To evaluate the clinical features, diagnostic routine, treatment, and prognosis of patients with double uterus with obstructed hemivagina and ipsilateral renal agenesis at a University Hospital. A retrospective study analyzing the medical charts of outpatients with similar complex genital malformations seen at the University Hospital of the Ribeirão Preto Medical School from 1994 to 2015. Fourteen patients were included in this retrospective study, all presenting with double uterus with obstructed hemivagina and ipsilateral renal agenesis. The main symptom was dysmenorrhea occurring shortly after menarche, and pelvic ultrasound was the examination of choice. The treatment consisted of resection of the vaginal septum, complemented by an abdominal approach in 5 cases. Complications of the syndrome observed in this case series included severe endometriosis, pelvic abscess, need for hysterectomy, and salpingectomy. Severe dysmenorrhea shortly after menarche is a typical symptom of this kind of malformation, even though the diagnosis of patients who present with fistulization of the vaginal septum can be delayed due to milder clinical features. Pelvic ultrasound can be considered the first-choice examination in diagnostic routine. Relief of pain and prevention of complications can be achieved successfully in most cases by resection of the vaginal septum. The presence of double uterus with obstructed hemivagina and ipsilateral renal agenesis, also referred to as Herlyn-Werner-Wünderlich (HWW) syndrome, or OHVIRA syndrome, is a type of complex anomaly associated with changes in the fusion of the müllerian ducts, with different degrees of uterine duplicity (class III of Buttran and Gibbons) , 2, in aMüllerian malformations are frequently associated with urinary malformations due to the intimate relationship between the müllerian ducts and the Wolff ducts during the embryonic period. If the Wolff duct fails to develop on one side, with the consequent occurrence of renal agenesis, the ipsilateral müllerian duct will develop in a more lateralized manner, thus impairing its fusion with the contralateral müllerian duct. In addition, the malformed hemivagina will not join the urogenital sinus in an appropriate manner, resulting in obstruction , 4. TherThe real prevalence of this anomaly is difficult to measure since in general the diagnosis is not made during a clinical gynecological examination but rather during some surgical procedure or by imaging evaluation. The prevalence is higher among groups with a specific condition such as infertility or endometriosis than among unselected populations. However, the estimated incidence is 0.1 to 0.8% and the condition is usually discovered after menarche by causing progressive dysmenorrhea due to the presence of the transverse vaginal septum which prevents blood flow through the vaginal canal, causing the formation of hematocolpos –9. In viThe objective of the present study was to analyze the clinical signs and symptoms, the procedures used at diagnosis and the short- and long-term prognosis of patients with this type of malformation seen in our service that could be compatible with the also called Herlyn-Werner-Wünderlich (HWWS) or OHVIRA Syndrome.This was a retrospective study based on the survey of the medical records of patients seen from 1994 to 2015 at the Human Reproduction, Gynecological Endoscopy and Children's and Pubertal Outpatient Clinics of the Department of Gynecology and Obstetrics of FMRP-USP with a diagnosis of double uterus with obstructed hemivagina and ipsilateral renal agenesis, according to diagnostic criteria established in the scientific literature [Date and age at first visit, symptoms, clinical examination, subsidiary exams, treatment instituted, associated pregnancies, and their results were obtained from the medical records.The data of 14 patients seen at the service during the follow-up period and fulfilling the diagnostic criteria of this kind of malformation were obtained from the medical records. Data regarding age and clinical signs and symptoms at the time of diagnosis, type of anatomical malformation, treatment, and the occurrence or absence of pregnancy during follow-up are presented in Most of the patients analyzed sought gynecological care a short time after menarche. Most patients had dysmenorrhea as the main clinical manifestation. In the initial approach, ultrasound was the examination of choice and was performed in almost all cases.Regarding treatment, in addition to exeresis of the vaginal septum, 6 patients required a joint abdominal approach. Three patients underwent salpingectomy due to large tubal dilation associated with hematosalpinxs. One patient underwent hysterectomy three months after the septum exeresis due to infectious complications, one underwent salpingectomy and oophorectomy due to tube ovarian abscess, and one patient was submitted to salpingectomy due to pyosalpinx associated with rudimentary horn exeresis.We observed not infrequent complications associated with this entity, among them 2 cases of severe endometriosis, 2 cases of abscess, 1 case of hysterectomy, and 4 cases requiring salpingectomy. In these cases the complications were not associated with age, the duration of symptoms, or type of surgical approach. Only 3 of the 14 patients studied reported pregnancy during a ten-year follow-up. But it is important to emphasize that conservative treatment with exclusive vaginal septum exeresis is the preferred treatment.The main symptom detected among the patients was dysmenorrhea and pelvic pain due to the presence of an obstructed hemivagina that resulted in the accumulation of metabolized blood, causing hematocolpos, hematometra, and hematosalpinx. Dysmenorrhea was reported to be moderate to intense and the patients with a less symptomatic condition had communication between the uterine horns or an incomplete or fistulized vaginal septum. In one of the most extensive reviews of published cases, 94% of the patients complained about dysmenorrhea, 14% about vaginal discharge, and 2% about an acute abdomen [The gynecological examination and investigation confirmed the diagnosis of uterus didelphys, transverse vaginal septum, and ipsilateral renal agenesis with hematocolpos, representing the most common form of the so-called Herlyn-Werner-Wünderlich syndrome. The exam most frequently used and most efficient for the diagnosis of the reproductive apparatus was ultrasound, applied to 13 of the 14 patients. The only exception was a patient who exhibited an infectious complication with purulent secretion through the vagina. In the present series, contrast radiography was used to confirm renal agenesis. Diagnostic hysteroscopy with vaginoscopy and diagnostic laparoscopy were used in the more complex cases. Magnetic resonance was carried out in 4 patients but did not modify the diagnosis or the management in this case series. Ultrasound is the first line examination for the complementary evaluation of these patients, with the primary condition being dysmenorrhea. The magnetic resonance can be considered as second-line examination because of the cost-effectiveness; however in cases of complex müllerian malformations it can be extremely helpful .The literature has extensively reported and confirmed the use of imaging methods such as ultrasound and magnetic resonance for the diagnosis of both müllerian and urinary tract malformations , 10, andComplicated evolution of the cases was due to either infection or endometriosis. Both occur in consequence of the existing obstruction to the menstrual flow: in the first case, when this accumulation of menstrual blood becomes infected and in the case of endometriosis due to menstrual blood reflux into the abdominal cavity.Patient treatment consisted of exeresis of the vaginal septum and drainage of hematocolpos, with consequent relief of symptoms. This approach is resolutive for cases of classical presentation as illustrated in The main clinical manifestation observed in the patients was progressive dysmenorrhea after menarche. However, the diagnosis of patients with fistulization of the vaginal septum or communication between the uterine horns was delayed since their dysmenorrhea was less severe.Although this is a rare condition, a high index of suspicion can lead to early diagnosis and timely intervention. It is also important to remember that, whenever malformation of müllerian ducts is diagnosed, it is essential to check for the associated renal malformations once they often coexist.


