ARID1A, are present in more than 50% of cases of ovarian clear cell carcinoma (OCCC), a histological subtype of ovarian cancer prevalent in Asian countries. To efficiently treat OCCC, which is refractory to conventional platinum-based chemotherapy, several therapeutic strategies based on SWI/SNF deficiency have been proposed, including gemcitabine-based chemotherapy, synthetic lethal therapy, and immune checkpoint blockade therapy. Implementation of these strategies would improve the prognosis of patients with this disease. Deleterious mutations in SWI/SNF chromatin remodeling genes, such as ARID1A, are common in OCCC but rare in HGSC. Because this complex regulates multiple cellular processes, including transcription and DNA repair, molecularly targeted therapies that exploit the consequences of SWI/SNF deficiency may have clinical efficacy against OCCC. Three such strategies have been proposed to date: prioritizing a gemcitabine-based chemotherapeutic regimen, synthetic lethal therapy targeting vulnerabilities conferred by SWI/SNF deficiency, and immune checkpoint blockade therapy that exploits the high mutational burden of ARID1A-deficient tumor. Thus, ARID1A deficiency has potential as a biomarker for precision medicine of ovarian cancer. Ovarian clear cell carcinoma (OCCC) is a histological subtype of ovarian cancer that is more frequent in Asian countries (~25% of ovarian cancers) than in US/European countries (less than 10%). OCCC is refractory to conventional platinum-based chemotherapy, which is effective against high-grade serous carcinoma (HGSC), a major histological subtype of ovarian cancer. Notably, deleterious mutations in SWI/SNF chromatin remodeling genes, such as  Ovarian clear cell carcinoma (OCCC) is a histological subtype of ovarian cancer that constitutes 25% of ovarian cancers in Asian countries, but less than 10% of ovarian cancers in US and European countries . OCCC isARID1A gene, which encodes the BAF250A/ARID1A protein, is the most frequently mutated SWI/SNF subunit gene in OCCC, although several other subunit genes, including SMARCA4 and ARID1B, are also mutated [ARID1A mutations, most of which are deleterious, are detected in about 50% of OCCCs, and loss of BAF250A/ARID1A protein, which functions as a regulatory subunit of the SWI/SNF complex, is observed at a similar frequency [ARID1A mutation [ARID1A gene impairs transcriptional and DNA repair activities within cells [OCCC is characterized by genetic alterations distinct from those found in HGSC, including frequent deficiency of genes encoding subunit proteins of the SWI/SNF chromatin remodeling complexes. The nucleosome, the basic unit of chromatin, is composed of 146 pairs of DNA bases wrapped around histone protein octamers. Nucleosomes prevent the binding of transcription factors and histone modifiers in the nucleus. Chromatin remodeling complexes regulate gene expression, DNA replication and repair, and cell division through changes in chromatin structure. The SWI/SNF complexes, which comprise tens of subunit proteins, obtain energy from ATP hydrolysis to cause nucleosome sliding, exposing specific regions of DNA and allowing interaction with histone modifiers . The ARI mutated . ARID1A requency ,13. Intein cells ; therefoThe proportion of OCCC among the four major histological types of epithelial ovarian cancer is higher in Asia about 25%) than in Europe and the US (less than 10%) 5% than i. The proWe estimated the numbers of new OCCC cases per year based on the projected number of ovarian cancer patients (PNP) in Japan, the US, and Australia in 2020, and the proportion of OCCC among all ovarian cancers, given above. The number of patients with OCCC, which we estimated by multiplying the PNP by the proportion of OCCC in each cohort, is shown in ARID1A, SMARCA4, PBRM1, and SMARCB1, are mutated in ~20% of all cancers [ARID1A as one of the top 10 most frequently mutated genes [ARID1A mutations [ARID1B and SMARCA4, are also mutated in a subset of OCCC [ARID1A is the most frequently mutated SWI/SNF gene, followed by ARID1B, SMARCA4, ARID2, and PBRM1. The mutation frequencies of these genes according to tumor type are shown in ARID1A mutation is a genetic property of OCCC. ARID1A mutations are detected in adjacent endometriotic lesions of OCCC, but not in distant endometriosis in the same patient, indicating that OCCC arises from endometriosis, and that ARID1A functions as a major tumor suppressor during development of OCCC [Multiple genes encoding subunits of the SWI/SNF complexes, including  