Events of spring 2020—the COVID19 pandemic and re-birth of a social justice movement—have thrown disparities in disease risk, morbidity, and mortality in sharp relief. In response, healthcare organizations have shifted attentions and resources towards equity, diversity, and inclusion (EDI) issues and initiatives like never before. Focused, proven equity-centered skill and mindset development is needed for healthcare professionals to operationalize these pledges and stated aims.This article highlights program evaluation results for this Clinical Scholars National Leadership Institute (CSNLI) specific to EDI. We will show that CSNLI imparts the valuable and essential skills to health professionals that are needed to realize health equity through organizational and system change.Initial cohort of 29 participants in CSNLI, engaging in the program over 3 years through in-person and distance-based learning offerings and activities.The CSNLI is a 3-year, intensive leadership program that centers EDI skill development across personal, interpersonal, organizational, and systems domains through its design, competencies, and curriculum.A robust evaluation following the Kirkpatrick Model offers analysis of four data collecting activities related to program participants’ EDI learning, behavioral change, and results.Over the course of the program, participants made significant gains in competencies related to equity, diversity, and inclusion. Furthermore, participants demonstrated growth in behavior change and leadership activities in the areas of organizational and system change. Results demonstrate the need to center both leader and leadership development on equity, diversity, and inclusion curriculum to make real change in the US Healthcare System.The online version contains supplementary material available at 10.1007/s11606-022-07529-x. Inequities, rooted in structural racism through historical policies and practices, are continued through current-day norms of our social and health systems and institutions, and are perpetuated by the myth that responsibility for an individual’s health outcomes lies solely within that individual’s sphere of control. The design and approaches of patient care in the American healthcare system further reinforce that myth. While the healthcare workforce still has the trust of the communities they serve, there is a particular responsibility and opportunity for that workforce to address inequities.While health inequities have long been recognized, events of 2020—the COVID19 pandemic and re-birth of a social justice movement—have thrown disparities in disease risk, morbidity, and mortality in sharp relief. From the COVID mortality rates in black and brown population to the designation of high-risk front-line “essential jobs” commonly filled by underrepresented minorities and immigrants, current health, social, and economic events have exposed the racism that permeates our country’s systems. Persistent and pervasive health inequities in the United States (US) begin at birth—starting with which babies are more likely to be carried to term and celebrate their first birthdayIn the wake of spring 2020, healthcare professional organizations and health professional schools have drafted and posted equity pledges noting the roots of structural racism, espousing the need for diversity, and committing to social justice. New positions for chief diversity officers have been created. Curriculum committees raced to find ways to include diversity, equity, and inclusion topics in undergraduate and graduate medical education. New committees have been formed to address diversity and inclusion at institutions. These changes are often championed by a small group of people who already recognize the need for change, leveraging new organizational enthausiam. However, for durable institutional shifts to occur, we need leaders throughout health systems and institutions with the knowledge, attitudes, and skills to dismantle structures that maintain health inequity and establish new structures that promote health equity.This paper describes our findings from the first cohort of an interprofessional leadership development program that uses an equity-centered approach to drive curricular components. We describe program evaluation results which illustrate how curricular competencies translate into participant learning, behavioral change, and ultimately organizational and community impact to advance health equity.5 Interprofessional teams apply to CS with a proposed Wicked Problem Impact Project (WPIP) that serves as their action learning project during the program. The goal of the WPIP is to generate positive community impacts by advancing health equity, promote sustainability, and to the extent possible, achieve scalability. Enrolled teams focus on a wide variety of health equity issues, from mental and physical health to healthcare deserts to community systems that support health. All projects are listed at the CSNLI website . CS supports successful WPIP implementation by fostering and strengthening participants’ skills as teams and as individuals.In 2015, the Robert Wood Johnson Foundation funded the Clinical Scholars (CS) National Leadership Institute, a leadership development program for clinicians that weaves the concepts of leadership, equity, diversity, and inclusion together in a robust 3-year curriculum. The CS mission is to “develop adaptive leaders from all health disciplines to extend their influence and impact through transformative leadership training centered in equity, diversity, and inclusion.” CS uses an equity-centered approach to teach leadership strategies to healthcare professionals, imparting skills to impact health inequities in their communities and organizations.Personal, Interpersonal, Organizational, and Community & Systems  with skill sets in the areas of equity, diversity, and inclusion (EDI) . The competencies are grouped into four domains: see Fig. . As a se6Over the course of the 3-year program, participants are challenged to learn, try on, and then fully step into the mindsets that help them grow from being individual contributors into being leaders of teams, communities, and systems. Sessions, activities, self-reflections, and assignments create opportunities in which participants learn, practice, and apply the skills, behaviors, and attitudes. Formats vary and include didactic lectures, small- and large-group discussions, case study debriefs, practice scenarios, book studies, reflective writing activities and simulation experiences. The leadership and EDI curriculum components exist both in tandem and in unison to provide the full CS experience, at times interweaving fully. A more detailed description of the pedagogical theory and curricular details can be found elsewhere.8 the socioecological model,10 and the social capital framework12 guide CS evalulation. Together, these theories suggest that an individual  is influenced by their interpersonal relationships, environment, community, professional network, and broader society. Our evaluation design recognizes and embraces this complexity and uses Kirkpatrick’s Four-Level Training Evaluation model 15 to frame implementation of a mixed-methods and multilevel evaluation approach. A detailed description of the CS evaluation approach is presented elsewhere.16 For the purposes of this paper, we explore Kirkpatrick's model levels 2-4, as defined below:Level 2: Learning—participants’ gains in knowledge, self-efficacy, skills, and attitudes of EDI-focused competenciesLevel 3: Behavior—translation of gained knowledge and skills into tangible EDI-relevant actionsLevel 4: Results—EDI-relevant impacts on participants’ individual leadership, organizations, and communitiesSocial cognitive theory,Aligned with our evaluation framework, we describe four data collection activities and the related methods for analysis used to evaluate CS EDI learning, behavior, and results.19 In a more traditional “pre-test, training, post-test” evaluation design, there is concern of a confounding response shift bias when participants self-rate items at two separate timepoints. Response shift bias is when a participant’s internal frame of reference for the item being measured changes, likely as a result of the training they attended where they learned about said item. Evaluative comparisons of the two designs have shown that a retrospective pre-test method can be used to control for the response shift bias. This design asks the participant to self-rate items at a single timepoint but reflect back on the “pre-training” time.To assess change in eight EDI competencies, we used a retrospective pre/post-test design—an approach demonstrated to reduce biases commonly associated with self-report data collection. see example below). Participants provided two ratings for each item—one rating for 6 months prior (retrospective pre-rating) and for current day . We assessed four dimensions of each competency—knowledge, attitude, self-efficacy, and intention to use across the four competency domains.We collected data at three timepoints . At each timepoint, we asked participants to rate an item for each dimension for each competency on a 7-point Likert scale, with one being the lowest level of agreement with the item and seven being the highest level of agreement, based on their levels 6 months prior and now  rubric.22Participants completed behavioral statements describing how they used each of the 25 CS competencies in their work during their time in CS as Online Wisdom Logs (OWLs). Submissions via Canvas Learning Management SystemWe used an inductive approach in initial analysis of OWLs to identify common themes of how participants reported using each of the eight EDI competencies. An evaluation staff member read through the statements submitted for each EDI competency and summarized the type of use described . Use types were categorized into thematic groups,  for each competency. We then calculated frequencies to determine the number of examples within each competency.23 is a participatory qualitative process that collects participants’ stories describing their most significant change during or resulting from participation in a program. MSC provides detailed data about how participants use the training concepts and competencies in their personal and professional lives, thus providing a more nuanced understanding of program outcomes. As part of their final report of WPIP project activities, each participant was asked to submit a story of what they felt was the most significant change they experienced during the program by responding to the following prompt:Describe in one or two paragraphs the most significant change that has resulted from your involvement with the Change Leadership Initiative. Please describe the situation, task, actions, results, or other details you can relate to the change.The Most Significant Change (MSC) evaluation approach to assess training outcomes26 An initial codebook based on CS goals grew as codes emerged as key themes from the first round of coding and were focused specifically on segments coded under “equity, diversity, inclusion.”27Stories were coded in three rounds and incorporated