A Quarter-Century of Online Informatics Education: Learners Served and Lessons Learned.

The value and methods of online learning have changed tremendously over the last 25 years. The goal of this paper is to review a quarter-century of experience with online learning by the author in the field of biomedical and health informatics, describing the learners served and the lessons learned. The author details the history of the decision to pursue online education in informatics, describing the approaches taken as educational technology evolved over time. A large number of learners have been served, and the online learning approach has been well-received, with many lessons learned to optimize the educational experience. Online education in biomedical and health informatics has provided a scalable and exemplary approach to learning in this field.

Comparing interteaching and discussion forums in an asynchronous online classroom.

The current study compared the effects of interteaching and discussion forum activities on quiz and assignment scores in a master's-level asynchronous research methods course. In an alternating-treatments design, six participants engaged in interteaching on half of the weeks and in the discussion forum on alternate weeks. Participants in the interteaching condition (M = 96.75) generally scored higher on quizzes than did those in the discussion forum condition (M = 75.95). The results of a paired-sample t test indicated statistically significant differences between the two conditions at p < .0001, with a substantial effect size of 0.6760. Significant differences in assignment scores were not observed between the interteaching (M = 87.28) and discussion forum (M = 89.08) conditions. Limitations and directions for future research are discussed.

Pharmacy Student Perceptions of Using AI-Based Interview Software (Big Interview) for Career Preparation.

OBJECTIVE: The goal of this project was to understand the use of AI-based interview software (Big Interview) for job interview preparation and its impact on pharmacy students' self-confidence and interview preparedness. METHODS: Two classes of third-year pharmacy students (n = 234) enrolled in Professional Development Seminar were assigned to use Big Interview after attending lectures regarding interview best practices. Following the activity, students were assigned to reflect on their experience using the software. Those responses were de-identified and retrospectively reviewed for analysis. RESULTS: Of the 234 students, 229 completed the activity, and 55.0% indicated they had increased self-confidence following the experience, 79.9% thought the activity increased their preparedness for interviews, and 34.5% and 38.9% had high or moderate self-confidence in their ability to earn a second interview or job offer, respectively. Thematic analysis identified positive themes of self-awareness and preparation for future interviews, while negative themes included lack of authenticity and lack of job descriptions. CONCLUSION: The data suggests that use of Big Interview increases student confidence and preparedness for future interviews.

Synaptotagmins 3 and 7 mediate the majority of asynchronous release from synapses in the cerebellum and hippocampus.

Neurotransmitter release consists of rapid synchronous release followed by longer-lasting asynchronous release (AR). Although the presynaptic proteins that trigger synchronous release are well understood, the mechanisms for AR remain unclear. AR is sustained by low concentrations of intracellular Ca2+ and Sr2+, suggesting the involvement of sensors with high affinities for both ions. Synaptotagmin 7 (SYT7) partly mediates AR, but substantial AR persists in the absence of SYT7. The closely related SYT3 binds Ca2+ and Sr2+ with high affinity, making it a promising candidate to mediate AR. Here, we use knockout mice to study the contribution of SYT3 and SYT7 to AR at cerebellar and hippocampal synapses. AR is dramatically reduced when both isoforms are absent, which alters the number and timing of postsynaptic action potentials. Our results confirm the long-standing prediction that SYT3 mediates AR and show that SYT3 and SYT7 act as dominant mechanisms for AR at three central synapses.

Development, Implementation, and Assessment of an Online Modular Telehealth Curriculum for Health Professions Students.

Purpose: Several national health profession organizations endorse or have developed competencies for telehealth, yet there is no standardized curriculum for teaching telehealth to health professions students. Additionally, implementing telehealth curricula is challenging due to limited curricular space and differing needs of various health profession programs. We describe the development, implementation, and pilot assessment of an online, modular telehealth curriculum for health professions students. Methods: An online, modular telehealth curriculum for health professions students was developed in 2021-2022. Nine modules were created, focusing on the logistics of performing a telehealth visit and system-based virtual assessments. In academic year 2022-2023, course directors from the Duke doctor of medicine (MD), physician assistant (PA), and nurse practitioner (NP) programs utilized modules in their courses. For modules taken, students were surveyed and self-assessed their confidence, knowledge gained, and likelihood of utilizing the telehealth skills taught in the module(s). Results: During the 2022-2023 academic year, MD, NP, and PA students at Duke participated in one or more of the telehealth modules in an existing course. The median responses to self-assessed confidence questions for all health profession students to be in the "moderately" or "very confident" range. Similarly, students reported a median response of "moderate knowledge gained" for each module taken. NP students reported slightly lower levels of confidence and likelihood of utilizing telehealth skills than other professions. No other significant differences in the remainder of responses were observed between health professions. Conclusion: Exposure of health professions students to telehealth through utilization of online, interactive modules may result in increased telehealth skill confidence and knowledge, and furthermore, a belief that they will utilize these skills in future practice. Larger scale implementation of the telehealth curriculum and development of outcome measures which assess clinical application of skills conveyed will provide more information about the efficacy of the curriculum.

