Telementoring seems to be a promising strategy to deliver training and counselling to physicians in remote areas. In Peru, early graduated physicians must work for the Rural and Urban-Edge Health Service Program where they face important training needs. The aim of this study was to describe the usage of a one-on-one telementoring program for rural physicians and evaluate the aspects related to the perceptions of acceptability and usability.Mixed methods study on recently graduated physicians who work in rural areas and participate in the telementoring program. The program used a mobile application to connect these young doctors with specialized mentors to answer queries about real-life problems raised by working in a rural area. We summarize administrative data to assess participant characteristics and their participation in the program. Additionally, we conducted in-depth interviews to explore the perceived usability, ease of use, and reason for non-use of the telementoring program.Of 74 physicians  enrolled, 12 (16.2%) actively used the program and performed a total of 27 queries, which received response in an average time of 5.4 ± 6.3 h. In the interviews, the main reasons for non-use were connectivity issues, feelings of shame, and self-efficacy. For those who used the telementoring program they referred it was easy to use and solve their inquiries timely.The implementation of a telementoring program sought to provide guidance to recently graduated physicians working in rural areas. Low use rates show that administrative and process-related deficiencies in the program implementation need to be improved. Educational interventions for health professionals have been continuously improved with the use of Information and Communication Technologies (ICT) since they facilitate the exchange of information and interaction between educators and their students . HoweverOne type of these interventions in rural areas is called telementoring, which consists of continuously providing, using ICT, practical and theoretical content from more experienced professionals (mentors) to other professionals with little experience (mentees), focusing on topics of interest depending on the context where the participants are . AlthougIn Peru, there is the Rural and Urban-Edge Health Service , where newly graduated physicians (SERUMS physicians) work for a year in primary health care facilities in different rural areas . This se© was used, which is a medical mobile application approved by the FDA to improve communication between health professionals, allowing the delivery of encrypted information, images, among other functionalities such as multi-device support, instant messaging, and video calling.The gap in knowledge and expertise that physicians present during the SERUMS is significant, likewise, the training needs would be different according to each case since they could differ, for example, according to their level of previous experience, the health needs of their community, the number of resources that have in their establishment, and the number of responsibilities that they will assume . In this context, the National University of San Marcos  created a one-on-one telementoring program to provide SERUMS physicians with guidance and personalized educational advice during their year of work in remote areas. To carry out this program, a mobile application called JOINSince the introduction of new technologies to provide distance education implies a continuous interaction of users with new platforms and applications, these must be evaluated in practice from the perspective of the user (e.g. acceptability and usability) , 13. TheWe conducted a mixed-methods study using a sequential explanatory design, which is a recommended approach that sequentially integrates quantitative and qualitative data for evaluating telehealth interventions . First, In March 2018, two months prior to SERUMS beginning, 124 physicians were invited to participate in the one-on-one telementoring program by sending emails and telephone contact. Only 74 physicians agreed to participate, the reasons for declining from those who did not accept were not available in UNMSM records. For the quantitative phase of the study, we include data from all physicians who agreed to participate in the program. For the qualitative phase, 16 of those enrolled were interviewed, 8 of them used the program and 8 did not. Said sample size was obtained using the saturation technique, recruiting participants until their answers no longer contributed to the objectives of the interview.Because medical training in Peru is hospital-based and often physicians go through many challenges to carry out their professional activities during SERUMS in rural areas , a telementoring Program using a mobile application was designed to communicate specialist physicians (mentors) with these newly graduated physicians in rural areas to provide them, in a short period of time, with information and personalized guidance on the problems they consulted.©  was used. This was a smartphone application approved in 2015 for FDA that allows healthcare professionals to share clinical data and multiple format files including DICOM medical images.Within the processes of the telementoring program, a mobile application called JOIN© follows the international standards HIPAA Compliance for securing confidentiality and anonymity [JOIN© was used as the platform of communication between SERUMS physicians and mentors or technical team. All the information shared via JOINnonymity . Partici©, where they could make inquiries by writing in the chat, sending documents, images, videos or in some cases by contacting the mentor with a video call.Young physicians in rural service, who were the end-users of the program. When the telementoring program started, all enrolled physicians were registered in an instant messaging channel in JOIN© and answered questions or problems of daily professional practice .Mentors from Family medicine. This group was the first line of response to queries made by SERUMS physicians. It was made up of 15 family doctors from Lima , who, based on a schedule, entered JOINMentors from other specialties. This was the second line of response when the family doctors considered that the consultations required the opinion of another specialist doctor. The program had one specialist from each of the following medical areas: internal medicine, surgery, gynecology, obstetrics, pediatrics, neurology, and legal medicineTechnical team. They provided technical support and ensured proper communication between SERUMS physicians and mentors when a query arose. It was made up of physicians, communications professionals, and IT professionals. The structure and workflow can be seen in Fig. The program was structured considering four types of users:Recruitment: Graduates of 2018 from the UNMSM School of Medicine who would start SERUMS were invited to an informational meeting about the telementoring program. The invitation was made through the institutional social media and website. Everyone who attended the informational meeting was then asked to register for the program through an online form.Training: Before starting the program, physicians and mentors received two weeks of training on the use of the application. This was done through asynchronous online training using a virtual classroom on the open platform Moodle. For this, multimedia materials (videos and documents) were used to teach about the use of the program including login, creation of user accounts, sending text, images, communication with mentors and video calls.Program engagement and monitoring: The use of the telementoring program was not mandatory. The participants could use the application if they consider that they need guidance with a situation in their professional work.Legal aspects and confidentiality of information: All participants had to sign a document of the terms and conditions of participation, where it was mentioned that the program was designed to provide personalized educational advice, not to solve clinical cases and it should not be used for emergency situations. The program does not represent a remote medical work, for which it was prohibited to carry out consultations sharing personal information of patients. The terms and conditions of use of this telementoring program can be downloaded in link .Program length: the program was offered from June 2018 to December 2018© application was financed by the Ministry of Telecommunications of Japan and granted to the UNMSM for research projects during the year 2018–2019.Program funding: The program was financed by UNMSM. The license to use the JOIN© app records. Descriptive analyses were performed using Stata 16 . Numerical variables were summarized means and standard deviations, and categorical variables were summarized as frequencies and percentages.First, we collected quantitative data from SERUMS physicians who enrolled in the telementoring Program in 2018 available in UNMSM registries of the telementoring program. Some variables were the level of resolution of the healthcare facility they work according to Peruvian normativity , dependeThen, we collected qualitative information through telephone interviews. We explored perceived ease of use, usefulness, and reasons for participating in the telementoring program. The interviews lasted an average of 15 min and were audio recorded. For the analysis, the ATLAS.ti v7.0 software was used, applying the thematic analysis methodology . ContentOf 74 SERUMS physicians who agreed to participate in the telementoring program and completed the initial training, 38 51.4%) were women and more than 70% of the participants reported no previous experience with medical applications and that 79.5% reported that they worked in health facilities located in areas of poverty and extreme poverty that depended mainly on the Ministry of Health of Peru (See Table .4% were Only 12 (16.2%) of physicians enrolled used the program, that is, made inquiries or questions to the mentors. A total of 27 consultations were carried out, with a mean of 2.1 ± 1.3 consultations for each physician. All queries were answered. The majority (62.5%) were answered in less than six hours and were mainly related to the topics of dermatology (40.7%), legal medicine (14.8%) and cardiology (11.1%) .SERUMS physicians who used the program reported that was easy to use because it was intuitive and similar to other instant messaging systems, they were more familiar with, such as WhatsApp groups. Also, due to the possibility of sharing a specific consultation in a structured way by attaching multimedia files, which were necessary for consultations with some specialties such as dermatology or pediatrics.“Almost all individual questions were done in the group chat. I didn’t really know how to use personal chat because it wasn’t very clear to me in the initial training and I’m not very familiar with apps. On certain occasions I would have liked to ask questions in private.” (Participant 1).However, it was also reported that some physicians found it difficult to use other features such as starting a personal chat, notification settings, etc. For this, the need for additional training was raised due to the little previous experience of some physicians in the use of medical applications.