Prolactin, 16-kDa Prolactin, and Cathepsin D Cascade There appears to be a cascade involving oxidative stress, the prolactin-cleaving protease cathepsin D, and prolactin in the pathophysiology of PPCM.9

Markers of cellular oxidation rise during pregnancy and hence an efficient antioxidant defense mechanism in the maternal heart is crucial, especially late in pregnancy and in the postpartum period. Experimental data in a mouse model of PPCM (mice with cardiomyocyte-restricted Inhibitors,research,lifescience,medical deletion of STAT3, signal transducer and activator of transcription-3) suggest that defective antioxidant mechanism may be responsible for the development of PPCM. Reduction in STAT3 appears to be a trigger that leads to activation of cathepsin

D in the cardiomyocytes, which subsequently causes increased cleavage of prolactin into an antiangiogenic and proapoptotic 16-kDa isoform.9 The 16-kDa prolactin fragment has potentially detrimental cardiovascular actions that could play a role in the pathophysiology Inhibitors,research,lifescience,medical of PPCM. It has been shown to inhibit endothelial cell proliferation and migration, induce endothelial apoptosis and disrupt already formed capillary structures, promote vasoconstriction, and impair cardiomyocyte function. The functional role of an activated oxidative stress-cathepsin D-16-kDa prolactin cascade is supported by Inhibitors,research,lifescience,medical the observation that Inhibitors,research,lifescience,medical in mice, treatment with bromocriptine, an inhibitor of prolactin secretion, prevented the development of PPCM. Also, patients with PPCM have increased serum levels of activated cathepsin D, total prolactin, and cleaved 16-kDa prolactin fragment.11 Autoimmune Mechanism High titers of auto-antibodies against selected cardiac tissue proteins have been found in the majority of women with PPCM.12 Warraich et al. investigated the role of humoral immunity and showed that unlike the selective upregulation of Capmatinib molecular weight immunoglobulins of the G3 subclass (IgG3s) in DCM, class G and all subclass immunoglobulins against cardiac myosin heavy Inhibitors,research,lifescience,medical chain were raised in PPCM.13 Of the serological variables, IgG3s (immunoglobulins with proinflammatory

characteristics) discriminated NYHA functional status at diagnosis. IgG3-positive patients were in a higher NYHA class at initial presentation. Similarly, Ansari et al. investigated the role of fetal Casein kinase 1 microchimerism (fetal cells in maternal blood) in patients with PPCM. In a small sample of patients, the amount of male chromosomal DNA in maternal plasma was significantly greater in patients with PPCM than in control mothers without PPCM during the third trimester of pregnancy, which could theoretically lead to the initiation of an autoimmune myocarditis.14 Inflammation Serum markers of inflammation like C-reactive protein, soluble death marker SFAS/Apo 1, interferon-gamma, interleukin (IL)-6, and TNF all have shown to be elevated in PPCM.

In order to further characterize HPV antibody responses in a 2- vs. 3-dose randomized controlled Q-HPV vaccine trial, we adapted and implemented the National Institutes of Health pseudovirus neutralizing antibody (PsV NAb) assay [9], in which a red fluorescent

protein (RFP) reporter plasmid was incorporated into the PsV [10]. Neutralizing antibodies block PsV entry into susceptible cells and prevent expression of the RFP which is visualized by fluorescence microscopy. While PsV NAb assays are technically complex and have not been standardized, they provide an alternative to vaccine manufacturers’ assays by detecting type-specific antibodies that block HPV infection of susceptible cells. We previously reported HPV 16 and 18 PsV #Modulators randurls[1|1|,|CHEM1|]# NAb and cLIA responses for the 2- vs. 3-dose trial at 7 months post-vaccination [11]. We now report HPV 16 and HPV

