Ketonuria and Seizure Control in the Medium Chain Triglyceride and Classic Ketogenic Diets.

We hypothesized that children receiving medium-chain triglyceride ketogenic diet (MCTKD) experience similar seizure reduction despite lower ketosis compared with classic ketogenic diet (CKD). Children initiating CKD or MCTKD were enrolled in a prospective observational study. Forty-five children completed 6 months of KD (n = 17 MCTKD, n = 28 CKD). The proportion achieving ≥50% seizure reduction was 71% CKD group and 59% MCTKD group; ≥90% reduction was 32% and 36% in CKD and MCTKD groups, respectively. CKD had higher urine ketones (≥8 mmol/L: 79% vs. 36%, p = 0.005). Children receiving MCTKD experience similar seizure control to CKD despite lower urine ketone measures.

Perceptions of women and partners on labor and birth positions: A meta-synthesis.

BACKGROUND: The risks and benefits of different birthing positions are commonly studied, but both paternal and maternal preferences and experiences of different birth positions are not examined. Therefore, this systematic review aims to explore the perceptions of women and their partners on birthing positions during the first and second stage of labor, so that maternity health care practitioners can provide better quality patient-centered care. METHODS: Six databases were searched from each database's inception through November 2020. Qualitative or mixed-methods studies exploring perceptions of women and/or their partners on birthing positions were included in the review. Key information and findings of the studies were extracted; qualitative data were meta-summarized, then meta-synthesized using thematic analysis. RESULTS: Seven studies were included, and four themes emerged: (a) Influences on choice and preference; (b) mixed experiences from "pain" to "more in control"; (c) impact on postpartum health; and (d) ways to empower couples in their choice. CONCLUSIONS: Women's preferences for birthing positions were influenced by a myriad of personal and socio-cultural beliefs and traditions. Findings suggest a need for health care practitioners to build better rapport and provide more culturally relevant informational support to both women and their birthing partners, so they are better able to make informed decisions on their preferred birthing position.

Effectiveness of healthy eating interventions among children: A quantitative systematic review.

AIMS: This review aimed to evaluate the effectiveness of healthy eating interventions among normal-weight children. DESIGN: A systematic review of randomized controlled trials. DATA SOURCES: Seven databases were searched from the inception of each database until September 2019. REVIEW METHODS: A systematic review of quantitative studies was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the PRISMA extension for reporting a synthesis without a meta-analysis. RESULTS: Fifteen studies were included in this review. A meta-analysis could not be conducted because of the observed heterogeneity across studies. There were mixed effects of the included interventions on healthy eating habits, ranging from effective to not effective. Only a few studies found behavioural determinants effective in enhancing healthy eating. CONCLUSION: Because of the observed heterogeneity and varied outcome variables, a meta-analysis could not be conducted, and the overall effectiveness of the included interventions could not be verified. Interventions that were theory based, parent focused, and delivered through the multimodal interactive approach were found to be effective in enhancing healthy eating habits among children. More studies involving peers that are institution based need to be conducted.

Paternal mental health during the perinatal period: A qualitative systematic review.

AIMS: To examine fathers' experiences and needs associated with mental health during the perinatal period. DESIGN: Qualitative studies were meta-synthesized using the steps outlined by Sandelowski and Barroso. DATA SOURCES: Six databases (PubMed, Embase, PsycINFO, CINAHL, Scopus and ProQuest) were searched for qualitative studies from each database's inception to 24 June 2019. REVIEW METHODS: Studies were critically appraised using the Critical Appraisal Skills Program tool. Qualitative data were extracted, meta-summarized, then meta-synthesized. RESULTS: Fourteen studies were included and four themes were identified: (a) negative feelings and psychological difficulties, (b) role strain and role conflict with multiple sources, (c) coping strategies that buffered negative feelings and psychological difficulties and (d) support needs to enhance mental health. CONCLUSION: Fathers reported poor mental health and expressed needs to enhance their mental health across the perinatal period. Future studies can focus specifically on paternal mental health. The development of theory-guided, family inclusive, technology-based healthcare services are needed to manage mental health. Healthcare providers can promote positive mental health to prepare fathers, increasing their awareness to manage their mental health and to seek timely help. IMPACT: Problem-focused coping (i.e. support and problem-solving with partners and childcare involvement) helped fathers to buffer their negative feelings and psychological difficulties. Future studies should focus on paternal mental health rather than on general fathering experiences. Healthcare providers should focus on promoting positive mental health and well-being. Policymakers should create awareness on paternal mental health across the perinatal period.