Mumps is a public health problem on a global scale caused by mumps virus, a member of family paramyxoviridae. An effective form of vaccination exists and is incorporated into routine immunization schedules in over 100 countries, usually in the form of the Measles, Mumps and Rubella (MMR) vaccine. This is not the case in India, as mumps is not viewed as a significant enough public health problem by the government to warrant such an intervention. This original research paper discusses about outbreaks of mumps in Kashmir, India and aims to add to the body of literature to support the routine immunization with the mumps vaccine. From July to September 2017, there were 15 outbreaks and 260 cases of mumps recorded in the region by the Integrated Disease Surveillance Programme (IDSP). We conclude that the Indian Government should include the MMR vaccination in the Universal Immunization Programme. This would result in clinical and economic benefits by reducing outbreaks and associated morbidity of mumps, in addition to tackling the recognized morbidity and mortality of rubella and measles. To support the global health security, there is a great need to strengthen surveillance, adhere to the World Health Organization’s International Health Regulations (IHRs), and pay attention to emerging and re-emerging infectious agents, including paramyxovirus group. The Universal Immunization Programme (UIP) of India does not include the measles, mumps and rubella (MMR) vaccination. It currently vaccinates against measles, however not rubella or mumps . By presMumps is a viral infection caused by a paramyxovirus. The virus spreads through direct contact with respiratory secretions, saliva, or through fomites. It replicates in the upper respiratory tract and the average incubation period is 16 to 18 days. Mumps primarily affects the salivary glands, causing pain, tenderness, and swelling in one or both parotid glands. Prodromal symptoms may precede parotitis by several days, consisting of low grade fever, myalgia, anorexia, malaise, and headache. The parotitis typically lasts for at least two days and further spread is enhanced by longer and closer contact with an infected individual. Therefore, it is advised that an infected individual should avoid contact with others from the time of diagnosis until five days post-onset of parotitis . VaccinaThe Integrated Disease Surveillance Programme (IDSP) of India aims to strengthen and maintain decentralized laboratory-based disease surveillance systems for epidemic-prone diseases to monitor disease trends and to detect and respond to outbreaks promptly through trained Rapid Response Teams (RRTs) . The KasThe Universal Immunization Programme began in India in 1985. It was an extension to the Expanded Programme for Immunization (EPI), which endeavoured to provide recommended vaccines against tuberculosis, polio, and other diseases for all Indian children. The national policy of immunization of all children during the first year of life with DPT , OPV  and BCG —with the series of primary vaccinations to be completed prior to the age of one—was adopted in 1978 with the launching of the EPI to increase the immunization coverage in infancy to 80%. The Ministry of Health and Family Welfare was responsible for the programme, with significant support from the international community.The UIP is one of the largest in the world in terms of quantities of vaccine used, the number of beneficiaries, the number of immunization sessions organized, the geographical spread, and the diversity of areas covered . AdvanceThe current vaccination schedule under the UIP is shown in At present, the vaccination schedule  does notThe reasoning behind this is that it is not a significant enough public health problem. Despite being a widely prevalent disease in the Country, it is considered as an insignificant public health problem mainly due to poor documentation of clinical cases and a lack of published studies. This paper endeavours to add to the body of literature which supports introduction of mumps vaccine as part of the UIP vaccination schedule .Globally, we see the issue of waning immunity, for instance an outbreak at a Kansas University in 2006 where there was a two-dose MMR policy . In 2009The IDSP has been recording outbreaks of diseases including mumps. The epidemiological methods employed in this instance involved collecting the number of outbreaks and diagnosing cases based on clinical signs and symptoms. The WHO-recommended clinical case definition is: ‘acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland, lasting two or more days and without other apparent cause’ .Door-to-door visits occurred for patients in the affected villages and schools, examining for signs and symptoms. Additionally, the living conditions and surroundings of the inhabitants were examined. The current rate of cases was compared to the background rate, and the outbreak described with respect to time place and person.From July 2017 to September 2017, 15 outbreaks were recorded in the Kashmir region by the IDSP, totalling 260 cases  as shownThe largest outbreak was in an educational institution, in keeping with findings from existing literature which indicates that group settings associated with educational institutions are at increased risk of outbreaks, be they small or large . The majTo provide more context, an outbreak in the Shopian District that was detected on 15 August 2017 will be looked at in detail. Twenty cases were identified in the Bal-Ashram Institute, which has a total enrolment of 55 people. The first case was reported on 14 August 2017 and clustering of cases occurred on 15 August 2017. The current rate of infection—36.36% (20/55)—was compared to background rate—0%—by reviewing weekly IDSP data for the years 2016 and 2017.Keep affected children isolated from gathering.Wash hands thoroughly with soap.Keep affected children at home for five days and avoid close contact with others in house.Interventions made due to the outbreak took the form of an infographic and door to door surveys relaying education about transmission and prevention of the disease. Advice comprised:Additionally, health advisory pamphlets were distributed and pasted to public place walls , a team This outbreak only affected children, resulted in no hospitalizations or deaths, and no children developed major long-term sequelae.Mumps vaccination is a proven way of preventing infection with the virus, reducing severity of disease if contracted, and reducing transmission. Two doses of the vaccine are 88% effective at protecting against mumps and one dose is 78% effective . Waning During mumps outbreaks in highly vaccinated communities, the proportion of cases that occur amongst the vaccinated population may be high. However this should not result in defaulting to the belief that the vaccine is not effective. The effectiveness of the vaccine is assessed by comparing the rate of infection in the vaccinated cohort to the rate of infection in the non-vaccinated cohort. In outbreaks in highly vaccinated populations, the non-vaccinated cohort tends to have a greater infection rate than the vaccinated cohort .Given the existence of the MMR vaccination, which is used in many countries globally, we suggest that the benefits of ensuring vaccination against mumps in addition to rubella and measles would be a plausible public health intervention that would have highly significant clinical and economic benefits. It would ensure vaccination against mumps in addition to greater immunization rates against measles and rubella.Studies have shown that two-dose MMR coverage reduces disease severity and transmission alongside a reduction in complications and hospitalization ,13. VaccIn 2017, the United States reported more than 6000 cases of contagious viral illness and there were 150 outbreaks that affected more than 9000 people across the country between January 2016 and June 2017. Nearly half of these outbreaks occurred in university settings where young adults were at the highest risk for mumps. A majority of 78% of patients had vaccination of which 70% had received two doses of the MMR vaccine. This rise in cases of mumps has