The Royal College of Physicians and Surgeons of Canada (RCPSC) adopted a plan to transform, over a seven-year horizon (2014-2021), residency education across all specialties to competency-based medical education (CBME) curriculum models. The RCPSC plan recommended implementing a more responsive and accountable training model with four discrete stages of training, explicit, specialty specific entrustable professional activities, with associated milestones, and a programmatic approach to assessment across residency education. Embracing this vision, the leadership at Queen’s University  applied for and was granted special permission by the RCPSC to embark on an accelerated institutional path. Over a three-year period, Queen’s took CBME from concept to reality through the development and implementation of a comprehensive strategic plan. This perspective paper describes Queen’s University’s approach of creating a shared institutional vision, outlines the process of developing a centralized CBME executive team and twenty-nine CBME program teams, and summarizes proactive measures to ensure program readiness for launch. In so doing, Queen’s created a community of support and CBME expertise that reinforces shared values including fostering co-production, cultivating responsive leadership, emphasizing diffusion of innovation, and adopting a systems-based approach to transformative change. This approach ensures that capable residents will move through training at an individualized pace (faster or slower) in a more efficient manner, saving valuable resources, creating greater flexibility, and better preparing them for their individual paths to independent practice.3 The benefits of CBME may not be limited to trainees; the potential of CBME extends to all stakeholder groups.According to Frank et al., competency-based medical education (CBME) approaches have the potential to positively alter the future of medical training.5 Embracing this challenge, the Queen’s Family Medicine program operationalized an approach to CBME that exceeded the requirements of the CFPC, and provided guidance to the faculty-wide initiative .6 The Queen’s approach, launched in 2010, required enhanced approaches to curricular planning, assessment documentation, and the use of EPAs.7Within Canada, the College of Family Medicine of Canada (CFPC), responsible for the accreditation of Family Medicine programs, initiated their transition to CBME in 2010.9 Embracing the potential of CBME, and with permission from the RCPSC, Queen’s University set a goal to be the first university in Canada to implement CBME across all of its twenty-nine specialty programs starting with the incoming cohort (n=93 trainees) in July 2017. It was a seminal decision to move all our postgraduate medical education programs in line with our Family Medicine program at the same time, rather than by the national specialty cohort design proposed by the RCPSC. This decision meant the entire system at Queen’s had to evolve in tandem to ensure readiness for CBME.Later in 2014, the RCPSC, the body responsible for the accreditation of all other graduate medical education programs, unveiled the Competency by Design (CBD) project and mapped out a seven-year transition for all postgraduate medical education specialty training programs across Canada. The RCPSC recommended implementing a more responsive and accountable training model with four discrete stages of training, explicit specialty-specific EPAs with associated milestones, and a programmatic approach to assessment across residency training programsUnique to its university environment, many circumstances seemed advantageous for Queen’s to make the transition: a relatively small institutional size, a collegial atmosphere, a centralized funding formula for teaching faculty, specialized assessment expertise, outstanding information technology resources, a state of the art clinical simulation centre, colleagues from the Department of Family Medicine who had successfully implemented competency-based education previously, and a shared educational vision from institutional leadership.Embarking on this ambitious path required a comprehensive implementation strategy that could leverage the numerous institutional strengths, engage all partners and key stakeholder groups in the change management process, build a central CBME governance structure, and promote a shared leadership model across twenty-nine postgraduate programs. Over a three-year period, Queen’s University School of Medicine navigated a systems-based approach to transformative change and launched CBME curricular models in residency education across all training programs on July 1, 2017.Beginning in 2014, the decanal leaders within the School of Medicine at Queen’s University set the foundation for CBME implementation. Key to this foundation was clearly articulating, in the School of Medicine’s strategy, that a collective goal was the design and implementation of new educational models. As such, delivering on this strategy was a shared responsibility of the decanal team and the School’s departmental leadership teams. The School of Medicine and its system-wide physician practice plan decided to co-invest in one-time start-up costs that provided each of the twenty-nine programs with the equivalent of one day per week protected time for a faculty member and the ability of each program to hire part-time education expertise. In addition, the School of Medicine provided significant in-kind support for information technology (IT) infrastructure, educational consultancy, and leadership salaries.Project governance was established to set operating boundaries for the CBME project through the appointed CBME Executive Team . The exe10 This process was essential because deviating from the existing national accreditation standards and implementing new CBME curriculum models across twenty-nine specialty programs at Queen’s required the permission from the postgraduate accreditation body in Canada – the Royal College of Physicians and Surgeons of Canada. From there, key priorities included:Development of an CBME Executive Team governance modelCreation of guiding principles for CBME implementationDevelopment of an institutional program evaluation initiativeCreation of a diverse stakeholder engagement processProvide supporting expertise and collaborative processes for the co-creation of stage-specific EPAs for all specialty programs.Creation of multiple institutional support systems for curricular reform, assessment reform, faculty development, simulation resource expansion, and medical education scholarshipCreation of a comprehensive CBME budget modelApproval for fundamental changes to the faculty’s accountability framework as it relates to the transition and sustainability of CBME across all postgraduate programs at Queen’s UniversityBeginning in 2015 and through to 2017, the CBME executive team carried out important foundational work. The first task was the submission and subsequent approval of the RCPSC Fundamental Innovations of Residency Education (FIRE) proposal.Meeting for over two years on a weekly basis, the CBME executive team was supported by five CBME sub-committees  that were led by members of the executive team. The sub-committees were comprised of faculty (MD & PhD), residents, and education consultants . These sub-committees provided regular direction and feedback to the central team that was integrated into the overall project implementation plan. The following provides an overview of each committee and their purpose within our CBME implementation.The Curriculum Sub-committee was established to provide a forum for program leaders to discuss methods of curricular reform within postgraduate medical education. The Curriculum Sub-committee provides leadership to the CBME project team in regard to best practices, policies and protocols to aid with Queen’s transition to a competency-based medical education model. This group acts in an advisory capacity and in consultation with the CBME Executive Leadership Team.Development and support of tools to assist specialty programs in aligning curriculum activities to EPAs within and across stagesDevelop a preparation course that supports all trainees for the Medical College of Canada Licensing Exam - Part IIContribute to the design of CBME workshops, specifically with regard to curricular components .The goals of the Curriculum Sub-committee were:Defining practice guidelines to support the development and evaluation of CBME programmatic assessment, guided by the principles of sound assessment practice.Providing in-put on the design of Elentra functionalities.Supporting the sharing of assessment innovation across programs.Establishing assessment-blueprinting strategies.Contributing to the refinement of CBME assessment policy.Supporting faculty development initiatives related to assessment.The Assessment Sub-committee was established as a collaborative working group to address assessment priorities related to Queen’s transition to a CBME model. Group membership was purposefully designed to leverage input from a wide range of specialties and sub-specialties, draw on assessment expertise from across the institution , and facilitate access to the Education Technology Unit responsible for CBME module development in Elentra™. Initially, members of this committee focused on developing the Queen’s constructive alignment curriculum design process. Employing a backwards design orientation, a template to guide program development of EPAs, assignment of enabling competencies/milestones, designation of required training experiences, and determination of assessment requirements was developed. Once CBME program development was underway, attention of the committee shifted to an advisory capacity, in consultation with the CBME executive leadership team. Priority responsibilities for the group were defined as:The Faculty Development Sub-committee was established to support the implementation of CBME at Queen’s through the development of program leaders and front-line faculty. Over a two-year period, the design and execution of a