The Effect of Mobility Assistance Dogs on Quality of Life in Children with Physical and Neurological Impairments.

AIMS: To measure the quality of life in children with impaired walking who receive a mobility assistance dog (MAD). METHODS: The parents of ten children who received a MAD completed the cerebral palsy quality of life questionnaire, before receiving their dog and at one, three, and six-month follow-up. Data were analyzed to assess changes for each participant and to the group. RESULTS: The group showed a positive change in the domains of social well-being and acceptance, feelings about functioning, and emotional well-being and self-esteem after six months. Children with less impairment (GMFCS I-II) showed a change in social-wellbeing and acceptance, feelings about functioning, participation, physical health, and emotional-wellbeing and self-esteem after six months. Children with more impairment (GMFCS III-IV) showed no change at any timepoint measured. CONCLUSIONS: This novel therapeutic area of receiving a MAD demonstrated some positive quality of life changes after six months for a small group of children with impaired walking. These are preliminary findings in a small sample and this intervention would benefit from further study.

Effective Teacher Professional Development for School-Based Mental Health Promotion: A Review of the Literature.

Teachers are critically involved in the delivery of school-based mental health promotion (SMHP) interventions in school, though pre-service teacher education often leaves teachers feeling underprepared in this area. Thus, understanding how best to build teachers' capacity for delivery through effective professional development (PD) is essential for teachers to fulfill their role as delivery agents to achieve SMHP outcomes. This systematized review focuses on identifying components of high-quality teacher PD for SMHP and examining the empirical support for these components. In a two-phase analysis, we examined the descriptive literature regarding teacher PD for SMHP to identify common elements. This resulted in the identification of components relevant to training (interactive, guided by staff input) and technical assistance (TA), including the goals (skill development, motivation, generalization/adaptation), approach (collaborative, individualized, data-driven, strengths-based), and activities (modeling, performance feedback, reflection, problem solving) involved. A second phase focused on the examination of empirical evidence for these PD components. While the empirical evidence for these components was limited, the identified components represent a current standard of practice in teacher PD for SMHP, based on the existing research. These components may provide a framework for practical use in planning teacher PD related to SMHP and for designing future research into effective capacity building in this area.

Effect of Back Plate Preheating Assistance System and Deep Rolling Process on Microstructure Defects and Axial Force Reduction of Friction Stir Welded AA6061 Joint.

This study investigates the effects of a back plate preheating assistance system and deep rolling (DR) on axial force and tunnel defects during friction stir welding (FSW). Different preheating configurations-advancing side (AS), retreating side (RS), and both sides-were examined to evaluate their impact on axial force reduction, temperature distribution, and defect minimization. Axial force measurements were taken using a dynamometer, and temperature histories were recorded with a thermal camera. The results demonstrate that a preheating temperature of 200 °C is optimal, reducing axial force by 30.24% and enhancing material flow. This temperature also facilitated deeper tool penetration, especially when preheating was applied to both sides. Preheating on the AS resulted in the smallest tunnel defects, reducing defect size by 80.15% on the RS and 96.91% on the AS compared to the non-preheated condition. While DR further reduced tunnel defects, its effectiveness was limited by the proximity of defects to the surface. These findings offer significant insights for improving the FSW process.

Exploring assisted dying policies for mature minors: A cross jurisdiction comparison of the Netherlands, Belgium & Canada.

Medical Assistance in Dying (MAID) was decriminalized in Canada in 2016 for individuals 18 years or older who met eligibility criteria. Currently, individuals younger than 18 years are legally permitted to access an assisted death in the Netherlands and Belgium, but not in Canada. To-date, no work has compared factors shaping the policy processes and outcomes in these three countries. Therefore, our objective was to explore the legalities of assisted dying for minors in the Netherlands and Belgium, along with how each jurisdiction arrived at their respective policies and why the trajectory differed in Canada. After screening and compiling peer-reviewed and grey literature, we used Yanow's interpretive method for comparative work to review included materials. We framed findings using Hajer's discourse coalition theory. The Dutch and Belgian contexts relied upon a parliamentary approach in legalizing assisted dying for mature minors that emphasized suffering, whereas Canada's approach was initiated by a Supreme Court of Canada decision and emphasized human rights. While the Netherlands and Belgium viewed mature minors as capable to make decisions about assisted dying, the Canadian position on mature minors' decisional capacity with respect to assisted dying remains unsettled. This work contributes to understanding how context and sociopolitical values shape assisted dying legislations and treatment of mature minors, while highlighting areas requiring further study amid ongoing debate in Canada.

