United States

Background:  Traumatic brain injury (TBI) is one of the major public health issues that is being faced by healthcare professionals. CDC has reported a burden of 223,1135 TBI-related hospitalizations in 2019 with another 64,362 deaths reported due to TBI in 2020 (CDC 2023). TBI is classified into different categories (mild, moderate, and severe) in accordance with the symptoms. Research has shown that TBI affects the cognitive domain of the brain along with mood and neurological symptoms. The pathophysiology is not very well understood and as such no treatment options have been effective up to date. Some postmortem studies have indicated accumulation of beta-amyloid and taupathy in TBI similar to AD. Hyperphosphorylation of tau proteins and decreased lysis of APP is hypothesized to be causing this accumulation (Leeds et al 2014; Shim and Stuzmann 2016). The role of medications that can help with the reversal or slowing of these disease patterns cannot be underemphasized and one such medication is Lithium. Lithium is an indirect GSK-3 inhibitor and several studies in rodents have shown it to be effective in improving symptoms of anxiety, depression, and cognitive symptoms associated with TBI as it is seen that GSK3 beta pathway is activated in TBI. One study showed lithium administration at 15 minutes and once daily for 2 weeks decreased lesion size, slowed the death of neurons, and inhibited the ongoing inflammatory processes (Shim and Stutzmann 2016; Matteo et al; Dell’Osso 2016; Fenshan et al 2013; Zhu et al 2010). The neuroprotective effects of lithium are demonstrated in other rodent studies (for Parkinson’s disease) where improved behavioral test performance was seen along with a decrease in aggregated alpha-synuclein. These effects were also appreciated for rodents who had TBI and Alzheimer’s Disease by decreasing pro-inflammatory interleukin 1B, reduced depressive behavior, helps increase dopaminergic receptors, decreased APP and neurofibrillary tangles respectively (Matteo et al 2021; Haupt et al 2021; Ciftci et al 2020; Carlson &amp; Dixon; Carlson et al, 2017; Yu et al 2012). 



Method:  Pubmed, SCOPUS and Web of Science literature databases were screened and filtered by using search terms, inclusion/exclusion criteria with articles/trials from 2010 to date. These gave us a result of about 221 citations from the databases. We further reviewed these citations and after careful review a total of 16 papers were reviewed for this abstract. 



Results: Although research is sparse in terms of Lithium use and TBI, data clearly shows that it can have neuroprotective effects that can be useful for patients with TBI. The mechanism of action of lithium including the reduction of neuroinflammation, indirect GSK3 inhibition and increase in dopaminergic receptors co-relate with possible insults that are seen in TBI. 



Conclusion: Further research is needed in the future on humans who have suffered from TBI and the emergent use of lithium in these patients. The mechanism of action of lithium can explain the benefits that it may provide to patients with TBI. The goal in the future could be to possibly help in formulating a treatment protocol for patients have had a TBI.

AMA Research Challenge 2023

Mysterious Role of Lithium in the treatment of traumatic brain injury - a new insight

Background:  Traumatic brain injury (TBI) is one of the major public health issues that is being faced by healthcare professionals. CDC has reported a burden of 223,1135 TBI-related hospitalizations in 2019 with another 64,362 deaths reported due to TBI in 2020 (CDC 2023). TBI is classified into different categories (mild, moderate, and severe) in accordance with the symptoms. Research has shown that TBI affects the cognitive domain of the brain along with mood and neurological symptoms. The pathophysiology is not very well understood and as such no treatment options have been effective up to date. Some postmortem studies have indicated accumulation of beta-amyloid and taupathy in TBI similar to AD. Hyperphosphorylation of tau proteins and decreased lysis of APP is hypothesized to be causing this accumulation (Leeds et al 2014; Shim and Stuzmann 2016). The role of medications that can help with the reversal or slowing of these disease patterns cannot be underemphasized and one such medication is Lithium. Lithium is an indirect GSK-3 inhibitor and several studies in rodents have shown it to be effective in improving symptoms of anxiety, depression, and cognitive symptoms associated with TBI as it is seen that GSK3 beta pathway is activated in TBI. One study showed lithium administration at 15 minutes and once daily for 2 weeks decreased lesion size, slowed the death of neurons, and inhibited the ongoing inflammatory processes (Shim and Stutzmann 2016; Matteo et al; Dell’Osso 2016; Fenshan et al 2013; Zhu et al 2010). The neuroprotective effects of lithium are demonstrated in other rodent studies (for Parkinson’s disease) where improved behavioral test performance was seen along with a decrease in aggregated alpha-synuclein. These effects were also appreciated for rodents who had TBI and Alzheimer’s Disease by decreasing pro-inflammatory interleukin 1B, reduced depressive behavior, helps increase dopaminergic receptors, decreased APP and neurofibrillary tangles respectively (Matteo et al 2021; Haupt et al 2021; Ciftci et al 2020; Carlson & Dixon; Carlson et al, 2017; Yu et al 2012). 



