Academic Emergency Medicine (EM) departments are not immune to natural disasters, economic or political forces that disrupt a training program’s operations and educational mission. Due process concerns are closely intertwined with the challenges that program disruption brings. Due process is a protection whereby an individual will not lose rights without access to a fair procedural process. Effects of natural disasters similarly create disruptions in the physical structure of training programs that at times have led to the displacement of faculty and trainees. Variation exists in the implementation of transitions amongst training sites across the country, and its impact on residency programs, faculty, residents and medical students.We reviewed the available literature regarding due process in emergency medicine. We also reviewed recent examples of training programs that underwent disruptions. We used this data to create a set of best practices regarding the handling of disruptions and due process in academic EM.Despite recommendations from organized medicine, there is currently no standard to protect due process rights for faculty in emergency medicine training programs. Especially at times of disruption, the due process rights of the faculty become relevant, as the multiple parties involved in a transition work together to protect the best interests of the faculty, program, residents and students. Amongst training sites across the country, there exist variations in the scope and impact of due process on residency programs, faculty, residents and medical students.We report on the current climate of due process for training programs, individual faculty, residents and medical students that may be affected by disruptions in management. We outline recommendations that hospitals, training programs, institutions and academic societies can implement to enhance due process and ensure the educational mission of a residency program is given due consideration during times of transition. Due process rights of physicians come from many sources. The legal requirement of due process in the United States (U.S.) ensures that an individual not lose rights without access to fair procedural process. In clinical practice, due process means clinicians do not lose their medical staff privileges without a fair hearing. For the specialty of Emergency Medicine (EM), residency program faculty are assigned their roles and duties as members of a larger clinical provider group, which in turn has a contractual relationship with a specific hospital/healthcare entity to provide clinical care. In a university-based model, the relationship between individual clinicians, the academic group and the hospital is well-defined. However, the traditional university-based model is not the only employment model. In some community training settings, the relationship between individual physicians, the contract holding group and the hospital is less secure and subject to change on short notice. A sentinel case created enormous upheaval for faculty, residents and medical students and demonstrated the problems that can occur for lack of due process and a standardized approach to transitions for emergency medicine training programs.The Council of Residency Directors in EM (CORD) Board of Directors formed the Faculty Due Process Task Force in 2017. The group was made up of 17 representatives from emergency medicine training programs across the country. The members were tasked to determine the key elements of due process for academic faculty and develop a position statement on due process to ensure the maintenance of high standards of excellence within training programs that undergo transitions.Three subgroups were identified to address the ways due process affects the major stakeholders: individual faculty, residency programs, and EM trainees. Each subgroup reviewed the relevant literature and identified best practice recommendations.Major program disruption may include administrative, financial or operational changes, or natural disasters. In 2017, a sentinel case in Ohio demonstrated that emergency medicine training programs are at risk. An academic group that administered an EM residency program since its inception lost its contract at the residency’s primary clinical site and was abruptly replaced.Major transitions as the result of natural disasters differ a bit, as they may occur without significant time for advanced planning. Hospitals, like all large institutions, are expected to have a disaster and business recovery/continuity plan. Based on our review, it is rare for these documents to address recovery/continuity of their educational mission.Individual Emergency Physicians (EPs) derive their due process rights from various sources, including the U.S. Constitution and position statements from national specialty organizations.7Physicians working outside of government institutions have other sources of due process rights. The Healthcare Quality Improvement Act of 1986 (HCQIA), which applies to all hospitals receiving federal funds, outlines fair hearing procedures for physicians and establishes immunity for members of peer review committees. The hearing requirements include: at least 30 days’ notice, a right to representation, the right to call and examine witnesses and to present evidence, the right to submit a written statement, the right to receive a written communication of the decision, and the right of appeal.10Several national physician organizations have documents that address the importance of due process protections for individual physicians. These include the Code of Medical Ethics of the American Medical Association (2007),660 Minutes special, “The Cost of Admission” details EPs pressured to perform unnecessary tests and admit a minimum number of patients.Common Sense details the story of a Florida emergency physician who was terminated without recourse after reporting a patient safety problem to hospital leadership.EPs have a fundamental role in patient safety. Emergency Medical Treatment & Labor Act (EMTALA) obligations ensure public access to emergency care regardless of insurance status or ability to pay. EPs are part of the safety net of emergency care and have a duty to advocate for the patient’s best interest. Physician autonomy is an essential component that enables an EP to provide safe care. EPs may face pressures regarding financial matters including admission, discharge or transfer of patients. In 2012, CBS’s In a 2013 study published in the Journal of Emergency Medicine, 62% (197 of 317) of EP respondents reported that their employer could terminate them without complete due process and 76% (216 of 284) reported that hospital administration could order their removal from the clinical schedule. Nearly 20% self-reported a “possible or real threat to employment” if they raised quality-of-care concerns.13Beyond the role of patient advocate, EP faculty members also advocate for their EM trainees to help maintain educational and professional standards within their training program. In 2011, an EP was terminated without a hearing after reporting concerns of a fellow faculty member harassing female residents. In 2016, a jury found in his favor despite claims by the hospital that their actions in firing him were for “legitimate, non-retaliatory purposes.”There are several essential elements to due process protection for individual EPs outlined in statements from the national physicians’ organizations above. The AMA Code of Ethics stipulates the principles of a fair and objective hearing and stipulates that specialty medical societies “provide procedural safeguards for due process.”A residency program is an entity with its own dimensions and identity, and unplanned changes can have repercussions on the program as a whole. The Accreditation Council of Graduate Medical Education (ACGME) notes that “residency is an essential dimension of the transformation of the medical student to the independent practitioner” and states that “the essential learning activity is interaction with patients under the guidance and supervision of faculty members who give value, context and meaning to those interactions.”en-masse turnover of a program’s faculty in the residency program. Any large-scale turnover of faculty is disruptive. The faculty “administer and maintain an educational environment conducive to educating EM trainees in each of the ACGME competency areas.”Evaluation of the residency program is outside the scope of this paper. Instead, we focus on the effects of If turnover of a program faculty does occur, the outgoing program leadership has a professional obligation to bequeath materials and processes necessary for the continued operation of the program. It would be helpful if the process for this handoff were standardized across the medical specialties. In the absence of such standardization, the faculty are left to determine which products and processes are the assets of the program and which are the intellectual property of the individual physicians. Examples of materials which are clearly in the program domain include resident evaluations, resident scholarly activities, curriculum organization, rotation goals and objectives, and Program Evaluation Committee (PEC) and Clinical Competency Committee (CCC) meeting minutes.The incoming program must assume the responsibility for continuation of the residency program according to the ACGME Common and EM Program Requirements with little tolerance for deviation. The incoming program faculty should start with all core requirements in place and the ability to maintain the program during their tenure as program faculty.The sponsoring institution of any program has an ethical, legal, and financial responsibility to residents and faculty of accredited programs to help ensure the stability of resources required to meet the educational mission of the training program. The ACGME has acknowledged the potential for the changing landscape of healthcare to impact residency education and as a result convened the Sponsoring Institution 2025 (SI2025) Task Force which wrote that “three forces—democratization, commoditization, and corporatization—were seen as drivers of change that appear to be guiding the future of healthcare, and thereby shaping the conditions to which GME and Sponsoring Institutions will need to adapt.”The sponsoring institution is ultimately responsible for safeguarding the educational environment of a residency program despite the many contractual paradigms by which EDs are staffed. Faculty must meet educational requirements such as scholarly activity and appropriate clinical oversight even during times of transition with close monitoring by the sponsoring institution. The task force recommends the development of clear and appropriate standards; expectations and guidelines in advance of transitions will provide hospital administrators, medical administrators, program directors, staff and EM trainees with transparency during transitions. Clear educational expectations should be delineated in contract language as well as in request for proposals (RFPs); see examples in Events that threaten the stability of a program’s faculty, leadership structure, clinical training environment, or administrative resources may also impact GME accreditation. In order to maintain the integrity of its academic mission, it is critical that each institution’s GME committee (GMEC) maintain oversight and sole governance of its training programs, similar to the self-governance of Medical Staff.Therefore, the task force recommends that the GMEC should ideally be notified of any potential threats to the stability of a program in order to anticipate intervention and provide guidance early. GMEC involvement may prevent transition and/or help mitigate potential negative impact that may ensue. The GMEC should be consulted with appropriate notice prior to any transition to ensure that all educational needs are addressed and should be notified when a current contract is at risk of being terminated. Core faculty should never be dismissed without due process, and the GMEC should be closely