Purpose: Residency recruitment events and interviews are widely considered an integral component of the residency match experience. Due to the COVID-19 pandemic, residency recruitment and interviewing throughout the 2020-2021 academic year were performed virtually, which created challenges for applicants’ ability to discern "fit" to a program. Given this change, it is reasonable to suspect that applicants would be less able to discern program fit. Therefore, this study evaluated how virtual interviews impacted pediatric residency applicants’ ability to assess factors contributing to fit and subsequently how applicants assessed their self-perceived fit to their top-ranked programs.Methods: An online, anonymous survey was distributed to all residency applicants who applied to any specialty at our large academic institution. The survey utilized a 5-point Likert-type scale to evaluate qualities of fit as well as the applicants’ self-perceived ability to assess these qualities through a virtual platform.Results: 1,840 surveys were distributed, of which 473 residency applicants responded (25.7% response rate). Among these responses, 81 were pediatric applicants (27.6%). Factors deemed most important in determining fit included how well the residents get along with one another (98.8%), how much the program appeared to care about its trainees (97.5%), and how satisfied residents were with their program (97.5%). Qualities deemed most difficult for applicants to discern included the quality of facilities (18.6%), patient diversity (29.4%), and how well the residents got along with one another (30.2%). When compared to all other residency applicants, pediatric applicants placed more value on whether a program was family-friendly (p = 0.015), the quality of the facilities (p = 0.009), and the on-call system (p = 0.038).Conclusion: This study highlights factors that influence pediatric applicants’ perception of fit into a program. Unfortunately, many factors deemed most important for pediatric applicants were also among the most difficult to assess virtually. These include resident camaraderie, whether a program cares about its residents, and overall resident satisfaction. Taken together, these findings and the recommendations presented should be considered by all residency program leaders to ensure the successful recruitment of a pediatric residency class. Residency interviews and recruitment events are important components of the residency match process for program leaders as well as applicants. The COVID-19 pandemic brought about multifaceted challenges in residency recruitment. Among the most notable changes was the implementation of universal virtual interviews for all residency programs nationwide . VirtualDespite the possibility that virtual interviews may become the norm in the future, there are distinct disadvantages to the process. First, studies have demonstrated the rise of “interview-hoarding” whereby the most competitive applicants interview at the greatest number of programs since there is little incentive to drop interviews -9. This Nonetheless, virtual interviews are becoming the norm within the residency interview process, particularly for large specialties. Unfortunately, virtual interviews come with their own unique set of concerns, notably the notion of “fit” within a program . This isThe primary objective of our study was to explore how the virtual recruitment and interview cycle impacted pediatric residency applicants’ ability to assess fit in programs where they interviewed. Secondarily, we sought to further identify which components of the recruitment and interview process were most important to applicants, and how well applicants could assess these components.An anonymous, online survey was implemented in accordance with Washington University in St. Louis School of Medicine's institutional review board. Participants were identified as those who applied to the following residency programs: dermatology, emergency medicine, general surgery, internal medicine, neurology, neurological surgery, orthopedic surgery, otorhinolaryngology, pediatrics, plastic and reconstructive surgery, physical medicine and rehabilitation, radiology and urologic surgery within a single, large academic institution during the 2020-2021 academic year. Participant email addresses were identified through the institution’s Office of Graduate Medical Education (GME) program-specific residency coordinator. This study is a sub-analysis of previously published data from our institution and compares the responses of applicants to pediatrics to those from other specialties . For thiEighteen unique variables were identified to quantify the notion of fit in accordance with previously published literature, expertise from our institution’s GME, and the NRMP ,24-26. FDemographic data such as gender, sexual orientation, race/ethnicity, region of the medical school attended, couples-match status, and preferred specialty was also collected.Descriptive statistics were performed to summarize the profile of respondents. Pearson’s Chi-Square test was used to identify associations between categorical variables. All data were analyzed using SAS 9.4 . We established statistical significance as a p-value < 0.05. “Importance” within pediatric applicant responses was determined as those who responded as either a 4 (important) or a 5 (very important) on the Likert scale within each question.A total of 473 residency applicants responded to the survey , 81 of which were pediatric residency applicants (pediatrics-specific response rate 27.8%). The survey can be seen in the Supplemental Table in the Appendix.The most important factors contributing towards perceptions of pediatric residency applicant fit among applicants included how well the residents get along with each other (98.8%), how much the program seems to care about its trainees (97.5%), and how satisfied residents seem with their program (97.5%). Conversely, the least important factors contributing towards pediatric applicants’ perception of fit included research emphasis (35.8%), cost of living (40.7%), and resident gender diversity (44.5%) Figure .Applicants were also asked to evaluate how easy it was to evaluate these factors via a virtual interview based on their experiences throughout the academic year. The easiest qualities for applicants to evaluate through virtual interviewing included academic recognition of the program (92.0%), cost of living (82.0%), and research emphasis 81.1%). The most difficult qualities to ascertain through virtual interviewing included the quality of the facilities (18.6%), patient diversity (29.4%), and how well the residents get along with each other (30.2%) , the resident-only virtual panel (35.7%), and the residency website's current residents and alumni page (26.8%) as the most helpful factors in discerning fit. Conversely, the programs' social media presence (9.4%), the virtual campus tour (5.7%), and the virtual open house (3.9%) were rated as the least helpful in discerning fit for a program. The most helpful qualities were determined as the highest number of '5' responses on the Likert scale, whereas the least helpful initiatives were determined by the greatest number of '1' responses on the Likert scale , the quality of the facilities (p = 0.009), and the on-call system (p = 0.038). Conversely, pediatric applicants placed less value on the resident gender diversity (p = 0.009) and emphasis on research (p = 0.10). Both pediatric and non-pediatric residency applicants placed significant weight on whether residents get along with one another, resident satisfaction, and whether the program appeared to care about their residents. These findings are illustrated in Figure The COVID-19 pandemic was a disruptive force across several institutional processes, and the residency interview experience was no exception. The implementation of a virtual interview season is among the most prominent changes and comes in accordance with the Coalition for Physician Accountability . Since tQualities that appeared to be most important for pediatric residents included how satisfied current residents seemed with their program, how much the program seemed to care about the residents, and how well the residents get along with one another. These themes appear in alignment with the current shifting landscape of residency towards a more inclusive culture focused on resident wellness ,31. UnfoCompared to the population at large, applicants applying to pediatrics placed more value on the importance of a family-friendly program and the on-call system. This appears in agreement with a specialty that inherently values a cohesive family unit, as it has been shown to promote healthy childhood development ,33. SecoThere were several limitations of this study. This survey study capitalized on the unique circumstances posed by the COVID-19 pandemic, which resulted in a rapid shift to a completely virtual interview cycle. Due to the limited timeframe and unprecedented nature of the situation, there was no formal validity testing. However, the survey instrument employed in this study was designed after a thorough literature review and in consultation with a team of research scientists from the NRMP. It was subsequently piloted internally with our institution’s education research group, which is composed of medical education expert faculty, residents of various levels, and medical students. Second, this survey was only distributed to those who applied to a single department, single institution at a large academic center. Given this, the qualities identified as most important and least important may not be generalizable to the population, as there may be specific qualities that led an applicant to apply to this residency program. Future studies should aim at increasing the scope across several institutions across a variety of geographic locations. Third, qualities measured through the survey were selected based on literature review as well as via consultation with several medical education experts, but despite the rigor of question selection, there were additional factors omitted from the survey that was important for applicant fit.Similarly, and as previously mentioned, the concept of fit is not well-defined in the literature and has been debated for years prior ,21. LastOur study highlights that many factors deemed most important for pediatric applicants, including resident camaraderie, whether a program cares about its residents, and overall resident satisfaction, are also the most difficult for applicants to assess virtually. This is especially important for residency programs in determining whether future interviews should continue to be held virtually. Although virtual recruitment and interviewing presents several advantages, including increased efficiency, cost-saving, and the ability to interview more candidates, there are also several disadvantages that should be considered, such as the potential for exacerbating inequities between applicants, the reduced ability to perform a holistic review, encouraging application hoarding, and possibly sacrificing a more engaging interview experience. Taken together, these findings should be considered by residency program leaders to ensure successful pediatric residency placement.


This presentation will trace the development of the Savvy Caregiver program from its beginnings as the Center for Nursing Research-supported Minnesota Family Workshop  through a further test as the Partners in Caregiving Program  to the Alzheimer’s Association-supported Savvy program . Three main developments occurred over this period: the program solidified its identity as a caregiver training program and its mechanism of action as that of self-efficacy development through an active learning approach; it sharpened its focus by concentrating on the principal family caregiver (moving away from a broader family approach and eliminating concurrent care recipient programming); and it developed interventionist training materials and programs to enable broader reach. Since 2002, Savvy has enjoyed wide dissemination as an evidence-based in-person psychoeducation program, fostered by support to sponsoring organizations by the Administration on Community Living.


