During a major earthquake, escape attempts or collapsed buildings can result in injury, disability, and even death for victims. The aim of this study is to examine the demographic characteristics, clinical outcomes, and injuries of victims admitted to the emergency department within the first week after an earthquake.This is a retrospective observational study conducted on earthquake victims who were admitted to the emergency services of a tertiary medical faculty and a training and research hospital in the city of Diyarbakir, located in the Southeastern Anatolia Region of Turkey, from February 6 through February 12, 2023.Of the eligible 662 earthquake victims, the mean age was 10.66  in children, 36.87  in adults, and 72.85  in the elderly. Women constituted 52.8% of the victims, 19.7% were children, and 8.0% were elderly. Sixty-one percent (61.0%) of earthquake victims were admitted to emergency services in the first three days following the disaster; 37.7% of all victims were transferred from other affected cities to Diyarbakır. In all, 80.2% of the victims were admitted as survivors to the emergency services  and 19.8% were deceased under rubble. The majority of the 131 deceased victims were women (52.7%), 20.6% were children, and 7.6% were elderly. An estimated 38.3% of victims were hospitalized (20.9% in the ward and 17.4% in the intensive care unit [ICU]). For all age groups that survived under the rubble, the extremities were most injured . Of adult survivors, 26.6% needed only fluid therapy, renal replacement treatment  was required 20.7%, and 11.8% required amputation. Of children survivors under the rubble, renal replacement treatment  was required for only four, seven required amputation, and 12 needed only fluid resuscitation for crush injury. Of elderly survivors, two needed only fluid therapy, renal replacement treatment  was required for two, and no amputation was required. Six patients survived under the rubble and died in the ICU.The definition of the demographic characteristics and clinical outcomes of earthquake patients is critical to the development of preparedness, response, and recovery policies for future disasters. On February 6, 2023, Turkey was struck by two of the most catastrophic earthquakes of the last century. During the early hours of February 6, Kahramanmaraş City in Turkey experienced its first earthquake with a magnitude of 7.7 on the Richter scale. A second earthquake with a magnitude of 7.6 struck the same region. In both earthquakes, the origin was approximately seven kilometers deep. More than 16 million people were affected by the earthquakes across 10 provinces, including Adana, Adıyaman, Diyarbakır, Gaziantep, Hatay, Kahramanmaraş, Kilis Osmaniye, and Şanlıurfa , over 1.5 million buildings were inspected during the damage assessment studies in the provinces affected by the earthquakes, and 202 thousand were determined to be demolished or heavily damaged in the emergency.The Turkish Ministry of Interior Disaster and Emergency Management Presidency  released an official announcement informing the public that 2,724 aftershocks occurred in the first week following the earthquake, 31,643 people died, and 158,165 people were evacuated from the region.There were several issues of concern about access to essential health services declared by the WHO in earthquake-affected regions of Turkey. Among the priority concerns reported were accessing the most vulnerable and affected populations in earthquake-affected areas, providing emergency trauma treatment and post-traumatic rehabilitation for the injured, and essential medicines, emergency kits, and supplies to meet urgent needs . The Health Ministry  reported 51,152 patients and injured people were transferred to other hospitals in the first days after the earthquakes.During the first earthquake in Turkey, people were asleep in their homes, and many were not able to get out, escape, or seek safety. As a result, thousands of buildings collapsed, trapping countless people under the rubble. According to a review, victims under the rubble could be extricated within hours to days of the initial injury. Due to the rush to provide emergency rescue and care, victims were separated, some of whom were taken to the nearest health facility. Additionally, earthquakes damaged hospitals in the disaster area, forcing victims to evacuate to other cities’ hospitals. The literature lacks information about emergency health services, demographic characteristics, and clinical outcomes among disaster victims. The aim of this study is to examine the demographic characteristics, clinical outcomes, and injuries of victims admitted to the emergency department within the first week after an earthquake. Research findings could contribute to developing preparedness, response, and recovery policies for future disasters after an earthquake.Despite disasters having similar magnitudes, vulnerabilities vary by community, so vulnerability research focuses on the factors that may cause damage to a community. Communities can assess their earthquake vulnerability based on the identified vulnerable characteristics. By doing so, the emergency response system will be strengthened, as well as the strategy for mitigating disaster losses.This is a retrospective observational study. The study involved patients affected by the earthquake who were admitted to the emergency services of a tertiary medical faculty and a training and research hospital in the city of Diyarbakir, located in the Southeastern Anatolia Region of Turkey, from February 6 through February 12, 2023 (the first week after the earthquakes). Patients with incomplete, inaccurate, or unreachable hospital records and emergency service admissions not related to the earthquakes were excluded. In accordance with the Helsinki Declaration, the Non-Interventional Clinical Research Ethics Committee of Dicle University Faculty of Medicine ethics committee approval  and institutional permission were obtained before the study. A 546-bed training and research hospital and a 1,226-bed tertiary medical faculty are located in the city of Diyarbakir. Health services are provided by these hospitals in nine provinces throughout the southeast. These hospitals also serve as Level 1 trauma centers.In the Southeastern Region of Turkey, Diyarbakir province consists of 17 districts, four of which are centers. Based on the data provided by Turkish Statistical Institute  for the year 2022, the province has 1,804,880 residents.Each hospital’s emergency department and hospital electronic medical records were used to collect patient data. The data obtained from the study were analyzed using IBM SPSS Statistics for Windows, version 26.0 . Descriptive statistics were presented as percentages (%) and numbers (n); continuous variables were expressed as mean (standard deviation/SD [minimum(min)-maximum(max)]).This study collected data on age, gender, the city affected by the earthquakes, the day of admission, the diagnosis, the emergency department’s clinical outcome, the type of injury , the anatomical region of the injury, and the number of injuries. The treatment of the survivors under the rubble was documented, as well as their causes of death during hospitalization. Earthquake victims were defined as deceased (under rubble) and survivors. Survivors were divided into three categories: children, adults, and elderly.A total of 662 earthquake victims had an average age of 34.60  years, 36.31 (SD = 19.43) years in females, and 32.69 (SD = 18.15) years in males. The mean age was 10.66  years in children, 36.87  years in adults, and 72.85  years in the elderly.Women constituted 52.8% of the victims, 19.7% were children, and 8.0% were elderly. Sixty-one percent (61.0%) of earthquake victims were admitted to emergency services in the first three days following the disaster; 37.7% of all victims were transferred from other affected cities to Diyarbakır. Most transfers were from Adıyaman province . In all, 80.2% of the victims were admitted as survivors to the emergency services  and 19.8% were deceased under the rubble. Among the survivors under the rubble, 54.7% were women, 25.1% were children, and 5.3% were elderly. The majority of the 131 deceased victims were women (52.7%), 20.6% were children, and 7.6% were elderly. An estimated 38.3% of victims were hospitalized (20.9% in the ward and 17.4% in the intensive care unit [ICU]); Table Twenty-eight percent 28.0%) of survivors (n = 508) who were trapped under the rubble or attempting to escape the earthquake had two or more anatomical site injuries. The anatomical site of injury was 66.3% in the extremities and 14.8% in the head. For all age groups that survived under the rubble, the extremities were most injured . Of the survivors who were trapped under rubble and attempted to escape, 46.1% were hospitalized (20.1% ICU and 26.0% ward). Under the rubble, 57.3% of children and 38.5% of elderly survivors were admitted to intensive care. One child and the three elderly survivors who attempted to escape the earthquake were admitted to the ICU. Under the rubble, 52 adults were admitted to the ICU, six of whom died  was required for 20.7%, and 11.8% required amputation. Of children survivors under the rubble, renal replacement treatment  was required for only four, seven required amputation, and 12 needed only fluid resuscitation for crush injury. Of elderly survivors, two needed only fluid therapy, renal replacement treatment  was required for two, and no amputation was required Table . Six pat Globally, more than 60 million people have suffered earthquake damage and approximately 0.4 million have been killed by earthquakes during the last 30 years. In recent years, the deadliest earthquake disaster occurred in Haiti. Two hundred twenty (220) thousand people died in this disaster, which affected 3.7 million people. An occasional disaster with a high impact, the Turkey earthquake of February 2023 was among the deadliest earthquakes on record. The AFAD reported on March 1, 2023 that over 41 thousand people were dead  and more than 115 thousand people were injured in the Kahramanmaraş-centered earthquakes.In earthquakes, strong ground motions occur over short periods of time and lead to catastrophic destruction. Several devastating effects of earthquakes can be observed in society, such as their social, physical, and economic impacts. An earthquake study in Yushu, China found 2,622 earthquake-related injuries among the victims. Of these, 54.81% were male with a median age of 36 years. An analysis of the Nepal Earthquake in 2015 found that 51.2% of the victims were women, and 17.2% were children. Due to being trapped under rubble, 48.9% of survivors suffered extremity crush injuries. In the present study, 80.2% of the 662 victims were admitted as survivors to the emergency services  while 19.8% had died under the rubble. The majority of the 131 deceased victims were women (52.7%), 20.6% were children, and 7.6% were elderly.During an earthquake, unfortunate deaths were associated with very young and very old ages, poor socioeconomic status, and living indoors or in poorly constructed buildings. Most often, earthquake-related mortality and injuries were caused by building collapses, which led to soft tissue injuries, fractures, and crush injuries. Sixty-eight percent (68.0%) of the 2,622 patients with earthquake-related injuries were admitted to the hospital within three days of the Yushu earthquake. During the Taiwan earthquake in 2016, 123 entrapped victims under collapsed buildings were extricated and transported to hospitals within 72 hours after the events. In the present study, approximately 61.0% of earthquake victims were admitted to emergency services in the first three days following the disaster.Health care demand increases suddenly after earthquakes and facilities face the