prompted the US panel to endorse third vaccine dose [In countries where vaccination was introduced and high coverage was sustained the incidence of the disease has dropped tremendously and circulation has stopped. In countries where vaccination was not introduced the incidence of mumps remains high, mostly affecting children aged 5–9 years ,15. CompThe main aim of global health security is to make our interconnected world safe from infectious disease threats. The framework emphasizes for global preparedness and response to emerging infectious diseases. Control of the international spread of infectious diseases is the primary and historical responsibility of WHO . The WHOThe Indian Government proposes that mumps is not a significant enough public health problem to warrant routine immunization, however the data presented from Kashmir suggests otherwise. Environmental methods alone are clearly not preventing outbreaks. Whilst the case study of the Shopian district did not result in any hospitalizations or deaths, there is still recognized morbidity associated with mumps infection and potential lifelong sequelae for infected individuals, which is a public health concern. Whilst this paper acknowledges that there are other communicable diseases with greater associated morbidity and mortality, it proposes that given the existence of the MMR vaccination, mumps is a virus that could easily be vaccinated against in combination with measles and rubella, as occurs in over 100 countries worldwide that routinely vaccinate against the virus. This paper should be taken into account alongside other literature within the body of evidence that proposes mumps as a significant enough public health problem to warrant investment in prevention through vaccination.


Tear fluid is a heterogeneous solution containing mainly proteins, lipids, mucins and electrolytes, which regulates the physiology of the human eye. The complex composition of tears can be altered in the presence of eye inflammations. The use of contact lenses is one of the most frequent causes of inflammatory responses of the eye, with the related discomfort often causing the wearer to give up using them. In this paper, we exploit the potentiality of Raman Spectroscopy to analyse the biochemical changes in tear fluid in a contact lens wearer. In particular, we analysed the tear fluid collected from a volunteer as a function of the wearing time for two types of monthly contact lenses (Hydrogel and Si-Hydrogel). Our experimental results show an alteration of the relative concentrations of proteins and lipids in both of the analysed cases. More importantly, our results highlight the diagnostic sensitivity of Raman analysis to select the proper contact lens type for each wearer and optimise the lens wearing conditions. Human tear fluid is a complex blend of both organic and inorganic components, synergically involved in carrying out many important functions for the eye, including lubrication, the cleaning of waste and particulate matter and protection against infective agents . ChangesOn the ocular surface, the tear film is arranged in three layers . The lowThis layered structure can be significantly altered by the wearing of contact lenses (CLs). The effect of CLs on the tear film is essentially twofold ,6. FirstRS has been previously used to analyse tears, typically spotted on a hydrophobic substrate and allowed to evaporate. This procedure, usually referred as drop coating deposition Raman spectroscopy (DCDRS), leads to concentrations of macromolecule samples, with consequent amplification of the detected Raman signal. As it is well known, tear fluid evaporation forms characteristic ferning patterns. Filik et al. ,14,15 haIn this work, we analysed the effect of CLs use on the composition of tear fluid. The investigation was performed using DCDRS analysis of tear samples as a function of the wearing time of monthly CLs. Since changes in tear fluid biochemistry are reported to be subject dependent , it was Our experimental results reveal a reduction in the concentration of proteins with respect to lipids in the first five days of CLs use, followed by a substantial recovery of the initial tear fluid content after two weeks. This behaviour was found for both types of CLs materials. More importantly, our work demonstrates that RS can be fruitfully used to probe the complex biochemistry involved in the interaction between CLs and eyes.As previously mentioned, a single healthy volunteer was recruited for tear fluid collection. Informed consent was obtained from him, after a full explanation of the tear fluid collection procedure and the scope of the investigation. The volunteer declared that he was not a contact lens wearer, and was free from ocular infection. Tears , provided with a Nd-YAG laser at 532 nm as Raman excitation source. The laser beam was focused on the sample through an oil-immersion 100× objective (NA = 1.4). Back-scattered light was collected using the same objective, filtered by an edge filter and sent to the spectrometer through a 50 In this work, we acquired Raman spectra in selected points and/or areas of the ferning region. Single spectra were acquired with 20 s of integration time while Raman spectral maps were performed on small areas  ,27 appliR. In particular, R was evaluated through the ratio of the areas underneath the two considered peaks (see dashed areas).The Raman spectra selected according to the procedure just described were used to evaluate the relative intensity of Raman bands associated with proteins and lipids. According to the literature, the ratio R obtained in a single scan from spectra corresponding to fern points (yellow bars) and to points not occupied by ferns (blue bars). As can be seen, the two distributions, although partially overlapped, present a slight different average value as a consequence of the spatial segregation of the biochemical components in the pattern. Notably, the average value of these two distributions derived from different Raman maps in the same sample are always consistent with each other, an outcome which confirms the effectiveness of our procedure to obtain reliable information on the sample biochemical content.In R values in these assays. From these data, it is possible to note that R is reasonably constant (within error bars) in all the measurements.Therefore, having assessed our experimental procedure, we applied it to some preliminary analyses. In particular, we collected tear fluid samples in five different experimental sessions, spanning two weeks (approximately one sample collection every three days). This analysis was performed in order to exclude any influence on tear fluid composition by external factors . R ratio is roughly conserved, with an initial decrease of this parameter and a substantial recovery after 21 days of CLs use. Clearly, our results for the two CLs types are not representative of the generic CLs user. In fact, this is strictly dependent on the volunteer, and, in principle, on factors related to the volunteer’s health during use. This is the main reason that we decided to perform this study on tear fluid collected from only one volunteer. A much wider statistical base would be necessary to investigate, e.g., the effect of a specific CLs type . However, this last issue was outside of the goals of our investigation.After this preliminary check, we finally proceeded by analysing the effect of CL use on the tear fluid. The present study is a Raman-based investigation of the tear fluid of a CLs wearer. The study was performed for two types of CLs worn by the same donor in order to eliminate possible interference due to the individual response to CLs. Our results show a decrease in the relative content of proteins with respect to lipids in the first days of CLs use, followed by a substantial recovery after ≈20 days. This paper demonstrates that Raman spectroscopy is a useful tool to monitor the biochemical change induced by CLs use. To this end, we think that the results we are presenting can be considered a preliminary investigation promoting the development of a real sensor devoted to the analysis of the influence of CLs use on tear fluid composition.