multi-faceted strategy for CBME program leader and frontline faculty development included: single and multi-day program leader workshops, regular small group sessions, seminars, webinars, on-line resources, regional teaching site orientation sessions, and weekly one-on-one consultations with expert members from the executive team.In the process, faculty leaders were required not only to become familiar with the tenants of CBME, but also needed to create new curricular documents for their individual programs such as stage-specific EPAs with milestones and develop stage-specific assessment plans that included novel assessment tools. This work was performed throughout the academic year, usingone-on-one consultative meetings with experts to meet the iterative and evolving needs of the faculty leaders, and through strategically planned collaborative workshops. Thereby all program leaders came together to talk about best principles in a shared leadership environment to create program specific documents defined by stage-specific EPAs. Most importantly, the series of multiple workshops over a period of more than two years provided a forum for all program leaders to engage in a community of shared learning and leadership, whereby collaboration and shared experiences greatly enhanced the momentum and acceptance of the shift to CBME.The CBME Resident Sub-committee was established to provide a forum for discussion and advocacy concerning resident issues in anticipation of the transition and implementation of CBME. The group provides support to the CBME executive team in developing effective and transparent communication strategies to inform current and incoming residents of CBME expectations and updates. The group also communicates closely with the Resident Doctors of Canada and the Professional Association of Residents of Ontario regarding CBME implementation at Queen’s, and represents the interest of residents at the hospital, provincial, and national levels during the CBME transition at Queen’s.Contribute to the design of ongoing faculty development workshops, specifically with regard to academic scholarshipDirect the allocation of grant money and supported projectsContribute to the development of a systematic institutional support structure for the development, implementation, and sustainability of CBME scholarly activitiesThe Scholarship Sub-committee was established for the purpose of leveraging the expertise of academic researchers and scholars within the Faculty of Health Sciences. The Scholarship Sub-committee provides leadership to the CBME project team related to research-based best practices, policies and protocols to aid with Queen’s transition to a CBME model. Its mandate is to review measures required to strengthen, enhance and promote the output of scholarly activity relating to Queen’s School of Medicine’s transition to a competency-based medical education model. Its goals are to:In addition to the five key executive sub-committees, four additional areas of focus were essential to the central plan of CBME institutional implementation: education technology, simulation capacity, stakeholder communications, and program evaluation.TM.11 Led by the manager of the Education Technology Unit, along with key members of the executive team, an iterative process of design, piloting, and feedback was created to ensure essential design elements required for the implementation of CBME were addressed.The education technology steering committee was assembled to oversee development of the electronic resident portfolio (CBME module), an extension of the integrated teaching and learning platform ElentraThe Elentra CBME module includes data collection, aggregation, and advanced display functionality and is customizable to differential program needs. Programs have the freedom to select from and customize a variety of assessment templates and tag assessments to any level of the curriculum hierarchy .Once published, assessments can be triggered by residents and faculty at the bedside or scheduled for distribution by a program. Assessment information gathered from multiple assessors  across various clinical and academic settings, and over time, are combined and displayed on the “resident dashboard” which is accessible to the resident, their program director, academic advisor, and the program competence committee.The dashboard supports residents and faculty to monitor performance in real time and track progress over time. Advanced filtering functionality allows users to easily search resident assessment data to inform progress and promotion decisions. Reporting functionality permits academic advisors to record performance review meetings and upload summaries for review by individual program leaders. Additional reporting functionality permits program leader sign-off EPAs on the dashboard interface.Essential to the project’s change strategy was regular and ongoing stakeholder and partner communication. With such an ambitious project, it was critical to inform and receive feedback from the many interconnected groups involved in postgraduate medical education. This feedback occurred in many forms on a regular monthly basis through one-on-one meetings, teleconferences, email communications, newsletters, committee meetings, and regional and national presentations.Stakeholders fall into into numerous overlapping groups that include many CBME sub-committee members, hospital partners at our University and distributed sites, frontline faculty, current resident trainees, program leaders, decanal leaders, patient advisors and community members, and the RCPSC executive leadership.Build and sustain the momentum of support for the institutional change to a competency-based medical education curriculum;Mitigate resistance to change, both internally and externally;Foster effective communications to all stakeholders; andEnhance Queen’s School of Medicine’s brand by ensuring the CBME transition aligns with the School’s mission to advance the science and practice of medicine to benefit the health and well-being of the population while doing this through excellence in education, care and research.The goals for our stakeholder group were:The introduction of CBME across all postgraduate medical education programs requires significant resources and a strategic vision for skill acquisition, training, and assessment at the Queen’s Clinical Simulation Centre (CSC) and the Department of Biological and Molecular Sciences (DBMS) Anatomy Lab.At present, the CSC and DBMS Anatomy Lab are responsible for providing simulation-based learning opportunities for all UGME and PGME trainees. The implementation of CBME across all of our graduate medical education programs requires additional resources to support our educational mandate, both in curriculum and assessment. This includes additional simulation equipment, supplies, simulation technician time, standardized actors, video equipment capabilities, task trainers, and cadaver specimens. Faculty support and faculty development must also occur to ensure faculty teachers develop the prerequisite skills required to lead newly created training experiences and enhanced competency assessment in simulation environments. As a result, additional funding was allocated to meet the needs of the new CBME curricula.12 The components are overlapping elements which, when taken together, can inform the process of change across an institution. In CBAM, change is described as a process encompassing three stages: creating the foundation, implementation, and ensuring sustainability. The strengths of this approach allow for the identification of stakeholder groups or specialty programs that may be struggling with the transition, and identifies needed supports early in the implementation process. Ongoing monitoring of CBME will continue using Outcome Harvesting.13 Outcome Harvesting is suitable for evaluating complex programming contexts and is especially useful when the aim is to understand how individual outcomes contribute to broader system-wide changes. This approach draws on the knowledge of key informants who understand the change that has taken place, as well as their contributions to that change. Overall, this comprehensive approach to capturing data across the institution will help inform the future directions and central support required for the CBME project.Starting in 2015 at the beginning of the CBME project, an institutional program evaluation strategy was initiated to document the many stages of the change process. The key methods being used for the evaluation of the initial CBME implementation are the Concerns Based Adoption Model (CBAM) and Outcome Harvesting. CBAM is based on three components: Stages of Concern questionnaires, Levels of Use interviews, and an Innovation Configuration map.14 and other approaches to program evaluation, all programs will be supported to complete ongoing program evaluation as the CBME implementation process continues to unfold.In addition to the comprehensive data captured from all stakeholder groups at an institutional level, individual programs have embarked on their own “program specific” program evaluation processes. At the program level, the shift to CBME represents many changes and iterative processes in action. Using rapid cycle evaluation modelsThe preliminary data associated with launching CBME at Queen’s University reveals that all 29 specialty programs (100%) launched their incoming resident cohorts into CBME training programs as planned with stage-specific EPAs and accompanying milestones adapted from the CanMEDS framework. All residents and frontline faculty have access to the electronic assessment platform (Elentra) and ongoing efforts are being made to reach out to all frontline faculty using “just in time” methods, as well as, formal teaching sessions within programs for ongoing faculty development. According to preliminary data, CBME assessment is on track with the estimated mean number of completed CBME assessments per month, per resident rising from five in September 2017 to six in February 2018. Apart from significantly reducing the