Pulmonary effects of expiratory-assisted small-lumen ventilation during upper airway obstruction in pigs

Novel devices for small-lumen ventilation may enable effective inspiration and expiratory ventilation assistance despite airway obstruction. In this study, we investigated a porcine model of complete upper airway obstruction. After ethical approval, we randomly assigned 13 anaesthetised pigs either to small-lumen ventilation following airway obstruction (n = 8) for 30 min, or to volume-controlled ventilation (sham setting, n = 5). Small-lumen ventilation enabled adequate gas exchange over 30 min. One animal died as a result of a tension pneumothorax in this setting. Redistribution of ventilation from dorsal to central compartments and significant impairment of the distribution of ventilation/perfusion occurred. Histopathology demonstrated considerable lung injury, predominantly through differences in the dorsal dependent lung regions. Small-lumen ventilation maintained adequate gas exchange in a porcine airway obstruction model. The use of this technique for 30 min by inexperienced clinicians was associated with considerable end-expiratory collapse leading to lung injury, and may also carry the risk of severe injury.

Predictors of interest in taking pre-exposure prophylaxis among men who have sex with men who used a rapid HIV-testing site in Montreal (Actuel sur Rue)

OBJECTIVES

The effective use of pre-exposure prophylaxis (PrEP) as an HIV prevention strategy depends on its uptake by individuals at high risk of infection. Few Canadian data are available on interest in PrEP among men who have sex with men (MSM). This study aimed to identify predictors of interest in PrEP among MSM clients of a rapid HIV-testing site in Montreal's gay village (Actuel sur Rue).

METHODS

Data were collected using a self-administered and a community agent-administered questionnaire. Among men reporting at least one male sexual partner and visiting the site between July 2012 and November 2013, we aimed to identify sociodemographic, sexual and temporal predictors of interest in taking effective PrEP with logistic regression analyses (univariate and multivariable).

RESULTS

Over half (55%; n = 653) of the sample of 1179 MSM were interested in PrEP. Among the 14 variables considered in the univariate analyses, only (younger) age, (greater) number of sexual partners (in the past 3 months), being part of a serodiscordant couple (in the past 12 months), ever combining sex with drugs and temporal events were associated with interest in PrEP at P < 0.20 and were included in the multivariable analyses. In the multivariable model, only being part of a serodiscordant couple [adjusted odds ratio (aOR) 2.56; 95% confidence interval (CI) 1.44-4.58], having > 10 partners (aOR 1.73; 95% CI 1.17-2.55) and responding after the publication of Quebec's interim PrEP guidelines (aOR 1.82; 95% CI 1.22-2.71) proved significant.

CONCLUSIONS

In this assessment of predictors of PrEP interest among Canadian MSM, partnering issues and the arrival of PrEP guidelines in Quebec (10 July 2013) were most closely linked to PrEP interest.

A novel canine kidney cell line model for the evaluation of neoplastic development: karyotype evolution associated with spontaneous immortalization and tumorigenicity

The molecular mechanisms underlying spontaneous neoplastic transformation in cultured mammalian cells remain poorly understood, confounding recognition of parallels with the biology of naturally occurring cancer. The broad use of tumorigenic canine cell lines as research tools, coupled with the accumulation of cytogenomic data from naturally occurring canine cancers, makes the domestic dog an ideal system in which to investigate these relationships. We developed a canine kidney cell line, CKB1-3T7, which allows prospective examination of the onset of spontaneous immortalization and tumorigenicity. We documented the accumulation of cytogenomic aberrations in CKB1-3T7 over 24 months in continuous culture. The majority of aberrations emerged in parallel with key phenotypic changes in cell morphology, growth kinetics, and tumor incidence and latency. Focal deletion of CDKN2A/B emerged first, preceding the onset and progression of tumorigenic potential, and progressed to a homozygous deletion across the cell population during extended culture. Interestingly, CKB1-3T7 demonstrated a tumorigenic phenotype in vivo prior to exhibiting loss of contact inhibition in vitro. We also performed the first genome-wide characterization of the canine tumorigenic cell line MDCK, which also exhibited CDKN2A/B deletion. MDCK and CKB1-3T7 cells shared several additional aberrations that we have reported previously as being highly recurrent in spontaneous canine cancers, many of which, as with CDKN2A/B deletion, are evolutionarily conserved in their human counterparts. The conservation of these molecular events across multiple species, in vitro and in vivo, despite their contrasting karyotypic architecture, is a powerful indicator of a common mechanism underlying emerging neoplastic activity. Through integrated cytogenomic and phenotypic characterization of serial passages of CKB1-3T7 from initiation to development of a tumorigenic phenotype, we present a robust and readily accessible model (to be made available through the American Type Culture Collection) of spontaneous neoplastic transformation that overcomes many of the limitations of earlier studies.