It is the position of the Society for Nutrition Education and Behavior that environmental sustainability should be inherent in dietary guidance, whether working with individuals or groups about their dietary choices or in setting national dietary guidance. Improving the nutritional health of a population is a long-term goal that requires ensuring the long-term sustainability of the food system. Current environmental trends, including those related to climate change, biodiversity loss, land degradation, water shortages, and water pollution, threaten long-term food security and are caused in part by current diets and agricultural practices. Addressing these problems while producing more food for a growing population will require changes to current food systems. Dietary choices have a significant role in contributing to environmental impacts, which could be lessened by consuming fewer overconsumed animal products and more plant-based foods while reducing excess energy intake and the amount of food wasted. Discussion of sustainability within governmental dietary guidance is common in many countries, is consistent with previous US guidelines, and is within the scope of authorizing legislation. Dietary choices are a personal matter, but many American consumers are motivated by a concern for the environment and would welcome sound advice from credentialed nutrition professionals. More opportunities are needed for developing such interdisciplinary knowledge among nutritionists. It is the position of the Society for Nutrition Education and Behavior (SNEB) that environmental sustainability should be inherent in dietary guidance, whether working with individuals or groups about their dietary choices or in setting national dietary guidance. Improving the nutritional health of a population is a long-term goal that requires ensuring the long-term sustainability of the food system. In early 2015, the Dietary Guidelines Advisory CommitteeDietary Guidelines for Americans (DGA),Global climate change is one of the most urgent problems that exists today. In their latest report, the Intergovernmental Panel on Climate Change,In addition to global climate change, pressing environmental problems include loss of biodiversity, land degradation, fresh water shortages, and water pollution. The importance of biodiversity for the functioning of ecosystems and human well-being has been officially acknowledged since the creation of the Convention on Biological Diversity at the Earth Summit in Rio de Janeiro, Brazil, in 1992.Reduction in the productive capacity of land, or land degradation, owing to loss of soil quality, biodiversity loss, salinization, or water depletion, is another serious problem. The United Nations Food and Agriculture Organization conducted a global assessment of the state of the planet's land resources and found that about 33% of all land is moderately or highly degraded.Changes in water resources are also a concern in terms of both quantity and quality. A global analysis of the freshwater systems that provide water for humans and are important for ecosystem functioning (as assessed by biodiversity) found that 80% of the world's population lives where water security for humans or for ecosystem functioning is highly threatened.19A serious concern is that agriculture, including livestock production, is one of the largest contributors to environmental damage, including extensive clearing of forests, overuse of freshwater resources, widespread water pollution, and global climate change.Currently an estimated 795 million people in the world lack adequate energy from foodA number of strategies have been suggested to meet these 2 long-term food challenges.,Nevertheless, repeated projection studies demonstrated that closing global yield gaps and other sustainable intensification measures will be insufficient to prevent further agricultural expansion and achieve the deep emission cuts needed to meet the Paris climate commitment; demand-side reductions will be necessary.32life cycle in the context of studying nutritional needs and how they change during the course of human life. Other scientists, such as industrial ecologists or environmental engineers, also use the term life cycle but in reference to products rather than humans. Life-cycle assessment (LCA) was developed as an analytical framework to assess the potential environmental impacts of industrial production systems across each stage of a product's life cycle, from resource extraction (cradle), manufacturing, and distribution to use and end-of-life disposal (grave).Nutritionists may recognize the term Ideally, LCA includes a broad range of environmental impact categories  so that trade-offs between impact categories can be evaluated and potential shifts from 1 impact category to another can be detected when comparing scenarios.Over the past 2 decades, the LCA framework has been applied to food and agricultural systems, addressing many of the unique challenges that arise when considering these complex systems.2eq), from a review of studies throughout the world. This unit of measure is used to place carbon dioxide, methane, nitrous oxide, and other gases on the same scale based on their relative contributions to global climate change. For vegetables and fruits, values are typically <1 kg CO2eq/kg of commodity. At the other end of the spectrum, beef has a value >30. Beef and products from other ruminant animals have such high values in large part because of methane gas released during enteric fermentation (part of ruminant digestion) and manure management, but also because of the energy used in growing feed grains and nitrous oxide released from soils receiving nitrogen fertilizers.In general, results from food LCA studies show that environmental impacts from food production are higher for animal products and higher still for ruminant animals. For example, the Figure displays the GHGE from the production of different foods in terms of their global warming potential, or carbon dioxide-equivalents , as opposed to losses owing to spoilage from mold or pests.Another important line of research investigated the potential impact on the environment of diets that follow national dietary recommendations. In the Netherlands, the official recommended diet was compared with the current Dutch diet, using a sustainability score based on GHGE and land use.,A number of studies were conducted in other countries that either compared average diets with a recommended diet or developed a new diet through optimization techniques to lower GHGE while meeting dietary recommendations. In France, Spain, Sweden, Germany, Denmark, and New Zealand, those studies all showed that diets that met recommendations could lower GHGE.per capita caloric intake and concluded that a shift to a recommended food mixture and caloric intake would increase GHGE by 6% and increase the energy and water used by the food system by 38% and 10%, respectively.In the US, 4 studies examined the impacts of diets that meet the 2010 DGA. If the USDA food plan were to be consumed at recommended energy intakes, 1 study estimated that there would be a reduction in GHGE of about 1%.These studies, as well as others that analyzed different dietary scenarios, highlight the importance that changes in diet composition could have in reducing environmental impacts. A systematic review of 14 recent peer-reviewed diet scenario studies conducted mostly in European countries concluded that changing current diets could have a significant impact on the environment, potentially reducing GHGE and land use from diet by up to 50%.,,Given the research showing that diets that follow national dietary guidelines for a healthy diet could lower