cancers . In parted genes ,23,24. Iutations ,13, whil of OCCC . Mutatio of OCCC , are sho of OCCC ,28,29.ARID1A is also frequently mutated in uterine endometrial and endometrioid ovarian cancers; therefore, aberrations in this gene are likely to be frequently involved in malignancies of the female genital tract. In addition, SMARCA4, which is frequently mutated in poorly differentiated non-small cell lung cancer  in small cell carcinoma of the ovary of hypercalcemic type (SCCOHT), occurring in about 98% of such cases. Somatic and germline SMARCA4 mutations drive development of this disease [g cancer g, is als disease ,31. TherARID1A mutations and loss of BAF250A/ARID1A protein expression in OCCC in studies to date [ARID1A mutations in OCCC is ~60% in the US, Canada, and Japan, and 40% in Australia, and the frequencies of loss of BAF250A expression are equal to or a bit lower than the mutation frequencies. These data indicate that a significant fraction of ARID1A mutations is associated with loss of expression of the gene product. Consistent with this, ARID1A mutations observed in OCCC in the Project GENIE Cohort consist mostly (>90%) of truncating mutations  and the C-terminal domain, which plays a critical role in promoting transcription [ARID1A mutations are a common feature of OCCC and other cancers. to date ,35,36,37 to date ,39,40. Lutations b, upper cription . Most trcription . This prARID1A and PIK3CA genes are detected in benign endometriosis [ARID1A deficiency, in concert with an oncogenic PIK3CA mutation, promotes OCCC formation in vivo by enhancing inflammatory cytokine signaling [ARID1A was also revealed in a pre-OCCC model system: ARID1A prevents super-enhancer hyperactivation, which leads to enhanced migratory properties exhibited by pre-OCCC cells [The pathogenic roles of ARID1A deficiency during OCCC development were recently elucidated. Indeed, somatic mutations in the etriosis ,43. Concignaling . In addiignaling . The epiCC cells . In addiCC cells . Thus, AThe BAF250A/ARID1A protein functions as a regulatory subunit of the SWI/SNF complex, which regulates multiple cellular processes, including transcription and DNA repair. Therefore, it is possible that cancer cells deficient in ARID1A or other SWI/SNF subunits share properties that are absent from noncancerous cells, and that some of those properties create vulnerabilities . TargetiARID1A increases the sensitivity of OCCC cells to gemcitabine by approximately 100-fold. Consistent with this, ARID1A-deficient cases of OCCC exhibited significantly longer progression-free survival after gemcitabine treatment than ARID1A-proficient cases [Gemcitabine is a deoxycytidine analogue that inhibits ribonucleoside reductase, resulting in depletion of deoxyribonucleotide pools required for DNA synthesis. Gemcitabine is often used in late lines of treatment for ovarian cancer after platinum-resistant recurrence; however, retrospective studies have shown that gemcitabine is especially effective against OCCC ,49,50. Nnt cases . The mecBRCA1 and BRCA2 genes have opened the prospect of developing new synthetic lethal therapies based on PARP inhibitors [BRCA1/BRCA2 mutations in these cancers [Loss-of-function mutations in the hibitors . However cancers . Consequ cancers . ClinicaThe SWI/SNF complex and another chromatin remodeling complex, polycomb repressive complex 2 (PRC2), work antagonistically during transcription. EZH2 serves as the catalytic subunit in the PRC2 complex and mediates gene silencing. Dysfunction of the SWI/SNF complex due to ARID1A-deficiency leads to predominance of PRC2 activity in cancer cells ,55. In lATR, HDAC2, BRD2, and HDAC6, have synthetic lethal relationships with ARID1A [In addition, several other genes, including h ARID1A ,60,61,62h ARID1A ,64. Amonh ARID1A ,66. In ah ARID1A . Belinosh ARID1A . The theWe recently reported that ARID1A deficiency is associated with reduced metabolism of the antioxidant glutathione (GSH) ; consistTumors with the deficient mismatch repair (dMMR) phenotype respond well to immune checkpoint blockade therapy, as these tumors express many neo-antigens associated with high mutational burden . BAF250AARID1A status. Analysis of the association between clinical response and ARID1A deficiency among studied cases might help to obtain further POC.At present, precision medicine for OCCC using SWI/SNF chromatin remodeling deficiency has not been implemented in daily oncology. The list of target molecules proposed for cancer therapy is expanding day by day. Therefore, it is quite important to consider how discoveries made in preclinical models are translated to clinical trials designed to test whether modulating the activity of specific targets leads to a clinical response . In partOn the other hand, however, to understand specific/preferential properties of OCCC conferred by gene alterations is also quite important; sensitivity to GSH inhibitors conferred by ARID1A deficiency is much higher in OCCC than other types of cancers, such as gastric cancer ,83, indi