thematic and phenomenological analysis methodologies.Data was collected regarding participants’ leadership activites via multiple strategies: direct communication from participants to program staff, targeted Google alerts, an online submission form and through annual review of CVs/resumes. Participants were encouraged throughout the 3-year program and at regular intervals after graduation to submit leadership activites. The types of activites collected include writing, training, and advocacy activities; achieving changes in public, organizational, and/or tribal policy; and formal recognition . Participants were also encouraged to report activites outside of the specific categories listed above. We report here activities tracked from September 2019 through April 2021.A deductive analysis approach identified EDI themes present in submitted leadership activities. CS staff assigned an activity type  to each item based on the selection made by the participant, or after reviewing the definition of each activity type, highlighting those that specifically discussed topics related to EDI competencies. We then calculated frequencies to determine the number of EDI activities per activity type.The sample consists of 27 of the 29 participants in the first cohort of CS enrolled in the program from Fall 2016 to Fall 2019 (Table ) shows changes in each EDI competency measured at the beginning (baseline) and end of CS. Each of the seven rings in the radar chart represents a value on the Likert scale of response options. The light gray shading indicates the average rating of a particular competency among Cohort 2016 Fellows at baseline. The dark gray shading indicates the average rating of a particular competency at endpoint. This graphic provides a visualization of the size of growth in each competency from baseline to endpoint. Endpoint competency scores were significantly higher than baseline  directly referenced an EDI issue Table . These aDespite arriving with a high level of EDI skills, CS participants made significant gains in competencies related to equity, diversity, and inclusion. Specifically, this mixed-methods, multilevel evaluation demonstrated significant growth in organizational, community engagement, and system change competencies with participants reporting behavioral examples and leadership activities demonstrating application and results in organizational and system change.33 Recently, the de Beaumont Foundation identified eight domains needed to address our current complexity: systems thinking, change management, persuasive communication, data analytics, problem solving, diversity and inclusion, resource management, and policy engagement.34 The field of leadership development has acknowledged we need skilled leaders to develop new solutions that better match the volatile, uncertain, complex, and ambiguous nature of our current society and that embrace the higher goal of advancing health equity. Our findings extend the leadership literature through providing program, competency, and curriculum descriptions for a comprehensive, robust program that demonstrates the ability of participants to acquire the skills to advance health equity, and to apply those skills to achieve organizational and system change.“Boundary Spanning Leadership” is the ability to span vertical, horizontal, stakeholder, demographic, and geographic boundaries in service of a higher goal.in principle but were met with some realizations of their own bias or lack of awareness through the discovery process of the work. The curriculum was designed with this flexibility in mind and was able to alter the pace when greater processing was needed and capitalize on group support to help individuals continue moving forward on their journey. The intentional interweaving of evidence-based curriculum with flexible application exercises allows intensive leadership development programs such as this to be accessible to a wide range of audiences. As organizations continue to make pledges of institutional commitment to the values of equity, diversity, and inclusion, they need to develop and invest in leaders who can affect the changes embodied in their statements. Leadership journeys can begin with personal or interpersonal level skills, but leadership development programs can and should build on this foundation to ensure leaders have skills in organizational, community engagement, and system change critical to advancing health equity. Still, these leaders will require institutional endorsement.The high level of proficiency in EDI skills of participants entering the program is likely reflective of both evolving societal understanding and appreciation for EDI and the program application requiring explicit articulation of a project to advance equity in a complex area in health. While strong capabilities in the personal, interpersonal, organizational, and system domains are important for all leaders, our finding of greater gains and impacts at the organizational and system levels that stem from our equity-centered framework shows that community engagement and system change competencies are crucial for healthcare system leaders to advance health equity. In addition, we acknowledge this type of program is unique in leadership development programs in both intensity and duration. However, the history of health inequities is long standing and efforts to this point have been insufficient in mitigating centuries of health disparities. We believe to move the needle in advancing health equity new frameworks and deep commitment, such as this program, are needed. While participants in our program on average entered with high levels of EDI interest, we did see heterogeneity in initial skills as would be expected, given that this journey both is quite personal and has no defined endpoint. We found that “buy-in” to these concepts varies as well, given that some individuals agreed 35 define leader development as expanding the capacity of the individual, and “…leadership development as the expansion of a collective’s capacity to produce direction, alignment, and commitment.” CS offers both by including developmental learning experiences that increase both individual and collective capacity. Grimm et al.36 described the essential difference between developing leaders as a group of individuals and developing leadership. In developing, refining, and validating6 our equity-centered leadership approach, we have formulated ways to achieve both leader development and fostering leadership. Data here and across our dissemination of findings41 illustrate individual growth of participants and provide clear evidence of impact in organizations and communities alike as they function both as individuals and in teams to effect real and meaningful change. In the goal of advancing equity, individual development as a leader is a critical foundation and precursor to the form of collective, communal, and collaborative leadership that advances diversity, equity, and inclusion in organizations and communities.This work adds to the literature in distinguishing between leader development and leadership development. Van Velsor, McCauley, and RudermanAs in all research, our study has limitations. Our design does not provide a control group and we were not able to assess the gains in participants compared with those who did not have the opportunity to participate in CS. However, our robust evaluation uses both qualitative and quantitative data triangulated across multiple levels of evaluation, showing consistent results that add to the confidence in our findings. We also need to acknowledge potential selection bias. In CS selection criteria, we looked for individuals who were ready to develop skills to advance health equity. The high self-reported levels of EDI skills at baseline suggest our selection efforts were successful in reaching the intended audience. When assessing the impact of the program through the most significant change approach and in leadership activities, we intentionally avoided asking participants specific questions related to EDI to keep open the full range of submissions. If we had queried about specific EDI-related impacts, the data would likely have been even richer and more compelling with regard to the impact program participants are having in their respective systems. However, the approach used allowed participants to define what was most salient for them in their experience. Finally, our evaluation was not able to identify whether there were specific components of the training program that resulted in the greatest learning gains in participants.Leadership development will be critical to health-related organizations that seek to go beyond pledges of support for EDI. Our experience with an intensive leadership program that centers EDI skill development across personal, interpersonal, organizational, and systems domains demonstrates the potential to develop leaders who can create and sustain environments that advance health equity. The results presented here demonstrate healthcare professionals can gain significant and relevant skills to move beyond the level of self-growth and apply their newly acquired skills to impact organizations and communities in meaningful ways that advance EDI. The challenges before our nation are immense, yet our healthcare workforce is vast. Since healthcare professionals are trusted members of their communities, providing those professionals with equity-centered leadership models as a part of their career development could create significant and lasting effects for their institutions and communities and broaden the field of allies in the fight for health equity.ESM 1(DOCX 35 kb)