18 PsV NAb, Merck cLIA and Merck TIgG antibody responses through to 36 months Selleck CH5424802 post-vaccine. The study population consisted of 824 females aged 9–26 years at three study sites in Canada (British Columbia, Québec and Nova Scotia), who were enrolled into one of three study arms as previously described [12]. Younger subjects (9–13 yr) were randomly assigned to receive two or three doses of Q-HPV vaccine, whereas older subjects (16–26 yr) received only the standard three dose regimen. Distribution among the study arms was: Group 1 (n = 259), 9–13 yr (mean age 12.4 yr), received two doses at months 0 and 6; Group 2 (n = 260), GBA3 9–13 yr (mean age 12.3 yr), received three doses at months 0, 2 and 6; and Group 3 (n = 305), 16–26 yr (mean age 19.3 yr), received three doses at months 0, 2 and 6 ( Fig. 1). Sera were collected from the entire cohort at baseline, months 7 and 24; in addition, half the cohort was randomly selected for serum collection at month 18, and the other half had serum collected at month 36. Group 3 subjects also provided self-collected vaginal swabs (HC™ Female Swab Specimen Collection Kit; Qiagen) to determine if HPV 16 or HPV 18 DNA positivity

at baseline impacted the respective antibody responses. Informed consent was obtained for all subjects after explaining the nature and possible consequences of the study. The study was approved by the University of British Columbia Clinical Research Ethics Board and by local research ethics boards at the other sites. The clinical trial was registered with ClinicalTrials.gov (NCT00501137). The PsV NAb assay was performed as previously described [10]. Briefly, HPV 16 and 18 PsV incorporating RFP were prepared by transfection of 293TT cells with HPV 16 or 18 L1 and L2 plasmids together with RFP plasmids. PsV preparations were purified and titrated in 293TT cells. The PsV L1 protein concentrations were estimated by comparing polyacrylamide gel electrophoresis L1 band densities for each PsV preparation with the densities of known concentrations of HPV 16 and 18 Merck vaccine VLPs.

8,10,11,15,25–27 During this period of neuropraxia, there is absence of spontaneous nocturnal erections that leads to the loss of production of nitric oxide (NO), both by the neuronal isoform of nitric oxide synthase (nNOS) via the nerves themselves and the inducible isoform of nitric oxide synthase (iNOS) via the cavernosal selleck compound library smooth muscle cells, due to loss of Inhibitors,research,lifescience,medical tissue

oxygenation produced by tumescence.11,14,15 These changes induce the production of proapoptotic factors and profibrotic factors within the corpora cavernosa.11 The loss of nocturnal erections or damage to the accessory pudendal arteries during RP contributes to prolonged periods of penile smooth muscle hypoxia/ischemia, which leads to the production of transforming growth factor-β1 (TGF-β1) and TGF-β1-dependent endothelin-1 (ET-1).25 ET-1 has been shown to be a potent constrictor of penile smooth muscle and a profibrotic peptide, which induces collagen deposition in cavernosal tissue.25 Daley and associates showed that the production of prostaglandin E-1 (PGE-1) suppressed Inhibitors,research,lifescience,medical TGF-β1-induced collagen accumulation in cavernosal muscle cells.28 Moreland and colleagues also showed that the addition of PGE-1 to cavernosal cultures suppressed TGF-β1-induced collagen synthesis.29 Thereby, Inhibitors,research,lifescience,medical loss of erections due to decreased vascular inflow or loss of NO-induced tumescence contributes

to the loss of PGE-1 feedback control on TGF-β1 production and perpetuates penile fibrosis, apoptosis, and programmed cell death.25 Some studies have shown in rats after bilateral neurectomy and in men after RP that smooth muscle degradation is followed by increased levels of collagen type I and collagen type III deposition.10 User and coauthors30 demonstrated loss of penile wet weight in rats that underwent both bilateral and unilateral Inhibitors,research,lifescience,medical cavernous nerve transection. Their data show that the average penile weight reduction was 13.6%, with the greatest reduction of 17.4% seen in the bilateral cavernous neurotomy group on postoperative day 60 (P < .005). A statistically

significant decrease in penile wet weight of 10.5% was seen at the 60-day point in the unilateral denervated penes (P = .029). They Inhibitors,research,lifescience,medical also demonstrated a statistically Terminal deoxynucleotidyl transferase significant decrease in DNA content in the bilaterally denervated penes (P < .05). Klein and associates showed increased DNA fragmentation and elevation of sulfated glycoprotein-2 (SGP-2) in the erectile tissue of denervated rat penes, which are both markers of apoptosis.27 Conversely, Müller and colleagues demonstrated the early use of hyperbaric oxygen therapy in rat cavernous nerve injury model improved erectile function recovery, endothelial nitric oxide synthase (eNOS), and nerve growth factor expression.31 The development of penile fibrosis leads to the long-term development of corporal veno-occlusive dysfunction/venous leakage because of the loss of cavernosal smooth muscle cell mass to adequately compress the subtunical veins during tumescence.

