cancer structures beyond standard visual inspection. Skilled interpretation of dermoscopic images improves diagnostic accuracy for skin cancer. Objectives: Design and validation of Cutaneous Neoplasm Diagnostic Self-Efficacy Instrument (CNDSEI)—a new tool to assess dermatology residents’ confidence in dermoscopic diagnosis of skin tumors. Methods: In the 2018-2019 academic year, the authors administered the CNDSEI and the Long Dermoscopy Assessment (LDA), to measure dermoscopic image interpretation accuracy, to residents in 9 dermatology residency programs prior to dermoscopy educational intervention exposure. The authors conducted CNDSEI item analysis with inspection of response distribution histograms, assessed internal reliability using Cronbach’s coefficient alpha (α) and construct validity by comparing baseline CNDSEI and LDA results for corresponding lesions with one-way analysis of variance (ANOVA). Results: At baseline, residents respectively demonstrated significantly higher and lower CNDSEI scores for correctly and incorrectly diagnosed lesions on the LDA (P = 0.001). The internal consistency reliability of CNDSEI responses for the majority (13/15) of the lesion types was excellent (α ≥ 0.9) or good (0.8≥ α