BCR-ABL1 and compared the results with reverse transcription quantitative polymerase chain reaction (RT-qPCR). We further investigated whether ddPCR could be used to determine TKI discontinuation in a clinical setting. Performance of ddPCR was evaluated using standard materials for BCR-ABL1, and a total of 197 clinical samples from 45 pediatric CML patients was included for comparison with RT-qPCR. ddPCR showed excellent analytical sensitivity with 0.001% international scale (IS) and linearity with R2 > 0.99 in log scale. BCR-ABL1 % IS results correlated well with those of RT-qPCR (R2 = 0.9435), however, they showed a moderate strength for agreement with a Cohen's kappa of 0.41 due to higher sensitivity of ddPCR. Among 45 pediatric CML patients, 42 were treated with first-line TKIs including imatinib  and dasatinib , and three patients that were started with imatinib were switched to dasatinib. When we evaluated whether follow-up samples fulfilled ABL1 copies ≥ 10,000 required for deep molecular response (DMR), all samples were acceptable by ddPCR, whereas 18% by RT-qPCR did not reached acceptable ABL1 copies. Moreover, 52 and 13% reached ABL1 copies ≥ 32,000 required for MR4.5 by ddPCR and RT-qPCR, respectively. Seven patients discontinued TKI and the median TKI treatment duration was 73 months prior to discontinuation. Prior to discontinuation, the median duration of sustained undetected BCR-ABL1 was 60 months. Two patients experienced loss of major MR (MMR) during follow-up and restarted dasatinib 5 months after discontinuation. They achieved MMR again and maintained better than DMR afterward. Results from those patients demonstrated that RT-qPCR did not match the need for adequate ABL1 copies for MR4.5 while majority of ddPCR could. Therefore, ddPCR was technically more acceptable to decide and monitor pediatric CML patients before and after TKI discontinuation.Lifelong treatment of pediatric chronic myeloid leukemia (CML) patients with tyrosine kinase inhibitors (TKIs) can affect their growth and development. For these reasons, clinical trials have explored the feasibility of TKI discontinuation in children with a sufficient TKI response. We evaluated the analytical performance of digital droplet PCR (ddPCR) to quantify  BCR-ABL1 MR4.5 and ≤ 0.0032% on the international scale (IS) is essential to select patients (Tyrosine kinase inhibitors (TKIs) are a cornerstone of successful clinical management of chronic myeloid leukemia (CML) patients. Since the introduction of TKIs as a treatment strategy in CML, prognoses have improved considerably not only in adult patients, but also in children , 2. Imatpatients .BCR-ABL1 monitoring was not only reliably detected in DMRs relevant to guiding treatment, but also helped to better identify patients prone to relapse after stopping TKI treatment (Reverse transcription-quantitative PCR (RT-qPCR) has been widely used for evaluating patient response to TKIs , 11. Howreatment , 14.Although pediatric and adult CML share common molecular pathogenesis and hematologic characteristics, CML studies in children and adolescents are different from those in adults , 15. DatBCR-ABL1 using RT-qPCR and ddPCR in pediatric CML patients treated with TKI. Subsequently, we evaluated the performance of ddPCR using reference materials and available clinical samples. Finally, we aimed to demonstrate the feasibility of ddPCR to determine TKI discontinuation and to monitor steady DMRs for pediatric CML patients by comparing the results with those of RT-qPCR.In this study, we quantified n = 30, 71%) and dasatinib . Three patients were started with imatinib and switched to dasatinib. The median duration of follow up was 48 months  for TKI treatment. Molecular responses (MRs) were monitored using RT-qPCR analysis at 3-month intervals and at 3- or 6-month intervals after major molecular response (MMR) was achieved. MR1, MR2, MR3 (MMR), MR4 (DMR), MR4.5, and MR5 are defined as the transcript ratio of BCR-ABL1/ABL1 being 10% or less, 1% or less, 0.1% or less, 0.01% or less, 0.0032% or less, and 0.001% or less, respectively, obtained from peripheral blood leukocytes on an international scale (IS)  morphology and cytogenetic and molecular genetic analyses . Among tale (IS) . All patBCR-ABL Quantification Kit  using an Applied Biosystems® 7500 Fast Dx Real-Time PCR Instrument  according to the manufacturer's instructions. We analyzed BCR-ABL1/ABL1 by ddPCR in addition to RT-qPCR after patients achieved MMR. In addition, 1,000 ng of total RNA was transcribed to cDNA by the Transcriptor First Strand cDNA Synthesis Kit  using a GeneAmp® PCR System 9700 . PCR was performed with a QXDx™ BCR-ABL %IS Kit  using a QX200™ Droplet Digital PCR System according to the manufacturer's instructions. The PCR reaction mix generated approximately 20,000 droplets per well by a Droplet Automated Droplet Generator , and PCR was performed using an Arktik™ Thermal Cycler . Data were analyzed by the QX200 Droplet Reader and QuantaSoft™ Software version 1.7.4 . Results were calculated based on raw data using QXDx™_BCR-ABL_Reporter_v.1.02 . The modification conversion factor value and minimum and maximum calibration qualities are supported by the manufacturer instrument. The absolute numbers of BCR-ABL1 and ABL1 copies were determined by Poisson statistics. Results were reported when the ABL1 copies were at least 10,000 per well.RT-qPCR was performed using 1 μg of total RNA with a Real-Q BCR-ABL1 negative clinical samples and certified reference material (CRM) with four levels of BCR-ABL1 mRNA ranging from 0.01 to 10% (10-fold), 1st WHO International Genetic Reference Panel for the quantitation of BCR-ABL1 translocation  containing freeze-dried K562 cells , and HL60 cells (BCR-ABL1 negative). Linearity was calculated using eight replicates of each concentration. Comparison between RT-qPCR and ddPCR was performed using data from 197 clinical samples.The analytical performance of ddPCR was evaluated using BCR-ABL1/ABL1 (% IS) by ddPCR was performed using polynomial and linear regression. Wilcoxon signed rank test was used to compare BCR-ABL1 and ABL1 copy numbers by RT-qPCR and ddPCR. The consistency of BCR-ABL1 detected vs. undetected and MRs between RT-qPCR and ddPCR were analyzed by Cohen's kappa and Chi-square test. Pearson's correlation analysis and linear regression were also performed to compare quantitative results, and a scatter plot was presented. All statistical analyses were performed using SPSS Statistics 20  and Microsoft Excel 2019  software.Linearity of R2 = 0.9988 in log scale . Results from ddPCR correlated well with those from RT-qPCR  .First, we evaluated the analytical performance using CRMs and found that ddPCR showed excellent sensitivity with 0.001% IS and linearity with og scale . The CV  <0.001) . MeanwhiBCR-ABL1, 136 of 197 results (69%) showed consistent results by RT-qPCR and ddPCR. Sixty-seven samples (34%) were both-positive and 69 samples (35%) were both-undetected. We found inconsistency in 61 samples, revealing a moderate strength for agreement with a Cohen's kappa of 0.41. The majority was ddPCR-detected but RT-qPCR-undetected , whereas only 8 samples (13%) were ddPCR-undetected but RT-qPCR detected. Because most inconsistent results were from patients after treatment, we compared the results according to MR. The comparison included all available samples for MR evaluation and showed a significant difference between the two methods (p <0.001 by χ2 test). We found inconsistent MR in 74 samples: 62 samples showed lower %IS by RT-qPCR, whereas only 12 samples did by ddPCR when comparing based on the cut-off for MR . When we evaluated whether those samples fulfilled ABL1 copies ≥ 10,000 required for DMR, all samples were acceptable by ddPCR, whereas 18% (n = 16) by RT-qPCR did not reached acceptable ABL1 copies. Among them, 46 and 12 samples (52 and 13%) reached ABL1 copies ≥ 32,000 required for MR4.5 by ddPCR and RT-qPCR, respectively.Next, we investigated the number of BCR-ABL1 by both RT-qPCR and ddPCR for at least 2 years. Six were treated with dasatinib and the other with imatinib. The median TKI treatment duration was 73 months  prior to discontinuation. The median age at TKI discontinuation was 20 years . Prior to discontinuation, the median duration of sustained undetected BCR-ABL1 was 60 months , and the median number of successive BCR-ABL1 measurements better than DMR was 9 . None of the RT-qPCR results showed ABL1 copies ≥ 32,000, while 55% of ddPCR results showed this level. TKI was discontinued with permission of patients and their parents. The BCR-ABL1 level was monitored every 2 months after discontinuation. The course of each patient can be seen in The achievement rate of MMR was 7% in the first 3 months, 31% at 6 months, and 50% at 12 months. Patients achieving DMR comprised 17% at 6 months, 29% at 12 months, and 40% at 18 months. The achievement rate of MR4.5 was 7% at 6 months, 24% at 12 months, and 36% at 18 months. Seven patients sustained undetected BCR-ABL1 results  under careful observation. One patient that suffered growth retardation has been catching up after TKI discontinuation. In addition, a condensed follow-up seemed to be necessary in pediatric CML patients after TKI discontinuation, which enabled us to evaluate patient status and to determine who needed to restart TKI at the right time. When compared the results in patients who maintained TKI more than 48 months, ddPCR revealed worse MR compared with RT-qPCR and provided more accurate information for TKI maintenance. We also found that RT-qPCR did not match the need for adequate s stable , 22. TheThe original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.This study was approved the Institutional Review Board (IRB)/Ethics Committee of the Catholic Medical Center, Seoul, Korea (IRB No. KC19SESI0235). It was conducted in accordance with the ethical guidelines and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.SK, JWL, BC, N-GC, and MK collected the clinical samples and reviewed the cases. YeK performed the experiments. YeK, JML, AA, JY, YoK, and MK interpreted the results and analyzed the data statistically. YeK, SK, N-GC, and MK wrote manuscript. The authors read and approved the final manuscript. All authors contributed to the study conception and design.This study was supported by Research Fund of Seoul St. Mary's Hospital, The Catholic University of Korea.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.


Furthermore, the participants had a higher Resilience index when they had completed the program, with a statistically significant difference from the pre-course mean . This non-technical skills training program was an effective method of improving emotional intelligence and resilience in nursing students. Therefore, its use is recommended as a psychoeducational strategy for training undergraduate nursing students, as it improves their personal and professional competencies, resulting in higher-quality care.There is a growing body of research on emotional intelligence and resilience in nursing students. However, there is little evidence of the development of these variables in intervention programs. This study aims to analyze the effects of a non-technical skills training program in emotional intelligence and resilience. Sixty students in the second year of Nursing Education from a Spanish public university completed this psychoeducational course. The pre-experimental design was longitudinal with pre- and post-intervention evaluation. The course consisted of 12 sessions of classroom education, three small-group workshops and a set of individual activities. Results in the emotional intelligence dimensions showed that Clarity (t = 3.10,  Promoting, establishing and maintaining health is a very great challenge in the nursing profession. These professionals hold an influential position in relation to the benefits derived from health, which demands strong dedication to their practice, performed in close proximity to patients and their families. In severe or more complicated patient care situations, nurses are exposed to a major risk of stress , which cEmotional intelligence enables complex processing of one’s emotions, guiding thought and action . AccordiPeople with high emotional intelligence have more confidence in themselves, are more optimistic and understand others better, which enables them to cope more successfully with environmental demands and pressures ,11. In tEmotional intelligence has also been associated with positive results of nursing students. Studies agree that high scores on emotional intelligence in samples of nursing students are related to better adjustment to university life ,20 and pDevelopment of resilience