environmental impacts,Nutritionists in the US have also had a long history of supporting such an approach. Over 30 years ago, Joan Gussow and Kate Clancy,consistent evidence indicates that, in general, a dietary pattern that is higher in plant-based foods, such as vegetables, fruits, whole grains, legumes, nuts, and seeds, and lower in animal based foods is more health promoting and is associated with lesser environmental impact  than is the current average U.S. diet.Given the mounting research on environmental damage and the links between diet and impacts on the environment, as well as the accepted practice around the world of considering sustainability in providing dietary guidance, the DGACThis is a straightforward, even modest reading of the overwhelming body of scientific evidence on both the relationships between diet and health and those between diet and the environment, which has now been reinforced with an updated systematic review by these experts.The Secretaries of the USDA and Department of Health and Human Services decided that sustainability considerations would not be included in the DGA because of a matter of scope.However, the DGAC report did provide dietary guidance based on the preponderance of scientific and medical knowledge. Moreover, the original authorizing legislation indicated that there was nothing out of scope about including sustainability in the DGA.The National Nutrition Monitoring and Related Research Act has 3 titles: Title 1, Nutrition Monitoring and Related Research; Title 2, National Nutrition Monitoring Advisory Council; and Title 3, Dietary Guidance.food supply and demand determinations. Title 2 on the Advisory Council, the presidentially established body that assisted in carrying out this Act, includes fields of expertise as selection criteria for Council members. One of the 3 sets of fields listed is food production and distribution, which includes a number of topics such as agriculture, and food-system management. Taken together, this makes it seem clear that congressional intent was to take a broad view of nutrition monitoring and dietary guidance that included food supply issues.A review of the rest of the Act, to understand the context for Congress's approach to this topic, makes clear that the DGAC's inclusion of sustainability is within the scope of the authorizing legislation. The introductory definitions section makes it clear that nutrition monitoring and related research includes develop and expand safe, effective, and sustainable agriculture and aquaculture practices to ensure availability of recommended amounts of healthy foods to all segments of the population.The 2015 DGAC were also consistent with previous developments of the DGA. The 2010 DGA had a Call to Action to ensure, among other things, that all Americans had access to nutritious foods and promoted a multipronged strategy that included a recommendation to,Ensuring access to healthy food includes consideration of food safety, a topic that has been discussed in DGA reports for over a decade.103Based on this evidence presented, the current authors make recommendations on dietary guidance policy, nutrition education practice, and research.Improving the nutritional health of a population is a long-term goal that requires ensuring the long-term health of the food system as well. Given the serious concerns about the natural environment, the ability to sustain expected increases in population with current dietary patterns, and the compelling nature of the science that link these issues, SNEB recommends that environmental sustainability considerations be included in future federal dietary guidance.This position paper supports the original statement of the US DGAC that a diet with more plant-based foods than the average American diet would represent an improvement in both the environment and the health of the American consumer.,Dietary choices are a personal matter and there are many different dietary patterns that can lead to health. In discussing dietary recommendations, nutritionists can discuss both the health and the environmental impacts of food choices. For example, reducing animal foods, particularly ruminant animal consumption in the US, can have beneficial health and environmental effects, as can reducing overconsumption of food energy.81Indeed, some individuals might find concerns about environmental impact more motivating than concerns about health when considering whether to make a dietary change. Based on the nationally representative American Climate Values Survey of 2014, >75% of Americans view clean air and water and unpolluted, toxin-free neighborhoods as rights that should be available to all people.flexitarianism, a term for part-time meat eaters.,111Such advice does not need to recommend absolutes. As the DGAC pointed out, a more environmentally sustainable diet can be achieved without excluding any food groups.Expanding the knowledge of nutritionists in sustainability and environmental studies is needed to facilitate the types of dietary advice recommended earlier. Academic institutions can have a role in this by increasing such interdisciplinary topics in the training of future dietitians and nutritionists. Continuing education opportunities are also needed for current professionals. Such developments would benefit from collaboration with SNEB's Sustainable Food Systems Division.Additional research on dietary patterns would assist in providing more concrete details for consumers about the specifics of a diet that is less impactful to the environment. Currently, the DGA publishes suggestions regarding several healthful eating patterns: a healthy US-style eating pattern, a healthy Mediterranean-style eating pattern, and a healthy vegetarian eating pattern.There are also significant gaps in the food LCA literature. In a recent review of 321 studies,That review also pointed to another gap in the LCA literature: More information is needed on environmental impacts beyond GHGE.Finally, even the most comprehensive, evidence-based dietary guidelines will have only limited influence on consumers if they are not motivated to make changes and if these are not supported by other dissemination and behavior change efforts. Studies are needed to determine what motivates specific personality types to change their behaviors and whether strategies such as price changes, food labeling, messaging campaigns, etc, can promote both healthy and environmentally sustainable food choices.People want to know what to eat today, so it is incumbent on those of us who are knowledgeable about nutritional science and education techniques to provide the best advice based on the available evidence to date. Clearly this advice might change as nuances in the science are discovered and resolved. To the credit of those who formulated the initial legislation authorizing the DGA, they required publication of a report at least every 5 years for precisely this reason.,26,34,21,26,34,32,42The best science we have today makes it clear that current environmental problems, including global climate change,21Taken together, the science on environmental impacts of food choices and diet has several implications for policy, practice, and future research. First, federal dietary guidelines should include environmental sustainability considerations. Second, nutrition advisors and educators can convey both the health and environmental benefits of dietary choices. Finally, more research is needed on changing consumer behavior regarding sustainable diets and on various topics related to the LCA of foods, including studies on a wider variety of foods with a greater number of environmental impacts and on more foods produced in the US.