Assessing the impact of educational methods on influenza vaccine uptake and patient knowledge and attitudes: a randomised controlled trial.

Introduction: Although influenza vaccination reduces rates of pneumonia, hospitalisation and mortality, influenza vaccination uptake remains low in older patients. The primary aim was to compare individualised counselling with educational pamphlets alone in improving influenza vaccination uptake. The secondary aims were to evaluate knowledge and attitudes towards influenza vaccination and factors influencing uptake. Methods: A randomised controlled study was conducted in two government polyclinics with 160 participants per arm. Patients aged 65 years and above attending for doctor consultation were recruited. All participants received an educational pamphlet on influenza vaccination. The intervention group received additional face-to-face counselling. Participants filled a pre- and postintervention questionnaire assessing knowledge of influenza and attitudes towards the vaccine. Follow-up calls and verification of electronic records was done at three months to determine actual vaccine uptake. Results: At three months, 16 (10%) patients in the intervention group and 20 (12.5%) patients in the control group had completed influenza vaccination (P = 0.48). Factors positively associated with vaccine uptake were willingness to receive vaccination immediately after intervention (adjusted odds ratio [OR] 12.15, 95% confidence interval [CI] 4.42-33.38), and male gender (adjusted OR 2.96, 95% CI 1.23-7.12). Individualised counselling was more effective in improving knowledge (P < 0.01). Overall knowledge scores did not influence actual vaccine uptake rates. (adjusted OR 1.10 [0.90-1.3]). Conclusion: Both arms of patient education increased uptake of influenza vaccination. Individualised counselling was not superior to pamphlets alone in improving uptake. Performing vaccination at the initial point of contact improves actual uptake rates.

Parents' perceptions of antenatal educational programs: A meta-synthesis.

BACKGROUND: Contents and mode of delivery of antenatal educational programs differed considerably. Yet there is a lack of high-level evidence about the delivery of these programs. OBJECTIVE: We aimed to understand the experiences and needs of parents who have attended antenatal educational programs. DESIGN: Six databases were searched from each database. Included studies were appraised using the Critical Appraisal Skills Program tool. Qualitative data were meta-summarized and meta-synthesized. FINDINGS: Seventeen studies were included, and three themes were developed: (1) Contradicting views on antenatal educational programs, (2) Feeling 'well prepared' after attending the antenatal educational programs, and (3) Parents' expectations and way forward for the antenatal educational programs. DISCUSSION: Findings revealed that the description of contents of antenatal educational programs needed to be more specific. Mindfulness strategies were well-received by parents in the included studies. Educators should take into account inclusivity and increase educational resources related to individual, cultural and community needs. Learning needs can be assessed before and after classes. Parents with specific needs that were not addressed should be identified and referred to the relevant professionals for continued support. More deliberate actions were needed during the programs to foster social and professional networks for attendees to support them throughout antenatal and postnatal periods. CONCLUSION: We consolidated the experiences and needs of parents who have attended antenatal educational programs. Findings can help refine policies related to antenatal care to improve pregnancy, birth and parenthood experiences for both mothers and fathers.

Women Living With Osteoporosis: A Meta-Synthesis.

BACKGROUND AND OBJECTIVES: The experiences and needs of individuals with osteoporosis, especially among women, are poorly understood. This meta-synthesis aimed to examine the experiences and needs of women living with osteoporosis. RESEARCH DESIGN AND METHODS: Six databases were searched for qualitative studies from each database's inception to July 18, 2019. Qualitative data were meta-summarized, then meta-synthesized. RESULTS: A total of 2,781 studies were obtained, and 2,768 studies were screened after the removal of 13 duplicates. Two thousand seven hundred and sixty studies failed to meet the eligibility criteria, resulting in the inclusion of eight studies in this meta-synthesis. Three themes emerged: (a) physical and psychological consequences of living with osteoporosis, (b) coping strategies to "live better" with osteoporosis, and (c) sources of support and support needs. DISCUSSION AND IMPLICATIONS: Women living with osteoporosis experienced negative physical and psychological consequences that led to changes in their lives, particularly in their relationships. They adopted various coping strategies such as acceptance and engaging in doing things that they loved. They expressed support needs such as educational and self-help groups that may help them to cope better. As the included studies were only from the West, more studies from geographically diverse backgrounds such as the Middle East and Asia are required to explore the experiences and needs of women living with osteoporosis. Theory-based health services that incorporate active coping strategies such as self-seeking behaviors should be designed to create awareness about osteoporosis to assist such women in maintaining their independence and overall well-being to age gracefully.

