There is a lack of studies on metaverse-based career mentoring for college students in both quantitative and qualitative research. This study aimed to examine the effect of metaverse-based career mentoring among nursing students and explore the experiences of mentors and mentees.This study used a mixed methods design using both a survey for collecting quantitative data and focus group interviews for a qualitative one. A total of 8 mentors and 43 mentees participated in the metaverse-based career mentoring program. The program covered eight career fields and was delivered across eight sessions of 60 min each, over six days. Career decision-making self-efficacy among mentees and platform and program satisfaction were measured before and after the program. Afterwards, 7 mentors and 12 mentees participated in the focus group interviews to investigate their experience of participating in the metaverse-based career mentoring program. Quantitative data were analyzed using descriptive statistics, paired t-test, Wilcoxon signed-rank test, and Mann-Whitney U test. The qualitative data underwent thematic analysis.After the metaverse-based career mentoring program, mentees’ career decision-making self-efficacy increased significantly compared to the baseline level. From the mentor–mentee focus group interviews, three key themes were derived: (i) communicating frankly and openly, (ii) being satisfied with realistic communication and program functions, and (iii) expecting an even more optimized program.A metaverse-based career mentoring program for nursing students can have a positive effect on their career decision-making self-efficacy. In addition, in terms of education, it is helpful as a non-face-to-face medium and feeling a sense of reality, so it is expected that it will be beneficial in education by applying various contents in the future.The online version contains supplementary material available at 10.1186/s12912-023-01323-8. With the demand for nurses increasing due to recent changes in the healthcare environment, such as the outbreak of a novel infectious disease, a growing number of chronic diseases, the growing share of the older population, and advances in medical technology, the career path of nursing graduates is becoming increasingly diversified .Meanwhile, due to the COVID-19 pandemic, a considerable proportion of theoretical lectures and clinical training at healthcare facilities have been switched to non-face-to-face settings, with more departments placing restrictions on nursing students’ clinical training. Students no longer have sufficient opportunities to explore career paths by exchanging information about career and employment in meetings with peers or alumni . This laCareer exploration refers to exploration regarding the external environment based on an understanding of internal factors, such as personality, aptitude, interest, and value for the purpose of career development, including career decision and preparation, employment, and post-employment adjustment . InsuffiIn a previous study, career mentoring was found to be effective in nursing students’ career exploration activities . ThroughDuring the current prolonged COVID-19 pandemic, where we have seen a paradigm shift of education from traditional classroom learning to online learning, the need to change the modality of career mentoring to increase students’ activities has also been raised . Non-facPrevious studies have applied metaverse in materials science education as a problem-based learning medium , universAgainst this background, this study aimed to examine the effect of metaverse-based career mentoring among nursing students. To this end, two objectives were set:1) Using quantitative research methods through questionnaires, mentees’ self-efficacy in career decisions and the satisfaction of mentors and mentees after metaverse-based career mentoring are confirmed.2) A qualitative exploration of mentors and mentees’ experiences with metaverse-based career mentoring using focus group interviews.This study used a mixed methods design using both a survey for collecting quantitative data and focus group interviews for a qualitative one. This study was conducted in a convergent parallel manner by collecting quantitative and qualitative data, analyzing the results separately, and deriving an overall interpretation during the discussion process .Participants consisted of mentors and nursing student mentees. Mentors were licensed nurses who had at least one year of working experience in various fields of nursing and were capable of providing career counseling to nursing students in their respective fields. The sampling strategy was convenience sampling. They were recruited through personal recommendations. Mentees were undergraduate nursing students aged 18 years and over, who were recruited through social network service announcement in two nursing schools. The sample size was calculated using the G Power 3.1.9.4 to determine the minimum sample size for performing paired t-test with the following parameters: a two-sided significance level (α) of 0.05, a statistical power (1-β) of 0.80, and a median effect size of 0.5. The minimum sample size was 34 participants. Those who understood the purpose of the study explained in the recruitment announcement and agreed to voluntarily participate were enrolled. An experience of at least six months in using Zoom was a prerequisite for both mentors and mentees. Eight mentors and 43 mentees were finally selected to participate in the metaverse-based career mentoring program developed in this study. The pre- and post-intervention questionnaire surveys were administered to all participants at the baseline and after the program. In the qualitative study, data collection continued until data satiation was reached and no new information emerged from the interviews. As a result, 19 participants (one mentor group of seven mentors and two mentee groups of six mentees each) participated in the focus group interviews.As the general characteristics of mentors and mentees, gender, age, school year (mentees) or career (mentors), nursing major satisfaction, videoconferencing fatigue, virtual reality (VR) content experience, and metaverse experience were examined. The mentees’ career decision-making efficacy was measured before and after the career mentoring. To compare platform satisfaction between Zoom and the metaverse, participants’ satisfaction with both platforms was assessed before and after conducting the metaverse-based career mentoring program, respectively. In addition, the satisfaction with career mentoring was assessed in both mentors and mentees after the program administration. The quantitative data were collected from February 16 to 26, 2022.Career decision-making self-efficacy among mentees was assessed before and after the administration of career mentoring and the scores were compared. It was measured with the Career Decision-making Self-Efficacy Scale Short Form (CDSES-SF) developed by Betz and Voyten . The CDSFor a quantitative assessment of platform satisfaction, participants’ satisfaction with Zoom and the metaverse were measured before and after conducting the metaverse-based career mentoring program in both mentors and mentees. For platform satisfaction, immersion, social presence, sense of being together, interactivity, fatigue, emotional expression, and overall platform satisfaction were measured with reference to previous studies , 16–19.Immersion was assessed by measuring the scope of influence of the levels of immersivity, virtual reality, and interactivity with avatars (including motion and voice interactions) on immersion. The immersion scale consists of six items, with each item rated on a 10-point scale , where a higher total score indicates a higher immersion in the program. The reliability of the scale (Cronbach’s α) in this study was 0.90.Social presence was measured using the 10-item social presence scale developed by Weidlich and Bastiaens . ExampleSense of being together refers to the sense of being together with other learners in the learning space. In this study, it was measured with the instrument developed by Kim et al. . Each ofInteractivity was measured with a tool developed by Oh  and modiFatigue was measured with a one-item scale for overall fatigue from platform use. The item is rated on a five-point Likert scale . A higher score indicates a higher level of fatigue from platform use.Emotional expressivity was measured with a one-item scale that measures the level of expressing one’s own opinion or feeling in the platform concerned. It is rated on a five-point Likert scale . A higher score indicates a higher level of freedom in expressing feelings on the platform.Overall platform satisfaction was measured with a tool developed by Lim et al. . It consSatisfaction with the metaverse-based career mentoring program was assessed through separate surveys with mentors and mentees. For program satisfaction, counseling satisfaction, utility, ease of use, and intention to use were measured with reference to previous studies –25.Counseling satisfaction was measured using the Client Satisfaction Questionnaire developed by Larsen et al.  and modiUtility was measured using the tool developed by Qiao and Han  for virtEase of use was measured with the tool developed by Qiao and Han  for virtIntention to use refers to the willingness to use the metaverse program in the future. It was measured using the tools developed by Venkatesh and Davis  and ChoiAfter completing the career mentoring program, focus group interviews were conducted only with those who completed the survey and wanted to participate in the interviews. One session of 60 to 70 min was held for each of the three focus groups (one mentor group of seven mentors and two mentee groups of six mentees each). Data were collected from February 21 to 26, 2022. In order to draw out free and diverse opinions from the interviewees, the researcher experienced in focus group interviews conducted the sessions in a comfortable atmosphere in a metaverse setting.Focus group interviews were conducted using a semi-structured questionnaire. The key question was “How did mentors and mentees experience metaverse-based career mentoring for nursing students?” More specifically, this issue was addressed by the following detailed questions: “Tell me about your experience with metaverse-based career mentoring,” “What feelings, emotions, and thoughts did you have during metaverse-based career mentoring?,” “What did you like about your experience with metaverse-based career mentoring?,” “What are the merits and demerits of metaverse-based career mentoring compared to other face-to-face or non-face-to-face mentoring styles?,” and “What should be improved in metaverse-based career mentoring?” During the interview process, interviewees were encouraged to freely talk about any additional questions they thought were necessary or anything else they wanted. Upon completion of the interviews, any doubts about the content were clarified via phone.This study was conducted according to the Analysis-Design-Development-Implementation-Evaluation (ADDIE) model  to develFirst, in the analysis phase, the career-related mentoring needs of nursing students were analyzed. To this end, a survey was conducted from January 24 to 28, 2022, with undergraduates enrolled in a