highest admissions within 72 hours of the earthquake. A Haitian earthquake in 2010 destroyed 60% of hospitals in the Ministry of Health, and more than 200 staff members perished. Most health care institutions in the earthquake area were unable to provide services. A district state hospital and two tertiary hospitals were destroyed in Hatay, Turkey after the earthquakes. There were also a number of private hospitals destroyed or permanently damaged in Hatay’s city center. A medical faculty hospital and three state hospitals were slightly damaged in Hatay. As a result of the recent earthquakes in Adana, moderate damage to the medical faculty hospital was found. Patients were transferred to other hospitals. One hundred fourteen (114) emergency response units and 25 field hospitals were established in the disaster area and 51,152 patients and injured were transferred to hospitals in other cities, according to the Ministry of Health. In the present study, 37.7% of all victims were transferred from other affected cities to Diyarbakır.In earthquake-prone areas, health facilities are particularly vulnerable because of direct and indirect damage (loss of utilities and infrastructure) that affects their ability to respond to emergencies.Most transfers were from Adıyaman province . Adyaman facilities were only slightly damaged and usable after the earthquakes. With only one tertiary hospital in Adyaman, it experienced the highest number of admissions after the earthquake. As a result of this situation, it can be explained why most transfers were made from Adyaman to Diyarbakır. A large number of people were asleep in their homes during the first earthquake in Turkey, and many of them were unable to escape or seek safety from the disaster. Numerous people were trapped under the rubble as a result of the collapse of thousands of buildings. Buried in rubble, victims can suffer crush injuries to their vital organs and extremities. In order to avoid complications, survivors from under the rubble needed a thorough evaluation, an early diagnosis, and aggressive treatment. The most common type of injury reported in the literature was crush extremity injuries that caused crush syndrome in people rescued alive from earthquake rubble. In this present study, the extremities were most injured in all age groups who survived under rubble .Researchers have found that earthquake injuries are also influenced by the location where the victims were and the time when the earthquake occurred. In the present study, due to crush injuries, all survivors received fluid resuscitation. Of adult survivors, 26.6% needed only fluid therapy, renal replacement treatment  was required by 20.7%, and 11.8% required amputation. Of children survivors, renal replacement treatment  was needed for only four, seven required amputations, and 12 were given only fluid resuscitation for crush injury. Of elderly survivors, two were given only fluid therapy, renal replacement therapy  was required on two of them, and no amputation was necessitated. In the present study, existing crush injuries were managed and treated using a multidisciplinary approach . Despite the multidisciplinary approach used, only six survivors under the rubble died during hospitalization in the first week following the disaster. As a result of this study, epidemiological knowledge of the demographics, injury types, treatment, and outcome will be provided, which will be very valuable in improving disaster relief.The initial treatment for earthquake-related crush injuries included fluid-electrolyte balance, renal replacement therapy, and surgery interventions .The present study has several limitations. Based on the retrospective nature of this study, the fact that only victims with access to health care were included. Due to confusion and increased demand for health care during the time of the earthquake, there was a lack of record keeping or incomplete record keeping among the deceased. This caused in turn limited data information about the deceased’s demographics and causes of death. Achieving similar goals and objectives can be achieved through large-scale surveys that include data from earthquake victims in other affected provinces.A large number of people were injured, left homeless, or lost their lives in the Turkey earthquakes. Women, children, and the elderly were also affected. Most of those who died under the rubble were admitted to hospitals as deceased. To cope with the negative effects of the disaster, national and international support was required. Health facilities were also damaged by the earthquakes, creating unforeseen health needs. The vast majority of earthquake victims were admitted to emergency services in the first days following the disaster. In some survivors, crush injuries necessitated amputations and hemodialysis. It may be helpful to develop policies for preparedness, response, and recovery for future disasters, emergency response systems, and disaster loss reduction strategies if the demographic characteristics, clinical outcomes, and injuries of victims admitted to the emergency department within the first week are known. Also, demonstrating the social, psychological, physical, and economic effects of earthquake disasters may contribute to public health protection.


Background: Liver transplantation is a lifesaving procedure for patients with end-stage liver disease (ESLD). However, many patients never receive a transplant due to insufficient donor supply. Historically, organs have been preserved using static cold storage (SCS). However, recently, ex vivo normothermic machine perfusion (NMP) has emerged as an alternative technique. This paper aims to investigate the clinical progress of NMP in humans. Methods: Papers evaluating the clinical outcomes of NMP for liver transplantation in humans were included. Lab-based studies, case reports, and papers utilizing animal models were excluded. Literature searches of MEDLINE and SCOPUS were conducted. The revised Cochrane risk-of-bias tool for randomised trials (RoB 2) and the risk of bias in nonrandomised studies for interventions (ROBINS-I) tools were used. Due to the heterogeneity of the included papers, a meta-analysis was unable to be completed. Results: In total, 606 records were identified, with 25 meeting the inclusion criteria; 16 papers evaluated early allograft dysfunction (EAD) with some evidence for lower rates using NMP compared to SCS; 19 papers evaluated patient or graft survival, with no evidence to suggest superior outcomes with either NMP or SCS; 10 papers evaluated utilization of marginal and donor after circulatory death (DCD) grafts, with good evidence to suggest NMP is superior to SCS. Conclusions: There is good evidence to suggest that NMP is safe and that it likely affords clinical advantages to SCS. The weight of evidence supporting NMP is growing, and this review found the strongest evidence in support of NMP to be its capacity to increase the utilization rates of marginal and DCD allografts. In the United States (USA) alone, more than 1000 patients die whilst waiting for a liver transplant annually, with many more removed from the wait list due to clinical deterioration . Wait liHistorically, donor allografts were preserved for transplantation using static cold storage (SCS), a technique developed in the 1960s which involves cooling the allograft in a preservation solution to reduce cellular metabolism and protect from ischaemic injury . Whilst Ex vivo machine perfusion is an alternative method of preserving liver allografts for transplantation, with hypothermic (HMP), sub-normothermic (SMP), and normothermic (NMP) variants being described . NMP supThis review aims to synthesise the available evidence investigating the clinical, biochemical, and logistical effects of NMP for liver transplantation in humans and provide a comprehensive overview of the technology.Papers evaluating the clinical or biochemical outcomes of NMP for liver transplantation in humans were sought. Retrospective and prospective trials were included, as were cohort studies, single-arm studies, and studies using historical-propensity-matched controls. Studies evaluating HMP, SMP, or normothermic regional perfusion (NRP) were excluded. Lab-based studies without transplantation of the graft, studies utilising animal models, studies investigating liver retransplantation, case-control studies, and case reports were excluded.A comprehensive literature search of MEDLINE and SCOPUS was completed. MEDLINE was searched with the input “human.mp. or Humans/AND liver transplantation.mp. or Liver Transplantation/ AND normothermic.mp AND Perfusion/or Organ Preservation/ or machine perfusion.mp” and SCOPUS with the input “machine AND perfusion AND normothermic AND liver AND transplantation AND human”. No time period or language restrictions were specified. Reference lists of papers identified as meeting the inclusion and exclusion criteria were reviewed to ensure all eligible papers were identified. All retrieved records from MEDLINE and SCOPUS were exported to EndNote 20 for cleaning and appraisal. MEDLINE and SCOPUS were last consulted on 20 October 2022.Duplicate articles were removed using the de-duplication tool in EndNote 20, and all unique records identified by the literature search were screened individually. Articles clearly not meeting the inclusion criteria based on their title were removed during initial assessment. Abstracts of articles possibly meeting the inclusion and exclusion criteria were assessed and removed only if it could be confidently determined that they did not meet the inclusion criteria. Articles likely to meet the inclusion criteria, and articles unable to be eliminated based on review of their abstracts were retrieved in full. Articles retrieved for review were screened, and individual articles meeting the pre-specified inclusion were ultimately included in this systematic review. Included articles were classified based on their level of evidence using the Australian Government National Health and Medical Research Council (NHMRC) evidence hierarchy, and risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomised trials (RoB 2) for randomised control trials (RCT) or the risk of bias in non-randomised studies for interventions (ROBINS-I) tool for all other included papers ,6,7. TheData were extracted from embedded tables or directly from the body of each individual article. No automated tools were used to extract data from individual reports, nor were any individual study investigators approached to confirm published data. Specific outcomes of interest included early allograft dysfunction (EAD), patient and graft survival, rate of graft discard, utilisation of DCD grafts, biliary complications, and hospital and intensive care unit (ICU) length of stay (LOS). All results that were compatible with each outcome domain were extracted and incorporated in our analysis. Articles which met the inclusion criteria but did not report on these pre-determined clinical outcome domains were considered to have novel clinical endpoints of interest and included in our analysis and conclusions. All extracted data were stored, collated, and organised using Microsoft Excel version 16.73.To enable systematic synthesis of data, specific outcome domains were grouped, and papers reporting on each domain were included in the analysis. Papers reporting on multiple outcome domains were encompassed in each relevant outcome domain. Microsoft Excel was used to tabulate and organise data for each outcome of interest. This systematic review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines .A total of 287 records were retrieved from the search of MEDLINE, and 319 were retrieved from SCOPUS. All 606 records were extracted to EndNote 20, and 214 duplicates were removed. The remaining 392 records were screened