Outcome measures included the Depression Anxiety Stress Scale-21, Posttraumatic Stress Disorder Checklist for DSM-5, Oxford Happiness Questionnaire, and Quality-of-Life Enjoyment and Satisfaction Questionnaire-Short Form. Paired samples t-tests revealed that within both the Individual and Couples programs, there were significantly fewer psychological symptoms and significantly greater levels of happiness and quality of life at post-intervention compared to pre-intervention. Reduced psychological symptoms were maintained at the three months follow-up for participants of the Couples program only. Independent samples t-tests revealed participants in the Couples program reported significantly less symptoms of depression, stress, and posttraumatic stress disorder (PTSD) at follow-up compared to participants in the Individual program. These results indicate there may only be meaningful benefits for equine-assisted therapy in the reduction of depression, stress, and PTSD symptoms for veterans, if partners are integrated into the intervention.The aim of this study was to evaluate outcomes of an equine-assisted therapy program for Defence Force veterans and their partners across the psychological domains of depression, anxiety, stress, posttraumatic stress, happiness, and quality of life, as well as compare the outcomes of an Individual and Couples program. A non-controlled, within-subjects longitudinal design was utilized with assessment at three time points . Between-subjects analysis with two groups was also conducted to compare the outcomes of the Individual and Couples programs. Participants were recruited from ten programs in 2016 with a total of 47 veterans and partners from both an Individual program ( Extensive research has highlighted substantial rates of psychiatric disorders as well as symptoms of posttraumatic stress disorder (PTSD), depressive and anxiety disorders among Australian military veterans –5. ReseaWorldwide, there are now more than 600 equine-assisted therapy programs designed for patients with a broad range of psychological and physical conditions . Equine-Lanning and Krenek  conducten = 31 veterans; n = 25 spouses/partners) utilized a self-report measure developed by the researchers , which included two sub-scales: Relieving Symptoms of PTSD subscale and Acquisition of Coping Skills subscale [Results from an evaluation of a series of pilot workshops of an equine-assisted learning program demonstrated positive outcomes for veterans diagnosed with PTSD . The pilsubscale . In termn = 8). The program was conducted through an established therapeutic horse farm and facilitators were masters-level trained social work and counselling professionals. The two-day program consisted of four segments including psycho-education, guided experiential equine activities, group processing, and personal reflection. Overall, participants’ qualitative responses about the perceived benefits of the program included “learning about self”, “spiritual connection”, “trust”, and “respect” [Recently, Ferruolo  describerespect” .Based on the available literature, there are limited conclusions that can be drawn regarding the efficacy of equine-assisted activities and therapy programs as an adjunct treatment for psychological conditions and associated symptoms among veterans. While demonstrating some promising trends, the studies outlined above include a number of limitations such as a large variation in methodological approach, absence of follow-up data, and limited use of quantitative and standardised psychometric assessment tools.The current study seeks to expand on prior research and contribute to the growing evidence regarding the utility of equine-assisted therapy programs for veteran populations. The aim is to evaluate the outcomes of an equine-assisted therapy program for veterans who identify as ‘wounded, injured, or ill’ and their partners across the psychological domains of posttraumatic stress, depression, anxiety, stress, happiness, and quality of life, as well as compare the outcomes of an Individual and Couples program using standardised psychometric questionnaires and longitudinal follow-up.The study utilized a non-controlled within-subjects longitudinal design. Between-subjects analysis with two groups was also conducted to compare the outcomes of the Individual and Couples programs. As the study is an evaluation of an existing program offered within a Veterans Service Organisation there was no random allocation to a control group condition or a naturally occurring control group available for comparison. Psychometric assessment measures were completed prior to starting the equine-assisted therapy program (pre-intervention), on conclusion of the program (post-intervention), and three months following the conclusion of the program (follow-up). Between the post-intervention and follow-up time points, participants continued treatment as usual and did not engage in further equine-assisted therapy or equine activities.Ethics approval was obtained from the Australian Department of Veterans’ Affairs Human Research Ethics Committee (EO16/005). Participants were members of a Veterans Service Organisation, Mates4Mates, who identify as wounded, injured, or ill and completed the equine-assisted therapy program in the 2016 calendar year. Potential participants were referred to the study by staff at the organisation during the enrolment process. Participants were informed of the purpose and aims of the study verbally by staff and through the provision of the Participant Information Sheet. They were advised that if they declined to participate in the study, it would not affect their enrolment in the program. Written informed consent was obtained prior to any study-specific procedures or assessments. The inclusion criteria for eligibility to participate in the study were: (1) ex-serving Defence Force personnel or partners of ex-serving Defence Force personnel; (2) member of the Veterans Service Organisation, Mates4Mates; and (3) approved to complete the program by a Mates4Mates’ psychologist. There were no additional study exclusion criteria. Membership of Mates4Mates is on the condition that you served/are serving in the Australian Defence Force (ADF) and you identify as ‘wounded, injured or ill’ which includes self-report of a physical and/or psychological condition.Equine Encounters Australia (EEA) was engaged by Mates4Mates as their provider of equine-assisted therapy courses. The equine-assisted therapy program is a live-in residential therapy course held over a period of five days. The programs are led by two EEA facilitators, certified in the Equine Psychotherapy Institute  Program Model of Equine Assisted Learning/Psychotherapy and accompanied by a registered psychologist who assists in group work throughout the program. Based on the Equine Psychotherapy Institute  Model of Equine-Assisted Learning/Psychotherapy , the proThe programs are run in an ‘Individual’ and ‘Couples’ format, with the latter including partners of veterans. The Couples program includes the same therapeutic activities as the Individual program but also incorporates couples dates and couples counselling to improve communication skills, build trust and respect, and develop shared and individual future goals. See Demographic information included age, gender, and current marital status. Veteran participants also reported service information including length and branch of service, if they were medically discharged, and years since discharge.Not at all) to 4 (Extremely) according to how much each symptom affected them over the previous month. A total symptom severity score is obtained by summing responses , with higher scores indicating greater severity. A provisional diagnosis of PTSD requires at least one symptom endorsed (rated 2 or above) in symptom Cluster B (items 1–5) and in Cluster C (items 6–7) and two symptoms endorsed in Cluster D (items 8–14) and in Cluster E (items 15–20). The PCL-5 has demonstrated strong psychometric properties in previous studies and is used regularly for monitoring symptom change within interventions [Participants’ PTSD symptoms were assessed using the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) . The PCLventions –39.Did not apply to me at all) to 3  according to how much they were affected by the symptom over the previous week. Higher scores on each subscale  indicate greater experiences of depression, anxiety, and stress. The scale has demonstrated excellent psychometric properties in previous research [Participants’ symptoms of depression, anxiety, and stress were measured using the Depression Anxiety Stress Scale– 21 (DASS-21)  The DASSresearch –42.Strongly disagree) to 6 (Strongly agree). Responses are summed and the total score is then divided by 29. Final scores range between 1 and 6 with higher scores indicating greater levels of happiness. Previous research has demonstrated the measure has good psychometric properties [The Oxford Happiness Questionnaire (OHQ), a 29-item self-report questionnaire, was included to assess participants’ perceived happiness . Respondoperties , 44.Very poor) to 5 (Very good) according to how satisfied they were in the item domain over the previous week. Total scores are created by summing the first 14 items  with higher scores indicating greater quality of life, satisfaction and enjoyment. Previous research has indicated the questionnaire has excellent psychometric properties [Participants’ perceived quality of life was assessed using the Quality of Life, Enjoyment and Satisfaction Questionnaire–Short Form (Q-LES-Q-SF) . The Q-Loperties .t-tests were used to examine differences on outcome measures at pre-intervention between programs as well as completers and non-completers, and a Pearson’s chi-square test to compare drop-out rates at follow-up between programs. Due to the missing data at follow-up, repeated measures ANOVAs could not be reliably used. As such, paired samples t-tests were used to examine differences between pre-intervention, post-intervention, and follow-up for each program. Independent-samples t-tests were used to examine if significant differences were present at each time point between the programs. The assumption of homogeneity of variances was upheld for all analyses. Bonferroni correction was applied to account for multiple testing (p < .017) [d effect sizes [All analyses were conducted using IBM SPSS 24. Independent samples  < .017)  and Cohect sizes , 49 weren = 25; Couples, n = 22) completed the equine-assisted therapy program. Demographic and service data for veteran participants are provided in SD = 9.42).Forty-seven participants  and 28 participants returned the PCL-5 (66.67%) and other measures (59.57%) at follow-up. Independent samples t-tests revealed no significant differences at pre-intervention between those who were ‘lost to follow-up’ and those who completed the follow-up questionnaires. Results of a chi-square test revealed no significant difference in ‘lost to follow-up’ rates between programs. Two participants at post-intervention and five participants at follow-up did not complete 13 or more items on the OHQ and as such, these incomplete questionnaires were removed from subsequent analyses. Independent samples t-tests were used to examine if significant changes on the measures occurred between pre-intervention and post-intervention, post-intervention and follow-up, and between pre-intervention and follow-up. For each program, paired samples r = 0.2 , r = 0.5 (medium effect), r = 0.8 (large effect) [For participants of the Individual program, analyses revealed significantly lower scores on the DASS-21 and PCL-5 at post-intervention compared to pre-intervention scores. Participants also reported significantly higher scores on the OHQ and Q-LES-Q-SF at post-intervention compared to pre-intervention. However, compared to post-intervention, participants reported significantly higher scores on the DASS-21 depression and stress subscales and the PCL-5 and significantly lower scores on the OHQ and Q-LES-Q-SF at follow-up. There were no significant differences between pre-intervention and follow-up on any of the measures. Effect sizes were examined and interpreted utilising Cohen’s d guidelines;  effect) , 49. EffAccording to interpretive guidelines of the DASS-21 , particiFor participants of the Couples program, analyses revealed significantly lower scores on the depression and stress DASS-21 subscales as well as the PCL-5 at post-intervention and follow-up compared to pre-intervention and