Oceanic eddy-induced meridional heat transport (EHT) is an important process in the Southern Ocean heat budget, the variability of which significantly modulates global meridional overturning circulation (MOC) and Antarctic sea-ice extent. Although it is recognized that mesoscale eddies with scales of ~40–300 km greatly contribute to the EHT, the role of submesoscale eddies with scales of ~1–40 km remains unclear. Here, using two state-of-the-art high-resolution simulations (resolutions of 1/48° and 1/24°), we find that submesoscale eddies significantly enhance the total poleward EHT in the Southern Ocean with an enhancement percentage reaching 19–48% in the Antarctic Circumpolar Current band. By comparing the eddy energy budgets between the two simulations, we detect that the primary role of submesoscale eddies is to strengthen mesoscale eddies (and thus their heat transport capability) through inverse energy cascade rather than directly through submesoscale heat fluxes. Due to the submesoscale-mediated enhancement of mesoscale eddies in the 1/48° simulation, the clockwise upper cell and anti-clockwise lower cell of the residual-mean MOC in the Southern Ocean are weakened and strengthened, respectively. This finding identifies a potential route to improve the mesoscale parameterization in climate models for more accurate simulations of the MOC and sea ice variability in the Southern Ocean. Based on two high-resolution simulations, the authors find that submesoscale eddies significantly boost poleward oceanic heat transport in Antarctic waters by strengthening transport capability of mesoscale eddies through inverse energy cascade. These mesoscale eddies with horizontal scales of 40–300 km are the oceanic analogs of atmospheric storms in dynamics and they have been demonstrated to play a leading role in the meridional transports of heat, salt, thickness, and other tracers in the Southern Ocean3. It is the eddy transport together with the competing wind-driven Ekman transport that jointly shapes the Southern Ocean’s residual-mean meridional overturning circulation (MOC)5. Given that large-scale fronts and their associated geostrophic currents  are nearly zonal in the Southern Ocean, mesoscale eddy-induced meridional heat transport (EHT) provides the key pathway to take warmer water from subtropical to subpolar regions7, whose variability substantially modulates the melting and re-freezing of sea ice around Antarctica10. Therefore, comprehensive knowledge of the EHT processes in the Southern Ocean is a prerequisite for understanding and predicting the variations of MOC and the Antarctic sea ice.Satellite altimeter observations in the past three decades suggest that the Southern Ocean, the Antarctic Circumpolar Current (ACC) in particular, has the most widespread and energetic mesoscale eddies of the world ocean13  with 1–40 km horizontal scales13 Fig. . Because 14 Fig. . Compare22. Furthermore, submesoscale eddies can interact with mesoscale eddies via a mutual energy exchange24 and may thus influence the mesoscale tracer transport indirectly25. Although it is known that submesoscale eddies potentially influence local divergence/convergence of heat fluxes, how and to what degree submesoscale eddies contribute to the total EHT in the Southern Ocean  is unknown. This is at least partly due to the fact that resolving submesoscale eddies over the entire Southern Ocean is still beyond the capability of existing observations and most model simulations.Besides transporting heat vertically, the advection effect of submesoscale eddies can also generate meridional eddy heat fluxes (EHF) locally in a way similar to mesoscale eddiesHere, we examine this issue by analyzing two state-of-the-art global ocean simulations, with one submesoscale permitting (1/48°) and the other only mesoscale resolving (1/24°). We find that submesoscale eddies effectively enhance the Southern Ocean total poleward EHT primarily by feeding mesoscale eddies via inverse energy cascade.26. The 1/48° simulation has a horizontal resolution of 1–2 km in the Southern Ocean, which is not only able to fully resolve mesoscale eddies, but also can to a large degree resolve submesoscale eddies therein. By comparing the 1/48° simulation-derived large-scale and mesoscale quantities with the concurrent satellite observations, we find that the simulation has accurately reproduced the large-scale and mesoscale features in the Southern Ocean with respect to both patterns and magnitudes  are used hereO(0.1) Rossby numbers and typically occur in the form of coherent vortices and meanders. The activity of mesoscale eddies and thus their associated velocity and temperature anomalies are significantly elevated in the regions with strong large-scale currents such as the ACC, the Agulhas and its Return Currents, and the Brazil Current . The submesoscale eddies tend to occur accompanying mesoscale eddies and their activities are particularly strong at the periphery of mesoscale eddies . By comparing the EHFs obtained from the 1/48° and 1/24° simulations, we find that magnitude of the former is significantly larger than that of the latter. Specifically, their difference shows negative and positive values in the southward- and northward-EHF regions, respectively. In the large EHF regions, the magnitude of this EHF increase exceeds up to one-third of the EHF itself  are calculated and compared  increases by 20–45% (19–48%) in the 1/48° simulation compared with the 1/24° simulation. The ACC band-averaged EHTs of the 1/48° and 1/24° simulations are −0.17 and −0.13 PW, respectively  is close to the total EKE and its magnitude is one order of magnitude larger than the submesoscale EKE  increase. The above EKE increase and its partition  are generally consistent with those of the EHT increase. Our results demonstrate that the enhancement of EHT in the 1/48° simulation is primarily attributed to the increased EKEme  while the direct role of the strengthened submesoscale eddies is limited.Similar to the EHFs and EHTs, both EKEone Fig. . The incme increase in the 1/48° simulation, we perform a budget analysis for the EKEme and the results are shown in Fig. ms) are the two largest EKEme source terms in both simulations. The large and positive baroclinic conversion is consistent with the knowledge that baroclinic instability is an important generation mechanism for mesoscale eddies in the Southern Ocean, which feeds the EKEme through releasing available potential energy31. The positive KTms term means that mesoscale eddies obtain kinetic energy from submesoscale eddies through an upscale energy transfer24 . Both the zonally integrated baroclinic conversion and KTms are prominently elevated in the ACC core band between 45–60 °S  simulation, this damping effect dissipates 31% (29%) of the EKEme obtained from the baroclinic conversion and KTms in the ACC band , the negative wind stress work that depends on the relative velocity between wind and sea surface current is also intensified. In addition, the negative pressure work divergence and the remaining three small positive terms also increase, but their increase amounts are one order of magnitude smaller than that of the KTms. In the ACC band, the increase of the above two negative terms is nearly offset by the increase of baroclinic conversion and the three small positive terms, which therefore cancel each other out in the EKEme budget  for the 1/48° simulation, particularly in winter36. Note that although the 1/24° simulation cannot resolve the mixed-layer instability process, it can still resolve some submesoscale eddies generated by other mechanisms such as mesoscale strain-induced frontogenesis and horizontal shear instability14. As a result, submesoscale eddies and the associated inverse energy cascade are also observed in the 1/24° simulation, although their strengths are much weaker.The above inverse energy cascade can also be inferred from the flattening of kinetic energy spectra in the meso- to submesoscale wavenumber range  compared with the y35 Fig. . Specifism itself is one order of magnitude smaller than the EHTme. The primary role of submesoscale eddies here is to enhance the mesoscale EHT  by strengthening the mesoscale EKE via inverse energy cascade. A schematic diagram of this submesoscale inverse energy cascade-mediated EHT enhancement can be found in Fig. me), which induce an anti-clockwise overturning that counteracts the westerly wind-driven clockwise one4.Our study has demonstrated that submesoscale eddies significantly enhance the poleward EHT in the Southern Ocean. Although submesoscale eddies can directly contribute to EHT, the EHT38. In addition, the submesoscale-mediated mesoscale eddy enhancement is supported by the comparison between the 1/48° simulation-derived EKEme and those derived from another four widely used 1/10° or 1/12° eddy-resolving simulations (see Methods for model details). Partly due to the absence of submesoscale eddies and their inverse cascading effect, the zonally integrated EKEme from these four eddy-resolving simulations on average accounts for 35–82% of that from the 1/48° simulation in the ACC band . However, the submesoscale inverse cascade that energizes mesoscale eddies as reported here has been demonstrated by localized in situ observations in different regionssm that depends only on the mixed-layer depth and cross-front buoyancy gradient, and which takes the form of an eddy-induced overturning streamfunction39. By comparing the “true” EHTsm directly calculated from the 1/48° simulation with the parameterized EHTsm based on the 1/24° simulation outputs (see the method in ref. 40), we find that although they have overall similar magnitudes, their spatial distributions are quite different . The LLC4320 (LLC2160) simulation has a nominal horizontal resolution of 1/48° (1/24°), which ranges from 0.75 km (1.5 km) near Antarctica to 2.3 km (4.6 km) at the Equator. Both simulations have 90 levels in vertical direction, whose grid ranges from 1 m near the sea surface to ~47 m near the 1000 m depth and to ~480 m at the maximum depth of 6760 m. The two simulations have the