Medicine and Health Sciences Commons^™

Understanding And Use Of Food Labeling Systems Among Whites And Latinos In The United States And Among Mexicans: Results From The International Food Policy Study, 2017, Claudia Nieto, Alejandra Jauregui, Alejandra Contreras-Manzano, Edna Arillo-Santillan, Simon Barquera, Christine M. White, David Hammond, Jim Thrasher

Faculty Publications

Background Obesity and chronic diseases could be prevented through improved diet. Most governments require at least one type of food labeling system on packaged foods to communicate nutrition information and promote healthy eating. This study evaluated adult consumer understanding and use of nutrition labeling systems in the US and Mexico, the most obese countries in the world.

Methods Adults from online consumer panels in the US (Whites n = 2959; Latinos n = 667) and in Mexico (n = 3533) were shown five food labeling systems: 1. Nutrition Facts Table (NFT) that shows nutrients of concern per serving; 2. Guideline …

Reliability Of The American Community Survey Estimates Of Risk-Adjusted Readmission Rankings For Hospitals Before And After Peer Group Stratification, Nathaniel Bell, Ana Lòpez-De Fede, Bo Cai

Faculty Publications

Importance Since the transition to the American Community Survey, data uncertainty has complicated its use for policy making and research, despite the ongoing need to identify disparities in health care outcomes. The US Centers for Medicare & Medicaid Services’ new, stratified payment adjustment method for its Hospital Readmissions Reduction Program may be able to reduce the reliance on data linkages to socioeconomic survey estimates.

Objective To determine whether there are differences in the reliability of socioeconomically risk-adjusted hospital readmission rates among hospitals that serve a disproportionate share of low-income populations after stratifying hospitals into peer group–based classification groups.

Design, Setting, …

Characterizing Cdk8/19 Inhibitors Through A Nfκb-Dependent Cell-Based Assay, Jng Li, Donald C. Porter, Eugenia Broude, Igor Roninson, Mengqian Chen

Faculty Publications

Cell-based assays for CDK8/19 inhibition are not easily defined, since there are no known cellular functions unique to these kinases. To solve this problem, we generated derivatives of 293 cells with CRISPR knockout of one or both of CDK8 and CDK19. Double knockout (dKO) of CDK8 and CDK19 together (but not individually) decreased the induction of transcription by NFκB (a CDK8/19-potentiated transcription factor) and abrogated the effect of CDK8/19 inhibitors on such induction. We generated wild type (WT) and dKO cell lines expressing luciferase from an NFκB-dependent promoter. Inhibitors selective for CDK8/19 over other CDKs decreased TNFα-induced luciferase expression in …

Using The Clinical Frailty Scale To Predict The Length Of Stay In Otolaryngology Unit In Taiwan, Wei-Kang Tung, Hsiang-Chin Hung, Wei-Chen Tung

Faculty Publications

Frailty was a common syndrome in geriatric clinic and general internal medical wards. Some authors had identified the Clinical Frailty Scale (CFS) as a predictor of length of stay in the acute medicine unit. However, the role of the Clinical Frailty Scale in the length of stay in otolaryngology unit had not been well studied. The objective of this study was to find out the correlation of the CFS in elderly patients admitted to otolaryngology unit and their length of stay. A retrospective medical chart review of 203 elderly patients admitted to the otolaryngology ward from January, 2014 to December, …

Does Family Communication Matter? Exploring Knowledge Of Breast Cancer Genetics In Cancer Families, Deborah O. Himes Phd, Aprn-Bc, Sarah H. Davis, Jane H. Lassetter, Neil E. Peterson, Margaret F. Clayton, Wendy Birmingham Phd, Anita Y. Kinney

Faculty Publications

Knowledge of breast cancer genetics is critical for those at increased hereditary risk who must make decisions about breast cancer screening options. This descriptive study explored theory-based relationships among cognitive and emotional variables related to knowledge of breast cancer genetics in cancer families. Participants included first-degree relatives of women with breast cancer who had received genetic counseling and testing. Study participants themselves did not have breast cancer and had not received genetic counseling or testing. Data were collected by telephone interviews and surveys. Variables analyzed included numeracy, health literacy, cancer-related distress, age, education, and the reported amount of information shared …

Addressing The Surgical Deficit: A Global Imperative For Plastic And Reconstructive Surgeons, Rachel W. Davis, Walter D. Johnson, Larry H. Hollier

Faculty Publications

Despite poor access to quality surgical and anesthesia care for the majority of the world's people, with greatest impact on low- and middle-income countries, surgery has only recently begun to gain acceptance as a necessary component of global health. As a leader in global surgical funding, the field of Plastic and Reconstructive Surgery is uniquely positioned to influence change in global policy and financial support. For improvements in surgical access and outcomes worldwide, investment in surgical systems, commitment to national surgery, obstetric, and anesthesia planning, and continued evaluation and improvement of care delivery should be pursued.

