Community-based spinal cord injury (SCI) organizations deliver peer mentorship programs in rehabilitation settings. Little is known on how these programs are delivered through the collaboration between community-based SCI organizations and rehabilitation institutions. This study aimed to identify barriers, facilitators, and collaboration processes within a SCI peer mentorship program provided by a community-based organization at a rehabilitation center.A qualitative case study design was applied. Seven participants were recruited, including two mentees, two mentors, one program director of the community-based SCI organization, and two healthcare professionals of the rehabilitation center. Each participant completed a one-on-one interview. Data were analyzed inductively and deductively based on the Consolidated Framework for Implementation Research (CFIR).Ten factors were identified to influence the delivery of the peer mentorship program, including nine CFIR constructs. Successful delivery of the program required strong, collaborative inter-professional relationships between health professionals and community organizational staff  as facilitators; whereas potential cost, minimal patient needs, and limited mentor resources were found to be barriers. Engaging health professionals by initiating communications, reflecting and evaluating the program collectively with health professionals were important collaboration processes for the community-based organization to maintain effective partnership with the rehabilitation center.The collaboration processes and strategies to addressing/leveraging the barriers and facilitators may inform evidence-based practice to establish and optimize the delivery of SCI peer mentorship programs in various rehabilitation settings. Spinal cord injury (SCI) refers to any damage or lesion to the spinal cord that results in autonomic, motor, and sensory impairments and lifelong disability. After an SCI, people often begin a rehabilitation process in which they experience significant adjustment to life . One strDelivering peer mentorship programs in rehabilitation settings often relies on collaborations between community-based SCI organizations and rehabilitation institutions . Peer meSome international studies examined the integration of SCI peer mentorship programs into rehabilitation settings –14. For Theoretical frameworks in implementation science may help us understand the collaboration between rehabilitation institutions and community-based SCI organizations in delivering peer mentorship programs . One fraThe purpose of this study was to identify barriers, facilitators, and collaboration processes within a SCI peer mentorship program provided by a community-based organization at a rehabilitation center. Framed around the CFIR, three main research questions were: (1) how was the peer mentorship program delivered through the collaborations between the community-based organization and the rehabilitation center; (2) what were the barriers and facilitators to the delivery of the program; and (3) what were the inter-professional relationships between the community organizational staff  and the rehabilitation professionals?We applied a qualitative case study design , which aWe identified a local community-based SCI organization that offers peer mentorship programs in both the community and rehabilitation settings, including a rehabilitation center that provides services to individuals with SCI. There is no cost to patients in the rehabilitation center to participate in the peer mentorship program. The community-based organizational staff, including SCI peer mentors, are on-site at the rehabilitation center and work directly with a multidisciplinary healthcare team including occupational therapists and physical therapists. The peer mentorship is mentee-focused in that topics of the conversations can vary depending on mentees' specific needs. Peer mentorship is delivered through both (a) informal, unstructured conversations between mentors and mentees, which can happen at bedside or common areas  at the rehabilitation center and (b) formal, structured conversations either by information sessions delivered by mentors and rehabilitation staff or individuals, topic-focused discussion with a mentee. The mentorship relationship can also continue after in-patient rehabilitation process as mentors also provide mentorship to people with SCI living in the community. We chose to look at this program because it is recognized as long-standing and successful, with more than forty years of continuous delivery.We recruited a purposive sample of seven participants from the community-based SCI organization and the rehabilitation center. Participants were individuals involved in the peer mentorship program with different roles, including two mentees, two mentors, one program director of the community-based SCI organization, and two healthcare professionals of the rehabilitation center . The sample size aligned with the qualitative case study design . All sevcfirguide.org/) and the questions were adapted to the different roles of the participants  and obtained participants' consent using an online consent form embedded in emails. Each participant completed a virtual, one-on-one, audio-recorded interview with the first author (ZS) using a semi-structured interview guide. The interview guide included questions selected from the CFIR interview guide tool  analytical approach . DeductiWe ensured the quality of this study following the eight universal criteria named by Tracy (2010) , includiThe data were organized into three overarching themes: program characteristics, local setting and individuals, and inter-professional collaboration. These overarching themes included ten of 39 CFIR constructs identified in the deductive analysis and one inductive, non-CFIR construct (marked with *). Adaptability, cost, and relative advantage were three characteristics of the peer mentorship program that were identified to influence the delivery of the program at the rehabilitation center.Having a variety of methods to deliver the peer mentorship program enables the community-based organization and the rehabilitation center to adapt, tailor, refine, or reinvent the program as needed [Adaptability]. The rehabilitation center and the community-based organization typically deliver the program by creating an environment where mentors and patients interact through informal conversations. However, they also offer mentees a regular magazine, group-based coffee meetings, and a series of courses on SCI, which allows mentees to interact with peer mentorship resources that meet their needs. Furthermore, the community-based organization and the rehabilitation center made adaptations to the program during the COVID-19 pandemic by coordinating formal in-person, one-on-one meetings between mentors and mentees to maintain the delivery of the program.“Normally we were able to do a lot of activities in-house, at the [rehabilitation center], but we couldn’t do any for a long time [during the pandemic]. The patients were [restricted] in their rooms… That's when we realized that it was so complicated to meet with the patients. We asked the nurse on the second floor to help us plan formal meetings in a local area with each patient with spinal cord injury. As I said, if we don’t do that, I would say we’re going to lose so many people, (and) we can’t do that. So, it's the way we adapted to the new situation.” —Julie (program director of the community-based organization)Despite the fact that the current peer mentorship program is free for patients with SCI at the rehabilitation center, any potential monetary cost to access the program can become a possible barrier for patients with SCI to participate in the program [Cost to mentee], as Jack (mentee) said:“You can get all the information on the Internet. Anyways, you know? … I can read all over the Internet and there's forums, you know, there's Christopher Reeves Foundation. There's all kinds of stuff where I can talk to many experienced paraplegics on the Internet. Yeah, so for me, there's no point in paying for [peer mentorship] at all… If they were to charge people for their services, I would not be… I’d rather pay for medical service.”Finally, the peer mentorship program was found to be a valuable addition to regular rehabilitation services [Relative advantage]. The health professionals noted the peer mentors were able to provide disability-specific tips and helpful suggestions based on their lived experience with SCI. These suggestions helped the health professionals supplement their medical and therapeutic recommendations. As Anna  noted:“We are professionals, we didn’t go through that [living with SCI]. They [mentors] really lived the situation, because some patients will say [to us] ‘you didn’t live it’ and they are right, we are here to accompany, we didn’t really live it, whereas the mentors have really lived the situations.”The delivery of the peer mentorship program related to three CFIR constructs, focusing on patients' needs, a positive organizational culture within the local rehabilitation center, and health professionals' adequate knowledge and beliefs about peer mentorship.A strong need for peer mentorship identified among the SCI patient clientele at the rehabilitation center appears to facilitate the delivery of the program. Because the community-based organization partners with multiple hospitals and rehabilitation centers in the region, it tends to allocate mentor resources and prioritize institutions with a larger SCI clientele and/or a greater patient need for the peer mentorship program [Patient Needs and Resources]:“In most settings, they don’t have a lot of people with SCI there. And there are no centers across our province other than the [rehabilitation center] where patients are onsite with a [SCI] group… We know that there's always 20 patients, so we have people in house all the time because we’re going to be crossing and seeing people at the center where you go in once or twice a week. You can’t hire somebody who's going to work two hours a week or three hours a week and say, ‘Be there on Tuesday from three to four and Thursday from ten to eleven.’ In those situations, we tend to typically offer services more personalized where somebody will talk over the phone, you know, when you’re interested in talking. But having somebody on site is not always feasible.” — Jean (mentor)Second, an organizational culture that values new changes and is willing to adapt to changes at the rehabilitation center was another facilitator for the delivery of the peer mentorship program [Culture]. In the current peer mentorship program, the program director of the community-based organization had experienced different organizational cultures within the rehabilitation center by working with health professionals over many years. She highlighted the impact of a recent change in staff that created a more positive organizational culture and resulted in improved outcomes of the peer mentorship program.“People who retired and the new people who came in found that there was a culture change. It's really healthier. We’re giving a very positive input to the patients.”