Get WalkIN' program is comprised of 16 email messages sent over 12 weeks. Email messages target social cognitive theory constructs of self-efficacy, goal-setting, self-monitoring, and social support. Program reach, effectiveness, adoption, implementation, and maintenance were assessed with quantitative measures in a pre-post design. Findings indicate that within the Extension system, program adoption was high and program maintenance was moderate. Program effectiveness was demonstrated with an increase of 77.1 ± 49.9 min in weekly walking post-program. This increase in walking was maintained 3 months post-program. Capturing data on the implementation process was challenging. Overall, the results indicate success in program adoption and maintenance with further efforts needed to improve follow-up data collection from participants.Using the RE-AIM framework, this study evaluates the statewide dissemination of an evidenced-based, email-delivered physical activity intervention implemented through Cooperative Extension. The  Despite the strong evidence of the physical, mental, and social health benefits of meeting national physical activity guidelines, a majority of U.S. adults remain inactive . United Walking is particularly suitable as a population-wide physical activity promotion approach because it is inexpensive and does not require the use of specialized equipment, aside from adequate shoes . Also, sOn a population level, changing health behaviors such as physical activity should focus on strategies that are effective, have a wide reach, and foster behavior change maintenance. Community-based physical activity interventions using informational approaches have demonstrated some success in increasing physical activity behavior across populations , 5. ThesCommunity-wide and informational approaches to promoting physical activity behavior change can reach a large number of people with modest effort. Email-based intervention studies also show these strategies can be a cost-effective way of disseminating a physical activity intervention to a wide range of individuals. Furthermore, self-instructional behavior change programs are likely to reach more people than traditional face-to-face methods .Get WalkIN', an email-based walking promotion program delivered through Extension.Effective dissemination of evidenced-based physical activity interventions require organizational commitment to ensure appropriate reach and implementation . One netGet WalkIN' has been previously published  and additional resources and handouts that could be shared with participants. Educators were also provided with a program toolkit to facilitate effective program delivery in their respective target communities. Get WalkIN' was made available to all Extension Educators across the state of Indiana. In addition to the use of recruitment materials available on the intranet site, Extension Educators were also encouraged to recruit using current listservs and during existing Extension programming events. Being an adult, age 18 or older, was the only inclusion criteria for program participation.In the fall of 2017, Get WalkIN'. As this intervention has previously demonstrated effectiveness in a small randomized controlled design , immediately post-intervention (at week 12), and at 3 months post-intervention (maintenance). The Qualtrics® survey was compatible for both computer and smart phone access. Participant characteristics of age, gender, marital status, household income, race, ethnicity, education, height, and weight were assessed at baseline only. Since this was a community-based program, completion of baseline and post-program surveys were not required to receive program emails.Participants were emailed a survey via QualtricsReach of the intervention was calculated in two ways. First, county-level reach was calculated as a percent using the number of participants who enrolled in the program divided by the total number of adults in each participating county who reported no leisure-time physical activity . Second,Efficacy of the intervention was assessed by examining change in self-reported physical activity. Secondary measures were changes in theoretical constructs. The International Physical Activity Questionnaire Short Form (IPAQ-SF) was used to assess physical activity during a typical 7-day period . This seSelf-efficacy and social support were measured using existing valid and reliable tools, modified specifically to walking behaviors , 22. WalSocial support for walking was assessed with seven Likert-scale items about the perceived social interactions and activities to support walking received from both family and friends . Scores Adoption rate was calculated as a percent using the number of Extension Educators who implemented the program within 2 years of program launch divided by the total number of Extension Educators in Indiana.®. This form asked Educators to acknowledge that the program was intended only for adults, attest they have watched the online training video, and that they agree to deliver the Get WalkIN' program in its entirety.Implementation was assessed by tracking program start and end dates as well as the date for the maintenance email message to be sent. In addition, all Extension Educators were asked to submit a protocol form via QualtricsMaintenance of the program was calculated as the number of Extension Educators who ran the program a second time within the 2-year period divided by the number of Educators who ran the program at least once.t-tests were used to assess differences between baseline and both post-intervention assessments (immediately post-intervention and 3 months post-intervention). Outliers in the self-reported walking, moderate, and vigorous activity were identified as scores exceeding z = |3.29| SD above the mean. These extreme values were winsorized to the next highest score of the range of the distributions  participate in no leisure time physical activity , middle aged (53 ± 23 years), and non-Hispanic white (95%). All participants completed high school or obtained a GED and 45.5% obtained at least a 4-year college degree see . Twenty-p < 0.05). Participants also reported significantly increased moderate and vigorous physical activity. At baseline, participants reported an average of 67.0 ± 64.3 min of moderate intensity activity per week. This significantly increased post-program to 107.6 ± 85.9 min per week and was maintained at the 3-month post-program assessment with participants reporting an average of 115.2 ± 88.7 min of moderate physical activity per week (p < 0.05). Vigorous physical activity also increased. At baseline, participants reported an average of 60.1 ± 69.2 min per week of vigorous physical activity. This significantly increased post-program to 102.7 ± 94.1 min per week, but decreased to 81.6 ± 77.4 min per week at the maintenance assessment (p < 0.05). Participants' average weekly MET score also significantly increased post-program from 1126.7 ± 909.0 to 1863.8 ± 1236.9 (p < 0.05). This increase was maintained during the 3-month post-program assessment .At baseline, participants reported walking an average of 115.2 ± 97.1 min per week. This significantly increased post-program to 187.2 ± 135.5 min per week. This increase was maintained 3 months post-program with participants reporting an average of 168.8 ± 108.5 min of walking per week (p < 0.05) which was maintained 3 months post-program (3.23 ± 0.89). Similar outcomes were seen in the making time subscale of self-efficacy which increased from 3.10 ± 0.75 to 3.35 ± 0.82 (p < 0.05) immediately post-program. This increase was maintained 3 months post-program . Participants also reported a significant increase in social support for physical activity immediately post-program . However, reports of social support for physical activity decreased during the maintenance assessment which were not significantly different from baseline measures .Both self-efficacy subscales significantly increased from baseline to post-program and this increase was maintained during the maintenance assessment see . On averp < 0.05). No significant associations between resisting relapse and social support with weekly minutes of walking were found at either time points. A similar pattern was seen when examining the relationship between changes in weekly METs with changes in the theoretical constructs. Increases in the making time self-efficacy subscale were significantly associated with an increased MET score immediately post-program  and during the maintenance assessment . No significant associations between resisting relapse and social support with weekly MET scores were found at either time points.When examining the relationship between changes in theoretical constructs with changes in weekly minutes of walking, increases in the making time self-efficacy subscale were significantly associated with increased walking immediately post-program  females (89%), which affects the external validity and public health relevance of the findings. However, in our state, this population is a large proportion of those served through Extension programming. It is also important to note that many of the participants who enrolled in this walking program were moderately physically active prior to the start of the program. At baseline, participants reported an average of 115 min of walking per week. This suggests that Get WalkIN' generally attracted participants who were more physically active, which limits the generalizability to a broader more inactive audience. To further examine the effectiveness of this program in more diverse populations, future implementations of this program will target more vulnerable audiences such as those residing in rural areas, those who have lower incomes and/or are considered racial or ethnic minorities. In addition, assessment of maintenance of behavior change should extend beyond 3 months.Despite recruitment materials displaying images of diverse populations, As with many community-based physical activity programs, this study utilized self-report measures to assess physical activity behavior. These self-report measures are known to be prone to biases such as self-report, social desirability, testing, and recall bias . These bWhile email-based health promotion studies can demonstrate effectiveness, technology is rapidly advancing and other distance-based mechanisms may be more appropriate. For example, in the era of smartphones and immediate response, text messaging could prove to be just as or an even more effective means of program implementation. However, the work for Educators or other program implementation staff may be more burdensome to send text messages than utilizing email. Furthermore, sending text messages could introduce an additional cost to both Extension and participants.Get WalkIN' email messages were created focusing on social cognitive theory constructs, which are well-studied in physical activity behavior change research (Get WalkIN' significantly increased and maintained increases in self-efficacy, which is a key factor in increasing and maintaining behavior change. Further, Get WalkIN' was systematically pilot tested before statewide launch which likely facilitated the effectiveness of this program (There are also strengths associated with this study that enhance findings. First, a partnership with an established county-based network of Educators through Cooperative Extension, provided the ability to reach large segments of the population. Successful intervention dissemination requires strong community partnerships such as Cooperative Extension . Second,research . Past coresearch , includiresearch , 33, hav program , 17. AddGet WalkIN' is an example of a community-based program derived from research, grounded in data supporting evidence of effectiveness, and making an impact through delivery by Extension Educators. This program also addresses the ability to be more equitable in providing health education programs, bringing more health and wellness opportunities to rural communities and residents through its email-based delivery mechanism, and its use of county-based Extension Educators. Community physical activity programs such as Get WalkIN' have the potential to increase physical activity levels and decrease sedentary behaviors. With continued evaluation and updates, these types of programs can also create a sense of community and synergy among participants, which in turn, could contribute to high program engagement. Further, community-based programs can also facilitate community linkages as many community physical activity programs are provided by community-based organizations such as health clinics, non-profit organizations, and hospitals. Cooperative Extension is a natural partner for such work given the strong investment in community health and existing linkages with residents and existing community-based programs.erichards@purdue.edu.The datasets for this article are not publicly available because of institutional review board restrictions. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by Purdue University Human Research Protection Program. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.ER and SW conceptualized the study and contributed to the collection, analysis, and interpretation of data as well as manuscript development. AF contributed to manuscript preparation. All authors read and approved the final manuscript.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.


