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Author Affiliations: College of Medicine (Drs Cook, Dupras, and Montori and Ms Erwin), Office of Education Research (Dr Cook), and Knowledge and Encounter Research Unit (Dr Montori), Mayo Clinic, Rochester, Minnesota, and McMaster University, Hamilton, Ontario (Drs Levinson and Garside).
Context The increasing use of Internet-based learning in health professions education may be informed by a timely, comprehensive synthesis of evidence of effectiveness.
Objectives To summarize the effect of Internet-based instruction for health professions learners compared with no intervention and with non-Internet interventions.
Data Sources Systematic search of MEDLINE, Scopus, CINAHL, EMBASE, ERIC, TimeLit, Web of Science, Dissertation Abstracts, and the University of Toronto Research and Development Resource Base from 1990 through 2007.
Study Selection Studies in any language quantifying the association of Internet-based instruction and educational outcomes for practicing and student physicians, nurses, pharmacists, dentists, and other health care professionals compared with a no-intervention or non-Internet control group or a preintervention assessment.
Data Extraction Two reviewers independently evaluated study quality and abstracted information including characteristics of learners, learning setting, and intervention (including level of interactivity, practice exercises, online discussion, and duration).
Data Synthesis There were 201 eligible studies. Heterogeneity in results across studies was large (I2 ≥ 79%) in all analyses. Effect sizes were pooled using a random effects model. The pooled effect size in comparison to no intervention favored Internet-based interventions and was 1.00 (95% confidence interval [CI], 0.90-1.10; P < .001; n = 126 studies) for knowledge outcomes, 0.85 (95% CI, 0.49-1.20; P < .001; n = 16) for skills, and 0.82 (95% CI, 0.63-1.02; P < .001; n = 32) for learner behaviors and patient effects. Compared with non-Internet formats, the pooled effect sizes (positive numbers favoring Internet) were 0.10 (95% CI, −0.12 to 0.32; P = .37; n = 43) for satisfaction, 0.12 (95% CI, 0.003 to 0.24; P = .045; n = 63) for knowledge, 0.09 (95% CI, −0.26 to 0.44; P = .61; n = 12) for skills, and 0.51 (95% CI, −0.24 to 1.25; P = .18; n = 6) for behaviors or patient effects. No important treatment-subgroup interactions were identified.
Conclusions Internet-based learning is associated with large positive effects compared with no intervention. In contrast, effects compared with non-Internet instructional methods are heterogeneous and generally small, suggesting effectiveness similar to traditional methods. Future research should directly compare different Internet-based interventions.
The advent of the World Wide Web in 1991 greatly facilitated the use of the Internet1 and its potential as an instructional tool was quickly recognized.2,3Quiz Ref IDInternet-based education permits learners to participate at a time and place convenient to them, facilitates instructional methods that might be difficult in other formats, and has the potential to tailor instruction to individual learners' needs.4- 6 As a result, Internet-based learning has become an increasingly popular approach to medical education.7,8
However, concerns about the effectiveness of Internet-based learning have stimulated a growing body of research. In the first decade of the Web's existence 35 evaluative articles on Web-based learning were published,9 whereas at least 32 were published in 2005 alone.10 Synthesis of this evidence could inform educators and learners about the extent to which these products are effective and what makes them more or less effective.6
Since 2001, several reviews (some of which also included non−Internet-based computer-assisted instruction) have offered such summaries.9- 17 However, each had important methodological limitations, including incomplete accounting of existing studies, limited assessment of study quality, and no quantitative pooling to derive best estimates of these interventions' effect on educational outcomes.
We sought to identify and quantitatively summarize all studies of Internet-based instruction involving health professions learners. We conducted 2 systematic reviews with meta-analyses addressing this topic, the first exploring Internet-based instruction compared with no intervention and the second summarizing studies comparing Internet-based and non-Internet instructional methods (media-comparative studies).
These reviews were planned, conducted, and reported in adherence to standards of quality for reporting meta-analyses (Quality of Reporting of Meta-analyses and Meta-analysis of Observational Studies in Epidemiology standards).18,19
We sought to answer (1) to what extent is Internet-based instruction associated with improved outcomes in health professions learners compared with no intervention, and (2) how does Internet-based instruction compare with non-Internet instructional methods? We also sought to determine factors that could explain differences in effect across participants, settings, interventions, outcomes, and study designs for each of these questions.
Based on existing theories and evidence,20- 24 we hypothesized that cognitive interactivity, peer discussion, ongoing access to instructional materials, and practice exercises would improve learning outcomes. We also anticipated, based on evidence25 and argument,26 that Internet-based instruction in comparison to no intervention would have the greatest effect on knowledge, a smaller but significant effect on skills, and a yet smaller effect on behaviors in practice and patient-related outcomes. Finally, based on previous reviews and discussions,27- 29 we expected no overall difference between Internet and non-Internet instructional modalities, provided instructional methods were similar between interventions.
We developed intentionally broad inclusion criteria in order to present a comprehensive overview of Internet-based learning in health professions education. We included studies in any language if they reported evaluation of the Internet to teach health professions learners at any stage in training or practice compared with no intervention (ie, a control group or preintervention assessment) or a non-Internet intervention, using any of the following outcomes30: reaction or satisfaction (learner satisfaction with the course), learning (knowledge, attitudes, or skills in a test setting), behaviors (in practice), or effects on patients (Box). We included single-group pretest-posttest, 2-group randomized and nonrandomized, parallel-group and crossover designs, and studies of "adjuvant" instruction, in which an Internet-based intervention is added to other instruction common to all learners.
Health professions learners
Students, postgraduate trainees, or practitioners in a profession directly related to human or animal health; for example physicians, nurses, pharmacists, dentists, veterinarians, and physical and occupational therapists.
Internet-based instruction
Computer-assisted instruction—instruction in which "computers play a central role as the means of information delivery and direct interaction with the learner (in contrast to the use of computer applications such as PowerPoint), and to some extent replace the human instructor."6—using the Internet or a local intranet as the means of delivery. This included Web-based tutorials, virtual patients, discussion boards, e-mail, and Internet-mediated videoconferencing. Applications linked to a specific computer (including CD-ROM) were excluded unless they also used the Internet.
Learning environment (classroom vs practice setting)
Classroom-type settings were those in which most learners would have attended had the course not used the Internet (ie, the Internet-based course replaced a classroom course or supplemented a classroom course, or other concurrent courses were in a classroom). Practice-type settings were those in which learners were seeing patients or had a primary patient care responsibility (ie, students in clinical years, postgraduate trainees, or on-the-job training).
Practice exercises
Practice exercises included cases, self-assessment questions, and other activities requiring learners to apply information they had learned.
Cognitive interactivity
Cognitive interactivity rated the level of cognitive engagement required for course participation. Multiple practice exercises typically justified moderate or high interactivity, although exercises for which questions and answers were provided together (ie, on the same page) were rated low. Essays and group collaborative projects also supported higher levels of cognitive interactivity.
Face-to-face discussion required dedicated time for instructor-student or peer-peer interaction, above and beyond the questions that might arise in a typical lecture. Online discussion required provision for such interactions using synchronous or asynchronous online communication such as discussion board, e-mail, chat, or Internet conferencing.
Tutorials were the online equivalent of a lecture and typically involved learners studying and completing assignments alone. These often comprised stand-alone Internet-based applications with varying degrees of interactivity and multimedia.
Synchronous or asynchronous communication
Synchronous communication involved simultaneous interaction between 2 or more course participants over the Internet, using methods such as online chat, instant messaging, or 2-way videoconferencing.
Internet conferencing
Internet conferencing involved the simultaneous transmission of both audio and video information. Video information could comprise an image of the instructor, other video media, or shared projection of the computer screen (ie, whiteboard).
Repetition (single-instance vs ongoing access)
Repetition evaluated the availability of interventions over time; coded as single instance (learning materials available only once during the course) and ongoing access (learning materials accessible throughout the duration of the course).
The time over which learners participated in the intervention.
Satisfaction (reaction)
Learners' reported satisfaction with the course.
Subjective (eg, learner self-report) or objective (eg, multiple-choice question knowledge test) assessments of factual or conceptual understanding.
Subjective (eg, learner self-report) or objective (eg, faculty ratings, or objective tests of clinical skills such as interpretation of electrocardiograms or radiographs) assessments of learners' ability to demonstrate a procedure or technique.
Behaviors and patient effects
Subjective (eg, learner self-report) or objective (eg, chart audit) assessments of behaviors in practice (such as test ordering) or effects on patients (such as medical errors).