nursing college. A total of 46 students participated in the preliminary needs survey, and the nursing field most desired to receive career mentoring was overseas nurses (30.5%), followed by pharmaceutical company researchers (28.3%), clinical nurses (23.9%), and nursing-related government officials (17.3%). In addition, previous studies regarding career mentoring programs for nursing students [Second, in the design and development phases, the career fields for applying the mentoring program were selected by reflecting the students’ needs, and the program was structured to have eight sessions on six days. The duration of each session was set to 60 min to give sufficient time for the mentor’s explanation of the relevant career field and answers to mentees’ questions. The program contents are outlined in Table Prior to the program implementation, a videoconferencing orientation session was given to each group (one mentor and two mentee groups) to explain the purpose and procedure of this study. Only after receiving online consent from each of those who wished to voluntarily participate, a preliminary 15-minute questionnaire survey was conducted.Mentors discussed the date and time among the six days when they were available, which was then reflected in the program planning; they were given a 15-minute preparation time for explaining the major tasks, strengths and weaknesses, and career-related preparations in their respective career fields.Mentees were allowed to check the career mentoring program schedule and write down the first and second preferences for the subgroup they wanted to participate in. Based on the application details of the mentees, the maximum number of mentees per group was set at eight. Before applying the career mentoring program in this study, a pilot test was performed on three junior and senior students of a nursing school. The metaverse platform used in this study was the Metaforest developed by YATAV Inc., which was tested preliminarily by using it in advance. As a result, problems that may occur in the mediation process, such as avatar operation and conversation participation, could be identified, and a detailed manual was prepared and supplemented.Third, in the implementation phase, the actual metaverse-based career mentoring program was performed from February 21 to 26, 2022. A week before participating in the program, the research assistant sent the mentors and mentees their respective metaverse program installation files and manuals to be used in this study, by e-mail with the instruction to install them in advance and try them out. The researcher explained the simple operation method to the mentors and mentees connected to the metaverse for about 20 min before the start of each mentoring program session, and instructed them to check for any problem in operation. The subgroup career mentoring was conducted over six days, and an online post-survey was conducted on completion of the program. At the beginning of the program, participants were recruited among those who wanted to be voluntarily interviewed about their participation experience after the program’s end, and interview dates were set for each group of mentors and mentees.Lastly, in the evaluation phase, pre- and post-intervention online surveys were conducted, using a self-report questionnaire, at the baseline and immediately after the program, respectively, in order to evaluate the program efficacy. The focus group interviews regarding experiences of participating in the program were directly conducted by the researcher, who was proficient in conducting qualitative research.Quantitative data were analyzed using SPSS 23.0 program. The participants’ general characteristics were analyzed using descriptive statistics. Testing for normality was performed to identify the pre-post differences in variables before and after the metaverse-based career mentoring. A paired t-test was applied to analyze mentees’ social presence, sense of being together, and overall platform satisfaction, which met normal distribution, and Wilcoxon Signed-Rank test and Mann-Whitney’s U test were applied to analyze the remaining variables, which failed to meet normal distribution.For qualitative data, a thematic analysis was performed, in which main themes were extracted by identifying the relationships between key concepts from the transcripts of each focus group interview, to explore the experiences of participants in the metaverse-based career mentoring program. The researcher listened to each transcript repeatedly, extracted and coded meaningful words, phrases, and sentences while carefully reading the statements made by the interviewee, grouped them into similar ones, and finally extracted the main theme.In order to ensure the rigor in qualitative research, credibility, fittingness, auditability, and confirmability were checked, as suggested by Guba and Lincoln . First, To ensure reliability of researchers who analyze qualitative data and train them to reflect on the results, all researchers have taken lectures on qualitative research at graduate courses and special lectures in related conferences. The researchers have also conducted several qualitative researches. In addition, since the researchers worked as professors in nursing colleges for more than 8 years and continuously conducted career counseling for nursing students, we were able to have sensitivity in understanding the career mentoring experience of nursing students. The researchers were excluded as much as possible so that the experiences and opinions of the participants could be fully reflected and the researcher’s opinions or prejudices could not affect the analysis of the results and maintain a neutral role.The study was approved by Kyungpook National University’s Institutional Review Board (no. KNU-2022-0020). To ensure participants’ anonymity, data points collected by the researcher were randomly assigned with numbers to minimize the risk of exposure. The informed consent was obtained from all participants for study participation. The study was conducted following the Declaration of Helsinki.Prior oral consent was obtained online from each participant in the qualitative study, and an online written consent form was received on the interview day after explaining the purpose of the study and interview procedure again. All interviews were recorded, and the interviewees were informed that their privacy would be protected, and all data would be processed as anonymized or coded data to prevent identity exposure. The participants were told that they could withdraw from the study at any time if they no longer wished to participate, without receiving any benefits from participation or disadvantages from nonparticipation. Ethical issues regarding plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, and redundancy were observed by the author.Of the 46 participants, 38 were mentees with the following general characteristics: 92.1% were female students; their mean age was 20.79 years; sophomores had the highest percentage (42.1%); 50% had high nursing major satisfaction; 71.1% had virtual reality experience; and 52.6% had metaverse experience. Mentors (n = 8) were all women; their mean age was 31.38 years and mean career length was 4.69 years; 87.5% had high major satisfaction; 62.5% had no virtual reality experience, and 50.0% had metaverse experience (Table A comparison of career decision-making self-efficacy in mentees before and after the metaverse-based career mentoring program showed that career decision-making self-efficacy significantly increased after participation in the program compared to the baseline level Table .Table The satisfaction of mentees and mentors with the metaverse-based career mentoring program showed that the level of counseling satisfaction was 8.66 ± 1.46 for mentees and 6.90 ± 1.92 for mentors. In the mentees, utility was 3.65 ± 0.79, ease of use was 3.57 ± 0.75, and intention to use was 3.64 ± 1.01. In mentors, utility was 3.29 ± 0.98, ease of use was 3.88 ± 0.73, and intention to use was 3.33 ± 1.17 (Table A total of 46 codes were drawn by classifying significant phrases and sentences stated by each of the mentors and mentees about their experience with the metaverse-based career mentoring program. The codes with similar contents were grouped together and classified into 28 items of more general forms, which were then subjected to further combination and separation. As a result, three main themes and five categories were drawn. The main themes thus drawn were “candid interviews without constraints,” “satisfaction with realistic talks and program functions,” and “expectation of an even more optimized program.” The qualitative content analysis results are summarized in Table Mentees noted that by anonymously participating in the career mentoring program via an avatar they selected, their face was not exposed to others, so they did not feel burdened while participating. Mentors also mentioned that participation without exposing their faces made them answer the mentees’ questions more candidly and comfortably; they could play their mentor role more honestly because mentees asked anything they wanted to know without any constraints. Since the existing online programs expose at least one’s face or some identifiable cues, timid participants face as much psychological pressure as in any offline program. However, all participants felt free to ask any questions in the metaverse-based career mentoring program, including sensitive ones, which made them participate in the program more actively.Mentees stated that listening to various onsite experiences and stories from mentors helped them in their career exploration. They obtained a wide variety of information different from what they had come across through career lectures or Internet queries, and were satisfied with their participation in the program because they could obtain candid and accurate information about the matters they had been curious to know; these included preparations necessary for a given field, major tasks after employment, welfare matters, and promotion. They also mentioned that it was an opportunity to broaden their perspective of nursing-career paths.Participants admitted that the avatars felt so realistic and lively that they even thought they were not virtual characters. They also found that although the metaverse was a virtual space, they could concentrate better through it than through video call or videoconferencing, by talking in a space created like a real-world conference room; it gave them a sense of realism.Some participants encountered the metaverse for the first time, and although it took some time to adapt, they said that the platform as a mentoring program was fresh compared to the existing offline and online programs. They were satisfied with the metaverse program because it allowed people to talk to each other via avatars in a virtual space, react to others by making facial expressions or movements, and chat; it was free from spatial and temporal restraints and could be applied to various spatial settings, in addition to lecture rooms. Both mentors and mentees said that they could participate with interest.Some participants found it regretful not being able to decorate their own avatars as much as they wanted, and some functions such as motions and facial expressions lacked diversity. In