The purpose of this study is to examine the role of positive workplace gossip (PWG) in employee innovative behavior, whereby a mediating effect of employee loyalty is proposed in this relationship. The moderating effect of organizational trust (OT) is also examined on the indirect of PWG on employee innovative behavior through employee loyalty.This research used a survey data of 327 employees from the enterprises selected from the Pearl River and Yangtze River Delta region of China. Based on the literature review, five main hypotheses were formulated and explored. The SPSS-Process Macro Plugin was used to analyze the hypothesized model.Results show there is a positive and significant relationship between PWG and employee innovative behavior. This study also confirm that employee loyalty is an intervening variable and OT as a moderator.Organizations should pay more attention to workplace gossip phenomena, encourage employees to take appropriate part in positive workplace gossip and to communicate positive information about other colleagues, and build an inclusive, open, sincere, and interdependent platform in the organization.Employee innovative behavior plays an essential role in organization’s survival and development. Few studies have investigated PWG may promote employee innovative behavior through employee loyalty. The data, model, and findings of this research address the gap and complement the current state of knowledge. Gossip is almost unavoidable in the real-world social network , deemed Although the existing literature on workplace gossip is extensive and focuses particularly on its “dark side” , some prResearchers have verified the impact of gossip on personal creativity or innovation . HoweverPWG could promote information and friendship bonds , bring aOn the above, with Chinese enterprises as the research object, this study explored the mediating effect and boundary condition of PWG on employee innovative behavior and made up for the deficiencies in existing studies, with main contributions in the following aspects: First, given that PWG is a new research topic , not onlPWG mainly involves individual fulfillment and reputation . SendingBesides, the social identity theory suggests that people classify themselves through social comparison and group identification and generate “in-circle” and “out-circle” consciousness. They form different attitudes and behaviors toward the groups that emotional preference for the “in-circle” and the rejection for the “out-circle” . Brady eH1: Positive workplace gossip positively affects employee’s innovative behavior.Frequent employee turnover can put the company in an awkward position, such as profit cuts, and affect the work efficiency and mental state of other employees within the company . TherefoPWG is one of the means to develop good social relations . InferioMeanwhile, employee loyalty is a key predicative variable affecting employee behavior, which has received wide attentions from the academia and the practice field. Employee loyalty is representative of organization members’ attitude of identifying with the organization, behavior of continuous support, and readiness to contribute their power and pay out more extra-role behaviors for the enterprise to achieve its goals . High-loH2: Employee loyalty acts a mediating role between PWG and employee innovative behavior.According to the social exchange theory, the employee-organization social exchange includes not only material exchange but also spiritual exchange, such as organizational trust. Organizational trust is a key situational variable in social exchange relations. When feeling benefited from the organization, employees would reward their organization in a positive manner. Some studies have pointed out that organizational trust is conducive to improving innovators’ organizational identification, stimulating employee’s OCBs , promotiTrust stems from social activities . AlthougIn addition, employee’s organizational trust stems from the organizational support perceived by employees. When feeling the support and trust from the organization due to the organization’s system, procedures, policies, and climate, employees would develop higher loyalty and professional ethics and are more ready to exhibit innovative behaviors in the work. H3: Organizational trust can positively regulate the positive effect of positive workplace gossip on employee loyalty. The higher (lower) the organizational trust, the stronger (weaker) the positive relation of positive workplace gossip to employee loyalty.H4: Organizational trust can positively regulate the positive effect of employee loyalty on employee’s innovative behavior. The higher (lower) the organizational trust, the stronger (weaker) the positive relation of employee loyalty to employee’s innovative behavior.H2 and H3, H2 and H4 show a moderated mediation effect, that is, employee loyalty plays a mediating role between PWG and employee innovative behavior, and OT moderates the conduction mechanism. Therefore, the following hypotheses are proposed:H5: The higher the OT, the stronger PWG affects the employee innovative behavior through employee loyalty.Based on the above theoretical groundwork, this study built the following model as shown in This study adopted the questionnaire survey method to attain the research objective. The sample enterprises were selected from the Pearl River Delta area and the Yangtze River Delta area of China. Gathering 23.64% of the Chinese population with 4.31% of the national territorial area, both Deltas created 34.65% of China’s economic aggregate . As important economic hinterlands of China and high-tech industry clustered areas and sci-tech innovation demonstration places confronted with intensely competitive environments, where innovative behaviors are highly required of employees, the Pearl River Delta and the Yangtze River Delta are quite suitable areas for the research. By dint of the advantage that the team members in this study had the membership of the local chamber of commerce, the efficiency of data collection was greatly boosted. To reduce the common method bias (CMB), this study complied with the suggestions of First, the research team made active contact with the corporate persons-in-charge, communicating the matters on questionnaire survey, informing them of the research objective and data collection method, and proclaiming that the survey data were to be used for academic research only. Subsequently, contingent on the condition of the enterprises involved, we handed over the pre-coded questionnaires to each corporate person-in-charge, entrusting him/her to tell his/her employees to fill out whenever appropriate and remind his/her employees to memorize their own number. To reduce the employees’ scruple, we assured the respondents that the information is confidential and that the answers would be made accessible only to the first author and the corresponding author. In the first round, a total of 450 questionnaires were issued, including question items on demographic information, PWG, and organizational trust, and 368 valid questionnaires were recovered  from 48 corporate teams. On month later, the 368 questionnaires from the first round were filled out for the second round, including question items on employee loyalty and employee innovative behavior, and 327 valid questionnaires were recovered (88.9%) eventually. We paid remunerations to improve the participants’ enthusiasm and control the quality of questionnaire filling. To be specific, we sent a red packet of RMB 10–50 in cash to each respondent in the first round of questionnaire filling.The industries in this regional survey were distributed mainly in manufacturing, high and new technology, financing, Internet, etc. Among the sampled under investigation, females (57.2%) outnumbered males (42.8%); in terms of age, the age groups of 21–30 years old and 31–40 years old predominated, accounting for 47.2% and 25.1%, respectively, most being front-line employees. Evidently, youngsters were the backbone force of enterprises in these areas; in terms of educational degree, respondents with academic credentials above undergraduate predominated, accounting for 68%; in terms of income level, most had an income of RMB 3,001–5,000 and RMB 5,001–10,000, accounting for 18% and 33%, respectively.All measurement scales selected in this investigation were widely used with good reliability and validity. Meanwhile, to ensure the local applicability of the scales, the question items of each scale were decided on by means of two-way translation, and experts were invited to assess the rigorousness and appropriateness of the questionnaires . All conPWG. This scale consisted of 5 questions in total, such as “I have had the deed of complimenting another colleague while talking with a colleague” and “I have spoken high of another colleague in front of one colleague,” and the coefficient of its internal consistency was 0.890 in this investigation.The scale compiled by employee loyalty. It consisted of five questions in total, such as “I speak positively about my company when talking to customers” and “I would not change immediately to another company if I got a job offer.” The coefficient of internal consistency of this scale was 0.863 in this investigation.In this investigation, the scale used by Employee innovative behavior was measured with In this investigation, the scale used by gender, age, and educational degree as the control variables. These were denoted in coded forms as gender: “1” for male and “2” for female; age: “1” for 20 years old and below, “2” for 21–30 years old, “3” for 31–40 years old, “4” for 41–50 years old, and “5” for 51 years old and above; educational degree: “1” for senior high school and below, “2” for junior college, “3” for university undergraduate, and “4” for postgraduate and above.Previous studies demonstrated that gender and educational degree could make a difference to individual innovative behavior, and that individual attitude toward gossip would change with the increase in age . TherefoThis study adopted the structural equation software Amos24 for confirmatory factor analysis (CFA), conducted reliability test, validity test, and correlation analysis by the software SPSS24, and completed hypothesis verification using the program Process developed by Hayes.SPSS24 was employed to make reliability analysis on all variables. The Cronbach’s alpha was >0.8 for all measurement variables. In the hypothetical model the factor loading between the measurement questions and latent variables ranged within 0.573–0.845 , the average variance extracted (AVE) ranged within 0.520–0.685 , and the composite reliability (CR) of latent variables ranged within 0.842–0.924  and is superior to any other alternative model, and the originally designed model has superior discriminant validity.Next, Amos24 was adopted to conduct CFA on the four variables to examine the model’s discriminant validity. CFA results are shown in All the data collected in this investigation were acquired by self-evaluation means, and the empirical results may be subject to CMB. In this study, the Harman single-factor test was used to assess CMB . The resr = 0.397, p < 0.01); PWG bears a significantly positive correlation to employee loyalty ; employee loyalty bears a positive correlation to employee innovative behavior . These results lend preliminary support to the hypotheses proposed in this study and lay a groundwork for the follow-up test.Pearson’s coefficient was utilized to analyze the correlation between variables. gender, age, and educational degree controlled, we tested the mediating effects of employee loyalty and PWG on employee innovative behavior. The results are shown in B = 0.365, t = 7.647, p < 0.001), H1 is verified. After the mediating variable was introduced on this base, the predictive effect of PWG on employee innovative behavior remained significant ; PWG has a significant predicative effect on employee loyalty ; employee loyalty has a positive significant effect on employee innovative behavior . Additionally, neither the bootstrap95% confidence interval of the direct effect of PWG on employee innovative behavior nor that of the mediating effect of employee loyalty contains 0 between the upper and lower limits, suggesting that PWG can predict employee innovative behavior not only directly but also via employee loyalty, H2 is also corroborated , so does the product term of employee loyalty and intraorganizational trust on employee innovative behavior , suggesting that intraorganizational trust can act a mediating role in the predictions of PWG about employee loyalty and of employee loyalty about employee innovative behavior. Hence, H3 and H4 are verified. Through further simple slope analysis, the positive influential effect of PWG on employee loyalty is strengthened under the circumstance of high organizational trust (+1 SD) compared to low organizational trust  on employee innovative behavior.Although this study has drawn some important conclusions from the investigation into the influence of PWG on employee innovative behavior, there remain some limitations and deficiencies, as manifested mainly in the following aspects. First, different cultural backgrounds would give rise to different