amount of time spent away from residents’ home programs in the initial stages of training, Curricular reform has been minimally effected in the first year of implementation. However, this will be an area of focus in ongoing implementation to ensure proper curricular changes accompany the vision of CBME.We identified the need for additional CBME champions to assist in leading program preparation and implementation of the CBME transition. This was identified as high priority and changes were made to the funding structure of postgraduate medical education to support the new CBME educational deliverables. At the outset of the project in 2015, the central CBME executive team understood that the scope of CBME implementation across twenty-nine specialty programs would require additional leadership within each program. This occurred initially with the creation of twenty-nine program CBME Leads and was instituted centrally across our funding framework. The title of CBME lead brought with it academic protected time (0.1-0.2 FTE) and a formal role description, for an additional faculty member in each program. The CBME Lead works collaboratively with the existing program director for that specialty.With support from the academic funding formula of the School of Medicine, education consultants were hired to provide program support. Their responsibilities included, but were not limited to curricular document creation, programmatic assessment development, facilitating frontline faculty training, and integrating EPAs and assessments into the Elentra platform. Over time, more than 80% of all programs had an education consultant on the program team. Most education consultants work across multiple programs and meet regularly as a group to promote the cross-pollination of CBME innovation. This distributed network of educational expertise is a powerful resource that supports CBME leads to operationalize CBME.One year prior to the institutional CBME launch, resident leads from each program were recruited to assist with preparation, readiness, and implementation by working alongside the program directors, program CBME leads, and educational consultants. In addition, the resident CBME leads were vital in the communication and promotion of CBME for residency selection within their programs and advocacy for the benefits that CBME could provide. After meeting monthly for six months, the co-chair of the Resident sub-committee was invited to become a permanent member of the CBME executive team and the critical role of resident leadership was well recognized within the program teams.st timeline launch  staffed with project leadership for a four-week period before and two-week period post-launch.In the six months before the July 1Creating numerous formal and informal opportunities for program leaders to collaborate regularly in small and large group settings has helped created a unique community of engaged medical education leaders. Delivering cross-specialty program leader workshops to co-create EPAs, milestones, novel assessment tools, and drive end-user development of our CBME electronic platform (Elentra) has been the most valued approach we undertook.Change management theory has provided a fundamental guide to the institutional plan. Concepts such as the diffusion of innovation allowed programs to progress through the CBME transition at their own pace, while being supported centrally to achieve baseline outcomes. Other principles such as early piloting of EPAs and assessment tools, ongoing stakeholder engagement using existing meeting forums, with resident leaders and supporting early scholarship work have been critical to the strategic planning process.CBME theory, including EPAs, milestones, programmatic assessment, and entrustment scores, involve many new concepts that require time for faculty leaders to fully grasp. In truth, understanding of these concepts evolves over time and the explicit acknowledgement of this emergent understanding must continue to occur. This is supported with program specific “just in time” faculty development and resident development sessions, as well as understanding gained through program evaluation processes.Everything is inter-connected within an academic health sciences center. Early on it was apparent that changes in any and all programs have an institutional impact. This relates to learner training, faculty needs, rotation schedules, ongoing patient care, administrative resources required, and leadership frameworks among other things. It is essential to keep the delivery of excellent patient and family centered care at the forefront of the CBME initiative and can be achieved with thoughtful integration of CBME educational initiatives into the clinical work flow across the many dynamic clinical settings.Engaging all stakeholders in regular and meaningful ways is a challenge, even when it is recognized as a high priority. Effective communication requires a substantial investment of time and comes in many forms. There is no substitute for keeping key enablers of change informed – both for their support and managing resistance to forward progress. As well, a unified message is paramount and must evolve as it incorporates stakeholder feedback into the strategic plan. This was achieved by integrating brief but frequent CBME touch point discussions during leadership meetings, academic teaching rounds, and protecting time for urgently evolving communication needs. The weekly CBME executive team meetings ensured that the principal leaders were kept abreast of emergent issues and remained responsive to the evolving nature of the transition.®) was also essential. This required ongoing leadership and collaboration to ensure all CBME project needs were being captured in the build process with the functionality maximally benefitting end users – residents, frontline faculty, academic advisors, and competence committees. Having a diverse group of experts involved in the design and development process  ensured a strong, user-friendly platform.Building a reliable, effective, and forward-thinking education technology platform  to this multi-year project.The CBME transition at Queen’s University is running concurrently with the Royal College of Physician and Surgeons of Canada (RCPSC) Competency by Design (CBD) project. Over time, all programs at Queen’s will transition with their specialty committees across the country to a national set of stage-specific EPAs and new training requirements within each program. This will demand a coordinated and careful approach so that no resident is adversely affected.Curricular reform and pursuing a more time-independent path to training brings with it many logistical challenges. Postgraduate medical trainees are learners within the university and are also patient care service providers paid by the hospitals. Designing a new training paradigm that provides more flexibility in clinical rotations  will be an ongoing experiment that will require patience.Developing an electronic platform to support all users to document, collate, track and monitor end user data for curricular, assessment, and evaluation purposes demands a process of iterative system development. This process must be integrated into the workflow of the development team and carefully managed with respect to prioritizing development decisions that provide both program specific enhancements, while at the same time delivering the greatest benefit to all users across all programs.With the CBME launch on July 1, 2017 and moving towards our next phase of CBME implementation at Queen’s University, the decanal leadership and CBME executive team will remain focused on ensuring that CBME is implemented as intended over the coming years. The ongoing engagement and collaborative contributions from key stakeholders will be essential to continue our journey towards meaningful transformative change in postgraduate medical education. There will also be unexpected challenges, and possibly unintended outcomes, with the adoption of this innovation. It will be imperative that we accumulate evidence of the impact of CBME and continue to approach implementation as an iterative process committed to programmatic quality improvement, informed by on-going program evaluation, and ultimately resulting in improved outcomes for our patients.


ARID1A mRNA, thereby increasing its stability in breast cancer cells. We further find that ARID1A expression suppresses the accumulation of DNA double-strand breaks (DSBs) caused by radiation and can rescue the loss of radioresistance triggered by HuR inhibition, suggesting that ARID1A plays an important role in HuR-driven resistance to radiation. Taken together, our work shows that HuR and ARID1A form an important regulatory axis in radiation resistance that can be targeted to improve radiotherapy in breast cancer patients.Tumor suppressor ARID1A, a subunit of the chromatin remodeling complex SWI/SNF, regulates cell cycle progression, interacts with the tumor suppressor TP53, and prevents genomic instability. In addition, ARID1A has been shown to foster resistance to cancer therapy. By promoting non-homologous end joining (NHEJ), ARID1A enhances DNA repair. Consequently, ARID1A has been proposed as a promising therapeutic target to sensitize cancer cells to chemotherapy and radiation. Here, we report that ARID1A is regulated by human antigen R (HuR), an RNA-binding protein that is highly expressed in a wide range of cancers and enables resistance to chemotherapy and radiation. Our results indicate that HuR binds  The human antigen R (HuR), also known as ELAVL1 , is an RNA-binding protein that binds preferentially to AU- or U-rich elements (AREs) usually located in the 3′ untranslated region (UTR) of its target transcripts . ThroughThe SWI/SNF (switch/sucrose non-fermenting) complexes are ATPase-powered chromatin remodelers. They bind to specific positions on the DNA and mobilize nucleosomes by the energy generated through the ATPase activity of either BRM or BRG1 . By alteARID1A), which encodes the protein BAF250, a key component of the SWI/SNF complex, is usually described