We aimed to evaluate the diagnosis of acute toxoplasmosis by IgG avidity test in pregnant women.Toxoplasma antibodies . It was not found any correlation between the history of raw meat consumption, cats keeping, education, and residency site. Moreover, 16 people (6.4%) had IgM antibody, of which, 10 cases (62.5%) with low avidity for IgG and 1 people (6.2%) with moderate avidity and 5 cases (31.3%) with high avidity for IgG. Moreover, 76% of pregnant women were seronegative.Total prevalence of IgG and IgM was 23.2% and 7.2%, respectively. A significant correlation was observed between the mean age and IgG level  with positive IgM antibody in their serum had a low avidity for IgG which revealed an acute infection among pregnant women.  Toxoplasmosis is a protozoan infection with worldwide prevalence. This infection is zoonotic between humans and animals. More than one-third of the world's population is infected with this parasite . ToxoplaToxoplasma is different in various parts of Iran, varying from 20%–35% in southern warm and dry conditions to 72 ºC in the temperate regions of the north  and in tropical areas of Latin American, or in African sub-Sahara countries in which cats are abundant and climate is favorable for survival of oocytes , 4. In t% and in he north .The three main ways of transmission of toxoplasmosis are through consumption of raw or semi-cooked meat, contact with infected cat-feces with the oocyte, and vertical transmission. During pregnancy, the most common route of contamination is through raw consumption or uncooked meat or contaminated water, or contact with soil (gardening without gloves) or cat. Transmission of toxoplasmosis rarely takes place through blood transfusion and organ transplantation , too , 7.Toxoplasmosis is linked to the immune system. Therefore, the clinical forms of this disease are different in people with the normal immune system and people with immunodeficiency. The most noticeable clinical symptoms in affected patients are lymphadenopathy and ocular lesions, but in 90% of affected people, no specific clinical symptoms are observed . One of T. gondii antibody. Usually, to show if a person has been infected in the past, or has recently been infected; a combination of serological tests be required  during 2015 were selected after obtaining written consent and completing the checklist of their demographic data.The study was approved by Ethical Committee of Mashhad University of Medical Sciences with number of IRMUMS.fm.rec.1394.563.Toxoplasma (IgM and IgG) using direct ELISA (Euroimmun Company) instructions and samples with positive IgM antibody titer were selected and to determine the early and acute infection.Then, 1 mL of blood sample was collected for detection of toxoplasmosis. After separating the serum from blood samples by Centrifuge at 3000 rpm, sera were stored in –20. Finally, the serum samples were evaluated for the presence of antibodies anti-For each IgG and IgM ELISA methods, sera were tested and the amount of cut-off was calculated by this formula: X±2SD . The absorbance more and less than the cut off was considered as positive and negative, respectively.The IgG cut off was as follows:Negative: proportion <8 IU/mL, borderline: 11 IU/mL > proportion > 8 IU/mL, Positive: proportion> 11 IU/mL. Also, The IgM cut off was as: proportion < 0.8 IU/mL, borderline: 1.1 IU/mL > proportion > 0.8 IU/mL, Positive: proportion> 1.1 IU/mL.IgG avidity test was used and after adding the avidity buffer and using anti-human IgG and comparing the antibody titer with no adding buffer, Optical Density (OD) was measured at length wave 450 nm. And its index was reported as the percent. Then the results were analyzed using SPSS  software.agammaglobulinemia, kidney transplantation and, malignancy, or people receiving immunosuppressive drugs were excluded.All pregnant women who were in the first four months of pregnancy entered the study. Women with a history of an immunosuppressive disease, RAI< 40%: Antibodies index containing low avidityRAI 40%–60%: EquivocalRAI > 60%: Antibodies index containing high avidityTo calculate the Relative Avidity Index (RAI), the OD Value of the sample washed with urea solution divided by the OD value of the sample washed with PBST solution, multiplied by 100 (according to the kit instructions).P-value<0.05 was statistically considered as significant.For data analysis, was used of Frequency, Pearson Chi-Square, Likelihood Ratio, and Fisher Exact Tests. And P=0.83) and (P>0.52), respectively. The most cases of acute toxoplasmosis in pregnant women who referred to health centers were in the first month of childbearing and the minimum in the third month. Moreover, no significant relationship was found between IgM and IgG antibodies of Toxoplasma and history of contact with the cat (P=0.54) and (P>0.61), respectively. Toxoplasma based on the consumption of uncooked meat in pregnant women who referred to health centers.The prevalence of anti-toxoplasmosis IgG and IgM in pregnant women referred to the health centers was 23.2% and 7.2%, respectively. Moreover, the highest frequency of IgG and acute toxoplasmosis was observed in the age group of 20–30 yr. accordingly, avidity index of acute toxoplasmosis cases between the pregnant women showed that 62.5%, 6.3% and, 31.3%, respectively had low, intermediate and high avidity. No significant correlation was found between toxoplasmosis IgM and IgG with occupation (Toxoplasma and consumption of uncooked meat (P=0.39) and (P>0.38), respectively.Moreover, no significant correlation was found between IgM and IgG antibodies of Toxoplasma based on educational level in pregnant women referred to health centers is presented in Toxoplasma and educational level (P=0.82) and (P>0.69), respectively.The frequency of IgM and IgG antibodies of Toxoplasma was found a significant correlation (P=0.02), but this issue was not observed about IgM (P=0.19).As shown in T. gondii causing toxoplasmosis is an obligate intracellular protozoan parasite that has the potential to infect most warm-blooded vertebrates with the global distribution. Toxoplasmosis in people with a healthy immune system is without clinical symptoms or causes mild clinical symptoms similar to the flu symptoms (symptoms .Serologic methods in the diagnosis of toxoplasmosis have different sensitivity and specificity and implemented based on the isolation and measurement of antibody using the avidity and affinity. In the present study, there was a significant correlation between age and anti-IgG titer.In line with our results, in Tehran, Iran , and In Toxoplasma IgM and IgG had a significant relationship with education that was in line with the studies conducted in Hamadan, (Based on educational level, the prevalence of anti-Hamadan,  and KhorHamadan, .Toxoplasma, which was consistent with other results (Toxoplasma (In the current study, there was not a significant correlation between the use of raw and semi-cooked meat and IgG and IgM antibodies anti- results 18, but xoplasma . In thisxoplasma –22.toxoplasma IgG and IgM antibodies, but the prevalence of antibodies in housewives was significantly higher than those employed which was accordant with the findings in France (Moreover, there was not a significant relationship between occupation and the prevalence of anti-n France .In the present study, the most prevalence was reported in the city dwellers, but contrary to our study, in England, the highest prevalence was in rural areas .Toxoplasma and consumption of uncooked meat. The undercooked meat is the famous risk factor for toxoplasmosis, although many studies did not report a significant association (In this study, as for IgG and IgM, the results were similar to another stuy in Tehran . In the ociation , 27 but ociation . In anotociation .Considering the high rate of IgM positive people had a high rate of avidity, we cannot use IgM for the diagnosis of acute toxoplasmosis alone. So, screening for determining the IgM status and also, performing IgG avidity test for the identification of women with acute infection and need for treatment are highly recommended.Toxoplasma infection should be considered as an important factor that affects the pregnancy and IgG avidity as an important test for screening the women who need the treatment. Moreover, according to a high prevalence of seronegative pregnant women reported in this study and the possibility of acute toxoplasmosis in this group, the preventive measures should be taken.