The experiences and needs of Asian older adults who are socially isolated and lonely: A qualitative systematic review.

PURPOSE: To examine the experiences and needs of Asian older adults who are socially isolated and lonely living in Asian and western countries. MATERIALS AND METHODS: Six databases were searched for qualitative studies from each database's inception to December 2019. Qualitative data were meta-summarized and then meta-synthesized. RESULTS: Fourteen studies were included in this review. Five themes emerged: (1) association with older adults' well-being, (2) loss of social support, (3) dealing with social isolation and loneliness (4) unique experiences of Asian older adults in western countries, and (5) wish list of older adults. The older adults felt psychologically down and experienced a lack of social support from their family members. They coped using strategies such as religious reliance and social engagement with peers. Asian older adults in western countries faced cultural barriers and tried to form ethnic communities. The older adults wished for more community resources and care. CONCLUSION: There were multiple associations of social isolation and loneliness on the Asian older adults' well-being and social support. Coping mechanisms such as acceptance and social engagement were adopted. They expressed support needs such as social programs and healthcare services. More geographically distributed studies are needed to gather a more comprehensive and causality-related perspectives of socially isolated and lonely older adults. Lay-led programs, technology, and active coping strategies are proposed and can be incorporated in healthcare services and social programs to assist these older adults.

Multidisciplinary Professional Roles Addressing Needs in Multiple Myeloma: An Innovative 'Virtual' Pharmacist Surveillance Clinic.

OBJECTIVES: Advances in pharmacologic options has rendered multiple myeloma a chronic disease for most patients. This article explores the role of the pharmacist in new therapy start counseling, supportive care, and patient navigation in people affected by multiple myeloma. The role of the pharmacist in the pharmacist-led 'Virtual Multiple Myeloma Clinic' and the foundations guiding pharmacist prescribing are described in detail. Directions for future patient-centered research and opportunities in multiple myeloma are explored, specific to this jurisdiction. DATA SOURCES: These include academic databases (PubMed, MedLine), professional guideline documents, and first-person experience. CONCLUSION: Although the treatment landscape for multiple myeloma therapy is rapidly evolving, the survival of patients with multiple myeloma has greatly increased, rendering this largely a chronic disease. Accordingly, the role of the clinical pharmacist in multiple myeloma clinics is extensive. Counseling on first-time therapies, supportive care (adverse events management, bone health, and vaccinations), and seamless patient care across local pharmacies and health care facilities are explored. The hematology pharmacist-led Virtual Multiple Myeloma Clinic, providing individualized efficacy monitoring and counseling to patients with stable multiple myeloma on oral immunomodulatory therapy, has been pivotal in optimizing clinic workload management. IMPLICATIONS FOR NURSING PRACTICE: Possessing additional prescribing authority is paramount to the efficiency of pharmacists in clinic. Outside of pharmacy, prescribers in community treatment centers require education on the management of novel multiple myeloma therapies. Family physicians and nurses may also benefit from an overview of common issues that patients may experience because of their multiple myeloma treatments, which may enable them to better manage side effects or complications resulting from treatment.

Learning styles, preferences and needs of generation Z healthcare students: Scoping review.

AIM: This scoping review aimed to consolidate evidence of the learning styles, preferences and needs of Generation (Gen) Z healthcare students. BACKGROUND: It is essential to update the educational framework and pedagogy to meet each generation's distinct learning styles and preferences. DESIGN: A scoping review of published and unpublished data. METHODS: Six electronic databases (PubMed, Embase, CINAHL, PsycINFO, ProQuest and Scopus) were searched for studies written in English from June 2016 to July 2021. The Arksey and O'Malley (2005) five-stage framework was adopted to guide this review: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarising and reporting the results using a thematic analysis. RESULTS: Seventeen studies were included and based on the thematic analysis, four themes were identified: (1) attributes of Gen Z healthcare students; (2) learning styles of Gen Z healthcare students; (3) learning preferences and needs of Gen Z healthcare students; and (4) teaching the Gen Z healthcare students: future directions and recommendations for educators. The findings implied more culturally diverse studies that adopt the mixed-methods or qualitative design are needed to capture deeper insights about Gen Z and in examining the effectiveness of technology integration and digital storytelling to boost students' learning and confidence in their future careers. CONCLUSIONS: Technology, campus resources and self-care strategies must be carefully integrated and planned to ensure an optimal and a safe learning environment for the students. The specific preferences and needs of the unique healthcare disciplines and educational subjects could be examined. A theory-based framework could be considered in designing future pedagogy. These future directions could allow educators to initiate vital change agents in guiding, supporting and nurturing students across generations.