significantly lower scores on the anxiety subscale at follow-up compared to pre-intervention. There was no significant difference in anxiety scores between pre-intervention and post-intervention and no significant difference in DASS-21 and PCL-5 scores between post-intervention and follow-up. Participants also reported significantly higher scores on the OHQ and Q-LES-Q-SF at post-intervention compared to pre-intervention; however, there was no significant difference between pre-intervention scores and follow-up on these measures. Additionally, participants reported significantly lower Q-LES-Q-SF scores at follow-up compared to post-intervention. Effect sizes for all significant differences were large.According to interpretive guidelines of the DASS-21 , particit-tests were used to compare scores on each measure, at pre-intervention, post-intervention, and follow-up, between the Individual and Couples programs (Independent samples programs . The resChi-square tests were utilized to determine if there were significant differences in frequency of provisional PTSD diagnoses between programs at pre- intervention, post-intervention, and follow-up . ResultsThis study aimed to evaluate the psychological outcomes of an equine-assisted therapy program for veterans and their partners, specifically across the domains of depression, anxiety, stress, posttraumatic stress, happiness, and quality of life as well as compare the outcomes of an Individual and Couples program. Given the limited research and methodological limitations in the existing literature examining the utility of equine-assisted therapy within military and veteran populations, this research contributes to the international literature through the inclusion of a couples condition as well as follow-up assessment.The analyses of the Individual program indicated that symptoms of depression, anxiety, stress, and PTSD significantly reduced and participants’ self-reported happiness and quality of life significantly increased from the beginning of the program to the conclusion of the program. However, results also demonstrated these gains were short-term, with scores on all measures, except anxiety, returning to pre-intervention levels three months following the conclusion of the program. Analyses of the Couples program indicated that symptoms of depression, stress, and PTSD significantly reduced by the conclusion of the program and this reduction remained three months later. The analysis also demonstrated a gradual reduction in anxiety symptoms from pre-intervention resulting in a significant reduction at the three month follow-up point. Participants’ self-reported happiness and quality of life significantly increased from the beginning to the conclusion of the program, although, this increase did not remain three months later. The results of the Couples program are in line with previous findings suggesting some benefits exist for the use of equine-assisted therapy with veterans with mental health difficulties , 33.When comparing participants’ outcomes in the Individual and Couples programs, both veterans and partners who completed the Couples program reported significantly less symptoms of depression, stress, and PTSD three months following the conclusion of the program, despite no difference prior to commencing the program or at post-intervention. In addition, significantly fewer participants in the Couples program met provisional diagnosis of PTSD at follow-up compared to participants of the Individual program. Further, the clinically significantly reduction in PTSD symptoms noted at post-intervention only remained three months later for participants of the Couples program. It could be possible that the Couples program may facilitate greater psychological outcomes long-term than the Individual program. As the Couples program includes involvement of the veteran’s partner, this perhaps indicates that adaptive coping strategies developed during the program can be rehearsed and reinforced with the partner once the program concludes, leading to ongoing stability of psychological symptoms. This is in line with previous literature, which suggests involvement of a family member in therapy may be beneficial for veterans , 52. TheDespite the strengths of the research, there are limitations that must be acknowledged. First, as this was an evaluation of an existing service, the study design did not include a control group. As such, conclusions regarding efficacy of the intervention cannot be made as outcomes could be attributed to other non-controlled factors including participation in other therapeutic activities. Additionally, the sample size for quantitative data analysis remained small and as such, the type of analysis that could be conducted was restricted. In particular, the impact of the dyadic data on the outcomes was not able to be assessed using multi-level modelling, and analysis of variance between the 10 programs was not completed. Finally, a substantial proportion of participants were lost to follow-up at three months. This further restricts the interpretation of the findings.To determine the utility of equine-assisted therapy within a veteran population with more certainty, future research should proceed in a number of ways. Conducting a wait-list controlled trial of the equine-assisted therapy program, increasing the sample size, and improving data collection procedures at follow-up to improve response rates would be of use. Using a mixed methods approach and collecting both qualitative and quantitative data may also be useful in determining effectiveness of a program, as well as providing greater insight regarding the mechanisms of change of the intervention. Finally, including an assessment of relationship quality would also be useful in the future, and may help determine if there is a mediating role of relationship quality between the Couples program and improved mental health. In terms of practical implications for the field, this study generates some questions regarding the durability of treatment gains of a five day EAT program. This means that EAT program developers and clinicians may need to carefully consider the length of the intervention being delivered and to ensure a method of follow-up is included, to mitigate potential mental health deterioration among participants. This may include the implementation of EAT ‘booster sessions’ which occur at regular intervals following core program conclusion, or referral to a mental health provider at the end of the program to facilitate ongoing self-reflection and consolidation of skills learnt. However, robust recommendations cannot be made until findings of this study are replicated with the above limitations addressed.Given the limited research examining the utility of equine-assisted therapy within veteran populations, this research contributes to the international literature by assessing the psychological outcomes of an EAT program using quantitative psychometric measures, comparing the outcomes of both a Couples and an Individual EAT program, and by including follow up assessment, 3 months after the program. The results indicate that equine-assisted therapy might be useful in the reduction of depression, anxiety, stress, PTSD symptoms and the improvement of happiness and quality of life, but that these gains may only be short-term unless partners are integrated into the intervention. While these findings demonstrate a promising trend, no conclusions regarding efficacy can be made and a controlled trial, with a larger sample size would help determine if equine-assisted therapy is an effective adjunct intervention for veterans.


Competency-based curricula require the development of novel simulation-based programs focused on the assessment of entrustable professional activities. The design and delivery of simulation-based programs are labor-intensive and expensive. Furthermore, they are often developed by individual programs and are rarely shared between institutions, resulting in duplicate efforts and the inefficient use of resources.The purpose of this study is to demonstrate the feasibility of implementing a previously developed simulation-based curriculum at a second institution. We sought to demonstrate comparable program-level outcomes between our two study sites.A multi-disciplinary, simulation-based, resuscitation skills training curriculum developed at Queen’s University was implemented at the University of Saskatchewan. Standardized simulation cases, assessment tools, and program evaluation instruments were used at both institutions.p < 0.001) after the course.Across both sites, 87 first-year postgraduate medical trainees from 14 different residency programs participated in the course and the related research. A total of 226 simulated cases were completed in over 80 sessions. Program evaluation data demonstrated that the instructor experience and learner experience were consistent between sites. The average confidence score  across sites for resuscitating acutely ill patients was 3.14 before the course and 4.23 (We have described the successful implementation of a previously developed simulation-based resuscitation curriculum at a second institution. With the growing need for competency-based instructional methods and assessment tools, we believe that programs will benefit from standardizing and sharing simulation resources rather than developing curricula de novo. Postgraduate medical education programs in Canada and the United States are transitioning or have transitioned to competency-based medical education (CBME) models that incorporate national milestones and entrustable professional activities (EPAs) -2. One oMedEdportal.org, EMSimcases.com). However, these cases are rarely part of a comprehensive curriculum, often do not contain assessment tools linking them to specific EPAs or milestones, and frequently lack program evaluation instruments.The emerging number of online sources of free open access medical education material and published simulation cases is slowly targeting this problem. There are numerous websites and repositories that provide access to cases that have been used elsewhere and, in some instances, even peer-reviewed  (Appendix 1). The leader also completed a scenario-specific self-entrustment assessment upon reading the case “stem” (Appendix 3) and again after leading the simulated case. The whole assessment was designed as a single five-point entrustment score  that wasInstitutional-specific methods: University of SaskatchewanScenarios were delivered at two sites - Saskatoon and Regina, depending on the location of each trainee. All sessions were conducted using a high-fidelity simulation mannequin, but the model differed between Saskatoon  and Regina . Twenty-three faculty credentialed in Anesthesia, Emergency Medicine, General Surgery, Internal Medicine, and Intensive Care Medicine were trained to conduct the simulation sessions. All facilitators were required to complete a simulation and debriefing course as part of taking on this role.Institutional-specific methods: Queen’s UniversityAll scenarios were delivered at Queen’s University using a high-fidelity simulation mannequin . A group of 10 faculty facilitators credentialed in Anesthesia, Emergency Medicine, General Surgery, Intensive Care Medicine, and Internal Medicine conducted the simulation sessions and completed the entrustment scores for each scenario. All facilitators had a self-identified interest in simulation-based teaching and resuscitation.Program evaluationAnonymous feedback from trainees was gathered using a modified version of a previously validated tool: the Evaluation of Technology-Enhanced Learning Materials: Learner Perceptions (ETELM-LP) inventory. Basic demographic data were collected with this survey including age, residency training program, and previous simulation experience. Faculty completed a modified version of the Evaluation of Technology-Enhanced Learning Materials: Instructor Perceptions (ETELM-IP) inventory. Basic demographic data, including age, sex, and specialty area, were collected along with the program evaluation. For both program evaluation surveys, modifications included the removal of questions that were not relevant to the course, altering the wording of questions to better fit the course, and adding additional questions related to the course objectives.Participant demographicsA total of 87 first-year postgraduate medical trainees from 14 different training programs participated in the resuscitation curriculum and provided