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New faculty orientation (NFO) programs are shown to increase faculty satisfaction, enhance collaboration, and support promotion, retention, and academic success. In an effort led by a clinical psychologist, the Children's National Hospital (CNH) NFO was developed, piloted, and is in its 3rd year. Data are shared regarding program development process, feasibility, and acceptability. In 2020, CNH faculty were surveyed about their new faculty member experience. CNH leaders were interviewed about important topics to include in an NFO. In FY22, the NFO was piloted across 15 Divisions. Year 2 (FY23) invited all new early career faculty. Year 3 (FY24) invited all new faculty. Feedback was obtained via REDCap after meetings and before/after the 10-month program. In 2020, 62% of recently hired faculty surveyed indicated not having any institutional level orientation. Leadership interviews supported the need for an NFO; suggested topics included promotion and provider wellness. In FY22, 27/38 invited faculty chose to participate. For FY23, 36/48 chose to participate. In FY24, 69/95 invited are participating. A needs assessment showed CNH faculty and leaders supported an NFO Program. Participants report finding the program helpful; they learned about institutional resources, benefits, and operations and appreciated the networking opportunities. Longer-term metrics include faculty satisfaction, promotion, and retention., Competing Interests: Declarations Conflict of interest Randi Streisand, Annika Hvide, Naomi Luban, and Stephen J. Teach declare that they have no conflict of interest. Human and Animal Rights and Ethical Approval This is an observational study. The CNH Institutional Review Board has confirmed that no ethical approval is required. Specific Consent for Publication Not applicable., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Student-completed course evaluations are often included in university faculty promotion and tenure packets but may not be the best metrics for student learning. This juxtaposition creates a challenge - the metric faculty first want to improve is student learning rather than student perception, but course changes improving student learning do not always result in higher course evaluation scores. Additionally, making course changes can be time consuming for faculty. The objective of this project was to assess the changes made to a course, the time spent making those changes, and the impact of the changes on course evaluation scores and student performance., Educational Activity: A single course focused on management with a business plan as the primary course project was revised in Fall 2023; the goal of revisions was to address poor course evaluation scores and negative student perceptions of the course in as little faculty time as possible while maintaining quality of student work. Primary changes centered around the business plan project and a shift in course communication. Evaluation of the changes occurred through mid-semester survey and discussion and end-of-semester survey for the 2023 cohort, and comparing course evaluations and student work products between the 2022 and 2023 cohorts., Critical Analysis of the Educational Activity: Course evaluation scores were improved and student feedback was more positive for the revised Fall 2023 course. The implemented changes did not negatively affect student performance as quality of the business plan project was maintained across both semesters. Instructor transparency and responsiveness through the mid-semester survey and discussion may have positively influenced course evaluations scores. Overall, the course changes did not take a significant amount of faculty time, but the desired outcome of improving course evaluation scores was recognized., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest. The authors have no funding sources to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Exercise programmes have been used to prevent injuries in military personnel, as they can reduce modifiable risk factors for injuries. Our aim was to review the literature to evaluate the effects of different exercise protocols on the prevention of injuries in military personnel., Methods: A systematic literature review examined the effects of different exercise protocols on the prevention of musculoskeletal injuries in the military. Several databases were explored to find experimental studies that investigated the effects of prevention programmes on the risk of injury. We have extracted from the studies: profile of participants, sample size, study design and characteristics of the control group (CG), the type of intervention and the relative risk (RR) in the experimental group and CG, with their significance levels. For data analysis, we used the RevMan V.5.3 software. The measure of RR was investigated. The risk of publication bias was analysed with Begg's test., Results: A total of 13 694 titles and studies were recovered from the databases and by manual search. After the removal of duplicate titles and studies that did not meet the eligibility criteria, 17 studies were selected. The protocols were composed of neuromuscular training, stretching, agility training or combined exercises. The meta-analysis showed that injury prevention exercise programmes reduced the risk of musculoskeletal injuries in military personnel by 14% (RR=0.86; 95% CI=0.76 to 0.98)., Conclusion: Injury prevention exercise programmes promoted a slight reduction in the risk of musculoskeletal injuries in military personnel., Level of Evidence: Very low., Trial Registration Number: CRD 42017077946., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The United Republic of Tanzania has had a 41.4% mortality rate in the intensive care unit. In Tanzania, the Ministry of Health and Social Welfare has implemented quality improvement (QI), yet the Tanzanian health sector continues to face resource constraints, unsustainable projects and gaps in knowledge and skills, contributing to unacceptably high mortality rates for Tanzanian patients. This research aims to determine if a Critical Care Training Program incorporating QI concepts can improve technical competence and self-efficacy of providers in a critical care setting in Tanzania., Methods: A 2-day Critical Care Training Program was developed for providers. It included the following modules: vital signs directed therapy (VSDT), cardiopulmonary and brain resuscitation (CPBR), blood glucose monitoring, introduction to critical care concepts and the QI concept of change management. For analysis, data were collected from pretests and post-tests and reported in REDCap. Descriptive statistics and paired t-tests were performed (alpha=0.05)., Results: A total of 77 nurses and three providers attended the training. The overall score changes among participants for CPBR and VSDT were significant (p<0.001). Six out of 10 questions in CPBR demonstrated significant improved change (p<0.001). All questions in the VSDT training showed significant improvement (p<0.001). Based on hospital guidelines, 63 (95.5%) passed the CPBR evaluation and 62 (95.2%) passed VSDT., Conclusion: A pre/post analysis demonstrated improvement in knowledge, skills and increased confidence towards emergencies. This study suggests a Critical Care Training Program significantly improves the knowledge among providers and that QI impacts culture of change. This research exemplifies a systematic approach to strengthening capacity of critical care delivery in limited resource settings, with implications for further innovation in other low- and middle-income countries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Veterans are at risk for mental and physical health problems but may not seek traditional health care services. Wellness-based interventions, including exercise and nutrition, have been associated with improvements in physical and mental health among this population. This study explores the acceptability, feasibility, and efficacy of a 3-month health and fitness program for veterans., Materials and Methods: Participants in 2 time-based cohorts from 2019 to 2023 (cohort 1: n = 261; cohort 2: n = 256) were cleared by a physician to participate. Participants then completed a fitness test and self-reported surveys (e.g., quality of life, sleep, and pain) before and after the 3-month program. Participants were recruited to participate at one of three sites: Boston, MA Fort Myers, FL, or Tampa, FL. The 3-month program consisted of weekly, supervised group fitness and one-on-one sessions, nutritional consultations, yoga, and other wellness activities. Primary program outcomes were measured by fitness assessments, self-report surveys, program completion, and program satisfaction. Fitness assessments included measures of weight, body mass index, grip strength, waist to hip ratio, body fat, lean mass, fat mass, heart rate, and blood pressure (BP). Self-report measures included quality of life, depression, loneliness, sleep quality, pain intensity, and pain interference., Results: In cohort 1, significant improvements were found for measures of weight (P = .01), left-handed grip strength (P < .01), body fat percent (P < .01), and quality of life (P < .01). In cohort 2, significant improvements were found for measures of waist:hip ratio (P = .02), right and left-handed grip strength (P < .01), body mass index (P = .02), body fat percent (P < .01), and quality of life (P = .02). For both cohorts, pain intensity (cohort 1: P = .01, cohort 2: P < .001) and pain interference (cohort 1: P = .02, cohort 2: P < .001) increased significantly., Conclusions: These data suggest that a 3-month health and fitness program for veterans is acceptable and feasible and may improve physical and mental health outcomes. Considerations for program retention and assessment completion are discussed., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Introduction: The management of healthcare waste is a crucial issue for public health and the environment. To minimise risks, it is essential to ensure that the management of healthcare waste is meticulously applied. Additionally, among the evaluation methods adopted by the hospital hygiene department to monitor the degree of compliance. The aim of this study was to assess the degree of compliance with healthcare waste management before and after a training and support programme., Methods: This is a pre-experimental study based on two audits of healthcare waste management at Farhat Hached University Hospital in Sousse, Tunisia. All medical, surgical and laboratory departments were included. The first audit was carried out, followed by training of the responsible staff, which was carried out according to a cycle of training and coaching hygiene technicians, and finally, a second audit was conducted. The compliance rate is compared between 2021 and 2022., Results: When comparing the averages of the compliance percentages for the four audit areas, there was a statistically significant improvement between the years 2021 and 2022 in the availability of equipment and consumables required for the management of infectious and sharp healthcare waste (p=0.029) as well as intramural transport (p=0.014)., Conclusion: The study highlights the central role of effective waste management training in promoting compliance, awareness and responsible practices. Constant attention and training are essential to maintain progress at Farhat Hached University Hospital. This helps create safer care environments, better public health outcomes and long-term sustainability., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This study evaluated the effectiveness of an 8-week digital detox program on digital screen use among 300 nursing students and explored associations between screen use and demographic variables. A one-group pretest posttest design was employed using the Social Media Addiction Scale Student Form. The digital detox program was implemented for 8 weeks. Digital hygiene, self-reflection and goal setting, mental wellness, screen time management, physical health, interpersonal relationships, digital detox challenges, and hobby-based activities. Chi-square test was employed to determine the associations between digital screen use and demographic variables, respectively. t-tests were conducted to compare the mean screen time across different demographic groups. Results showed that 42% of students had high social media use, while 20% had low use. The overall mean score of social media use decreased significantly from 64.13 to 47.79 postintervention (p < 0.05), indicating the program's effectiveness. The study suggests incorporating digital detox routines to balance technology use with health, productivity, and external connections., (© 2024 John Wiley & Sons Australia, Ltd.)