same forcing fields and vertical mixing parameterizations.In order to investigate the EHT processes in the Southern Ocean, the MITgcm LLC4320 and LLC2160 simulations carried out on a latitude-longitude polar cap (LLC) grid are used44. The model simulation outputs are stored hourly from 10 September, 2011 to 15 November, 2012 (14 months) and the daily averaged variables are used here . For the 1/48° LLC4320 (1/24° LLC2160) simulation, its effective resolution ranges from 8 km to 4 km (16 km to 8 km) in the Southern Ocean between 30 °S and 65 °S26, which is smaller (larger) than the horizontal scale of the submesoscale mixed-layer instability at the same latitude45  reanalysis product and the 16 most significant tidal constituents; their vertical mixing is parameterized using the widely used Richardson number-based K-profile parameterization scheme34, both the 1/48° and 1/24° simulations can well resolve the generation process of mesoscale eddies therein. The submesoscale permitting LLC4320 simulation has recently been applied to submesoscale studies in various regions of the world ocean47. More details about these two simulations can be found in Su et al.18. The model setup is available at https://github.com/MITgcm-contrib/llc_hires/.Given that horizontal scale of the baroclinic instability that generates mesoscale eddies is larger than 50 km in the Southern Ocean48, the 1/10° OFES49, the 1/10° BRAN50, and the 1/10° LICOM51. These four eddy-resolving simulations are different in several aspects, including the horizontal and vertical grids, the atmospheric forcing, as well as the subgrid parameterizations. The key similarity among them is that they can all resolve mesoscale eddies but cannot resolve submesoscale eddies in the Southern Ocean. Detailed configurations of these simulations can be found in references 51.In addition to the 1/48° and 1/24° MITgcm simulations, to highlight the role of submesoscale eddies, another four widely used eddy-resolving ocean circulation realistic simulation products are used for comparisons. These simulation products include the 1/12° HYCOMwww.aviso.altimetry.fr/) and OISST (www.ncei.noaa.gov/data/), both of which have 1/4° spatial and daily temporal resolutions. For the large-scale process , both the simulated mean kinetic energy and temperature show close distributions and magnitudes with the satellite observed ones  in the simulation also display similar patterns and magnitudes to the observed results  and Yu et al. (2019) (ref. 52) that compared the LLC4320 simulation with the satellite altimeter or surface drifter data.To evaluate the performance of the 1/48° MITgcm LLC4320 simulation in the Southern Ocean, we compare its 14-month mean large-scale and mesoscale quantities at sea surface with the results from the concurrent satellite altimeter (including sea surface height and absolute geostrophic velocity) and surface temperature data , which is defined as the ratio of inertial to Coriolis terms in the horizontal momentum equations, is an important dimensionless parameter to characterize the relative importance of geostrophy. Typically, the Rossby numbers of mesoscale and submesoscale eddies are on the orders of 1 and 0.1, respectively14. Practically, the Rossby number can be quantified using the ratio between the vertical relative vorticity and the planetary vorticity, i.e.u, v, and f are the zonal velocity, meridional velocity, and planetary vorticity, respectively. In order to depict the simulated features of mesoscale and submesoscale eddies, the Rossby number is calculated using the 1/48° daily averaged simulation outputs here.The Rossby number . At present, the prevailing climate ocean models with a nominal resolution of ~100 km are only able to resolve processes with scale larger than ~400 km54. It means that even the largest mesoscale eddies  cannot be resolved by most of the present climate models.In this study, we define the 14-month mean field with a horizontal scale larger than 4° as the large scale . After removing the large-scale signals, we further define the perturbations with horizontal scales smaller and larger than 0.5°  as the submesoscale and mesoscale signals, respectively. In another word, the horizontal scale of mesoscale signals is between 0.5–4° . The isolation of different horizontal scales is completed using the corresponding low-, band-, or high-pass spatial filters. Here, the 0.5° separation scale between meso- and submesoscale is same as the LLC4320-based submesoscale study of Su et al. ρ is the sea water density, Cp = 4000 J kg−1°C−1 is the specific heat of sea water, and T′ and v′ are the temperature and velocity vector perturbations, respectively. Here, the subscript “e” denotes the mesoscale or submesoscale component, and the bracket denotes 4° or 0.5° spatial running mean based on the calculation object. Given that the EHFe vector contains both rotational and divergent components but the former does not contribute to the net heat transport, we only retain the divergent EHFe through applying the Helmholtz decomposition. Because we are concerned only with the vertically integrated meridional EHF, if not specified, the terms EHFme and EHFsm refer only to the meridional and divergent part of the corresponding EHFe integrated over the upper 1000 m. The term EHF is used to denote the sum of EHFme and EHFsm.The EHF is defined asme and EHFsm, the corresponding EHT across each latitude is obtained through a circular zonal integral. Here, the reasons why we only focus on the upper 1000 m are twofold. First, the averaged EHT in the Southern Ocean accounts for ~80% of the total one integrated over the whole water column of the model . Second, including levels below 1000 m will result in large errors due to topography contamination in the spatial filters . In a similar way, the meridional large-scale mean heat transport can also be calculated.Based on the EHFme budget is analyzed based on the vertically integrated EKE budget equation that simultaneously considers mesoscale’s interactions with both large scale and submesoscales. If we decompose the variable A into 55.p is the pressure, w is the vertical velocity, and Vtop (τw) is the horizontal velocity (wind stress) at the sea surface; primes and stars denote the mesoscale and submesoscale anomalies, respectively, and overbars denote the large-scale  spatial running mean. Physically, the left-hand term is the EKEme tendency (ET), and the right-hand terms from left to right represent EKEme advection (ADV), divergence of mesoscale pressure work (PD), baroclinic conversion from available potential energy (BC), kinetic energy transfer between large- and mesoscales (KTlm), kinetic energy transfer between meso- and submesoscales (KTms), mesoscale wind stress work (WW), and dissipation of EKEme (DS). The DS is a generic dissipation term that includes contributions from bottom friction, turbulent viscosity, and pseudoviscosity in the model. Briefly, Eq.  along each latitude or over the ACC band.Based on the EKESupplementary Information


Robotic surgery is a form of minimal access surgery, also known as robotic-assisted surgery. The Da Vinci Surgical (DVS) system was authorized in 2000. Robotic technology was introduced to facilitate surgeons during challenging operations, keeping the concept of minimal accessIn Pakistan, the first DVS system was deployed in 2011 at the Sindh Government Qatar Hospital in Karachi. However, this system collapsed after performing a few procedures, probably due to poor maintenance. The second robotic platform, which was more sophisticated and a generation higher (DVSi) than the previous one, was installed in Civil Hospital Karachi in 2013Robotic surgery in Pakistan is in an infantile phase and is slowly gaining momentum. It is important to review the financial implications and ongoing costs of robotic surgery in Pakistan. The introduction of robotics in public sector hospitals is a quite challenging task in light of Pakistan’s current economic state. The major hurdle and biggest concern in setting up a robotic program in low-income countries like Pakistan is the cost of robotic surgical procedures. Private sectors may be more suitable due to affordability issues, but only a limited number of people can get benefited thereA substantial investment is needed to install a new robotic platform. Therefore, a comprehensive, well-designed plan focusing on the maintenance, future development, and progress will be needed for the successful adoption of a robotic program in Pakistan, fulfilling international standards. The overall cost, available resources, patient load, suitability, and efficacy of the program should be evaluated before setting it up. To ensure the future success of robotic surgery in Pakistan, the economic model should be designed to be compatible with the country’s health system. For a low-income country like Pakistan, frequent remodeling and tailoring of the program may be essential during the initial phases after regular and vigilant assessments keeping a view on the expenses and available funds for the program, to enhance the efficacy and outcome of the program. The robotic surgery supervision should include a careful financial analysis and market trends. Maintenance, upgradation, recruitment of new team members, and staff training will be needed at regular intervals during various phases of the program. Due to the high installation cost and maintenance expenses, many hospitals may be reluctant to start a robotic program.For a successful robotic program, a well-trained OR team, devoted and enthusiastic surgeons, supportive hospital administration, sufficient funding sources, and a proper marketing strategy are crucial. For program sustainability, a special focus on marketing should be one of the best strategies, as it can compensate for the high procedure cost by increasing the patient volume.Not applicable.The author(s) received no financial support for the research, authorship, and/or publication of this article.All authors contributed equally.The author(s) declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.Not Applicable.Sidhant Ochani.