is important for mitigating stress related to continual exposure of nursing professionals to the emotional demands of relations with patients and their families and with other healthcare professionals . ResilieHowever, there are very few empirical studies on the effectiveness of emotional intelligence training programs for nursing students or professionals ,5, and tIn view of the results of the research above, the objective of this study consisted of evaluating the efficacy of a non-technical skills training program on emotional intelligence and resilience for nursing students. In contrast to the quoted earlier similar intervention studies, our training program combines both individual and group interventions aimed at a better understanding and management of emotions. In addition, our time intervention is longer than previous studies, improving an adequate non-technical skills development that needs more time and experience for their control. Lastly, we have provided a psychologically safe environment to nursing students during the training program, providing them with a shared belief that the team is safe for interpersonal risk-taking. Our main hypothesis was that emotional intelligence and resilience of university students would improve after participation in the program.This pre-experimental descriptive study had a longitudinal design with a single-group pre- and post-intervention evaluation. The research and reporting methodology followed STROBE-cross-sectional studies.The participants in this study were second-year undergraduate nursing students at the University of Almeria, a public university in Spain. A non-technical skills training program was completely integrated into the “Health Promotion and Safety” course in the second-year study plan for a Degree in Nursing. Participation in the study was offered to all the students and their acceptance was voluntary. A total of 129 students were enrolled in this course. At first, the sample was 111 students. Of these, 60 students completed the psychoeducational program in which non-technical skills training was included and answered the questionnaire afterwards. The study was carried out from October 2019 to January 2020.The non-technical skills training program consisted of a theory and practice course taking up matters related to emotions, emotion management and resilience as part of the second-year subject “Health Promotion and Safety”. The teaching strategies employed were general knowledge sessions on the subject of study with explanatory videos and case-solving; small-group work (18 students) with experiencing and role-playing. Finally, individual activities related to promoting resilience were scheduled to be done at home.The program was implemented by an instructor trained in teaching emotional intelligence and resilience. The students filled out a self-report questionnaire at the beginning (pretest) and at the end of the course (posttest).First, an ad hoc questionnaire was applied to collect sociodemographic and educational data , as well as a series of items for assessing the attitudes and evaluation of including work in non-technical skills in the practice training program. This was answered on a five-choice Likert-type response scale , where the participants could express how much they agreed with the items. Each item was written with little variations to adjust to the pre- and post-intervention measures. Specifically, they were asked about the importance of working on non-technical skills , evaluation of the weight of nontechnical skills in the undergraduate curriculum  and finally on the need to promote/widen these contents in the training planned for the degree .On the one hand, to evaluate the emotional intelligence we used the Trait Meta-Mood Scale (TMMS-24) by Fernández-Berrocal et al.  based onOn the other hand, to evaluate the resilience the Resilience Scale (RS) was used. This was a brief version validated by Wagnild  based onp-value near 0.05, the Vovk-Sellke maximum p-ratio or the maximum diagnosticity of a two-sided p-value was computed [First, frequency analyses were done of the students’ attitudes and opinions on practice programs that include non-technical training content as taken from their answers at the two measurement times (before and after program startup). To check the relationship between the study variables , bivariate correlation analyses were done for the two measurement times (pre and post). When the correlations had a computed ,48.The Student’s t for related samples was found to check for any variations in the emotional intelligence and resilience scores before and after participation in the program. The effect size was estimated by Cohen’s d  based onTo examine the reliability of the instruments used for data collection, McDonald’s Omega coefficient was estimated, following the proposal and indications of Ventura-León and Caycho . The GreThe study was approved by the Research Ethics Committee from the Department of Nursing, Physical Therapy, and Medicine from the University of Almeria (n° EFM-26/19). All the participants were informed of the study objectives and gave their written consent for participating in the study. Research followed the recommendations of the Helsinki Declaration.n = 44) women and 26.7% (n = 16) men, with mean ages of 20.91 (SD = 5.65) and 19.75 (SD = 1.69), respectively. Their prior healthcare training was: 80% had no training, and of the remaining percentage, 8.3% (n = 5) were certified nursing assistants, 5% (n = 3) were laboratory technicians, 3.3% (n = 2) both (nursing assistant and laboratory technician), 1.7% (n = 1) X-ray technician, and the 1.7% (n = 1) remaining had another university degree (Physiotherapy).The mean age of the sample was 20.60 (SD = 4.92). The sex distribution of the sample was 73.3% (n = 11) of the sample agreed and 81.7% (n = 49) strongly agreed with the importance of working on these skills. After participation in the program, 25% (n = 15) of the students agreed on the usefulness of the program in future care practice, and 71.7% (n = 43) strongly agreed.First, concerning the importance of studying non-technical skills in their degree coursework, before the program, 18.3% (n = 20) or strongly agreed  with it. After the program, 53.3% (n = 32) agreed and 40% (n = 24) strongly agreed with the need to continue working in this line.Concerning the perceived need for improving their non-technical skills, before participation in the program, most of them said they agreed  agreed and 55% (n = 33) strongly agreed that they were insufficient. After their participation in the program, 35% (n = 21) agreed and 56.7% (n = 34) strongly agreed, that more time should be devoted to this type of training for the degree.Concerning their opinion of the hours of degree education devoted to non-technical skills, 36.7% , and afterwards (38.3% agreed and 58.3% strongly agreed).First, the results of the correlations found (pre and post), between the emotional intelligence dimensions and resilience are shown in p = 0.046), so its diagnostic value was tested. p-ratio: the maximum diagnosticity of a two-sided p-value [p = 0.046 would lead us to reject the null hypothesis, however, it is only 2.6 times more probable under the best H1 than under H0.The positive relationship between the two dimensions of emotional intelligence (Clarity and Repair) and Resilience is maintained in both measurements (pre and post). Furthermore, the correlation between Emotional attention and Resilience was negative before participation in the program began, and after it ended, that correlation between the two variables was lost. The level of significance of this relationship, before the program was near 0.05 ( p-value ,48. In tThe statistically significant differences between the measurements before and after the non-technical skills training program are shown in The scores in the emotional intelligence dimensions, Clarity and Repair, increased significantly after participation in the program. Nevertheless, in Emotional attention, the differences between measurements were tendential. Participant Resilience was statistically significantly higher than the pre-program mean after completing the program.This study evaluated the efficacy of a non-technical skills training program in topics related to emotions, emotion management and resilience for undergraduate nursing students in Spain. There are not many studies analyzing these behaviors in intervention programs over time. The main results of the study have shown that after participation in the program, the students scored higher in the Emotional Intelligence dimensions of Clarity of feelings and Emotional repair. Similar results have been found in other studies evaluating emotional intelligence in university student samples, although with other measurement instruments ,5. Some According to the Four Branches Model formulated by Mayer and Salovey , our psyHowever, scores were statistically significantly above the pre-program scores on capacity for resilience at program completion. Intervention for resilience is important, as it can facilitate nurses’ resources for dealing with the effects of emotional dissonance in their work , enablinThe results of this study show that inclusion of a psychoeducational program in undergraduate nursing education is highly recommendable, as it would contribute to improving their personal and professional competencies, leading to high-quality care. Based on these findings, our study suggests the need to include training programs in non-technical skills in emotional intelligence and resilience in nursing education study plans to train students in coping more successfully with the challenges of clinical practice.Nonetheless, the evaluation of the effects of this program is based on short-term results, and it would be advisable to evaluate these variables over a longer period of time. Such measurements would enable decisions to be made on widening training in such non-technical skills to higher courses. Furthermore, future research could have an experimental design including a control group to be able to compare the results. Finally, these findings, are from a program for Spanish university students, and therefore, adaptation to other contexts are suggested so results can be generalized.Intervention programs on emotional intelligence and resilience for nurses are few at this time. The success of this non-technical skills training program could inspire other nursing schools to set up similar programs and contribute to the development of these personal competencies. Keeping in mind the complexity of the patient care environment, professors of nursing education who prepare students to promote health, should consider a focus on non-technical skills along with training in technical competencies.Therefore, the university environment may be an ideal context for increasing students’ emotional intelligence and resilience. The study plan of future nursing professionals should be directed and recognizing and valuing training in emotional intelligence and resilience by starting up effective programs that prepare the future nursing professionals to cope successfully with clinical practice.


