Source: UNIVERSITY OF MISSOURI submitted to NRP
SHOW-ME VET ECHO: VETERINARY EDUCATION AND TRAINING (VET) THROUGH EXTENSION FOR COMMUNITY HEALTHCARE OUTCOMES (ECHO) PROGRAM
Sponsoring Institution
National Institute of Food and Agriculture
Project Status
COMPLETE
Funding Source
Reporting Frequency
Annual
Accession No.
1023746
Grant No.
2020-70024-32367
Cumulative Award Amt.
$238,228.00
Proposal No.
2020-03926
Multistate No.
(N/A)
Project Start Date
Sep 1, 2020
Project End Date
Aug 31, 2024
Grant Year
2020
Program Code
[VSGPE]- Veterinary Services Grant Program Education Grants
Recipient Organization
UNIVERSITY OF MISSOURI
(N/A)
COLUMBIA,MO 65211
Performing Department
Veterinary Medicine & Surgery
Non Technical Summary
Telecommunications-based food animal continuing education will provide expert-facilitated experiential learning opportunities, in an evidence-based approach to reduce professional isolation for rural veterinarians lacking the ability to take time off or the financial means to travel. Telecommunication strategies have been successful for rural human healthcare providers. The University of Missouri Telehealth Network's Show-Me ECHO (Extension for Community Healthcare Outcomes) program has created an innovative, case-based learning community where local healthcare professionals present cases to one another and a panel of experts during prescheduled videoconferences. Using this same format and philosophy, the long-term goal of the proposed Show-Me VET ECHO program is to provide sustainable, telecommunications-based food animal continuing education for veterinary practitioners, students and technicians working with rural livestock producers. This goal will be accomplished by: 1) creating an online, Show-Me VET ECHO networking community, including veterinary practitioners, students and technicians, and collaborating topic experts and 2) development of monthly, case-based videoconferences involving members of this community. Integration of existing Show-Me ECHO evaluation and feedback tools will be used to guide the evolution of the Show-Me VET ECHO program. This program will provide rural veterinary professionals with accessible food animal continuing education with opportunities to present cases and participate in expert-facilitated topic discussions. The Show-Me VET ECHO program will help address key factors contributing to shortages in rural veterinary professionals by improving mental well-being and reducing intellectual isolation of rural veterinarians, enabling them to more effectively apply progressive knowledge and techniques to increase the profitability of their clients' livestock production enterprises.
Animal Health Component
100%
Research Effort Categories
Basic
(N/A)
Applied
100%
Developmental
(N/A)
Classification