Public health programs are charged with implementing evidence-based interventions to support public health improvement, however, to achieve long term population based benefit these interventions must be sustained. Empirical evidence suggests that program sustainability can be improved through training and technical assistance, but few resources are available to support public health programs in building capacity for sustainability.Program Sustainability Action Planning Model and Training Curricula. Using Kolb’s experiential learning theory, we developed this action-oriented training model to address the program-related domains proven to impact capacity for sustainability as outlined in the Program Sustainability Framework. We evaluated the intervention using a longitudinal mixed-effects model using Program Sustainability Assessment (PSAT) scores from three time points. The main predictors in our model included group (control vs intervention) and type of dosage (active and passive). Covariates included state level American Lung Association score (proxy for tobacco control policy environment) and percent of CDC-recommended funding (proxy for program resources).This study sought to build capacity for sustainability among state tobacco control programs through a multiyear, group-randomized trial that developed, tested, and evaluated a novel Twenty-three of the 24 state tobacco control programs were included in the analyses: 11 received the training intervention and 12 were control. Results of the longitudinal mixed-effects linear regression model, where the annual PSAT score was the outcome, showed that states in the intervention condition reported significantly higher PSAT scores. The effects for CDC-recommended funding and American Lung Association smoke-free scores (proxy for policy environment) were small but statistically significant.Program Sustainability Action Planning Model and Training Curricula was effective in building capacity for sustainability. The training was most beneficial for programs that had made less policy progress than others, implying that tailored training may be most appropriate for programs possibly struggling to make progress. Finally, while funding had a small, statistically significant effect in our model, it virtually made no difference for the average program in our study. This suggests that other factors may be more or equally important as the level of funding a program receives.This study found that the NCT03598114, Registered on July 26, 2018  Public health programs are charged with implementing evidence-based interventions to support public health improvement. For a population to receive the full benefits of implementing an evidence-based intervention, the intervention must be sustained over time. While empirical evidence has established that program sustainability can be improved through training and technical assistance,, 2 few rSustainability is the presence of adaptive structures and processes which enable a program to effectively implement and institutionalize evidence-based policies and activities over time. This defOnly a few conceptual models focus exclusively on the ‘how’ or the programmatic process for building capacity for sustainability. The Dynamic Sustainability Framework offered by Chambers et al., considers the context in which an evidence based intervention is implemented and operationalized within a system . HoweverThe Program Sustainability Framework, which wThe “how” to plan for sustainability or increase programmatic capacity for sustainability has become increasingly more important in the past five years as funders have become more concerned with or required sustainability plans. For examProgram Sustainability Action Planning Model and Training Curricula. be have an effect on the sustainability outcomes measured?Program Sustainability Action Planning Model and Training Curricula study sought to build capacity for sustainability among evidence-based state tobacco control programs (TCPs) through a multiyear, group-randomized trial that developed, tested, and evaluated a novel urricula. Using Kourricula. we develurricula. This papProgram Sustainability Action Planning Model and Training Curricula, to increase the capacity for sustainability among state level tobacco control programs. This study was approved by the Institutional Review Board of Washington University in St. Louis (reference number 201801196). This study also received approval under Washington University’s Protocol Review and Monitoring Committee. This study was also registered retrospectively on July 26, 2018, as a clinical trial The PACT study utilized a utilized a multiphase outcome evaluation incorporating a group-randomized experimental design testing the effectiveness of a novel intervention, the Program Sustainability Action Planning Model and Training Curricula.The primary goal of the PACT was to provide an in person, manualized training for sustainability action planning and assessment in public health programs. We used a multiphase approach over five years (2018–2023) to develop and implement an assessment of the effectiveness of the Program Sustainability Action Planning Model and Training Curricula. In the first phase of the PACT study, the intervention was developed through a rigorous multidisciplinary literature review process and a series of expert consultations. We used SCOPUS, ERIC (ProQuest), PubMed, Education Full Text, and PsychINF databases to conduct formative review to inform the development and evaluation of the training intervention. Specifically, we performed literature reviews regarding experiential models of learning  and technical assistance (type and duration) to design the intervention. To design the evaluation of the intervention, we conducted formative reviews to assess previous metrics of experiential learning and technical assistance effectiveness. We also consulted with two academic experts in sustainability, two state tobacco control program directors, and three officials from the CDC Office on Smoking and Health to determine the final Program Sustainability Action Planning Model and Training Curricula was delivered to 11 TCPs. The intervention consisted of a two-day workshop to design a program sustainability action plan, two years of tailored technical assistance for implementing the action plan and sustainability outcome assessment. Participants of the workshops actively engaged in developing state TCP-specific sustainability action plans. Each state action plan outlined one or two domain-focused objectives, matched with time-specific activities to be shared across stakeholders present. One person at each workshop claimed responsibility for overseeing the implementation process. Sustainability plans were designed to be implemented over the course of two years. All Program Sustainability Action Planning Training workshops followed the same structure, but were tailored to each state depending on the Program Sustainability Framework domain chosen for the action plan. The two-day workshop involved the TCP staff and as well as a number of stakeholders  actively participating to design a sustainability action plan and develop an implementation strategy. Inclusion of and participation by all stakeholders engaged was an important component of the sustainability action plan development process and ensuring all components of the state TCPs were considered through tailored workshops at baseline and ongoing, robust TA through their three year participation.. Ultimately, 11 intervention and 12 control TCPs participated. The cipation.H1: Intervention group states will increase their capacity for sustainability more than the control group.H2: There will be a positive interaction effect between group and the amount of dosage, meaning those in the intervention group will benefit more as dosage increases.H3: The intervention will be more effective for states with lower policy progress (as proxied by the ALA smoke-free score) than those with higher policy progress.Our main hypotheses for the trial included:Our original sample consisted of the 50 US state tobacco control programs. Power analyses (at α = 0.05) revealed that between 9 (power = 0.8) and 12 (power = 0.9) states per group (control and intervention) would be appropriate. To randomize the two groups, we stratified the 50 states into four quadrants based on states’ needs (as adult smoking rates) and tobacco control policy environments (as American Lung Association (ALA) smoke-free scores, 2015). The ALA Data metrics were defined following recommendations from the advisory board and tobacco control experts and included organizational indicators, Program Sustainability Assessment Test (PSAT) scores, and intervention dosage. Organizational data was collected via record abstraction from annual state-level reports to the CDC Office of Smoking and Health. These reports address fulfillment criteria for the DP15-1509 funding announcement and describe the infrastructure, personnel, and activities of state tobacco control programs in detail. The funding announcements are a requirement of state programs, set by the CDC, to complete yearly reports of progress, goals, and challenges in order to receive federal funding. In addition to the CDC reports, other data was collected via secondary data sources, including the ALA’s annual State of Tobacco Control report and the In addition, we collected two primary sources of data. First, because it was not feasible to collect all data points through CDC program records, the study team developed a key informant interview tool to collect remaining information. The interviews were conducted by phone interview with state program managers or other qualified surrogate and lasted 15–20 minutes. Responses were recorded, transcribed, and reviewed for completeness and accuracy. An online Qualtrics survey was developed with identical questions for the convenience of state program managers that preferred not to complete a phone interview.Data from the Program Sustainability Assessment Tool (PSAT) was also collected at three time points . The PSAT consists of 40, 7-point Likert-scale items organized into the eight domains of the program sustainability framework . The PSAT was emailed to all stakeholders who participated in the sustainability action planning process in each state. The range of participants per states was 7–15. To complete the PSAT, respondents rated the extent  to which the program has or does what the item describes . We calculated state-specific means for each of the 40 items. State specific domain scores were obtained by averaging item scores within a domain. Overall domain scores were obtained by averaging the scores from all participating stakeholders for each domain, and standard deviations were calculated to show variability by state. These scores were used as the outcome in our analyses. The PSAT is a reliable instrument developed to evaluate capacity for sustainability of public health, social service, and clinical care programs.https://sustaintool.org/psat/resources/ and https://prcstl.wustl.edu/pact-resources/), referred to as passive dosage. A summary of intervention and control group activities can be seen in Active dosage was measured in hours spent in sustainability training, technical assistance, or workshops delivered in-person or virtually. All programs (including control and intervention state TCPs) were given access to online sustainability resources  and two types of dosage (active and passive). Active dosage was measured in contact hours spent in sustainability training, technical assistance, or workshops delivered in-person or virtually. Passive dosage was measured as binary where 0 = no resource use and 1 = any resource use, as reported in annual surveys of programs. Other covariates included the percentage of CDC-recommended funding as a pr ; and Year 2–21 (91%).Twenty-three of the 24 state programs were included in the analyses; one state dropped out of the study before data could be collected. Descriptive statistics are shown in Table 3 contains the results of the longitudinal mixed-effects linear regression model, where the annual PSAT score was the outcome. States in the intervention condition reported significantly higher PSAT scores, suggesting greater capacity for sustainability after receiving the PACT training. The effects for CDC-recommended funding and ALA smoke-free scores were small but statistically significant indicating that 1) as a program’s funding rose by 1% its PSAT score would increase by 0.01 (95% CI: 0.01–0.02), and 2) as a program’s ALA score increased by 1 (regardless of group) its PSAT score would increase by 0.04 (95% CI: 0.02–0.05), all else equal. Finally, in states with a higher ALA score, and therefore stronger policy environment, the impact of the intervention mattered less. This effect is explored more below. The remaining variables were not statistically significant. It is also useful to note that we experimenting collapsing the program manager tenure variable to three and four categories and results were similar and not statistically significant.To complement the results in Table 3, Program Sustainability Action Planning Model and Training Curricula to increase the sustainability capacity of tobacco control programs. There is a growing body of research on aspects affecting sustainability, at between 0.85 and 0.90. We also proxied staff turnover with program manager tenure, due to data availability issues, and these two phenomena may be less related than we assume. Future studies should focus directly on the relationship between sustainability and staff turnover to further illuminate the mechanisms at work.Program Sustainability Action Planning Model and Training Curricula, programs who utilize the training should track sustainability measures over a greater amount of time.Finally, while this study analyzed sustainability data over three years, we believe to determine true effectiveness of the Program Sustainability Action Planning Model and Training Curricula to improve sustainability over time. The benefits of program sustainability will not only benefit the state programs themselves, but also the health of state populations through the continuation of evidence based public health initiatives. This study’s findings will contribute to the field of implementation science by providing knowledge on “how” to mature and sustain activities over time, thereby achieving the full benefit of significant public health investments. Future research is needed to further validate the results of this study. First, research testing the implementation of the Program Sustainability Action Planning Model and Training Curricula within other public health and chronic disease program areas would extend the utility of our work. Second, given the growth in online based training because of the COVID pandemic and need for social distancing, testing the implementation of the Program Sustainability Action Planning Model and Training Curricula intervention in an online format could possibly allow for more programs to access the training and for more stakeholders to participate in the planning, especially in more rural states.Research consistently indicates that even effectively implemented interventions risk failure when funding, planning, or training ends ., 29–31 IImplementation of newly funded programs does not guarantee long term sustainment, so programs and evaluators should take a more exhaustive focus on the factors that influence sustainabilityTargeting tailored trainings at relatively lower-performing programs may conserve resources for programs, evaluators, and implementation scientists.Training curricula materials provided to broader public health audiences are associated with increased sustainability of evidence-based practices