Studies were excluded if they reported no outcomes of interest, did not compare Internet-based instruction with no intervention or a non-Internet intervention, used a single-group posttest-only design, or evaluated a computer intervention that resided only on the client computer or CD-ROM or in which the use of the Internet was limited to administrative or secretarial purposes. Meeting abstracts were also excluded.
A senior reference librarian with expertise in systematic reviews (P.J.E.) designed a strategy to search MEDLINE, Scopus, CINAHL, EMBASE, ERIC, TimeLit, Web of Science, Dissertation Abstracts, and the University of Toronto Research and Development Resource Base for relevant articles. Search terms included delivery concepts (such as Internet, Web, computer-assisted instruction, e-learning, online, virtual, and distance), study design concepts (such as comparative study, evaluative study, pretest, or program evaluation), and participant characteristics (such as education, professional; students, health occupations; internship and residency; and specialties, medical). eTable 1 describes the complete search strategy. We restricted our search to articles published in or after 1990 because the World Wide Web was first described in 1991. The last date of search was January 17, 2008. Additional articles were identified by hand-searching reference lists of all included articles, previous reviews, and authors' files.
Working independently and in duplicate, reviewers (D.A.C., A.J.L., S.G., and D.M.D.) screened all titles and abstracts, retrieving in full text all potentially eligible abstracts, abstracts in which reviewers disagreed, or abstracts with insufficient information. Again independently and in duplicate, reviewers considered the eligibility of studies in full text, with adequate chance-adjusted interrater agreement (0.71 by intraclass correlation coefficient31 [ICC], estimated using SAS 9.1 [SAS Institute Inc, Cary, North Carolina]). Reviewers resolved conflicts by consensus.
Reviewers abstracted data from each eligible study using a standardized data abstraction form that we developed, iteratively refined, and implemented electronically. Data for all variables where reviewer judgment was required (including quality criteria and all characteristics used in meta-analytic subgroup analyses) were abstracted independently and in duplicate, and interrater reliability was determined using ICC. Conflicts were resolved by consensus. When more than 1 comparison intervention was reported (eg, both lecture and paper interventions), we evaluated the comparison most closely resembling the Internet-based course (ICC, 0.77).
We abstracted information on the number and training level of learners, learning setting (classroom vs practice setting; ICC, 0.81), study design (pretest-posttest vs posttest-only, number of groups, and method of group assignment; ICC range, 0.88-0.95), topic, instructional modalities used, length of course (ICC, 0.85), online tutorial (ICC, 0.68) or videoconference (ICC, 0.96) format, level of cognitive interactivity (ICC, 0.70), quantity of practice exercises (ICC, 0.70), repetition (ICC, 0.65), presence of online discussion (ICC, 0.85) and face-to-face discussion (ICC, 0.58), synchronous learning (ICC, 0.95), and each outcome (subjective or objective [ICC range, 0.63-1.0] and descriptive statistics). When outcomes data were missing, we requested this information from authors by e-mail and paper letter.
Recognizing that many nonrandomized and observational studies would be included, we abstracted information on methodological quality using an adaptation of the Newcastle-Ottawa scale for grading the quality of cohort studies.32 We rated each study in terms of representativeness of the intervention group (ICC, 0.63), selection of the control group (ICC, 0.75), comparability of cohorts (statistical adjustment for baseline characteristics in nonrandomized studies [ICC, 0.49], or randomization [ICC, 0.93] and allocation concealment [ICC, 0.48] for randomized studies), blinding of outcome assessment (ICC ≥ 0.74), and completeness of follow-up (ICC, 0.37 to 0.79 depending on outcome).
We analyzed studies separately for outcomes of satisfaction, knowledge, skills, and behaviors or patient effects. For each outcome class we converted means and standard deviations to standardized mean differences (Hedges g effect sizes).33- 35 When insufficient data were available, we used reported tests of significance (eg, P values) to estimate the effect size. For crossover studies we used means or exact statistical test results adjusted for repeated measures or, if these were not reported, we used means pooled across each intervention.36,37 For 2-group pretest-posttest studies we used posttest means or exact statistical test results adjusted for pretest or, if these were not reported, we used differences in change scores standardized using pretest variance. If neither P values nor any measure of variance was reported, we used the average standard deviation from all other included studies.
To quantify inconsistency (heterogeneity) across studies we used the I2 statistic,38 which estimates the percentage of variability across studies not due to chance. I2 values greater than 50% indicate large inconsistency. Because we found large inconsistency (I2 ≥ 79% in all analyses), we used random-effects models to pool weighted effect sizes across studies using StatsDirect 2.6.6 (StatsDirect Ltd, Altrincham, England, http://www.statsdirect.com).
We performed subgroup analyses to explore heterogeneity and to investigate the questions noted above regarding differences in participants, interventions, design, and quality. We used a 2-sided α level of .05. We grouped studies with active comparison interventions according to relative between-intervention differences in instructional methods; namely, did the comparison intervention have more, less, or the same amount of interactivity, practice exercises, discussion (face-to-face and Internet-based discussion combined), and repetition.
We conducted sensitivity analyses to explore the robustness of findings to synthesis assumptions, with analyses excluding low-quality studies, studies with effect size estimated from inexact tests of significance or imputed standard deviations, 1 study39 that contributed up to 14 distinct Internet-based interventions, studies of blended (Internet and non-Internet) interventions, and studies with major design flaws (described below).
The search strategy identified 2045 citations, and an additional 148 potentially relevant articles were identified from author files and review of reference lists. From these we identified 288 potentially eligible articles (Figure 1). Following a single qualitative study reported in 1994, the number of comparative or qualitative studies of Internet-based learning increased from 2 articles published in 1996, to 16 publications in 2001, to 56 publications in 2006. We contacted authors of 113 articles for additional outcomes information and received information from 45. Thirteen otherwise eligible articles contained insufficient data to calculate an effect size (ie, sample size or both means and statistical tests absent) and were excluded from the meta-analyses. Ultimately we analyzed 201 articles, 5 of which contributed to both analyses, representing 214 interventions. Table 1 summarizes key study features and eTable 2 provides detailed information.
Five studies compared the Internet-based intervention with both no intervention and a non-Internet comparison intervention.
Internet-based instruction addressed a wide range of medical topics. In addition to numerous diagnostic and therapeutic content areas, courses addressed topics such as ethics, histology, anatomy, evidence-based medicine, conduct of research, biostatistics, communication skills, interpretation of electrocardiograms and pulmonary function tests, and systems-based practice. Quiz Ref IDMost interventions involved tutorials for self-study or virtual patients, while over a quarter required online discussion with peers, instructors, or both. These modalities were often mixed in the same course. Twenty-nine studies (14.4%) blended Internet-based and face-to-face instruction. Non-Internet comparison interventions most often involved face-to-face courses or paper modules but also included satellite-mediated videoconferences, standardized patients, and slide-tape self-study modules.
The vast majority of knowledge outcomes consisted of multiple-choice tests, a much smaller number comprised other objectively scored methods, and 18 of 177 studies assessing knowledge (10.2%) used self-report measures of knowledge, confidence, or attitudes. Skills outcomes included communication with patients, critical appraisal, medication dosing, cardiopulmonary resuscitation, and lumbar puncture. These were most often assessed using objective instructor or standardized patient observations. Skills outcomes were self-reported or the method could not be determined for 7 of 26 studies (26.9%). Behavior and patient effects included osteoporosis screening rates, cognitive behavioral therapy implementation, workplace violence events, incidence of postpartum depression, and various perceived changes in practice. Ten of 23 articles (43.5%; representing nearly two-thirds of the interventions) used self-reported behavior or patient effects outcomes. Most objective assessments used chart review, although 1 study used incognito standardized patients.
Table 2 summarizes the methodological quality of included studies, and eTable 3 contains details on the quality scale and individual study quality. Nine of 61 (14.8%) no-intervention 2-group comparison studies determined groups by completion or noncompletion of elective or "required" Internet-based instruction. Although such groupings are susceptible to bias, sensitivity analyses showed similar results when these studies were excluded. Eight of 43 studies (18.6%) assessing satisfaction, 42 of 177 (23.7%) assessing knowledge, 4 of 26 (15.4%) assessing skills, and 5 of 23 (21.7%) assessing behaviors and patient effects lost more than 25% of participants from time of enrollment or failed to report follow-up. The mean (SD) quality score (6 points indicating highest quality) was 2.5 (1.3) for no-intervention controlled studies, and 3.5 (1.4) for non-Internet comparison studies.