Knowledge Area (KA)Subject of Investigation (SOI)Field of Science (FOS)Percent
9036099302050%
3113910302050%
Goals / Objectives
The long-term goal of the proposed Show-Me VET ECHO program will be to provide sustainable, telecommunications-based continuing education opportunities for practicing and future veterinarians, as well as veterinary technicians, working with rural livestock producers.The project has two objectives:Objective 1: Creation of the online, Show-Me VET ECHO networking communitySpecific aims:Develop a Show-Me VET ECHO webpage in conjunction with the existing Show-Me ECHO website. The webpage will be used for advertisement and communication of events. The webpage will also allow current and future veterinarians and veterinary technicians to enroll in the program and join the listserv.Develop internet-based communication with members of the community, including a listserv and program email account. These communication networks will be used to provide reminders pertaining to upcoming events and allow members of the community to provide information to project personnel.Objective 2: Development of monthly, case-based, videoconferences with members of the Show-Me VET ECHO communitySpecific aims:Schedule monthly continuing education videoconferences with Show-Me VET ECHO community members on selected topics, based on recommendations given by practitioners.
Project Methods
The program will be a collaborative effort including personnel from the MU Veterinary Health Center (VHC), MU Veterinary Medical Diagnostic Laboratory (VMDL), MU Extension, MU Telehealth Network, and the Missouri Veterinary Medical Association (MVMA).Objective 1: Creation of the online, Show-Me VET ECHO networking communityAShow-Me VET ECHO webpage will be created. The webpage will include information about how the ECHO videoconferences will work, a schedule including dates and topics for upcoming videoconferences, and information on how to join the Show-Me VET ECHO community. The webpage will advertise the Show-Me VET ECHO email address, which can be used to submit questions or topic suggestions. When an individual signs up to join the community, they will be asked to provide their email address, so they can be added to the Show-Me VET ECHO listserv. The listserv will be used to advertise upcoming topics, provide reminders to sign in to videoconferences, send details to access the online file sharing platform, and plan follow up details after a videoconference occurs.The program and webpage will be advertised through several outlets. Local advertisement will be done by mailing fliers to all MU graduates from the last 5 years as well as mixed and large animal practices within Missouri. The MVMA will assist with advertisement to their members and organize opportunities for project personnel to advertise the program at local and state association meetings. National advertisement will be done by posting program information through MU CVM social media as well as practitioners' listservs. All fliers and on-line advertisements will include the link to the Show-Me VET ECHO webpage, allowing interested parties to register to join the community.At the time of registration for the Show-Me VET ECHO community, participants will be asked to read and agree to terms of the program. Program terms will include the following: maintain patient information discussed during the conference confidential, complete periodic surveys to assess the program content and quality, use required software, provide updates and de-identified outcomes, assume responsibility for patient treatments regardless of recommendations provided by Show-Me VET ECHO participants, ensure clients are aware of the veterinarian's participation in the program and that de-identified information will be shared, and understanding that conferences will be photographed and recorded. Additionally, at the time of enrollment into the community, participants will be asked to provide demographic and contact information including phone number, practice address, the way in which they were made aware of the program, the veterinary school attended, and year of graduation. Objective 2: Development of monthly, case-based, videoconferences with members of the Show-Me VET ECHO communityShow-Me VET ECHO videoconferences will be scheduled once monthly. Videoconferences will be conducted using a Zoom Pro account (Zoom Video Communications, San Jose, CA, USA), which may host up to 100 participants and includes video and voice, active speaker view, and full screen and gallery view. Zoom meetings can be accessed by computer or mobile device and is compatible with numerous operating systems including Mac, Windows, Linux, iOS, and Android. Users also have the option to call in.Show-Me VET ECHO videoconferences will be approximately one hour in duration. The target number of participants per session is 60-80. Each videoconference will have a facilitator, which will be one of the MU project personnel or the topic expert. All facilitators will be trained by Show-Me ECHO personnel, to ensure that each facilitator fully understands the goals and objectives of the program and will work to maintain a collaborative telecommunication community. The videoconference will begin with a few minutes for introductions. Announcements will follow, including updates, questions, concerns, and reminders. Following announcements, there will be a 10-15 minute didactic presentation, which will be delivered by the topic expert and will focus on the specific topic of the session. The didactic will be followed by 5-20 minutes of case presentation, which will be presented by a practitioner. Depending on the case length, more than one case may be presented per session. All cases presented will be preselected and related to the session topic. During the next 15 minutes, the facilitator will request clarifying questions, including questions from the audience and/or from topic specialists. Case recommendations/impressions will then follow. At the end of the hour, the facilitator will summarize recommendations.Topics covered will be selected from requests made by practitioners. A proposed schedule for the first year of the program has been developedand is based on input from Missouri food supply veterinarians.Schedules for year 2 will be made based on feedback. All selected topics will be related to food supply veterinary medicine, food safety, or public health and may include preventive medicine, reproduction, genomics, nutrition, toxicology, pathology, infectious diseases, medicine, and surgery of livestock species. All topic experts will be given a $100 honorarium for their time and involvement in the session.A schedule of topics will be made available and posted on the program website. Topics will be announced in ample amount of time to allow the Show-Me VET ECHO community the opportunity to submit information pertaining to cases they have seen related to the topic. Case information will be sent in and later disseminated to community members using Box(Box, Inc. Redwood City, CA, USA), the online file sharing platform. Box is a cloud-based file storage system, allowing access and sharing of large documents (including images and videos) to a group of people. The Box service has been approved by MU as secure for storage of all classifications of data. All documents in Box may be viewed, without downloading, preventing the viewer from having to store large files on their system. All cases submitted for discussion will have client/farm information redacted prior to circulation. Any community member that submits information will be asked prior to the scheduled videoconference if they are willing to present the case (which is preferred) or if they would prefer to have it discussed with the group while remaining anonymous. Information pertaining to specific cases will be submitted through the Show-Me VET ECHO Box program, allowing MU ECHO and program coordinators time to disseminate the information to the topic expert prior to the scheduled topic videoconference.Veterinarians will be encouraged to participate in the Show-Me VET ECHO community and participate in the videoconferences, as attendance at each videoconference will count as one hour of CE credit through MU Continuing Education. Also, to advertise the program and allow dissemination of information to participants unable to attend, the 15-minute didactic portion of the videoconference will be recorded and uploaded onto the Show-Me VET ECHO webpage as a mini webinar, freely available to interested parties. Additionally, during the funding period supplemental diagnostic tests at MU VMDL for cases being presented during a videoconference session will be supported through the grant.The results of the program will be communicated to stakeholders and the public through the Show-Me VET ECHO webpage as well as presentations at local and state MVMA meetings. Additionally, after three years of the program, demographic and satisfaction survey results will be summarized and analyzed for peer-reviewed publication. Information will be submitted for review to a selected refereed journal subscribed to by practicing veterinarians, such as the Journal of the American Veterinary Medical Association.