Reference dosimetry for light-ion beams based on graphite calorimetry

Developments in hadron therapy require efforts to improve the accuracy of the dose delivered to a target volume. Here, the determination of the absorbed dose under reference conditions was analysed. Based on the International Atomic Energy Agency TRS-398 code of practice, for hadron beams, the combined standard uncertainty on absorbed dose to water under reference conditions, derived from ionisation chambers, is too large. This uncertainty is dominated by the beam quality correction factors, [Formula: see text], mainly due to the mean energy to produce one ion pair in air, wair. A method to reduce this uncertainty is to carry out primary dosimetry, using calorimetry. A [Formula: see text]-value can be derived from a direct comparison between calorimetry and ionometry. Here, this comparison is performed using a graphite calorimeter in an 80-MeV A(-1) carbon ion beam. Assuming recommended TRS-398 values of water-to-graphite stopping power ratio and the perturbation factor for an ionisation chamber, preliminary results indicate a wair-value of 35.5 ± 0.9 J C(-1).

Incidents of potential public health significance identified using national surveillance of US poison center data (2008-2012)

BACKGROUND

The Centers for Disease Control and Prevention (CDC) and the American Association of Poison Control Centers conduct national surveillance on data collected by US poison centers to identify incidents of potential public health significance (IPHS). The overarching goals of this collaboration are to improve CDC's national surveillance capacity for public health threats, identify early markers of public health incidents and enhance situational awareness. The National Poison Data System (NPDS) is used as a surveillance system to automatically identify data anomalies.

PURPOSE

To characterize data anomalies and IPHS captured by national surveillance of poison center data over 5 years.

METHODS

Data anomalies are identified through three surveillance methodologies: call-volume, clinical effect, and case-based. Anomalies are reviewed by a team of epidemiologists and clinical toxicologists to determine IPHS using standardized criteria. The authors reviewed IPHS identified by these surveillance activities from 2008 through 2012.

RESULTS

Call-volume surveillance identified 384 IPHS; most were related to gas and fume exposures (n = 229; 59.6%) with the most commonly implicated substance being carbon monoxide (CO) (n = 92; 22.8%). Clinical-effect surveillance identified 138 IPHS; the majority were related to gas and fume exposures (n = 58; 42.0%) and gastrointestinal complaints (n = 84; 16.2%), and the most commonly implicated substance was CO (n = 20; 14.4%). Among the 11 case-based surveillance definitions, the botulism case definition yielded the highest percentage of identified agent-specific illness.

CONCLUSIONS

A small proportion of data anomalies were designated as IPHS. Of these, CO releases were the most frequently reported IPHS and gastrointestinal syndromes were the most commonly reported illness manifestations. poison center data surveillance may be used as an approach to identify exposures, illnesses, and incidents of importance at the national and state level.

A double-blind, placebo-controlled randomised trial evaluating the effect of a polyphenol-rich whole food supplement on PSA progression in men with prostate cancer--the U.K. NCRN Pomi-T study

Background:

Polyphenol-rich foods such as pomegranate, green tea, broccoli and turmeric have demonstrated anti-neoplastic effects in laboratory models involving angiogenesis, apoptosis and proliferation. Although some have been investigated in small, phase II studies, this combination has never been evaluated within an adequately powered randomised controlled trial.

Methods:

In total, 199 men, average age 74 years, with localised prostate cancer, 60% managed with primary active surveillance (AS) or 40% with watchful waiting (WW) following previous interventions, were randomised (2:1) to receive an oral capsule containing a blend of pomegranate, green tea, broccoli and turmeric, or an identical placebo for 6 months.

Results:

The median rise in PSA in the food supplement group (FSG) was 14.7% (95% confidence intervals (CIs) 3.4–36.7%), as opposed to 78.5% in the placebo group (PG) (95% CI 48.1–115.5%), difference 63.8% (P=0.0008). In all, 8.2% of men in the FSG and 27.7% in the PG opted to leave surveillance at the end of the intervention (χ²P=0.014). There were no significant differences within the predetermined subgroups of age, Gleason grade, treatment category or body mass index. There were no differences in cholesterol, blood pressure, blood sugar, C-reactive protein or adverse events.