employee behaviors. All survey samples in this study coming from the Pearl River Delta area and the Yangtze River Delta area of Chinese mainland, the research findings have certain limitations in general applicability. Future studies can make a supplement from the perspective of multicultural background. Second, all data in this study stemmed from employees’ self-evaluation. Although the same-source variance of data was tested after the investigation, and the results were in a reasonable range, the problem of same-source variance could not be eradicated. To ensure higher preciseness of data, the data sources in future studies can be compensated for The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Material preparation, data collection, and analysis were performed by YD, XZ, JH, and BL. The first draft of the manuscript was written by YD. All authors contributed to the study conception, design, and commented on previous versions of the manuscript. All authors read and approved the final manuscript.houjie918@163.com), School of Foreign Languages, Huaibei Normal University (235000).This work was supported by the National Social Science Foundation (21FYYB056), and JH (The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The 13-year Program to Reduce Maternal Deaths in Tanzania employed multifaceted maternal, newborn, and reproductive health interventions that contributed to increasing the availability and utilization of high-quality obstetric and family planning services and reducing maternal and perinatal mortality in Kigoma. The Program in Kigoma demonstrated that decentralizing high-quality maternal and reproductive health services to lower-level facilities in remote, low-resource settings is both feasible and effective.Between 2013 and 2018, Kigoma achieved significant reductions in maternal and perinatal mortality and increases in contraceptive prevalence by improving the availability of and access to obstetric and family planning services.Program implementing partners who are familiar with the local community and health care system can help foster an environment of collaboration, knowledge sharing, and coordination among stakeholders at all levels.Donors should consider providing flexible support that responds in real time to the needs identified through monitoring and evaluation data to achieve meaningful progress toward reducing maternal mortality.The Program's foundation for successful sustainability included: implementation by Tanzanian teams, as opposed to teams from the Global North, embedding all interventions within existing government health system structures to foster strengthening from within, and working in partnership with all levels of government and in service of government plans and priorities. The Program to Reduce Maternal Deaths in Tanzania was a 13-year (2006–2019) effort in the Kigoma region that evolved over 3 phases to improve and sustain the availability of, access to, and demand for high-quality maternal and reproductive health care services. The Program intended to bring high-quality care closer to more communities. Cutting across the Program was the routine collection of monitoring and evaluation data. The Program achieved significant reductions in maternal and perinatal mortality, a significant increase in the modern contraceptive prevalence rate, and a significant decline in the unmet need for contraception. By 2017, it was apparent that the Program was on track to meet or surpass many of the targets established by the Government of Tanzania. Over the following 2-plus years, efforts to sustain Program interventions intensified. In April 2019, the Program fully transitioned to Government of Tanzania oversight. Four key lessons were learned during implementation that are relevant to governments, donors, and implementing organizations working to reduce maternal mortality: (1) multistakeholder partnerships are critical; (2) demand creation for services, while critical, must rest on a foundation of well-functioning and high-quality clinical services; (3) it is imperative to not only collect robust monitoring and evaluation data, but to be responsive in real time to what the data reveal; and, (4) it is necessary to develop a deliberate sustainability strategy from the start. The Program in Kigoma demonstrates that decentralizing high-quality maternal and reproductive health services in remote, low-resource settings is both feasible and effective and should be considered in places with similar contexts. By embedding the Program in the existing health system, and through efforts to build local capacity, the improvements seen in Kigoma are likely to be sustained. Follow-up evaluations are planned, providing an opportunity to more directly assess sustainability. Dominico et al.See related article by Despite a 38% decline in the global maternal mortality ratio (MMR) between 2000 and 2017, approximately 810 women continue to die every day from preventable causes related to pregnancy and childbirth. Sustainable Development Goal (SDG) 3 includes a target to reduce the global MMR by 2030 to less than 70 maternal deaths per 100,000 births.The Program to Reduce Maternal Deaths in Tanzania (hereafter referred to as the “Program”) was a 13-year effort (2006–2019) in the Kigoma region. At the time of its initiation, the MMR in Tanzania was 578 per 100,000 live births,The approach taken was unique and adaptive. This was not a short-term, donor-driven pilot project with a rigid, predetermined set of interventions designed by and managed from the Global North but an organically developed initiative designed to fit the health conditions and needs of the region. This experience revealed that it is possible to significantly improve maternal and reproductive health in remote, low-resource settings, but this requires several factors: long-term investment; robust, multipartner collaboration in which the government plays a central role; locally determined and context-appropriate interventions; and demand creation that rests on a foundation of well-functioning and high-quality clinical services. Also essential is a willingness to not just collect evaluation data, but to respond to it, which may mean deviating from initial plans and strategies. We describe the Program's key interventions, how these evolved over time, major outcomes, and lessons learned. We hope this experience is instructive to others working toward maternal mortality reduction.The Program was an organically developed initiative designed to fit the health conditions and needs of Kigoma.–The Program started in late 2006. At the time, approximately 12,000 women died annually in Tanzania as a result of pregnancy and childbirth, which placed it sixth in the world for maternal deaths (tied with Pakistan and Indonesia).all women at all times.Although the high number of maternal deaths in Tanzania was a compelling justification for action, it was a novel and locally devised approach that provided the impetus for the Program. Dr. Godfrey Mbaruku, a Tanzanian obstetrician who served as a regional medical officer in Kigoma, proposed a strategy to decentralize lifesaving emergency obstetric care, traditionally offered in hospitals, to health centers that women could more readily access. Given that an estimated 15% of pregnant women experience obstetric complications requiring emergency care,Dr. Godfrey Mbaruku proposed a novel and locally devised approach to address high maternal mortality in Tanzania: decentralize lifesaving comprehensive emergency obstetric care to health centers.,Recognizing that few doctors and no obstetricians worked within the public health care system in rural communities in Kigoma, and based on evidence from other countries,AMOs have been trained and deployed in Tanzania since 1963 and are well-accepted and recognized among physicians.This 2-pronged approach—task sharing and infrastructure upgrades—formed the basis of the initial investment by Bloomberg Philanthropies in 2006. The approach was subsequently adopted in the Government of Tanzania's policy, “The National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008–2015—the One Plan.”Initially, the Program operated in underserved communities and health facilities in 3 regions of Tanzania . These communities and facilities were selected at the direction of the Tanzanian government, with the vast majority of investment in Kigoma. Support for Morogoro and Pwani ended in December 2015. The government recommended winding down support in these regions—both more urban, less disadvantaged, and with high facility delivery rates, 75% and 83%, respectivelyWe focus on Kigoma because it was the most comprehensive Program effort and important progress was made at a relatively large population scale.Kigoma is 1 of 31 administrative regions in Tanzania. It is situated in the northwest of the country along the eastern shore of Lake Tanganyika. Kigoma region has a population of 2.3 million . In 2004, Kigoma lagged behind the national average for delivery in a health facility, cesarean delivery, and unmet need for family planning (FP), among other indicators . Kigoma ,–The initial conception of the Program and what it ultimately became are significantly different. We provide an overview of the Program's interventions in Kigoma and how and why the program evolved over time. Greater detail about each element of the program is included elsewhere.A critical feature of the Program was the multipartner collaboration, which recognized that each partner had a unique role, and by joining efforts, it was possible to achieve much more. The Government of Tanzania participated at multiple levels: nationally through the Ministry of Health, Community Development, Gender, Elderly, and Children (MOHCDGEC) and the President's Office, Regional Administration and Local Government; regionally through the health management team; and at the district level via council health management teams. Rounding out the core partnership were implementing organizations with expertise in obstetric care and reproductive health care ; an evaluation partner (U.S. Centers for Disease Control and Prevention); and donors (with major funding from Bloomberg Philanthropies and Fondation H&B Agerup).The partnership met regularly to review progress and plans, including monthly meetings convened by the Regional Medical Officer. The Program had a very strong stakeholder engagement strategy; all key stakeholders, including the health providers and the community, were regularly consulted before any new intervention was implemented. All meetings to disseminate evaluation findings were attended by government officials and health providers, and their feedback informed Program improvements. It is worth noting that when the decision to focus on Kigoma was made, both implementing organizations established offices there and relocated staff, and Bloomberg Philanthropies brought on a Tanzanian program manager to coordinate the effort from Kigoma. The presence of partners locally allowed for constant communication and collaboration with local government and health facility staff, a deeper understanding of the local needs and context, and the building of trust with local communities. Furthermore, the Program was able to form an administrative and technical structure that, over time, built the capacity of the regional and council health management teams (R/CHMTs) to provide operational, technical, and logistical support to promote sustainability.The presence of partners locally allowed for constant communication and collaboration with local government and health facility staff, a deeper understanding of the local needs and context, and the building of trust with local communities.Total donor support for the Program, across all regions over 13 years, was approximately US$44 million. The vast majority of funding went to implementation activities and partners in Tanzania. While Bloomberg Philanthropies and Fondation H&B Agerup contributed most of the funds, the Program also received funding for discrete programmatic components from Blue Lantern Foundation, Merck for Mothers, Svenska PostkodStiftelsen, and the Swedish International Development Cooperation Agency (Sida). The Program operated within the public health care system, and as such, additional costs were borne by the Tanzanian government . A detailed cost analysis is not included in this article; the external funding amount is provided to give donors and implementing organizations an idea of what it costs to support an initiative of this nature.availability of high-quality maternal and reproductive health services; (2) to improve and sustain access to maternal and reproductive health services; and (3) to create and sustain demand for maternal and reproductive health services (The Program evolved over 3 phases: Phase 1 (2006–2012), Phase 2 (2012–2015), and Phase 3 (2015–2019). Within each phase, the interventions implemented can be categorized into 3 broad strategies: (1) to increase and sustain the services . These iservices . By the ,,–,The phased approach allowed for gradual expansion of interventions and coverage. While each phase had distinct areas of focus, the program was nevertheless a continuum with later phases building on earlier phases. Cutting across the Program was