Immunoglobulin detection is important for immunoassays, such as diagnosing infectious diseases, evaluating immune status, and determining neutralizing antibody concentrations. However, since most immunoassays rely on labeling methods, there are limitations on determining the limit of detection (LOD) of biosensors. In addition, although the antigen must be immobilized via complex chemical treatment, it is difficult to precisely control the immobilization concentration. This reduces the reproducibility of the biosensor. In this study, we propose a label-free method for antibody detection using microcantilever-based nanomechanical resonators functionalized with erythrocyte membrane (EM). This label-free method focuses on the phenomenon of antibody binding to oligosaccharides (blood type antigen) on the surface of the erythrocyte. We established a method for extracting the EM from erythrocytes and fabricated an EM-functionalized microcantilever (MC), termed EMMC, by surface-coating EM layers on the MC. When the EMMC was treated with immunoglobulin M (IgM), the bioassay was successfully performed in the linear range from 2.2 pM to 22 nM, and the LOD was 2.0 pM. The EMMC also exhibited excellent selectivity compared to other biomolecules such as serum albumin, γ-globulin, and IgM with different paratopes. These results demonstrate that EMMC-based nanotechnology may be utilized in criminal investigations to identify blood types with minimal amounts of blood or to evaluate individual immunity through virus-neutralizing antibody detection. Immunoglobulin (Ig), also known as an antibody, is a glycoprotein that binds to an antigenic epitope . Ig playImmunoassay is based on a biological method that analyzes a specific reaction between an antigen and an antibody ,15. An iω) of the MC is inversely proportional to the square root of the mass of the MC. That is, an increase in the mass of the MC due to molecular adsorption decreases the ω of the MC. Using the ω shift (Δω), defined as ω − ω0, it is possible to assay biomolecules such as viruses [MC-based sensors have been widely used in immunoassays due to their advantages of high sensitivity , low cos viruses , bacteri viruses ,41,42, a viruses , and pro viruses . Further viruses ,47,48,49 viruses ,51. Spec viruses .Herein, inspired by IgM-induced hemolysis, we have fabricated a novel EM-functionalized MC (EMMC) for IgM detection a,b. EM wAdvanced PAP pen , distilled water (DW), deionized water (DIW), phosphate buffer saline , human serum, human serum albumin (HSA), and γ-globulin were purchased from Sigma Aldrich . Additionally, 18:1 PE CF fluorescent lipid was purchased from Avanti Polar Lipid . Anti-A (ABO1) and Anti-B (ABO2) were purchased from DIAGAST .k = 45 N/m; Probes, Seoul, Korea) was mounted on to an AFM aqua head . The laser voltage before MC tuning was about 2.0V. Next, the ω of the MC was calibrated using the ‘Auto Tune’ method in the ezAFM v10.20 software. All the MCs were mounted on to AFM aqua heads after they were completely dried.Morphology and fluorescence images of the MCs were characterized by microscopy . An MC  and stored in the refrigerator for 1 h. Then, to obtain pure EM, they were centrifuged under specific conditions  and washed 3 times with 1× PBS. The obtained clear ruby-colored EM was stored in a freezer (−80 °C). Before use, each EM solution was diluted with DW, and then sonicated and vortexed for 5 min.EM was extracted from human whole blood using the previously mentioned method . The bloSeveral steps were taken to functionalize the EM in the device. First, a liquid blocker was coated only on the base of the AFM probe (PR-T190) and dried at 23 °C for 5 min. Coating the base with a liquid blocker allows the EM to selectively functionalize only on the MC surface. Specifically, the MCs were functionalized by slowly pipetting 60 μL of EM solution (1%) and washing them 100 times to resolve EM residues.ω) in dry air follows the elastic continuum model [MCL, EI, MCρ, A, MCK, and MCM are the MC’s length, bending rigidity, density, cross-sectional area, the MC’s effective stiffness, and the MC’s effective mass, respectively. In detail, MCK = β4EI/MCL3 and MCM = MCA.ρ The β satisfies the transcendental equation such that cosβcoshβ + 1 = 0. Here, the dimensions of the MC are given by MCL × MCW × MCT (length × width × thickness), where MCL = 215 μm, MCW = 37.5 μm, and MCT = 8 μm. Following this equation, our MC’s ω is 149.54 kHz. The average of ω was experimentally obtained to be 153.25 ± 1.58 kHz. This shows that our MC satisfies the elastic continuum model. Because the MCT of the MC is much larger than that of the molecular layer, the mass is the main factor causing the resonant frequency shift (Δω) [ω in the air as follows:ω is the resonant frequency shift measured in air, and ΔM is the total mass of the molecule, including molecular interactions. The EMMC can detect IgM using this Δω.The MC’s resonance frequency (um model .(1)ω=βLift (Δω) . Therefoω was measured through frequency sweeping  were dispensed on to the EMMC. Afterward, the EMMC was shaken at 60 rpm for two hours at 23 °C. The IgM-bound EMMC was carefully washed with PBS and fully dried. The EMMC’s ping see .ω of the MC, we compared the ω of the MC before and after the liquid blocker coating was applied. The ω of the MC with the liquid-blocker-coated base was slightly different from that of the bare MC. Subsequently, EM was functionalized on the MC. In order to fabricate the EMMC, it is important to coat only a single layer of the EM on the MC surface. The two variables of EM concentration and the number of washes are very important. If high EM concentration was treated on the bare MC, the number of washes of the EMMC should be increased to remove excessive EM residues. These variables will depend on the type of materials and the shape of the MC. We can only describe the conditions for fabricating an EMMC based on the MC : agitate 100 times by repetitively pipetting with 1% EM solution (60 μL), and subsequently wash 100 times. As shown in During the EM functionalization process, it is difficult to coat only the MC surface and not the MC base. To solve this problem, scientists use microinjection or microcapillary technology, which is considered to be a major limitation in the mass production of EMMCs ,64. To pω occurs due to EM coating, the MC’s ω was measured before and after the EM coating was applied. The ω for the bare MCs and the EMMCs are 153.25 ± 1.58 and 153.06 ± 1.56 kHz (mean ± standard deviation); a 0.17 ± 0.06 kHz decrease was observed after EM functionalization on the MC surface . This suggests that IgM binds proportionally to antigens present on the EM surface. This plot also shows that Δω and log(IgM) are linearly related. The analyzed semi-log regression analysis was ‘Δω = 0.05 × log(X) + 0.08′, and the limit of detection (LOD) calculated as 3.3 × (σ/S) was 2.04 pM. The σ is the standard deviation of the response, and S is the slope of the linear fit. According to Equation (2), 2.04 pM LOD corresponds to 17.32 pg IgM, which can be considered the resolution of the EMMC in IgM detection  dissolved in 1× PBS (pH 7.4). Here, Δetection .ω values of the EMMC treated with IgM (Anti-A), HSA, and γ-globulin were 0.05 ± 0.01, 0.05 ± 0.03, and 0.05 ± 0.02 kHz, respectively (ω for IgM (Anti-A), HSA, and γ-globulin normalized by Δω values in the IgM (Anti-B) condition were 14.79 ± 3.05, 14.90 ± 9.04, and 17.17 ± 6.41%, respectively , whereas blood type B contains antigens (Type B) only on erythrocytes. Therefore, type B erythrocytes do not interact with IgM (Anti-A) and bind selectively to IgM (Anti-B). Note that our EMMC was fabricated with erythrocytes from blood type B. The selectivity of the EMMC sensor was verified by measuring high concentrations of major proteins present in the blood, such as IgM (Anti-A), HSA, and γ-globulin . The treectively a. The inectively b. These ω of the EMMC decays sharply at high concentrations of IgM (>220 nM) and remains almost unchanged. Specifically, the Δω of EMMCs exposed to 220 nM and 22 μM IgM were 0.07 ± 0.04 and 0.05 ± 0.03. This implies that the EMMC will normally operate below 22 nM IgM, but may malfunction above 220 nM . This is indeed challenging and would be a desirable research theme for future work.We investigated the detection ability of the EMMC at high IgM concentrations. Interestingly, the e 220 nM a. This he 220 nM b. Moreove 220 nM c. From tω and IgM concentration (0–22 nM) under a semi-logarithmic scale , HSA, and γ-globulin. Our results prove that the EMMCs are highly sensitive and can selectively detect antibodies with a simple procedure and a label-free method. Although the EMMC successfully detected IgM in PBS and serum, further investigation is required for IgM detection in patient samples. We expect that our approach to EMMC fabrication and biosensing performance will shed light on the development of highly sensitive and selective label-free biosensors capable of detecting target molecules by single-step cell membrane functionalization.