written consent for their assessment data to be used for research purposes. Thirty-four trainees were from the University of Saskatchewan and 53 from Queen’s University Table .Assessment of traineesA total of 226 cases were conducted across both sites, 93 at Queen’s University and 133 at the University of Saskatchewan. Fifty-nine of 87 trainees (68%) led a scenario and received feedback on their performance. Following a scenario, the leader received an average of 7.5 assessments: one from each of faculty and nursing staff, a self-assessment, and three to five peer assessments. Qualitative comments were included on 84% of assessments.Program evaluationp < 0.001). Institution-specific pre-course confidence scores for the University of Saskatchewan and Queen’s University were 3.00 and 3.26, respectively, and post-course confidence scores were 4.12 and 4.33, respectively (p < 0.001 for both comparisons).Thirty-three of 34 trainees at the University of Saskatchewan, and 47 of 53 at Queen’s University completed the ETELM-LP (Table Twenty-two of 23 faculties at the University of Saskatchewan and 11 of 11 at Queen’s University completed the ETELM-IP Table . NotablyThis paper addresses a current and growing challenge in postgraduate medical education. Namely, the development and distribution of competency-based curricula designed to teach and assess EPAs that are not well suited to a clinical-based model. Moreover, CBME requires that postgraduate training programs directly observe the abilities of their trainees and provide them with formative feedback, even for rare and unpredictable EPAs. Developing simulation-based curricula to address these challenges will require significant resources. Instead of creating simulation curricula de novo within each training program or institution, we believe that certain EPAs and their instructional and assessment methods are well-suited for widespread distribution.In addition to the efficiency rationale for using established curricula and their programs of assessment, there is a tremendous potential for scholarship. The small sample size is very often a limitation of educational research. The use of similar curricula and assessment tools at different institutions allows for a more robust synthesis of data for research purposes. The implementation of a common curriculum at a second institution has effectively doubled our subject numbers and will allow analyses that were not previously possible.EMSimCases.org using their standardized template. A blog post published on the site will provide an overview of the simulation program and allow the faculty from other institutions to access the curriculum and course-specific assessment and program evaluation tools.This paper describes the comprehensive and successful transfer of a resuscitation curriculum to a second institution. To facilitate further adoption of this curriculum, we plan to make it readily available online. The simulation cases used for the program will be peer-reviewed and published on The costs associated with this curriculum were $120 per session at Queen’s University and $96 per session at the University of Saskatchewan. This amount paid the nursing confederate and simulation technician salaries. Additional costs included faculty time and the use of the simulation laboratory. At Queen’s University, faculties receive “teaching points” for their respective departments and access to the simulation laboratory was granted through the Office of Postgraduate Medical Education. At the University of Saskatchewan, faculties are paid variable rates depending on their respective agreements with the College of Medicine and access to the simulation laboratory was funded via block payments to the simulation centers by the College of Medicine.We have demonstrated the feasibility of transposing a multi-disciplinary simulation-based resuscitation curriculum from one institution to another, including cases, assessment tools, and program evaluation instruments. We hope this example of successful curricular adaptation will encourage other institutions and departments to foster collaboration in future curriculum development and scholarship.


Background: Most pediatric nephrologists work in academia. Mentor-mentee relationships provide support and guidance for successful research career. Mentorship program implementation is valuable in medical fields for providing research opportunities to young faculty.Methods: The American Society of Pediatric Nephrology (ASPN) established a research mentorship program to (a) assist with matching of appropriate mentor-mentee dyads and (b) establish metrics for desirable mentor-mentee outcomes with two independent components: (1) the grants review workshop, a short-term program providing mentor feedback on grant proposals, and (2) the longitudinal program, establishing long-term mentor-mentee relationships. Regular surveys of both mentors and mentees were reviewed to evaluate and refine the program.Results: Twelve mentees and 17 mentors participated in the grant review workshop and 19 mentees were matched to mentors in the longitudinal program. A review of NIH RePORTER data indicated that since 2014, 13 NIH grants have been awarded. Mentees in the longitudinal program reported that the program helped most with identifying an outside mentor, improving grant research content, and with general career development. Mentors perceived themselves to be most helpful in assisting with overall career plans. Email communications were preferred over phone or face-to-face communications. Mentees endorsed strong interest in staying in touch with their mentors and 100% of mentors expressed their willingness to serve in the future.Conclusion: This mentorship program was initiated and supported by a relatively small medical society and has shown early success in cultivating mentoring relationships for a future generation of clinician-scientists. Mentoring is a special partnership between two people based on common goals and expectations, focus, and mutual trust and respect . SuccessAlthough a number of papers and internet resources address mentorship programs –8, very Recognizing the need, the American Society of Nephrology (ASN) recently introduced an extensive set of electronic educational resources, presented in brief animations, podcasts, and other media for internal medicine nephrologists. These resources detail effective communication, identifying the right mentor or mentee, navigating mentorship challenges, and assessing a mentee's understanding of expectations . These rAs with other pediatric subspecialties, many pediatric nephrologists work in small divisions with as few as 1–3 faculty in a group. Thus, the lack of a local, experienced research mentor to guide research development and review early faculty progress is common. Recognizing that many junior investigators could benefit from the addition of established senior investigators to their mentoring team, the ASPN created a research mentorship program in 2014.The specific goals of the ASPN mentorship program were (1) to provide junior investigators with successful research mentors outside their home institutions who have similar research interests, and (2) to provide mentorship training to more established investigators who are ready to become mentors. This program allowed mentors to support junior faculty career development, academic pursuits, and development of grant funding proposals. In this descriptive paper, we present the unique experiences and early data gathered during the ASPN research mentorship program development and implementation. Our experiences may serve as an example for other medical societies seeking to improve junior faculty research mentoring experiences.The ASPN Mentorship Program was conceived and developed by the ASPN Research Committee in 2014 to match mentors with self-identified mentees and establish an environment for desirable mentor-mentee research outcomes. The program was designed to be dynamic and open to modifications based on periodic surveys and evaluations by all participants. In 2016, a Quality Improvement (QI) framework was formalized with creation of an American Board of Pediatrics (ABP)-approved Maintenance of Certification (MOC) Part 4 program. The program was administered by the co-chairs of the Research Committee, who typically serve 3-year terms. ASPN senior leadership (Council of the Society) ensures management support and monitors step-by-step progress reports.The mentoring program had two components: (a) the short-term grant review program, designed to help a mentee with a specific grant submission and (b) the longitudinal program, which facilitates the establishment of long-term mentor-mentee relationships to aid in career development. Mentors and mentees can choose to participate in one or both components. Furthermore, the mentee can participate in the grant review program as often as desired. One of the most important approaches to ensure success of the program is optimal matching of mentors and mentees.The ASPN Research Committee co-chairs selected potential mentors for each mentee among the existing research committee members, current members of the Society, or established non-Society mentors aligned within the field of pediatric nephrology. The selection process was iterative, with feedback from both mentees and potential mentors to ensure no conflicts of interest or conflicts in commitment. To participate in the program, mentees need only to be ASPN members in good standing. ASPN mentees who entered in the longitudinal program perceived that mentors would help with their career and research development.The grant review program consisted of an annual in-person grant review workshop held in conjunction with a large national meeting. These workshops were held in a “mock study section” format, with 3–4 mentors serving as primary and secondary reviewers for 2–3 grants presented orally by groups of mentees. The structure of these workshops was tailored to the needs of the mentees who were assigned to small groups based on research topic or methodology. Mentors are selected based on proven track record of grantsmanship sufficient for the mentees' stage of training. However, often mid-level and senior investigators were assigned as reviewers for the same career development grants in order to also provide experience for mid-level faculty on grant review. Mentees submitted drafts of their grant applications in advance of the in-person workshop, and the mentors were asked to complete a written review using a standard NIH-style review template. Mentees were required to submit a specific aims page at a minimum and were also encouraged to submit other grant sections . All participants were asked to keep the review process confidential.Mentees and mentors in the longitudinal program signed a Mentoring Partnership Agreement on enrollment to formalize the relationship and clarify individual expectations. These expectations included committing to regular meetings , maintaining confidentiality, reviewing and revising the mentees' goals statements annually, providing each other with honest, direct, and respectful feedback, and providing program feedback to the Research Committee. Mentees were asked to write a goals statement, to be reviewed/updated annually with their mentors. Mentees were also encouraged to contact the mentor regularly via phone or electronic communication to discuss specific needs related to grant review, programmatic development, promotion, and tenure.Mentors in the program are experienced, independently-funded physician scientists, who are able to work with mentees to develop goals with realistic expectations and individualized career development plans. Mentors who reviewed grants for mentees also participated in the grant review component were often selected to become a longitudinal mentor. It was important for mentors to commit to meeting routinely with the mentees to review progress, give feedback, provide recommendations for improvements, and guide academic career development . The Program leadership maintains Mentorship Partnership Agreements but does not review goals statements or drafts of grants/manuscripts, which are only shared between mentees and their mentors.The role of the ASPN in the mentorship program was to advertise the program, elicit participation, judiciously select and contact mentors for each new mentee in the program, review program feedback and outcome metrics regularly to improve the program organization, and develop education