In order to achieve wide-scale impact in community settings, programs must be sustained. Theory and empirical evidence suggest that intervention characteristics, organizational context, capacity for program implementation, and processes related to implementation are associated with continued program delivery. However, few studies examine how combinations of these factors work together in different settings to influence program sustainment.n = 59) at SFP 10-14 implementation sites across Washington State completed an online survey reporting on their current level of SFP 10-14 sustainment. They also completed PSAT, with eight scales designed to assess conditions that consistently produce sustainment. Data were analyzed using qualitative comparative analysis.Using scales specified in the Program Sustainability Assessment Tool (PSAT), the current cross-sectional study aims to identify the necessary and sufficient conditions for the sustainment of the Strengthening Families Program for Parents and Youth 10-14 (SFP 10-14). Staff  environmental support, organizational capacity, and funding stability; (2) environmental support, organizational capacity, communication, and program evaluation, in the absence of strategic planning; (3) environmental support, organizational capacity, program evaluation, and partnerships, in the absence of strategic planning; and (4) environmental support, communication, partnerships, and funding stability, in the absence of program evaluation.Environmental support in combination with organizational capacity appeared to most consistently produce sustainment of SFP 10-14 programs in Washington State. Program providers will benefit from a focusing on enhancing those conditions to increase program sustainment. Contributions to the literatureThis study builds on the growing body of empirical studies that use a validated quantitative instrument and conceptual framework  to understand antecedents of program sustainment.This study uses Qualitative Comparative Analysis to improve understanding of which combinations must be present and which are sufficient for the program sustainment of a community-based youth substance misuse prevention program.Results from this study can begin to inform the development and testing of evidence-based sustainment strategies and support systems that acknowledge and allow for the various needs of diverse programs working in diverse settings.Nearly all the most common causes of morbidity and mortality in the USA are preventable . As a reStrengthening Families Program for Parents and Youth 10-14 (SFP 10-14), an internationally recognized evidence-based family skills training program for youth ages 10–14 and their caregivers, is one of the leading adolescent substance misuse abuse prevention programs in the country. In a systematic review of 56 clinical trials of substance use prevention programs, Foxcraft and colleagues  found thIn addition to having a strong evidence base, SFP 10-14 is also one of the most widely disseminated evidence-based programs in the country and across Washington State. For over 15 years, Washington State University and community partners have trained SFP 10-14 facilitators who have implemented nearly 650 programs and reached nearly 11,000 caregivers and youth. The program is typically delivered by community-based organizations  often in partnership with a local school or school district that can serve as a source for recruiting families to participate. These organizations often receive grant funds to coordinate and implement the program, including providing hourly pay for two to four certified facilitators to coordinate and deliver the program to parents and youth in 2 h, once-a-week sessions for 7 weeks. The location for the sessions is often at schools, community centers, or houses of faith in the evenings. Most organizations choose to implement a single 7-week program to 10–12 families at a time.Although wide dissemination is important, programs like SFP 10-14 are unlikely to have a measurable impact on the critical social problems of today if they are not sustained beyond the initial start-up grant dollars allocated to promote their adoption . SustainAs was documented in a systematic review of 125 empirical studies of health-focused interventions, most sustainability research focuses on categorizing factors presumably associated with program continuation—known as program sustainment . From thThose that were more quantitative in nature rarely utilized validated instruments to measure predictors , and desThe present study used the Capacity for Sustainability Framework and its resultant Program Sustainability Assessment Tool (PSAT) to guide data collection, analysis, and interpretation , 29. LukUsing the scales specified in the PSAT and the aforementioned definition of sustainment, the current study aims to enhance our understanding of explanatory factors associated with sustainment by identifying the necessary  and sufficient  conditions for the continued delivery of SFP 10-14 among a sample of Washington State sites that have all successfully implemented SFP 10-14 in the past, but that vary in their current level of successful sustainment. We analyzed survey data collected from staff at SFP 10-14 implementation sites using crisp-set Qualitative Comparative Analysis (QCA), which assesses the quantitative associations between configurations of conditions and the presence or absence of an outcome .N = 119). Participants were eligible to complete the cross-sectional survey if they considered themselves coordinators, facilitators, or other staff associated with at least one successful delivery of the 7-week SFP 10-14 program and responded to the survey within the data collection period. Of the 119 contacted, 59 (49.6%) staff from SFP 10-14 sites across Washington State completed an online survey between January and February 2015 assessing factors associated with the sustainment as well as level of current and future program sustainment. Eighty-nine percent of respondents were female: 77% were White (non-Hispanic) and 16% were Hispanic/Latino, 79% had earned a Bachelor’s degree or higher, and 48% had been a family educator for 6 years or more. In addition, 79% lived in the same community in which they implemented SFP 10-14, 87% were financially or otherwise compensated for their SFP 10-14 work, 91% reported that SFP 10-14-related duties were not their primary job, and 32% reported delivering the program to special/targeted populations. The characteristics of this study sample closely resemble other SFP 10-14 facilitator samples [We identified potential study participations through two existing databases—the Washington State University SFP 10-14 evaluation database and the Washington State Division of Behavioral Health and Recovery prevention services database. Both databases included names and contact information for SFP 10-14 coordinators and facilitators that were successfully implementing or in the past had successfully implemented at least one instance of the 7-week SFP 10-14 program in Washington State. Recruitment emails were sent by the first author to all contacts that provided email addresses  influences the observation of an outcome. Additionally, QCA is not burdened by the same sample size constraints that parametric statistics must navigate . QCA canThere are various approaches to QCA ; however, as noted by several implementation researchers, crisp-set QCA can improve interpretation and provide clearer practice implications , 40. ForCrisp-set QCA requires conditions and outcomes to be dichotomized  and it requires complete data for each case; only cases with complete data for each analysis will be retained. See below for details. For this study, all conditions measured by the PSAT scales were dichotomized via mean-split, with average or greater levels indicating the presence of a condition. The program sustainment outcome was dichotomized such that any SFP 10-14 implementation site indicating their SFP 10-14 implementation was routinized (Level 4) was considered sustained and denoted as present. The remaining levels (1–3) were coded as absent. Details are presented in the results section.After calibration of the data, truth tables were created. Each row in the truth table represents the configuration of conditions and outcome present for a specific respondent . Several cases may share the same configuration of conditions. For each configuration that was represented by at least one case, a raw consistency value was obtained. This value reflects the percentage of cases sharing that configuration of conditions that also had achieved program sustainment. For instance, in our analyses, one configuration was common to six separate cases. Five of these cases achieved program sustainment, while one did not. As a result, the consistency value is noted as 0.83 (five out of six). The software used, fs/QCA, defaults to an inclusionary consistency cutoff value of 0.8, which was used in the present study.Following the construction of the truth table, configurations which demonstrated less than a 0.8 consistency in achieving the outcome of sustainment were removed. A necessity analysis was then undertaken in which all redundant conditions were also removed. These “non-difference-making factors”  are thosAny condition, or combination of conditions, may be considered sufficient when it includes the necessary condition(s) and also demonstrates the outcome of program sustainment. Sufficiency analyses may generate three sets of solutions: complex, intermediate, and parsimonious. The debate has transpired over the last decade about which solution set to report, with significant expert disagreement , 45, 46.Determining the validity of the solutions generated by QCA was accomplished by examining two indices of model fit: solution coverage and solution consistency. Coverage may be conceptualized much the same as variance explained in parametric statistics. Values range from 0 to 1, where higher values demonstrate equivalently greater empirical relevance . No miniAccording to Kahwati & Kane , researcWe specified a consistency value of 0.9 or greater to indicate conditional necessity. Environmental support was the only condition that met this criterion, with 94% of the cases with average or above environmental support also reporting routinized SFP 10-14 sustainment  was present. These findings align with existing implementation and sustainment frameworks. The Exploration, Preparation, Implementation, and Sustainment (EPIS) model of implementation  and the The role of environmental support in combination with organizational capacity may be especially important for the sustainment of community-based, family-focused programs like SFP 10-14. Scheirer et al.  posit anFunding is often identified as the major barrier to program sustainment , 31, 55.Another surprising finding from the current study was that the absence of strategic planning was associated with program sustainment. In the PSAT, strategic planning is measured by five items: (1) the program plans for future resource needs, (2) the program has a long-term financial plan, (3) the program has a sustainability plan, (4) the program’s goals are understood by all stakeholders, and (5) the program clearly outlines roles and responsibilities for all stakeholders. Items 1, 2, and 3 are particularly suggestive of sustainment success and also had the highest factor loadings in Luke et al.’s  initial Program evaluation has been consistently recognized in the literature as a key ingredient for program sustainment , 21, 56.Our study contributes to the growing literature which uses QCA to understand and quantify complex implementation constructs , 57, 58.Although the present study makes important contributions to the study and support of sustainment, these results must be interpreted within the context of several potential limitations. First, the small sample size in the current study might have limited our ability to identify all possible combinations of factors that could lead to program sustainment. Second, the results may be potentially biased due to the QCA requirement of complete data on all variables included in the truth table. Third, we did not use any missing data techniques to account for any potential bias caused by systematic missing data. Fourth, the dichotomization of sustainability domains and outcomes as being present or absent might have obscured the potential influence of domains that contribute in some measure to sustainment and our chosen calibration method  may have limited the generalizability of the findings. We did however complete a series of sensitivity analyses to compare the mean-split calibration to other cutpoints and found highly similar results. Also, it is important to note that the current study relied on a single-reporter to assess both the conditions and sustainment success of the SFP 10-14 program being implemented by their organization. It is also possible  that multiple staff from the same site/organization completed our survey. To the extent that this happened, and to the extent respondents from the same site reported similar perceptions of their organization’s capacity and SFP 10-14 sustainment, this may have artificially inflated associations between these variables. Finally, we did not include the effect of implementer characteristics, as well as other intervention characteristics that research has shown to be associated with sustainability in community-based programs .In order to achieve wide-scale impact in community settings, programs must be sustained. Theory and empirical evidence suggest that intervention characteristics, organizational context, capacity for program implementation, and processes related to implementation are associated with continued program delivery. However, few studies examine how combinations of these factors work together in different settings to influence program sustainment. The present study helped move us forward in this regard by using an innovative case-oriented technique to uncover multiple pathways to the sustainment of one community-based youth substance misuse prevention program, SFP 10-14. Future studies should aim to extend and determine the generalizability of these findings by using QCA to determine whether similar or different combinations of conditions are necessary and/or sufficient for achieving the sustainment of other types of prevention programs. Leveraging other features of QCA such as fuzzy set (which can accommodate continuous variables) and complementing the quantitative analyses with in-depth qualitative data for each case would also improve our understanding of the multiple pathways to sustainment. We did conduct semi-structured interviews with a subset of the present study’s sample and analyses are currently in progress. These will be presented in a separate paper where we plan to compare results from the quantitative and qualitative data and further explain the patterns uncovered via the QCA analyses. Ultimately, results from this body of work should form the foundation needed to develop and test evidence-based sustainment strategies and support systems that acknowledge and allow for the various needs of diverse programs working in diverse settings.