—Julie (program director of the community-based organization)Third, the positive attitudes toward and the value placed on the peer mentorship program by the health professionals were identified as key facilitators to the delivery of the program [Knowledge and Beliefs about the Intervention]. The ongoing interactions with the mentors helped the health professionals expand their knowledge on SCI peer mentorship and thus develop a strong commitment to collaborating with the mentors.“We learn a lot from their [mentors] experience…If we need to realign our thinking, our vision, it's always a question we ask [mentors], ‘what you had wanted to change in rehabilitation, what we could have done better, and how you would have liked it if we had talked about [certain] things.’ To have this feedback from them [mentors] is very important for us to be able to align our work and to be in the right direction.” —Nada (kinesiologist)The peer mentorship program requires a cohesive interprofessional collaboration that consists of engaging the health professionals in the program, as well as evaluating and reflecting on the delivery of the program. Interprofessional collaboration can also be built by establishing strong communication channels and clear boundaries between the health professionals and the community-based organizational staff, particularly the mentors.One mechanism that appeared to build inter-professional collaboration is having quality social networks and communications between the mentors and the health professionals [Networks & Communications]. In this case, the peer mentors have an office at the rehabilitation center and share workspace with the health professionals. This proximity creates opportunities for frequent, informal communications between the health professionals and the mentors, while facilitating resolution of misunderstandings around patient care:“The mentors are on the same floor as us, they are practically in our offices so we get to see them. It's [the communication] quick, it's easy, it's efficient. They are also often around the floor for a variety of reasons, so we can interact with them as they pass… Sometimes it [the communication] can be informal, like in the hallway and we bump into a member of [community-based organization]. Sometimes something happens where they [mentors] might have made a suggestion, such as about an adjustment or type of wheelchair, but as we know the client, and our recommendation might be a reason that's not so obvious to someone else, so we might have to talk about why we suggested what we did vs. what they thought.” —Nada (kinesiologist).Another mechanism that the community-based organization strengthens the interprofessional collaboration is attracting and involving the health professionals in the peer mentorship program by helping them understand mentors' roles and benefits of the peer mentorship program [Engaging]:“They [health professionals] have to know the [SCI] organization well, the [healthcare] team has to understand the importance of that [mentorship]. It must be well explained to the teams that are giving the care: what is the role of a peer mentor and what they bring to people. You [health professionals] really must understand that as a base. Once they understand that, they’re going to be more motivated to put in place a service like [peer mentorship], and they’re going to be able to see how it can help them in their interventions.” —Julie (program director of the community-based organization)Consistent evaluation and reflection on the progress and quality of the peer mentorship program was another important process of the interprofessional collaboration [Reflecting and Evaluating]. Within the current program, the program director of the community-based organization has been taking an integral role in tracking the progress and quality of the peer mentorship program. However, a team approach through collaborating with the health professionals and the mentors is needed due to emerging challenges in delivering the program. As these two quotes below demonstrated,“I do all the budgeting, I hire the people, all the work of a manager… I make sure that they [mentors] are present at the [rehabilitation center]. I make sure that as much as possible we meet all the people who come to the [rehabilitation center], obviously those with an SCI… Of course, when there are new employees, new senior integration mentors, I make sure that the [rehabilitation center's] management is aware of this, that they [the mentors] have training… We are challenged in different ways. We arrive and sometimes the clientele is really older so we have to adapt our intervention a little bit, the activities we offer to succeed in getting people interested.” —Julie (program director of the community-based organization)“I think we [the health professionals and the community-based organizational staff] could have even more discussions [on letting patients participate in the peer mentorship program]. I think sometimes there might be disagreement between us [the health professionals] and the mentors, [because] in the rehabilitation environment where we [the health professionals] have to be a little more careful with new spinal cord injuries [patients]. Sometimes [the health professionals believe] they are not ready to be sent to an activity of [the community-based organization] because they may not have someone to help them transfer.” —Nada (kinesiologist)While the interprofessional collaboration is key to the peer mentorship program, maintaining professional boundaries between the health professionals and the community-based organizational staff is also important [Professional Boundaries*]. As Betty (mentor) mentioned, “We are not registered in their rehabilitation program. We are completely independent. Yes, we collaborate with the health specialists, but we remain an independent entity”. In this case, the rehabilitation center and the community-based organization have an agreement that explicitly outlines the boundaries regarding the mentors' access to patient confidential information. Although the agreement does not include all aspects of the mentors' responsibilities, it helps the health professionals and the mentors understand and adhere to their roles in patient care:“We [mentors] must not interfere with the role of social workers in the rehabilitation center. For example, an occupational therapist should not feel challenged in what she does in comparison to a senior mentor in the center. If this happens, we have to resolve the situation. Everyone has to know their place. So that's really important… We never directly give the patient the clinical judgment, that's being a professional.” —Julie (program director of the community-based organization)Although the professional boundaries were clear to the mentors and the health professionals, these boundaries might be blurry for patients. Patients may expect clinical guidance from mentors and can potentially create difficult situations during their interactions with mentors and/or health professionals, as Frank (mentee) said: “I was putting them [mentors and health professionals] together. They all did the same thing. That is to say, answer my questions and enlighten me on the various aspects of reduced mobility. On both sides, I would say that they did a lot on the same job. For me the plus side is that it [the mentor] brings sports into our exchanges.” Patients' confusion in these roles might impede their participation in the peer mentorship program because they might not perceive the benefits of engaging with mentors.The purpose of this study was to identify barriers and facilitators to the delivery of the peer mentorship program provided by a community-based SCI organization at a rehabilitation center and characterize the collaboration processes between the community organizational staff and the health professionals. We gathered multiple perspectives from the individuals directly involved in the program, including peer mentorship program director, peer mentors, mentees, and health professionals. In addition to the barriers, facilitators, and collaboration processes identified, our study highlighted multiple strategies that the rehabilitation center and the community-based organization have taken to address/leverage these barriers/facilitators. The strategies may inform collaborative processes needed to establish a partnership between rehabilitation institutions and community-based organizations as per this peer mentorship program.In alignment with previous studies using the CFIR in a healthcare context , 29, thePeer mentorship programs within rehabilitation settings often target specific health outcomes for people with SCI  , while tCommunication among staff members tends to be an important aspect to successful implementation of services/programs across healthcare contexts , 33. SimInterprofessional collaboration has received growing attention in healthcare (maybe add a reference here as an example?). In our study, “networks and communication” and “professional boundaries” were the two largest constructs identified in terms of data volume. The interprofessional relationship between the mentors and the health professionals was interpreted as a key aspect of program implementation and maintenance. In alignment with previous research, the interprofessional collaboration between the mentors and the health professionals has resulted in multiple benefits, including personal and professional growth, as well as good work efficiency , 37. AddAnother important collaboration process that can be challenging for community-based organizations was engaging and building buy-in among health professionals prior to the program delivery. Frequent staff change can hinder the process of engaging health professionals in the peer mentorship program . To addrFirst, we were only able to recruit two health professionals from the rehabilitation center during the COVID-19 pandemic, although there might be multiple other health professionals who were directly or indirectly involved in the peer mentorship program. The two recruited health professionals might have a favorable opinion about the peer mentorship program as they consented to participate in this study. However, obtaining the perspectives from the peer mentorship program coordinator, the mentors, and the mentees still enabled us to capture a broad picture of individuals actively involved in the program. Another limitation was that we did not apply the updated version of CFIR  because Using the CFIR to guide the data collection and analysis, we identified multiple barriers, facilitators, and collaboration processes to delivering the peer mentorship program within the local rehabilitation center. Our results may help other community-based SCI organizations and rehabilitation institutions develop, maintain, and optimize peer mentorship programs in various rehabilitation settings. Community-based SCI organizations and rehabilitation institutions may enhance interprofessional collaborations between organizational staff  and health professionals by creating shared workspace, facilitating informal conversations, and establishing professional boundaries.