the collection of evaluation data, including at the population level, where possible. These data served 2 related purposes: (1) to track progress; and (2) to shape the program's strategy through the identification of gaps. Phases 2 and 3 arose in response to evaluation findings that suggested changes and/or new interventions. The different types of evaluations that were conducted are described further in This phase largely focused on expanding the supply and quality of CEmONC, with an emphasis on expanding women's access to obstetric surgery. Specifically, 6 health centers were upgraded by constructing operating theaters and providing equipment and supplies. Three hospitals that served as referral sites for the upgraded health centers received critical renovations, supplies, and equipment. Housing was built for health providers as a recruitment and retention mechanism.,Simultaneously, associate clinicians and nurses underwent intensive 3-month competency training in CEmONC or anesthesia. The practical and theoretical curriculum was originally developed by the Ifakara Health Institute and endorsed by the MOHCDGEC.During the Program's first phase, availability of CEmONC was expanded by upgrading health centers.First evaluation efforts (2010–2011) included a mixed-method approach that documented the operational performance and outcomes in program-supported facilities.,,,This phase was marked by 3 major programmatic enhancements. The first was more robust, systematic, facility- and population-level evaluation data to gauge impact . EvaluatThe second programmatic enhancement emerged through a new funding commitment made by Bloomberg Philanthropies to support FP globally. Incorporating FP services was logical given the large unmet need for modern contraceptives and the estimate that eliminating this need could reduce the annual global number of maternal deaths by an additional 27%.Integrating FP and postabortion care services into the Program was logical given the large unmet need for modern contraceptives and that reducing this need could help reduce maternal mortality.All 6 health centers supported by the Program received minor renovations as well as equipment and supplies, and health providers across various cadres were trained to provide FP and CPAC. Seven additional health centers were selected and supported during Phase 2, with upgrades and training for the full package of services: CEmONC, FP, and CPAC. Efforts to further improve and to maintain quality of care through supportive supervision and clinical audits continued and were augmented by using the client-oriented, provider-efficient approach;The third programmatic enhancement focused on building demand for health services. Findings from the 2013 health facility assessment and pregnancy outcomes evaluations revealed that, while access to CEmONC services had improved, key indicators remained low, including the population-level institutional delivery rate (48.8%), met need for obstetric care (44%), and cesarean delivery rate (2.6%).This phase coincided with the decision to wind down efforts in Morogoro and Pwani and ramp up efforts in the Kigoma region. At this point, the Program established operational targets to improve the institutional delivery rate, met need for emergency obstetric care, and the modern contraceptive prevalence rate, all aligned with government targets.The Program adopted the government's operational targets to improve institutional delivery rate, met need for EmONC, and modern contraceptive prevalence rate.Accordingly, this phase was marked by 4 programmatic enhancements that had several benefits: (1) an expanded geographic reach, covering almost all of Kigoma's 2 million inhabitants; (2) strengthened referral systems; (3) improved newborn health outcomes, which had not been an explicit focus for the Program but lagging indicators compelled action; and (4) a person-centered, improved health care experience, bolstering demand for services. At the same time, the Program continued to support demand creation with a third mass-media campaign and further support for community health workers. Reaching young people was a challenge, so the team partnered with a local youth-led organization to provide FP information and to mobilize young people to access FP and CPAC services in supported health facilities; efforts were made to make facilities more youth-friendly. Community-based activities were also supported by the mass media campaign, and health education sessions were used to dispel myths and misconceptions about services. The evaluations initiated in Phase 2 continued and new evaluations were introduced in Phase 3 (described further later). The process of phasing out direct Program support and handing over the Program to the government was integrated into all aspects of Phase 3 and included building the capacity of the R/CHMTs to provide facilities with mentorship and in-service training.Decentralize Emergency Obstetric Care, FP, and CPAC. The first program enhancement was further decentralization of emergency obstetric care, FP (particularly provision of long-acting contraceptives to expand women's method choice), and CPAC to dispensaries, which are much more numerous and accessible. CDC evaluations showed that dispensaries were the most used level of facility for preventive services and delivery care. These findings aligned with the government's national strategy to improve maternal and reproductive care in primary health facilities. In total, 67 dispensaries were supported through infrastructure upgrades, training, and supportive supervision. All 67 were upgraded to provide FP, of which 35 were supported to provide CPAC; within this group, 18 were supported to provide some of the lifesaving interventions required for basic EmONC . The same criteria used for the selection of health centers in Phase 2 were used to select dispensaries.Strengthen Referral Systems. While strength-ening service delivery at the dispensary level further expanded women's geographic access, it was also important to strengthen referral systems for obstetric complications. For the Program's second enhancement during this phase, the team worked with communities, providers, and government officials to design and enable context-specific referral pathways to reduce delays in women reaching EmONC services. The focus was on developing local solutions: creating detailed referral plans in communities and facilities, establishing community-managed funds to cover the cost of transport , age 24 years. The mother of 3 was in labor with her fourth child at the Gwarama dispensary near her home. Her health provider realized her labor was not progressing and decided to refer her to Nyanzige health center in Kakonko district, one of the upgraded health centers offering comprehensive emergency obstetric and newborn care (CEmONC).The problem was transport. Nyanzige is 15 km from Gwarama, and the catchment area's only ambulance was not working.I was scared and thought I was going to lose my pregnancy or die because there was no possibility of getting the ambulance. We had no money in the house and my husband didn't contribute to the emergency fund when the village leaders asked him to contribute. —ShamiraWhile everyone in the community was asked to participate in the fund, the funds were available to all families, including those who were unable to contribute.Her health provider went to the village chairman who asked the emergency fund committee to release the funds to cover the cost of hiring private transport. At the time of Shamira's obstetric emergency, the fund in Gwarama had more than 247,000 TZS (about US$95) in reserve, of which 25,000 TZS was used to transport her to the CEmONC center at Nyanzige.bodaboda driver (motorcycle) arrived and quickly brought Shamira to Nyanzige health center, where she had a cesarean delivery.The The community emergency scheme fund saved my life and the baby. Without it, I could have died. —ShamiraImprove Newborn Health Outcomes. To complement the extensive work done to improve the quality of intrapartum services for women, and to respond to evaluation results showing persistently high perinatal deaths, the Program's third enhancement during this period was focused on newborn care. This included introducing Helping Babies BreatheImprove the Health Care Experience. Over time, as the technical/clinical quality of services improved and the Program looked to attract more women to facilities, it began to focus on strengthening the nonclinical elements of quality of care . This new area of work, the fourth enhancement, was informed by a new evaluation method: interviews with health providers and with women being discharged  in Kigoma, from 303 to 174 per 100,000 live births . The insThese favorable maternal and neonatal outcomes were complemented by significant increases in current contraceptive use—particularly the use of long-acting, reversible contraceptives and other modern methods among married women, which rose by 35% (from 15.6% to 21.0%). Consequently, the unmet need for contraception declined by 11% (from 39.2% to 35.1%).Favorable maternal and neonatal outcomes were complemented by significant increases in current contraceptive use.Our experience in Kigoma demonstrates that decentralizing high-quality CEmONC, FP, and CPAC in remote, low-resource settings is both feasible and effective and can be considered in places with similar contexts. Here we describe 4 critical lessons learned for governments, donors, and implementing organizations working to reduce maternal mortality.First, multistakeholder partnerships are critical. Where resources are limited, no one stakeholder can effectively address a complex problem like maternal mortality in a high-quality, comprehensive, and sustainable manner. A major strength of the Program was the collaboration between all levels of government, implementing partners, evaluation partners, funders, health providers, and the communities of Kigoma. These relationships deepened over more than a decade and were built around a shared commitment to improving maternal and newborn health. The government played a central role in setting the strategy, and all partners were committed to keeping Program interventions within the confines of the public health care system, thus avoiding the creation of unsustainable parallel systems.[The Program] approach has worked because they went to the people and came up with what the people actually wanted before implementing the project…. We will sustain the achievements.A major strength of the Program was the collaboration between all levels of government, implementing partners, evaluation partners, funders, health providers, and the communities of Kigoma.In the last 4 years of the Program, Bloomberg Philanthropies brought on a Tanzanian program manager who was based in Kigoma and fostered an environment of collaboration, knowledge sharing, and coordination. In retrospect, it would have been advantageous to bring on such a program manager from the start.A second lesson learned is the importance of increasing both the supply of high-quality maternal and reproductive health services and the demand for these services. Initially, the Program was focused on increasing the number of health facilities capable of providing EmONC, based on the assumption that better availability of high-quality care would result in increased use of services. Yet, the 2013 pregnancy outcomes evaluation showed this was not the case. It was at this point that the Program began its demand-creation activities—multilevel communication campaigns and the recruitment and support of community health workers to serve as trusted sources of information. Two critical factors that allowed the Program to expand in this way were the flexibility of the funders to make resources available for activities that were not initially anticipated and the engagement of technical experts to design locally resonant and evidence-based communications campaigns. Demand creation must rest on a foundation of well-functioning and high-quality clinical services if it is to be effective—driving people to services that are not available or effective can backfire—and demand-side activities need to be anticipated from the start of a program and implemented as soon as quality services are available.The third lesson is the importance of not only collecting robust monitoring and evaluation data but also being responsive in real time to what the data reveal. For example, the Program did not initially plan to carry out demand-generation activities, but these activities were incorporated based on interim evaluation data. It was also important to monitor the functioning of services over time, as service readiness  fluctuated.Although the Program did not initially plan to carry out demand-generation activities, these were incorporated in response to interim evaluations.