“It has been an important and useful tool because in some specific issues we had inexperience. Especially since we are working at the first level of care, and we do not receive specific training for some situations here… It was also useful when you share and see the cases of your colleagues, it encourages you to think about similar problems, you learn from it.” (Participant 4) .It was reported that the system was of great help in resolving cases since, due to the physicians’ lack of experience, they were not clear on how to act in certain situations. Also, because the queries of others could be seen in the chat, and served as learning material to develop skills to solve similar problem situations.“When I joined the program, I was inexperienced, so I was encouraged to consult ... now I have more knowledge in these aspects, for example, how to act when faced with an autopsy request for a legal medical problem ... The program it is especially useful in the first months of SERUMS.” (Participant 10).Additionally, it was mentioned that the response time of the questions played an important role. Although they initially expected responses to be immediate, given the nature of the program (not used for urgent/emergencies) and given the limited availability of specialists, most agreed that the time delay was adequate.“It seemed that those who did write in the groups put really difficult cases… and it was embarrassing to write simple questions. I know of a friend who sometimes had questions but didn’t want to show that he didn’t know because they could later identify him with his full name. In the case of us (physicians)... even more so, we are too proud to admit it.” (Participant 2).It was reported that although it would have been very helpful to have the opinion of a specialist physicians or a university professor, recent graduated physicians did not ask questions because they had a certain degree of embarrassment and fear of appearing foolish or inexperienced to other colleagues. It was reported that they would prefer no group chats, only direct communications, and that it would be good for some not to show their full name but an alias.“In my case at this point I have no longer had any doubts about cases. That would be the main reason why I did not have the need to consult or present a clinical case. It would have been especially helpful at the beginning of SERUMS when we were adapting”. (Participant 4).Another reason was because they started accessing the program late when they had already obtained enough experience to solve most of the frequent doubts on their own. The reason for this was that they had never participated in a similar telehealth program before and did not fully understand how it worked. Most agreed that the program should be prioritized in the first months of social service.Other reasons referred by SERUMS physicians were related to technical aspects. Internet bandwidth was mentioned to be a main issue, being in most cases of poor quality or simply inaccessible for some settings. Also, some physicians mentioned they did not desire to install new mobile-phone apps, instead they preferred and use frequently commercial messaging apps, such as WhatsApp, to performed clinical queries to their peers.“I do not use the application because of the internet problem… The truth is that the connection was bad almost all last year, only calls or text messages came in” (Participant 13).Our results reflect that the participation rates in this first version of the telementoring program were low and that the physicians indicated the feelings of embarrassment to ask in groups, the lack of familiarity with new apps and low connectivity as the main reasons. However, users who did use the system reported that the program was easy to use and useful for resolving their queries in a timely manner.Other one-on-one telementoring experiences showed to be equally effective on developing medical procediments compared to physical mentoring or virtual reality assisted training , 19, 20.In general, all mentoring programs have the advantage of being more student-centered than traditional teaching . HoweverFirst, the design of the program did not include conducting an educational survey to assess the specific needs of graduate physicians and how they would like to be provided with such information. Consequently, despite previous evidence suggesting an important need for clinical guidance during SERUMS , the maiSecond, some SERUMS physicians referred to the presence of limited mobile internet connectivity in their healthcare facilities. This is a common problem in rural areas, where regardless of mobile phone signal coverage, connectivity could be affected considering various geographic and climatic conditions . DespiteThirdly, despite having a telementoring system with family doctors and specialist doctors available, the SERUMS physicians preferred to consult with their own networks of contacts, generally made up of other recently graduated physicians, with whom they had more confidence. Some degree of embarrassment in asking questions and fear of appearing inexperienced to other colleagues was reported. This situation was also evidenced in other countries such as Colombia  and suggFourth, most of the physicians who participated in the study had no prior experience using medical apps. This would imply that, despite having a smartphone, it is possible that many of them do not trust or prefer not to use new applications or technological tools to support their professional training, as observed in medical students and recent graduates in our country , 33.On the other hand, among the physicians who did actively use the Telementoring program, it was found that most of the consultations are related to dermatology and legal medicine, specialties not initially included in the program. Possibly due to little prior training in these specialties at the primary care level during university . This leIn terms of ease of use, our findings were similar to a study conducted at Jikei University Hospital in Japan, in which interns reported that the use of the JOIN© was intuitive and similar to other apps. Messaging as LINE . Still, Although these are important findings, some limitations must be considered. First, the recruitment of participants was not random but was done through invitations by mail and telephone, which implies a possible selection bias, more specifically a voluntary bias. Second, the interviews were conducted at the end of the SERUMS year, so there might be some possibility of recall bias. Finally, we do not know if the sociodemographic or occupational characteristics of physicians from other universities are similar to those from UNMSM, so our findings may not be extrapolated to all contexts.Despite these limitations, our study provides important insights into the potential of telementoring interventions using mobile technologies to close knowledge gaps in rural physicians in low- and middle-income countries. Although we were unable to measure the direct impact of the program, our results suggest that this impact exists and would merit evaluation in future cohorts. In addition, the Telementoring program presented several strengths that have previously been shown to generate positive results in medical education, such as the ease of use of the technology, the confidential transmission of information, and the adequate response time to queries about real problem situations of a recently graduated physicians working in a rural area .Telementoring through a mobile application represents a useful alternative to provide educational support to young physicians who work in rural areas and who need help to face problems that arise in their professional work. However, its implementation may be limited by the physicians' lack of experience in using mobile applications, limited Internet access, lack of anonymization when asking questions, and the presence of medical specialist mentors with whom they did not trust to ask openly. This tells us that telementoring interventions designed for physicians working in rural areas should include the considerations discussed above such as conducting an initial formative study and a final evaluation of the impact of improving physicians' experience while serving in rural areas.


E. coli, and the activity was retained for a prolonged period on the surfaces of the covalently modified materials.Orthopedic-device-related infections are notorious for causing physical and psychological trauma to patients suffering from them. Traditional methods of treating these infections have relied heavily on antibiotics and are becoming ineffectual due to the rise of antibiotic-resistant bacteria. Mimics of antimicrobial peptides have emerged as exciting alternatives due to their favorable antibacterial properties and lack of propensity for generating resistant bacteria. In this study, the efficacy of an antibacterial polymer as a coating material for hydroxyapatite and glass surfaces, two materials with wide ranging application in orthopedics and the biomedical sciences, is demonstrated. Both physical and covalent modes of attachment of the polymer to these materials were explored. Polymer attachment to the material surfaces was confirmed via X-ray photoelectron spectroscopy and contact angle measurements. The modified surfaces exhibited significant antibacterial activity against the Gram-negative bacterium  E. coli constitute a significant threat owing to the difficulty of treating these infections [Orthopedic-device-related infections (ODRIs) pose serious technological and economic challenges to healthcare institutes and governments around the world, while causing physical and psychological trauma to patients suffering from them . Althougfections ,4,5.ODRIs have traditionally been treated with antibiotics ,7,8, eitTheir interesting properties notwithstanding, natural AMPs do not have ideal pharmacological properties ,24,25. TAn exciting class of non-peptide-based AMP mimics is antimicrobial polymers (APs) ,33,34. AS. aureus [In the context of ODRIs, coating bone implant materials with antimicrobial agents that demonstrate a reduced susceptibility to bacterial resistance is crucial for the fight against antibiotic resistance, and to improve health outcomes of patients with implants. Hydroxyapatite (HA), a calcium phosphate-based bioceramic ,47,48,49. aureus .E. coli. For covalent attachment, an Plasma Immersion, Ion Implantation, and Deposition (PIIID) technique was used, followed by spin-coating. Attachment of the AP to HA was confirmed via XPS, and antibacterial activity was monitored via direct-contact antibacterial assay and SEM imaging. PIIID is a linker-free, single-step process for attaching compounds directly to surfaces of nonpolymeric materials [The aim of the current study was to determine whether AP physically adsorbed or covalently bound to HA is able to influence the colonization by aterials ,62,63,64aterials , and theaterials . In the E. coli. The study aims to investigate the influence of mode of attachment of the AP  on the antibacterial activity of the coated surfaces.In summary, ODRIs pose significant challenges to healthcare systems and patients. Unfortunately, the over-reliance on antibiotics for treatment has led to the emergence of antibiotic-resistant bacteria. As an alternative, antimicrobial peptides (AMPs) and their synthetic mimics have been explored due to their broad-spectrum activity and reduced susceptibility to bacterial resistance. Among the mimics, antimicrobial polymers (APs) show promise as they emulate the physical properties of AMPs and exhibit biocompatibility. Coating bone implant materials such as hydroxyapatite (HA) with antimicrobial agents is crucial in combating ODRIs. In this study, we report strategies for attaching an AP to HA surfaces and investigate the efficacy of such coated surfaces in combating colonization by the Gram-negative bacterium HA nanoparticles and, subsequently, HA discs, were synthesized according to protocols described previously . BrieflyHA discs were fabricated using the sintered nanoparticles. Briefly, the nanoparticles were first disaggregated and powdered. Powder particles larger than 0.2 μm were separated out from the rest by running the powder through a sieve. Particles larger than 0.2 μm were ground further to bring their size down while the particles smaller than 0.2 μm were used to prepare a 40 wt% (40 g of nanoparticles in 60 g of water) mixture in water. The mixture was subsequently homogenized for 60 min inside a ball mill and then cast into cylindrical molds. The casts were dried overnight inside a vacuum desiccator. Dry, cylindrical HA discs were subsequently sintered for 6 h at 1100 °C inside a furnace.