Elderly individuals who are hospitalized due to emergency abdominal surgery spend over 80% of their recovery time in bed, resulting in early and rapid muscle loss. As these elderly individuals have a lower physiological reserve, the impact of muscle wasting on function may be profound. The objectives of this study are to (1) create an independently led post-surgical reconditioning program and (2) pilot its implementation, while assessing the feasibility and safety of the program.The BE FIT program was generated with hospital rehabilitation staff to target lower limb strength, balance, and endurance. This pilot study was assessed using a sequential before and after trial, with a cohort of patients aged ≥ 65 years enrolled in the Elder-friendly Approaches to the Surgical Environment (EASE) study. Change in 30-s sit-to-stand performance between postoperative day 2 and discharge was compared between Usual Care pre- and post-BE FIT participants.p = 0.05). There were no reported adverse events.A total of 66 patients participated in the sub-study, 33 Usual Care and 33 BE FIT. Mean (SD) age was 76.2 (8.78); 44 (67%) were female, with 11 (17%) reporting mild/moderate frailty on the CHSA Clinical Frailty Scale. BE FIT participants had a median of three rehab days and self-reported completing an average of 83% of the exercises. The adjusted between group difference showed that the BE FIT patients were able to complete more stands than the Usual Care (1.9 stands (0.94), The reconditioning program was shown to be safe and feasible within the hospital setting for the elderly emergency abdominal surgery patients. More rigorous assessment is needed to confirm this effectiveness and to better assess patient adherence to self-directed exercise.NCT02233153 through ClinicalTrials.gov. Registered September 8, 2014.Registration # With our rapidly aging population and advancements to allow surgery as a viable option for those with increased age, a greater number of surgical procedures are now performed on seniors ≥ 65 years) in Canada and the USA –3. Unfor years inThe traditional approach to postoperative surgical care has largely centralized around activity restrictions to optimize wound healing. However, prolonged bed rest is not a viable option for the frail elderly as evidence strongly supports its detrimental effects on muscle mass that can compromise independence . CurrentThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Best Practices Guideline suggests early mobilization with a focus on positioning assistance, balance, and gait training . Newer eFor these reasons, new rehabilitation strategies are needed to improve functional outcomes in older adults following abdominal surgery, especially for those done urgently when pre-admission optimization is not feasible . The objPrior to program development, the author AM, a kinesiologist, shadowed in-hospital physical and occupational therapists who were responsible for the standard physical therapy of the population group of interest. The purpose of this was to familiarize the author with current hospital rehabilitation practices, safe movement with recent incision sites, common areas of physical weakness for elderly inpatients, and the accessibility of the hospital ward. The program was based around the progressive use of multi-disciplinary teams within Alberta’s Health Care system. The goal of the program was to provide a uniform transitional program that all members of the health-care team would be knowledgeable about and comfortable using. The program was designed with input from exercise physiologists, physical therapists, occupational therapists, and surgeons.An initial list of exercises was selected by authors AM and MM, based on expert opinion and the American College of Sports Medicine’s recommendations for elderly individuals , with thTesting of the BEdside reconditioning for Functional ImprovemenTs (BE FIT) program was done using a prospective, sequential before-and-after sub-study of the Elder-friendly Approaches to the Surgical Environment (EASE) study . The maiParticipants for EASE-BE FIT sub-study were consecutively enrolled elderly patients (≥ 65 years old) who had been referred directly to Acute Care Surgery services for emergency abdominal surgery at the University of Alberta Hospital in Edmonton, Canada, from May 2015 to May 2016. Patients were excluded if they (1) received elective or palliative surgery, (2) were admitted due to trauma, (3) were dependent in three or more activities of daily living or were non-ambulatory prior to admission, and (4) could not read/speak or comprehend English. The research coordinator approached the eligible patients prior to their surgery, and willing participants were consented.Participants included prior to the implementation of the BE FIT program received only usual care, which may have included physical therapy if it was requested by the clinical team . The physiotherapist would assess the frequency and timing of the clinical physiotherapy involvement, independent of the study. Participants included after the BE FIT program implementation received usual care plus the BE FIT reconditioning program beginning on postoperative day 2 (BE FIT cohort). The appropriate level of the program was determined using the participant’s frailty within 2 weeks prior to admission, assessed using CHSA Clinical Frailty Scale , along wChart review was completed to determine age, sex, race, marital status, living situation prior to admission, type of surgery, postoperative physical and occupational therapy intervention, any occurrence of in-hospital falls, discharge status, and length of stay.Participants completed a 30-s sit-to-stand (STS) test on postoperative day 2 (prior to receiving the BE FIT program for the BE FIT cohort) and again on the day of discharge. The STS test is a measurement used to assess functional lower extremity strength in older adults . BrieflySix weeks after discharge, for those participants who returned for their scheduled follow-up with their surgeon, a Timed Up and Go (TUG) test was completed . The TUGp = 0.05 and a power value of 0.90, the necessary value for the STS tests was based on the mean and standard deviation values normalized by Jones et al. [Sample size was calculated based on the few normative values currently published in scientific literature, along with the established minimal clinically important difference scores  by the number of possible rehab days (discharge date minus postoperative day 2 date). Informal feedback and participant comments about the program were captured on the logbook and notes written by the research coordinator during final testing at discharge.p = 0.001), had fewer cholecystectomies (p = 0.04), were more often mild or moderately frail (p = 0.02), and received more physical or occupational therapy intervention (p = 0.009) compared to the BE FIT group (see Table n = 29), median number of possible rehab days was 3 (IQR 1–6) and mean (SD) adherence was reported as 2.56 (0.65), suggesting that participants completed 83% of their exercises. The logbook was completed by 18 (55%) of BE FIT participants. Two falls occurred during the duration of the study , but neither was associated with performance of the functional testing or completion of the BE FIT program.A total of 66 participants were enrolled in the study with 33 participants in each group. The Usual Care group had more intestinal revision or resection surgeries  of participants felt that postoperative day 2 was too soon to complete exercises after surgery  and either delayed beginning the program or chose not to complete the exercises during their hospital stay. No concerns were brought forth by the clinical team regarding the program.p = 0.01). After adjusting for sex, Clinical Frailty Scale, and surgery type, the difference of difference was 1.9 (0.94) (p = 0.05)  of participants completed the STS reps without using their arms, 37 (56%) completed their STS reps with the assistance of using their arms, and 19 (29%) used a combination of without-arm and with-arm reps. Combining all reps, regardless of arm use, the BE FIT group completed 5.0 (3.9) more stands at discharge compared to postoperative day 2, while the Usual Care group completed 2.7 (3.0) (between group difference 2.3 (0.45) stands, p = 0.004). After adjusting for sex, Clinical Frailty Scale, and surgery type, the difference between groups remained significant (mean difference 4.1 (1.4), p = 0.006)  participants in the Usual Care group and 10 (30%) participants in the BE FIT group. BE FIT participants completed the TUG in 9.0 (2.8) s, while the Usual Care completed it in 13.1 (5.2) s , This is one of the first pilot studies to develop a structured postoperative reconditioning program for elderly emergency surgery patients. Using an integrated knowledge translation approach to generating the BE FIT program contributed to the successful implementation for the program. The reconditioning program was feasible and safe within our hospital setting. There were no reported associated adverse events, and the self-directed nature of the program and use of a progress monitoring via logbook allowed us to remain resource neutral. Both the change in STS between postoperative day 2 and discharge and the TUG at 6 weeks post-discharged showed greater improvement in the BE FIT group, compared to Usual Care, even after adjusting for sex, clinical frailty, and surgery type. Leaving the hospital in a better functional state places BE FIT participants to a reduced risk of injury and falls and loss of