Are internal medicine residents being trained to address health disparities, and what are their perceptions of such training?This survey study of 227 program directors and 22 723 internal medicine residents in training found that residents’ perceptions of training in health disparities and its quality were not associated with the presence of a curriculum.These findings suggest that adding health disparities curricula in their current forms may not adequately train residents to address gaps in care. This survey study examines the associations of internal medicine program directors’ perceptions of health disparities programs with those of the residents in internal medicine programs. Health disparities continue to exist despite the call to increase education of health care practitioners. An assessment of health disparities education has not been previously studied in a national cohort.To describe and compare the curriculum on health disparities from the perspective of program directors and perceptions of training among internal medicine residents.This cross-sectional survey study used a survey of US internal medicine program directors, the 2015 Association of Program Directors in Internal Medicine annual survey, which included questions about health disparities curriculum, and a 1-time survey of US internal medicine residents that asked questions related to their training in health disparities on the American College of Physicians 2015 Internal Medicine In-Training Examination. All internal medicine program directors who were members of Association of Program Directors in Internal Medicine (368 of 396 accredited programs), and internal medicine residents who took the Internal Medicine In-Training Examination were eligible. Final analysis of the merged data set was completed in 2018.Questions were included on the annual Association of Program Directors in Internal Medicine survey and the Internal Medicine In-Training Examination.Program directors reported on presence of health disparities curriculum, educational methods, quality, barriers and challenges to curriculum, and Clinical Learning Environment Review. Residents reported whether they received training and quality of the training in health disparities.A total of 227 program directors  and 22 723 residents  responded to the surveys. A total of 90 program directors (39.6%) reported a curriculum in health disparities, but among these, only 16 program directors (17.8%) felt quality of their education was very good or excellent. In more than half of the programs (52 programs [55.9%]), outcomes of the curriculum were not measured. After merging, the combined data set included 18 883 residents from 366 APDIM member programs with 225 program director responses. Among these, 13 251 residents (70.2%) reported some training in caring for patients at risk for health disparities. Of residents who reported receiving training, 10 494 (79.2%) rated the quality as very good or excellent.These findings suggest that that despite the Clinical Learning Environment Review mandate and Accreditation Council for Graduate Medical Education required competencies for training in health disparities, relatively few internal medicine programs in the US provided educational curriculum. Additionally, the existence of health disparities curricula in internal medicine training programs was not associated with resident’s perception of training or its quality. Despite significant attention to that report, the 2018 “National Healthcare Disparities Report”2 found that while some disparities in health care based on race, ethnicity, socioeconomic status, disability, and in populations with special health needs were getting smaller, disparities persisted for poor and uninsured populations in all priority areas. The 2003 report1 prompted calls for increased education for all health care practitioners (including physicians) to begin to address these disparities.4 This charge is further reflected in the Health Quality Pathways of the Clinical Learning Environment Review (CLER)5 and required Accreditation Council for Graduate Medical Education (ACGME) competencies. Nevertheless, many trainees do not feel prepared to care for patient populations most at risk for health disparities.8In 2002, the Institute of Medicine, now the National Academy of Medicine, produced their seminal report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,”9 a 2014 review of health care disparities training in residency programs in the US10 demonstrated few published reports of graduate medical education programs that ensure that residents are competent to address disparities. The first national report of findings for the CLER program,11 highlighted health disparities as an area of challenge and opportunity for graduate medical education.12 The major findings were that the primary source of learning involved clinical experiences with patients who were at risk, mainly occurring in primary care settings and was generic, not tailored to the specific populations served by their medical center or hospital. In the second report based on residency site visits, 32.8% of residents and fellows reported their health disparities training was specific to their at-risk populations.13While these recommendations have existed for at least a decade,17 and a recent survey of internal medicine program directors highlighted disparities related to patients with limited English proficiency in their curricula.18Previous Association of Program Directors in Internal Medicine (APDIM) surveys have addressed some issues related to health disparities, including cultural competency training and quality improvement projects. In the 2012 survey, 16.6% of internal medicine programs reported the presence of a health disparities curriculum. There are studies describing educational curriculum within internal medicine residencies for special populations,19 found that only 14% of residents surveyed felt confident in their knowledge of underserved populations. However, a 2011 national survey20 showed that residents’ attitudes toward topics regarding medically underserved populations and health disparities were generally favorable. The goals of this study were to describe what internal medicine residency training programs provide as curriculum and/or educational experiences on health disparities, to determine residents’ perception of training in health disparities, and to determine the association of program curriculum with resident perception of training.A 2010 multi-institutional study of internal medicine residents’ health disparities educationAAPOR) reporting guideline.The survey study was reviewed and deemed exempt by the Mayo Clinic institutional review board. Program director surveys were granted a waiver of informed consent because data were deidentified, per APDIM policy. All residents who completed surveys provided written informed consent. This study is reported in accordance with the American Association for Public Opinion Research  resident survey has been reported previously.Data from the program director and resident surveys were linked by training program via a unique examination identification number for each internal medicine examinee prior to being deidentified to compare program director responses with residents’ perceptions of training in health disparities. The inclusion of questions on the APDIM and IM-ITE surveys related to training in health disparities provided a unique opportunity to compare the program director–reported curriculum within their internal medicine training programs with the perceptions and experiences of the residents in training.P values were 2-sided, and the threshold for statistical significance was set at P < .01 to account for multiple comparisons. Statistical analyses were conducted using SAS statistical software version 9.4 (SAS Institute). Final analysis of the merged data set was completed in 2018.Univariate summaries of program director and resident responses were reported as count (with percentage) or mean (with SD), as appropriate. To test the association of resident report of receiving training on health disparities with the proportion of patients considered at-risk whom they cared for, a generalized linear mixed model with a binary response distribution was used to estimate odds ratios. To test the association of PD report of presence of a health disparities curriculum with resident rating of the quality of their training in care for underserved, a generalized linear mixed model with a Gaussian response distribution was used to estimate the mean difference between groups. Both models included random effects to account for nesting of residents within programs. The program-level data set included 408 training programs, including 396 ACGME internal medicine programs (97.1%), and 368 were APDIM member programs (92.9%), among which 227 program directors (61.7%) responded to the survey. The resident-level data set included 22 723 residents who completed the survey and consented to research use . After merging, the combined data set included 18 883 residents from 366 APDIM member programs, with 225 program director responses. For analyses requiring identifiably linked PD and resident survey responses, there were 11 583 resident responses available from these 225 responding programs. There were no differences in response rates based on geographical region or program type.Most respondents had experienced a CLER visit (160 program directors [71.0%]). Among 66 program directors who had not experienced a CLER visit, 43 (65.1%) expected one in the next 6 months. Only 57 program directors (25.0%) reported that benchmark data on patient diversity or groups at risk for health disparities was disseminated at their institutions. Slightly more than half (127 program directors [56.4%]) reported that some resident quality improvement projects addressed health disparities.A total of 91 program directors (39.6%) reported a health disparities curriculum. While the mean (SD) time dedicated to the curriculum was 11.4 (20.9) hours, the median (interquartile range) was only 6 (4-10) hours. Nearly all programs included education about racial/ethnic diversity (84 programs [90.3%]) as well as socioeconomic status (84 programs [90.3%]). More than half of programs reported including information about limited English proficiency (54 programs [58.1%]), gender (54 programs [58.1%]), and gender identity/sexual orientation (49 programs [52.7%]). Religious beliefs were addressed in 41 programs (44.1%). Reported educational methods included lectures (66 programs [71.0%]), group discussion (50 programs [53.8%]), and clinical experiences (37 programs [39.8%]). Most program directors rated the quality of their health disparities educations as fair (35 program directors [38.9%]), good (39 program directors [42.4%]), or very good (15 program directors [16.7%]). For most of the programs (52 programs [55.9%]), outcomes of the curriculum were not measured. Assessment of the curriculum included direct observation of residents (33 programs [35.5%]), but more rarely clinical outcomes (9 programs [9.7%]), resident attitudes (8 programs [8.6%]), or knowledge (8 programs [8.6%]).Among 132 programs that did not have a curriculum, barriers to development included time within the current curriculum (reported by 64 program directors [48.5%]), insufficient faculty skill (reported by 63 program directors [47.7%]), lack of institutional support (reported by 42 program directors [31.8%]) and lack of faculty interest (reported by 29 program directors [22.0%]). Only 40 program directors (30.5%) intended to develop and implement a curriculum within 1 year; 40 program directors (30.5%) had no plans for a curriculum, and 51 program directors (38.9%) were unsure.The 18 883 resident survey responses were similarly distributed across the 3 years of training, with 6403 residents (33.9%) in postgraduate year 1, 6571 residents (34.8%) in postgraduate year 2, and 5909 (31.3%) in postgraduate year 3. Overall, 13 251 residents (70.2%) reported some training in caring for patients at risk for health disparities. This percentage did not differ significantly based on geographic location of training. The perception of receiving training increased with each additional postgraduate year.Among 13 251 residents who reported training, more than three-quarters (10 294 residents [77.7%]) rated the quality of this training as being very good (5503 residents [41.5%]) or excellent (4791 residents [36.2%]) . There wWhile less than 40% of program directors reported a curriculum for training in health disparities, most residents reported training in the care of patients who are at risk for health disparities . We observed no association between the