Police officers often serve as first responders to mental health and substance abuse crises. Concerns over the unintended consequences and high costs associated with this approach have motivated emergency response models that augment or completely remove police involvement. However, there is little causal evidence evaluating these programs. This preregistered study presents quasi-experimental evidence on the impact of an innovative “community response” pilot in Denver that directed targeted emergency calls to health care responders instead of the police. We find robust evidence that the program reduced reports of targeted, less serious crimes  by 34% and had no detectable effect on more serious crimes. The sharp reduction in targeted crimes reflects the fact that health-focused first responders are less likely to report individuals they serve as criminal offenders and the spillover benefits of the program . Mental health first responders successfully managed targeted police calls, reducing the reporting of and actual crime. Police often serve as first responders to emergency calls involving nonviolent individuals in mental health distress or suffering from alcohol or drug abuse. This procedural norm has been the subject of debate and criticism for two broad reasons. One is that serving as first responders to calls involving mental health crises is a substantial drain on scarce police resources and comes with heavy human and social costs, even in the absence of police violence and use of lethal force  approach emphasizes training police officers how to respond to individuals in crisis and connect them with appropriate services  program in Denver provides a mobile crisis response for community members experiencing problems related to mental health, depression, poverty, homelessness, and/or substance abuse issues. The STAR response consists of two health care staff  who provide rapid, on-site support to individuals in crisis and direct them to further appropriate care including requesting police involvement, if necessary. The design of the STAR program is based on the Crisis Assistance Helping Out On The Streets program developed in Eugene, Oregon , where the need for STAR services was anticipated to be the greatest. The pilot area was in the central downtown area of Denver (fig. S1) and largely represents neighborhoods with residents who are more affluent, educated, and white than the city as a whole (see table S1). However, all but one of the neighborhoods in the STAR pilot service area are also designated by the city as “displacement-vulnerable” areas, rapidly gentrifying city spaces where poor and otherwise at-risk residents are being pushed out . The identification of emergency calls eligible for STAR services relied on two specific screening criteria. First, the incident had to designate at least one of several codes: calls for assistance, intoxication, suicidal series, welfare checks, indecent exposure, trespass of an unwanted person, and syringe disposal (We identify the impact of the STAR program on STAR-related and STAR-unrelated measured crime using “difference in differences” (DD) and “difference in difference in differences” (DDD) designs that effectively rely on before-after comparisons across treated and comparison precincts . To identify the impact of the STAR program, we consider all criminal offenses reported by the City and County of Denver through data collected as part of their participation in the federal National Incident-Based Reporting System (NIBRS). These data include calls for police assistance that escalated to offenses reported by the police regardless of whether they led to formal charges (including arrest) or whether the STAR team was dispatched or responded to the call. However, offenses are not differentiated by whether they led to an arrest or some other offense-related outcome . We also do not have access to such arrest and citation data and recognize their possible confounding. That is, such data may be missing  and may be confounded further by police and prosecutorial discretion around whether to sustain an arrest or citation for a given offense.Before our analysis, we coded each offense as directly related to STAR operations  or not . For this focal outcome , we expect either the STAR team or the police to often engage the individual in question. If a criminal offense is recorded during such service calls, then it implies either an arrest or a citation. If no crime is recorded, then it implies either a field determination that no criminal offense occurred or a discretionary decision not to record such low-level criminal offenses .The impact of the STAR program on the frequency of these offenses is theoretically uncertain. For example, to the extent police who respond to mental health and substance abuse incidents consistently direct individuals in crisis to health care services without also identifying them as low-level criminal offenders, the overall effects of the STAR program would be muted—or even null. The Denver police have participated in CIT training designed to support their capacity to identify individuals who need mental health support and to direct those individuals to appropriate care. Because the comparison condition in this study consists of such CIT-trained police as first responders, the introduction of the STAR team could, in theory, have small or nonexistent effects on recorded crime.This study provides quasi-experimental evidence on the overall  effect of STAR’s community response approach on the number of recorded crimes. With respect to reducing recorded criminal offenses, the STAR program’s overall impact could reflect the combination of two broad, underlying mediating mechanisms that merit careful emphasis. One involves program-induced reductions in the recording of existing criminal offenses, while the other concerns reductions in actual crime.The first mediating mechanism would occur when STAR first responders simply do not record an existing criminal offense  that police officers would record when responding to a given incident. This reporting mechanism has clear empirical relevance given that (i) under NIBRS procedures, law enforcement officials  identify and report criminal offenses and (ii) the program data from the period we study indicate that STAR staff did not involve police in their service calls  when responding to an incident . However, we do discuss two pieces of ancillary evidence that indicate whether STAR’s overall impact partly reflects lower levels of actual crime in addition to the reduced reporting of criminal offenses. First, we provide direct evidence for genuine crime reductions by examining the impact of the STAR program on crimes occurring outside STAR’s operating hours . Second, we compare the total crime reduction attributable to STAR to the amount that would be expected if STAR’s effects only operated through its service calls. We construct this expected number by multiplying the number of STAR service calls conducted during the pilot period by the number of criminal offenses typically recorded in such criminal incidents during the pretreatment period.As an initial and unrestrictive way to visualize the impact of the STAR program, b = −0.41, SE = 0.07, t = −6.09, P < 0.001). This estimated impact on the natural log of STAR-related crimes implies that the program reduced these targeted crimes by 34% . By contrast, the estimated effect of the STAR program on measured crimes that were not directly related to STAR services was comparatively small and statistically insignificant . This finding suggests that the targeted fielding of mental health professionals as first responders did not increase the frequency in reporting more serious criminal incidents in treated precincts. This null result can also be understood as affirming the causal warrant of the DD design by indicating that there were not unobserved and confounding determinants of crime unique to the precincts and months associated with the STAR pilot, a finding consistent with the causal warrant of the DD design. The DDD specification . This DDD estimate suggests that the STAR program led to a 30% reduction  in STAR-related offenses (see table S4 for full numeric results).Estimates based on the DD and DDD designs i.e.,  and 2 alon i.e.,  leverageP = 0.71). These results are consistent with the “parallel trends” assumption of the DD design and with a causal interpretation of the results based on The Supplementary Materials presents several ancillary analyses that explore the robustness of these findings. For example, Poisson and negative binomial specifications that recognize both the count nature of the crime data and the presence of fixed effects  and event studies (figs. S5 to S7).Several additional internal validity checks detailed in the Supplementary Material provide evidence on the coronavirus disease 2019 (COVID-19) pandemic as a possible confound and related evidence that speaks more generally to the validity of the parallel-trends assumption. In particular, estimates near the bottom of table S6 indicate that the estimated effects of the STAR program are similar in specifications that only rely on data following the beginning of COVID-19 shutdown orders . Second, the estimated effects of the STAR program are also similar when based on generalized synthetic control design . In addition, in table S6, we show that DD specifications that allow for spatial spillover effects of the STAR program in geographically adjacent districts indicate that the estimated effect of STAR operations on neighboring precincts was small and statistically insignificant. However, there do appear to be meaningful temporal spillover benefits of the STAR program within treated precincts. Specifically, the reductions in STAR-related measured crimes in treated precincts also occurred during days of the week and times when the program was not active (table S6). This pattern is consistent with the hypothesis that the STAR program provided helpful services to individuals in crises that were somewhat persistent rather than brief and episodic. However, these temporal spillovers do not extend to precincts adjacent to those with STAR operations.Last, the Supplementary Materials also presents analyses that explore the potential heterogeneity in these results. For example, the event-study results  suggest There remains the possibility of spatiotemporal spillover. For example, “near repeat” crime is the phenomenon in which criminal incidents increase near to and shortly after the occurrence of a crime , from December 2019 to November 2020, we have used a DD model that effectively compares the changes in police-recorded criminal offenses both before and after the pilot program and across the treated and untreated precincts. We complement the results of this preregistered design with a variety of robustness checks . We also examined whether STAR operations influenced the frequency of more serious offenses that were not directly targeted by the program and found no discernable impact.We find that the program led to large and sustained reductions in reports of STAR-related offenses in treated precincts, while unrelated offenses over the treatment period changed little in those same police