Appendiceal intussusception from endometriosis.

An asymptomatic 39-year-old woman was noted to have occult bleeding by faecal immunohistochemical test. Investigations showed a 3 cm×2 cm caecal lesion by colonoscopy that was consistent with abdominal CT scan findings of a 1.6 cm×1.9 cm×2.3 cm enhancing focus in the medial caecal wall. The patient underwent laparoscopic right hemicolectomy after diagnostic laparoscopy and intraoperative colonoscopy revealed an intussuscepted appendix. The final histopathology was an appendiceal intussusception secondary to endometriosis.

Adults living with irritable bowel syndrome (IBS): A qualitative systematic review.

OBJECTIVE: To consolidate existing qualitative studies which examined the experiences and needs of adults living with IBS, and to gather a holistic insight for future directions and avenues to support these adults. METHODS: A qualitative systematic review was conducted and six databases were searched for qualitative studies, beginning from each database's inception to July 2020. The qualitative data were meta-synthesised and thematic analysis was adopted. Any discrepancies that arose were discussed between the reviewers until a consensus was reached throughout the process of data screening, selection, critical appraisal and synthesis. RESULTS: Seventeen studies with a total of 299 adults diagnosed with IBS were included. Four themes were identified: (1) physical, psychological, and social consequences; (2) impact of IBS on working adults; (3) dealing with IBS; and (4) sources of support and support needs. CONCLUSION: Future research across geographically diverse locations are needed to gather a thorough perspective of the experiences and needs of adults living with IBS. The development and evaluation of technology-based, trained peer-led volunteers, and interventions that adopt mindfulness, active coping strategies, cognitive behavioural therapy and acceptance, and commitment therapy are needed. Ultimately, the collaboration between the relevant stakeholders is essential for standardised instruments and materials for accurate testing, diagnosis, assessment, treatment and management of IBS.

The Phenotypic Spectrum of Tuberous Sclerosis Complex: A Canadian Cohort.

OBJECTIVE: We aimed to further elucidate the phenotypic spectrum of Tuberous Sclerosis Complex (TSC) depending on genotype. METHODS: A retrospective review of patients seen in the TSC clinic at the Hospital for Sick Children was conducted and the frequency of TSC manifestations was compared based on genotype. RESULTS: Nineteen-patients had TSC1 mutations, 36 had TSC2 mutations and 11 had no mutation identified (NMI). Patients with TSC2 mutations had a higher frequency of early-onset epilepsy and more frequent systemic manifestations. The NMI group had milder neurologic and systemic manifestations. Our data did not demonstrate that intellectual disability and infantile spasms were more common in TSC2 mutations. CONCLUSIONS: This is the first Canadian pediatric cohort exploring the genotype-phenotype relationship in TSC. We report that some manifestations are more frequent and severe in TSC2 mutations and that NMI may have a milder phenotype. Disease surveillance and counseling should continue regardless of genotype until this is better elucidated.

Neutropenia in Children Treated With Ketogenic Diet Therapy.

OBJECTIVES: The objectives were to investigate the relationship between ketogenic diet therapy and neutropenia in children with epilepsy. METHODS: A retrospective chart review of children who initiated ketogenic diet at the Hospital for Sick Children between January 1, 2000, and May 1, 2018 was performed. Factors associated with the development of neutropenia during ketogenic diet therapy were evaluated and the relationship between development of a significant or suspected infection and neutrophil count was analyzed. RESULTS: One hundred two children met inclusion criteria and were followed on the diet for up to 24 months. Thirteen of 102 (13%) children were neutropenic at diet initiation. In the remaining 89 children, 27 developed neutropenia. Developing neutropenia was significantly associated with the ketogenic diet at 6 (13%), 12 (23%), and 24 (25%) months follow-up. Developing neutropenia was associated with higher urinary ketones (OR = 4.26, 95% CI: 1.27, 14.15) and longer duration of ketogenic diet therapy (OR = 3.29, 95% CI: 1.42, 7.96). There was no significant association between development of a clinically significant infection and neutropenia. CONCLUSION: Ketogenic diet therapy is associated with neutropenia in children with epilepsy, however, it does not have a significant clinical impact. Concern regarding neutropenia should not discourage the use of the ketogenic diet in children.