Four LOVED groups completed an eight-week intervention that consisted of six online video education modules and eight group video chat sessions led by a Black navigator. Qualitative analysis from post-study focus groups resulted in six themes: (1) video chat sessions provided essential support and encouragement, (2) videos motivated and made participants more knowledgeable, (3) connectivity with tablets was acceptable in most areas, (4) material was culturally sensitive, (5) participation was overall a positive experience and (6) participants were more willing to ask for a kidney now. The video chat sessions were pertinent in participant satisfaction, though technology concerns limited program implementation. Results showed that the LOVED program was acceptable to engage minorities in health behavior changes for living donor advocacy but barriers exist that require future refinement.Marked racial disparities exist in rates of living donor kidney transplantation (LDKT). The Living Organ Video Educated Donors (LOVED) program is a distance-based, mobile health program designed to help Black kidney transplant wait-list patients advocate for a living donor. This study reported on the acceptability outcomes to aid in future refinements. Participants were randomized to LOVED ( However, there was a few times where there was miscommunication.”The LOVED group specific questionnaire on trust demonstrated high mean scores for both 8-weeks  and at 6 months. Focus group comments also showed high levels of trust when speaking about their navigators, research staff, and medical staff.“I have had two prior kidney transplants within a twelve-year period. The doctors and surgeons at [the facility] are very knowledgeable in their field. They perform hundreds of transplants per year. I trust them completely with my life.”“He’s [speaking about their navigator] had that experience and he told us about stuff that he experienced. Which was great, because to hear somebody else talk about it, without them turning up their nose at you and saying, “oh, you have this”, and they don’t want to hear what you have or whatever, he wasn’t even like that. Not at all. He was great.”The LOVED arm’s results on discrimination were very positive at 8 weeks ) and 6 months for the study staff during the trial. Scores did not differ compared to usual care for either follow-up time ) or at 6 months). Many comments reinforced this idea. When asked if they thought whether the program was culturally sensitive, there was agreement that there was “no problem”.“Me personally? I don’t have a problem with it [meaning discrimination]. But by the way things are looking, this is a disease that affects African Americans a lot, I mean because that basically who’s in this group.”“For me it was helpful because I was blind to the fact. I thought because I’m a black man, that only a black person could donate a kidney to me, and I found out that’s not true.”The LOVED-specific questionnaire on shared decision making was strongly skewed toward high levels of empowerment  at 8 weeks, with lower scores representing a stronger sense of empowerment). These results corresponded to various comments from the focus groups, especially when participants spoke about their navigator.“The format was good because he been through the process I’m going through so any advice that he gave helped me cross that bridge in my process so…the way it was laid out, the way he gave it was good.”