Background After completing university education, biomedical laboratory scientists work in clinical laboratories, in biomedical research laboratories, in biotech, and in pharmaceutical companies. Laboratory diagnostics have undergone rapid development over the recent years, with the pace showing no signs of abatement. This rapid development challenges the competence of the staff and will most certainly influence the education of future staff. This study aimed to examine what was considered the necessary competencies needed to pursue a career as a biomedical laboratory scientist. Methods A modified Delphi technique was used, with the panel of experts expressing their views in a series of three questionnaire. Consensus was defined as the point which 75 % or more of the panel participants agreed that a particular competency was necessary. Results The study highlights the perceived importance of mostly generic competencies that relate to quality, quality assurance, and accuracy, as well as different aspects of safety, respect, trustworthiness (towards patients/clients and colleagues), and communication skills. The results also stress the significance of self-awareness and professionality. Conclusions We identified important competencies for biomedical laboratory scientists. Together with complementary information from other sources, i.e., guidelines, laws, and scientific publications, the competencies identified can be used as learning outcomes in a competency-based education to provide students with all the competencies needed to work as professional biomedical laboratory scientists.

Salivary pellicles display exceptional hydration and lubrication performance. At present, there are still gaps in the understanding of how this is achieved. The aim of this thesis was therefore to increase our knowledge on the mechanisms underlying these properties and deepen the understanding of how they are related to the composition and structure of pellicles, with a focus on those formed under in vitro conditions. This has applications ranging from the development of artificial saliva and lubricating coatings for biomedical applications to methodological approaches for initial testing of oral healthcare products. For this, we also focused on developing suitable methodological approaches for these studies, centering on atomic force microscopy, quartz crystal microbalance with dissipation monitoring, ellipsometry and neutron reflectometry techniques, to investigate in vitro and model salivary pellicles.

First, we confirmed a two-layer structure for in vitro salivary pellicles and showed that the outer layer is mainly composed by the oral mucin MUC5B, but that it also contains other salivary components that enhance swelling and hydration. In the presence of bulk saliva, the outer layer also contains a reversibly and loosely bound fraction. This fraction increases the adhesiveness of the pellicle but unexpectedly has no significant effect on its lubrication performance. We also investigated the effect of mechanical confinement on model salivary pellicles by means of Neutron Reflectometry, revealing that at a pressure of 1 bar they are already completely compressed and dehydrated. Finally, with the aim to advance towards better oral healthcare products, we investigated the effect of nonionic and amphoteric surfactants on salivary pellicles, showing that they have a gentler effect on pellicle structure than the commonly employed anionic surfactants.

Antibodies have become a critical component of many diagnostic assays and are used for therapeutic purposes. Nevertheless they often fail to meet the strict performance demands raised in industry and in the clinic (e.g. stability, reproducibility, selectivity, affinity). These issues are especially notable for assays targeting post translational modifications (PTM) of proteins (phosphorylation, glycosylation, sulfation etc.). Antibody-based technologies suffer from problems of a more general nature associated with the analytical use of biological receptors i.e.: i) limited stability requiring cold chain logistics, ii) high production costs, iii) batch to batch variability. The above emphasizes the need for alternative robust, reproducible and low cost “binders” and assays. The aim in this thesis is to design, develop and test molecularly imprinted polymers (MIPs) which were synthesized epitope and stoichiometric imprinting approaches targeting phosphorylation as a PTM. Protein phosphorylationis one of the most common PTM, which is based on covalent attachment of phosphate group to particular amino acids. Misregulation of phosphorylation process is found related with diseases such as cancer, diabetes, and neurodegeneration. MIPs are synthesized through copolymerization of functional monomers and crosslinkers in the presence of N- and C- terminal protected templates. The key recognition element employed in developed synthetic receptors was 1,3-diaryl urea functionalmonomer 1. This monomer is a potent hydrogen bond donor forming strong cyclichydrogen bonds with oxyanions. Amino acid sequence specific and side chain imprinted binders were prepared targeting phosphorylation on tyrosine (pTyr) and on histidine (pHis). pHis MIP-based approach is proposed as a solution to enrich pHis peptides in the presence of other phosphoesters such as phosphoserine (pSer) in complex mixture without pre-treatment like β-elimination. In pTyr, ZAP-70 (zeta associated 70 kDa protein), which is prognosticator for chronic lymphocytic leukemia (CLL), and pTyr-sequence specific motif Src-SH2 domain were chosen as targets to evaluate regio- or stoichiometric selectivity performance of imprinted polymers. The synthesized polymers are used as effective enrichment tools for target phosphorylated peptides from complex mixture prior to mass spectrometry. Overall, the results demonstrate unique proteomics enrichment tools that link with personalized medicine relying on diagnostic coupled cancer treatment strategies based on kinase inhibitors.