Adolescent and young adult cancer patients (AYAs) often experience profound psychological distress, with various unmet supportive care needs that can be alleviated with appropriate screening and attention by healthcare workers. The Distress Thermometer and Problem List-Japanese version (DTPL-J) is our previously developed screening tool to facilitate individual support of AYAs. This study evaluated the feasibility and preliminary effectiveness of a psychosocial support program based on the DTPL-J for AYAs in clinical practice.This multicenter, retrospective, observational study included 19 of 126 wards and 9 of 75 outpatient clinics at 8 institutions in Japan. Over 200 patients were expected to participate during the eligibility period. Patients participated in a support program at least once, and approximately once a month based on the DTPL-J results. The program was evaluated using the RE-AIM  implementation framework.p < 0.05), suggesting the preliminary effectiveness of the program. The program was continued at the 8 institutions as part of routine care after the study.The screening rate of the 361 participants was 90.3%, suggesting high feasibility. Distress Thermometer scores, the number of supportive care needs, and the rates of AYAs with high distress were significantly reduced 1 month after screening  UMIN000042857. Registered 25 December 2020—Retrospectively registered. Adolescent and young adult cancer patients (AYAs) are defined as those aged 15 to 39 at the time of initial cancer diagnosis , 3.AYAs require more support than older adults or younger children with cancer . Though In Japan, the Ministry of Health, Labour and Welfare released the Third Basic Plan to Promote Cancer Control Programs in 2018 . This poThe Distress Thermometer and Problem List (DTPL), which was developed by the National Comprehensive Cancer Network, was found to be useful in Singapore for identifying clinically significant psychological distress in AYAs . In AustThis program designed to provide psychosocial support to AYAs in cooperation with multidisciplinary experts was developed with reference to the support system of the NCCH . In thisIn recent years, the RE-AIM framework has been used to evaluate the feasibility and preliminary effectiveness of support programs in various fields –29. ThisThis multicenter study aimed to evaluate the feasibility and preliminary effectiveness of a psychosocial support program based on the DTPL-J for AYAs, using the 5 dimensions of the RE-AIM framework.We conducted a multicenter, retrospective, observational study to evaluate the feasibility and preliminary effectiveness of a psychosocial support program for AYAs. This study was approved by the National Cancer Center Institutional Review Board  and was conducted in accordance with the principles of the Declaration of Helsinki. The requirement for informed consent was waived due to the retrospective design, and opt-out information was published on the website of the National Cancer Center Hospital (NCCH) in Japan. This study was registered at the UMIN Clinical Trials Registry (UMIN000042857).The following 8 institutions participated, all of which were members of a research group defined by a Grant-in-Aid from the Japanese Ministry of Health, Labour and Welfare: NCCH, Nagoya City University Hospital (NCUH), Shizuoka Cancer Center (SCC), St. Luke’s International Hospital, Nagoya Medical Center (NMC), Aichi Cancer Center (ACC), Saitama Children’s Medical Center (SCMC), and the National Center for Child Health and Development (NCCHD).The sample size was pre-set to 200 patients , based on the average numbers of patients at the targeted departments of the 8 institutions over the previous 3 years, and under the assumption that about 20% of the patients would drop out. Although the rate of dropout was approximately 10% in our previous study at the NCCH , the valA program designed to provide psychosocial support to AYAs in cooperation with multidisciplinary experts was developed with reference to the support system of the NCCH . Based oBecause each institution had different multidisciplinary expert resources, the secondary care to which referrals were made for each need was determined in advance. The manual included the role of each expert and how they should support AYAs in order to ensure the professionalism of psychosocial support.In this program, healthcare workers provided screening using the DTPL-J for AYAs, identified the needs of AYAs, and determined the necessary support. The DTPL-J for AYAs consisted of the Distress Thermometer (DT) and a list of 49 problems potentially experienced by patients . A nursePrimary support was handled by nurses. After screening to determine patients’ needs, nurses provided information on necessary support. In addition, with the consent of the patients, the obtained information was shared with the primary care team. The consent was verbally obtained from AYAs in the course of a treatment interaction. If not an adult, verbal consent was obtained not only from them, but also from their parents/guardians. This procedure was approved by prior ethical review. Patients who required intervention received expert support at an early stage. The main occupations of the experts involved in secondary support were attending physicians, specialized nurses, psychologists, and medical social workers.Attending physicians were responsible for incorporating information such as the physical, psychological, and social backgrounds of the patients into their treatment plan. They shared information with multidisciplinary experts at conferences and considered the best medical care. Specialized nurses played a central role in sharing information and collaborating with multidisciplinary experts so that healthcare workers could provide comprehensive support to AYAs and their families. In addition to administering direct care such as daily primary care, therapeutic decision support, and self-care support, specialized nurses also educated and provided logistics support to nurses responsible for primary support. Psychologists addressed psychological distress that could not be alleviated by primary support. They provided psychological care not only to AYAs and their families, but also to healthcare workers who supported and facilitated the relationship between AYAs, their families, and healthcare workers. Medical social workers played roles such as presenting information on financial issues and the use of social systems, providing support regarding employment and school attendance, and modifying the medical treatment environment.In addition to the above, it was desirable that various additional multidisciplinary experts pharmacists, nutritionists, rehabilitation staffs, psychiatrists, child life specialists, appearance care staff, child support, and palliative care team be involved in the program according to the resources of each institution.The relevant data sources for each of our study aims, including how they map onto the RE-AIM framework, are listed in Table Beginning in August 2020, each institution implemented the program for AYAs in clinical practice. The eligibility period was from August 2020 to March 2021. After the end of the eligibility period on April 1, 2021, collaborators from each institution extracted the data listed in Table The data extracted from the medical records and DTPL-J for AYAs included the following: age, gender, cancer type (primary site), stage, days from diagnosis, treatment setting, treatment type (outpatient or inpatient), DT score, checked items on the problem list, and experts who supported each patient’s needs.Regarding the items on the problem list, St. Luke’s International Hospital and NMC added several items such as marriage, caregiving, heredity, and available systems and services to the DTPL-J for AYAs.Before the program was implemented in clinical practice, healthcare professionals at the 8 institutions were interviewed about factors that facilitated or hindered program setup. After the end of the eligibility period, the same individuals were interviewed about the benefits and challenges involved in implementing the program and whether or not the program was continued after the eligibility period. One interviewer (T. H.) conducted a total of two interviews per institution online according to the manual. Each interview lasted 1 h with at least one member of the research team in each institution. The interviews were recorded and the conversations were transcribed by one researcher (T. M.). As interview participants, M. F., Y. I., Y. I., A. T., M. O., N. M., K. Y., S. T., M. M., K. T., K. H., and T. A. participated in two interviews in their institution. The interview content was classified based on similarities and differences between elements that promoted or impeded program sustainability. Content analysis of the interview data was conducted by a psychiatrist (T. H.) and a psychologist (M. F.) using the KJ method .We mapped our study aims, specifically the feasibility and preliminary effectiveness of the program, to the (re-ordered) RE-AIM dimensions presented below.To assess feasibility, we described each of the following: the establishment (Adoption) of the program, including factors that facilitated or hindered setup; described and evaluated the extent to which patients participated in the program (Reach); assessed the extent to which the program was delivered as intended (Implementation), along with relevant facilitating and obstructing factors; and the sustainability of the program as part of routine care (Maintenance).To assess preliminary effectiveness, we evaluated how well the program worked (Effectiveness).Based on our previous study , we pre-Descriptive statistics were used to retrospectively calculate the number of cases at each institution, the types of specialists involved in each patient’s care, and the percentage of items on the problem list that were checked by each patient.If clinically feasible, the utility of the program was evaluated by conducting a second screening about 1 month after the first, or at the time of discharge if the inpatient was discharged within 1 month.t-test. The overall patient sample, including individuals who missed the second screening, was analyzed using the unpaired-samples t-test. Only patients who completed both the first and second screenings were analyzed using the paired-samples t-test. A 2-sided p value < 0.05 was used to indicate statistical significance. A DT score of ≥ 5 was defined as high distress because a score of 5 resulted in the best clinical screening cutoff on DT in AYAs [The DT score and the number of checked items at the first and second screenings were compared using the  in AYAs . The ratNineteen of 126 wards (15.1%) and 9 of 75 (12%) outpatient clinics at 8 institutions participated. Factors that facilitated setup were as follows: (a) the impetus for building a system to support AYAs (awareness of the need for AYA support and clarification of the procedure of this support); (b) increased opportunities to share information with multidisciplinary experts to help them support AYAs (study meetings and periodic conferences); and (c) provision of early and appropriate support (establishment of a screening system and clarification of consultation services). Reported barriers to setup were as follows: (a) concerns about an increased daily burden in clinical practice; (b) burden on patients in terms of responding to screening; and (c) gaining the approval of the targeted departments to implement the program and establishing a system of cooperation.A total of 361 of 1262 (28.6%) targeted patients participated in the study. The number of patients who participated at each institution was as follows: 138 of 202 (68.3%) at the NCCH, 86 of 86 (100%) at the SCC, 19 of 219 (8.7%) at the ACC, 50 of 50 (100%) at the NCUH, 19 of 115 (16.5%) at the NMC, 31 of 495 (6.3%) at St. Luke’s International Hospital, 11 of 32 (34.4%) at the SCMC, and 7 of 63 (11.1%) at the NCCHD.n = 131, 36.3%), breast cancer , gynecological cancer , hematological cancer , brain tumor , and others . Stage IV  was the most common cancer stage at diagnosis, followed by recurrence . The most common treatment setting was curative .Regarding participants’ demographic characteristics, 206 males (57.1%) and 155 females (42.9%) with an average age of 28.2 years were included. Three hundred four subjects (84.2%) were inpatients. Cancer types were bone and soft tissue cancer , followed by psychologists  and child life specialists .Patient problems and the experts who supported patient needs are shown in Table Of the 8 institutions, 5 targeted inpatients, 2 targeted outpatients, and 1 targeted both outpatients and inpatients. The implementation status and the characteristics of each institution are shown in Table The percentage of participants who underwent the first screening was 90.3% (326/361), which was higher than the 90% we had defined as the cutoff indicating feasibility. The interviews identified the following factors in cases