Diagnosis of antiphospholipid syndrome (APS) requires the presence of a clinical criterion (thrombosis and/or pregnancy morbidity), combined with persistently circulating antiphospholipid antibodies (aPL). Currently, laboratory criteria aPL consist of lupus anticoagulant (LAC), anticardiolipin antibodies (aCL) IgG/IgM, and anti-β2 glycoprotein I antibodies (aβ2GPI) IgG/IgM. Diagnosis and risk stratification of APS are complex and efforts to standardize and optimize laboratory tests have been ongoing since the initial description of the syndrome. LAC detection is based on functional coagulation assays, while aCL and aβ2GPI are measured with immunological solid-phase assays. LAC assays are especially prone to interference by anticoagulation therapy, but strategies to circumvent this interference are promising. Alternative techniques such as thrombin generation for LAC detection and to estimate LAC pathogenicity have been suggested, but are not applicable yet in routine setting. For aCL and aβ2GPI, a lot of different assays and detection techniques such as enzyme-linked immunosorbent and chemiluminescent assays are available. Furthermore, a lack of universal calibrators or standards results in high variability between the different solid-phase assays. Other non-criteria aPL such as anti-domain I β2 glycoprotein I and antiphosphatidylserine/prothrombin antibodies have been suggested for risk stratification purposes in APS, while their added value to diagnostic criteria seems limited. In this review, we will describe laboratory assays for diagnostic and risk evaluation in APS, integrating applicable guidelines and classification criteria. Current insights and hindrances are addressed with respect to both laboratory and clinical implications. In the 1950s, multiple cases were reported about the presence of a circulating anticoagulant that inhibited the conversion of prothrombin to thrombin in patients with systemic lupus erythematosus (SLE), resulting in prolonged clotting times ,3,4,5. FAlong with the LAC phenomenon finding, the association of false-positive syphilis testing in patients with other infectious and autoimmune diseases drew attention ,12,13. IIn 1983, Harris et al. reported the development of a solid-phase radioimmunoassay for detecting antibodies against cardiolipin. They observed a strong correlation between anticardiolipin antibodies (aCL) and LAC, and a significant correlation between high aCL IgG/IgM levels and thrombosis . In the Since it became clear that antiphospholipid antibodies (aPL) were significantly associated with vascular thrombosis and pregnancy morbidity, the need for consensus criteria for APS resulted in 1999 in preliminary classification criteria for definite APS, named the Sapporo criteria . As reseThe term LAC comprises a heterogeneous group of autoantibodies, responsible for prolongation of phospholipid-dependent coagulation tests. LAC can be detected by different phospholipid-dependent coagulation tests. The most recent update of the ISTH guidelines on LAC detection recommends parallel testing of the dilute Russell’s viper venom time (dRVVT) and aPTT . dRVVT iBesides dRVVT and aPTT, other phospholipid-dependent coagulation assays are not recommended due to variability in reagent composition, poor reproducibility or limited commercial availability . The dilPerformance of LAC assays has to be validated or verified before implementation in routine practice. Part of the verification process includes testing of samples with known LAC potency. Ideally, properly stored and well-characterized LAC samples are used in the evaluation process ,29,69. TLAC measurement traditionally consists of a three-step procedure performed on platelet-poor citrated plasma: screen, mix, and confirm ,27. PlatThe screening step comprises testing with both dRVVT and aPTT reagents at low phospholipid concentration. As factor deficiency or inhibitors other than LAC can cause a positive screening assay, it has to be followed by a mixing and confirmation step for the assays positive in the screening procedure. This step-wise procedure can reduce costs, as this avoids unnecessary performance of the mixing and confirmation step if the screening step is not prolonged, although in daily practice, paired assays screening and confirmation assays are often performed simultaneously, followed by the mixing test in a next step. A positive screening test is followed by a mixing test and confirmatory test, irrespective the result of the mixing test .In the confirmatory step, an excess of anionic phospholipid is added to the test reagent, which reduces or neutralizes the inhibitory effect of antibodies causing the prolonged clotting time. In paired tests, usually dRVVT, where screen and confirm assays are performed in parallel, the result of the confirmation step is expressed as normalized LAC ratio [(screen patient)/(screen PNP)]/[(confirm patient)/(confirm PNP)], or as normalized percentage correction [(screen patient)/(screen PNP) − (confirm patient)/(confirm PNP)]/[(screen patient)/(screen PNP)] ∗ 100 ,29. In the mixing step, the screening assay is performed on a mixture of 1:1 patient plasma and PNP (screen mix). The mixing test is expressed as the normalized ratio [(screen mix)/(screen PNP)]. When the clotting time in the confirmatory assay is prolonged, meaning that no full correction is observed by adding excess phospholipids, an additional mixing step with the confirmatory reagents (confirm mix) should be performed ,29. The Integrated assays exist that perform all three steps in one procedure. In these assays, both screening and confirmation tests are performed concomitantly on patient plasma mixed with PNP and results are mostly expressed as the difference  between both tests. Paired tests perform both screening and confirmation in one procedure, meaning that the mixing step still needs to be performed when the screening step is positive .LAC interpretation requires determination of adequate cut-off values to determine positivity in all three steps. Preferably, laboratories determine in-house cut-off values using a sufficiently large population of healthy reference individuals (at least 120), determining the cut-off as 99th percentile after outlier rejection . Using aThe large number of 120 normal individuals to calculate adequate cut-off values hampers many laboratories, as illustrated in a survey from the ISTH showing that only 12% of participants who consider the 99th percentile use at least 120 healthy volunteers . An apprInherent to the test principle of phospholipid-based coagulation assays, LAC testing is prone to interferences.C-reactive protein interferes in vitro with aPTT testing through its affinity for phospholipids, leading to false-positive results of the LAC test. While this effect was not observed for the dRVVT assay based on in vitro experiments, this could differ between reagents and effect of CRP cannot be excluded for reagents using a different phospholipid composition ,76. IncrAnticoagulation treatment complicates LAC testing and interpretation by prolonging aPTT and dRVVT. LAC testing during anticoagulation treatment is discouraged ,27,29,68VKAs cause prolongation of aPTT and dRVVT through production of incomplete coagulation factors by inhibition of vitamin K-dependent gamma carboxylation of factors II (prothrombin), VII, IX, and X . This acUnfractionated heparin (UFH), LMWH and heparinoids mainly interfere by indirectly inhibiting thrombin and FXa action . Most dR® and DOAC-Remove®) to avoid DOAC interference in LAC testing [DOACs directly inhibit thrombin  or FXa  , with va testing ,102,103. testing ,105,106. testing ,105. In  testing ,101. The testing . The two testing . ResultsInformation on the patient’s anticoagulation status is mandatory for adequate interpretation of results. While aPTT, PT and thrombin time should be performed before starting LAC testing to have more information on the coagulation background of the patient, this is not fully conclusive because normal aPTT and/or PT do not exclude presence of DOACs or LMWH. Whenever the test results are suggestive of LAC, but there is no knowledge or doubt on the anticoagulation status, results should be reported along with warnings on the possible false positivity because of the unknown treatment status. Key messages on LAC measurement are summarized in Besides the drawback of interference on coagulation assays, LAC measurement is labor intensive and interpretation is complicated. Further search for functional assays, or other biomarkers measured with solid-phase immunoassay as alternatives for the established LAC assays should be encouraged.Interest in thrombin generation assays (TGAs), reflecting a significant part of the coagulation system with more information compared to clotting time based assays, is growing. TGAs measure thrombin formation in plasma after addition of tissue factor and phospholipids. Contrarily to classical coagulation assays, both procoagulant and anticoagulant processes are dynamically investigated, resulting in a thrombogram with multiple derivate parameters reported . TGAs caAntiphosphatidylserine/prothrombin antibodies (aPS/PT) measured by solid-phase assays have been investigated as surrogate marker for LAC (see further on).aCL and aβ2GPI are detected by solid-phase immunoassays, traditionally ELISA. The APS classification criteria indicate the measurement of aCL and aβ2GPI by standardized ELISA . Since tIn essence, assays used for aCL and aβ2GPI detection are based on the same immunoassay principle . An antiLarge heterogeneity in assay techniques, reagents, and calibrators leads to high inter-assay variability. Variability is observed both in qualitative (positive/negative) and quantitative (antibody titer) interpretation of aCL and aβ2GPI results, especially between ELISA and automated platforms using newer techniques such as chemiluminescence ,124,125.IgG aCL and aβ2GPI are more strongly associated with thrombosis and obstetric morbidity compared to the IgM isotype, independent of the solid-phase assay used ,127. BasIn analogy with LAC testing guidelines, the ISTH-SSC published guidelines for detection of aPL with solid-phase assays, focusing on the analytical aspects .Solid-phase assays need to be evaluated before implementation in routine practice. Because of the substantial inter-assay variability and lack of a gold standard, direct comparison of assays is not advised and local validation of its performance should be based on clinical and analytical criteria. Preferably, the association between solid-phase aPL results and clinical manifestations is evaluated ,118. UnfSerum or platelet-poor plasma can be used for aCL and aβ2GPI testing, provided that the assay specifications and cut-off values are verified for the sample type. Use of platelet-poor plasma for LAC testing is required to avoid false-negative results due to interaction of platelet-phospholipids and aPL. By extension, this reasoning could be made for solid-phase assays as well when using plasma. Therefore, current ISTH guidelines advise on use of serum (no specification to be platelet poor) or platelet-poor plasma  .Need for duplicate sample and quality control analysis in the same run is dependent on assay performance characteristics ,118. DupCalibration curves need to be determined in every ELISA run, or for every reagent lot in automated systems to reliably determine aPL titers. Recalibration can be warranted based on internal quality control results. Each calibration should be evaluated, and rejected when not meeting the manufacturer’s requirements or when the correlation coefficient between test values and target values is beneath 0.90 . There iCurrent APS classification criteria consider detection of aCL IgG or IgM to be significant if present in moderate to high titer, measured with a standardized ELISA. Moderate to high titer is defined as > 40 GPL or MPL, or > 99th percentile based on a reference population ,39. DeteStudies showed that higher titers of IgG aCL, but not IgM, are more associated with clinical APS events compared to lower titers ,140. IntInterference in immunological testing is assay dependent and known interferents should be specified in the product insert. If possible, the highest concentration not causing significant bias should be stated by the manufacturer, especially for rheumatoid factor and hemolysis/icterus/lipemia ,144. PreAPS is a rare disease with an estimated yearly incidence of 2 per 100,000 persons per year and a prevalence of 50 per 100,000 with similar incidence and prevalence in both sexes . The prePositivity in one of the criteria aPL  is sufficient for diagnosing APS in presence of a clinical criterion ,44, althInformation from aPL antibody profiles can be quantified by calculating a score for risk assessment. In 2012, Otomo et al. developed the antiphospholipid score (aPL-S) based on LAC and solid-phase aPL results in SLE patients with and without clinical APS manifestations. aPL-S was constructed with odds ratio-dependent values for clinical manifestations of each parameter individually. Variables in the aPL-S were different laboratory tests for LAC testing , aCL IgG/IgM, aβ2GPI IgG/IgM, and aPS/PT IgG/IgM with further discrimination between high and low/medium antibody titers for IgG antibodies, but not for IgM . The aPLIn contrast to IgG and IgM aCL/aβ2GPI, IgA antibodies are not included in the current APS criteria as the role of IgA aCL and aβ2GPI in APS was, and still is, not clear ,174,175.Multiple studies have demonstrated a significant relationship between occurrence of thrombotic events or obstetric morbidity and aPS/PT IgG/IgM. However, aPS/PT studies are very heterogeneous and should be interpreted with care ,184. aPSβ2-glycoprotein I consists of five homologous domains, with domain I bearing a cryptic epitope considered to be the target of pathogenic, clinically relevant aβ2GPI . Anti-doaDI IgG are often found with high antibody titer in patients with a triple-positive, high-risk aPL profile ,197,198,Other non-criteria antibodies are the subject of investigation for their value in APS, and especially for identifying SNAPS patients. Antibodies including those directed against phosphatidylserine (PS), phosphatidylethanolamine (PE), phosphatidic acid (PA), phosphatidylinositol (PI), vimentin/cardiolipin complex, annexin V, and annexin II are investigated. However, assays detecting these antibodies are currently poorly standardized and commercial availability is limited. Testing for antibodies against PS, PA, and PI shows potential for identifying certain obstetric SNAPS patients, but routine measurement is currently not recommended as there is limited added value compared to current criteria aPL. Antibodies against PE, vimentin/cardiolipin, and annexin V show potential to identify SNAPS patients but more research is needed to evaluate their potential role in diagnosis and risk stratification of APS ,204,205.All criteria aPL should be reported separately, but with an overall interpretation as the antibody profile determines the risk for clinical events in APS . AntibodLaboratory investigation of aPL for diagnosis and risk stratification of APS remains a challenge, both for clinicians and laboratory staff. All currently used aPL assays have their limitations. LAC testing is a labor-intensive procedure, prone to multiple sources of interference such as acute-phase proteins and anticoagulants. Strategies for circumventing anticoagulation interference are increasingly recognized. aCL and aβ2GPI testing can be performed by an extensive range of assays and platforms, resulting in large variation of results. LAC, aCL IgG/IgM, and aβ2GPI IgG/IgM analysis should be performed and interpreted in parallel as this increases diagnostic performance. Additional biomarkers such as aPS/PT and aDI demonstrate possibilities for confirming risk estimates. Interpretative reporting of aPL results should be provided by qualified laboratory professionals.