workshops. Research Committee members who participated in the QI project had to attend meetings to review survey data at least twice yearly for 2 years to be eligible to receive ABP MOC Part 4 credit.https://projectreporter.nih.gov/reporter.cfm). Metrics were collated by the ASPN Research Committee co-chairs and reviewed in aggregate at Committee meetings on a quarterly basis. Program improvements were implemented on an ongoing basis.Surveys were sent to mentees and mentors using Survey Monkey®. Surveys were designed based on program metrics and questions were left unchanged from year-to-year to allow tracking of program efficacy over time in a standard fashion. Mentees and mentors in the longitudinal program were asked about methods and rates of contact with each other within the context of the program. Mentees and mentors in the grants review workshop were asked about what portions of their grants were specifically reviewed. Metrics selected to rate the quality of the program included expectations, number, and format of meetings between mentors and mentees, type of grants reviewed, number and content of sections of grants reviewed, and perceived helpfulness of mentee-mentor interactions in specific areas . NIH grants are tracked using the RePORTER database  represents a substantial source of research support this information was more difficult to track. We are planning to collect this information in our upcoming surveys.Specific Aims of their grants but interactions were less focused on their overall career development plan  as well as data about number of proposals funded by the NIH, industry and foundations.It is fundamental that mentors and mentees who entered a mentoring program have a clear understanding of the goals, objectives, and desirable outcomes of the collaboration. Mentors should be willing to commit to working one-on-one with mentees and ideally should have a successful track record of grant awards and research publications. Mentors should help young clinical scientists to plan, develop, grow, and manage their careers. Mentors also have an important role in helping junior faculty members become resilient in times of change, more self-reliant in their careers, and more responsible as self-directed learners. Mentees should clearly understand expectations and should be willing to provide feedback to the program.Provide concrete advice on specific research pursuits and promote interaction between mentors and mentees as well as other content experts with successful research careers;Provide infrastructure that enables pairing of mentors and mentees, completion of goals statements, assurance of confidentiality, and successful program completion;Facilitate planning and management of program assessments, track scheduling, and report documentation;Inform program participants about available specialty focused NIH and non-NIH funding opportunities;Complete thorough and consistent evaluations of the participants' progress;Perform continuous review and evaluation of program assignments and activities throughout the program cycles and make appropriate changes;Employ continuous QI techniques (Plan-Do-Study-Act) to improve programmatic effectiveness;Provide enticements for senior investigators and experienced mentors to stay involved, such as Maintenance of Certification (MOC) Part 4 credits from the American Board of Pediatrics (ABP) for participants;Train a future generation of mentors through role modeling and feedback.Motivate others with dedication, enthusiasm and good will.Based on our ASPN experience, we identified that the 10 key elements (in no specific order) for successful mentorship programs are to:In summary, a structured and well-organized research mentorship program with strong medical society leadership, brings professional fulfillment to academic physicians. In addition, providing increased research mentorship helps to increase and sustain the research workforce, which results in more robust research and improved child health.The ASPN Research Mentorship Program, initiated and supported within a relatively small medical society; showed early success in training a future generation of clinician-scientists who will be able to undertake valuable research that we hope will 1 day lead to better patient outcomes.TV participated in the program and led the writing group, correspondent author. MD-G substantial contribution in Program improvement and correction of manuscript. DH led a mentorship program, participated in writing. JH led mentorship program, participated in writing. LH actively participated in mentorship program and manuscript writing. KR actively participated in mentorship program evaluation and manuscript writing. TB led the program, writing. DO led the program, writing. DS manuscript revision, suggestions, writing. SW led the program, participated in survey, data analysis and writing. EH led the program, survey, data analysis, graphs for paper, writing and revisions.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. The handling Editor declared a shared affiliation at the time of review, though no other collaboration, with one of the authors JH.


The chromosome is a functionally dynamic structure. The dynamic nature of chromosome functionally connects it to almost every event within a cell, in health and sickness. Chromatin remodeling system acts in unison with the cell survival pathway in mediating a variety of cellular functions, including mitosis, differentiation, DNA damage repair, and apoptosis. In humans, the 16 SWI/SNF complexes are a class of nucleosome remodelers, and ARID1A, an epigenetic tumor suppressor, is a member of mammalian 17 chromatin remodeling complex, SWI/SNF. Alterations of chromatin remodeling system contribute to tumorigenic events in various cancers, including ovarian cancers. Oncogenic changes of genes of the PI3K pathway are one of the potential genetic determinants of ovarian carcinomas. In this review, we present the data demonstrating the co-occurrence of mutations of ARID1A and the PI3K pathway in our cohort of ovarian cancers from the Avera Cancer Institute . Taking into account data from our cohort and the cBioPortal, we interrogate the opportunity provided by this co-occurrence in the context of mutation-driven signals in the life cycle of a tumor cell and its response to the targeted anti-tumor drugs.  A eukaryotic chromosome is the best known decisively-packaged product of evolution. The marvel of the packaging of chromosomal DNA by nucleosomes not only condenses the genetic material but also organizes the genome, its millions of years’ worth of evolutionary facts in a millionth of a length. The packaging is at the cost of limiting its access to critical regulatory DNA element(s) meant for the function of the chromosome. And yet a eukaryotic chromosome is dynamic. It is dynamic in its precise transcriptional regulation of a particular gene in a spatiotemporal manner. Years of evolution have enabled a eukaryotic cell to develop controlled dynamic access to the packaged-DNA as well as to tailor its nucleosome composition at a chosen chromosomal region; a regulated alteration of chromatin structure by a set of specialized complexes called remodeling complexes. The chromatin remodeling causes a change in chromatin structure that occur during regulatory processes in a life-cycle of a cell by altering the nuclease sensitivity of a region of chromatin . RemodelIn humans, the SWItch/Sucrose Non-Fermenting (SWI/SNF) complexes, caused by defects in the transcription of the SUC2 invertase gene, are a class of nucleosome remodelers . As one ARID1A ranks top among the mutated chromatin regulator across all human cancers. SWI/SNF is the most frequently mutated chromatin-regulatory complex in human cancers, exhibiting a broad mutation pattern, similar to that of TP53 . SomaticThe mutation of ARID1A has been reported in rare epithelial ovarian tumors, which was first published in 2010 ,16. Oncohttp://www.cbioportal.org). Quarried gene was altered in 104 (18%) of queried patients [104 (17%) of queried samples]. http://www.cbioportal.org). The heatmap was superimposed on the alterations of the ARID1A gene in respective samples. In patients with a low expression of mRNA/protein for ARID1A, alterations of PTEN and PIK3CA were observed.We present  alteratiWe analyzed the expression pattern of different genes in 90 ovarian cancer samples from patients with ovarian cancers whose tumors were subjected to comprehensive genomic-profiling (FoundationOne) who were seen in our Avera Center Institute from February 2014 . This fiAs ARID1A is a part of SWI/SNF chromatin remodeling complexes, we also tested genes encoding subunits of this remodeling complex, such as ARID1B, ARID2, SMARCA2, and SMARCA4. As multi-subunit protein complexes, SWI/SNF utilizes the energy of ATP hydrolysis, sliding nucleosomes along a DNA template in the course of remodeling chromatin structure . The SWIThe mutational spectrum of ARID1A alterations is presented in A conditional PTEN deletion within the ovarian surface epithelium has been reported to induce pre-neoplastic ovarian lesions with an endometrioid glandular morphology using the first genetic models of peritoneal endometriosis and endometrioid ovarian adenocarcinoma in mice . FrequenARID1A protein regulates transcription. Wu and Roberts have presented following modes of action of the SWI/SNF complex to explain its role in the regulation of transcription: (1) mobilizing nucleosomes at promoters, enhancers, and/or gene bodies; (2) facilitating the binding of transcription factors; (3) recruiting coactivator/corepressor complexes; (4) recruiting histone-modifying enzymes; and (5) facilitating chromatin looping to facilitate enhancer and promoter interaction . Thus a In vitro knockdown of wt ARID1A/re-expression of clinically relevant mutant ARID1A studies in cancer cell lines and ES cells demonstrated that ARID1A’s effect on the proliferation of normal ovarian surface epithelial cells [Several studies have identified that ARID1A contributes to tumorigenesis by influencing several cellular functions, (1) proliferation, (2) differentiation, (3) mitosis, (4) DNA damage repair, and (5) apoptosis. al cells . Guan etal cells . Guan etal cells . Growth al cells . In contal cells ,42 whileal cells . ARID1A al cells . A complal cells . By contributing to DNA damage repair and telomere cohesion, ARID1A plays a critical role in maintaining mitotic integrity in a cell. ARID1A promotes STAG1 expression required for telomere cohesion. ARID1A inactivation causes defects in telomere cohesion, leading to DNA damage at telomeres and defects in mitosis. ARID1A inactivation in human ovarian clear cell carcinoma cell line (RMG-I) causes telomere damage that can be rescued by STAG1 expression. Thus ARID1A inactivation is selective against the gross chromosome aberrations and the survival of cells during mitosis . ARID1A Recruited to DNA double-strand breaks (DSBs) via its interaction with the upstream DNA damage checkpoint kinase ATR, ARID1A impairs DSB-induced ATR activation and regulates the G2/M DNA damage checkpoint by facilitating efficient processing of DSB to single-strand ends, and sustains DNA damage signaling. ARID1A deficiency has been shown to sensitize cancer cells to PARP inhibitor, BMN673 . ARID1A Several potential targets selective against ARID1A mutation in cancers have been proposed based on the context of the cellular signaling in the respective organ-type cancers ,52,53,54PIK3CA was overexpressed in 73%, while PTEN expression was negative in 5% of the ovarian clear cell carcinomas. Overexpressed PIK3CA, which correlated with the presence of mutation or amplification of the PIK3CA gene in tumors, was found to be associated with p-AKT overexpression . In our Two major genes reported to be mutated in ovarian clear cell carcinoma are PIK3CA and ARID1A, which frequently coexist with each other . A frequThe exact cooperative nature of this co-alteration has not been completely understood. In neoplasms originating from the uterine endometrium, a coexistent ARID1A and PI3K mutations promote epithelial trans-differentiation and collective invasion wherein Wilson et al. observed siARID1A and PIK3CA-H1047R convergence on the NFκB pathway, as previously described in ovarian clear cell carcinoma, and the EMT pathway . Interesin vitro [Collectively, studies so far strongly suggest a cooperating mechanism between the two co-occurring ARID1A and PI3K pathways ,37. It iin vitro .The most commonly encountered mutations of ARID1A lead to a loss of expression/function of ARID1A, making ARID1A a poor therapeutic target. Hence studies are conducted to find out the molecular consequences of ARID1A deficiency to identify therapeutic options in ARID1A-mutant tumors. The dependence on HDAC6 activity in ARID1A-mutated ovarian cancer cells has been reported to be correlated with direct transcriptional repression of HDAC6 by ARID1A as HDAC6 inhibition selectively promoted apoptosis of ARID1A-mutated cells . As a prIt remains to find out the role ARID1A plays in the continuum model for tumor suppression  and how