Overweight, obesity, and their associated health complications have become a major public health issue. Online approaches have been rarely attempted to address the problem. The aim of this study was to evaluate the effectiveness of using social media networking for people living with overweight and obesity to adopt a healthier lifestyle with a three-month multidisciplinary healthcare program. Effectiveness was assessed through questionnaires on patient-related outcome measures (PROMs).Two non-profit associations designed the program delivered to people living with overweight and obesity in a closed group via Facebook, the popular social network. The three-month program had three main axes, namely nutrition, psychology, and physical activity. Anthropomorphic data and sociodemographic profiles were collected. Quality of life (QoL) was assessed at the beginning and at the end of the intervention using PROM questionnaires for six different domains, i.e., body image, eating behavior, physical, sexual, social, and psychological functioning.Six hundred and twenty persons participated in the program; 567 persons consented for the study, and 145 completed the questionnaires entirely. QoL was significantly improved in five out of six domains, i.e., body image, eating behavior, as well as physical, sexual, and psychological functioning. The improvement was valid regardless of age, gender, initial body mass index, person with or without children, educational level (primary versus secondary versus high school), and occupation . In multivariate analysis, living as a couple was an independent factor correlated to a positive progression in four domains, i.e., body image, eating behavior, as well as physical, and psychological functioning.This study showed that an online lifestyle intervention might be a promising way of improving the quality of life of people living with overweight or obesity. OverweiImplementing health interventions via the Internet and social media networking have the great advantage of treating large numbers of persons at reduced costs . When inSeveral online programs have already been set up. The results are heterogeneous, probably due to different methods and target populations; nevertheless, they remain promising –19. One The aim of this study was to evaluate the effectiveness of a multidisciplinary health program for people living with overweight and obesity using PROMs questionnaires delivered via Facebook, the social media network, by two Swiss-based non-profit organizations (NPOs).2.2.1.2. The BMI was calculated according to the declared weight and height of the participants. There were no exclusion criteria other than a BMI <25 kg/m2 and the geographical component for operational reasons. This was the decision and will of the promoting organizations to be as inclusive as possible, targeting large public health interventions. Involvement was charge-free for participants. Registrations began following a press conference for the local traditional press on August 15, 2021 along with an announcement on social media networks. The program was delivered from September 5 to December 5, 2021.Two non-profit organizations have launched a health program for people living with overweight and obesity –26 in th2.2.The program was designed in the form of posts with either short written messages and/or didactic videos. Field professionals developed all educational materials and recommendations, and a team of experts dedicated to the management of obesity reviewed and validated it. Community managers published the posts usually once a day during weekdays and twice to three times on weekends. These managers moderated the debates between attendees, and they were also available to answer questions or refer to specific enquiries to the healthcare professionals in charge of each domain. Some face-to-face events were also organized upon registration to allow participants to meet for activities such as outside walking and mindful eating. 2.3.Physical activity: A professional sports coach was in charge of this aspect. The aim was to find a daily or weekly routine habit to move and do exercises. A pedometer was provided. The participants were asked to report the count of their daily steps. The project revolved around the symbolic objective of an odyssey to reach Beijing (China) on foot from Neuchâtel (Switzerland) counting the steps of all participants during the 3 months. Adapted fitness exercises, including several levels of difficulty to be accessible to all, were shown and encouraged with videos.Nutrition: The first objective was to break the vicious circle of repetitive restrictive low-calorie diets that many candidates previously experienced. A dedicated dietician prepared the posts. The objectives were to allow attendees to reconnect with their appeased food sensations and to eat with pleasure. Another point was to promote a healthy diet according to the recommendations of the Swiss Society of Nutrition .Once registered, participants were able to join a closed group on Facebook. The animation was delivered via this channel to promote group dynamics and mutual aid between participants.The global costs of the program were estimated at 130,000 Swiss Francs (CHF). At inclusion, participants completed a questionnaire with items related to their anthropomorphic and sociodemographic characteristics such as weight, height, waist circumference, gender, age, educational level, family status , occupation, and place of birth. They were also asked to complete questionnaires about their QoL, health condition, and expectations at the start and at the end of the program. The QoL questionnaires used included the Body-Q PROMs specific to obesity treatment . Six dif2.4.All the data came retrospectively from the program described above and called “Neuchâtel s’attaque au surpoids” (“Neuchâtel tackles overweight”). It is why the criteria for participation, inclusion, and exclusion are by extension similar to those of the studied program.The program ran from September 5 to December 5, 2021. The anthropomorphic data and sociodemographic profiles of the participants at the start and at the end of the program, as well as the QoL PROMs were available. Only the participants who consented to the use of their data for scientific purposes were examined. We assessed changes in QoL, as well as weight loss and waist circumference between the beginning and the end of the program. For this step, only data from participants who entirely provided the data and completed questionnaires were considered.3.p ≤ 0.05. Afterwards, we calculated whether the evolution of the QoL varied according to anthropomorphic data and sociodemographic profiles registered at the start of the program.The statistical analyses were performed using the R software. The analyses on the effect of the program were conducted using Student’s parametric tests for paired samples. The scores obtained in the QoL, weight, and BMI at the beginning and at the end of the program were compared. If the difference was significant, a multiple linear regression was applied to the differences between the values on the final balance sheet and those on the initial balance sheet. The objective of this multiple linear regression was to determine whether gender, age, marital status, presence of children, occupation, educational level, and BMI were related to the evolution of the QoL. This procedure was automated by the glmulti function  to fit tFor the QoL domains which showed significant improvement, a multivariate analysis was performed. The following parameters were considered: age and baseline BMI as linear parameters, followed by gender, family status (living as a couple or being single), persons with or without children, educational level (primary versus secondary or high school), and occupation , as well as country of birth (Switzerland versus another country) as binary parameters.4.Six hundred and twenty persons subscribed to the program; 567 of them gave their consent for this study. These respondents made up the entire group (EG). Among the 567 persons, 145 had fully completed the QoL questionnaires at the start and at the end of the program. These 145 persons made up the study group (SG). p < 0.001), except for the domain of social function (p = 0.176).For the QoL domains that showed significant improvement, a multivariate analysis was conducted. The parameters of the multivariate analysis are summarized in p < 0.01) in favor of people living as a couple compared to single persons was found regarding the improvement in the following domains of the QoL: body image, eating behavior, as well as physical and psychological functioning.A positive correlation (p < 0.01) in favor of female compared to male participants was found for the progression of the physical function QoL domain.A positive correlation (p < 0.01) was found in favor of persons with a lower initial BMI used as a linear parameter for the body image QoL domain improvement.A positive correlation  in five out of the six domains studied including body image, eating behavior, as well as physical, sexual, and psychological functioning.To the best of our knowledge, this is the first article which specifically assesses the use and effectiveness of a social media-delivered multidisciplinary program open to all adults presenting with overweight or obesity in a geographical area with the primary outcome being the evolution of QoL with PROMs questionnaires. Our major finding is that the QoL of the participants improved . Requests to access these datasets should be directed to All procedures performed in this study were in accordance with the ethical standards of the non-profit organizations involved and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.AS: substantial contributions to the conception and design, analysis and interpretation of data for the work, and drafting the work. J-MF, JB-M, CP-B, CB, VC, FA, BC, PF, MD, and SS: substantial contributions to the conception and design, interpretation of data, and revising critically the work. LV and MM: substantial contributions to the conception and design, acquisition and analysis of data, and revising critically the work. All authors contributed to the article and approved the submitted version.This study was supported by the two non-profit organizations which delivered the program , 23.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The median duration of the stent program was 34 months , and procedural complications were rare. Conclusions: EBSP is safe, but lengthy and successful in only about half the patients. Intrahepatic strictures were associated with an increased risk of cholangitis.Background: Non-anastomotic biliary strictures (NAS) are a common cause of morbidity and mortality after liver transplantation. Methods: All patients with NAS from 2008 to 2016 were retrospectively analyzed. The success rate and overall mortality of an ERCP-based stent program (EBSP) were the primary outcomes. Results: A total of 40 (13.9%) patients with NAS were identified, of which 35 patients were further treated in an EBSP. Furthermore, 16 (46%) patients terminated EBSP successfully, and nine (26%) patients died during the program. All deaths were caused by cholangitis. Of those, one (11%) patient had an extrahepatic stricture, while the other eight patients had either intrahepatic  or combined extra- and intrahepatic strictures . Risk factors of overall mortality were age ( Biliary complications are a common cause of morbidity and mortality following liver transplant. Biliary strictures can be distinguished into anastomotic and non-anastomotic biliary strictures (NAS) ,2.Anastomotic strictures usually occur limited to the biliary anastomosis between the donor and the recipient bile duct. They are caused by fibrotic healing of a short segment, narrowing the anastomosis . The freThe characterization of NAS is less defined in the literature. NAS can be described as one or more strictures and/or dilatations of the bile ducts proximal to a biliary anastomosis. Typically, the strictures are longer, at multiple sites, and they occur 3–6 months after liver transplantation, which is earlier than with anastomotic strictures .There are two different subtypes of NAS: ischemic biliary lesions (IBLs) caused by a thrombosis in the hepatic artery, and ischemic-type biliary lesions (ITBLs) . The etiIn comparison to anastomotic strictures, endoscopic approaches to treat NAS have only been examined by few retrospective trials ,10,11,12The present study was designed as a retrospective single-center study conducted at the Department of Internal Medicine 1 at