as a tumor suppressor. It is one of the most frequently mutated genes in many types of cancer, especially in ovarian, gastric, lung, and breast cancers . Li. LiHuR apatients . NeverthDue to these observations, we next wanted to evaluate whether there was a clinical relevance of HuR and ARID1A expressions in breast cancer patients. For this, we performed disease-free survival curve analysis on breast cancer patients expressing high levels of both HuR and ARID1A. We found that the probability of disease-free survival was severely reduced in patients expressing high levels of HuR and ARID1A, highlighting the clinical role of the HuR–ARID1A axis in patients with breast cancer . ARID1A mRNA. To assess a potential role of ARID1A in the radiation resistance conferred by HuR, we downregulated ARID1A in a panel of human breast cancer cell lines—MDA-MB-231, MDA-MB-468, and SUM159PT—and assessed their clonogenic survival potential. ARID1A silencing significantly sensitized all three cell lines to the cytotoxic effects of radiation compared to control siRNA transfected cells  cells (data not shown). HuR-induced expression of ARID1A is essential to reduce the levels of DNA fragmentation during radiation, expanding our understanding of the mechanisms by which HuR promotes radioresistance in breast cancer. In addition, the fact that HuR–ARID1A interaction contributes to radiation resistance points that ARID1A can play roles as a tumor promoter even though it is mainly described as a tumor suppressor. It also highlights the importance of targeting the HuR–ARID1A axis in order to sensitize cancer cells to chemotherapy and radiation.In summary, we demonstrate for the first time that HuR binds to the 2 and 37 °C. MDA-MB-231, Hs578t, MCF-7, and MDA-MB-468 cells were purchased from American Type Culture Collection (ATCC). MDA-MB-231 and MCF-7 were cultured in Dulbecco’s Modified Eagle Medium (DMEM)  supplemented with 10% fetal bovine serum , 1% pen–strep, and 1% L-glutamine . MDA-MB-468 was cultured in DMEM (Corning CellGro) supplemented with 10% fetal bovine serum, 1% pen–strep, 1% L-glutamine, 1% sodium pyruvate, and 1% Minimum Essential Medium (MEM) amino acids (Corning CellGro). Hs578t was cultured in MEM supplemented with 10% fetal bovine serum, 1% pen–strep, and 1% L-glutamine (Corning CellGro). SUM159PT cells were obtained from Asterand and cultured in Ham’s/F-12 (Corning CellGro) supplemented with 10% fetal bovine serum, 1% pen–strep, 1% L-glutamine, 10 mM 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid (HEPES), 1 μg/mL hydrocortisone, and 5 μg/mL insulin. All cell lines were maintained in a humidified incubator at 5% COHuR–FLAG was a kind gift from Dr. Myriam Gorospe. ARID1A-V5 was obtained from the nonprofit plasmid repository Addgene . pLenti-Breast cancer patient-derived xenograft (PDX) tissues for our analysis were provided by Dr. Alana Welm. PDX mice were produced and maintained as previously described ,55. Brea5) were seeded in 6-well plates and transfected with 20 nM of HuR siRNA or 50 nM ARID1A siRNA (Dharmacon) using DharmaFECT2 transfection reagent (Dharmacon), as previously described [Cells were transfected with 20 nM of HuR siRNA  or 50 nM of ARID1A siRNA  using the DharmaFECT2 transfection reagent (Dharmacon), following the manufacturer’s instructions. MDA-MB-231 and Hs578t cells (1 × 10escribed . Six houARID1A (5′-CCT GAA GAA CTC GAA CGG GA-3′ and 5′-CGG CTC CGT GAG GTT ATT G-3′), HuR (5′-ATG AAG ACC ACA TGG CCG AAG ACT-3′ and 5′-AGT TCA CAA AGC CAT AGC CCA AGC-3′), and GAPDH (5′-AGC CTC AAG ATC AGC AAT GCC-3′ and 5′-TGT GGT CAT GAG TCC TTC CAC GAT-3′). Using GAPDH as internal control, the expression abundance of targeted genes was determined in triplicate using the ΔΔCt method. Experiments were conducted at two separate times, and the data obtained were analyzed for statistical significance. Data shown are average of the two experiments.Reverse transcription (RT) followed by real-time quantitative (q)PCR analysis was performed as previously described . BrieflyCells were lysed with RIPA buffer  supplemented with Halt Protease Inhibitor Cocktail and Halt Phosphatase Inhibitor Cocktail (Thermo Scientific). Equal volumes of 30 μg of whole cell lysate and 2X Laemmli buffer were mixed, boiled for 5 min, and resolved on 10% polyacrylamide gels. After transfer, membranes blocked with 5% nonfat dry milk were incubated with antibodies against HuR , p27 (1:5000 Santa Cruz), actin , FLAG , γ-H2AX , or ARID1A . MDA-MB-231 cells, plated at 50% confluence on 10 cm plates, were harvested 24 h later and subjected to immunoprecipitation using either 30 μg of anti HuR antibody (clone 3A2 Santa Cruz) or immunoglobulin (IgG) control (Santa Cruz), as indicated by Keene et al. . RNA iso® Reporter Assay System , according to the manufacturer’s instructions. A Renilla luciferase vector was used as a normalizing control.MDA-MB-231 cells  plated on 6-well plates were transfected with control (siScr) or HuR-directed (siHuR) siRNAs. Twenty-four hours later, cells were subjected to a second transfection with 100 ng of the corresponding luciferase vectors. Sixteen hours later, lysates were collected and analyzed for luciferase activity in a luminometer using the Dual-LuciferaseARID1A mRNA was assessed in MDA-MB-231 cells transfected with either siScr or siHuR and treated 24 h later with actinomycin D (5 µg/mL) in the cell culture medium to inhibit mRNA transcription. At the indicated time points, the relative amount of specific mRNA remaining in each sample could be correlated with mRNA degradation. Total RNA was prepared as described [ARID1A mRNA levels were analyzed by RT-qPCR. Since the mRNA levels for H2AX were unchanged after actinomycin D treatment, H2AX was used as a reference gene. ARID1A mRNA half-lives were calculated from typical decay curves by linear regression between 0 and 8 h [The stability of escribed . Total R and 8 h . Values Cells were exposed to radiation using a Gamma Cell 40 Exactor  at a dose rate of 0.81 Gy/min at room temperature. Immediately after exposure, the cells were returned to the incubator and harvested at specified time points for each experiment. MDA-MB-231, MDA-MB-468, and SUM-159PT cells were transfected with 100 nM siHuR, 50 nM ARID1A siRNA, or control siRNA (siScr), and irradiated at 2, 4, and 6 Gy using a Gammacell 40 Extractor  24 h later. Cells were then trypsinized, plated in triplicate in two sets of different cell numbers, and incubated for 10–14 days to allow colony formation. Once colonies reached a given size, the plates were stained with 0.5% gentian violet in methanol. Colonies were counted once they reached the cut-off of 50 cells per colony. ARID1A 3′UTR  were cloned into pGEM T-Easy vectors (Promega) and linearized by digestion with MluI . For positive and negative controls, we respectively used 3′UTRs of c-Myc and GAPDH previously cloned into pGEM T-Easy vectors, a kind donation of Dr. Anita Corbett from the Department of Biochemistry at Emory University, Atlanta, GA [DNA sequences corresponding to the anta, GA . BiotinyARID1A and HuR mRNA expression levels were analyzed in normal breast and breast cancer patient samples using the following cohorts from Oncomine and cBioportal: The Cancer Genome Atlas (TCGA)  and Stickeler et al. (n = 57) [ARID1A and HuR mRNA expression were carried out from malignant samples. T-test was used to determine significant differences in ARID1A and HuR expression levels in different patient populations. Time to outcome analyses  were examined using Kaplan–Meier and statistical significant differences were determined using the log-rank test, and the ARID1A/HuR high patient population was separated using a threshold of Z score + 1 for both genes.(n = 57) . CorrelaThe ability of ARID1A to influence DNA DSBs either alone or in the context of HuR knockdown in the presence and absence of radiation was determined using the neutral comet assay , as described previously . Cells wARID1A as a novel HuR target and provides evidence for a pivotal role of the HuR/ARID1A axis in breast cancer radioresistance, thereby supporting the potential therapeutic targeting to enhance radiotherapy in breast cancer.This study identifies


This is achieved through direct and indirect data collection of community factors and program impact that can showcase the need for program sustainability and potential for future dissemination sites. Testimonials, individual feedback, and program process and outcomes contribute to the direct data while data collected from census, county, and state databases and reports allow for indirect information to be captured and analyzed. Capturing data in the two levels allow eB4CAST to forecast program need and highlight program impact through a footprint. eB4CAST framework for dissemination tool creation is organized into four sections: Capture, Assemble, Sustainability, and Timelessness. Capture encompasses the collection of indirect and direct data related to intervention goals. Assemble is the compilation of the data into a visually appealing and easily understood media. Sustainability encourages the use of dissemination tools to provide forecast of program need and footprint of program impact back to community participants, program leaders, and key stakeholders to endorse program sustainability. Lastly, timelessness encourages cyclic movement through these constructs to continue program monitoring and data sharing to ensure timeless program evaluation and conformation to change in needs. The eB4CAST framework provides a systematic method to capture justification of program need and impact of community-based research that can be modified to fit diverse public health interventions providing a necessary D & I tool.eB4CAST,  Dissemination and implementation (D & I) science focuses on understanding the systematic processes of sharing evidence-based interventions and promoting uptake to make sustainable change to health ,2. D & IPublic health is one field where D & I research is important to make widespread improvements on population health across diverse communities. Specifically, within public health