Method:  Pubmed, SCOPUS and Web of Science literature databases were screened and filtered by using search terms, inclusion/exclusion criteria with articles/trials from 2010 to date. These gave us a result of about 221 citations from the databases. We further reviewed these citations and after careful review a total of 16 papers were reviewed for this abstract. 



Results: Although research is sparse in terms of Lithium use and TBI, data clearly shows that it can have neuroprotective effects that can be useful for patients with TBI. The mechanism of action of lithium including the reduction of neuroinflammation, indirect GSK3 inhibition and increase in dopaminergic receptors co-relate with possible insults that are seen in TBI. 



Conclusion: Further research is needed in the future on humans who have suffered from TBI and the emergent use of lithium in these patients. The mechanism of action of lithium can explain the benefits that it may provide to patients with TBI. The goal in the future could be to possibly help in formulating a treatment protocol for patients have had a TBI.

poster

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Background
• To assess knowledge regarding MDI and its technique amongst healthcare
personnel and to understand its importance.
• To spread awareness regarding the same via educational tools
• To compare the understanding of the technique before and after the use of
educational tools.
Methods
A study group of 213 participants consisting of residents from the
departments of internal medicine (48), pediatrics (36), respiratory medicine
(8), community medicine (11) and staff nurses (110) of all departments were
selected as these acquire most of the cases related to the usage MDI. They
were provided with educational tools. A comparison was made in their
knowledge about the technique of MDI before and after the use of education
tools using a pre-validated questionnaire and the results were obtained in
terms of the mean scores.
Results
The mean score attained by residents of the internal medicine department
was 6.5/16 (standard deviation (S.D)-2.44) in the pre-test and 12.82/16 (S.D-
2.61) in the post-test with an improvement of 6.32 marks (t-value-10.00) and
a p-value of 0.0001. The residents in the pediatrics department had a mean
score of 5.76/16 (S.D-2.36) in the pre-test and 12.36/16(S.D-3.47) in the post
test with an improvement of 6.60 (t-value-10.22) and a p-value of 0.0001. The residents in respiratory medicine had a mean score of 6.33/16(S.D-2.87) in the pre-test and 13.66/16(S.D-2.42) in the post-test with an improvement of 7.33 marks(t-value-4.82) and a p-value of 0.005. The residents in the community medicine department had a mean score of 3.90/16 (S.D-1.37) in the pre-test and 10.09/16 (S.D-3.08) in the post-test with an improvement of 6.18 marks (t-value-6.43) and a p-value of 0.0001. The nurses had a mean score of 4.81/16 (S.D-2.43) in the pre-test and 11.75/16 (S.D- 2.94) in the post-test with an improvement of 6.93 marks (t-value 18.33) and a p value of 0.0001.
Conclusion
Residence of all departments performed significantly better after audiovisual educational tools. Maximum improvement was seen amongst the nurses. Most of the healthcare personnel had better knowledge regarding the usage of the MDI technique after the education tools. In developing countries like India where the number of asthma patients is so high, formal and systematic training should be provided to the healthcare personnel who are directly involved in prescribing and instructing the use of MDI technique to patients to improve patient outcomes by increasing adherence and to decrease healthcare burden by decreasing the number of exacerbations.