where screening could not be provided: (a) patients were in poor general condition due to emergency hospitalization; (b) patients refused to respond to a request for screening because they were repeatedly screened each time they were admitted to the hospital for a short period of time; and (c) nurses were too busy.p < 0.05) and among those who completed both the first and second screenings (p < 0.05) (Table p < 0.05).Both the DT score and the number of checked items on the problem list were significantly lower after the program, both among all patients  Table . There wAfter this study ended, the program was continued at all 8 participating institutions as part of routine care. Reported factors that increased sustainability were as follows: (a) understanding the differences in support and resources between institutions; (b) increased awareness by healthcare providers that AYAs require support; and (c) establishment of a consultation service to support AYAs, thus facilitating medical treatment and multidisciplinary cooperation. Reported barriers to sustainability were as follows: (a) an increased daily burden in clinical practice; (b) challenges in gaining an understanding of the entire institution (including other departments) so as to maintain the system; and (c) ensuring high-quality support for identified needs.In this multicenter, retrospective study, we used the RE-AIM to demonstrate the feasibility and preliminary effectiveness of a psychosocial support program based on the DTPL-J for AYAs.AYAs want to receive a controllable amount of information from their healthcare professionals and to participate in decision-making about their care . The facThe participation rate was 90.3%, which was higher than the 90% that we defined as the cutoff for feasibility. Since most of the subjects (84.2%) were inpatients, this program may be more easily implemented in this population. Although outpatients were more likely than inpatients to check items in all 5 categories of the problem list, the number of the types of experts who provided support was higher for inpatients (12 types) than outpatients (6 types). Future research should address the implementation of this program in outpatient settings.Patients who participated in the program included many patients with cancer types with high support needs. In bone or soft tissue cancer, the risk of chemotherapy affecting fertility has been reported , 37. Bren = 130, 36.0%), anxiety problems , worry problems , pain problems , and fatigue problems . These problems are consistent with previous studies in AYAs in Asia [The checked items in the problem list mostly concerned practical and emotional issues. The top 5 were work problems or school problems , hematological oncology, and pediatrics. This suggests that research cooperation was easily obtained from departments with a high need for AYA support .Screening could not be provided in cases of emergency hospitalization or refusal to repeat screening in a short period of time. The appropriate timing and frequency of screening should be considered. Another challenge was how to efficiently provide screening in a busy clinical practice.There was a need for this program among healthcare workers; however, it could be burdensome for both patients and healthcare workers. Future studies should consider ways to provide support programs that are less burdensome for all involved.The DT score, the number of checked items on the problem list, and the rates of AYAs with high distress were significantly lower after this program based on the DTPL-J for AYAs, suggesting its preliminary effectiveness. In a previous study, DT scores decreased significantly over time . HoweverThough the rate of AYAs with high distress before receiving the support program was 33.5%, a previous study of AYAs within 3 months of diagnosis reported that 42% experienced distress using the same cutoff (DT of 5) of this study . Our stuAfter this study ended, the program was continued at all 8 institutions as part of routine care because of its benefits regarding the increased understanding of and the need for AYA support. However, there are challenges concerning the burden on both patients and providers and the need to gain an understanding of the entire institution. Just as psychosocial support for AYAs is a national project in Australia , it needThis study suggests the feasibility and preliminary effectiveness of a psychosocial support program based on the DTPL-J for AYAs. The program allows healthcare workers to identify distress and determine the supportive care needs of AYAs, and to address these needs.A previous study showed that AYAs in Japan had a threefold higher risk of major depressive disorder within 6 months before and 12 months after cancer diagnosis compared with cancer‐free controls . FurtherOur findings suggest that the program using the DTPL-J for AYAs may lead to cross-specialty collaboration and improved performance of multidisciplinary teams that support AYAs. This may lead to early palliative care for patients with cancer . As a neThis study has several limitations. First, it used a retrospective, observational design that may have caused several systematic biases. The effectiveness of the program for addressing AYAs’ distress and needs may have been overestimated because of bias, for instance, due to the effect of other factors such as the support of family members. To evaluate the effectiveness of the program, a prospective trial is needed as a next step. Second, the 8 participating institutions all belonged to a research group defined by a Grant-in-Aid, raising the question of institutional bias. Although the median number of newly diagnosed AYAs per hospital is only 3 per year in Japan , the numThis study suggests the feasibility and preliminary effectiveness of a psychosocial support program based on the DTPL-J for AYAs.


With the move to virtual interviewing, residency websites are an important recruitment resource, introducing applicants to programs across the country and allowing for comparison. Recruitment is highly competitive from a common potential pool between vascular surgery, thoracic surgery, and interventional radiology with the ratio of applicants to positions being highest in interventional radiology, followed by thoracic surgery and lastly vascular surgery, as reported by the National Resident Matching Program.The aim of this study is to evaluate the accessibility and availability of online content for those integrated residency programs.A list of accredited vascular surgery, thoracic surgery, and interventional radiology residencies was obtained from the Accreditation Council for Graduate Medical Education (ACGME) database. Program websites were evaluated by trained independent reviewers (n=2) for content items pertaining to program recruitment and education (scored absent or present). Statistical analysis was performed in R software.P=.12). Vascular surgery websites contained a median of 26 (IQR 20-32) content items, thoracic surgery websites contained a median of 27 (IQR 21-32) content items, and interventional radiology websites contained a median of 23 (IQR 18-27) content items. Two content items considered highly influential to applicant program decisions are procedural experience and faculty mentorship, which were reported at 32% (18/56) and 11% (6/56) for vascular surgery, 19% (5/27) and 11% (3/27) for thoracic surgery, and 50% (37/74) and 15% (11/74) for interventional radiology (P=.008 and P=.75), respectively. Key deficits were work hours, debt management, and curriculum for interventional radiology; resident profiles, sample contracts, and research interests in vascular surgery; and operative experiences and the program director’s contact and message for thoracic surgery. Interventional radiology deficits were work hours, and thoracic surgery deficits were procedural experience. Both interventional radiology and thoracic surgery websites lacked information on evaluation criteria and faculty mentorship.Of ACGME-accredited programs, 56 of 61 (92%) vascular surgery, 27 of 27 (100%) thoracic surgery, and 74 of 85 (87%) interventional radiology programs had functional websites (This study has uncovered key differences in the availability of online content for residencies recruiting from the same pool of applicants. Thoracic surgery has the most information, followed by vascular surgery, with interventional radiology reporting the least content. In the era of virtual interviewing from the same potential pool of applicants, programs should review and revise their web presence with the aim to increase the availability of online content to attract valuable candidates. The role of vascular surgeons in the medical environment has changed considerably with the increasing use of endovascular approaches for treatment of vascular lesions . By 2026Candidates for residency programs increasingly use the internet to research potential programs for application -6. OnlinA comprehensive list of accredited integrated vascular surgery, thoracic surgery, and interventional radiology residencies was obtained from the Accreditation Council for Graduate Medical Education (ACGME) database. Programs participating in the 2020 National Resident Matching Program (NRMP) were eligible for study inclusion. Following identification of all programs with websites, programs were accessed and evaluated by two independent reviewers  for availability of recruitment and educational content items. The websites were viewed independently by each reviewer. The program search and review was performed in November 2019.Are there key differences in the three specialty program websites for integrated residencies that could potentially impair recruitment efforts in the virtual environment?direct (landing directly on the program webpage) or indirect .Accessibility of websites was determined by surveying the ACGME database for the total number of programs listed and the presence or absence of website links. Links, if they were provided, were characterized as either functional or nonfunctional. Functional links led to a website. Nonfunctional links led to an error page. Functional links were then evaluated as being either Websites for integrated vascular surgery, thoracic surgery, and interventional radiology residency programs were analyzed for availability of information used to inform and recruit prospective applicants. Content items on recruitment and education (listed in Program recruitment (n=41)Program descriptionNumber incoming positions availableFaculty listingFaculty education and training historyFaculty profile (descriptive)Faculty publicationsFaculty contact informationCurrent residentsResident education historyResident profilesResident contact informationAlumni listingAlumni education historyAlumni contact informationAlumni career placementBoard examination performanceProgram chair messageProgram director messageProgram director contactAdministrative/coordinator contactFacility descriptionApplication requirementsSelection processInterview datesInterview day detailsElectronic Residency Application Service (ERAS) linkIf present, is ERAS link functional?Call requirementContractSalaryWork hoursBenefitsVacationCity informationDomestic considerationsWell-being strategiesDebt managementMeal allowanceEducational fundParkingVisaProgram education (n=16)Rotation scheduleDidactic instructionResearch requirementsResearch interests (department/faculty)Operative experienceJournal clubConference scheduleNational/regional meetings attendedEvaluation criteriaFaculty mentorshipNational organization linkCurriculumCompany linkElective rotationSimulation trainingVascular labWebsites were evaluated for content relevant to program recruitment and education. Program recruitment information included faculty listings, faculty and departmental research interests, alumni career placements, and information on current residents. Recruitment information regarding the application and interview process as well as general resident quality of life metrics were also evaluated see . ProgramEach website was accessed and evaluated by two reviewers  for availability of content items as well as quality of websites . Each reviewer was trained by examining an optimal website, an average website, and a below average website with the senior author. Disputed assessments were resolved by consensus following discussion with the senior author. Reviewers were not blinded.