End‐ischemic viability testing by normothermic machine perfusion (NMP) represents an effective strategy to recover liver grafts having initially been discarded for liver transplantation (LT). However, its results in the setting of significant (≥30%) macrovesicular steatosis (MaS) have not been specifically assessed. Prospectively maintained databases at two high‐volume LT centers in Northern Italy were searched to identify cases of end‐ischemic NMP performed to test the viability of livers with MaS ≥ 30% in the period from January 2019 to January 2022. A total of 14 cases were retrieved, representing 57.9% of NMP and 5.7% of all machine perfusion procedures. Of those patients, 10 (71%) received transplants. Two patients developed primary nonfunction (PNF) and required urgent re‐LT, and both were characterized by incomplete or suboptimal lactate clearance during NMP. PNF cases were also characterized by higher perfusate transaminases, lower hepatic artery and portal vein flows at 2 h, and a lack of glucose metabolism in one case. The remaining eight patients showed good liver function  and had a favorable postoperative course. Overall, NMP allowed successful transplantation of 57% of livers with moderate‐to‐severe MaS. Our findings suggest that prolonged observation (≥6 h) might be required for steatotic livers and that stable lactate clearance is a fundamental prerequisite for their use. To expand the organ donor pool and improve access to liver transplantation (LT), the use of so‐called extended‐criteria donors has become commonplace in recent years. Frequently, extended‐criteria grafts are defined as those proceeding from donation after circulatory death (DCD), elderly donors, or livers with significant steatosis, in particular macrovesicular steatosis (MaS).The paradox of steatotic liver grafts is well known; despite apparent normal liver function in the donor, fatty livers are more susceptible to ischemia/reperfusion injury and are exposed to an increased risk of functioning poorly in the recipient, proportionally to the degree of MaS.The number of organ donors suffering from non–alcohol‐associated or metabolic dysfunction–associated liver diseaseIn the current scenario characterized by a growing prevalence of extended‐criteria donors, machine perfusion techniques have been introduced to improve organ preservation and overcome the limitations of static cold storage (SCS).Prompted by the suboptimal results obtained with end‐ischemic hypothermic oxygenated machine perfusion for steatotic liversThus, with the aim of facilitating clinical decision makingn = 8) and Azienda Socio‐Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda . Analyzed data included baseline recipient and donor characteristics, NMP data, and post‐LT outcomes. The primary end point was utilization rate, defined as the percentage of transplanted livers among those evaluated with NMP. Secondary end points were patient and graft survival rates, rates of PNF and early allograft failure (EAF), and other measures of post‐LT outcomes. The study was conducted in accordance with the principles of the 2013 Declaration of Helsinki and was approved by institutional ethics committees.Prospectively maintained databases of machine perfusion procedures and LTs performed between January 2019 and January 2022 were retrospectively analyzed to retrieve NMP procedures in liver grafts with MaS ≥ 30% performed with the aim of assessing graft viability before LT. The centers participating in the study were Azienda Ospedaliero Universitaria Città della Salute e della Scienza  and transported under SCS to the transplantation center. The indication for NMP was shared between the procuring and transplanting surgeons and was based on donor characteristics, the macroscopic aspect of the liver, and histological findings. Only grafts with histologically proven MaS ≥ 30% were included in this series. Graft histology was determined on liver biopsies obtained at procurement or before NMP, which were centrally reviewed by a single pathologist (A.G.) to homogenize MaS assessment.After backtable preparation and cannulation, livers underwent a minimum of 4 h of NMP using either the OrganOx Metra  or LiverAssist  devices. Reconstruction of aberrant hepatic arteries, if any, was performed during backtable preparation, before connecting the liver to the NMP device. A total of 20–30 mEq of sodium bicarbonate was added to the perfusate to equilibrate pH during the priming phase. Perfusate composition and machine perfusion protocols for each device have been described elsewhere.Livers that were deemed suitable for LT were preferentially allocated to recipients with low Model for End‐Stage Liver Disease (MELD) scores while considering donor–recipient size matching. LT was performed using the piggyback technique and portal reperfusion first. Standard immunosuppression included induction with basiliximab, tacrolimus, steroids, and mycophenolate mofetil.Postreperfusion syndrome was defined according to Aggarwal et al.Variables were reported as median (interquartile range [IQR]) or count (percentage), as appropriate. Mann‐Whitney U, Fisher's exact, and chi‐square tests were used to compare variables among different groups. Statistical analysis and data visualization were performed using R Version 4.1.1 .During the study period, 25 grafts were evaluated by NMP. In 14 cases (56%), the indication for viability assessment was based on graft steatosis, representing the cohort included in this study  and MELD‐sodium  scores, of whom nine (82%) underwent LT for HCC. Median recipient BMI was 27 , reflecting the attention to size matching during the allocation process.Donor and graft characteristics were comparable between transplanted and discarded grafts Table , whereasPatient outcomes are summarized in Table 3−, 37.2 mmol/L; glucose, <4 mg/dl; difference between perfusate and bile glucose, 153 mg/dl. Despite some concerns as a result of the slow lactate clearance, the liver was deemed transplantable, and the LT operation was started. Unfortunately, although all other parameters were stable, the lactate level increased to 6.7 mmol/L at 3 h and only slightly decreased to 6 mmol/L at 5 h. Second‐hour perfusate AST and ALT levels became available and were 9444 IU/L and 4433 IU/L, respectively. The 4‐h perfusate AST and ALT levels were only slightly increased . As donor hepatectomy was already at an advanced state, the procedure could not be aborted, and the liver was transplanted.The first PNF liver (tx_5) was characterized by insufficient lactate clearance during NMP Figure . At 2 h The second PNF liver (tx_10) initially showed good lactate clearance  followed by a rebound in lactate levels up to 3.5 mmol/L at 5 h of NMP. This liver also failed to metabolize glucose, whereas other viability parameters  were met. Perfusate AST and ALT levels at 2 and 4 h of NMP became available only after NMP had ended and were constantly above the laboratory determination limit (7000 IU/L for AST and 5000 IU/L for ALT). Bile produced during NMP (5 ml during the first 2 h and 30 ml at 5 h) was not analyzed in this case.Overall, the common feature of livers developing PNF was insufficient or suboptimal lactate clearance, which was associated with high perfusate transaminases levels and lack of glucose metabolism in one case Table  and 4. HRegarding the histopathology of the two PNF cases, the tx_5 liver presented large‐droplet steatosis only, showing a unique large lipid vacuole per hepatocyte leading to an overall increased cellular size compared with nearby hepatocytes and displacing the nucleus to the periphery of the cell. Steatosis presented a zonal pattern of distribution, and within the areas of steatosis, hepatocytes presented features of collapse/compression (cell and cytoplasm shrinkage). There was a mild inflammatory infiltrate mainly represented by lymphocytes and neutrophils located in the lobules. No inflammation or major signs of injury were observed along the portal tracts. The tx_10 liver presented similar histopathological features but with combined small‐ and large‐droplet steatosis. Similar to tx_5, collapsing hepatocytes were noticed in steatotic areas, whereas the inflammatory infiltrate was more conspicuous, and the relative neutrophils component was more prevalent. In addition, portal tracts showed mild lymphocytes infiltrate but with no features of specific immune‐mediated injury.After the exclusion of the two PNF cases, NMP parameters were compared between the discarded and transplanted viable livers and showed lower perfusate lactate, potassium, and transaminase levels in viable livers at 2 and 4 h of NMP Table . Viable Overall, utilization rate was 71%, whereas successful utilization rate, that is, the proportion of grafts transplanted and not suffering from EAF, was 57%. The recipients of grafts not suffering from EAF had a favorable postoperative course, as reflected by the low L‐GrAFT , EASE , and CCI (35.5) scores Table . After aThis study shows that, by using end‐ischemic NMP, approximately 60% of liver grafts with moderate‐to‐severe MaS can be transplanted with good outcomes. Although this compares negatively with previously published studies,The downside of the reported experience is represented by the two PNF cases in our series, which points to the difficulty of assessing viability of these high‐risk livers. The main feature of the PNF cases was insufficient or suboptimal lactate clearance during NMP, which highlights the importance of this parameter in defining liver viability. Lactate perfusate levels during NMP reflect the balance between production and clearance. As the liver has a broadly redundant capacity to metabolize lactate,Besides refining viability criteria, which applies to all livers subjected to NMP, the real challenge with steatotic livers appears to be finding a strategy to increase their use rate. As proposed by the Groningen group,To define which approach could increase the safe use of steatotic livers, the prerequisite for future randomized studies will be a uniform and consistent assessment of MaS, allowing a comparison of data across different studies. Steatosis represents probably the most concerning histopathological feature with regard to its impact on LT outcomes. However, as recently pointed out by the Banff guidelines,Limitations of our study include the low number of cases and the lack of evaluation of cholangiocellular viability biomarkers.In conclusion, in our experience, end‐ischemic NMP allowed the successful transplantation of about 60% of livers with moderate‐to‐severe MaS. Viability assessment of these livers, in particular effective and stable lactate clearance, must be very rigorous, as PNF is still possible despite most other viability criteria being met, highlighting the need for new reliable viability biomarkers. Further studies are needed to investigate whether alternative approaches, such as preconditioning by hypothermic oxygenated machine perfusion before end‐ischemic NMP, upfront NMP, or ischemia‐free LT, may increase the use rate and improve the outcomes of these high‐risk livers.