Surgical site infections (SSIs) are associated with readmissions, reoperations, increased cost of care, and overall morbidity and mortality risk. The National Healthcare Safety Network (NHSN) and the National Surgical Quality Improvement Program (NSQIP) have developed an array of metrics to monitor hospital-acquired complications. The only metric collected by both is SSI, but performance as benchmarked against peer hospitals is often discordant between the 2 systems. In this commentary, we outline the differences between these 2 surveillance systems as they relate to this potential for discordance. NHSN and NSQIP metric reports have often painted conflicting pictures of our hospital’s SSI performance as benchmarked against our peers. This discordance has raised questions about the validity of the SSI metric and has threatened to undermine the original intent of the surveillance endeavor, which is to improve care. Both inflated and deflated perceptions of performance can have undesired effects on patient safety (via misappropriation of resources) and on provider confidence. Therefore, we sought to understand what, if any, differences between these 2 surveillance systems may have caused this discordance.Surgical site infections (SSIs) are associated with readmissions, reoperations, increased cost of care, and overall morbidity and mortality risk, but they also have negative effects on patient trust and provider morale. The National Healthcare Safety Network (NHSN) and the National Surgical Quality Improvement Program (NSQIP) have developed an array of metrics used to monitor for hospital-acquired complications. The one metric collected by both surveillance systems is SSI. We noticed that at our facility, as has been reported by others,In this commentary, we analyze the rules, processes, and language that characterize each program’s data-gathering and reporting approach, and we discuss the impact of these differences upon reported results Table . We stri is a program of the Centers for Disease Control and Prevention (CDC) used to monitor hospital-acquired infections at no charge to the institution. Surveillance is typically performed by infection preventionists. In addition to SSIs, NHSN also collects data on device-associated infectious complications and antimicrobial use and resistance trends. Participation is mandatory for certain metrics and optional for others. Surveillance for SSI events is conducted over a 30- or 90-day period after surgery, depending on the procedure type. Procedures are grouped by category, which is determined by current procedural terminology (CPT) and/or International Classification of Disease, Tenth Revision (ICD-10) procedure classification system code. Reporting of SSIs is federally mandated for certain case types. Therefore, >3,000 acute-care hospitals report SSI data to the NHSN. Additional case types might be mandatory in certain states. Hospitals can choose to perform surveillance and report on other case types voluntarily based on their own internal risk assessment.The NHSNRegardless of whether the case type is mandatory or voluntary, statistical representation is the same: the denominator entered into the system consists of all cases (with some defined exclusion criteria) of that type performed and the numerator consists of every infection detected through routine surveillance processes. The NHSN reports a risk-adjusted summary measure back to the hospital in the form of a standardized infection ratio (SIR) Fig. , a basel is a program of the American College of Surgeons (ACS) that hospitals can choose to subscribe to, for a fee, to benchmark their performance across a large array of postoperative complications, including SSI events occurring within 30 days after surgery. The NSQIP Essentials surveillance plan provides data for 9 service lines, though hospitals can opt to participate in the NSQIP Procedure Targeted surveillance, which provides data on more specific procedure categories. Of all NSQIP-eligible surgical cases, a subsample of 20% are chosen for analysis via an 8-day systematic sampling cycle to ensure that cases from each day of the week have equal representation in the final sample. NSQIP reports risk-adjusted outcomes back to hospitals in the form of an odds ratio (OR) (Fig. The NSQIPAs of January 2019, NSQIP membership was comprised of 715 hospitals, of which 103 are outside the United States. NSQIP surveillance at all participating hospitals is performed by ACS-trained surgical clinical reviewers from outside the institution. In addition to SSIs, NSQIP also monitors trends in other outcomes such as mortality, unplanned intubations, readmissions, and returns to the operating room. Participation in NSQIP qualifies hospitals for a Joint Commission Merit Badge and meets the CMS measure “participation in a systematic clinical database registry for general surgery.” For example, at our institution, infection preventionists monitor admission and readmission lists, lists of patients on contact precautions, all positive microbiology results, and morbidity and mortality conference case lists. Inherent to this inpatient-focused methodology is a lack of resources to detect SSI events that are diagnosed at outpatient visits or at other facilities; this occurs most often in the case of superficial incisional SSIs, which may not warrant culture, readmission, or reoperation. Institutions that employ more robust outreach in the form of patient mail or telephone surveys may not experience this discrepancy to the same degree. These gaps in surveillance combined with variable implementation across case types between hospitals diminish the usefulness of NHSN as a tool for benchmarking hospitals against each other, particularly for the voluntarily reportable procedures. However, since the SIR is calculated using the same baseline data for several years in a row, the system has great merit as a tool to measure trends over time in an individual hospital’s SSI performance.Surveillance for the purpose of reporting to the NHSN involves a process that varies from hospital to hospital, with general instructions outlined by the CDC in the NHSN Patient Safety Component Manual.NSQIP, on the other hand, is characterized by strong and standardized follow-up with patients once they have left the hospital, made possible by their focus on a subsample of the total surgical patient population. Sets of cases in the sample are assigned to a surgical clinical reviewer, who has 90 days from the procedure date to detect SSI events before the case is locked to edits. Reviewers abstract from inpatient and outpatient medical records related to the operation, and in the absence of documentation stating that no complications occurred within 30 days post-op, they call providers and/or patients as needed confirm the patient’s status. Thus, outpatient diagnoses are less likely to be missed, regardless of the individual hospital’s human resources to perform the surveillance.However, smaller denominators come with consequences because individual SSI events may skew the rate due to the smaller sample size. Bias is minimized to some extent by using the 8-day sampling method described above. Additionally, given that one of the core features of NSQIP data analysis and presentation is comparison with other hospitals, the formal training provided by the ACS to its surgical clinical reviewers engenders consistent implementation between its member hospitals. This feature adds validity to the NSQIP as a tool to compare performance with other hospitals. Furthermore, the inclusion of international facilities in NSQIP could affect the validity of comparisons between facilities, owing to potential differences in practice, patient population, and healthcare system/insurance availability. However, because many of the overseas facilities are US military hospitals or are affiliated with US institutions, this may not be a large confounding factor.Despite the sometimes-striking differences between the outcomes reported by the 2 systems in the same facility, the definitions of infection used by the 2 systems are quite similar Fig. . Both suFor example, both systems state in their supplemental information that cellulitis alone does not meet criteria for a superficial SSI. However, the NSQIP adds to those criteria in its supplement that if the documented cellulitis was treated with antibiotics, it is considered a diagnosis of superficial incisional SSI. In contrast, the NHSN does not offer a scenario in which documentation of “cellulitis” can be used to meet criteria for SSI; thus, application of NHSN and NSQIP definitions results in different conclusions regarding the presence or absence of SSI.As part of its supplemental information for superficial incisional SSI, NSQIP provides a flowchart algorithm providing additional guidance on criterion C, which concerns return to the operating room for suspected SSI Fig. . NSQIP-pAlthough these scenarios depict fairly specific sequences of events, they highlight the danger of including a clinical diagnosis in the definition of SSI. In these examples, an individual clinician’s judgment regarding the cause of cellulitis or indication for antibiotics can change the classification from no infection to SSI. Both the NHSN and the NSQIP include clinician diagnosis of superficial SSI as a standalone criterion for superficial SSI assignment, though The NSQIP goes on to include clinician diagnosis of SSI as a criterion for deep incisional and organ-space SSI as well. This criterion is a barrier to standardization of definitions across hospitals. The distinction between infection and inflammation is often elusive to even the most experienced clinician. In addition, surgeons have an inherent conflict of interest when making a diagnosis of infection because each infection counts against them as a complication. It is easy to see why reported SSI rates might vary between surgeons depending on their practice habits around assessment, diagnosis, and documentation.Although both sets of criteria rely to some extent on clinical decisions made by a patient’s care team, with decisions such as whether to send a culture from the surgical site affecting the likelihood of meeting the definition of a case, the NSQIP places more emphasis on subjective measures in that antibiotic administration is considered indicative of SSI in certain circumstances. This information should be kept in mind when interpreting benchmarked data received from each of these programs. It would be prudent to be aware of specifically which criteria were fulfilled in the determination of a hospital’s infection rate, as that information may be more telling of a hospital’s performance than an OR or SIR alone. Consider the difference between a selection of SSIs identified based on positive wound cultures, SSIs identified through superficial wound changes observed in the office, and SSIs identified due to overzealous administration of antibiotics. Larger proportions of SSI assignments based on antibiotic use may be more related to the strength of a hospital’s antimicrobial stewardship program or the level of education of its surgeons around issues of prudent antibiotic use than to true infection rates.There is likely little to no benefit to having 2 sets of epidemiological eyes watching for the same events, as the benefit of possible cross examination by a separate party does not outweigh the ambiguity that results from high levels of discordance. It may lead to more