program director–reported presence of a curriculum and the resident report of training or their rated quality of their training in the merged data set of 225 program director responses matched with 11 583 resident responses .This survey study is the first to our knowledge to report on the breadth of health disparities training within internal medicine training programs in the US. While approximately 70% of program directors reported a CLER visit, suggesting awareness of the requirement for health disparities training, only 40% of program directors reported having a curriculum. The curriculum was often limited to a few hours and lecture-based, which may not effectively engage learners. There was limited assessment of the impact of the curriculum on outcomes for the learner or the patients they care for. Only 30% of internal medicine programs without a current curriculum planned to address this need within the next year. While this was an improvement over the 2012 survey, in which only 16.6% of programs reported a curriculum, our findings raise concerns that additional efforts are needed for internal medicine graduate medical education to increase health disparities curricula.30Challenges to developing curriculum were identified by program directors, most significantly competing curricular priorities. There was the additional challenge of determining what a health disparities curriculum should contain . Unlike undergraduate medical education, time for authentic community engagement is limited during graduate medical education. This leaves didactic curricula  and quality improvement work as the primary educational activities. Didactic curriculum, while efficient, does not fully foster understanding of the lived experience of health inequities nor foster cultural humility. Results of this study suggest that quality improvement initiatives aimed at reduction of practice-based health disparities are hampered by lack of access to data, that is, only 25% of program directors reported access to data that stratify according to different populations. Indeed, most published reports of curricular innovations in health disparities education in residency focus on educational outcomes rather than improvement in patient outcomes.31 this may provide an opportunity for meaningful learning in the context of graduate medical education. Point of care teaching around health disparities and social determinants of health can be a powerful mechanism for residents to internalize these complex topics through the eyes of their own patients.32 A comment on the program director survey summarized this practice: “…we take care of the patients in our community with health care disparities. We live it every day!” However, reliance on learning in the context of caring for patients who are underserved does not ensure residents will receive the training and acquire the skills they will need. Accordingly, a 2019 study found that increased care of at-risk populations did not translate into increased relevant knowledge among resident physicians.33 Additionally, while some data suggest a positive influence of care of underserved populations on the attitudes of residents, there was no improvement in patient care with additional training and an inverse association was found between self-reported skills and knowledge.34 Our finding that residents’ rating of the quality of their training was not associated with the presence of a curriculum in health disparities in their program also raises a concern that perceptions may overestimate the acquisition of needed skills.To our knowledge there are no prior studies that have reported results from a national survey of internal medicine resident perceptions on training in health disparities. Overall, 70% of residents reported training. Residents who cared for a larger proportion of underserved patients perceived that they received health disparities training at a higher rate. Since an essential component of graduate medical education is direct patient care and academic medical centers provide care for a disproportionate proportion of underserved populations in the US,Strengths of this study include a large, representative, and comprehensive sample of all internal medicine residents and program directors in the US with high survey response rates. Furthermore, the ability to link responses of residents with their programs through coincident surveys in the same calendar year provided a powerful tool for comparison of resident perceptions and curriculum.The study has limitations. A major limitation was that residents were not asked directly if they were exposed to a curriculum in health disparities but rather if they received training in the care of patients who would be at risk, which raises the concern that we cannot distinguish between their recognition of a formal and informal curriculum. Additionally, while program directors were asked explicitly whether they had a curriculum, we cannot know with certainty that they were aware of all training, but given their reporting responsibilities, we feel it is a reasonable assumption. Furthermore, because the survey items were embedded in larger program director survey, we were limited in the ability to ask them to define more specifically the components of their health disparities curricula.This survey study found that the existence of health disparities curricula among internal medicine residency programs were below goal levels established by national accrediting bodies and that existing curricula were not associated with resident’s perception of training in these domains. Residents who cared for more patients who are underserved reported higher disparities training despite a lack of formal curricula, highlighting the opportunity to teach around health disparities at the point of care, but also the need for standardized curriculum and capable faculty. Additionally, program directors reported a lack of practice-level data to examine health disparities, which emphasizes the opportunity for institutional collaboration with residency programs for quality improvement initiatives aimed at the reduction of health disparities.Future research is needed to develop and assess the most relevant domains for health disparities curricula in graduate medical education, including for point-of-care encounters and quality improvement. There are opportunities to explore partnerships among residencies, institutional clinical practices, and communities for productive collaborations around disparities-related quality improvement projects to address gaps in health care that are specific to the populations they serve.


Physician assistants (PA) are an important part of emergency department healthcare delivery and are increasingly seeking specialty-specific postgraduate training. Our goal was to pilot the implementation of a PA postgraduate program within an existing physician residency program and produce emergency medicine-PA (EM-PA) graduates of comparable skill to their physician counterparts who have received the equivalent length of EM residency training to date .The curriculum was based on the Society for Emergency Medicine Physician Assistants (SEMPA) recommendations with a special focus on side-by-side training with EM resident physicians. In reviewing the program, the authors examined faculty evaluations, as well as procedure and ultrasound experience that the trainees received. We found comparable evaluations between first-year EM-PA and physician trainee cohorts. This program serves as a pilot study to demonstrate the feasibility of collocating clinical and didactic programming for physicians and EM-PAs during their postgraduate training. This brief innovation report outlines the logistics of the clinical and didactic curriculum and provides a summary of outcomes evaluated. Physician assistants (PA) are an important part of the modern emergency department (ED), facilitating the practice of emergency physicians and serving as independent providers of patient care.Research shows that collaborative healthcare teams decrease cost, improve patient satisfaction, and reduce morbidity and mortality through enhanced patient safety and reduction in errors. At the same time, interprofessional teams improve overall provider satisfaction and professional relationships.The United States currently has 49 clinical postgraduate EM-PA training programs.9The goal of the program presented here was to pilot an implementation of PA postgraduate training embedded within the existing educational infrastructure of an EM residency program. Both PA and physician trainees engage in identical clinical and academic responsibilities together. Through this unique approach of collocating both trainee groups within the same educational milieu, EM-PA residents engage in identical clinical and academic activities as their physician resident counterparts.This program was established at a Level I trauma, quaternary care referral center with an existing four-year physician residency consisting of 15 physician residents and two PA residents per class. The logistics of recruiting and credentialing of PA providers were similar to that of hiring non-resident PA providers and was based on institutional guidelines as well as best practices described in literature.Following the 2012 Society for Emergency Medicine Physician Assistants (SEMPA) recommendations,During all rotations, EM-PA residents functioned as primary team members. They worked alongside attending physicians with the same responsibilities as their EM postgraduate year 1 (PGY-1) (for the first 12 months of EM-PA training) or PGY-2 (for months 12–18 of EM-PA training) physician counterparts who were at the same point in their EM training. EM-PA residents also maintained procedure and ultrasound logs .The program’s effectiveness and breadth of PA training was reflected in a number of parameters, including evaluations and procedure and ultrasound logs. We assessed for program feasibility by filling of available trainee positions in subsequent years, and retention of graduating EM-PAs in the field of EM immediately upon program completion.Resident evaluations were collected at the end of the first year of EM training via an online software tool  implemented in 2016 for both trainee groups.PA residents had experience in all procedures and ultrasounds expected . SimilarSince its inception, the two positions available in the PA residency were filled each year. In the current academic year 2020–2021, the program increased to four positions per year. Upon graduation, all PA residents secured clinical positions in EM.Several EM-PA residencies exist, with prior publications outlining best practices in the logistics of some of these programs.It is important to note that the PA residency is 18 months long, in accordance with SEMPA recommendations. Graduates’ knowledge is not exhaustive, and on-the-job training after residency remains critical. The program, as designed, is not meant to provide PA trainees with the same level of training as EM residents upon residency completion. For that reason, the evaluation comparisons provided here are at the PGY-1 level. Finally, although there is much evidence supporting the benefits for integrated interprofessional educationThe structure of this program can be replicated across other EDs. Investigation should continue in evaluating the efficacy of this approach with higher numbers of graduates and more years of follow-up. Analyses of team management and communication skills as outcomes of such programs is needed. Although the authors intend to formally explore how the PA and physician residents feel about this interprofessional approach, the anecdotal response of both groups of learners has been predominantly positive. Despite the fact that the addition of PA residents has increased the number of learners in the department, our faculty, patient, and procedure numbers are able to support the additional trainees. In the authors’ experience, through informal observations and discussions with the residents, the fact that both groups share orientation, didactics, and social events from the moment they start residency, has contributed to their positive experience in clinical teamwork and colocation in the ED. From early experience, it stands to reason that the combination of adequate patient, procedure, and supervision availability in the clinical setting combined with outside educational experiences  and social events, allowed these two groups of learners to achieve a positive learning experience. With further study and evaluation, training PAs and physicians together clinically and in the classroom may prove effective in graduating well-trained, extremely competent and highly recruited EM-PAs.