During the Coronavirus disease (COVID-19) pandemic, countries implemented border control and quarantine measures to reduce transmission. The Alberta Border Testing Pilot Program (ABTPP) allowed international travellers entering Alberta to reduce their quarantine period following two negative COVID-19 tests. We evaluated participant experiences with the ABTPP and implementation.n = 21,089; n = 13,839) and semi-structured telephone interviews (n = 30). We evaluated implementation through three staff focus groups (n = 11). We analysed questionnaires using descriptive statistics and analysed interviews using inductive and deductive thematic analysis. We deductively coded focus group data using the 2009 Consolidated Framework for Implementation Research (CFIR).We used a parallel convergent mixed-methods design to explore participant experiences through electronic web-based questionnaires , symptom reports (95.5%), and COVID-19 testing (95.7%). Most respondents (95.1%) expressed willingness to participate in the ABTPP again. Interviews revealed three themes related to participant experience: program efficiency, clarity of information, and requisite effort. Focus groups identified key implementation facilitators including the single health information system, strong stakeholder partnerships, and good communication across partnerships. Barriers included program complexity, implementation timeline, and evolving external context.Participants reported high satisfaction with the ABTPP. Border testing programs should have high efficiency, require low effort, and use messaging that is clear and consistent. The effective implementation of border testing programs may be facilitated by strong leadership, adaptability, automated components, good communication, and simple technology. Learnings from participants and staff may help improve the implementation of border control programs for future pandemics or other emergencies.The ABTTP was a novel border control measure during the COVID-19 pandemic. Our evaluation of both participant and staff experiences demonstrated high levels of traveller satisfaction and identified areas for improvement that can inform the development of future border control measures. Due In March 2020, the Government of Canada introduced a travel advisory on non-essential travel and a partial border closing as well as a mandatory 14-day quarantine period for international travellers arriving in Canada . On NoveTo inform border control program design and delivery for future health emergencies, we evaluated the participant experience and implementation of the ABTPP.2.Full details of the study methods are described in 2.1.We used a parallel mixed-methods convergent evaluation involving an online, structured questionnaire, semi-structured individual interviews, and focus group discussions. Our questionnaire and qualitative studies aligned with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES)  and COns2.2.When the ABTPP was implemented in November 2020, border measures had been implemented at Canadian airports and land borders for approximately 6 months. A significant drop in international flights due to these measures and the pandemic at large had been observed globally , includiMany stakeholders were involved in the design and delivery of the ABTPP, including the PHAC, Transport Canada (TC), the Government of Alberta, Alberta Health Services (AHS), and vendors contracted for logistics, customer support, and information technology (IT) services. The University of Calgary was commissioned to evaluate the program's effectiveness and implementation. The program commenced on November 2, 2020, and ran until February 21, 2021, once 52,000 travellers had participated.2.3.Two types of participants were included: (1) travellers that volunteered to participate in the ABTPP program (herein referred to as participants) and (2) program staff who were involved in the implementation of the program (herein referred to as staff). To evaluate participant experience, we used an online questionnaire and semi-structured individual interviews. To evaluate implementation, we held focus group discussions with staff.2.4.We distributed an online questionnaire to one member of each travel party on days 3  and 13  post-arrWe used purposive sampling to select a subgroup of participants based on age, gender, location of residence, and traveller type for a semi-structured interview by telephone. We interviewed both exempt and non-exempt participants after they had completed the program. A female research assistant, with training and experience conducting qualitative interviews conducted all telephone interviews, in her place of residence with no other persons present. An interview guide was utilized to facilitate the individual interviews .We recruited staff involved in the program implementation separated by role  using a convenience sampling approach for focus group discussions, which were facilitated using an interview guide .2.5.We analyzed quantitative data from the participant questionnaire using descriptive statistics measures of frequency (percent) and measures of central tendency (median). The qualitative data from the interviews and focus groups were analysed using different approaches. For participant interviews, we used a combination of deductive and inductive thematic analysis approaches following the approach introduced by Braun and Clarke . Two ind2.6.The University of Calgary Conjoint Health Research Ethics Board (CHREB) approved this study (REB20-2147). All participants provided informed consent.3.3.1.In total, 21,006 non-exempt participants received a link to complete the day 3 questionnaire and 20,199 (96.1%) submitted responses . The res3.2.A large majority of respondents reported no difficulties with the early phases of the program, including the online registration form (91.7%), finding the in-person registration desk (94.0%) or testing site (95.7%) at the port of entry, or completing the first 3 daily check-in reports (95.5%). In total, 7.0% of participants felt the arrival test result turnaround time was not acceptable, most of whom had not received their result by the time of their day 3 questionnaire . Overall, 16.8% reported difficulties accessing their arrival COVID-19 results.3.3.Most respondents reported no difficulties booking (92.9%) or completing (96.1%) their second COVID-19 test. 10.9% of respondents felt the second test result turnaround time was not acceptable. 95.1% of respondents reported that they would use the ABTPP program again and 50.4% reported that they would not have traveled had the ABTPP been unavailable. While participants were not required to pay for COVID-19 tests as part of the program, 48.4% of respondents were willing to use the program even if required to cover costs associated with testing or administration. Of those willing to pay, 30.7% reported willingness to pay between $150 to $250 .3.4.We completed 30 semi-structured interviews with participants who arrived between December 1 and December 28, 2020. Interview participants had a median age of 41 years and 30.0% were men. 13.3% were exempt from quarantine; 83.3% were Canadian citizens or permanent residents . Includi3.5.Information was shared with participants about what the program entailed, who was eligible, and participation instructions. For example, the program website described eligibility and processes, a handout distributed at registration included instructions participants needed to follow, a daily email or text message containing the link to the check-in report, and COVID-19 test results and any resulting actions were also delivered by email or text. Interviews with participants indicated that the clarity of this information impacted their satisfaction with the program.. Others were confused by redundancies and inconsistencies in the program instructions. One participant commented on the confusion of having to submit two check-in reports across the Federal (ArriveCAN) and provincial programs, which led to anxiety.Participants who found this program information to be clear and easy to follow often described a positive experience. Specifically, some participants commented on how well staff were informed and helpful in communicating the various steps or instructions. Some expressed difficulties finding information about the program and requirements to participate3.6.Second, perceptions about how smoothly the program operated were correlated with participant satisfaction. There were many steps involved in the process, including completing the online registration form, finding the program site at the airport or border crossing, providing consent, completing the arrival COVID-19 test, receiving test results, booking and completing the follow-up COVID-19 test, and submitting the daily check-in reports. Some participants described these processes as straightforward and simple and reported a positive experience.On the contrary, participants with negative remarks described the steps of the program as inefficient, repetitive, and a waste of time. Having to wait on arrival was inconvenient for some. Others complained that the registration process was repetitive or posed technical challenges.3.7.Third, the effort required to complete the various program components also influenced participants' experience. Although some complained of long lineups and repetitive forms at arrival, many felt the amount of effort required was