IMPACT OF AUDIO-VISUAL AIDS IN IMPROVING THE KNOWLEDGE OF THE
METERED DOSE INHALER (MDI) TECHNIQUE AMONG HEALTHCARE
PERSONNEL

Background
The current radiology education provided to medical students and non-radiologist clinicians is not adequately effective or comprehensive, leaving them underprepared to handle the immense quantity of radiological studies they will be responsible for in the future practice. Furthermore, imaging over-utilization can harm patients and add to the burden on the already overstressed radiology workforce. This study explores the implementation and efficacy of an online, interactive, case-based radiology education tool, Wisdom in Diagnostic Imaging (WIDI) Case- Based Intro to Radiology (CBIR). The 140 cases include a patient history, physical exam, relevant labs, ACR appropriateness criteria, key images, full DICOM sets, video explanations, radiology reports, learning points, and socioeconomic factors. Learners are asked to make a provisional diagnosis, select appropriate imaging, assess imaging findings, determine acuity and need for further imaging, make a final diagnosis, devise an assessment and plan, and are given feedback on their responses.

Methods
A focus group consisting of one undergraduate, seven medical students, nine physician assistant students, and three PhD students participated in this study. We tested three different teaching methods: a didactic approach without WIDI, a proctored didactic approach using WIDI,
Ó 2023 American Medical Association. All rights reserved.
and a flipped classroom approach using WIDI. An online survey was conducted to assess student preference and feedback on these methods and the use of WIDI in their curriculum.

Results
Most students preferred the proctored didactic approach with WIDI. They reported that the platform complemented their curriculum and encouraged critical thinking. Most students noted that the modules covered adequate clinical and imaging details and enhanced their skills in imaging interpretation. Despite limitations of a small sample size and reliance on self-reported outcomes, this study suggests that the WIDI platform could be integrated into PA and medical school curricula throughout the US, offering a standardized radiology curriculum.

Conclusion
The UF Wisdom in Diagnostic Imaging (WIDI) appears to be a promising tool for modernizing radiology education, improving imaging interpretation skills, and enhancing appropriate imaging selection among non-radiologist medical learners. By offering structured, active learning with iterative feedback on image interpretation and utilization through this platform, we can potentially minimize disparities in imaging skills acquired across medical and PA schools and improve proficiency in radiology interpretation and utilization. This may ultimately contribute to a reduced workload for radiologists and lead to improved patient outcomes.

Enhancing Radiology Education with a Case-Based Intro to Radiology on the UF WIDI e-Learning Platform

Purpose 
The anatomy lab is often the first-time medical students are exposed to complex, 3-dimensional relationships of anatomy, as well as the specialty of radiology. Unfortunately, in cadaver-based labs, the anatomy as well as the intimate association between deep internal organs is lost during dissection. This study seeks to create a protocol for accurately capturing soft-tissue data from embalmed organs using Diffusible Iodine-based Contrast-Enhanced Computed Tomography (diceCT). This study compares and contrasts how 1% and 3% iodine concentrations penetrate pig hearts and affect soft tissue resolution under standard hospital CT scans.1

Methods/ Materials
Two hearts from Sus domesticus (Suidae) were used, as pigs have proven to be useful analogs for human clinical anatomy.2 Specimen 1 weighed 373 grams (Fig. 1) and Specimen 2 weighed 388 grams (Fig. 2). Following the methods of Gignac et al. 1, both specimens were soaked in a 20% sucrose solution for 48 hours to prophylactically reduce dehydration from the iodine agent. Specimen 1 was then placed in a 1% iodine solution and Specimen 2 into a 3% iodine solution. Both specimens were stored in a dark room for four weeks. Following the iodine soak, the specimens were taken to St. Bernard’s Imaging facility for CT scanning using a GE LightSpeed VCT 64 slice CT scanner at a slice thickness of 0.625 mm. CT data were exported in DICOM format for reconstruction using the imaging and 3D analysis software, Avizo (ThermoFisher Scientific).

Results
Both specimens had a Hounsfield range of -1115 to 3071 and generated two high-value peaks. The second peak of the 1% heart quickly decayed whereas the second peak of the 3% heart almost plateaued, indicating more voxels (3D pixels) in the higher positive range, and thus greater contrast for the 3% solution specimen. 
Volume rendered images of the 1% and 3% hearts in lateral view show fainter contrast at the same Hounsfield range for the 1% heart. Overexposure along the outer surface of the 3% heart specimen indicated rinding from the high iodine uptake along the surface.

Conclusion 
Our results found that a 3% solution was most effective at penetrating the muscular wall of the heart and better capturing the soft-tissue anatomy. However, extensive “rinding” along the outer surface indicates that a 4-week soaking period may be too long for such a relatively high concentration.