the University Hospital in Frankfurt, Germany. The study was approved by the Institutional Review Board of Frankfurt Goethe University (365/17). All research was conducted in accordance with both the Declarations of Helsinki and Istanbul.DefinitionsNAS was defined as one or multiple strictures in the biliary tract system not related to the anastomotic region following liver transplantation . NAS wasAfter liver transplantation, all patients underwent a follow-up focusing on clinical conditions, changes in laboratory values, and sonographic findings. As indicated, a computed tomography scan or a magnetic resonance imaging with contrast agent during the arterial phase was performed to confirm occlusion of the hepatic artery, thereby confirming IBL with consecutive surgery to regain arterial perfusion.All NAS cases were classified by the ERCP reports into extrahepatic (type I), intrahepatic (type II), or combined extra- and intrahepatic strictures (type III) . ProgresTM Stent, TaeWoong Medical, Gimpo-si, Republic of Korea).In this study, the phrase “ERCP-based stent program” is defined as all endoscopic stenting treatments performed in each patient with NAS after liver transplantation until successful resolution of NAS with removal of all stents, switch to a surgical approach, death, or end of follow-up (31 May 2020). In cases of NAS being diagnosed in patients after liver transplant receiving an ERCP due to other reasons, previous ERCPs since transplant were retrospectively analyzed for unrecognized signs of NAS. The duration of ERCP-based stent programs was measured from the first ERCP with signs of NAS to program termination due to any of the abovementioned reasons. The total number of ERCP procedures and the number of ERCP procedures since diagnosis of NAS were counted. The biliary stents placed were plastic stents  or metal stents  underwent liver transplantation and (II) developed NAS (either IBL or ITBL) with (III) subsequent ERCP-based stent program at our hospital.Exclusion criteria were (I) patients not fulfilling all inclusion criteria or not undergoing the entire stent program at our hospital, (II) patients with strictures other than NAS, (III) patients with isolated anastomotic stricture without simultaneous NAS, (IV) patients who underwent surgical management of NAS either before or instead of ERCP, except for prior surgical revascularization of the hepatic artery.EndpointsFirst, all procedures and outcomes were collected from selected patients diagnosed with NAS after liver transplantation who met the study criteria.Then, the procedural outcomes and success rates and peri-interventional data such as duration and number of performed ERCPs, change in treatment approach, technical parameters, and complication rates of patients who underwent an ERCP-based stent program as the first-line approach were analyzed. All patients were further subdivided into those with ITBL vs. IBL and further by location of strictures (type I to III).Lastly, regression analysis of baseline variables and laboratory values was performed, assessing successful termination of the ERCP-based stent program and overall mortality.Statistical methodsStatistical analysis was performed using IBM SPSS Statistics version 21  and R , Vienna, Austria).Descriptive statistics were computed to provide frequencies for categorical variables and median with 25th and 75th percentiles for continuous values.Laboratory values were included as time-dependent variables, and death was defined as competing risk using the Aalen–Johansen estimator.Univariate Cox regression and univariate competing risk regression were used to find predictive factors for overall mortality and successful termination of the ERCP-based stent program. The Cox proportional regression model assumes a linear relationship between the endpoint and quantitative predictor variables. Predicator variables that have a highly skewed distribution, as expected by the laboratory values, may require logarithmic transformation to reduce the effect of extreme values. A survival analysis was performed using Kaplan–Meier survival analysis and Cox regression analysis.p-values ≤ 0.05 were considered statistically significant.Results were expressed as hazard ratios (HRs) with 95% confidence intervals (CIs). The test for the influence of laboratory values was one-sided, while all other tests were two-sided; A total of 287 patients underwent liver transplantation between 2008 to 2016. Of these patients, 40 patients (13.9%) were diagnosed with NAS . Follow-up was ended in May 2020.Median time to diagnosis of NAS, ITBL, and IBL was 5, 6, and 3 months after liver transplantation, respectively.Descriptive analysis of all patients with NASOne patient underwent a single ERCP with stent exchange because of cholangitis but was lost to follow-up afterward. A total of 35 patients (88%) were treated in an ERCP-based stent program, and four (10%) were treated primarily with a bilioenteric anastomosis. Two of the four surgically treated patients underwent an additional PTBD program. Three of the four patients needed re-transplantation, of which two survived. One patient was successfully treated by a combination of bilioenteric anastomosis and PTBD program.Of the 35 patients primarily treated in the ERCP-based stent program, 16 patients (41%) successfully finished endoscopic stenting without needing a different treatment approach, five patients (13%) were still undergoing endoscopic stenting at the end of follow-up, five patients (13%) switched to a surgical approach, and three of them (9%) switched to PTBD treatment. Cholangitis was the cause of death in all nine patients (23%) who died during the ERCP-based stent program. Organ transplantation was indicated in all these patients. However, one patient refused further treatment; one patient was not listed again for liver transplantation because of their expressed wish against transfusion of blood products; four patients had contraindications to transplantation ; lastly, three patients did not receive an organ in time. Analysis of the ERCP-based stent programIn one subgroup, only patients in the ERCP-based stent program were analyzed, including 35 of 40 (88%) patients . One patient who only received a single stent replacement and four patients who had primary surgical treatment were excluded . All 35 patients who were in the ERCP-based stent program to treat NAS received a first ERCP including endoscopic papillotomy and cholangiography to visualize the biliary system and classify NAS into type I to III. In all patients, a stent placement was performed after lavage of the biliary system: 28 (80%) received single stent placement, whereas two stents were placed  in seven patients (20%).According to the medical report, the major stricture was successfully stented in 30 patients (85%) after the first ERCP.p = 0.01) and bile stones (p = 0.04) were significantly more often extracted in those patients who only underwent endoscopy, but no further multidisciplinary treatment, as shown in In 15 (43%) patients, additional balloon dilatation was performed at least once during the ERCP-based stent program. Casts were extracted in 23 (66%) patients, and bile stones were removed in 20 (57%) patients. Casts . In 3 patients, self-expanding metal-stents (SEMS) were placed.A total of 29 (83%) patients had an additional anastomotic stricture, which was resolved in 27 (93%) cases during the endoscopic stenting program. Of the remaining two patients, one patient died due to cholangitis and liver abscesses, and one patient was still undergoing the stent program at the end of follow-up.Furthermore, 16 (46%) patients terminated the ERCP-based stent program successfully . The median duration of the ERCP-based stent program was 34 months, with a median of 14 performed ERCPs. Furthermore, insertion of stents increasing in size and/or number was the aim, with the insertion of up to four stents at one time.Five (14%) patients underwent a subsequent surgical approach with a bilioenteric anastomosis. All these had either extrahepatic or combined strictures of the biliary system.At the end of follow-up, 21 (60%) patients were still alive, nine (26%) died due to cholangitis , one (3%) patient died during subsequent surgery after failure of the ERCP-based stent program, and four (11%) patients died due to causes not related to NAS after successful termination of the ERCP-based stent program. Of the nine patients who died during the period of the ERCP-based stent program, one (11%) patient had a solitary extrahepatic stricture, and eight patients had either a solitary intrahepatic stricture  or a combined extra- and intrahepatic stricture . However, no statistical significance was found between intrahepatic or extrahepatic strictures as shown in p = 0.1) or successful termination of the ERCP program (p = 0.7). Data are displayed in We did not observe any statistical differences between ITBL and IBL with respect to mortality during the ERCP-based stent program (Patients with primary biliary cholangitis (PSC) represent a special patient group because they already have diffuse strictures as an underlying disease comparable to NAS. Three patients with PSC were represented in the present study. Two patients had an ITBL, and one patient had an IBL. In all three cases, the primary ERCP-based stent program failed. Two patients received surgical intervention by bilioenteric anastomosis, and one patient was further treated by PTBD. The one patient without procedural change had pure intrahepatic strictures and died due to cholangitis with multiorgan failure.The most common complications during the ERCP-based stent program were cholangitis in 26 (74%) patients, mild post-ERCP pancreatitis during the entire stent program in eight (23%) patients, and bleeding in one (4%) patient. No patient died or had a perforation directly associated with the ERCP. All data on complications related to ERCPs are presented in Variables for termination of ERCP-based stent program and overall mortalityITBL vs. IBL and type of NAS for the primary endpoints successful termination of ERCP-based stent program and overall mortality showed no significant difference among the different types of strictures. Data are shown in Regression analysis of Furthermore, univariate analysis was performed for the primary endpoints. No patient or surgical variables or laboratory values had an impact on successful termination of the ERCP-based stent program.p < 0.05), bilirubin , alanine aminotransferase , and aspartate aminotransferase . Complete data of the Cox proportional hazards regression analyses are presented in Overall mortality was associated with increased age (HR: 1.13, 95% CI: 1.01–1.26; Data on NAS and its therapy are still scant in the literature, even though NAS occurs in up to 30% of patients following orthotropic liver transplantation ,22,23,24While IBL is less common than ITBL, the overall mortality, success rate of the ERCP-based stent program, and switch to a surgical approach did not differ significantly between the two. However, the present data might be underpowered to detect differences in IBL and ITBL. Despite a different pathogenesis leading to strictures in IBL and in ITBL, both appear alike on cholangiography . TherefoOur data confirm that strictures can be resolved in about 50% of cases by repeat endoscopic stenting. Other studies found a slightly higher success rate of up to 66% ,26. ThisCompared to intrahepatic strictures, treatment of extrahepatic ones had a trend toward higher success of the stent program, a better outcome of bilioenteric anastomosis, and a lower mortality. Reasons might be that intrahepatic strictures beyond the hilar region are usually neither reachable with stents nor resolved with a bilioenteric anastomosis. Only PTBD is a reasonable option in intrahepatic strictures, but it is limited to a single bile duct. Therefore, balloon dilatation might be a solution for multiple intrahepatic strictures. Balloon dilatation of biliary anastomotic strictures alone was compared to dilatation plus stenting and found to yield significantly better results . As stenElevated bilirubin and transaminase levels were shown to be risk factors for higher mortality of NAS. No good predictive marker for successful termination of the ERCP-based stent program could be found, as similarly shown by Graziadei et al. . In theiLimitations of this study were due to its retrospective character. Nonetheless, compared to previous studies, patients’ characteristics and incidence of NAS appear representative ,23,24,31Patients with NAS and additional anastomotic stricture were included in the present study. This could have introduced bias, as it remains unclear which stricture led to the observed results. However, it seems reasonable that the effects of anastomotic strictures on the endpoints were negligible because almost all anastomotic strictures were resolved within 1 year, and no patient died during that time. Another limitation is that the ERCP-based stent program could have been terminated at the discretion of the endoscopist. However, patients underwent further clinical and laboratory follow-up with continuation of the stent program if indicated.Primary endoscopic stenting followed by subsequent surgery with PTBD is the current standard of care in NAS treatment ,27,28,29Furthermore, no laboratory values and patient- or procedure-related characteristics were found that help to predict a successful termination of endoscopic stenting, while age, bilirubin, AST, and ALT were associated with increased mortality. Procedure-related mortality was low. Major adverse events during the ERCP-based stent program were cholangitis and mild pancreatitis, with cholangitis being the most important cause of death in the presence of NAS.Further trials with expanded cohort sizes are needed to allow development of predictive models for treatment outcomes. Special focus should also be placed on the number of strictures in NAS and on further investigation of which intrahepatic strictures are resistant to endoscopic and multidisciplinary treatment, to predict the need for early re-transplantation to avoid cholangitis with multiorgan failure without further treatment options.