Merging the Worlds of Pets and Pills: Development and Evaluation of an Interprofessional Activity Linking Pharmacy and Veterinary Medicine.

Interprofessional education (IPE) is noticeably lacking between pharmacy and veterinary medicine students despite the two health professions overlapping in practice. To address this, an asynchronous IPE activity was developed together with practicing pharmacists and veterinarians. Students worked in groups across two campuses to discuss clinical cases, specifically requiring input from both professions. Students reported they learned more about the two professions' interconnection, felt prepared to interact with the other professionals in the future, and found value in learning from each other. Overall, the results of this study outline a successful pilot IPE activity between veterinary medicine and pharmacy students.

Effects of acute hippocampal stimulation in the nonhuman primate penicillin model of temporal lobe seizures.

Asynchronous distributed multielectrode stimulation (ADMES) is a novel approach to deep brain stimulation for medication resistant temporal lobe epilepsy that has shown promise in rodent and in vitro seizure models. To further evaluate its effects on a pre-clinical model, we characterized the effect of unilateral ADMES in an NHP model of temporal lobe seizures induced by intra-hippocampal injection of penicillin (PCN). Four non-human primates were used for this study in two contemporaneous cohorts. One cohort (n = 3 hemispheres) was implanted with the Medtronic RC + S stimulation (GIN cohort) and recording system connected to two 4-contact ring electrodes to evaluate three unilateral stimulation patterns: 7 Hz Ring ADMES, 20 Hz Dual Ring, and 125 Hz Dual Ring (analog of clinical stimulation). In an additional cohort (EPC cohort, n = 2), two 12-contact segmented electrodes were implanted in the right hippocampus and connected to an externalized recording and stimulation system to allow more flexibility in the stimulation pattern. In this second cohort, 4 variations of stimulation were evaluated (7 Hz Full ADMES, 7 Hz Ring ADMES, 31 Hz Wide Ring, and 31 Hz Dual Ring). In the GIN cohort, we found an increase in seizure frequency and time spent in seizure during the 7 Hz Ring ADMES stimulation compared to the respective post-stimulation. A similar post-stimulation effect was found in the EPC cohort. We also found an increase in seizure frequency during the 7Hz full ADMES compared to the respective post-stimulation. However, we did not find a difference between pre-stimulation and stimulation conditions suggesting a possible post stimulation effect of the 7Hz hippocampal stimulation. In conclusion, in the NHP PCN model of temporal lobe seizures, acute asynchronous hippocampal stimulation was not therapeutic, however, our findings related to the post-stimulation effect can support future studies using hippocampal stimulation for the treatment of temporal lobe epilepsy.

An At-Home Laparoscopic Curriculum for Junior Residents in Surgery, Obstetrics/Gynecology, and Urology.

Introduction: Laparoscopic surgery requires significant training, and prior studies have shown that surgical residents lack key laparoscopic skills. Many educators have implemented simulation curricula to improve laparoscopic training. Given limited time for dedicated, in-person simulation center practice, at-home training has emerged as a possible mechanism by which to expand training and promote practice. There remains a gap in published at-home laparoscopic curricula employing embedded feedback mechanisms. Methods: We developed a nine-task at-home laparoscopic curriculum and an end-of-curriculum assessment following Kern's six-step approach. We implemented the curriculum over 4 months with first- to third-year residents. Results: Of 47 invited residents from general surgery, obstetrics/gynecology, and urology, 37 (79%) participated in the at-home curriculum, and 25 (53%) participated in the end-of-curriculum assessment. Residents who participated in the at-home curriculum completed a median of six of nine tasks (interquartile range: 3-8). Twenty-two residents (47%) responded to a postcurriculum survey. Of these, 19 (86%) reported that their laparoscopic skills improved through completion of the curriculum, and the same 19 (86%) felt that the curriculum should be continued for future residents. Residents who completed more at-home curriculum tasks scored higher on the end-of-curriculum assessment (p = .009 with adjusted R 2 of .28) and performed assessment tasks in less time (p = .004 with adjusted R 2 of .28). Discussion: This learner-centered laparoscopic curriculum provides guiding examples, spaced practice, feedback, and graduated skill development to enable junior residents to improve their laparoscopic skills in a low-stakes, at-home environment.