“And I really learned that from him. Because I’m just like, “I’m tired, I’m ready to move forward in my life, I’m just tired of waiting.” So, you know, I learned that from him. That is the most valuable thing that I can get from the program.”This study investigated the feasibility and acceptability of a mobile health interventional program for Black kidney wait-list patients to approach and ask others about being a PD. Results will inform refinement of LOVED and provide value to other transplant center programs in promoting culturally tailored strategies to increase living donations for Black ESRD patients. From the previous findings, the LOVED program was found to be well tolerated and improved quantitative measures in approaching others for a transplant. This was evident in the attitudinal measures and in donor inquiries when compared to usual care. The primary results of this report found six themes expanding upon the previous findings that explains how participants were either supported or hindered during the intervention. Overall, participants reported being satisfied with the program, being more confident about their knowledge on LDKTs and were more comfortable to ask others about being a PD. A key tactic suggested by the thematic results emphasized the importance of video chat sessions due to the mentorship role of the navigators and the encouragement from the group members. Comments were overwhelmingly positive when referring to content and discussions during the chat sessions, skill building, and comradery that ensued during the program. We found the design and elements of LOVED was successful to address the concerns of our sample. Participants also commented that the program could be inclusive of other races both in membership and navigator choice due to the strong bond of being a kidney disease patient overcoming the issue of race. In this sample, there were no issues of distrust or discrimination involving the navigators, research staff or their transplant team.The themes highlight several tactics that may enhance living donation programs. The theme, (1) Video chat sessions provided essential support and encouragement, was a crucial element in the delivery of the LOVED program. It is possible that LOVED could be performed solely using the video chat sessions if more time was allotted to go over the knowledge content. The emphasis on the video chat sessions from focus group feedback shows future iterations of the LOVED program should involve this intervention component. The theme, (2) videos motivated and made participants more knowledgeable, provided basic knowledge to be used in their discussions during the video chat sessions. The videos allowed the same knowledge to be communicated regardless of the navigator, standardizing much of the content across all groups. The reinforcement of video content by the navigator-led discussions allowed reiteration of the material and strengthened knowledge. Although the videos included motivational and skill building messages, the focus groups did allude to the video chat sessions being the primary factor to become more comfortable approaching others. Overall, the education videos were perceived as relevant and important to the intervention.The theme related to technology, (3) connectivity with tablets was acceptable in most areas, was the primary area where improvements could be made. The technology aspects of this study should underscore the pace of technology changes in cellular network connectivity, as well as video chat applications used during the study timeframe. During the trial, we experienced many technical issues where participants could not connect to chat rooms, buffering and frozen video connections and participants not completing the questionnaires due to connectivity issues. Even though we provided 3G LTE connected tablets with unlimited data, throughput was not adequate to enable a seamless experience. As improvements in high-speed cellular services evolve  and next-generational video data compression algorithms become available, not only will connectivity improve, but participants may be able to utilize their own smartphone or tablet devices easier.Pertaining to the theme, (4) the material was culturally sensitive, LOVED was designed utilizing focus groups of Black living donor kidney recipients, Black ESRD patients, and Black family members and caregivers. The culturally tailored aspect of this study was foundational in the LOVED videos and interventional content. This was evident in the race of the navigators, the education videos using predominantly non-White speakers, and using focus group feedback from prior studies. Our positive findings from the focus groups, trust and discrimination measures show that participants were receptive to the program content and staff.The emphasis of the last two themes, (5) participation was overall a positive experience and (6) participants were more willing to ask for a kidney now, implied the LOVED program was successful in enacting the behavior change and attitudes toward finding a PD. Each of the four LOVED groups’ responses showed