individually, with 324 records being discarded and 68 full articles being retrieved for assessment. On review of each full-text article retrieved, 43 were excluded, and a total of 25 records deemed to meet the inclusion criteria . A revieFive papers investigated the role of NMP in assessing and transplanting previously discarded “orphan grafts” ,15,16,17p = 0.001 and 10.1% cf. 29.9%, p < 0.01, respectively) [All articles evaluating the rate of EAD utilise the definition of EAD proposed and validated by Olthoff et al. . Sixteenctively) . The basctively) .p < 0.001). Chen et al. also describe a novel surgical technique which avoids a second period of CIT during implantation [p = 0.089), however, subgroup analysis demonstrated NMP without re-cooling significantly reduced rates of EAD compared to SCS  [p = 0.02). However, similarly to Guo et al. and Chen et al., they describe a novel technique which may not be applicable to the wider use of NMP technology.The prospective, non-randomised trial by Guo et al. describes a novel IFLT technique, which avoids cold ischaemia time (CIT) during procurement and implantation . The IFLantation . Their r= 0.022) . Liu et = 0.022) . The autp = 0.034). Three propensity-matched trials by Fodor et al., Bral et al., and Ravikumar et al. report no significant difference between rates of EAD for livers transplanted with NMP when compared to SCS [The prospective, single-arm trial with contemporary matched controls by Mergental et al. was designed to assess the viability of NMP to rescue previously discarded orphan grafts . All 22 d to SCS ,33,34. Ad to SCS ,18,23,24d to SCS ,20,22,24Overall, the true rate of EAD following NMP when compared to SCS is difficult to ascertain given the heterogeneity of evidence and the inability to complete a pooled analysis due to trials utilising novel NMP techniques or demonstrably different patient cohorts. Despite this, the two largest trials encompassing the highest quality of evidence both show a significant reduction in EAD using NMP when compared to SCS, which would lend weight to the view that NMP is superior in this regard.p = 0.11 and p = 0.20, respectively. However, a lack of detail regarding the propensity score matching process and baseline donor characteristics mean it is not possible to rule out confounding or selection bias, especially given baseline characteristics for all NMP liver transplants recipients were significantly more likely to be older , have a higher BMI , originate from DCD  and ECD  when compared to SCS [19 papers investigate graft and patient survival; however, no paper reports a significant difference for either endpoint . This lad to SCS .p < 0.001) patient survival for NMP compared to SCS at both 1 and 12 months [p = 0.326 and 92.1 cf. 82.3%, p = 0.142 respectively) [Most early studies were designed and powered to demonstrate the safety of NMP, not its superiority, given it was a new technology competing with a proven reliable, safe, and well-understood allograft preservation method. Available evidence demonstrates the safety of NMP when considering both patient and graft survival, as outlined by all three RCTs, which report patient and graft survival at 12 months to be non-inferior to SCS ,29,30. Tctively) . Guo et p = 0.06) [The trial with the longest period of follow-up was conducted by Seidita at al., who completed a retrospective analysis of 202 liver transplants with a 3-year follow-up period . At 3 ye = 0.06) . However = 0.06) .p = 1.0). However, they did report a significant reduction in the rate of IC with NMP  [Biliary complications were an endpoint for 13 papers . Specifi= 0.002) . Convers= 0.002) . It shou= 0.002) .p = 0.854). However, sub-analysis showed a significant reduction in IC with NMP  [Fodor et al. reported no overall difference in rates of biliary complications between NMP and SCS  . This fi= 0.047) ,29. Guo = 0.047) .Conversely, Mergental et al. and Chen et al. reported a trend towards an increased rate of biliary complications associated with NMP. However, neither reported statistically significant results ,18. Mergp = 0.007), whilst Nasralla et al. demonstrated a significantly reduced rate of allograft discard in the NMP group  [p < 0.001) and a lower rate of overall graft discard  with NMP amongst their cohort of 30,596 cases [Both large RCTs provide good evidence that NMP increases the utilisation of marginal or ECD liver allografts ,30. Mark= 0.008) ,30. The 96 cases . It shouAll NMP cases included in the trials by Quintini et al., Reiling et al., and those in both papers penned by Mergental et al. were discarded orphan allografts that had been previously rejected for transplantation ,12,13,14p = 0.119). Notably, the RCT by Markman et al. does not report on ICU or hospital LOS [The RCT authored by Nasralla et al. encompasses a total of 220 transplantations. However, it failed to detect a significant difference for ICU or hospital LOS between NMP and SCS . The smaital LOS .p = 0.006) but reported no reduction in overall hospital LOS compared to SCS. Conversely, the small, non-randomised, prospective-propensity-score-matched trial by Bral et al. reported NMP allograft preservation to be associated with significantly longer ICU LOS  [Guo et al. reported that IFLT is associated with a significantly shorter ICU LOS  . Of note= 0.004) ,33. The p = 0.006) [p = 0.01) [Fodor et al. reported a significantly shorter total hospital LOS following the transplantation of allografts preserved using NMP  . This is = 0.01) . Similarp = 0.010), increased rate of clot formation , increased clot lysis time (p = 0.004) and increased maximum clot strength  [p = 0.001), however, no change to the requirement of FFP (p = 0.070), packed red cells (p = 0.655) or cryoprecipitate (p = 1.00) [Ionescu et al. showed that preserving liver allografts using NMP is associated with significantly improved intraoperative coagulation profiles and reduced requirement for intraoperative platelet transfusion . Their r= 0.044) . Clinica = 1.00) .Whilst a total of 25 papers were identified to meet the inclusion criteria for this review, there was significant heterogeneity in regard to study design, donor characteristics, surgical technique, and transplantation protocols between papers. Additionally, the lack of standardised viability criteria between trials obscures the interpretation of results and perpetuates heterogeneity between trials. Many papers use common perfusion endpoints, such as lactate clearance, perfusate pH, bile production, vascular flows, and macroscopic inspection to assess organ viability. However, cut-off values and the combination of parameters assessed are highly variable between papers. This heterogeneity prevented pooled analyses due to the unacceptable risk of introducing selection, confounding, and technical biases. As such, only qualitative analyses were possible, limiting the generalisability and certainty of our findings. A narrower focus and more restrictive inclusion criteria to ensure included studies are sufficiently homogenous would be required to complete a high-quality meta-analysis on specific outcome domains.p < 0.001). As such, these RCTs—encompassing a total of 513 patients—provide high-level evidence that NMP is—at minimum—non-inferior and likely associated with clinical benefits compared to SCS.The highest-quality evidence for NMP is provided by two large RCTs by Markmann et al. and Nasralla et al. ,30. Bothp < 0.001) and ICU LOS  provide evidence to suggest that their IFLT technique has benefit. However, teasing out the relative effect of eliminating CIT versus the benefits of NMP is not possible without further investigation.Whilst both RCTs were based on similar study designs, each of the largest non-randomised control trials differ significantly in their design. Guo et al. employed an IFLT technique, which eliminates CIT; Seidita et al. incorporated only ECD allografts; Gaurav et al. incorporated only DCD allografts; and Fodor et al. stipulated restrictive inclusion criteria based on high-risk donor, recipient, or logistic factors ,18,19,21p = 0.142) [Whilst reductions in EAD and reduced peak post-operative transaminase levels have been reported to be surrogate markers for graft function ,41, the = 0.142) . RegardlDespite a lack of evidence to suggest improved survival outcomes, there is good evidence that NMP can reduce allograft discard rates and increase DCD graft utilisation. The ability to assess donor allograft viability using SCS is limited. However, NMP allows dynamic assessment of biochemical and synthetic function, vascular characteristics, and bile production, which greatly enhance graft evaluation ,43. BothA significant weakness of the overall quality of evidence for NMP is the large number of studies with small sample sizes and the reliance on propensity-matched controls. In total, 12 of the 22 papers directly comparing NMP to SCS have 21 or fewer patients in the NMP arm of each trial; 8 papers rely on propensity-matched controls, and 6 are single-arm trials with no comparator cohort. This lack of sufficiently powered trials with contemporary controls not only impacts the ability to detect subtle effects of NMP but also introduces significant risk of bias. This issue may have been mitigated through the pooling of data; however, this was not possible due to the heterogeneity of the study design and patient cohorts. Additionally, papers without comparator cohorts provide useful insights into the increasing use of NMP worldwide. However, they provide little evidence to support the continued expansion of the technology.An important consideration is that all studies included in this review describe a short-term model of NMP. Each paper utilised NMP for less than 24 h prior to transplantation, with the majority perfusing each liver with NMP for only a small number of hours. This is notable given that recent technological advancements allow prolonged ex vivo perfusion of livers using NMP . Our groNMP has also been described as an effective preservation technique for other thoracic and abdominal organs for transplantation. Its use in kidney transplantation is expanding, and emerging evidence suggests that it can facilitate improved viability testing and reduced organ discard rates, mirroring the findings of this review . NMP hasOverall, there is a significant need for further large, well designed, and generalisable trials evaluating the long-term clinical effects of NMP. An abundance of evidence demonstrates the viability of NMP technology, but data on long-term benefit are lacking. In particular, future studies should be designed to investigate clinically relevant endpoints, such as surgical or graft complication rates, graft and patient survival, or rates of re-transplantation. Until there is compelling evidence that NMP is associated with significant and durable patient benefit, the economic cost, technological challenges, and novel skills required to use NMP will likely impair its uptake into everyday clinical practice.The evidence base for NMP is advancing rapidly, with all papers identified to meet the inclusion criteria for this review being published more recently than 2016. Whilst no paper has been able to show a survival benefit for NMP, the lack of well-designed, sufficiently powered papers with follow-up beyond 12 months means it is not possible to draw robust conclusions to this endpoint. Despite this, there is some evidence to suggest that NMP leads to lower risk of EAD and biliary complications compared to SCS, and there is high-quality evidence to suggest that NMP can facilitate the increased utilisation of ECD and orphan grafts. Overall, it is evident that NMP has the potential to revolutionise liver transplantation, however, further high-quality papers, possibly with a focus on long-term NMP protocols, are required to demonstrate its superiority to SCS.