Progress 09/01/23 to 08/31/24

Outputs
Target Audience:Target audience for this project includes rural veterinarians, food animal veterinarians, veterinary students, and veterinary technicians. We reached our target groups through our seminar series that was presented once monthly. Over the last year we provided 12 virtual sessions and each session included a food animaldidactic topic and a case presentation. Overall, a median of 38 people (range: 22-76) attended each session. The target audience was also reached through advertisement of each session, which was done through email communications and social media platforms. We also reached target audiences by presenting data on our program at 1 national and 1 local conference. Conference attendees included program directors for other states that provide similar seminar series, with the goal of expanding these programs into more veterinary communities. Changes/Problems:No major changes or problems occured. This program was successfully establish and we were able to achievethe planned goals. What opportunities for training and professional development has the project provided?The primary focus of this project was training and professional development. Each VET ECHO session was provided to veterinarians, veterinary students, and veterinary technicians. The sessions provided a didactic portion that focused on food animal topics as well as a case presentation that was done by either a member of the program hub team or someone in private practice. Continuing education credits were available for veterinarians for each session attended. How have the results been disseminated to communities of interest?Information about the project has been disseminated to the community through multiple routes. First, we communicated about each session through emails as well as through social media posts. We discussed the program as a whole at local and statewide veterinary organization meetings, such as the Missouri Veterinary Medical Association (MVMA) annual conference and chapter meetings of the regional MVMA associations. Results of the project were also communicated at two meetings, one state level meeting and one national level meeting. Both events focused on the ECHO model as a whole and at both events we presented our VET ECHO program and discussed how this educational model can be used in the veterinary community and is useful for reaching veterinary practitioners that struggle to get away to attend larger in person continuing education events. What do you plan to do during the next reporting period to accomplish the goals?This project is ending, however we do plan to continue to hold monthly continuing education sessions following the same format. The USDA funding has provided us the ability to establish this program and now we are able to keep it going, continuing to provide monthly food animal continuing education opportunities for our veterinary community.

Impacts
What was accomplished under these goals? During the reporting period, we focused on Objective 2, as Objective 1 was completed in previous years. Over the last year, we provided 12 monthly, case-based, videoconference meetings for members of the Show-ME VET ECHO community. Topics covered over the last year have included bovine leukosis, backyard poultry, urinary obstruction in small ruminants, leptospirosis, orthopedic concerns in show pigs, joint disease in small ruminants, and more. We were also able to incorporate information about timely topics, such as Theileria and Highly Pathogenic Avian Influenza in dairy cattle, sharing updates on these topics with all participants. Over the course of the year, cases were presented at 10/12 presentations. Cases were presented by members of academia on 4/10 presentations and from private practice veterinarians on 6/10 presentations. Overall, sessions were attended by a median number of 38 people/session with a range of 22-76 people/session.