The aim of the US Centers for Disease Control and Prevention's (CDC) National Diabetes Prevention Program (National DPP) is to make an evidence-based lifestyle change program widely available to the more than 88 million American adults at risk for developing type 2 diabetes. The National DPP allows for program delivery using four delivery modes: in person, online, distance learning, and combination. The objective of this study was to analyze cumulative enrollment in the National DPP by delivery mode. We included all participants who enrolled in CDC-recognized organizations delivering the lifestyle change program between January 1, 2012, and December 31, 2019, and whose data were submitted to CDC's Diabetes Prevention Recognition Program. During this time, the number of participants who enrolled was 455,954. Enrollment, by delivery mode, was 166,691 for in-person; 269,004 for online; 4,786 for distance-learning; and 15,473 for combination. In-person organizations enrolled the lowest proportion of men (19.4%) and the highest proportions of non-Hispanic Black/African American (16.1%) and older (65+ years) participants (28.2%). Online organizations enrolled the highest proportions of men (27.1%), younger (18-44 years) participants (41.5%), and non-Hispanic White participants (70.3%). Distance-learning organizations enrolled the lowest proportion of Hispanic/Latino participants (9.0%). Combination organizations enrolled the highest proportions of Hispanic/Latino participants (37.3%) and participants who had obesity (84.1%). Most in-person participants enrolled in organizations classified as community-centered entities (41.4%) or medical providers (31.2%). Online and distance-learning participants were primarily enrolled (93.3% and 70.2%, respectively) in organizations classified as for-profit businesses or insurers. Participants in combination programs were enrolled almost exclusively in organizations classified as medical providers (89%). The National DPP has reached nearly half a million participants since its inception in 2012, but continued expansion is critical to stem the tide of type 2 diabetes among the many Americans at high risk., Competing Interests: The authors have no potential conflicts of interest relevant to this article., (Copyright © 2022 Michael J. Cannon et al.)

Objective: To assess the use of Medicaid programs, including waivers, to address the needs of aging autistic individuals., Data Sources: We gathered data on Medicaid programs in place between 2004 and 2015 for 50 states and the District of Columbia from the Centers for Medicare and Medicaid Services website, by contacting state Medicaid administrators and advocacy groups, and by reviewing the Medicaid Analytic eXtract Waiver Crosswalk., Study Design: This retrospective analysis classified each Medicaid program and documented state changes over time in eligibility criteria: those serving autism spectrum disorder only, autism spectrum disorder or intellectual disability, and intellectual disability only., Data Collection/extraction Methods: We captured age and diagnosis eligibility criteria for Medicaid programs serving any of the three target groups., Principal Findings: A total of 269 Medicaid programs met our criteria and most programs (51%) were 1915(c) waivers. The number of autism-specific 1915(c) waivers grew more than fivefold during the study period, outpacing increases in waivers serving individuals with intellectual disability., Conclusions: States varied in their use of Medicaid to address the needs of the aging autism population. Further study of characteristics of states that changed their Medicaid programs, and of the health care use and outcomes associated with these changes, are needed to identify opportunities to replicate effective approaches to meeting the needs of this population., (© 2021 Health Research and Educational Trust.)

Background: Delirium is a common, devastating, and underrecognized syndrome in the intensive care unit (ICU). The study aimed to describe and evaluate a multicomponent education and training program utilizing a "Train-The-Trainer" (TTT) model, to improve delirium detection across a large health system., Methods: Fourteen ICUs across nine hospitals participated in a multicomponent delirium program consisting of a 1-day workshop that included: (1) patient testimonials, (2) small group discussions, (3) didactics, and (4) role-playing. Additionally, four ICUs received direct observation/training via telehealth (tele-delirium training). The Kirkpatrick model was used for program evaluation in a pre/post-test design., Results: A 1-day delirium workshop was held at two time points and included 73 ICU nurses. Of the 65 nurses completing the post-workshop satisfaction survey, most (46.2) had >10 years of clinical experience, and no or minimal delirium training (69.2%). All nurses (100%) identified lack of knowledge as a barrier to delirium detection, while time constraints and lack of importance accounted for only 25%. Overall, nurses rated the workshop positively (excellent 66.7%, and very good 23.3%), and likely to change practice (definitely 73.3% and very likely 15.0%). All validated Confusion Assessment Method for the ICU (CAM-ICU) cases demonstrated improvement in number of correct responses. Delirium detection across the health system improved from 9.1% at baseline to 21.2% in ICUs that participated in the workshop and 30.1% in those ICUs that also participated in the tele-delirium training (p = 0.005)., Conclusion: A multicomponent delirium education and training program using a TTT model was rated positively, improved CAM-ICU knowledge, and increased delirium detection., (© 2021 The American Geriatrics Society.)

During the COVID-19 pandemic, the Virtual Training Academy (VTA) was established to rapidly develop a contact-tracing workforce for California. Through June 2021, more than 10 000 trainees enrolled in a contact-tracing or case investigation course at the VTA. To evaluate program effectiveness, we analyzed trainee pre- and postassessment results using the Wilcoxon signed-rank test. There was a statistically significant ( P  < .001) improvement in knowledge and self-perceived skills after course completion, indicating success in training a competent contact-tracing workforce. ( Am J Public Health . 2021;111(11):1934-1938. https://doi.org/10.2105/AJPH.2021.306468).

Importance: The Veterans Health Administration (VHA) implemented a national clinical program using a suicide risk prediction algorithm, Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), in which clinicians facilitate care enhancements for individuals identified in local top 0.1% suicide risk tiers. Evaluation studies are needed., Objective: To determine associations with treatment engagement, health care utilization, suicide attempts, safety plan documentation, and 6-month mortality., Design, Setting, and Participants: This cohort study used triple differences analyses comparing 6-month changes in outcomes after vs before program entry for individuals entering the REACH VET program (March 2017-December 2018) vs a similarly identified top 0.1% suicide risk tier cohort from prior to program initiation (March 2014-December 2015), adjusting for trends across subthreshold cohorts. Subcohort analyses (including individuals from March 2017-June 2018) evaluated difference-in-differences for cause-specific mortality using death certificate data. The subthreshold cohorts included individuals in the top 0.3% to 0.1% suicide risk tier, below the threshold for REACH VET eligibility, from the concurrent REACH VET period and from the pre-REACH VET period. Data were analyzed from December 2019 through September 2021., Exposures: REACH VET-designated clinicians treatment reevaluation and outreach for care enhancements, including safety planning, increased monitoring, and interventions to enhance coping., Main Outcomes and Measures: Process outcomes included VHA scheduled, completed, and missed appointments; mental health visits; and safety plan documentation and documentation within 6 months for individuals without plans within the prior 2 years. Clinical outcomes included mental health admissions, emergency department visits, nonfatal suicide attempts, and all-cause, suicide, and nonsuicide external-cause mortality., Results: A total of 173 313 individuals (mean [SD] age, 51.0 [14.7] years; 161 264 [93.1%] men and 12 049 [7.0%] women) were included in analyses, including 40 816 individuals eligible for REACH VET care and 36 604 individuals from the pre-REACH VET period in the top 0.1% of suicide risk. The REACH VET intervention was associated with significant increases in completed outpatient appointments (adjusted triple difference [ATD], 0.31; 95% CI, 0.06 to 0.55) and proportion of individuals with new safety plans (ATD, 0.08; 95% CI, 0.06 to 0.10) and reductions in mental health admissions (ATD, -0.08; 95% CI, -0.10 to -0.05), emergency department visits (ADT, -0.03; 95% CI, -0.06 to -0.01), and suicide attempts (ADT, -0.05; 95% CI, -0.06 to -0.03). Subcohort analyses did not identify differences in suicide or all-cause mortality (eg, age-and-sex-adjusted difference-in-difference for suicide mortality, 0.0007; 95% CI, -0.0006 to 0.0019)., Conclusions and Relevance: These findings suggest that REACH VET implementation was associated with greater treatment engagement and new safety plan documentation and fewer mental health admissions, emergency department visits, and suicide attempts. Clinical programs using risk modeling may be effective tools to support care enhancements and risk reduction.

Importance: It is unclear whether mobile technology hypertension self-management programs are associated with blood pressure (BP) control., Objective: To examine whether engagement with a hypertension self-management program with a BP monitor and connected smartphone application with clinically based digital coaching was associated with BP control during a follow-up period of as long as 3 years., Design, Setting, and Participants: This cohort study enrolled US adults with elevated BP or hypertension between January 1, 2015, and July 1, 2020. The hypertension self-management program was provided through the participant's (or their spouse's) employer health plan., Exposures: Program engagement, defined by average number of application sessions., Main Outcomes and Measures: Systolic and diastolic BP measured by a US Food and Drug Administration-cleared BP monitor, with categories defined as normal (systolic BP, <120 mm Hg), elevated (systolic BP, 120-129 mm Hg), stage 1 hypertension (systolic BP, 130-139 mm Hg), and stage 2 hypertension (systolic BP ≥140 mm Hg). Other measures included age, gender, depression, anxiety, diabetes, high cholesterol, smoking, geographic region, area deprivation index, self-reported weight, and device-measured physical activity (steps per day)., Results: Among 28 189 participants (median [IQR] age, 51 [43-58] years; 9424 women [40.4%]; 13 902 men [59.6%]), median (IQR) baseline systolic BP was 129.5 mm Hg (120.5-139.6 mm Hg) and diastolic BP was 81.7 mm Hg (75.7-88.4 mm Hg). Median systolic BP at 1 year improved at least 1 category for 495 of 934 participants (53.0%) with baseline elevated BP, 673 of 966 (69.7%) with baseline stage 1 hypertension, and 920 of 1075 (85.7%) with baseline stage 2 hypertension. Participants in the program for 3 years had a mean (SEM) systolic BP reduction of 7.2 (0.4), 12.2 (0.7), and 20.9 (1.7) mm Hg compared with baseline for those starting with elevated, stage 1 hypertension, and stage 2 hypertension, respectively. Greater engagement was associated with lower systolic BP over time (high-engagement group: 131.2 mm Hg; 95% CI, 115.5-155.8 mm Hg; medium-engagement group: 133.4 mm Hg; 95% CI 116.3-159.5 mm Hg; low-engagement group: 135.5 mm Hg; 95% CI, 117.3-164.8 mm Hg; P < .001); these results persisted after adjusting for age, gender, depression, anxiety, diabetes, high cholesterol, smoking, area deprivation index rank, and US region, which was partially mediated by greater physical activity. A very high BP (systolic BP >180 mm Hg) was observed 11 637 times from 3778 participants. Greater engagement was associated with lower risk of very high BP; the estimated probability of a very high BP was greater in the low-engagement group (1.42%; 95% CI, 1.26%-1.59%) compared with the medium-engagement group (0.79%; 95% CI, 0.71%-0.87%; P < .001) and the high-engagement group (0.53%; 95% CI, 0.45%-0.60%; P < .001 for comparison with both groups)., Conclusions and Relevance: The findings of this study suggest that a mobile technology hypertension self-management program can support long-term BP control and very high BP detection. Such programs may improve real-world BP monitoring and control.