harm because there is no clear way for clinicians to work on improvement. Neither system should be thought of as a “gold standard” for SSI surveillance, and based on our analysis of the definitions and assessment of the strengths and weaknesses of each approach, it would not be appropriate to make the blanket statement that one system is inherently more valid than the other. Many factors, such as the size of the hospital being monitored, the reach of the infection prevention and antimicrobial stewardship teams, and follow-up tendencies of the patient population, will dictate which metric might be more useful or problematic for a specific hospital. In practice, such a move would be adding yet another method of surveillance to which hospitals would need to allocate more resources. For providers who already feel frustrated by contradictory judgments that have been passed on their practice, confidence in surveillance measures may already be compromised. Adding yet another set of eyes may only increase frustration.Previous analyses of the lack of concordance between the NHSN and the NSQIP have concluded with a call-to-action to develop a single, universally reliable, surveillance system.SSI incidence is the only outcome monitored by both the NHSN and the NSQIP. Reducing redundancy and relying on 1 system per metric could control evaluation fatigue and allow for more clinical trust in reported metrics. We recommend removal of subjective elements, especially clinician diagnosis and initiation of antibiotics, from all SSI definitions. Hospitals should then be permitted to choose between the NSQIP and the NHSN for their reporting of SSI data. For larger hospitals, where the sampling strategy used by the NSQIP has the potential to miss a substantial proportion of surgeries, and with enough infection preventionist resources to perform active surveillance and report through the NHSN, that system is likely a better choice because it is already in use for other hospital-acquired infections. Other hospitals might choose to save human resources and invest financially in a NSQIP contract, which comes with outsourced surveillance and case ascertainment.In conclusion, for hospitals that do use both programs to benchmark SSI data, stakeholders should be warned to expect divergent conclusions and educated on why it is likely to occur. Care should be taken to prevent staff from feeling demoralized based on benchmarks that may be flawed. Action plans should not be developed based on the results from 1 program alone if data from the other are discordant; efforts should be made to examine individual SSI cases for patterns and opportunities for improvement. No metrics are perfect, but if captured in a consistent way over time, both NSQIP and NHSN SSI data can be used to drive safer patient care, which is the ultimate goal.


Enterococcus avium infection. To our knowledge, such a report is considered unprecedented in the Middle East. A literature review on IGM will be presented, as well as the clinical presentation, association with bacterial infection, treatment, and pathological and radiographic findings.Idiopathic granulomatous mastitis (IGM) is defined as an uncommon, benign, chronic inflammatory disease of unknown etiology that affects the breast and can mimic breast cancer. It usually manifests as a solid, ill-defined breast lump in postpartum women of reproductive age. Furthermore, because it lacks a particular radiographic finding, core biopsy and histology are the only ways to make a conclusive diagnosis. There is no agreement on the best way to treat IGM. Ideally, a multidisciplinary approach should be used to weigh the benefits and drawbacks of each treatment option, with options such as observation, antibiotics, surgery, and medication therapy being examined (steroids and immunosuppressants). In this report, we review a case of a patient who had IGM with superimposed  Enterococci are common gram-positive pathogens found in intestinal flora. Some enterococcal species cause serious illnesses. Clinical symptoms include endocarditis, intra-abdominal infections, and urinary tract infections, whereas soft tissue and bone infections are uncommon [Enterococcus avium account for approximately 1% of all human infections, only a few case reports of E. avium infection have been published [E. avium infection in a Saudi woman. To our knowledge, this is the first case report of IGM associated with E. avium infection in the Middle East. The rareness of E. avium infection, as well as its unusual appearance and high degree of radiological overlap with breast cancer, increases its novelty and clinical significance.uncommon . Becauseublished .Idiopatublished . IGM is ublished . It usuaublished . The lumublished ,6. NipplA previously healthy 46-year-old Saudi woman visited the emergency room complaining of pain and a mass in her right breast. She first noticed the mass almost one month ago, and it had been expanding rapidly and becoming more tender. A mammogram performed in another facility showed findings suspicious of cancer (BI-RADS 5). She had nipple retraction, but no fever, redness, or discharge. She was a nonsmoker and did not drink alcohol. She was breastfeeding and taking oral contraceptives. She had a history of mastitis secondary to milk stasis, which had been treated with antibiotics. Her parity was 7+2, and she had undergone a cesarean section three years ago with no complications. There was no family history of breast, colon, ovarian, or prostate cancer.At the breast surgery clinic, both her vital signs and laboratory workup were within the normal range. Physical examination revealed slight peau d’orange changes, skin thickening, a retracted nipple, and a 5 × 4 cm retro-areolar mass with no palpable axillary lymph node. A mammogram was requested, and it showed an incomplete evaluation of the right breast (BI-RADS 0), and a normal left breast BI-RADS 1). Breast ultrasound revealed changes in the right breast that showed a predominantly inflammatory pattern; however, an associated malignancy could not be excluded (BI-RADS 4B), and thus right axillary lymph node and right breast biopsies were suggested  and ciprofloxacin (500 mg) for seven days. After one week, she appeared healthy with no fever, redness, or abscess, but complained of pain at the site of the biopsy, and thus the antibiotics were continued for an additional two weeks. The patient was still experiencing pain and had signs of a small abscess. Culture of a fine-needle aspirate of the abscess showed Clinical featuresIGM typically presents in women aged 30-45 years as a mass with oblique margins in the upper outer quadrant of the breast. The lesion typically appears in one breast. It can occur in any quadrant, but primarily in the upper outer quadrant . AbscessImagingIGM has no pathognomonic features on mammography, and mild lesions are frequently concealed by the relatively dense breast tissue . MammogrIn IGM, breast ultrasound can help with diagnosis. In more than 80% of cases, it reveals a heterogeneously hypoechoic mass lesion . It can HistologyHistological analysis of tissue obtained from an open or a core needle biopsy is used to reach a conclusive diagnosis of IGM . Fine neMicroorganismCorynebacterium infection, suggesting that Corynebacterium could play a role in IGM [Corynebacterium in the breast tissue of 35 (55%) of 64 patients with IGM, and was more common in patients with fever or an abscess [Corynebacterium infection had IGM pathologically [Corynebacterium infection in IGM may be linked to the infiltration of polymorphonuclear leukocytes in response to infection [Corynebacterium can be isolated from normal breast tissue [E. avium organism. To our knowledge, this is the first case to show an association between IGM and E. avium infection.IGM is sometimes associated with bacterial infections, with gram-positive bacteria being the most common bacteria identified . Some ste in IGM ,16. One  abscess . Anotherogically . A thirdTreatmentThere is no consensus on the best method for treating IGM. Ideally, a multidisciplinary approach should be used to weigh the benefits and risks of each treatment option. The treatment options include observation, antibiotics, surgery, and medication (steroids and immunosuppressants). In as many as half of the cases, IGM may become a chronic illness. Surgical therapy should be undertaken with caution, as the potential risks may outweigh the potential benefits ,10. In rE. avium organism, which was susceptible to ampicillin and gentamicin; therefore, the antibiotic was switched to amoxicillin/clavulanic acid 625 mg orally. A week later, the patient’s symptoms improved, and thus the antibiotics were discontinued.Antibiotics have a limited therapeutic effect on IGM. Only 3% of individuals who receive antibiotics show improvement in their condition . HoweverE. avium infection.In conclusion, the etiology of IGM remains unclear. Hence, a very high index of suspicion is essential to reach the diagnosis, which must be confirmed by core needle biopsy since IGM does not have specific radiological features. A link between bacterial infection and IGM has been suggested. To our knowledge, this is the first report of IGM associated with


IntroductionPhysicians have increasingly used social media platforms to review new research, expand networks, and communicate. However, few studies have evaluated how the integration of social media into residency programs affects training. This is relevant during the COVID-19 pandemic, with a shift towards virtual formats for medical education, community building, and recruitment.ObjectiveThe objective of this study was to evaluate how the integration of social media platforms, including Slack, Twitter, and Instagram, influences education, social connectedness, and recruitment within a residency program.MethodsIn 2020, pediatric residents at one institution were encouraged to create personal Twitter and Instagram accounts if they did not already have one and follow the residency program's Twitter and Instagram accounts. Residents were also encouraged to enroll in a private Slack network within the residency program. We surveyed residents in May and June 2020 (pre-intervention) and March 2021 (post-intervention). Analytics from the residency program's social media accounts and Slack were recorded. Data were analyzed using a mixed-methods approach.ResultsResponse rates from residents regarding the impact of social media interventions on education, connectedness, and recruitment were 98% (100/102) pre-intervention and 74.5% (76/102) post-intervention. During the study period from May 2020 to March 2021, chief resident posts on the residency program's Twitter and Instagram accounts garnered 447,467 and 151,341 impressions, respectively. Posts with the highest average impressions were those related to advocacy. After the intervention, residents reported increased connectedness to residents in other classes and increased usage of their personal Twitter and Slack accounts for learning and education. Residents rated the program's Instagram account as a useful recruitment tool. Feasibility of posting was assessed by the number of posts by chief residents during the study period . There were no costs.ConclusionOur data shows that social media in residency is feasible, cost-effective, and valuable for education, connectedness, and recruitment. We outlined specific ways social media was feasible and useful in these domains. Even before