κ=0.74).Overall, there was considerable interrater reliability with 81% agreement .Intergroup analysis of continuous variables was performed using ANOVA. Categorical variables were compared using chi-square analysis. Statistical significance was defined as All data reviewed was open to the public, and there was no contact with fellowship staff; thus, no institutional review board review, ethics approval, or informed consent was necessary.P=.18). Of those programs that provided links, the majority of the links were functional with no difference between the specialties (P=.24). However, few links landed directly on the program webpage. Less than one-third of the programs with functional links provided links that landed directly on the program webpage (P=.52). Overall, 56 of 61 (92%) vascular surgery, 27 of 27 (100%) thoracic surgery, and 74 of 85 (87%) interventional radiology programs had a dedicated webpage  of the vascular surgery, 89% (24/27) of the thoracic surgery, and 95% (81/85) of the interventional radiology programs provided a link to their program webpage on the ACGME webpage  content items, thoracic surgery program webpages contained a median of 27 (IQR 21-32) content items, and interventional radiology program webpages contained a median of 23 (IQR 18-27) content items. Of the 41 recruitment content items included in this analysis, vascular surgery program webpages contained a median of 19.5 (IQR 15-24) content items, thoracic surgery program webpages contained a median of 20 (IQR 16-24) content items, and interventional radiology program webpages contained a median of 18 (IQR 15-21) content items. Of the 16 education content items included in this analysis, vascular surgery program webpages contained a median of 7 (IQR 4-9) content items, thoracic surgery program webpages contained a median of 6 (IQR 4-7) content items, and interventional radiology program webpages contained a median of 4 (IQR 3-7) content items .For program recruitment, almost all programs provided information on program description, faculty listing, faculty education, administrator or coordinator contact information, facility description, descriptive faculty profiles, and the number of incoming positions. The majority of programs provided information on application requirements, a functional link to the Electronic Residency Application Service (ERAS), benefits, salary, current residents, city information, resident education history, domestic considerations, vacation policy, and interview dates. Less than one-half of programs provided information on program director contact information, faculty publications, well-being strategies, faculty contact information, program director message, alumni listing, alumni career placement, educational fund, parking, nonnational visa information, meal allowance, call requirement, alumni career placement, and debt management. Fewer than one-quarter of the programs provided information on sample contracts, resident profiles, interview details, work hours, and alumni education history. Almost no programs provided information on their selection process, resident contact information, program director message, board examination performance, and alumni contact information .For program education, almost all programs provided information on rotation schedule . The majority of programs provided information on didactic instruction, research requirements, journal club, and vascular lab training (Registered Physician in Vascular Interpretation [RPVI]). Less than one-half of programs provided information on departmental research interests, operative experience, meetings attended, elective rotations, conference schedule, curriculum, and simulation training. Fewer than one-quarter of the programs provided information on evaluation criteria and faculty mentorship. Almost no programs provided information on national organizational links and cardiovascular product company links .For program recruitment, almost all programs provided information on program description, faculty listing, faculty education, administrator or coordinator contact information, facility description, and application requirements. The majority of programs provided information on descriptive faculty profiles, a functional link to ERAS, benefits, the number of incoming positions available, salary, current residents, faculty publications, well-being strategy, city information, resident education history, vacation policy, call requirements, and domestic considerations. Less than one-half of programs provided information on program director contact information, interview date, faculty contact information, sample contracts, resident profiles, alumni listings, debt management, educational fund, parking, nonnational visa information, meal allowance, and work hours. Fewer than one-quarter of the programs provided information on program director message, alumni career placement, interview details, and resident contact information. Almost no programs provided information on selection process, alumni education history, program chair message, board examination performance, and alumni contact information .For program education, the majority of programs provided information on rotation schedule, departmental research interests, didactic instruction, and research requirements. Less than one-half of programs provided information on journal club, meetings attended, elective rotation, curriculum, national organization links, and simulation training. Fewer than one-quarter of the programs provided information on operative experiences, conference schedule, faculty mentorship, and evaluation criteria . Almost For program recruitment, almost all programs provided information on program description, faculty listing, faculty education, administrator or coordinator contact information, and descriptive faculty profiles. The majority of programs provided information on application requirements, a functional link to ERAS, facility description, vacation policy, benefits, the number of incoming positions available, salary, current residents, program director contact information, and faculty publications. Less than one-half of programs provided information on well-being strategies, city information, educational fund, parking, nonnational visa information, meal allowance, call requirement, resident education history, domestic considerations, interview dates, faculty contact information, and sample contracts. -quarter of the programs provided information on a program director message, resident profiles, interview details, alumni listing, alumni career placement, selection process, and debt management. Almost no programs provided information on resident contact information, work hours, alumni education history, program chair message, board examination performance, and alumni contact information .For program education, the majority of programs provided information on rotation schedule, departmental research interests , didactic instruction, and research requirements. Less than one-half of programs provided information on operative experiences, journal club, meetings attended, and elective rotations. Fewer than one-quarter of the programs provided information on conference schedule, curriculum, faculty mentorship, vascular lab training (RPVI), and national organization links. Almost no programs provided information on evaluation criteria, simulation training, and cardiovascular product company links .P=.02, P=.008, and P<.001, respectively). Vascular surgery webpages provided less information on departmental research interests as compared to thoracic surgery and interventional radiology webpages . Thoracic surgery webpages provided less information on descriptive faculty profile as compared to vascular surgery and interventional radiology webpages . Interventional radiology webpages provided less information on facility description, debt management (P=.007), research requirements (P<.001), curriculum (P=.04), and simulation training (P<.001) as compared to vascular surgery and thoracic surgery webpages , the average thoracic surgery website score was 2.18 (SD 0.92), and the average interventional radiology website score was 2.25 (SD 0.88). The vascular surgery websites had the highest scores in content, design, organization, and user-friendliness. The thoracic surgery websites had the lowest scores in content, organization, and user-friendliness, while the interventional radiology websites had the lowest score in design. Additional details regarding website quality, broken down by category, are visible in As resident recruitment moves to a virtual platform, the internet is an increasingly important resource for residency applicants as they research programs. Thoracic surgery program webpages had the most information, followed by vascular surgery program webpages, with interventional radiology program webpages reporting the least content. This trend in availability of content items mirrors the percent of positions filled by each specialty, with 100% of PGY-1 thoracic surgery positions filled, 97% of vascular surgery PGY-1 positions filled, and 97% of PGY-1 interventional radiology positions filled , as reported by the NRMP 2020 Main Residency Match Results and Data report .Other factors, beyond program websites, that have been identified to influence applicant interest in a program include geography, advice from a mentor, advice from a peer, and other online information. The integrated vascular track was first accredited by the ACGME in 2006 , the firOf ACGME-accredited programs, 56 of 61 (92%) vascular surgery programs, 27 of 27 (100%) thoracic surgery programs, and 74 of 85 (87%) interventional radiology programs had functional websites. Thoracic surgery program webpages had the most information , then vascular surgery program webpages , with interventional radiology program webpages reporting the least content . The greater amount of content on vascular surgery and thoracic surgery program webpages could be expected, given the young age of many interventional radiology programs. Previous studies have acknowledged integrated interventional radiology program webpages to be a work in progress . This stP=.008 and P=.75), respectively. Additional notable deficits for vascular surgery websites were resident profiles, sample contracts, and departmental research interests. Thoracic surgery websites lacked program director contact information and message as well as information on operative experience. Interventional radiology websites had deficits in work hours, debt management, and curriculum. All specialty websites had deficits in evaluation criteria and faculty mentorship. In addition to addressing the deficits in program recruitment and education content items, the deficits in lifestyle management cannot be disregarded; medical students increasingly report controllable lifestyle as a major factor in specialty choice [Two content items that have been identified to be highly influential to the applicant program decision are operative experience and faculty mentorship -33. Thisy choice ,35.The deficits identified by this analysis are comparable to deficits identified for other specialties. Other studies have found considerable deficits in newsletter, resident listings and photographs, faculty contact information, and away elective rotation information for dermatology websites ; residenOverall, we recommend that programs address the deficits in specific content items identified by this analysis. Given the increasingly important role of online information in the residency application process and the anticipated transition to a virtual application process for the 2021 cycle, it would behoove programs to increase their online presence. In addition to the content items included in this analysis, it might be fitting for programs to include more personal information  to give applicants a better idea of the personality of different programs, replacing the role previously served by in-person away rotations and interviews.This study had several limitations. First, this data is representative of what information was available online at the time of data collection. It is possible that websites could have been edited or new program websites could have been published since that time. Additionally, though an extensive list of content items were evaluated by reviewers regarding program recruitment and education, it is possible that other unmentioned content items could hold bearing on an applicant’s decision. Finally, reviewers were not blinded to what program they were evaluating. Thus, any inherent bias reviewers might have had for particular programs was not controlled for. The nature of this study did not lend itself to evaluating the association between website content, to what specialty and to what programs applicants apply, and ultimate applicant program placement. Future studies could seek to characterize this trajectory.This study has uncovered key differences in the availability of online content for residency programs recruiting from the same pool of applicants. Thoracic surgery program webpages have the most information, then vascular surgery program webpages, with interventional radiology program webpages reporting the least content. Recruitment is highly competitive between vascular surgery, thoracic surgery, and interventional radiology with the ratio of applicants to positions being highest for thoracic surgery, then interventional radiology, and lastly vascular surgery, as reported by ERAS. To attract valuable candidates, programs should aim to increase the availability of online content for potential applicants.