Sialic acids are an important family of monosaccharides that are typically found as terminal moieties of glycans. Aberrant sialylation has been proven to correlate with various diseases including cancer. Glycosylation analysis is complex due to high diversityof the glycan isomers and their low abundance. Antibodies and lectins are commonly used in glycan purification and enrichment. However, high cost, poor availability, and limitation in storage/testing conditions hinders their application on a broader scale. This thesis is focused on the development of alternative glycan specific receptors with their potential applications in glycomics and cell imaging. The underlying technique for producing the synthetic receptors is molecular imprinting. Highly complementary binding sites are formed by fixing pre-ordered template/functional monomer complexes into a highly crosslinked polymer matrix. Fundamental investigation of this intermolecular imprinting approach in the imprinting of glycosylated targets is reported here. The core of this study focuses on the elucidation of relative contribution of orthogonally interacting functional monomers, their structural tuning and the importance of monomer, solvent and counterion choice on the imprinting. Molecularly imprinted polymers (MIPs) are developed as particles of different sizes for glycan/glycopeptide enrichment applications or combined with fluorescent reportergroups for use as glycan imaging nanolabels. Special attention is given to the improvement of sialic acid MIP selectivities toward particular structures associated with cancer biomarkers. Development of MIPs against such complex targets includes design of linkage selective MIPs with comprehensive studies of the affinities and selectivities of the final glycan specific materials.

Aberrant sialic acid expression is one of the key indicators of pathological processes. This acidic saccharide is overexpressed in tumor cells and is a potent biomarker. Development of specific capture tools for various sialylated targets is an important step for early cancer diagnosis. However, sialic acid recognition by synthetic hosts is often complicated due to the competition for the anion binding by their counterions, such as Na+ and K+. Here we report on the design of a sialic acid receptor via simultaneous recognition of both the anion and cation of the target analyte. The polymeric receptor was produced using neutral (thio)urea and crown ether based monomers for simultaneous complexation of sialic acid's carboxylate group and its countercation. Thiourea and urea based functional monomers were tested both in solution by 1H NMR titration and in a polymer matrix system for their ability to complex the sodium salt of sialic acid alone and in the presence of crown ether. Combination of both orthogonally acting monomers resulted in higher affinities for the template in organic solvent media. The imprinted polymers displayed enhanced sialic acid recognition driven to a significant extent by the addition of the macrocyclic cation host. The effect of various counterions and solvent systems on the binding affinities is reported. Binding of K+, Na+ and NH4+ salts of sialic acid exceeded the uptake of bulky lipophilic salts. Polymers imprinted with sialic or glucuronic acids displayed a preference for their corresponding templates and showed a promising enrichment of sialylated peptides from the tryptic digest of glycoprotein bovine fetuin.

Atherosclerosis is the main killer in the west and therefore a major health challenge today. Total serum cholesterol and lipoprotein concentrations, used as clinical markers, fail to predict the majority of cases, especially between the risk scale extremes, due to the high complexity in lipoprotein structure and composition. In particular, low-density lipoprotein (LDL) plays a key role in atherosclerosis development, with LDL size being a parameter considered for determining the risk for cardiovascular diseases. Determining LDL size and structural parameters is challenging to address experimentally under physiological-like conditions. This article describes the biochemistry and ultrastructure of normolipidemic and hypertriglyceridemic LDL fractions and subfractions using small-angle X-ray scattering. Our results conclude that LDL particles of hypertriglyceridemic compared to healthy individuals 1) have lower LDL core melting temperature, 2) have lower cholesteryl ester ordering in their core, 3) are smaller, rounder and more spherical below melting temperature, and 4) their protein-containing shell is thinner above melting temperature.