involved to ensure this essential protection is not threatened. Similarly, efforts on recruitment and installation of new program oversight must involve the GMEC. The ACGME has demonstrated its willingness to suspend both Program and Institutional Accreditation if these expectations are not met at all times.EM residents are subject to the oversight of both the ACGME and their individual employer, which complicates their potential due process rights. From an ACGME and Residency Review Committee (RRC) perspective, EM trainees are learners. Legally, the majority are considered employees of their sponsoring hospital as well. GME funding contributes to the complexity of due process for EM residents. Federal GME funds are appropriated to hospitals, not medical schools. However, many training programs have expanded the number of residents they sponsor beyond the Centers for Medicare and Medicaid Services (CMS) cap imposed in 1997, using alternative funding including hospitals and other arrangements.During major program disruption, residents are at risk due to preexisting commitments. Many have purchased homes or signed leases, have families and/or an employed spouse, children attending school, and limited financial resources, to name a few of their immediate challenges. Faculty who have been their support through EM training may now face personal employment concerns. To the trainees, communication about a transition or closure may be limited at a time when they desire transparency. These circumstances may leave the resident without clear knowledge of what to do or where to go for guidance.This confusion may be compounded because many residents are unaware of the source of their training funds. They are also contractually bound to the residency program where they have matched, and in the event of program or hospital closure their transition to a new program is contingent upon their federal funding being released by their sponsoring institution. Funding is even more complicated for 4-year training programs, individuals with prior training or when funding comes directly from the hospital, as is the case with institutions over their CMS cap. Given the myriad of potential sources of funding for faculty positions, it is not surprising that many trainees do not understand how their EDs are staffed and under which circumstances staffing might change.Departmental, hospital, program and GME administrators have an ethical obligation to keep residents informed of the details of an expected or ongoing major transition of staff. In the case of a potential contract changeover, trainees should be made aware of general timelines for business decisions and opportunities to initiate contingency plans. The RRC-EM should be informed in advance of the potential for program disruption to allow for an independent body to provide support and ensure clear communication to affected residents. Historically, the RRC appears to have been hesitant to get involved until change has occurred. This task force recommends a more proactive stance to better support the affected residents.Strong, clear, and proactive hospital, departmental, and program leadership is critical. Accurate and timely information helps alleviate uncertainty. The GMEC and program leadership should work together to update residents and detail available options. While faculty will have varied availability or capability to provide advice, CORD may provide a cadre of experienced program directors to guide residents through their available options in a “just in time” fashion. A clearly identifiable point of contact to address EM trainees’ concerns is essential.Patient safety during times of transition or disaster is a primary concern. During a transition or disaster, ACGME-mandated levels of clinical supervision may be compromised to meet increased demand for emergent care of patients in need. Every effort must be made to quickly return to the accepted standard of practice, including appropriate clinical supervision. Similarly, abrupt change in faculty composition may also compromise patient care and safety. Clinical workflow processes are essential in EM and new staff may be unfamiliar with these. As EPs who are invested in residency training, faculty in emergency medicine training programs should be on the forefront of protecting both our residents and our patients. Patient and trainee safety in the clinical environment must be paramount during times of transition.An emergency medicine training program is a complex enterprise with multiple stakeholders. Disruptions to the educational mission include natural disasters that impact the physical training environment and wholesale faculty turnover, both of which have the potential to affect patient care and resident education. Due process protections are particularly important for individual faculty to ensure the ability to advocate for both patients and trainees. Better processes and procedures are needed to ensure the best interests of the many involved parties - the faculty, sponsoring institution, GME enterprise, trainees and patients. Clear guidelines around transitions are needed to protect the educational integrity of a training program and meet the requirements outlined by the ACGME. Improved education for residents regarding due process and GME funding issues are also essential, as we face the increasingly complex employment models that are commonplace in our specialty.


To date, the evaluation of diet has mostly been based on questionnaires and diaries that have their limitations in terms of being time and resource intensive, and a tendency toward social desirability. Loyalty card data obtained in retailing provides timely and objective information on diet-related behaviors. In Finland, the market is highly concentrated, which provides a unique opportunity to investigate diet through grocery purchases.The aims of this study were as follows: (1) to investigate and quantify the selection bias in large-scale  loyalty card (LoCard) data and correct the bias by developing weighting schemes and (2) to investigate how the degree of loyalty relates to food purchases.Members of a loyalty card program from a large retailer in Finland were contacted via email and invited to take part in the study, which involved consenting to the release of their grocery purchase data for research purposes. Participants’ sociodemographic background was obtained through a web-based questionnaire and was compared to that of the general Finnish adult population obtained via Statistics Finland. To match the distributions of sociodemographic variables, poststratification weights were constructed by using the raking method. The degree of loyalty was self-estimated on a 5-point rating scale.On comparing our study sample with the general Finnish adult population, in our sample, there were more women , individuals with higher education , and employed individuals . Additionally, in our sample, there was underrepresentation of individuals aged under 30 years  and over 70 years , as well as retired individuals . Food purchases differed by the degree of loyalty, with higher shares of vegetable, red meat & processed meat, and fat spread purchases in the higher loyalty groups.Individuals who consented to the use of their loyalty card data for research purposes tended to diverge from the general Finnish adult population. However, the high volume of data enabled the inclusion of sociodemographically diverse subgroups and successful correction of the differences found in the distributions of sociodemographic variables. In addition, it seems that food purchases differ according to the degree of loyalty, which should be taken into account when researching loyalty card data. Despite the limitations, loyalty card data provide a cost-effective approach to reach large groups of people, including hard-to-reach population subgroups. Diet has a substantial impact on human health. Poor dietary habits are associated with obesity and a wide range of chronic diseases, including type 2 diabetes, cancer, and cardiovascular diseases ,2. SubopTo date, the evaluation of diet has mostly been based on questionnaires and diaries . AlthougThe continued development of innovative digital tools and digital data repositories provides novel opportunities for epidemiological research -13. Web-Food purchase data have invoked interest as a novel approach to enrich diet and nutrition research efforts -26. So fThe aims of this study were as follows: (1) to investigate and quantify selection bias in Finnish large-scale loyalty card (LoCard) data and further develop a means to correct this bias by characterizing the loyalty card data consenters and comparing their sociodemographic background to that of the general Finnish adult population and (2) to assess how the degree of loyalty relates to food purchases by investigating the self-perceived degree of loyalty  and its association with food purchases. The overall purpose of this research was to increase the understanding of how loyalty card data should be understood and subsequently analyzed in dietary and health research.The LoCard data used in this study were obtained from S Group, which is the largest commercial operator of retail grocery stores in Finland. According to S Group, their full coverage is 2.4 million households, meaning that 88% of households in Finland have registered purchases in their databases. The members of S Group’s loyalty card program are provided with an electronic customer card to be used when making purchases, and customers are rewarded for their purchases by getting a maximum 5% financial bonus that is refunded to them on a monthly basis. Individuals of the same household may link their purchases to the same loyalty account. In this study, only purchases of the household’s main cardholder were used.Members of S Group’s loyalty card program (primary cardholders) across Finland were contacted via email and were invited to take part in the study, which involved consenting to the release of their grocery purchase data to be used for research purposes and voluntarily responding to the study questionnaire. Members who did not have an email address declared or who had prohibited the retailer from contact them with any marketing or research-related material were excluded. Cardholders under 18 years of age were also excluded. All invitations were sent by S Group as they had customers’ contact information.The grocery purchase data used in this study covered the period from January 1, 2017, to December 31, 2018. Each purchase was associated with item description, time stamp, quantity , and expenditure on the item.All consenting participants were asked to fill out a web-based background questionnaire that included the following sociodemographic variables: education, marital status, size of the household, number and age of children, occupational status, income, and perceived health. The background data were complemented with information on participant sex, age, and postal code obtained from the retailer’s electronic database.As part of the baseline questionnaire, all participants were asked to estimate their degree of loyalty as a share of purchases made in the retailer’s shops and supermarkets on a five-item ordinal scale. The response categories were as follows: “0%-20%,” “21%-40%,” “41%-60%,” “61%-80%,” and “81%-100%.”The LoCard grocery purchase data required preprocessing to be usable in further analyses. First, we identified food groups from all the grocery product groups. Second, we regrouped the identified food groups into new groups that were formed on the basis of the commonly used food groupings in nutritional studies  and earlOut of 4234 grocery product groups, 865 (20.4%) were assigned into one of the new food groups used in this study. In addition, 42 food groups were left out as they involved either (1) a mixed dish or food group with no definite primary ingredient or (2) a rarely purchased product. The food groups used in this study included “vegetables,” “skimmed milk & sour milk,” “sugar-sweetened beverages,” “rye bread,” “red meat & processed meat,” “fat spreads,” and “sweets & chocolate.” These groups were used as indicators for evaluating the nutritional quality of household food purchases. A detailed description about the grouping of the food purchase data is included in Population statistics on the general adult population were obtained from Statistics Finland using StatFin databases that can be freely accessed . The datThe FinHealth survey is a national population health study on Finnish citizens. The study encompasses a series of cross-sectional population surveys carried out every 5 years in Finland. The latest FinHealth survey was carried out at 50 localities in 2017, with a participation rate of 71% among those invited for the study . The purThe sociodemographic characteristics of the LoCard study participants were first compared with the characteristics of the Finnish adult population and participants of the FinHealth study to identify traits in LoCard participants that deviated from traits in the general Finnish adult population.survey package in R [Second, we constructed poststratification weights for the LoCard participants to match their sociodemographic distributions with the adult Finnish population distributions as closely as possible. The individual weights were calculated using the raking function available in the age in R . The rakage in R .The advantage of the raking function is that the algorithm allows multiple two-dimensional  tables to be matched simultaneously . For exaThe following two-way tables were available for both the LoCard data and the Finnish adult population: sex and age, sex and education, sex and marital status, sex and occupational status, age and education, age and marital status, age and occupational status, and education and occupational status. All tables were subsequently used to construct the poststratification weights. In addition, the distribution of children aged under 18 years living in the household was used alone because corresponding two-dimensional tables with any of the background variables were not available in Statistics Finland. In total, eight two-way tables and a single one-way table were used in the construction of the weights. Finally, the obtained weights were trimmed to avoid extreme values and instability by setting a minimum value of 0.1 and a maximum value of 10. Without trimming, the poststratification weights ranged from 0.04 to 32.7, and there was a single extremely high weight of 82.4.Owing to missing data, the poststratification weights were constructed in two phases. First, the weights were calculated as described above for participants for whom all baseline characteristics used in the matching were available. These data were available for 36,094 individuals. Participants with missing data for any of these variables  obtained their weights in the second phase, where the poststratification weights were calculated for the whole LoCard sample using sex and age variables only. This information was available for 47,045 participants. Finally, the combined weights were rescaled to add up to 47,045. Twenty-one participants without data on sex and/or age remained without weights.The selected food group variables were analyzed to describe the volume and money (€) spent on their purchases over the 2-year period (2017-2018). For descriptive purposes, median values and IQRs were reported for each variable because the distributions were strongly skewed to the right, and there was an excess number of zero values in some of the food variables. The same variables were used to demonstrate how the poststratification weights affected the results.rfm package in R [To validate the self-assessed degree of loyalty, we conducted the recency, frequency, and monetary (RFM) value analysis using the transaction data of all participants and compared the RFM scores across the five degree of loyalty groups. RFM analysis is a behavior-based technique used to segment customers by examining their transaction history from three dimensions . RFM analysis is also widely used in customer relationship management. Based on these three dimensions, the RFM score is generated for each individual, with a higher score indicating higher loyalty. The analysis was conducted using the age in R . In addiTo assess the impact of the degree of loyalty on food purchasing profiles, the selected food group variables were compared among the five degree of loyalty groups. The Kruskal-Wallis test was applied for differences across the groups.The association between the degree of loyalty and background characteristics was analyzed by comparing the distribution of each sociodemographic variable among the five degree of loyalty groups. The differences across the groups were tested using the chi-square test.The study was approved by the University of Helsinki Review Board in the Humanities and Social and Behavioral Sciences (Statement 21/2018). Informed consent was electronically obtained from all participants included in the study when they were invited via email to release their loyalty card data and fill out the background questionnaire. The data were pseudonymized by S Group before the researchers could obtain the data.S Group had approximately 2.4 million primary loyalty card owners, and all of them were assessed for eligibility . ApproxiOn comparing the LoCard sample to the FinHealth study participants, there were differences in sex, education, and marital status distributions, with more women and individuals with higher education and fewer married individuals in the LoCard sample. The age distributions were not comparable owing to the fact that the FinHealth study included only individuals aged at least 30 years. Distortion in the distribution of occupational status was similar in the two studies compared with the Finnish adult population.The reweighted distributions of the sociodemographic variables demonstrated that the constructed poststratification weights corrected the deviations successfully, and thereafter, the sociodemographic distributions of the LoCard sample matched well with the Finnish adult population.After applying the poststratification weights, there was an increase in the purchase of red meat & processed meat and small increases in sugar-sweetened beverages and fat spreads. The purchase of vegetables and sweets & chocolate decreased as a result of reweighting. The largest change was seen in red meat & processed meat; the weighted amount of purchase increased from €387 to €417 (cost) and from 48 kg to 54 kg (weight), corresponding to relative percentage increases of 7.8% and 12.6%, respectively.F4=4625.5, P<.001). The poststratification weights also differed significantly across the five groups , indicating that the degree of loyalty was associated with individuals’ sociodemographic characteristics. However, the observed differences were rather small, with a maximum difference of six percentage points between the groups . The result was expected owing to the large sample size. The shares of vegetable, red meat & processed meat, and fat spread purchases increased as the degree of loyalty increased. In the other food groups, there were no major differences across the degree of loyalty groups.Additionally, The findings of this study showed that individuals who consented to the release of their loyalty card data for research purposes tended to diverge from the general Finnish adult population. Similar to many other health and nutrition studies, including those encompassing electronic data collection tools ,35,40,41However, the size  and heterogeneity of the LoCard sample enabled a successful correction of the differences seen in the sociodemographic variables. We developed the poststratification weights using all sociodemographic background variables available with the two-way joint distributions to correct the background distributions of the LoCard participants to make them closer to the Finnish adult population. The large sample size provided a sufficient number of participants for hard-to-reach population subgroups, and thus, it was possible to construct the poststratification weights for them as well. The highest weights were seen for unmarried men aged under 30 years, who indeed are often underrepresented or not enrolled in health studies .Of the 1.1 million loyalty card holders contacted, approximately 4% n=47,066) took part in the LoCard study. Although low, the participation rate was similar to that for other massive data collection methods ,066 took, email uImportant aspects are whether and when informed consent from loyalty card owners is needed. Recently, Aiello et al  publishe. The sociodemographic profiles of the LoCard participants and bias related to them might, at least partly, explain these results. The FinDiet study showed that women, who were overrepresented in the LoCard sample and thus had smaller weights, tended to consume more fruits and vegetables than men [Poststratification weights were further applied in evaluating the purchases of the main food groups. The corrections demonstrated small changes in some food groups; the purchase of vegetables and sweets & chocolate decreased after the correction, whereas the purchase of red meat & processed meat, sugar-sweetened beverages, and fat spreads increasedthan men . In linethan men . Moreovethan men ,47. In lthan men .The degree of loyalty was fairly high in the LoCard sample with 64%  of the participants reporting making over 60% of their grocery purchases at the retailer’s shops and supermarkets. The food purchases were rather similar in the higher loyalty group (60% or higher), whereas individuals making less purchases in the retailer’s grocery stores showed some differences. In particular, individuals reporting the lowest degree of loyalty tended to buy fewer vegetables and fat spreads and fewer red meat & processed meat products. Although some variation was seen, the differences across the loyalty groups were smaller than expected. One reason could be the food groups selected for the current analyses. There could be other products, such as alcohol and tobacco, that are differently purchased. These results, together with the differences seen in the sociodemographic variables between the loyalty groups, underline the importance of estimating and accounting for the degree of loyalty in future studies using loyalty card data. A direct way to address the problem of coincidental purchases is to focus on a subsample with at least 60% loyalty. It is also important to note that loyalty card data can enable research on longitudinal trends in food purchases, which can be performed regardless of the degree of loyalty.Although we used a large set of matching variables for developing the poststratification weights, some limitations concerning these remain. First, we were not able to compare or account for possible differences in income, as there was no comparable reference data available in Statistics Finland. Therefore, it remains unclear whether the LoCard sample was representative in terms of income, which is an important contributor to food purchase. The higher education level of the LoCard participants and the lower prevalence of young and retired individuals clearly suggest that the income levels might be overestimated in our sample. Second, although we matched families with children, the number of children and their ages, which can clearly affect a household’s food purchases, were not used in weighting. Importantly, we were able to correct the differences only in the observed sociodemographic variables, and thus, unidentifiable selection bias cannot be ruled out. This may include factors that would be associated with willingness to participate, such as special dietary restrictions and socially excluded people. In particular, among those participants who did not have complete background information and whose poststratification weights were thus based on sex and age only, the risk for unidentifiable selection bias could be even higher.It is important to note that grocery purchases reflect consumption on a household level, which may consist of more than one person, and not everybody might eat the same foods. Thus, accuracy of loyalty