–While an intention to sustain the program was always part of the approach, the fourth and final lesson learned is the importance of developing a deliberate, structured sustainability strategy. The following domains played a key role in ensuring the Program's sustainability: (1) political support; (2) funding stability; (3) partnerships; (4) organizational capacity; (5) program evaluation and adaptation; and (6) communications. Specifically, the Program's foundation for sustainability included: implementation by Tanzanian teams, as opposed to teams from the Global North; embedding all interventions within existing government health system structures to foster strengthening from within; and working in partnership with all levels of government and in service of government plans and priorities. In the final 2 years of the Program, dedicated sustainability efforts were incorporated, including the creation of a regional mentorship team, budget advocacy, and the nurturing of both political and community-based champions committed to maintaining the Program once donor funding ceased. It was important to expand the partnership to include people and organizations who had political advocacy experience and knowledge of government budget processes. Only 2 budget cycles could be supported before the Program concluded. In hindsight, this activity should have started even sooner to mobilize sufficient domestic resources to sustain and scale the Program. When developing the sustainability strategy, Program partners looked to the global health literature for guidanceThe Program demonstrated that reducing maternal and perinatal mortality through the decentralization of lifesaving health services can work, and with sufficient resources and technical expertise, it could be a feasible approach in places with similar contexts. It is important to note that task sharing of obstetric surgery was already well accepted and supported in Tanzania at the start of the Program and may not be a strategy that can be quickly adopted in other countries. At the same time, the Program was constrained by external structural factors which were beyond the scope of this Program to address, such as shortages of human resources ; pharmaceutical and medical supply stockouts; and social determinants that affect women's health throughout Kigoma. Collaboration with different government agencies and civil society organizations focused on addressing these structural factors might have allowed the Program to achieve more; it is a sobering reminder that health programming does not operate in a vacuum. Siloed approaches to development are limited in the impact they can have.The Program was constrained by external structural factors; a sobering reminder that health programming does not operate in a vacuum.The multifaceted, 13-year Program in Kigoma made important progress toward improving the availability, access, and utilization of high-quality maternal and reproductive health services, resulting in significant reductions in maternal and perinatal mortality. By embedding the Program within the existing health system, and through the efforts made to build local capacity, the improvements are likely to be sustained. A follow-up evaluation in Kigoma in the coming years will explore the longer-term impact of the Program and, along with the implementation lessons described in this article, will provide critical information for others interested in replicating the Program and continuing the effort to save the lives of mothers and babies worldwide.


Introduction Burnout rates for emergency medicine residents are high. One intervention and initiative to enhance wellness and address burnout is the resident retreat. Retreats have multiple formats and are often designed with an emphasis on social events. This longitudinal retreat curriculum for a three-year residency training program was designed emphasizing rest, a step away from what is familiar, and reflection. MethodsIndividual resident retreats were designed for each year of postgraduate training. The agenda for each is organized and intentional. Activities focused on personal well-being, self-reflection, team building, professional development, and physical activities are coupled with topics unique to class year roles and responsibilities. Retreats are held away from the hospital establishing a separation from the workplace.ResultsThe retreat program has been sustainable for almost decades with trainees evaluating it highly. Faculty and residents enthusiastically participate in the program and consider it a fundamental part of the residency; 93.75% of residents surveyed strongly agreed that the retreats benefit their training while 94.2% strongly agreed that retreats increased their enthusiasm for training.ConclusionsAn emergency medicine resident retreat program focusing on unique elements for each post-graduate year is achievable and sustainable in an emergency medicine residency program. Over time, the retreat has become an integral part of the residency experience with positive experiences for both faculty and trainees. The Accreditation Council for Graduate Medical Education (ACGME) requires residencies to incorporate well-being into the clinical work environment as well as scheduling, and accessibility to mental health resources . AdditioFew reports exist on the successful implementation of a structured resident retreat program. In pediatrics, a retreat program at the University of Washington has evolved over 20 years to include curriculum components such as stress management, professional fulfillment attainment, and the management of feelings of incompetence during training . Using aAlthough up to 91% of program directors in emergency medicine report using retreats as a wellness initiative , only onThis work was originally presented at the 2015 Council of Residency Directors in Emergency Medicine Academic Assembly on April 14, 2015.This work received exemption from the IRB at the Icahn School of Medicine at Mount Sinai.To execute a longitudinal program with multiple retreats over the course of the academic year, it is critical to address multiple elements in the developmental phase: messaging, faculty involvement, agenda, location, finances, retreat timing, resident and faculty expectations. Program leadership must emphasize consistent messaging that retreats are not purely social and aim to achieve the objectives outlined above. Engaged and enthusiastic faculty serving as team members and facilitators is critical. Each retreat’s agenda incorporates some elements consistently: personal check-ins , self-reflection questions , physical activities , professional development activities targeted to the postgraduate year , wellness topics , and community building Tables -4. RetreBased on years of collective leadership experience and reflection on the specific experiences of each post-graduate year, the program leadership designs the agendas to emphasize stressful situations and contributors to burnout unique to that year. The faculty wellness champion and program leadership reassess the agenda each year for appropriateness and relevance based on the current training environment. For messaging consistent with clarity, health, and wellness, we design the one-day retreats as alcohol-free. While we allow alcohol on the overnight retreat, consumption is de-emphasized and neither funded nor provided by the faculty or residency program.The program requires resources  and departmental leadership support, without which it will not succeed. The location should minimize distractions, have outdoor space for activities, and serve as a peaceful respite, especially for urban residencies. Residents must leave the work setting to create a mental separation from the hospital. We choose faculty homes for single-day retreats, and a retreat center for the one overnight retreat in the PGY2 year. This longer and more comprehensive retreat is strategically placed in the middle of the three-year program. Doing so infuses energy and renewed dedication to training at a time when most residents begin to run out of steam; the novelty of internship is over and the completion of training seems far away and daunting.We hold class-specific retreats throughout the year, always including the weekly protected conference time: PGY-1 in the winter to address seasonal challenges and burnout associated with that time of year, PGY-2 in the autumn to mark the midway mark for their residency, and again in the spring as a transition to senior year, and PGY3 in the spring preparing for graduation and the transition to academic or community practice. The retreat team  reviews the agenda and identifies facilitators for each session. Residents are protected from clinical duties beginning overnight before the retreat until the morning after the retreat by other residents in the program. The tradition of retreats and benefit to each resident for their own relief of clinical duties allows for the sustainability of this model. The post-retreat protection from clinical shifts following completion of the agenda allows for protected time for socialization and class bonding. To get the most out of the experience, participants are asked to prepare and begin to enter the retreat mindset ahead of the event. The residents journal ten minutes after each shift for two weeks prior to the retreat. We offer limited guidance on the process and assure residents that they will not be required to share their journal entries. We provide a standardized burnout inventory for self-assessment prior to the retreat used by the residents for self-reflection prior to the event. Our first retreat was in 2005. Five years of annual program evaluation data using Likert scale assessments (2012-2013 and 2015-2017) has demonstrated the achievement of our objectives. Over this five-year period, 205 surveys were administered (45 residents each year) and 115 returned (56.1%); 93.75% of residents strongly agreed that the retreats benefitted their training, while 93.50% strongly agreed that retreats increased their enthusiasm for training and served as a useful intervention for goal setting. And 94.25% of trainees strongly agreed that the retreat program aided them in their current resident roles and helped them prepare for future responsibilities and careers; 94.75% strongly agreed that the retreat experience improved unity and mutual respect amongst peers. Finally, 91.75% of residents strongly agreed that the program enhanced their awareness of the importance of compassion and humanism in medicine.Anecdotally, both resident and faculty participants have reported that the retreats allowed them to refresh and refocus. Many faculty members attend repeatedly, feeling that they get as much out of the program as they give to it. Graduates who have remained on the program’s faculty are often the first to volunteer as facilitators. The retreats have a cumulative effect moving from guarded discussions in the PGY-1 year to greater and deeper sharing of challenges, goals, and experiences in the PGY-2 and PGY-3 years commensurate with the development of a culture of support, safety, and camaraderie.The overarching need to offer protected time and space for trainees to step away from daily responsibilities, recommit to core values, and gain new insight and inspiration is critical in graduate medical education. In a recent survey, emergency medicine has shifted to become the specialty with the highest degree of burnout . Many heThese undertakings require monetary and explicit support from the sponsoring department. Additionally, other trainees must value the program in order to accept schedule modifications to accommodate colleagues in other classes to attend their sessions. From a participant standpoint, trust in the program’s mission and process are crucial. The more skeptical of the retreat program and/or the less vulnerable and open the participants are during group discussions and guided reflection activities, the less successful the overall impact of the program will be. While the activities vary, a universal theme year to year is an emphasis on returning to the goals and values that initially attracted the residents to medicine, integrated with their current experiences in training. We see this process as an antidote for the burnout caused by a loss of meaning in work that occurs during training for many residents. The goal is to remind residents why they chose this arduous path and to provide avenues for them to reclaim those goals and values.The retreat program is constantly evolving. We use feedback and experience from each retreat to improve subsequent ones. We trial new experiences including the involvement of a mediation expert, and the use of mental health practitioners for focused discussions on the trauma that emergency physicians experience. These thoughtful retreats are critical in establishing a meaningful wellness program and have been widely successful in our program. Our goals for next steps involve coaching to help residents incorporate the skills they gain on retreats into their daily lives and to encourage regular access to mental health care to facilitate more lasting wellness.Using a standardized curriculum across years of training, an emergency medicine retreat program is both sustainable and well-received. Each year of training presents different challenges for residents, which may contribute to decreased job satisfaction and increased rates of burnout. A protected social experience for residents can positively impact training, address challenges of professional identity, build community, and foster skills development for trainee well-being in emergency medicine.