The Role of Food and Beverage Environments in Child Health and Weight-Related Behaviors.

This article explores how food and beverage environments influence child health and obesity risk and addresses institutional settings, retail environments, food assistance programs, and food and beverage industry marketing. It emphasizes social determinants of health, evidence-based interventions, and policy recommendations to promote healthier food options and reduce inequities. Pediatric health care providers play a critical role in addressing the need for systemic changes to eliminate inequities in food environments and the systems that support these inequities.

Associations between Household- and Child-Referenced Food Security Status and Dietary Intake among Low-Income Urban Black Children.

We examined whether dietary intake differs across household and child food security (FS) status, and Supplemental Nutrition Assistance Program (SNAP) participation among Black children (ages 9-15) in a low-income urban setting. This cross-sectional survey used the USDA 18-item Household Food Security Survey, that includes the 8-item Child Module, and a validated FFQ to assess children's diet (n=451). Nutrient intake differed across child FS status, but not household FS. SNAP participation was associated with better micronutrient intake (vitamin D and calcium) among food secure children. Assessing child-specific FS and nutrient adequacy clarifies children's actual experience and informs child-targeted policies.

Modern Contraceptive Use of National Health Insurance Participants before and during the COVID-19 Pandemic in South Kalimantan, Indonesia: Using Data from the Official Website of the National Population and Family Planning Agency.

Objective: This study aims to explore and analyze the modern contraceptive use of National Health Insurance (NHI) participants before and during the COVID-19 pandemic in South Kalimantan, Indonesia. Methods: This research is an ecological study using aggregated data from 13 Districts/Cities in South Kalimantan. This study used secondary data in 2018-2020 from the official website of the National Population and Family Planning Agency. Spatial analysis and paired T-test were used. Results: There were 30.7% of Districts/Cities in stagnation and 30.7% in the decline of modern contraception use during the pandemic (2019-2020). In addition, the study showed that there were differences in the use of modern contraception before (2019) and during the COVID-19 pandemic (2020) among active family planning acceptors of NHI participants (p=0.048). Conclusion: The existence of NHI, especially recipients of contribution assistance, can increase the use of modern contraception in South Kalimantan. There are differences in the use of modern contraception before and during the COVID-19 pandemic among NHI participants.

[Study on direct ventricular assist loading mode based on a finite element method].

To investigate the biomechanical effects of direct ventricular assistance and explore the optimal loading mode, this study established a left ventricular model of heart failure patients based on the finite element method. It proposed a loading mode that maintains peak pressure compression, and compared it with the traditional sinusoidal loading mode from both hemodynamic and biomechanical perspectives. The results showed that both modes significantly improved hemodynamic parameters, with ejection fraction increased from a baseline of 29.33% to 37.32% and 37.77%, respectively, while peak pressure, stroke volume, and stroke work parameters also increased. Additionally, both modes showed improvements in stress concentration and excessive fiber strain. Moreover, considering the phase error of the assist device's working cycle, the proposed assist mode in this study was less affected. Therefore, this research may provide theoretical support for the design and optimization of direct ventricular assist devices.

Meta-analysis of the safety effect of electronic stability control.

OBJECTIVE: Electronic Stability Control (ESC) is a standard feature on most modern cars, due to its reported efficiency to reduce the number of crashes of several types. However, empirical studies of safety effects of ESC for passenger vehicles have not considered some methodological problems that might have inflated the effects. This includes self-selection of drivers who buy/use ESC and behavioral adaptation to the system over long time periods, but also the dominant method of induced exposure. This study aimed to investigate whether such methodological problems might have influenced the results. METHOD: A meta-analysis was undertaken to investigate whether there are systematic differences between published studies. Moderators tested included when the study was undertaken, the type of vehicle studied, the percent ESC in the sample, size of sample, the length of the study, whether matched or un-matched vehicles were studied, whether induced exposure was used, and two variants of types of crashes used as controls. RESULTS: The effects found ranged from 38% to 75% reduction of crashes for the main targets of singles, running off road and rollover crashes. However, these effects were heterogeneous, and differed depending on the methods used. Most importantly, information that could have allowed more precise analyses of the moderators were missing in most publications. CONCLUSIONS: Although average effects were large and in agreement with previous meta-analyses, heterogeneity of the data was large, and lack of information about important moderators means that firm conclusions about what kind of mechanisms were influencing the effects cannot be drawn. The available data on ESC efficiency are not unanimous, and further investigations into the effects of ESC on safety using different methodologies are warranted.