card data in investigating individual diet may not be as high as that obtained with traditional data collection methods. However, good compatibility between respondent-collected household-level food purchase data and individual-level dietary data has been demonstrated ,48. MoreFinally, the degree of loyalty remains a challenge. In this study, the degree of loyalty was self-estimated, and it is difficult to estimate possible bias related to this self-report. However, we showed that the RFM scores increased steadily with the groups of loyalty, indicating that higher frequency, higher engagement, and more money spent on grocery purchases were associated with a higher degree of loyalty. Moreover, a positive correlation was found between the proportional increases in money spent (€) and weight (kg) regarding food purchases and the degree of loyalty. These results suggest that this self-assessment seemed to provide a feasible estimate of the true values. In another study, the researchers defined loyalty through the frequency of purchases made in the supermarket combined with the amount of money spent on purchases. However, in this study, the degree of loyalty was not specifically defined .Despite its limitations, we see real potential in the use of these automatically collected longitudinal food purchase data in the population-based assessment of dietary patterns, which are important determinants of health and carbon footprint . LoyaltyIndividuals who consented to the use of their loyalty card data for research purposes tended to differ from individuals in the general Finnish adult population. The sociodemographic distributions were toward similar characteristics, as is frequently seen in health and nutrition studies. However, the high volume of data enabled the inclusion of sociodemographically heterogeneous subgroups, potentially including hard-to-reach subgroups, and further correction of the differences so that distributions matched well with those of the general Finnish adult population. A potential confounder in studies using loyalty card data is the degree of loyalty, which in this study, was associated with food-purchasing profiles and also the participants’ background characteristics. This underlines the importance of obtaining sufficient background information when using loyalty card data for health research.Despite the limitations, loyalty card data provide a cost-effective approach for large groups of individuals with minimum data collection effort and for the investigation of diet-related behaviors on a large scale with less information bias. Importantly, loyalty card data enable the monitoring of longitudinal trends in grocery purchases.


We evaluate the impact of a fisheries management program centered on the definition of Fish Conservation Zones on biodiversity, measured as the number of species caught in the last 12 months. Data comes from a set of 32 villages in central Lao PDR, of which half participated in the program, and the remaining are a set of matched control villages. The estimated causal effects are large (an increase between 29 and 32 species) and robust to the potential importance of unmeasured confounders. We also show that initial conditions may matter, as the program seems particularly effective in villages with high probability of participating in the program. These results are particularly important given the paucity of evidence regarding the impact of conservation programs on biodiversity, particularly in the context of freshwater ecosystems. Further directions of research suggested by these results are discussed. There is a widely accepted recognition that freshwater ecosystems are extraordinarily rich in terms of biodiversity: representing approximately 2.3% of the global land surface, fresh waters host approximately 9.5% of the described animal species . It is aAdding to this diagnostic, there is also a suspicion that approaches to conservation adopted in terrestrial ecosystems, based on the definition of high habitat quality that can be well defined and bounded (“fortress conservation” in the words of ), are diAlthough these examples suggest that the difficulties in implementing freshwater conservation are not universal or unsurmountable, they tell us little about whether they “work” in the sense that they contribute to avoid reductions in biodiversity. This is a shortcoming that is shared with earlier conservation work: in the mid-2000s,  asked whThe work presented in this article contributes to that growing literature. Our data comes from Lao PDR, a landlocked country where the Mekong, one of the richest and most threatened river basins in terms of freshwater biodiversity , 18, seeThere is a long history of local knowledge about the definition of no-take areas as a mechanism to manage local fisheries in Lao PDR . Those aThis knowledge has been incorporated in different fisheries conservation programs in Lao PDR, including the third phase of the Community Fisheries program (ComFishIII), implemented by WWF Laos, during the period 2012-2015, in collaboration with the Ministry of Agriculture and Forestry (MAF) and with local participation of village authorities. Its guidelines  reflecteIts implementation involved a series of decisions by WWF and MAF that, typically, started with the preparation of a list of potentially eligible villages, presented to WWF by the District representatives of MAF. This list reflects perceptions of the importance of fishing  and implicitly assumes that these criteria reflect a healthy ecosystem, as no baseline data on biodiversity is ever collected. This initial submission is then followed by a series of steps that end with the development of local regulations to manage fisheries  and, finally, a preliminary discussion regarding willingness in changing the way that local fisheries are managed. It also includes the clarification of whether deep pools exist (as the creation of FCZ hinges on its existence). This step typically involves one or more visits by WWF staff , from which then emerges a final list of eligible villages.The next steps involve the drafting and re-drafting of local regulations. The approval of these regulations at local level  precedes the formal approval by the District Governor. The process ends with the advertising of the new fishing regulations as well as the limits of the newly created FCZ .Yi(1)) and another one in its absence (Yi(0)). The actually observed outcome (Yobs) can be expressed as a combination of these two potential outcomes according to the expression:Ti = {0, 1} indicates treatment status , making clear that we cannot observe counterfactual potential outcomes—for example, [Yi(0)∣Ti = 1] defined as the outcome of a treated unit had it not been treated.We follow Rubin’s potential outcome model of causal inference  and starATT) asE[.] is the expectation operator and Ti = 1 indicates that the unit participated in the program. If a program is randomly placed then, by design, units participating in the program will be (on average) identical to those that do not participate, henceATT takes the simple form of E[Yi(1) ∣ Ti = 1] − E[Yi(0) ∣ Ti = 0]. When the program is purposefully placed and/or participation is voluntary, there is no a priori certainty that If nothing can be done at individual level, at population level we can quantify the Average Treatment on Treated  on the estimates of utcomes.  shows thach ). Unconfoudedness means that either ui = uj  or γ = 0 . If any of these is not true, then two observationally identical individuals will have different probabilities of getting treatment. Rosenbaum ).One additional question is that recall data is potentially fraught with problems, given that memory is limited. However, the importance of fishing for the respondents  suggests that there is no reason to find a systematic difference in recall between treated and control units. Finally, the fact that the research team was not connected to the implementing agency  and the fact that FCZ had been defined at least three years before the time of this evaluation should contribute to minimize any experimenter effects (positive or negative).This approach also has important advantages, chiefly among them its low cost and the reduction of concerns about seasonality. Taken together, these advantages allow for the collection of data on a large number of treated and control villages, hence avoiding the shortcoming of case studies or very small samples.As shown in p-value<0.05) and robust to the choice of matching algorithm.To rigorously quantify the average impact of the program, treated and control villages are first matched one-to-one on the propensity score using the nearest neighbor algorithm . The resThese estimates can be interpreted as causal when the CIA holds. There is no way to directly test this assumption, and instead we present an analysis of the sensitivity of the estimates to the importance of potential unmeasured confounders trough the estimation of Rosenbaum bounds, implemented using the command –rbounds– described in . The resATT. For that reason, we focus on the lower values of statistical significance of our estimates (sig+) and the lower bound of ATT (t-hat+) under varying importance of potential confounders, as measured by eγ. At the usual cut-off of eγ = 2 (to be interpreted as “unmeasured confounders importance in explaining treatment status is the double of the importance of measured confounders”), our estimates are still statistically different from 0 at the usual levels of significance  and the estimate of ATT is still important, with implementation of ComFishIII leading to an average increase in species richness of 19 species.Because we mostly worry about positive selection bias , we mostly care about the possibility that we are over-estimating the ATT being re-estimated locally in the neighborhood of each observation (characterized by their propensity score), allowing for an analysis of the relation (trend) between these local estimates and the propensity score. The program is less effective in driving increases in biodiversity in those villages that were least likely to be included in the program , with large impacts on biodiversity observed in the (few) villages with relatively higher probability of participating in ComFishIII.Finally, in Understanding whether conservation efforts work, in the sense of what they deliver on their direct environmental objectives, requires a larger effort to incorporate impact evaluation into the design of environmental policies and programs. This article presents evidence that, at least in a context such as the Mekong in Lao PDR, it is possible for freshwater conservation initiatives to achieve improvements in biodiversity.Our analysis quantifies the causal impact of a fisheries management program, centered on the definition of no-take areas (Fish Conservation Zones) on the number of species caught in the previous 12 months. The effects are large (approximately 29 species), and these estimates are robust to the potential importance of unmeasured confounders, an important concern when using observational data. Our analysis also shows that average impacts are heterogeneous and that initial conditions (as summarized in the probability of participating in the program) matter for the success of this program, suggesting that better targeting of participating villages may further improve its impact.We conclude with three comments. Firstly, we note that these conclusions are based on a matching design, implemented in a relatively data poor environment. Although we don’t disagree with  that theSecondly, this article raises the need to clarify the potentially multiple mechanisms through which conservation may impact on biodiversity, a relatively unexplored area of research , 39. OurFinally, it is perhaps useful to emphasize that, before their wider adoption, FCZ were built on indigenous knowledge of species’ biology and reproduction, the importance of seasonal variation in their habitat and the local importance of spillovers  . Their iThe promise of sustainable development , 50 restS1 Appendix(PDF)Click here for additional data file.