Tetragonula pagdeni is distributed over a vast Southeast Asian territory. This species is commonly used as a commercial insect pollinator. Pollination efficacy of T. pagdeni was investigated with tomato (Solanum lycopersicum L.) cultivated in greenhouse environments. In the first experiment, the number of fruit sets, number of seeds, fresh weight, and fruit height were quantified in the greenhouse with stingless bees, without stingless bees, and with pollination by mechanical vibration by hand. In the second experiment, the treatments were conducted with tomatoes of indeterminate growth in the greenhouse with and without stingless bees to prevent variation among the different tomato plants. The obtained results showed that a greenhouse with stingless bees presented 85 ± 4.24 fruits per 100 flowers, more than a greenhouse with mechanical vibration (79.5 ± 2.12 fruits per 100 flowers) or a greenhouse without stingless bees (15 ± 0.00 fruits per 100 flowers). In addition, fruit produced in a greenhouse with stingless bees showed greater fruit weight and number of seeds than fruit produced in a greenhouse without stingless bees or pollinated by mechanical vibration. According to the obtained results, we suggest that T. pagdeni could be beneficial as an insect pollinator of greenhouse tomatoes in tropical regions, where the use of honeybees and bumblebees would be more difficult.The stingless bee  Solanum lycopersicum L.) flower is self-compatible, but releasing the pollen grains through the apical flower requires vibration of the poricidal anthers (Apis mellifera L.) or bumble bees (Bombus terrestris) in greenhouse tomatoes. The results show that bumble bees were effective on tomatoes in greenhouses, whereas honey bees were not (Melipona quadrifasciata) and honey bee (Apis mellifera) were tested and compared in tomato greenhouses. Stingless bees were significantly more effective than honey bees in pollinating greenhouse tomatoes. In addition, under greenhouse conditions, the quality of tomato fruits can be increased by the use of stingless bee species with different flower-visiting behaviors (Tomato ( anthers . In an o anthers . However anthers . Mechani anthers . Anotherwere not . Bumble were not . Additiowere not . The polehaviors . In tempScaptotrigona aff. depilis and Nannotrigona testaceicornis) were found to be successful in pollinating strawberry greenhouses in Brazil  that have been successfully domesticated at the farm scale. Colony populations of this species have several thousand individual female workers headed by a single female queen , conventionally used for meliponiculture in Thailand. In addition, all colonies were queen-right and contained similar quantities of honey and pollen storage pots at the beginning of the experiments . The climate is tropical, with an average precipitation of 553 mm and an average temperature ranging from 26–30 °C. The experiments were conducted between August 2020 and March 2021. The colonies of eriments . One heaThirty-day-old seedlings were each placed in a five-liter plastic pot (one plant per pot) that contained 5 kg of substrate. The substrate used in each pot consisted of five shares of forest soil and one of cattle manure supplement, with 20 g of NPK 4-14-8 . Thirty The greenhouses had flat-arch roofs . The roof was covered with transparent low-density polyethylene with a sheet thickness of 0.1 mm. To exchange the heat and humidity inside the greenhouse, the lateral walls were installed with an insect proof net with a stitch dimension of 50 mesh. Each greenhouse was 1.5 m away from the next. Three greenhouses with three treatments were used in this experiment. The treatments were one greenhouse with stingless bees (WSB), one greenhouse without stingless bees (WoSB), and one greenhouse without stingless bees but using hand vibration (WoSBHV: each cordon of plants was vibrated by hand for 5 s between 08:00 and 10:00 am twice a week). The temperature and humidity of each greenhouse were measured during the foraging activity experiment using digital sensors ; temperature < ±0.5 °C). All three experiments were performed in parallel.Tomato has a period of flower blooming 45–50 days after seeding. Thirty pots of tomato were grown in each greenhouse. Thirty inflorescences (with 6.00 ± 1.40 flowers/inflorescence) were randomly selected for each experiment. All pots were maintained approximately 80–120 days after seeding for fruit production. After fruit harvesting, all plants were executed. The new set of seedlings was generated for the second replication, and in total, 60 plants were used for each experiment.T. pagdeni) were used in the WSB experiment. Before colony introduction into the greenhouse, the colonies were checked for substantial honey and pollen storage. One colony  (T. pagdeni in a standard wooden box was introduced into the greenhouse as soon as flowers first bloomed (approximately 45 days after transplantation) and was removed 7 days later. One colony was placed in each greenhouse in this experiment. For the WoSBHV treatment, each cordon of plants was vibrated by hand for 5 s at 08.00 and 10.00 am twice a week for 4 weeks (Stingless bees ( colony)  of T. pa 4 weeks . For theT. pagdeni on tomatoes, 10 flowers of each of 10 tomato plants per treatment  were randomly tagged. The number of fruit sets of tagged flowers was determined to evaluate the percentage of fruit sets of each group (T. pagdeni (WSB) was compared to that under the other treatments (WoSB and WoSBHV). Analysis of variance (ANOVA) followed by Tukey’s multiple comparison test (p < 0.05) was performed to compare the number of fruit sets, number of seeds, fruit weight, fruit diameter, and fruit height. Multiple regression analysis was performed to investigate the relationship between the treatments and the number of seeds, fruit weight, fruit diameter, and fruit height. The statistical analyses were performed using the R program . The camera was positioned 30 cm from the nest entrance, setting aside a nest entrance to avoid disturbing forager activity. The returning foragers with and without a pollen load attached to their corbicula were counted  followed by Tukey’s multiple comparison test (p < 0.05) was carried out to compare the fruiting rate, fruit weight, fruit height and fruit diameter, and the number of seeds from bagged and unbagged flowers in greenhouses with and without stingless bees . The number of incoming and outgoing forager bees was not consistent, peaking around 7 am to 1 pm, then slightly declining, and then stopping after sunset (around 6:00 pm)     (After we introduced the 6:00 pm) . The hig6:00 pm) . The tem< 0.001)  and humi< 0.001) . Similar< 0.001)  and humi< 0.001) .T. pagdeni foragers visited the tomato flowers in the greenhouses  both increased the number of fruit sets compared to the WoSB treatment (without pollination agents)  = 86.519; p < 0.001; seed number: 17.75 ± 2.39 and 13.42 ± 2.60, F = 48.489; p < 0.001; fruit height: 27 ± 3.31 and 23.3 ± 3.24, F = 92.374; p < 0.001; and fruit diameter: 16.82 ± 2.43 and 14.28 ± 2.25, F = 13.558; p < 0.001) , fruit height , and fruit diameter .We found that enhouses . The forenhouses . Howeverenhouses . As expe agents) . No data< 0.001) –3E. AddiF = 20.832; p < 0.001) (p ≥ 0.05).In greenhouses with stingless bees, the number of fruit sets of the unbagged flowers (90%) was significantly larger than that of the bagged flowers (20%) or flowers in greenhouses without stingless bees  (< 0.001) . We also< 0.001) . HoweverT. pagdeni increases the quality and production of tomatoes in greenhouses similarly to those pollinated by hand vibration, but pollination by mechanical vibration is more labor intensive . They reported that the number of foraging bees returning to the hive was high between 08:00 am and 11:00 am. Melipona quadrifasciata foraged on tomatoes from 08:00 am through 11:00 am. For the genus Tetragonula, the foraging activity of Tetragonula iridipennis Smith had a high peak at 10:00 am (8.17 bees/five plant/5 min), and then the activity decreased after 11:00 am  and sweet pepper (Capsicum spp.)  .T. pagdeni in tropical climate greenhouses is the effective transfer of pollen among flowers. This study did not directly determine the removal rate of pollen grains. However, we did find that the number of seeds per tomato fruit produced in greenhouses with T. pagdeni was significantly higher than that in greenhouses with hand vibration or greenhouses without stingless bees .Although eenhouse  or by usng range  and can ng range . HoweverT. pagdeni could be beneficial as an insect pollinator of greenhouse tomatoes in tropical regions, where the use of honey bees and bumblebees would be more difficult. Another advantage of keeping colonies of T. pagdeni is the safety of farmers because they do not sting. The species is commonly found in both disturbed and undisturbed habitats. T. pagdeni is easily managed using artificial hive boxes and propagation (T. pagdeni is perennial, it is not necessary to replace the hive as would be necessary for bumblebees. More research is needed on the foraging behavioral biology of this stingless bee species and a rigorous investigation of its value as a pollinator compared to currently used bee species.According to our results, we suggest that pagation . Because10.7717/peerj.15367/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.15367/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.15367/supp-3Supplemental Information 3Click here for additional data file.10.7717/peerj.15367/supp-4Supplemental Information 4Click here for additional data file.