minimal. Similarly, many participants felt the burden of submitting the daily check-in reports was low.To complete the second COVID-19 test, participants were required to schedule an appointment at a nearby pharmacy. Some participants felt the effort to schedule and attend these appointments was minimal. On the other hand, some participants complained that completing the second COVID-19 test was more burdensome than expected. Lastly, some participants criticized the process of receiving COVID-19 test results, especially related to the encryption software.Overall, participants reported a positive experience, despite some inconvenience, and felt the program benefited themselves and society at large by reducing risks associated with international travel.3.8.n = 4), February 26 (n = 4), and March 2 (n = 3), 2021. Staff included members of AHS (group 1), a logistics and operations vendor (group 2), and a participant support vendor (group 3). Using the CFIR framework  and its laboratory health information system were also essential for the ABTPP. Prior to program launch, AHS had a well-established and provincial IT department, which included a single health information system for COVID-19 testing data. In the focus groups, staff highlighted that the successful launch of the ABTPP was facilitated by leveraging AHS's pre-existing structure and experience.Further, the ABTPP program was the result of partnerships across the Federal and Provincial governments, the provincial health authority, laboratory services, the airport authority, and other private vendors. Many of these stakeholders were involved in the design, deployment, and evaluation of the ABTPP. Establishing strong networks and rapid and reliable communication channels between these groups was essential for program success. Some staff highlighted the advantages that stemmed from frequent meetings and strong internal communication between leaders and their staff.However, others  felt communication within the networks was sometimes challenging, which negatively impacted the implementation of the program. Although discussions with core implementation leads took place, external partners were not always included. Further, not all operations staff understood how roles and responsibilities were divided across all stakeholders and suggested that a group discussion with all involved may have been useful. Challenges across these partnerships and connections were noted due to overlapping boundaries or unclear roles across the various operational teams, particularly related to activities at the airport and border crossing. One staff member described a lack of acceptance when working with other organizations. Others commented on the challenges of having to shift their typical workflow to that of the airport.3.12.Due to the rapid and urgent onset of the COVID-19 pandemic, the time available to prepare and plan program delivery were limited. This was especially felt by contracted vendors , who were hired shortly before launch and some only had 4–5 days to prepare.4.This evaluation identified key lessons learned from implementing a border testing program in Alberta, Canada during the first year of the COVID-19 pandemic . OverallEvaluating COVID-19 border testing programs can help inform policies and decisions for future pandemics. Just as the lessons learned from the 2003 SARS and 2009/2010 H1N1 pandemics improved Canada's capacity to respond to the COVID-19 pandemic –35, lear4.1.Due to the rapidly evolving nature of the COVID-19 pandemic, clear communication with travellers and also within the program implementation team was imperative for operational success. This aligns with an evaluation of a similar border testing program in Alaska that also identified communication as an essential factor for operational success . The ABTGood communication with travellers participating in a program ensures that they understand who is eligible, what they need to do, and how to complete the various steps. A key finding in our evaluation was that participants were confused about certain aspects of the program. For example, who was eligible, which application they were required to use for the program , and the process for receiving test results. While not specifically identified in our study as a key theme, Ohlsen et al. noted the importance of managing travellers' expectations , which c4.2.Given the large number of operational partners involved in the ABTPP, there was initial confusion regarding logistics and decision-making on-site. Instead of operating at an AHS facility, popup COVID-19 testing stations were being created at the airport and land border crossing. During the early implementation phase, there was uncertainty around how responsibilities  or decision-making capacity  should be divided among airport and border staff, AHS, and contracted vendors. Given that healthcare, the airline industry, and border services are all independently complex, a program that combines these sectors would benefit from establishing clear roles and responsibilities among these operational teams. Additionally, establishing a designated space at these locations for public health activities, such as screening, enrollment, and testing, may reduce some of the barriers and could be considered for future pandemics.4.3.Throughout implementation, ABTPP administrators and staff were faced with a rapidly evolving context that impacted operations, including changes in the risk of COVID-19 transmission, flight or border crossing patterns, or restrictions on entry. As with other industries , designChanges in ABTPP eligibility due to new variants also caused traveller confusion. In December 2020, travellers arriving from certain jurisdictions  were required to quarantine and thus not eligible. Ensuring participants are clear on eligibility through a current website or helpline may reduce this confusion. Involving airlines with program delivery may allow travellers to be informed about the program's requirements while still in flight, which may streamline processes on arrival.4.4.Resource use is another consideration when planning or implementing a border testing program . MateriaOf note, Alberta was well positioned to execute mass COVID-19 testing due to its single health information system; however, evidence from other jurisdictions that lack such a system confirms the importance of strong laboratory information systems for COVID-19 prevention and control –42. Expl4.5.During implementation, adequate time to plan is needed to design, test, and refine the program. Due to the urgency of the COVID-19 pandemic, such planning time was limited. Further, airports and border crossings are not traditional healthcare facilities, and workflow, logistical, and legal expertise outside of the traditional health authority was required. Therefore, external vendors were contracted for logistics planning, program application software development, and customer support. These contractors were given only a few days from the time the contract was awarded to launch. Establishing prepositioned contracts  for publ4.6.Staff  noted that some participants may have experienced greater barriers than others, especially those that do not speak English or French, do not have access to a smartphone or tablet, or live in rural areas. Having online forms that can easily be translated, tablets on-site with support to assist with registration, and rural testing areas or remote testing may improve program accessibility.4.7The scope and applicability of our findings and recommendations emerging from this evaluation should be approached while accounting for the limitations of this study.Firstly, this evaluation includes select perspectives on the implementation of the ABTPP. Although the program occurred from November 2, 2020, to February 21, 2021, questionnaires were only administered beginning December 13, 2020, and only respondents arriving between December 1 and December 28, 2020, were interviewed. We intentionally began collecting feedback a few weeks after the program start date to eliminate challenges related to early program initiation, which has reduced our ability to reflect on this phase of the program.Secondly, only members of the travel party who self-identified as the “head of the household” received a questionnaire or were selected to participate in the interview and so we may have missed some perspectives. Respondents that tested positive for or re-entered quarantine for any other reason did not receive the 13-day questionnaire and a technical error resulted in missing day 13 questionnaires from all travellers arriving between December 13, 2020, and January 1, 2021 .Thirdly, while focus groups offer a dynamic group interaction, there may be limitations if participants have an existing relationship. For example, staff may be less willing to share ideas if their supervisors are present or they are concerned their opinions or participation may negatively impact their employment. Further, not all personnel involved in implementation participated in the focus groups and important perspectives may have been missed.Fourthly, our intention was to evaluate the implementation of the ABTPP throughout its entire duration. We included participant perspectives throughout; however, staff may have potentially reflected on the challenges during the initial launch, which could have over-emphasized barriers.Lastly, perspectives may have differed systematically between certain sub-groups . However, as this study was not powered to look at subgroups, we were unable to determine whether any discordances indeed existed.5.Our evaluation of the ABTPP participant experience and implementation demonstrates a high degree of traveller satisfaction and indicates that most respondents were willing to volunteer for the program again during its implementation period. To ensure participant satisfaction, border testing programs should be efficient, require low effort from participants, and use clear and consistent messaging. Strong leadership, good communication across networks (including contracted vendors), adaptability, automated components, and simple technology may facilitate effective implementation. These lessons learned may help to inform border control measures during future pandemics or other emergencies.