Figures 2, 3, 4, and eTable 4 summarize the results of the meta-analyses comparing Internet-based instruction with no intervention. Satisfaction outcomes are difficult to define in comparison to no intervention, and no studies reported meaningful outcomes of this type. We used inexact P values to estimate 17 of 174 effect sizes (9.8%), and we imputed standard deviations to estimate 10 effect sizes (5.7%). eTable 4 contains detailed results of the main analysis and sensitivity analyses for each outcome. Sensitivity analyses did not affect conclusions.
Boxes represent the pooled effect size (Hedges g). P values reflect paired or 3-way comparisons among bracketed subgroups. Participant groups are not mutually exclusive; thus, no statistical comparison is made. There are 126 interventions because the report by Curran et al39 contributed 10 separate interventions to this analysis. I2 for pooling all interventions is 93.6%.
For a definition of figure elements, see the legend to Figure 2. All interventions were tutorials; hence, no contrast is reported for this characteristic. I2 for pooling all interventions is 92.7%.
For a definition of figure elements, see the legend to Figure 2. All interventions occurred in a practice setting; hence, no contrast is reported for this characteristic. There are 32 interventions because the report by Curran et al39 contributed 14 separate interventions to this analysis. I2 for pooling all interventions is 79.1%.
Knowledge. One hundred seventeen studies reported on 126 interventions using knowledge as the outcome. The pooled effect size for these interventions was 1.00 (95% confidence interval [CI], 0.90-1.10; P < .001). Because effect sizes larger than 0.8 are considered large,40 this suggests that Internet-based instruction typically has a substantial benefit on learners' knowledge compared with no intervention. However, we also found large inconsistency across studies (I2 = 93.6%), and individual effect sizes ranged from −0.30 to 6.69. One of the 2 interventions yielding a negative effect size41 was an adjunct to an existing intensive and well-planned course on lung cancer. The other42 compared Internet-based educational order sets for medical students on a surgery clerkship to students at a different hospital without access to these order sets, which could arguably be construed as an active comparison intervention.
In subgroup analyses exploring this inconsistency, we failed to confirm our hypotheses that high interactivity, ongoing access to course materials, online discussion, or the presence of practice exercises would yield larger effect sizes (P for interaction≥.15) (Figure 2). However, we found a significant interaction with study quality, with studies scoring low on the modified Newcastle-Ottawa scale showing a greater effect than high-quality studies (mean score, 1.07; 95% CI, 0.96-1.18 vs mean score, 0.71; 95% CI, 0.51-0.92; P for interaction = .003).
Skills.Quiz Ref IDSixteen interventions used skills as an outcome. The pooled effect size of 0.85 (95% CI, 0.49-1.20; P < .001) reflects a large effect. There was large inconsistency across trials (I2 = 92.7%), and effect sizes ranged from 0.02 to 2.50.
The pooled effect size for interventions with practice exercises was significantly higher than those without (pooled effect size, 1.01; 95% CI, 0.60-1.43 vs pooled effect size, 0.21; 95% CI, 0.04-0.38; P for interaction <.001), but once again interactivity, repetition, and discussion did not affect outcomes (P for interaction ≥.30) (Figure 3).
Behaviors and Effects on Patient Care. Nineteen studies reported 32 interventions evaluating learner behaviors and effects on patient care. These studies demonstrated a large pooled effect size of 0.82 (95% CI, 0.63-1.02; P < .001) and large inconsistency (I2 = 79.1%). Effect sizes ranged from 0.06 to 7.26.
In contrast to skills outcomes, practice exercises were negatively associated with behavior outcomes (0.44; 95% CI, 0.33-0.55 if present; 2.09; 95% CI, 1.38-2.79 if absent; P for interaction <.001) (Figure 4). We also found statistically significant differences favoring tutorials, longer-duration courses, and online peer discussion.
Figures 5, 6, 7, and 8 and eTable 4 summarize the results of the meta-analyses comparing Internet-based instruction with non-Internet instruction. We used inexact P values to estimate 1 of 124 effect sizes (0.8%), and we imputed standard deviations to estimate 5 effect sizes (4.0%). Sensitivity analyses did not alter conclusions except as noted.
Studies are classified according to relative between-intervention differences in key instructional methods; namely, did the comparison intervention have more (comparison >Internet), less (comparison <Internet), or the same (equal) amount of interactivity, practice exercises, discussion (face-to-face and Internet-based discussion combined), and repetition. Boxes represent the pooled effect size (Hedges g). P values reflect paired or 3-way comparisons among bracketed subgroups. Participant groups are not mutually exclusive; thus, no statistical comparison is made. All outcomes were subjectively determined; hence, no contrast is reported for this characteristic. Crossover studies assessed participant preference after exposure to Internet-based and non−Internet-based interventions. I2 for pooling all interventions is 92.2%.
For a definition of figure elements and study parameters, see the legend to Figure 5. I2 for pooling all interventions is 88.1%.
For a definition of figure elements and study parameters, see the legend to Figure 5. All interventions were tutorials, and all outcomes were objectively determined except for 1 study in which the method of assessment could not be determined; hence, no contrasts are reported for these characteristics. I2 for pooling all interventions is 89.3%.
For a definition of figure elements and study parameters, see the legend to Figure 5. I2 for pooling all interventions is 94.6%.
Satisfaction. Forty-three studies reported satisfaction outcomes comparing Internet-based instruction to non-Internet formats. The pooled effect size (positive numbers favoring Internet) was 0.10 (95% CI, −0.12 to 0.32), with I2 = 92.2%. This effect is considered small40 and was not significantly different from 0 (P = .37). Individual effect sizes ranged −1.90 to 1.77.
We had no a priori hypotheses regarding subgroup comparisons for satisfaction outcomes, but we found statistically significant treatment-subgroup interactions favoring short courses, high-quality studies, and single-instance rather than ongoing-access Internet-based interventions (Figure 5).
Knowledge. Sixty-three non-Internet-controlled studies reported knowledge outcomes. Effect sizes ranged from −0.98 to 1.74. The pooled effect size of 0.12 (95% CI, 0.003 to 0.24) was statistically significantly different from 0 (P = .045) but small and inconsistent (I2 = 88.1%). A sensitivity analysis excluding blended interventions yielded a pooled effect size of 0.065 (95% CI, −0.062 to 0.19; P = .31).
In accord with our hypothesis, effect sizes were significantly higher for Internet-based courses using discussion vs no discussion (P for interaction = .002) (Figure 6). A statistically significant interaction favoring longer courses was also found (P for interaction = .03). However, our hypotheses regarding treatment-subgroup interactions across levels of interactivity, practice exercises, and repetition did not find support.
Skills. The twelve studies reporting skills outcomes demonstrated a small pooled effect size of 0.09 (95% CI, −0.26 to 0.44; P = .61). As with other outcomes, heterogeneity was large (I2 = 89.3%). Effect sizes ranged from −1.47 to 0.93.
We found statistically significant treatment-subgroup interactions (P for interaction≤.04) favoring higher levels of interactivity, practice exercises, and peer discussion (Figure 7). However, these analyses were limited by very small samples (in some cases only 1 study in a group). Contrary to our expectation, single-instance interventions yielded higher effect sizes than those with ongoing access (P for interaction = .02).
Behaviors and Effects on Patient Care.Quiz Ref IDSix studies reported outcomes of behaviors and effects on patient care. The pooled effect size of 0.51 (95% CI, −0.24 to 1.25) was moderate in size, but not statistically significant (P = .18). Inconsistency was large (I2 = 94.6%) and individual effect sizes ranged from −0.84 to 1.66.
We again found a statistically significant treatment-subgroup interaction favoring discussion (P for interaction = .02); (Figure 8) but as with skills outcomes, the results are tempered by very small samples. Once again, single-instance interventions yielded higher effect sizes than those with ongoing access (P for interaction = .006).
We found that Internet-based learning compared with no intervention has a consistent positive effect. The pooled estimate of effect size was large across all educational outcomes.40 Furthermore, we found a moderate or large effect for nearly all subgroup analyses exploring variations in learning setting, instructional design, study design, and study quality. However, studies yielded inconsistent (heterogeneous) results, and subgroup comparisons only partially explained these differences.
The effect of Internet-based instruction in comparison to non-Internet formats was likewise inconsistent across studies. In contrast, the pooled effect sizes were generally small (≤0.12 for all but behavior or patient effects) and nonsignificant (CIs encompassing 0 [no effect] for all outcomes except knowledge).
Heterogeneity may arise from variation in learners, instructional methods, outcome measures, and other aspects of the educational context. For example, only 2 no-intervention controlled studies41,42 had negative effect sizes, and in both instances the lack of benefit could be ascribed to an educationally rich baseline or comparison. Our hypotheses regarding changes in the magnitude of benefit for variations in instructional design were generally not supported by subgroup analyses, and in some cases significant differences were found in the direction opposite to our hypotheses. These findings were not consistent across outcomes or study types. Unexplained inconsistencies would allow us to draw only weak inferences if not for the preponderance of positive effects on all outcomes in the no-intervention comparison studies. For comparisons with non-Internet formats these inconsistencies make inferences tenuous. Additional research is needed to explore the inconsistencies identified in this review.