Peptide oligomerization dynamics affects peptide structure, activity, and pharmacodynamic properties. The thrombin C-terminal peptide, TCP-25 (GKYGFYTHVFRLKKWIQKVIDQFGE), is currently in preclinical development for improved wound healing and infection prevention. It exhibits turbidity when formulated at pH 7.4, particularly at concentrations of 0.3 mM or more. We used biochemical and biophysical approaches to explore whether the peptide self-associates and forms oligomers. The peptide showed a dose-dependent increase in turbidity as well as α-helical structure at pH 7.4, a phenomenon not observed at pH 5.0. By analyzing the intrinsic tryptophan fluorescence, we demonstrate that TCP-25 is more stable at high concentrations (0.3 mM) when exposed to high temperatures or a high concentration of denaturant agents, which is compatible with oligomer formation. The denaturation process was reversible above 100 µM of peptide. Dynamic light scattering demonstrated that TCP-25 oligomerization is sensitive to changes in pH, time, and temperature. Computational modeling with an active 18-mer region of TCP-25 showed that the peptide can form pH-dependent higher-order end-to-end oligomers and micelle-like structures, which is in agreement with the experimental data. Thus, TCP-25 exhibits pH- and temperature-dependent dynamic changes involving helical induction and reversible oligomerization, which explains the observed turbidity of the pharmacologically developed formulation.

The thesis is focused on biological electric power sources based on transparent and flexible nanostructured electrodes. The power generating part of these biodevices was decorated with different biomaterials electrically wired to transparent electrodes based on either thin gold films, or indium tin oxide. Planar electrodes were additionally nanostructured by applying different nanomaterials to the electrode surfaces (such as indium tin oxide nanoparticles, graphene, carbon nanotubes) or by using nanoimprint lithography to increase the real surface area and thus boost enzyme loading. Bilirubin oxidase was used a cathodic biocatalyst for oxygen electroreduction, whereas different biomaterials were exploited as anodic bioelements, viz. redox enzymes (cellobiose and glucose dehydrogenase, as well as glucose oxidases) and thylakoid membranes, for glucose electrooxidation and light harvesting, respectively. Charge-storing parts of biodevices were based on electroconducting polymers, e.g. poly(3,4-ethylenedioxythiophene), carbon nanotubes, graphene, and indium tin oxide nanoparticles. The bioelectrodes were characterised in detail electrochemically, and also using scanning electron microscopy and atomic force microscopy. Transparent, membrane-free enzymatic fuel cells, as well as chemical and solar biosupercapacitors were assembled and basic parameters of biodevices, viz. open-circuit voltages, power and charge density, as well as stability, were studied in continuous and pulse operating modes.

The adsorption from 0.2% (w/w) chlorhexidine and black tea solutions onto an in vitro pellicle from whole unstimulated saliva on hydroxyapatite discs was studied by ellipsometry. It was found that chlorhexidine adsorbed to the pellicle causing a modification of the pellicle properties, leading to a subsequent increase in adsorption of salivary and black tea components. There was a distinct order of addition effect, whereby chlorhexidine followed by black tea gave an overall greater adsorption of components compared to black tea followed by chlorhexidine. This increase in adsorption gave a concomitant increase in colour or stain as measured by a reflectance chromameter. The increase in adsorbed amounts and stain was modified in part by the adsorption of salivary fractions between the chlorhexidine and black tea treatments. In all cases, the chlorhexidine and black tea modified pellicles were not readily removed by either phosphate or sodium dodecyl sulphate rinses. Thus, following chlorhexidine exposure, the accelerated adsorption of salivary and black tea components can ultimately lead to increased staining of the pellicle.

Structural properties of the acidic proline rich protein PRP-1 of salivary origin in bulk solution and adsorbed onto a negatively charged surface have been studied by Monte Carlo simulations. A simple model system with focus on electrostatic interactions and short-ranged attractions among the uncharged amino acids has been used. In addition to PRP-1, some mutants were considered to assess the role of the interactions in the systems. Contrary to polyelectrolytes, the protein has a compact structure in salt-free bulk solutions, whereas at high salt concentration the protein becomes more extended. The protein adsorbs to a negatively charged surface, although its net charge is negative. The adsorbed protein displays an extended structure, which becomes more compact upon addition of salt. Hence, the conformational response upon salt addition in the adsorbed state is the opposite as compared to that in bulk solution. The conformational behaviour of PRP-1 in bulk solution and at charged surfaces as well as its propensity to adsorb to surfaces with the same net charge are rationalized by the block polyampholytic character of the protein. The presence of a triad of positively charged amino acids in the C-terminal was found important for the adsorption of the protein.