N = 41) and cultured in vitro for 1 week. Furthermore, the supernatants of the cultured PBMCs were analyzed by Luminex single-antigen beads. Results: Analyses using Luminex single-antigen beads revealed the presence of immunoglobulin (Ig) G donor-specific anti-HLA antibodies (DSAs) was detected in the supernatants of cultured PBMCs collected more frequently than IgM in de novo DSA-sensitized patients with AMR, and IgM were detectable in patients with stable graft function mainly and several IgM DSAs were detectable in the supernatants of the cultured PBMCs before detecting the IgG levels in sera. We also found that the DSA-specific IgM-secreting memory B cells (mBCs) were more sensitive to the chronic use of immunosuppressive agents than to the IgG-secreting mBCs. Conclusions: In the transplant recipients, the assessment of supernatants of cultured PBMCs provide more details of immune reactions than the commonly used method that directly measures IgG DSA levels in patient sera and some IgM DSA detection may be a better predictor of IgG DSAs production, which may cause AMR and enable early intervention, in initial stages of AMR development.Background: Antibody-mediated rejection (AMR) is a crucial barrier in the long-term prognosis of transplant recipients. Methods: Peripheral blood mononuclear cells (PBMCs) were collected from kidney allograft recipients ( TechnolDSAs are produced from the plasma cells (PCs) via the recognition of donor-specific antigens by antigen-presenting cells, which are utilized by naïve B cells, processed, and are presented on the surface of the cells where they bind to the antigen-specific T-cell receptors. The activated T cells then promote B-cell proliferation, immunoglobulin (Ig) class-switching, gene conversion, and enhanced antigen affinity via VDJ  recombination through the germinal center (GC). In addition, the macrophages and dendritic cells activated by the effector T cells produce cytokines, which aid in B-cell proliferation and differentiation. Subsequently, the selected memory B cells (mBCs), which have a high affinity for donor-specific antigens, differentiate into PCs ,5. It haFurthermore, the chronic use of immunosuppressive agents to repress T-cell proliferation may not significantly inhibit PC survival, because PCs may survive in a T cell-independent manner . More reThis study followed the principles of the Declaration of Helsinki, and all subjects provided informed consent to participate. The Osaka university ethics committee has approved this study. Peripheral blood (8 mL) and serum were collected from 41 kidney allograft recipients  before and after transplants, which had been performed in Osaka University Hospital between January 2000 and January 2017. de novo DSAs and then cultured in vitro. Whereas Luminex single-antigen beads successfully detected IgG DSAs in cultured supernatants of PBMCs more frequently than IgM DSAs in de novo DSA-sensitized patients with AMR , certain IgM DSAs were detected in the cultured supernatants before IgG DSAs being detectable in cultured supernatants or sera. In cases #4 and #5, IgG DSAs were not detected in the cultured supernatants or serum after the detection of IgM DSAs within an observation. In several patients (cases #1–3), certain IgM DSAs were detected in the cultured supernatants before IgG DSAs being detectable in cultured supernatants or sera. In cases #4 and #5, IgG DSAs were not detected in the cultured supernatants or serum after the detection of IgM DSAs within an observation.N = 6) after sensitization to the primary donor antigens and were then cultured in vitro. Subsequently, the supernatants from these cultures were assayed before and after transplantation, and recipients were then treated with rituximab  as an induction therapy, followed by chronic use of the immunosuppressive agents prednisolone, tacrolimus, and mycophenolate. In the ensuing analyses, almost all IgGs against the primary donor antigens were detected at similar or higher levels at both time points  analyses, which revealed that a high frequency of DSA-specific mBCs in the peripheral blood was associated with greater injury to the kidney grafts and patient history of AMR ,11,15. T+ B cells were cultured on CD40 ligand feeder cells (EL4-B5) with growth factors and cytokines from activated T cells [Alternatively, some researchers attempted to induce mBCs differentiation into PCs in vitro and analyze mBCs-derived Abs from the cultured supernatants. In these studies, CD19 T cells ,17,18. N T cells ,21,22. A T cells ,24. It h T cells ,26.However, in our culture system, phorbol myristate acetate (PMA) may be involved in inhibiting NK cell differentiation and activation , phytoheConsidering the evaluation of DSA isotypes, IgG DSAs have gained attention in the field of transplantation mainly due to their antigen specificity. By contrast, IgM DSAs have been considered to be unreliable markers, even though some IgM mBCs activate T cells dependent on reactions in the GCs and produce IgM Abs with high affinity for antigens . Certainde novo DSAs. Our findings suggested that IgG DSAs were mainly present in the culture supernatants of PBMCs from de novo DSA-sensitized patients with confirmed AMR, which represented the activation of humoral immunity against donor-specific antigens.In the present experiments using Luminex single-antigen beads, we evaluated the production of IgG and IgM DSAs in the cultured PBMCs from allograft recipients who were sensitized to de novo DSA-sensitized patients with stable graft function  and IgG DSAs were detected in sera soon afterwards. In case #2, AMR was confirmed in the biopsy samples 9 days after detecting IgG DSAs in the serum.While detecting IgM DSA in the supernatant of the cultured PBMCs and IgG in sera, the DSA-specific IgM mBCs may grow and class-switch to IgG-.In cases #3, #4, and #5, IgM DSAs were produced in the cultured supernatants from one to a few months after transplantation ; however, several months had lapsed between the detection of IgM DSA in supernatants and detection of IgG in serum or IgG was not detected in serum within this observation.de novo DSA production and the probability of graft loss due to de novo DSA are higher than those in adults [In addition, we reported previously that activation of the antigen–antibody reactions through B-cell receptors might mediate class-switching of IgM to IgG and that the production of growth factors and cytokines by activated T cells, macrophages, and dendritic cells promoted this process . Thus, in adults , there mIn further experiments, we examined the differences in responsiveness to the immunosuppressive agents between DSA-specific IgG mBCs and circulating IgM levels in peripheral blood. In these experiments, PBMCs were collected from secondary kidney recipients who were sensitized using primary donor antigens, and IgG and IgM levels against primary donor-specific antigens were compared before and after secondary transplantation. Induction therapy to inhibit T-cell survival and chronic use of immunosuppressive agents were administered at the time of secondary transplantation.Subsequent analyses revealed that IgG DSA levels in the supernatants of cultured PBMCs were maintained after induction therapy, whereas IgM DSAs were remarkably reduced . These d5 cells/well) in basal B-cell culture medium composed of Iscove’s modified Dulbecco’s medium (Sigma–Aldrich) with 10% fetal calf serum  supplemented with 50 µg/mL human transferrin–selenium and 5 µg/mL human insulin  in the presence of the molecules as follows: 50 ng/mL interleukin (IL)-21, 2.5 µg/mL phosphorothioate CpG-oligodeoxynucleotides (ODN) 2006, 2.5 µg/mL phytohemagglutinin/leucoagglutinin (PHA-L), and 15 ng/mL phorbol myristate acetate (PMA).PBMCs were isolated using a Ficoll-Hypaque density gradient . The cells were cultured in 24-well flat-bottomed plates . PHA-L and PMA were purchased from Sigma–Aldrich .We collected PBMC culture supernatants and concentrated these by 5-fold prior to the FlowPRA screening test based on Flow PRA 60 kits . For only positive cases, LABScreen Single Antigen HLA Class I and/or Class II  was used to analyze antigen specificity.t test was used to evaluate the significance of differences between variables. Prism 7 software  was used for statistical analyses. A two-tailed p value < 0.05 was considered statistically significant.All data are expressed as median values and ranges unless otherwise indicated. An analysis of variance (ANOVA) or a paired or unpaired Student’s The assessment of IgM DSAs levels in cultured PBMCs may be employed as a biomarker, which may provide an opportunity for early interventions before IgG DSAs production, which may result in AMR development in serum by using 8 mL of peripheral blood, after determining the characteristics of DSA-specific IgM mBCs and subsequent class-switching to IgG. Moreover, risk factors promoting IgM class-switching to IgG and the time required for DSA-specific IgM mBC to differentiate into IgG PCs warrant further investigation in a larger cohort for clinical application.