physical independence [As there are few studies of this nature available in the literature, similar results are limited; however, improvement in STS scores due to early exercise interventions has been found in patients undergoing elective hip and knee arthroplasty , elderlyMost participants were eager and willing to perform the exercises as often as they felt they could; however, a small portion of participants felt that they should not be performing exercises so soon after surgery and therefore did not complete the program. Self-reported adherence was adequate, though overall use of the logbook was variable. While this was not formally assessed, we expect barriers to logbook use likely include time constraints, misunderstanding around logbook use, or sensory impairments . Unfortunately, participants who did not perform the program also did not complete the logbook, creating reporting bias and limiting our knowledge of the barriers to exercise in this group. Participants’ informal feedback regarding exercise after surgery prompts us to believe that the lack of education and sharing information around postoperative mobility exists at the level of not only heath care providers but patients and their families as well. Education opportunities for health-care staff may increase uptake of postoperative mobility programs and should be assessed and incorporated into further research.Unfortunately, the concurrent EASE interventions, small sample size, and unclear adherence due to poor completion rates of logbooks limit our interpretation of this sub-study. For these reasons, a dedicated study is required to determine the optimal program and resources necessary to improve patient outcomes. Our future work will be to perform a pragmatic randomized controlled trial examining our exercise intervention, tailored to frailty.As this sub-study included a small cohort and occurred in the setting of the concurrent implementation of other elder-friendly initiatives, our ability to interpret our finding and report unequivocal success is limited. However, our pilot reconditioning program results show promise in helping offset declines in physical function in elderly patients following emergency abdominal surgery and warrants further, more rigorous investigation to assess patient uptake and adherence, safety, and effectiveness.


The Georgetown Public Hospital Corporation (GPHC) started the Internal Medicine/Infectious Diseases residency program in 2013. It was a collaborative initiative between GPHC and University of Maryland. Since that time the program has gone through many trials and developed new partnerships and collaboration and emerged as a young successful program with close international links that have worked and persevered in developing the successful academic and professional careers of its residents. International collaborations have resulted in applying innovative methods of teaching to deliver the curriculum in a sustainable manner in a resource-limited setting. The article discusses in detail the history of the program and the roles that the collaborative partners have played in the evolution of the program. The Cooperative Republic of Guyana  is] is1)] iOver the past five decades, Guyana’s population annual growth rate has fluctuated widely due to the influence of multiple factors, such as the political establishment and socioeconomic conditions of the day, on the degree of outward migration. For example, during the 1980s when Guyana’s economy became heavily indebted and its currency was significantly devalued, the population declined to its lowest in modern times, due to an increased rate of emigration . DiffereLike many of its Caribbean counterparts, Guyana is experiencing an epidemiologic transition with the highest burden of morbidity and mortality now being due to non-communicable diseases, such as ischemic heart disease and diabetes mellitus, while some communicable diseases still present formidable challenges. Human immunodeficiency virus (HIV) infection/AIDS is also a significant contributor to morbidity and mortality and is in fact the leading cause of mortality in both males and females in the 25–44 years age group . The vasBefore the establishment of the University of Guyana Medical School and its 5-year Bachelor of Medicine; Bachelor of Surgery program in 1985 . As a reSubsequent to the introduction of the above mentioned programs, several other graduate medical education programs including residencies in Emergency Medicine, Obstetrics and Gynecology, Pediatrics, Internal Medicine, and Family Practice were established at the GPHC in the 2011–2015 period, through the Institute of Health Science Education (IHSE) in collaboration with the University of Guyana and a multitude of international partners. These programs would not only provide opportunities for medical professionals to get specialist training locally but potentially be cost effective, having a holistic curriculum, teaching effective and relevant patient care skills and forming a pool of candidates to make the programs a sustainable venture.Through a joint initiative by the IHSE, GPHC, and the Institute of Human Virology, University of Maryland and with support by a new 5-year grant from the US Centers for Disease Control and Prevention (CDC) as part of the President’s Emergency Plan for AIDS Relief, a 3-year Masters in Internal Medicine Degree program, accredited through the University of Guyana, was designed. The first batch of six residents started on January 14, 2013.It was envisioned that the program would be supervised under the continuous presence of faculty from the University of Maryland, with the support of local faculty. The latter proved difficult with very few local IM specialists and none that were able to champion the program in leadership capacity. In August 2013, the University of Maryland hired an ID-trained physician to be the full-time in-country program director and to serve as the local champion. Somewhat unexpectedly, the funding support for the program was terminated early, creating a new challenge for the program. At this point, the program had not yet graduated its first class and had enrolled more participants. As notable gains in patient care and education had been shown, the Ministry of Health and IHSE recruited the program director to stay beyond the end of grant funding period. The primary goals during the extension were for the director to facilitate the graduation of students who would become faculty and to form new academic partnerships for curriculum development and integrity. Over the past 3 years, much progress has been made in this respect and the curriculum, in its present form, is the result of collaboration with faculty from many internationally recognized institutions of learning. This is further discussed in the sections below.In the past more than 500-odd inpatients per month were managed by one consultant and a few general medical officers and interns, with no morning handover and rounds lasting from morning till evening. Now, a similar number of patients are managed by more than 30 doctors divided into six teams, headed, respectively, by graduates from the first cohort of students, 10 residents , several general medical officers, and interns. In terms of the resident demography, there are nine female residents and seven male residents (this includes the graduates as well), and among them nine graduated from medical school in Cuba, two in Russia, and five from the University of Guyana. The increase in the number of physicians has also been augmented by an influx of Cuban consultants hired by the Ministry of Health  and large numbers of Cuban-trained Guyanese medical graduates who are returning home for further clinical training.The stated goal of the IM residency program is to provide specialty training in IM with special focus on IDs in order to develop high-quality IM physicians who will enhance the quality of the health care and well-being of the people of Guyana. To achieve this goal, the curriculum encompasses both academic and clinical training components.Modular systems-based didactic series—each module is accompanied by a study guide and it usually takes 1–2 months to complete the specific lecture series. Didactic lectures are conducted once or twice weekly either (a) in a classroom by resident or visiting faculty using slideshows, whiteboard, and bedside demonstrations where applicable or (b) via teleconference  during the morning conference.2.ID ward: this is dedicated to the investigation and treatment of tuberculosis. Residents rotate on this service at least once per year, and this entails interacting with unique patient populations and collaborating with the National Public Health Reference Laboratory and Georgetown Chest Clinic. Students are exposed to the use of modern technologies such as GeneXpert and plan and organize long-term care for patients.3.General cardiology and cardiac intensive care unit: this inpatient service and unit were recently established by professors from the Libin Cardiovascular Institute, University of Calgary—presently one of the major collaborators with our IM/ID residency program. Residents work at least one block a year on this service under the guidance of visiting cardiologists and fellows, and a resident registrar, being exposed to a wide range of cardiovascular pathologies in stable and critically ill patients.4.Outpatient medicine: weekly clinics are included as part of all inpatient rotations which provide residents with an experience in outpatient management and