Associations Among Neighborhood Socioeconomic Deprivation, Physical Activity Facilities, And Physical Activity In Youth During The Transition From Childhood To Adolescence, Morgan N. Clennin, Min Lian, Natalie Colabianchi, Andrew Kaczynski, Marsha Dowda, Russell R. Pate

Faculty Publications

Background: This study aims to examine the longitudinal association of neighborhood socioeconomic deprivation (SED) with physical activity in youth during the transition from elementary to middle school, and to determine if access to physical activity facilities moderates this relationship. Methods: Data were obtained from the Transitions and Activity Changes in Kids (TRACK) study, which was a multilevel, longitudinal study designed to identify the factors that influence changes in physical activity as youth transition from elementary to middle school. The analytic sample for the current study included 660 youth with complete data in grades 5 (baseline) and 7 (follow-up). A repeated …

If We Don’T Look, We Won’T See: Measuring Language Development To Inform Literacy Instruction, Suzanne M. Adlof, Tiffany P. Hogan

Faculty Publications

Oral language abilities enable children to learn to read, and they predict future academic achievement and life outcomes. However, children with language impairment frequently go unidentified because schools do not systematically measure oral language development. Given that identification paves the way for treatment, schools should increase attention to oral language development, particularly within response to intervention (RTI) frameworks, which aim to prevent learning disabilities by identifying and intervening at early stages. Formal schooling should address language comprehension (in addition to word reading) to ensure an adequate foundation for future reading comprehension. In support, we overview the developmental relations between oral …

The Household Water Insecurity Experiences (Hwise) Scale: Development And Validation Of A Household Water Insecurity Measure For Low-Income And Middle-Income Countries, Sera L. Young, Godfred O. Boateng, Zeina Jamaluddine, Joshua D. Miller, Edward A. Frongillo, Torsten B. Neilands, Shaleans M. Collins, Amber Wutich, Wendy E. Jepson, Justin Stoler

Faculty Publications

Objective Progress towards equitable and sufficient water has primarily been measured by population-level data on water availability. However, higher-resolution measures of water accessibility, adequacy, reliability and safety (ie, water insecurity) are needed to understand how problems with water impact health and well-being. Therefore, we developed the Household Water InSecurity Experiences (HWISE) Scale to measure household water insecurity in an equivalent way across disparate cultural and ecological settings.

Methods Cross-sectional surveys were implemented in 8127 households across 28 sites in 23 low-income and middle-income countries. Data collected included 34 items on water insecurity in the prior month; socio-demographics; water acquisition, use …

The Household Water Insecurity Experiences (Hwise) Scale: Development And Validation Of A Household Water Insecurity Measure For Low-Income And Middle-Income Countries, Sera L. Young, Godfred O. Boateng, Zeina Jamaluddine, Joshua D. Miller, Edward A. Frongillo Jr., Torsten B. Neilands, Shelean M. Collins, Amber Wutich, Wendy E. Jepson, Justin Stoler, On Behalf Of The Hwise Research Coordination Network

Faculty Publications

Objective

Progress towards equitable and sufficient water has primarily been measured by population-level data on water availability. However, higher-resolution measures of water accessibility, adequacy, reliability and safety (ie, water insecurity) are needed to understand how problems with water impact health and well-being. Therefore, we developed the Household Water InSecurity Experiences (HWISE) Scale to measure household water insecurity in an equivalent way across disparate cultural and ecological settings.