To identify key elements of an outreach strategy for a youth contraception navigator program designed to help young people overcome barriers to contraception access.A human-centered design approach was used to engage adolescents aged 15–17 in co-design sessions. Human-centered design techniques, such as affinity diagramming and model building were used to inform key elements of the communication model and the final outreach strategy messages.Messages focused on the individual, normalizing talking about birth control, acknowledging the challenges to obtaining birth control, explaining how the navigator program works resonate with young people. Having images of diverse participants, offering information about birth control, and showing images of reputable sources will enhance trust.A name (IN Control) and key elements of an outreach strategy were determined for the navigator program. It is important to work with key stakeholders and co-design the optimal strategy and messages to assure that the intended audience is reached, and the desired behavior change is achieved.Human-centered design techniques can be used to provide insight into programmatic outreach strategies for a contraception navigator program to increase their impact and ultimate success. •Increasing access to contraception for youth is critical.•Human-centered design techniques can be used to engage youth on outreach strategies.•Messages focused on individuals and normalizing contraception are key.•Engaging stakeholders is important for ultimate behavior change. ApproYoung people often lack adequate support for overcoming barriers to obtaining contraception prior to, within and after interactions with clinical care. The current landscape of contraception care and the information that adolescents receive within schools can lack comprehensiveness or may be insufficiently evidenced based ,12. A huHCD, which is increasingly being used within healthcare, is an iterative design process where stakeholders most closely affected by the solution are engaged in developing the solution . This isUsing a similar HCD approach, we sought to develop an outreach strategy to activate adolescents who desire contraception to seek help through the contraception navigator program. We hypothesized that an HCD approach could be used to identify key elements of the communication model and inform an outreach strategy for the contraception navigator program.22.1Research Jam (RJ), Indiana Clinical and Translational Sciences Institute's Patient Engagement Core, provided expertise in human-centered design (HCD) techniques. The HCD approach was used to uncover elements of the Reasoned Action Approach (RAA) that impact intentions and ultimate behavior—in particular normative, behavior and control beliefs around obtaining contraception that can be used in messaging strategies ,23..For this project, the objective was to work with youth to co-create messages for a program focused on contraception navigation and access at various parts of a clinical encounter. To meet this objective, the project consisted of two phases: (1) a co-creation phase in which adolescents were asked to begin the message-building process by creating prototypes and (2) a testing and refinement phase in which refined messages created by the team were brought to adolescents for feedback and further refinement . These pAdolescent participants were recruited through social media advertisements and relationships with community organizations that interact with young people, such as schools and standing youth advisory boards. The social media advertisements were displayed on Facebook (Appendix A) and directed to young people that met the geographic and age demographics for the study. After clicking on a social media advertisement or the QR code on a flyer, potential participants were directed to an online survey to confirm their interest and eligibility and provide their contact information. Recruitment continued until adequate numbers of participants in each group had been confirmed eligible and had been contacted.At the time of enrollment, participants were asked to self-identify as White, African American, or Hispanic, and the sessions were conducted separately for each group. We asked participants to choose a group that most reflected their identity, acknowledging not everyone would fit into one alone or at all. Separate design sessions were conducted for each self-identified group to collect data of their specific outreach needs in the event there were differences. Inclusion criteria were the following: age 15–17, ability to speak/read English, access to the internet to utilize the online platform, living in central Indiana, and self-identified as female. The Indiana University Institutional Review Board approved of this study with a waiver of parental permission, participants signed an online written consent. Participants were compensated $75 for the asynchronous prototype message development, and $40 for the one-hour refinement sessions.2.2For the co-creation phase, the RJ team designed activities to engage adolescents in creating prototype visual and written messages about contraception. Activities took place online using Google Sites, Docs, and Slides and consisted of an ice breaker, three prototyping activities and an opportunity for questions to be asked and answered between both participants and facilitators. At the time of consent, a baseline demographic survey was completed by participants, but no question was required to be answered. Participants were given approximately one week to complete the activities with reminders provided via email. Throughout, participants were encouraged to leave comments about what other participants had contributed to create a conversation and build upon ideas.Each human-centered design session followed the same agenda, and the activities were released in sequence and built upon one another with various scenario prompts . For exa2.3The collected data were downloaded and placed into an online whiteboard called Miro . All texexperience maps and personas . Fo. Fo30]. “I think it's a good idea to normalize talking about birth control”.When these prototype messages  were tes“That makes me feel more comfortable to ask questions. It also makes me feel safer with decisions about getting birth control.”“That is a lot of information at once”.“I think we should represent more minorities in birth control. In black communities and other cultures.”The following was noted by participants when asked who should be visually represented in these messages:“Anybody with a uterus because the people who use birth control is a diverse group.”There was also feedback of using simple words and actual terms, instead of innuendos.“Plainly please! Don't sugar coat it, it makes it seem like it's not very serious.”“If you sugar coat it, some people won't understand.”“Don't try to be ‘hip’, speak to us normally.”The overall feedback on messages about the program resulted in the following message guidelines to be considered and final proposed messages .3.3Various program names and versions were presented to the participants and included the following: Birth Control Match, Birth Control Shippers, Mission: Control, IN Control, and BC AF (Birth Control Advisor Force).“It's catchy and it makes the person know/feel that they are in control.”Participants' feedback was that the BC AF name was “funny, but maybe not the most professional” and “trying way too hard to be hip, no offense.” Opinions were split on Birth Control Match and Birth Control Shippers with some noting that it was “straight to the point” but others saying it sounds “very generic” and “misleading” because we aren't shipping birth control directly to participants. The program name “IN Control” resonated the most with participants' sentiments about the program and additional feedback included that the name was empowering and preserved privacy about the topic because it didn't mention birth control.“I like that it is lighthearted but remains professional.”“I like this one, it makes me feel powerful.”“Makes the user feel protected, safe”.The name also included the abbreviation for the state of Indiana, which was noted by participants to be an additional benefit to let young people within our state aware this program was ours and to further increase trustworthiness.44.1A human-centered design approach enabled co-creation of key program communication elements and final messages with young people. Key elements of an outreach strategy, including the name “IN Control” for a youth contraception program were determined. Our findings highlight that adolescents want messages that communicate key elements of the program in a way that normalizes birth control use, helps them feel comfortable learning about birth control options, and acknowledges the challenges to obtaining birth control. The messages need to be focused on the individual and show that the program is trustworthy, open and inviting, and explains how the program itself works. Furthermore, messages should emphasize the focus on client-led decisions and the programmatic support for any decision made as young people may be building competence as health care consumers for the first time.We examined public health campaigns from government entities and organizations around birth control use for similarities and discovered analogous findings . Namely,Additional research has shown that with online media outreach, attention to how messages are constructed is important when thinking about the audience's race and ethnicity . It is wThe use of media campaigns to change health-related behavior is not novel and has shown mixed results depending on the behavior being targeted and how long the impact lasts . In partOur study has some limitations. First, we engaged adolescents in central Indiana and thus the messages may not resonate to all adolescents within the state. The sessions had diversity with prompts and scenarios to address the various geographic landscapes within our state, but it is possible that not all aspects were captured or illustrated in the final proposed messages. Second, the adolescents were asked to self-identify into only three distinct racial/ethnic groups and there exists many more groups within central Indiana. While analysis showed similar results in all three groups, it is possible that messages will not resonate with all adolescents. In addition, our inclusion criteria was limited to those that self-identified as females, leaving potential gaps in our messaging strategy for gender-diverse individuals. We also did not engage parents or sexual partners, who we know play an important role for many adolescents making decisions around contraception use. Finally, although the messages were refined through an iterative process, ongoing feedback will be necessary as this navigator program is piloted and grows.4.2Human-centered design is not new, but its use within healthcare is still in its early stages when compared to other research methodologies. Engagement of ultimate end-users is necessary to create successful interventions. The combination of using HCD approaches to create an outreach strategy and navigator program to impact various elements of the reasoned action change model of behavior change is novel. Our findings are similar to other studies examining how to message reproductive health effectively with young people but augment the literature as they are focused on bringing young people outside of the healthcare system into contact with a navigator who can facilitate that.Our study used an HCD approach which enabled messages to be created and edited with young people's input and to identify key elements that are essential to be included. Our results illustrate the importance of having an outreach strategy that creates trust and provides individual focused information for young people interested in help obtaining contraception. These messages will be integral to the “IN Control” navigator program's ultimate success. While this name has elements that are associated with the state of Indiana, choosing a program name that resonates for various reasons for the end users is important to keep in mind.4.3Our study involved adolescents as key stakeholders and HCD techniques in co-design of messages for a contraception navigator program named “In Control.” The goal of this program is to reach adolescents in Indiana seeking birth control by using a youth-informed messaging strategy and ultimately improve clinical care access within our state.Supplementary Appendix AImage 1Supplementary Appendix BImage 2Supplementary Appendix CImage 3Supplementary Appendix DImage 4The following are the supplementary data related to this article.10.13039/100006975Indiana Clinical and Translational Sciences Institute .This work was supported by an NICHD Award (K23HD099274-01) and through the None.