addition, it took some time to install the program or get familiarized with basic functions, which made the process of prior preparations somewhat cumbersome.Participants regretted that they could not form a close affinity during the career mentoring program due to lacking information on the mentors and other mentees. Moreover, it was difficult for a mentor to check whether the mentees were listening to their words, including what emotions or responses they were displaying through the motions or facial expressions shown by their avatars. In the process of mentees writing questions in the chat box to avoid overlapping voices and the mentor answering them verbally, the mentor felt like performing a solo show. She expressed her wish that the affinity among participants could be enhanced more easily through functions, such as boosting the interactions between a mentor and her mentees as well as among all participants, or checking others’ reactions.This study aimed to provide an understanding of the effects of metaverse-based career mentoring for nursing students, including the related experiences of mentors and mentees, applying a mixed research method. In this study, career decision-making self-efficacy was significantly increased after the administration of career mentoring, which is consistent with the finding of a previous study  in whichA comparison of the participants’ platform satisfaction between Zoom and the metaverse showed that the mentees perceived significantly higher levels of platform satisfaction with the metaverse than with Zoom, for the variables “immersion,” “interactivity,” “emotional expressivity,” and lower level of “fatigue.” This may be due to the fact that the mentees who participated in this study fall in the age range of Generation Z members, and are, therefore, familiar with the Internet and digital devices since their childhood, with their affinity for the metaverse presumed to be high . In addiHowever, mentors showed a significantly higher level of platform satisfaction with metaverse than with Zoom only in emotional expressivity, and no significant differences with Zoom were observed in the other variables. Moreover, their counseling satisfaction was significantly lower than that of mentees after the administration of career mentoring. This may be ascribed to the difficulties in playing their role of attending to the atmosphere of mentoring and counseling due to constraints in interactions with the mentees; the use of avatar characters made it more difficult to understand the spontaneous responses of the mentees during the counseling process compared with face-to-face or videoconferencing interactions. This lack of advantages of the metaverse over Zoom in immersion or fatigue may have led to rather low counseling satisfaction among the mentors. Conversely, with anonymity guaranteed, the mentees could ask more sensitive questions and the reactions of other participants were not very important to them, which may explain the difference in platform or program satisfaction between mentors and mentees. Therefore, in order to achieve high-level communication and interaction activities, which involve catching the inter-participant reactions, it is necessary to develop various communication patterns of the avatar, including the eye direction, body posture, and facial expressions that recognize each other’s presence in avatar characters . It is aThe participants in this study perceived a sense of being together in the same counseling space, but felt that it was insufficient to form close affinity. This lack of affinity building was ascribed partly to limitations in the implementation of the metaverse program, and partly to the lack of mutual information due to anonymity. The persistence of the COVID-19 pandemic has accelerated the transition to a contact-free society, and the metaverse provides a novel social space to enable connection that allows people to meet and communicate among themselves . In the This study was significant in that it delivered metaverse-based career mentoring to enhance the career decision-making self-efficacy of nursing students. The mentees’ satisfaction with the metaverse platform was higher compared with existing videoconferencing platforms in immersion, sense of being together, interactivity, fatigue, and emotional expressivity. Regarding the limitations of this study, it may be pointed out that since career mentoring was administered only once to nursing students in two nursing schools of Korea, it is difficult to generalize the study results. Moreover, since only single-group testing was performed to analyze the effects of career mentoring, it is necessary to test the effectiveness of metaverse-based career mentoring more objectively through randomized controlled trials.In this study, metaverse-based career mentoring was found to be effective in enhancing nursing students’ career decision-making self-efficacy. Through the focus group interviews, it was found that participants experienced positive program functions, such as candid interviewing, facilitated concentration, and acquisition of new information on career path, also lacking certain functions, such as insufficiencies in building a close affinity among participants. In order to check whether career decision-making self-efficacy enhanced through the career mentoring program will be maintained, a longitudinal study needs to be conducted to determine individuals’ satisfaction with the career decision-making at the time of graduation. In this context, studies focusing on the development and interventional effects of a hybrid-type career mentoring program that combine the advantages of the metaverse and face-to-face counseling should be conducted.Below is the link to the electronic supplementary material.Supplementary Material 1


Mw (moment magnitude) 8.2 Chignik, Alaska, earthquake and determine ~1.4 meters cumulative co- and post-seismic horizontal displacement ~60 kilometers from the megathrust front. Only for the 2011 Mw 9 Tohoku event have closer subduction zone earthquake displacements been observed. We estimate ~2 to 3 meters of megathrust afterslip shallower than 20 kilometers, a portion of the megathrust on which both inter- and co-seismic slip likely had occurred previously. Our analysis demonstrates that by 2.5 months, shallower and deeper moment had effectively equilibrated on the megathrust, suggesting that its tsunamigenic potential remains no more elevated than before the earthquake.The shallower portions of subduction zone megathrust faults host Earth’s most hazardous tsunamigenic earthquakes, yet understanding how and when they slip remains elusive because of challenges making seafloor observations. We performed Global Navigation Satellite System Acoustic seafloor geodetic surveys before and ~2.5 months after the 29 July 2021  Mw 8.2 Chignik subduction zone earthquake.Seafloor geodesy reveals rapid up-dip afterslip following the  Subduction zone earthquakes and tsunami are some of Earth’s most impactful and societally relevant natural hazards  (2). In It often has been assumed that earthquake ruptures were inhibited by shallow megathrust sections tending to exhibit stable, “velocity strengthening (VS),” frictional character  8.2 Chignik Alaska, subduction zone earthquake was the largest earthquake within the U.S. territory in 58 years .Mw 8.3 earthquake  to a trench   with nonzero mean values ; the twoM0= μAs; where μ shear modulus is taken to be 30 GPa, A is the subfault area, and s is the average subfault slip) calculated from our analysis are distributed similarly and compare favorably with the NEIC’s  of the estimated up-dip post-seismic moment.The moment equivalence strongly suggests that the shallower slip is post-seismic afterslip rather than co-seismic slip: If the deeper and shallower moment both resulted from co-seismic slip, then the summed moment estimate would be roughly double the independent teleseismic co-seismic moment estimates . This coOur observations and analysis, combined with the instrumental and observational history of the region, permit placing rare process and hazards constraints on the up-dip, potentially tsunamigenic, portions of a subduction zone megathrust. In An important realization that emerges from this compilation is that the Chignik up-dip afterslip occurred on portions of the megathrust at the same depth that had previously experienced end-member slip styles—stable sliding and dynamic rupture. To the best of our knowledge, only for the Tohoku event, where the co-seismic slip overlapped with a previously inferred SSE zone . A We have shown that, as anticipated ; this, iRapid seafloor geodetic response and attendant analysis of the state of slip on a portion of a shallow megathrust could be replicated and refined for other similarly hazardous subduction zones. Moreover, mobilization and deployment of autonomous surface vessels do not require large oceanographic research vessels and so response times could certainly be reduced to days or hours. This could also motivate construction of seafloor geodetic networks to establish pre-event baselines. Even with these seafloor geodetic measurements in Alaska, some of the closest ever made to the trench, our observations are still ~60 km from the trench itself. The technical capability exists to make seafloor geodetic measurements at the deeper water depths where megathrusts reach closest to the seafloor and these regions could be prioritized in future observational efforts.The GNSS-A method for seafloor positioning with precision adequate for geophysical applications such as seismo- or volcano-tectonic studies was developed over the past ~3 decades  13 May to 28 May 2018, (ii) 2 June to 15 June 2019, (iii) 1 October to 15 October 2021(table S1). Figure S2 shows an overview of the GNSS-A residuals for each of the three surveys at SEM1. In this figure, we averaged the residuals from the three transponders in the array and rotated them into a local East-North frame to present a clearer picture of the apparent motion of the array we witnessed throughout the surveys. The spatial scatter is a good assessment of the positional uncertainty, and the offset observed after the Chignik earthquake is readily apparent. The residuals indicate a repeatability at two SDs (2σ) of better than 5 cm, which is fairly standard for the GNSS-A technique.To estimate the cumulative co- and post-seismic offset due to the Chignik event, we fit a linear trend to the two pre-event locations, project that to the date of the earthquake, and then calculate an offset (fig. S3). The 2019 position has a 1σ uncertainty of 0.2 cm in the east component and 0.22 cm in the north component. For the 2021 position, these numbers are 0.61 cm in east and 0.65 cm in north. Thus, a 2σ SD for the offset between these two is ~1.3 to 1.4 cm.http://geodesy.unr.edu/news_items/20210730) (http://geodesy.unr.edu)  and individual component models computed with teleseismic broadband (fig. S4B), regional strong-motion accelerometer (fig. S4C), high-rate GNSS (fig. S4D), and static GNSS observations (fig. S4E). All data used in the inversions have been previously published , using M0= 10*Mw+ 16.1)(1.5M0= 10*Mw+ 9.05) until the last day of GNSS-A surveying of site SEM1 (1 November 2021) and with epicenters in subfaults 2, 3, 8, 12 to 14, 18, 19, 23, and 24 (ainshock .