We analyze the effects of the Mexican universal health insurance program, Seguro Popular, on key variables associated with the provision of healthcare services. Given that the program was introduced gradually over a period that lasted more than a decade, the dynamics of the roll-out of the program and its reaction to the expansion of healthcare services it caused should be accounted for when evaluating the program.We present a new semiparametric procedure to analyze time-varying continuous interventions. This is accomplished by bringing together the literatures on continuous and on dynamic treatments. Our approach allows the researcher to estimate mean and quantile dose-response functions by applying local regression methods to appropriately weighted samples that control for time-dependent confounding.Using administrative data, we show compelling evidence that Seguro Popular has incremented the human and physical resources available for healthcare services over the period 2001–2013. Moreover, we show that these effects have been heterogeneously distributed.The program has proven most helpful in less vulnerable territories, leaving behind those in greater need. Traditionally, health insurance in Mexico has been part of the social security system that provides healthcare services, retirement pensions, and several other benefits, for everyone with a formal employer that paid the contributions into the system. Since its introduction in 1943, however, the social security system has remained far away from achieving universal coverage. Basically, all informal workers and their families, about half of the population, remained uncovered and therefore had very limited access to affordable healthcare services. At the start of the millennium, the newly-installed government proposed and enacted a health insurance program for those in informal employment, with the intention to achieve universal health coverage . By 2014We intend to estimate the effect of the health insurance program, (SP), on key variables associated with the provision of healthcare services in Mexico. An important characteristic of the program is that it unfolded with varied intensity over a period of more than 10 years. Therefore, analyzing its effects under the assumption of a single homogeneous action at a single point in time is far from reality. When a program evolves over time in a deterministic way, it may be possible to control for confounders using only preprogram covariates (see for example ). If, onRobins et al. , RHB froWe propose a procedure that takes the application of RHB’s methodology for binary dynamic processes to an implementation for continuous treatments. We use the resulting IPTWs to estimate Mean and Quantile Dose-Response Functions (DRFs) in these dynamic contexts, analyzing the impact SP has had on the expansion of the number of doctors’ offices and of physicians and nurses with day-to-day contact with patients.In line with previous research , 7, we fThe paper proceeds as follows. “Although the risk that the observed correlation between the outcomes and the treatment is due to some other confounding variable is not different from single homogeneous interventions, in dynamic settings such as the one under scrutiny in this paper, confounders may share the time-varying nature of the intervention. A time-varying confounder can, potentially, both affect future exposure to the program as well as be affected by past exposure . In thisBy way of a generalization of IPTW estimators  for longi index program recipients, with i=1,…,n, and let t=1,…,T be the stage of the intervention, where T is the last stage of the program recorded in the data. At every stage t, recipients are observed receiving the exposure level ait to the benefits of the program; that is, one possible realization of the exposure variable Att gives us the history of exposure, t, Xt is the most recent set of variables that could have affected At, and that may have been affected by past exposure, In the counterfactual framework of dynamic causal inference, this assumption is referred to as sequential ignorability  or condiEach possible exposure history t given the covariate and exposure histories up to that stage, that is, At given At) and, secondly, that at any stage t, it is not the case that there is a covariate history at. That is, if at – each exposure history must have a positive probability of occurring. This last assumption is closely related to the traditional of common support assumption; in “With this notation, the assumption of sequential ignorability states that for any exposure history The problem researchers face in estimating the causal effect of a program is that typically the potential outcomes, At given i actually experienced.However, what RHB showed is that, under the aforementioned assumptions , it is possible to generate a reweighted version of the observed outcomes that, conditional on If we assume that all confounders are observable, the idea is to decompose the joint distribution of the observed data into an equivalent product of conditional probabilities representing different causal mechanisms. Doing this allows us to find the weighting function that removes all the factors from the product that are in excess to simulate the potential outcome distribution.X1 and X2, two stages with exposures, A1 and A2 and one outcome, Y. Assume further that the temporal order of these variables is  and that every variable is affected by all its predecessors. In this case, we would have that the joint pdf of the observed values of Y, A and X is:To illustrate the mechanism, assume that we have two covariates, where the first equality follows from consistency, the second and fourth from the definition of a conditional pdf, the third from the definition of a marginal pdf and the last from sequential ignorability. At this point the reweighting function suggests itself asApplying these weights to the distribution of the observed data enables the simulation of the distribution of fA|X with fA in the observed data, the process alters the distribution of A breaking the links between the exposure and the factors that affect it. With longer histories, this leads naturally to the stabilized weights proposed by RHB asThe use of the transformed data allows us to estimate the causal effects of the program. Intuitively, as the weighting replaces i, SWi, we find the probability density of the observed exposure history of that recipient conditional on the past, expressed as the product of the respective probability density at every stage, hence the name Inverse Probability of Treatment Weighting. As we have seen, the SW removes any confounding by ensuring that the distribution of exposure histories Notice that in the denominator of the weight corresponding to recipient SW we need to model the exposure in each stage, conditional on the past. When exposure to the intervention comes as a single action that either occurs or not, a common approach is to estimate the probability of being exposed, propensity score.To estimate the At on α,σ2). We can obtain these estimates, In the case of continuous interventions, RHB suggest the use of Ordinary Least Squares (OLS) regression of h, that better suits the program under analysis. Hirano and Imbens [while for the numerator, d Imbens  coined tHowever, RHB’s suggestion does not take you all the way as to how to actually implement this continuous extension, leaving out important details which complicate matters in this context. In the remainder of the paper we work out these details, for the first time, and apply them to the evaluation of the SP program.In the single-shot framework a crucial diagnostic to validate the estimated propensity score consists of checking for covariate balance. We have seen in “At is still predictive of Xt, then it is likely that we have residual confounding of the relationship between the outcome and the exposure [X at stage t on the cumulated exposure before t, and the level of exposure at t. We would expect that the coefficient associated with the latter regressor, At, would be statistically insignificant in the weighted data.If after reweighting the data and conditioning on past exposure, exposure . We can X differs among groups with different degrees of exposures. In the case of fixed continuous interventions, a natural strategy, proposed by Flores et al. [Also of importance in the impact evaluation literature are “common support” or “overlap region” considerations. In the single-shot framework these terms refer to restrict the estimation of causal effects to comparable recipients: those with similar distributions of covariates across exposures. The idea is to avoid the bias that may arise when the support of the distribution of s et al.  – FFGN fi is from the rest, the less comparable it is, since its particular value of Xi sets it apart from the rest of the recipients. Intuitively, it differs too much from the other recipients in the data and so is not readily useful for estimating causal effects.As the number of blocks grows and ultimately reaches the number of observations in the data, comparisons end up being on individual recipients and how “far away” every one of them is from the rest in terms of the covariates. The farther away recipient xi and xj is defined as the average absolute distance between the elements of the two points, divided by the range of the data:King and Zeng , 14 haverk=max(Xk)−min(Xk) and the min and max functions return the smallest and largest elements, respectively, in the set including the kth element of the covariates X. Informally, we can see G2 as the distance between two points expressed as a proportion of the distance across the data – although technically speaking the distance measure is G, the square root of this quantity.where the range is js equal to 0.5 means that the average distance between recipient i and all other recipients requires to travel the equivalent distance as 50% of the way across the data set. Nonetheless, in a time-varying context – with recipient-stage observations– defining the cut-off value is not sufficient to determine which observations to compare. Given the progressive way the weights Xt before analyzing Xt+1, keeping in the end only those recipients whose covariates Xt are deemed “nearby” at every stage t.A natural possibility is to use the mean distance between the recipient under scrutiny and the rest of the observations. In this fashion a mean value of It is important to note that removing the recipients outside common support from the analysis changes the population of inference, restricting it, in principle, to those recipients for which we can produce reliable answers to our causal questions. Once the common support has been determined, the exposure assignment model estimated and the stabilized weights validated by checking for covariate balance, we can use them to estimate the causal quantities of interest.With time-varying interventions, estimating the causal effect of every exposure history as we would in a single-shot framework, proves a technically impossible task because even with interventions that only take a handful of different degrees of intensity at every stage, the number of possible exposure histories grows geometrically with the number of stages, let alone with a continuum of different degrees of exposure.To estimate the effect of a time-varying intervention we need additional assumptions about which exposure histories should have similar potential outcomes: a response model that would allow for the entire exposure history to affect the outcome in a structured, low-dimensional way. We may assume, for instance, that recipients with the same cumulative exposure should have similar potential outcomes.The substance of the evaluation, and more often than not the amount of data on hand, will determine what response model makes sense for the potential outcome. If summarizing the recipients’ exposure