The POM designation provides gerontology programs with an AGHE “stamp of approval,” which can be used to verify program quality to administrators, to lobby for additional resources to maintain a quality program, to market the program, and to recruit prospective students into the program. This worldwide process of evaluation for both Gerontology programs verifies for students that the program is consistent with globally vetted criteria in gerontology endorsed and recognized by AGHE; assures the public of the quality of programs and their graduates; clarifies for employers the knowledge and skills imparted to students who graduate from POM designated gerontology programs; informs campus administrators of global guidelines, expectations, and practice in gerontology education programs; and indicates to interested students that the program is of high quality. Those interested in the Gerontology Program of Merit will be able to ask questions, understand the application process, and ask for technical assistance.


Residency programs invest a significant amount of time and resources on the recruitment process, and maintaining efficiency and cost-effectiveness are very important. Virtual Reality (VR) has become an adaptive substitute for ‘real life’ experiences and its use during the interview season could help save time and resources.With the intention to maximize the interview day and provide a cost-effective alternative to facility tours, a Med-Peds residency training program introduced a VR tour of their children’s hospital during recruitment.The Med-Peds program replaced an in-person facility tour of the children’s hospital with a VR tour. Applicants were asked to complete an anonymous, voluntary survey on their VR experience at the end of the interview season, and rank features of the interview day in order of importance.There were 33 respondents out of 54 interviewees. Approximately two thirds (63–66%) agreed that VR was non-inferior and superior to in-person facility tours, and that the use of VR had a favorable impact on their perception of the program. However, almost 50% of the applicants had some difficulty using VR technology.Use of VR facility tours as an alternative to in-person tours of affiliate training facilities during a residency interview day is a viable and innovative option that can save time and money and favorably impact the applicant’s impression of the program. More research is necessary to assess whether VR tours can replace in-person tours at the main teaching site, however, while social distancing measures are in place, VR tours may become necessary for programs moving forward.Med-Peds: Internal Medicine-Pediatrics; VR: Virtual Reality; AAMC: Association of American Medical Colleges; IRB: Institutional Review Board Residency programs invest a significant amount of time and resources on the recruitment process, with a recent surgery publication estimating approximately 100,000 USD ± 87,000 per interview season for university-based programs. [Many university-based residency training programs are faced with providing applicants an accurate portrayal of what their residency experience will be like, but are challenged with the fact that their residents participate in clinical rotations at multiple teaching hospitals. These hospitals include a combination of private, public and military affiliated sites, and often result in residents being required to travel several miles between sites. During the interview season, programs choose to either provide tours of all hospitals or to only provide tours of the primary teaching site and describe the alternate teaching sites. COVID-19 is dramatically changing these traditional strategies as national organizations like the Association of American Medical Colleges (AAMC) are strongly encouraging that interviews and tours be held ‘in a virtual setting – either by phone or video conferencing.’ Virtual Reality (VR) is a technology that has emerged as a cost-effective and impactful tool for use in medical education. By immersing the user in a computer generated real or artificial three-dimensional environment, it has become an adaptive substitute for ‘real life’ experiences. The primary component of a VR experience typically includes a motion sensitive screen built into a goggle or headset. The user then wears the headset and immerses themselves in a 360-degree visual environment. By steering the motion sensitive device with head movements, they are able to navigate the virtual environment as if they were actually there. The 3D-environment can range from static images to full-motion video and can have audio associated with it. The technology has become less expensive since its introduction and is now more widely used in different industries ranging from medicine, gaming and education, to tourism and sales. [Its use and acceptance in the medical field has been rapidly growing, and it has become an emerging educational strategy with the potential of transforming health professional education. Some studies show that VR improves post-intervention knowledge scores and health professionals’ cognitive skills compared to traditional learning.  During tWith the intention to maximize the interview day and provide a cost-effective alternative to off-site hospital tours, the Internal Medicine-Pediatrics (Med-Peds) Residency Program at Rutgers New Jersey Medical School introduced a VR tour of its off-site children’s hospital during recruitment and reviewed feedback from the applicants. While this study was performed prior to COVID-19 pandemic and the new AAMC recommendations, we take the opportunity to discuss the implications of VR technology on the future of the applicant interview process.The Med-Peds residency training program interviewed 54 applicants during the 2018–2019 interview season. In previous years, applicants would receive an in-person hospital tour of the primary teaching site and then be shuttled to the alternate teaching site where an in-person tour of the children’s hospital would follow. Applicants would then be shuttled back to the primary teaching hospital before finishing the interview day. Transportation costs between hospitals totaled 2,520 USD over 7 interview days, and total travel time between both hospitals accounted for 1 hour per interview day, not including the tours themselves. To minimize travel time and costs, the program introduced VR as a substitute for the alternate site, in-person, hospital tour as part of the 2018–2019 interview, but maintained the in-person hospital tour of the primary hospital. Both tours included several points of interest, ranging from the intensive care units to the cafeteria, but removed the travel required to go from site to site.To create the VR experience of the alternate teaching site, a VR headset utilizing Google Cardboard and the Google Cardboard application (app) for VR were used. Photos of the alternate teaching site were taken with a 360-degree camera prior to the start of the recruitment season. Applicants were asked to download the free app as well as thirteen 360-degree images of several points of interest to their smart phones about 1–2 weeks prior to their interview day. On the interview day, applicants were then given a cardboard-constructed goggle that can house the user’s smart phone and be worn over the eyes with an elastic headband. If the applicant did not have a smart phone, they were able to borrow one from a current resident or faculty member. The app pulled the 360-degree images from the user’s smart phone which appeared three-dimensional when viewed inside of the headset. As the user turns the head left, right, up, and down, the viewer’s perspective moves accordingly, allowing for 360-degree visualization of the virtual environment. A faculty member guided the applicants on a VR tour of the children’s hospital, providing an explanation of the different points of interest, while the applicants remained seated at the primary site. The applicants were encouraged to browse freely through the images and ask questions. Afterwards, they were given the Google Cardboard set to take home and could access the images for future reference. The cardboard goggles had a purchase price of 3 USD/goggle and a total cost of 175. USD The entire VR tour experience took approximately 20–30 minutes.After the rank list submission was due in February and before Match Day 2019, applicants were invited to complete an anonymous, voluntary survey about their interview experience with the program. The survey included specific statements about the use of VR and its potential advantages, and asked applicants to indicate their level of agreement or disagreement.  