Methods

Cross-sectional surveys were implemented in 8127 households across 28 sites in 23 low-income and middle-income countries. Data collected included 34 items on water insecurity in the prior month; sociodemographics; water acquisition, use …

Penicillin Allergy Assessment And Skin Testing In The Outpatient Setting, Wesley D. Kufel, Julie Ann Justo, P. Brandon Bookstaver, Lisa M. Avery

Faculty Publications

Penicillin allergies are among of the most commonly reported allergies, yet only 10% of these patients are truly allergic. This leads to potential inadvertent negative consequences for patients and makes treatment decisions challenging for clinicians. Thus, allergy assessment and penicillin skin testing (PST) are important management strategies to reconcile and clarify labeled penicillin allergies. While PST is more common in the inpatient setting where the results will immediately impact antibiotic management, this process is becoming of increasing importance in the outpatient setting. PST in the outpatient setting allows clinicians to proactively de-label and educate patients accordingly so beta-lactam antibiotics may …

Exploration Of Factors Associated With Perceived Barriers To Cervical Cancer Screening Among Chinese American Women, Wei-Chen Tung, Minggen Lu, Michelle Granner, Jiani Mcdonough, Susan Ervin

Faculty Publications

This study explored factors associated with perceived barriers to Pap smear testing among Chinese American women (CAW). A total of 121 CAW, ages 21–65, living in California and Nevada completed a self-report questionnaire. Data included demographics, prior screening behavior, risk factors, and perceived barriers to screening. Logistic regression models revealed that participants with less education, and who have never been screened were more likely to report (I) worry about getting a Pap smear, (II) expense of a Pap smear, and (III) not knowing where to get a Pap smear. Partner’s resistance to the women’s participation in screening was another barrier …

Smoke-Free Policies And Smoking Cessation In The United States, 2003–2015, Andrea R. Titus, Lucie Kalousova, Rafael Meza, David T. Levy, Jim Thrasher, Michael R. Elliott, Paula M. Lantz, Nancy L. Fleischer

Faculty Publications

(1) Background: Smoking restrictions have been shown to be associated with reduced smoking, but there are a number of gaps in the literature surrounding the relationship between smoke-free policies and cessation, including the extent to which this association may be modified by sociodemographic characteristics. (2) Methods: We analyzed data from the Tobacco Use Supplement to the Current Population Survey, 2003–2015, to explore whether multiple measures of smoking restrictions were associated with cessation across population subgroups. We examined area-based measures of exposure to smoke-free laws, as well as self-reported exposure to workplace smoke-free policies. We used age-stratified, fixed effects logistic regression …

Direct Measurement Of Performance: A New Era In Antimicrobial Stewardship, Majdi N. Al-Hasan, Hana Rac Winders, P. Brandon Bookstaver, Julie Ann Justo

Faculty Publications

Penicillin allergies are among of the most commonly reported allergies, yet only 10% of these patients are truly allergic. This leads to potential inadvertent negative consequences for patients and makes treatment decisions challenging for clinicians. Thus, allergy assessment and penicillin skin testing (PST) are important management strategies to reconcile and clarify labeled penicillin allergies. While PST is more common in the inpatient setting where the results will immediately impact antibiotic management, this process is becoming of increasing importance in the outpatient setting. PST in the outpatient setting allows clinicians to proactively de-label and educate patients accordingly so beta-lactam antibiotics may …

Penicillin Allergy Skin Testing In The Inpatient Setting, Julie Ann Justo, Wesley D. Kufel, Lisa Avery, P. Brandon Bookstaver

Faculty Publications

The consequences of a documented penicillin allergy in the medical record are especially troublesome in acutely ill, hospitalized patients. A penicillin allergy label may lead to alternative or second line therapies resulting in adverse drug events, negative clinical outcomes and increased costs. Reconciling penicillin allergies is a necessity to facilitate early, optimal therapy and is a shared responsibility among the healthcare team. Penicillin skin testing (PST) has been utilized successfully in hospitalized patients to de-label erroneous penicillin allergies and optimize antibiotic therapy. This targeted review aims to discuss the practical development and implementation of PST in the inpatient setting. This …

Would You Test For 5000 Shillings? Hiv Risk And Willingness To Accept Hiv Testing In Tanzania, Jan Ostermann, Derek S. Brown, Axel Mühlbacher, Bernard Njau, Nathan Thielman

Faculty Publications

Objectives: Despite substantial public health efforts to increase HIV testing, testing rates have plateaued in many countries and rates of repeat testing for those with ongoing risk are low. To inform policies aimed at increasing uptake of HIV testing, we identified characteristics associated with individuals’ willingness-to-accept (WTA) an HIV test in a general population sample and among two high-risk populations in Moshi, Tanzania.