allow them to appreciate the natural history of disease and become familiar with common problems encountered in the practice of general IM. There is a focus on preventive medicine, cost containment, and psychosocial/behavioral issues. They are also taught how and when to seek subspecialty consultation and how to provide general medicine consults to other clinical specialties.5.HIV outpatient clinic: this rotation occurs once per year at the National Care and Treatment Institute under the guidance of its director and provides interaction with various populations including prisoners, pregnant women, members of the LGBT community and these are patients with both newly diagnosed HIV and its complications. On this rotation, residents are also exposed and involved in the diagnosis and treatment of other sexually transmitted infections.6.Emergency room (ER): this is an intense one block rotation, the goals of which are twofold: to provide an opportunity for residents to care for patients in an acute setting with a broad spectrum of medical, surgical, and gynecological diagnoses and to expose them to a full range of acuity—from trauma and medical resuscitations to ambulatory care.7.Intensive care unit: the intensive care unit receives patients primarily from the medical wards, ER, and transfers from other hospitals. The main goal of this rotation is to provide a milieu for residents to learn the basic principles of critical care medicine. Residents work one block per year in this unit, where they care for critically ill patients with a broad variety of medical illnesses under the guidance of a faculty member and in conjunction with the anesthesia program at GPHC.8.Senior regional service rotations: this is a two block rotation done by senior residents at a regional hospital, such as the West Demerara Regional Hospital, in their third year of the program. The goals of this rotation are to provide the experience of more independent clinical practice, increase awareness of the systems outside of GPHC, the challenges, and advantages of practicing in such a setting. Residents are also required to provide a service to the regional hospital in either a quality improvement, educational, or research project.9.International rotations: in collaboration with international partners from McMaster University and the University of Calgary, senior residents in their third year are able to do a two-block elective in nephrology, general IM, or cardiology at teaching hospitals associated with these institutions. International electives are an essential part of the program and not only expose residents to advanced diagnostics and treatments, and increase their depth of knowledge, but they also see what it is to practice in a highly efficient system, and inspire ideas for quality improvement back home.In the future, there is also plan to take the residents on outreach programs to the rural areas to screen and assess for chronic medical diseases such as diabetes and hypertension and to do patient education regarding these diseases.Clinical evaluations: residents receive clinical evaluations for each rotation based on the six-core competencies outlined by the Accreditation Council for Graduate Medical Education: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems-Based Practice . In addiSubject exams: at the end of a lecture series of a particular module, residents are assessed in a multiple choice question exam with case-based questions.American College of Physicians (ACP) In-training exam: once a year, second- and third-year residents do the ACP In-training computer-based residency exam. Residents receive individualized reports and assessment of knowledge based on content areas for the purposes of directing their study efforts. The in-training exam is not used for purposes of promotion.Annual written examination: the annual exam is written by program faculty and assesses content covered during the year. A passing score is required for promotion.Final examination: at the end of the program, residents undergo a final exam to determine their competence to practice as Internists. This is both a written and oral examination. The oral portion is administered as an Objective Structured Clinical Examination designed to test communication, procedural, and clinical reasoning skills. The examination is written by program faculty in collaboration with external examiners from partners at Caribbean and/or North American Universities.In addition to actively taking part in the academic and clinical training aspects outlined in the curriculum, residents undergo several assessments that serve a variety of purposes for both the resident and the program:Our first cohort of six residents passed their final examinations successfully in November 2016. They started as registrars in the hospital and remain an integral part of the residency program. Since the program started, four residents left the program; one had to leave after repeatedly failing remediation courses and three left due to other personal commitments.A young residency program needs a lot of nurturing to bloom to its full potential. A resource-limited setting with just one resident faculty member can lead to a challenging environment in which to make this feasible. Although GPHC had other residency programs that could mentor the medicine program—partnerships and collaborations became a necessity to develop further on the foundation of the residency program and help develop and sustain the program at international standards. Collaborations with academic leaders in the field foster a process of self-appraisal and improvement and provide networking opportunities that broaden the horizon of medical education and academic scholarship far beyond the local boundaries.1.Clinical teaching and supervisionAt present the GPHC program collaborates with the following universities: McMaster University, University of Calgary, University of Pittsburgh, and a recently expanded collaboration with Health Volunteer Overseas (HVO). The collaborations have been developed with an open, trusting, and negotiable memorandum of understanding. The goals of the collaboration are to focus on the following:Visiting faculty from each of the universities volunteer their academic and clinical time at GPHC and are provided medical licensure by the Guyana Medical Council. They provide clinical supervision, mentorship, and bedside teaching to the residents, medical students, medical officers, and interns participating in patient care. Having experts from different specialty areas and academic backgrounds provides the learners at GPHC ongoing dynamic perspectives by which to discuss different approaches to the clinical cases that they see everyday. It also gives them an opportunity to discuss evidence-based medicine and understand the application to their local surroundings and resources.via teleconference on a fixed schedule by faculty and residents from partner universities.Visiting faculty also fill in the gaps in the delivery of the formal curriculum—i.e., delivery of lectures, case discussions, and supervision of journal clubs. Didactic lectures and case-based discussions are not only facilitated in person but also 2.Curriculum development and assessmentAlthough a formal curriculum has been developed by the program director and has been adapted to the local health-care needs and to the requirements of the academic program, fresh perspectives, critical appraisal, and assessment are essential. Faculty in partner universities have been recruited to collaborate on further development and delivery of the curriculum. Assessment (summative and formative) tools are being adapted and implemented to allow for more well-rounded assessment of the residents. Simulation Figure  has beenRecently, 10 residents and 6 recent graduates of the IM residency program were surveyed to get their feedback on the current curriculum. This included formative feedback and summative feedback using a Likert scale (from 1 to 10 with 10 being excellent) to rate the different modalities of teaching employed in the curriculum. Ninety percentage scored the simulation-based teaching above 7, and 70% scored the didactic teaching above 7. Morbidity and mortality teaching and journal clubs were scored above 7, 80% of the time. The formative feedback included the following—the residents enjoy the simulation-based teaching as it is practical and engaging and they found they can apply the teaching to the cases that they see. As long as the didactic sessions are high quality and delivered by engaging and experienced physicians, they find the sessions relevant and informative. They did find that since the didactic sessions are done by faculty who also have to manage the patient load, some sessions were rushed. Due to the paucity of visiting faculty, it is recognized that there is a lack of diversity in subspecialty teaching. The teleconferences are useful if they are interactive and use local cases as points of discussion. The ECG teaching is repeatedly reported as being of very high quality and very applicable to their clinical practice. Although the mortality and morbidity rounds and journal clubs are scheduled regularly, the residents feel that the discussions and presentations do not always facilitate learner engagement and discussion. The point of care ultrasound was particularly identified as adding value to their clinical teaching and practice as they felt more comfortable doing bedside procedures such as thoracentesis, central line insertion, and paracentesis and are now also