A cancer research training program explored different approaches for staffing their in-person and virtual programs for high school students. The inclusion of undergraduate near-peer mentors had a universal benefit when implemented across in-person and virtual training programs of one- and ten-week durations. Benefits are described for four stakeholder groups: the high school trainees, program staff, scientist partners, and peer mentors themselves. Peer mentors described that their involvement enhanced their own professional development and, for some, drove a new interest in cancer research. Scientist partners described that peer mentors helped translate their work in the virtual environment for high school students. High school trainees reported their sessions with peer mentors to be one of their favorite parts of the program. Interprofessional peer mentors were highly relatable to students and modeled communication and paths in biomedical research. Staff reported that peer mentors supported student engagement during community shadowing sessions, allowing staff to focus on developing the shadowing experiences with partners. The benefit of including peer mentors was substantial from all viewpoints explored. Their intensive inclusion in cancer research training programs supports sustainability and capacity building in biomedical workforce development. Advances in biomedical research depend on innovation, with the increasingly complex nature of biomedical research requiring new ways to tackle scientific problems. Scientists from historically underrepresented backgrounds produce higher rates of scientific innovation yet their careers are more likely to end prematurely . In the The National Institutes of Health (NIH) has called for an increased emphasis on diversity and inclusion within biomedical research  and fundThe Youth Enjoy Science initiative from the National Cancer Institute trains students in cancer research . While tThis manuscript details how the inclusion of peer mentors evolved over time for a statewide-focused cancer research training program for high school students. We describe the backgrounds and roles of peer mentors across training settings  and program durations ranging from 1–10 weeks. Outcomes were thematically coded from stakeholder feedback and experiences, which were reported by the program’s target audiences, including trainees, scientist partners, program staff, and the peer mentors themselves. These multiple approaches permit triangulation of impact across stakeholder groups and offer new perspectives and avenues for enhancing sustainability of cancer research training programs using interprofessional peer mentors.The Knight Scholars Program (KSP) was developed at Oregon Health and Science University , Oregon’s only academic health center and comprehensive cancer center, to train Oregon high school students from historically underrepresented backgrounds in cancer research using approaches that align with the National Cancer Institute’s Youth Enjoy Science initiative . The proPeer mentors were recruited from the NIH-funded BUILD EXITO program at Portland State University (PSU) through Enrichment workshops. EXITO is a three-year mentored training program in biomedical research . BrieflySix peer mentors were hired for the one-week training program in 2019, in which they served as resident advisors and stayed in dormitories with high school trainees (n=25), all of whom were minors under age 18 years. Five peer mentors were hired for the virtual training programs in 2021 during which two programs were run: a one-week Introduction  and a ten week Immersion . No program was held in 2020 due to COVID-19 restrictions at the host university. Peer mentors were paid $600 for the 7-day residential program (Peer mentors provided feedback to program staff (AC and LKM) in one-to-one and group meetings, and via email during and after the program, with notes and lessons learned used for quality improvement throughout the program as well as documentation of peer mentor roles and activities. In 2021, peer mentors of the virtual program shared reflections anonymously using Google Jamboard during the last week of the program to compile reflections and areas for growth for involving peer mentors in cancer research training programs.After each summer program, peer mentors from that year participated in summative evaluation with the program’s external evaluator  without the presence of program staff. After the 2019 program, peer mentors were emailed to schedule a short phone interview (15 min) about their experiences with the program. The objective was to learn more about any professional growth they may have experienced as a result of their participation  facilitated focus groups with program trainees on their last day of the program, with scripts, procedures and full findings described in Research learning communities  were sent an online Qualtrics survey immediately after their scholar hosting experience . One queKnight Scholars Program staff (n=7) debriefed the summer 2021 program and used Google Jamboard to share comments and suggestions anonymously. Staff comprised faculty, community liaisons, and program coordinators, all of whom are co-authors on the trainee experience paper  and playAt the conclusion of the summer 2021 program, it was clear to program staff that there were strong benefits for including peer mentors in programmatic activities with scholars. Peer mentors described interest in continuing with the program to design programmatic features for future scholars, consistent with what 2019 peer mentors reported after the program. Peer mentors became more than dormitory chaperones as originally conceived and became integral members of our program team over the study period. Peer mentors’ continued interest in engaging with the program in an advanced capacity is highlighted by their active role in co-designing the program based on data-driven feedback and lived experience. In line with Community-Based Participatory Research (CBPR) principles for advancing equity , KSP reaPeer mentors were not paid for their time after the summer program, including follow-up data collection, data analysis, or manuscript preparation activities that occurred in fall and winter. Peer mentors tracked their contributions on an online spreadsheet , with coThe IRB-approved protocol (OHSU #22889) entitled ‘Biomedical Workforce Development’ specifically describes conditions that allow all participants (including peer mentors) to engage in data collection and analysis activities, as well as define the sharing permissions for their own information. As the goal of the IRB protocol is to support the training of the future biomedical workforce, these IRB-approved sharing considerations allow our peer mentors to share relevant contextual data and considerations for others to walk that same path. Peer mentor co-authors of this manuscript were able to describe their training paths independently and then worked together to summarize how they wanted their information shared.A short electronic survey  was emailed to peer mentors in December 2021 with all data blind to peer mentors until data collection was complete. The eight question perspectives survey  asked whUpon completion of the perspectives survey, an end message prompted peer mentors to complete a companion survey  where they could complete demographic questions . As peerIn cases where the OHSU Evaluation Core performed external evaluation, thematic analysis was performed by their faculty and staff using Dedoose and Taguette qualitative coding software, including peer mentor interviews and trainee focus groups. The 2021 peer mentor focus group was facilitated by the OHSU Evaluation Core who de-identified the transcript, with thematic analysis performed using Taguette qualitative software. Focus group codes and excerpts were exported to Excel for secondary analysis by the study team based on a coding dictionary . ColumnsA total of 11 peer mentors participated in the cancer research training program, including six in the in-person residential program (1-week duration) and five in the virtual programs (one and ten week durations). Approximately 7% of eligible BUILD EXITO trainees at PSU applied to be a peer mentor, with half (49%) accepted . Peer mePeer mentor demographics were summarized at the time of follow-up , with alNine of 11 (82%) self-identified as first-generation college student status, which increased to 10 of 11 (91%) when verified against their self-reported parent/guardians’ educational attainment. A discrepancy was observed for Health Professional Shortage Area (HPSA) eligibility when zip codes were verified using PY2020 data , with ovAll peer mentors were current or former trainees of the NIH-funded BUILD EXITO program, with 3/11 (27%) participating after sophomore year, 4/11 (37%) after their junior year, and 4/11 (37%) after their senior year. Seniors had completed EXITO training but not all seniors had graduated from the university at their time of participation and were completing final graduation requirements at their time of participation. BUILD EXITO scaffolds mentored research training, with sophomores having completed an academic year (three quarters) of research preparation and