Methods: In total, 721 individuals, including randomly selected community members (N = 402), female barworkers (N = 135), and male Kilimanjaro mountain porters (N = 184), were asked in a double-bounded contingent valuation format if they would …

Odds Of Acute Kidney Injury In Patients Receiving Dipeptidyl Peptidase 4 Inhibitors: A National Cohort Study Within The Department Of Veterans Affairs, Shawn Scott Sutton, Joseph Maggnoli, Tammy H. Cummings, James W. Hardin

Faculty Publications

Preclinical and clinical data of dipeptidyl peptidase 4 (DPP‐4) inhibitors have demonstrated discordant data regarding acute kidney injury (AKI). Therefore, we aimed to evaluate the association between DPP‐4 use and AKI. This cohort study utilized data from the Department of Veterans Affairs evaluating patients diagnosed with type 2 (T2) diabetes with a DPP‐4 inhibitor and compared with nondiabetic and diabetic patients. The primary end point is the development of AKI, and statistical analyses were performed to examine the association. DPP‐4 use is associated with a lower odds of AKI compared with diabetics (adjusted odds ratio (OR) = 0.39; 95% confidence …

A Novel Eye Tracking Paradigm For Indexing Social Avoidance-Related Behavior In Fragile X Syndrome, Jessica Klusek, Carly Moser, Joseph Schmidt, Leonard Abbeduto, Jane E. Roberts

Faculty Publications

Fragile X syndrome (FXS) is characterized by hallmark features of gaze avoidance, reduced social approach, and social anxiety. The development of therapeutics to manage these symptoms has been hindered, in part, by the lack of sensitive outcome measures. This study investigated the utility of a novel eye tracking paradigm for indexing social avoidance-related phenotypes. Adolescent/young adult-aged males with FXS (n=24) and typical development (n=23) participated in the study. Participants viewed faces displaying direct or averted gaze and the first fixation duration on the eyes was recorded as an index of initial stimulus registration. Fixation durations did …

Designing High-Quality Implementation Research: Development, Application, Feasibility And Preliminary Evaluation Of The Implementation Science Research Development (Impres) Tool And Guide, Louise Hull, Lucy Goulding, Zarnie Khadjesari, Rachel E. Davis, Andy Healey, Ioannis Bakolis, Nick Sevdalis

Faculty Publications

BACKGROUND: Designing implementation research can be a complex and daunting task, especially for applied health researchers who have not received specialist training in implementation science. We developed the Implementation Science Research Development (ImpRes) tool and supplementary guide to address this challenge and provide researchers with a systematic approach to designing implementation research. METHODS: A multi-method and multi-stage approach was employed. An international, multidisciplinary expert panel engaged in an iterative brainstorming and consensus-building process to generate core domains of the ImpRes tool, representing core implementation science principles and concepts that researchers should consider when designing implementation research. Simultaneously, an iterative process …

Dietary Inflammatory Index And Non-Communicable Disease Risk: A Narrative Review, Catherine M. Phillips, Ling-Wei Chen, Barbara Heude, Jonathan Y. Bernard, Nicholas C. Harvey, Liesbeth Duijts, Sara M. Mensink-Bout, Kinga Polanska, Giulia Mancano, Matthew Suderman, Nitin Shivappa, James R. Hébert

Faculty Publications

There are over 1,000,000 publications on diet and health and over 480,000 references on inflammation in the National Library of Medicine database. In addition, there have now been over 30,000 peer-reviewed articles published on the relationship between diet, inflammation, and health outcomes. Based on this voluminous literature, it is now recognized that low-grade, chronic systemic inflammation is associated with most non-communicable diseases (NCDs), including diabetes, obesity, cardiovascular disease, cancers, respiratory and musculoskeletal disorders, as well as impaired neurodevelopment and adverse mental health outcomes. Dietary components modulate inflammatory status. In recent years, the Dietary Inflammatory Index (DII^®), a literature-derived …

Increased Dietary Inflammatory Index Is Associated With Schizophrenia: Results Of A Case-Control Study From Bahrain, Haitham Jahrami, Mo'ez Al-Islam Faris, Hadeel Ali Ghazzawi, Zahra Saif, Layla Habib, Nitin Shivappa, James R. Hebert