The applThe survey was distributed via email using Qualtrics as a platform for anonymous reply. It was completed by applicants between February and March 2019 and weekly reminders were sent to non-respondents until the survey was closed on Match Day, March 15th, 2019. The responses were analyzed using Excel. The study protocol was approved as an exempt review by the Rutgers Health Sciences IRB in Newark.The online survey was completed by 33 out of the 54 applicants who interviewed. Two-thirds of respondents  either agreed or strongly agreed that VR was a comparable substitute for in-person facility tours and 63% (n = 21) agreed or strongly agreed that they preferred VR tours over in-person facility tours. Two-thirds of respondents  also agreed or strongly agreed that the use of VR had a favorable impact on their perception of the program while 63% (n = 21) agreed or strongly agreed that they would like to see more programs using VR in the interview day. However, nearly half of the applicants  agreed or strongly agreed that they had difficulty using the VR goggles. Most applicants  agreed or strongly agreed that it was helpful to review the facility images after the interview day and 75% (n = 25) agreed or strongly agreed that they appreciated being able to use the provided VR head set for recreational purposes after the interview day .Figure 1The in-person tour of the primary teaching hospital rated an average 4.34 out of 5 and VR tour of the children’s hospital was rated an average 3.93 out of 5. In order of importance from 1 to 11, 1 being the most important, applicants rated several items of the interview process. The in-person facility and VR tours were ranked 8th and 9th out of 11 respectively . ApplicaDuring the previous interview season, applicants spent 1.5 hours at the off-site children’s hospital, 1 hour in transport time, and completed the interview day by approximately 3:30 PM. During the 2018–2019 season, applicants spent 30 minutes touring the children’s hospital via VR, and of the time saved from eliminating the transport period and a second walking tour, 1 hour was used towards additional face-to-face time with residents and program leadership at an extended lunch provided at the primary hospital. The interview day was completed by 2 PM with the 2018–2019 schedule.During the previous season, the Rutgers Med-Peds department spent 2,520 USD USD on transportation between sites. The personalized VR cardboard headsets saved 2,345 USD USD, which was then utilized to fund applicant pre-interview dinners and to support other program activities throughout the year.Substituting a VR tour of the off-site children’s hospital in place of an in-person tour significantly impacted the 2018–2019 interview season by saving time and money while improving applicants’ perception of the program. The time saved by implementing the VR tour permitted more face to face time with the residents, faculty and program director, which were rated as the top 3 most important features of the interview day and allowed for earlier completion of the day by 90 minutes. While this study provided a VR experience in-person, it is also possible to provide applicants a similar experience remotely in order to save applicant time and money.Most applicants interview at several institutions as part of the matching process, which may result in ‘interview fatigue’ as exemplified by one of the comments: ‘Virtual tour was great! Too many walking tours this season.’ This could explain why a majority of the applicants preferred VR tours over in-person tours. However, it is important to highlight that despite both tours being ranked low (positions 8 and 9 respectively) on the applicants’ list of priorities, it is difficult to assess the overall importance of having facility tours from our data. Data from an Emergency Medicine Program that surveyed over 200 applicants suggests that facility tours are the least important part of the interview day for applicants, while the overall ‘feel’ or ‘personality’ of a program is the most important.  On the oSaving 2,345 USD in recruitment funds allowed for the program’s budget to be spent on other necessary resources like applicant pre-interview dinners, in which current residents spend time with the applicants the night prior to the interview. Even more cost savings could be distributed to the applicants by allowing this technology to be used from home and avoiding travel costs all together. Especially in light of the current pandemic and recommendation from the AAMC to do all interviews ‘virtually,’ one could simply mail the google cardboard headsets to each applicant with directions on its use for a nominal postage fee. Photos and video files can be easily downloaded from any website or share drive for free and interactive tour guides can be pre-recorded or provided to the applicants through teleconferencing. It still remains to be seen whether programs throughout the country opt for a fully virtual interview process or for a mixed one, in which parts of the interview are conducted remotely but allowing applicants to also physically visit the institution. VR in either situation would allow for significant cost savings, while keeping social distancing measures in place.The VR tour also had a favorable impact on more than half of the applicants’ perception of the program and almost as many would like to see VR used by other programs. One applicant commented, ‘Exciting and new technology made the day fun and interesting.’ The current pandemic will likely make it even harder for programs to make a significant impression through virtual media, especially if teleconferencing becomes a standardized approach. In a highly competitive environment where residency training programs try to increase their appeal to prospective residents, innovative technology, such as VR, can make a difference on the applicants’ rank lists. Incorporating VR into a program’s interview process can be a tricky process. As nearly half of the applicants had difficulty using the goggles, it is necessary to have dedicated staff or expertise available to the applicants to help troubleshoot the process. The ease of the VR tour was largely reliant on the applicant’s ability to download the app and photos to their smart phones prior to the interview day, and there seemed to be a large variability of app functionality and phone quality. Some of the comments from the applicants showed how technically challenging the process can be, even in person, and suggest that a poor implementation risks a detrimental impact to the applicant’s impression of the program. Purchasing headsets that include a screen and have the images pre-loaded could overcome these technical difficulties, however, would increase the cost of the technology and would unlikely be offered remotely. Some individuals even experienced motion sickness while using the headset. Having an alternative for the VR tour such as a slide show of images from the off-site hospital should be an alternative for applicants who are unable to tolerate VR. None-the-less, this program’s experience can assist those wishing to adapt the technology to their own needs. The implementation of VR for hospital tours has the potential of becoming common place during the current pandemic and, if done well, can make a program stand-out.It will need to be determined by each program how essential the hospital tour is to the overall application process considering that our applicants ranked facility tours low on the list of interview components. Due to the pandemic, losing face time with residents and faculty could make the facility tour more important to the applicants. This pilot study suggests that VR facility tours have the potential of replacing in-person tours at alternate hospital sites, but a direct comparison between a VR tour done remotely versus in-person of the same site would remain to be validated. Even though 66% of the applicants either somewhat or strongly agree that VR tours are comparable to in-person ones, the in-person tour was rated higher than the VR tour (4.34 vs 3.93), however, these results are difficult to interpret since they evaluate different facilities . This lack of a ‘randomized-control’ trial limits this study’s ability to directly compare the quality of the in-person tour of the primary teaching site versus the VR tour of the children’s hospital. Performing such a study would require randomizing applicants to either an in-person tour group or a VR tour group of the same site, which would be hard to accomplish during an interview season. Studies would also need to compare the effectiveness of doing VR tours remotely versus receiving VR instruction in-person.Use of VR facility tours as an alternative to in-person tours of off-site teaching hospitals during a residency interview day is a viable and innovative option that can save time and money, and favorably impact the applicant’s impression of the program. More research is necessary to assess whether VR tours can replace in-person tours at the main hospital teaching site. However, as parts of the interview process become remote to comply with social distancing requirements and recommendations, having the experience and infrastructure to implement VR tours might become necessary for programs moving forward.