Effective Engagement Techniques Across the Agricultural Conservation Practice Adoption Process.

Encouraging agricultural landowners to adopt conservation practices is crucial to enhancing ecosystem services in privately-owned farm landscapes. To improve engagement with landowners and increase adoption rates, much research has been dedicated to investigating how different psychological, social, economic, and political factors correlate with adoption. However, these studies largely measure adoption as a discrete, binary event. Doing so obscures sequences of landowner decisions and engagement techniques that conservation practitioners use to encourage landowners' progression through the adoption process. We report on two studies that contribute to the emerging literature on the agricultural conservation practice adoption process and the varying effectiveness of engagement techniques throughout. First, interviews with conservation practitioners in the Chesapeake Bay watershed, USA, yielded a preliminary model of the different stages in the adoption process and what techniques practitioners find effective at each stage. Second, an online experiment examined the effectiveness of a visualization intervention across two sequential outcomes in the adoption process, seeking further information and contacting a practitioner. Our results suggested that practitioners use a wide variety of engagement techniques, most of which are unique to a single stage in the adoption process, and that the effectiveness of the visualization technique varies substantially between different stages. Together these studies outline a suite of techniques that other practitioners may find effective at different stages of the adoption process, and suggest that research can better inform practice by accounting for variation in the effectiveness of different techniques across stages of adoption.

Simulated real-world feasibility and feedback session for a lift assistance device, Raymex™: a mixed-method descriptive study.

Background: Fall risk and incidence increase with age, creating significant physical and mental burden for the individual and their care provider. Lift assistive devices are used in multiple healthcare facilities, but are generally not portable nor self-operational, limiting their use outside of medical supervision. The Raymex™ lift is a novel lift assistance device within a rollator to address these limitations. We aim to gather user-centered feedback on the Raymex™ lift, set up instructions, safety protocols to improve feasibility and usability, and explore the potential usability as a fall recovery or prevention device. Methods: Four older adults, two informal caregivers and 16 formal caregivers (clinicians and continuing care assistants) participated in a focus group. Participants provided feedback on the Raymex™ lift after viewing a demonstration and using the device. Qualitative and quantitative data were analysized using thematic and descriptive analysis respectively. Results: Participants highlighted three major themes: (1) Design features requiring improvement, (2) Positive feedback and suggestions to optimize the Raymex™ lift and (3) Pricing vs. social utility. Participants suggested widening the seat, changing the braking button layout, and lowering the device weight to improve usability. Participants believed the main device feature was fall recovery and had implications for social utility by reducing the need for ambulance visits to the home. Price point led to a concern on affordability for older adults. Conclusion: The feedback gained will advance the development of the Raymex™ lift and may highlight cost-effective design choices for other developers creating related aging assistive technologies.

Determinants of carbon emissions in Kenya and policy implications.

Carbon dioxide emissions are the primary greenhouse gasses behind global climate change and its associated effects. Climate change adversely impacts the environment, biodiversity, and human health. The ability to tame carbon dioxide emissions will help in the fight against climate change. However, the recent pace of rising carbon dioxide emissions raises concerns about winning the war against climate change. World leaders are determined to take actions that will lower emissions. Thus, there is a worldwide effort to achieve net-zero emissions. Consequently, it is crucial to comprehend the specific factors that contribute to carbon emissions of specific economies so that countries can develop and enforce effective strategies for reducing carbon output, mitigating the effects of climate change, and improving recovery programs. Despite many empirical studies conducted in Africa on the determinants of carbon emissions, the results remain inconclusive and inadequate, leaving a void for further research. This study seeks to fill this knowledge gap by modeling the relationship between Kenya's carbon emissions (which have been increasing since the early 2000s), and mobile technology adoption, renewable energy mix, tourism development, development assistance, income, and global financial crises, utilizing the most current data from 1995 to 2021 from the World Bank's database. The ARDL, FMOLS, CCR, and DOLS analysis results reveal that mobile technology, tourism, development aid, and global financial crises increase Kenya's carbon emissions in the long run. At the same time, income and renewable energy reduce short- and long-term impacts. The significant insight from these results is that enhancing renewable energy development, mobile technology, and development assistance can promote a sustainable environment. From these findings, the study proposes many policy recommendations to help decision-makers, communities, companies, and the government in Kenya allocate resources and implement resilience and mitigation policies and programs in the areas most susceptible to the effects of climate change.