precincts . Our comThe overall  estimated impact of the STAR program  reflects the simultaneous influence of two distinct, broad, and policy-relevant mechanisms. One is due to STAR first responders providing health care to individuals in mental health or substance abuse crises simply not recording them as low-level criminal offenders subject to arrest or citation. The second mechanism is due to actual reductions in crime. The empirical relevance of these two complementary mechanisms cannot be exactly identified. However, the fact that the total reduction in criminal offenses attributable to STAR  clearly exceeds the highest number of criminal offenses likely to have been confronted by STAR staff  suggests that the STAR program reduced actual crimes. In addition, the evidence that the STAR program reduced the number of low-level criminal offenses during hours when the program was inactive  provides direct support for the existence of this underlying mechanism.Last, we find that STAR’s operation during the pilot phase did not increase reports of more serious or violent offenses. Under the broken windows theory, less police enforcement of low-priority criminal violations will increase the prevalence of more serious and violent criminal offenses being recorded . These results provide a compelling motivation for the continued implementation and assessment of this approach. However, successfully replicating the STAR program is likely to rely on key implementation details such as the recruitment and training of dispatchers and mental health field staff as well as the successful coordination of their activities with the police. Furthermore, the generalizability of the community response approach to a broader set of potentially preventable charges is uncertain and a design feature worthy of further study. There are also additional details about programs such as STAR that merit further investigation and clarification. For example, we are unsure of whether the existence of STAR may have increased the trust and the willingness of community members to call 911. However, we note that such an effect is likely to imply that our estimates underestimate the true effect of the STAR program. That is because increase in trust and willingness to call 911 is likely to increase measured crime in the short run as some of these calls would result in police engagement regardless of arrest status. Future studies may also consider the effects of programs like STAR on health-related outcomes, such as access to health services  and related measures of well-being.Another important policy consideration is its cost-effectiveness. The total cost of the 6-month STAR pilot program was $208,141  and based on the NIBRS. Because Denver’s reporting is NIBRS-compliant, a mere civilian call is not, by itself, sufficient to imply that a criminal offense is registered. Specifically, the NIBRS User Manual notes that “Participation in NIBRS requires law enforcement agencies to report certain facts about each criminal incident coming to their attention within their jurisdictions.” However, because at least some calls will involve a complaint without clear criminality, they will not rise to the level of a “criminal incident coming to their attention.” Thus, not every complaint or incident investigated by police will result in an offense being recorded in our data—instead, only those incidents that result in an arrest or citation are recorded as offenses.Our coding identifies the types of reported offenses the STAR program would conceptually be expected to reduce  rather than just the kinds of incidents the program targets. “Disarming a peace officer” is an illustrative example of the distinction between STAR-related and STAR-targeted offenses. The dispatch protocol would not send out a STAR team in response to such an offense . However, this is exactly the sort of offense that might be reduced by having mental health specialists as first responders rather than police .However, there are differences between the data reported to NIBRS and what is reported on Denver’s ODC that we use here. That is, NIBRS records all serious incidents such as homicide and arson but only reports records of arrests made for less serious offenses such as the STAR-related ones that are our focus here. Conversely, we have confirmed through correspondence with M. Lunn, the Manager of Strategic Initiatives for the Denver Police Department, that their data record not only those crimes resulting in arrests or formal charges  but also all criminal incidents recorded by the police. To that end, our main results identify program-induced reductions in substantiated criminal incidents identified by or reported to the police. Conceptually, these reductions combine the relabeling of existing behaviors that occur when individuals in crisis receive health care rather than being directed into the criminal justice system and a reduction in criminal offenses by individuals in crisis who would offend repeatedly in the absence of health care.The ODC contains incident-level data on all criminal offenses reported to law enforcement from January 2016 to November 2020. From that data catalog, we constructed a panel dataset of criminal offenses observed in each of 36 precincts over each of 12 months for the period from December 2019 to November 2020 . This period includes the 6-month pilot phase and the 6 months before the pilot phase.https://osf.io/nqhvf) focuses on the impact of the STAR program in a static DD specification that takes the following formpmY is the natural log of STAR-related criminal offenses for precinct p in month m. The term, pmS, is a binary indicator equal to 1 only for STAR-participating precincts observed during the period when the program was active. The coefficient of interest, θ, represents the effect of the STAR program conditional on fixed effects unique to each precinct and to each month . The term, εpm, is a mean-zero error term with clustering at the precinct level. The static DD specification in Eq. 1 embeds the assumption that the STAR program implies a one-time level shift in crimes. To explore possibly time-varying treatment effects, we also report the results of “semi-dynamic” DD that unrestrictively allow for effects to vary uniquely in each of the six treatment months. In the Supplementary Materials, we also present the results based on versions of The single confirmatory hypothesis in our preregistered analysis plan . A key identifying assumption of this design is that the time-varying changes within the comparison precincts provide a valid counterfactual for what would have happened in the treated districts in the absence of treatment. We examine the empirical validity of this assumption in two ways. One is to estimate “event study” DD specifications that unrestrictively allow for effects unique to treatment precincts in each month. The event-study estimates indicate the extent to which the treatment and comparison precincts had similar month-to-month variation in STAR-related crimes before the pilot began . If treatment and comparison precincts have similar trends in STAR-related crimes in the months before STAR operations, then it would be consistent with the internal validity of the DD design.n = 864) and estimate the following specificationA second, important robustness check is to use pm), month-offense (γmo), and precinct-offense (δpo). Critically, the DDD specification controls for unobserved determinants of crime unique to each precinct-month combination. The parameter of interest reflects the estimated effect associated with the three-way interaction unique to STAR-related offenses observed in treated precincts during the treatment period .This specification includes unrestrictive fixed effects unique to each possible two-way interaction: precinct-month (α


BCR‐ABL1 transcript level is an essential part of routine disease monitoring in patients with chronic myeloid leukemia. One patient sample (e13a2 transcript detected by nested PCR) attracted attention by revealing an aberrantly spliced BCR‐ABL1 transcript variant e13a1. The last 38 base pairs (bp) of BCR exon 13 were replaced by a 37 bp insertion of the ABL1 intron 1–2/exon 1 sequence. The rare aberrant BCR‐ABL1 fusion transcript can cause discrepancies in molecular diagnostics. This scenario highlights the importance of an individual characterization of the BCR‐ABL1 fusion sequence in case of unclear qRT‐PCR results.Quantitative reverse transcription polymerase chain reaction (qRT‐PCR) of  The occurrence of different BCR‐ABL1 mRNA fusion variants  results in the expression of an abnormal BCR‐ABL1 fusion tyrosine kinase in the majority of the patients. In most cases, the breakpoints occur within the major breakpoint cluster region (M‐bcr) within the BCR gene. The breakpoints are less often located in two other breakpoint cluster regions, termed minor (m‐bcr) and micro (μ‐bcr). Rare atypical BCR breakpoints outside these cluster regions, novel BCR‐ABL1 transcripts with insertion and/or deletion of different BCR and ABL sequence sections, and atypical splicing events were detected  and TaqMan [TM]) for molecular monitoring of usual fusion transcripts [A 69‐year‐old female patient was diagnosed with CML in 2005. At diagnosis, the translocation t and the transcript type e13a2 were determined extramurally. The patient samples were obtained with written informed consent in accordance with the declaration of Helsinki, and the analysis was approved by the institutional review board of the Medical Faculty of Mannheim, Heidelberg University . The first monitoring sample was investigated in our laboratory 6 months after the start of imatinib therapy. At this time, a qualitative multiplex PCR assay [nscripts . Both me3For evaluation of the externally transmitted e13a2) transcript type, we performed our qualitative in‐house multiplex PCR assay as previously described [a2 transcBCR‐ABL1 quotient or a binding failure of primer(s) or probe. Therefore, we performed a nested‐PCR assay [Since the patient received imatinib therapy over 6 months, the negative multiplex PCR result for any transcript variant could be explainable by a low CR assay  and we sBCR‐ABL1 transcript variant (e13a1) as shown in Figure ABL1 intron 1–2/exon 1 sequence. This sequence exchange resulted in missing PCR amplicons. Using the primer/probe combination of the LC qRT‐PCR method [Sanger DNA sequencing of one‐step PCR products revealed an atypical variant ea1 as shoR method , PCR ampBCR exon 13 fragment), to the last four bases of ABL1 exon 1, resulted in the in‐frame fusion NM_004327.4:c.2670_2707delinsAACAGCTCTGCCTCTGGGAGCGGAGAGGACTGGGATAGAAA of BCR and ABL1 . The potential impact of this amino acid exchange on protein folding and activity requires further investigations. For future monitoring, the qRT‐PCR method for this patient has to be performed by LC instead of the TM PCR system.In addition, the fusion of the 37 bp intron sequence , Pfizer, ARIAD, and research funding from Novartis Pharma GmbH and BMS. All other authors declare no conflict of interest.The study design adhered to the tenets of the Declaration of Helsinki and was approved by the relevant institutional review board . The patient gave written informed consent.