able to use the ultrasound for bedside assessments to help in making clinical decisions given the lack of portable chest X-rays for critically sick patients.3.ElectivesOne two-block international elective in subspecialties  has been organized where GPHC residents gain experience and exposure to different medical settings and practices. They are encouraged to reflect and implement some of the learned practices in their local medical environment. Residents and medical students from US and Canadian Universities are also given the opportunity to do supervised elective rotations in GPHC and participate in the academic rounds, as well as be involved in resident and medical student teaching that enriches their global health experience.4.ResearchAs the residency program develops a sound foundation, research projects are being fostered with supervision and collaboration from partner universities. An online quality improvement course was taken by all the residents through the Institute of Health Improvement website, and project plans are on their way to being implemented. Small, locally applicable projects are a good way to start to garner understanding of the process and make it more feasible.5.Mentorship and training the trainer programsThe first residents graduated in November 2016 and are now part of the local resident faculty. There is a need for ongoing mentorship as these graduates move into leadership and clinical educator roles. And collaborative partners are vital. Online sessions are organized for the graduates to meet with their mentors for debriefing and regular reflection and self-evaluation. Online and local courses are being organized for training the trainer initiatives that build on their teaching and leadership skills.6.Resource supportIn the public health-care system in Guyana , select essential medications and health-care services are free to all patients. Some of the collaborators have participated in improving public health care in Guyana by donating medical equipment and hard to obtain medications. Partner universities have also assisted in providing resources such as partial task trainers and mannequins for simulation training, portable ultrasound machines, learning materials, online resources, etc.1.The need for strong support from local leadershipWhile the need for specialists in IM and IDs is evident based on the number of health-care personnel in the country and the trends in the morbidity and mortality statistics, developing credible and sustainable programs to have specialist doctors trained locally is a paradigm shift in policy in Guyana. The success of such efforts is multifaceted and depends on collaboration and the continued support of a number of vital partners locally and internationally. In the case of the Guyana IM/ID residency program, the necessary local support was provided from the Ministry of Health, with favorable opinions of post-graduate medical education from the Minister and other political entities; the IHSE, which provided the platform for the program to be delivered; GPHC, which provided the clinical teaching site; and the University of Guyana, which confers the degree offered on completion of the program. As noted, the presence of a local “champion of the program” also proved to be an essential component. The local “champion” provided necessary representation to local leadership, assisted in developing bidirectional partnerships, and advocated for the specific needs of the program with international partners.2.Diversified fundingThrough engagement with multiple local and international stakeholders, funding for various aspects of the program has become diversified. The benefit of such support became evident, when the success of the program was threatened by a loss of funding from the CDC in its first year.3.Balance and adaptation to local educational systemThe curriculum was initially based on typical course work of a US-based residency program, with the addition of a focus on IDs, because of its relevance in Guyana. However, the curriculum had to be adapted within the first year for several reasons: (1) there were differences in baseline knowledge from medical school, which meant more basic science and background knowledge needed to be targeted; (2) many of the program participants had several years of clinical experience as general medical officers, so the clinical teaching needed to be targeted to a higher level; (3) similar to many resource-limited health-care settings, there are significant deficits in efficiencies and processes, so a sharper focus on system-based practice, high-quality care, and principles of quality improvement were needed in the educational program.4.Using a variety of learning platformsTraditional specialist training has revolved around the combined learning platforms of bedside teaching, didactic lectures, and group learning sessions. Technology is increasingly being used to diversify learning experiences and optimize use of face-to-face time between learners and experts. With the globalization of technology, programs with limited access to faculty and expertise can capitalize on the use of technology to maximize learning. The IM/ID program adopted several of these alternatives and routinely uses: teleconferencing, virtual libraries, social media, online modules for didactic teaching and interactive case discussions, and simulation-based education. These teaching modes have not only enhanced the learning experience for residents in the program, but have expanded access to expertise and clinical teaching in a way that is flexible and feasible for our international partners.1.Transition of leadership and ongoing mentorship of junior facultyAs the program produces graduates, the reins of leadership will be gradually transferred to these new locally trained specialists who will not be just clinicians but will add to the pool of “program champions” and take on the responsibility of moving the program forward. This will be another phase in the process of ensuring the program remains sustainable and is envisioned to require ongoing mentorship over the next few years. Of note, selection of residents for admission to the program, delegation of duties throughout the years of residency, implementation of resident-initiated quality improvement projects, etc. are all done in consideration of this larger picture.2.Formal quality improvement training and collaborative QI projects based at GPHCOne of the major goals of the IM/ID residency program is to improve the standard of care for patients with conditions falling under the care of internists. While having specialists trained locally is an excellent step toward this end, implementation of best practices at a systemic level is also necessary. With all IM residents initiating various quality improvement projects during their residency years, the intellectual environment created is one that is conducive to fostering projects that will result in positive tangible changes in the delivery of cares. Having basic, formal training in quality improvement can strengthen this process and help build capacity for even larger projects.3.Expansion of subspecialty servicesAs part of the collaboration with various internationally recognized institutions of learning, the possibility of having graduates of the GPHC Internal Medicine Residency pursue fellowships in subspecialties such as nephrology and cardiology is being considered. Several of the international partners have already made strides in establishing subspecialty services at the GPHC so that these ventures can be sustainable. Having a local specialist is important. This would not only be an opportunity for further professional development for the new graduates but also on a larger scale it will enhance the capacity of both the health-care and educational workforce. It will also advance the cause of improved health care for the citizens of Guyana.4.Research collaborationsTo improve both clinical and academic standards, it is vital that research should be part of the GPHC residency program. Further collaborations with partner universities are planned to encourage residents to ask, enquire, and then answer their research questions with mentorship to foster the development of adequate methodology. Ideally, the residents and medical officers at GPHC will take the lead on such research projects and then disseminate it by presenting at local and international conferences and submitting for publication in peer reviewed journals. Balancing research responsibilities with heavy clinical loads will be challenging and, therefore, priority will be given to research on quality improvement projects around medical education and patient care and safety.5.Assessment of programs and interventions to identify what does/does not work in the settingOngoing external and internal, local and international assessment and appraisal of the program are vital for ongoing success, preservation, and sustainability. A memorandum of understanding outlining roles and responsibilities is vital to partnership development and enrichment of the global health curriculum and experience. Committees involving local and international stakeholders are needed to meet and review all aspects of the program. These committees will make recommendations to evolve the program and build on local and international partnerships and continue to be innovative in the field of global health.The GPHC program has come a long way since its implementation in 2013. Much of its success is attributed to the dedication and perseverance of the