Our study has several limitations. First, many reports failed to describe key elements of the context, instructional design, or outcomes. Although the review process was conducted in duplicate, coding was subjective and based on published descriptions rather than direct evaluation of instructional events. Poor reporting might have contributed to modest interrater agreement for some variables. Although we obtained additional outcome data from several authors, we still imputed effect sizes for many studies with concomitant potential for error. Sparse reporting of validity and reliability evidence for assessment scores precluded inclusion of such evidence. Furthermore, methodological quality was generally low. However, subgroup and sensitivity analyses did not reveal consistently larger or smaller effects for different study designs or quality or after excluding imputed effect sizes.
Second, interventions varied widely from study to study. Because nearly all no-intervention comparison studies found a benefit, this heterogeneity suggests that a wide variety of Internet-based interventions can be used effectively in medical education. Alternatively, this finding may indicate publication bias with negative studies remaining unpublished. We did not use funnel plots to assess for publication bias because these are misleading in the presence of marked heterogeneity.43
Third, we report our results using subgroups as an efficient means of synthesizing the large number of studies identified and simultaneously to explore heterogeneity. However, subgroup results should be interpreted with caution due to the number of comparisons made, the absence of a priori hypotheses for many analyses, the limitations associated with between-study (rather than within-study) comparisons, and inconsistent findings across outcomes and study types.44 For example, we found contrary to expectation that interventions with greater repetition (Internet-based course permitting ongoing access vs non-Internet intervention available only once) had lower pooled effect sizes than interventions with equal repetition. These results could be due to chance, confounding, bias, or true effect. Another example is the finding that practice exercises were associated with higher effect sizes for skills outcomes and lower effect sizes for behavior or patient effects; this could be explained by true differential effect of the interventions on these outcomes, variation in responsiveness across outcomes, unrecognized confounders, or chance.
Finally, by focusing our review on Internet-based learning, we of necessity ignored a great body of literature on non−Internet-based computer-assisted instruction.
Our review also has several strengths. The 2 study questions are timely and of major importance to medical educators. We intentionally kept our scope broad in terms of subjects, interventions, and outcomes. Our search for relevant studies encompassed multiple literature databases supplemented by hand searches. We had few exclusion criteria, and included several studies published in languages other than English. All aspects of the review process were conducted in duplicate with acceptable reproducibility. Despite the large volume of data, we kept our analyses focused, conducting relatively few planned subgroup analyses to explain inconsistency and sensitivity analyses to evaluate the robustness of our findings to the assumptions of our meta-analyses.
The last meta-analyses of computer-assisted instruction in health professions education45,46 were published in or before 1994, and computer-assisted instruction has changed dramatically in the interim. To the 16 no-intervention controlled and 9 non-Internet comparative studies reported in the last comprehensive review of Web-based learning,9 we add 176 additional articles as well as a meta-analytic summary of results. This and other reviews11- 14,16,17,47 concur with the present study in concluding that Internet-based learning is educationally beneficial and can achieve results similar to those of traditional instructional methods.
This review has implications for both education and research. Quiz Ref IDAlthough conclusions must be tempered by inconsistency among studies and the possibility of publication bias, the synthesized evidence demonstrates that Internet-based instruction is associated with favorable outcomes across a wide variety of learners, learning contexts, clinical topics, and learning outcomes. Internet-based instruction appears to have a large effect compared with no intervention and appears to have an effectiveness similar to traditional methods.
The studies making comparison with no intervention essentially asked whether a Web-based course in a particular topic could be effective. The answer was almost invariably yes. Given this consistency of effect and assuming no major publication bias, there appears to be limited value in further research comparing Internet-based interventions against no-intervention comparison groups. Although no-intervention controlled studies may be useful in proof-of-concept evaluations of new applications of Internet-based methods (such as a study looking at rater training on the Web48), truly novel innovations requiring such study are likely to be increasingly rare and will infrequently merit publication.
Studies making comparison to alternate instructional media asked whether Internet-based learning is superior to (or inferior to) traditional methods. In contrast to no-intervention controlled studies, the answers to this question varied widely. Some studies favored the Internet, some favored traditional methods, and on average there was little difference between the 2 formats. Although the pooled estimates favored Internet-based instruction, for all but behavior or patient effects the magnitude of benefit was small and could be explained by sources of variation noted above or by novelty effects.27 These findings support arguments that computer-assisted instruction is neither inherently superior to nor inferior to traditional methods.10,27- 29 Few non-Internet comparison studies reported skills and behavior or patient effects outcomes, and the CIs for these pooled estimates do not exclude educationally significant effects. Additional research, using outcome measures responsive to the intervention and sensitive to change, would be required to improve the precision of these estimates. However, inconsistencies in the current evidence together with conceptual concerns27,28 suggest limited value in further research seeking to demonstrate a global effect of Internet-based formats across learners, content domains, and outcomes.
The inconsistency in effect across both study types suggests that some methods of implementing an Internet-based course may be more effective than others. Thus, we propose that greater attention be given to the question, "How can Internet-based learning be effectively implemented?" Elucidating how to effectively implement Internet-based instruction will be answered most efficiently through research directly comparing different Internet-based interventions.7,10,27- 29,49 Inconsistency may also be due to different learning contexts and objectives, and thus the question, "When should Internet-based learning be used?" should be considered as well.10
Finally, although our findings regarding the quality of this body of research are not unique to research in Internet-based instruction,50- 52 the relatively low scores for methodological quality and the observed reporting deficiencies suggest room for improvement.
Corresponding Author: David A. Cook, MD, MHPE, Division of General Internal Medicine, Mayo Clinic College of Medicine, Baldwin 4-A, 200 First St SW, Rochester, MN 55905 (email@example.com).
Author Contributions: Dr Cook had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Cook, Levinson, Dupras, Garside, Erwin, Montori.
Acquisition of data: Cook, Levinson, Dupras, Garside, Erwin.
Analysis and interpretation of data: Cook, Montori.
Drafting of the manuscript: Cook.
Critical revision of the manuscript for important intellectual content: Cook, Levinson, Dupras, Garside, Erwin, Montori.
Statistical analysis: Cook, Montori.
Obtained funding: Cook.
Administrative, technical or material support: Cook, Montori.
Study supervision: Cook.
Financial Disclosures: None reported.
Funding/Support: This work was supported by intramural funds and a Mayo Foundation Education Innovation award.
Role of Sponsor: The funding source for this study played no role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation of the manuscript. The funding source did not review the manuscript.
Additional Information: Details on included studies and their quality, and on the meta-analyses are available at http://www.jama.com.
Additional Contributions: We thank Melanie Lane, BA, Mohamed Elamin, MBBS, and M. Hassan Murad, MD, from the Knowledge and Encounter Research Unit, Mayo Clinic, for assistance with data extraction and meta-analysis planning and execution, and Kathryn Trana, from the Division of General Internal Medicine, Mayo Clinic, for assistance in article acquisition and processing. These individuals received compensation as part of their regular employment.
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Is the Mac right for me?
by Lee Koo (ADMIN) - 3/22/07 12:08 PM
I've got very interested in photography to the extent that I want to use it as a source of income on the side when I retire. I have all PCs but recently got a demonstration of an iMac. I was swayed, but need to really research the differences before I spend that kind of money. I looked at a 24-inch iMac, basically set up for photography, therefore any Microsoft Office needs would not be an issue for a computer with such 'big guns'. Should I continue down this road, or focus back to a PC. I don't want to be crashing often, and the Mac guys say it won't happen (wrong people to ask). Need feed back from users to be more confident. Any guidance would be appreciated.
Submitted by: Chaz
Answer voted most helpful by our members:
To be honest about this, my PCs (there are 7 of them here) lock up or crash about once a year, and I believe that the whole idea that a quality PC is less stable than a Mac is a myth. The marketing side of me loves the Mac vs. PC commercials ... they are great commercials, well done, funny, and they do a good job of selling Macs ... but they present one very simplified and dumbed down side of a situation that is not nearly so simple as the commercials portray.