non-formal peer discussion . All five (100%) participated in 2021 focus groups that probed for themes reported in 2019. Universally positive benefits were reported for including peer mentors in both in-person and virtual training cancer research training programs for high school. . Core thIn 2019, all reported some level of experience in mentoring prior to being a peer mentor, although not directly with high school students. Peer mentors in both years agreed that their mentoring skills had improved through the program. When probed in 2021, peer mentors emphasized developing their leadership and teamwork skills in particular. Peer mentors described having others in a similar role  was helpful in making the job better and easier as a mentor. They reported strong benefits of working as an interprofessional mentoring team who could provide different perspectives and expertise. In both years, peer mentors described that sharing similar backgrounds as trainees enhanced their relatability. Overall, the peer mentor experience was impactful for reinvigorating interest and career trajectories in biomedical sciences . Peer meBenefits were also reported by high school trainees who described peer mentors as a major theme when asked in focus groups “What parts of the program did you like the most?” . TraineeDue to COVID-19, research rotations and shadowing experiences were virtual. Trainees were matched with four rotations comprising 2-day experiences based on trainee interests. Nine research learning communities participated in summer 2021 and eight unique scientist partners provided feedback . ExcerptStaff were universally in favor of peer mentors continuing with the program and observed strong connections between high school trainees and undergraduate peer mentors, finding them helpful for liaising between program staff and students. Staff reported that peer mentors could facilitate and co-experience more research activities with scholars , which would solve staffing challenges while potentially providing better experiences for trainees . Staff dAll 11 peer mentors completed the follow-up perspectives survey (100%), representing six from the 2019 in-person program (55%) and five from the 2021 virtual program (45%). Post-program themes  were proCore themes centered around strong growth in professional communication, with the program influencing confidence, comfort, and skills in mentoring others. Peer mentors described that their participation “improve[d their] communication skills, pedagogical knowledge, and cultural competence.” All peer mentors described pursuance of biomedical sciences in their future careers (100%) and all cited mentoring (100%) in their current and future goals . Many  and with other training programs supporting high school through graduate students. When asked what they would want NIH or other programs to know about involving peer mentors in research training programs, a prominent theme was their insight and relatability to trainees because they “just went through a similar experience”. Peer mentors described their ability to liaise between students, staff, and scientists in meaningful ways that permitted early identification of emergent issues and opportunities to co-design training programs that improved experiences for target audiences.Undergraduate peer mentors offer a robust strategy for building workforce capacity in biomedical research. Peer mentors were highly relatable to high school trainees in our program and supported their mentored guidance in cancer research across in-person and virtual contexts of 1–10-week durations. All stakeholder groups reported peer mentors to be highly beneficial, including high school trainees, program staff, scientist partners, and the peer mentors themselves. Peer mentors formed an interprofessional mentoring team to improve research training experiences for underrepresented high school students. Peer mentors described significant growth in their professional communication as a result of the program (82%), which was described in the context of leadership and teamwork. All wanted to continue biomedical sciences (100%) and mentoring (100%), with 73% describing an increased interest in cancer. This case study offers strong support for involving peer mentors in cancer research training programs, which may help to retain diverse students in research training necessary for enhancing representation in the biomedical workforce .Peer mentors served varied roles across the course of the program, including resident advisors in dormitories during the in-person program, where they chatted with scholars about their day . In the virtual program, peer mentors led online debrief sessions with scholars in the afternoon that were consistently highly rated by scholars. Likewise, scholars appreciated having peer mentors in longer networking sessions with cancer professionals to facilitate communication. Scholars reported most comfort and interest in talking with near-peer mentors, which occurred in both formal and informal settings modeled after BUILD EXITO Enrichment workshops . The strA major strength of this case study is the documentation that peer mentors with less hands-on research experience can be highly beneficial to research training programs. Peer mentors comprised BUILD trainees in various stages of pursuing independent research. Their diverse paths and interests modeled for high school students what research, academic, and personal paths could look like. Approximately half of our high school trainees were first-generation college students  and citePeer mentors were not required to be interested in or studying cancer research at their time of application, yet after the program 73% described an increased interest in cancer, a third (33%) described intentions or pursuance of additional cancer-related training, and one (9%) explicitly cited cancer research as their career trajectory. Even without explicitly describing cancer in their trajectories, peer mentors described interest in fields directly related to cancer, including biomedical informatics, clinical psychology, and clinical care. Peer mentors cited that the interprofessional teams enabled them to recognize their own strengths and those of their team, which was a prominent theme observed in follow-up evaluation. Consistent with our prior work, we found the training program’s interprofessional focus enabled students across physical, biological, clinical, and social sciences to share similar experiences and feelings about professional identity development, which helped others realize they were not alone when questioning how they could become a scientist and what it means to be one, which was “key for underrepresented professionals to distinguish personal barriers from systemic barriers, and identify when solutions needed more individual effort or better access to systems” . As descWorking with the youth reminded me of how scary it is to be a first-generation and underrepresented high school student trying to figure out whether college or STEM was meant for me. Hearing their stories, lived experiences, and struggles made me realize that we can help students individually but what needs to change is the system and approach. I originally wanted to become a doctor (MD) but this entire experience reminded me of the type of legacy I want to leave behind, which is to help communities and change institutionalized systems to make the process more equitable, experience more endurable, and process/ funding sustainable, which is why I’ll be pursuing a dual medicine/ political role.The feed forward impact of peer mentor participation was substantial and highlights a team science approach for improving research training programs for youth. Team science supports scientific advancements in biological, physical, and social sciences  and is cRepresentation matters for diverse trainees in biomedical research, with 64% of peer mentors describing relatability to trainees as a strong benefit that helped them provide valuable insight, academic support, share recent similar experiences, and offer comfort since they had just walked the same path. All peer mentors of our cancer research training program were historically underrepresented, as defined by NIH criteria . When asPeer mentors afford students an opportunity to navigate and grow in an often unfamiliar pathway. This becomes paramount for underrepresented students in less pursued academic pathways such as STEM. In addition, as a peer-mentor, I have benefited from mentor-student relationships. I have been able to improve my communication skills, pedagogical knowledge, and cultural competence.As program peer mentors were once mentees in BUILD EXITO, they connected mentor-mentee relationships as important for supporting growth during biomedical training in ways that may be more challenging for program staff:As a former mentee, I felt intimidated and shy speaking my mind to the people leading the program but I was always open to my peer mentor. She was close to my age and recently went through what I was going through and she always had the right resources for me. She was also a voice for me when I didn’t want to speak up and called me out when I needed it most.The sentiment was echoed by another peer mentor who highlighted