This review discusses the techniques and uses of atraumatic restorative treatment (ART) and interim therapeutic restoration (ITR) and states the differences between these two approaches. ART and ITR are similar approaches and are performed using the same material, but they differ in the purpose of their use. ART is used in cases when there are obstacles to reaching dental care units and has been proven to have high success rates in primary and permanent dentitions. ITR is used as a temporary restoration that will be replaced with a more definitive one. ITR is used in cases when the ideal dental treatment cannot be performed. Conventional glass polyalkenoate (ionomer) restorative cement (GIC) is the material of choice that has been used for ART and ITR. This is because of its fluoride release properties, including its ability to bond to enamel and dentine, its pulpal biocompatibility, and its ease of manipulation. High-viscosity glass ionomer performed better than low and medium-viscosity glass ionomer in ART. Combining GIC with conditioner, as well as the use of a chemo-mechanical approach, improved the success rate of ART. Both ATR and ITR are acceptable strategies, with success rates comparable to the traditional treatment methods. Atraumatic restorative treatment (ART) and interim therapeutic restoration (ITR) have had increased interest in the past few years. ART and ITR are similar approaches and are performed using the same material, but they differ in the purpose of their use . ART is ART was developed as a treatment approach in developing countries, where resources might not be available for a more definitive treatment . FollowiConventional glass polyalkenoate (ionomer) restorative cement (GIC) is the material of choice that has been used for ART and ITR. This is because of its fluoride-releasing properties, including its ability to bond to enamel and dentine, its pulpal biocompatibility, and its ease of manipulation ,13,14,15Much research has been carried out regarding ART . The indThe purpose of this review is to discuss the techniques and uses of atraumatic restorative treatment (ART) and interim therapeutic restoration (ITR) and to report the differences between the two approaches.ART is used in cases when routine dental treatment cannot be performed because of a lack of facilities or accessibility to a dental clinic . In addiART is a treatment strategy that requires trained personnel and suitable materials for its success ,20. ART The fluoride-release from GIC seems to be advantageous for ART. Fluoride that is released from GIC makes the tooth structures (enamel and dentine) more resistant to acidic invasion by bacteria ,27,28,29®, 3M ESPE, Seefeld, Germany) [A glass ionomer that is specifically designed for ART is available, which is termed a high-viscosity glass ionomer (such as Ketac Molar EasymixGermany) ,31,32. IGermany) ,31. A hiGermany) ,34. A hiGermany) . DiffereAdditionally, silver diamine fluoride (SDF) is a valuable material that can be used in ART . The indMoreover, the hand instruments used in ART have been manipulated to be very sharp, as to make the process of ART faster and to produce some form of cavity preparation ,31.ART is performed by using a sharp hand instrument to remove the carious tooth structure, followed by restoration with GIC or RMGIC ,43. The In 2001, a study was conducted in China regarding the success rate of ART performed on the primary teeth in various cavity designs . They foAnother study was performed in 2003 that showed that, in 24 months of follow-up, the success rate of ART performed in Class I cavities was high (89.6%) [A meta-analysis was conducted in 2006 which addressed the success rates of ART in primary and permanent dentitions . It concSeveral studies have addressed the success of ART performed in proximal cavities. They all showed that the durability of the GIC placed on the proximal surfaces of teeth treated with ART was significantly lower than the durability of the GIC placed on the occlusal surfaces ,48,49. TRecently, a study was conducted in India addressing the success rate of ATR applied to one or two surfaces . They foRegarding the method of the application of GIC in ART, a study was carried out in Brazil in 2016 which addressed the success rate of ART performed using a bilayer method . It concThe properties of GIC in ART have been influenced by the use of certain materials. For example, GIC was proven to produce better results when used in conjunction with a dentin conditioner  ,52. The The chemo-mechanical method of the removal of caries is a desired method that can be used in ART. The chemo-mechanical approach comprises the use of a chemical material that softens the carious tooth structure, followed by the mechanical removal of caries . This meSeveral studies have been carried out regarding the chemical material that can be used in the chemo-mechanical removal of caries ,60,61,62Papacarie and Carisolv are used to dissolve carious tooth structures by breaking the collagen fibrils infected by caries, with the ability to preserve sound tissues ,65. TherThe ART approach enables the treatment of many children in a community-based setting. This approach is considered economic, as it is performed using simple equipment . HoweverChildren with disabilities have several barriers to dental treatment . They miA recent study was carried out regarding the effectiveness of ART as an alternative treatment for disabled children . They peITR is indicated in cases where there are obstacles to the performance of an ideal dental treatment . Either The indications for the use of ITR include young patients, uncooperative patients, patients with special needs, and cases when traditional dental treatment cannot be performed and needs to be postponed ,77. In aThe term ITR was implemented to describe the provisional nature of ITR . ITR is The procedure of ITR requires the removal of carious tooth structures using hand or rotary instruments, followed by restoration with GIC or RMGIC ,84.The increased success of ITR was detected in one surface or two small surface restorations ,85. The Generally, ITR should be replaced with a more definitive restoration within six months of the placement to ensure maximum benefit to the patient and to reduce the risk of failure, as the levels of oral cariogenic bacteria might return to pre-treatment levels after six months of treatment .In 2016, a study was carried out comparing the success of ITR with conventional drilling treatment methods in the treatment of early childhood caries (ECC) . It was In a recent study, ITR was compared with general anesthesia for managing young uncooperative patients . The stuDespite the similarities between ART and ITR, there are certain aspects that make the two approaches different. In most of the cases that ART has been used, there was no plan to replace it with a more definitive treatment. This is because the indications for its use stated that it was used when there were obstacles to reaching dental care units. Therefore, there were also most probably obstacles to replacing it with a more definitive treatment . ART is On the other hand, ITR was developed as a temporary approach that would be replaced with a more definitive restoration, and hence it is named ITR. ITR should be replaced with a more definitive restoration within six months of the placement to ensure its maximum benefit is attained and to reduce the risk of failure .Based on the available literature, we conclude that ATR and ITR are suitable treatment approaches for the management of dental caries in several conditions in both primary and permanent teeth. ART and ITR are similar approaches and are performed using the same material (GIC). ATR is used in cases where there are obstacles to reaching the dental care units. ITR, on the other hand, is used for treating patients in dental clinics in order to control the progression of caries or to manage certain health characteristics of the patient. A high-viscosity glass ionomer performed better than low and medium-viscosity glass ionomers in ART. Combining GIC with conditioner, as well as the use of the chemo-mechanical approach, improved the success rate of ART.Both ATR and ITR are acceptable strategies, with success rates comparable to the traditional treatment methods. Finally, the literature is deficient in studies on ITR, therefore, more studies should be carried out regarding this treatment approach.