The next phase of this study is to have these specimens μCT scanned using the μCT scanner on the Long Island campus of NYITCOM. This will allow us to determine how effective this current concentration was at capturing the different tissues in the heart. Our future work aims to target the best mix of iodine concentration and soaking time for the most effective contrast. For instance, our 1% solution could provide equivalent or more contrast at the cost of a substantially longer soak time. In contrast, our 3% solution had a high amount of rinding on the perimeter at only 4 weeks. It is possible that an iodine solution of 1.5–2% is the most appropriate mix. The appeal of this protocol is that it can be injected into the blood vessels of cadaveric specimens, allowing the vessels to distribute the iodine more naturally and with faster uptake; a process called SPICE-CT. This would allow images to be generated with the heart still inside the cadaver. In this manner, complex 3D relationships can be maintained and studied. 




Utilizing Iodine to Enhance Radiographic 3D Visualization of Cadaveric Hearts

**Scoring is only possible in the semifinals hall**

**Abstract:**



Use of Community Outreach Events to Increase Knowledge of Cardiothoracic Surgery

Background
In academic medicine, research plays an important role in faculty promotions, development of medical student skills, and strengthening of residency applications in competitive specialties like urology. H-index (Hi) has also been shown to be associated with academic rank at top urology programs in the United States. Our study is the first in the field of urology to examine the effect of student authorship on the scholarly impact score of principal investigators (PI’s) as measured by Hi. 

Methods
A database of authors from the Journal of Endourology during the years 2011, 2014, 2017, and 2020 was created. Author degree and designation as student author (SA), PI, or other author were recorded. Author gender was determined through Gender-API software, and Hi was accessed through Scopus. PI’s were classified based on whether their articles contained SA’s or not (nSA). Article categories were defined by the Journal of Endourology. Independent t-tests assessed differences in mean Hi between SA and nSA groups. ANOVA assessed differences in mean Hi by publishing year. Linear trends were examined using a goodness of fit model and reported as R^2. Significance was defined by p<0.05.

Results
Out of 819 total articles from the selected years, 26% listed a SA. Of 5,307 total authors, 6.7% were classified as SA’s. A majority of SA’s published in the categories: Laparoscopy and Robotic Surgery, General Research, and Experimental Endourology. Geographically, SA papers were concentrated in the Western, North Central, and Southeastern AUA sections. When analyzing the proportion of SA to nSA papers within each category, we found that nSA papers outnumbered SA papers for every category. Articles containing SA’s increased from 22.3% in 2011 to 31.1% in 2020. There was an increasing trend in female authorship overall (R^2=0.84); however, there was no clear trend in student, PI, or first female authorship. PI’s publishing with a SA had a significantly greater mean Hi (30.91) than PI’s without SA’s (27.45), across all years (p=0.025).

Conclusion
Within the Journal of Endourology, student involvement in research enhanced PIs’ research impact, as manifested by significantly greater Hi, suggesting the mentor-mentee collaboration is mutually beneficial. Although female authorship in the Journal of Endourology is increasing overall, women still are disproportionately underrepresented in urology compared to other surgical subspecialties. Given the aging urologic workforce, programs to encourage faculty mentorship and student involvement in research can both enhance student interest and reduce the gender gap within urology.

Scholarly Impact of Urology Student Authorship

Phenomenon: To analyze changes in student study strategies within a flexible curriculum after the United States Medical Licensing Examination (USMLE) Step 1 exam grading shifted from a 3-digit numerical score to pass/fail on January 26, 2022. Little data exists regarding if and how medical students should change their approach to preparing for the new Step 1 exam. 
Approach: We distributed a survey that included questions regarding (1) study schedule, (2) resources utilized, (3) performance on practice tests, and (4) trusted sources of advice. Surveys were distributed to third and fourth-year medical students at the University of Michigan Medical School (UMMS) in Ann Arbor through our institution’s internal email listserv. To offer context, UMMS has a 1-year preclinical period with student flexibility/choice in timing of Step 1 post clinical year. A total of 101 respondents graduating in the class of 2024 or beyond were included in the analysis performed in Excel and RStudio. 
Findings: Students studied anywhere between 2 weeks or less and 10 weeks or more, with the largest proportion (18.81%) of students choosing 8 weeks of study time. Most students took their exam as initially scheduled, however, 40.59% of students increased the length of their study period beyond their initial scheduled date. To determine the amount of time to allocate for dedicated study, 37.26% of respondents talked to students who had already taken Step 1. Students also considered personal prior experiences with standardized tests (15.57%), life events/personal reasons (14.62%), and conversations with medical school advisors (13.21%). During dedicated study time, 44.55% of students studied for 9-11 hours a day, and 42.57% studied for 5-8 hours a day. On average, students completed a total of 2982 (SD 1253) practice questions. 52.69% of students scored between 70-80% on their most recent NBMEs before sitting for their actual Step 1 exam. Everyone who completed the survey passed the exam. Exam non-extenders achieved the same end goal as exam extenders of a pass on Step 1 and a significantly higher end average practice test score with a shorter study period. No differences in Step 1 study time or intensity were found when comparing students stratified by competitiveness of intended specialty.
Insights: Overall, our results demonstrated aspects of both adherence and deviations to widely accepted studying norms for the scored Step 1 exam after the exam was changed to a pass/fail grading system.