Introduction: A junior doctor teaching program delivered by near-peers can foster collaboration in a less-pressured and conducive learning environment. The aim of this study was to provide an analysis of an orthopedic teaching program in a high-resource environment utilizing readily available tools and resources that are potentially available in most hospitals globally. Methods: This study involved the utilization of an outcome-based learning approach with regular formal feedback. An anonymized Google Forms survey using a 10-point Likert scale was conducted after a 30-week period. The survey tool was sent out to 28 doctors and two senior nurse practitioners who participated in the program either as tutors, learners, or both. A total of 19 out of 30 respondents completed the survey giving a 63% survey completion rate. The setting for this study was the trauma and orthopedics department in a United Kingdom district general hospital.Results: Learners’ confidence in their orthopedic knowledge and skills pre-program had a median response of eight with a mode of seven whereas confidence following engagement on the program improved with a median response of nine and a mode of 10. At an alpha level of 0.05, this observed improvement was statistically significant using the Mann-Whitney U test (p=0.466). Tutors’ perception of the usefulness of the teaching feedback had a median response of nine with a mode of 10. Relevance of the selected topics had a median response of nine and a mode of 10. Inclusion in the teaching program to cater to learner diversity had a median response of nine and a mode of 10. The effectiveness of a blended approach for learning had a median response of nine and a mode of 10. Conclusion: This study has provided evidence of the benefits of a near-peer teaching program. This is especially important in the post-coronavirus disease (COVID) pandemic recovery period where easily accessible and well-grounded educational programs will be useful to complement the deanery teachings for trainees. This is important as this may be the main source of formal teaching for non-trainee junior doctors in many hospital settings. Additional research will be needed to further explore the pros and cons of such programs within a surgical specialty like orthopedics with an emphasis on the various pedagogical approaches to teaching and learning for junior doctors working in a busy clinical setting.  Near-peer teaching can be described as teaching by tutors who are a few years ahead of learners but on the same training or career spectrum . A junioThere are challenges with conducting teaching sessions for doctors in clinical practice, especially with the current pressures faced by the United Kingdom (UK) National Health Service (NHS) as a result of the COVID-19 pandemic-induced backlog. This means that such teaching programs have to strike a delicate balance between the clinical workload and teaching. A junior doctor teaching program delivered in a structured manner with appropriate educational principles and quality feedback has the potential to contribute to improved patient care delivery through the provision of important knowledge and skills to junior doctors. The correlation of knowledge gained from theoretical discussions to real-life clinical practice is quite beneficial in an experiential learning model from the concrete shared experience to active experimenting as part of Kolb's learning cycle -8. MedicThe Joint Committee on Surgical Training (JCST) in the United Kingdom recommends a minimum of two hours of a formal teaching program per week for all trainees . The teaThe aim of this study is to present the learning points gained from this teaching program and provide a critical analysis of the strengths, weaknesses, opportunities, and possible threats (SWOT) facing such programs, in order to guide other program designers who are currently implementing or plan to implement similar programs within their various local contexts. The setting for this study was an NHS district general hospital or trauma unit in the southeast of England. We instituted a junior doctor teaching program targeted at trauma and orthopedics core trainees, foundation year doctors, trust grade house officers, and rotating medical students within the department. Senior trauma nurse practitioners also participated as learners in the program. Tutors were mainly registrar-level doctors  while some sessions involving orthogeriatric topics were delivered by the orthogeriatric consultants. Consultants were in attendance to provide supervision for 11 out of 30 sessions (37%). Sessions were delivered once weekly on a fixed day and time. Each session was designed to last approximately 45 min. A structured teaching format based on an outcome-based learning approach was utilized. A list of orthopedic and orthogeriatric topics selected based on feedback from the junior doctors and the tutors was fed into a rota schedule displaying the dates and names of tutors Table . This waPeer collaborative discussions and review workshops were used for most sessions. Sessions were delivered in a blended manner to promote access and flexibility with a combination of face-to-face and virtual attendance using Webex . Formal feedback was collected using the Survey Monkey online tool  for each session and used to improve future sessions. The attendance for each session ranged from 5 to 15 doctors over the duration of the program. There was no summative assessment and attendance was voluntary but encouraged. Formative assessments in the form of clinical problem-based scenarios and interactive multiple-choice questions were built into the sessions utilizing "buzz groups" of two to three students per group.The program was analyzed after a 30-week period . This analysis was conducted using anonymized responses collated via online Google Forms  sent out at the end of the 30-week period. The survey tool was sent out to 28 doctors and two nurse practitioners who participated in the program either as tutors, learners, or both. Feedback responses were provided on a 10-point Likert scale with one being the lowest rating for the assessed item in the questionnaire and 10 being the highest rating or best available positive response (see Appendix section). Data were transferred to a Microsoft Excel sheet  for analysis.Overall, a total of 19 respondents completed the survey giving a 63% survey completion rate. Some 57.9% of respondents were learners in the program, 10.5% served as tutors while 31.6% were both tutors and learners on different occasions. Some 94.7% of respondents were working in orthopedics while 5.3% were in orthogeriatrics. Some 31.6% of respondents were registrars, 26.3% were resident medical officers, 15.8% were trust grade senior house officers, 15.8% were core trainees, and 10.5% were orthopedic nurse practitioners.For respondents' confidence in their orthopedic knowledge and skills prior to the commencement of this program, out of the 18 completed responses for this domain, the median response was eight, and the mode was seven . For tutors’ perception of the usefulness of the formal feedback provided per teaching session, the median response was nine with a mode of 10 Figure .Relevance of the selected teaching topics among both tutors and learners had a median response of nine and a mode of 10. The inclusion of the teaching program to cater to learner diversity had a median response of nine and a mode of 10 Figure .For the effectiveness of the use of technology to improve access to sessions via a blended approach, the median response was nine and the mode was 10 Figure . Some 89.5% of respondents felt the presence of a consultant to provide direct supervision for each session would have been beneficial while 79% felt a bleep-free or protected time period for the once-weekly teaching program was needed. As seen from the results, this teaching program increased learners' confidence in their orthopedic knowledge and skills. A randomized control trial employing near-peer teaching on a surgical skills course demonstrated improved learner performance in some skill-set domains . HoweverFor this study, the learners were quite diverse in terms of medical training with some being UK-trained and others international medical graduates. There was some variation amongst learners in terms of knowledge level, skill level, cultural differences, being a trainee vs non-trainee, gender, ethnicity, and work commitments. The program had to be inclusive bearing in mind this rich learner and tutor diversity, in order to address both intrinsic and extrinsic factors that could potentially affect learning. A learning environment as obtained in this teaching program allows for open interaction and questioning fostering psychological safety . LearnerAnother strength of the program was the well-defined structure and ease of access as it was delivered through a blended learning approach enabling clinicians who were working off-site to participate. This was reflected in the positive response from most learners and tutors in the program. Finally, the results from this study showed that most respondents found the use of formal feedback to be important and beneficial. There was a strong utilization of reflective practice through formal feedback per session and utilized to improve future sessions using Pendleton’s model . The proSome of the limitations of this study include the lack of a bleep-free time period for these sessions which was due to the clinical pressures meaning some clinicians had to employ a great deal of flexibility and time management to actively engage with the teaching sessions. This was the main limitation identified in the survey of learners and tutors on the program. A potential way of overcoming this challenge might be to allocate a single bleep holder for the wards during the teaching program except when an emergency situation arises. This technique is utilized by some other NHS hospitals but this is a relatively complex issue to address. Another possible limitation is the lack of consultant supervision for all sessions. This may not be a major issue if anybody implementing a similar program ensures it is well-structured and built on a sound medical education pedagogy. Furthermore, orthopedics has a good culture of daily trauma meetings which provides an avenue for consultant teaching in most cases. However, consultant attendance to provide supervision at the formal teaching program potentially helps foster teamwork and provides an avenue for junior doctors to gain clarifications on certain complex issues beyond the time-constrained trauma meeting setting. Another limitation of this study is the lack of a control group in order to compare the results. Finally, a larger sample size could have increased the study quality. However, the population studied was restricted to a single orthopedic unit in a single hospital. Opportunities for future development of the index program or similar programs in other hospital settings exist. Formal training/courses on higher education learning theory and practice can be provided for all tutors within such a program, in order to improve the learning experience. Ring-fenced sources for funding for practical sessions on such programs will be useful. This can be provided through appropriate collaboration with the industry or through utilizing the department’s medical education budget. A certificate or letter of recognition for teaching in such programs can also improve enthusiasm and be useful evidence for annual appraisal or review of competence progression. Anybody planning a similar program should be aware of the aforementioned challenges and threats to implementing a successful program. In addition, there has to be an effective, highly motivated leader of the program for it to be maintained and successful. Effective collaboration with colleagues and the clinical leadership of the department should be cultivated in order to ensure such a program is well-institutionalized. Regular audits of such programs as part of quality improvement will ensure standards are maintained and innovations are introduced on a regular basis.This study has demonstrated key lessons for a junior doctor teaching program in orthopedics employing near-peers for teaching. This has not been extensively studied in the literature as it applies to trauma and orthopedics. An analysis of the program has been provided to guide other medical educators planning or already engaged in similar programs. Such a program can complement the deanery-organized teaching for trainees and maybe the main source of regular, formal teaching for non-trainee junior doctors. This study has provided evidence within a relatively small cohort of the benefits of such a teaching program, especially in the post-COVID pandemic recovery period where easily accessible, cost-effective, and well-grounded educational programs will be useful for many hospitals and departments. These can be adapted for use even in low-to-middle-income settings. Additional research will be needed to further explore the strengths and limitations of such programs within a surgical specialty like orthopedics with an emphasis on the various pedagogical approaches to teaching and learning for junior doctors working in a busy clinical setting.