Popliteal swelling is a common complaint seen in the practice of orthopaedics. Although imaging is useful to aid in the diagnosis of popliteal swelling pre-operatively, definitive diagnosis is often obtained post-operatively through histopathological report of the swelling. Baker’s cyst arises medially and hence usually spares the posterolaterally located neurovascular bundle until it becomes larger in size. A thrombosed aneurysm can mimic that of Baker’s cyst on computed tomography (CT) imaging in view of its location and the absence of contrast within the lesion. Diagnosis of a popliteal swelling with neural or vascular compression is not as straightforward and surgeons should be well aware that intra-operative findings may differ from diagnosis made pre-operatively. Meticulous exploration is pertinent in identifying the origin of the swelling and structures related to it. MRI imaging of the swelling should be done pre-operatively whenever possible. The developing swelling may cause compression to the popliteal neurovascular bundle with symptoms such as tibial or common peroneal neuropathy, resulting in gastrocnemius muscle atrophy, pseudothrombophlebitic syndrome, and rarely arterial compression with claudication of the lower extremity2. Many times, even with a thorough history and examination, it is difficult to ascertain the type of popliteal swelling. Although imaging is useful to aid in the diagnosis of popliteal swelling pre-operatively, definitive diagnosis is often obtained post-operatively through histopathological report of the swelling. Therefore, during the attempt to remove a popliteal swelling, meticulous exploration is pertinent in identifying the origin of the swelling and structures related to it.Popliteal swelling is a common complaint seen in the practice of orthopaedics. They are routinely discovered in up to 38% of magnetic resonance imaging scans (MRIs) performed in the symptomatic kneeIn the following, we present an interesting case in our experience of managing a patient with popliteal swelling.We present the case of a 61-year-old Iban man with underlying polycythemia rubra vera and hypertension. He presented to a general practitioner with right calf pain for a month with claudication distance of 200m, the pain was relieved at rest and reduced when kept at a lower level. He was referred to our hospital for peripheral vascular disease of the right lower limb.On examination he was generally well with stable vital signs. Local examination of the right lower limb revealed a 4x3cm globular swelling at the popliteal fossa with a well-defined margin, smooth edges, no redness, not warm or tender, firm in consistency, not pulsatile, not reducible and mobile from side to side. Right popliteal pulse was not palpable with reduced pulses and monophasic Doppler over dorsalis pedis artery (DPA) and posterior tibial artery (PTA).3compressing part of the right popliteal artery and vein  with long segment non-opacification of the popliteal artery from the level of cystic mass within the popliteal fossa until the trifurcation at the level of the proximal tibia with distal reconstitution  and tibial neuropathy (22%) while isolated arterial compression is the least common phenomenon (7%)2. Other differential diagnoses includes ganglion cyst, meniscal cyst, adventitial cyst, synovial sarcoma and artery aneurysm.Baker’s cyst or popliteal synovial cyst is a valvular opening of the posterior capsule, high up on the medial side and deep to the medial head of the gastrocnemius. It is present in up to 40% to 54% of healthy adult knees, based on cadaveric studies3.Before the advancement of advanced imaging technique such as CT and MRI, combined imaging modalities were often used for the diagnosis of popliteal swelling. Olcott C 4th and Mehigan JT reported a case of Baker’s cyst compressing unto popliteal artery in 1986. Arteriography, arthrography and sonography were employed and initial diagnosis was cystic adventitial disease of the popliteal artery. However, intra-operatively they noticed a Baker’s cyst that was in continuity with the knee joint enclosing a severely inflamed popliteal arteryet al also reported a similar case as ours where they successfully differentiated Baker’s cysts from popliteal aneurysms with the use of musculoskeletal Doppler ultrasound which could visualise the aneurysm walls and its internal clots4. However, the technically demanding nature of musculoskeletal ultrasound limits its use. MRI has been shown as a reliable technique in characterising lesions around the knee and is suggested as the investigation of choice in the pre-operative workup of Baker’s cyst5.In our case, CT angiogram findings of a thrombosed saccular aneurysm mimic that of a Baker’s cyst in view of its location and the absence of contrast within the lesion. C. Chalmeta Verdejo Despite thorough pre-operative workup, cautious intra-operative exploration including identification of origin of the swelling is utmost important. Specimen taken should always be sent for histopathological examination. Long term follow-up is needed to monitor recovery of symptoms and to look for recurrence.In conclusion, diagnosis of a popliteal swelling with neural or vascular compression is not as straightforward as it seems. Surgeons should be aware that intra-operative findings may differ from diagnosis made pre-operatively. CT imaging (with/without contrast) might not be sufficient, and we suggest MRI imaging of the swelling pre-operatively whenever possible, especially in patients with risk of thrombosis such as artherosclerosis, chronic inflammatory disease and hypercoagubility state.