Conclusions:

This study found a significant short-term, favourable effect on the percentage rise in PSA in men managed with AS and WW following ingestion of this well-tolerated, specific blend of concentrated foods. Its influence on decision-making suggests that this intervention is clinically meaningful, but further trials will evaluate longer term clinical effects, and other makers of disease progression.

Hope of rural women caregivers of persons with advanced cancer: guilt, self-efficacy and mental health

INTRODUCTION

Caring for a person with advanced disease can have a detrimental impact on the quality of life of family caregivers. This is further compounded in rural areas that have few or no palliative care services. Hope has a positive influence on the quality of life of family caregivers of persons with advanced cancer but factors influencing hope specifically in rural women caregivers of persons with advanced cancer have not been examined.

PURPOSE

The purpose of this study was to determine factors influencing the hope of rural women caring for persons with advanced cancer, by examining the relationship of hope with demographic variables, self-efficacy, guilt, and caregiver physical and mental health.

METHODS

A cross-sectional prospective correlational design was used. Inclusion criteria for the study were: (a) female, (b) 18 years of age or older, (c) caring for a person diagnosed with advanced cancer, (d) home address with a rural postal code, and (e) English-speaking. Using a modified Dillman technique, surveys and an invitation to participate were mailed to 780 persons with advanced cancer living in rural areas using two western Canadian provincial cancer registries. A reminder card was sent 4 weeks later. The persons with advanced cancer were asked to give the survey to their primary caregiver to complete. Surveys included measures of hope (Herth Hope Index (HHI)), general self-efficacy (General Self-Efficacy Scale (GSES)), grief (Non Death Version Revised Grief Experience Inventory (NDRGEI)), mental and physical health (Short Form Health Survey Version 2 (SF-12v2)), and demographic data such as their relationship to the person for whom the caregiver was caring. Data were entered into the Statistical Package for the Social Sciences v19 (SPSS) and analyzed using generalized linear modeling.

RESULTS

Significant factors (p ≤ 0.05) influencing HHI scores were GSES ( p ≤ 0.0001), NDRGEI subscale (p=0.001), and SF-12v2 mental health summary scores (p=0.002). Participants with higher GSES, lower NDRGEI, and higher SF-12v2 mental health summary scores had higher HHI scores. The SF-12v2 physical health summary mean score of 43.30 (standard deviation (SD)=4.63) was below the 25th percentile (46.53) of US population norms. The SF-12v2 mental health summary mean score of 45.24 (SD=5.98) was just above the 25th percentile of US population norms (45.13).

CONCLUSION

Participants with higher hope scores had higher mental health scores, lower perceptions of loss and grief scores, and higher scores in their confidence in their ability to deal with difficult situations (self-efficacy). The significant relationships found between hope and mental health, general self-efficacy, and perceptions of guilt provide a foundation for future research and underscore the importance of hope to rural women caregivers. The low physical and mental health scores of rural women caregivers are of concern and highlight the need to support this population.

"Bored out of my gourd": a cancer survivor's return-to-work experience

“The cancer had to accommodate my life. My life was not going to be built around this diagnosis.”[...]

Local adaptation with high gene flow: temperature parameters drive adaptation to altitude in the common frog (Rana temporaria)

Both environmental and genetic influences can result in phenotypic variation. Quantifying the relative contributions of local adaptation and phenotypic plasticity to phenotypes is key to understanding the effect of environmental variation on populations. Identifying the selective pressures that drive divergence is an important, but often lacking, next step. High gene flow between high- and low-altitude common frog (Rana temporaria) breeding sites has previously been demonstrated in Scotland. The aim of this study was to assess whether local adaptation occurs in the face of high gene flow and to identify potential environmental selection pressures that drive adaptation. Phenotypic variation in larval traits was quantified in R. temporaria from paired high- and low-altitude sites using three common temperature treatments. Local adaptation was assessed using Q(ST)-F(ST) analyses, and quantitative phenotypic divergence was related to environmental parameters using Mantel tests. Although evidence of local adaptation was found for all traits measured, only variation in larval period and growth rate was consistent with adaptation to altitude. Moreover, this was only evident in the three mountains with the highest high-altitude sites. This variation was correlated with mean summer and winter temperatures, suggesting that temperature parameters are potentially strong selective pressures maintaining local adaptation, despite high gene flow.