Despite the high proportion of female medical students, the leading positions in almost all medical departments are still considerably less often held by female clinicians than by male. The aim of this project report is to introduce a career mentoring curriculum for female clinician scientists at Ruhr-University of Bochum in Germany.The career mentoring program was developed for young female clinician scientists who aim for a leading position in academic medicine. We describe and discuss herein its planning and implementation over two years (11/2020-11/2022) focusing on the needs of the target group. The mentoring program is based on an agile twin-track strategy. It includes peer mentoring, content-related input and interdisciplinary three-to-one mentoring by the coordinators. Additionally, the mentees develop and conduct a scientific project to practice their acquired skills in a protected environment. The quality assurance system of the mentoring program includes a continuous evaluation of the mentees’ satisfaction with the content and organisation of the program, whose results serve as the basis of the prompt adjustment of the latter. It also includes an evaluation of the sustainable impact of the program on the mentees’ career development based on an adapted role matrix. The role matrix addresses the mentees to acquire the competencies required for them to become a successful clinician, scientist and academic teacher.A 2-year innovative and unique career mentoring program for female clinician scientists was developed and already successfully launched. Making use of different mentoring strategies, the program has the potential to promote gender equality and encourage female physicians to pursue a career in academic medicine. Mentoring originally belonged to the area of human resources development , althougThe mentoring programs that have been established at Ruhr-University Bochum in Germany have been designed addressing medical researchers in an interdisciplinary context  . These p1 in human medicine/health sciences, the percentage of women was 35%  and in  was 35% , 23], ,  we we“MentÄThe program has the following objectives:to encourage the program participants to engage in career thinking, and strategy development to motivate the program participants to consider career feasibility and to aspire for a leading positionto encourage the program participants to engage in self-organisation and project managementto encourage the participants to communicate and to make them visibleto initiate and promote networking among the program participants and with others.The Committee for Equal Opportunities of Ruhr University Bochum and the integrated Lore Agnes Program financially support gender-oriented programs every year . The afoThe mentoring program presented herein is based on a unique twin-track strategy. On the one hand, we adopted common features of other mentoring programs, such as peer mentoring, (modified) one-to-one mentoring and content-related workshops. On the other hand, we integrated an interdisciplinary project within the program to enable the program participants to practice all their acquired skills in a protected environment. Thus, the mentoring program includes the main blocks below  practical approachscientific projectdevelopment and implementation of an interdisciplinary Peer mentoring is used to establish a network and to jointly strengthen the motivation for clinical research and teaching projects in addition to everyday clinical practice. The focus is on the participants (peers), who motivate each other in their individual careers. A short input on the topic of “collegial advice” at the beginning provides the theoretical basis for peer mentoring including an agreement on the use of discretion. Subsequently, in a group discussion, the participants regularly reflect on their goals and interests and receive feedback from the other peer group members on their work plan, with the support of the coordinators. The networking between the peers is intended to facilitate exchange within the scientific network and to motivate the participants to focus on career development with its various aspects at an early stage.(three-to-one mentoring). Thus, the coordinators also serve as a “mentor team” with an interdisciplinary background from the surgical and conservative fields covering multiple facets of the work of a clinician scientist. Further, they continuously share their latest experiences on the balancing act between clinical practice, research, teaching and private life.In addition, the mentees get individual feedback and input about strategic career planning from the coordinators content-related workshops offered to strengthen competencies for future clinical research and to give input on possibilities and important milestones for a clinical career. These include self-organisation, project management, leadership, communication skills and conflict management. Another important component of the program is the scientific project. Thus, they are being encouraged to actively participate in academic medicine . In fact, the programs’ goal should be the provision of equal opportunities for all motivated and qualified actors. “MentÄ – Successful in clinics, academics and science”) was developed and successfully launched at Ruhr University Bochum. Making use of different mentoring strategies, the program has the potential to promote equal opportunities for female clinical scientists and encourage young female physicians to be an active part of the academic medicine.An innovative and unique 2-year career mentoring program for female clinicians  for the time of 6 years (2020-2026).The authors declare that they have no competing interests.


Since 2007, voluntary medical male circumcision (VMMC) programs have been associated with substantially reduced HIV incidence across 15 prioritized countries in Eastern and Southern Africa. Drawing on the programmatic experience of global VMMC leaders, this report reviews progress made in the first 15 years of the program, describes programmatic and research gaps, and presents considerations to maximize the impact of VMMC.Overall, key programmatic and research gaps include a lack of robust male circumcision coverage estimates due to limitations to the data and a lack of standardized approaches across programs; challenges enhancing VMMC uptake include difficulties reaching populations at higher risk for HIV infection and men 30 years and older; limitations to program and procedural quality and safety including variations in approaches used by programs; and lastly, sustainability with limited evidence-based practices. Considerations to address these gaps include the need for global guidance on estimating coverage, conducting additional research on specific sub-populations to improve VMMC uptake, implementation of responsive and comprehensive approaches to adverse event surveillance, and diversifying financing streams to progress towards sustainability.This report’s findings may help establish a global VMMC research and programmatic agenda to inform policy, research, and capacity-building activities at the national and global levels. Voluntary medical male circumcision (VMMC) was first formally recommended in 2007 by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) as an effective and essential HIV prevention strategy . Since tIn 2007, WHO and UNAIDS’s recognition of VMMC as an efficacious prevention strategy was prompted by findings from randomized controlled trials (RCTs) conducted in Kenya, Uganda, and South Africa, demonstrating a reduction in the acquisition of HIV in men by up to 60% Fig.  4–7]. C–7. C4–7]In 2011, WHO and UNAIDS published a framework to guide the development of VMMC programs . The proFrom 2007 to 2020, adolescents aged 10–14 years comprised the greatest proportion of VMMC clients. In 2020, there was a shift in the age distribution of VMMC clients due to updated global guidance and changes in PEPFAR’s age eligibility restricting procedures to clients 15 years and older ••, 17••.After the initial scale-up phase, programs were meant to enter a second phase, the sustainability phase, where the focus would shift to younger adolescents and infants who were not eligible for VMMC during the first phase. Programs were intended to enter this phase once they had achieved at least 80% male circumcision coverage among 15–49-year-old males. Each country established a national program providing VMMC services to all infants up to 2 months old. During the implementation of this second phase, VMMC services were also meant to be integrated into national health systems. In practice, both proposed phases of the program were implemented differently from the original plan.Although VMMC programs were implemented differently than initially planned, the growth and achievements of the VMMC program to date carry immediate and future benefits . By 2020This section outlines relevant VMMC programmatic and research gaps and recommends priority steps to address them Table . IdentifCircumcision coverage estimates play a critical role in VMMC program planning, target setting, and monitoring progress towards HIV epidemic control goals. The VMMC programs use a variety of survey and sampling methodologies, statistical tools, and data to estimate coverage. National household surveys, including the Population-based HIV Impact Assessment (PHIA) and the Demographic and Health Surveys (DHS), are commonly used to inform the estimation of VMMC coverage , 27••. HThere are limitations to national household surveys when used to estimate coverage. Typically, the subnational circumcision estimates are less robust than national-level estimates when using national household surveys. Less robust estimates at the subnational level are partly because of inaccurate or dynamic denominator data with limited information on internal and external population migration, particularly in countries with older census data, high mobility, or areas with an unstable population with a high proportion of unregistered immigrants, migrant workers, and refugees. This denominator issue is particularly pronounced in countries where granular clinical data are missing at lower administrative levels and in countries with great variation in coverage across geographic regions. The lack of robust subnational-level estimates is partly because national household surveys are not designed statistically for estimating male circumcision coverage.Additionally, there are limitations to how male circumcision is measured, usually through self-report, with challenges distinguishing medical and non-medical male circumcision. Previous research has found conflicting findings with self-reported circumcision status may be subject to reporting errors in some settings. At the same time, in other areas, there is high concurrence with physical exams , 30. TheAccording to anecdotal reports, another challenge to estimating accurate coverage is VMMC may be “replacing” non-medical male circumcision in some settings. However, the models and tools used to estimate coverage sometimes