program director and the residents who have worked on local and international collaborations to weave a strong mesh on which to support and build this program. Barriers related to limited financial and human resources continue, and the program is working hard to be more self-sustaining and self-preserving by training the program graduates to be leaders in clinical care, education, and research. Ultimately, they will take on independent leadership of the residency program. The future definitely is not free of bumpy (yet interesting) rides but does promise new horizons for developing the program and its partnerships. The program leaders hope to move toward a competency-based design that provides a standard of assessment for graduating physicians and providing more holistic, evidence-based health care to the Guyanese population.Dr. Dev Persaud is a current third year resident in the GPHC IM/ID residency program. Dr. Joanna Cole is the current program director for the IM/ID residency program and works as an Infectious Disease specialist at V.A. Medical Centre, Spokane, WA. Dr. Ramdeo Jainarine is a 2016 graduate of the IM/ID program and now the assistant program director for the residency program and the on site program director for the HVO volunteer program. Dr. Zahira Khalid is associate professor at McMaster University, Volunteer Assistant Program Director for the GPHC IM/ID residency program and external site director for the HVO volunteer program.DP is the first author and contributed to 40% of the writing and gathering of the information for the article. JC is the second author and contributed to 30% of the material in the article. RJ contributed to 10% of the article in terms of material and writing. ZK supervised and mentored DP in the writing and editing of this manuscript and contributed to 20% of the material in the script.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Caregivers report poorer health and wellness than the general population and identify numerous barriers to their attending programs to improve health and wellness. The purpose of this study was to explore the feasibility of employing a telehealth delivery method to enhance access to caregiver wellness programs. This article presents the quantitative results of a mixed methods feasibility study of translating the Powerful Tools for Caregivers (PTC) program to a telehealth delivery format. Four unpaid family caregivers of older adults participated in a telehealth delivered PTC program, a wellness program with established outcomes in the in-person environment. The program was delivered using synchronous videoconferencing methods. High class attendance and a high median total average Telehealth Usability Questionnaire score of 5.7 indicated the telehealth delivery method was feasible. This research suggests that telehealth is a feasible delivery format for a caregiver program traditionally delivered in an in-person format. Caregivers are an important component of the health care system. Informal family caregivers of adults with chronic conditions provide unpaid care estimated at 470 billion dollars a year in the United States . The demCaregiver wellness programs can address some of the issues caregivers face and prevent declines in their health. Powerful Tools for Caregivers (PTC) is one such program. PTC has demonstrated positive outcomes in the in-person format. Quasi-experimental trials of the PTC program demonstrate improved self-care behaviors , increasCaregivers with heaviest burdens were at the greatest risk for decreased health and wellness . CaregivPast programs for caregivers designed specifically for telehealth delivery have employed a variety of delivery methods: telephone , videophTelehealth delivery methods continue to improve. Past programs have primarily employed asynchronous methods, utilized synchronous methods without video components, or employed specialized equipment not available in a typical home. Programs that included synchronous audio and video delivery formats have not included synchronous audio and video connection between caregivers , or haveTransferring a successful in-person caregiver wellness program to the virtual environment via an in home synchronous videoconferencing telehealth method has not been tested. The goal of this study was to determine if a program traditionally delivered in the in-person environment can be accomplished via telehealth delivery methods. This article presents the quantitative results of a mixed methods feasibility study of translating the PTC program to a telehealth delivery format. Qualitative results are presented elsewhere . The quaThis feasibility study of a telehealth delivered PTC course engaged participants in a six-week program delivered using synchronous videoconferencing methods. Participants met in-person in their homes with the researcher the week before and the week after participation in the course. Participants completed initial assessments and received training in telehealth software use at the first meeting and completed post-assessments at the second meeting. This research was approved by the Texas Woman’s University Institutional Review Board and the Concordia University Institutional Review Board, and all participants provided informed consent prior to participation.Participants were recruited through purposeful advertisement of the program through a local area Aging and Disability Resource Center (ADRC). Inclusion criteria included: serving as an unpaid caregiver for an older adult who has a chronic condition; report of at least one barrier to attending an in-person program; ability to use a laptop computer and VSee® software; agreeable to meet with the researcher for an initial and post-intervention in-person meeting at the ADRC or the participant’s home; English speaking; and residence in southeastern Wisconsin. The primary investigator (PI) screened participants for eligibility both by phone and at the initial meeting.Eight caregivers responded to the advertisement. Five caregivers signed up for the program, and one dropped out after the first PTC session, reporting that her caregiving situation was too different from the others. The final sample of four caregivers represented a convenience sample of eligible participants who responded to targeted advertisement of the study. All four participants were married, Caucasian, and lived in southeastern Wisconsin in a suburban or small town setting. ® software for synchronous videoconferencing. VSee® is Health Insurance Portability and Accountability Act (HIPAA) compliant, adjusts to the available bandwidth by scaling down video quality to maintain call quality, and is free in the basic HIPAA Messenger version  the week following the last PTC class. The TUQ measures usability of a telehealth system and has established reliability and validity . Partici® and SPSS® version 22 software were used to summarize data with descriptive statistics. Results include: changes in the caregiving situation, class attendance, and telehealth system usability.Microsoft ExcelThe Caregiver Helpbook (Three out of the four caregivers reported a change in caregiving situation post-PTC participation . ParticiHelpbook  to gain The TUQ provides information on usability of the telehealth system. TUQ total scores ranged from 5.0 to 6.4 on the seven-point scale, with a median total score of 5.7. A score of seven represents the most favorable score related to usability. ® as scheduled with three of the four participants attending every class and the fourth missing two classes due to scheduled work.This research explored the feasibility of delivering a traditionally in-person wellness program via telehealth synchronous delivery methods. Class attendance and TUQ scores informed the research question: “Is telehealth in a synchronous videoconferencing format a feasible delivery method for a caregiver wellness program such as PTC?” The delivery method proved feasible; the PTC class leaders delivered the six classes using VSeeTUQ results indicate the telehealth PTC program was feasible. Participants viewed the method positively with a median total score higher than five out of seven. Previous telehealth feasibility studies employing the TUQ found ratings of five out of seven or higher in programs that proved feasible . ParticiPersonal opinion of telehealth and not encountering system errors may have decreased the TUQ total usability rating; however, the high median total score indicates participant agreement that the telehealth method employed was feasible for delivering the PTC program and overall the experience was positive.Caregiving situation may affect participation rates. An e-mail based program found caregiver competence had an impact on participation rates, with lower levels of participation in caregivers who reported greater competence . A need The small sample size of four and lack of diversity in participants limits generalizability of results. Participants were Caucasian and from the same geographical area of southeastern Wisconsin. Participant level of education and some prior experience with computers for all participants may have influenced results.The purpose of the study was to examine the feasibility of a telehealth delivered PTC program. Future research should examine the feasibility of the telehealth delivery format for caregivers from a variety of backgrounds and with caregivers who have no prior computer experience. Future research is also needed to determine best outcome measures to examine effectiveness of a telehealth delivered program.