research, type 2 (T2) translation, which addresses the progression of evidence-based interventions into sustainable practice and policy change at the population level, is integral to achieving population level health impacts . ResearcHowever, to our knowledge, there is no dissemination tool that captures both publicly available and research driven outcome data and transforms it into one visual report developed for community populations. Programs may evaluate publicly available (indirect) data to justify program need when planning an intervention, although it is not always shared with the community at large. Further, the sharing of research outcomes, beyond research presentations and technical reports, is not always guaranteed . Communievidence-Based forecast C-capture, A-assemble, S-sustain, T-timelessness (eB4CAST) framework addresses the current research to practice gap and seeks to fill guidelines set forth by existing implementation frameworks by disseminating research findings to participants, community members and stakeholders in a format that is accessible to the general population. This framework uses CBPR principles to create a novel dissemination tool through infographic reports that can help bridge the research to practice gap. For future sustainability and change to take place within community-based participatory research, expansion on current dissemination and implementation frameworks is needed. This manuscript will express the rationale behind the presented, novel tool and show a case study of its application in two community-based, public health programs. Currently, this infographic dissemination tool is built by researchers and sent to program leaders for use in community dissemination, with future direction to have reports automated through a web-based platform for sustainability.This manuscript details the development of eB4CAST, a novel dissemination framework, to address the lack of a comprehensive dissemination tool using community-based research to help bridge the current science to practice gap. The Multiple frameworks have been developed to provide guidelines for effective implementation and dissemination of community-based, public health research . The RE-Primarily, eB4CAST is an adaptation of the RE-AIM framework which was developed for the health care setting to monitor clinical evidence-based practice . eB4CASTThe TSci Impact framework has been developed by the Society for Prevention Research to specifically address Type 2 (T2) research translation . T2 tranSimilarly, the Quality Implementation Framework is a four phase, fourteen step process to increase quality implementation . In the The forecast and footprint created are combined into a comprehensive report, capturing the pre and post measures of an intervention. This report ensures a program’s suitability and timelessness by providing evidence of its impact to stakeholders in a concise, visual, user-friendly format. eB4CAST describes the need and impact of an intervention using four constructs: capture, assemble, sustain, and timelessness shown in Researchers and communities can benefit from using the data from a research driven program to aid community leaders in promoting the need for continued community-based, public health programming. Capturing both indirect and direct data related to program goals provides justification for program implementation and shows the impact the program has had and can continue to have on the community members and address the areas of need. Further, capturing the success of programming in one community can help justify the dissemination and implementation of programming into similar communities in need. Expanding from RE-AIM’s “Reach” construct, which records socioeconomic status and family income but does not account for the culture of the community and incorporating the pre-adoption TSci function, the eB4CAST tool encompasses both the individual and community levels in the “capture” section. The data captured is flexible to the intervention goals and can address the important data specific to each community. Data on recruitment, socioeconomics, and interests of community members captures the individual environment for program implementation with additional community data such as information on staffing of the program, the setting of program, and additional services such as extension and adding information on the intervention environment. Outcome data from process and program evaluations aid in understanding the change that the intervention can have on the community well-being and achievement of program goals. Understanding the entire social setting on an indirect and direct level can help researchers better predict how the program will operate, allowing for forecasting in other potential locations and show program footprint through outcome impacts for program sustainability.The “assemble” section takes complex, research driven data and transforms it into an eye-catching, comprehendible report. There is a divide between scientific and community communication, making it essential for program outcomes to be comprehendible to all populations ,13. FurtIt is important to guide the translation of programming from researcher-driven to community-driven for program sustainability. The sustainability construct of eB4CAST promotes the translation of data in a visual format to communities to promote program longevity. The eB4CAST infographic dissemination tool provides communities the power to share their program need and impact with stakeholders and policy-makers as means to endorse continued community-based programming for public health change. This construct of eB4CAST incorporates components of the QIF by promoting a feedback mechanism, the “maintenance” section of RE-AIM to guide incorporation of programming into the community, and the “implementation” and “sustainability” functions of TSci Framework to reach participants and overcome factors influencing implementation to promote supportive policy change. The sustainability construct of eB4CAST empowers community champions to campaign for program longevity and expansion through subjective and objective data (capture construct) of behavior change documented in a comprehensive format (assemble construct) to confirm program effectiveness as a catalyst for continued public health programming.As communities change, the need of communities will expand, and public health programming will need to be adjusted to fit the community needs. Therefore, D & I frameworks need to be cyclic to ensure program timelessness by continuing to capture data and share impact over time. The “timelessness” section of eB4CAST encourages the promotion of long-term, community level monitoring of implementation outcomes to adjust programming to address everchanging issues in diverse populations. This process allows community-based public health programs to adapt over time and create timeless behavioral and environmental change. The timelessness construct of eB4CAST builds on prior findings to produce a strong understanding of the longevity of the program and adapt as necessary. This cyclic process will allow eB4CAST to continue to monitor community-based programs in longitudinal settings and show impact for years to come.The eB4CAST tool captures both indirect and direct data to ensure a comprehensive forecast of a particular program environment and to measure the program footprint in order to expand program implementation and dissemination. Indirect data for this project includes data from publicly available sources that is repurposed to showcase the program setting. Direct data are the data being collected from the program, including process and program evaluations, and shows the outcomes from the program. Data collected as indirect and direct data are modifiable depending on the community-based intervention being implemented. For example, a physical activity program’s indirect data may include the physical activity index of the community while a culinary program may include the number of grocery stores in the community. Therefore, the data collected is adjusted to fit the community program being evaluated. The community and environment needs are identified and combined with information of community socioeconomic status, interests, and population statistics. This allows researchers to better identify other locations in need for future dissemination and forecast success in these areas.The indirect data collected includes county and state statistics that can justify initial program need and be used to gauge program dissemination into similar communities. Information and statistics include, but are not limited to, county and state population, age distribution, ethnicity, gender, unemployment, average family income, average obesity rate, various health behaviors, and food insecurity measures such as percentages of poverty level, families receiving government assistance, and children receiving school breakfast. Community program utilization is also recorded: various programs may include Extension Services, Supplemental Nutrition Assistance Program Education (SNAP-Ed), Expanded Food and Nutrition Education Program (EPNEP), Boys and Girls Club, YMCA, 4-H, Boy Scouts, Girl Scouts, and Health Science and Technology Academy (HSTA). The combination of these statistics creates a comprehensive picture of a current community and areas that need change or support in which a program could be of assistance. The need and feasibility of a project is captured by compiling indirect data from publicly available sources to create a snapshot of the environment in a particular community. This data is assembled into a “forecast” of the need and potential impact of a project. The forecast is a user-friendly, highly accessible infographic that can be distributed to potential stakeholders and participants to gain support for a project.After a project is implemented, a footprint is created to show the positive impact of a program and used towards ensuring program sustainability and timelessness. The footprint compiles direct measures, both quantitative and qualitative