Receptor-specific delivery of protein antigen to dendritic cells by a nanoemulsion formed using top-down non-covalent click self-assembly

A new class of targeted and immune-evading nanocarrier made using only biological components and facile processes is assembled in a bottom-up fashion. Simple top-down sequential addition of immune-evading or receptor-specific antibody elements conjugated to biosurfactant protein DAMP4 promotes self-assembly at an interface previously formed in the presence of peptide surfactant AM1, leading to a functional display at the interface through non-covalent molecular self-assembly.

Receptor-specific delivery of protein antigen to dendritic cells by a nanoemulsion formed using top-down non-covalent click self-assembly

A new class of targeted and immune-evading nanocarrier made using only biological components and facile processes is assembled in a bottom-up fashion. Simple top-down sequential addition of immune-evading or receptor-specific antibody elements conjugated to biosurfactant protein DAMP4 promotes self-assembly at an interface previously formed in the presence of peptide surfactant AM1, leading to a functional display at the interface through non-covalent molecular self-assembly.

Quality and shelf life evaluation of pork nuggets incorporated with fermented bamboo shoot (Bambusa polymorpha) mince

Pork nuggets were processed by incorporating fermented bamboo shoot mince and their physico-chemical, microbiological and sensory characteristics were evaluated during 35 day storage at refrigeration temperature (4±1 °C). Addition of fermented bamboo shoot significantly affects the pH, moisture, protein, fat, fiber, instrumental color values and texture profiles of nuggets, especially at 6% and 8% addition levels. Nuggets with 6% and 8% FBSM had significantly lower TBARS values at the end of the storage period (i.e. 0.39 and 0.33 mg malonaldehyde/kg respectively) compared to the control (0.84 mg malonaldehyde/kg). Bamboo shoot addition significantly improved the microbial and sensory qualities of the pork nuggets. Incorporation of fermented bamboo shoot at 8% level increased the shelf life of pork nuggets by at least two weeks i.e. from 21 days to 35 days at 4±1 °C compared to the control.

The pre-treatment prevalence and types of sexual dysfunction among patients diagnosed with prostate cancer

Erectile dysfunction (ED) following prostate cancer therapy is a common condition that is well documented in literature. Despite the significant focus placed on ED and prostate cancer, very little is known regarding the baseline prevalence of other aspects of sexual dysfunction (SD) in this specific cohort of patients. The objective of the current manuscript was to assess the prevalence of subtypes of SD, including ED, ejaculatory dysfunction (EjD) and decreased libido among men with newly diagnosed prostate cancer. To achieve this objective, patients presenting to our clinic with a new diagnosis of prostate cancer from July 2011 and May 2012 completed the Male Sexual Health Questionnaire (MSHQ) to assess baseline sexual function. A total of 60 patients completed an MSHQ, with a mean age of 60.28 ± 6.25 (range 44-73 years). Of patients surveyed, 14% reported no sexual activity within the previous month, while 53% had sex at least once weekly. The percentage of patients reporting ED, EjD and decreased sexual desire ≥50% of the time was 37, 26 and 48% respectively. Eleven to 18% of patients reported that these symptoms were 'very' or 'extremely' bothersome. Patients noted dissatisfaction with the quality of their sexual relationship, frequency of sexual activity and quality of sex in 18, 31 and 20%, respectively. Overall findings suggest that patients with newly diagnosed prostate cancer experience a high rate of SD at baseline. Knowledge of these prevalence rates may assist physicians managing patient's expectations with planned therapies.

Variations in surgical management from a national bowel cancer screening programme

OBJECTIVE

Population screening for colorectal cancer (CRC) was introduced to Wales in October 2008. The aim of this study was to evaluate the early impact of screening on CRC services.

DESIGN

Prospectively collected data from the Bowel Screening Wales (BSW) programme and the Welsh Bowel Cancer Audit (WBCA) were used to identify all screen-detected (SD) CRC diagnoses in Wales between April 2009 and March 2011. Data from the WBCA were used to calculate surgical outcomes.