Monoclonal paraproteinaemia is an increasingly common reason for referral to haematology services. Paraproteinaemias may be associated with life-threatening haematologic malignancies but can also be an incidental finding requiring only observation. Immunoglobulin M (IgM) paraproteinaemias comprise 15–20% of monoclonal proteins but pose unique clinical challenges. IgM paraproteins are more commonly associated with lymphoplasmacytic lymphoma than multiple myeloma and can occur in a variety of other mature B-cell neoplasms. The large molecular weight of the IgM multimer leads to a spectrum of clinical manifestations more commonly seen with IgM paraproteins than others. The differential diagnosis of B-cell and plasma cell dyscrasias associated with IgM gammopathies can be challenging. Although the discovery of MYD88 L265P and other mutations has shed light on the molecular biology of IgM paraproteinaemias, clinical and histopathologic findings still play a vital role in the diagnostic process. IgM secreting clones are also associated with a number of “monoclonal gammopathy of clinical significance” entities. These disorders pose a novel challenge from both a diagnostic and therapeutic perspective. In this review we provide a clinical overview of IgM paraproteinaemias while discussing the key advances which may affect how we manage these patients in the future. Monoclonal proteins or paraproteins arise from the clonal expansion of an antibody-secreting B-cell or plasma cell . Plasma The majority of referrals for paraproteinaemias are for those of the immunoglobulin G (IgG) or IgA subtypes ,10. ThouPeripheral neuropathies are also a common association of IgM gammopathies and are discussed further in IgM MGUS is defined by the International Myeloma Working Group (IMWG) as a serum IgM monoclonal protein of <30 g/L, with a lymphoplasmacytic lymphoid infiltrate in the bone marrow of <10%. Furthermore, there must be no evidence of anaemia, hyperviscosity, lymphadenopathy, hepatosplenomegaly, constitutional symptoms, or other end-organ damage attributable to the underlying lymphoproliferative disorder . IgM MGUTypically, primary progression events include WM, ALA and other B-cell lymphoproliferative disorders (LPD) at a rate of 1.5–2% per year ,16. IndeWM is defined by the histopathologic finding of a lymphoplasmacytic lymphoma (LPL) with an IgM monoclonal protein . WM accoSymptomatic anaemia, hyperviscosity and immune manifestations are common modes of presentation . HyperviThough a variety of rituximab-based regimens  have shown efficacy against WM, there is currently no consensus that one regimen is superior to others ,26,27,28IgM MM is a rare subtype of MM comprising less than 1% of cases . ClinicaMarginal zone lymphomas (MZL) are a heterogeneous group of tumours comprising three major subtypes: mucosa-associated lymphoid tissue (MALT) lymphoma, splenic marginal zone lymphoma (SMZL) and nodal marginal zone lymphoma (NMZL) . MZL ariIgM paraproteins can be associated with a variety of other mature B-cell LPDs ,38. ParaAs discussed above, the differential diagnosis for IgM paraproteinaemias is wide and patients may present with a variety of symptoms and signs. Constitutional symptoms such as weight loss, night sweats and fever are suggestive of a lymphoproliferative disorder . SymptomThe assessment should also always include a physical examination, in search of lymphadenopathy and hepatosplenomegaly suggestive of a lymphoproliferative disorder. AL amyloid patients might also have macroglossia and periorbital ecchymosis . AlthougFollowing an appropriate history and examination, basic laboratory tests are warranted. These include a full blood count, peripheral blood film , urea and electrolytes, liver function tests, serum calcium and lactate dehydrogenase.SPEP, IFE and SFLC are the standard screening investigations required for the diagnosis of paraproteins ,6. DurinSFLC assays target the epitopes on immunoglobulin kappa and lambda light chains which are usually obscured by the normal immunoglobulin conformation . A ratioQuantification of monoclonal proteins can be achieved using densitometry of the spike on SPEP . The gelExamination of the bone marrow (BM) is often key to the diagnosis of B and plasma cell neoplasms. Morphologic analysis of the BM aspirate may reveal a lymphoplasmacytic lymphoid infiltrate in WM and IgM MGUS while less commonly, a plasma cell infiltrate may be seen, indicating IgM MM . It is nFlow cytometric immunophenotyping (FC) is playing an increasingly important role in the diagnosis of haematological malignancies . FC analConventional karyotyping and fluorescent in situ hybridisation looking for MM specific translocations should also be performed on BM specimens. The identification of specific chromosomal abnormalities such as t will indicate a diagnosis of IgM MM and would not be in keeping with WM . It is nShould clinical suspicion of ALA with cardiac involvement be aroused, an electrocardiogram, serum troponin, NT-proBNP  and an echocardiogram are appropriate . AlthougComputed tomography (CT) and X-ray skeletal survey (SKS) are both recommended modalities of screening for bone lesions in patients with MGUS . The appFrom the point of view of excluding a lymphoproliferative disorder, a whole-body CT scan with contrast would be considered the modality of first choice with the objective of excluding significant lymphadenopathy or hepatosplenomegaly . Again, LPL/WM and MZL are both small B-cell LPDs arising from a post germinal centre B-cell . Whilst Discerning between WM and MZL is of importance with regards to prognostication, as MZL and WM have distinct prognostic scores ,70. The The last decade has seen major advances in our understanding of the molecular biology of indolent B-cell LPDs. One of the key discoveries in this respect has been the identification of the MYD88 L265P mutation in 80–90% of patients with WM, as well as in other B-cell LPDs ,72. MYD8The association between the MYD88 L265P mutation and WM was first made by Treon et al.  in 2012,The phenomenon of paraproteinaemic neuropathy occurring in the absence of an active B-cell or plasma cell malignancy has been recognised for many years . More reIgM-related neuropathy usually presents a picture of progressive and symmetrical distal neuropathy, which can include impairment of both sensory and motor functions . FindingThe second challenge in paraprotein-associated peripheral neuropathy is the lack of effective management strategies. This is particularly true in the case of IgM MGUS where there is no haematologic indication for clone-directed therapy. Intravenous immunoglobulin might be considered, though there is only evidence of limited, short-term benefit, and the mechanism of action is not well understood . RituximAs discussed above, patients with renal impairment are commonly screened for monoclonal proteins. The challenge in the setting of a patient with a paraprotein and renal impairment is the decision as to whether the renal injury can be attributed to the paraprotein or whether it is related to other medical conditions. As renal impairment is a defining feature of MM and is associated with other monoclonal gammopathies, excluding an active plasma cell or B-cell LPD is crucial ,89. ParaThe first step in diagnosing MGRS is to differentiate it from kidney disease unrelated to paraproteinaemia ,90. A reAchieving an accurate diagnosis requires close collaboration between haematologists, nephrologists and pathologists. The histopathologic diagnosis of MGRS requires expertise and electron microscopy is recommended , making it challenging outside specialised centres . FurtherCold agglutinin disease (CAD) comprises 15% of haemolytic anaemias and is characterized by IgM binding to red blood cell (RBC) membranes where it results in complement activation and haemolysis . The larA variety of dermatological disorders may be associated with paraproteinaemias and these range from relatively benign conditions, such as xanthoderma, to more destructive lesions such as pyoderma gangrenosum ,101. PatType 1 cryoglobulinaemia can cause a number of cutaneous manifestations including livedo reticularis and urticaria . Type 2 As is the case for MGRS and paraproteinaemic neuropathy, the diagnosis of skin lesions related to IgM paraproteins requires a multidisciplinary approach. Given the rarity of these conditions, a high index of suspicion is necessary to avoid overlooking these entities. As in other subtypes of monoclonal gammopathy of clinical significance, the optimal treatment is uncertain. Indeed, a watch and wait approach is appropriate if the skin manifestation is indolent . With reTreon et al.  highlighSuch a prognostic score could also have therapeutic implications. The differential effect of ibrutinib on the molecular subtypes of WM has been striking: 100% of MYD88 L265P, CXCR4 WT patients responded to ibrutinib, compared to 85.7% and 60% of patients in the double mutant and double WT groups respectively . In a reThe accurate quantification of IgM paraproteins is of critical importance for diagnosis and response assessment in IgM related B-cell and plasma cell disorders ,115. ParThe use of mass spectrometry (MS) to quantify monoclonal paraproteins has been proposed based on the fact that paraproteins have a unique molecular mass which allows MS to distinguish them from the polyclonal background . The uniHeavy/light chain immunoassays (hevylite/HLC) identify junctional epitopes that span the heavy and light chain constant domains ,124. HLCGreat strides have been made in our understanding of IgM paraproteinaemias in the last decade. This fascinating group of disorders nevertheless continue to pose a diagnostic and therapeutic challenge due to the overlap between clinical entities associated with IgM clones. Close collaboration between haematologists, histopathologists and related medical specialists is vital in arriving at an accurate diagnosis. The importance of correlation between clinical presentation and laboratory findings cannot be emphasized enough in the evaluation of these patients. Advances in molecular diagnostics are bringing us closer to a more refined classification of these disorders with the eventual aim of developing more effective targeted therapeutics to improve patient outcomes.