So let me first make a comment on Mac vs. PC: Macs are made, entirely, by one company, on whom you are almost totally dependent for everything. They are of generally high quality, but they are also generally quite expensive. PCs are made by .... well, by everyone including your neighbors teenage son in the garage or on the kitchen table, and both the price and quality can vary all over the place. A kit of haphazardly matched surplus last-generation ultra-parts obtained for $89 (after two dozen rebates) from JungleAnimalDirect and assembled by a high school student who is doing this for the second time and thinks he now knows it all is not going to have the same quality as a $2,000 Dell XPS system, but they are both PCs. So when we talk about the stability of a system and how often it crashes, I come back to the point that a quality PC is as good as a Mac.
Another point that is related here is that Macs now use Intel CPUs and chipsets, they use PCI, they use AGP and USB, they can actually run ... directly ... Microsoft Windows XP instead of the Mac OS. The Mac, in other words, IS a PC, just one that can use the Mac OS, which a non-Mac PC cannot. Mac hardware is, again, no more stable than quality PC hardware. Because, in fact, they are at this point pretty much the same thing, from a hardware perspective.
So lets talk about your primary interest, digital photography. There is nothing about any PC that is hardware specific to photography. And as to software, there are tons and tons of digital photography applications available for the PC, and tons for the Mac OS as well. Of course if you are really, really serious about doing professional level photography on a computer (Mac or PC), you are probably talking about using Adobe full-version Photoshop, which is available on both platforms (and, again, the Mac can run Windows XP if you want to go that route (although the Mac may well not be the best platform for XP)).
So the real issues with Mac vs. PC are going to come down to the following items:
If you buy a PC, you have to select a source for the PC, and all PCs are not created equal. The issue, from a quality, reliability, stability and cost perspective is not so much Mac vs. PC as PC vs. PC
You can run XP on a Mac, but a Mac is not the optimum Windows XP platform, and switching back and forth between different OS, while entirely possible, is a pain (Currently, you cant officially run Vista on a Mac as far as I know, but I am certain that this will change at some point)
While some products (including Photoshop) are available for both the Windows and the Mac platform, for the most part the two platforms have different software offerings. There is no argument that some of the Apple software for multimedia (photography and video) is very good, and you cant run the Apple software on a PC. So if you want to use the Apple software, your decision is pretty clear. But there is a lot more software (superb, good, bad and yes, ugly) for the PC, so determining the software that you want to use is a key element in making this decision
Unless you plan to use this computer only for your digital photography, there are probably two orders of magnitude more software, overall, for PCs vs. Macs. So keep in mind, also, the entire universe of what you will be using this computer for. Very few computers are used for only one single application.
The problems that people have with PCs come down to the fact that a typical PC system is made up of hardware and software from dozens or even hundreds of different firms, and that even with billions of PCs on the planet, the exact combination of both all of the hardware and all of the software found in any one PC is probably completely unique. On top of that, because PCs running Windows are 90% of the installed base of personal computers, they are the preferred target for virus and malware authors. It is the abundance and variety of both hardware and software offerings that gives PCs their versatility and low cost, but, at the same time, its that exact combination that also causes most of the problems that people have with PCs. You cant have the good without the bad ... they go together. If you go with a Mac, you can avoid some of the pitfalls that exist in the PC world, but at the same time you will be avoiding a lot of the benefits as well, and precluding yourself from running most of the software that is currently being written (at least without switching operating systems and converting the Mac back into what is probably a sub-optimal PC).
In the end, however, its an individual choice that only the person actually using the system can really make.
Barry Watzman
Submitted by: Barry W. (CNET member Watzman)
If you have any additional advice or recommendations for Chaz, let's hear them. Click on the "Reply" link to post. Thanks!
(Note: Please keep your advice and opinions objective. We are here to help this member with your knowledge and guidance. Let's not turn this into a heated PC vs. Mac flame war. Respect each other, and keep it civil. Thank you.)

subset: commoncrawl


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Michelle Holmgren, Public Affairs & Community Relations Specialist
(Office) 413-967-2296 (Cell) 413-237-6743
Ware, MA (May 24, 2013) – "There are few areas more important to a community than emergency medical services," said Dr. Richard Gerstein, Chair of Emergency Medicine at Baystate Mary Lane Hospital. "EMS providers work countless hours to ensure that our community members have access to highly skilled, quality emergency care."
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On June 5, Emergency Department physician, Dr. Paul Gerstein, will present Risk Management for EMS Providers beginning at 6:30 pm in the Main Conference Room.
Classes offered by the Baystate Mary Lane Hospital EMT Continuing Education Program are offered free of charge as part of Baystate Mary Lane's ongoing commitment to local Emergency Medical Providers and are held on the First Wednesday of every month, unless otherwise noted, from 6:30 pm to 8:30 pm in Main Conference Room located on the second floor.
Baystate Mary Lane Hospital EMT Continuing Education Program 2013
June 5 Risk Management for EMS Providers Paul Gerstein, MD –BMLH ED
July 11* M & M Rounds Roger Lafleur, MD-BMLH ED
August 7 Pre-hospital Care of STEMI Amir Lotfi, MD -
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November 6 Infectious Diseases Richard Romano, BMLH-ED
December 4 M & M Rounds Roger Lafleur, MD-BMLH ED
Registration is not required, for more information call Michelle Holmgren, Public Affairs & Community Relations Specialist at 413-967-2296.


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Visa ServicesVisaHQ is vayama's visa processing partner. In addition to holding a passport with sufficient unused pages, that will remain valid for at least six months, many countries require that you obtain a visa in order to enter that country. The need for a visa and related entry requirements vary greatly based on your nationality and country of destination. Countries issue visas through their embassies and consulates based in the Canada and the U.S. There are different types of visas depending on the purpose of travel (tourist, business, transit, student, etc). Each country has its own rules, fees, application forms, length of stay, and entry requirements. Please use the table below to find out more information about visa requirements and costs.
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RRP: kr217,14
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The Zipp Speed Box offers the convenience of the classic top-tube box with a few new features to make it more user-friendly. Pulling sideways on a Velcro panel can be awkward when you're focused on nailing that bike split, so Zipp put a zipper running parallel to the top tube.
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Cooling Gel Bed Pad
Sleep cool and comfortably with this extra-large gel filled Cooling Pad. It drops the temperature of your bedding without any electricity or refrigeration necessary. Keeps your bed refreshingly cool for hours. Simply place under your fitted sheet to enjoy a more comfortable night's sleep. Durable gel core with nylon taffeta cover. Wipe clean. 35 1/2"L x 31"W.
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This does feel good at first, but after a few hours of laying on it, it does come up to my body tempurature. Now I'm laying on something that is as hot as I am and it has to be removed. Does fold up nicely to fit in a fridge for extreme cooling. Great if you need to cool your entire back at once for a short time. Just dont expect it to feel cool all night like I had hoped it would.
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Unfortunately Gerber Mini-Remix 2 Blade Knife is no longer carried by OpticsPlanet. You can also explore other items in the Pocket Knives category yourself to try and find the perfect replacement for you!
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Volcanoes are formed by a fissure in the earth's crust through which molten lava and gases erupt. These formations are usually found on diverging or converging tectonic plates or above mantle plumes, in places called hotspots. There are numerous types of volcanoes: fissure vents, shield volcanoes, cinder cones, stratovolcanoes, cryptodomes, submarine volcanoes, supervolcanoes and many more.
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(Source: Volcano World, WordNet, Earth Observatory / Photo: Flickr)


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4 Health Foods With Hidden Dangers
ACE Fit Share
March 25, 2013, 12:00AM
Parents often ask me, "What changes can I make to my child's lifestyle to help them be healthier?" Many have begun to realize that, compared to previous generations, today's children are largely sedentary, have poor eating habits, get less sleep and participate in less physical activity. Not only does this cause them to suffer from risk factors for heart disease, type 2 diabetes and other obesity-related illnesses, many experts worry this could be the first generation of children whose life expectancy may be shorter than their parents. For parents who want to create a healthier lifestyle for their children, here are my top tips, which mirror the 5-2-1-0 campaign advocated by the American Academy of Pediatrics.
5 Servings of Fruit and Vegetables Per Day
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0 Servings of Sugar-sweetened Beverages
And, not to be forgotten:
If you found this to be article useful to you or someone else, please share it with your friends!
How Can I Teach my Child About Portions?
Healthy School Lunches Kids Will Love
ACE Pro Homepage
Copyright © 2015 The American Council on Exercise. All Rights Reserved.4851 Paramount Drive, San Diego, California 92123 1 (888)-825-3636


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1/12/12 - Bolton Hall Surges to Northwest Quadrant
Bolton Hall Surges to Northwest Quadrant
Currently, UWM faculty on floors 4-8 of Bolton Hall have begun their temporary move to the Northwest Quadrant "B" building, located at 2025 E. Newport Ave. The Northwest Quadrant was formerly Columbia-St. Mary's before UWM purchased the property at the end of 2010. This temporary relocation will allow HVAC and fire suppression improvements in Bolton Hall. The relocation is underway and faculty should be fully moved in to their temporary offices prior to the Spring 2012 semester, which begins January 23, 2012. The improvements at Bolton Hall will take about 12-18 months.