histories with a scalar function, such as the cumulative exposure Since the pseudo-sample generated by In this Section, the procedures so far discussed are used to estimate the effects of the Mexican universal health insurance program, Seguro Popular (SP), on the actual capacity of the Secretaría de Salud –Ministry of Health– (SSA) to meet the new demand for healthcare services. In particular, as outcome variables we consider the observed increment in the relative number  of SSA’s doctors’ offices, physicians and nurses in day-to-day contact with patients , which can be considered the most basic human and material resources involved in the provision of healthcare services.We use administrative records of the SP program containing the number of families and individuals affiliated from 2002 to 2013, and the federal records on infrastructure and human resources employed by the SSA over the same time periodEnrollment into the system is voluntary and is granted to all legal residents in Mexico who lack health insurance, ascertained with the mere declaration of the applicant. Figure Although SP was meant to correct previous imbalances in the distribution of financial, physical, and human resources across the federal states , its impThe SP program is therefore a clear example of a time-varying intervention. Moreover, it is not unlikely that the roll-out of the program was affected by the density of SSA’s personnel and infrastructure in its regional administrative units and that, at the same time, the program helped build up these human and material resources. In such a situation, it becomes necessary to account for this dynamic selection if one is to assess the effectiveness of the program, for which, moreover, addressing regional disparities is suggested to be an important theme.The existing evaluations have focused on households’ healthcare expenditures, use of services, and labor market effects, without taking into consideration the potential relevance of the gradual roll-out of the program. Key findings include that SP affiliates see reduced their out-of-pocket health expenditures –25 and cPractically no attention has been paid to the effects that the expansion of the SP program might have had on the supply side of the healthcare services. So far, only Bosch and Campos-Vázquez  have tacIn our analysis we focus on the 233 SJs as recipients of SP coverage, defined as the number of persons affiliated to the program relative to the size of the target population in every SJ, that is, the number of individuals who do not have access to the health insurance provided by law through the social security system to formal workersYi). It is natural to assume that SJs that exhibit a lower density of human and material resources, for one reason or another, experience difficulties to translate the financial resources into additional investments in personnel and infrastructure. If this lower density of resources had been a criterion for intensifying the coverage efforts of SP, or even if in a more mechanical way the pace of the affiliation efforts were determined by the availability of SSA’s personnel, then particular exposure histories would have followed SJs according to their capacity to respond to the program, thus biasing naive estimates.If we were to estimate the effect of SP coverage as we would in a randomized evaluation, that is, as if we knew that To address these concerns, we include in our estimates of SP’s effect the density of resources employed by the SSA in the provision of healthcare services as time-varying covariates −MeanDRF(0), that is, the difference between full coverage and absence of SP affiliates. Our estimates suggest that, on average, the full coverage of the SP program would represent, for the SJs in our sample, an increase in the relative number of doctors’ offices, physicians and nurses providing clinical care  of 0.18, 0.47 and 0.64 respectively. Given that in 2001 the densities of these resources were 0.45, 0.81 and 1 respectively, we can see that the program has had an important impact on the human and material resources of the SSAAlso of importance is the difference between the end points of the mean response curves, The almost linear relationship depicted in all three graphs also suggests the absence of any economies of scale in the use of the financial resources being provided by the program. This is most striking in the case of doctors’ offices, where one would expect new infrastructure to be costlier. According to our estimates, the increment in the relative number of resources is, on average, directly proportional to the per-affiliate amount of money destined for the program.A number to keep in mind is that in 2014 the government contribution reached an average of 2843.40 pesos (about 185 USD of the time) per affiliate, which constitutes 99% of the financial resources of the program .However informative the mean dose-response functions are, they do not provide a complete description of the program’s impact on other parts of the distribution of our outcome variables. It would be important to investigate the conditions under which the same coverage of the program has a differential response, possibly ascertaining subpopulations for which the program is most effective and help improve its design and steer it in the desired direction. We can see the relevance of this exercise in Fig. As previously stated, we can estimate quantile versions of the DRFs using the same kernel-weighted regression framework, only this time with linear quantile regressions of the outcome on the cumulative exposure. This will give us a clear understanding of how the program is affecting the whole distribution of our outcome variables, taking us one step further into characterizing the determinants of possible heterogeneous responses to the program.i response curve, CentileiDRF(1)−CentileiDRF(0). All three figures show a positive tendency for the expected response to full coverage of the program. The fact that these figures do not exhibit horizontal lines suggests that going from zero to full coverage of SP has different responses along the distribution of the outcome variables, showing greater effects on the upper part of the distributions. In other words, the better the SJ is doing in seeing increased the relative number of its human and material resources, the greater its response to the program. Note that this is not a tautology; what this means is that the program gives greater boosts to those SJs increasing the most their resources – again almost in a direct proportion.Figures There are at least two reasons why this might be happening. The first is that it could be a simple reflection of the SJ’s investment priorities. It may well be that those SJs exhibiting greater increases in the relative number of their resources prioritized such expansion, and the program’s financial resources help them to do exactly that. If this were the case, it is only natural to observe that those SJs whose investment priorities lie elsewhere, other than expanding the density of their human and material resources, do not use the program’s money in this fashion.A second reason for the positive slope in Figs. In light of Figs. Similar patterns are found for physicians and nurses in day-to-day contact with patients. We have also plotted the average SP coverage by decile in 2013 to show that this pattern is hardly explained by differences in the roll-out of the program. Nearly all the the SJs achieved complete program roll-out by 2013, but the eventual level of the outcome measure –the increment between 2001 and 2013– is almost entirely determined by where they were in 2001. Moreover, the dotted lines showing the mean and median increments observed in the trimmed sample demonstrate how limited the conclusion would be if we had only looked at the average treatment effect disregarding the huge differences in the impact the program has had across the SJs.Perhaps as a natural result of the better-off SJs making the most of such a sizable program as SP, Fig. Together, the increment incidence curves and inequality indices suggest that the SJs making the least of the SP program are precisely those in greater need. The initially worse-off SJs are also the ones showing the least increment in basic human and material resources at roughly the same coverage levels of the program. Without making any assumption as to the degree in which SP has contributed to the more unequal distribution of health resources in Mexico, at this point, all we can say is that it has contributed. This should be a matter of major concern for any program directed at vulnerable population groups.We have analyzed the effects the implementation of a universal health insurance program in Mexico, Seguro Popular (SP), has had on key variables associated with the provision of healthcare services by the Secretaría de Salud –Ministry of Health– (SSA). The roll-out of SP unfolded over a period of more than a decade, with different treatment intensities across recipients –the Sanitary Jurisdictions (SJs) that are responsible for the provision of services. The expansion of insurance coverage and of the healthcare services formed a complicated interactive process that the milieu itself helped to create as it unfolded. Hence, the application of a traditional single-shot causal inference method would have implied imposing assumptions that do not reflect reality.To control for the time-dependent confounding inherent to the dynamic nature of these kinds of programs, in this article we have brought together two strands of the literature on causal inference in observational studies: one focusing on fixed non-binary treatments and the other on binary dynamic treatments. The procedure we present here elaborates on Robins et al.  showing Our empirical set-up allows us to identify that SP has had a positive effect on the density of human and material resources available for healthcare services. We have shown that these positive effects grow in magnitude as we move to the right in the distribution of outcomes –that is, SJs with a stronger growth benefited more. Moreover, we have shown that those SJs that were better off in 2001 –before the roll-out of SP started– are the ones on the right of the outcome distribution showing the greater increases. Hence, unlike previous evaluations, we have found compelling quantitative evidence that the program has proven most helpful in less vulnerable territories, leaving behind those in greater needBeyond the problems inherent to the lack of accountability , it is aEven though Seguro Popular’s general aim of reducing inequalities appears uncontroversial, the practical notions of equity that should inform policy and the ways in which these should be implemented are far from clear. Seguro Popular does give absolute priority to those outside the social security network, a group previously without access to affordable healthcare services. However, our results indicate that the worst-off individuals among those are still left behind. In Mexico, there is an undeniable social gradient in health resources, meaning that the poorest areas are also those with the least healthcare resources. Also, it is well-known that poor people are more likely to have unhealthy lifestyles due to deficient educational services, local economic conditions, inadequate social support systems, and transportation. There is still a lot to be done in the quest for ensuring that, as far as possible, Mexican people have equal access to basic health resources. Without explicit considerations regarding a more specific priority setting, the situation depicted in this article is likely to remain unchanged; at least, our results indicate that the poorest regions have not been able to catch up. Moreover, in targeting the poorest of the poor, it may well be necessary to recognize that remote rural communities in Mexico can only receive primary healthcare through mobile medical units or telemedicine –and that even in that case, improved road infrastructure will be needed to guarantee access.If Seguro Popular is taking efficiency to be paramount when distributing benefits, this gives rise to profound ethical concerns about the actual provision and financing of healthcare. Although perfect equality may not be achievable, whatever the trade-off between equity and efficiency in the allocation of healthcare resources, there should be an open discussion about the most cost-efficient ways of rationing those resources that also takes equity criteria into account.