The majority of resilience interventions focus on the individual. Workplace resilience is a growing field of research. Given the ever-increasing interconnectedness in businesses, teamwork is a guarantee. There is also growing recognition that resilience functions at the team level.The objective of our work was to address three shortcomings in the study of workplace resilience interventions: lack of interventions focusing on group-level or team resilience, the need for brief interventions, and the need for more theoretical precision in intervention studies.The authors took an established evidence-based program (Team Resilience) and modified it based on these needs. A working model for brief intervention evaluation distinguishes outcomes that are proximal (perceptions that the program improved resilience) and distal . A total of 7 hypotheses tested the model and program efficacy.Two samples (n=118 and n=181) of engineering firms received the Web-based training and provided immediate reactions in a posttest-only design. The second sample also included a control condition (n=201). The findings support the model and program efficacy. For example, workplace resilience was greater in the intervention group than in the control group. Other findings suggest social dissemination effects, equal outcomes for employees at different stress levels, and greater benefit for females.This preliminary research provides evidence for the capabilities of e-learning modules to effectively promote workplace resilience and a working model of team resilience. Recent national studies indicate increases in worker stress ,2 and itThis individual-level focus ignores research showing psychosocial factors impact stress and health ,4. EffecThe study of WR interventions may be advanced in several ways. First, interventions could more fully address resilience at the group or team level. Indeed, recent studies support resilience as a team phenomenon -30. SecoTo address these needs, we selected Team Resilience (TR), cited previously and also independently recognized as evidence-based by the national government , for adaTR promotes social dissemination, or peer-to-peer sharing, of resilience. Employees assessed at follow-up who were not exposed to the original training or employed at the time of the intervention had reduced stress and exposure to counterproductive work behaviors (CWBs) . CWBs inboth in the individual and among their social resources [Several factors suggest that TR is promising for e-learning: a detailed and modular training manual; evidence for effectiveness; potential for social dissemination; advances in our understanding of team or social resilience; and a strong theoretical basis. A core feature of TR was the inclusion of participant exercises on 5 resilience competencies ,41. Thisesources -52. The Centering (positive coping skills)Confidence (self-efficacy and positive thinking)Commitment Community Compassion .In their meta-analysis, Leppin et al  stated tTo modify the previous classroom training for e-learning delivery, we reviewed original TR training manuals and studies on effective e-learning features. Such features include customization to the user or workplace, interactive elements, regular quizzing, personalized feedback, multimodule information, and psychoeducational resources ,32,55. TAs noted, progress in the study of resilience has been limited because of lack of conceptual clarity. Recently, the use of “wise interventions”  suggestsperceived improvement (PI): ability to be resilient at work, knowledge of resilience, of where to get help, and willingness to get help. As perceived WR (this is an employee’s ability to adapt to workplace stress and associated perceptions that their workplace and coworkers contribute to their resilience) to recognition of inner resources (IR) for resilience and to an enduring trait or dispositional resilience (DR). An employee’s recognition of her own WR should affect her behavior in a positive way, following Ajzen’s theory of planned behavior [These perceived changes should correlate with proximal outcomes, yet ultimately affect distal outcomes also targeted by the intervention. We propose a “situational-to-dispositional” ordering of outcomes, from behavior .First, as a result of the training, participants should perceive that their workplace—including their coworkers—provides them with resources for resilience . For example, TR makes multiple references to their Employee Assistance Program (EAP) and other workplace health resources. Although newcomer employees learn about these resources during orientation, they may be overwhelmed with information. Reminders (in the context of resilience) are designed to heighten awareness of their workplace as a resource.internal resources  through self-reflection exercises, a common feature of other resilience programs . ,54. inteadaptive cycle) [Furthermore, resilience may best be measured in the context of adversity  . Thus, re cycle) . AccordiThe primary goals of this pilot project were to assess (1) the feasibility of condensing a classroom training into e-learning and (2) employees’ reactions to the program using the working model described previously see .A total of 7 hypotheses were derived from these goals:As a study of self-reported resilience, we explore a new measure to distinguish ratings of WR, IR, and DR. H3 and H4 reflect these distinct outcomes:To support construct validity, we examined other distinctions between workplace and DR. Accordingly, variables should relate to those variables one would expect them to relate to  and not relate to those expected to be different . For convergent validity, measures of resilience would be expected to show an inverse relationship with recent stress. For example, employees who have either DR or WR might be less inclined to experience recent stress; therefore, we examined how both of these correlate with stress:This study purposely assessed only short-term reactions to training. As noted previously, research suggests resilience training may be more effective in a high-stress sample . Thus, wOne aspect of the original TR is its potential for social dissemination . In thisThis paper also explores other factors related to the sample. First, we examine whether the training is more effective for women. A recent meta-analysis suggested that women may benefit more from increases in resilience . Second,Participants were recruited in 2015 and 2017 from firms within a national engineering association. Most firms were using a wellness benefit through the association for between 1 and 4 years. All 2015 participants were recruited to receive the program. In 2017, participants were also recruited to receive the program; a month later, only those who had not previously participated were then eligible to participate in a control sample. A total of 217 participants from 40 firms began the survey; 174 ultimately completed it. Firm size ranged from 6 to 142 participants. The average number of participants from each firm was 4.28 (SD 3.91). The sample was 56.9% (99/174) female, and the modal (40%) age group was 26 to 40 years. Most participants had at least a Bachelor’s degree .22=19.0, P<.01). Overall, most participants had at least a Bachelor’s degree . Moreover, 32 firms, ranging in size from 13 to 67 employees, participated in the intervention . A total of 31 firms, ranging in size from 6 to 234 employees, comprised the control group . The control sample was acquired after completion of the intervention. Specifically, the recruitment invitation asked employees to participate only if they had not previously done so.A total of 121 experimental participants began the survey, and 118 ultimately completed it. The control group consisted of 186 individuals. More men  than women  participated in the control group  to begin the training program. Participants had access to the modules at all times, via desktop, mobile, or tablet. More details about the program are discussed below.The same program was administered in 2015 and 2017. However, the 2 samples received different program completion incentives. Sample 1 received both individual- and firm-level incentives. Participants were informed at the beginning of the survey that they would be entered into a raffle to win a fitness armband. Sample 1 firms with the highest proportion of participants earned a US $200 award to use their wellness program. Sample 2 participants received US $5 for completing the program and an additional US $5 for completing the survey. Sample 2 control group participants received a US $5 Amazon.com gift card for filling out the survey after reading a short article on resilience tips.For purposes of estimating social dissemination, we assessed how many 2017 participants came from 2015 firms. Of the 118 employees participating in the 2017 program, 36 participants came from 16 firms with no prior participation, 10 from 5 firms with one prior participant, and 54 from 11 firms with 2 or more participants. Of 201 employees participating in the 2017 control condition, corresponding numbers were 95 participants from 17 firms with no prior participation, 28 from 4 firms with one prior participant, and 56 from 10 firms with 2 or more participants. In 2017, 20 firms participated in the program condition, 19 firms participated in the control condition, and 12 firms participated in both conditions.The e-learning module sought to increase participants’ ability to be resilient in the workplace, their knowledge of resiliency, their awareness of resources, and their willingness to access those resources when necessary. The program consisted of tips and strategies around building “5 Cs of Resilience” .brevity, ease of access, self-paced—limit to 45 min, viewable in segments, with user ability to leave and return anytime; (2) mimic team environment—show scenarios of characters who are part of a team, with exercises guiding users to reflect on their own coworkers; (3) tailored feedback—require users to complete a self-assessment and receive feedback on personal resilience; (4) customized EAP resources—give access to behavioral health resources (EAP); (5) guided facilitation—provide a facilitator/narrator who shares personal stories around resilience; and (6) team assessment of strengths—require users to reflect on the Five Cs in their coworkers and also their perceptions of how coworkers view the user’s own strengths.We followed 6 design goals for developing the electronic module: (1) Welcome with videos introducing characters explaining the importance of a healthy team; (2) Best