Medical school academic achievements do not necessarily predict house staff job performance. This study explores a selection mechanism that improves house staff-program fit that enhances the Accreditation Council for Graduate Medical Education Milestones performance ratings.fit with Program values and goals. It was hypothesized cohort performance ratings will improve because of the intervention.Traditionally, house staff were selected primarily on medical school academic performance. To improve residency performance outcomes, the Program designed a theory-driven selection tool to assess house staff candidates on their personal values and goals Prospective quasi-experimental cohort design with data from two house staff cohorts at a university-based categorical Internal Medicine Residency Program. The intervention cohort, comprising 45 house staff from 2016 to 2017, was selected using a Behaviorally Anchored Rating Scales (BARS) tool for program fit. The control cohort, comprising 44 house staff from the prior year, was selected using medical school academic achievement scores. House staff performance was evaluated using ACGME Milestones indicators. The mean scores for each category were compared between the intervention and control cohorts using Student’s t-tests with Bonferroni correction and Cohen’s d for effect size.The cohorts were no different in academic performance scores at time of Program entry. The intervention cohort outperformed the control cohort on all 6 dimensions of Milestones by end-PGY1 and 3 of 6 dimensions by mid-PGY3.Selecting house staff based on compatibility with Residency Program values and objectives may yield higher job performance because trainees benefit more from a better fit with the training program.The online version contains supplementary material available at 10.1186/s12909-022-03801-0. We hypothesize that interviewees who are evaluated on rubrics that are explicitly anchored to organizational values will outperform those who are not similarly evaluated and selected.Selecting house staff candidates takes time and considerable resources. Program directors for medical and surgical residency programs often rely on cognitive examination-based metrics, such as the United States Medical Licensing Examination (USMLE) scores, and other academic metrics, such as Alpha Omega Alpha (AOA) Honor Medical Society membership, to select program candidates , 2. Howeevaluation of house staff candidates. The first is person-organization fit [We base our hypothesis on two organizational concepts that suggest a way to improve the tion fit , which ption fit , which etion fit –20. ConvTo test our hypothesis, we assess a cohort of house staff on the fit between their professional and personal attitudes and values with values and objectives of the Program during the interview. We use a behaviorally anchored rating scale (BARS) tool, together with blinded interviewers, to improve intra- and inter-rater reliability, during the evaluation phase of the house staff interviewing process . In the This quasi-experimental prospective study employs data from two cohorts of house staff at a university-based categorical Internal Medicine Residency Program. Both cohorts had previously been shortlisted for interviews based on academic qualifications and extra-curricular experiences. Both cohorts were interviewed twice by two different interviewers during the site visit. The INTERVENTION cohort comprised all 45 house staff selected from 323 applicants who interviewed between November 2016 and January 2017. 97 faculty from across the Department of Medicine participated in the interviews. Interviewers were asked to use the BARS scoring rubric in which 1 (high), 3 (average), and 5 (low) ratings for each criterion were anchored to exemplar behaviors, narratives, or critical incidents critical to the values and objectives of the Residency Program for that criterion , 23. TheThe CONTROL cohort comprised all 44 house staff selected from 404 applicants who interviewed between November 2015 and January 2016. Interviewers evaluated the applicants using an overall single numerical score between 1 and 10, with 1 as the highest. Interviewers were drawn from approximately the same pool for the two cohorts except those who left the institution or were new hires. The latter set comprised less than 5% of the interviewer pool.The Institutional Review Committee approved this study and data were deidentified.Interviewer-candidate pairs were randomly assigned. To minimize the Hawthorne and other selection biases, interviewers were blinded to the study’s objective. To standardize the intervention and to ensure complete data collection, interviewers were given a set of questions and the scoring rubric. Subsequently, house staff annual performances were evaluated by 12 standing members of the faculty from the Clinical Competency Committee (CCC) who use the Accreditation Council for Graduate Medical Education (ACGME) Milestones Performance indicators , 25. MemHouse staff performance for both CONTROL and INTERVENTION groups was evaluated on 22 items in Milestones Performance comprising six core competency areas: Patient Care (PC) includes 5 items that measure physicians’ taking a patient-centered approach to healthcare; Medical Knowledge (MK) includes 2 items that measure physicians’ ability to apply medical knowledge to clinical situations; Systems-based Learning (SBL) includes 4 items that measure physicians’ ability to coordinate patient care within the healthcare system; Practice-based Learning (PBL) includes 4 items that measure physicians’ commitment to lifelong learning; Professionalism (PROF) includes 4 items that measure physicians’ treating all people with respect, compassion, and dignity; and Interpersonal Communication (IC) includes 3 items that measure physicians’ ability to effectively exchange information with patients, their families, and professional associates , 25. MilUS News and World Report. The fifth covariate was each house staff’s interview ranking.All house staff’s academic performance were collected at the time of the interview and included as covariates. These comprised USMLE Step 1 and Step 2 scores, which proxy the measurement of clinical knowledge, AOA membership , which recognizes performance representing the top 10% of the graduating medical school class, and medical school ranking listed in the The INTERVENTION comprises the cohort of house staff selected on Program fit using a BARS scoring rubric, coded as 1. The CONTROL comprises the cohort of house staff selected on academic performance, coded as 0. Intervention subjects were selected on behavioral and attitudinal fit with the Program’s clinical, scholarly research, and leadership task expectations, values, and an overall assessment on potential success as a house staff in the Program. The BARS scoring rubric consisted of 5-point rating scales in which ratings of ‘1’, ‘3’, and ‘5’ were anchored to exemplar behaviors for each criterion.clinical competency, which is the ability to apply theoretical knowledge to clinical practice. House staff are expected to take responsibility for their patients and make clinical decisions when assessing patients and performing procedures. Another criterion and Program value is self-directed learning and scholarly research. House staff are expected to conduct original research and publish papers to contribute to the general body of medical knowledge. Engagement in research provides house staff with opportunities to acquire knowledge to handle novel and unpredictable situations as well as be thought leaders in specialty domains [leaders to meet challenges in quality, safety, and patient-centered care [Program fit and potential success measure candidates’ attitudinal fit to the Program’s values and their potential to succeed in the Program respectively.Specifically, a criterion and Program value is  domains . A thirdred care . CandidaTo determine if the house staff in the INTERVENTION and CONTROL cohorts were comparable, medical school achievement at the start of the Residency Program were evaluated for differences using Student’s t-tests. To test the hypothesis that the INTERVENTION was associated with higher performance, we compared the Milestones Performance scores between the INTERVENTION and CONTROL cohorts using Student’s t-tests. Bonferroni correction was applied to adjust the statistical significance threshold for multiple comparisons and Cohen’s d was applied to determine the effect size of the differences or the practical significance of the outcomes between the two groups.To further test the hypothesis that the intervention was associated with house staff performance, hierarchical regression analysis was performed in which their academic and interview rankings were first entered into the regression model, followed by the binary Intervention variable. We report the standardized regression coefficients or beta, which allows for easier comparisons among variables that are measured in different units or dimensions to standardize the relationship with the outcome variable. Statistical significance is set at p < 0.05 and with the Bonferroni correction threshold at p = 0.008. A statistical significance on INTERVENTION indicates that an interview process that evaluates applicants’ clinical, research, and leadership behavioral and attitudinal fit, fit with Program values, and overall potential success in the Program not only shows significant differences between the cohorts but also add incremental prediction on performance beyond factors related to academics and interview ranking.Total possible number of participants was 45 for the INTERVENTION and 44 for the CONTROL, which were the entire class of respective cohorts. Actual number of participants was 45 for the INTERVENTION and 44 for the CONTROL for a response rate of 100% for both cohorts. Table Table Since the INTERVENTION cohort had higher AOA membership scores, we include medical school academic performance covariates in the regression analysis to control for potential bias between the two groups. Table While USMLE Step 1 scores had a significant influence on faculty evaluations 6 months into the Program, academic achievements from medical schools had no significant influence by the middle of PGY3, which is consistent with past results –9. InsteThe interviewers from both