Monomeric Fe(III)-Hydroxo and Fe(III)-Aqua Complexes Display Oxidative Asynchronous Hydrogen Atom Abstraction Reactivity.

This paper presents the synthesis and characterization of a series of novel monomeric aqua-ligated iron(III) complexes, [FeIII(L5R)(OH2)]2+ (R=OMe, H, Cl, NO2), supported by an amide-containing pentadentate N5 donor ligand, L5R [HL5R=2-(((1-methyl-1H-imidazol-2-yl)methyl)(pyridin-2-yl-methyl)amino)-N-(5-R-quinolin-8-yl)acetamide]. The complexes were characterized by various spectroscopic and analytical techniques, including electrochemistry and magnetic measurements. The Fe(III)-hydroxo complexes, [FeIII(L5R)(OH)]1+, were generated in situ by deprotonating the corresponding aqua complexes in a pH ~7 aqueous medium. In another way, adding one equivalent of a base to a methanolic solution of the Fe(III)-aqua complexes also produced the Fe(III)-hydroxo complexes. The study uses linoleic fatty acid as a substrate to explore the hydrogen atom abstraction (HAA) reactivity of both hydroxo and aqua complexes. The investigation highlights the substitution effect of the L5R ligand on reactivity, revealing a higher rate when an electron-withdrawing group is present. Hammett analyses and(or) determination of the asynchronicity factor (η) suggest an oxidative asynchronous concerted proton-electron transfer (CPET) pathway for the HAA reactions. Aqua complexes exhibited a higher asynchronicity in CPET, resulting in higher reaction rates than their hydroxo analogs. Overall, the work provides insights into the beneficial role of a higher imbalance in electron-transfer-proton-transfer (ET-PT) contributions in HAA reactivity.

A model-based brain switch via periodic motor imagery modulation for asynchronous brain-computer interfaces.

Objective.Brain switches provide a tangible solution to asynchronized brain-computer interface, which decodes user intention without a pre-programmed structure. However, most brain switches based on electroencephalography signals have high false positive rates (FPRs), resulting in less practicality. This research aims to improve the operating mode and usability of the brain switch.Approach.Here, we propose a novel virtual physical model-based brain switch that leverages periodic active modulation. An optimization problem of minimizing the triggering time subject to a required FPR is formulated, numerical and analytical approximate solutions are obtained based on the model.Main results.Our motor imagery (MI)-based brain switch can reach 0.8FP/h FPR with a median triggering time of 58 s. We evaluated the proposed brain switch during online device control, and their average FPRs substantially outperformed the conventional brain switches in the literature. We further improved the proposed brain switch with the Common Spatial Pattern (CSP) and optimization method. An average FPR of 0.3 FPs/h was obtained for the MI-CSP-based brain switch, and the average triggering time improved to 21.6 s.Significance.This study provides a new approach that could significantly reduce the brain switch's FPR to less than 1 Fps/h, which was less than 10% of the FPR (decreasing by more than a magnitude of order) by other endogenous methods, and the reaction time was comparable to the state-of-the-art approaches. This represents a significant advancement over the current non-invasive asynchronous BCI and will open widespread avenues for translating BCI towards clinical applications.

Leveraging technology to improve access to medical education in anatomy and physiology in resource-limited settings: A mixed methods study.

This study assesses the acceptability, appropriateness, feasibility, and efficacy of a novel asynchronous video-based intervention for teaching respiratory physiology and anatomy to medical students in resource-limited settings. A series of short video lectures on pleural anatomy, pulmonary physiology, and pathophysiology was created using Lightboard and screen capture technology. These were uploaded to YouTube and Google Drive and made available to 1st-3rd year medical students at two Latin American universities for 1 week. Employing a parallel-convergent mixed methods design, we conducted surveys, focus groups, interviews, and pre/post testing for qualitative and quantitative data. Thematic Analysis was used to analyze qualitative data and McNemar's test for quantitative analysis. Seventy-six students participated. The videos' short format, interactivity, and Lightboard style were highly valued for their flexibility, time efficiency, and educational impact. Students recognized their clinical relevance and trusted their content, suggesting potential applicability in similar settings. Despite infrastructure and connectivity challenges, the use of flexible streaming and downloadable options facilitated learning. Survey results indicated high levels of feasibility (99%), appropriateness (95%), and acceptability (95%), with significant knowledge gains observed (37% correct pre-test answers vs. 56% post-test, p < 0.0001). Our findings demonstrate high acceptability, appropriateness, feasibility, and efficacy of a targeted asynchronous education centered on short-format videos in resource-limited settings, enabling robust learning despite local barriers. Flexible access is key for overcoming localized barriers. Taking an adaptive, learner-centered approach to content creation and delivery to address constraints was pivotal to success. Our modular videos could serve as versatile models for flexible education in resource-constrained settings.