Abstract: International evidence-based guidelines recommend self-management support for stroke survivors to improve their health outcomes. We developed a 4-week nurse-led stroke self-management programme (SSMP) and conducted a randomised controlled trial to assess its effects. This paper reports the findings of a qualitative study nested within the randomised controlled trial to explore stroke survivors' experiences of SSMP participation. Semi-structured interviews were conducted with all adult participants who were clinically diagnosed with a first or recurrent ischaemic or haemorrhagic stroke, residing at home, communicable in Cantonese, had a Montreal Cognitive Assessment score below the second percentile, and participated in at least 1 SSMP session. All interviews were conducted in Cantonese, lasted approximately 45 minutes, and were audio-recorded. Interview data were transcribed verbatim and analysed thematically. Sixty-four stroke survivors (mean age 66.33 years, SD 12.34) were recruited, and 59 were interviewed via phone immediately after completion of SSMP. Three themes were derived. Overall, participants were satisfied with the SSMP. Their understanding of self-management was improved, and they recognised its importance in recovery. Their confidence in self-management was also enhanced through the use of multifaceted strategies. Suggestions were made to enhance their participation experiences, including increased home visits and group sessions, making group session attendance optional and arranging them more accessibly, meeting the survivors who shared their survival experiences in the videos, and access to the videos online. This study concurred that the SSMP enhanced stroke survivors' self-efficacy in self-management. Rearrangement of the programme format and enhancements in accessibility could be further examined to enable more effective stroke self-management., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Group pre-operative education has usually been limited to conditioning expectations and providing education. Prehabilitation has highlighted modifiable lifestyle factors that are amenable to change and may improve clinical outcomes. We instituted a pre-operative 'Fit-4-Surgery School' for patients scheduled for major surgery, to educate and promote healthy behaviour. We evaluated patients' views having attended the school, and after surgery we asked how it had changed their behaviour with a lifestyle questionnaire. The school was launched in May 2016 and was attended by 586/1017 (58%) of invited patients. Patients who did not attend: lived further away, median (IQR [range]) 8 (4-19 [0-123]) miles vs. 5 (3-14 [0-172]) miles, p < 0.001; and were more deprived, Index of Multiple Deprivation Rank decile median (IQR [range]), 6 (4-8 [1-10]) vs. 7 (4-9 [1-10]), p = 0.04. Of the 492/586 (84%) participants who completed an evaluation questionnaire, 462 (94%) would recommend the school to a friend having surgery and 296 (60%) planned lifestyle changes. After surgery, 232/586 (40%) completed a behavioural change questionnaire, 106 (46%) of whom reported changing at least one lifestyle factor, most commonly by increasing exercise. The pre-operative school was acceptable to patients., (© 2021 Association of Anaesthetists.)

Objective: In order to be able to develop surgical training of residents through simulation, we carried out a descriptive study, evaluating the satisfaction of participating residents and the benefit of the workshops offered during the 4 th Junior Master Class, free annual training organized in 2017 in Lille University Hospital. It is dedicated to ob-gyn residents in France, overseas departments and territories., Material and Methods: During two days, plenary sessions and practical workshops on animal models or simulators were organized in laparoscopy, diagnostic and operative hysteroscopy, vaginal surgery and robotic surgery. A questionnaire was given anonymously to each student, collecting on the one hand their surgical curriculum, on the other hand, the evaluations of the theoretical contribution and the quality of the interventions and materials offered during the plenary sessions. The last part was subdivided into a questionnaire specific to each workshop., Results: The 48 residents who voluntarily followed this training were overwhelmingly satisfied with the quality of the training offered. The practical benefits outweighed the theoretical benefits. These workshops improved their practical skills from 63 % to 84 % depending on the workshops offered. In addition, 100 % of students would recommend this training to other residents and consider it useful for their future practice., Conclusion: These very satisfactory results encourage us to organize new surgical training. Simulation is the key point for an appropriate surgical learning., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: The emergence of cell-free fetal DNA (cfDNA) testing technology has disrupted the landscape of prenatal screening for trisomies 21 (T21) and 18 (T18). Publicly funded systems around the world are grappling with how to best integrate this more accurate but costly technology, as there is limited evidence about its incremental value in real-world conditions. The objectives of this study were to describe the population-based performance of Ontario's prenatal screening program, which incorporates publicly funded cfDNA screening for specific indications, and the effect of cfDNA testing on the screening and diagnostic choices made by pregnant people., Methods: We conducted a retrospective, descriptive cohort study using routinely collected data from Better Outcomes & Registry Network (BORN) Ontario, which captures linked population data for prenatal and neonatal health encounters across Ontario. We included all singleton pregnancies with an estimated due date between Sept. 1, 2016, and Mar. 31, 2019, that underwent publicly funded prenatal screening in Ontario, and a comparison cohort from Apr. 1, 2012, and Mar. 31, 2013. We assessed performance of the screening program for the detection of T21 or T18 by calculating sensitivity, specificity, positive predictive value and negative predictive value against diagnostic cytogenetic results or birth outcomes. We assessed the impact of the program by calculating the proportion of T21 screen-positive pregnancies undergoing subsequent cfDNA screening and invasive prenatal diagnostic testing., Results: The study cohort included 373 682 pregnancies. The prenatal screening program had an uptake of 69.9%, a screen-positive rate and sensitivity of 1.6% and 89.9% for T21, and 0.2% and 80.5% for T18, respectively. The test failure rate for cfDNA screening was 2.2%. Invasive prenatal diagnostic testing decreased from 4.4% in 2012-2013 to 2.4% over the study period; 65.2% of pregnant people who received a screen-positive result from cfDNA testing went on to have invasive prenatal diagnostic testing., Interpretation: This publicly funded screening program, incorporating cfDNA analysis for common aneuploidies, showed robust performance, a substantial reduction in invasive prenatal diagnostic testing and that pregnant people exercise autonomy in their choices about prenatal screening and diagnosis., Competing Interests: Competing interests: Nan Okun reports funding from Roche Diagnostic, outside the submitted work. No other competing interests were declared., (© 2021 CMA Joule Inc. or its licensors.)

Background: The threat of antimicrobial resistance driven by inappropriate and unnecessary use of antimicrobials is a global issue of great concern. Evidence-based approaches to optimising antimicrobial prescribing to improve patient care while reducing the rate of antimicrobial resistance continue to be implemented worldwide. However, the successes or failures of implementation of such approaches are seldom evaluated., Objectives: To evaluate the impact of an implemented antimicrobial stewardship programme (ASP) in reducing the spread of antimicrobial resistance in the intensive care unit (ICU) of a large academic hospital using the RE-AIM framework., Methods: A descriptive quasi-experimental study was conducted with adult patients who had been admitted to the ICU of an academic hospital in Johannesburg, South Africa. Data were extracted from patients' records using a structured questionnaire. Descriptive statistics of four RE-AIM dimensions (reach, effectiveness, adoption and implementation) and the overall impact of the implemented antimicrobial stewardship programme were calculated., Results: From the 59 participant records, 21 patients (35.6%) developed hospital-acquired infections and all were prescribed antimicrobials during their stay in the ICU. Twenty-seven pathogens (bacterial species) were isolated from samples acquired from the patients, including Staphylococcus aureus (n=6; 22.2%), Escherichia coli (n=4; 14.8%), Acinetobacter baumannii (n=4; 14.8%) and Streptococcus pnuemoniae (n=3; 11.11%), as well as 10 other bacterial species (37.0%) including Corynebacterium species, Enterococcus faecium, Haemophilus influenzae, Klebsiella species, Clostridium difficile and Salmonella species. Of the 27 pathogens isolated, 19 (70.4 %) were resistant to the prescribed antimicrobials. The overall impact of the ASP implemented in the studied facility was 67.2%., Conclusions: An ASP requires both thorough implementation and leadership support to have an impact in the reduction of antimicrobial resistance. Lack of leadership support poses a significant challenge to sustainability. There is an urgent need for behavioural change in hospital leadership.

Background: Studies evaluating the efficacy of ATLS in low- and middle-income countries are limited. We followed up ATLS providers certified by the ATLS India program over a decade (2009 to 2019), aiming to measure the benefits in knowledge, skills, attitude and their attrition over time., Methods: The survey instrument was developed taking a cue from published literature on ATLS and improvised using the Delphi method. Randomly selected ATLS providers were sent the survey instrument via email as a Google form, along with a statement of purpose. Results are presented descriptively., Results: ATLS India trained 7,847 providers over the study period. 2500 providers were selected for the survery using computer-generated random number table. One thousand and thirty doctors (41.2%) responded. Improvement in knowledge (n = 1,013 [98.3%]), psychomotor skills (n = 986 [95.7%]), organizational skills (n = 998 [96.9%]), overall trauma management (n = 1,013 [98.7%]) and self-confidence (n = 939 [91%]) were reported. Majority (904 [87.8%]) started ATLS promulgation at workplace in personal capacity. These benefits lasted beyond 2 years in majority (>60%) of respondents. More than 40% reported cognitive (n = 492 [47.8%]), psychomotor (n = 433 [42%]), and organizational benefits (n = 499 [48.4%]) lasting beyond 3 years. Improvement in self-confidence, ATLS promulgation at the workplace, and retention of organizational skills were more pronounced in ATLS faculties than providers. All other benefits were found to be comparable in both sub-groups. Lack of trained staff (n = 660 [64.1%]) and attitude issues (n = 495 [48.1%]) were the major impediments in implementing ATLS at the workplace. More than a third of respondents (n = 373 [36.2%]) could enumerate one or more incidents where ATLS principles were life- or limb- saving., Conclusions: Cognitive, psychomotor, organizational, and affective impact of ATLS is overwhelmingly positive in the Indian scenario. Until formal trauma systems are established, ATLS remains the best hope for critically injured patients in resource-contrained settings., (Copyright © 2021 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Introduction: the Chilean Ministry of Health implements the Vida Sana (VS) program with the objective of reducing risk factors for chronic diseases in overweight/obese (OW/OB) individuals, aged 2-64. Objective: to determine the effectiveness of VS in OW/OB women (20-44 yrs) in terms of their engagement in the recommended activities. These consist of participating in a minimum number each of three core activities (psychologist consultations, lifestyle workshops, and physical activity sessions) during 6 months, to obtain a 5 % weight loss and improved physical fitness (PF). Methods: a retrospective study involving secondary analyses of the 2017 VS database (n = 5,179 OW/OB women). We determined effectiveness by: a) comparing changes in weight and PF in participants who achieved one or both outcomes, using t-tests and tests of proportions, and b) assessing the probability of achieving the program´s goal, according to participation in 1, 2, or 3 core activities, individually and jointly, using the OR (95 % CI) and trend analysis. Results: around 32 %, 88 %, and 29 % of women achieved 5 % weight loss, improved PF, and both, respectively. The high percentage of women who improved PF was due to a permissive criterion. Although 20 % of women attained the program´s goal with 0 engagement, among participants, the ORs (95 % CI) for achieving the program´s goal when engaging in 1, 2, or 3 core activities were 1.55 (CI 1.2-2.03), 2.34 (1.76-3.11), and 3.5 (2.21-5.53), respectively. Conclusion: effectiveness parallels degree of engagement in the recommended activities of VS. A characterization of a program´s participation rate is crucial for improving its effectiveness.