−5 torr to remove oxygen, before the treating gas was flowed in. Chamber evacuation was performed with a turbomolecular pump backed by a scroll pump and nitrogen and acetylene gases were flowed in equal volume ratios into the chamber at a combined pressure of 350 mTorr. A schematic of the PIIID treatment setup is presented in PIIID treatment of HA discs and glass surfaces was carried out using a dielectric barrier discharge (DBD) apparatus . NitrogeE. coli is 32 µg/mL, or 1.4 µM [The AP used in this study was synthesized according to a protocol described by Boyer and coworkers ,41. It ir 1.4 µM .Native HA discs were conjugated to the polymer via physical interactions while PIIID-modified HA discs and glass surfaces were utilized for covalent conjugation with the AP. AP attachment to the HA discs, PIIID-HA discs, and PIIID-glass surfaces was achieved via spin coating. Briefly, 500 and 1000 μg of the polymer were dissolved in two different vials containing 1 mL of MilliQ water each, resulting in two solutions containing different concentrations of the polymer (500 μg/mL and 1000 μg/mL). Subsequently, HA discs, PIIID-HA discs and PIIID-glass coverslips were transferred to well plates and incubated in these solutions for 24 h at room temperature and under mild shaking. After incubation, the solutions were removed from the wells and the discs and coverslips were washed thrice with distilled water. The discs were then subjected to mild vortexing to ensure the removal of loosely bound and unbound polymer. After the washing and the vortexing steps, the discs and the coverslips were left to dry for 24 h at room temperature. Two different test groups (discs and coverslips coated with 500 and 1000 μg/mL) were used for all the experiments. Uncoated samples (incubated in MilliQ water without the polymer) were used as controls. HA discs incubated in 500 and 1000 μg/mL solutions of the polymer are referred to as HA 500p and HA 1000p, respectively, in the relevant places in this text, while the corresponding PIIID-treated discs and glass coverslips are referred to as PIIID-HA 500p, PIIID-HA 1000p, PIIID-glass coverslip 500p, and PIIID-glass coverslip 1000p, wherever necessary. To minimize confusion, the nature of the samples being discussed is specified in the text.A field-emission scanning electron microscope (FE-SEM), NanoSEM 230, was used for all the imaging performed in this study. Native HA discs and PIIID-HA discs were imaged to observe the morphological changes brought about by the PIIID treatment on the surface of HA. For this, untreated and PIIID-HA discs were sputter coated with 30 nm of platinum in a Leica sputter coater, and then imaged under the microscope. Spot sizes between 3 and 5 and an accelerating voltage of 15 kV were found to be suitable for imaging.−1.FT-IR spectroscopy was performed to analyze the surfaces of HA discs . The motivation behind this analysis was to assess the types of chemical species introduced to the surface of native HA discs via the PIIID treatment. Furthermore, data from FT-IR and RAMAN spectroscopy are complementary in nature, and can therefore be used to corroborate each other. For this analysis, we used a Spectrum 100/Spotlight 400 FT-IR spectrometer and operated it within the scanning range of 650 to 4000 cm−1.RAMAN spectroscopy was further performed to analyze the surfaces of untreated HA discs, PIIID-HA discs, and PIIID-HA discs coated with the two different concentrations of the polymer. Similar to FT-IR spectroscopy, the primary motivation behind this study was to assess the types of chemical species introduced to the HA surface via the PIIID treatment. Furthermore, RAMAN spectra of the PIIID-treated samples were used as an indicator of the success of the PIIID treatment. A grating of 1800 L/mm and a standard diode laser setting of 532 nm (green) was used for the analysis. In order to determine the extended spectra of the samples, the scanning range was adjusted from 44 to 4000 cm9 mbar. A mono-chromated Al Kα (energy 1486.68 eV) was used as the X-ray source and a spot size of 500 μm was found to be suitable for the analysis. The device was operated at a power of 120 W and at a photoelectron take-off angle of 90°.In order to qualitatively confirm the attachment of the polymer onto the unmodified HA discs, and the PIIID-HA discs, and PIIID-glass coverslips, and to further characterize the changes in the chemical composition of the HA disc surface brought about by the PIIID treatment, XPS was performed on the surfaces. For this analysis, a Thermo ESCALAB250Xi X-ray photoelectron spectrometer was used, and it was operated at a background vacuum greater than 2 × 10To characterize the nature of the attachment of the polymer to the PIIID-HA discs and PIIID-glass, these surfaces, along with the corresponding polymer-coated ones, were incubated in a solution of 2% sodium dodecyl sulfate (SDS) for one hour at a temperature of 70 °C. This assay was performed in a water bath to ensure a constant temperature throughout the one-hour period. SDS wash at an elevated temperature is a standard procedure for the removal of electrostatically bound entities from treated surfaces ,62. SubsThe effect of PIIID treatment and subsequent polymer attachment on the wettability of glass coverslip surface was evaluated via contact angle measurement. The analysis was performed only on the glass coverslips as the HA discs did not allow for the formation of stable droplets due to their extremely porous nature. However, the change, or lack thereof, of the wettability the glass surface due to PIIID treatment and subsequent polymer attachment can serve as a reasonable indicator of what happens to HA surfaces too after similar modifications. For this analysis, a ramé-hart contact angle goniometer was used. A syringe was used to deposit water droplets on the surfaces of glass coverslips that were placed on a stage. The volume of the droplets deposited on the samples was kept approximately the same. Three droplets were deposited per sample and the contact angle was measured using the software DROPimage Standard (v2.1.3).E. coli K12 strain  was used to assess the antibacterial performance of the surfaces described in this study. The antibacterial activity of the unmodified and PIIID-treated HA discs coated with the polymer, and PIIID-glass surfaces coated with the polymer was determined by culturing E. coli (ATCC 10798) directly on them [ on them . SurfaceE. coli K12 (ATCC 10798) was grown in Mueller Hinton Broth at 37 °C overnight. The next day, the bacteria were collected via centrifugation for 10 min at 3500 rpm. Subsequently, the bacteria were dissolved in fresh broth to an absorbance of 0.1 at 600 nm, corresponding to a bacterial concentration of 1 × 108 bacteria/mL. The broth was further diluted 1000-fold to obtain a final bacterial concentration of 105 bacteria/mL.In the first study, the number of bacteria growing in the solution in contact with the polymer-coated surfaces was determined. Briefly, 5 bacteria/mL. Post incubation, the plates were retrieved and the media from each well was collected into separate Eppendorf tubes and serially diluted from 1 to 10-fold. Sterile PBS was used for preparing the dilutions. The diluted medium was subsequently collected from the tubes and pipetted out onto nutrient agar plates. For this, nutrient agar plates were divided into five segments of roughly equal area, and each segment was used for growing bacteria corresponding to a single dilution. Therefore, ten different segments (two nutrient agar plates) were utilized to grow bacteria corresponding to all the ten dilutions of a single group. The plates containing the diluted media were further incubated overnight at 37 °C. Post incubation, the number of visible single bacterial colonies, referred to as the Colony Forming Units (or CFUs), in each segment of the nutrient agar plates were counted, and the values were assigned to the corresponding dilutions. The CFUs in nth dilution was then used to calculate the CFUs/mL of the undiluted media using the following formula: Three sets of samples were used in this study, and three groups were included in each set. The first set comprised untreated HA disc as control, and HA disc incubated in 500 and 1000 μg/mL polymer as the two test groups. The second set comprised PIIID-glass coverslip as the control group, and PIIID-glass coverslips incubated in 500 and 1000 μg/mL polymer as the two test groups. Finally, the third set comprised PIIID-HA discs as the control group, and PIIID-HA discs incubated in 500 and 1000 μg/mL polymer as the two test groups. Samples were transferred to 96-well plates and incubated overnight at 37 °C in MHB media containing 10A modification of a previous protocol was followed to quantify the number of bacteria attached to surfaces of the materials . Three s5 bacteria/mL. Post incubation, the samples were washed three times with PBS with mild shaking for 5 min in order to remove loosely attached bacteria. All the samples barring the glass coverslips were subsequently removed from the wells and transferred to Eppendorf tubes containing broth. The tubes were then placed on a vortex mixer and the samples were vortexed vigorously for 5 min. The glass coverslips were retained in the well plates and submerged in fresh broth. The plates were placed on a vortex mixer and the coverslips were vortexed gently for 5 min. Vortexing was performed to ensure the dissociation of strongly attached bacteria from the discs and the coverslips. After vortexing, the media from the Eppendorf tubes (in case of the HA disc) and the well plates (in case of the glass coverslips) were collected into separate Eppendorf tubes and serially diluted from 1- to 10-fold. Sterile PBS was used for preparing the dilutions. The diluted medium was subsequently collected from the tubes and pipetted out on nutrient agar plates. For this, the nutrient agar plates were divided into five segments of roughly equal area, and each segment was used for growing bacteria corresponding to a single dilution. Therefore, ten different segments (two nutrient agar plates) were utilized to grow bacteria corresponding to all the ten dilutions of a single group. The plates containing the diluted media were further incubated overnight at 37 °C. Post incubation, the number of visible single bacterial colonies, referred to as colony forming units (or CFUs), in each segment of the nutrient agar plates were counted, and the values were assigned to the corresponding dilutions. The number of CFUs in the nth dilution was then used to calculate the CFUs/mL of the undiluted media using the following formula: Briefly, the samples were transferred to 96-well plates and incubated overnight at 37 °C in MHB media containing 105 bacteria/mL. Post incubation, the samples