data, collected from the intervention and uses this data to create a second part, the infographic, visually representing the impact of a program in a user-friendly way. The direct data collected from program evaluation tools are sent to the eB4CAST team as part of the “capture” construct. Program measures, including process and program evaluations, are a key part of direct data to show the impact of the community intervention. Additionally, community participants, program leaders, and key stakeholders communicate their experiences and perceptions of different aspects within the program to gain qualitative data beyond typical research measures. Direct participant and stakeholder feedback are vital to forecasting and implementing a program in new areas to advance the progress made and benefits that result.Following data collection, the complex dataset is evaluated by authors and data assembled into a visual infographic and narrative report of the program. The infographic reports are created by the eB4CAST authors using Adobe® Illustrator® software . The infographic reports are reviewed by a graphic designer to ensure aesthetic appeal and data clarity. The infographic report is provided back to the program leaders in both print and electronic format. Program leaders are encouraged to use the infographics to share program outcomes and vie for program dissemination. Thus, the infographic can help “sustain” community programming by showing participants and stakeholders the program’s benefits within the community. This not only helps participants visualize and understand the benefits of the program, but justify the time, efforts, and manpower used for community members and stakeholders to ensure support. Currently, these infographic reports are created by the eB4CAST team but is expected to become and online platform that will ensure a sustainable model for eB4CAST infographics.The eB4CAST framework and infographic tool has been used in two community-based programs to date and are presented below as case study examples. This shows the flexibility of eB4CAST to capture data from differing community-based programs and assemble into a dissemination report to promote sustainability of the program for timeless change.iCook 4-H is an out-of-school obesity prevention program for youth aged 9–10 years and their primary food preparer founded around “Cooking, Eating, and Playing Together” ,15,16. TTo date, eB4CAST infographic reports have been sent to 14 communities that participated in the iCook 4-H program. The final reports consisted of four pages that included a program overview, community profile (indirect data), program impact (direct data), and Ripple Effect Mapping (direct data). These reports have been evaluated through external review in the iCook 4-H program, with results presented elsewhere , but werGetFruved is a research project designed to decrease obesity in older adolescents through behavioral intervention and environmental support on college campuses . This prIndirect data that aligned for the GetFruved program were collected from both the institution website and national websites and focused on the healthfulness and safety of the environment as well as health determinants . InstituDirect data was collected as part of the GetFruved RCT and shared with eB4CAST researchers to create the infographic report. Direct data included the Health Campus Environmental Audit (HCEA) that evaluated campus policy, dining, and recreation ,29,30,31To date, 66 college campuses have received eB4CAST infographic tools to use to show the impact of GetFruved on campus and sustain the program. Depending the data provided, the final reports consisted of six to eight pages and were provided to campuses after collection of baseline data and post intervention data to show allow campuses to monitor their own change. These reports were evaluated, similar to the iCook 4-H study, with results submitted elsewhere . The GetD & I research has faced many barriers to successful translation for public health change . This maAlthough D & I and CBPR principles call for sharing results with community partners, there is evidence that traditional methods of research communication are ineffective for community dissemination. Often researchers are often not incentivized to spend time developing dissemination materials for nonscientific audiences and instead are encouraged to focus on developing manuscripts to disseminate findings in academic journals . BecauseFurther, eB4CAST infographics can also support communication with funders and stakeholders. When speaking with funding agents, such as policy makers, evidence needs to be presented efficiently to provide a clear impact as time communicating is often limited . Using vAs with any new framework, eB4CAST is not without limitation. First, the eB4CAST framework relies on the capture and assemblage of constructs to be accomplished for the development of the eB4CAST infographic to accomplish the additional constructs. Although this is a cyclic process over time to continue program monitoring and necessity, the constructs must be achieved linearly. Second, the eB4CAST infographic tool is currently created by researchers, which requires a large resource allocation to achieve completed infographics. Additionally, this requires community programs to provide data back to researchers for infographic creation prior to continuing with program dissemination and the sustainability construct. Therefore, it is envisioned that eB4CAST infographics will be transformed into a web-based platform in which community members can directly input their data and received a generated report. This makes the eB4CAST model more sustainable. Lastly, the eB4CAST framework has not been tested vastly. To date, only two community-based programs have used this framework and dissemination tool. Although both programs had positive feedback from community participants and stakeholders, the long-term impact of using the eB4CAST infographics is not known at this point. Additional research will be necessary to evaluate the timelessness of the programs that implemented the eB4CAST framework. Other community-based programs are also encouraged to collaborate with eB4CAST researchers to use this framework and test the model in other public health interventions and beyond.The eB4CAST framework supports community-based, public health intervention in translating research into the community through an infographic dissemination tool. This tool can be used to disseminate program impact back into communities following community-based participatory research interventions and overcome previous barriers of D & I. eB4CAST is available for use and testing in other CBPR and public health interventions and the authors encourage use of the tool to aid in dissemination and implementation.


The Accreditation Council for Graduate Medical Education’s required Annual Program Review of Educational Effectiveness (APREE) has helped us improve our program and change its culture to one of continuous quality improvement. This report outlines our systematic process and describes specific outcomes it has produced over a 10-year period. We identified ways to enhance our APREE after reading articles that described various ways to conduct the process found in a PubMed and OvidSP search and relevant policies from our local Graduate Medical Education Office. After discussing options, we incorporated new ideas into our APREE and tasked our Program Evaluation Committee to track outcomes from objectives developed by faculty and residents during each APREE. Objectives from faculty and residents in 10 years of our APREE led to major improvements  in our program. In addition, the enhanced APREE process gradually changed our residency’s culture to one that embraces continuous quality improvement. A systematic APREE process can engage residents and faculty in improving specific components of a residency. Besides providing outcomes for Web Ads and Self-Study items, the APREE models quality improvement techniques to residents, involves a wide array of stakeholders, and helps program stakeholders embrace continuous quality improvement. For over a decade, Accreditation Council for Graduate Medical Education (ACGME) and institutional policies required residencies to conduct an Annual Program Review of Educational Effectiveness (APREE) –3. ConduThe UT Health San Antonio Family Medicine Residency is an academic-based program with clinical sites supported by University Health System, which manages CareLink , and the South Texas Veterans Health Care System (STVHCS). We have 15 residents per class, 31% of who are US graduates, and a core faculty of 20 physicians who also teach medical students.We used two strategies to improve our APREE process. One, we searched PubMed and OvidSP for articles using these terms: Annual Program Review, Program Review Residency Process Improvement, Program Review Medical Process Improvement, and other combinations of these words. The initial literature search, conducted for the 2007 article , made us realize that describing our APREE process with outcomes would be useful to others. For this article, we expanded our review to include articles published after 2007. These recently published articles described how other programs conducted their APREE and the outcomes their process produced, but they gave limited information about best practices. Reviewing the program improvements associated with our process made us aware that our process had elements of strategic planning coupled with continuous quality improvement. We communicated this perspective to the residents and faculty in our next APREE. Second, we followed our Designated Institutional Official’s (DIO) policies for conducting the APREE . We incoStaff blocks the half-day APREE meeting on resident and faculty calendars.Chiefs and class representatives summarize anonymous resident evaluations and a curricular review during a PEC meeting.PEC members specify residency components to address in online surveys that faculty and residents complete.Faculty and residents complete the