that overall, they felt less alone in their situation and started getting the word out. Focus group members reported having new hope in eventually identifying a PD. When prompted for what to change, several participants expressed desire to remain connected and have follow-up sessions. Most participants were happy with the content, the length of the program and the opportunity to connect with others who share their circumstances.Although intentions to find a PD were voiced, no living donations were performed in the post-study, 6-month timeframe, though several participants had received deceased donations. Several barriers to finding a PD included running out of immediate or extended family members to ask and not being as confident speaking to friends or strangers. Comments also included that many family members lived unhealthy lives, had diabetes or were already sick with multiple chronic diseases. Lastly, many stated that obesity-related barriers were present in PDs that were interested in donating. It is likely that additional content or other programs based on common barriers may need to be incorporated in programs to recruit living donors. Overall, the participants showed motivation to ask others, but they were having issues identifying suitable donors.p = 0.001) [This study shares several aspects with other living donor programs seeking to enhance LDKTs. We were able to replicate the findings from the LOVED proof of concept study, where patients reflected positively to develop social support, LDKT knowledge, and increased behavioral skills to seek a PD . As with= 0.001) . Both prThere are several limitations that should be discussed when interpreting the results. This trial was rigorously conducted at an academic medical center using Ph.D. level study staff. The navigators were college educated and have had experience promoting donation in their communities. Therefore, their level of enthusiasm, education, and medical center oversight may not be generalizable to community-based programs. It is also unknown whether the LOVED elements can be independently used due to the concurrent use of all study elements in this trial. Future studies are warranted using different combinations of the LOVED elements. The formative nature of these results limits the implications of the LOVED program on clinical outcomes for transplant centers. Primarily, changes in attitudes and behaviors may not directly result in successfully identifying a PD and completion of an LDKT. There are many complex factors related to the donor and the patient and that may limit the chance of a successful LDKT. Identifying these barriers will provide important information to include in a comprehensive program aimed at improving living donation rates in the southeastern United States and in the nation.Several themes suggest future improvements for the LOVED program. Primarily, the connectivity of the tablet computers was found in both the proof of concept and the current trial. The sample included patients from across the state, representing both rural and urban areas. Efforts to increase connectivity and problem-solving weak signals need to be emphasized in future studies or any video-chat-directed studies. Solutions could range from cellular extenders, hot spot devices and other packaged content for the education videos such as being stored locally rather than using streamed video content from a server. It is also reasonable to reformat the program to be utilized on participants’ smartphones instead of supplying tablets, which lowers the cost and administration burden of the program. Even though the length of the program was judged acceptable by the participants, there are data to support modification of program content to increase education video completion rates and video chat adherence. This may include shortening the program. Longer term contact with participants such as inclusion of booster sessions may also be considered to sustain the behavior changes elicited by the LOVED program.The results of this study are timely considering the current pandemic and risk of holding in-person meetings at transplant centers or other community venues. The push to conduct education online has been an important consideration prior to this restriction due to ESRD patient barriers including transportation needs, burden of dialysis and conflicting schedules. This study found the LOVED program to be a feasible and acceptable method for Black kidney wait-list patients to get the word out about their need for an LDKT.