Building a strong public health nursing workforce in Canada: A continuing education solution.

Building a strong public health nursing (PHN) work-force capable of advancing population health and reducing inequities is critical. Though undergraduate nursing education is expected to provide introductory knowledge and practice of PHN in Canada, this is not always sufficient to adequately prepare nursing graduates for the complexity of PHN practice. To be practice ready for the full scope of PHN roles and interventions, new baccalaureate nurses and new registered nurses in public health are required to apply PHN competencies, theory, and knowledge of nursing and public health sciences, and to practice within the mandates of provincial and territorial public health legislation. To advance practice readiness a formal continuing education program is essential to foster these critical roles in PHN. This article describes the development of a postgraduate continuing education program for preparation to practice in PHN.

Hybrid films loaded with 5-fluorouracil and Reglan for synergistic treatment of colon cancer via asynchronous dual-drug delivery.

Combination therapy with oral administration of several active ingredients is a popular clinical treatment for cancer. However, the traditional method has poor convenience, less safety, and low efficiency for patients. The combination of traditional pharmaceutical techniques and advanced material conversion methods can provide new solutions to this issue. In this research, a new kind of hybrid film was created via coaxial electrospraying, followed by a casting process. The films were composed of Reglan and 5-fluorouracil (5-FU)-loaded cellulose acetate (CA) core-shell particles in a polyvinylpyrrolidone (PVP) film matrix. Microscopic observations of these films demonstrated a solid cross section loaded with core-shell particles. X-ray diffraction and Fourier-transform infrared tests verified that the Reglan and 5-FU loaded in the films showed amorphous states and fine compatibilities with the polymeric matrices, i.e., PVP and CA, respectively. In vitro dissolution tests indicated that the films were able to provide the desired asynchronous dual-drug delivery, fast release of Reglan, and sustained release of 5-FU. The controlled release mechanisms were shown to be an erosion mechanism for Reglan and a typical Fickian diffusion mechanism for 5-FU. The protocols reported herein pioneer a new approach for fabricating biomaterials loaded with multiple drugs, each with its own controlled release behavior, for synergistic cancer treatment.

Enhancing hematopathology peripheral blood smear education through asynchronous video material: A pilot report.

This study explores the effectiveness of asynchronous video material as a supplementary educational tool for trainees in hematopathology. Traditional pedagogical methods often rely heavily on faculty involvement, potentially limiting the breadth of information trainees receive due to constraints in faculty time and the variety of cases covered in a limited time interval/rotation. Asynchronous video-based learning presents a potential solution to these challenges. This concept has been utilized effectively in various fields of medical education. In this study, we describe our implementation of an educational program utilizing asynchronous video material to supplement traditional learning methods for peripheral blood smear interpretation for learners on a hematopathology clerkship. Following a pre-test/post-test assessment with 13 trainees, we analyzed the correlation between video viewing percentage and changes in test scores. The results indicate an improvement in test scores following exposure to video content, supporting the positive impact of asynchronous video material on hematopathology education. Trainees had positive feedback regarding this new educational tool. This study suggests that such self-directed learning could enhance traditional teaching methods, ensuring broader and more consistent coverage of hematopathology concepts.

Co-creating with students to promote science of learning in higher education: An international pioneer collaborative effort for asynchronous teaching.

Recent insights from Science of Learning (SoL) are informing instruction, training, and curriculum. Here, we present a project on promoting SoL-related content through co-creating online asynchronous learning resources. By building a 7-person cross-institution team, we strategically harnessed (1) student-faculty partnerships as a mechanism to promote training and professional development, (2) co-creation as a model to curricula development, (3) blended asynchronous learning as a modality for content delivery, and (4) internationalization as a strategy to embrace globalization. This co-creation of curricula project included three stages-literature review, design and production, and evaluation. The project evaluation deployed a mixed methods approach with 6 student evaluators across both participating institutions, who explored the effectiveness of the learning resources. In addition, student partners contributed reflective statements on their co-creation experience. This paper reports on the procedural pipeline to co-creation and the project evaluation, as well as on new insights emerging for curriculum development. We conclude that project's co-created learning resources may enhance effectiveness of instructional design and students' learning experience. Further, we demonstrate that student partners acquire new knowledge and research, design and delivery skills, futureproofing their academic progression.