Non-medical prescribing (NMP) is a key feature of the UK healthcare system that refers to the legal prescribing rights granted to nurses, pharmacists and other non-medical healthcare professionals who have completed an approved training programme. NMP is deemed to facilitate better patient care and timely access to medicine. The aim of this scoping review is to identify, synthesise and report the evidence on the costs, consequences and value for money of NMP provided by non-medical healthcare professionals.Scoping reviewMEDLINE, Cochrane Library, Scopus, PubMed, ISI Web of Science and Google Scholar were systematically searched from 1999 to 2021.Peer-reviewed and grey literature written in English were included. The research was limited to original studies evaluating economic values only or both consequences and costs of NMP.The identified studies were screened independently by two reviewers for final inclusion. The results were reported in tabular form and descriptively.A total of 420 records were identified. Of these, nine studies evaluating and comparing NMP with patient group discussions, general practitioner-led usual care or services provided by non-prescribing colleagues were included. All studies evaluated the costs and economic values of prescribing services by non-medical prescribers, and eight assessed patient, health or clinical outcomes. Three studies showed pharmacist prescribing was superior in all outcomes and cost saving at a large scale. Others reported similar results in most health and patient outcomes across other non-medical prescribers and control groups. NMP was deemed resource intensive for both providers and other groups of non-medical prescribers .The review demonstrated the need for quality evidence from more rigorous methodological studies examining all relevant costs and consequences to show value for money in NMP and inform the commissioning of NMP for different groups of healthcare professionals. This scoping review addresses an under-researched area to provide evidence on resource use and consequences  of non-medical prescribing (NMP) from a large body of peer-reviewed and grey literature.The review was limited to original studies that evaluated the economic impacts only or both costs and consequences of NMP.Drawing conclusions on the cost-effectiveness and value for money in NMP remains difficult as the existing literature is heterogeneous with significant variation in participants, NMP types, comparators, study designs, costs and consequences evaluated.Doctors have traditionally been authorised as the main group of healthcare professionals to prescribe medicines.7–9Non-medical prescribing (NMP) is a key feature of the UK healthcare system that refers to the legal prescribing rights granted to nurses, pharmacists and other healthcare non-medical professionals who have completed an approved programme of education,et al on the effectiveness and cost-effectiveness of NMP from three randomised controlled trials (RCTs),Reviews of NMP developments and its benefits in the UK and other countries have been reported by others.10.17605/OSF.IO/PSR3N, accessible from https://osf.io/psr3n). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) reporting guideline recommended by Tricco et al to report our scoping review study.et al and the Joanna Briggs Institute to ensure rigour in reporting the review and its methodology.The scoping review protocol was registered with the Open Science Framework Registry on 31 July 2021  have been implemented and evaluated across eligible groups of healthcare professions  in different studies?What measures and tools have been used to evaluate the economic values, safety, effectiveness and other consequences of prescribing by non-medical prescribers in various settings?What are relevant costs, resource use and consequences  associated with services provided by non-medical prescribers in both peer-reviewed and grey literature?et al and Carey et al, these medicine management activities include ‘making recommendations for patients to buy medicine(s) over the counter; amending prescribed medication; medication review; written recommendation to general practitioner (GP); recommending in patients’ hospital notes; prescribing via hospital medication charts; patient group directions; remote prescribing via telephone, email and fax; issuing hospital-specific prescription; signing issued prescription via GP repeat prescribing system; issuing private prescription directly to the patient’.20 27The scope and practice of NMPs vary globally.A comprehensive search strategy was developed by the research team to enable a stepwise search process. Based on initial exploratory research, we included grey literature and journal and conference articles with full-text written in English from 1999 to 2021.The detailed search terms and strategies for different databases are presented in tables A.1 to A.5 in 10.1136/bmjopen-2022-067907.supp1Supplementary dataThe scoping review included original research, RCT studies and grey literature analyses of resource use only or both consequences and costs to evaluate NMP provided by non-medical healthcare professionals. Commentaries, letters, protocols and editorials were excluded. A broad search strategy was implemented to ensure that the inclusion of studies was as comprehensive as possible. Search terms were derived from titles, abstracts and keywords identified in key publications and from search terms used in previous reviews related to NMP.All articles identified from the searches were transferred to the EndNote reference manager software V.20.2, and all duplicates and titles in languages other than English were removed. The PICOS  framework was used to establish eligibility criteria.et al and Carey et al.20 27The review process included an initial screening of the title and abstract of the studies by three authors  to assess their eligibility for full-text retrieval. Any studies that were not excluded confidently through title and abstract screening during the initial screening step were included for full-text screening. The full-text screening of the selected studies was divided between authors and carried out independently by two reviewers . Any disagreement on selected papers was resolved through discussion among the authors. After identifying and removing duplicates, studies were excluded if (1) they were not original studies, (2) no abstract or full-text was available, (3) they were not in English, or (4) the focus of the study was outside the scope of our review see , or (5) Data from the articles and grey literature based on the inclusion criteria mentioned above were extracted using a bespoke data extraction form. A Microsoft Excel 2019 based form was initially developed by the first author and validated by other authors for charting the data from selected studies and reporting the variables regarding the study, participants, interventions and outcome characteristics—for example, authors, publication year, study context and design, sample size, type of prescribing, cost and consequence outcomes measures and key findings—based on our research questions  using the outcomes from an earlier trial with an assessment of uncertainty .40 41The resource use and costs evaluated in the included studies fall into the following three main categories:Four out of nine articles applied direct costs associated with prescribing training and NMP courses ,7 41Expenses applied in this category by some studies included tests and other relevant services, referrals to other healthcare professionals, frequency of follow-up, time spent preparing for a prescribing consultation, time taken to prescribe, review or complete the medication plan for a patient, and the number of patients prescribed for, consultation frequency, time spent discussing the patient and obtaining prescriptions or clinical advice sought from GPs or other NMP practitioners, unplanned consultations for the health condition after the index consultation and frequency of new medications.7 41Some studies also considered the expenses associated with service utilisation, for example, hospital admissions, outpatient expenses, inpatient days and A&E visits,37–39Health-related quality of life was one of the main health outcomes evaluated using EQ-5D  or SF-6D (Short Form Six Dimensions) questionnaires,39A summary of the key cost and consequence findings is provided for pharmacists, nurses and other non-medical prescribers in turn .39The NMP practices by pharmacists were evaluated across a range of health conditions , and significant improvements in health and clinical outcomes were reported at the end of the observation in three studies.et al, two other studies—that is, Al Hamarneh et al and Hale et al—reported that pharmacist prescribing was cost-effective and cost saving for patients with CVD and venous thromboembolism, respectively.et al found that, relative to the usual-care arm, pharmacist prescribing for chronic pain was more costly (£77.5 for prescribing and £54.4 for review arms) and provided similar QALYs. Neilson et al recruited a total sample of 125 patients in this RCT, but the authors recommended a larger sample size (between 460 and 690 for a threshold of £30 000 QALY gained or 540–780 for a threshold of £20 000 QALY gained) according to an expected value of sample information analysis .40Consistent with Marra et al indicated that patients in the mental health nurse prescriber group had a significantly higher level of satisfaction with nurse prescribers than those in the medical prescriber group.et al reported that the average patient satisfaction for some specified aspects of care was significantly higher among diabetic patients in the nurse prescriber group than among those of the non-prescribing nurses.et al and Black et al. Other specific or generic health and social outcomes were found to be similar among nurse prescribers and the control groups in these three studies.7 34 41Norman et al, the training-related costs included the course fee (paid fully by employers or training grants—ranging from £900 to £3555 in 2016), an average of 20.1 of employer-paid study days for 92% of nurse prescribers (ranging from 1 to 31 funded by employer), and an average of 7.4 supervised days  for each nurse—ranging from £1283 to £11 138) during training.et al.et al reported longer consultations for patients with diabetes managed by nurse prescribers suggesting it was more costly relative to GPs and non-prescribing nurses.7 34 41NMP was deemed resource-intensive for both providers and nurse prescribers. According to Black et al showed the level of satisfaction with consultation and services was significantly higher in both non-medical prescriber groups. Patients of physiotherapist or podiatrist independent prescribers were more likely to receive medicine information or advice during consultations (39.7%) compared with patients managed by non-prescribers (24.5%). No significant differences were reported in the quality of life in patients for all groups.20Only one study evaluated the benefits and costs of services by physiotherapist and podiatrist independent prescribers compared with non-prescribing physiotherapists and podiatrists.Building on a previous systematic review37–39 Others reported similar results in most health, clinical and patient outcomes across other non-medical prescribers and control groups . NMP was deemed resource intensive for both providers and other groups of non-medical prescribers .Our scoping review identified nine sources of evidence that evaluated the economic impacts, resource use and consequences of NMP. Three studies showed pharmacist prescribing was superior in all outcomes and cost saving at a large scale.This scoping review revealed evidence sources were heterogeneous with regard to design, setting, range of cost and consequence outcomes, NMP types and comparators. In general, the existing evidence indicates that services provided by non-medical prescribers might positively influence patients’ satisfaction with care, medication and their quality of life.The costs and