why this connection is so important for trainees:Peer mentors are absolutely essential to any program that hopes to prepare a generation of professionals for their work. […] Peer mentors allow younger students to forget the pressures of professionalism long enough to ask the most pressing questions.Integrating peer mentors into training programs could reassure [trainees] that they belong in the sciences.”Peer mentors play important roles on cancer research training teams; their paths illustrate possibilities that contribute to successful trainee experiences. Peer mentors help surface important questions and issues faced by trainees when navigating career paths. The training experience enhanced professional development of both peer mentors and trainees , which hPeer mentors were a critical part of the Knight Scholars Program training team who helped translate program activities for trainees, such as shadowing experiences and community research projects. Most peer mentors (82%) cited growth in professional communication as a result of the program, including their “ability to convey thoughts and information to others in a digestible fashion.” Professional communication with trainees, staff, and scientists had transferable benefits on peer mentors’ confidence and networking:For me, it was improving my networking skills. I had the opportunity to meet so many professionals over the summer, which helped me expand my network. It was also beneficial because talking with professionals helped ease the anxiousness that I experienced when speaking with experts in their fields of work. This growth became noticeably apparent during the program’s final weeks when I had to staff shadowing sessions. I felt confident in my ability to communicate with professionals vocally and via email.While these strong benefits may suggest to some individuals that peer mentors would volunteer for such positions, we strongly advise programs to offer paid placements. All of our peer mentors are from a self-reported disadvantaged background, with 90% eligible for need-based financial aid through Pell grants. Almost half have experienced house-lessness in their lifetimes (45%). Therefore, offering financial incentives (e.g. $15/hour) to our peer mentors enabled them to focus intently on the scholars, while minimizing barriers to paying rent or affording food. The high cost of living in Portland and many other cities around the country needs to be adequately considered when implementing research training programs. Without compensation, peer mentors who represent higher socioeconomic backgrounds may apply at disproportionately higher rates because they have the luxury to afford a volunteer position. Yet, if we are to engage and retain historically underrepresented trainees, we find strong benefits of including peer mentors from backgrounds that are representative of the trainees. As many of our program’s scholars are also from disadvantaged backgrounds, we find that paying peer mentors for their participation enables individuals from all backgrounds to participate, resulting in strong outcomes that benefitted every stakeholder group measured.When defining underrepresentation of our peer mentors, we found that rural eligibility was underreported by peer mentors when verified using zip code. More than half the peer mentors (60%) incorrectly listed their HPSA designation, suggesting this data field may warrant verification to prevent underrepresentation of disadvantaged background eligibility. First generation college student status was underreported by 9% of peer mentors when verified against guardians’ educational attainment, consistent with data from high school trainees who also underreported this important eligibility metric for scholarships and programs .Limitations of this case study include a lack of pre-evaluation with peer mentors beyond application essays, which is included in the evaluation of 2022 program peer mentors (work in progress). Thus, while COVID-19 interrupted peer mentor plans to return between 2019 and 2021, peer mentors from both cohorts applied and were selected to the 2022 summer program, forming an interprofessional leadership program in cancer research mentoring that leverages lessons learned from past summer and enhances experiences for students in the Knight Scholars Program.Together, strong outcomes were observed for including interprofessional, undergraduate peer mentors in cancer research training programs for high school students. Our project offers robust support for two cross-cutting themes in the 2021–2025 NIH Strategic Plan  includinAppendix AAppendix BAppendix CAppendix D


Qki-knockout mice. Loss of QKI resulted in the differential expression of 17% of the circRNAs in adult mouse hearts. Interestingly, the majority of the QKI-regulated circRNAs (58%) were derived from genes undergoing QKI-dependent splicing, indicating a relationship between back-splicing and linear splicing. We compared these QKI-dependent circRNAs with those regulated by RBM20, another cardiac splicing factor essential for circRNA formation. We found that QKI and RBM20 regulate the formation of a distinct, but partially overlapping set of circRNAs in the heart. Strikingly, many shared circRNAs were derived from the Ttn gene, and they were regulated in an opposite manner. Our findings indicate that QKI not only regulates alternative splicing in the heart but also the formation of circRNAs.Circular RNAs (circRNAs) are a class of non-coding RNA molecules that are gaining increasing attention for their roles in various pathophysiological processes. The RNA-binding protein quaking (QKI) has been identified as a regulator of circRNA formation. In this study, we investigate the role of QKI in the formation of circRNAs in the heart by performing RNA-sequencing on  Summary: A genetic loss-of-function study in mice reveals that the splicing factor Quaking (QKI) is a crucial regulator of circular RNA formation in the heart. TTN and RYR2 transcripts  to preserve mitochondrial DNA stability and prevent cardiomyocyte apoptosis, after doxorubicin treatment in mice  are a class of non-coding RNA molecules that are increasingly being recognized for their regulatory roles in critical biological pathways. Although the function of most circRNAs is currently unknown, it has been shown that some circRNAs exert a regulatory function by acting as miRNA sponges, as protein-scaffolding molecules or as transcription or splicing regulators . Some cinscripts . Multipltor E2F1 . The hig in mice . In humand RBM20 .As our knowledge of circRNAs in the heart keeps growing, so does the need to understand the factors that control its formation. CircRNAs are generated by a non-canonical form of RNA splicing known as back-splicing, where the splice donor site of one exon is ligated to the splice acceptor site of an upstream exon. This back-splicing event creates a covalently closed single-stranded circular RNA structure consisting of one or multiple exons, and in some cases also introns. Owing to the unusual disposition of the exons within this circle, a new sequence called the back-spliced junction (BSJ) is formed. The BSJ is not present in the linear transcripts and is used to identify the circRNAs from RNA-sequencing reads. Mechanistically, the back-splicing reaction is executed by the spliceosome, and it requires that the two introns flanking the back-spliced exons are brought into close proximity of each other. This can be achieved by looping of the pre-mRNA, mediated by base-pairing of cis-acting elements (e.g. by complementary Alu repeats flanking the back-spliced exons) or by dimerization of trans-acting elements, such as splicing factors . One of Qki in cardiomyocytes to study the function of QKI in the heart  mouse model. By performing ultra-deep RNA-sequencing and de novo circRNA prediction, we show that 17% of the circRNAs that are present in the adult heart are differentially expressed after loss of QKI. We uncovered a relationship between back-splicing and linear splicing by QKI, as the majority of the QKI-regulated circRNAs (58%) were found to be derived from mRNAs that underwent QKI-dependent alternative splicing as well. Finally, we compared the differentially expressed circRNAs in the Qki KO model with those in an Rbm20 KO model and found that QKI and RBM20 regulate the formation of a distinct, but overlapping, set of circRNAs. Strikingly, the Ttn-derived circRNAs that are regulated by QKI and by RBM20, are mostly regulated in an opposite manner.Given the essential role of QKI in the alternative splicing program of cardiomyocytes , and theQki knockout (KO) mouse line that we previously developed. This mouse line was generated by crossing the QKI-floxed mice (TgMyh6-MCM) line , Casq2 and Rcan1. Cardiac dysfunction was attributed to sarcomere disorganization and splicing defects in important cardiac genes, such as Ttn, Camk2d and Tpm1  line . Deletioand Tpm1 .Qki KO model for the expression of circRNAs  and five wild-type hearts , 1 week after tamoxifen injections. CircRNA detection was performed with the bioinformatics tool MapSplice2  (see data at https://doi.org/10.6084/m9.figshare.23056598.v1).To investigate whether QKI regulates circRNA formation in cardiomyocytes, we analyzed our previous