Project SUCCESS: Youth Substance use and Mental Health.

This study aims to assess whether students at schools implementing Project SUCCESS (PS) have different substance use and mental health outcomes than those at schools not implementing PS. Surveys were administered to 18,151 middle and high school students from 29 school districts and 50 schools. Multivariable logistic and linear regressions controlling for individual- and school-level characteristics were used. Students at schools with PS had lower odds of past month cigarette use, vaping, alcohol use, marijuana use, past year suicide ideation, and had fewer depressive symptoms relative to students at schools without PS. Findings suggest students at schools with PS may be less likely to engage in substance use and less likely to experience mental health challenges than students at schools without PS.

The association of increased SNAP benefits during COVID-19 with food insufficiency and anxiety among US adults: a quasi-experimental study.

OBJECTIVES: The COVID-19 pandemic and subsequent policy response to mitigate disease spread had far-reaching impacts on health and social well-being. In response, the Supplemental Nutrition Assistance Program (SNAP) underwent several pandemic-era modifications, including a 15 % monthly benefit increase on January 1, 2021. Research documenting the health effects of these SNAP modifications among low-income households and minoritized groups who were most impacted by the economic fallout during the first years of the pandemic is lacking. We aimed to estimate the health effects of the 15 % SNAP benefit increase in January 2021, among SNAP-eligible US households. DESIGN: We estimated the effects of the SNAP increase on food insufficiency, mental health, and financial well-being using a rigorous quasi-experimental difference-in-differences (DID) analysis. SETTING: August 19, 2020, to March 29, 2021. PARTICIPANTS: Participants were drawn from the national US Census Bureau Household Pulse Survey waves 13-27 (n 44 477). RESULTS: Compared with SNAP-eligible non-recipients, SNAP-eligible recipients experienced decreased food insufficiency (-1·9 percentage points (pp); 95 % CI -3·7, -0·1) and anxiety symptoms (-0·09; 95 % CI -0·17, -0·01), and less difficulty paying for other household expenses (-3·2 pp; 95 % CI -4·9, -1·5) after the SNAP benefit increase. Results were robust to alternative specifications. CONCLUSIONS: Expansions of federal nutrition programmes have the potential to improve health and financial well-being. This study provides timely evidence to inform comprehensive safety net nutrition policies during future economic crises and public health preparedness response plans.

Microbial-assistance and chelation-support techniques promoting phytoremediation under abiotic stresses.

Phytoremediation, the use of plants to remove heavy metals from polluted environments, has been extensively studied. However, abiotic stresses such as drought, salt, and high temperatures can limit plant growth and metal uptake, reducing phytoremediation efficiency. High levels of HMs are also toxic to plants, further decreasing phytoremediation efficacy. This manuscript explores the potential of microbial-assisted and chelation-supported approaches to improve phytoremediation under abiotic stress conditions. Microbial assistance involves the use of specific microbes, including fungi that can produce siderophores. Siderophores bind essential metal ions, increasing their solubility and bioavailability for plant uptake. Chelation-supported methods employ organic acids and amino acids to enhance soil absorption and supply of essential metal ions. These chelating agents bind HMs ions, reducing their toxicity to plants and enabling plants to better withstand abiotic stresses like drought and salinity. Managed microbial-assisted and chelation-supported approaches offer more efficient and sustainable phytoremediation by promoting plant growth, metal uptake, and mitigating the effects of heavy metal and abiotic stresses. Managed microbial-assisted and chelation-supported approaches offer more efficient and sustainable phytoremediation by promoting plant growth, metal uptake, and mitigating the effects of HMs and abiotic stresses.These strategies represent a significant advancement in phytoremediation technology, potentially expanding its applicability to more challenging environmental conditions. In this review, we examined how microbial-assisted and chelation-supported techniques can enhance phytoremediation a method that uses plants to remove heavy metals from contaminated sites. These approaches not only boost plant growth and metal uptake but also alleviate the toxic effects of HMs and abiotic stresses like drought and salinity. By doing so, they make phytoremediation a more viable and effective solution for environmental remediation.