Publications


    Progress 09/01/20 to 08/29/24

    Outputs
    Target Audience:Throughout the project, the target audiences were rural veterinarians, food animal veterinarians, veterinary students, and veterinary technicians. The primary means of reaching these targeted audiences was through the creation of once monthly virtual case-based continuing education sessions. The program that was developed during this project is call the Show-Me VET ECHO program. The program was modeled off of the University of Missouri ECHO (Extension for Community Healthcare Outcomes) program,https://showmeecho.org. Using this model of interactive sessions with an interdisciplinary team of specialists (hub members), we were able to create a program that focused on continuing education for the rural and food animal community. Beyond the continuing education sessions, members interested in the program were reached through advertisement of our program website, https://showmeecho.org/clinics/veterinary-education-training/ . On the website, interested parties can register for the program. Once registered, the participant gets monthly emails to remind them about upcoming sessions, inform them about the topics to be covered at the upcoming sessions, and provide a link to log into each session. Information about the website was shared on social media, through local and national food animal veterinary listservs, and through advertisement at in person veterinary continuing education meetings. Changes/Problems:There are no major changes or problems to report. This program was successfully created and implemented. We plan to continue to run the program beyond the life of the grant. This funding provided the necessary financial support to get this program started and we can now continue to operate and to provide ongoing educational opportunities to our target populations. What opportunities for training and professional development has the project provided?The focus on this program was training and professional development opportunities. All sessions were open and advertised to rural and food animal veterinarians, veterinary students, and veterinary technicians. Overall, we offered a total of 42 continuing education sessions that provided professional development to attendees. We were able to provide content to over 450 individual participants that attended at least one session. How have the results been disseminated to communities of interest?Results of this project have been disseminated through presentations at local and national conferences. We have presented data on the program at a national ECHO conference. The conference was focused on all ECHO programs, which primarily target human medicine and educational fields. At this conference we presented data on our VET ECHO to try to encourage more veterinary based ECHO programs, which would provide more virtual learning opportunities to the target audience. We also presented results at the Missouri Veterinary Medical Association annual meeting, providing data on the program results and also advertised the program. We plan to publish the results of the program in a peer reviewed journal to share results and hopefully share the idea, which could easily be replicated by others. What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

    Impacts
    What was accomplished under these goals? The long-term goal of the proposal was to create a sustainable, virtual continued education (CE) program for rural and food animal veterinarians, veterinary students, and veterinary technicians. We were able to successfully accomplish this long-term goal and have a sustainable program that will continue into the future, beyond the life of this grant. Objective 1: Creation of the online, Show-Me ECO network community. This goal was accomplished by creating a program specific website,https://showmeecho.org/clinics/veterinary-education-training/ . The website was used for advertisement. Additionally, on the website, interested parties could register for the program. Once registered, participants would automatically get monthly reminders about upcoming sessions, information about topics to be covered at each session, and also the link to the virtual session. On the day of the specific sessions, all registered participants would get an additional email right before the event as a way to provide short term reminders. The website also provides a location for interested parties to submit a case. Cases were presented at each CE sessions as part of the educational discussion. The website also includes information about the specialist hub team, a group of veterinarians that were selected to provide expert input on specific topics related to food animal medicine. Objective 2: Develop a monthly, case-based, videoconferences with members of the Show-Me VET ECHO community. This objective was successfully completed. We offered a total of 42 virtual sessions. Each session had a didactic presenter, which includes topic experts identified and selected to participate. Topic experts were people from all over the country that were willing to participate. Cases were also presented at 34/42 (81%) virtual session. Cases were presented by veterinarians in academia or in private practice. As the program developed, we saw growth in participation. In the first year (2021) we had a median of 25 participants/session, which grew to 30/session in 2022, 55/session in 2023, and 38/session in 2024. Overall, we had over 450 individual participants that attended at least one session.Topics covered included bovine, small ruminant, poultry, swine, bee, deer, and nonspecific topics. Topic selection was completed by the hub team members and input from participant surveys were used in the selection of topics. Survey's were conducted to evaluate content and were completed by those that attended at least one session. In general, participants thought the most helpful aspect of the VET ECHO was the case presentation and discussion (74%), followed by the didactic lecture and presentation (53%).