consequences evidence on NMP has slowly grown since 2010 and appears to be concentrated in three countries, the UK, Canada and Australia, where prescribing rights are more developed. Despite the large increase in NMP in the UK and around the world and the increasing number of studies on NMP, there is still very limited information on the effectiveness, costs and cost-effectiveness of NMP by different professions. Many papers evaluated NMP delivered by nurses and pharmacists using various sources of costs, health, clinical and patient outcomes with varied comparators for a range of health conditions, which limits their generalisability and usefulness for other settings and professions. Only three studies conducted a cost-effectiveness analysis to evaluate and demonstrate value for money in pharmacist prescribing.44The number of studies, particularly economic evaluation studies, assessing the economic burden and effectiveness of NMP has been increasing, but there is still a dearth of evidence on the cost-effectiveness and value for money in NMP authorities by recently awarded non-medical prescribers such as radiographers and dietitians. As most cost-effectiveness evidence relates to pharmacists, it is important to evaluate the impact, safety, resource use and economic value of prescribing by non-medical prescribers in other professions to inform policy and practice around NMP where it provides value for money. It is also important to acknowledge and further explore the challenges related to capturing these data, as NMP has been introduced as an additional role for healthcare professions, and hence it is not easy to separate and capture some of the added costs and values in terms of these additional prescriptive authorities.20 25There seem to be research-quality gaps in the literature. Although we did not assess the quality of included studies, some of the studies have performed non-model-based analysis using small samples that might affect the analysis, and in some cases, the main outcomes and sources of costs  were not included in the analysis. Despite the importance of rigour in quantitative research, sample size reporting and sufficiency assessment remained inconsistent and partial in these studies.A rigorous search was conducted, allowing for a diverse set of literature (from both peer-reviewed and grey) to be identified in a robust and reproducible manner. To our knowledge, this is the first scoping review covering and representing the largest and most up-to-date evidence on the costs and consequences of prescribing practices by nurses, pharmacists and other non-medical prescribers. This scoping review contributes to the discussion of the costs and consequences of NMP and the existing research gaps regarding value for money in NMP for different groups of healthcare professionals. Original studies that did not report resource use and costs associated with NMP were not included in our review. While this strategy contributed to a more focused search, studies that reported only the effectiveness and benefits of NMP practices without evaluating costs are missing. Comparison of studies was challenged by heterogeneity regarding the profession, type of NMP, costs and consequences evaluated.NMP practice is now an integrated feature of healthcare delivery in the UK and around the world, but considerable uncertainty remains regarding the costs, consequences and cost-effectiveness of the prescribing rights granted to non-medical prescribers, including therapeutic radiographers and dietitians. In order to determine accurate mean values and detect cost and benefit differences across non-medical prescribers and control groups, it is important that future studies involve larger and more representative samples with greater power. Adopting a model-based approach within each profession using targeted outcome measures would also enable a more robust comparison and improve understanding of how to best use NMP and healthcare professionals’ skills and ensure it offers a cost-effective solution to providing faster and improved access to medicine and healthcare services for patients by the most appropriate healthcare professionals.


The COVID-19 pandemic altered how residency interviews occur. Despite 2 years of web-based interviews, these are still perceived as inferior to in-person experiences. Showcasing a program and location is critical for recruitment; however, it is difficult to highlight the program’s location and community digitally. This article presents the authors’ viewpoints on designing and implementing a virtual second look for residency applicants.Our objective was to host a web-based event to feature the benefits of living in Winston-Salem, North Carolina, for residency applicants, enhance recruitment efforts, and ensure a successful residency match. The goal was to cover topics that interested all applicants, highlight how Winston-Salem is a special place to live, involve current residents, and engage community members.Three programs–child neurology, neurology, and family medicine were chosen for a pilot virtual second look. All residency program directors’ were asked to recommend community contacts and help identify residents and faculty who may serve as content experts on one of the topics in the panel discussions. A total of 24 community leaders from restaurants, venues, schools, and businesses were contacted, and 18 agreed to participate. The panel discussions included living in and raising a family in Winston-Salem, experiencing Winston-Salem arts and music, where to eat and drink like a local, and enjoying sports and outdoors in the area. The 2-hour event was hosted on Zoom. Postevent feedback assessments were automatically sent to each registrant through Research Electronic Data Capture (REDCap). This study was deemed exempt from Wake Forest University Health Sciences institutional review board review (IRB00088703).There were 51 registrants for the event, and 28 of 48 registrants provided postevent feedback, which was positive. The authors found in the MATCH residency results that 2 of 2 child neurology positions, 4 of 6 adult neurology positions, and 1 of 10 family medicine positions attended our second look event. One adult neurology resident who did not participate was an internal candidate. All respondents agreed or strongly agreed that the session was valuable, well organized, and met their expectations or goals. Furthermore, all respondents gained new information during this web-based event not obtained during their interview day.The virtual second look event for residency attendees featured the benefits of living in Winston-Salem, and the perspectives of current residents. Feedback from the session was overall positive; however, a top desire would be devoting more time for the applicants to ask questions directly to the community leaders and our resident trainees. This program could be reproducible by other institutions. It could be broadened to a graduate medical education–wide virtual second look event where all medical and surgical programs could opt to participate, facilitating an equitable opportunity for prospective applicants. In March 2020, the COVID-19 pandemic disrupted typical medical education operations. Only 6 days after declaring a global pandemic, the Association of American Medical Colleges (AAMC) recommended ceasing all medical student clinical rotations .Social media swiftly became an essential focus in digital recruitment, with a significant rise in residency program social media accounts during the pandemic -6. ProgrSocial interactions, work-life balance, and location culture are priorities for applicants . ApplicaWake Forest University School of Medicine (WFUSOM), headquartered in Winston-Salem, North Carolina. Since the founding of the medical school in 1902 and the medical center in 1923, Wake Forest has grown into a nationally recognized academic medical center and health care system. The catchment area is a 24-county region, including western North Carolina and Southwest Virginia, extending to Tennessee and West Virginia. The hospital is the largest tertiary care center for the Piedmont region of the Southeast. However, Winston-Salem is a midsize city with an estimated population size of 250,000 .The AAMC recently recommended a third season of web-based recruitment . HoweverThe Graduate Medical Education (GME) Committee at WFUSOM recognized that there was a need to feature the benefits of living in Winston-Salem to applicants. Therefore, the GME invited one program’s leadership (authors LDS and JMM) to plan a web-based pilot event with 3 residency programs. Our aim was to host a successful web-based event to feature the benefits of living in Winston-Salem for residency applicants, enhance recruitment efforts, and ensure a successful residency match. Each program has hundreds of applicants, so the event would need to be scalable to a larger potential audience in the future if the initial session was a success. The web-based offering would cover topics that interest applicants, highlight how Winston-Salem is a special place to live, involve current residents from various programs, and engage community members.LS, an executive member of the GME and program director of the child neurology residency, presented to the GME in the August of 2021 to propose objectives, dates, and timelines. All residency programs were invited, and the first 3 programs that responded were included in the pilot- child neurology, neurology, and family medicine. A planning committee was formed, including authors JMM, NC, and LDS and GME specialist Mikell White. Four themes were identified from collective feedback following a presentation at a GME meeting with program directors and from discussions with adult neurology and child neurology residents (1) living in and raising a family in Winston-Salem, (2) experiencing Winston-Salem arts and music, (3) where to eat and drink like a local, and (4) enjoying sports and outdoors.A planning committee was formed with GME and program leaders. As a result, a date was chosen on a Friday in February 2022 to not conflict with interview dates and to reflect a typical working day for community members. Additionally, this date was chosen to allow programs to have submitted their rank list yet allow applicants to have time to adjust their decisions. Logistically, this also allowed enough time to finalize an agenda and attendees from the community.Program directors from all residency programs were asked to recommend contacts for the community and help identify residents and faculty who may serve as content experts on one of the topics in the panel discussions. The event was free. None of the participants or community partners were compensated for their time.Authors LDS and JMM partnered with a local tourism company to identify a speaker to introduce the Winston-Salem tourism industry and develop contacts for the community leaders and organizations. A final agenda, including panelists, was reviewed for content with our GME executive team. The GME had already held a successful web-based Diversity and Inclusion event led (led by authors AKB and NDT) for invited underrepresented minorities, so careful consideration was made not to overlap in content . Our AccA total of 24 community leaders from restaurants, venues, schools, and businesses were contacted, and 18 agreed to participate as panelists. Individual meetings were arranged with each community leader to share the prospective resident interests and help narrow the focus of their discussion during the panel session. This connection helped answer questions about the target audience and why we recruit them. The authors also used this time to propose questions and learn about opportunities in the community for residents. Consent was received from all community leaders to include their organization’s brand in our advertisements and communications with invited applicants. This process took several weeks and occurred between November 2021 through January 2022. The authors added faculty moderators (n=4) from the school of medicine