The hydrophobic interaction between two methane molecules in salt-free and high salt-containing solutions and the structure in such solutions have been investigated using an atomistic model solved by Monte Carlo simulations. Monovalent salt representing NaCl and divalent salt with the same nonelectrostatic properties as the monovalent salt have been used to examine the influence of the valence of the salt species. In salt-free solution the effective interaction between the two methane molecules displayed a global minimum at close contact of the two methane molecules and a solvent-separated secondary minimum. In 3 and 5 M monovalent salt solution, the potential of mean force became slightly more attractive and in a 3 M divalent salt solution the attraction became considerably stronger. The structure of the aqueous solutions was determined by radial distribution functions and angular probability functions. The distortion of the native water structure was increased with ion valence. The increase of the hydrophobic attraction was associated with (i) a breakdown of the tetrahedral structure formed by neighboring water molecules and of the hydrogen bonds between them and (i) the concomitant increase of the solution density.

Dimethyldodecylamine-N-oxide (DDAO) has only one polar atom that is able to interact with water. Still, this surfactant shows very hydrophilic properties: in mixtures with water, it forms normal liquid crystalline phases and micelles. Moreover, there is data in the literature indicating that the hydration of this surfactant is driven by enthalpy while other studies show that hydration of surfactants and lipids typically is driven by entropy. Sorption calorimetry allows resolving enthalpic and entropic contributions to the free energy of hydration at constant temperature and thus directly determines the driving forces of hydration. The results of the present sorption calorimetric study show that the hydration of liquid crystalline phases of DDAO is driven by entropy, except for the hydration of the liquid crystalline lamellar phase which is co-driven by enthalpy. The exothermic heat effect of the hydration of the lamellar phase arises from formation of strong hydrogen bonds between DDAO and water. Another issue is the driving forces of the phase transitions caused by the hydration. The sorption calorimetric results show that the transitions from the lamellar to cubic and from the cubic to the hexagonal phase are driven by enthalpy. Transitions from solid phases to the liquid crystalline lamellar phase are entropically driven, while the formation of the monohydrate from the dry surfactant is driven by enthalpy. The driving forces of the transition from the hexagonal phase to the isotropic solution are close to zero. These sorption calorimetric results are in good agreement with the analysis of the binary phase diagram based on the van der Waals differential equation. The phase diagram of the DDAO-water system determined using DSC and sorption calorimetry is presented.

EARLY ACTIVATION MARKERS EXPRESSED BY HUMAN PERIPHERAL DENDRITIC CELLS Peter Hellman and Håkan Eriksson University of Malmoe, Department of Biomedical Laboratory Science E-mail address: peter.hellman@hs.mah.se Two major populations of immature dendritic cells, myeloid (M-DCs) and plasmacytoid (P-DCs) can be identified in human peripheral blood. Activation of these subsets through their Toll-like receptors (TLRs) (TLR4 for M-DCs and TLR9 for P-DCs) induced production of the chemokine Il-8, already within two hours of stimulation. The production of IL-8 preceded the expression of the activation marker CD40 in both M-DCs and P-DCs. Although both populations of DCs secreted Il-8 upon activation, the levels of Il-8 produced was several times higher in the M-DCs compared to the P-DCs population. Before activation both subsets of DCs expressed the IL-8 receptor type B (CD128b), however, upon stimulation the Il-8 receptor became undetectable in both M-DCs and P-DCs. Increased expression of MHC class II molecules is regarded as an early activation marker of DCs. However, only the P-DCs showed a significantly increased expression of MHC class II after 4 hours of stimulation through TLR9. Noteworthy, the M-DCs showed an unexpected increase of MHC class II molecules after conditioning in medium for 4 hours, and no further increase in MHC class II expression after stimulation through TLR4 was observed. In conclusion, we propose that during activation of human DCs the production of Il-8 and loss of CD128b are the earliest signs of activation preceding both MHC class II, CD40, CD80 and CD86 expression.