Research in lifestyle interventions focusing on nutrition and physical activity in people living with psychotic illness, highlights anthropometric and metabolic benefits of these interventions. However, little is known about potential factors to consider during implementation into real-world contexts. Community-managed organisations (CMOs) that provide services for people with mental illness, offer an ideal implementation context for lifestyle interventions. Successful translation of lifestyle interventions into CMOs may be achieved though considering the factors associated with program access and delivery in these settings. This study primarily aimed to identify the factors that affect program access in a local CMO from the perspective of consumers and staff. The secondary aim was to describe the elements that impact on program delivery from the perspective of staff.Thirteen semi-structured interviews were conducted with 6 consumers and 7 staff in a CMO in regional Australia. Topics explored in interviews were based on implementation concepts identified in the “Integrated Promoting Action on Research Implementation in Health Systems” (i-PARIHS) knowledge translation framework. Thematic data analysis was conducted using Nvivo software.Emergent themes on issues that influenced program access were (1) consumer financial status, domestic responsibilities, and health; (2) the design and delivery of programs; (3) structure and practices of the organisation; (4) attitude, skills and effort of staff involved in program delivery; and (5) social connections and stigma experienced by consumers during program access. Moreover, staff perceptions on elements that impacted program delivery highlighted themes on consumer attendance and interest in prospective programs, availability and restrictions to the use of funding, as well as the organisational structure and practices.The factors affecting program access and delivery can generally be managed or planned for during the design of lifestyle interventions and subsequent translation into the CMO context. However, resolution of issues related to consumer financial status and health requires the collaboration of various government sectors for system-wide solutions. Psychosis is a condition marked by the experience of delusions, hallucinations, psychomotor retardation and catatonic behaviour  . The expp < 0.000), body mass index , waist circumference , total cholesterol , triglycerides  and fasting blood glucose , when compared to control conditions , so travel training and being able to pick them up and things, so unless they can get into centre, a lot of them can't get here and a lot of them just won't take public transport.”Consumers and staff stated that the timing of programs affected the consumer’s capacity to attend. This was primarily due to medication side effects (which included feelings of lethargy early in the morning). Staff 7 summarised this by stating:“We talked to the guys, they don't like groups early morning. They all struggle to get up and get motivated, and out the door, and that's a lot around their [sic] medication that they take.”One staff participant mentioned that seasonal timing of programs affected attendance because interruption of programs by holidays resulted in consumers failing to return. This is how Staff 4 explained her experience regarding consumers’ initial response to a program:“Initially very good. We had about six people, which I think is quite big for here. They thought it was really good. Just ... … ... I think there was a holiday that happened.”Staff added the importance of considering individual consumer needs when planning program sessions, and involving consumers in planning and executing programs. This provided a sense of ownership, and contributed to enjoyment, participation in program activities, and attendance. Staff 6 expressed this in a response on consumer incentives for attending existing programs:“If they feel that their voices is [sic] being heard and if they feel that they're going to get something out of it—everybody would be different … … … . You know, so it's gonna [sic] be different for everyone who comes and I think what you gotta [sic] do, you’ve got to be flexible to be able to cater for everybody's needs.”Finally, two staff participants noted the importance of ensuring consumers had the right perceptions about what programs entailed, to prevent anxiety pertaining to the unknown which could influence their attendance. When asked why consumers cancelled participation in certain programs, Staff 5 said:“Some of it is to do with their perception of what it's going to be.”Consumers and staff agreed that activities offered in programs influenced whether consumers enjoyed the programs, which affected continued program attendance. Consumer 2’s response to why she continued to attend one of the available programs was:This theme comprised determinants of program access that relate to the CMO and how it was run.“I couldn't come for such a long time to things because they're all up here and they didn't have a chair lift … … .. And there are other people who are older, who won't use the stairs either because they're very steep.”Staff indicated that dissemination of program information to CMO consumers was poor as it was not always clear whose responsibility it was, or how it was to be done. When asked whose responsibility it was to distribute fliers with information on consumer programs, Staff 2 stated:“That's the problem. Not every support worker comes into the office and not every support worker would print them at home and hand them to their clients”.One consumer reported that a lack of equipment for those with mobility disabilities hindered program attendance; however, this was later rectified. Consumer 2 reported this by saying:This theme described the effect of staff involved with program delivery on attendance.“Depending on the support worker that I have, ‘cause, I get along with some better than others. Some of them, if they came to my house and talked to me for a while, they can probably twist my arm to come.”In addition, follow-up provision was regarded as essential by consumers and staff. Follow-up included checking why consumers could not attend program sessions, or providing attendance reminders. Consumer 4 commented:“I think I get enough support. Like [states name] rings me and says, each second Wednesday morning, ‘Am I coming?’”Consumers and staff admitted that the attitude and professional skills of staff affected rapport with consumers, which was a motivator for continuing with programs. Important staff characteristics included friendliness, empathy, showing interest in the lives of consumers, providing step-by-step guidance, and well-planned program sessions. Consumer 5 described the effect staff can have in her decision to attend programs by explaining:The effect of social factors on program access was presented in this theme.“I was very, very shy and very shell-shocked for the first 10 years of the group. It's only in the last couple of years that I've started to spread my wings, you might say. So, people will remember me as being particularly shy. But I get social connections out of it.”In contrast, stigma associated with mental illness was considered a possible deterrent of attendance by staff. They perceived that consumers had a fear of being recognised as having a mental illness or associating with those with mental illness. When asked why some consumers failed to attend programs, Staff 3 responded:“Some don't want to identify with other people with mental health problems and we only have mental health clients.”Furthermore, one consumer expressed satisfaction with a service delivery name change that no longer reflected a focus on mental illness, due to the associated stigma. Consumer 2 stated:“Every time somebody gets killed or something happens, it's always someone with schizophrenia. So, I was really glad when [states the service name] changed its name.”Attaining strong social connections with those attending programs motivated program attendance as per consumer and staff reports; one manager recognized that staff could facilitate and foster a social environment during program delivery. Consumer 6 described his objective for attending one of the available programs:Three themes emerged from staff perceptions on elements that impacted on program delivery, that is introducing or running programs  shows that organised transport provision promotes attendance of appointments, hence should be utilised by CMOs . Other pEquipment availability and dissemination of information about programs, were the only organisational structure and practices that impacted program access. Translation of lifestyle intervention research into the community could be hampered by equipment discrepancies, if specialised equipment and trained personnel are required . ConsideThe potential effect of staff attitude towards consumers, and relevance of their professional skills during program delivery, were important considerations for consumer program attendance. This was in addition to provision of follow-up by staff, affirming literature that highlights the key role of mental health staff in facilitating or hampering health service attendance , 30, 31.Consumer attendance and interest in prospective services were parameters used to determine which programs could be delivered in the CMO, indicating the application of person-centred approach . ClinicaProgram delivery in the CMO was limited by lack of funds to cover program activity costs or employ specialised staff, with the NDIS allotments. Additionally, program cost-effectiveness had to be ensured through a financially justifiable consumer-to-staff ratio, to ensure NDIS funding was sufficient to cover running costs. Programs and services funded under the NDIS are required to minimize impairments that inhibit consumers from performing activities of daily living or engaging in the community , 27, 34.Organisational structure and practices that influenced program delivery, including the availability of facilities, policies and procedures, staff input and ideas, and the role limitations of staff, generally require consideration prior to lifestyle intervention implementation . Facilitn = 13), information provided on the factors which affect program access, mirrors some previously reported challenges in people with psychotic and other severe mental illness [Although the present study was characterised by a relatively small sample size ( illness , 25, 32. illness , 25, 32. illness . In ligh illness .This study identified the factors that affect program access and delivery in a CMO delivering services to people with mental illness. Consideration of the issues cited by consumers and staff led to the notion that various strategies could be applied to address challenges associated with the programs delivered, the organisation structure, staff involved, consumer social issues and funding available for programs , 24. AltAdditional file 1. Interview Questions for Patricipants.