and resident panelists (n=4) from neurosurgery, neurology, child neurology, and family medicine residency programs.A web-based brochure included photos, bios, social media contacts, and website resources. This brochure was an aid for the moderators to learn more about panelists and a guide shared with all applicant attendees to learn more about the community. The brochure was reviewed with all participants before being shared with applicants.The session  was desiWelcome presentation (30 minutes)Introduction: Child Neurology Program DirectorWelcome: Wake Forest University School of Medicine’s Graduate Medical Education Designated Institutional OfficialHistory of Winston-Salem: Local Visitor Center Director of Marketing and CommunicationsSchedule introduction: Child Neurology Associate Program DirectorPanel 1: Living in and raising a family in Winston-Salem (30 minutes)Panelists: family medicine resident, child neurology resident, resident spousal association leader, local gymnasium president, local sports chief executive officer, city’s recreational special events coordinatorModerator: Adult Neurology Program DirectorPanel 2: Experiencing Winston-Salem arts and music (20 minutes)Panelists: conductor of the local medical orchestra and current medical student, local boarding school teacher, local music venue owner and cofounder, University of North Carolina School of the Art director of media relations and communications, local arts council directorModerator: Adult stroke neurologistPanel 3: Where to eat and drink like a local (20 minutes)Panelists: neurosurgery resident, local restauranteur, local restaurant and bar assistant general manager, local vineyard co-owner, local brewery managerModerator: Child Neurology Program DirectorPanel 4: Enjoying sports and outdoors (20 minutes)Panelists: Family medicine resident, University sports executive associate athletic director, Winston-Salem Open Tournament director, area minor league baseball president and general manager, city parks and recreation special projects coordinator, local district director for community relationsModerator: Child Neurology Associate Program DirectorWrap-up: All moderators (5 minutes)To minimize bias of attendance on the rank list, the adult and child neurology program submitted their finalized rank list before the web-based event. The family medicine program director was not present at the event nor given a list of attendees. Applicants present were not required to turn on their cameras or show their names, although many applicants opted to do so.A welcome room allowed necessary audio or visual testing to minimize disruption. All moderators and panelists had their cameras turned on with listed names and organizations.Finalizing the panelists and general agenda was necessary before advertising to applicants, which led to a shorter advertisement period. The event was advertised on social media and through an Electronic Residency Application Service (ERAS) communication. On February 09, 2022, an ERAS communication was sent by the program directors of the included programs inviting all interviewed applicants to register. ERAS invites were sent to 50 child neurology, 100 adult neurology, and 167 family medicine applicants. On the same day, a promotional PowToon video created by JMM was posted on the Wake Forest Neurology Residency Twitter account @WakeNeuroRes . This isApplicants were emailed a Zoom link for the event upon successful registration through Research Electronic Data Capture (REDCap), which included demographics, which residency program they were applying to, the applicant’s goals for the event, and how the applicant heard about it . RegistrPostevent feedback assessments were automatically sent through REDCap to each of the registrants. The initial feedback request was sent immediately after the web-based event. Automatic weekly reminders to complete the feedback were sent through REDCap for 1 month following the event. Feedback assessments  evaluateThis study was deemed exempt from Wake Forest University Health Sciences institutional review board review (IRB00088703).During event registration, participants were asked “Do you consent to us using your deidentified data for future event planning and research purposes? This will not affect your ability to register or participate in the event.” Registrants could opt-in to have their deidentified data included in the data analysis. Written consent was not obtained. Study results were published in lieu of providing individual subjects with additional information regarding the study. Participants were not compensated.Confidentiality was protected by collecting only information needed to assess study outcomes, minimizing to the fullest extent possible the collection of any information that could directly identify subjects, and maintaining all study information in a secure manner.Between initial advertising and the event date , there were 51 registrants for the event. Forty-eight consented to have deidentified data included for future event planning and research purposes . Most reRegistrants indicated their goals for attending the virtual second look event during registration. Most attendees wanted to learn more about living in the community  and learn from current residents about their experience . However, learning about the culture of Winston-Salem  and restaurants, bars, and wineries  were other top priorities for attending the event. Learning about raising a family in the Winston-Salem community was rated the lowest, with only 21% (10/48) of registrants identifying it as a goal for attending the event.We received a postevent feedback response rate of 58% (28/48) of registrants. Overall, the feedback was overwhelmingly positive. All respondents  agreed or strongly agreed that the session was valuable, well organized, and met expectations or goals. Additionally, all respondents  agreed or strongly agreed that new information was gained during the event about restaurants, bars, arts, music, and the welcome session that was not provided during the interview days. While it still felt valuable, there were more mixed responses to the arts and music panel and the living and raising a family in the area panel . On a scRespondents also provided their top 3 highlights and suggestions for future event improvements. JMM developed a codebook of relevant concepts and emerging themes. Two team members coded all comments (JMM and RAC), and coding discrepancies were discussed and resolved. We analyzed the comments using deductive thematic content analysis practices to identify themes and subthemes .The top 3 themes for event highlights included hearing about entertainment or things to do, the living and culture of Winston-Salem, and personal experiences . RespondThe event feedback was overwhelmingly positive. The top theme for feedback was allowing more time for questions. While respondents did have the option to use the chat function for questions, this was not used. Additional improvement themes included increased interaction or breakout sessions, hearing more from residents, and more visuals of the hospital or area .The authors recognize that the second look event likely attracted a group of applicants more interested in the participating programs. We found in the MATCH residency results that 2 of 2 child neurology positions, 4 of 6 adult neurology positions, and 1 of 10 family medicine positions attended our second look event. One adult neurology resident who did not participate was an internal candidate.The recent transition to web-based interviewing has increased interest in developing and expanding web-based content for applicants in various interactive and passive formats. Through this interactive pilot program, we learned that there was high interest from many residency programs to have a GME-led effort on commonly shared needs. Enthusiasm was high for this program even in the first year, making limiting it to only 3 programs in our pilot challenging. Although the content was generalizable to all residency programs, there must be careful consideration of possible challenges in scaling up the number of programs included. A higher volume of attendees could add unanticipated difficulties. In addition, several matches, including the medicine specialty match and fellowship matches, occur throughout the year, so expansion of programming would need to be mindful of timing.We heard from program directors, residents, and applicants that this was a unique opportunity to add resident and faculty voices that may not be present on an individual program’s web-based interview day. The authors note smaller programs can leverage partnerships with more extensive residency programs. A positive effective resident communicator could help recruit for other residency programs.Previous in-person and most web-based interview days do not typically include interactive participation from the GME. Our model allowed the GME to share resources directly with applicants. The GME leader spoke about our training institutions’ health, growth, and variety.Community partners also found the experience to be mutually beneficial. This was seen as a way to help advertise and showcase their opportunities directly to the end user. Most community partners connected us with the owner, the lead of marketing or communication, or the head of programming. Some applicants may choose our health system for residency. However, community leaders saw this as a way to promote our city for future travel or encourage residents to consider our health system again for future fellowship or faculty positions.Additionally, our faculty reported that it was engaging to see the community partners share their experiences as experts in that content area and cater to a broader audience of varied interests. Program leadership or interviewing faculty may need to learn the answers to some applicant questions because of their interests or community experiences. Of note, although we invited several daycares and preschools, unfortunately, we could not have representation due to the time chosen.We used REDCap for our invitation and sharing of content, including our web-based brochure and event surveys. REDCap had additional benefits as it allowed registering attendees to sign up without involving our GME staff as it was automated. It also created a list of all those registered that allowed us to follow up on Match and the possible effects of the second look on recruitment. Careful consideration must be given to confidentiality and minimizing the risk of bias on rank list decisions. Options could include finalized rank list submissions for participation in the virtual second look event or blinding the programs from participants.We had several residents and programs ask to share the content following the event so it could continue in the future as a passive format option to expand our reach. Unfortunately, we did not plan on recording the event and could only make the welcome presentation available. A recording of the event may prove valuable in faculty or resident onboarding.The majority of the feedback for the sessions was positive. However, some feedback included that the sessions on raising a family and sports and outdoors could have been more valuable. Raising a family was a lower priority for many individuals attending the session initially, likely reflective of different stages of their lives. No specific narrative comments were provided on either of these sessions in the feedback for suggested improvements. The art and music session was also not rated as valuable as the other sessions. In the future, we could modify the types of community members and organizations invited to the sessions to engage and entertain a diverse audience of all ages and stages of life.The advantages of this event are that it is cost and time efficient for applicants and allows applicants not to take time off from their clinical rotations at their home institution. In addition, having a virtual second look decreases barriers among prospective applicants by giving everyone an equitable opportunity