Background: Demand for high-quality surveillance data for malaria, and other diseases, is greater than ever before. In Uganda, the primary source of malaria surveillance data is the Health Management Information System (HMIS). However, HMIS data may be incomplete, inaccurate or delayed. Collaborative improvement (CI) is a quality improvement intervention developed in high-income countries, which has been advocated for low-resource settings. In Kayunga, Uganda, a pilot study of CI was conducted in five public health centres, documenting a positive effect on the quality of HMIS and malaria surveillance data. A qualitative evaluation was conducted concurrently to investigate the mechanisms of effect and unintended consequences of the intervention, aiming to inform future implementation of CI., Methods: The study intervention targeted health workers, including brief in-service training, plus CI with 'plan-do-study-act' (PDSA) cycles emphasizing self-reflection and group action, periodic learning sessions, and coaching from a CI mentor. Health workers collected data on standard HMIS out-patient registers. The qualitative evaluation (July 2015 to September 2016) included ethnographic observations at each health centre (over 12-14 weeks), in-depth interviews with health workers and stakeholders (n = 20), and focus group discussions with health workers (n = 6)., Results: The results suggest that the intervention did facilitate improvement in data quality, but through unexpected mechanisms. The CI intervention was implemented as planned, but the PDSA cycles were driven largely by the CI mentor, not the health workers. In this context, characterized by a rigid hierarchy within the health system of limited culture of self-reflection and inadequate training and supervision, CI became an effective form of high-quality training with frequent supervisory visits. Health workers appeared motivated to improve data collection habits by their loyalty to the CI mentor and the potential for economic benefits, rather than a desire for self-improvement., Conclusions: CI is a promising method of quality improvement and could have a positive impact on malaria surveillance data. However, successful scale-up of CI in similar settings may require deployment of highly skilled mentors. Further research, focusing on the effectiveness of 'real world' mentors using robust study designs, will be required to determine whether CI can be translated effectively and sustainably to low-resource settings.

Importance: The Supplemental Nutrition Assistance Program (SNAP) is a federal program that provides food-purchasing assistance to low-income people; however, its current design does not account for the time availability of SNAP recipients to prepare meals., Objective: To evaluate the association of the availability of funding for food purchases and time for meal preparation with the nutritional quality of meals of SNAP recipients., Design, Setting, and Participants: This study used decision analytical modeling to evaluate the nutritional quality of meals of SNAP recipients. The model was developed from February 6, 2017, to December 12, 2020, using data from 2017 and is based on discrete optimization. The model describes food and grocery purchasing, in-home meal preparation, and meal plan choices of a family of SNAP participants (2 adults and 2 children) while considering food preferences, meal preparation time, and food costs. The model assumes food preferences match the foods typically purchased by SNAP households. Costs of food ingredients and prepared foods are taken from a single zip code., Exposures: Time availability and total amount and type of funding were varied. Allowing prepared delicatessen foods and disallowing frozen prepared foods for purchase using SNAP funds were considered., Main Outcomes and Measures: The primary outcome was the number of home-cooked meals and the amounts of fruits, vegetables, protein, sodium, sugar, and fiber consumed from generated meal plans. Amounts were evaluated as a percentage of the quantity recommended by established dietary guidelines., Results: Increased time availability was associated with increases in the percentage of home-cooked meals and servings of fruits/vegetables and decreased sodium consumption. Higher levels of funding were associated with increased consumption of fiber, fruits/vegetables, protein, sodium, and sugar. With 20 min/d of cooking time, $400/mo of SNAP benefits, and $100/mo of self-funding, the meal plan had a mean (SE) of 20.1% (0.3%) of meals home cooked, 0.5 (<0.1) servings/d per person of fruits/vegetables, 100.3% (0.6%) of daily recommended protein per person, 115.1% (0.8%) of daily recommended sodium per person, 241.8% (1.0%) of daily recommended sugar per person, and 31.2% (0.3%) of daily recommended fiber per person. With 20 min/d of cooking time, $400/mo of SNAP benefits, and $600/mo of self-funding, the meal plan had a mean (SE) of 23.9% (1.0%) of meals home cooked, 2.8 (0.1) servings/d per person of fruits/vegetables, 134.9% (1.6%) of daily recommended protein per person, 200.9% (3.1%) of daily recommended sodium per person, 295.1% (3.1%) of daily recommended sugar per person, and 90.1% (1.0%) of daily recommended fiber per person. With 60 min/d of cooking time, $400/mo of SNAP benefits, and $100/mo of self-funding, the meal plan had a mean (SE) of 52.7% (0.9%) of meals home cooked, 1.4 (<0.1) servings/d per person of fruits/vegetables, 109.0% (1.1%) of daily recommended protein per person, 108.7% (1.0%) of daily recommended sodium per person, 298.6% (2.0%) of daily recommended sugar per person, and 38.8% (0.4%) of daily recommended fiber per person. With 60 min/d of cooking time, $400/mo of SNAP benefits, and $600/mo of self-funding, the meal plan had a mean (SE) of 42.8% (1.2%) meals home cooked, 4.3 (0.1) servings/d per person of fruits/vegetables, 144.4% (1.8%) of daily recommended protein per person, 165.2% (2.8%) of daily recommended sodium per person, 322.4% (2.4%) of daily recommended sugar per person, and 91.0% (0.9%) of daily recommended fiber per person., Conclusions and Relevance: In this decision analytical model, meal preparation time was associated with the ability of SNAP recipient families to consume nutritious meals, suggesting that increased funding alone may be insufficient for improving the nutritional profiles of SNAP recipients. Given the current US food supply, governmental interventions that provide the equivalence in increased time availability to achieve nutritious meals may be needed.

Purpose: To report trends in the number and types of applicants and matched trainees to radiation oncology in comparison to other specialties participating in the National Resident Matching Program (NRMP) between 2010 and 2020., Methods and Materials: Data from the NRMP and Electronic Residency Application System (ERAS) were obtained for 18 medical specialties between 2010 and 2020. We assessed the numbers and types of applicants and matched trainees relative to available positions in the NRMP and Supplemental Offer and Acceptance Program (SOAP)., Results: In the 2020 NRMP, 122 US MD senior graduates preferentially ranked radiation oncology, a significant decrease from a median of 187 between 2010 to 2019 (interquartile range [IQR], 170-192; P < .001). Across all 18 specialties, radiation oncology experienced the greatest declines in the 2020 NRMP cycle relative to 2010 to 2019, in both the number of ERAS applicants from the United States and Canada (-31%) and the percentage of positions filled by US MD or DO senior graduates (-28%). Of 189 available positions, 81% (n = 154) filled in the NRMP prior to the SOAP, of which 65% (n = 122) were "matched" by US MD senior graduates who preferentially ranked radiation oncology as their top choice of specialty, representing a significant decrease from a median of 92% between 2010 to 2019 (IQR, 88%-94%; P = .002). The percentages of radiation oncology programs and positions unfilled in the NRMP prior to the SOAP were significantly increased in 2020 compared with 2010 to 2019 (programs: 29% vs 8% [IQR, 5%-8%; P < .001]; positions: 19% vs 4% [IQR, 2%-4%; P <.001]). Despite >99% (n = 127 of 128) of US MD or DO senior applicants preferring radiation oncology successfully matching to a radiation oncology position in the 2020 NRMP, 16 of 35 remaining unfilled positions were filled via the SOAP. Radiation oncology was the top user of the SOAP across all specialties participating in the 2020 NRMP, filling 15% of total positions versus a median of 0.9% (IQR, 0.3%-2.3%; P <.001)., Conclusions: The supply of radiation oncology residency positions now far exceeds demand by graduating US medical students. Efforts to nullify a market correction revealed by medical student behavior via continued reliance on the SOAP to fill historical levels of training positions may not be in the best of interest of trainees, individual programs, or the specialty as a whole., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: COBRA-BPS (Control of Blood Pressure and Risk Attenuation-Bangladesh, Pakistan, Sri Lanka), a multi-component hypertension management programme that is led by community health workers, has been shown to be efficacious at reducing systolic blood pressure in rural communities in Bangladesh, Pakistan, and Sri Lanka. In this study, we aimed to assess the budget required to scale up the programme and the incremental cost-effectiveness ratios., Methods: In a cluster-randomised trial of COBRA-BPS, individuals aged 40 years or older with hypertension who lived in 30 rural communities in Bangladesh, Pakistan, and Sri Lanka were deemed eligible for inclusion. Costs were quantified prospectively at baseline and during 2 years of the trial. All costs, including labour, rental, materials and supplies, and contracted services were recorded, stratified by programme activity. Incremental costs of scaling up COBRA-BPS to all eligible adults in areas covered by community health workers were estimated from the health ministry (public payer) perspective., Findings: Between April 1, 2016, and Feb 28, 2017, 11 510 individuals were screened and 2645 were enrolled and included in the study. Participants were examined between May 8, 2016, and March 31, 2019. The first-year per-participant costs for COBRA-BPS were US$10·65 for Bangladesh, $10·25 for Pakistan, and $6·42 for Sri Lanka. Per-capita costs were $0·63 for Bangladesh, $0·29 for Pakistan, and $1·03 for Sri Lanka. Incremental cost-effectiveness ratios were $3430 for Bangladesh, $2270 for Pakistan, and $4080 for Sri Lanka, per cardiovascular disability-adjusted life year averted, which showed COBRA-BPS to be cost-effective in all three countries relative to the WHO-CHOICE threshold of three times gross domestic product per capita in each country. Using this threshold, the cost-effectiveness acceptability curves predicted that the probability of COBRA-BPS being cost-effective is 79·3% in Bangladesh, 85·2% in Pakistan, and 99·8% in Sri Lanka., Interpretation: The low cost of scale-up and the cost-effectiveness of COBRA-BPS suggest that this programme is a viable strategy for responding to the growing cardiovascular disease epidemic in rural communities in low-income and middle-income countries where community health workers are present, and that it should qualify as a priority intervention across rural settings in south Asia and in other countries with similar demographics and health systems to those examined in this study., Funding: The UK Department of Health and Social Care, the UK Department for International Development, the Global Challenges Research Fund, the UK Medical Research Council, Wellcome Trust., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Purpose: Despite a demographic surge in U.S. minority children, pediatric workforce diversity has failed to keep pace. The study aim was to evaluate the Research in Academic Pediatrics Initiative on Diversity (RAPID), a research-education program aimed at recruiting, retaining, and professionally advancing diverse early-career faculty in general pediatrics who are pursuing research careers., Method: RAPID includes the following components: small research grants, mentoring by nationally renowned senior investigators, mentoring and networking at an annual breakfast, an annual career-development conference, and monthly mentoring conference calls. Outcomes data from the first 5 years (2012-2017) of RAPID were analyzed. Data sources were Academic Pediatric Association (APA) membership data and postconference, baseline, and end-of-program/follow-up surveys. Outcome measures included mentoring quality, presentations, publications, subsequent grants, impact on career success, conference ratings, and APA membership diversity., Results: For the 10 Scholars from the first 4 cohorts, mean scores were 4.5 (5 = strongly agree) for RAPID fostering mentoring, developing research skills, and helping Scholars feel more comfortable as underrepresented minority (URM) faculty; 78% delivered platform or poster presentations on their project. They published 56 total articles and received a mean of 2.5 subsequent grants. Their mean score for RAPID "advancing my career by facilitating promotion or getting a job" was 4.6. The first 4 RAPID Conferences were highly rated (mean scores = 4.2-4.8) and brought in 33 additional URM young investigators. Pre-RAPID, URM APA membership stagnated at 6%-7% for 5 years. In RAPID's first year, URM APA membership rose to 8%, then to 10% by 2017 (43% increase; P < .001)., Conclusions: RAPID Scholars generated multiple presentations and publications. RAPID mentoring and Conferences were highly rated. RAPID was associated with career advancement and increased professional society diversity. RAPID could serve as a national model for enhancing URM career development and professional society diversity., (Copyright © 2020 by the Association of American Medical Colleges.)