were washed three times with PBS under mild shaking condition for 5 min in order to get rid of loosely attached bacteria. Subsequently, the firmly attached bacteria were fixed to the surfaces via incubation for two hours in a 2.5% glutaraldehyde solution at ambient temperature. Post fixing, the samples were washed sequentially with increasing concentrations of ethanol, starting at 50%, then 60%, then 70%, all the way up to 100% ethanol. After the last wash, the samples were dried at the critical point of carbon dioxide in a critical point dryer and then sputter coated with 30 mm of platinum in a Leica sputter coater. For native HA discs (uncoated and polymer-coated), a spot size of 3 and an accelerating voltage of 15 kV were found to be suitable for imaging. For PIIID-glass surfaces and PIIID-HA discs, a spot size of 3 and an accelerating voltage of 5 kV were found to be suitable for imaging.Bacteria attached to the surfaces were also imaged using SEM. Untreated HA discs and HA discs incubated in 500 and 1000 µg/mL polymer, PIIID-HA discs and PIIID-HA discs incubated in 500 and 1000 µg/mL polymer, and PIIID-glass coverslips and PIIID-glass coverslips incubated in 500 and 1000 µg/mL polymer were imaged in this study. Briefly, the samples were transferred to 96-well plates and incubated overnight at 37 °C in MHB media containing 109 mbar. A mono-chromated Al Kα (energy 1486.68 eV) was used as the X-ray source and the power was maintained at 120 W. A photoelectron take-off angle of 90° and a spot size of 500 μm was chosen for the analysis.The surfaces of HA and PIIID-HA discs coated with 1000 µg of the antimicrobial polymer  were analyzed via XPS after their incubation in PBS for 7 days. A Thermo ESCALAB250Xi X-ray photoelectron spectrometer was used at a background vacuum higher than 2 × 105 bacterial/mL of media. Subsequently, after 24 h of bacterial growth, the total number of bacteria growing in the supernatant and on the surface of the discs was measured according to the protocols already described above. The degree of reduction in the number of viable bacteria, both in the supernatant and the sample surface, was compared to the antibacterial activity of newly coated discs. The ability of the modified HA discs to retain their antibacterial activity over a period of two weeks in PBS was tested. Newly coated HA discs  were incubated in PBS inside 24-well plates. Each day after incubation, the PBS from each sample was removed and replaced with fresh PBS. After 7 and 14 days of incubation, the samples were removed and air dried. The dry samples were then incubated with fresh bacteria at a concentration of 10E. coli K12 (ATCC 10798) bacteria were grown in MHB for 18 h and then diluted in MHB to obtain a final bacterial concentration of 106 CFU/mL. 100 µL of the bacterial solution was then added to the wells of a 96-well plate containing HA, PIIID-HA, HA + 1000p, and PIIID-HA + 1000p discs and glass, PIIID-glass, glass + 1000p, and PIIID-glass + 1000p coverslips. The plates were subsequently incubated at 37 °C for 48 h. Following incubation, the media from the wells were pipetted out and the discs were washed thrice with 125 µL of Milli-Q water to get rid of loosely bound bacteria and residual polymer. The adherent biofilms on the discs were then stained with 125 µL of 0.1% (w/v) crystal violet solution at room temperature. After 10 min of staining, the discs were washed again, being washed thrice with 200 µL of Milli-Q water. After the final wash, 200 µL of 70% (w/v) ethanol was added to each well to solubilize the crystal violet. The ethanol–crystal violet solutions from each well were then transferred to another 96-well plate and their optical densities were measured at 595 nm in a microplate reader. The percentage of biofilm inhibition compared to negative controls  was calculated using the following formula.The ability of AP-coated HA discs and glass coverslips to inhibit formation of biofilms was measured by quantifying the biomass of biofilms via a crystal violet staining assay. Briefly, 5 bacteria/mL. Post incubation, the plates were retrieved, and the medium from each well was discarded by pipetting. The samples were washed thrice with PBS under mild shaking conditions for 5 min in order to get rid of loosely attached bacteria. Subsequently, the strongly attached bacteria were fixed to the surfaces via incubation for two hours in a 2.5% glutaraldehyde solution at room temperature. Post fixing, the samples were washed sequentially with increasing concentrations of ethanol, starting at 50%, then 60%, then 70%, all the way up to 100% ethanol. After the last ethanol wash, the samples were dried at the critical point of carbon dioxide in a critical point dryer, sputter coated with 30 mm of platinum in a Leica sputter coater and taken for imaging. For native HA discs (uncoated and polymer-coated), a spot size of 3 and an accelerating voltage of 15 kV were found to be suitable for imaging. A spot size of 3 and an accelerating voltage of 5 kV were found to be suitable for imaging all the samples.In addition to quantifying the biofilm biomass, bacteria attached to the surfaces were also imaged under SEM. Briefly, the samples were transferred to 96-well plates and incubated overnight at 37 °C in MHB media containing 102 chamber which was maintained at 5% CO2 and 37 °C. After one passage, the cells were used for alamar blue cytotoxicity assay.In vitro cytotoxicity studies were performed to analyze the biocompatibility of the modified surfaces. Human fetal osteoblast cells, hFOB 1.19 (at passage 4), were revived from a frozen stock in DMEM/F-12 media supplemented with 10% Fetal Bovine Serum (FBS), streptomycin (5000 μg/mL), and penicillin (5000 unit/mL). The cells were then grown in a humidified CO4 cells/disc and cultured up to 72 h. The medium was replaced every 24 h. After 24 and 72 h of cell growth, the medium was supplemented with alamar blue reagent at 10% (v/v). The cells were then incubated for 2 h in a humidified CO2 chamber at 37 °C. Post incubation, the medium was pipetted out from the wells and transferred to a 96-well microtiter plate. The absorbance of the medium was then measured at 570 nm with a reference wavelength of 600 nm. The cell viability was compared to cells grown on tissue culture plates. The percentage cell viability was then calculated from the absorbance values using the following formula:The cytotoxicity of the physically and covalently coated HA disc surfaces was determined by measuring the metabolic activity of hFOB 1.19 cells grown on the discs for 24 and 72 h. For the physically coated discs, uncoated HA discs were used as the control. For the covalently coated PIIID-modified discs, uncoated PIIID-HA discs were used as the control. The cytotoxicity of all the groups were compared to that of nascent tissue culture plates. Briefly, the discs were incubated in DMEM/F-12 media supplemented with 10% FBS for 24 h to ensure the adsorption of nutrients from the media onto the surface of the materials. The medium was discarded, and the discs were resuspended in fresh media for cell seeding. Cells harvested by trypsinized from tissue culture plates were seeded onto the discs at a density of 10M1 = molar extinction coefficient (E) of oxidized alamar blue (blue) at 570 nm;M2 = molar extinction coefficient (E) of reduced alamar blue (red) at 600 nm;A1 = absorbance of test wells at 570 nm;A2 = absorbance of test wells at 600 nm;P1 = absorbance of positive growth control well (cells in tissue culture plate) at 570 nm;P2 = absorbance of positive growth control well at 600 nm.p-values less than 0.05 were considered statistically significant. The following symbols are used to signify statistical significance throughout the article: ns = no significance (p > 0.05); * = p < 0.05; ** = p < 0.01; *** = p < 0.001; **** = p < 0.0001.All data presented in this study are plotted as mean ± standard deviation. Unless mentioned otherwise, all the experiments were performed in triplicate and repeated at least three times. GraphPad Prism software (10.0.0) was used to statistically analyze the data from the experiments. One-way Analysis of Variance  was used to determine significant differences between groups and The surface morphologies of the HA discs, PIIID-HA discs, glass coverslips, and PIIID-glass coverslips were visualized via SEM. The PIIID process deposits a layer of reactive polymer over the surface on which it is performed. Therefore, our starting point was to observe the morphological changes brought about by this technique on HA and glass surfaces. The surface of the PIIID-HA discs exhibited a blistered appearance, while no such feature was observed on the unmodified HA disc surface a. Simila−1, corresponding to v1 nondegenerate symmetric stretching characteristic of P-O bonds was observed in the spectra of HA. The spectra of HA also revealed peaks associated with the v3 vibration mode of the PO43− at 1036 and 1095 cm−1. The FT-IR spectrum of the PIIID-HA discs showed the peaks corresponding to the groups introduced by the PIIID treatment, and masked the peaks found in pure HA. Peaks were observed between 1650 and 1800 cm−1  are provided in The chemical groups present on the surfaces of unmodified and modified HA discs were analyzed via FT-IT spectroscopy. The FT-IR spectra of untreated HA discs revealed peaks corresponding to the functional groups present in pristine HA a. A peak800 cm−1 b. These cetylene c. Attach−1, 1046 cm−1, 1030 cm−1, and 961 cm−1, corresponding to the asymmetric and symmetric stretching modes of the PO4 group  are provided in The RAMAN spectra of PIIID-HA discs further revealed the characteristic peaks corresponding to the groups added by the PIIID treatment. Notably, peaks were observed between the wavenumbers 1500 and 1700 cm−1 d. These Attachment of the polymer to the surfaces of HA discs, PIIID-HA discs, and PIIID-glass coverslips was confirmed via XPS. A significant increase in the percentage of the surface occupied by carbon and nitrogen was observed on HA discs that were physically bonded to the polymer . UntreadPIIID treatment results in the deposition of a thin carbon film containing reactive radicals and functional groups on the HA disc surface . The ideXPS data from the glass coverslips revealed similar trends in the amount of carbon, nitrogen, and oxygen as the HA discs . PIIID tThe covalent bonds formed between the polymer and the PIIID-HA  and glasAttachment of the polymer to PIIID-glass surfaces was further confirmed by measuring the changes in the hydrophobicity of the polymer-coated surfaces compared to an uncoated control surface. Furthermore, the change in the surface hydrophobicity brought about by PIIID treatment of native glass coverslips was also observed. PIIID modification resulted in an increase in the hydrophobicity of the surface b, raisin10 reduction in the number of viable bacteria in the media  exhibiting a 3-loghe media b. No dos10 reduction in the number of viable bacteria on both the coated discs. Additionally, unlike the bacteria in the supernatant, a dose-dependent increase in the toxicity towards bacteria on the surface was observed.Similarly, the number of bacteria attached to the polymer-coated discs after one day of growth was lower compared to the control HA disc . HoweverE. coli. K12 exhibited a cylindrical rod-like morphology on all the discs, and no structural deformities were visible on the bacteria grown on the uncoated disc  and a 3-log10 (1000 µg/mL polymer solution) reduction in the number of attached bacteria was observed  was monitored over a period of 14 days. HA discs physically coated