Echobronchoscope-guided transbronchial needle aspiration (EBUS-TBNA) is mainly used as the transbronchial approach to hilar/mediastinal lymph nodes or lesions, for diagnostic or staging purposes. Moreover, the role of linear EBUS-TBNA as a diagnostic tool for central intrapulmonary lesions adjacent to the trachea or the major bronchi is also well established. However, since the tip of the ultrasound probe at the distal end of the echobronchoscope is very thin, it can be wedged through smaller peripheral bronchi, reaching the distal parenchyma and allowing for peripheral pulmonary lesion sampling. The main aim of this retrospective study was to evaluate the diagnostic yield and the safety of EBUS-TBNA in the diagnosis of pulmonary peripheral nodules. The database of the Interventional Pulmonology Unit of Azienda Ospedaliero-Universitaria delle Marche  was evaluated to identify peripheral pulmonary nodules approached by EBUS-TBNA. Thirty patients with a single peripheral pulmonary nodule located peripherally to the subsegmental bronchi of the lower lobes and adjacent to a small bronchus greater than 3 mm in diameter were included in this study. The nodule was visible using endoscopic ultrasound in 28 patients and the diagnosis was obtained via EBUS-TBNA in 26 cases . The diagnostic yield was 86.6% for all 30 patients and 92.8% if only the 28 patients in which the lesion was visualized via echobronchoscopy were considered. No relevant adverse events were observed. We conclude that EBUS-TBNA may be an effective and safe option to sample pulmonary peripheral nodules in selected patients with lower lobe peripheral pulmonary lesions adjacent to small bronchi greater than 3 mm in diameter and reachable with the EBUS-TBNA probe. Peripheral pulmonary nodules (PPNs) represent a frequent incidental finding on a chest computed tomography scan (CT). With the increase in lung cancer screening trials using low dose CT, the incidence of PPNs has also risen, reaching up to 33% in the high-risk smoker population ,2. AlthoA PPN can be approached for diagnostic purposes using CT-guided transthoracic needle biopsy or with guided bronchoscopy sampling. While transthoracic needle biopsy provides a better sensitivity, it is associated with a higher incidence of complications, particularly pneumothorax . In receThe convex-probe echobronchoscope is usually not mentioned among the instruments used for sampling PPNs, as it is mainly used for the transtracheal or transbronchial approach to hilar/mediastinal lymph nodes or masses, for both diagnostic and staging purposes ,7. HowevTo our knowledge, the possible role of EBUS-TBNA for diagnosing PPNs was not previously assessed.The aim of the present study was to evaluate the feasibility and the diagnostic yield of EBUS-TBNA for the diagnosis of bronchoscopically invisible peripheral pulmonary nodules located in the lower lobes.Secondary endpoints included evaluating the rate of complications and the adequacy of the samples for lung cancer molecular profiling.(a)pulmonary nodule located in the lower lobes, in an area adjacent to the subsegmental or a more distal bronchus;(b)evidence at CT scan of an airway ≥ 3 mm in diameter adjacent or close (≤1 cm) to the nodule;(c)absence of endobronchial abnormalities visible based on conventional flexible bronchoscopy.This was a retrospective study undertaken at the Interventional Pulmonology Service of the Azienda Ospedaliero-Universitaria delle Marche  between January 2018 and February 2023. The EBUS-TBNA database was reviewed, and the EBUS-TBNA procedures performed for diagnosis of PPNs ≤ 3 cm in diameter were identified. Typically, patients with a PPN were submitted to a convex-probe EBUS evaluation in the presence of the following criteria:In all patients, EBUS-TBNA was performed after the nebulization of topical anesthesia (lidocaine 2%) by experienced bronchoscopists  under moderate sedation (midazolam 0.035 mg/kg + fentanyl 0.00035 mg/kg). During the procedure, arterial oxygen saturation and electrocardiographic tracing were systematically monitored.Following a conventional bronchoscopy aimed at ruling out the presence of visible endobronchial lesions, the echobronchoscope  was introduced into the airways and brought into the subsegmental bronchus thought to lead to the lesion based on the evaluation of the CT axial and multiplanar reconstructions. The tip of the scope was then wedged into the airway, and the instrument was rotated until the nodule was ultrasonographically visible. If the lesion was not immediately identified, the position of the echobronchoscope with regard to the nodule location was assessed using fluoroscopy, and an attempt at again directing the scope towards the nodule was made.If the nodule was identified, transbronchial needle aspiration was performed under real-time ultrasound guidance using a 22-gauge needle (Olympus NA-201SX-4022).After the procedure, the patients were monitored in a recovery room for 2 h to capture any adverse effect before being discharged from the Interventional Pulmonology Service.Four needle passes were carried out for each patient. The sample retrieved with the first needle pass was smeared on clean glass slides. One slide was immediately stained using a rapid method  for rapid-on-site evaluation (ROSE), and the other slides were fixed in 95% ethanol and later stained in the Pathology Lab with the Papanicolau method for definitive cytological evaluation. Then, the other 3 needle passes were carried out, and the material was flushed in 10% neutral-buffered formalin for cell-block.In the case of a final diagnosis of pulmonary adenocarcinoma, cytological smears were used for DNA extraction (QIA amp DNA mini kit). Smears were considered adequate for tumor genotyping if at least 500 neoplastic cells were present with a tumor vital cellularity equal or above 50%. Mutational analysis of the 10 genes commonly tested in the setting of non-small cell lung cancer  was performed via MALDI-TOF Mass Spectrometry  using the Myriapod Lung Status Kit (Diatech Pharmacogenetics). Cell blocks were utilized for the immunohistochemical predictive markers ALK , ROS1  and PD-L1 (PD-L1 IHC 22C3 pharmDx for Autostainer Link 48-Agilent) .The primary endpoint for this study was to assess the feasibility and the diagnostic yield of EBUS-TBNA for the diagnosis of pulmonary nodules located in the periphery of lower lobes. Secondary endpoints included the following: (i) the evaluation of the complication rate, and (ii) the adequacy of the samples for the molecular profiling of lung cancer.The diagnostic yield was calculated as the number of cases in which EBUS-TBNA provided a diagnosis relative to the total number of cases with a PPN for whom EBUS-TBNA was performed for diagnostic purposes.To evaluate if the size of the lesion may influence the diagnostic yield, a subgroup analysis according to the diameter of the nodule  was carried out using Fisher’s Exact Test.This retrospective study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Marche Region (CERM:172/2023). Due to the retrospective nature of the study and since data were de-identified, the need for patient informed consent was waived.From January 2018 to February 2023, 844 EBUS-TBNAs were performed at the Interventional Pulmonology Service of the “Azienda Ospedaliero-Universitaria delle Marche”, Ancona, Italy.n = 57) or peripheral masses greater than 3 cm (n = 18). In the remaining 30 patients, who represent the cohort of the present study, a bronchoscopically invisible peripheral nodule ≤3 cm, close to a subsegmental or more distal bronchus, was sampled.Here, 739 procedures were performed to