Faculty should be back in Bolton Hall in the summer of 2013. This is the first of many temporary relocation events for which the Northwest Quadrant will provide space during improvements around Campus. To accommodate faculty and students, there will be a Grind Coffee Shop and Convenience Store established in the Northwest Quadrant "A" building. Below, are a few resources that will assist those experiencing this relocation. If you have any questions or concerns you can contact Tami McCullough at 414-229-2827 or firstname.lastname@example.com.
11/17/11 - UWM's Building Dashboard - Keeping Track of Energy Usage
UW-Milwaukee's Building Dashboard
UWM's energy usage is more transparent than ever. Through the Lucid Building Dashboard, UWM's buildings display real-time, web-based data on our electric, heating, and cooling usage. Ever wonder how much electricity EMS uses? Want to know how many toilet flushes there are per hour in Cambridge Commons? Curious to know who uses more heat per square foot, Enderis or Curtain Hall? The answers are all part of the new dashboard.
The Lucid Building Dashboard was brought on to UW-Milwaukee through the measurement & verification procedures that are part of Energy Matters. Building by building, phase by phase, all UWM buildings are currently going through energy conservation measure upgrades. The buildings that are complete make their way onto the dashboard. University Housing is also making use of the building dashboard. Several residence halls, including Sandburg, Cambridge Commons, and Riverview are also monitoring their energy usage online, as well as water consumption.
The goal through these measures is to reduce our campus energy usage by 25% by 2013. Through a partnership with Honeywell, UWM is modernizing our building HVAC systems, lighting, and building envelope. Five campus buildings are complete and six others are underway. Current measurements are showing that we are trending closer to a 43% savings, far beyond our 25% reduction goal.
Campus building occupants now have a part in the savings. Through the building dashboard, buildings are able to compete for further energy savings. By powering down, taking the stairs, and even removing unnecessary appliances, the campus community is reaching for additional savings. Engineering and Mathematical Sciences was the winner this fall in a two week competition, with a 7% reduction over and above the operational changes. They were very happy to receive their 10lbs of organic, fair trade coffee for winning the competition.
Measurement and verification is an essential component to this project. There is a vigilance to ensuring that UWM's buildings are performing the way that they are supposed to, while also attaining occupant comfort. The building dashboard is just one of these tools. A tool that is readily available to the entire campus community.
To view UW-Milwaukee's Building Dashboard, go to: www.buildingdashboard.net/uwm/


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Every time one of our customers uses one of our products, we donate a portion of their charges to selected causes.
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Get a card, ride 11 trails, earn a t-shirt.
You can buy a $10 membership card at any participating Muddy Spokes Club state park or call 770-389-7401 or sending an email to email@example.com. Then, visit the 11 state parks in the Muddy Spokes Club and ride the designated bicycle trail at each -- for a total of 68 miles. Some trails are fairly easy, some are moderate and some are strenuous and will give you a challenge. Be sure you are in good health, wear safety gear and take plenty of water along. By law, bicycle helmets are required for anyone under age 16 but it's a good idea for everyone to wear a helmet.
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City of Fountain Valley - Police Department
The Fountain Valley Police Department has been awarded a new traffic safety grant for an anti-DUI program aimed at preventing deaths and injuries on our roadways. Additional enforcement measures to combat impaired driving are coming as a result of a recent $15,430 grant awarded by the California Office of Traffic Safety to Fountain Valley. The Fountain Valley Police Department is dedicated to keeping our streets safe through both enforcement and education.
Chief Daniel S. Llorens said that, "DUI checkpoints remain an important tool to enforce DUI laws and educate the public regarding the danger of impaired driving. When residents see Fountain Valley Police Officers working a checkpoint, they know we are using all the tools in our toolbox to keep drivers safe. "
The special DUI Checkpoint grant is to assist in efforts to reduce the number of persons killed and injured in alcohol and other drug related collisions in the community. The grant activities will specifically target impaired driving offenders as well as educating the public on the dangers of impaired driving through the use of DUI/driver's license checkpoints. When possible, specially trained officers will be available to evaluate those suspected of drug-impaired driving.
Drunk and drugged driving are among America's deadliest crimes. In 2010, 791 people were killed and over 24,000 injured in alcohol and drug-impaired crashes in California. In 2011, Fountain Valley experienced 14 injured persons in these tragic crashes. Crashes involving alcohol drop by an average of 20 percent when well-publicized checkpoints are conducted often enough. Checkpoints have proven to be the most effective of any of the DUI enforcement strategies, while yielding considerable cost savings of $6 for every $1 spent.
"DUI checkpoints have been an essential part of the phenomenal reduction in DUI deaths that we witnessed from 2006 to 2010 in California," said Christopher J. Murphy, Director of the Office of Traffic Safety. "But since the tragedy of DUI accounts for nearly one third of traffic fatalities, Fountain Valley needs the high visibility enforcement and public awareness that this grant will provide."
Funding for this program is from the California Office of Traffic Safety through the National Highway Traffic Safety Administration.
(714) 593-45
FVPD Case Number: December


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After enduring a rare health condition that obstructed her vision, the finish line has never been clearer for Lenoir Community College student Kristen Polito.
During what was supposed to be her final semester last October, she was hit with pseudotumor cerebri, a condition causing the body to produce excessive spinal fluid.
Polito, 21, was diagnosed after her optometrist noticed an abnormality during a vision test.
"It started with my eye doctor," she said. "No matter what size he put up there, I could not read the letters. It was all blurry, and I thought it was just my glasses."
She experienced grueling headaches and her sensitivity to light had noticeably increased, which was the reason for her visit to the doctor.
"When he did some pictures behind my eyes, he realized that I couldn't see," Polito said. "There was so much fluid that they were just swollen."
The Culinary Arts student said the disproportionate fluid running through her body caused her brain to swell and medical doctors later discovered her gallbladder was the problem after a CT scan. The organ was leaking unclean fluid to the rest of the body, so it was removed.
"After I had surgery, everything resolved itself," said Polito, whose driving was impaired as she spent a year suffering from the cerebri, causing her to drop all her on-campus classes.
Today, her vision has returned to the way it was before the condition.
She would have already completed her degree program, but Friday evening, she graduated with 396 other students at LCC.
Nearly 400 Lancers walked the stage, and some received diplomas and certificates instead of, or along with degrees. The commencement was held in the college's gymnasium with Hilda Pinnix-Ragland, the chair of the state's Board of Community Colleges, delivering the event's address.
Pinnix-Ragland, also the vice president of corporate public affairs for Duke Energy, was recognized as one of the Top 100 Influential Women in Corporate America in 2012 by Savoy Magazine.
LCC President Brantley Briley said her speech made the 2013 graduation one of the best ever.
"This is an exciting time of year for our graduates and for the employees at the college," Briley said. "It's a time of year where everyone's hard work is recognized and rewarded."
Student Michelle Griffin was this year's Academic Excellence Award Winner.
Polito earned outstanding grades during her college career, which began at Johnson & Wells University in Charlotte.
"I hated it," she strained out through a light laugh.
She said she disliked the city because it was too busy and she was overloaded with course work at the expensive campus.
"Looking at Lenoir (Community College), the place is perfect — the kitchens and everything," Polito said. "I like the instructors a lot better."
She said LCC culinary instructors — and even her supervisor during her internship — were flexible with her when her condition flourished.
Polito is from New Bern and plans to attend ECU in January after a semester off. She said the support of the school, her husband, Ryland Matthews, and her mom, Rosemarie McCardle lifted her through adversity.
"It was a struggle," said McCardle, who helped her daughter write essays and take online tests when her vision was impaired. "It was not easy seeing her sick and knowing that she was getting frustrated. Right now, it's more of a celebration because she got through everything, she doubled up on her classes, she worked through it, and she got really fantastic grades.
"I couldn't have asked for a better school for her to go to."
McCardle plans to open her own bakery one day and will fight through her fear of the pseudotumor cerebri returning as she moves on to the next phase of her life — which began Friday evening with a walk across a stage in LCC's gym.
Jessika Morgan can be reached at 252-559-1078 or at firstname.lastname@example.com. Follow her on Twitter @JessikaMorgan.