with 1000 μg/mL polymer demonstrated no antibacterial activity both in the surrounding solution and on the disc surface after 7 and 14 days of incubation in PBS. The activities of freshly coated discs measured previously were assigned to day 1. In the supernatant, the activity reduced from a 3.5-loger day 7 a. On theer day 7 b. The la10 reduction in CFUs at day 1 in the surrounding solution. After day 7 and day 14 of incubation in PVS, the discs exhibited 1.2- and 0.6-log10 reductions in CFUs in the surrounding solution, respectively  than the corresponding tissue culture plate control, while after 24 h of cell culture, the viability of cells on PIIID-HA discs was nearly 100% b. Upon aE. coli. The AP used in the current study has previously demonstrated significant antibacterial activity against the Gram-negative pathogen in solution [The prevalence of ODRIs demands concerted effort by researchers ,3. The lsolution ,40,41. HThe AP was successfully coated on the surface of HA discs via physical and covalent attachments and on glass coverslips via covalent attachment. Physical attachment of antibacterial compounds to biomaterials has been a common strategy for imparting antibacterial properties to biomaterials ,82. PhysE. coli attached to the surface of AP-coated HA discs appeared to be distorted, while those on the control HA disc appeared normal. This indicates that the AP, in its physically bound state, could be killing bacteria by disrupting their membranes [Physically coated HA discs exhibited significantly higher antibacterial activity in the supernatant compared to the surface of the discs . This can be attributed to the leaching out of the AP from the discs . Physicaembranes ,87. Membembranes ; howeverCovalently coated PIIID-HA discs and glass coverslips exhibited significantly higher antibacterial activity on their surfaces compared to the supernatants. This can be attributed to the retention of the AP on the covalently coated surfaces. Further characterization via XPS confirmed that the covalently coated PIIID-HA discs successfully retained the surface-bound AP even after 7 days of incubation in PBS, which was not the case for the physically coated HA discs. Interestingly, no disruption in membrane morphology was observed on the bacteria attached to the covalently coated surfaces. This could be attributed to different modes of action exhibited by the AP in their physically bound and covalently bound states but will need to be tested experimentally via membrane disruption, depolarization assays.E. coli-mediated infections on orthopedic biomaterial surfaces.The anti-biofilm activity of the physically and covalently coated discs and glass surfaces was quantified. AP coating  resulted in a significant reduction in the magnitude of biofilm formation. However, the degree of reduction in biofilm formation was much higher on the covalently coated surfaces compared to the physically coated ones. This can once again be attributed to the higher retention of the AP on the covalently coated surfaces. SEM images of the biofilms on the control surfaces revealed large clumps of bacteria, while only single bacteria and small clumps of bacteria were visible on the AP-coated surfaces. Further characterizations of the mechanism of action of the AP in physically bound and covalently bound states should reveal some interesting results. Nonetheless, the AP investigated in this study is a promising candidate for controlling E. coli. Although both forms of coating yielded surfaces with antibacterial activity, covalently coated surfaces retained their activity over a longer period of time compared to physically coated surfaces. This work paves the way for further research into PIIID modification of orthopedic surfaces for the attachment of biologically relevant molecules, including novel antimicrobial entities.In summary, we successfully synthesized antibacterial coatings for HA surfaces via two different techniques: physical and covalent attachment of APs. The detailed mechanism of action of these coatings needs to be understood further, but the coatings demonstrated significant antibacterial activity against the Gram-negative pathogen


In 2020, coinciding with its 60th anniversary, the International Society of Nephrology (ISN) launched its Emerging Leaders Program (ELP), the first of its kind by a major nephrology society. The program was conceived with the intention to build a global cadre of nephrology leaders who would strive together for a future where all people would have an equitable access to sustainable and quality kidney health care, in alignment with the mission and vision of the ISN. This can be achieved by providing the opportunity to partake in ISN’s global capacity-building programs and workgroups, and work closely with international experts to develop skills in implementation science and research. The program also aims to enhance capacity at developing and implementing context-specific, resource-sensitive, evidence-based, multidisciplinary care to those with and at-risk of kidney diseases. In addition, the focus is on acquiring the necessary skills in the evaluation, development, and management of health systems along with principles of entrepreneurship, advocacy, and communication to ensure better equity and diversity. Finally, the program provides access to continuous professional development to take on leadership roles locally and globally.A call for expression of interest was sent to early career ISN members, defined as those who have been less than 10 years out of professional training. Candidates were asked to submit a portfolio detailing their professional, scholarly, and academic activities to date but most importantly to identify issues related to kidney health that they planned to address through collaborative studies within the program. Of the 71 applications representing all 10 ISN geographical regions, the ELP Steering Committee selected a total of 14 candidates from 12 countries (6 ISN regions). In terms of gender distribution and disciplines, 5 were women, 11 were adult nephrologists, 2 were pediatric nephrologists along with a non-physician entrepreneur, who had established a dialysis provider network in East Africa.Over the course of 12 months, we attended webinars, courses, and workshops aimed at nurturing our understanding of global nephrology challenges, building capacity in leadership and communication, and leveraging advocacy and partnership skills. We met with major ISN leaders who have forged the organization’s identity, and with major global health actors from the World Health Organization and the Noncommunicable Disease Alliance. In addition, we were invited to work with various ISN working groups. This provided us with deep insights into various ISN core programs such as the design of the ISN Academy; the coordination and design of networks of clinical trials; and the development of fellowship, mentorship, and advocacy programs and structures. To nurture further communication and advocacy skills, we were solicited to moderate topical networking sessions during the last 2 editions of World Congress of Nephrology, which centered around a variety of topics such as chronic kidney disease prevention, social justice, and kidney outcomes . In addiKidney International Reports, demonstrated poorer access to all essential kidney medicines in community settings compared with tertiary settings.A unique feature of the program was the opportunity to work on collaborative projects impacting the kidney health agenda worldwide. We were first invited to reflect on the access to essential medicines in nephrology. To that effect, we developed and disseminated an international survey evaluating barriers to accessing essential medicines in low-income and low-middle income countries for people with chronic kidney disease. Our results that were published in The ELP program has had an invaluable impact on our personal and professional developments as young leaders in nephrology. Many of us, for instance, were given the opportunity to play active roles in international projects such as the Global Kidney Health Atlas, the ISN/DOPPS collaborations with numerous publications,S1However, the most valuable impact was widening our individual perspectives. Working with a diverse group of like-minded professionals from all over the world not only exposed us to different healthcare systems, skillsets, cultural specificities, but also allowed us to realize that the barriers faced by patients and health care providers to achieve sustainable kidney care are often universal. We also learned to collaborate with people from different backgrounds and were able to appreciate different outlooks. Listening to and coordinating the views of 14 different leaders was at times challenging, and taught us to know when to assume leadership, and when to let go of it. Another important lesson learned was the necessity at times to redesign ambitious projects at a smaller scale to achieve more realistic goals with the available skills and resources. Indeed, when working at the national or international stages, many barriers can come from actors as large as major governmental organizations. This allowed us to cultivate determination and perseverance and prepared us to better deal with setbacks. Furthermore, the program empowered us to take more active leadership roles in our own organizations and health systems. Most importantly, the program catalyzed the establishment of a unique collaborative network, and of special friendships and sets of skills for many years to come in a distinguished collegial atmosphere and environment .Figure 112 members of the second ELP cohort began activities on collaborative leadership and problem-solving in global kidney health. Composed of a diverse cohort of nephrologists, pathologists, and researchers, their area of focus is the complex interplay of environmental factors and kidney health, and will be addressed through different angles and projects geared at increasing awareness and implementation of “Green Nephrology”.In May 2022, the The unique ELP of the ISN has provided us a unique experience with involvement that extends far beyond the official duration of the program . Members


Treating mental health problems adequately is of paramount importance given the tremendous burden it places on the individual and on society. Knowing and realizing there is no one size-fits-all-solution, some methods do yield better results. The yardstick as such can be interpreted with scores on questionnaires, subjective accounts and/or having the need for further future follow-up treatments.Within the Yes We Can Clinics, based in the Netherlands, we provide a very intensive 10-week residential treatment program where clients learn to acknowledge their problems and get to the root of these problems. The program is centered around confrontation in group sessions from counselors and peers, a well-thought out activity program from early morning till late evening, multiple psychotherapeutic sessions on a daily basis and if possible, minimize the use of medication.Different Routine Outcome Measurement tests were applied.Here we measured willingness to participate in the program, which fluctuates from average to low at the start, reaching a significant low motivational point after 2/3 weeks, in accordance with the quintessential confrontational aspect, but following the principles of the program in combination with reconnecting with parents and family (systems-approach), a tremendous increase in willingness and commitment towards the program, but also towards life and facing mental health struggles in general, arises.Herewith confirming the effectiveness of our intensive, immersive, confrontational and protocolized 10-week residential program for youth with mental health problemsNone Declared