sample hilar/mediastinal lymph nodes or masses for diagnostic and/or staging procedures; 75 EBUS-TBNAs were performed for diagnosing intrapulmonary central lesions adjacent to the trachea or main bronchi . The mean diameter of the lesions was 20.3 mm . Twelve patients had a PPN ≤ 15 mm. Seventeen nodules were located in the right and 13 in the left lung.In 19 cases (63.3%%), the lesion was directly identified ultrasonographically without the need for any other imaging guidance, whereas in 9 cases (30%) the localization of the nodule was achieved with the help of fluoroscopy, which allowed for the identification of the correct direction in which the bronchoscope had to be repositioned and wedged. In the remaining two cases, the lesion could not be visualized by the echobroncoscope despite the use of fluoroscopy; of these, one was in the medial segment of the right lower lobe and the other was in the lateral segment of the left lower lobe, and both lesions had a diameter of 20 mm.We did not notice any difference in the relationship between the lesion and the airway (close or adjacent) in cases in which fluoroscopy was used. The reason why the nodule was not immediately visualized ultrasonographically was the placement of the instrument in a subsegmental bronchus, not close or adjacent to the lesion.Of the 28 nodules identified by the echobronchoscope, a needle aspiration was possible in all cases (93.3% feasibility) and the definitive diagnosis was obtained in 26 . The diaIn 20 cases, the nodule was closely adjacent to the bronchus, and in 10 cases, it was near the bronchus with a maximum distance of 10 mm.In the two cases in which the lesion could not be visualized via EBUS, the diagnosis was obtained in one case with bronchoscopy guided by radial EBUS and fluoroscopy (pulmonary adenocarcinoma) and in the other case, in the surgical resection specimen (carcinoid tumor).In the remaining two patients, the lesion was correctly visualized and sampled, but the EBUS-TBNA failed to provide a definitive diagnosis, showing non-specific inflammatory material. These two patients are still under clinical and radiological follow-up.p = 0.63).The diagnostic yield of EBUS-TBNA was not significantly different for a nodules ≤ 15 mm or >15 mm . In these two cases, systematic endosonographic staging was performed, but no evidence of lymph node metastases was found during the histological examination.No serious adverse events were reported. In two patients, mild bleeding occurred, which was easily controlled using bronchoscopic suction without the need of supplementary therapeutical measures and without clinical consequences.The transbronchial diagnostic approach to peripheral pulmonary nodules currently remains a challenge for interventional pulmonologists. Despite the availability of new techniques and advanced guidance systems  that allow for the visualization of even small nodules in most cases, the diagnostic sensitivity of guided bronchoscopy does not exceed 80% in most series, as very recently confirmed by a comprehensive systematic review with a meta-analysis ,10.Of the above guidance systems, the radial ultrasound miniprobes (rEBUS), is one of the most used, alone or in association with other technologies ,12. rEBUThe use of EBUS-TBNA for sampling central parenchymal lesions that do not compress or infiltrate the tracheobronchial mucosa, but are adjacent to the airways, has been already described in several papers. Tournoy KG et al.  retrospeBesides peri-bronchial central lung lesions, peri-esophageal nodules and masses can be sampled with an echobronchoscope by inserting it into the esophagus (EUS-B-FNA). In a multicenter study, Mondoni et al. described the results of EUS-B-FNA with 107 patients with a pulmonary paraesophageal lesion . The diaTo the best of our knowledge, the present study is the first one that assesses the possible role of convex-probe EBUS for the diagnosis of peripheral pulmonary lesions < 3 cm in long-axis size. Remarkably, the 92.8% diagnostic yield that we obtained in patients in whom the lesion could be visualized ultrasonographically is even higher than that reported in the literature with the use of the more advanced technologies, such as electromagnetic navigation bronchoscopy (EMNB), cone beam CT or robotic bronchoscopy. The diagnostic yield of EMNB, evaluated in systematic reviews with metanalyses, ranges from 64.9 to 82% ,24,25,26In our series, only nodules ≤ 3 cm were included, but EBUS-TBNA can obviously be used for larger lesions located in the lung periphery. Interestingly, the lesion size did not influence the likelihood of obtaining the final diagnosis in our series, a result suggesting that once the lesion is visualized ultrasonographically, the chances of retrieving diagnostic tissue is independent of its size. Indeed, we could visualize and sample even 8 or 9 mm nodules (cases B and C of The major limitation of EBUS-TBNA in sampling PPNs is the possibility of using this technique almost exclusively for lesions localized in the lower lobes. Due to the outer diameter of the instrument and to the anatomy of the bronchial tree, in fact, it is not possible to thrust the echobronchoscope in the subsegmental bronchi of the upper lobes.We tried to insert the echobronchoscope in the subsegmental bronchi of the middle lobe, but we succeeded in making it progress, at most, at the level of the segmental bronchi. The same difficulty of making the instrument progress into the subsegmental bronchi of the middle lobe could be predicated for the superior bronchus n.6 of the lower lobe. In our series, no one case was located in the superior segment of lower lobes.Recently, thinner echobronchoscopes have been introduced into the market , with anAnother limitation to the successful use of EBUS-TBNA in diagnosing PPNs is the need for a bronchus ≥ 3 mm adjacent to the lesion, although this airway does not need to be in close contact with the nodule. Indeed, in our experience (as reported in case B of As already reported in our previous experiences ,34, the Only two minor bleeding cases, easily managed using a bronchoscope and without clinical consequences, were noticed in our study. This confirms the safety of EBUS-TBNA both overall and more specifically for diagnosing PPNs.The results of this study should be interpreted in the context of some limitations, in particular the retrospective design and the small sample size. For instance, important procedural details, such as the duration of the exam, were not systematically recorded. In addition, we set the inclusion criteria based on our personal clinical experience. A prospective evaluation of the role of the “thin” convex probe EBUS for the diagnosis of any PPNs located in the lower and middle lobes, ideally not setting “strict” inclusion criteria regarding the size of the bronchus adjacent to the lesion, could help to more reliably define feasibility, the diagnostic yield and predictors of a successful procedure. Finally, the study was carried out at a high-volume center by experienced operators; as a consequence, the reproducibility of the results in settings with less experience is unclear.In conclusion, this preliminary experience demonstrates that in patients with peripheral pulmonary nodules located in the lung lower lobes and adjacent or close to a bronchus ≥ 3 mm in diameter, EBUS-TBNA can be a safe and effective means of sampling, regardless of the lesion size.Knowledge of this possibility would offer interventional pulmonologists a safe, cheap and successful alternative to more advanced guided bronchoscopy systems for diagnosing PPNs with the above-described characteristics.