Inhibition of DcR3 expression may provide a novel immunotherapeutic approach to restoring immunity in HCC patients.Hepatocellular carcinoma (HCC) is a leading cause of tumour-associated mortality worldwide, but no significant improvement in treating HCC has been reported with currently available systemic therapies. Immunotherapy represents a new frontier in tumour therapy. Therefore, the immunobiology of hepatocarcinoma has been under intensive investigation. Decoy receptor 3 (DcR3), a member of the tumour necrosis factor receptor (TNFR) superfamily, is an immune suppressor associated with tumourigenesis and cancer metastasis. However, little is known about the role of DcR3 in the immunobiology of hepatocarcinoma. In this study, we found that overexpression of DcR3 in HCC is mediated by the TGFβ3-Smad-Sp1 signalling pathway, which directly targets DcR3 promoter regions. Moreover, overexpression of DcR3 in HCC tissues is associated with tumour invasion and metastasis and significantly promotes the differentiation and secretion of Th2 and Treg cells while inhibiting the differentiation and secretion of Th1 cells. Conversely, knockdown of DcR3 expression in HCC significantly restored the immunity of CD4 The leading factor associated with HCC is chronic hepatitis virus infection, which contributes to liver injury and concurrent regeneration, giving rise to fibrosis, cirrhosis and, eventually, HCC2. During the process, the extensive expression of cytokines and chemokines is believed to create a microenvironment that favours the development of HCC3. However, the mechanism governing how cytokines and chemokines regulate the occurrence of HCC in such a microenvironment has not been elucidated to date. Therefore, the elucidation of the molecular regulation mechanism is likely to create novel avenues for the early identification and therapeutic intervention of HCC.Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide and has a notably poor prognosis+ T cells, CD8+ T cells, and associated cytokines5. Naive CD4+ T cells derived from the thymus differentiate into different subtypes at the periphery in response to antigen stimulation. The first classification divided CD4+ effector cells into two subsets: Th1, characterised by the production and release of interferon gamma (IFN-ɣ), and Th2, characterised by producing and releasing IL-4. In recent years, it has become evident that more functional subsets of CD4+ T cells can be induced by various stimuli in vivo and in vitro7. Another subset is the regulatory T cells (Tregs) expressing the transcription factor Foxp3 and T-cell surface molecules CD25/CD127. Treg cells can suppress the function of other effector T cells and antigen-presenting cells by cell–cell interactions and the release of suppressive cytokines, such as TGFβ and IL-10, and play a key role in maintaining immunotolerance9. Although some papers have shown that immunotolerance exists in HCC, the specific mechanism governing this phenomenon has not been elucidated to date. Therefore, the identification of the key factors mediating tumour-induced immunotolerance in HCC remains to be undertaken.The immune system functions as a host defensive mechanism that protects against tumour development. Patients with tumours exhibit weaker immune surveillance capability and a variety of immune dysregulations, including an imbalance of CD411. Three isoforms of TGFβ, i.e., TGFβ1, TGFβ2 and TGFβ3, all function as secreted polypeptides. The isoforms regulate the transcriptional expression of tumour cytokines and chemokines by binding to TGFβ receptors13. Moreover, accumulating evidence indicates that one efficacious mechanism by which TGFβ promotes tumour progression and metastasis is regulating CD4+ T-cell-mediated immunity by inducing the differentiation of CD4+ T cells into various subpopulations of T cells14. In the HCC microenvironment, we found that the expression of TGFβ3 was higher than that in normal liver tissues. However, the effect of TGFβ3 to HCC and the molecular basis for such effect has not been fully elucidated.Transforming growth factor β (TGFβ), a notable molecule in the tumour inflammatory microenvironment, plays critical roles in promoting tumour development, progression, and immune escape15. DcR3 has three ligands: Fas ligand (FasL), TNF-like molecule 1 A (TL1A), and lymphotoxin-related inducible ligand, which competes with herpes simplex virus glycoprotein D for herpesvirus entry mediator on T cells (LIGHT)18. DcR3 is barely detectable in normal tissue and serum of healthy subjects, whereas its expression is increased in various tumours, such as breast cancer19, gastric cancer20, glioma21, pancreatic carcinoma22, and renal cell carcinoma23. There is strong evidence indicating that overexpression of DcR3 causes it to function as a decoy receptor for FasL, TL1A, and LIGHT and inhibits these ligands, mediates apoptosis, angiogenesis, proliferation, differentiation and lymphokine secretion of lymphocyte, which makes DcR3 a potential therapeutic target in cancers25. In a previous study, we demonstrated that DcR3 was one of the key molecules that regulated colorectal cancer (CRC) tumourigenesis and metastasis26. Whether DcR3 plays a role in HCC development and whether it induces immunosuppression of HCC through inhibiting proliferation, differentiation and lymphokine secretion of lymphocytes have not been determined. The goal of this study was to investigate whether DcR3 has the potential to be used as a target for HCC immunotherapy.Decoy receptor 3 (DcR3), a member of the tumour necrosis factor receptor (TNFR) superfamily, is a soluble secretory protein lacking a transmembrane sequenceThe cytokine expression profile analysis between the samples from four patients with HCC and those paired adjacent normal hepatic tissues was performed by RayBio® human biotin-label-based cytokine antibody arrays, which covered 1000 well-characterised human cytokines. Interestingly, as shown in Fig. N)  compared with their paired adjacent normal hepatic tissues (N) Fig. .P < 0.001), HbsAg infection (P < 0.001), tumour differentiation (P = 0.033), metastasis (P = 0.013), and portal vein tumour thrombus (PVTT) (P = 0.012).In addition, IHC was used to determine the expression level of DcR3 in 91 cases of paraffin-embedded HCC sections. As shown in Fig. P < 0.001). Taken together, these results indicate that increased DcR3 expression is clinically relevant to the occurrence of HCC.As DcR3 is a soluble secretory protein lacking a transmembrane sequence, DcR3 serum levels were detected by enzyme-linked immune sorbent assay (ELISA). As shown in Fig. To investigate the possible mechanisms underlying DcR3 expression in HCC, we treated MHCC97L and SMMC7721 HCC cell lines  promoting the expression of DcR3 were analysed by bioinformatics algorithms. In JARSPAR databases, Sp1 was a predicted TF that is able to bind to the promoter of DcR3 gene. Meanwhile, a previous study showed that the transcription factor of Sp1 directly bine to Smad3 and co-regulated transcription of the target geneTo determine whether Sp1 plays a role in regulating the expression of DcR3 through the TGFβ3-Smad signalling pathway, we detected the interaction between P-Smad2/3 and Sp1 by Co-IP assays Fig. . A clearModulating the immune system to treat tumours is a major goal of immunotherapy. Since T lymphocytes function as a host defensive mechanism protecting against tumour development and because overexpression of DcR3 has been found in HCC, whether DcR3 can also modulate the T-cell numbers and their components in HCC were investigated.+ T and CD8+ T cells in HCC, we measured the percentage of CD4+ T and CD8+ T cells in peripheral blood lymphocytes (PBMCs) from HCC patients and normal control samples. We found a significant decrease in the CD4+ T cells in patients’ PBMCs but no notable difference in the CD8+ T cells compared with the normal controls . We then analysed the expression profile of CD4+ T-cell subtypes, which are commonly modulated in tumours. Th1 and Th2 cells, two of the most common CD4+ subtypes, are generally modulated in tumours. Treg cells, another subset of CD4+ T cells, play an important role in tumour immunosuppression18. However, the functional impact of CD4+ T-cell subtypes on HCC has not been fully elucidated. Therefore, the CD4+ T-cell subtypes, Th1, Th2 and Treg cells, were detected after treatment with rhDcR3 by flow cytometry. The results demonstrated that compared to controls, the frequency of CD4+IL-4+ Th2 and CD4+CD25+ Treg cells was significantly increased, and the frequency of CD4+IFN-ɣ+ Th1 cells was decreased in rhDcR3-treated groups . In our previous study, DcR3 promoted CRC cell proliferation in vitro and CRC tumour growth in vivo by mediating the EMT of CRC cells34. These observations indicate that DcR3 plays an important role in HCC progression and may serve as a valuable biomarker for monitoring HCC development in humans.Meanwhile, DcR3 expression was also associated with liver cirrhosis, HbsAg infection, tumour differentiation and metastasis. Moreover, DcR3 is a secreted protein because DcR3 lacks an apparent