Although great strides have been made in maternal and newborn health in Nepal, the maternal mortality ratio (MMR) is still high at 186 per 100,000 births. Many maternal deaths are preventable if there is access to a skilled birth attendant (SBA). The Ministry of Health and Population of Nepal launched the in-service SBA training program in 2007 and has trained over 10,000 SBAs to date. Evidence shows that one episode of training is not enough to retain skills. Therefore, the Nick Simons Institute (NSI) in collaboration with National Health Training Center (NHTC) devised a Follow-Up and Enhancement Program (FEP) in 2011 where the knowledge, clinical skills, and working environment of SBA graduates were assessed directly at their worksites. FEP allows on-site coaching and feedback so that graduates may continue to improve upon any gaps in their knowledge, skills, and working environment. This study aims to assess the effectiveness of FEP.We used a mixed-methods research design. A total of 73 SBAs who had a pre-FEP assessment in 2016 were followed up for a post-FEP assessment in 2017. We also collected data from 3 additional districts (115 SBAs) that had not previously had FEP, to compare SBAs in FEP versus non-FEP districts. Qualitative data was collected from 16 health facilities on the perceptions, motivation, and satisfaction of stakeholders.Of the total 188 SBAs that were sampled, a one-time FEP increased knowledge scores by 9%, clinical skills scores by 29%, and enabling environment scores by 7%. The number of deliveries conducted improved with a one-time FEP, although this increase was not statistically significant. We found a trickle-down effect of working in a facility that has had prior FEP, with SBAs that have never had FEP improving their clinical skills. FEP was found to be a highly accepted program and is beneficial to SBAs, trainers, and the Hospital Management Committee (HFOMC). However, a one-time FEP is not sufficient in retaining clinical skills and knowledge.FEP is a highly effective program by both quantitative and qualitative evaluation. Our study suggests that FEP should be frequent and continuous to retain the knowledge and clinical skills of SBAs, motivate them through on-site coaching, and improve their working environment through direct feedback to the Ministry of Health and Population. Although great strides have been made in maternal and newborn health in Nepal, the maternal mortality ratio (MMR) is still high at 186 per 100,000 births . In addidirectly at their working sites  refreshes us. We can revise whatever we have forgotten. We can correct our mistakes.” Additionally, SBAs felt that FEP enhanced their ability to conduct deliveries according to protocol. In the words of one SBA working in the birthing center of the Plain area (Bardiya) “Now we can successfully conduct deliveries using the methods of infection prevention in a skilled way. We used to do deliveries in a haphazard way prior to the [FEP] training but after the training, we are doing deliveries in a systematic way.”Our qualitative interviews and data found that FEP is an ideal monitoring and support program that is highly accepted and appreciated . It was “Providing messages only is not enough. If we go to the FEP, then we can understand how the SBA trainees are doingat their sites of work, whether they are doing what we taught them or not.” FEP is beneficial to the HFOMC because they become aware of what their responsibilities are. It energizes the HFOMC and establishes a linkage between the HFOMC and SBAs, with one HFOMC member in Hill area (Makawanpur) reporting, “Communication is frequently made with the staff. We are also aware of the various aspects of their work so that a better working environment can be created, and maximum service can be provided. We focus our concentration on making things easier for the staff.”FEP also updates knowledge and skills, provides an opportunity to see real-world scenarios, and establishes linkages between the different stakeholders involved, with one trainer from Bharatpur recounting, “If you visited our organization every six months…we can remember. We cannot remember about the activities which were conducted 1.5 years ago.” In addition, participants generally would have preferred FEP to occur over a few days with a shorter working day, with one SBA of Hill area (Makawanpur) lamenting, “This one-day duration is too little, and we have to do everything in a hurry.”Although FEP was generally well received, informants offered several suggestions to improve the program . Most paAs they come here and observe and tell us the things we need to improve, but it would be good if they manage (help us get or give us) materials too.” In terms of the training, participants also wanted more educational materials, training during live deliveries, training more applicable to the environment of uncomplicated deliveries, and in some cases better teaching methods. Besides providing educational materials in person, a few participants mentioned sending updated materials throughout the year.Some respondents wanted to receive equipment and incentives after participating in FEP. For instance, one member of the HFOMC from the Plain area (Bardiya) said, “Our study evaluated the effect of FEP on the knowledge, clinical skills, enabling environment, and number of deliveries of SBAs in Nepal. We found that a one-time FEP significantly increases the knowledge and clinical skills scores of SBAs. Additionally, we found that a one-time FEP significantly improves the enabling environment of the health facilities in which the SBAs work. There was also an improvement in the delivery volume conducted by SBAs following a one-time FEP, although this was not statistically significant. Our study found that there is even a trickle-down effect of working in a facility that has had prior FEP, with SBAs that have never undergone FEP showing improved clinical skills.The improvement in knowledge and clinical skills through an on-site mentoring program like FEP has been confirmed in other studies. A study conducted in Karnataka, India from 2012–2014 implemented a nurse mentor program at PHCCs to improve quality services . Using a“During FEP feedback, we discussed and met with the management committee. Now, it (HFOMC) has become active. They came to know their responsibilities. They listen to us and fulfill the essential materials we need”. A study conducted in Nepal between 2014 and 2015 found that the HFOMC’s role was confined to mobilizing additional resources for the health facility, supporting infrastructure, and raising health awareness [In addition, both the qualitative and quantitative data suggested that the FEP program establishes communication linkages between the HFOMC and the SBAs, which is crucial for improving the enabling environment. One SBA working in the birthing center of Bajhang district stated, wareness . There wMany of the SBAs and other stakeholders involved in FEP reported that a one-time FEP was not enough and that it must be carried out with greater frequency. This need for continuous mentoring has been supported by other studies including a study conducted in Bihar, India that evaluated 319 public PHCCs and compared the intrapartum quality of care between 179 mentored and 80 non-mentored PHCCs .The investigation boasts several strengths, including a mixed methods research design that integrates both quantitative and qualitative research methods to provide a more comprehensive understanding of the effectiveness of the Follow-Up Enhancement Program (FEP). The quantitative section of the study is strong in that it includes not only a pre-post analysis but also a comparative analysis of data from three additional districts that had not previously had FEP, enabling a comparison of skilled birth attendants (SBAs) in FEP versus non-FEP districts. Importantly, the study draws actionable conclusions that recommend frequent and continuous FEP to retain the knowledge and clinical skills of SBAs, motivate them through on-site coaching, and improve their working environment through direct feedback to the Ministry of Health and Population. These conclusions provide clear recommendations for policymakers and practitioners to improve maternal and neonatal health in Nepal.Though we sampled a total of 188 SBAs for our study, this is a relatively small sample size which may affect generalizability. Moreover, we assessed SBAs only in Nepal, and the results may be specific to this region which could further impede generalizability. As with any observational study, we cannot determine causality. Residual confounding could also be present even after controlling for other factors.If a one-time FEP can result in this level of improvement, a continuous FEP program will surely bring about improved and ongoing competency of SBAs.Although the SBA program is currently being phased out in Nepal to be replaced by a midwifery curriculum, many of the lessons from FEP for SBAs can be applied to FEP for midwives as well. FEP allows SBAs who have been trained at various SBA training sites in the country to be assessed with regard to their knowledge and clinical skills as well as the number of deliveries they are conducting. Our prior study of the quality of SBAs in Nepal found that SBAs are conducting very few deliveries, with only 7 percent (38/511) meeting the minimal volume recommended to maintain competence by the WHO, and a substantial fraction  performing an average of no monthly deliveries at all . On multthe discussion can be made regarding the strengths and weaknesses of the health facility. It has also acted as a connecting medium between public representatives and health personnel at the facility, district, and central level as well.” Creating a system of feedback is vital to ensuring that knowledge, skills, and the enabling environment meet the marks required for proficiency and practice. This allows for an open discussion regarding the strengths and weaknesses of health facilities which then opens the window to discussions regarding improvement. By connecting health care personnel, the HFOMC, and the central government, the FEP program is successful in cultivating communication and awareness of the responsibilities among the stakeholders involved. Thus, utilizing the findings from the FEP tool, policies to improve and standardize the working environment in turn improve the quality of SBAs and the care that they can provide, ultimately improving health outcomes.A frequent and continuous FEP program establishes linkages between SBAs, trainers, and HFOMCs. As one HFOMC in Bajhang reported, “…Overall, FEP is a highly effective program by both quantitative and qualitative evaluation. A one-time FEP significantly increases the knowledge and clinical skills scores of SBAs as well as the enabling environment of the health facilities in which they work. Our study suggests that FEP should be frequent and continuous. Continuation and scaling up of the FEP program are vital to retaining the knowledge and clinical skills of SBAs, motivating them through on-site coaching, and improving the working environment through direct feedback to the MoHP. FEP allows for an intimate understanding of the local working environment of SBAs and thereby leads to more effective health policies.S1 Checklist(DOCX)Click here for additional data file.S2 Checklist(DOCX)Click here for additional data file.