The results showed high correlations between SOL and GL in pretest (r = 0.803, P < 0.01) and posttest (r = 0.770, P

< 0.01). The GL and GM were highly correlated in pretest (r = 0.818, P < 0.01) and posttest (r = 0.847, P < 0.01). Furthermore, there were medium correlations between GM and SOL in pretest (r = 0.671, P < 0.05) and no significant correlations in posttest (r = 0.595, P > 0.05). Comparing the regression lines of SOL pretest versus GL pretest with SOL posttest versus GL posttest, one can see a shift to the left upper side. This can be ascribed to the decrease in GL activity and the increase in SOL activity as indicated exemplarily by one participant (Fig. 3, gray arrow). Figure 3 Inhibitors,research,lifescience,medical Correlations of the electromyography (EMG) activity of m. gastrocnemius lateralis (GL) and m. soleus (SOL) in pretest (open circles) and posttest (filled circles), respectively. The regression lines are presented for EMG activity of GL and SOL in pretest … Discussion This is the first study that demonstrated an Inhibitors,research,lifescience,medical increase in synergistic EMG activity Obeticholic Acid molecular weight during maximal voluntary isometric

contractions following NMES Inhibitors,research,lifescience,medical of one muscle. Due to the NMES of the GL, the EMG activity decreased to 81% in posttest. This decline was compensated by the EMG activity of SOL that increased to 112% in posttest. The force during MVC did not change significantly after NMES of the GL (Fig. 2D). Following sustained NMES of the GL, voluntary GL muscle activity during maximal Inhibitors,research,lifescience,medical isometric contractions was reduced (Fig. 2A). The results are in line with other studies that found decreased EMG amplitudes after high-frequency NMES (Boerio et al. 2005). The decline in EMG activity occurs due to failure of electrical propagation at the muscle fiber membrane of the GL induced by high-frequency fatigue (Cairns and Dulhunty 1995; Badier et al. 1999). Furthermore, studies using the interpolation Inhibitors,research,lifescience,medical twitch technique showed that electrical stimulation of the triceps surae lead to central fatigue (Boerio et al. 2005) accompanied by a force decline. In our studies, the force did not change significantly

(P = 0.388) after NMES of the GL. For that reason, we assume that the decline in GL in the presented study occurred more prominently due to peripheral fatigue than due to central fatigue (Badier et al. 1999). Reducing knee angle leads to reduced GM length and decreased muscle activation during MVC (Cresswell et al. 1995; Arampatzis et al. 2006). This may be due to (1) Unoprostone the “drive,” i.e., the neural outflow from spinal motor neurons, may be reduced to a shortened muscle; (2) neuromuscular transmission–propagation in a shortened muscle may be impaired, and (3) shortening a muscle may alter the electrode configuration with respect to the recording volume, thereby resulting in less myoelectric activity recorded (Cresswell et al. 1995). In our experiments, knee and ankle angle and therefore the muscle length were kept constant during pre- and posttests.

Also, the precise spectral location of the peak frequency for the alpha (8–12 Hz) range is Small Molecule Compound Library variable across individuals, and the location of this peak is a meaningful parameter that has been

correlated with development (Cragg et al. 2011) and cognitive performance (Angelakis et al. 2004). Engagement with an individual’s unique spectral EEG fingerprint is not possible with technologies that Inhibitors,research,lifescience,medical rely on standard broadband EEG frequency ranges. HIRREM and EEG artifact or noise Artifact identification and rejection are thematic to the field of EEG. EEG artifacts may include a variety of discrete phenomena including abnormalities of the EEG tracing which are due not to neural oscillation but rather to scalp muscular contraction, eyeblinking, or head or sensor movement. For the practice of EEG operant conditioning, the identification of EEG artifact is mission-critical, because the presentation of reward or inhibit signals in response to peripheral Inhibitors,research,lifescience,medical muscular contractions (for example), rather than neuronal oscillations, is subversive to the purpose and basis of the enterprise. (Likewise, artifact identification is critical for medical EEG especially insofar as definitive diagnosis depends on accurate characterization of EEG waveforms which are abnormal

but may manifest inconsistently.) Because HIRREM technology does not aim Inhibitors,research,lifescience,medical to consciously teach the individual through signals of reward or inhibition, we postulate that there is little if any jeopardy associated with providing auditory signals which are informed by nonneural sources and are therefore “meaningless.” (Nor does HIRREM aim to Inhibitors,research,lifescience,medical diagnose disease.)