The purpose of this study was to analyze the relative importance and priority of what factors should be reflected in the administration to efficiently consider the needs of people with disabilities for the physical activity (PA) environment in South Korea. To achieve the purpose of the study, 32 experts  with more than 5 years of experience with PA for people with disabilities were asked to prioritize the factors that should be reflected in the PA environment. The questionnaire consisted of 4 factors in the upper-layer (H2), 8 factors in the middle-layer (H3), and 38 items in the low-layer (H4). The research instrument was composed of a pairwise comparison of decision elements to analyze the priority. For the analysis of the questionnaire data, the relative importance and priority were analyzed using Expert Choice 2000, a solution dedicated to priority analysis. The results are as follows. The relative importance of H2 was determined by programs, instructors, facilities, and information. In the relative importance among H3, the program type was determined as the highest factor in the program, and instructor expertise was determined as the highest factor in the instructor. The type of facility was determined as the highest factor in the facility, and the information provider was determined as the highest factor in the information. As a result of analyzing the priority of H4, it was found that the program within the sports facilities had the highest priority. Physical activity (PA) can be defined as any body movement generated by skeletal muscle that necessitates power expenditure . AccordiAccording to data from the 2020 National Survey on the Current Status of Participation of Lifetime Sports for Persons with Disabilities, conducted by the Korea Ministry of Culture, Sports, and Tourism , the parAlthough the participation in PA of individuals with disabilities has many advantages, it is very low compared to the 60.8% participation rate of people without disabilities in South Korea . HoweverIn South Korea, studies are continuing to identify the needs of people with disabilities to facilitate their participation in PA or to investigate factors that make it difficult for them to actively participate in PA ,13,14,15Since the 1990s, the Australian Government has launched several policies to increase the participation of people with disabilities in recreation and sports . Based oThe purpose of this study was to identify the priority for establishment of the PA environment for persons with disabilities by reflecting the needs of people with disabilities. The participants of this study selected 32 disabled PA experts who understood the purpose of the study and agreed to participate in this study. The participants consisted of 12 faculty members who majored in PA with more than 5 years of research experience and 20 administrators who had worked at the Korea Paralympic Committee for more than 5 years. The reasons why the participants of this study were selected as faculty members and administrators of the Korean Paralympic Committee were that they were key experts in planning and implementing the administration of PA for people with disabilities in South Korea. The purpose of the study was explained to the participants of this research, and the PA environment for people with disabilities that should be developed first to reflect the needs of individuals with disabilities was investigated. The demographic characteristics of experts participating in this study are in The study extracted the relative importance and priority using the priority analysis method ) to investigate which needs of the people with disabilities in the field of PA and experts’ thoughts should be reflected in the administration for PA environment for persons with disabilities. The questionnaire was constructed in the form of a pairwise comparison questionnaire for priority analysis . The AHPThe research instrument of this study was based on the results of a focus group interview  conducted by the pilot study  on the nFor the investigation of the study, the researchers first found two faculties based on PA for people with disabilities and two PA administrators in Korean Paralympic Committee. After that, the participants were secured by a snowball sampling method in which experts were introduced to other faculty members and PA administrators in Korean Paralympic Committee. A schedule was set with experts, and the purpose and contents of the study were explained to them. Since the pairwise comparison questionnaire is not a familiar questionnaire, the response method of the pairwise comparison was explained in detail. Participants in the study were asked to participate in the questionnaire, and the researchers collected it immediately after the questionnaire. In addition, the period of this study was 3 months from December 2021 to February 2022.The AHP was applied to analyze priorities for establishing the PA environment for people with disabilities. A hierarchical analysis is a method of calculating the relative importance between factors, and after identifying the hierarchical structure, priorities are selected through the analysis process ,28. The In the relative importance of H2, the program showed the highest ranking as follows, followed by the instructor, facility, and information. The weight of the program was derived 38.9%, instructor (34.5%), facility (17.7%), and information (8.8%). The CI of the experts’ responses was 0.07, indicating that the respondents’ perceptions of the questions met consistency. The results of the relative importance of H2 for the establishment of the PA environment for people with disabilities are in As for the relative importance of the program in H3, the type of program was the highest factor, followed by the content of the program. As for the degree of importance perception of priority, the weight for the type of program was analyzed as 79.6%, and the content of the program (20.4%). The CI of the experts’ responses was 0.001, indicating that the respondents’ perceptions of the questions met consistency. The results of the relative importance of the program among H3 are in As for the relative importance of the instructor in H3, the expertise of the instructor was the highest factor, followed by the competency of the instructor. As for the degree of importance perception of priority, the weight for the expertise of the instructor was analyzed as 73.1%, and the competency of the instructor (26.9%). The CI of the experts’ responses was 0.001. The results of the relative importance of the instructor among H3 are in As for the relative importance of the facility in H3, the type of facility was the highest factor, followed by the operation of the facility. As for the degree of importance perception of priority, the weight for the type of facility was analyzed as 76.1%, and the operation of the facility (23.9%). The CI of the experts’ responses was 0.001. The results of the relative importance of the facility among H3 are in As for the relative importance of the information in H3, the provider of information was the highest factor, followed by the content of information. As for the degree of importance perception of priority, the weight for the provider of information was analyzed as 74.1%, and the content of information (25.9%). The CI of the experts’ responses was 0.001. The results of the relative importance of the information among H3 are in The results of the relative importance of low-layer  by H3 were analyzed for the establishment of PA environment for persons with disabilities.As shown in As for the results of the relative importance of H4 by the content of the program in H3, the weight for programs by type of disability was 30.2%, inclusive  programs (16.8%), rehabilitation exercise programs (16.4%), program by sports events (16.2%), programs by age group (12.5%), and home training programs (8.0%). The CI of responses of the experts in this study was 0.01. The explanation of H4 by the program in H3 is in As shown in As for the results of the relative importance of H4 by the competency of instructor in H3, the weight for understanding disability and human rights education were 36.2%, teaching method education by type of disability (33.4%), safety education for PA (15.4%), and practical education for each sport event (15.1%). The CI of responses of the experts in this study was 0.02. The explanation of H4 by the instructor in H3 is in As shown in As for the results of the relative importance of H4 by the operation of facility in H3, the weight for education on understanding of disability for all employees and users was 26.4%, promotion of facilities and programs (26.1%), participation in sports program vouchers (19.9%), accept and correct complaints (15.4%), and operation of health counseling office (12.3%). The CI of responses of the experts in this study was 0.01. The explanation of H4 by the facility in H3 is in As shown in As for the results of the relative importance of H4 by the content of information in H3, the weight for information about the location and program of the sports facilities was 37.6%, health information to motivate PA participation (23.2%), sports club information about people with disabilities (22.0%), and information about the center for physical fitness and health measurement (17.1%). The CI of responses of the experts in this study was 0.01. The explanation of H4 by the information in H3 is in The results of the priority of H4 were analyzed for the establishment of the PA environment for individuals with disabilities. There was the priority of 1st to 40th of all H4. The priority of 1st to 40th of all H4 is in The aim of the study was to determine the relative importance and priority for the establishment of the PA environment for persons with disabilities by 32 experts with more than 5 years of experience with PA for people with disabilities. This study analyzed the relative importance and priority of establishing the PA environment based on the opinions on the PA of persons with disabilities offered in the pilot study. The relative importance and priority of establishing the PA environment for people with disabilities were analyzed by AHP. The discussion based on the results of the study was as follows; first, the results of the relative importance of H2 for the establishment of the PA environment for persons with disabilities was the rankings of program, instructor, facility, and information. The program was chosen as the highest factor in H2 to establish the PA environment for individuals with disabilities. However, there are no various PA programs for people with disabilities in South Korea. It may be helpful to motivate people with disabilities for participating in PA . In bothSecond, the results of the relative importance of the program in H3 were the type of program and content of the program. The results of rankings of the relative importance of H4 by the type of program in H3 were programs within sports facilities, sports or exercise clubs, programs of public outdoor facilities, and non-face-to-face programs. The results of rankings of the relative importance of H4 by the content of the program in H3 were programs by type of disability, inclusive programs, rehabilitation exercise programs, programs by sports event, programs by age group, and home training programs. The highest item of H4 by the type of program in H3 was the programs within a sports facility. There are various PA programs  for individuals without disabilities in more than 1070 facilities and swimming facilities in South Korea. However, the PA programs  for people with disabilities are only played at about 70 sports facilities in South Korea . These pThird, the results of the relative importance of the instructor in H3 were the expertise of the instructor and competency of the instructor. The results of rankings of the relative importance of H4 by the expertise of instructor in H3 were instructor who has 2 or more certificates, instructor for persons with disabilities, instructor who has a disability, instructor for each sport event, instructor for all. The results of rankings of the relative importance of H4 by the competency of instructor in H3 were understanding disability and human rights education, teaching method education by type of disability, safety education for PA, practical education for each sport event. The highest item of H4 by the expertise of instructor and competency of instructor in H3 were the instructor who has 2 or more certificates related to PA and understanding disability and human rights education. The professionalism  of PA instructors who know the characteristics of people with disabilities and PA is very important due to the activation of PA for individuals with disabilities . A studyFourth, the results of the relative importance of the facility in H3 were the type of facility and operation of the facility. The results of rankings of the relative importance of H4 by the type of facility in H3 were public sports facilities for persons with disabilities, dedicated sports facilities for persons with disabilities, private sports facilities for persons with disabilities, sports facilities by sports events for persons with disabilities, public sports facilities, use of school sports facilities, and neighborhood simple sports facilities. The results of rankings of the relative importance of H4 by the operation of the facility in H3 were education on the understanding of disability for all employees and users, promotion of facilities and programs, participation in sports program vouchers, accept and correct complaints, and operation of a health counseling office. The highest item of H4 by the type of facility and operation of the facility in H3 was the public sports facilities for persons with disabilities and education on the understanding of disability for all employees and users. As mentioned earlier, sports facilities for persons with disabilities in South Korea are insufficient compared to sports facilities for people without disabilities . SeveralFifth, the results of the relative importance of the information in H3 were the provider of information and content of information. The results of rankings of the relative importance of H4 by the provider of information in H3 were city and province sports association for people with disabilities, government, community, sports facilities for people with disabilities in the local community, and welfare center for people with disabilities. The results of rankings of the relative importance of H4 by the content of information in H3 were information about the location and program of the sports facilities, health information to motivate PA participation, sports club information about people with disabilities, and information about the center for physical fitness and health measurement. The highest relative importance of H4 by the provider of information and content of information in H3 was the city and province sports association for people with disabilities and information about the location and program of the sports facilities. The studies of Pia  and LyusSixth, the results of the priority of H4  were the programs within sports facilities, instructor who has 2 or more certificates related to PA, sports or exercise clubs for individuals with disabilities, programs of public outdoor facilities, instructor for persons with disabilities, instructor who has a disability, public sports facility for persons with disabilities, education on understanding of disabilities and human rights, instructor for each sport event, teaching method education by type of disability and so on. The highest priority of H4 for the establishment of the PA environment for persons with disabilities was the programs within sports facilities because there was a lack of sports facilities for people with disabilities, but also programs for individuals with disabilities in South Korea . AccordiTherefore, these findings demonstrated that the programs, instructors, facilities, and information are all necessary for the successful establishment of the PA environment for individuals with disabilities. However, it will be possible to save time and to establish an effective PA environment for persons with disabilities based on the results of the relative importance and priority presented in this study.There are several limitations. First, this study is difficult to generalize because it was limited to specific participants  in South Korea. Therefore, future studies should be conducted using data from various participants . Second, the participants of this study were only Korean people with disabilities. Therefore, the establishment of the PA environment for people with disabilities according to cultural differences was not considered. Therefore, future research should be conducted in consideration of the PA environment for individuals with disabilities recommended by the world association for adapted PA or WHO. Third, this study analyzed the priority that should be reflected in the administration for the establishment of the PA environment for persons with disabilities, but there are no specific administrative plans presented in this study. Therefore, there is a need for a study that specifically suggests administrative plans that reflect the needs of individuals with disabilities and the opinions of experts.The purpose of this study was to analyze the priority of what factors should be reflected in the administration to efficiently consider the needs of persons with disabilities for the PA environment in South Korea. To achieve the purpose of the study, 32 PA experts were asked about the factors that should be reflected in the PA environment first through the questionnaire in the pairwise comparison format. The conclusions shown through the hierarchical analysis are as follows; first, the relative importance between H2 was determined by program, instructor, facility, and information. Second, in the relative importance among H3, the type of program was determined as the highest factor in the program, and the expertise of the instructor was determined as the highest factor in the instructor. The type of facility was determined as the highest factor in the facility, and the provider of information was determined as the highest factor in the information. Third, the results of analyzing the priority of H4, it was decided as the program within a sports facility had the highest priority.