cohorts were drawn from the same pool of attending physicians, the Program curriculum did not change between the INTERVENTION and CONTROL cohorts, and the performance evaluators and Milestones Performance dimensions were the same between the cohorts. The difference, after accounting for individual candidate differences at time of entry, was the criteria in which the candidates were selected. Instead of selecting applicants on academic performance, explicit evaluation of applicants using a BARS rubrics based on fit with Program’s values and objectives that considered non-cognitive dimensions such as leadership, clinical skill acquisition, and research work ethic was associated with higher performance, which is consistent with other studies that highlight such dimensions that make for a ‘great’ resident , 4, 7–9.prima facie, that structured interviews reduce bias. On the other hand, structured interviews that do not have an explicit scoring rubric for interviewees’ responses may not improve the predictability of the candidate’s performance. Our study neatly closes this gap with the BARS tool because it quantifies the assessment of the candidates’ interview responses.With respect to the implications of our results in the context of previous studies, one of the most interesting findings from previous studies in internal medicine and other disciplines, is the weak relationship between the use of structured interviews and subsequent house staff performance. On the one hand, this is surprising because one would expect, consistent statistical significance of the performance differences reveals the strength of the Intervention.A potential limitation is the unequal restriction of range in interview scores (25 points in the INTERVENTION and 10 in the CONTROL). Although we did not use the data to compare the selection committee’s scores across groups, we are unable to ascertain the degree of unobserved bias, if it exists in the selection process. For example, a larger range of 25 points from the BARS scores could result in a smaller number of ties which will require the selection committee to make a decision that is not strictly based on the scoring. Even though we evaluated the entire class for each cohort, the statistical power of the sample is likely to be small. In our study, this is a strength since, despite the small sample, the Another limitation is that we cannot ‘prove’ that program compatibility was better established in the intervention cohort than the control during the interviewing stage of the selection process. However, we know that the data on compatibility in the INTERVENTION cohort is more consistent because the scoring rubrics in the BARS tool ensures that all the interviewers rated the interviewees on rubrics that reflect the values of the Program. As well, the selection committee used these data to make their selection decisions. While interviewers in the CONTROL cohort may have asked questions related to program compatibility, we do not have the same degree of confidence that everyone did so, because they were not explicitly told to evaluate interviewees’ responses on Program values.Although this is a single center study, it makes sense that the approach to selecting house staff on program fit could be generalized since every training program has specific learning objectives and assessments of learning criteria. The key to standardizing the selection process is to minimize unwanted variation, which was the purpose of the BARS tool. An obvious extension would be to replicate the BARS development procedure in more sites, using the ACGME Milestones Performance criteria as a standard outcome measure. We also recognize that medical education is constantly evolving, so recent cohorts could naturally outperform prior cohorts over time. We have no evidence from the literature that this is happening but acknowledge the possibility. Finally, it would be easy to attribute the results to the fact that this study was conducted in an elite residency program. However, the intervention is designed to be extensible and adaptable to any training program because it is based on a selection mechanism that improves the match between candidates and program values and objectives. The lesson from this intervention is for program directors to clearly translate their programs’ values and objectives, which can be challenging, to measurable dimensions on which interview data can be judged against.Below is the link to the electronic supplementary material.Supplementary Material 1


PET-CT scan 18F-fluorodeoxyglucose (FDG) uptake in levels 1, 2, and 3 LN had a tissue adequacy of 76.67%, 54.64%, and 35.56%, respectively (p = 0.0009). EBUS bronchoscopy method could be used to achieve an accurate diagnosis, with IP-trained operators yielding the best results. There is no correlation with PET scan positivity, indicating that both PET and EBUS are complementary methods needed for staging.Mediastinal lymph node assessment is a crucial step in non-small cell lung cancer staging. Positron emission tomography (PET) has been the gold standard for the assessment of mediastinal lymphadenopathy, though it has limited specificity. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is quick, accurate, and a less invasive method for obtaining a diagnostic sample in contrast to mediastinoscopy. We performed a retrospective chart analysis of 171 patients to assess the adequacy of tissue obtained by EBUS for diagnosis and molecular profiling as well as the assessment of staging and lymph node (LN) stations diagnostic yield, in correlation to PET scan and the operator’s level of experience. A significantly increased tissue adequacy was observed based on the operators’ experience, with the highest adequacy noted in trained Interventional Pulmonologist (IP) (100%), followed by >5 years of experience (93.33%), and 88.89% adequacy with <5 years of experience ( Mediastinal lymph node (LN) assessment is crucial in the staging and management of non-small cell lung cancer (NSCLC). The extent of involvement of hilar and mediastinal LN plays a major role in the multidisciplinary treatment decisions that range from neoadjuvant therapy, surgical resection, chemoradiation, or eligibility for clinical trials ,2,3,4.Pathological staging of the mediastinum through either mediastinoscopy or endobronchial ultrasound bronchoscopy (EBUS) has excellent specificity and sensitivity. Unfortunately, their potential complications, need for anesthesia, and costs make imaging techniques a widely-used initial modality for mediastinal staging for lung cancer patients. A clinical staging positron-emission tomography-computed tomography (PET-CT) scan is the most commonly used imaging modality. PET-CT relies on a standardized uptake value (SUV) calculation compared to normal tissue, thus providing the relative metabolic activity value in an LN. PET-CT is relatively sensitive in identifying metabolically active LNs but has low specificity with pathological diagnoses other than malignancy, such as inflammation and infection ,7,8,9,10The American College of Chest Physicians recommends that lung cancer patients treated by surgical resection on a curative basis should be monitored by CT every six months for two years, then annually thereafter . HoweverThe standard of care for mediastinal staging in patients with lung cancer is endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). This procedure is minimally invasive, highly effective, and can be used to diagnose lung cancer, infections, and other diseases causing enlarged lymph nodes in the chest. EBUS-TBNA allows for real-time imaging of the airways, lungs, lymph nodes, blood vessels, and the potential to biopsy difficult-to-reach areas through needle aspiration. Compared to mediastinoscopy, EBUS-TBNA is less invasive, can access more lymph node stations for sampling, and has a lower complication profile.In this study, we reviewed the adequacy of tissue obtained for diagnosis, successful molecular profiling, adequate staging, and diagnostic yield by the EBUS-TBNA at a major academic institution compared to PET-CT imaging. In addition, we analyzed the effect of the operator’s level of experience on the adequacy of the resulting tissue.This retrospective chart review study included [X] LN stations of 171 patients who underwent EBUS at the University of Cincinnati Medical Center over a period of three years. The study included patients with the diagnosis of advanced stage III and IV NSCLC. Charts were reviewed for pathological diagnosis, EGFR status, LN stations, PET scan results, and EBUS operator experience. The availability of tissue was assessed and pathological diagnosis has been described.Diagnostic accuracy was measured by the diagnostic yield and the percentage of malignancies found in patients with known metastatic disease.Diagnosis of advanced NSCLC, stages III or IV;Undergone EBUS at the University of Cincinnati Medical Center;Presence of EGFR status.Patients must have met all of the following criteria to be included in this study:The inclusion criteria of a diagnosis of advanced NSCLC of stage III or IV was considered the diagnostic gold standard. If the tissue sampled were diagnostic, whether positive or negative, for malignant cells, then the EBUS was considered adequate. If the pathology results were inadequate for a diagnosis, then the EBUS was deemed inadequate. Adequacy was determined on a patient level.Success of obtaining a positive biopsy was considered as the endpoint. Chi-square test was used to compare the different levels of operator’s diagnostic accuracy as well as tissue adequacy with FDG uptake levels. Data were analyzed using SAS software Version 9.4 .171 patients underwent EBUS and were included in this retrospective study.p < 0.0001). Of all lymph node (LN) stations tested, LN stations 4R and 4L showed more positive tissue results compared to the other stations, but with no statistical significance. No correlation was found between PET-CT positivity and tissue adequacy for diagnosis by EBUS (p = 0.6410).Most of the 171 patients who underwent EBUS in our study achieved adequate tissue levels upon sampling for diagnostic purposes (p = 0.0019). Operators with greater than five years of general experience achieved a diagnostic accuracy of 93.33%. Operators with less than five years of experience obtained an 