Deep brain stimulation (DBS) is a promising treatment for many memory-related disorders including dementia, anxiety, and addiction. However, the use of DBS can be a paradoxical conundrum—dementia treatments aim to improve memory, whereas anxiety or addiction treatments aim to suppress maladaptive memory. In this review, the key hypotheses on how DBS affects memory are highlighted. We consolidate the findings and conclusions from the current research on the effects of DBS on memory in attempt to make sense of the bidirectional nature of DBS in disrupting and enhancing memory. Based on the current literature, we hypothesize that the timing of DBS plays a key role in its contradictory effects, and therefore, we propose a consolidated model of how DBS can both disrupt and enhance memory. Memories define who we are, they affect the way we think, the way we interact with each other, and the way we interact with the world. Memory systems can be affected by diseases manifesting as memory-related disorders. For example, dementia leads to a loss of memory that eventually affects daily functioning, and diseases such as anxiety and addiction have roots in maladaptive learning and memories , 2. ReseDeep brain stimulation (DBS) is a minimally invasive neuromodulation surgical technique. This method typically involves a stereotaxic surgery in which burr holes are drilled into the skull of patients/animals, and an electrode, typically made of platinum-iridium or stainless steel, is implanted in the desired region of the brain. Electrodes can then be connected to stimulators that provide electrical currents directly to the targeted location of the brain. This provides the benefit of high spatial and temporal specificity as compared to most other neuromodulation techniques, however the major inherent downside to this is its invasiveness. Although the nature of how DBS works is rather complex, the overarching principle is to modulate the firing of neurons in highly specific brain regions with high temporal resolution through electrical stimulation, which makes it a prime technique for altering memory systems. Much research has focussed on applying DBS to alter memory as possible treatments for learning and memory-related disorders such as Alzheimer’s disease and other dementias -7, anxieThe application of electrical stimulation in the brain, which is the precursor to DBS, has long been used and studied, with evidence of its use appearing as early as the 1900s . DespiteThe hippocampus plays a crucial role in the formation and retention of many types of memories, which is thought to happen through synaptic plasticity , 34. SinHigh frequency stimulation (HFS) of various targets related to the hippocampus have been shown to increase neurogenesis. For example, in rodent studies, DBS of the anterior thalamus has been shown to increase hippocampal neurogenesis and restore corticosterone-induced suppressed neurogenesis -40. StonThere is mounting evidence that DBS exerts its effects by evoking changes in distal neural activity through axonal activation , and resMonoamines  are a group of neurotransmitters containing an amino group connected to an aromatic ring by a carbon-carbon chain. Monoamines have been strongly linked to learning and memory, as well as mood and anxiety-related disorders -51, makiAcetylcholine, a neurotransmitter best known for its role in neuromuscular junctions, also plays a key role in learning and memory in the brain , 67. MorGlutamate is the main excitatory neurotransmitter in the brain and plays major roles in learning and memory through both fast (ionotropic receptors) and slow modulatory mechanisms (metabotropic receptors) -78. As eThere is a wide array of neurotransmitters implicated in memory, and the effects of DBS on memory are likely to involve a complex combination of neurotransmitters. This might explain the paradoxical nature of DBS on memory and also explain the difficulty in fully understanding the mechanisms of how DBS exerts its effects.Given the immense complexity of neurotransmitter involvement in DBS, an arguably more consolidated method of study would be to measure the overall changes in electrical potential caused by DBS, which could be seen as a summation of changes in neurotransmitters. In this regard, researchers have studied neural oscillations in relation to learning and memory. Increased gamma oscillations in the hippocampus, for example, have been shown to predict successful encoding of new verbal memories and retrieval of memories, which were distinguishable from incorrect responses . FurtherAnother way of studying the electrical impact of DBS on memory is to examine its effects on the engram, a hypothetical representation of the physical/biochemical storage of memories encoded in neurons in structures like the hippocampus , 93. As We have yet to directly address how DBS is able to both enhance and disrupt memory. In this section, we will discuss the timing of DBS as a possible explanation for this paradoxical effect.Given the complexity of human memories, different genetic and environmental backgrounds, and ethical considerations in performing implantation surgery on humans, animal models could represent an alternative way to study the effects of DBS on memory. Unfortunately, animal studies on the effects of DBS on memory are limited. Among the relevant animal studies that we identified, most found DBS had beneficial effects on memory  with theThere are a few pieces of evidence that back up our hypothesis. Although optogenetic stimulation is mechanistically different from DBS, it shares the same concept of axonal activation. In terms of memory disruption, high-frequency optogenetic stimulation of amygdala projections to the PFC has been shown to disrupt consolidation but not acquisition of memory , which mIn terms of improved memory, a beneficial effect of DBS elicited through changes in plasticity or neurogenesis (as discussed above) might explain why benefits are seen when stimulation is applied before a behavioural task. Given the chronic nature of mental illness and the long-term protocols of the DBS stimulations, it is likely that therapeutic benefits result from longer-term changes in plasticity , 98, 99.We propose a consolidated model to incorporate all the findings presented in this review. The circuitry of how DBS can both disrupt and enhance memory through its various mechanisms is shown in Studies looking at the effects of DBS on memory have been relatively scarce and have confounding and contradictory results. Although there have been some animal and human studies attempting to understand the effects of DBS on memory, little has been done to consolidate the findings. In this review, we studied the current literature on the effects of DBS on memory and proposed a consolidated model on the possible mechanisms of how DBS can both disrupt and enhance memory, which suggests time is a major factor in the bidirectional memory effects.The current treatments for anxiety/addiction disorders and dementia all have problems in their efficacy. For example, the most common treatment for both anxiety and addiction disorders is cognitive-behavioural therapy (CBT) in which maladaptive memories are targeted, but CBT has unfortunately been shown to be ineffective in the long-term with many patients relapsing -106. ThiGiven the invasive nature of DBS, studies on humans have proven incredibly difficult. Animal studies allow us to study the effects of neuromodulation on memory in a more controlled environment, and furthermore, it also allows us to study the molecular mechanisms through terminal experiments. Given the relatively unknown nature of DBS on memory, elucidating how 1) the time of application, 2) length of stimulations (chronic or acute), and 3) optimal stimulation targets can affect neuromodulation in animal models would be crucial before testing in humans. Although much of the human experience cannot be modelled by animals, ethical concerns on the changes that DBS may have on agency and personality , which w