Rather we infer that the brain responds to epochs of HIRREM sounds generated from grossly noisy EEG artifact in the way Inhibitors,research,lifescience,medical that it would respond to grossly noisy sounds. Furthermore, artifact-associated data will tend to be distributed symmetrically, and because HIRREM algorithms are based on the relationship of activity between homologous brain regions, artifactual signals will tend to cancel one another out in the algorithmic equation. We also hypothesize that, paradoxically, a possible mechanism for benefit of HIRREM could be the engagement between HIRREM and what is generally considered background noise or randomness in the EEG. The core technical aim of HIRREM is to resonate with dynamically changing Edoxaban dominant frequencies in the spectral EEG. Variations of amplitudes in these frequencies are typically characterized in stochastic terms. That is, the energies of interest to HIRREM are in the category of apparently random fluctuations in the EEG, or noise. Variations in system noise levels can change the probability that a weak periodic signal will cross a threshold for sensory processing. The presence of an optimal noise level in a system can improve detection of a weak periodic signal, by boosting the signal sufficiently to cross the output threshold.

The delay in urethroplasty was due to nonmedical, administrative, and personal factors. Five months later, evaluation of urinary obstructive symptoms revealed a 0.5 × 0.5 cm papillary urethral lesion. Resection of this lesion necessitated check details simultaneous placement of another buccal mucosal graft. The surgical pathology from this resection revealed only focal condylomatous changes, underlying fibrosis,

and chronic inflammation. Thereafter, the patient was evaluated for elective phalloplasty using a radial forearm flap, but he has failed to complete his preoperative preparation and has been lost to follow up. Carcinoma of the penis is rare in developed countries. The highest incidence is reported in Asia (China, Vietnam, Sri Lanka, Burma, and India), Africa (Uganda), and Latin America (Mexico). The average age at presentation is late Modulators 50s-60s. The etiology is typically multifactorial

and includes poor hygiene, pre-existing condyloma acuminatum, squamous intraepithelial lesions with warty features, and human papillomavirus infection. Approximately 40% of penile cancers have been shown to be attributable to human papillomavirus types 16 and 18. Type 16 has preferentially been associated with a small subset of penile cancers, including basaloid, mixed warty-basaloid, and pure warty squamous carcinomas.1 Most penile neoplasms are squamous cell carcinomas, of which there are multiple variants (Table 1). They usually demonstrate 1 of 3 growth patterns: superficial spreading with minimal stromal invasion, vertical growth with deep invasion, or exophytic growth. Warty carcinomas comprise 5%-10% of all penile carcinomas.2 The diagnosis see more of warty carcinoma is confirmed by histology, which is essential before definitive treatment. Urethroscopy

why may also be considered. MRI of the penis to identify invasion into the corpora cavernosa or spongiosum is helpful when the depth and extent of tumor remain unclear on physical examination. Abdominal and pelvic CT or MRI may be useful to exclude metastatic disease. Partial penectomy with a 2-cm proximal resection margin was traditionally recommended for adequate local control of T1-T2 tumors and remains the gold standard. However, penile length sparing by decreasing the margin of resection is now acceptable in select cases. Alternative penile-sparing techniques include Mohs micrographic surgery, laser ablation, and radiation therapy (RT). Mohs surgery does not offer much benefit over surgical excision with intraoperative frozen section because of high risk of recurrence,5 whereas laser ablation offers comparable extirpative results with additional functional benefits. Using the neodymium:yttrium-aluminum-garnet laser in conjunction with tumor base biopsies to ensure negative margins, Frimberger3 reported a mere 7% recurrence rate at 47 months for 29 patients. Laser ablation has also been associated with a 75% rate of resumption of sexual activity and a 78% rate of patient satisfaction.

Statistical guidelines forjudging validity of linkage reports in complex disorders have been suggested.36,40 These guidelines suggest thresholds for an initial report of “significant” linkage (LOD score ≈3.6 or nominal P≈0.00002) and for confirmation (LOD score =1.2 or P≈0.01). These guidelines should limit false positives

to less than 5%. It should be remembered that these guidelines refer to analysis of a single phenotypic definition (eg, BP I and BP II disorders). If multiple (overlapping) phenotypes are analyzed, some statistical adjustments for multiple hypothesis testing may be necessary. An associated critical issue is the Inhibitors,research,lifescience,medical power of a confirmation study to detect the Inhibitors,research,lifescience,medical effect size initially described. Effect sizes are often expressed as the increased Venetoclax relative risk41 due to a specific genetic locus.42 This increased relative risk refers to the ratio of the risk to a BP proband’s relative (eg, sibling) to develop the disorder divided by the risk for the general population.