Supplemental Nutrition Assistance Program healthy eating incentives and fruit and vegetable spending across the month.

OBJECTIVE: To estimate how incentives that encourage healthy eating among Supplemental Nutrition Assistance Program (SNAP) participants impact intra-monthly variation in fruit and vegetable spending. DESIGN: We used transaction data from three Alabama grocery stores participating in a programme that offered dollar-matching coupons for fresh produce. For each store, we calculated daily spending on fresh produce out of SNAP benefits and daily incentive coupon redemptions. We compared total daily spending on fresh produce and daily coupon redemptions on days over which SNAP benefits are distributed in Alabama with spending and redemption on days at the end of the month with no SNAP distribution. SETTING: SNAP and incentive transactions in three Alabama grocery stores. PARTICIPANTS: SNAP participants purchasing fruit and vegetables April 2023-July 2023. RESULTS: Daily spending with SNAP on produce dropped by 38% at the end of the month. Incentive coupon redemption did not significantly drop at the end of the month. The share of total SNAP spending going to fresh fruits and vegetables increased by two percentage points and the share of fresh fruits and vegetables spending coming from redemptions increased by ten percentage points at the end of the month. CONCLUSIONS: SNAP households may use incentive coupons to smooth drops in produce consumption at the end of the month. These findings also highlight trade-offs inherent in different delivery mechanisms for SNAP incentives.

Investigating the Social Correlates Associated With Getting Help After a Suicide or Not: An Important Unexamined Bereavement Question.

Seeking to provide more systematic information on treatment-seeking and those not seeking help after a suicide, we investigated demographic, experiential and grief problems related correlates among recently suicide bereaved adults, conducting an on-line survey of a sample of U.S. 1,132 adults who lost a loved one to suicide during the last six years. Focusing upon first-degree relative loss survivors (n = 222) we hypothesized those not seeking help would be more likely to report conventional religiosity, greater social support and more use of alternative treatment modalities. Instead, we found those not seeking help were almost twice as likely to not attend religious services, compared to help seekers. Social support enhanced the bereaved individuals' pursuit of treatments and those who did not obtain help appeared reluctant to getting non-traditional treatment support. Help seekers were more likely to experience post-traumatic growth and less likely to see suicide loss survivorship as stigmatizing.

TB-related technical enquiries received at the Research Institute of Tuberculosis, Japan, during COVID-19.

SETTING: Japan: a low-TB-burden country. OBJECTIVE: To characterise TB-related technical enquiries received in 2020-2022, and share the lessons learnt. DESIGN: This was a descriptive study. RESULTS: We received 1,898 communications, of which 1,447 (40.2 per month) were classified as technical enquiries, 34% fewer than the 2,197 enquiries received in 2017-2019. The enquiry rates were highest for Shimane (4.32/100,000 population) and Yamanashi (2.59/100,000 population) prefectures, and lowest in Ehime (0.00/100,000 population) and Yamagata (0.09/100,000 population) prefectures. The main organisations the enquirers belonged to were local governments (n = 989, 68.3%) and healthcare facilities (n = 242, 16.7%). The enquirers included medical doctors (n = 236, 16.3%), nurses (n = 814, 56.3%), and the general public (n = 141, 9.7%). The most frequent enquiries were about TB diagnosis and treatment, including laboratory diagnosis (n = 442, 30.6%), followed by the regulatory framework (n = 216, 14.9%), contact investigation (n = 151, 10.8%), and TB in foreigners (n = 112, 7.9%). CONCLUSION: During the COVID-19 era, we received two-thirds of technical enquiries compared with 2017-2019, because local health offices were overwhelmed by the pandemic. Since the most frequent enquiries were about diagnosis and treatment of TB, the health ministry of Japan should maintain a few specialised TB institutions with TB physicians to provide technical assistance.