Faculty Publications

Background: Several studies have indicated that chronic low-grade inflammation is associated with the development of schizophrenia. Given the role of diet in modulating inflammatory markers, excessive caloric intake and increased consumption of pro-inflammatory components such as calorie-dense, nutrient-sparse foods may contribute toward increased rates of schizophrenia. This study aimed to examine the association between dietary inflammation, as measured by the dietary inflammatory index (DII (R)), and schizophrenia. Methods: A total of 120 cases attending the out-patient department in the Psychiatric Hospital/Bahrain were recruited, along with 120 healthy controls matched on age and sex. The energy-adjusted DII (E-DII) was computed based …

Increased Dietary Inflammatory Index Is Associated With Schizophrenia: Results Of A Case–Control Study From Bahrain, Haitham Jahrami, Moez Al-Islam Faris, Hadeel Ghazzawi, Zahra Saif, Layla Habib, Nitin Shivappa, James R. Hébert

Faculty Publications

Background: Several studies have indicated that chronic low-grade inflammation is associated with the development of schizophrenia. Given the role of diet in modulating inflammatory markers, excessive caloric intake and increased consumption of pro-inflammatory components such as calorie-dense, nutrient-sparse foods may contribute toward increased rates of schizophrenia. This study aimed to examine the association between dietary inflammation, as measured by the dietary inflammatory index (DII^®), and schizophrenia. Methods: A total of 120 cases attending the out-patient department in the Psychiatric Hospital/Bahrain were recruited, along with 120 healthy controls matched on age and sex. The energy-adjusted DII (E-DII) was computed …

Information Diffusion And Social Norms Are Associated With Infant And Young Child Feeding Practices In Bangladesh, Phuong H. Nguyen, Edward A. Frongillo Jr., Sunny S. Kim, Amanda A. Zongrone, Amir Jilani, Lan Mai Tran, Tina Sanghvi, Purnima Menon

Faculty Publications

Background

Interaction within mothers’ social networks can theoretically diffuse messages from interventions and campaigns into norms and practices for infant and young child feeding (IYCF).

Objectives

We hypothesized that mothers’ social networks, diffusion of information, and social norms differed in intensive [intensive interpersonal counseling (IPC), community mobilization (CM), and mass media (MM)] compared with nonintensive (standard IPC and less-intensive CM and MM) intervention areas, were associated with IYCF practices, and partly explained practice improvement.

Methods

We conducted household surveys at endline in 2014 and follow-up in 2016 (n = ∼2000 each round). We used multiple regression to test differences …

Higher Pro-Inflammatory Dietary Score Is Associated With Higher Hyperuricemia Risk: Results From The Case-Controlled Korean Genome And Epidemiology Study_Cardiovascular Disease Association Study, Hye Sun Kim, Minji Kwon, Yi Hyun Lee, Nitin Shivappa, James R. Hebert, Cheongmin Sohn, Woori Na, Mi Kyung Kim

Faculty Publications

In previous studies, the elevated dietary inflammatory index (DII^®) scores have been consistently associated with several chronic diseases. However, the relationship with hyperuricemia remains unknown. The aim of this study was to determine if the DII is associated with hyperuricemia risk. The study included 13,701 participants (men 5102; women 8599) in a large-scale cross-sectional study in South Korea. A validated semi-quantitative food frequency questionnaire (SQFFQ) was used to measure dietary intake, and blood samples were obtained to determine hyperuricemia. As the DII score increased, the hyperuricemia risk increased among women (OR 1.35, 95% CI 1.03–1.77, p trend = …

Identifying Cancers For Cdk8/19 Inhibitor Therapy, Igor Roninson, Balázs Győrffy, Zachary T. Mack, Alexander A. Shtil, Michael S. Shtutman, Mengqian Chen, Eugenia Broude

Faculty Publications

CDK8 and CDK19 Mediator kinases are transcriptional co-regulators implicated in several types of cancer. Small-molecule CDK8/19 inhibitors have recently entered or are entering clinical trials, starting with breast cancer and acute myeloid leukemia (AML). To identify other cancers where these novel drugs may provide benefit, we queried genomic and transcriptomic databases for potential impact of CDK8, CDK19, or their binding partner CCNC. sgRNA analysis of a panel of tumor cell lines showed that most tumor types represented in the panel, except for some central nervous system tumors, were not dependent on these genes. In contrast, analysis of clinical samples for …