For BP disorder, family studies suggest that the relative risk for siblings is increased by a factor of ≈8 to 9 (see Gershon et al,20 for Inhibitors,research,lifescience,medical example). Because BP disorder is almost certainly an oligogenic syndrome, in which at least several loci contribute to Inhibitors,research,lifescience,medical the increased relative risk, locus-specific relative risk

(the increased risk due to a single locus) is expected to be much less than 9. For complex traits, such as hypertension, diabetes, and BP disorder, loci that increase risk by factors greater than 2 are unusual. One such locus is near the ITLA locus for insulin-dependent diabetes mellitus (relative risk ≈3),43 another is the apolipoprotein E locus in late-onset Alzheimer’s disease.44 If three loci of equal effect size are used in an interactive Inhibitors,research,lifescience,medical multiplicative model to explain the increased relative risk in BP disorder (each locus increases relative risk by ≈2), then these three hypothetical interactive loci explain most of the relative risk (2 × 2 × 2 = 8). Thus, loci that increase risk for BP disorder until will have minor to moderate effects. Substantial sample sizes are required to detect such loci of minor effect. As Hauser and Boehnke45 have shown, ≈400 affected sibling pairs are needed to have >95% power to detect initially (LOD >3) loci which increase risk by a factor of 2, while 200 pairs are needed to have >95% power to provide confirmation (P≤0.01) of a previously detected locus. Review of bipolar molecular linkage studies Molecular methods have been used in BP linkage studies to localize susceptibility genes. A linkage study of Old Order Amish pedigrees described evidence (LOD score >4.

Authors cited in relevant reports were followed with citation

tracking. The reference lists of relevant articles were hand searched for additional relevant papers. Search results were imported into bibliographic management software and duplicates AZD2014 chemical structure discarded. The titles and abstracts were screened against the inclusion inhibitors criteria (Box 1) by one author (JH). The full text of potentially relevant papers was obtained and assessed against the same criteria. Non-English language publications were excluded. Design • Prospective cohort studies Participants • Aged 18 years or younger Outcomes • Risk of subsequent onset

of low back pain associated with a previously measured factor, where an episode of low back pain and any recall period are clearly defined, and where the low back pain does not develop as a result of serious pathology, as defined by red flags (Rosen 1994). Quality: There is no ‘gold standard’ for assessing the quality of the methods used in studies of risk factors. Bias, confounding, and chance can distort the validity of epidemiological studies ( Zaccai 2004) and studies of predictive Panobinostat ic50 utility. Quality assessment criteria were therefore developed to identify sources of bias that might affect the credibility of conclusions about the relationships between possible risk factors and the first episode of low back pain. Nine quality assessment criteria

were chosen, based on arguments made in the MOOSE Statement ( Stroup et al 2000) and by Hoogendorn and colleagues (2000). The criteria were grouped under three out questions related to the representativeness of the study population, the definition of an episode of low back pain, and the data collection and analysis. Included studies were awarded a ‘yes’ for each of the quality criteria that were clearly met and a ‘no’ for criteria that were not met or that could not be determined from the methods reported. The maximum quality score that could be achieved was 9. Box 2 Questions and criteria used to assess the methodological quality of included studies.

It is important to be aware of the unusual morphologic variants of pancreatic endocrine tumors, and select immunohistochemical markers can help avoid misdiagnosis (3). The mitotic rate is an important measure of aggressiveness in PETs. Well-differentiated PETs are defined to have less than 20 mitotic figures per 10 high power fields (hpf); neoplasms with 20 or more mitoses per 10 hpf are considered poorly differentiated (high grade) neuroendocrine carcinomas (Table 1). In many PETs, mitotic figures are nearly undetectable, a search of 50

hpf (or more) may be required for a Inhibitors,research,lifescience,medical single mitotic figure. Some PETs have a higher proliferative rate; and the finding of 2 or more mitotic figures per 10 hpf places a PET in a worse prognostic category. Necrosis is also variably present; most commonly it is accompanied with an increased in proliferative rrate, thus signifing a more aggressive PET (5) (Figure 1). Table 1 Inherited Inhibitors,research,lifescience,medical genetic neuroendocrine syndromes Figure 1 A.