Nano-meter sized particles of de-aluminated zeolite Y has a high adsorption capacity of both low molecular weight bio-molecules and macromolecules. In this study we used de-aluminated zeolite Y as a novel approach to study the mechanisms of endocytosis in immature human peripheral blood dendritic cells (DCs). Probes detecting pH neutral and acidic endosomes were adsorbed to the zeolite and used as a tracer of the endosomal pathway of a cell in the form of acidification and lysosomal function. Both the myeloid (M-DCs) and the plasmacytoid (P-DCs) dendritic cell subsets showed an endocytosing capacity comparable to peripheral blood monocytes but only the M-DCs were able to form acidic endosomes after internalization of zeolite particles. Furthermore, during lipopolysaccharide (LPS) stimulation of the DCs population, an enhanced induction of acidic endosomes was only seen in the M-DC population. Proteolytic degradation of endocytosed proteins was detected using self-quenched DQ-ovalbumin adsorbed to zeolite particles and our results showed a clear difference between the two DC populations. The M-DC population, that showed formation of acidic endosomes, also showed proteolytic degradation of ovalbumin. The P-DC population on the other hand, showed no formation of acidic and no proteolytic degradation of ovalbumin. Various bio-molecules can be adsorbed by de-aluminated zeolites and in conclusion we propose the use of zeolite particles as a useful tool in the study of the endocytosing mechanisms of a cell.

The contribution of nonspecific interactions to the overall interactions of thiol-ssDNA and dsDNA macromolecules with gold nanoparticles was investigated. A systematic investigation utilizing dynamic light scattering and cryogenic transmission electron microscopy has been performed to directly measure and visualize the changes in particle size and appearance during functionalization of gold nanoparticles with thiol-ssDNA and nonthiolated dsDNA. The results show that both thiol-ssDNA and dsDNA do stabilize gold nanoparticle dispersions, but possible nonspecific interactions between the hydrophobic DNA bases and the gold surface promote interparticle interactions and cause aggregation within rather a short period of time. We also discuss the adsorption mechanisms of dsDNA and thiol-ssDNA to gold particles.

The aim is to illuminate aspects of dental hygienists' work in multiethnic/multicultural societies, with focus on the intersection between the institutional activity and migration, ethnic diversity and culture issues. Hence, a tension between equality and diversity are discussed. The thesis has two analytical approaches, practice and discourse. The focus is on talk-in-interaction with patients (practice) and how the dental hygienist conceptualise their work when treating people with migrant background (discourse). The theoretical and methodological considerations are drawn from the sociological tradition of "Verstehen", Foucault and discourse analysis. The empirical material is based on documented observations (VCR) and interviews with dental hygienists and patients. The analysis of practice suggests that the interaction is organised by the institutional activity type. A patient’s readiness to position oneself as a "knowing subject", opposed to ethnicity, is crucial to how the interaction is structured. Migration related categories and phenomenon are related to the institutional task and understood as situated including practices. In discourse, ethnicity intersects with gender and class. The patient's power resources are of vital importance in a discourse on "immigrant patients". The hygienists relates to culture, in terms of relationship with dental care. References in exclusionary discourses were also found. Based on multilayered findings and theories of multiculturalisms, the concept of culture is discussed in connection to agency, ethics of care and equal treatment.

High levels of the triacylglycerol-rich lipoproteins, very low density lipoprotein (VLDL) and intermediate density lipoprotein (IDL) have been identified as independent risk factors for coronary heart disease, and inflammation is thought to contribute to atherosclerosis and its complications. To understand how dyslipidemia promotes inflammation, we have characterised the effects of VLDL treatment on production of tumor necrosis factor-α (TNF) by human monocyte-derived macrophages. VLDL strongly potentiated lipopolysaccharide (LPS)-induced expression of TNF mRNA and secretion of TNF protein. VLDL activated mitogen-activated protein kinase-ERK kinase 1/2 (MEK1/2), and potentiated LPS-induced MEK1/2 activation. The MEK1/2 inhibitor U0126 strongly diminished TNF expression, indicating that MEK1/2 plays a central role in the regulation of TNF expression. VLDL did not activate transcription factors NF-κB and PPAR-γ, but it activated AP-1 at least as potently as LPS, and potentiated LPS-induced activation of AP-1. The inhibitor U0126 completely prevented this potentiation. Inhibition of AP-1 by decoy oligonucleotides abolished potentiation of TNF secretion by VLDL. In conclusion, VLDL treatment potentiates TNF expression in macrophages by activation of MEK1/2 and AP-1. These findings suggest that triacylglycerol-rich lipoproteins are involved in inflammatory processes associated with atherosclerosis.