Dietary Inflammatory Index And Its Relationship With Cervical Carcinogenesis Risk In Korean Women: A Case-Control Study, Sundara Raj Sreeja, Hyun Yi Lee, Minji Kwon, Nitin Shivappa, James R. Hébert, Mi Kyung Kim

Faculty Publications

Several studies have reported that diet’s inflammatory potential is related to chronic diseases such as cancer, but its relationship with cervical cancer risk has not been studied yet. The aim of this study was to investigate the association between Dietary Inflammatory Index (DII^®) and cervical cancer risk among Korean women. This study consisted of 764 cases with cervical intraepithelial neoplasia (CIN)1, 2, 3, or cervical cancer, and 729 controls from six gynecologic oncology clinics in South Korea. The DII was computed using a validated semiquantitative Food Frequency Questionnaire (FFQ). Odds ratios and 95% CI were calculated using multinomial …

Cryolipolysis: A Guide For Primary Care Practitioners, Miryam Harper, Jane H. Lassetter

Faculty Publications

A desire for the ideal body image has influenced the development of a nonsurgical body-shaping procedure known as cryolipolysis. The purpose of this clinical feature is to inform nurse practitioners about the risks and benefits of cryolipolysis so they can educate their patients. Cryolipolysis is a safe, effective method of reducing small areas of unwanted fat. Adverse effects are minimal and include pain, redness, bruising, and swelling. Results are seen within 12 weeks, but long-term effects are unknown. There are contraindications, and it is relatively expensive; however, it may be a safer option than invasive surgery.

Behavior Change Interventions Delivered Through Interpersonal Communication, Agricultural Activities, Community Mobilization, And Mass Media Increase Complementary Feeding Practices And Reduce Child Stunting In Ethiopia, Sunny S. Kim, Phuong Hong Nguyen, Yisehac Yohannes, Yewelsew Abebe, Manisha Tharaney, Elizabeth Drummond, Edward A. Frongillo Jr., Marie T. Ruel, Purnima Menon

Faculty Publications

BACKGROUND: Appropriate infant and young child feeding practices are critical for optimal child growth and development, but in Ethiopia, complementary feeding (CF) practices are very poor. Alive & Thrive (A&T) provided intensive behavior change interventions through 4 platforms: interpersonal communication (IPC), nutrition-sensitive agricultural activities (AG), community mobilization (CM), and mass media (MM).

OBJECTIVES: The aim of this study was to evaluate the impact of A&T intensive compared with nonintensive interventions (standard nutrition counseling and agricultural extension service and less intensive CM and MM) on CF practices and knowledge and child anthropometric outcomes.

METHODS: We used a cluster-randomized …

Deep Learning-Based Structure-Activity Relationship Modeling For Multi-Category Toxicity Classification: A Case Study Of 10k Tox21 Chemicals With High-Throughput Cell-Based Androgen Receptor Bioassay Data, Gabriel Idakwo, Sundar Thangapandian, Joseph Luttrell Iv, Zhaoxian Zhou, Chaoyang Zhang, Ping Gong

Faculty Publications

Deep learning (DL) has attracted the attention of computational toxicologists as it offers a potentially greater power for in silico predictive toxicology than existing shallow learning algorithms. However, contradicting reports have been documented. To further explore the advantages of DL over shallow learning, we conducted this case study using two cell-based androgen receptor (AR) activity datasets with 10K chemicals generated from the Tox21 program. A nested double-loop cross-validation approach was adopted along with a stratified sampling strategy for partitioning chemicals of multiple AR activity classes (i.e., agonist, antagonist, inactive, and inconclusive) at the same distribution rates amongst the training, validation …

A Cross Sectional Study Of Medical Students’ Perception Of Their Educational Environment In Ghana, Temitope Ade-Oshifogun, Jean Amost Cadet, Jochebed B. Ade-Oshifogun

Faculty Publications

Background: The quality of medical education is affected by many factors, one of which is the educational environment of medical education. However, there is paucity of studies addressing the educational environment from African medical schools. The aim of this study was to determine the clinical year students’ perceptions of their educational environment at a medical school in Ghana. This was done with the goal of identifying factors that may impact positive changes in the school. Methods: A cross-sectional study was undertaken using the DREEM questionnaire. The questionnaire was administered to students in clinical years 1, 2, & 3 at the …