surveys by rating residency components, explaining ratings, and commenting on topics not included. Program leaders analyze faculty and resident ratings and narratives to identify program components to present in the APREE.A faculty member starts the APREE meeting by presenting its agenda, stating last year’s objectives and outcomes to reaffirm the meeting’s value, highlighting major accomplishments, describing findings from faculty and resident surveys, and leading the group to complete a strengths, weaknesses, opportunities, and threats (SWOT) analysis.Faculty and residents select five to six most pertinent issues from surveys to discuss in small groups.Participants in the small groups draft action items after discussion of the identified issue.A spokesperson from each small group presents the group’s findings and action items.The large group discusses and votes on four to six action items for the coming year. The PEC finalizes the APREE by:Reviewing the small and large group discussions, the SWOT analysis, and items on the action plan.Developing a durable SWOT document to ensure the program complies with and documents all ACGME requirements for improvement throughout the year.Stating SMART goals for the coming year using this SWOT analysis, developing an action plan for implementing the goals, discussing how the action plan aligns with the Self Study, and evaluating the usefulness of this document to align with future requirements to include the program description and AIMS.Our APREE involves these steps:Each year, our APREE process produces three products. First, a SWOT analysis from the group and PEC see  providesp value of 0.00007;however, more data in the future will help support causality.Two major program outcomes illustrate the process’ value: Scholarly activity and ABFM Certification Examination pass rates. In the 5 years before our first APREE, our residents presented rarely at regional and national conferences. Since faculty and residents identified scholarly activity as a concern in 2010, there was purposeful quality improvement surrounding this issue focused on mentorship, venues, and financial support. Following this process, residents, currently on average, present five posters at the national NAPCRG conference. This has also produced, on average, 12 resident contributed 5-min Clinical Consult book chapters. We have residents presenting at over five different venues each year. Focusing on the ABFM Certification Examination pass rates from several APREEs produced significant improvements see . MultiplFinally, the APREE process has changed our program’s culture to one of continuous improvement. ‘Begin with the end in mind’, the recommended maxim from the 7 Habits of Highly Effective People, is especially apt here. InitialOur APREE now allows us to openly discuss our strengths, weaknesses, opportunities, and threats and plan changes that will improve our program. Engaging stakeholders in the process and discussing the impact of changes models quality improvement and makes faculty and residents value participating. Many programs can benefit from an expanded view of the APREE process. Established programs with few identified issues can increase dialogue with all stakeholders and enhance established processes to produce continued improvements even in strong areas. For example, scholarly activity among our residents met the ACGME standard, but is now an area of excellence after we instituted faculty development, mentorship, and support following one APREE. New programs or those with multiple resident concerns can achieve many improvements by giving faculty and residents ownership in this APREE process. Modeling the desire for continuous improvement and showing stakeholders their suggestions are embraced can quickly change a program’s culture and climate.Improvements in a residency vary in complexity and the extent to which they resolve an issue. Some issues can be addressed quickly when programs control the issue at hand. For example, two of our faculty began consistently teaching an electrocardiogram workshop after residents expressed concerns about reading EKGs. However, a program’s lack of complete control may impair its ability to quickly resolve an issue. For example, our health system obtained a grant for long-acting reversible contraception (LARC) for indigent patients, but did not include family physicians among those authorized to use the grant money for LARCs. We are presently collaborating with the health system to address this educational and clinical issue. Faculty engagement develops bonds with faculty in other departments, resident engagement provides insight into opportunities and resources in other departments, and administrative engagement presents clinical and educational needs in the family health center within the context of the system.A program may never completely resolve an issue  due to system limitations, but residents can recognize efforts and improvements. After residents expressed safety  and wellness  concerns about the lack of parking at our hospital in an APREE, program leaders tried to improve the situation. Since resident safety and wellness are top priorities in our program, leaders agreed that solving the parking concerns would enhance resident safety and wellness. Program leaders described residents’ concerns with our department chair, medical school officials, and health system personnel  to provide more parking slots closer to the hospital. Constraints  limited completely resolving the residents’ concerns, but measures like police escorts and parking slots open at night, addressed some concerns. Leaders’ routinely reporting progress on parking satisfied most residents and showed them we were committed to resolving the parking issue long term. Since needs can change, other issues may resolve with reassessment . With this transparency, we do not use energy on issues that stakeholders no longer value. When department resources alone fail, system resources  can remedy some needs.Our APREE process tracks and continuously improves areas that reaffirm our AIMS, creating safe, reliable, patient-centered, and data-driven family medicine physicians. Each year, we use 4 hours during our Wednesday afternoon didactic period to conduct the APREE. Residents are required to attend didactics, so the APREE does not decrease their clinical activity. Faculty usually attend unless they are on vacation or ill, so faculty participation in the APREE accounts for a loss of about 40 clinical hours. We think engaging residents and faculty at the same time makes the process more transparent and allows the residents to hear what faculty think about an issue without having to discuss concerns with individual faculty. Residency leaders prefer the present process because it facilitates documentation and helps meet an important ACGME and local institutional requirement.Planning for the APREE consumes some time. A meeting to agree on items for the resident and faculty surveys takes about 6 hours. Revising and distributing the surveys on Survey Monkey and compiling the resident and faculty responses take 4 hours of a faculty member’s time. Placing these responses on Canvas, our institution’s educational management system, takes less than 10 minutes of staff time. Stakeholders can access, download, and bring faculty and resident responses to the meeting, so there is no expense for photocopying or distributing responses.


The ability to rapidly access optical satellite imagery is now an intrinsic component of managing the disaster response that follows a major earthquake. These images provide synoptic data on the impacts, extent, and intensity of damage, which is essential for mitigating further losses by feeding into the response coordination. However, whilst the efficiency of the response can be hampered when cloud cover limits image availability, spatio-temporal variations in cloud cover have never been considered as part of the design of effective disaster mapping. Here we show how annual variations in cloud cover may affect our capacity to respond rapidly throughout the year and consequently contribute to overall earthquake risk. We find that on a global scale when accounting for cloud, the worst time of year for an earthquake disaster is between June and August. During these months, 40% of the global population at risk from earthquakes are obscured from optical satellite view for >3 consecutive days. Southeastern Asia is particularly strongly affected, accounting for the majority of the population at risk from earthquakes that could be obscured by cloud in every month. Our results demonstrate the importance of the timing of earthquakes in terms of our capacity to respond effectively, highlighting the need for more intelligent design of disaster response that is not overly reliant on optical satellite imagery. Today, most nations explicitly include SEM in their disaster response plans5, the International Charter on Space and Major Disasters6 has been developed to provide a unified system for space data acquisition and delivery as part of post-disaster response, and both the International Working Group on Satellite-based Emergency Mapping (IWG-SEM) and the Committee on Earth Observation Satellites Working Group on Disasters (CEOS WGDisasters) have been created to help inform SEM during disasters8. The fundamental goal of SEM is to improve the speed and effectiveness of disaster response by providing a situational overview of the extent and scale of the disaster that would otherwise be difficult to obtain from ground-based observations, particularly in remote, rural, or inaccessible locations10. UN disaster response protocols require an initial Situation Analysis within 72 hr of a disaster followed by a more detailed assessment within two weeks11, setting a time frame within which SEM can be most effective. Persistent cloud cover at the time of the disaster therefore presents a severe impediment when optical data are required for the post-event analysis by obscuring the affected area from optical satellite view (irrespective of how frequently imagery is