    Publications


      Progress 09/01/22 to 08/31/23

      Outputs
      Target Audience:The target audience for this project is food animal, mixed animal, and rural veterinarians, veterinarian technicians, and interest veterinary students. We have reached our audience by providing 12 sessions (1 session/month) of virtual continuing education. Our continuing education program is free,open to the public, and accessible online. To date, more than 269 different participants have attended our sessions. In 2022, a median of 30 people attended each session and tso far in 2023, a median of 56 people have attended each session. All sessions topics are food animal focus topics, with the majority of topics being related to bovine health and a minority of topics relating to swine, poultry, bees, deer, and none species specific. Changes/Problems:There have been no major challenges. We have been granted a one year extension. We asked for the extension because we wanted to try to work on getting more practicing veterinarians involved in the case presentation component of the program. We have funding to provide support for some diagnostic proceduresand we plan to offer support for casesif the veterinarianis willing to present the case at a VET ECHO session. We also plan to use the extension to work on broadening our outreach to interest groups, by presenting data from this program nationally through a scientific meeting and publication. What opportunities for training and professional development has the project provided?We have successfully provided a total of 30 (1 session/month) continuing educationsessions, each session worth 1 CE hour, provided by the University of Missouri. All sessions are open to veterinarians, veterinary technicians, and veterinary students. How have the results been disseminated to communities of interest?We advertise about our program to local veterinarians and veterinary students through our Veterinary Medical Association CE events, including both local chapter meetingsand the annual meetings. We also advertise to all within the University of Missouri CVM, providing notification about each months sessions. We further advertise through our CVM Facebook website, which gets shared with other Facebookveterinary interest groups. What do you plan to do during the next reporting period to accomplish the goals?During the next reporting period, we plan to continue to hold continuing education sessions, continuing to hold 1/month. We also plan to use funds to increase case presentations of local veterinarians. We hope to work to get more vets interested in presenting cases, helping to stimulate discussion and a community of support for challenging cases. Additionally, we will be providing a scientific presentation about the program at the upcoming MetaECHO global conference in Albuquerque NM (September 18-21). This conference is attended by ECHO leaders (mostly medical and public health groups), governmnet officials, funders, industry experts, and more. We hopethis presentation will provide a plateform to share the idea of veterinary based ECHOs and demonstration how this program could be useful for other veterinary communities. We also plan to publish a manuscript about our program in the journal of Veterinary Education. We hope this again will provide information to the veterinary community about the idea of veterinary based ECHOs and how they could be successful for other groups.

      Impacts
      What was accomplished under these goals? All project goals have successfully been accomplished and the program is ongoing. The program has created an online format for participants to join the VET ECHO community. We havealso developed monthly, case-based, virtual sessions for members of the community. Since the start of the program, we have successfully held 30 virtual continuing education sessions that are avaialble to the veterinary community. All session are based on food animal topics and cases, with the focus of our work being on rural food animal or mixed animal veterinarians, veterinary technicians, and interested veterinary students. We plan to continue to hold monthly CE sessions throughout 2023.

      Publications


        Progress 09/01/21 to 08/31/22

        Outputs
        Target Audience:The target audiences reached during the reporting period included veterinarians, veterinary students, animal scientists, nurses, pharmacy students, and those working with the Missouri or U.S. department of agriculture. Our ultimate goal is to reach veterinarians in rural settings. All audiences have been reached through our virtual educational program. We are currently offering once monthly virtual continuing education sessions. During the sessions we have a short didactic lecture, a case presentation, and time for questions and discussion. Over the last year, we have held 12 virtual sessions.Holding once monthly sessions was the plan and we have met that expectation.Over the last year, we have had 235 people register to join the VET ECHO community and 88 unique learners have attended our VET ECHO sessions. We have reached audiences from 25different counties in Missouri. On average, there are 27 attendees per VET ECHO session. Changes/Problems:No major changes have been made to this program. We have been able to successfully implement our plan as stated in our proposal. What opportunities for training and professional development has the project provided?This year we have held a total of 12 professional development sessions. Each session has been worth 1 hour of veterinary continuing education credit through the University of Missouri. All session have been conducted through virtual meetings and all session has been open to the target audience. All sessions have been attended by veterinarians, veterinary students, animal scientists, and others. How have the results been disseminated to communities of interest?We have disseminated information about the program to the target audience through several avenues. We have announced the program through theMissouri Department of Agriculture veterinary listserv and also used this communication route to advertise our survey to get input on topic suggestions. We have also advertisedabout the program with Missouri veterinarians through our state veterinary medical association annual meeting as well as during regional association meetings. At the annual MVMA meeting we gave a sample presentation to help veterinarians learn how each session works.We advertise each month through University of Missouri social media platforms, including facebook pages. We sent out a reminder each month to the University of Missouri Bovine Club to advertise to the student body.We also send members of the VET ECHO community monthly email reminders about upcoming sessions. What do you plan to do during the next reporting period to accomplish the goals?During the next reporting year, we will continue to have monthly virtual continuing education sessinos. All sessions will continue to be based on food animal topics. We will continue to ask for feedback from our attendees as well as an open target audience to determine if changes need to be made to the program and also help us to develop the session program. Our sessions have had increased attendance compared to the first 6 months, but we will continue to advertise the program through social media, student groups, and local veterinary organization meetings.