Extracellular vesicles (EVs) are tissue-specific particles released by cells containing valuable diagnostic information in the form of various biomolecules. The characterization of EVs released by kidney grafts during normothermic machine perfusion (NMP) may present a promising avenue to assess graft status before transplantation.We phenotyped and determined the concentrations of EVs in the perfusate of 8 discarded expanded-criteria donor human kidneys during 6 h of NMP. Perfusate samples were taken at 0/60/180/360 min and examined with nanoparticle tracking analysis and imaging flow cytometry (IFCM). Using IFCM, EVs were identified by their expression of common EV markers CD9, CD63, and CD81 (tetraspanins) in combination with either platelet endothelial cell adhesion molecule (CD31), pan-leukocyte protein (CD45), or carboxyfluorescein succiminidyl ester (CFSE) fluorescence.Nanoparticle tracking analysis measurements revealed the release of nanoparticles <400 nm into the perfusate during NMP. With IFCM, tetraspanin protein signatures of the released nanoparticles were characterized, and the majority (~75%) of CFSE+ EVs were found to be CD81+, whereas ~16% were CD9+ and ~8% CD63+. Correlation analysis of concentrations of identified EV subsets with crude donor characteristics and NMP viability characteristics revealed significant correlations with cold ischemia time, donor age, and renal flow.Our findings demonstrate that discarded expanded-criteria donor kidney grafts release distinct EV subsets during NMP. Because these subsets correlate with well-established indicators of transplant outcome, EVs might represent new potential candidates for assessment of kidney graft quality.  Combined, this has forced the transplant community to (1) investigate new methods of organ preservation aimed at reducing ischemia-reperfusion injury and (2) to develop tools to evaluate transplant kidney quality.The shortage of available grafts, the increasing number of patients on the waiting list, and the general aging of the population have led to an increased use of expanded-criteria donor (ECD) grafts as well as grafts procured from donation after circulatory death (DCD).6 Because metabolism is activated, NMP offers the possibility to assess graft status before transplantation through monitoring of the perfusion dynamics and analysis of biomarkers in the perfusion fluids.8The most recent development in organ preservation is normothermic machine perfusion (NMP). In contrast to hypothermic machine perfusion (HMP), NMP aims to restore cellular metabolism and function to the organ, which is achieved through the circulation of a warm, oxygenated red blood cell-based solution through the organ before transplantation.9) involved in cellular communication.10 They express surface markers and carry a “cargo” (eg DNA/RNA/lipids/proteins11), both of which are thought to be indicative for the status of its cell of origin. EVs are excreted by virtually all cell types and are considered an excellent, stable biomarker platform as their cargo is protected from fragmentation and degradation by the lipid bilayer.12 In transplantation, levels of (human) donor-specific EVs in animal models have been shown to be associated with acute rejection of the allograft.14 Additionally, micro RNA, RNA, and proteomic profiling of EVs obtained from kidney preservation fluids15 or the urine of kidney recipients17 suggest that EV analysis might enable kidney health assessment and prognostication in kidney transplantation.Potential candidates for the assessment of graft status are extracellular vesicles (EVs). EVs are lipid bilayer membrane structures –based methodology23 to identify, phenotype and determine the concentration of EVs ≤400 nm in diameter released by discarded human kidney grafts during NMP. We show the identification of distinct EV subsets based on their tetraspanin profile in combination with the detection of esterase activity, platelet endothelial cell adhesion molecule (CD31), or the pan-leukocyte protein (CD45). Additionally, in the absence of kidney function, we perform a correlation analysis of the identified EV subsets with crude donor and NMP viability characteristics to explore the potential clinical implications of the identified EVs.Previously, our group was able to quantify the release of nanoparticles (such as protein aggregates and EVs) by ECD kidneys during NMP.Ethical approval (number B19.019) for experiments with discarded donor kidneys was granted by the Medical Ethical Committee of the Leiden University Medical Center and University Medical Center Groningen. Research consent was obtained from the relatives of all donors before organ retrieval.24 Kidneys were subjected to subsequent NMP when the cold ischemia time (CIT) did not exceed 24 h at arrival.The included kidney grafts (N = 8) were procured from deceased donors according to the Dutch national guidelines and were deemed untransplantable because of procurement-related factors or factors determined before retrieval (specified in Table Perfusate samples were drawn before (0) and after 60/180/360 min of NMP, centrifuged at 3700 rpm at room temperature, and the supernatant was stored at −80 °C.Size distribution and concentration of nanoparticles within the perfusates were measured with the Malvern Panalytical NanoSight NS300 and analyzed with nanoparticle tracking analysis (NTA) software version NTA 3.4 Build 3.4.003. Samples were diluted in 0.2 µm filtered phosphate buffered saline until 20–60 particles were in the field of focus during acquisition and 10 videos of 15 s were recorded with camera level 11 and analyzed with detection threshold 5.23 and detailed in SDC, http://links.lww.com/TP/C460, Materials and Methods; Sample Labelling.Perfusates were stained with monoclonal antibodies (mAbs) and carboxyfluorescein diacetate succinimidyl ester (CFDA-SE) as extensively described in our previous work25: buffer only, buffer with reagents, unstained samples, isotype controls, and detergent treatment, which aims to disrupt the membranous structure of EVs thereby allowing discrimination between biological and artificial events. Detergent treatment was performed by adding 20 µL of a 10% (V/V) TritonX-100 detergent to the samples followed by 30 min of incubation at room temperature before acquisition.To ascertain EV measurements the following controls were applied, as recommended by the MIFlowCyt-EV frameworkx; Luminex). Settings as extensively described in our previous work23 and detailed in SDC, http://links.lww.com/TP/C460, Materials and Methods; Acquisition were used.All samples were acquired on an ImageStreamX MkII instrument  populations in unstained and single stained samples, and arbitrary fluorescent intensities were converted into equivalent molecules of fluorescence (ERF) values based on previously published calibration data.23 Lower and upper gating area cutoffs were defined as 677–112,201 ERF for BV421; 35.40–3776 ERF for carboxyfluorescein succiminidyl ester (CFSE); 206–14,770 ERF for phycoerythrin; and 6.40–123 ERF for allophycocyanin.Data analysis was performed using Amnis IDEAS software (version 6.2). To ensure the analysis of EVs we (1) selected all particles with side scatter intensities ≤900 a.u., and (2) identified and excluded coincidence detection by counting the number of fluorescent spots within the pixel grid for each event acquired; events showing multiple spots were excluded from the analysis.http://www.rstudio.com/) version 1.1.463. Statistical significance between EV concentrations and binary data was determined through two-sided t-tests and 95% confidence intervals with unpaired data. Linear correlations with continuous variables were examined using the Pearson correlation method. R2 values ≥0.6 and P values <0.05 were considered significant.Statistical analysis was performed using R version 4.0.2 and RStudio  within the perfusate before contact with the kidney . Total particle concentrations were observed to increase over time during NMP: 1.96E10 ± 7.21E8/ 2.54E10 ± 7.85E8/ 3.06E10 ± 6.27E8 objects/mL at 60, 180, and 360 min, respectively. Average particle size was established to be <400 nm irrespective of the time of sampling.To study whether discarded kidneys release nanoparticles during NMP, perfusate samples drawn at 0/60/180/360 min were measured with NTA to determine the particle concentration and size distribution Figure . We obseFigure S1, SDC, http://links.lww.com/TP/C460.Next, we stained the perfusate samples of 8 NMP kidneys with CFDA-SE and an anti-tetraspanin antibody mixture (anti-CD9/anti-CD63/anti-CD81) labeled with allophycocyanin and measured the samples with IFCM. CFDA-SE is converted to CFSE by intravesicular esterases and was used to discriminate EVs from contaminating agents such as lipoproteins. Identification and validation of single EV measurement by IFCM are presented in For the stained samples, we observed CFSE and tetraspanin single-positive—but very few double-positive (<70 events)—fluorescent background events in perfusate samples drawn before exposure to the kidney (T0). Samples collected after 60/180/360 min of NMP showed increases in fluorescent events across all 3 populations . Detergent treatment was applied on each sample after initial acquisition to discriminate between vesicular and nonvesicular events  samples before detergent treatment.First, concentrations of fluorescent objects before and after detergent treatment were compared for each time point. For CFSE single-positive objects we observed a ~69%/72%/76% reduction in concentration after detergent treatment at T60/T180/T360, respectively . Comparing the mean concentration of tetraspanin single-positive events to the mean concentration of tetraspanin and CFSE double-positive events revealed ~4/5/6—fold differences at 60/180/360 min of NMP respectively—indicating that less CFSE-positive EVs were detected as NMP progressed.Taken together, these findings