RESULTS

444 SD cancers were registered during the study period representing 11% of all CRC diagnoses. There was a 9.9% increase in CRC incidence following the introduction of the BSW. SD patients presented with earlier stage disease; SD Dukes' A 35.1% vs 13.9% symptomatic patients (p<0.001) and SD Dukes' D 7.4% vs 21.8% symptomatic, (p<0.001). There were more colonic cancers among the SD population (p<0.001). The resection rate for SD cancers was 89%, significantly higher than symptomatic cancers (67.7%; p<0.0001). There was variability in the use of polypectomy as a definitive procedure to treat CRC between units. Overall laparoscopic resection was used in 52% of cases but with considerable interunit variability (0-92%).

CONCLUSIONS

The introduction of screening has increased the workload of the colorectal multidisciplinary teams in Wales. This has occurred through both an increase in case volume and the identification of more patients with early stage disease. There is considerable interunit variability in the use of techniques of local excision and rates of laparoscopic resection that need to be addressed.

Compartment syndrome of the testicle: a case report and review of the literature

In this case report we describe a patient presenting with symptoms of right sided testicular torsion who, upon surgical exploration, was noted to no longer have a torsion of the spermatic cord but persisted in having an ischaemic testicle refractory to reperfusion. A testicular compartment syndrome was suspected and the patient underwent fasciotomy of the tunica albuginea, leading to full reperfusion and good clinical outcome at three weeks and 10 months. This case raises the question of the value of performing such fasciotomies in patients who would otherwise undergo orchidectomy. Following a review of the literature, we feel the technique may well have a place in the management of torsion, pending further study.

Databases searched were Medline, Embase, Cochrane, Trip and NHS Evidence. Search criteria included ‘compartment’, ‘testicle’, ‘testicular’, ‘syndrome’, ‘compartment syndrome’ and testis’ and combinations of these key words.

The information needs and media preferences of Canadian cancer specialists regarding breast cancer treatment related arm morbidity

The information needs and media preferences of Canadian cancer specialists regarding breast cancer treatment related arm morbidity. Breast cancer treatment related arm morbidity is a common but pernicious condition that is under-recognised, under-diagnosed, and can result in long-term impairment and disability. Despite the prevalence of this condition, little is known about breast cancer specialists' information needs and media preferences around this issue. In-depth telephone interviews with 14 Canadian cancer specialists were conducted, and were coded and analysed using a grounded theory approach. Findings revealed that cancer specialists were open to receiving all types of information about treatment related arm morbidity, and have preferences for particular types of media formats. However, barriers that could problematise the uptake of research findings into clinical practice were also noted and included gaps in specialists' knowledge of the complex nature of treatment related lymphoedema. Hence providing specialists with summary information about arm morbidity will not suffice, and an educational campaign around this condition, including the importance of physician vigilance in regularly monitoring patients for early and latent indications of this morbidity may be necessary.

The golden ratio in facial symmetry

Symmetry is believed to be a hallmark of appealing faces. However, this does not imply that the most aesthetically pleasing proportions are necessary those that arise from the simple division of the face into thirds or fifths. Based on the etymology of the word symmetry, as well as on specific examples and theories of beauty, we conclude that &#966;-value, a ratio also known as the golden ratio or the divine proportion, can also characterize symmetrical forms. Therefore, we propose the utilization of this ratio in facial aesthetics.

Using genetic variation to infer associations with climate in the common frog, Rana temporaria

Recent and historical species' associations with climate can be inferred using molecular markers. This knowledge of population and species-level responses to climatic variables can then be used to predict the potential consequences of ongoing climate change. The aim of this study was to predict responses of Rana temporaria to environmental change in Scotland by inferring historical and contemporary patterns of gene flow in relation to current variation in local thermal conditions. We first inferred colonization patterns within Europe following the last glacial maximum by combining new and previously published mitochondrial DNA sequences. We found that sequences from our Scottish samples were identical to (92%), or clustered with, the common haplotype previously identified from Western Europe. This clade showed very low mitochondrial variation, which did not allow inference of historical colonization routes but did allow interpretation of patterns of current fine-scale population structure without consideration of confounding historical variation. Second, we assessed fine-scale microsatellite-based patterns of genetic variation in relation to current altitudinal temperature gradients. No population structure was found within altitudinal gradients (average FST=0.02), despite a mean annual temperature difference of 4.5 °C between low- and high-altitude sites. Levels of genetic diversity were considerable and did not vary between sites. The panmictic population structure observed, even along temperature gradients, is a potentially positive sign for R. temporaria persistence in Scotland in the face of a changing climate. This study demonstrates that within taxonomic groups, thought to be at high risk from environmental change, levels of vulnerability can vary, even within species.