Many Paths to the Summit: Survey of Step 1 Study Methods with Pass/Fail Scoring

Background: Despite the increase in use of telemedicine, the evidence base on virtual supervision (VS) in graduate medical education (GME) is not well described.
Objective: To systematically review the use of VS in GME, investigating its characteristics, effectiveness, benefits, and limitations.
Methods: Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, three databases were searched in December 2022. The inclusion criteria were peer-reviewed, full-text, English-language articles reporting the use of VS in GME in Accreditation Council for Graduate Medical Education (ACGME)-accredited specialties. Studies that included direct supervision, supervisors who were not credentialed physicians, and non-GME trainees were excluded. Two investigators independently extracted data and appraised the methodological quality of each study using the Mixed Methods Appraisal Tool (MMAT).
Results: Twenty-six studies were included in our qualitative synthesis. Virtual supervision facilitated efficient and rapid communication between supervisors and trainees, leading to improved patient care quality in some studies. Additionally, several studies reported a high level of agreement in diagnosis and treatment plans between supervisors and trainees. Based on self-reported surveys, supervisor and trainee satisfaction with VS was mixed, while patient satisfaction was generally high. The MMAT ratings suggested limitations in sampling strategy, outcome measurement, and inclusion of confounding factors.
Conclusions: Virtual supervision is applicable to various specialties and training levels, offering advantages such as increased training opportunities, trainee autonomy and communication. Future studies should employ large sample sizes, objective outcome measures, and rigorous methodology to expand the evidence base.


Use of Virtual Supervision in Graduate Medical Education: A Systematic Review

Background: ChatGPT is an artificial intelligence large language model that can comprehend and generate human-like text. Previous studies have evaluated the success of its earlier models on USMLE Step 1 questions, but have not examined differences in performance by subjects or disciplines. The current study utilizes the newer model of GPT-4 to assess performance by subject and disciplines and explore its implications for medical education.
Methods: Questions were obtained from the AMBOSS Step 1 question bank and inputted into ChatGPT to analyze accuracy. Questions from 18 systems and 12 disciplines were randomly selected and differences of accuracy between the various domains were assessed. ChatGPT accuracy was also compared to the accuracy of students towards the individual questions.
Results: A total of 1,300 questions were analyzed. ChatGPT-4 achieved an overall accuracy of 86% across all questions. There were no significant differences between the various systems or disciplines. ChatGPT accuracy increased as the student accuracy increased for each question (p<.001).
Conclusion: ChatGPT-4 demonstrated high accuracy towards USMLE Step 1 questions, validating the proficiency of the software. The 86% accuracy observed is notably higher than percentages noted on previous studies assessing Step 1 questions that used earlier models of ChatGPT and exceeds the 60% passing threshold with a large margin. The lack of a difference in accuracy by systems and disciplines further demonstrates its reliability in being adopted as a supplemental learning platform for medical students. In addition to ChatGPT’s multi-step processing and ability to provide detailed and logical explanations to questions, we demonstrate an example of how it may be further utilized to enhance understanding of medical topics through applying prompts. In leveraging this technology, we stand on the brink of significant breakthroughs in our ability to enhance learning outcomes, especially in fields as critical and demanding as medicine.