        Impacts
        What was accomplished under these goals? Objective 1: The work for this objective was completed durng the last reporting period. The website has remained open and functional. We have continued to have people register for the program. Those that register get monthly emails with session information and a zoom link to the meetings. Objective 2: At the end of last year, we developed a survey to get input from Missouri veterinarians on topic suggestions. This information was used to develop the 2022 program. We have worked to diversity our presenters this year and have included presenters not only from academic, but also from industry and private practice. Based on feedback, we have also incorporated more topics on minor species, including small ruminants and honeybee medicine.

        Publications


          Progress 09/01/20 to 08/31/21

          Outputs
          Target Audience:The target audiences reached during the reporting period included veterinarians, veterinary students, animal scientists, nurses, pharmacy students, and those working with the Missouri or U.S. department of agriculture. Our ultimate goal is to reach veterinarians in rural settings. To date, we have reached audiences from 6 different states (AR, IA, KS, LA, MO, and OK), including 26 different counties. All audiences have been reached through our virtual educational program. We are currently offering once monthly virtual continuing education sessions. During the sessions we have a short didactic lecture, a case presentation, and time for questions and discussion. To date, we have held 6 virtual sessions. The first session was held in March 2021 and we have had one monthly through August 2021. Changes/Problems:No major changes have occurred. We have been able to reach our goals as expected and plan to continue as planned. What opportunities for training and professional development has the project provided?To date, 6 professional development sessions have been held. Each session has been worth 1 hour of veterinary continuing education credit through the University of Missouri. All session have been conducted through virtual meetings and all session has been open to the target audience. All sessions have been attended by veterinarians, veterinary students, animal scientists, and others. How have the results been disseminated to communities of interest?We are communicating about the program through several avenues. We have announced the program through our state veterinary medical association newsletters as well as through the Missouri Department of Agriculture veterinary listserv. We have talked about the program with Missouri veterinarians through our state veterinary medical association annual meeting as well as during regional association meetings. We advertise each month through University of Missouri social media platforms. We also send members of the VET ECHO community monthly email reminders about upcoming sessions. What do you plan to do during the next reporting period to accomplish the goals?During the next year, we plan to continue to hold monthly virtual continuing educational sessions. All sessions will be based on food animal topics, all of which have been requested by practicing veterinarians. We have had some suggestions of topics that members would like to hear and we plan to incorporate those suggestions into the upcoming program. Although we have successfully developed the program, one area that we will continue to work on is increasing the attendance at each session. We are currently reaching some members of the target audience, but would like to reach more. We will increase our advertising by sending fliers through the mail, reaching out to veterinarians directly, and increase face to face communication about the program with veterinarians throughout the state. We hope to do this through attending local more events (regional meetings).

          Impacts
          What was accomplished under these goals? Objective 1: Creation of the online, Show-Me VET ECHO networking community A website for our program has been created ( https://showmeecho.org/clinics/veterinary-education-training/ ). Through the website, the target audience members learn about the program, includes the goals and objectives of the program, what the program offers, and information about topics that are covered through the sessions. The website also includes information about the expert team that participate in all virtual sessions. The program coordinators contact information is present on the website as well as a button to register for the program. One the register button is selected, one can easily register for the program. When registering, contact information and demographics are collected. The contact information is then used to send emails to all registered members to remind them about upcoming virtual sessions and to share zoom links to enable one to log on and attend the virtual session. Objective 2: Development of monthly, case-based, videoconferences with members of the Show-Me VET ECHO community. To date, 6 monthly videoconference sessions have occurred. Each session has been attended by members of the target community, with a median number of 17 community attendees (range: 12-20). Each session has included approximately 20 minutes of didactic lecture, 20 minutes of case presentation and discussion, and 10 minutes of overall discussion. The feedback about these first sessions have been good, with most rating the session as good to excellent.

          Publications