Mental health problems are highly prevalent in people with type 1 diabetes mellitus (T1DM), which adversely impact physical health and quality of life. This study aimed to explore the experiences of people with T1DM who had completed the Mental health IN DiabeteS Optimal Health Program (MINDS OHP), a novel intervention developed to bridge the gap between physical and mental health care. Participants with T1DM were invited to take part in a focus group or semi-structured interviews. Participants were recruited from outpatient and community settings. The focus group and interviews were audio-recorded and transcribed verbatim. Thematic content analysis was used and identified themes were cross-validated by researchers and member-checked by participants.Ten people with T1DM were included. Two key themes emerged: ‘MINDS OHP experiences’ and ‘lived experiences of diabetes’. MINDS OHP experiences included five sub-themes: program benefits, follow-up and timing, suggested improvements, collaborative partners, and materials suitability. Lived experiences also included five sub-themes: bridging the gap between mental and physical health, support networks, stigma and shame, management intrusiveness, and adolescence and critical life points.The MINDS OHP for people with T1DM was generally well received, though study findings suggest a number of improvements could be made to the program, such as including family members, and consideration being given to its routine early inclusion in diabetes management, ideally in primary care.The online version contains supplementary material available at 10.1186/s12902-021-00760-3. Care for people with T1DM often fails to adequately address the needs of family members and adolescents, and early intervention and inclusion of families in the diabetes care process has the potential to improve diabetes outcomes and experience.People with T1DM appear to appreciate novel interventions such as the MINDS Optimal Health Program which bridge the diabetes and mental health care divide, and welcome consideration being given to the inclusion of diabetes educators in their routine care.Individuals with type 1 diabetes mellitus (T1DM) are at increased risk of poor mental health, particularly depression and anxiety . The intAdditionally, T1DM has a notable impact upon family members of individuals with the condition, particularly parents and caregivers –10. FamiIn an attempt to address diabetes-specific aspects of care we developed the Mental health IN DiabeteS Optimal Health Program (MINDS OHP), a psychoeducational self-empowerment intervention . It has We therefore, as part of a larger study evaluating effectiveness of the program , 15, con We conducted a qualitative study with a convenience sample of people with T1DM who were invited to participate in a focus group or, if unable to attend, an individualized face-to-face semi-structured interview. Participants were considered eligible for inclusion if they had a confirmed diagnosis of T1DM, were 18 years of age or over, and were able to converse in English without an interpreter . ParticiFor the purpose of this study, an interview schedule was prepared to guide questions and prompts about participants’ experiences  of the MINDS OHP  and conducted in accordance with the Declaration of Helsinki.Informed consent was obtained from 14 individuals, though one subsequently declined the interview, one withdrew due to personal circumstances, and two did not respond to repeated contact attempts, leaving 10 participants. Five of the 10 participants took part in a focus group and the remaining five were interviewed individually, face-to-face. LF conducted all the interviews.The 10 participants  were aged from 25 to 70 (mean 47) years.Two themes (MINDS OHP experiences and lived experience with diabetes), each with five sub-themes  respectively emerged from the data Table .Participants [P] discussed their overall experiences from the program, with five sub-themes arising.Feedback about the program was highly positive throughout the interviews. Most participants emphasised the relevance, educational value, and broad perspective of the program. For example, one [P1] stated that the program “turned my life on its head”, “made me refocus” and think about their diabetes “more holistically”.Most participants appreciated the program’s timing and novelty, with one [P2] suggesting that ideal timing of program delivery should be “not long after you’re diagnosed”, and another [P3] that it should be from “day 1” of diagnosis.Participants recommended ways in which the program could better support people with T1DM, including diabetic educators being involved in session formulation and facilitation due to their unique perspective and expertise, and better training facilitators in diabetes management. One participant [P4] recommended that “a list of psychiatrists” or other mental health professionals who were familiar with the program would be a valuable referral source; another [P5] that more health professionals should be “aware that the program is on offer”.Participants praised the support and flexibility of program facilitators in adapting to their individual circumstances. Some participants emphasised that the program should be offered to and by health professionals involved in T1DM care, as one [P6] reflected that “no health professional had ever brought this up with me” prior to this program. A participant [P5] suggested that the program should encourage attendance of a carer or family member for at least one session, and that “a program for carers” would be appreciated; another [P3] recommended that “type 1’s and their partners…should be counselled at the same time”.Mode of delivery and access to the program were consistently mentioned as areas for improvement. Some participants recommended that program outreach could be improved via phone or videoconferencing technology: one participant [P7] suggested that the