Quick facts about the LenoirCommunity CollegeGraduation 2013
- Student Speaker: Michelle Griffin, Academic Excellence Award Winner
- Commencement Speaker: Hilda Pinnix-Ragland, Chair of the State Board of the N.C. Community College System
- Number of graduates: 397
- LCC awarded: 327 degrees, 35 diplomas and 154 certificates
- President — Brantley Briley


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Business travelers love our hotel's location in Perrysburg, Ohio for its close proximity to companies like Chrysler, First Solar, Rexam and Owens-Illinois. We also feature meeting rooms with U-shaped conference tables and Ballroom for your social events or business functions.
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Hypoparathyroidism Center - Hutchinson, KS
Hutchinson Endocrinologist Doctors for Hypoparathyroidism
Type of Physician: Endocrinologist
What is a Endocrinologist?
A subspecialty certification by the Board of Internal Medicine; practitioners treat disorders of the internal (endocrine) glands such as the thyroid and adrenal glands. Endocrinology also deals with disorders such as diabetes, metabolic and nutritional disorders, pituitary diseases, and menstrual and sexual problems.
Specialty: Endocrinology
Common Name:
Endocrinologist Doctors in Hutchinson *
UK School Med Endocrinology
Via Christi Clinic
Via Christi Clinic
Via Christi Clinic
Via Christi Clinic
Via Christi Clinic
Galichia Medical Group
Galichia Medical Group
Tatpati Medical Group
Mid America Diabetes Associates
Mid America Diabetes Associates
Kansas University Adult Medcn
Kansas University Adult Medcn
Lillian R Harstine MD
Hutchinson, Kansas
Hypoparathyroidism facts*
*Hypoparathyroidism facts by John P. Cunha, DO, FACOEP
Other Related Hypoparathyroidism Articles
Emergency Contact for Hutchinson
Nearby Hutchinson Hospitals *
Hutchinson Regional Med Ctr
Mercy Hospital
Rice County District Hospital
Mcpherson Hospital
Kingman Community Hospital
Newton Medical Center
Via Christi Hospital St Teresa
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The WebMD 'Provider Directory' is provided by WebMD for use by the general public as a quick reference of information about Providers. The Provider Directory is not intended as a tool for verifying the credentials, qualifications, or abilities of any Provider contained therein. Inclusion in the Provider Directory does not imply recommendation or endorsement nor does omission in the Provider Directory imply WebMD disapproval.


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Jumbo Gaff Cards
Item Number: TA1763
Each of these jumbo cards measures 4 1/2" x 7" (11.43cm x 17.78cm) Prices shown are for 1 card
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At a Glance
Why Get Tested?
To help evaluate a pregnant woman's risk of preterm delivery
When to Get Tested?
When you are 22 to 35 weeks pregnant and are having symptoms of premature labor; sometimes if you are at high risk, such as if you have had a previous preterm delivery or have a short cervix
Sample Required?
A cervical or vaginal fluid sample
Test Preparation Needed?
None, but to reduce the chance of a false-positive result, avoid sexual intercourse for 24 hours prior to sample collection and collection should be performed before a physical exam.
The Test Sample
What is being tested?
Fetal fibronectin (fFN) is a glycoprotein that can be used to help predict the short term risk of premature delivery. fFN is produced at the boundary between the amnionic sac (which surrounds the baby) and the lining of the mother's uterus (the decidua) in an area called the uteroplacental (or choriodecidual) junction. Fetal fibronectin is largely confined to this junction and is thought to help maintain the integrity of the boundary. fFN is normally detectable in cervicovaginal fluid during early pregnancy and, in a normal pregnancy, it is no longer detectable after 24 weeks. However, it reappears and is again detectable after about 36 weeks.
According to the American College of Obstetricians and Gynecologists (ACOG), a normal pregnancy is 40 weeks, with a woman going into labor between 37 and 42 weeks. Finding fFN in cervicovaginal fluids after 36 weeks is not unusual as it is often released by the body as it gets ready for childbirth. The elevated fFN found in vaginal fluids early in pregnancy may simply reflect the normal growth and establishment of tissues at the uteroplacental junction, with levels falling when this phase is complete. What is known is that fFN should not be detectible between 22 and 35 weeks of pregnancy. Elevated levels during this period reflect a disturbance at the uteroplacental junction and have been associated with an increased risk of preterm labor and delivery.
How is the sample collected for testing?
A swab is used to take a sample of cervical or vaginal fluid from the posterior portion of the vagina or from the area just outside the opening of the cervix.
NOTE: If undergoing medical tests makes you or someone you care for anxious, embarrassed, or even difficult to manage, you might consider reading one or more of the following articles: Coping with Test Pain, Discomfort, and Anxiety, Tips on Blood Testing, Tips to Help Children through Their Medical Tests, and Tips to Help the Elderly through Their Medical Tests.
Another article, Follow That Sample, provides a glimpse at the collection and processing of a blood sample and throat culture.
Is any test preparation needed to ensure the quality of the sample?
Anything that physically disturbs the cervix or uterus has the potential to elevate fFN levels. Therefore, cervicovaginal fluid samples should be collected before any physical examinations. Lubricants, lotions, soaps, and douches should be avoided. Semen may contain enough fFN to create a positive test result, so sexual intercourse should also be avoided within 24 hours of sample collection.
The Test
Common Questions
Ask a Laboratory Scientist
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This was not an easy step for us to take, as the volunteers on the response team are dedicated to the work they do and are often inspired by the help they can provide. We are actively seeking to expand our capability so that we can again accept and answer all user questions. We will accept and respond to the same limited number of questions tomorrow, but expect to resume the service, 24/7, as soon as possible.
Article Sources
NOTE: This article is based on research that utilizes the sources cited here as well as the collective experience of the Lab Tests Online Editorial Review Board. This article is periodically reviewed by the Editorial Board and may be updated as a result of the review. Any new sources cited will be added to the list and distinguished from the original sources used.
Sources Used in Current Review
Rigby, F. and de Souza, K. (Updated 2012 November 12). Fetal Fibronectin Tests. Medscape Reference [On-line information]. Available online at http://emedicine.medscape.com/article/2035269-overview through http://emedicine.medscape.com. Accessed August 2013.
Artal, R. (Revised 2013 March). Risk Factors for Complications During Pregnancy. Merck Manual for Healthcare Professionals [On-line information]. Available online through http://www.merckmanuals.com. Accessed August 2013.
Grenache, D. (Updated 2012 November). Fetal Lung Maturity - Neonatal Respiratory Distress Syndrome. ARUP Consult [On-line information]. Available online at http://www.arupconsult.com/Topics/FLM.html?client_ID=LTD through http://www.arupconsult.com. Accessed August 2013.
(Reviewed 2012 October). Fetal fibronectin. March of Dimes [On-line information]. Available online at http://www.marchofdimes.com/pregnancy/fetal-fibronectin.aspx through http://www.marchofdimes.com. Accessed August 2013.
Mayo Clinic staff (2012 February 23) High-risk pregnancy: Know what to expect. Mayo Clinic Mayo Medical Laboratories [On-line information]. Available online at http://www.mayoclinic.com/health/high-risk-pregnancy/MY01923/METHOD=print through http://www.mayoclinic.com. Accessed August 2013.
(Reviewed 2013 June) Preterm labor. March of Dimes [On-line information]. Available online at http://www.marchofdimes.com/pregnancy/preterm-labor-and-birth.aspx through http://www.marchofdimes.com. Accessed August 2013.
Pagana, K. D. & Pagana, T. J. (© 2011). Mosby's Diagnostic and Laboratory Test Reference 10th Edition: Mosby, Inc., Saint Louis, MO. Pp 452-453.
Clarke, W., Editor (© 2011). Contemporary Practice in Clinical Chemistry 2nd Edition: AACC Press, Washington, DC. Pp 488-489.
Sources Used in Previous Reviews
Thomas, Clayton L., Editor (1997). Taber's Cyclopedic Medical Dictionary. F.A. Davis Company, Philadelphia, PA [18th Edition].
Pagana, Kathleen D. & Pagana, Timothy J. (2001). Mosby's Diagnostic and Laboratory Test Reference 5th Edition: Mosby, Inc., Saint Louis, MO.
Palkhivala, A.(2002 October 23). AAFP: Foetal Fibronectin Testing May Reduce Need for Transfer to Tertiary Care Centers. Doctor's Guide Global Edition [On-line information]. Available online at http://www.pslgroup.com/dg/221052.htm through http://www.pslgroup.com.
A Diagnostic Test for Accessing the Risk of Preterm Delivery. fFN Professional Home Page, Adeza [On-line information from company]. PDF available for download at http://www.ffntest.com.
Fetal Fibronectin (fFN): A Test for Preterm Delivery. March of Dimes, Professionals and Researchers, Quick Reference and Fact Sheets [On-line information]. Available online at http://www.marchofdimes.com/professionals/681_1149.asp through http://www.marchofdimes.com.