Endobronchial ultrasound (EBUS) elastography assists in the differentiation of benign and malignant lymph nodes (LNs) during transbronchial needle aspiration (TBNA). However, previous studies have not compared B‐mode sonographic images (BSIs) and EBUS elastography images (EEIs) with final pathological diagnoses in radiologically normal‐sized (computed tomography [CT]‐negative) LNs.Consecutive patients with CT‐negative LNs, who received EBUS‐TBNA, were retrospectively reviewed. Images of BSIs and EEIs of each LN were stored and independently evaluated. EEIs were assessed by calculating the stiffness area ratio . The receiver operating characteristic curve was used to calculate the cutoff value for the SAR. Diagnostic test parameters were evaluated for each EBUS finding.P < 0.001). At the SAR cutoff of 0.41, the sensitivity, specificity, positive predictive value, negative predictive value (NPV), and diagnostic accuracy rate (DAR) of elastography were 88.2%, 80.2%, 78.9%, 89.0%, and 83.9%, respectively. The logistic regression analysis showed that elastography was the strongest predictor of malignancy . The highest NPV (96.6%) was achieved with a combination of BSIs and EEIs.A total of 132 patients (149 LNs) were enrolled, and the median SAR of malignant LNs was significantly higher than that of benign LNs (0.58 vs. 0.32, EBUS elastography predicted malignant LNs with a high DAR and NPV in CT‐negative LNs. The NPV was highest when EEIs were combined with BSIs. Therefore, the combined evaluation of CT‐negative LNs using EEIs and BSIs may help bronchoscopists perform EBUS‐TBNA more efficiently.Endobronchial ultrasound elastography accurately predicted malignancy with a high diagnostic accuracy rate and negative predictive value in radiologically normal‐sized lymph nodes. The additional use of B‐mode sonographic features resulted in a higher negative predictive value.Endobronchial ultrasound elastography can guide the accurate collection of specimens with transbronchial needle aspiration, even in radiologically normal‐sized lymph nodes. It can also readily distinguish benign and malignant lymph nodes, thus avoiding unnecessary punctures. Endobronchial ultrasound elastography accurately predicted malignancy with a high diagnostic accuracy rate and negative predictive value in radiologically normal‐sized lymph nodes. The additional use of B‐mode sonographic features resulted in a higher negative predictive value. Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) has developed into the most widely used standard sampling technique for mediastinal and hilar lesions, irrespective of their benign or malignant status.Recently, one cohort study reported that proper preoperative staging was associated with survival benefits in patients with non‐small cell lung cancer (NSCLC).For diagnosing and staging with EBUS‐TBNA in patients with lung cancer, it is necessary to accurately select the LNs to be punctured. B‐mode sonographic findings  and vascular patterns on power Doppler mode have previously been reported as useful EBUS parameters for distinguishing benign and malignant LNs.Elastography is an ultrasonographic method for generating objective strain images of tissue compressibility. EBUS elastography has made it possible to detect and colorize the hardness of LNs. Hard tissues are shown in blue, while intermediate tissues are shown in green, and soft tissues are shown in yellow or red. A recent meta‐analysis characterized the differences between benign LNs and malignant LNs when evaluated using EBUS elastography.Elastography has been previously used in the breast, thyroid, liver, pancreas, and gastrointestinal tract.The aim of this study was to evaluate the diagnostic utility of EBUS elastography, and identify the most accurate EBUS parameters for the differentiation of benign and malignant CT‐negative LNs.The medical records of consecutive patients with mediastinal and/or hilar LNs, who underwent EBUS‐TBNA at the university hospital of the University of Occupational and Environmental Health, Japan (UOEH) between April 2015 and November 2018, were retrospectively analyzed. Targeted LNs that underwent EBUS‐TBNA had enlargements on chest CT (short axis diameter ≥ 5 mm) or high [18F]‐fluorodeoxyglucose (FDG) uptake on PET‐CT . CT‐negative LNs were defined by a short axis diameter of less than 1 cm on chest CT. Before EBUS‐TBNA, each patient underwent thin section CT, using a 1 mm slice thickness. This study was approved by the institutional review board (No. H30‐074), and written informed consent was obtained from all participants. EBUS‐TBNA was used when clinically required, and was not performed solely for the purposes of this study.z‐axis modulation with Real E.C. technique, Toshiba Medical Solutions). All PET‐CT images were obtained using a PET‐CT scanner . Patients received an intravenous administration of 4.0 MBq/kg 18F‐FDG in the sitting position after fasting for 6 hours, and a PET‐CT scan 60 minutes later. Chest CT images were reviewed by two pulmonologists (KU and SH) who were blinded to the results of the final pathological diagnoses, as well as the BSIs and EEIs. PET‐CT images were evaluated by an independent and blinded radiologist.Chest CT scans were performed using a single source 32‐detector or 64‐detector CT scanner . The settings were as follows: 1 mm collimation, 0.5 second rotation time, 27 or 53 pitch , and 120 kV. The noise level was set at 10 standard deviations using automatic tube current modulation  and a 22‐gauge needle . All procedures were performed by residents under the supervision of a bronchoscopist (KU) with sufficient experience, as previously reported.A dedicated ultrasound processor  was used to evaluate EBUS images in B‐mode sonography and EBUS elastography, and vascular patterns were evaluated with power Doppler ultrasound. The target LN was evaluated in B‐mode ultrasonography at its maximum diameter, and the images were stored in JPEG format. EEIs evaluated at the same location were also stored in JPEG format, as previously reported.The BSIs and EEIs were reviewed by two pulmonologists (KU and SH), who were blinded to the results of the pathological diagnoses and CT images. Based on a previously reported BSI classification,The image analysis software program ImageJ 1.45sThe evaluation of the utility of a combination of elastographic and B‐mode sonographic features was based on a previous retrospective study.Histological and cytological specimens were evaluated by an independent cytologist and pathologist blinded to the BSIs and EEIs. The final diagnosis of each LN was based on the pathological evidence obtained from EBUS‐TBNA, surgery, and bacterial culture, or the demonstration of the absence of disease progression on clinical and radiological follow‐up (at least six months).P‐values. P‐values <0.05 were considered statistically significant. The statistical analyses were performed with EZRData are presented as frequency, median (range), and percentage. The sensitivity, specificity, positive predictive value (PPV), NPV, and DAR were calculated for each LN according to standard definitions. ROC analysis and Youden index (sensitivity + specificity − 1) were used to calculate the optimal cutoff for the SAR value. Based on a two‐sided hypothesis, comparisons between the two groups were examined using the Fisher's exact test or Mann‐Whitney U test. All B‐mode sonographic and EBUS elastographic parameters, which were potentially predictive of malignant LNs,Between April 2015 and November 2018, EBUS‐TBNA was performed in 464 patients (663 LNs) at the UOEH hospital. A total of 143 (164 CT‐negative LNs) patients underwent EBUS‐TBNA; among these patients, six (eight LNs) with insufficient follow‐up and five (seven LNs) with missing imaging data were excluded. Thus, 132 patients (149 LNs) were eventually included in the study.Table P < 0.001)  Fig . The sen001) Fig .Figure P < 0.001), heterogeneous echogenicity (P < 0.001), absence of CHS (P = 0.004), presence of CNS (P = 0.048), and malignancy on elastography (P < 0.001). Logistic regression analysis revealed that when EBUS elastography was suggestive of malignancy, the EBUS elastographic finding was the strongest independent predictor of malignant LNs . The sensitivity, specificity, PPV, NPV, and DAR were 88.2%, 80.2%, 78.9%, 89.0%, and 83.9%, respectively. Additionally, by adding B‐mode sonography to EBUS elastography, the sensitivity of LN malignancy increased to 98.3% (58/59) and the NPV increased to 96.6% (28/29).Table P = 0.046). On EBUS images, all three LNs with a short‐axis diameter less than or equal to 5.0 mm were finally diagnosed as benign. The median short‐axis size of the false negative LNs on EBUS elastography was 9.3 mm.Table This is the first study to compare detailed EBUS findings, including elastography, with pathological diagnoses in CT‐negative LNs. The results suggested that EBUS elastography can be more predictive of malignancy compared to other B‐mode findings. Combined evaluation using EBUS elastography and B‐mode sonography in CT‐negative LNs yielded the highest NPV for predicting malignancy in small‐sized mediastinal and hilar LNs.P = 0.001); however, the sensitivities were equivocal .Various EBUS elastography evaluation methods for mediastinal and hilar LNs have been described.The present study demonstrated that quantitative evaluation of EBUS elastography using the SAR could accurately predict malignancy in CT‐negative LNs with a high NPV; this result is supported by two prior retrospective studies,Small‐sized breast lesions have been reported to result in false negative diagnoses on breast ultrasonography with elastography.LNs can be hardened due to calcification in patients with a history of pulmonary tuberculosis, pneumoconiosis, or anthracosis; this can result in false positive results for malignancy on EBUS elastography.A retrospective study of 1061 mediastinal and hilar LNs reported that 96.0% (381/397) were benign, based on the following features: round shape, distinct margin, heterogeneous echogenicity, and CNS.Two recent meta‐analyses have reported the prevalence of occult LN metastasis to range from 12.8% to 15.0% in NSCLC patients with CT‐negative LNs.Small LNs on EBUS tended to be finally diagnosed as benign. To date, no studies have evaluated the final diagnosis  of CT‐negative LNs based on 1 mm size increments on EBUS and CT. This is the first study to report that such differences in LN size affect the frequency of malignancy in CT‐negative LNs. Furthermore, the final diagnosis was benign in all LNs with a short‐axis diameter less than or equal to 5.0 mm on EBUS. This result is similar to that of a previous retrospective study, which reported a final benign diagnosis for all 14 patients with mediastinal LNs smaller than 5.0 mm on EBUS images.This study had several limitations. First, it utilized a single‐center retrospective design, and had a relatively small sample size. Second, the same bronchoscopist did not perform all the procedures; therefore, the skill of the bronchoscopist may have affected EBUS image analysis. Third, the BSIs and EEIs were only analyzed with static images; therefore, image selection bias may also have occurred. Fourth, this study also included LNs that had not been surgically removed in patients with lung cancer. Nevertheless, the true benignity of the LNs was clinically and radiologically evaluated. Further prospective, multicenter trials are required to confirm the results of this study.In conclusion, the high DAR of EBUS elastography can predict malignancy in CT‐negative LNs with a higher NPV compared to B‐mode findings. Additionally, EBUS elastography demonstrated the highest NPV for malignancy, when used in combination with B‐mode sonography. Consequently, the combined evaluation of CT‐negative LNs using EEIs and BSIs may be helpful for bronchoscopists to perform EBUS‐TBNA efficiently.The authors declare that they have no competing interests.