assume the proportion of non-medical male circumcision in a national population remains constant. Therefore, additional research is needed to estimate non-medical male circumcision coverage more precisely in various settings.Robust estimation of male circumcision coverage is important for all aspects of the program but is particularly critical for setting program targets. UNAIDS establishes VMMC targets roughly every 5 years, aligning with goals for ending the AIDS epidemic. Prioritized countries adopt these targets nationally, typically establishing 5-year plans to reach these goals. In addition, PEPFAR supports national governments in establishing program targets annually. However, the accuracy of these targets, particularly at the subnational level, is limited by the reliability of male circumcision coverage estimates discussed above. Overall, there has also been a lack of a standardized approach to establishing coverage estimates and set targets. In 2020, the UNAIDS Reference Group on Estimates, Modeling, and Projections, along with partners, worked with prioritized countries to integrate VMMC into the UNAIDS HIV estimates process to standardize the process , 32. HowDefining the types of data collected to supplement national household surveys could help countries determine when additional survey data is needed and which sources are best used in triangulating data. Guidance may be helpful to identify programmatic and service delivery gaps among specific eligible sub-populations with lower male circumcision coverage. Establishing standardized framework countries could easily adapt for estimating coverage at the district or lower administrative level or help identify pockets of low coverage could increase reliability in estimates. Additionally, improvements can be made to national household surveys to improve the accuracy of VMMC reporting. For example, a standardized male circumcision module could be included in national household surveys to more accurately document circumcision status among males through direct observation of circumcision status. As countries reach higher male circumcision coverage, estimating VMMC coverage will become increasingly challenging considering, as coverage rises, estimates become increasingly sensitive to errors in target population estimates.Despite the success of the VMMC program, there is an ongoing effort to improve strategies to increase VMMC uptake to reduce HIV incidence to reach epidemic control. Programs currently use a variety of approaches and strategies to tailor the most successful interventions for enhancing uptake ••, 33–35Programs are also facing a digital divide. There is varying capacity to implement technology in social media campaigns across prioritized countries. Only programs with the specialized knowledge, infrastructure, and financial resources to develop the mobile tools have the advantage of utilizing the algorithms social media affords reaching targeted groups with tailored messaging. Programs have experienced recent success in using innovative technology to target specific audiences through social media, particularly to engage older men .A promising strategy for improving uptake of VMMC is psychographic-behavioral segmentation, using human-centered design (HCD). Through segmentation, potential VMMC clients are categorized according to certain characteristics, which allows for specific messaging based on a client’s profile . InitialDevice-based male circumcision may influence men’s perceptions of VMMC and may be a promising approach to increase uptake ••, 46. HVoluntary medical male circumcision is a preventive procedure typically performed on healthy males. Safety has been a critical priority for VMMC programs, and VMMC has demonstrated it is a safe procedure. Adverse events have been monitored since program inception, and overall, < 2% of VMMC clients have been identified through passive reporting as having moderate or severe AEs , 50. In Quality assurance and quality improvement activities commonly practiced by VMMC programs include AE surveillance, AE investigations and contributing root cause analyses, external quality assessments, and continuous quality improvement. However, each national program has its approach to quality and safety, which often changes over time and is frequently determined in reaction to an event. Therefore, the lack of a deliberate approach to program quality can lead to inadequate monitoring, missed epidemiologic signals, insufficient AE investigations and analyses, improper corrective actions, and ultimately, missed opportunities to improve safety for clients and staff.With any surgical intervention, it is impossible to eliminate all complications. When AEs occur, timely diagnosis and optimal management can minimize long-term sequelae. Although tools and guidance have been developed to standardize and improve the management and prevention of commonly reported AEs, there is considerable variation in how national VMMC programs manage certain severe AEs , 54, 55.Informed consent/assent is a critical component of preoperative counseling. Counseling on risks and benefits can be transparent and delivered in easy-to-understand language with ample opportunities for clients to ask questions. Clients, especially younger adolescents, have a wide range of maturity and capacity to understand the procedure, potentially impacting their ability to give informed consent/assent. Although the general need for client understanding of risks and benefits prior to surgery is well-accepted, there is a potential need for greater assessment and support of adolescents’ capacity for autonomous decision-making in healthcare settings .Improving VMMC safety is a constant priority for VMMC program planners and implementers. Recommended priority steps for improving the quality and safety of VMMC programs include a responsive, standardized, and comprehensive approach to AE surveillance. Through continuous quality improvement, surveillance data for action gives purpose to surveillance by translating safety events to improved outcomes for future clients and overall improved program safety. Continued monitoring of quality and safety activities can remain a critical component of VMMC programs. Standardized summaries of risks and benefits could be developed for VMMC programs to translate and use for eligible clients to improve informed consenting practices. In addition, global guidance is needed on how VMMC counselors can assess the ability of younger clients and their parents or guardians to comprehend and provide consent or assent for VMMC.Robust networks and coordination across programs are needed to improve the safety and quality of VMMC programs. Establishing a network of shared safety experiences within and across national VMMC programs could amplify best practices and provide a mechanism to share AE management experiences. Additionally, improved coordination within and among countries to optimize the management of serious, complex AEs is needed. Additional research on the categorization of attributes of clients at higher risk for AEs or who missed follow-up appointments could help to identify higher risk clients to prevent adverse outcomes. Additionally, male circumcision devices warrant monitoring to inform programming decisions around safety and sustainability. Finally, another important gap is that the program has primarily concentrated on the quality of the procedure but has not focused as rigorously on the quality of other areas such as HIV testing services, medical record keeping, demand creation, and client education. Additional attention and resources may be needed to ensure all aspects of quality for the VMMC program are rigorously monitored.Following the first 15 years of program expansion, the sustainability of national VMMC programs is becoming increasingly important. Although sustainability was initially conceived as a distinct phase of program transition, sustainability of VMMC will require a more gradual evolution including measured integration of VMMC services into national health systems. The sustainability of VMMC is particularly important with economic modeling predicting the program will continue to be a cost-effective prevention strategy and, in fact, cost-saving in most countries over a 50-year horizon . In 2020Priority steps could be taken to progress successfully to fully sustainable VMMC programs. The VMMCs programs have relied largely on donor support, and the need for diversified financing streams is evident, as donor-funded programs alone are not sustainable. Engaging ministries of health and finance will be critical as national health priorities are financed. However, careful evolution of financial responsibility is essential, with most countries lacking the resources to fully support HIV prevention services. Priority components for VMMC sustainability for each of the building blocks are outlined in the WHO framework summarized in Table For the supplies and equipment building block, integration of procurement and distribution of supplies into national procurement systems are recommended. This area may be easier to transition, with several ministries of health already procuring supplies for other health services. Although the scale-up phase of the program primarily relied on single-use instruments, more recent guidance has prioritized reusable instruments, not only for the sustainability of services but also to reduce costs and environmental impact. Considerations for the leadership and governance building block focus on integration with local governance. Leadership and governance for VMMC have been country-led since the program’s inception and maintaining this momentum will be critical for the program’s sustainability. Lastly, key actions for the service delivery building block focus on strategic planning of health services and promotion of VMMC as part of a comprehensive package of care.Measuring a country’s progress towards sustainability is critical for countries to understand and assess their transition. A 2022 landscape analysis conducted by WHO and UNAIDS applied the above-referenced framework and summarized the status of each country’s VMMC program in relation to the sustainability of services. The overwhelming majority of the WHO building block designations were either at an early or intermediate phase with minimal or only a few sustainable features present. A full report on the analysis is expected to be published in mid-2022.Many countries have taken steps towards sustainability. Actions range from developing national plans for sustainability to piloting the transition of service delivery from donor-funded community organizations to government services , 61. ForThe issues presented in this report contribute to policy and research agenda-setting and action at the global and national levels. Continuing the progress VMMC programs have made during the first 15 years of the program is important to reduce HIV incidence and achieve the UNAIDS 2025 AIDS Targets for 90% of males 15 years and older to have access to VMMC in prioritized countries –64. Howe