The role of saliva in the oral cavity is manifold; an important function is to serve as lubricant between hard (enamel) and soft (mucosal) tissues. Intraoral lubrication is of crucial importance in order to maintain functions such as deglutition, mastication and the faculty of speech. A large number of people suffer from impaired salivary functions, displaying symptoms such as 'dry mouth'. This results in a need for methods to assess the lubricating properties of both native saliva and potential artificial saliva formulations. Here, normal as well as lateral forces, acting between adsorbed salivary films, have been measured for the first time by means of colloidal probe atomic force microscopy (AFM). It was found that the presence of salivary pellicles between hard surfaces reduces the friction coefficient by a factor of 20. This reduction of friction is consistent with the long-range purely repulsive nature of the normal forces acting between the salivary films. The lubricating mechanism is presumably based on a full separation of the sliding surfaces by the salivary films. The friction between salivary films has been investigated at normal loads that cover the clinical jaw closing forces, and it can be concluded that the lubricating properties are maintained within this load interval. The present study indicates the usefulness of colloidal probe AFM, which offers a direct and quantitative measure of lubrication at a molecular level, in the study of biotribological phenomena. In particular, the results obtained here may have implications for the development of saliva substitutes.

The adsorption of black tea and red wine components onto a pellicle-like protein layer formed in vitro by adsorption from whole unstimulated saliva on hydroxyapatite discs were studied by in situ ellipsometry. It was found that components from black tea readily adsorbed to the pellicle. Subsequent exposure to saliva led to further adsorption of salivary components to give an overall increase in the amounts adsorbed. The amounts adsorbed increased still further following a third tea and saliva exposure. Components of red wine gave significantly greater amounts of adsorption to the pellicle than black tea. The adsorption of components of black tea gave a concomitant increase in colour or stain as measured by a reflectance chromameter. In all cases, the black tea- and red wine-modified pellicles were not eluted by either phosphate buffer or sodium dodecyl sulphate (SDS) rinses. Thus, black tea and red wine components have been shown to have a profound effect on in vitro pellicle maturation, causing thickened layers of stained material to build up, which are not readily removed.

Competitive adsorption between B-casein and B-lactoglobulin (B-Lg) during spray-drying was studied by the new surface sensitive technique using fluorescence quenching of pyrene labelled protein at the powder surface. The difference in competitiveness of B-casein when present as monomers and as associated into micellar like structures were studied. Results were compared with the adsorption of single proteins at the powder surface. The adsorption of monomeric B-casein alone gave an apparent surface load of 1 mg/m2 at a protein concentration of 0.3% dry weight and then remained constant with an increasing protein concentration. In the presence of Ca2+, associated B-casein gave a lower affinity adsorption than monomeric B-casein and did not reach a plateau value, instead it continued to increase with an increasing protein concentration. B-Lg showed a low-affinity adsorption during spray-drying compared to monomeric B-casein, although not as low as associated B-casein. Competitive adsorption between monomeric B-casein and B-Lg resulted in a higher apparent surface load of B-casein than B-Lg at both protein concentrations studied (total 0.3 and 3.3% dry weight). However, in an associated form B-casein was less competitive than B-Lg. At a low bulk protein concentration (0.3% dry weight) B-Lg dominated the powder surface, whereas at a higher concentration (3.3% dry weight) there was little difference between the proteins. The results indicate that the competitiveness of a protein during spray-drying is highly influenced by the ability of the protein to attach and rearrange at the droplet's air?water interface during the spray-drying process.

This study compared respondents who completed an Internet sexuality questionnaire and those who dropped out before completion. The study was in Swedish and comprised 3,614 respondents over a 2-week period (53% males, 47% females). There were significant differences between males, of whom 51% dropped out before completion of the 175-item questionnaire, and females, of whom 43% dropped out. Dropout in both genders followed a curve of negative acceleration. The data suggest that dropout is likely to be significant and gender and demographically biased, and to occur significantly earlier for men than for women. Geography, education, sexual orientation, age, relationship status, living arrangements, and Internet connection speed were related to dropout for men, while only relationship status and living arrangements, which were in the opposite direction from men, were related to dropout in women.