88.89% diagnostic accuracy (p = 0.0019)  achieved the most significant tissue diagnostic accuracy of 100% ( 0.0019) .18F-fluorodeoxyglucose (FDG) uptake was binned into two classes: 1, 2, and 3. The percentage of tissue adequacy in relation to the PET-CT scan positive uptake depended on the degree of uptake noted in each scan, with 18F-fluorodeoxyglucose (FDG) uptake levels of 1, 2, and 3 achieving a tissue adequacy percentage of 76.67%, 54.64%, and 35.56%, respectively (p = 0.0009)  .Effective treatment of lung cancer is challenging due to its incidence, high mortality, and inability to diagnose at early stages. While there have been many advances in the surgical treatment of early stage lung cancer, medical treatments are only beginning to see the effectiveness of targeted therapies.The recent advances in diagnostic techniques have eliminated the need for invasive procedures to diagnose and stage lung cancer. This leap in efficiency has been facilitated by the expanding field of biomarkers and molecular markers that make personalized approaches to cancer treatment possible ,19,20. HDespite this positive result, the authors recommended including biopsies in patient management to properly diagnose genetic mutations and thus avoid inappropriate treatment and misdiagnoses . The 18FEBUS-TBNA was first described in 1992 and has quickly become the preferred mediastinal lymph node sampling method. The technique proved to be more efficient and accurate, less invasive, and more cost-effective than mediastinoscopy . Its senAn important utility of EBUS-TBNA lies in its ability to obtain adequate tissue quantities to provide a molecular diagnosis in cases of NSCLC. This role cannot be emphasized enough, as specific chemotherapeutics and targeted immunotherapies have been shown to improve progression-free survival . LabarcaThe proficiency of the endoscopist is an essential factor due to the complex methodology of EBUS-TBNA and the importance of collecting an adequate diagnostic sample. The American Thoracic Society (ATS), European Respiratory Society (ERS), and the American College of Chest Physicians (CHEST) recommend that an endoscopist should perform at least 40–50 procedures under supervision to acquire initial competence, then 20–25 procedures per year to maintain these skills ,31, whicEBUS for diagnosis of LN stations has been repeatedly investigated in comparison to mediastinoscopy with satisfying sensitivity (81% vs. 79%), specificity (100% vs. 100%), negative predictive value (91% vs. 90%), and diagnostic accuracy (93% vs. 93%) . EBUS-TBThe ability to combine EBUS with rapid on-site evaluation (ROSE) has led to a decreased length of procedures and fewer passes for biopsies. Harangus et al. investigated ROSE in conjunction with EBUS to evaluate the optimization of the procedure. The authors achieved adequate tissue sampling in 100% of their cases when evaluating for EGFR and ALK mutations. They found that ROSE allowed for a highly sensitive (92%) adjunct to EBUS with an equally high positive predictive value (93%) that clinicians could use to predict the final tissue diagnosis in cases of NSCLC . Thus, tOne aspect of EBUS that requires further study is the standardization, or lack thereof, associated with the procedure. There are currently no defined criteria by which tissue adequacy can be repeatedly determined. A retrieved tissue sample is generally considered “adequate” when a diagnosis can be made, but this relative term leaves room for interpretation and lack of uniformity. Thus, efforts should be made to standardize the definition of “adequate” regarding tissue sampling to allow for a more congruent implementation across the clinical and scientific community.The main limitation of our retrospective study was the inadequate data on molecular profiling that has been the cornerstone for treatment decisions in patients with advanced NSCLC. We plan further studies to assess tissue adequacy in relation to the full panel of molecular profiling in a subset of patients.Most patients who underwent EBUS had adequate tissue samples available for diagnosis. Since no correlation was found between PET positivity and tissue adequacy for diagnosis by EBUS, we recommend that PET scans and EBUS-TBNA should be used in a complementary manner for proper diagnosis and staging in patients with NSCLC. Regarding tissue adequacy, the most reliable samples were attained by an IP-trained operator, followed by an operator with more than five years of experience. Our results underscore the importance of employing a highly trained operator, particularly one with a specific focus on the biopsied organ.As discussed previously, the efficiency of EBUS in achieving adequate tissue for pathological and molecular diagnosis has improved over the years and makes it an incredibly valuable procedure. Given the shift in the management of lung cancer to a genetically focused, personalized approach, greater emphasis should be put on EBUS as a tool to diagnose lung cancer patients more accurately and to subsequently administer therapies targeted to the genetic abnormalities found in their particular cancer.


Modern nursing has gained more space and scientific recognition. As a result, health postgraduate programs, including postgraduate education in nursing, are being increasingly expanded and implemented in numerous universities, higher education institutions, public and private colleges and institutes in several countries of the world. At the same time, more nurses have sought qualification in the field of teaching, research and professional practice, thereby resorting to master's and doctoral programs, specialization programs and MBA courses. Master’s and doctoral programs are the most sought after in the world nowadays. This demand has required from bodies responsible for education that these programs find new ways of qualifying the training of professionals who decide to ascend in the academic career. Therefore, having broken the banking model of education in higher education in most countries of the world, postgraduate students started to contribute directly to the qualification of these programs, even though their contribution still needs more recognition and seriousness in educational institutions.The liberating perspective of education defended by Paulo Freire was fundIn the last two years, the scenario imposed by the COVID-19 pandemic forced these higher education institutions to reorganize their ways of operating. In additNote that a low percentage of people in the world manage to enter higher education, and of these, few choose or have access to an academic career through master’s or doctoral studies. In a morIn view of this, scientific production and thinking must be stimulated during undergraduate studies, so researchers can perform better in postgraduate studies, especially in academic master’s and doctoral programs. This incentive is justified because postgraduate students produce science and technical materials, and the survey of their production throughout the program is an important quality assessment criterion to be considered. All these aspects are essential to consolidate these subjects’ training and maintain the quality of programs.However, professionals who choose to enter a postgraduate program should not only emphasize their academic-professional profile based on ethical-aesthetic-political attitudes, or by their willingness to fulfill the mission and philosophy of the program and produce science within his area. Their role as students of the program is also to seek solutions and answers to the various critical nodes surrounding educational institutions themselves from a political, social and economic perspective, as well as their influence on the development of master’s and doctoral students. These subjects’ involvement in technical production and their contribution to social responsibility and innovation are necessary.Over the years, postgraduate programs had to seek means of self-evaluation to correct existing flaws in their operationalization, and the instances above them had to guide strategies and methods to properly evaluate them. Since stStudents have the know-how to evaluate their postgraduate programs and the right to seriousness and respectful listening especially regarding the following demands: the faculty, management and the dynamics of operationalization of the program. Undoubtedly, this type of evaluation forms and consolidates a highly qualified program. Positive rates related to the quality of the program contribute substantially to achieve greater federal, state and municipal financial incentives for financing relevant, transformative and high-impact research of students.Since the last century, master’s and doctoral programs in nursing have sought to overcome the Cartesian paradigm still present in the academic environment, which is based on the assumption that in order to know the whole, it is necessary to fragment it. With thiThe training of master’s and doctoral students in nursing contributes to produce new forms of knowledge in the field of nursing and health sciences in general. Therefor