Doctor of physical therapy preparation requires extensive time in precepted clinical education, which involves multiple stakeholders. Student outcomes in clinical education are impacted by many factors, and, in the case of failure, it can be challenging to determine which factors played a primary role in the poor result. Using existing root-cause analysis processes, the authors developed and implemented a framework designed to identify the causes of student failure in clinical education. This framework, when applied to a specific student failure event, can be used to identify the factors that contributed to the situation and to reveal opportunities for improvement in both the clinical and academic environments. A root-cause analysis framework can help to drive change at the programmatic level, and future studies should focus on the framework’s application to a variety of clinical and didactic settings. Approximately one-third of the curriculum of a doctor of physical therapy (DPT) program is composed of clinical education experiences . The ComThere are many stakeholders involved in clinical education, including the academic program and academic faculty, the student, the patient, and the clinical faculty . The reaRoot cause analysis (RCA) is one way in which programs may examine student failure in clinical education. RCA is utilized frequently in various fields, including healthcare and business, to examine a challenging or unsuccessful situation from multiple perspectives. The RCA process serves to understand what happened in a situation, why it happened, and what can be done to prevent similar situations from occurring again . The anaAcademic faculty at a DPT program drew from the RCA approach and developed the Analysis of Clinical Education Situations (ACES) framework as a mechanism for formal, objective analysis of student failure in DPT clinical education experiences. This framework examines student failure events from multiple perspectives to determine potential strategies to prevent similar situations from occurring again.Duke University’s DPT program includes a 3-year curriculum with 43 weeks of clinical education coursework. The third year of the program includes three 12-week full-time terminal clinical experiences. The full-time clinical experiences occur at clinical sites external to the academic program, and practicing clinicians employed by the clinical site serve as clinical instructors (CIs).In each full-time clinical experience, CIs use the Clinical Performance Instrument (CPI) to evaluate student performance. The CPI is a validated assessment tool that includes 18 separate performance criteria with defined benchmarks. Student failure in clinical education is defined as the student not achieving the expected performance outcome of the clinical education course, which can include failure to meet benchmarks on the CPI, issues with professional behavior, or a combination of both. If deemed appropriate by the program, student failure in a clinical education course may result in the student repeating the clinical experience following an individualized remediation program. The program had an established process to determine whether a student could and should repeat a clinical experience, but there was no systematic process to review causes of student failure.While the term ‘root cause analysis’ implies that there is one primary cause of an adverse event, the framework designers recognized that any process that analyzes challenges in clinical education must account for the multitude of factors that may impact such situations. Therefore, the authors aimed to create a process that would account for the complexities of clinical education. The ACES framework  was deveThe ACES framework is a 3-step process that begins with an examination of the central situation of student failure, focusing on factors related to the student and CI. The process then broadens in step 2 to examine how the clinical environment, the academic curriculum, the academic program, and the director of clinical education (DCE) may have influenced the situation. Each factor in step 1 and step 2 is evaluated along 3 dimensions: impact, predictability, and modifiability. The first dimension, impact, utilizes a 5-point scale from very positive to very negative. Predictability and modifiability are dichotomous, with the response to each being “yes” or “no.” A characteristic is determined to be predictable if the academic program could have predicted the impact of this characteristic on the situation, and it is determined to be modifiable if the academic program could have modified or acted upon this characteristic at any point to change it in some way.In the final step, the framework user is prompted to review each characteristic. Analysis of the characteristics that have the greatest impact and are predictable and/or modifiable should result in actions or strategies to address these root cause(s). Accountability is built into the framework by the specific identification of responsible parties and a timeline for completion of the action.A DPT student completed all on-campus didactic and integrated clinical education experiences during the first 2 years of the program. In the third year of the program, the student successfully completed the first 12-week full-time clinical experience in an outpatient orthopedic practice by achieving the prescribed advanced intermediate level on the CPI evaluation. The student began a second 12-week full-time clinical experience at an inpatient rehabilitation facility.During the fifth week, the student and the CI reached out to the academic program’s DCE to discuss performance concerns. From that point forward, the DCE was in frequent contact via email and phone with the student, the CI, and the Site Coordinator of Clinical Education (SCCE). The DCE spoke at least twice a week with the student, and the phone calls included coaching on clinical reasoning, communication strategies, and self-reflection. The DCE received weekly updates from the CI by email and phone regarding the student’s performance in the clinic that week, areas of improvement, and areas of continued challenge. The DCE performed a site visit in week 8 that included observation of the student and CI during a patient encounter and during a post-encounter debriefing session. Following the site visit, the DCE, CI, SCCE, and student established a learning plan and specific learning objectives. Ultimately, the clinical experience was terminated in week 10 due to significant and ongoing concerns regarding safety and clinical reasoning. The student received a failing grade for the clinical education course.The ACES framework was applied to this student’s case . The anaThe action plan detailed in step 3 addressed the curriculum factors and programmatic processes. The curriculum committee and course directors reviewed the current assessment strategies in core coursework related to clinical reasoning. The DCE reviewed advising strategies and clinical site matching processes to address the concern that, in this case, the student and clinical site were not a good fit. Finally, the program leadership recognized a need for more specific faculty onboarding procedures, as well as gaps within the current policies and procedures related to management of student progression issues.The use of the ACES framework within the authors’ academic program has resulted in a formalized mechanism to evaluate student failure situations and to describe programmatic outcomes at a more detailed level. The approach provides a needed mechanism to evaluate the clinical education program through a multifaceted approach that accounts for all stakeholders. The sample case is an example of how this process can result in avenues for greater academic-clinical partnership, as the RCA process may lead to collaborative efforts between academic and clinical stakeholders to address opportunities for program refinement.The important impact of the ACES framework results from the action recommendations determined in step 3. The United States Department of Veterans Affairs National Center for Safety developed an ‘Action Hierarchy’ for RCA processes in 2001. This hierarchy categorizes action recommendations based on their effectiveness and sustainability, using the classifications of strong, intermediate, and weak . The InsFurther use of the framework and formalized study of its applicability are necessary to determine its effectiveness, reliability, and validity in consistently identifying the root problems in clinical education situations. This would include application of the framework within a variety of academic programs and clinical situations, potentially allowing for further refinement of the tool to maximize its effectiveness. The ACES framework also has the potential to be applied to other student situations beyond clinical education, resulting in a formalized and structured programmatic evaluation mechanism. However, applications in the didactic setting may require an altered version of the framework, as there are different influences, factors, and characteristics to consider in the classroom setting. Ultimately, the authors of the framework intend to utilize the framework in a multi-institutional study that aims to examine trends in clinical education situations across institutions.The use of a structured and multifaceted approach to analyzing clinical education problems may provide programs with a standardized way to assess situations and make changes to prevent repeat issues. Furthermore, the use of ACES may also provide programs with a tool for organizing discussion and collaboration among the stakeholders involved in clinical education. By implementing standardized approaches to program evaluation that result in opportunities for change, programs can reduce the time and effort involved in ongoing problem mitigation and student remediation.