ChatGPT-4 performance on USMLE Step 1 questions and its implications for medical education: A comparative study across systems and disciplines

Background: The COVID-19 pandemic exposed the gap in the effective communication of health information between the medical community and general public. For example, vaccine hesitancy demonstrated the need to engage patients in challenging conversations, explain complex scientific research and advancements, and appropriately acknowledge areas of medical uncertainty. To meet this need, medical educators play an important role in the training of rising physicians. Specifically, we can employ innovative training models such as medical improv which utilizes improvisational theatre principles to enhance trainees’ communication skills. To this end, we examined the use of medical improv as a tool for teaching clinical communication skills to UC Davis medical students ahead of their first clinical clerkships.
Methods: We piloted a four-part medical improv workshop for second-year medical students in January of 2022 to teach core improv communication skills such as active listening, quick thinking, and collaboration. After initially assessing the workshop impact through pre-and-post workshop surveys, we conducted one year of follow up by distributing digital surveys after 4 of the 7 clinical clerkships. Surveys were comprised of Likert scale and open-response questions to assess how, if at all, medical students employed improv communication skills during clerkships. Data was analyzed using mixed methods. Of note, enrollment was limited due to the spread of the Omicron variant in Winter of 2022.
Results: Of the 10 enrolled students, 8 (80%) completed the workshop, and 3-7 respondents submitted each follow-up survey. Participants implemented improv skills an average of 3 times during a day of clinic activity. Thematic analysis of the narrative responses revealed that students most commonly implemented their improv skills when 1) actively listening to patients, 2) answering questions posed by patient’s families, and 3) having difficult conversations. Students described how active listening was critical to establishing connections with patients and understanding their perspectives. One student remarked, “actively listening to the patient was much more important than trying to pre-form a response to what I imagine they are going to say.”
Conclusion: After one-year of follow up, this pilot study shows that medical improv can meaningfully impact students’ clinical communication skills by teaching the difference between responding and reacting in conversations with patients and their families. Through honing active listening skills, we can better equip future physicians to minimize the communication gap between them and their patients.

Responding vs. Reacting: How medical improv can enhance clinical communication skills in rising physicians

Background
Adoption has life-long health implications for nearly 8 million adopted people and their families in the United States. Most U.S. adoptees have limited family medical history (LFMH) and adoptees are also 3.7 times more likely to attempt suicide than their non-adopted siblings. Genetic testing kits promising health information to consumers have become increasingly available in recent years, amplifying the need to address genetic testing for adult adopted patients with LFMH. Numerous patient narratives by adult adoptees with LFMH illustrate encounters with clinicians that trigger medical anxiety, shame, guilt, and distrust. However, adult adoptees with LFMH are nearly absent from medical literature and training and little work has been done examining the perspectives, approach, and training of PCPs caring for this population.

Methods
This exploratory, qualitative study is the first to explore primary care physicians’ (PCPs) training and approaches to adult adoptees with LFMH. PCPs in Minnesota and Rhode Island specializing in family medicine, medicine, and medicine-pediatrics were recruited via convenience and reputational sampling. Twenty-three semi-structured hour-long interviews were conducted utilizing hypothetical clinical vignettes. Interview transcripts were coded according to the template organizing method, and then interpreted via immersion crystallization.

Results
Findings from this study suggest that PCPs typically receive little education, training, or resources throughout medical school, residency, and continuing medical education about adopted patients with LFMH. PCPs reported limited knowledge and discomfort in managing adoption issues and mental health concerns of adopted patients. Although previous research has observed an increased likelihood of attempted suicide among adopted people, half of PCPs were unaware of local mental health professionals or community organizations that specialize in adoption. Most PCPs expressed uncertainty around best practices for adult adoptees with LFMH and genetic testing, especially recreational direct-to-consumer kits. PCPs varied widely on whether they believed genetic testing beneficial or harmful for adoptees with LFMH. Lastly, many PCPs reported obtaining family medical history in ways that may cause miscommunication and risk being interpreted as devaluing non-biological families. Nearly all PCPs endorsed additional training about adult adoptees with LFMH as beneficial, particularly for mental health issues and genetic testing.

Conclusion
Given that these issues remain largely unaddressed by medical literature, curricula, and professional physician societies, future research should expand education and training opportunities for medical professionals to improve health care for adult adoptees with limited family medical history.

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IMPACT OF AUDIO-VISUAL AIDS IN IMPROVING THE KNOWLEDGE OF THE METERED DOSE INHALER (MDI) TECHNIQUE AMONG HEALTHCARE PERSONNEL