There remains a question of whether graduates trained internally are different than those trained elsewhere. We examine the difference between physicians trained within our Graduate Medical Education (GME) programs versus physicians trained elsewhere. Our large integrated healthcare system is unique in addressing this objective due to its large physician labor hiring needs across different specialties of GME graduates.p < 0.05 was significant.A retrospective review was performed from Jan 2000 to August 2020 of Kaiser Permanente Southern California (KPSC) physicians hired: KPSC GME trained versus non-KPSC GME trained. We examined five variables: retention, leadership , physician relations cases, member appraisal of physician and provider services survey (MAPPS) scores, and rate of board certification. Chi-square test of proportions was used for comparison, p =  < 0.01), Leadership [current 13% vs 10% (p =  < 0.01)or historical 17% vs 14% (p = 0.01)], Physician Relations 23% vs 26% (p = 0.04), MAPPS 75% vs 69% (p =  < 0.01), and Board Certification 81% vs 74% (p =  < 0.01)), KPSC outperformed non-KPSC GME-trained physicians to a statistically significant degree.From Jan 2000 to August 2020, 2940 residents and fellows graduated from KPSC GME programs, of which 1127 (38%) were hired on at KPSC as full time attendings. Across all five metrics (Retention 82% vs 76% (We have shown that an internally sponsored GME program can represent an opportunity for recruitment of physicians that may have higher retention rates, higher probability of being physician leaders, decreased likelihood of physician relations issues, improved patient satisfaction, and increased rates of board certification. The United States is predicted to face a substantial shortage of physicians. Recent estimates project a shortfall of between 41 000 and 105 000 doctors by 2030 [In the setting of rising NHE, there has been increased scrutiny of the expenses required to maintain Graduate Medical Education (GME) programs, manifested by multiple proposals to decrease funding , 5. BetwAs health care costs increase, the population ages, and the physician shortage grows, hospitals will face accelerating challenges in recruiting and retaining talented physicians. Physician recruitment is a time-consuming and costly endeavor that can vary in its rate of success based on hospital location and practice finances. Furthermore, retaining experienced physicians becomes another important area of focus as more doctors report burnout and career changes .For these reasons, the goal of any healthcare system is to hire physicians who possess the particular skills that will equip them to succeed in this challenging environment. The concept of “hire your own” has the obvious benefits of familiarity with the health system and hospital culture, and reduced costs of recruitment. We hypothesize that there may be other quantifiable benefits as well. Can hiring graduates of your own training program improve physician retention, cultivate leadership, and perhaps improve patient satisfaction?This study was approved by our institutional review board. A retrospective review was performed within the Physician Human Resources database of the Kaiser Permanente Southern California (KPSC) Human Resources Department. KPSC is an integrated healthcare system, currently with 15 medical centers serving more than 4.5 million members across Southern California. During the study period from Jan 1, 2000 to August 28, 2020, there were more than 7,000 full time KPSC physicians. KPSC Graduate Medical Education (GME) has been accredited since 1955. It is currently the ACGME Sponsoring Institution for 18 residency and 15 fellowship programs. During our study period, KPSC GME graduated 131–150 residents and fellows annually. Physician names were blinded for the analysis and interpretation of data. All KPSC physicians who were trained either in KPSC residency and/or fellowship from 1/1/2000 to 8/28/2020 were included in the study population. Physicians who trained in KPSC residency followed by any KPSC fellowship were counted as fellowship trained only.The five dependent variables gathered and analyzed were Retention, Leadership , Physician Relations cases, MAPPS  scores, and Board Certification. Active is defined as a physician currently working at least 80% of full time with KPSC. Inactive includes any physician deceased, on leave, or working < 80% of full time. Leadership, current or historical, is defined as any physician who holds or has held a recognized leadership role with salary stipend and/or dedicated administrative time. Physician relations (PR) cases is defined as any record of behavioral and/or performance deficiencies in the KPSC Physician Risk Office. MAPPS score is a standardized patient satisfaction survey that is mailed to randomly selected patients who have had recent interactions with KPSC physicians. All KPSC physicians have an ongoing MAPPS score from their patient encounters that is tallied annually. A score of > 9/10 is recognized as meritorious within the organization and qualifies as “eligible” for this study. Board certification is defined as KPSC physicians who are continuously certified in their primary clinical role  by a member Board of the American Board of Medical Specialties.p-value of < 0.05 was considered statistically significant.Statistical analysis was performed using Microsoft Excel. A Chi-squared test of proportions was used for comparison of variables between the two groups. KPSC trained versus non-KP trained physicians were compared. A During the study period from Jan 1, 2000 to August 28, 2020, 2940 residents and fellows graduated from KPSC GME programs, of which 1127 (38%) were hired on at KPSC as full time attendings.Across all five metrics  for physicians hired by KPSC from January 2000 to August 2020, those who had trained at a KPSC GME program outperformed non-KPSC GME-trained physicians to a statistically significant degree Table .Table 1KRetention, measured as active versus inactive KPSC practice status as of August 2020, was significantly greater for KPSC-trained physicians with 82% currently active compared to 76% of non-KPSC trained physicians Table .p < 0.01). For historical leadership, KPSC-trained physicians were more likely to have held a leadership position at any point in their career at Kaiser Permanente compared to non-KPSC trained physicians, 17% vs 14%, respectively (Table p = 0.01).Current leadership was measured as holding a recognized leadership position such as chief of service, service line leader, program director, medical director, etc., at KPSC as of August 2020. Significantly more KPSC-trained physicians 14%) currently hold a leadership position compared to non-KPSC trained physicians (10%) (Table 4% currenp = 0.04). MAPPS, a tool for KP members  to assess physicians or other clinicians, benchmark performance of >  = 9/10 for KPSC trained physicians was 75%, compared to 69% of non-KPSC trained physicians (Table p < 0.01).For Physician Relations, 23% of KPSC-trained physicians had a case filed against them during the studied period, compared to 26% of non-KPSC trained physicians (Table p < 0.01).As of August 27, 2020, 81% of KPSC-trained physicians held an active ABMS board certification, compared to 74% of non-KPSC trained physicians . This difference in retention could be explained by increased familiarity with institutional culture and understanding of workflows.Leadership helps inform and establish culture within a health care system. Greater proportions of internal hires who progress to positions of leadership can be beneficial for maintaining institutional knowledge and culture. GME graduate hires will have pre-existing relationships and thus have an assumed advantage in obtaining leadership positions, particularly in positions selected by peers. Proportionally, current and historical leaders have been over-represented by KPSC GME-trained physicians. This could be, at least partly, explained by greater investment in the institution, as well as greater knowledge and understanding of the underlying systems. Leadership has also been shown as critical to a culture of safety within a health care system; safety performance is directly impacted by leadership .Lower rates of Physician Relations cases were seen among KPSC GME-trained physicians. These cases were related to behavioral and/or performance deficiencies that were managed by Physician Risk Officers. Disruptive behaviors or other adverse behavioral issues among physicians can have significant impacts on patient care . While mPatient satisfaction, as recorded by MAPPS surveys, was significantly higher among KPSC GME-trained physicians. Higher patient satisfaction scores are not only important to subjective patient experiences, but are also associated with improved outcomes, including lower 30-day hospital readmission rates . KPSC GMBoard certification criteria are determined by each respective specialty and imply that the physician has achieved a minimum level of qualifications and skills. It allows an organization to guarantee a baseline practice standard. Current board certification was found to be significantly higher (81% vs 74%) among KPSC GME-trained physicians compared with non-KPSC trained peers. Higher rates of board certification are commonly associated with higher quality of care , 18.There are some limitations of our study. First, Kaiser Permanente is unique; it is the largest integrated health care system in the United States, and KPSC is one of the largest health care organizations in the state of California. Therefore, our findings may not be fully generalizable to other health care systems or community health care groups. Second, the KP culture is also differentiated by many factors, including a focus on preventive care, and physicians who are salaried rather than paid on a fee-for-service basis. It can be argued that these and other cultural factors attract residents and fellows who preselect for affinity to KPSC, as the organization is well known across the regions it serves. It is also possible that departments may harbor unconscious bias in favoring KPSC GME-trained physicians, improving their chances of leadership roles and/or confronted with less Physician Relations cases, thus resulting in higher retention rates. Furthermore, demographic information such as age, gender and marital status could play a role in retention, as well as exact time of hiring start and stop dates were not examined and may have provided a better baseline comparison of the study groups. Finally, statistical samples are non-random, group sizes are asymmetric, and study variables are non-standard, as previously defined.However, we strongly believe that this analysis represents an accurate picture of the value that GME-trained hires can bring to their own health care systems, and that the setting in which this study is conducted is unique to address the question asked. We believe these results demonstrate the additional value that internal physician hires can bring to medical groups, integrated systems of care, and their patients. Future research is needed to investigate the potential associated with recruitment cost savings. Further, an in-depth analysis is important to learn why non-KPSC trained physicians, which consists of most of the physicians hired, did not perform as well. Finally, in the era of increasing flexible working schedules, it would be beneficial to study how part-time physicians fare in these metrics in our cohorts.In this retrospective study, we demonstrate that internally sponsored GME programs represent an opportunity for teaching hospitals to accrue quality-of-care benefits by recruiting physician graduates from their own programs. These benefits include increased retention, higher probability of ascending to physician leadership, decreased likelihood of Physician Relations issues, improved patient satisfaction, and increased rates of board certification. Recruiting home-grown trainees could save on recruitment costs, integrate new physicians faster into practice, and increase the familiarity of new hires with institutional culture.