COVID-19, communication in training programs was challenging. Residents use many modes of communication that include emails, paging, and smartphone-enabled applications such as Voalte, WhatsApp, iMessage, and Epic Secure Chat. Over time, the best use of technology will continue to evolve as current literature shows that social media's effect on residency education, recruitment, and professionalism is mixed . The risSocial media platforms such as Twitter, a public microblog social media community, have been increasingly utilized among various medical professions to gain exposure to new research, expand networks, increase engagement, and disseminate information -17. DuriSocial connectedness is a concept that can be useful in exploring the experience of belonging and relatedness between people . This stStudy designFrom May to June 2020 during the COVID-19 pandemic, all 2020-2021 residents in the Stanford University pediatric residency program  were enrolled in our residency-specific Slack account, which was sponsored by the University. Residents were also encouraged to create a personal Twitter and Instagram account if they did not already have one in an effort to study if there was a perceived improvement in communication, connectedness, and education. Education and training on these platforms were provided by the chief residents for all the residents during a class-wide retreat. Slack was introduced as a workplace communication platform for announcements, postings, and sharing of educational materials. Chief residents posted on Slack using their individual accounts. The residency program's Twitter account was used for educational tweetorials , advocacy, and recognition of others. The residency program's Instagram account was included after the pre-survey was administered and was used to assess social connectedness and virtual recruitment through posts related to advocacy, recognition of others, featuring residents in a series called "Behind-the-Mask", and highlighting rotations and social events. Chief residents posted collectively as a group on the residency program's Twitter and Instagram accounts. All posts occurred as part of chief residents' communication, teaching, and recruitment responsibilities. Data collection and analysisData were collected using a mixed-methods approach, including surveys with Likert-scale items and open-ended responses and data from social media. Social media data included metrics such as impressions  and followers . This data was pulled from analytics provided by the social media sites respectively. We administered a pre-intervention survey using Qualtrics  to rising second-year and third-year residents in May 2020 and incoming interns in June 2020. A post-intervention survey was administered to all three aforementioned classes in March 2021. The survey assessed residents' sense of connectedness to one another and to the residency program and their use of and perceptions of social media platforms. Residents also provided anonymized free-text responses to evaluate the effect of social media on their residency experience. Sense of connectedness questions were adapted from previously published research, and additional questions were created de novo to address study objectives [Data were analyzed using the Wilcoxon signed-rank test, a nonparametric test, to compare pre- and post-responses. Feasibility was measured by the number of chief residents' posts during the study period. All three chief residents shared equal responsibility in creating posts. This study was deemed exempt by the Stanford Institutional Review Board.There were 100/102 (98%) respondents for the pre-intervention survey and 76/102 (75%) respondents for the post-intervention survey. Of these respondents, 67 pre- and post-surveys were pairable for Wilcoxon signed-rank test analysis. We received pre-intervention responses from rising second-year (n=33) and third-year residents (n=32) in May 2020 and incoming interns (n=35) in June 2020, and post-intervention responses from all three aforementioned classes (n=76) in March 2021.Social media usageAs of March 2021, the Slack network had an average of 67 weekly active users, the residency program's Twitter account had 615 followers, and the residency program's Instagram account had 1297 followers. From May 2020 to March 2021, the residency program's Twitter posts (n=806) garnered 447,467 impressions, and the residency program's Instagram posts (n=67) garnered 151,341 impressions. Posts with the highest number of impressions were those related to advocacy  followed by video posts . For example, the highest number of views for a single tweet was 26,260 , which was related to advocacy for the COVID-19 vaccine rollout. Social media for educationFor residents' self-reported usage of Slack and Twitter for learning, the Wilcoxon signed-rank test supported the rejection of the null hypothesis , thus there is a significant increase in resident use of both Slack and Twitter in the context of learning  that the residency program's Instagram account was a useful tool for recruitment Table .In a separate post-match survey, 86% (n=31) of our newly matched interns starting June 2021 viewed our residency program's Instagram account during recruitment season and reported that it was extremely useful (4.7/5). The most useful posts were the "Behind-the-Mask" series which spotlighted residents for applicants and other residents. Other helpful series included videos that showcased "A-day-in-the-life" of the residents in different rotations, Instagram live streams that connected applicants with the residents, and posts that showcased the residency program leaders. We report here a social media intervention to bring Slack, Twitter, and Instagram to our pediatric residency program. The COVID-19 pandemic encouraged a need for virtual tools in the areas of medical education, communication, and recruitment. While some results of our interventions were expected based on the common use of social media platforms, we were also surprised that residents and applicants utilized these tools in new and unexpected ways. Slack was used to promote connectedness and sharing resources internally. Twitter was perceived as effective for education, while Instagram was most appreciated for recruitment and connectedness. These findings align with prior research showing that social media supports education and recruitment -24.Social media for educationSocial media is increasingly used in medical education as a platform to share research, information, and resources , 25-29. Twitter was heavily used for educational purposes to allow anyone public access to our educational conferences through our residency program's Twitter account. Tweets that included interactive components such as polls often garnered the most interest. Many residency programs maintain Twitter handles, and many more residency programs created accounts during the 2020-2021 academic year, given the pandemic . Our finSocial media and connectednessSocial media has long been utilized to network. In this study, Slack and Instagram were platforms used to increase connectedness within our residency program. Slack was often used for quick communications with residency program leadership as well as within and between classes. Examples of how Slack was used to communicate include arranging group events such as pick-up sports or hikes, as well as current/incoming residents creating a shared moving/selling channel at the end of the year.Instagram provided a means to share personal stories and residency-related experiences publicly using our residency program's Instagram account, allowing residents and applicants to connect virtually. Instagram is increasingly used by residency programs to share content, and our intervention demonstrates novel ways of promoting connectedness. While our data show improved interclass connectedness, we would anticipate that to naturally occur with time in any given year. And although our data did not show changes in resident connectedness to the residency program or to others in their class, this finding could be a reflection of the isolation and separation caused by the COVID-19 pandemic. It is also worth noting that not all residents interacted with social media regularly, and a small number of survey respondents expressed a sense of "fear of missing out" (FOMO) which made them feel less connected. This should be further evaluated as existing literature shows concerns that social media can have impacts on the mental health of individuals . Social media and recruitmentRecruitment quickly became a focus of our social media efforts, given the shift toward virtual recruitment during the COVID-19 pandemic. Residents regarded Instagram as a platform for recruitment for its visual appeal, interactivity, and utility in showcasing residents and the culture of the residency program during a time when applicants were not permitted to visit the residency program. Through a variety of recurring series on our residency program's Instagram account, including our "Behind-the-Mask" series, Instagram live Q&As, "A-day-in-the-life," and team features, we were able to showcase residents, hospital teams, and experiences. Instagram also allowed us to reach a broad audience, many of whom were also looking to get to know our residency program as prospective residents. Most who matched had viewed and positively rated the residency program's Instagram account.LimitationsOur survey data are from a single institution and are based on self-reports, which may not accurately represent the true frequency of social media use. Not all study participants responded to the post-survey, which may have led to nonresponse bias. The effects of COVID-19-related restrictions may have overpowered the results of our social media intervention. Furthermore, our evaluation of Instagram was limited due to its non-inclusion in the pre-survey. Social media analytics are limited in that it is impacted by any viewing of a post, including by the study designers, and do not necessarily imply a post was read, only that it appeared on a screen. We are also unable to assess the source of impressions, which may be influenced by several factors, including retweets, bots (profiles not controlled by a person), and other unmeasurable unknowns. Overall we report a social media intervention in our residency program that included Slack, Twitter, and Instagram. The COVID-19 pandemic impacted residents during this intervention, and the effect of social media should continue to be evaluated outside of a global pandemic. This was a cost-effective intervention that required a shift towards the usage of newer and more interactive social media platforms that have the potential to reach wider audiences, as evidenced by nearly 600,000 cumulative impressions from our social media platforms. A longer-term evaluation of a social media intervention could be helpful as more trainees and educational leaders become engaged in social media, and there is an increased use of these platforms in future virtual recruitment seasons. The negative comments and sentiments around social media should be further explored to better understand the risks. Further studies should also assess the knowledge retention of residents using social media interventions. Nonetheless, our findings demonstrate the potential of social media to impact education, connectedness, and recruitment, and we outlined specific ways social media was feasible and useful in these domains.