to learn about WFUSOM and the Winston-Salem community.There were several limitations to this study and event. This is the experience and viewpoints of the authors at an academic center in a moderate city. This may not be generalizable or meet the needs of all institutions. One limitation is the applicant’s ability to access reliable internet and the appropriate technology to attend the event. It also requires time off from clinical duties for the duration of the event. Despite being a high-yield overview of Winston-Salem, it may not highlight the desired aspects for all applicants. Additionally, although virtual second looks facilitate equity, some applicants may prefer to travel to the area to learn more about Winston-Salem.Regarding the feedback, selection bias may be a limitation. Most of the feedback was positive, and those who enjoyed the event were often more likely to provide feedback. Although narrative comments were requested, there could be more purposeful questioning as to why specific sessions were rated higher or lower. Feedback on the event was requested during a period when programs were submitting their rank lists. While both the adult and child neurology programs had submitted their rank list and the attendee list was not shared with the family medicine program directors, being more transparent with this process may reduce concerns about attendance influencing programs’ rank list. Alternatively, the feedback survey could be sent after the ranking was closed balancing timing to the event to risk the loss of survey participation.Additionally, those more interested in WFUSOM may have been more likely to attend the virtual second look in the first place. As the child and adult neurology program leadership were involved in creating the event, they could promote the event during their interview season and advertise it on social media. This may have influenced more attendees from these 2 programs over family medicine for the first year. Furthermore, as we waited for a finalized agenda before promoting the event, the advertising period needed longer. This affected the number of applicants and programs we were involved in during our first year of the virtual second look event. Longer and more strategic advertising would increase the reach of recruitment of applicants to attend the virtual second look. Additionally, broadening to a GME-wide virtual second look event where all medical and surgical programs could opt to participate would facilitate an equitable opportunity for prospective applicants.The virtual second look event was valuable for child neurology, neurology, and family medicine attendees. It featured the benefits of living in Winston-Salem and the perspectives of current residents. It filled a gap faced in the web-based environment of how to showcase a city and institution. The program has the potential to be expanded to more residency programs at the WFUSOM with the advantages of decreasing barriers among applicants, including the cost of travel and time away from clinical rotations at home institutions.Feedback from the session was overall positive; however, a top desire would be devoting more time for the applicants to ask questions directly to the community leaders and our resident trainees. In our first year, we had most of the questions scripted; however, with continued partnership with our community leaders, preparing for open questions in future years would be easier. In addition, time could be set aside for applicants to ask questions directly to the panelists, making the session more interactive for applicants, community leaders, and resident trainees. Future sessions could be recorded so applicants unable to attend could still receive the information and benefits of the session.Future evaluations of the second look event could assess whether registrants are attending because they are precontemplative, contemplative, and already familiar with the area. Additional areas of interest would include how such an event influences their rank-list decision-making, their decision to attend in-person second look events, and granular feedback about the event itself. Furthermore, comparing the demographics of web-based event attendees to program interviewees, applicants, or the GME demographics as a whole to evaluate the effect of the program on these factors over time would be valuable.There could be other ways to advertise to increase registration. We learned from our recruitment data that most applicants discovered the event through regular ERAS communication from the programs. Suppose the date is selected far in advance. In that case, it could be shared with applicants during the interview season through web-based interview day discussions, the residency program website, and the GME website. The session could also be scheduled earlier in interview season so applicants could learn more about the Winston-Salem community before ranking their residency choices and help highlight the benefits of our residency program. However, this would need to be carefully balanced bias towards or against applicants while rank lists were open. Last, this program could be expanded to more specialties at the WFUSOM, aiding residency recruitment.


Science communication plays a crucial role in tackling pressing regional, national, and global health issues. Effective communication with various audiences is integral to dissemination of science findings.This study evaluates changes in self-efficacy and attitudes toward science communication skills over time and also assesses program outcomes and satisfaction with a Faculty Fellows in Science Communication (FFSC) program among faculty (N = 30) with interest in environmental health science and/or education in Appalachia Kentucky.A mixed methods program evaluation was employed using longitudinal data on behaviors, attitudes, and program outcomes from three cohorts of Faculty Fellows who participated in the year-long UK-CARES Faculty Fellows in Science Communication (FFSC) program from 2018 to 2021. Repeated Measures Analysis of Variance was used to evaluate changes over time in self-efficacy and attitude scores.F = 7.6, p = 0.002), outside department , and lay audiences  and evaluations of the program were positive. Qualitative feedback from participants offered insights into how program participation helped them communicate with different audiences, incorporate narratives or stories to engage audiences, and develop innovative methods of communicating with lay audiences.A total of 30 Fellows enrolled in the program. Participation in the FFSC program significantly increased self-efficacy in communicating with peers in one’s own department (The FFSC program provides a useful framework for other institutions and supports faculty as they build the communication skills necessary to effectively translate science with various audiences. The climate crisis and COVID-19 pandemic are examples of timely global health issues that require the public to understand scientific concepts— in these cases, viral transmission, vaccine effectiveness, and the factors that contribute to natural disasters, among others. In the U.S., Appalachia Kentucky is one of the most socioeconomically disadvantaged and underserved regions,A good understanding of scientific concepts often involves having basic knowledge of life science, physical science, and earth science, with skills in numeracy and even graphing.The University of Kentucky Center for Appalachian Research in Environmental Sciences (UK-CARES), a National Institute of Environmental Health Sciences (NIEHS) Environmental Health Sciences Core Center, launched a Faculty Fellows in Science Communication (FFSC) program in 2018 to build capacity among faculty from colleges and universities, technical schools, and high schools in the Central Appalachian region of Kentucky to translate and disseminate environmental health science to various audiences. The goal of this intensive training in science communication is to prepare early-stage academic and community faculty to practice effective science communication skills, develop a repertoire of these methods, and build confidence in their ability to effectively communicate scientific concepts and information to those outside their field and to the lay public. The goal is to enable enhanced capability for outreach and success in research, teaching, and service.The FFSC program consists of a series of seven workshops offered over one year (see The purposes of this paper are (1) to describe the FFSC program and evaluate changes in perceived self-efficacy and attitudes toward science communication skills over time; and (2) to assess program outcomes and participant satisfaction with the program. Self-efficacy and attitude scores were hypothesized to increase over time as Fellows gained additional skills and practice in science communication.This mixed methods program evaluation was a longitudinal analysis of behaviors, attitudes, and program outcomes from three cohorts of Faculty Fellows who participated in the year-long UK-CARES FFSC program from 2018 to 2021.Beginning in 2018, UK-CARES sent an annual request for FFSC program nominations to administrators and faculty at a state land-grant university, as well as to surrounding regional colleges, universities, vocational/trade schools, and high schools in southeastern Kentucky. Faculty with interest in environmental health science and/or education in Appalachia were eligible to apply. Interested applicants were encouraged to self-nominate or ask a mentor or administrator to put forth their nomination. Faculty applied by submitting a curriculum vitae and a brief  video to describe their interest in becoming a Faculty Fellow in Science Communication. The UK-CARES Center Director, Community Engagement Coordinator, and Science Communication Consultant reviewed the applications. Final selection into the program was based on the applicant video, CV, and overall strength of the application. In total across the three cohorts (2018–2020), 30 Fellows self-nominated and were invited to participate in the year-long program; 25 completed the program (83% completion rate).Participants were invited to complete a preprogram, midpoint, and end-of-program survey to assess their perceived selfefficacy and attitudes toward communicating with members of their own discipline or department, individuals outside their discipline, and lay audiences. For each audience, participants were asked to rate their level of agreement (strongly disagree [1] to strongly agree [4]) with three self-efficacy items: ability to communicate effectively, time to communicate, and ease of communication. The self-efficacy scale scores range from 8 to 32, with higher scores reflecting greater self-efficacy. For each audience, participants also rated their level of agreement using the same scale, with five (5) attitudes items: whether they like presenting, are comfortable presenting, tense and nervous, or calm and relaxed, and whether they can communicate clearly in writing. The attitudes scale scores range from 5 to 20, with higher scores indicating more positive attitudes toward their ability to communicate science with different audiences.The pre-program, midpoint and end-of-program surveys asked participants to share their formal training in science communication . The midpoint and end-of-program surveys assessed their research or educational activities since starting the program . An open-ended question asked if they had learned anything from the program that had changed the way they do their job. In addition to the quantitative survey questions, participants were invited to complete five open-ended questions via email: (1) what motivated them to apply; (2) most valuable aspect of the program; (3) how they applied what they learned to research and/or teaching; (4) how the program enhanced their career; and (5) tips for future Fellows.After each session, participants were invited to complete a brief online survey to assess what they learned and any suggestions for improvement. Attendees were also asked to