RNA-sequencing data of the pSplice2 , which ipSplice2 A,B. A toan heart , such asQki KO and WT samples with the bioinformatics tool circRNAprofiler (2(fold change) (log2FC) ≥1.0, adjusted P≤0.05], with 25 circRNAs being downregulated and 61 upregulated (23-13circSlmap) and 13 circRNAs were uniquely expressed in the Qki KO mice . We also noted that many genes give rise to more than one dysregulated circRNA, with Ttn being the gene with the highest number of dysregulated circRNAs  ≥0.5], but there was no significant correlation with the expression of circRNAs arising from these genes. This indicates that the differences observed in circRNA formation are not dependent on changes in transcription  could in part be explained by more generic changes induced during the development of the cardiomyopathy. To dissect the changes that are specific for loss of Qki, we quantified circRNA expression in hearts where cardiac dysfunction was induced by transverse aortic constriction (TAC) as compared to sham surgery (n=4 sham versus 4 TAC). At 3 weeks after TAC surgery, hearts became hypertrophic and displayed a reduced ejection fraction  were differently expressed in TAC hearts compared to the sham operated control hearts  was based on expression levels and statistical significance in the Qki WT versus Qki KO comparison. In order to exclusively amplify the circRNA molecules and not the linear transcripts, divergent primers were designed flanking the BSJ, with the forward primer annealing to the downstream exon and the reverse primer to the upstream exon. As shown in 14-11circPlekha5 was validated in Qki KO samples, given that this circRNA was only detected in the KO and not in the WT hearts  hearts to check whether they presented an intermediate circRNA expression level. We confirmed the reduction in 5-3circOgdh and 113-107circTtn in the Qki KO; and the increase in 9-3circPdlim5, 9-4circPdlim5, 14-11circPlekha5, 18-14circArhgap32, 12-6circMyzap, 8-5circPde4dip, 121-87circTtn and 121-88circTtn  and 19 circRNAs were associated with splicing changes upstream and/or downstream of the back-spliced exons ]. 32-21circClasp1, 20-2circPicalm, 9-3circSlc8a1, 10-3circSlc8a1 and 11-circSlc8a13). All five circRNAs shown contain alternatively spliced exons between the back-spliced exons. 32circClasp1-21 is an interesting circRNA, as it shows, besides alternative splicing changes in an exon located between the back-spliced exons, also alternative splicing changes in two exons immediately upstream and immediately downstream the back-spliced exons. In conclusion, our findings reveal that regions with QKI-dependent back-splicing are often associated with QKI-dependent linear splicing.In order to assess where the QKI-mediated alternative splicing changes were occurring in these 50 circRNAs, we focused on the regions were circRNAs were arising and we divided it into five parts: (1) the acceptor back-spliced exon, (2) the donor back-spliced exon, (3) exons located between the back-spliced exons, and exons (4) immediately upstream and (5) immediately downstream of the back-spliced exons B. We couRbm20 KO mice to investigate the role of RBM20 in the heart, including in circRNA formation . The scatterplot in 8-3circFan and 8-5circPde4dip changed in the same direction in both KO models, 20-10circSorbs1 and 11-7circArghap26 expression changed in the opposite direction  , a well-ormation . These RTtn gene . We compirection C.Ttn splicing has been recognized as a significant biological mechanism and that Ttn generates the largest quantity of circular RNAs (circRNAs), many of which exhibit differential expression in both the Qki KO (24 circRNAs) and the Rbm20 KO hearts (12 circRNAs), we next explored the exact location of the back-spliced exons of the Ttn-derived circRNAs. First, we visualized the genomic location of the back-spliced exons of all 33 Ttn circRNAs detected in WT hearts (Ttn circRNAs originate by back-splicing of exons located in the middle I-band (i.e. exons 47 to 143). This region includes the two most highly expressed circRNAs: 121-88circTtn and 121-87circTtn. A smaller subset of circRNAs arise from the distal I-band, but their expression levels are lower. Strikingly, when comparing the upregulated and downregulated circRNAs in the Qki KO and the Rbm20 KO hearts, an opposite regulation was observed: the circRNAs in the middle I-band are increased in the Qki KO, but reduced (or even absent) in the Rbm20 KO hearts  and identification of splicing factors that QKI interacts with across different cell types will provide insights in (back)splicing regulation by QKI in the heart.Conn et al. were the first to postulate that QKI promotes the formation of circRNAs . They obQki and Rbm20 KO models revealed surprising little overlap between QKI- and RBM20-dependent circRNAs, except for circRNAs derived from the Ttn gene. Interestingly, Ttn-derived circRNAs were mostly regulated in an opposite manner by QKI and RBM20. The intricate pattern of splicing and back-splicing in the Ttn transcript is noteworthy for the following two reasons. First, the Ttn gene generates the largest number of circRNAs, which are highly expressed and mainly produced from the middle I-band region , whereas in the Qki KO only a smaller region is included (exons 88–121)  controls the splicing activity of RBM20 and SRSF10. This finding suggests that circRNAs derived from Ttn might be part of a positive-feedback loop to maintain proper splicing of Ttn itself.Comparison of the d region . This red region . Second, 88–121) . This smcircRNAs , as obseepressor , whereasepressor . The mecepressor . Adding 113-107circTtn, 13-11circFhod3 and 7-2circStrn3) when investigating the cardioprotective function of QKI against doxorubicin toxicity , but 13-11circFhod3, which was expressed in our dataset, did not appear to be a target of QKI, at least in cardiomyocytes. Some of the QKI-dependent circRNAs that we identified have been previously reported to be implicated in cardiomyocyte function. For example, decreased expression of 113-107circTtn has been shown to increase doxorubicin-induced apoptosis in mouse HL-1 myocytes  (Jackson Laboratory stock #005657) . The MCM recombinase allele was present in one copy in all the mice. Both males and females were included in the experiments. Rbm20 KO mice were previously generated and characterized (Generation of the cardiomyocyte-specific eviously . In briexed line  with the#005657)  line in cterized .Transverse aorta constriction (TAC) was performed in 8-week-old male mice [mixed background (F2) of C57BL/6 and FVB] as previously described . At 3 wePRJNA831665 (Qki KO); Qki KO) was extracted by using TRI reagent . RNA quality was determined using the Agilent RNA 6000 Nano Kit and the Agilent 2100 Bioanalyser. All samples had an RNA Integrity score ≥8. Library preparations were made with the Kapa RNA Hyperprep with RiboErase (Roche) and sequenced on a NovaSeq platform . Quality control of FASTQ files was performed using FASTQC , using MapSplice2 (version 2.2.0). For circRNAs detection, we set the following options: --min-fusion-distance 200 (as suggested by the authors), --filtering 1, and --min-map-len 50.RNA sequencing of the Qki KO mice used in this study had been previously performed [NCBI bioprojects g FASTQC . Trimmomg FASTQC  was used2FC≥1.0 and adjusted P≤0.05 were deemed significantly differentially expressed  was performed at QIAGEN Benelux B.V. (The Netherlands) . Bioinformatic analysis was performed using the same bioinformatics pipeline as for the Rbm20 KO mice (three WT and three KO mice) had been previously performed by Khan et al. [NCBI bioprojects PRJNA417769 (Rbm20 KO); Qki QKI KO mice, but in the mouse genome annotation GRCm39/mm39. In order to compare the differentially expressed circRNAs in the Rbm20 KO with the QKI-dependent circRNAs, coordinates of the back-spliced exons were converted to the GRCm38/mm10 annotation with the LiftOver tool from the UCSC genome browser  at 37°C for 10 min followed by heat inactivation at 95°C for 3 min.To validate circularity of circRNAs, an RNase R digestion step was performed on three QKI WT and three For cDNA synthesis, 500 ng of total RNA were treated with DNase I  and retrotranscribed into cDNA with random hexamers  and Superscript II .® DNA polymerase (Solis Biodyne). The thermal cycling protocol included an initial denaturation at 95°C for 15 min to activate the HOT FIREPol® DNA polymerase, followed by 25–35 amplification cycles of denaturation at 95°C for 30 s, annealing at 59–62°C for 30 s, extension at 72°C for 45 s, and 5 min of final extension at 72°C. Primer sequences are found in RT-PCRs were performed in a 25 µl reaction containing 5 ng cDNA, 1 M Betaine, 1× Buffer B2, 2.5 mM MgCl2, 200 µM dNTPs, 0.4 µM forward primer, 0.4 µM reverse primer and 0.05 U/µ HOT FIREpolcircRNAs were visualized on the UCSC genome browser  by creatP≤0.05 was considered statistically significant. Statistical tests concerning RNA-seq data are indicated in the RNA sequencing section.Data is presented as mean±s.d., unless otherwise stated. Results were analyzed with statistical tests in GraphPad Prism 9 , as indicated in the respective figure legends. A value of 10.1242/joces.261120_sup1Supplementary informationClick here for additional data file.