Comparing Peer and Faculty Feedback for Asynchronous Laparoscopic Skill Acquisition.

OBJECTIVE: Traditionally, expert surgeons have provided surgical trainees with feedback about their simulation performance, including for asynchronous practice. Unfortunately, innumerable time demands may limit experts' ability to provide feedback. It is unknown whether and how peer feedback is an effective mechanism to help residents acquire laparoscopic skill in an asynchronous setting. As such, we aimed to assess the effect of peer feedback on laparoscopic performance and determine how residents perceive giving and receiving peer feedback. DESIGN: We conducted a convergent mixed methods study. In the quantitative component, we randomized residents to receive feedback on home laparoscopic tasks from peers or faculty. We then held an end-of-curriculum, in-person laparoscopic assessment with members from both groups and compared performance on the in-person assessment between the groups. In the qualitative component, we conducted interviews with resident participants to explore experiences with feedback and performance. Three authors coded and rigorously reviewed interview data using a directed content analysis. SETTING: We performed this study at a single tertiary academic institution: the University of California, San Francisco. PARTICIPANTS: We invited 47 junior residents in general surgery, obstetrics-gynecology, and urology to participate, of whom 37 (79%) participated in the home curriculum and 25 (53%) participated in the end-of-curriculum assessment. RESULTS: Residents in the peer feedback group scored similarly on the final assessment (mean 70.7%; SD 16.1%) as residents in the faculty feedback group (mean 71.8%; SD 11.9%) (p = 0.86). Through qualitative analysis of interviews with 13 residents, we identified key reasons for peer feedback's efficacy: shared mental models, the ability to brainstorm and appreciate new approaches, and a low-stakes learning environment. CONCLUSIONS: We found that peer and faculty feedback led to similar performance in basic laparoscopy and that residents engaged positively with peer feedback, suggesting that peer feedback can be used when residents learn basic laparoscopy.

Decision-Making During Asynchronous Electives: Insights From Emergency Medicine-Bound Medical Students.

Introduction While asynchronous learning is gaining popularity, little is known about learners' decisions regarding compliance with assigned asynchronous material. We sought to explore how medical students make decisions about the use of their time when engaging in asynchronous learning during the residency interview season.  Methods After implementing a four-week blended elective for emergency medicine-bound fourth-year medical students, we conducted a mixed methods study with an explanatory sequential design. We analyzed weekly surveys regarding accountability and barriers to assignment completion and conducted semi-structured focus groups exploring the decisions students made regarding compliance with asynchronous assignments. Using a constructivist approach, we performed a thematic analysis of the transcripts. Results The average assignment completion rate was 36%, with the highest rates for podcasts (58%) and the lowest rates for textbook readings (20%). Compliance with assignments was enhanced by a desire for increased ownership of learning but was hindered by a lack of accountability, learner burnout, and higher prioritization of interviews. Students preferentially selected resources that were shorter in length, entertaining, and more convenient for travel. Conclusion Our study highlights factors impacting student compliance when engaging in asynchronous learning and offers insights into educational and institutional strategies that can be utilized to enhance learner motivation.

Implementation of a Web-Based Outpatient Asynchronous Consultation Service: Mixed Methods Study.