evaluate each session on a satisfaction scale of 0  to 10 (very satisfied). Each session evaluation included five statements about different aspects of the session content and delivery. Respondents were asked to rate their level of agreement with each statement on a 1 (strongly disagree) to 4 (strongly agree) scale. The midpoint and end-of-program surveys also assessed reasons for not attending sessions, from scheduling conflicts to location of the meeting, too busy, or not interested.A day or two prior to individual coaching sessions, participants were asked to provide the coach with information on whether they had a communication success or concern to share, their most pressing need, and what solutions they considered. The midpoint and end-of-program survey evaluated satisfaction with coaching sessions on a five-point scale (strongly disagree to strongly agree) including whether it was a good use of their time, helpful, if they learned something new, and whether they would participate in more sessions.Descriptive statistics, including means and standard deviations or frequency distributions, as appropriate, were used to summarize study variables. Open-ended responses were reviewed for themes. Comparisons between Fellows’ characteristics who completed and did not complete the program were evaluated using the two-sample t-test, Fisher’s Exact test, or Mann-Whitney U test, as appropriate. Changes over time in self-efficacy and attitude scores were evaluated using Repeated Measures Analysis of Variance. All data analysis was conducted using SAS, version 9.4, with an alpha of 0.05 throughout.SD = 9.2; see A total of 30 Fellows enrolled in the program; however, baseline data were available for 29 Fellows. The average age was 42.9 years , outside department , and lay audience  to both the midpoint  and endpoint  follow-up assessments. For outside department communication self-efficacy, endpoint scores  were significantly higher than both baseline  and midpoint  assessments. Self-efficacy for communicating with lay audience peers increased from baseline  to endpoint . Attitude scores reflecting positive attitudes toward one’s ability to communicate science with different audiences did not significantly increase over time. Based on a potential range of 5–20, attitudes scores were relatively high at baseline, ranging from M = 15.09 (SD = 0.2) to M = 15.8 (SD = 0.2) on the endpoint survey.In the repeated measures models for self-efficacy, there was a significant change over time in perceived self-efficacy in communicating with peers in one’s own department “Before this fellowship program, I knew that science communication was important; however, I didn’t know how to tangibly work on improving this skill for my career. This program has given me concrete strategies that I have already started applying.” Participants also reported the program helped them “learn how to relay science to different communities, including funding agencies,” and believed the training was, in part, the reason they were awarded an R01 grant.When assessing program outcomes, participants reported the program had helped them consider their communication styles and examine ways to improve how they shared their research with others: “The need to connect research to a narrative or story—that people need an example to grab on to in order to stay engaged/pique their interest,” “I have learned the importance of personal narratives in science classes, and the value in anecdotal information used judiciously.” One Fellow shared their personal experience growing up in Appalachia and the constant uncertainty of having clean drinking water. In sharing their story and how this led to a career studying water quality, the Fellow forged a connection built on mutual experience, helping to build trust with the audience. Participants also learned that tailoring their message for various audience members is important so that the message is understood by everyone: “I tend to think more about the presentation of my work so that, even if I am giving a discussion to a technical audience, that I ... provide insight that a lay person ... can take away the message,” “This fellowship helped me develop a clearer sense of audience…the activities forced me to simplify and focus my ideas.” Furthermore, participants sought out innovative ways to communicate their science to lay audiences. For example, one participant began a citywide science festival in 2018, titled “Everything is Science,” where faculty share their research at community venues such as ice cream shops or local breweries. The science festival has recently held its 5th annual festival, demonstrating continued engagement with lay community members. Another Fellow shared their science as part of a university podcast available on major digital platforms. Finally, another Fellow received an academic award for developing a novel water testing technique and conducted an informal water testing training at a neighborhood association meeting, as residents were concerned about water quality following the upstream installation of a dog park.Participants learned how using stories to disseminate science can be an effective tool to engage audiences and help them understand the message: Several research and educational outcomes were commonly reported across the follow-up surveys: planned or submitted research proposal (82%), data collection (73%), presentation at a conference or meeting (68%), manuscript submitted for review (68%), manuscript published (64%), and media article or event (55%).Across all sessions, most respondents (96.2%) rated overall satisfaction between seven and ten, while 3.8% rated overall satisfaction between five and six. Overall, the evaluation statements were rated positively (98.7%). Most respondents agreed or strongly agreed that the content was useful, they planned to use what they learned in the future, and the session facilitator effectively communicated the material.n = 10 midpoint; n = 12 end-of-program) rated their satisfaction with the coaching session as high. Most agreed or strongly agreed that the session was a good use of their time ; and they received helpful guidance communicating their research  and learned something new (100% midpoint and 83% end-of-program). On the midpoint survey, the majority (80%) agreed or strongly agreed they wanted to participate in more coaching sessions, and more than half (58%) expressed interest in more coaching sessions on the end-of-program survey.Fellows who attended at least one individual coaching session  by (a) assessing changes in self-reported self-efficacy  and attitudes toward participants’ own science communication skills over time; and (b) measuring program outcomes and satisfaction. Results support the hypothesis that self-efficacy scores would increase over time but did not support the hypothesis that attitude scores toward science communication skills would rise over time see . The sigQualitative feedback from participants revealed a gap in science communication resources. The FFSC program offered an opportunity not otherwise available on the campus to build science communication skills. Further, the program provided participants with new specific strategies to improve science communication, such as stories or narratives to better connect with the audience and develop innovative methods for communicating with the public . Lastly, the program helped Fellows intentionally tailor their science communication to the specific audience. Many of the self-reported research or education outcomes were traditional pursuits expected by most academic faculty , but over half the participants reported contributing to a media article or community event at follow-up.Participants rated session evaluations positively overall. Fellows reported the sessions to be useful, and they planned to incorporate what they were taught into future science communication opportunities. Session feedback was reviewed by the team after each session to consider curriculum modifications for the next cohort. For example, session evaluations were used over time to add a session, alter the order of the sessions, and make changes to session components to allow for more participant interaction. For example, a “pitching” session allowed participants to create and receive feedback on short, persuasive statements focused on aspects of science in the public interest. As a result of the session, one participant reported enhanced ability to relay research effectively in both written and video formats, and they were awarded a prize for innovation after successfully pitching their research idea. Individual coaching sessions were found to be particularly helpful at improving communication skills for those who took advantage of the opportunity. This may be due to the nature of 1-on-1 coaching where the Fellow gives a presentation and the coach provides immediate feedback in a cyclical format, allowing the Fellow to practice communicating their science repeatedly while receiving feedback until they feel confident in their ability to clearly communicate their message. Findings reveal that individual coaching sessions were perceived as most useful at the beginning of the FFSC program and less helpful as participants gained confidence in their ability to communicate science.The UK-CARES FFSC program was successful in providing early career faculty with skills training for communicating science to a broader audience, including colleagues from different fields, lay audiences, and the media, leading to enhanced capability for outreach and success in research, teaching, and service. A strength of this study was the use of both quantitative and qualitative approaches to describe program outcomes.Despite its success, this study has limitations. This was a new program, with only three faculty cohorts over a three-year period, and the sample size for the program evaluation was limited. In addition, the use of self-report items to determine self-efficacy and attitudes toward science communication and satisfaction with the program may be impacted by recall or response bias. While participants were given feedback from the program facilitator and other Fellows throughout the program, future cohorts would benefit from receiving feedback from members of lay audiences on their communication skills, in particular from members of the Central Appalachian community. In doing so, Fellows will have a better idea of how the lay audience received their message and can make adjustments to their message accordingly. Furthermore, while Fellows were taught to consider their audience when crafting the message, the program did not explore potential communication challenges with Appalachian audiences.The need for effective research translation and science communication has never been more important as faculty strive to address pressing environmental health issues with global impacts. This is particularly true in underserved regions of the country, like Central Appalachia, which are rich in culture and pride, yet have historically seen residents in hardship as a result of exploitation of people and resources. Often, academic and community faculty are provided opportunities to disseminate scientific findings to colleagues through professional meetings, presentations, and publications. Although cultivating opportunities for communicating science to policymakers, the media, and other lay communities is greatly needed, these opportunities are rarely emphasized in the academic setting and are particularly absent for faculty in the early-career stage.What is already known about this topic?Effective science communication is essential in building trust and is critical for tackling environmental health issues and reaching sustainable solutions.What is added by this report?Intensive faculty training in science communication improved participant selfefficacy in communicating with various audiences.What are the implications for future research?Future research is needed to test the effectiveness of specific elements  of science communication training.