Bioprosthetic heart valves (BHVs) are less thrombogenic than mechanical prostheses; however, BHV thrombosis has been proposed as a risk factor for premature BHV degeneration.We aimed to explore whether fibrin deposition on bovine pericardium tissue could lead to calcification.Fibrin clot was obtained by blending three reagents, namely, CRYOcheck™ Pooled Normal Plasma (4/6), tissue factor + phospholipids (Thrombinoscope BV), and 100 mM calcium (1/6), and deposited on pericardium discs. Non-treated and fibrin-treated bovine pericardium discs were inserted into the subcutaneous tissue of 12-day-old Wistar rats and sequentially explanted on days 5, 10, and 15. Calcium content was measured with acetylene flame atomic absorption spectrophotometry. Histological analysis was performed using hematoxylin–eosin staining, Von Kossa staining, and immunohistochemistry.p < 0.001). Von Kossa staining confirmed this finding. In hematoxylin–eosin staining, the bovine pericardium discs were more extensively and deeply colonized by inflammatory-like cells, particularly T lymphocytes (CD3+ cells), when pretreated with fibrin.Calcification levels were significantly higher in fibrin-treated bovine pericardium discs compared to those in non-treated bovine pericardium discs (27.45 ± 23.05 µg/mg vs. 6.34 ± 6.03 µg/mg on day 5, 64.34 ± 27.12 µg/mg vs. 34.21 ± 19.11 µg/mg on day 10, and 64.34 ± 27.12 µg/mg vs. 35.65 ± 17.84 µg/mg on day 15; Fibrin deposition on bovine pericardium tissue treated with glutaraldehyde, used for BHV, led to increased calcification in a rat model. BHV thrombosis could be one of the triggers for calcification and BHV deterioration. Its prevalence is rising with the aging of the population, as degenerative valve disease is the most common etiology, in particular, in industrialized countries . Heart vp < 0.001). The causal relationship between BHV thrombosis and SVD is a key feature to explore.Although BHVs are less thrombogenic than mechanical prostheses, BHV thrombosis is an increasingly recognized entity that raises the issue of initial anticoagulation treatment in this population. Reduced leaflet motion because of thrombosis or impaired leaflet coaptation has been described, which may or may not be associated with thromboembolic complications , 11. Petin vitro fibrin recovery followed by subcutaneous implantation in rats.This study aimed to explore the role of fibrin in bovine pericardium calcification. Furthermore, we compared the calcium content of pericardium tissue with and without 2.2.1.Neovasc® pericardium tissue was stored in 0.6% glutaraldehyde and was cut into discs of 0.8 cm in diameter. The discs were washed in cold tris-buffered saline (TBS) + fetal bovine serum (FBS) 10% for 5 days at 4°C with gentle shaking (2 discs/ml) for flushing glutaraldehyde. Three baths were realized on the first day, and then rinsing baths were changed three times during the 5 days. Then, two groups were prepared: pericardium discs not treated with fibrin and pericardium discs treated with fibrin on both faces. The fibrin recoveries were obtained by blending three reagents as follows: tissue factor + phospholipids (Thrombinoscope BV)  and CRYOcheck™ Pooled Normal Plasma  were mixed in an Eppendorf. At the last moment, 100 mM of Ca  was added. Three volumes of this final solution were tested for deposition on the pericardium disc before planning animal implantation: 10, 20, and 50 µl. Thus, immediately after adding 100 mM of Ca, 10, 20, or 50 µl of this fibrin solution was disposed of on each pericardium disc placed beforehand in a 24-well plate. The discs were turned over after 2 h incubation at 37°C, and the same operation of fibrin clot deposition was repeated on the other side. After 2 h of re-incubation, 1 ml of EGM2-FBS 10% was added to each well, and the plate was incubated for 24 h .2.2.Before initiating the animal procedure, we explored on SEM the surface aspect of the pericardium tissue with fibrin recovery. The samples were fixed with 0.6% glutaraldehyde and then post-fixed with 1% osmium tetroxide. Dehydration with ethanol and drying with hexamethyldisilazane were performed before the samples were mounted on a stub and metalized.2.3.Animal implantation was scheduled for the next day. Twelve-day-old Wistar rats  were used for the experimentation as previously described , 13. Sed2.4.2.4.1.The first part of the discs was allocated to calcification quantification. The discs were hydrolyzed in a 68% nitric acid bath at 90°C for 20 min, allowing calcium dosage, performed by air–acetylene flame atomic absorption spectrophotometry (VARIAN AA240). The results are given in µg/mg of pericardium.2.4.2.The second part of the discs was allocated to histology. The samples were dehydrated with ethanol and paraffin-embedded. Hematoxylin–eosin staining (H&E) and Von Kossa staining were then carried out to examine cell morphology and calcium deposit, respectively. Immunohistochemistry (IHC) with anti-CD3  was performed to highlight T-cell infiltration in explanted pericardium discs. T-cell infiltration was quantified using ImageJ software on 10 different slides. Slide staining was observed with an optical microscope.2.5.U test was performed to compare calcium dosage at any time and for CD3+ cell quantification on IHC staining. All analyses were two-sided, and p < 0.05 was considered statistically significant. Statistical analyses and curves were realized using GraphPad software.A Mann–Whitney 3.3.1.in vitro as detailed in p = 0.45 between days 10 and 15 for non-treated pericardium discs and p = 0.17 between days 10 and 15 for fibrin-treated pericardium discs)  . Moreove3.2.+ cell infiltration demonstrated a higher level of T lymphocytes in the fibrin-treated pericardium discs compared to that in the non-treated ones   .4.ex vivo of the calcification potential of fibrin on top of bovine pericardium used for BHVs in clinics for the past 30 years. Fibrin-treated pericardium also showed an increased ability to be infiltrated by inflammatory cells. Indeed, inflammation and related potential residual immunogenicity could also participate to increase the calcification process as previously described (In this study, we demonstrated here an increased calcification process in a rat model after fibrin recovery of bovine pericardium tissue treated with glutaraldehyde. To our knowledge, we provided here the first exploration escribed .Non-degenerated explanted bovine pericardium biomaterials are rarely available for in-depth studies. However, an early phase of fibrin deposit has already been described in four explanted aortic bioprostheses made of porcine pericardium , 17. In However, the mechanism linking BHV thrombosis and premature SVD remains unclear. It has been widely reported that fibrin can induce inflammatory responses , 22. FurIn our study, we found that fibrin-treated bovine pericardium discs were more largely and more deeply infiltrated with inflammatory-like cells, while they were also significantly more calcified. This finding supports the hypothesis that inflammatory cells may be involved in BHV calcification. Furthermore, we showed that T-cell infiltration was higher in fibrin-treated pericardium discs. Dahm et al.  reportedSubcutaneous implantation has certain limitations as it lacks direct contact between the pericardium tissue and circulating blood. Furthermore, the mechanisms of calcification involved in the rat model may differ from those in humans. However, the subcutaneous implantation in a 12-day-old Wistar rat model has been deemed sufficiently reliable for preclinical studies of xenograft calcification , 13. We All in all, we demonstrate here for the first time that fibrin deposition on bovine pericardium tissue, treated with glutaraldehyde and used for BHV, led to calcification in the rat model. The initial antithrombotic treatment after BHV implantation remains a point of debate. We suggest that, beyond preventing hemodynamic risks and thromboembolic complications related to BHV thrombosis, it could also be important to prevent the risk of early SVD through the inhibition of fibrin deposits.


Dear Editor,With integrative molecular profiling and case‐control profiling, we identified immunoglobulin M (IgM) as a tumour‐derived serum biomarker for ocular adnexal extranodal marginal zone lymphoma (OA‐EMZL) and further constructed a preoperative diagnostic model.OA‐EMZL is the commonest subtype of ocular adnexal lymphomas (OALs),R = 0.56, p < 0.001), and the most dysregulated DEP in the proteome (Log2(foldchange) = 2.64, p < 0.001)  Figure . The dys) Figure .IGHM encodes an indispensable constant region of the IgM heavy chain. EMZL originates from marginal zone B‐cell,p < 0.001) was the independent predictor for EMZL   Figure . Thus, w) Figure .To simplify the usage of serum IgM concentration in the clinical context, we conducted propensity score matching (PSM) to minimize the potential bias and further converted IgM into an ordinal variable Figure . After Pp = 0.017), IgM ≥1.46 g/L (p < 0.001), and age at diagnosis < 47 (p = 0.008) were independent predictors of EMZL  for OAL.Although EMZLs exhibited a high IgM, the results suggested an intertumoral heterogeneity Figures  and 2A. 1Serum IgM is a tumour‐derived biomarker used to differentiate OA‐EMZL from idiopathic orbital inflammation, IgG4 related disease and orbital lymphoproliferative disorders. The preEM constructed based on ordinal serum IgM, age at diagnosis, and lacrimal gland involvement is a practical preoperative diagnostic tool for OA‐EMZL.The authors declare no conflict of interest.This work was supported by the Project of Biobank of Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine. . The funding organization had no role in the design or conduct of this research.Supporting InformationClick here for additional data file.Supporting InformationClick here for additional data file.Supporting InformationClick here for additional data file.