Adjacent segment foraminal stenosis is a significant adverse event of lumbar fusion. Conventional revision surgery with an extended fusion segment may result in considerable surgical morbidity owing to extensive tissue injury. Transforaminal endoscopic lumbar foraminotomy (TELF) is a minimally invasive surgical approach for symptomatic foraminal stenosis. This study aimed to demonstrate the surgical technique and clinical outcomes of TELF for the treatment of juxta-fusional foraminal stenosis. Full-scale foraminal decompression was performed via a transforaminal endoscopic approach under local anesthesia. A total of 22 consecutive patients who had undergone TELF were evaluated. The included patients had unilateral foraminal stenosis at the juxta-fusional level of the previous fusion surgery, intractable lumbar radicular pain despite at least six months of non-operative treatment, and verified pain focus by imaging and selective nerve root block. The visual analog scale and Oswestry Disability Index scores significantly improved after the two-year follow-up period. The modified MacNab criteria were excellent in six patients (27.27%), good in 12 (55.55%), fair in two (9.09%), and poor in two (9.09%), with a 90.91% symptomatic improvement rate. No significant surgical complications were observed. The minimally invasive TELF is effective for juxta-fusional foraminal stenosis. Lumbar fusion surgery is considered the standard procedure for degenerative spondylolisthesis or combined foraminal and intracanal stenosis. This procedure may provide sufficient decompression and immediate segmental stabilization, which can be maintained in the long term. However, it may also cause significant adjacent segment disease (ASD), defined as the subsequent development of spinal stenosis or instability at the juxta-fusional level ,5,6,7,8.Surgical treatment options for juxta-fusional foraminal stenosis can be summarized into two categories: (1) extension of fusion surgery, and (2) open or minimally invasive foraminotomy. The first option is based on wide decompression with an extension of the fusion, which may simultaneously provide thorough decompression and stabilization. However, the invasiveness of this approach can lead to considerable morbidity or surgical trauma ,13,14,15Transforaminal endoscopic lumbar foraminotomy (TELF) is an efficient and minimally invasive surgical option for various foraminal stenosis ,21,22,23In this study, we demonstrate the technique and clinical outcomes of TELF for adjacent-level foraminal stenosis after fusion surgery. Furthermore, we discuss the clinical importance of MISS approaches for ASD.Between January 2018 and April 2021, 22 consecutive patients with intractable radiculopathy secondary stenosis underwent TELF. Patients were prospectively registered in our surgical database, and their medical records were retrospectively reviewed. The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (GDIRB 2022-118), and written informed consent was obtained. The inclusion criteria were: (1) unbearable radicular leg pain despite more than three months of non-operative therapies; (2) at least 12 months of a pain-free period after the primary lumbar fusion surgery; (3) exiting nerve root (ENR) compression resulting from severe foraminal stenosis ,29 at thThe surgical procedure was primarily based on a previously demonstrated TELF method . Full-scThe fluoroscopy guidance aimed to ensure the safe placement of the working sheath at the foraminal zone. The outside-in approach was preferred over the inside-out method to prevent ENR irritation or injury during the procedure. The tip of the working sheath was located immediately in front of the ENR, and did not pass through the nerve root. The skin entry using the approach angle was determined based on preoperative imaging studies. Usually, the primary approach angle is approximately 45° or higher for full-scale foraminal decompression and endoscopic flexibility. However, the rod or screw head of the previous instrument could be in the approach route. In the patients included here, the approach trajectory was changed to a shallow angle. The location of the nerve root in the neural foramen and the severity of neural compression should be checked in the imaging studies. The initial trajectory should be directed to the foraminal pathologies while avoiding direct injury to the nerve root. First, an 18-gauge needle was inserted posterolateral to the foraminal zone. The needle tip targeted the disc surface or foraminal vertebral body, touching the surface of the superior articular process (SAP). After a preemptive epidural block through the needle, the guidewire was replaced, followed by serial obturator insertion, until the final obturator was placed at the foramen without any sign of irritation. The bevel-ended working sheath was fitted into the foramen with its sharp end away from the ENR using gentle mallet tapping A. IdeallThis step focused on resecting the SAP and shoulder osteophytes to enlarge the bony foraminal aperture. The early endoscopic view included the ENR covered with perineural fat and the disc surface. The surface of the SAP was then exposed by rotating the endoscope and working sheath. The terminal part of the SAP was gradually resected using special endoscopic burrs and micro-punches until the ligamentum flavum (LF) and foraminal ligaments were adequately exposed. Proper exposure of the facet joint is essential for effective bony unroofing. Both SAP and the pedicle, including the synovium, should be exposed. Then, the SAP resection can proceed along the synovium surface. Finally, the surgeon can reach the axillary epidural space and LF. Bleedings from the resected bone surface and epidural veins were controlled using a radiofrequency coagulator tip and hemostatic agents B.After sufficient foraminal unroofing and widening, the soft tissues, including the LF, foraminal ligaments, and redundant discs, were removed to release the pinched nerve root. When the tip of the SAP was sufficiently cleared to expose the ligamentous structures, delicate soft tissue decompression was performed. The hypertrophic LF, foraminal ligaments, or extruded discs were removed using forceps, micro-punches, Kerrison punches, and radiofrequency designed for endoscopic use. Most importantly, the main decompression was directed proximally and obliquely to the ENR route instead of parallel to the disc space. As the removal of soft tissue proceeded, ENR began to appear and was gradually released. Tissue adhesions were dissected using endoscopic probes and radiofrequency ablation. The removal and dissection procedures were conducted until the axillary epidural point at which the ENR started from the dural sac was exposed. Once the proximal axillary zone was identified, nerve root decompression was performed in the lateral exit zone. The remaining soft tissues or disc fragments were trimmed during full-scale foraminal decompression C.The TELF endpoint was determined by identifying the axillary epidural space and providing sufficient release to the ENR from the proximal to the lateral exit zone. Decompressed ENR was confirmed by solid pulsation based on the patient’s heartbeat D. PostopData comprising a two-year follow-up period were collected during regular outpatient office visits and telephone surveys. Surgical outcomes were assessed using the visual analog scale (VAS) and Oswestry disability index (ODI) . The glot-tests. Statistical significance was set at p < 0.05.Statistical analyses were conducted by an independent statistician using SPSS . Pre- and postoperative clinical data were compared using repeated-measures analysis of variance and paired The mean age of the 22 patients included  was 70.4 years  for the lumbar radiculopathy significantly improved from 8.41 ± 0.85, preoperatively, to 3.36 ± 1.99, 2.95 ± 1.86, 2.09 ± 1.37, and 2.23 ± 1.34 at 6 weeks, 6 months, 1 year, and 2 years postoperatively, respectively , good in 12 (54.55%), fair in two (9.09%), and poor in two (9.09%). Therefore, the rate of symptomatic improvement was 90.91% . Two of p < 0.001). The mean ODI improved by 45.57 (67.41%) at the final follow-up (p < 0.001). According to previous studies, a VAS score change > 50% [Our results revealed that clinical improvement was relevant in pain scores, disability, and global functional status. The mean VAS score for radicular pain improved by 6.14 (74.01%) at the final follow-up . Decompression parallel to the disc space, as performed in TELD, cannot sufficiently release the ENR. Incorrect direction is one of the main reasons for surgical failure. Moreover, the initial endoscopic landing should be as close as possible to the ENR while avoiding nerve root irritation. Based on our experience, we recommend aiming at the posterior vertebral body surface near the upper endplate of the disc. The sharp end of the working sheath should be directed away from the ENR, allowing the surgeon to observe the epidural fat of the ENR in the initial endoscopic visual field without causing nerve root irritation. Finally, the surgeon must confirm the axillary epidural space and free mobilization of the ENR to complete the procedure.Exposure to ENR alone is insufficient for full-scale foraminal decompression. Though the ENR can be observed during the process, even at an early stage, surgeons must continue to decompress the exposed ENR until the neural tissue is released. Once released, the ENR begins to beat according to the arterial blood flow and epidural pressure.Our study had some limitations. First, the study was conducted retrospectively without an appropriate control group. Therefore, a considerable selection bias might have been involved in patient enrollment. Second, the reduced number of patients precludes drawing credible conclusions. Third, the two-year follow-up period may have been relatively short for tracing long-term spinal stability at the treatment level. Therefore, a long-term prospective cohort study or randomized trial with a larger number of patients is required to verify the effectiveness of TELF in this particular ASD pathology.Finally, we could not evaluate the natural course or incidence of ASD after fusion surgery. Although foraminal stenosis after fusion surgery comprises a minority of the pathologies seen in ASD, we strictly included adjacent segment foraminal stenosis cases in our study. First, most of our patients underwent primary surgery at another institute. Only three of the 22 patients underwent fusion surgery at our hospital. Therefore, we could not obtain the clinical and radiological data at the time of the primary surgery in most patients. Second, the main purpose of this study was to evaluate the clinical outcome of the TELF technique for juxta-fusional foraminal stenosis cases. Central stenosis, intracanalicular disc herniation, or spondylolisthesis was not indicated for this procedure. Third, this study was retrospective, and most patients lacked detailed primary data. Therefore, we could not demonstrate the postoperative course or incidence of ASD after the primary surgery.With increasing average life expectancy, the number of patients with adjacent segment disease after primary lumbar spine surgery is predicted to increase. Therefore, the need for endoscopic procedures performed under local anesthesia is increasing. Our data revealed that the clinical outcomes of TELF in post-spinal surgery syndrome are relevant and reliable. Surgical approaches, devices, and optical technologies have advanced remarkably. The working channel endoscope with a bigger working space enables more potent instruments. Steerable or navigable forceps and punches can reach the corner-side pathologies. Various articulating burrs will make the bony resection safer and more efficient. A high-definition monitor system will make the surgeon perform the procedure more precisely. The spinal navigation system will be applied to the endoscopic spine surgery to increase the accuracy of the surgery and to decrease the radiation exposure during the surgery. Eventually, the spine society will accept this kind of novel endoscopic technique as a mainstream spine surgery protocol to address patients’ needs.TELF can be effective against foraminal stenosis at the level adjacent to the previous lumbar fusion. If there is no definitive segmental instability, full-scale foraminal decompression can be achieved using a percutaneous transforaminal endoscopic approach under local anesthesia, without requiring extensive revision surgery.