BACKGROUND: Asynchronous outpatient patient-to-provider communication is expanding in UK health care, requiring evaluation. During the pandemic, Aberdeen Royal Infirmary in Scotland expanded its outpatient asynchronous consultation service from dermatology (deployed in May 2020) to gastroenterology and pain management clinics. OBJECTIVE: We conducted a mixed methods study using staff, patient, and public perspectives and National Health Service (NHS) numerical data to obtain a rounded picture of innovation as it happened. METHODS: Focus groups (3 web-based and 1 face-to-face; n=22) assessed public readiness for this service, and 14 interviews with staff focused on service design and delivery. The service's effects were examined using NHS Grampian service use data, a patient satisfaction survey (n=66), and 6 follow-up patient interviews. Survey responses were descriptively analyzed. Demographics, acceptability, nonattendance rates, and appointment outcomes of users were compared across levels of area deprivation in which they live and medical specialties. Interviews and focus groups underwent theory-informed thematic analysis. RESULTS: Staff anticipated a simple technical system transfer from dermatology to other receptive medical specialties, but despite a favorable setting and organizational assistance, it was complicated. Key implementation difficulties included pandemic-induced technical integration delays, misalignment with existing administrative processes, and discontinuity in project management. The pain management clinic began asynchronous consultations (digital appointments) in December 2021, followed by the gastroenterology clinic in February 2022. Staff quickly learned how to explain and use this service. It was thought to function better for pain management as it fitted preexisting practices. From May to September 2022, the dermatology (adult and pediatric), gastroenterology, and pain management clinics offered 1709 appointments to a range of patients (n=1417). Digital appointments reduced travel by an estimated 44,712 miles (~71,956.81 km) compared to the face-to-face mode. The deprivation profile of people who chose to use this service closely mirrored that of NHS Grampian's population overall. There was no evidence that deprivation impacted whether digital appointment users subsequently received treatment. Only 18% (12/66) of survey respondents were unhappy or very unhappy with being offered a digital appointment. The benefits mentioned included better access, convenience, decreased travel and waiting time, information sharing, and clinical flexibility. Overall, patients, the public, and staff recognized its potential as an NHS service but highlighted informed choice and flexibility. Better communication-including the use of the term assessment instead of appointment-may increase patient acceptance. CONCLUSIONS: Asynchronous pain management and gastroenterology consultations are viable and acceptable. Implementing this service is easiest when existing administrative processes face minimal disruption, although continuous support is needed. This study can inform practical strategies for supporting staff in adopting asynchronous consultations (eg, preparing for nonlinearity and addressing task issues). Patients need clear explanations and access to technical support, along with varied consultation options, to ensure digital inclusion.

TEACHING STATISTICS ONLINE: COMPARING COMPETENCY-BASED AND TRADITIONAL LEARNING.

Background: Interdisciplinary undergraduate students are expected to develop statistical competence to interpret research findings as they advance in their healthcare studies and careers. However, students often report anxiety related to learning statistical course content.This descriptive study examined differences in statistical knowledge and self-efficacy scores of undergraduate students enrolled in online competency-based and traditional learning statistics courses.A sample of 20 nursing and interdisciplinary, undergraduate students from a Midwestern University who were enrolled in introductory statistics courses were recruited for this study. Methods: Significant differences between pre-test and post-test statistical knowledge and self-efficacy scores were compared for students receiving online competency-based learning and traditional learning statistical course content. The Current Statistics Self-Efficacy (CSSE) and the Self-Efficacy to Learn Statistics (SELS) measures determined the statistics self-efficacy scores. Results: There was a significant difference in knowledge scores from pre- to post-test in the areas of hypothesis testing (p =.02), measures of central tendency (p =.001), and research design (p =.001), but there was not a significant difference in overall mean scores between competency-based learning and the traditional learning groups (p =.10). The pre-test to post-test Current Statistics Self-Efficacy student scores improved significantly in both the competency-based learning (p <.001) and traditional learning (p <.001) statistics course sections; and the Self Efficacy to Learn Statistics pre-test to post-test scores were also significantly improved in the competency-based (p <.001) and traditional (p =.02) learning groups. Conclusions: Both online competency-based and traditional learning methods improved interdisciplinary undergraduate students' statistical knowledge and self-efficacy scores. Online competency-based learning was described by the students as at least as beneficial as traditional learning for studying statistics while allowing more flexibility to repeat content until it was mastered. Purpose: This study compared pre- and post-test differences in statistical knowledge and self-efficacy scores of students enrolled in online competency-based learning and traditional learning statistics class sections.

Multi-recurrent Asynchronous Bilateral Malignant Phyllodes.

In this comprehensive study, we present an exceptionally rare case characterized by the occurrence of multi-recurrent asynchronous bilateral malignant phyllodes tumors. Phyllodes tumors, known for their rapid growth, originate within the stromal tissue of the breast and predominantly manifest as benign entities. Our case stands out as an extraordinary anomaly, not only due to its bilateral malignant nature but also owing to the manifestation of a multi-recurrent pattern on both sides. This unprecedented presentation underscores the complexity and heterogeneity of malignant phyllodes tumors, necessitating further in-depth investigation to unravel the underlying mechanisms driving their aggressive behavior and to explore innovative therapeutic strategies aimed at optimizing patient outcomes and prognosis.