Public safety personnel (PSP) are exposed to traumatic events due to their work environments, which increases the risk of mental health challenges. Providing effective and evidence-based interventions, such as SMS text messaging programs, can improve PSP's overall mental well-being with high user satisfaction rates.This study aims to evaluate users’ satisfaction, receptiveness, and perceptions of a cognitive behavioral therapy (CBT)–based supportive SMS text messaging intervention (Text4PTSI).Participants self-subscribed to Text4PTSI and received unidirectional cognitive behavioral–based supportive text messages for 6 months. Participants completed a web-based survey delivered via SMS text message at enrollment, and 6 weeks, 3 months, and 6 months post enrollment. Respondents’ perception and receptivity of the program were assessed using a questionnaire measured on a 5-point Likert scale. Data were collected as categorical variables, and overall satisfaction with the Text4PTSI program was measured on a scale from 0 to 100.There were 131 subscribers to the Text4PTSI program; however, only 81 subscribers responded to the survey, producing 100 survey responses across the 3 follow-up time points. The overall mean score of satisfaction was 85.12 (SD 13.35). More than half of the survey responses agreed or strongly agreed that Text4PTSI helped participants cope with anxiety , depressive symptoms , and loneliness . Similarly, most of the survey responses agreed or strongly agreed that the Text4PTSI program made respondents feel connected to a support system, improved their overall mental well-being , felt more hopeful about managing concerns about their mental health or substance use , and helped enhance their overall quality of life . The available survey responses suggest that the majority always read the supportive text messages , took time to reflect on each message , and returned to read the text messages more than once .PSP who responded to the follow-up surveys reported high user satisfaction and appreciation for receiving the Text4PTSI intervention during the 6-month program. The reported satisfaction with the service provided could pave the way to ensuring a better uptake of the service with potential effectiveness to end users. Mental well-being is an important issue for public safety personnel (PSP) in Canada, as these individuals often experience high levels of stress and psychological trauma due to their occupations. The definition of PSP advancing includes but is not limited to the paramedic, police, correctional workers, firefighters, and all first responder groups . The strThe challenging and complex nature of PSP’s work is one of the main sources of stress. These individuals are often exposed to traumatic events, such as accidents, natural disasters, and violent crimes -5. TheseA study among Canadian PSP revealed that about 44.5% self-reported at least 1 mental disorder ,8. To adHowever, despite these supportive efforts, there is still work to be done to improve the mental well-being of PSP in Canada. The Canadian Institute for Public Safety Research and Treatment reports that 44.5% of PSP in Canada screened positive for 1 or more mental health symptoms . Some ofWhile several interventions for PSP, ranging from pharmacology to psychotherapies, have been described in the research literature , it is eWhen supportive intervention is provided, most studies have demonstrated a decrease in mental health symptoms. For example, in a longitudinal study to assess the effectiveness of an SMS text message intervention, PSP who subscribed to the texting program reported that they were able to manage depression, anxiety, and other psychological symptoms . SimilarWe hypothesize that participants who subscribe to the Text4PTSI program will have high user satisfaction, positive program perceptions, and receptivity, which will remain stable over time. Hence, we propose the following research questions: (1) how satisfied are subscribers with the Text4PTSI program for 6 weeks, 3 months, and 6 months? (2) what are the participants’ perceptions of the Text4PTSI program at 6 weeks, 3 months, and 6 months? and (3) how are the satisfaction rates and subscriber perception of Text4PTSI similar or dissimilar across the 3 time points?This research was designed as a longitudinal cross-sectional study, which assessed participants’ satisfaction and experiences with the Text4PTSI program at 6 weeks, 3 months, and 6 months post intervention. The sample reported in this study is less than anticipated since PSPs who subscribed to the Text4PTSI program were less than 10% of the projected 5000 subscribers indicated in the published protocol.Text4PTSI was launched in July 2021 to support PSP’s mental health in Alberta, Canada ,32. The Trauma can feel like a gloomy cloud over all areas of your life. The first step in treatment is to understand what trauma is, the symptoms, and how and why it is treated.If you find yourself worrying excessively, make some boundaries with these thoughts. Jot down your worries throughout the day and let them go. Then set a time aside for 20 minutes to review what you wrote down.Similar programs have demonstrated effectiveness in mitigating mental health symptoms like mood disorders in the general population with high user satisfaction rates. For example, a study on the impact of supportive messages among subscribers of Text4Mood reported that about 82% of the respondents felt hopeful about managing life issues and experienced an overall mental well-being .PTSI” to 1-844-990-4343. From the day of enrollment, participants receive 1 text daily, which is unidirectional computer-programmed supportive text messages. These messages are based on CBT principles. Users are at an advantage similar to CBT sessions, where a therapist helps participants to evaluate and challenge negative thoughts, feelings, and emotions [Data collection procedures used in this study are described in the published study protocol . In summemotions . ParticiSTOP.”Participation in the Text4PTSI program was voluntary, with no incentives. Receiving supportive messages was independent of survey completion. Participants could opt out of the program at any time by texting back the word “Satisfaction data were collected between September 7, 2021, and October 27, 2022. The Text4PTSI study received ethical approval from the University of Alberta Health Research Ethics Board (Pro00108966) . InformeThe primary outcome measure was the participants’ overall satisfaction with the Text4PTSI program, which delivered to subscribers daily supportive text messages designed to support mental health. Responses were calculated by using subscribers’ responses to 1 question “Using any number from 0  to 100 (very satisfied), how would you rate your overall satisfaction with Text4PTSI?”Secondary outcomes included the perceived impacts of the program on participants’ mental health and feedback of the supportive text messages at 6 weeks, 3 months, and 6 months from enrollment. Text4PTSI participants provided feedback on the text messaging intervention by responding to questions assessing the following two focal areas:Perception on how participants coped with stress, anxiety, and depression; connection to a support system; quality of life; and overall mental wellness after receiving the daily supportive text messages : The questionnaire was measured on a 5-point Likert scale; agree, strongly agree, neutral, disagree, and strongly disagree. For the purpose of analyses, responses were collapsed into 3 points: agree or strongly agree, neutral, and disagree or strongly disagree.Receptivity of the Text4PTSI program: These questionnaires were assessed on a 5-point Likert scale: always, often, sometimes, rarely, and never.Although reliability and validity measures for the satisfaction scale have not been assessed, the survey questions have been used in previous studies to evaluate user satisfaction with similar supportive text messaging programs ,34.Data were analyzed using SPSS  statistical software for Windows . ParticiWe summarized the satisfaction and participants’ perception of the program at different time points . Satisfaction data were presented as categorical variables and reported as frequency and percentages across all the study participants at all 3 time points. The average percentage of all 3 time points was then tabulated and reported.A chi-square analysis was run to examine any differences in reporting satisfaction across the 3 time points. There was no imputation for missing data, and the results were based on completed survey responses.As illustrated in Participants rated the program by indicating their overall satisfaction on a scale of 0-100, with zero indicating very dissatisfied, 50 indicating neutral (neither satisfied nor dissatisfied), and 100 representing very satisfied. The total number of participants providing their feedback was 100, with an overall satisfaction mean score of 85.12 (SD 13.35). The descriptive analysis also recorded a mean 95% CI of 82.5-87.8. This result indicates that, overall, respondents were satisfied with the Text4PTSI program.Overall, the chi-square analysis revealed no significant difference in reporting the different satisfaction items among the 3 time points.This study presents novel findings on how PSP perceived daily supportive text messages and their receptiveness to the Text4PTSI program. The results from the study indicated high respondents’ satisfaction with the program, with a mean score of 85.12 (SD 13.35) that is similar to other studies ,36. OverThe survey responses suggested participants were satisfied with the frequency of the messages, and 3 in 4 (75%) responses suggested participants would prefer to receive supportive text messages once daily. Similarly, the majority of responses reported that participants perceived supportive text messages as always positive, affirmative, and succinct. In addition, the supportive text messages were reported as always inclusive and relevant to 60 (60%) of the respondents’ identity background , while respondents always or often read the messages and took time to reflect on the messages.Reported satisfaction with the Text4PTSI program aligns with satisfaction with other supportive text messaging programs geared toward improving the mental health of subscribers ,34,37. FHigh satisfaction with the Text4PTSI intervention implies respondents benefit from the program and highly recommend Text4PTSI to help broadly manage the mental health burden of PSP. A study among first responders, which focused on the usage of telehealth care, reported that out of 38 individuals who were recommended to seek mental health services, about 29 (76%) agreed to adhere to treatment via web-based or telehealth means [PSP often benefit from evidence-based iCBT to assist with mental health symptoms, process emotions, and address potentially traumatic or morally distressing events. Qualitative research reveals that PSP positively perceives iCBT intervention to manage their mental health concerns .Our study results aligned with similar studies focused on other PSP or who use a similar texting service. Another program providing supportive care based on iCBT revealed similar results among PSP . The resText messaging technology can help improve access to health care in an era of inadequate health resources. Six months after the Text4PTSI program, 87.2% of study responses agreed or strongly agreed that they felt connected to a support system. This result aligns with the research literature indicating how supportive text messages can expand one’s perceived support network and increase personal support systems . The finRecent studies indicate how mental health interventions delivered via mobile phones are positive, affirmative, and relevant ,34,43,44This study included questions about how participants return to read, reflect, and take action after reading the supportive text messages they received. Reflective and impulsive processes are correlated and intentionally help individuals identify their intentions and activities and develop coping skills . Across There are several limitations to the study, which need to be considered when interpreting the results. First, the web-based questionnaire to measure the satisfaction and perception of the study participant was not a validated instrument and may limit the confidence of user satisfaction rates. Second, our sample was not randomized; it would have been ideal to include a control group to compare Text4PTSI subscribers’ and nonsubscribers’ satisfaction, perception, and impact of the program on their mental health. Third, the number of first responders who subscribed to the Text4PTSI program was less than 10% of the projected 5000 subscribers indicated in the published protocol . ChallenFourth, the sample size of participants who completed all follow-up assessments was fairly small, which may be attributed to participants who still needed to complete the survey and those providing incomplete responses. Out of the 131 subscribers, only 81 responded to the survey. A total of 393 responses were expected during the follow-up; however, 100 survey responses were provided by participants. In addition, the low sample size may be a result of the web-based nature of the surveys. Surveys delivered via SMS text messages are less likely to retain participants for follow-up assessment than paper-based surveys .Notwithstanding these limitations, the findings from our study suggest that text-based health interventions designed for PSP have high satisfaction rates and may be beneficial to improve quality of life and help bridge the gap in seeking mental health services.Our results highlighted findings relating to the rationale for PSP’s desire to subscribe to supportive text messaging programs. The study generated important insights into the self-reported perception of supportive text messages that improved quality of life and overall mental well-being; coping with anxiety, depression, and loneliness; and being connected to a support network. These results are derived from a few samples who completed the follow-up survey; more research is needed to better understand what is happening with nonrespondents. Additionally, future randomized controlled studies are recommended to comprehensively assess the impact, user satisfaction, perception, and receptivity of the SMS text messaging intervention on PSP and can be scaled up to other occupations, and to better understand the reasons why study participants may opt not to respond to the study surveys that could assess their well-being and satisfaction with the service. Furthermore, research needs to explore possible ways that could be used to reach those who do not respond to the surveys. SMS text messages have fewer character limits, which may improve the participants’ desire to read.The results of this study provide additional evidence for scale up and spread of supportive text message interventions for PSP and other stressful occupations.