"Where-There-Is-No-Psychiatrist Integrated Personal Therapy" among Community-Dwelling Older Adults: A Randomized Pilot Study.

In Singapore, many older adults suffer from subsyndromal depression and/or subsyndromal anxiety, which can negatively impact their physical and mental well-being if left untreated. Due to the general public's reluctance to seek psychological help and the low psychiatrist-to-population ratio in Singapore, this study aims to examine the preliminary efficacy, perceptions, and acceptability of a trained volunteer-led community-based intervention on community-dwelling older adults. Twenty-one participants (control: n = 11; intervention: n = 10) completed the randomized pilot study. A mixed-methods approach (questionnaires, semistructured interviews, examining blood samples, intervention fidelity) was adopted. No significant differences were found between the intervention and the control groups in depression, anxiety, life satisfaction, friendship, and quality of life. However, there was a positive change in quality-of-life scores from baseline to 6 months in the intervention group. The control group had significantly higher cortisol levels and lower annexin-A1 levels at 6 months, while the intervention group did not. Three themes emerged from the interviews: (1) impact of the intervention on older adults' well-being, (2) attitudes toward intervention, and (3) a way forward. However, intervention efficacy could not be established due to small sample size caused by the coronavirus pandemic. Future randomized controlled trials should evaluate volunteer-led, technology-based psychosocial interventions to support these older adults.

Lessons from past epidemics and pandemics and a way forward for pregnant women, midwives and nurses during COVID-19 and beyond: A meta-synthesis.

OBJECTIVE: To consolidate qualitative research studies that examined the experiences and needs of pregnant women, midwives, and nurses of maternity units to provide a way forward for future research and practices during the current pandemic and future epidemics and pandemics. DESIGN: Qualitative systematic review and meta-synthesis. DATA SOURCE: Four electronic databases-PubMed, Scopus, PsycINFO, and Cumulative Index to Nursing and Allied Health (CINAHL). REVIEW METHODS: Qualitative studies with samples of pregnant women, midwives, and/or nurses of maternity units who experienced epidemics and/or pandemics were searched from 1 January 2000 to 4 April 2020. The included studies were critically appraised using the ten-item Critical Appraisal Skills Programme (CASP) tool. FINDINGS: Eight studies were included in this review. Four themes emerged from the synthesis: (1) psychological responses, (2) challenges faced, (3) coping strategies, and (4) sources of support and support needs. KEY CONCLUSIONS: Pregnant women, midwives, and nurses experienced negative psychological responses during epidemics and pandemics. Challenges, such as limited available information and public stigma, were faced. Various coping strategies, such as actively looking for more information and seeking solace in religions, were practiced by pregnant women, midwives, and nurses. Families were both sources of support and stress and they expressed needs for more informational, emotional, and financial support during pandemics. IMPLICATIONS FOR PRACTICE: More culturally diverse research in the future that includes the development of technology-based programs, trained community volunteer-led programs, psychosocial interventions, and anti-stigma and awareness initiatives are needed to combat the current pandemic and future public health crises.

A Review of Investigations for Patients With Tuberous Sclerosis Complex Who Were Referred to the Tuberous Sclerosis Clinic at The Hospital for Sick Children: Identifying Gaps in Surveillance.

OBJECTIVE: As a newly established tuberous sclerosis clinic (TSC) clinic at The Hospital for Sick Children, we reviewed our referrals to determine if children with TSC received appropriate surveillance as advised by the 2012 International Tuberous Sclerosis Complex Consensus Recommendations. METHODS: We completed a retrospective review of all patients seen in the TSC clinic from January 2016 to December 2017 to determine if children referred to the clinic had appropriate surveillance as suggested by the Tuberous Sclerosis Complex Consensus Recommendations. RESULTS: Ninety patients were seen in the TSC clinic. The median age at first visit was 9.9 years, and 47 were males. Seventy-six percent had undergone genetic testing before the initial clinic visit; however, genetic counseling was completed in only 66%. Brain magnetic resonance imaging was completed in 94%, abdominal imaging was completed in 91%, and an echocardiography and electrocardiography in 88% and 83%, respectively. In addition, dermatology and ophthalmology evaluations were completed in 78% and 91%, respectively. Assessment of TSC-associated neuropsychiatric disorders (TAND) was only completed in 4% of the patients. CONCLUSIONS: Systems surveillance was completed in the majority before the first TSC clinic visit. However, TSC-associated neuropsychiatric disorder screening was completed in few cases. This suggests that referring physicians may not be familiar with the neuropsychiatric manifestations of TSC and that there may be underdiagnosed or undertreated illness. Future emphasis should be placed on educating all practitioners to assess and treat tuberous sclerosis complex-associated neuropsychiatric disorder in tuberous sclerosis complex.