indicate that (1) kidneys release EVs during NMP and (2) different subpopulations (based on tetraspanin expression in combination with the absence/presence of CFSE) can be identified using IFCM.Following the identification of EVs based on tetraspanin expression, we examined the tetraspanin distribution on the released EVs by staining the NMP samples with CFDA-SE and one of the individual components of the antitetraspanin antibody mixture at a concentration equal to that used within the mixture. We observed that CD81+ EVs represented ~86% and ~74% of single and double-positive fluorescent events, respectively, across the time points analyzed  despite high specificity of the mAbs as indicated by isotype controls , and high specificity as indicated by isotype controls  or CD31  on the CD81+ EVs. We performed double staining of the perfusates with anti-CD45 or anti-CD31 in combination with anti-CD81 and analyzed each fluorescent population. For the CD45 single-positive events, ~52% of the events were still present after detergent treatment (data not shown) and no significant increases were observed during NMP when compared to baseline perfusates (T0 – 2.7E5 ± 1.8E4 objects/mL), and an isotype background of 6.39E5 ± 4.67E5 objects/mL. For CD81 and CD31 double-positive events, we observed >99% reduction of fluorescent events after detergent treatment, ~950/ 1130/ 1100 – fold difference in objects/mL at each time point of sample drawing compared to T0 (2.2E4 ± 1.9E4 objects/mL), and an isotype background of 3.28E4 ± 1.53E4 objects/mL —but not after 180 and 360 min—of NMP , or kidneys that were deemed transplantable after 6 h of NMP K3 and K5), when analyzing each kidney individually  immune responses.29 However, although EVs are subject to intensive biomarker studies in various fields,31 little is currently known regarding EV release by kidney grafts during NMP and its association with kidney status.A major benefit of machine perfusion is that it allows for the assessment of kidney quality before transplantation through the analysis of biomarkers (such as EVs) in the perfusion fluid.22 we found that the majority of released nanoparticles were <400 nm in size irrespective of the time of sampling and that total particle concentrations increased as NMP progressed. Using IFCM we found that EV concentrations significantly increased during the first 60 min of NMP and that concentrations remained relatively stable during the remainder of the NMP procedure (up to 6 h). We reason that the observed stabilization of EV concentrations is due to the establishment of an equilibrium between EV biogenesis and breakdown during NMP and/or uptake by  cells of the kidney. These findings may contribute to the debate regarding optimal NMP perfusion times: since EV release is considered an active process,32 release dynamics during NMP may be dependent on the metabolic status of the kidney graft.In this observational study, we examined and characterized the release of EVs by discarded human ECD kidneys during NMP. In line with our previous findings,33 Given that the majority of detected EVs released during 6 h of NMP expressed the CD81 epitope 5A6, the fusion of these CD81+ EVs with recipient B cells may have a dampening effect on B cell signaling as the addition of extra CD81 onto the B cell membrane may affect CD81-CD19 dissociation kinetics. Additionally, it has been shown that allograft-derived EVs bearing intact donor major histocompatibility complex molecules (CD63+ and CD9+CD81+ EV subsets) are able to cross-decorate and activate alloreactive recipient B cells in a mouse skin-transplant model.29 In a human setting, this cross-decoration might be facilitated by CD81+ EVs.Examination of the tetraspanin profile on the released EVs revealed that the majority of detected EVs expressed tetraspanin CD81. Recently, CD81 has been shown to serve as a regulator of B cell signaling through complex formation with CD19 at the plasma membrane. Upon B cell activation CD19 dissociates from CD81 whereas in naïve B cells CD81 (epitope 5A6) is complexed by CD19.20 . Moreover, the released particles were determined to be <400 nm  and therefore were assumed to consist largely of exosomes. Exosomes form through inward budding of the membrane of early endosomes (forming multivesicular bodies in the process), which eventually fuse with the cell plasma membrane, releasing its content into the extracellular space.34 Consequentially, it is hypothesized that not all exosomes necessarily bear parental cell surface markers—which may explain why >90% of CD81+ EVs were found to not be colocalized with either anti-CD31 or anti-CD45.When determining the origin of detected CD81+ EVs, we found only marginal colocalization of CD81 with endothelial and hematopoietic markers CD31 and CD45. However, part of the CD81+CD31+EV may represent CD45+EVs derived from monocytic origin. Additionally, the low percentages of colocalization may be influenced by the usage of mAbs targeting extravesicular epitopes26Correlation analysis of CFSE+EVs and CIT revealed negative correlations for EVs bearing tetraspanins CD9 or CD63 (during the first 60 min of NMP)—but not CD81. Since CFDA-SE needs intravesicular esterases to acquire its fluorescent properties (CFSE+), these negative correlations may be explained by (1) the negative impact of CIT on cellular (and thus vesicular) enzyme (esterase) activity or (2) reduced release of EVs containing intravesicular esterases as a consequence of CIT. Diminished correlations of CFSE+ and CD9+/CD63+ double-positive EVs with CIT were found after 180 and 360 min of NMP—which might be explained by the restoration of cellular metabolism during the course of NMP.35 We demonstrate that the release of CD31+ single-positive EVs  is positively correlated with renal blood flow, and consequently inversely correlated with intrarenal vascular resistance. As it is well-known that the endothelial cell layer of microvessels is a key modulator of vasodilation through the synthesis and release of vasoactive substances,36 CD31 single-positive EVs might be indicative for kidney quality before transplantation. Recently, to aid clinicians in determining kidney quality during NMP, a scoring system has been developed based on the macroscopic appearance and thresholds of renal blood flow and urine output.35 The presence of different EV subsets (such as CD31+ EVs) might be added—after extensive validation in transplanted cohorts—to this scoring system. Potential identification of other EV subsets and their correlation with kidney function post KTx may provide insight into (1) kidney quality and (2) the specific compartment(s) of the kidney which are injured/functioning sub-optimally before transplantation. However, in the current work, correlation analysis of the other identified EV subsets with donor kidney characteristics or NMP viability markers did not result in any statistically significant correlations; either when analyzed as a group or when examining EV release for each kidney individually. Although K3 and K5 were determined to be of sufficient quality to be transplantable after 6 h of NMP, we did not observe any trends that differentiated these kidneys from the other ECD kidneys during NMP for any of the markers examined in this study.As the perfusion pressure during NMP is fixed, the perfused kidneys autoregulate their blood flow according to intrarenal vascular resistance. The inverse correlation between low renal blood flow and high intrarenal vascular resistance during NMP has been described in the literature and has been associated with increased vascular injury or interstitial edema.37It must be noted that no direct inferences could be made between kidney quality before transplantation (or transplant outcome) and the released EV subsets as none of the kidneys studied were actually transplanted. Additionally, as these kidneys represent ECD kidneys the reported concentrations and observed correlations might be different for non-ECD kidneys. Another limitation of this study is the small sample size: the heterogeneity among the ECD kidneys with respect to for example, cause of donor death and the type of organ storage might (further) impact the amount and/or subsets of EVs released. However, the observed correlations of different EV subsets with CIT and donor age during the first 60 min of NMP do indicate that EV release is related to well-established indicators of kidney quality: both CIT and donor age are known to be detrimental to kidney quality/transplant outcome.In conclusion, our findings demonstrate that discarded human ECD kidney grafts release different EV subsets during NMP and that their release is correlated with well-established indicators of kidney quality such as CIT, donor kidney age, renal blood flow and intrarenal vascular resistance. The identification, quantification and phenotyping of kidney-derived EVs released during NMP may represent a starting point to study the role of EVs as potential biomarkers for kidney graft quality before transplantation. How and if the identified (and other) EVs subsets are correlated with kidney function posttransplantation will be the focus of future research.The authors would like to thank the members of the PROPER Consortium (PROlonged ex vivo normothermic machine PERfusion for kidney regeneration) for setting up the study, provision of the normothermic machine perfusion samples and input in research design: Dr Ian Alwayn, Dr Rutger Ploeg, Dr Dorottya de Vries, Dr Volkert Huurman, Jason Doppenberg, and Asel Arykbaeva from the Leiden University Medical Center; Dr Henri Leuvenink, Dr Robert Pol, Dr Cyril Moers, Tim Hamelink, Veerle Lantinga, and Leonie van Leeuwen from University Medical Center Groningen; and Dr Robert Minnee from the Erasmus Medical Center, Rotterdam, The Netherlands. Additionally, the authors would like to thank Manou van Alphen for her assistance with NMP sample measurements with IFCM.