To develop an e-learning education program targeting patients with rheumatoid arthritis.The development process involved content specification and creative design. It was theoretically framed within theories of multimedia learning and entertainment-education and empirically based on evidence of patient education in rheumatoid arthritis and focus group discussions with stakeholders. We conducted a feasibility test among ten patients to assess the acceptability and usability of the program, and to identify areas to be adjusted.“Knowledge of rheumatoid arthritis,” he disease course and prognosis,” “Medical treatment,” “A new life situation” and “Daily life with rheumatoid arthritis.” Based on this, an e-learning program covering the disease course, examinations, treatment, and daily life, was created. It combines animations, videos, podcasts, text, speech, and tests. Test persons found the program feasible—that is, clear in content and easy to understand with a suitable pace and coherence between graphics, speech, and text.The following themes for educational needs were found in focus group discussions: This e-learning program is based on solid theoretical knowledge that meets users' needs and is easy to use.This study contributes to the innovation of health care by the development of a new digital tool for patient education. •Involving stakeholders is essential in the design of digital health tools•User involvement in the design strengthen the usability of the e-learning programme•Digital health tools should allow for patients varying needs, abilities and competencies•Users prefer the use of visual tools over text in the e-learning programme This reThe World Health Organization (WHO) points out that advances in digital technologies can support healthcare delivery by offering alternatives to standard care . It is aClinicalTrials.gov: NCT04669340).Recently, the importance of paying attention to health literacy in the development of multimedia PE tools has been emphasized . In addi22.1The development process involved several steps, including a content specification phase involving a systematic literature review and focus group discussions and a creative design phase involving development of the e-learning program following a feasibility test. The program was developed from April 2019 to July 2020 via an iterative process between the primary investigators , patient research partners, a communication consultant, digital and graphic designers, and experts on e-learning. We formed a project group comprising the primary investigators  and a communication consultant on an ad hoc basis. Further, a rheumatologist and two patient research partners were affiliated with the project to ensure advice on contents, presentation forms, and structure. The technical parts of the project, production and design were carried out by an e-learning company and external consultants, including graphic and digital designers, a software developer, a speaker, a journalist and a communication consultant. The development process is inspired by a systematic process map for the development of web-based decision support interventions . Fig. 1 The study was conducted in accordance with the Helsinki Declaration and the Central Denmark Region Scientific Committee approved the study (no. 1–16–02-52-19). According to Danish Law and the Central Denmark Region Committee of Health Research Ethics, ethical approval is not required for this study. A data processing agreement with the hosting company of the e-learning program is approved by the Technology Transfer Office at Aarhus University. Verbal and written informed consent were obtained from each participant.2.2Initially, a needs assessment was undertaken. This endeavor included a systematic review of the literature on the educational needs of patients with RA and web-based PE tools followed by qualitative focus group discussions with patients and health professionals (HPs) . The aim. Two rheumatologists and three nurses with various lengths of employment and levels of experience within rheumatology formed the HP group  and a group with longer disease durations (>1 year). Inclusion criteria were a diagnosis of RA according to the American College of Rheumatology/European League Against Rheumatism 2010 (ACR/EULAR 2010) criteria  and abilHP group .Table 1P“a method for identifying, analysing and reporting patterns (themes) within data” [Focus groups were held for patients and HPs separately and were facilitated by LRK and observed by AdT or a communication consultant to make notes, ask additional questions, and qualify the comprehension of the data. Literature covering educational needs and everyday life with RA  were usein data” . LRK carin data” . Subsequ2.3Following the focus group discussions, the contents were described in manuscripts written by LRK and AdT and adjusted by the e-learning company. Hereafter, they were adapted to storyboards by graphic and digital designers. In that way, the textual manuscripts were converted into a graphic web-based entity followed by the recording of speech to support the graphical illustrations.Our e-learning program is based on a program theory inspired by Funnel and Rogers , who desStructure and presentation of contents in spoken language, consistency, and a common thread in the tone were ensured through the firm design process. In doing this, text-heavy presentations were avoided, and text was applied only to support the spoken words. CTML outlines an active learning process through which people build coherent mental representations from words and images. Thus, the program offers a combination of animations, graphics, videos with patients and HPs, podcasts, written text, and spoken words. The intentions behind E-E are implemented via personal patient stories, podcasts, and interactive quizzes.2.4In order to evaluate the acceptability and usability of the e-learning program and its user interface the creative design phase was followed by a feasibility test of the prototype. The final program has been adjusted accordingly.. These test subjects were selected purposively to achieve diversity regarding sex, age, and disease duration , medical treatment, examinations, the disease course, expected prognosis, and emotional issues were highly prioritized by all groups. Furthermore, patients with longer disease durations emphasized information on non-pharmacological treatment and vaccines. All groups found aspects of daily life essential for coping with the disease but more on a “nice-to-know” basis. Variation within the theme “Daily life with RA” was evident and presumably associated with individual needs and preferences from the perspectives of both patients and HPs. Details on the themes derived in the analysis and illustrative quotes can be found in appendix C.The four following themes covering educational needs emerged from the analysis of focus group discussions: Different presentation forms were discussed, primarily based on the participants' experiences of using the internet for health information and their perceptions of different digital communication tools. In these discussions, it became evident that preferences differed depending on the content. However, graphics, animations, speech, text, and videos were all acknowledged as relevant presentation forms, and a common preference was to use less text and more graphical elements.3.2Worth knowing about RA” (Module 1), “Additional information about RA” (Module 2), and “Daily life with RA” (Module 3).We have created a platform that consists of a navigation site with an overview of the program and individual user progress (appendix D). The e-learning program is divided into the three following learning modules: “The contents of the three modules can be seen in 3.3In general, test-persons had a positive impression of the e-learning program, and contents were considered relevant and useful. In particular, the mandatory medical information of RA and treatment (Module 1) was emphasized as important information when newly diagnosed. Participants liked the flexibility of the program, including the possibility of moving around in the optional parts. Suitable amounts of information were presented, and the contents were considered clear and easy to understand. Test-persons also found the pace suitable, and coherence between graphics, speech, and text was present. In addition, most appreciated the animations and graphics as entertaining, which created a less serious atmosphere despite the seriousness of their situation. Further, the test-persons were satisfied with the navigation site, user interface, and design , which was described as “calm” and “attractive.”The feasibility test offered suggestions for improvements/alterations. Some issues were corrected immediately, including small technical issues; minor adjustments in colors; changes in the gallery of characters ; and minor misconceptions in illustrations, text and speech. Other adjustments were discussed with the e-learning company and implemented if possible.The test-persons held different views on the personal patient stories in the videos and podcasts. Some expressed that they facilitated the personalization of the program; others found them less attractive, and many found them too lengthy. Thus, we decided to make patient stories optional by gathering them in modules 2 and 3. Several test-persons were distracted from automatic links with supplementary information, for example, to other websites or additional documents, and therefore, the automation was removed and this was also made optional. Small adjustments were made in podcasts regarding supporting images and background still photography to support speech and enhance attention.44.1The overall focus of our study was to develop a web-based PE program to support self-management in patients with RA. We have designed an e-learning program that allows for complexity in telehealth interventions by incorporating a substantial evidence base and theoretical framework, stakeholder involvement, and the health literacy of the users . The queFirst, the evidence based on contents in PE within RA was explored. Overall, the topics included in our PE program  are in alignment with previous studies examining the educational needs and preferences of patients with RA ,28.Second, the theoretical framework in the design of the e-learning program, including multimedia learning theory (CTML ) and E-EThird, several studies and reports suggest that user involvement should be prioritized when developing digital health tools . RecentlFinally, we intended to develop a program that would accommodate a wide target group with different needs, health literacy levels, and learning skills to improve the usability and acceptability of the program. A major Danish study of health literacy showed that people with chronic conditions had more difficulties in understanding health information and engaging with healthcare providers compared with the general population . FurtherA limitation of this study could relate to the composition of the focus groups, especially the patient groups. Although the patients varied in terms of age, gender, and disease duration, most were women and had a longer disease duration. However, as the agreement on the content to be included in the e-learning program was in alignment with the existing evidence on educational needs in patients with RA, we assume that this factor had a minor impact. Another limitation could be the design of our feasibility study, including the sample size. On this basis, it is not possible to evaluate or determine the effect of the learning outcomes behind the program, and further, this study may benefit from a supplementary survey investigating the acceptability of the e-learning program among a larger group of users.4.2This study contributes to the innovation of health care by the development of a new digital tool for patient education in RA. By this tool, we offer a supplement to conventional modes of delivering health information using multimedia and interactive components in patient education. Furthermore, our study builds knowledge to the innovative design process of digital tools and how to include several perspectives, that is the use of experiential and professional knowledge of patients, health professionals and professionals within communication and digital learning into the design.4.3Web-based patient education in rheumatic diseases is needed; however, knowledge on the development process of digital tools is limited. Our study is based on evidence, solid theoretical knowledge and collaboration involving end users, healthcare providers, and experts in communication and digital learning. Thus, this study offers a concise survey of possible elements integrated in the development of web-based patient education tools that can guide future development processes.We have developed an e-learning PE program that allows for varying needs, abilities, and competencies among patients with RA attending patient education. Unanswered questions to be examined are the effectiveness of the e-learning program in improving self-management among patients with RA, the patient experiences of receiving information and guidance through this digital tool, and facilitators and barriers to implementing this new technology in clinical practice. This will be investigated in three future studies among patients with RA treated at five rheumatology clinics in Denmark.10.13039/501100004191Novo Nordisk10.13039/100005930Research Foundation (grant number: NNF 18OC0052886), which had no role in any phase of the study, the writing of the manuscript, or the decision to submit the manuscript for publication.This work was supported by a grant from All authors were involved in drafting the article and revising it, and all authors have approved the final manuscript before submission.None.