captured). While this issue has previously been documented2, to-date no studies have quantified the effect of cloud cover despite a lack of satellite imagery being a major inhibitor to an effective disaster response and an increasing humanitarian reliance on satellite imagery1.In the last two decades, satellite-based emergency mapping (SEM) capacities have steadily increased15, and whilst survival rates for victims extricated from collapsed buildings within 72 hrs can be more than 80%, this typically drops to less than 10% beyond the fourth day13. Time to rescue is therefore a key earthquake mortality risk14, with early emergency care potentially preventing a substantial portion of fatalities16. As a result, the IWG-SEM has proposed a series of guidelines for the rapid assessment of building damage from optical satellite imagery17. Any delay to identifying and undertaking a triage of relative impacts must therefore consequently result in an increase in overall earthquake disaster risk. While the use of optical satellite imagery has proved effective at rapidly identifying building damage following earthquakes19, lack of imagery due to cloud cover has previously delayed the identification of severely affected remote locations for more than a week, for example the Langtang Valley following the 2015 Nepal earthquake20.This is particularly important in the case of earthquake disasters. The majority of earthquake fatalities result from building collapseOur study addresses a need to quantify the likely availability of unobscured (i.e. cloud free) optical satellite imagery to inform the design of future rapid earthquake disaster response in any given location at any given time of year. Our analysis is intended to define when imagery can be expected based on statistical analysis of historical cloud data, and so can inform decisions based upon what information disaster managers may expect to be able to access and when. The impact of our results centres around quantifying spatial and temporal variations in the resultant earthquake disaster risk, highlighting locations and timings when satellite imagery is expected to be unavailable. Our results are intended to inform the disaster response plans of national governments and humanitarian agencies based on the likely (un)availability of satellite imagery, facilitating more targeted contingency plans for specific locations and times of year.22. We also argue here that the eventual impact of an earthquake, and therefore the total earthquake risk, additionally relates to the agility and effectiveness of the ensuing response.We focus on global earthquake risk in terms of the number of people exposed to earthquake impacts annually, and explore how monthly variations in cloud cover obscure the at-risk population from satellite view. Earthquake risk is a function of hazard, in terms of the strength of ground shaking; exposure, in terms of population exposed to that shaking; and vulnerability, in terms of the exposed populations likelihood to be directly impacted by that shaking23, which has established the annual rate of earthquake occurrence based on combined analysis of the Global Centroid Moment Tensor catalog (1977–2004) and the Global Strain Rate Model (version 2.1) on a grid with 0.1° × 0.1° cell size. We then resample high resolution (0.008° × 0.008°) estimates of global population24 onto the same 0.1° × 0.1° grid. We combine both datasets with vulnerability proxies (namely Corruption Index and Human Development Index (HDI), Fig. 25. The principle underlying this work is to establish the global population at risk of earthquake impacts for any given year, and the total number of these at-risk people that may be invisible to optical satellites for >3 consecutive days for any given month of that year. This ultimately results in two raster outputs with a 0.1° × 0.1° cell size: (i) a global earthquake risk map showing the population at risk of earthquake disasters annually , we first compute the number of people exposed to damaging levels of ground shaking in a single year Figs  and S2.  catalog 977–2004 lly Fig. . We comblly Fig.  highligh26, further exacerbating earthquake disaster risk through increased hazard during these periods.Our analysis indicates that each year, 1.5 million people, predominantly living in the Alpine-Himalayan belt, the Malay Archipelago, Central America, and northern South America, are at risk of earthquake impacts , which accounts for 8.4% of world population but 29.7%  of the global annual population at risk of earthquake disasters  in September 2018; New Zealand (Kaikōura) in November 2016; and Wenchuan in May 2008. The results highlight how the timing of these six earthquakes could have influenced the ability to collect cloud free optical satellite imagery across the affected area Fig. . Notably27, which broadly validates our results. While our work suggests an average wait across the affected region of Nepal in April of 1.6 days, the longest wait in an individual cell is 16.8 days over the mountains in the north-west of the area, while over Kathmandu and the low-lying areas to the south wait times are just 1–2 days  scales following major (M > 7.5) earthquakes. In the interim, a concentrated reliance on optical-based SEM for earthquake emergency response may only be appropriate in countries like Turkey and Iran, where limited cloud cover means optical satellites present a reliable tool for rapid assessment year-round. Elsewhere, emergency response plans need to be designed to recognise that optical SEM will be reliable only at certain times of year and so planning for alternative means of impact assessment, including SAR and non-space-based approaches, is essential during these times.While results from our study do not causally link cloud cover with higher rates of earthquake fatalities, or SEM with lower rates of fatalities, they nonetheless highlight how the timing of an earthquake can affect SEM activities and the humanitarian disaster response. A reliance on optical satellite imagery alone to inform rapid emergency response may therefore exacerbate earthquake risk globally, highlighting the need to develop other means of rapidly assessing impacts. Recent advances in coherence mapping with Synthetic Aperture Radar (SAR) satellites may present a viable solution, as this has the ability to ‘see’ through cloud as well as identify buildings that have undergone ‘pancake-style’ collapse, which is difficult in optical imagery23, which provides estimates of the annual number of earthquakes occurring above set magnitude thresholds for each 0.1° × 0.1° cell and has been recently validated by comparison with globally observed earthquakes35. However, because large magnitude earthquakes can cause impacts across areas larger than 0.1° × 0.1°, we convert this to the likelihood of damaging shaking occurring in each cell. This allows for direct comparison across a range of earthquake magnitudes and accounts for impacts resulting from earthquakes located in neighbouring cells.To establish global earthquake hazard, we use the GEAR1 global seismicity model36, and the large majority of earthquake casualties result from building collapse15. To estimate the total number of pixels exceeding 0.22 g of shaking for each magnitude range, we compare the results from 15 different ground motion prediction equations (GMPEs)45 for various fault mechanisms, locations, and tectonic regimes and average the results to derive a single radial distance for each magnitude bin. For simplicity, azimuthal variations in this distance depending on earthquake size or type are not considered. Site effects are ignored due to the need for a global threshold and focal depths are held constant at 15 km. The distances for each magnitude bin are: M 6.0–6.5 = 19.7 km; M 6.5–7.0 = 24.3 km; M 7.0–7.5 = 35.4 km; M 7.5–8.0 = 53.0 km; M 8.0–8.5 = 77.2 km; and M > 8.5 = 107.9 km  to derive a single vulnerability proxy ing Fig. . Many faoxy Fig. . Corrupt27 and the rapid decrease in survival rates for trapped victims beyond this time13. We do not include estimates of seasonal changes in daylight through the year in our calculations as most optical satellites are on sun-synchronous orbits that are only affected by seasonal variations in daylight at high (>65°) latitudes, where both population and earthquake hazard are low  for each month in order to examine how the timing of the event may have changed the use of imagery in the response. To calculate the average number of days wait for each cell globally, we set the probability in Equation Monthly obscured earthquake riskSupplementary Information


OBJECTIVES/SPECIFIC AIMS: The Clinical Research Operations Program is a free educational program designed to educate clinical research personnel on the conduct of clinical research (CR). The participant completes 16 required core sessions (24 h), 4 elective sessions (4 h), and passes the final exam to receive a certification in CR operations at Stanford. Sessions focus on the 9 domains of CR , such as Ethical & Participant Safety Considerations, Clinical Study Operations, & Data Management/Informatics. METHODS/STUDY POPULATION: Sessions are taught by volunteer lecturers. Participants may also attend the sessions without pursuing the certification. The program objective is to provide easy-access education in CR in order to increase regulatory compliance, staff retention, and improve CR at Stanford. The program targets CR coordinators, however, staff, postdocs, fellows, and faculty also participate. RESULTS/ANTICIPATED RESULTS: Since the program’s launch in January 2017, 119 individuals have enrolled in the certification program. The most represented group is the Department of Medicine. Sessions consistently reach their maximum with a waiting list. Each core session requires that the participant complete an evaluation  of the registration process (4.5/5), the class environment (4.6/5), the presented content (4.5/5), and the instructor (4.6/5). Data from these evaluations are positive to date and is used to continually refine the program. DISCUSSION/SIGNIFICANCE OF IMPACT: N/A.