The Green Chemistry & Chemical Stewardship Certificate Program was designed using the Community of Inquiry (COI) model as a framework for developing curriculum that engages students across the entire program to meet interdisciplinary, professional development program outcomes. The COI framework allows faculty and course developers to develop courses that consider cognitive, social, and teaching presence as equal components of successful learning experiences. In this program, students focus on systems thinking around green chemistry, business, environmental health, chemical alternative assessment tools, and social and environmental justice. They complete a capstone project that identifies a particular environmental or human health issue associated with a chemical and suggest suitable substitutions that are less harmful but equally effective. This paper describes the program’s curriculum, partnerships, delivery modalities, and student feedback as a framework developing professional development opportunities that offer a rich interdisciplinary experience for learners.  Synthetic chemists have developed considerable expertise in designing chemicals with very specific applications and functions. Advances in toxicology and environmental health sciences have improved our knowledge of chemicals associated with human health risks and environmental hazards. Yet little progress has been made in focusing curriculum on how to prioritize chemical design and selection with knowledge of associated health hazards in current chemicals to lower these health and environmental issues preemptively. Integration of chemistry education with other disciplines is a critical need when solving some of these larger challenges of design and use –5. ReseaOnline learning is an effective modality for delivering continued and professional education to working professionals, especially when offered with interactive delivery methods, discussion boards, and multiple audio/visual resources –16. New Professional development curriculum should be informed by industry, labor, and community needs, with outcomes rooted in goals that foster achievements not just at the individual-level but that also meet the rising challenges that face our nation and beyond. During the curriculum development process, it is important to align course outcomes, modules, and assessments with these larger initiatives in mind. Students benefit when curriculum is focused on developing skills that allow the graduate to contribute to the industry and global, systemic issues, rather than existing as a “rehash” of already developed curriculum and programs designed to educate but not allow for mobilization.Green chemistry is “the utilization of a set of principles that reduces or eliminates the use or generation of hazardous substances in the design, manufacture, and application of chemical products” . The purThe GC/CS Program was developed through several collaborations and funding opportunities brought together by the University of Washington Department of Environmental and Occupational Health Sciences Continuing Education Programs (UW DEOHS CEP). The UW DEOHS has a continuing education program committed to delivering professional development courses, building partnerships, and engaging regional communities to promote safe workplaces and sustainable environments. UW DEOHS CEP targets practitioners working in environmental and occupational health including occupational medicine, occupational health nursing, industrial hygiene, safety, hazardous materials management, pollution prevention specialists, and related disciplines. To develop the GC/CS Program, UW DEOHS CEP partnered with the MoDRN consortium, the Center for Green Chemistry & Green Engineering at Yale University, and the Sustainable Technologies, Alternate Chemistry Training and Education Center (STAC-TEC) at UW DEOHS. These centers provided expertise from a diverse range of faculty, staff, and resources for the development of the GC/CS Program. UW DEOHS CEP collaborated with UW Professional & Continuing Education  to deliver the program for the first two years. The third year was delivered by UW DEOHS CEP.All aspects of the certificate program, from the predesign phase to the post-launch evaluation, were informed by an advisory board .Informational webinar sessions with instructors are offered three times each academic year (AY) to allow potential students to learn more about the program and the specific skills they will gain. Each course in the GC/CS Program introduces major aspects of green chemistry, business, sustainability, toxicology, environmental health, and industry. This is the only currently running program that focuses on an interdisciplinary approach to green chemistry and chemical design. Previously, the UC Berkeley Extension offered a professional certificate program entitled “The Essentials of Green Chemistry” with 5 courses offered in both classroom and online environments during 2010–12. Two members of our GC/CS Program Advisory Board completed the UC Berkeley certificate program. In addition, the UC Berkeley Center for Green Chemistry ran a course entitled “Green Chemistry: An Interdisciplinary Approach to Sustainability” in 2011 and 2013. These two offerings served as a starting point for the GC/CS Program envisioning process, although they were no longer offered by the time the advisory board was formed for the GC/CS Program. Marketing new and innovative programs to professionals that do not have requirements for continuing education, such as chemists, limits the demand for these courses and programs. It also takes significant outreach and time to build a targeted audience, which may have been one aspect of the decision to cancel the UC Berkeley Extension Green Chemistry program and course.GC/CS Program courses were designed to integrate and build on knowledge gained from course to course, while recognizing that the breadth of student backgrounds meant basic background information in toxicology, health, and green chemistry was required before building toward a higher-order knowledge synthesis. The current (AY 2018–2019) course descriptions and student learning outcomes for each course can be found in Each module within the courses is two weeks long and contains one content page of written material embedded with research articles, videos, and lectures; one assignment or interactive discussion board; and one discussion board for general questions on that unit’s topic.Faculty response time to student questions is 24–48 h and all detailed feedback and grades are delivered within 7 days of submission.Each course concludes with a capstone project that builds from course to course (see more below).Quality Matters, Inc. (QM) guidelines were used to develop and design each course to provide students with a high quality online learning experience. Each course within the program replicates key components that reflect QM best practices in online course delivery:Each course includes a final capstone project that, while specific to the content areas for each individual course, work together to form a final document that identifies a particular environmental or human health issue associated with a chemical, describes the issue, and suggests suitable substitutions of a less harmful but equally effective substitution while considering business, manufacturing, and economic impacts of the substitution. This capstone project is designed to allow students to address actual needs within their industry or place of work and develop a proposal they could use to help their team or managers consider a chemical substitution, removal of a hazard, change in protocol, implementation of policy, etc. To date, student capstone projects have revolved around safer chemical substitutions, not the development of new or re-designed compounds, given that the program is more interdisciplinary and systems-based rather than technically focused.The GC/CS Program was designed using the Community of Inquiry (COI) model as a framework for developing curriculum and student learning outcomes. The COI model is based on seminal work by Garrison et al.  who intrTriggering involves identifying an issue that leads to exploring the potential solutions and integrating these ideas into a resolution . Students are asked in week one to post a picture and description of their background, current work scope, and reason for joining the certificate program. Students comment on each other’s posts and develop social connections and relationships that extend through the end of the program and beyond. Another way to develop social presence is the use of live webinars. For example, during AY 16–17, Dr. Paul Anastas, co-founder of the Principles of Green Chemistry, was available during a live lecture for all GC/CS Program students as well as live-streamed to one of the program faculty’s toxicology courses. Students interacted with each other through the webinar and felt connected via a social presence in the courses. The COI model helped mitigate some of the potential drawbacks of online programs or courses that involve social presence issues that were discussed in the development stages of program design.The final aspect of the COI model is teaching presence. Teaching presence requires that the selection and the presence of content be appropriate, relevant, and current . Advisorn = 16) and third (n = 17) cohorts of students also represented a wide variety of sectors and job titles.The GC/CS Program’s first cohort (AY 2015–2016) had 18 students from diverse career paths: Cosmetics, Synthetic Chemistry, Chemical Engineering, Academia, Research & Development Engineering, Sustainable Procurement, Lab Management, Environmental Health, Sustainability Coordination, Customer Relations, and Industrial Engineering. The second  of the students responded; a response rate typical for a certificate program offered by UW PCE. For course 3, fifty-six percent (9/17) of the students responded and provided feedback. Students rated the instructors, engagement, and workload/expectations. Standard formative items included questions related to course organization, assigned readings, instructor explanations and feedback, and student performance. On a scale from 0 to 5 (0 = lowest), the overall median summative rating for instructors ranged from 4.4 to 4.7. On a scale from 0 to 7 (0 = lowest), the median challenge and engagement index (CEI), a commonly used measure that combines student responses to questions about engagement and rigor, ranged from 4.9 to 5.5. Students were asked to rank the GC/CS Program content and its application to real world issues as compared to other programs and college courses, and median scores ranged from 6.7 to 6.9 (7 = highest). Students also reported spending approximately 7.5–8.5 h a week completing readings, reviewing content, and completing course work.Based on student feedback, modifications were made to the courses after the first year and instructors continue to add new resources and materials annually. One example involved student requests for recorded lectures. In response, faculty from each course developed and recorded several traditional-style lectures to support the content, videos, and interactive quizzes that were already available. Faculty also began to offer “office hours” whereupon students could log in virtually and ask their faculty questions, although student participation in such sessions is extremely low due to difficulty in finding shared availability between students and faculty. Certain content in different modules of the courses was also re-written due to student feedback, mostly in an effort to pair-down the amount of reading on the topic and increase the visual representation of the information instead.