Background: Responding to National Academy of Medicine and National Council of State Boards of Nursing recommendations, the Department of Veterans Health Affairs (VHA) implemented full practice authority (FPA) for Advanced Practice Registered Nurses in VHA medical centers (VAMCs) in 2017., Purpose: To evaluate FPA policy implementation's impact on quality indicators including access to care as measured by new patient appointments in primary, specialty and mental health services., Methods: Linear growth models compared early (n = 85) vs. late (n = 55) FPA implementing VAMCs on the trajectories of each of the three quality indicators., Findings: Early FPA implementing VAMCs showed greater rates of improvement over time in new patient appointments completed within 30 days of preferred date for primary care (p = .003), specialty care (p = 0.05), and mental health (p = 0.001)., Discussion: VAMCs that started implementation of FPA policy early showed greater improvement in access to care for Veterans over time than VAMCs that did not., (Published by Elsevier Inc.)

Background: The positive effect of the Geriatric Emergency Department Intervention (GEDI) model, on the outcomes of frail older adults, is established. This study aimed to describe and evaluate the structures and processes required for the effective delivery of the GEDI model to assist in its potential translation into emergency departments in Australia and overseas., Methods: This was a descriptive qualitative study. Twenty-four semi-structured interviews were conducted with emergency department staff and GEDI doctors and nurses from a regional hospital in Queensland, Australia. An a priori framework guided interview questions and analysis., Results: Structures required for successful model deployment included having an emergency department physician champion and nurses with gerontology experience, adequate funding, and geriatric specific resources. Processes identified as fundamental to the GEDI model included having a targeted approach to assessment, a patient-centred approach to care, and staff with inter-facility, intra-facility and inter-personal communication skills., Conclusions: The GEDI model addresses the specific care needs of our aging population. For optimal performance of the model, key structures and processes require identification and acknowledgement. Research involving qualitative methodology is vital for successful translation and integration of emergency department models of care., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

Problem: High-quality training opportunities for providers in limited-resource settings are often scarce or nonexistent. This can lead to a dearth of boots-on-the-ground workers capable of translating knowledge into effective action. The tested telehealth education model of Project ECHO (Extension for Community Healthcare Outcomes) can help address this disparity. However, the planning and logistical coordination required can be limiting., Approach: Medical student volunteers interested in health disparities and global health can be leveraged to reduce the costs of administration for Project ECHO programs. From mid-2018 to present (2020), student organizations have been formed at Vanderbilt University School of Medicine, University of California, San Francisco, School of Medicine, and Albert Einstein College of Medicine. These organizations have recruited and trained volunteers, who play an active role in assessing the needs of local clinics and providers, developing curricula, and coordinating the logistical aspects of programs., Outcomes: In the first 4 student-coordinated Project ECHO cohorts (2019-2020), 25 clinics in 14 countries participated, with a potential impact on over 20,000 cancer patients annually. Satisfaction with the telehealth education programs was high among local clinicians and expert educators. Students' perceived ability to conduct activities important to successfully orchestrating a telehealth education program was significantly greater among students who had coordinated one or more Project ECHO programs than among students who had yet to participate for 7 of 9 competencies. There also appears to be an additive effect of participating in additional Project ECHO programs on perceived confidence and career path intentions., Next Steps: The student-led model of coordinating telehealth education programs described here can be readily expanded to medical schools across the nation and beyond. With continued expansion, efforts are needed to develop assessments that provide insights into participants' learning, track changes in patient outcomes, and provide continuing medical education credits to local clinicians., (Copyright © 2020 by the Association of American Medical Colleges.)

Abstract: Pediatric procedural sedation (PPS) is often performed outside of the operating room, and by various sub-specialty providers. There is no consistency in how pediatric emergency medicine (PEM) fellows are trained in PPS. The objective of this study was to survey PEM program directors (PDs) and PEM fellows about their current sedation teaching practices via a direct survey. While many fellowship programs train PEM fellows in PPS, we hypothesize that there is no consistent method of developing and measuring this skill.A 12-question survey was sent to PEM PDs directly via email. A separate 17-question survey was sent to current PEM fellows via their program coordinators by email. Each survey had multiple choice, yes-no and select-all program questions. Responses were collected in an online (REDCap) database and summarized as frequencies and percentages.Based on identifiable email, 67 programs were contacted, with a PD response rate of 46 (59%). Sixty-two program coordinators were contacted based on identifiable email with 78 fellow responses. We noted that 11/46 PD respondents offer a formal PPS rotation. Thirty programs report using propofol in the emergency department and 93% of PD respondents (28/30) actively train fellows in the use of propofol. Approximately 62% of PEM fellow respondents (48/78) report sedating without any attending oversight. Twenty-eight percent of PEM fellow respondents report using simulation as a component of their sedation training.PPS is a critical skill. However, there is a lack of consistency in both education and evaluation of competency in this area. An organized PPS rotation would improve PPS case exposure and PPS skills., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Problem: Primary care providers are responsible for the majority of pain care and opioid prescribing, but they are often inadequately trained. Training current providers to address the crisis of excessive opioid prescribing and inadequate pain management is a substantial workforce problem that requires urgent action. This educational need is vast and requires a staged solution to amplify its effect., Approach: The University of California, Davis Train-the-Trainer (T3) Primary Care Pain Management Fellowship targets the most pressing topics related to pain management, including prescription drug abuse, responsible opioid prescribing, and substance abuse, as well as broad coverage of comprehensive pain management. It offers an innovative, scalable solution to address the education gap in pain management that, in part, fuels the opioid epidemic in the United States. The T3 Fellowship incorporates a competency-based curriculum and a hybrid educational model of in-person and distance-based learning and direct faculty-fellow mentoring to comprehensively train primary care providers in pain care and prepare them to train others. Since it was established in 2017, 2 cohorts (of 17 and 26 fellows) have completed the 10-month fellowship and a third cohort of 38 fellows started the program in September 2019., Outcomes: Pre- and postprogram surveys for the first 2 cohorts, and a 6-month postprogram survey for the first cohort, demonstrated fellows' improvement and sustained performance in pain competencies as well as increased recognition and understanding of pain and related topics., Next Steps: If adopted by other institutions and expanded across the country, the T3 Fellowship holds potential for developing an ever-growing legion of trained professionals who will locally fill the need for effective pain management, including appropriate opioid prescribing. Advancing this model will require further economic and feasibility studies to assess costs, resources, and other variables, as well as a robust comprehensive outcomes program., (Copyright © 2020 by the Association of American Medical Colleges.)