Aim: We aimed to estimate the coverage of a population-based Non-communicable Disease (NCD) screening program using lot quality assurance sampling (LQAS) and identify factors affecting its implementation in district Nuh of Haryana, India.Method: A mixed-methods study was conducted with an initial LQAS coverage survey, followed by in-depth interviews. Thirty lots (villages or towns) were sampled in the district, and 20 people aged ≥ 30 years were randomly sampled from each lot. Participants were asked about receiving services under the program. Weighted coverage estimates, which is the proportion of people who had received screening services, were estimated. Using a decision value of more than nine negative responses out of 20 persons, all 30 lots were classified as good or poor performing. In-depth interviews of healthcare providers of good performing lots and district-level health officials were conducted, and factors affecting program implementation were identified.Findings: Six hundred participants were interviewed . The proportion of people who reported having undergone screening for diabetes or hypertension was 2.1%, and all lots performed poorly based on decision value. Key factors affecting the program were leadership, prioritization of NCD activities, ensuring human resource and material requirements, regular incentives, qualities of workers, and community engagement.Conclusion: The screening coverage under the population-based NCD screening program was low in district Nuh, Haryana. This needs to be improved by addressing the identified health system and community-related factors. The Population-Based Screening (PBS) program was rolled out through the National Program for the Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) in 2017 to integrate health promotion, screening, and management of five common non-communicable diseases (NCDs): diabetes, hypertension, oral cancer, breast cancer, and cervical cancer, for people who are ≥ 30 years of age ,5. Nuh iThe targets for achieving coverage for screening under the program are 50% in year one, 65% in year two, and 80% in year three post-implementation . It is dTo estimate the coverage of population enumeration and the Community Based Assessment Checklist (CBAC) by ASHA under the NPCDCS PBS program in Nuh (Mewat) district, Haryana, using the LQAS technique, and to determine the factors facilitating and limiting implementation and coverage of the program.Study characteristicsA mixed methods study consisting of two phases was designed to meet the objectives: an initial quantitative phase to estimate coverage and a qualitative phase where in-depth interviews were conducted to explain and supplement the quantitative survey findings. Lot quality assurance sampling (LQAS) was used to perform the coverage estimation of population enumeration, administration of CBAC, and screening activities by ASHA and ANM in the villages and towns of district Nuh, Haryana, India. The study was performed during the period December 2019 and January 2020. The study population was people who were ≥ 30 years of age and residents of the village/town for > six months.Sample size and samplingFor the desired level of confidence and accuracy for the coverage estimate of 4% and 95%, respectively, World Health Organization (WHO) manual for using LQAS was used to estimate a sample size of 600 . A lot wQuantitative analysisThe proportion for categorical variables and mean with standard deviation for continuous variables were calculated for descriptive analyses. Sample weight was calculated as the inverse of the probability of selection  and applied to all the individuals in the dataset before analysis. Coverage estimates with a 95% confidence interval for various indicators were calculated using the command for estimating proportions for survey data in StataCorp. 2011. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP. In addition to evaluating the overall coverage, lots were classified as good and poor performing for various indicators using a decision value of nine, obtained from Lemeshow & Taber LQAS tables . A decisQualitative methodsThe qualitative part was designed to supplement and explain the survey's quantitative findings and determine the factors facilitating and limiting the program. In-depth interviews were conducted over the telephone or in person using interview guides from July to September 2020. One of the good-performing lots was selected for elucidating the facilitating factors. As the investigator couldn’t contact the health workers in poor-performing lots due to COVID-19 lockdown restrictions, interviews with district health officials were used to identify barriers to program implementation. A total of three interviews were conducted, one each for an ASHA, a CHO, and a MO from one of the good-performing lots. And two interviews were conducted with one district NCD Officer and the district's Chief Medical Officer (CMO). The persons in charge during the first year of program implementation, were contacted and interviews were arranged.Qualitative analysisInterviews were conducted in Hindi and English. Interview audio records were transcribed into Hindi and translated into English using Microsoft Word . Scripts were coded manually by the deductive coding method. Facilitators and barriers to program implementation and coverage were then identified. Themes were formed by grouping the codes to identify critical areas of focus for the overall improvement of program implementation based on the framework of Health System Building Blocks and the role of the community.Ethics approvalEthical approval for conducting the study was obtained from the Institute Ethics Committee, AIIMS New Delhi . Informed consent was obtained from the village or town representatives and study participants.LQAS survey resultsA total of 622 houses were approached for the study. Four houses were locked, and five had no eligible persons for the study. Of the 613 houses with at least one eligible person, four houses did not have the selected participants available for the interview even after two visits. Nine people did not consent to participate in the study. Finally, a total of 600 participants were interviewed for the survey. The mean ± standard deviation of the age of the participants was 44.8 ± 12.2 years. Most of the participants were women (57.2%), housewives (55.2%), followed by laborers (15.8%), had no schooling (68.5%), and belonged to the Muslim religion (80.2%). According to the Udai Pareek scale [Coverage of population-based screening program activitiesThe coverage of the key activities under the population-based screening program is shown in Table Of the 12 participants out of 600 who reported having undergone screening for diabetes or hypertension, two participants were detected to be screen positive (one person with diabetes and another hypertensive). They were referred to Primary Health Centre (PHC) for diagnosis and were then diagnosed with the disease.Results from in-depth interviewsA total of five in-depth interviews were conducted. On coding the scripts, facilitating and limiting factors for program implementation and coverage were identified. These factors, whichever recurred across the interviews, were grouped to identify key areas of focus for overall improvement of program implementation, giving eight themes. The various facilitating factors, limiting factors and themes identified are shown in Figure Key facilitating factors that emerged were i) Leadership at all levels of implementation to conduct the enumeration activity or organize the screening camps, and work management skills, ii) Prioritization of NCD activities, iii) Arrangements to ensure human resource and material requirements, iv) Identify CHO as a critical person coordinating the PBS activities, v) Regular incentives for various PBS-related activities to CHO, vi) Positive worker qualities and coordination capabilities, and vii) Engaging community and beneficiaries by informing them of the need and resolving their queries. Key limiting factors for the program implementation were i) Low priority is given to NCD activity relative to other programs, at different levels, from district to ASHA, ii) Lack of adequate equipment and infrastructure to perform screening activities, iii) An inadequate number of health workers from the local community in the cadre of ANM and CHO, iv) Nonpayment of incentives for PBS activities to ASHAs and their need for awareness about the same, v) Lack of ownership over their community, hesitancy to start new initiatives, and vi) Poor response from the community. In addition to these factors, it is imperative to note that lockdown measures implemented for COVID-19 pandemic control efforts led to a temporary cessation of all screening-related activities in the village.Eight themes were identified at the end of the thematic analysis: leadership and management, NCD as a priority, material resources and infrastructure, human resources, training for PBS, work incentives, workers’ qualities, community characteristics, and community engagement. These themes could be considered critical areas of focus for improving the implementation and coverage of the PBS program when a program review is performed at the district and state levels.Our LQAS survey found that the estimated coverage of screening under the population-based NCD screening program was less than the desired target of 50% in district Nuh, Haryana. Using the LQAS technique permitted the classification of villages or towns into good or poor performance for the various program activities and explored multiple factors that could be attributable to their performance. Designing an LQAS survey has made the study operationalizable in a setting without a prior sampling frame, which otherwise would have been difficult through a survey using usual sampling methods. Also, it was found that this technique gives results rapidly, making it a preferable method choice. Studies that assess the feasibility and efficiency of using LQAS as part of routine monitoring systems at the district level could give more evidence about its overall utility.A similar study by Nambiar D et al. assessed the coverage of screening for diabetes and hypertension under the PBS program in four districts of two states using the LQAS technique . HoweverThe study's strengths were that random sampling methods were used at all sampling levels , increasing the coverage estimate's generalizability. Also, the random selection at the village level to select sampling areas gave an equal probability of communities with different socio-demographic statuses being chosen for the study. The qualitative method through in-depth interviews helped to supplement the quantitative findings.The study's limitations include that during the data collection period, there was social unrest in the community, which could have affected the validity of the findings . Also, iThe screening coverage under the population-based NCD screening program was low in district Nuh, Haryana. This needs to be improved by addressing the identified health system and community-related factors. Making NCD a priority, leadership and management, provision of material and human resources, training for PBS, work incentives, workers’ qualities, and community engagement could be key areas of focus for improving the implementation and coverage of a community-based NCD screening program in India.