(1) Was this class intellectually stimulating?; (2) What aspects of this class contributed most to your learning?; and (3) What aspects of this class detracted from your learning? Students commented on the value of the connections between the chemical toxicity and human health; identifying stakeholders for decision-making; and how relevant completing the capstone projects were to their industries and organizations. The following is student-provided feedback in response to the three questions above:“Absolutely! I think a lot of the concepts were not unusual, but at the same time were not things I often consider or think about it. There a lot of things that are floating around on the periphery, but this class really helped to develop them more fully and explain what impacts they can have. I also really enjoyed the soft, theoretical approach and some of the more technical examples we got into like our capstone.”“Definitely. While I continued to add to the methodology from the other two classes, it brought in real life examples and applications, which I loved. I’m much more of an application learner and while I loved the theory we learned throughout the program, I was anxious to see how it worked in the ‘real world’”.Was this class intellectually stimulating?“Discussions where feedback on replies was given.”“I think the alternative assessment methods and case studies were extremely valuable to learn about, but I really liked all the of the readings. I also thought the assignments and discussion topics helped reinforce each lesson.”“The tools we learn to evaluate the hazardous properties of the materials.”“The required tasks taught me how to research any product, provided critical links and encouraged exploration of many more which were then shared among the student body. Very interactive and memorable. This is not one of those ‘do now and forget later’ courses so I’d have to say the theory and practical application balance was just right to enhance the learning process and develop skill.”“The ability to tailor material to my interests and engaged professors.”What aspects of this class contributed most to your learning?“I would have liked the opportunity to interact with the professors a little more or maybe had a videotaped or live lecture from them.”“I would spend a lot of time typing and retyping my posts in word before finally adding them to the board. It felt difficult trying to meet all of the requirements of the posts  and keep conversations flowing. This was my first online course though, so this might be something that gets easier with time.”What aspects of this class detracted from your learning?In addition, the following open-ended questions were asked: Students were emailed an evaluation exit survey within three months of completion of the program. This survey included questions about how well the program met student goals, the types of benefits gained, and changes in job responsibilities following completion of the program. During 2015–2016, 5 students responded to the exit survey. The primary reason for student enrollment in the program was career advancement and career change. On a scale of 1–5 , 80% ranked a 4 or 5 indicating that the certificate program prepared them well for implementing the knowledge and skills gained into their career or job responsibilities. 60% reported that their career or job responsibilities changed within their company or organization after completing the program.Establish a diverse and technically strong advisory board to drive the curriculum.Facilitate academic faculty and industry relationships and connections to strengthen relevancy for student learning.Update curriculum each year with new tools and academic advances.Use multiple learning modalities to stimulate learning and increase interaction.Increase methods for engagement with instructors with discussion boards, timely responses, live stream videos, and assignments.Design self-directed capstones that creates relevancy and addresses direct professional needs.Identify an administrative champion and key faculty to sustain the program over time.Follow standardized protocols to provide students with high quality online learning experiences .Online learning certificate programs have many advantages for working professionals. A COI framework for curriculum development increases engagement for student learning and provides a validated model for successfully connecting content and outcomes of this certificate program to the student’s practice world. Best-practices learned from this interdisciplinary program includes:It is important to also consider student and industry feedback and make changes when a collective concern or new opportunity arises. Being responsive to student and industry feedback allows programs to shift nimbly and avoid becoming outdated and passive. Over the last three years, this program has supported students in their quest to minimize chemical hazards for themselves and others, locally to globally. There is a need for more continuing education opportunities in green chemistry, toxicology, and environmental health. This certificate program can serve as a guide for the development of related programs and beyond.


Medical students often have difficulty selecting a residency training program. The internal medicine clerkship rotation occurs primarily on the general internal medicine ward, making it difficult for students to experience the breadth of IM subspecialties prior to making career decisions. Herein, we describe a two-week student-led program  designed to give interested pre-clerkship students an overview of the internal medicine subspecialties in order to broaden their understanding of the opportunities within the field. We believe that medical students across the country would benefit from such exposure in order to make more informed decisions about residency.Les étudiants en médecine ont souvent de la difficulté à choisir un programme de résidence. Le stage de médecine interne (MI) se déroule principalement à l’étage, ce qui rend difficile pour les étudiants d’expérimenter l’étendue des sur-spécialités en MI avant de prendre des décisions relatives à leur carrière. Dans cet article, nous décrivons un programme de deux semaines dirigé par des étudiants (EDMI : Enrichissement et développement en médecine interne), conçu pour donner aux étudiants du pré-externat intéressés un aperçu des sous-spécialités en médecine interne dans le but d’élargir leur compréhension des opportunités offertes dans ce domaine. Nous croyons que les étudiants en médecine de partout au pays pourraient tirer profit d’une telle exposition pour leur permettre de prendre des décisions plus éclairées au sujet de leur résidence.1 A contributing factor may be that the residency application deadline often predates clinical exposure to all specialties. Researchers suggest most students decide on residency programs during pre-clerkship.2 However, without adequate exposure, this decision may be rooted in bias. Multiple studies support the notion that clinical exposures in pre-clerkship influence residency decisions, regardless of specialty.4Medical students often find it challenging to select a residency program.5 Therefore, it is difficult for students to experience the breadth of IM subspecialties prior to making career decisions. Two medical students conceived the idea for the IMED  program to provide students with adequate exposure to the breadth of IM subspecialties during pre-clerkship, and to allow for informed decisions regarding residency planning.At many medical schools, the clerkship Internal Medicine (IM) rotation is based in the general IM ward.IMED is a two-week summer program organized by the medical student-run Internal Medicine Interest Group (IMIG) at the University of Ottawa. Participants spend each morning in a clinical setting observing a different IM subspecialty with one-on-one assignment to a staff physician. Participants convene at lunchtime for a career-oriented presentation delivered by a different subspecialty physician each day. Topics include scope-of-practice, work-life balance, and factors influencing choice of specialty. Students then proceed to hands-on workshops pertinent to said specialty, including procedural skills such as central line insertion, code blue simulation, and joint ultrasound. The final day of the program focuses on general IM and includes a team-based case competition that incorporates topics covered throughout the program. A sample student schedule is shown in The IMIG executive committee garners support for the program by approaching department heads in all IM subspecialties to discuss program objectives. Each year interested departments with the staffing capacity to accommodate learners are included in the program. The number of interested departments determines the overall length of the program. Department heads recruit staff physicians to supervise student learners for morning observerships, and the department secretary schedules students in either hospital or community clinics. Department heads also nominate educators to deliver the lunchtime career talk and the afternoon workshop. The goal of the afternoon subspecialty workshop is to pique student interest by offering participants a unique insight into the chosen field, either by way of novel, innovative, and breakthrough practices and/or through an introduction to procedural skills not otherwise incorporated into the medical school curriculum. IMIG obtains funding for catered lunches and honorarium for presenters. Notably, the program can operate without funding if necessary, as students can bring personal lunches.The organizing committee selected 20 interested pre-clerkship students  via random lottery for the inaugural IMED in 2018. The organizing committee reviews the program size annually depending on the number of students that interested subspecialties can accommodate. Students’ interest in IM residency is not a pre-requisite to participate.The REB exempt this study as a program evaluation. The sixteen participants of IMED in 2019 completed pre-program and post-program surveys (survey completion was 100%). To assess whether students felt they had been exposed to the breadth of IM through IMED, they responded to 3 statements using a 5-point Likert scale  before and after IMED:I understand what a career in IM entails in terms of hours, pay, research opportunities, job prospects, and lifestyleI understand which subspecialties of IM are more “procedure heavy” vs. “medicine heavy”I understand the differences between community and academic practice in IMp < 0.01 for each question (I-III) respectively. Following IMED, participants were asked if they were more, less or equally likely to pursue internal medicine as a career. Thirteen participants  indicated that IMED made them more likely to pursue a career in IM, two (13%) answered less likely, and one (6%) answered equally likely. Our results suggest that IMED provided students with new information regarding a career in IM, which will likely aid in making career decisions. Due to the self-selected sample and the prospective nature of the questions, it is possible that results may be influenced by projection bias and confirmation bias.A Wilcoxon Signed-ranks test revealed that post-IMED scores were significantly higher than pre-IMED scores with Z=3.5, Z=3.4, and Z=3.2, all 6 We encourage other universities to consider implementing such a program to give medical students the opportunity to explore the breadth of IM at an early stage. Organizing such an initiative requires student dedication to recruit subspecialty departments and to coordinate the efforts of faculty to accommodate student learning. In the future, we hope to follow participants longitudinally to examine IMED’s influence on residency selection. Adding a control group comprised of interested applicants not selected for the program would allow us to determine whether the program promotes informed decision-making surrounding residency and career planning.In future iterations of IMED, we plan to include other common subspecialties such as respirology and geriatrics, as well as smaller subspecialties where there exists a societal demand, such as addiction and pain medicine.