Coworker Exercise where users review the Five Cs as qualities that exist in coworkers; (3) Resilience where users (a) watch 2- to 3-min video vignettes of employees who used one of the Five Cs to overcome a health, stress, or performance challenge (often with the help of a coworker); (b) complete a self-assessment on the Five Cs; (c) review definitions, tips, and journal exercise reflecting on the Cs; and (4) a Summary where users (a) see a final profile of their previous self-assessments and (b) rate their team on the Five Cs. The module was created using Articulate Storyline  and included video, audio, interactive exercises, and quizzes in 4 sections: (1) Participants in both samples were given 4 to 6 weeks to complete the program and accessibility from any computer or mobile device. The program contained 55 slides; the minimum number of slides to be viewed to receive credit for the program was 38, but most participants viewed at least 45 slides. Immediately after program completion, participants were automatically provided the survey link.On completion of the 2017 program condition, wellness champions sent an email to employees asking for input from those who had never completed any wellness program. Participants filled out a survey after reading a one-page article featuring 8 tips on how to “build resilience” . Participants were given 1 week to complete the survey. Any individual who had previously participated was removed from data analyses.A survey assessed participants in 4 areas: (1) demographic information; (2) PI or impact of the resilience module ; (3) measures in 3 areas of resilience: WR, IR, and DR; and (4) one satisfaction item . Response options were on 5-point Likert scales for PI (1—“Stayed the same” to 5—“Improved greatly”) and for resilience (1—“Not true about me” to 5—“Very true about me”). WR was evaluated using 3 items derived from a review of recent writings on the topic ,23,30 anReliabilities, assessed by combining data across all samples, were PI: alpha=.92; WR: alpha=.68; IR: alpha=.59; and DR: alpha=.86. The 2017 survey included an item asking about stress: “How much has stress hurt your ability to stay healthy and productive in the past month?” Response options ranged from “not at all” (1) to a “great amount” (5). This survey was given to participants on completion of the training program.Pvalues>.05). Hence, samples 1 and 2 were combined into a single program group (n=299).We compared responses for all items for samples 1 and 2 and found no significant differences . For the control group, only one item differed from 2.5, t200=2.26, P=.03. This item—knowledge of how to be more resilient—was also highest rated, suggesting that both e-learning and the reading improved knowledge of resilience. In support of H2, ratings on all 4 items reflected higher ratings on improvements for program  than control , t498=6.19, P<.001.H1 proposes the idea that the mean PI score would be greater than chance. A mean rating of 2.5 was used as a conservative baseline, as it represented the mid-point between improving “slightly” and “some.” For the program group, ratings on all 4 items reflected significant improvements  versus control , among coworkers and access to resources within the work setting. As shown in rpartial=−.19), but other findings were consistent with H4.H4 proposes that WR would correlate most strongly with PI. Again, training objectives sought to improve both TR r=−.56). This relationship is maintained  after controlling for the other aspects of resilience. The relationship between both WR and IR and stress become insignificant after controlling for DR. In contrast to confirming H5 in the program group, there were no significant correlations between any resilience measures including DR and stress within the control group.H5 predicted that DR would have the strongest relationship with stress (measured in sample 2). There was no difference in stress levels between program  and control  participants. Because the brief resilience program focused on helping employees with stress, we explored whether those across 3 levels of stress  benefitted from the program . ParticiA two (condition) by three (stress level) analysis of variance (ANOVA) was conducted while controlling for demographics . There was a main program effect for PI, WR, and program satisfaction. Consistent with correlations in Employees in the 2017 sample worked in firms that had different amounts of previous exposure to the resilience training. Both the 2015 and 2017 datasets allowed comparison of employees from “nonexposed” firms to those firms where employees may have learned something from previous participants. H7 posited that PI and WR would be strongest among employees from firms with two or more previous participants versus only one or no previous participants.F2,81=3.96, P=.02. In addition, employees from firms with no previous exposure were the most satisfied; none , one , or more than one , F2,97=4.93, P<.01. Comparisons within control group found no differences in stress  or satisfaction .No differences in PI or WR were found across these 3 levels of previous exposure for either the program or control groups. However, stress was lowest among program participants coming from firms where two or more employees had previously had the training: none , one , or more than one , Additional tests, shown in A total of 7 hypotheses were tested through an exploratory pilot study. Results generally support the conclusion that a brief Web-based resilience program can lead to proximal improvements in resilience as a social resource within work settings. This finding is supported by tests of H1, H2, and H3; the latter hypothesis included a control group comparison. Experimental versus control study comparisons showed positive outcomes for PI, WR, and satisfaction.Stress has an impact on employee health and performance, and employees have a need for effective programs to address stress. Ideally, employers who purchase or promote such programs should know that their investments are wise ones, based on evidence . FortunaWe add this to list the need for programs that enhance social well-being and educate workers about the impact of their own health on coworkers. This social focus can enhance potential dissemination or ripple effects , furtherwithin their workplace. It follows that the training would influence participants’ responses toward items that evaluate WR, but not as much with items that assess DR or IR.In support of H4, PI (ratings of how much the training improved resilience at work) showed a correlation with WR. Several factors could account for these results. In particular, TR was designed to be distributed to employees In support of construct validity, only DR was significantly and inversely correlated with recent stress, after controlling for the other resilience measures , H5. H6 Overall, findings also support a newly proposed working model for brief intervention evaluation that distinguishes proximal outcomes from longer-term dispositional resilience. Given the lack of clarity in previous resilience intervention studies, we hope that the findings from this study lead future researchers to clearly distinguish WR from dispositional measures.Of special interest was a test of dissemination effects. We compared sample 2 (2017) employees from firms with no previous (2015) exposure to the resilience training with employees from firms that had previous exposure. H7 claimed that the previously exposed group would show more positive outcomes. Results did not show any differences among the variables in the working model for brief intervention evaluation . However, those in the program group who came from firms with previous exposure reported less recent stress and lesser program satisfaction. It is difficult to say whether these employees benefited from their previous coworker’s experience or whether those who were less stressed also self-selected into the program. However, the same finding was not apparent in the control sample, suggesting that TR may have made previous coworker’s exposure more salient to current and new participants.This study contained several important limitations. First, we used a nonrandomized quasi-experimental design, with a self-selected, convenience sample. Differences found between conditions may be due to preexisting characteristics in these groups or some other sampling artifact. This includes types of incentives used , varying study time frames, and a sole focus on engineering firms. Although the findings of intervention-control comparisons are strengthened by the fact that there were 2 samples in the intervention condition, the control group was highly selected. Employees were recruited who specifically had not participated in any previous wellness program and who were asked to participate partly to share why they had not previously engaged in previous programs.Other limitations may be considered in light of the pilot nature of the study. The measures that were used were themselves piloted, without full-scale development and factor analyses. Although the DR measure was adapted from Connor and Davidson , it was Another limitation of this study was its focus on only immediate or proximal reactions. A more useful test would assess longer-term outcomes, especially taking ongoing stress into consideration. However, the workplace training literature suggests that utility types of reactions—as used here with PI—may correlate with more distal outcomes  ,61. The Finally, the organizations sampled in this study varied in size, and none of them employed a substantial amount of people, compared with large organizations . It could be safely assumed that there is a positive linear relationship between the number of employees and the number of teams that are within the organization, which could result in stronger findings . This would be an interesting avenue to explore in further research, especially as research on small business wellness is limited .Overall, this study is best viewed as an exploratory pilot. However, it makes several contributions. First this work also included both a new theoretical model and an e-learning extension or adaptation of an established classroom training. Furthermore, besides adapting the classroom training into an e-learning training, this work also tested the intervention on a different occupational sample (engineers) than the original study (restaurant workers). Findings suggest further and more rigorous tests of the model may be promising for the science of Web-based workplace TR training.


Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has increasingly been performed for the diagnosis and staging of thoracic malignancies. Findings of a necrotic lymph node raise concern for infectious process and malignancy. A hypoechoic area on ultrasound/EBUS within a lymph node without blood flow is suggestive of pathologies like infections or malignancy. Inspection of the fluid could suggest a diagnosis; clear aspirates usually suggest bronchogenic or mediastinal cysts and purulent material suggests abscesses or necrotic lymph nodes. Growing tumor cells require a blood supply; if the vascular stroma is insufficient due to rapidly growing malignant tumors this could lead to large central areas of ischemic necrosis. Necrotic aspiration of lymph nodes is not always of infectious etiology. Aspiration of fluid in EBUS-TBNA is a rare occurrence, and malignancy should be considered when purulent fluid material is obtained. We present an elderly woman who underwent bronchoscopy with EBUS-TBNA for evaluation of upper lung nodule and mediastinal lymphadenopathy. Pus-like material was obtained on needle aspiration and endobronchial biopsy and mediastinal core biopsy revealed squamous cell carcinoma. Ultrasound imaging has become part of the armamentarium of the pulmonologist; EBUS-TBNA plays an important role in the evaluation and diagnosis of several diseases especially malignancy .EBUS-TBNA is well accepted and increasingly being used as a safe minimally invasive procedure for the diagnosis and staging of lung cancers; it carries an overall sensitivity of 89% and a negative predictive value of 91% . It is aA 71-year-old woman from Dominican Republic was admitted for dyspnea, fever, and nonproductive cough of one-day duration. Her medical history was significant for diabetes mellitus, systolic heart failure, gastric B-cell lymphoma treated with chemotherapy, and surgically treated basal cell carcinoma of forehead. She was a heavy smoker with 40 packs/year. She denied alcohol or illicit drug use. Family history was noncontributory. There were no sick contacts, recent traveling, or occupational exposures and no history of exposure to tuberculosis.Initial examination showed an elderly woman on respiratory distress. Chest auscultation revealed bibasilar crackles and diffuse expiratory wheezing. There were no palpable lymphadenopathy, organomegaly, or skin lesions. The rest of exam was unremarkable. Significant laboratory findings included elevated Pro-BNP; there was no leukocytosis and renal and liver function was normal. A right sided thoracentesis was performed with pleural fluid analysis revealing transudative effusion with pleural/serum LDH ratio of 0.12 and pleural/serum protein ratio of 0.19.Patient was treated for exacerbation of heart failure with diuretics and antibiotics were given for presumptive community acquired pneumonia with clinical improvement.Chest-roentgenogram (CXR) on admission showed bilateral pleural effusion and infiltrates which rapidly improved suggesting a diagnosis of heart failure rather than pneumonic process . A chestPatient underwent flexible fiberoptic bronchoscopy (FFB) that revealed a small endobronchial lesion at the right upper lobe before the takeoff of anterior segmental bronchus. Endobronchial biopsy (EB) of the EBL as well as transbronchial biopsy (TBBx) of right upper nodule and EBUS-TBNA of the right paratracheal and subcarinal lymph nodes was performed. A 19′′ gauge needle was used for the EBUS-TBNA with a total of four needle passes per lymph node. Twenty ml of purulent appearing fluid was aspirated from the right paratracheal lymph node . AspiratAspiration of liquid material in EBUS-TBNA is uncommon. A hypoechoic area on ultrasound/EBUS within lymph nodes without blood flow is suggestive of pathologies like infections or malignancy. Inspection of the fluid is suggestive of a diagnosis; clear aspirates suggest bronchogenic or mediastinal cysts and purulent material suggests infection or rarely necrotic lymph nodes. Growing tumor cells require a blood supply; if the vascular stroma is insufficient due to rapidly growing malignant tumors this could lead to large central areas of ischemic necrosis , 5. Othe Histoplasma capsulatum leading to mediastinal abscesses and necrotic mediastinal lymphadenopathies [ Streptococcus related mediastinitis and mediastinal abscesses have also been reported in the literature [Necrotic mediastinal lymphadenopathy has been described in a wide variety of pathologies which include infectious and noninfectious etiologies. Tuberculosis is one of the most common infectious causes, especially in areas with high prevalence of tuberculosis . Other iopathies , 10. Bacterature .Noninfectious causes include histiocytic necrotizing lymphadenitis which is a benign lymphadenitis, characterized by enlarged lymph nodes with histopathological findings of proliferation of lymphocytes and histiocytes, nuclear debris, and necrotic lesions affecting mainly young women ; systemiLymphomas also may present as necrotic mediastinal lymphadenopathy. Usually metastases present more frequently as parenchymal lung nodules, but these are closely followed by mediastinal lymphadenopathy and pleural effusions .The initial differential diagnoses in our patient were infectious etiologies versus malignancy due to the strong medical history of malignancies and imaging findings. Bronchoscopic findings were conflicting, inspection revealed an endobronchial lesion, and EBUS sampling revealed cyst-like structure and aspirated material looked purulent. It is also important to note our patient had no clinical signs to suggest a rheumatologic disorder. To our knowledge, 2 cases of EBUS-TBNA of mediastinal lymph node revealing purulent material with a final diagnosis of malignancy have been reported in the English literature , 5. In bThe increased use of EBUS-TBNA to assess mediastinal diseases will likely lead to an increase in the number of patients with malignancies presenting with purulent aspirate. We suggest neoplastic conditions, especially squamous cell carcinoma, to be included in the differential diagnosis in patients where the EBUS guided needle aspiration reveals purulent material. Specimens should be analyzed to evaluate for infections like tuberculosis, fungal, and bacterial infections as well as malignancy.