Problem: Medical schools have implemented various ways to engage students in improving medical curricula. These systems, however, usually focus on the preclerkship curriculum, perhaps because medical students move through this phase of medical education synchronously, making it easier to collect student input. In contrast, clerkship and postclerkship curricula often lack similar levels of student engagement in program evaluation., Approach: To increase communication among students, faculty, and administration during the clinical years of medical education, the Student Curricular Board (SCB) at the University of Illinois College of Medicine's Chicago campus (UICOM-Chicago) developed a student-driven feedback model in 2016 that aimed to parallel the system previously implemented in the preclerkship years. Interested fourth-year students were selected by their peers to represent individual core clerkships, and they communicated regularly with clerkship directors about concerns from current clerkship students. Third-year students applied and were selected to represent their cohort of peers moving through clerkship tracks. Proposed changes and improvements were tracked via novel, student-driven SOAP-Education (SOAP-Ed) progress notes written throughout the academic year., Outcomes: In response to a program evaluation survey conducted after implementation of this pilot, third-year students said they felt that their feedback was taken seriously by faculty and administration. Furthermore, student feedback led to meaningful changes in core clerkship curricula and in the system used to gather clerkship feedback. Clerkship directors expressed appreciation for this partnership, and students said they gained valuable leadership experience and knowledge of curricular development., Next Steps: Current SCB members and curricular leadership plan to assess student and faculty perceptions of this system and its efficacy and work toward expansion to all UICOM campuses. Lessons learned from this student-driven model of feedback in third-year core clerkships will likely add to the conversation on how to better engage medical students as active stakeholders in their own education., (Copyright © 2020 by the Association of American Medical Colleges.)

Purpose: The aim of this study was to determine the status of radiology quality improvement programs in a variety of selected nations worldwide., Methods: A survey was developed by select members of the International Economics Committee of the American College of Radiology on quality programs and was distributed to committee members. Members responded on behalf of their country. The 51-question survey asked about 12 different quality initiatives which were grouped into 4 themes: departments, users, equipment, and outcomes. Respondents reported whether a designated type of quality initiative was used in their country and answered subsequent questions further characterizing it., Results: The response rate was 100% and represented Australia, Canada, China, England, France, Germany, India, Israel, Japan, the Netherlands, Russia, and the United States. The most frequently reported quality initiatives were imaging appropriateness (91.7%) and disease registries (91.7%), followed by key performance indicators (83.3%) and morbidity and mortality rounds (83.3%). Peer review, equipment accreditation, radiation dose monitoring, and structured reporting were reported by 75.0% of respondents, followed by 58.3% of respondents for quality audits and critical incident reporting. The least frequently reported initiatives included Lean/Kaizen exercises and physician performance assessments, implemented by 25.0% of respondents., Conclusion: There is considerable diversity in the quality programs used throughout the world, despite some influence by national and international organizations, from whom further guidance could increase uniformity and optimize patient care in radiology.

Abstract: A significant increase in nurse practitioner program enrollment has resulted in a critical need for committed preceptors willing to offer clinical learning opportunities for students. Academic practice partnerships have been proposed as a strategy to address the preceptorship crisis. This project evaluated the impact of a longitudinal immersive clinical experience designed for nurse practitioner students in collaboration with two federally qualified health centers and an underserved clinic within an academic health center. The study used a pre- and postsurvey method to determine the impact of an immersive clinical experience on preceptor perceptions of benefits and rewards, support, and commitment to the role. A statistically significant increase in preceptor perception of support was noted in three areas. Participants reported increased opportunity to share information with other preceptors, improved support from nursing faculty to help identify students' performance problems, and greater clarity in faculty responsibilities related to the preceptor role. Increases in perceptions of benefits and rewards and commitment to the preceptor role did not reach statistical significance. Immersive clinical experiences have the potential to improve the levels of preceptor support, commitment, and perceived opportunities for benefits and rewards, which may facilitate the development of high-quality, sustainable clinical learning opportunities for nurse practitioner students., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2019 American Association of Nurse Practitioners.)

Background: Seasonal malaria chemoprevention (SMC) aims to prevent malaria in children during the high malaria transmission season. The Achieving Catalytic Expansion of SMC in the Sahel (ACCESS-SMC) project sought to remove barriers to the scale-up of SMC in seven countries in 2015 and 2016. We evaluated the project, including coverage, effectiveness of the intervention, safety, feasibility, drug resistance, and cost-effectiveness., Methods: For this observational study, we collected data on the delivery, effectiveness, safety, influence on drug resistance, costs of delivery, impact on malaria incidence and mortality, and cost-effectiveness of SMC, during its administration for 4 months each year (2015 and 2016) to children younger than 5 years, in Burkina Faso, Chad, The Gambia, Guinea, Mali, Niger, and Nigeria. SMC was administered monthly by community health workers who visited door-to-door. Drug administration was monitored via tally sheets and via household cluster-sample coverage surveys. Pharmacovigilance was based on targeted spontaneous reporting and monitoring systems were strengthened. Molecular markers of resistance to sulfadoxine-pyrimethamine and amodiaquine in the general population before and 2 years after SMC introduction was assessed from community surveys. Effectiveness of monthly SMC treatments was measured in case-control studies that compared receipt of SMC between patients with confirmed malaria and neighbourhood-matched community controls eligible to receive SMC. Impact on incidence and mortality was assessed from confirmed outpatient cases, hospital admissions, and deaths associated with malaria, as reported in national health management information systems in Burkina Faso and The Gambia, and from data from selected outpatient facilities (all countries). Provider costs of SMC were estimated from financial costs, costs of health-care staff time, and volunteer opportunity costs, and cost-effectiveness ratios were calculated as the total cost of SMC in each country divided by the predicted number of cases averted., Findings: 12 467 933 monthly SMC treatments were administered in 2015 to a target population of 3 650 455 children, and 25 117 480 were administered in 2016 to a target population of 7 551 491. In 2015, among eligible children, mean coverage per month was 76·4% (95% CI 74·0-78·8), and 54·5% children (95% CI 50·4-58·7) received all four treatments. Similar coverage was achieved in 2016 (74·8% [72·2-77·3] treated per month and 53·0% [48·5-57·4] treated four times). In 779 individual case safety reports over 2015-16, 36 serious adverse drug reactions were reported (one child with rash, two with fever, 31 with gastrointestinal disorders, one with extrapyramidal syndrome, and one with Quincke's oedema). No cases of severe skin reactions (Stevens-Johnson or Lyell syndrome) were reported. SMC treatment was associated with a protective effectiveness of 88·2% (95% CI 78·7-93·4) over 28 days in case-control studies (2185 cases of confirmed malaria and 4370 controls). In Burkina Faso and The Gambia, implementation of SMC was associated with reductions in the number of malaria deaths in hospital during the high transmission period, of 42·4% (95% CI 5·9 to 64·7) in Burkina Faso and 56·6% (28·9 to 73·5) in The Gambia. Over 2015-16, the estimated reduction in confirmed malaria cases at outpatient clinics during the high transmission period in the seven countries ranged from 25·5% (95% CI 6·1 to 40·9) in Nigeria to 55·2% (42·0 to 65·3) in The Gambia. Molecular markers of resistance occurred at low frequencies. In individuals aged 10-30 years without SMC, the combined mutations associated with resistance to amodiaquine (pfcrt CVIET haplotype and pfmdr1 mutations [86Tyr and 184Tyr]) had a prevalence of 0·7% (95% CI 0·4-1·2) in 2016 and 0·4% (0·1-0·8) in 2018 (prevalence ratio 0·5 [95% CI 0·2-1·2]), and the quintuple mutation associated with resistance to sulfadoxine-pyrimethamine (triple mutation in pfdhfr and pfdhps mutations [437Gly and 540Glu]) had a prevalence of 0·2% (0·1-0·5) in 2016 and 1·0% (0·6-1·6) in 2018 (prevalence ratio 4·8 [1·7-13·7]). The weighted average economic cost of administering four monthly SMC treatments was US$3·63 per child., Interpretation: SMC at scale was effective in preventing morbidity and mortality from malaria. Serious adverse reactions were rarely reported. Coverage varied, with some areas consistently achieving high levels via door-to-door campaigns. Markers of resistance to sulfadoxine-pyrimethamine and amodiaquine remained uncommon, but with some selection for resistance to sulfadoxine-pyrimethamine, and the situation needs to be carefully monitored. These findings should support efforts to ensure high levels of SMC coverage in west and central Africa., Funding: Unitaid., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Importance: In 2019, hepatitis C virus (HCV) infection contributed to more deaths in the US than 60 other notifiable infectious diseases combined. The incidence of and mortality associated with HCV infection are highest among American Indian and Alaska Native individuals., Objective: To evaluate the association of the Cherokee Nation (CN) HCV elimination program with each element of the cascade of care: HCV screening, linkage to care, treatment, and cure., Design, Setting, and Participants: This cohort study used data from the CN Health Services (CNHS), which serves approximately 132 000 American Indian and Alaska Native individuals residing in the 14-county CN reservation in rural northeastern Oklahoma. Data from the first 22 months of implementation (November 1, 2015, to August 31, 2017) of an HCV elimination program were compared with those from the pre-elimination program period (October 1, 2012, to October 31, 2015). The analysis included American Indian and Alaska Native individuals aged 20 to 69 years who accessed care through the CNHS between October 1, 2012, and August 31, 2017. Cure data were recorded through April 15, 2018., Exposure: The CN HCV elimination program., Main Outcomes and Measures: The main outcomes were the proportions of the population screened for HCV, diagnosed with current HCV infection, linked to care, treated, and cured during the initial 22 months of the elimination program period and the pre-elimination program period. Data from electronic health records and an HCV treatment database were analyzed. The cumulative incidence of HCV infection in this population was estimated using bayesian analyses., Results: Among the 74 039 eligible individuals accessing care during the elimination program period, the mean (SD) age was 36.0 (13.5) years and 55.9% were women. From the pre-elimination program period to the elimination program period, first-time HCV screening coverage increased from 20.9% to 38.2%, and identification of current HCV infection and treatment in newly screened individuals increased from a mean (SD) of 170 (40) per year to 244 (4) per year and a mean of 95 (133) per year to 215 (9) per year, respectively. During the implementation period, of the 793 individuals with current HCV infection accessing the CNHS, 664 were evaluated (83.7%), 394 (59.3%) initiated treatment, and 335 (85.0%) had documented cure. In less than 2 years, the 85% 3-year goal was reached for cure (85.0%), and the goal for linkage to care was nearly reached (83.7%), whereas screening (44.1%) and treatment initiation (59.3%) required more time and resources., Conclusions and Relevance: This cohort study found that after 22 months of implementation, the CNHS community-based HCV elimination program was associated with an improved cascade of care. The facilitators and lessons learned in this program may be useful to other organizations planning similar programs.