H&E stained section of a well-differentiated pancreatic neuroendocrine tumor (G1) showing an organoid/nested growth pattern; B. immunostaining revealed low Ki-67 (<2%); C. strong expression Inhibitors,research,lifescience,medical of synaptophysin; D. weak expression of insulin. ... Pathogenesis of PETs Most pancreatic neuroendocrine selleck chemical tumors occur sporadically (90%). Inhibitors,research,lifescience,medical However, they may be part of hereditary syndromes: multiple endocrine neoplasia type 1 (MEN1 syndrome), von Hippel-Lindau disease (VHL), von Recklinghausen’s disease or neurofibromatosis type 1 (NF-1), and tuberous

sclerosis (TSC) (5). In these cases, the underling genetic abnormalities play a significant role in the development of PETs which are often Inhibitors,research,lifescience,medical found to be mutlifocal. The pathological features of familial/hereditary PETs are generally similar to the sporadic form, although PETs arising in VHL syndrome patients may have clear cell features (6). Germline loss-of-function MEN-1 mutation leads to the formation of numerous microadenomas, mostly resulting in non-functional PETs and insulinomas (7). NF-1 or TSC1/2 mutations result in loss of function of their protein products neurofibromin and tuberin, respectively. Notably, the intact proteins suppress the function of a common target, namely mTOR (mammalian target of rapamycin) (7). Furthermore, hypoxia-induced why factor (HIF)-dependent mTOR activation links disturbed mTOR signaling to VHL disease (8,9). mTOR is a key regulator of cell growth and integrates a wide variety of cellular inputs, such as growth factors, nutrients, energy status and hypoxia-induced stress, thus, it is a good therapeutic target for PETs. Somatic MEN1 gene mutations accompanied by a loss of the wild-type allele are demonstrated in 10-27% of insulinomas and 39-45% of gastrinomas.

Furthermore, this training methodology had not been in place for the initial training of EMTs surveyed and, taking cognisance of the survey results, it would appear that EMTs might use e-learning followed by practical reinforcement, but would appear less eager to use e-learning alone as a means to maintain competence. Our survey included 22 potential CPC activities (see Table 4) and asked which activities did EMTs believe were

relevant/irrelevant. The find more results showed that practical, hands-on activities were preferred over theoretical/non-practice type activities. Also, there were less negative responses regarding activities related to practical skills than to theoretical Inhibitors,research,lifescience,medical skills. This further substantiates the case for practical, hands-on activities,

whether as a standalone activity or coupled with the e-learning approach. The EMTs surveyed in this study seemed to share the view of Ruiz et al in that perhaps they did not value e-learning as a replacement for traditional instructor-led Inhibitors,research,lifescience,medical training but rather as a complement to it, forming part of a blended-learning strategy [31]. EMTs function in environments that require lateral thinking [34]. Arguably, variation in learning methodologies could be encouraged so to Inhibitors,research,lifescience,medical facilitate the variations in personal learning styles while also taking cognisance of nuances in practice. Previous studies with Irish advanced paramedics and paramedics Inhibitors,research,lifescience,medical reinforce the concept of practical-type learning as a preferred methodology and as an effective way of maintaining skills [7,35] and that skills practice is an integral part of maintaining competence [36]. Indeed, our results, in part, reinforce the focus of older/traditional basic training curricula for ambulance staff in the United Kingdom and Ireland, which for the most part, was skills-based [37]. Inhibitors,research,lifescience,medical This is quite different to results seen for other professions who tend to prefer attending conferences, lectures and reading of

relevant journals [9,12], even though there Urease is little evidence to suggest that attending conferences had any direct impact on improving professional practice [38]. CPC annual hours Internationally, there are similarities in the way in which CPC hours are recorded, most being based on an hours-related credit system, in which one hour of educational activity equates to one credit and the number of credit/hours required vary from between 50–100 per year [30]. Irish doctors now, under the Medical Practitioners Act [27] must meet professional competence requirements [39] and this currently is 50 hours per year. In that context, the respondents in this survey believe that it would not be unreasonable to expect EMTs to complete 20–40 hours annually. Limitations The study had a number of strengths and weaknesses.