transmembrane domain. In other words, DcR3 is easily detectable in the blood serum of patients, raising the possibility of using DcR3 as a biomarker for diagnosis, treatment and prognosis of some diseases. Therefore, in this study, DcR3 expression in serum was detected, showing that DcR3 in serum from HCC patients was higher than that in serum from humans without HCC, in keeping with the findings of Yanqiang Hou and Giorgos Bamias37. In contrast, the expression of DcR3 is low in the thymus and undetectable in PBMCs38. Paradoxically, in some autoimmune diseases, DcR3 regulates immune responses via inhibiting T lymphocyte functions41. For example, Hsu et al.25 reported that DcR3 mediated anti-inflammation by skewing the Th1/Th2 cell balance towards the Th2 response and suppressing the phagocytic activity of macrophages42. In this study, we verified that DcR3 expression in the serum of HCC patients was higher than that in the serum from those without HCC. At the same time, we also proved that an immune imbalance existed in HCC patients exhibiting a significant decrease in CD4+ T cells in HCC patients. These results support the hypothesis that overexpression of DcR3 in the serum of HCC patients suppresses immune regulation of CD4+ T cells. The assays further suggest that overexpression of DcR3 in HCC suppresses CD4 + T cells to differentiate into Th1 cells and promotes CD4+ T cells to differentiate into Th2 and Treg cells. This effect is further supported by the fact that due to decreased CD4+ T cells and the release of anti-inflammatory cytokines, the immune system exhibits immune suppression. This immune suppression phase may determine the outcome of HCC. Moreover, the results from animal models have demonstrated that DcR3 decreases the percentage of CD4+ T cells and IFN-ɣ and IL-2 secretion of Th1 cytokines. At the same time, DcR3 facilitates HCC cell growth and shortens the survival time of immunocompetent BALB/c mice. Therefore, we concluded that DcR3 promotes placing HCC patients in an immunosuppressive state and that DcR3 may accelerate the development of HCC by suppressing the CD4+ T-cell immune response.DcR3 is expressed not only in tumour tissues but also in some healthy adult tissues, such as lung, stomach, lymph node, and trachea22. Previous studies validated that DcR3 mediated immunomodulatory functions through competition for ligands. For example, DcR3 inhibits the TL1A-DR3 interaction, contributing to Th1-mediated immune responses by downregulating the secretion of proinflammatory cytokines17. As a decoy, DcR3 promotes tumour cell proliferation via inhibition of FasL-induced apoptosis22. Similarly, DcR3 promotes chemotaxis of the T cells through inhibiting LIGHT-HVEM interaction43. Nevertheless, DcR3 can ameliorate T-cell responses to antigens by neutralising LIGHT-HVEM association44. However, there are no reports on how DcR3, secreted by HCC cells, suppresses CD4+ T-cell proliferation and differentiation. In our study, we first found that the expression of LIGHT is upregulated in HCC tissues along with DcR3 expression. Next, we co-cultured HCC cells that highly expressed DcR3 protein with CD4+ T cells and found that LIGHT and DcR3 proteins co-localised on CD4+T cells. To further detect DcR3 secreted by HCC cells that could combine LIGHT ligands, we treated CD4+ T cells with rhLIGHT and rhDcR3 and observed the location and expression of LIGHT and DcR3 proteins in CD4+ T cells. The results of the immunofluorescence assay showed that when treated with rhDcR3, CD4+ T cells were co-localised with LIGHT and DcR3. Flow cytometry showed that after CD4+ T cells were treated with rhDcR3, the percentage of Th1 cells was decreased, while the percentages of Th2 and Treg cells were increased. From these results, we conclude that the DcR3 protein can combine to ligand LIGHT, which is highly expressed on CD4+ T cells after being activated. The mechanism of LIGHT is highly expressed in CD4+ T cells, regardless of whether it is related to the stimulation of the DcR3 protein, and we will further explore it in subsequent experiments. However, when treated with rhLIGHT, CD4+ T cells express LIGHT only. On the one hand, the reason for this result may be elevated LIGHT expression of CD4+ T cells after activation. On the other hand, the finding may be due to the combination of rhLIGHT with other receptors on the CD4+ T cells, such as HVEM. Consistent with these results, an ELISA indicated that DcR3 decreased the secretion of IFN-γ and increased the secretion of IL-10. It can be concluded that DcR3 suppresses CD4+T-cell proliferation and differentiation into Th1 cells and promotes CD4+T cells to differentiate into Th2 and Treg cells by interacting with its ligand LIGHT. In addition, it has been reported that the LIGHT:DcR3 complex consists of two independent chains of LIGHT and two independent chains of DcR3 which, upon application of crystallographic three-fold rotational operators, form two canonical three-fold symmetric TNF:TNFR hetero-hexameric assemblies. This report has revealed the structural basis of DcR3-mediated neutralisation of LIGHT and enabled the design of novel molecules to antagonise and probe DcR3 function18. Therefore, developing inhibitors of DcR3 and increasing expression of LIGHT might provide a novel immunotherapeutic approach to restore immunity in HCC patients.Prior studies have shown that DcR3 has three known ligands: FasL, LIGHT and TL1A. The soluble DcR3 binds these ligands and mediates immunomodulatory functions through competition for ligand binding with the respective functional receptors Fas, herpesvirus entry mediator (HVEM), and death receptor 3 (DR3)45 has shown that epidermal growth factor receptor (EGFR) signalling plays a central role in modulating DcR3 expression in keratinocytes. Furthermore, inflammatory cytokines, especially transforming growth factor (TGF)-α, can induce DcR3 expression in keratinocytes and endothelial cells, which may further contribute to the progression of psoriatic skin lesions. Moreover, DcR3 is regulated in a PI3K/AKT-dependent manner involving the transcription factor nuclear factor of activated T cells23. In addition, Yang et al.46 reported that DcR3 may be regulated by kinase 1/2 (Erk1/2) in the development of gastric cancer. However, the regulation of DcR3 overexpression in HCC tissues has not been fully elucidated. In this study, we first demonstrated that the TGFβ3-Smad signalling pathway regulated DcR3 expression by activating the transcriptional activity of transcription factor Sp1 which, combined with the DcR3 promoter, indicates that DcR3 may be a promising therapeutic target for HCC.The regulatory mechanism of DcR3 is different depending on cell types or experimental systems. For example, a study from Wu et al.47.According to the specifications of the S-P kit, paraffin-embedded tissues were cut into 5-μm-thick sections, dehydrated with organic solvent, retrieved with citrate buffer, incubated with primary antibody  and then detected with an avidin-biotin complex with 3,3′-diaminobenzidine. The degree of staining was observed and scored independently by two pathologists. Immune staining intensity was rated as follows: 0 (no staining), 1 , 2  and 3 . Immune staining quality was rated as follows: 0 (no staining), 1 ( < 30%), 2 (30–70%) and 3 ( > 70%). Tumour tissue intensity was scored via summation as follows: 0–1 (−), 2–3 ( + ), 4 ( + + ) and 5–6 ( + + + ). Tissues scored 0–1 (−)/2–3 ( + ) were classified into the low-expression group, and tissues scored 4 ( + + )/5–6 ( + + + ) were classified into the high-expression groupProteins were extracted by lysis buffer from QGY7701 cells. Sp1 , P-Smad2 and P-Smad3 antibodies  were added to cell lysates differently. Subsequently, 20 μL of agarose-protein G beads was added. The beads were incubated for 6 h and then washed five times in PBS , and the proteins were eluted in Laemmli buffer. Western blotting was used to analyse the interacting proteins.Cells seeded on confocal dishes, were fixed with 4% paraformaldehyde for 30 min and were washed with PBS, after which they were permeabilized in 0.5% Triton X-100/PBS for 10 min at room temperature. Then, cells were incubated with primary antibodies at 4 °C overnight. Following that, the cells were washed with PBS and incubated with the appropriate fluorescent secondary antibody in the dark at room temperature for 1 h. Finally, the confocal dishes were mounted using an anti-fade mounting solution containing 4, 6-diamidino-2-phenylindole (DAPI) served as a nuclear counterstain and were washed with PBS. Staining was examined, and images were recorded using an an inverted fluorescence microscope .t-test. Relationships between DcR3 expression and clinicopathological characteristics were tested using Pearson’s χ2-test. Differences were considered significant if P < 0.05*; P < 0.01**; P < 0.001***.All statistical analyses were performed using SPSS 19.0 . The quantitative results of all experiments are expressed as the mean ± SD. Differences among/between sample groups were analysed by one-way ANOVA or the independent-samples SUPPLEMENTAL MATERIAL