Immunoglobulin class switch recombination (CSR) plays an important role in humoral imm\une responses by changing the effector functions of antibodies. CSR occurs between highly repetitive switch (S) sequences located upstream of immunoglobulin constant gene exons. Switch sequences differ in size, the nature of their repeats, and the density of the motifs targeted by the activation-induced cytidine deaminase (AID), the enzyme that initiates CSR. CSR involves double-strand breaks (DSBs) at the universal Sµ donor region and one of the acceptor S regions. The DSBs ends are fused by the classical non-homologous end-joining (C-NHEJ) and the alternative-NHEJ (A-NHEJ) pathways. Of the two pathways, the A-NHEJ displays a bias towards longer junctional micro-homologies (MHs). The Sµ region displays features that distinguish it from other S regions, but the molecular basis of Sµ specificity is ill-understood. We used a mouse line in which the downstream Sγ3 region was put under the control of the Eµ enhancer, which regulates Sµ, and analyzed its recombination activity by CSR-HTGTS. Here, we show that provision of Eµ enhancer to Sγ3 is sufficient to confer the recombinational features of Sµ to Sγ3, including efficient AID recruitment, enhanced internal deletions and robust donor function in CSR. Moreover, junctions involving Sγ3 display a bias for longer MH irrespective of sequence homology with switch acceptor sites. The data suggest that the propensity for increased MH usage is an intrinsic property of Sγ3 sequence, and that the tandem repeats of the donor site influence the choice of the A-NHEJ. HC) genes of the Ig heavy chain (IgH) locus, ultimately leading to a change of the constant domain of Ig molecules. CSR thus enables activated B cells to switch from the expression of the initial IgM to the expression of downstream isotypes  with novel effector functions  loci through V(D)J recombination, generating a vast array of antigenic specificities –3. Upon unctions –7. CSR oromoters –7.cis-acting elements, including enhancers and insulators  to ~12 kb (Sγ1), and there is evidence that the number of tandem repeats determines, at least in part, the efficiency of CSR .The WT and mutant mice are of 129Sv background. All analyses were performed on homozygous A150Mice were generated as previously described .FITC-conjugated anti-IgG3 and anti-IgA antibodies were purchased from BD-Pharmingen. APC-conjugated anti-B220, PE-conjugated anti-IgM, FITC-conjugated anti-IgG1, IL4, TGF-β, BLyS, and IL5 were from BioLegend. LPS was purchased from Sigma, anti-IgD-dextran from Fina Biosolutions, and anti-CD40 from eBiosciences. Anti-IgG antibody was purchased from Diagenode and anti-AID antibody from Abcam.- splenic B cells were cultured for 2 days and 4.5 days, respectively, at a density of 5 × 105 cells per ml in the presence of LPS (25 µg/ml) + anti-IgD-dextran (3 ng/ml) (hereafter LPS stimulation), LPS (25 µg/ml) + anti-IgD-dextran (3 ng/ml) + IL4 (25 ng/ml) (LPS+IL4 stimulation), anti-CD40 (1 µg/ml) + IL4 (25 ng/ml) (anti-CD40+IL4 stimulation), or anti-CD40 (1 µg/ml) + IL4 (10 ng/ml) + IL5 (5 ng/ml) + BLyS (5 ng/ml) + TGF-β (2 ng/ml) (anti-CD40+TGF-β stimulation).Single cell suspensions from spleens were obtained by standard techniques and splenic B cells were negatively sorted using CD43-magnetic microbeads and LS columns (Miltenyi). To induce switch transcription and CSR, negatively sorted CD436 cells/assay) were stained and gated as indicated in figure legends. Data on 1 × 104 viable cells were obtained using a BD LSR Fortessa X-20 flow cytometer.Single-cell suspensions from spleens from 6- to 8-weeks old mice were prepared by standard techniques. Cells  and subjected to qPCR using Sso Fast Eva Green (BioRad). escribed .6 d2-activated splenic B cells. Chromatin was cross-linked for 10 min at RT with 1% formaldehyde, followed by quenching with 0.125 M glycine. Cross-linked chromatin was then lysed  and sonicated for 20 cycles 30 s ON–30 s OFF (Diagenode Bioruptor). Sonicated chromatin was diluted 10 times  and precleared with 100 μl of Dynabeads protein-A magnetic beads (Invitrogen) and 5 μl of anti-IgG (Diagenode) for 2 h at 4°C. 5-10% of the precleared chromatin was used as the input sample. Immunoprecipitations were performed overnight at 4°C with 1 × 106 cells and 0.5 μg of anti-AID  or control anti-IgG  per immunoprecipitation. Immunoprecipitated material was recovered with protein A magnetic beads (2 h at 4°C) and washed. Crosslinking was reversed overnight at 45°C. Eluted DNA was extracted by standard techniques and subjected to qPCR. Results are presented as fold enrichment, taking into account both the input and the negative (IgG) sample.Chromatin was prepared from 5 × 10Genomic DNAs were purified from day4-anti-CD40+IL4-activated WT and A150 splenic B cells and were processed exactly as previously described . Specifit test. ns, not significant, * p < 0.05, ** p < 0.005, *** p < 0.0005, **** p < 0.0001.Results are expressed as mean ± SD, and overall differences between values were evaluated by an unpaired two-tailed H-VDJ-Eµ cassette (hereafter A150 mutation or mouse line)  or with anti-CD40+TGF-β (which induces Sα transcription and CSR to IgA). At day 2 post-stimulation, switch transcript levels were quantified by RT-qPCR. We found a moderate increase of Sµ transcript levels in both anti-CD40+IL4- and anti-CD40+TGF-β-activated A150 B cells compared to WT controls .To investigate the impact of the replacement mutation on CSR, surface Ig (sIg) expression was monitored by FACS at day 4.5 post-stimulation. Both sIgG1 and sIgA were reduced following appropriate stimulation of A150 B cells   which pr~6% of joins corresponded to ISD joins within A150 Sµ region. As expected, the majority (~63%) corresponded to CSR Sµ/Sγ1 joins, and only ~11% to Sµ/Sε joins  corresponded to CSR Sγ3/Sγ1 joins, and only ~4.5% to Sγ3/Sε joins , and ~2.2% of Sµ/Sγ3 and ~0.8% of Sµ/Sε inversions in the context of CSR. Sµ/Sγ1 inversions were more frequent (~13.5%) , the overall efficiency and switching pattern of Sγ3 was roughly similar to that of Sµ  are the preferential substrates of C-NHEJ, whereas ends with longer MH (≥4 bp) involve the A-NHEJ preferentially , 28. HavThe data show that the percentage of Sµ/Sγ1 CSR junctions with direct joins was slightly higher than for Sγ3/Sγ1  or lower homology (Sε and Sα)  occur at comparable frequencies in Sµ and Sγ3 ISDs following both anti-CD40+IL4 , we provided evidence that Sγ3 acquired most of the features of Sµ. In addition to its continuous and constitutive transcription along B cell development  , transcription of a subset of S regions and its correlation with CSR efficiency, as well as the (co-)transcriptional events and the epigenetic landscape at Sγ3 itself, which are crucial for AID recruitment and activity  transcript levels were normal. At the quantitative level, the precise threshold of switch transcript levels required for efficient CSR has not been determined yet. Nonetheless, the high frequency of CSR to Sγ1, as seen at the genomic level with CSR-HTGTS, suggests that the modest decrease of A150 Sγ1 transcript levels is not the critical issue.H configuration and only a small fraction undergoes proximal VH-DJH recombination (i.e. that did not delete Sγ3). Thus, the recombining activity of Sµ makes it difficult to establish a strong correlation between sIg expression and CSR events at the genomic level in A150 line. However, this issue was circumvented by using CSR-HTGTS, which provided a powerful tool to track, at the nucleotide resolution level, in allele- and orientation-independent manner, the recombination events involving both Sµ and Sγ3.A likely explanation stems from the lingering efficiency of Sµ as a donor site and the combinations of alleles with different rearrangement status. Indeed, switched sIg positive A150 B cells (other than IgG3) can originate from CSR events involving either Sµ or Sγ3. However, the majority of A150 alleles are in a DJbination , of whicH promoter in A150 setting, acquisition of Sµ properties by Sγ3 is likely due to the proximity of Eµ enhancer. In normal B cells, Sµ is known to undergo CSR on both partially rearranged DJH alleles and fully rearranged VHDJH alleles  but highly reproducible and statistically significant. Based on the criterion of MH extent, this suggests that Sγ3 tends to favor the recruitment of A-NHEJ regardless of the outcome of the DNA DSBs (i.e. ISDs or CSR) and of the acceptor site. This bias appears therefore to be directed by Sγ3, not by sequence homology with the partner S regions. We propose the following speculative model to account for this finding. Upon B cell activation, AID initially targets the switch donor region ultimately leading to multiple and heterogeneous DNA ends that recruit C-NHEJ and A-NHEJ pathways. When the partner S region is targeted by AID, the DNA ends that did not undergo short-range repair (ISDs) at the donor site will engage in bona fide CSR while tethering the components of the pathway initially recruited.In agreement with the notion that C-NHEJ is the major repair pathway during CSR , 28, theCT motifs (be it at Sµ or Sγ3), or on very close AGCT motifs (more frequently at Sµ than Sγ3), the resulting ends would require very limited resection (and/or filling), ultimately leading to C-NHEJ-mediated repair. In contrast, if AID initiates nicks at distant motifs on opposite strands (more frequent at Sγ3 than Sµ), the long overhangs would require more extensive resection (and/or filling), favoring MH search and usage and A-NHEJ-mediated repair. This is in agreement with the notion that the structure of staggered DSBs influences the mode of end processing and recruitment of A-NHEJ during CSR GGGT motifs whereas the AGCT units are relatively more distant within Sγ3 repeats. It is plausible that if AID-initiates nicks on both strands of the palindromic, overlapping  AGCT motring CSR –58. Recering CSR . In thisIt is arguable if increased usage of MH is promoted by DNA damage response deficiencies , 60–63 ahttps://www.ncbi.nlm.nih.gov/geo/, GSE174296.For FACS data / FlowRepositery ID : FR-FCM-Z3SX Access with the following link : https://flowrepository.org/id/RvFrFuSmwmwDXnmHOsLKZvnlUyMgrKRdBybKuJo4HfMcahREDfK4mNLE3OHJvSYG.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: The animal study was reviewed and approved by The Regional Ethical Committee (Accreditation N° E31555005). All experiments on mice have been carried out according to the CNRS ethical guidelines.CO, XZ, NP, FA, and AK actively participated to the experimental design of the study. CO, XZ, NK, AK, and FA designed CSR-HTGTS and interpretation of the data. CL and F-ZB contributed to experiments. AD handled the mouse lines. All authors participated in the scientific discussion for manuscript writing, read and approved the manuscript. AK designed the project and obtained financial grants and agreement of the relevant ethic committees to perform the study. All authors contributed to the article and approved the submitted version.This work was supported by the Agence Nationale de la Recherche [ANR-21-CE15-0019], the Institut National du Cancer , the Fondation ARC pour la Recherche sur le Cancer [PJA 20191209515], the Ligue Contre le Cancer . FA is an investigator of the Howard Hughes Medical Institute. CO was a fellow of the Ministry of Higher Education & Research and recipient of a fellowship from the “Fondation pour la Recherche Médicale”. TRI- IPBS has the financial support of ITMO Cancer Aviesan  within the framework of Cancer Plan.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.