Botox treatment for migraine and chronic daily headache in adolescents.

Children and adolescents experience headaches as do adults and usually present with migraine and chronic daily or tension-type headaches. As some adolescents are unable to achieve headache relief after various treatment strategies, we currently provide botulinum toxin type A (Botox) injections as a clinical treatment (off-label use) in selected cases. Botulinum toxin type A by injection has been found to be effective in the treatment of headache disorders in adults. We treated 12 adolescents (aged 14 to 18 years) with Botox injections for migraine and chronic daily headache. Six patients (all female adolescents) were in long-term treatment and received Botox in the standard "migraine" and "follow-the-pain" patterns every 3 months. Effectiveness was evaluated using pain scales and a standardized quality-of-life survey at baseline and prior to each treatment session. Duration of treatment was 3-29 months. Each patient had 9-63 (average = 42) injections per treatment. All 6 long-term patients reported improvement in headache symptoms, with decreases on pain scales and an average of 33%-75% improvement in quality of life. Two long-term patients had complete relief of headaches between injection series. Four patients had only one series of injections with good results. Two patients had no improvement and refused additional injections. Side effects were mild ptosis (n = 1), blurred vision (n = 1), hematoma at neck injection site with tingling in one arm lasting 24 hours (n = 1), and burning sensations at all injection sites which lasted 1 week (n = 1). Our group findings warrant a controlled trial evaluation of Botox because it may be an effective treatment option for certain adolescents with intractable migraine and chronic daily headaches.

Development and implementation of coral reef biocriteria in U.S. jurisdictions.

Coral reefs worldwide are declining at an alarming rate and are under continuous threat from both natural and anthropogenic environmental stressors. Warmer sea temperatures attributed to global climate change and numerous human activities at local scales place these valuable ecosystems at risk. Reefs provide numerous services, including shoreline protection, fishing, tourism and biological diversity, which are lost through physical damage, overfishing, and pollution. Pollution can be controlled under provisions of the Clean Water Act, but these options have not been fully employed to protect coral reefs. No U.S. jurisdiction has implemented coral reef biocriteria, which are narrative or quantitative water quality standards based on the condition of a biological resource or assemblage. The President's Ocean Action Plan directs the U.S. Environmental Protection Agency (EPA) to develop biological assessment methods and biological criteria for evaluating and maintaining the health of coral reef ecosystems. EPA has formed the Coral Reef Biocriteria Working Group (CRBWG) to foster development of coral reef biocriteria through focused research, evaluation and communication among Agency partners and U.S. jurisdictions. Ongoing CRBWG activities include development and evaluation of a rapid bioassessment protocol for application in biocriteria programs; development of a survey design and monitoring strategy for the U.S. Virgin Islands; comprehensive reviews of biocriteria approaches proposed by states and territories; and assembly of data from a variety of monitoring programs for additional metrics. Guidance documents are being prepared to assist U.S. jurisdictions in reaching protective and defensible biocriteria.

What's in a Prerequisite? A Mixed-Methods Approach to Identifying the Impact of a Prerequisite Course.

Despite the ubiquity of prerequisites in undergraduate science, technology, engineering, and mathematics curricula, there has been minimal effort to assess their value in a data-driven manner. Using both quantitative and qualitative data, we examined the impact of prerequisites in the context of a microbiology lecture and lab course pairing. Through interviews and an online survey, students highlighted a number of positive attributes of prerequisites, including their role in knowledge acquisition, along with negative impacts, such as perhaps needlessly increasing time to degree and adding to the cost of education. We also identified a number of reasons why individuals do or do not enroll in prerequisite courses, many of which were not related to student learning. In our particular curriculum, students did not believe the microbiology lecture course impacted success in the lab, which agrees with our analysis of lab course performance using a previously established "familiarity" scale. These conclusions highlight the importance of soliciting and analyzing student feedback, and triangulating these data with quantitative performance metrics to assess the state of science, technology, engineering, and mathematics curricula.