Recommendations for the development of e-modules for the continuing professional development of European dentists

AIMS

To provide evidence-based and peer-reviewed recommendations for the development of dental continuing professional development (CPD) learning e-modules.

METHODS

The present recommendations are consensus recommendations of the DentCPD project team and were informed by a literature research, consultations from e-learning and IT expert, discussions amongst the participants attending a special interest group during the 2012 ADEE meeting, and feedback from the evaluation procedures of the exemplar e-module (as described in a companion paper within this Supplement). The main focus of these recommendations is on the courses and modules organised and offered by dental schools.

RESULTS AND DISCUSSION

E-modules for dental CPD, as well as for other health professionals' continuing education, have been implemented and evaluated for a number of years. Research shows that the development of e-modules is a team process, undertaken by academics, subject experts, pedagogists, IT and web designers, learning technologists and librarians. The e-module must have clear learning objectives (outcomes), addressing the learners' individual needs, and must be visually attractive, relevant, interactive, promoting critical thinking and providing feedback. The text, graphics and animations must support the objectives and enable the learning process by creating an attractive, easy to navigate and interactive electronic environment. Technology is usually a concern for learners and tutors; therefore, it must be kept simple and interoperable within different systems and software. The pedagogical and technological proficiency of educators is of paramount importance, yet remains a challenge in many instances.

CONCLUSIONS

The development of e-courses and modules for dental CPD is an endeavour undertaken by a group of professionals. It must be underpinned by sound pedagogical and e-learning principles and must incorporate elements for effective visual learning and visual design and a simple, consistent technology.

Guidelines for the organisation of continuing professional development activities for the European dentist

AIM

Free movement of dental professionals across the European Union calls for more uniform continuing education in dentistry to ensure up-to-date, high-quality patient care and patient safety. This article provides guidelines for the management and delivery of high-quality continuing professional development (CPD) by European dental schools and other CPD providers.

METHOD

The guidelines are based on an extensive literature inventory, a survey of existing practices (both available as separate publications), discussions during meetings of the Association for Dental Education in Europe in 2011 and 2012 and debate amongst the members of the DentCPD project team representing six dental schools.

RESULTS

On the basis of the literature review, survey and discussions, we recommend that (i) every dentist should be given the opportunity for CPD, (ii) providers should be quality-approved and impartial, (iii) educators should be approved, impartial, suitably trained, and with educational expertise, (iv) the mode of CPD delivery should suit the educational activity, with clear learning objectives or outcomes, (v) effort should be made to assess the learning, (vi) participant feedback should be collected and analysed to inform future developments and (vii) uniform use of the pan-European system of learning credit points (ECTS) should be implemented.

CONCLUSION

Implementation of these guidelines should make dental CPD more transparent to all relevant parties and facilitate the transferability of earned credits across the European Union. It will also enable better quality control within dentistry, resulting in enhanced dental care and ultimately the improvement in patient safety.

The development of an exemplar e-module for the continuing professional development of European dentists

AIM

To present the development of an exemplar e-module for dental continuing professional development (CPD) provided by dental schools and other dental educational providers.

MATERIALS AND METHODS

The exemplar e-module covered the topic of 'Sterilisation and cross-infection control in the dental practice' as this is one of the most recommended topics for dental CPD in Europe. It was developed by a group of topic experts, adult learning and distance learning experts and a technical developer. Major concerns were pedagogy, interoperability, usability and cost reduction. Open-source material was used to reduce the cost of development.

RESULTS

The e-module was pre-piloted in dental practitioners for usability and then evaluated by experts in the field and dental academics through an electronic questionnaire and an online presentation and discussion at the ADEE 2012 Special Interest Group on DentCPD-Lifelong learning. This facilitated refinement before final production. A Creative Commons License was implemented to ensure the developers' rights and facilitate wider distribution and access to CPD providers.

DISCUSSION AND CONCLUSIONS

The e-module was developed according to well-defined pedagogical and technical guidelines for developing e-learning material for adult learners. It was structured to promote self-study by directing learners through their study, promoting interaction with the material, offering explanation and providing feedback. Content validity was ensured by extensive review by experts. The next step would be to expand the evaluation to practising dentists in various countries after relevant translations, and adaptations to local policies have been made.