(2000 Spring). Cervical-Vaginal Fetal Fibronectin (fFN) Testing to Predict Preterm Labor & Delivery. University of Washington Dept of Laboratory Medicine Perspectives [Online community newsletter]. PDF available for download at http://depts.washington.edu/labweb/test/pers/perspr00.pdf through http://depts.washington.edu.
High Risk Pregnancy, Preterm Labor. University of Utah Health Sciences Center [On-line information]. Available online at http://www.uuhsc.utah.edu/healthinfo/pediatric/hrpregnant/ptl.htm through http://www.uuhsc.utah.edu.
(2002 April 25, Updated). Fetal Fibronectin for the Prediction of Preterm Labor. Institute for Clinical Systems Improvement, Knowledge Resources Technology Assessment Report [On-line information]. Available online at http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=281 through http://www.icsi.org.
Goldenberg, R. (2002 November). High-Risk Pregnancy Series: An Expert's View, The Management of Preterm labor [On-line information]. Available online through http://www.acog.org/.
(2002 July). FFN, A Test to Aid in the Assessment of Preterm Delivery Risk. Adeza Biomedical Fetal Fibronectin Enzyme Immunoassay and Rapid fFN for the Tli System [On-line information]. PDF available for download at http://www.ffntest.com.
Mark, P. et. Al. (2000 January). ICSI Medical Brief, Fetal Fibronectin for the Prediction of Preterm Labor. ICSI Technology Assessment Report, TA #47 [On-line report]. Available online at http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=281 through http://www.icsi.org.
Von Der Pool, B. (1998 May 15). Preterm Labor: Diagnosis and Treatment. AAFP American Family Physician [On-line Journal]. Available online at http://www.aafp.org/afp/980515ap/vonderp.html through http://www.aafp.org.
Pagana, Kathleen D. & Pagana, Timothy J. (© 2007). Mosby's Diagnostic and Laboratory Test Reference 8th Edition: Mosby, Inc., Saint Louis, MO. Pp 445-446.
Wyatt, S. and Rhoads, S. (2006 September 19). A Primer on Antenatal Testing for Neonatal Nurses: Part 1. Tests Used to Predict Preterm Labor. Medscape from Adv Neonatal Care. 2006;6(4):175-180 [On-line information]. Available online at http://www.medscape.com/viewarticle/543521 through http://www.medscape.com. Accessed on 2/28/07.
(© 2007). Fetal Fibronectin (fFN): A Test for Preterm Delivery. March of Dimes [On-line information]. Available online at http://www.marchofdimes.com/professionals/681_1149.asp through http://www.marchofdimes.com. Accessed on 2/27/07.
(© 2007). What is Preterm Labor. The American College of Obstetricians and Gynecologists (ACOG) [On-line information]. Available online at http://www.acog.org/publications/patient_education/bp087.cfm through http://www.acog.org. Accessed on 3/4/07.
FullTerm, The Fetal Fibronectin Test. ADEZA [On-line information]. Available online at http://www.ffntest.com/html/HCP_US_FullTerm.htm through http://www.ffntest.com. Accessed on 3/3/07.
March of Dimes. Fetal Fibronectin (fFN), A Test for Premature Delivery. Available online at http://www.marchofdimes.com/professionals/14332_1149.asp through http://www.marchofdimes.com. Accessed November 2009.
March of Dimes. About Prematurity, Complications in the Newborn. Available online at http://www.marchofdimes.com/prematurity/index_about_6306.asp through http://www.marchofdimes.com. Accessed November 2009.
American College of Obstetricians and Gynecologists (ACOG). Management of Preterm Labor. ACOG Practice Bulletin, number 43, May 2003 (reaffirmed 2008).
HologicTM. Facts About Fetal Fibronectin Testing.
HologicTM. Frequently Asked Questions: Preterm Birth and Fetal Fibronectic Testing.
Mayo Clinic. Fetal Fibronectic Test. How you prepare. Available online at http://www.mayoclinic.com/health/fetal-fibronectin/MY00128/DSECTION=how-you-prepare through http://www.mayoclinic.com. Accessed November 2009.
Mayo Clinic. Preterm labor: Take prevention seriously. Available online at http://www.mayoclinic.com/health/preterm-labor/PR00118 through http://www.mayoclinic.com. Accessed November 2009.
Clinical Laboratory News. Fetal Fibronectin October 2008: Volume 34, Number 10. Available online at http://www.aacc.org/publications/cln/2008/october/Pages/series_1008.aspx through http://www.aacc.org.


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February 18, 2013
Lawrence Russell Gabriel (Larry) died on Saturday (Nov. 26, 2011) at Wooster Community Hospital.
Larry was born on April 8, 1924 in Marysville at the home of his parents, Fred and Alma (Russell) Gabriel. He graduated from Marysville High School in 1942. He enlisted in the U.S. Army and served until 1946. Larry received his B.A. from the College of Wooster and an M.B.A. from the University of Michigan. He and Alice Louise Hudson of Cuyahoga Falls married on Feb. 25, 1950. They shared 60 happy years together. Alice preceded him in death in January 2010. Larry and Alice moved to Wooster in the fall of 1955 when Larry began working at Rubbermaid, where he continued working until his retirement 35 years later. He was an active member of the First Presbyterian Church of Wooster, where he was an elder, deacon and trustee and served on many committees. He was also very involved in a variety of civic organizations in Wooster.
He is survived by his sister, Alfreda Campbell of Wooster; his son, Frederick (Rick) of Wayne County; his son, Russell, and grandsons, Elijah Lincoln Gabriel and Fredrick Davis Gabriel all of Athens, Ga.; many loving nieces and nephews; and a large community of extended family and friends. All will miss him dearly.
Larry is predeceased by his sister, Catherine May Kipp.
A memorial service and a reception following will be held at 2 p.m. Saturday, Dec. 17, at the First Presbyterian Church in Wooster. All are welcome to attend.
In lieu of flowers contributions may be sent to People to People or the Viola Starzman Free Clinic in Wooster.


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Global Adaptation Institute (GAIN)
The Global Adaptation Institute (GAIN) is a non-profit organization guided by a vision of building resilience to climate change and other global forces as a key component to sustainable development. Our mission is to enhance the world's understanding of the urgency for adaptation to climate change and other global forces and the support needed through private and public investments for developing countries.
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© 2014 United Nations Framework Convention on Climate Change


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The P-32 is a 7 round double action only semi-automatic, locked breech pistol, chambered for the .32 Auto cartridge. Thanks to its locking dynamics and superior ergonometry, perceived recoil and practical accuracy are comparable to much larger guns. The P-32 is mainly intended for plainclothes police officers as a secondary weapon, or for concealed carry by licensed citizens. The small grip size and light trigger pull make the P-32 ideal for female shooters.
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Type : PistolAction : Double Action OnlyCaliber : 32 Automatic Colt Pistol (ACP)Barrel Length : 2.68"Capacity : 7 + 1Safety : Hammer blockGrips : PolymerSights : FixedWeight : 6.6 oz (Empty)Finish : Hard Chrome
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Become a Member!
Support the Museum by becoming a member today!
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Seizing the initiative following his astounding victory at Chancellorsville, Robert E. Lee gathered all available Confederate forces for an invasion of the North. The Department of North Carolina, commanded by Lee's former lieutenant, D.H. Hill, was expanded to include Virginia south of the James River. Hill deals with the shocking personal loss of his brother-in-law, Stonewall Jackson, and the loss of his best troops to Lee's Army, now 200 miles away, when Richmond is threatened by Federal attacks. Panicky citizens and a nervous War Department ecstatically acclaim Hill and his men, who marched from Petersburg to defend the Capital on July 4, 1863, a day that otherwise, brought disastrous news from Vicksburg and Gettysburg. Based on actual letters, Doug & Terri Batson give first person impressions of D.H. and his wife, Isabella, for this unsung Civil War Sesquicentennial event.
Richmond native Douglas Batson is Defense Department geographer in Northern Virginia. He holds a Master of Education from Boston University and Bachelor's degrees in history and geography. Retired from the U.S. Army Reserve, he was awarded the Bronze Star Medal during Operation DESERT STORM. His Living History website is at www.dhhill.org.
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All of the rooms have International programming, Direct dial access telephone, Private deluxe bathrooms, spacious lounging area, irresistibly comfortable two double beds or one king size bed and private balconies (balconies subject to availability).
All the amenities you expect from the Solaris hotels are at hand. Alarm clocks, voicemail, hairdryers, ironing boards and cribs (cribs upon request).