Quitlines are effective, evidence-based tobacco cessation interventions that help tobacco users quit through a variety of services. The present study was done to evaluate the cost effectiveness of the National Tobacco Quitline Service (NTQLS). We calculated twoyear program use and costs for establishment, salary of the staff, media promotions, intervention services, Quitline registration calls and the number of quitters since inception of NTQLS in the year 2016, we examined whether NTQLS is cost-effective or not. Out of 63,350 callers, 9420 (97.9% males) callers with the mean ±SD age at 37.5±12.6 years; were registered for tobacco cessation counselling services at the National Tobacco Quitline Services (NTQLS) between 30th May 2016 and 31st May 2018. 3012 (32%) quitted their tobacco use till the last proactive calls. Average cost per completed counselling was 22.37 US$. Our study concludes that Tobacco Quitline as a tobacco control intervention is an excellent investment and cost-effective measure in India. Average cost per quitter at 69.96 US$ is comparatively very low to other country's Quitline, representing the ideal utilization of funds.

Ulceration of the foot is a major complication of diabetes mellitus, and optimal self-care may help prevent its development. Research suggests that mobile applications (apps) may affect behavioral change., Objective: The purpose of this study was to develop the Mobile Diabetic Foot Personal Care System (m-DAKBAS) and evaluate its effectiveness for patients with diabetes., Method: During Phase 1, a mobile app that included communication features, remote patient monitoring, and information was developed and pilot-tested among 10 patients. The Phase 2 study, conducted from June 2017 to April 2018, used a 2-group, pre-test/post-test design to evaluate the effect of the app on patients' knowledge, behavior, and self-efficacy scores when used for 6 months. Both the experimental (app) and control groups participated in 1 education session at the start of the study., Results: Of 106 patients who enrolled, 88 completed the study (44 in the experimental group and 44 in the control group). Only 6 patients had received education about foot care previously. The average age of all participants was 51.63 years (SD = 8.08). There were significantly more women in the experimental group than in the control group (65% vs. 45.5%; P = 0.5). Each participant used the app for 24 weeks, and the data entry rate was 72.9%. Throughout the study, participants had 1977 data entries (blood glucose and foot observation) in total. Differences between pre- and post-intervention test scores were significantly higher for knowledge, behavior, and self-efficacy in both groups, but the difference was greater in the experimental group (P < .05). Only post-test knowledge scores were significantly higher in the experimental compared with the control group (P < .05). Compared to the start of the study, the proportion of participants with cracked/dry skin and inappropriate footwear was significantly lower in the experimental group but not in the control group., Conclusion: In this study, education and follow-up via the mobile app and verbal-only instruction increased the knowledge, behavior, and self-efficacy scores of patients in both groups. Post-study knowledge scores were significantly higher in the experimental group than in the control group. Patient education remains a crucial component of optimal care, and further development, refinement, and testing of mobile applications to improve self-efficacy and reduce the risk of diabetic foot are warranted.

Background: Midwifery practice is essential in achieving high-quality maternal and newborn care in all settings and countries. However, midwifery practice has become more complex over the past decades. Considerable demands are being placed on midwives to meet increasing epidemiological, socio-economic, and technological challenges. These require a well-trained midwifery workforce ready to shape the care in the near and long-term future., Objective: To discuss advanced midwife practitioner role implementation in Belgium as a possible answer to healthcare-related challenges that impact midwifery practice. Furthermore, to stimulate a debate within the profession at all levels in Belgium and in countries considering advanced midwife practitioner roles., Method: The framework by De Geest et al. (2008) served as a basis for discussing the drivers for advanced midwife practitioner role implementation: the legal, policy and economic context, workforce issues, education, practice patterns, and healthcare needs of the population., Findings: A legal basis for advanced midwife practitioner role implementation is lacking in Belgium. Remuneration opportunities for the non-clinical part of these roles (e.g. leadership and innovation activities) are missing. It might be challenging for healthcare organisations to support the implementation of such roles, as immediate revenues of non-clinical activities are absent. However, sufficient potential resources are available to fill in future advanced midwife practitioner positions. Additionally, advanced midwife practitioner specific master programmes are being planned in the near future., Conclusions: Although several barriers for the implementation of advanced midwife practitioner roles were identified, a discussion should be held on the opportunities of implementing these roles to facilitate the development of new models of care that meet current and future challenges in midwifery practice and healthcare. After initial discussions amongst midwives in academic, managerial, and policy positions, stakeholders such as obstetricians, general practitioners, associations representing healthcare organisations, and policy makers should be involved as a next step., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Evidence on current, national physical activity (PA) and sedentary behaviour (SB) policies is limited. We, therefore, analysed availability, comprehensiveness, implementation, and effectiveness of PA and SB policies internationally., Methods: In this cross-sectional study, Global Observatory for Physical Activity (GoPA!) Country Contacts from 173 countries were asked to provide data on their national PA and SB policies by completing GoPA! Policy Inventory. Data were collected for 76 countries (response rate = 44%)., Results: Formal written policies for PA and SB were found in 92% (95% confidence interval [CI]: 86, 98) and 62% (95% CI: 50, 75) of countries, respectively. Sixty-two percent (95% CI: 51, 73) of countries have national PA guidelines, while 40% (95% CI: 29, 52) have SB guidelines. Fifty-two (95% CI: 40, 64) and 11% (95% CI: 3, 19) of countries have quantifiable national targets for PA and SB, respectively. The most represented ministries/departments involved in the promotion of more PA and/or less SB were in the sport (reported by 99% countries; 95% CI: 96, 100), health (97%; 95% CI: 94, 100), education (94%; 95% CI: 88, 100), and recreation and leisure (85%; 95% CI: 71, 99) sectors. The median score (0-10) for the comprehensiveness of PA and SB policies was 4 (95% CI: 4, 5) and 2 (95% CI: 2, 3), respectively. For PA and SB policy implementation it was 6 (95% CI: 5, 6). For the effectiveness of PA and SB policies it was 4 (95% CI: 3, 5) and 3 (95% CI: 2, 4), respectively. PA and SB policies were generally best developed in high-income countries and countries of European and Western-Pacific regions., Conclusions: Most of the included countries have PA policies, but their comprehensiveness, implementation, and effectiveness are generally low-to-moderate. SB policies are less available, comprehensive, implemented, and effective than PA policies. PA and SB policies are better developed in high-income countries, compared with low- and lower-middle-income countries, and in countries of European and Western-Pacific regions, compared with other world regions. More investment is needed in development and implementation of comprehensive and effective PA and SB policies, particularly in low- and lower-middle-income countries.

A growing body of literature has documented that community-based early childhood development (ECD) interventions can improve child developmental outcomes in vulnerable communities. One critical element of effective community-based programs is consistent program participation. However, little is known about participation in community-based ECD interventions or factors that may affect participation. This paper examines factors linked to program participation within a community-based ECD program serving 819 infants and their caregivers in 50 rural villages in northwestern China. The results find that more than half of families did not regularly attend the ECD program. Both village-level social ties within the program and proximity to the program significantly predict program participation. Increased distance from the program site is linked with decreased individual program participation, while the number of social ties is positively correlated with participation. The average program participation rates among a family's social ties is also positively correlated with individual participation, indicating strong peer effects. Taken together, our findings suggest that attention should be given to promoting social interactions and reducing geographic barriers among households in order to raise participation in community-based ECD programs., Competing Interests: The authors have declared that no competing interests exist.

Climate change will adversely affect the health of populations and the ability of healthcare systems to deliver appropriate and timely care. Furthermore, resource scarcity requires nurses to practice in more sustainable ways. This study investigated the extent to which student nurses reported that they were able to apply their knowledge of sustainability in clinical practice following educational sessions on relevant topics. Students were exposed to scenario-based sustainability education in years 1, 2, and 3 of their 3-year program. Data were collected using a questionnaire that asked participants if they were able to implement sustainable practice. In year 2,121 students, and in year 3, 68 stated they made a change or challenged practice as a consequence of learning about sustainability. Barriers preventing them from challenging unsustainable practice were lack of confidence and resistance to change. Year-3 students were more able to influence unsustainable practice than were those in year 2. This study indicates that sustainability sessions, focused on aspects of clinical relevance, can support nurses to implement change; barriers remain that require confidence building for the students., (© 2020 The Authors Nursing & Health Sciences Published by John Wiley & Sons Australia, Ltd.)

Health disparities in diabetes management and control are well-documented. The objective of this study is to describe one diabetes education program delivered in the United States in terms of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) Planning and Evaluation Framework. Questionnaires, clinical data, and administrative records were analyzed from 8664 adults with diabetes living in South Texas, an area characterized by high health disparities. The Diabetes Education Program delivered was a professionally led 12-month program involving 8 h of in-person workshop education followed by quarterly follow-up sessions. Changes in average blood glucose levels over the past 3 months (e.g., A1c levels) were the primary clinical outcome. Descriptive and multiple generalized linear mixed models were performed. This community-based initiative reached a large and diverse population, and statistically significant reductions in A1c levels ( p < 0.01) were observed among participants with Type 2 diabetes at 3 months. These reductions in A1c levels were sustained at 6-, 9-, and 12-month follow-up assessments ( p < 0.01). However, considerable attrition over time at follow-up sessions indicate the need for more robust strategies to keep participants engaged. For this diabetes education program, the RE-AIM model was a useful framework to present study processes and outcomes.

Children's fussy eating is associated with a reduced vegetable intake. This quasi-experimental study evaluated "Big Chef Little Chef" (BCLC), a nursery-based cooking skills programme aimed at reducing food fussiness and increasing willingness to try green vegetables by incorporating repeated exposure and sensory learning. Parent and child (3-5 years) dyads attended BCLC for four/1.5 h weekly sessions. A comparison group was recruited after BCLC completion and attended a single education session at week 1. A questionnaire measured food fussiness at week 1 and week 4. At week 4, all children were offered six green vegetables (raw and cooked) and an average score (1 = did not try; 2 = tried it/ate some; 3 = ate it all) was calculated for willingness to try vegetables. In total, 121 dyads (intervention: n = 64; comparison: n = 57) participated. The food fussiness score (1 min-5 max) in the intervention group decreased significantly from 3.0 to 2.6 ( p < 0.01) between time points, while there was no change in the comparison group (3.1 (week 1) and 3.0 (week 4)). The intervention group was more willing to try green vegetables with significantly higher ( p < 0.001) median scores for raw and cooked vegetables (2.5 for both) compared with the comparison group (2.0 and 1.7, respectively). The BCLC reduced food fussiness and increased willingness to try green vegetables.