CONTEXTE: Japon, un pays à faible taux de TB. OBJECTIF: Caractériser les demandes de renseignements techniques liées à la TB reçues en 2020­2022 et partager les enseignements tirés. MÉTHODE: Ceci est une étude descriptive. RÉSULTATS: Nous avons enregistré 1 898 communications, parmi lesquelles 1 447 (soit 40,2 par mois) ont été identifiées comme des demandes de renseignements techniques, ce qui représente une baisse de 34% par rapport aux 2 197 demandes reçues en 2017­2019. Les taux de demandes de renseignements étaient les plus élevés dans les préfectures de Shimane (4,32/100 000 habitants) et de Yamanashi (2,59/100 000 habitants), et les plus faibles dans les préfectures d'Ehime (0,00/100 000 habitants) et de Yamagata (0,09/100 000 habitants). Les principaux demandeurs étaient des médecins (n = 236 ; 16,3%), des infirmières (n = 814 ; 56,3%) et le grand public (n = 141 ; 9,7%). Les demandes les plus fréquentes concernaient le diagnostic et le traitement de la TB, y compris le diagnostic en laboratoire (n = 442 ; 30,6%), suivi du cadre réglementaire (n = 216 ; 14,9%), de la recherche des contacts (n = 151 ; 10,8%) et de la TB chez les étrangers (n = 112 ; 7,9%). CONCLUSION: Pendant la période de COVID-19, nous avons reçu deux tiers de demandes de renseignements techniques en comparaison avec 2017­2019, en raison de la surcharge des bureaux de santé locaux causée par la pandémie. Étant donné que les demandes de renseignements les plus fréquentes concernaient le diagnostic et le traitement de la TB, le ministère de la santé du Japon devrait maintenir quelques institutions spécialisées dans la TB avec des médecins tuberculeux pour fournir une assistance technique.

Employment Experiences and Employability of People in China Living With Schizophrenia: A Qualitative Study.

OBJECTIVE: Employment support for people living with schizophrenia in China currently focuses only on patient-level factors. The authors' aim was to assess the employment experiences of this population and to identify factors related to their employability. METHODS: In-depth interviews were conducted with 24 purposively selected respondents. A thematic analysis was performed. RESULTS: A framework for examining the employment experiences and factors affecting employability of people living with schizophrenia was developed. Employability varied by individual characteristics, personal circumstances, and external factors. Individual-level characteristics, such as health and well-being, work skills and experience, educational attainment, personal social network, gender, and age, influenced individuals' work motivation and performance. Personal circumstances, such as family socioeconomic status and caregiving responsibilities, affected whether individuals decided to seek employment. External factors, such as labor market conditions, macroeconomic context, stigma and discrimination, mental health services, and policy factors, determined how likely individuals were to be employed and the types of jobs they were likely to obtain. CONCLUSIONS: A multifaceted combination of factors was found to influence employability among people living with schizophrenia. This research provided a thematic framework to structure effective employment support for people in China living with schizophrenia.

Robot-Assisted Microsurgery-what does the learning curve look like?

Background: The introduction of robotic assistance in surgical practice has led to advancements such as the MUSA-2 robotic system that was designed for microsurgical procedures. Advantages of this system include tremor filtration and motion scaling. Initial studies showed promising results in skill acquisition for robot-assisted microsurgery. This study evaluated the learning curve for microsurgical anastomosis with and without robotic assistance among surgeons of varying experience levels. Methods: Fifteen surgeons were divided into 3 groups (novice, intermediate, and expert) based on their microsurgical experience. They performed 10 anastomoses by hand and 10 with robotic assistance on synthetic polyvinyl alcohol vessels (diameter of 2 mm) in a laboratory setting. Participants were timed and mistakes such as backwall and leakage were assessed and recorded. Demographic information was collected. Results: Statistical differences were found in manual anastomosis times between the intermediate and novice groups compared to the experts (p < 0.01). However, no statistical difference was found in the mean time between groups for the robot-assisted anastomoses. Novice doctors had the steepest learning curve for hand-sewn anastomosis. Experts had the fastest completion time at the end of the 10th robotic session, finishing at 14 min, compared to 33 min at the 2nd session. All groups reduced their mean time in half through their 10 robotic sessions. Conclusion: This study indicated similarities in the learning curves for robot-assisted anastomosis among surgeons with varied experience levels. Experts excelled technically in manual anastomoses, but robot-assistance enabled novice and intermediate surgeons to perform comparably to the experts. Robotic assistance may aid more novice learners in performing microsurgical anastomosis safely at earlier points in their education.