Background: Despite multiple harm reduction (HR) programmes worldwide, there are still an important number of people who use drugs (PWUD) who do not access those services. Their difficulties to obtain HR tools are due to their inability to reach such services (remoteness and/or limited customer service hours), costs, quantitative restrictions, fear of judgement, lack of confidentiality in pharmacy, and unfamiliarity with HR programmes. We tested an innovative approach using the power of remote online communication and the national postal distribution network to improve HR tool access and counselling., Methods: Based on these observations, SAFE association created HaRePo in 2011, a free and confidential programme designed for people who have difficulties accessing HR tools and counselling. PWUD can access the programme by phone and/or email. An HR professional delivers HR counselling and HR tools and connects PWUD to other HR services, medical, and social workers. HR tools are prepared and sent according to the person's needs through the French postal service to consumers across Metropolitan France and overseas territories., Results: Since 2011, 1920 PWUD have benefited from HaRePo: 10,450 parcels were sent accounting for more than 1.7 million syringes and 6 million HR-related items. HaRePo receives positive feedback from PWUD who have improved their practices through remote but trusted communication. The percentage of people that, after joining the programme, never reuse and/or share HR tools have significantly increased. On average, 71.5% of beneficiaries never reuse syringes and 81% do not reuse needles. And they are 98.5% consumers who never share syringes and 99% needles any longer. Between 44 and 80% HaRePo beneficiaries have reported that their drug-related practices (injection, inhalation, and snorting) are now safer. Finally, between 39 and 53% HaRePo consumers declared that their overall physical state has improved (e.g. venous condition, the appearance of point of injection, swelling of arms, legs, and hands)., Conclusion: HaRePo is an innovative HR programme efficient for hard-to-reach PWUD. It shows evidence of a positive feedback loop for PWUD in improving their practices. Finally, HaRePo represents a clear benefit for health authorities in France, who decided to expand the programme in 2016.

Background: Pre-gestational diabetes mellitus is associated with increased risk of maternal and perinatal adverse outcomes. This systematic review was conducted to evaluate the effectiveness and safety of pre-conception care (PCC) in improving maternal and perinatal outcomes., Methods: Databases from MEDLINE, EMBASE, WEB OF SCIENCE, and Cochrane Library were searched, including the CENTRAL register of controlled trials, and CINHAL up until March 2019, without any language restrictions, for any pre-pregnancy care aiming at health promotion, glycemic control, and screening and treatment of diabetes complications in women with type I or type II pre-gestational diabetes. Trials and observational studies were included in the review. Newcastle-Ottawa scale and the Cochrane collaboration methodology for data synthesis and analysis were used, along with the GRADE tool to evaluate the body of evidence., Results: The search identified 8500 potentially relevant citations of which 40 reports of 36 studies were included. The meta-analysis results show that PCC reduced congenital malformations risk by 71%, (Risk ratio (RR) 0.29; 95% CI: 0.21-0.40, 25 studies; 5903 women; high-certainty evidence). The results also show that PCC may lower HbA1c in the first trimester of pregnancy by an average of 1.27% (Mean difference (MD) 1.27; 95% CI: 1.33-1.22; 4927 women; 24 studies, moderate-certainty evidence). Furthermore, the results suggest that PCC may lead to a slight reduction in the risk of preterm delivery of 15%, (RR 0.85; 95% CI: 0.73-0.99; nine studies, 2414 women; moderate-certainty evidence). Moreover, PCC may result in risk reduction of perinatal mortality by 54%, (RR 0.46; 95% CI: 0.30-0.73; ten studies; 3071 women; moderate-certainty evidence). There is uncertainty about the effects of PCC on the early booking for antenatal care (MD 1.31; 95% CI: 1.40-1.23; five studies, 1081 women; very low-certainty evidence) and maternal hypoglycemia in the first trimester, (RR 1.38; 95% CI: 1.07-1.79; three studies; 686 women; very low- certainty evidence). In addition, results of the meta-analysis indicate that PCC may lead to 48% reduction in the risk of small for gestational age (SGA) (RR 0.52; 95% CI: 0.37-0.75; six studies, 2261 women; moderate-certainty evidence). PCC may reduce the risk of neonatal admission to intensive care unit (NICU) by 25% (RR 0.75; 95% CI: 0.67-0.84; four studies; 1322 women; moderate-certainty evidence). However, PCC may have little or no effect in reducing the cesarean section rate (RR 1.02; 95% CI: 0.96-1.07; 14 studies; 3641 women; low-certainty evidence); miscarriage rate (RR 0.86; 95% CI: 0.70-1.06; 11 studies; 2698 women; low-certainty evidence); macrosomia rate (RR 1.06; 95% CI: 0.97-1.15; nine studies; 2787 women, low-certainty evidence); neonatal hypoglycemia (RR 0.93; 95% CI: 0.74-1.18; five studies; 880 women; low-certainty evidence); respiratory distress syndrome (RR 0.78; 95% CI: 0.47-1.29; four studies; 466 women; very low-certainty evidence); or shoulder dystocia (RR 0.28; 95% CI: 0.07-1.12; 2 studies; 530 women; very low-certainty evidence)., Conclusion: PCC for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations. In addition, it may improve the risk of preterm delivery and admission to NICU. PCC probably reduces maternal HbA1C in the first trimester of pregnancy, perinatal mortality and SGA. There is uncertainty regarding the effects of PCC on early booking for antenatal care or maternal hypoglycemia during the first trimester of pregnancy. PCC has little or no effect on other maternal and perinatal outcomes., Competing Interests: The authors have declared that no competing interests exist.

Background: 'Physical Activity 4 Everyone' (PA4E1) was an efficacious multi-component school-based physical activity (PA) program targeting adolescents. PA4E1 has seven PA practices. It is essential to scale-up, evaluate effectiveness and assess implementation of such programs. Therefore, the aim is to assess the impact of implementation support on school practice uptake of the PA4E1 program at 12 and 24 months., Methods: A cluster randomised controlled trial, utilising a type III hybrid implementation-effectiveness design, was conducted in 49 randomly selected disadvantaged Australian Government and Catholic secondary schools. A blinded statistician randomly allocated schools to a usual practice control (n = 25) or the PA4E1 program group (n = 24), with the latter receiving seven implementation support strategies to support school PA practice uptake of the seven practices retained from the efficacy trial. The primary outcome was the proportion of schools adopting at least four of the seven practices, assessed via telephone surveys with Head Physical Education Teachers and analysed using exact logistic regression modelling. This paper reports the 12-month outcomes., Results: Schools were recruited from May to November 2017. At baseline, no schools implemented four of the seven practices. At 12 months significantly more schools in the program group had implemented four of the seven practices (16/24, 66.7%) than the control group (1/25, 4%) (OR = 33.0[4.15-1556.4], p < 0.001). The program group implemented on average 3.2 (2.5-3.9) more practices than the control group (p < 0.001, mean 3.9 (SD 1.5) vs 0.7 (1.0)). Fidelity and reach of the implementation support intervention were high (both > 80%)., Conclusions: Through the application of multiple implementation support strategies, secondary schools were able to overcome commonly known barriers to implement evidence based school PA practices. As such practices have been shown to result in an increase in adolescent PA and improvements in weight status, policy makers and practitioners responsible for advocating PA in schools should consider this implementation approach more broadly when working with schools. Follow-up is required to determine whether practice implementation is sustained., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12617000681358 registered 12th May 2017.

Objectives: To explore how to integrate the "best" practice into nursing of venous thromboembolism (VTE) based on the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework., Methods: A mixed-methods design was used. A steering group for clinical evidence implementation (EI) was established to conduct pre-implementation baseline surveys, a thorough analysis of the evidence, and an analysis of the survey results. The hindering and enabling factors associated with the clinical implementation of the evidence were analysed based on the three core elements of i-PARIHS, to formulate the clinical implementation plan for VTE nursing evidence. On-site expert reviews and focus group interviews were used to evaluate the feasibility of the draft plan, make adjustments, and finalize the evidence-based practice plan, which was then put into practice and evaluated., Results: A new nursing process, a health education manual and a nursing quality checklist on VTE has been established and proved to be appropriate through the implementation. Compliance with evidence related to VTE nursing increased significantly in the two units, with better compliance in unit B than unit A. The knowledge, attitude and behaviour scores for VTE nursing increased substantially in both nurses and patients., Conclusion: The EI programme of incorporating the "best" evidence on VTE nursing into clinical practice using the i-PARIHS framework demonstrated feasibility, appropriateness and effectiveness and could serve as a reference., Competing Interests: The authors have declared that no competing interests exist.

In line with the Sustainable Development Goals (SDGs) and the target for achieving Universal Health Coverage (UHC), state level initiatives to promote health with "no-one left behind" are underway in India. In Kerala, reforms under the flagship Aardram mission include upgradation of Primary Health Centres (PHCs) to Family Health Centres (FHCs, similar to the national model of health and wellness centres (HWCs)), with the proactive provision of a package of primary care services for the population in an administrative area. We report on a component of Aardram's monitoring and evaluation framework for primary health care, where tracer input, output, and outcome indicators were selected using a modified Delphi process and field tested. A conceptual framework and indicator inventory were developed drawing upon literature review and stakeholder consultations, followed by mapping of manual registers currently used in PHCs to identify sources of data and processes of monitoring. The indicator inventory was reduced to a list using a modified Delphi method, followed by facility-level field testing across three districts. The modified Delphi comprised 25 participants in two rounds, who brought the list down to 23 approved and 12 recommended indicators. Three types of challenges in monitoring indicators were identified: appropriateness of indicators relative to local use, lack of clarity or procedural differences among those doing the reporting, and validity of data. Further field-testing of indicators, as well as the revision or removal of some may be required to support ongoing health systems reform, learning, monitoring and evaluation., Competing Interests: We further wish to clarify that AN is employed by ACCESS Health International (https://accessh.org/ - not ACCESS Health. ACCESS Health International is a registered not for profit organisation and is not a commercial company. We are in full adherence of PLoS One policies on sharing data and materials. I wish to confirm that all authors have no competing interests to declare.