program could “meet them in their homes” to improve accessibility and engagement, and another [P6] reflected upon the geographical “barrier” to participation in regional areas. Most participants commented positively on the program workbooks and “homework” exercises, although some described the exercises as being “generic” rather than diabetes-specific.Participants emphasised their lived experience with T1DM, which arose as a distinct theme despite some overlap with their MINDS OHP experiences. Five sub-themes were identified.bridging the gap between mental health and diabetes care, and the importance of diabetes educators as astute patient advocates, with one participant [P2] describing diabetes educators as being “a therapist and medical help at the same time”, and another [P4] as “gold” due to their unique understanding of management complexities.Participants emphasised the importance of the program in supporting wellbeing. Many described the mental health impacts they experienced due to the complexity and intrusiveness of diabetes management, alongside the reciprocal impacts of stress upon their diabetes. One participant [P2] described the “stress and trauma” often experienced by people with diabetes, and another [P8] identified that “outside stresses, they make a mess of your diabetes”. Furthermore, participants consistently raised the concept of Participants consistently emphasised the importance of peer connection and support in living with T1DM, particularly the unique understanding provided by peers with diabetes. A participant [P4] reported “it’s a very big thing, that peer support”, and another [P8] reflected “nobody knows what it’s like except for those who’ve got it”. A participant [P2] described family support as “integral” to T1DM management, particularly spouses and parents. All participants reflected on their earlier experiences of diabetes support, including parents often being responsible for managing their child’s T1DM and being their “greatest advocate and supporter” [P3], and having needed additional support themselves. They felt that the program could provide greater education and support for family members. Participants identified stigma as a key stressor in T1DM, with one [P6] describing T1DM as a disease that people were ashamed to disclose due to “numerous negative connotations”. Participants also emphasised the perceived ignorance of T1DM by society and family members, and feeling ashamed or obligated to internalise their diabetes concerns. A participant [P5] reflected “the ignorance out there, it’s unbelievable” and criticised the media for circulating misinformation about T1DM, and other participants agreed that wider awareness and education is needed to address this. Participants explored the importance of T1DM advocacy and individualised care, and one [P8] reflected “nobody…is a better advocate or a better source of information that someone who’s got it”. Many participants expressed feeling unheard and dismissed by health professionals, and the need for clinicians to validate patients’ concerns and help them understand their T1DM.just diabetes, but it was everything else that came with it”. Another participant [P6] reflected upon a number of “really nuanced scenarios”, such as exercise and stress, that may adversely impact diabetes management.Participants identified that the constant vigilance associated with diabetes management contributes to diabetes-related stress. They reported that constantly monitoring blood sugars exacerbated stress and anxiety in themselves and their families, with one participant [P1] identifying that these mental health impacts “[weren’t] Participants identified adolescents as being particularly vulnerable to diabetes-related distress and adverse health consequences, and participants reflected on their own adolescent experiences. A participant [P1] described the importance of addressing “critical time points” such as initial diagnosis or during adolescence, particularly given the difficulties for adolescents adjusting to their diagnosis, and being able to “process their feelings and emotions” alongside their physical health. Participants identified that the program could be an appropriate intervention at this particular life transition point.This qualitative study of the MINDS OHP identified two key themes - program experiences and lived experiences with T1DM - which have implications for informing program development, reach and impact. Although the sample may appear relatively small, it was judged to be of sufficient size for this type of study . However We found that though the program was generally well regarded by participants there were some areas requiring improvement, especially concerning the needs of family members and adolescence as a critical time-point. These findings highlight a gap in routine T1DM care, and provide valuable insights into how the MINDS OHP could be improved to best fill the gap. They also have broader implications for the integration of interventions such as MINDS OHP into routine and earlier clinical practice, ideally in primary care, and the role of health professionals such general practitioners and diabetes educators.Participants praised the broader perspective offered by the MINDS OHP, consistent with the literature regarding paucity of comprehensive interventions addressing mental health in T1DM . However An unexpected facet of the interviews was the participant use of the focus group as a peer support environment, and participants suggesting that the program itself could include a group component to enable this. This emphasis on psychosocial support is consistent with the literature on T1DM . ParticiStigma was also identified as a key issue, with associated shame and fear of disclosure, due to misperceptions of T1DM and moralistic societal ideas of personal guilt impressed upon them. This finding echoes those from other studies that stigma is a notably negative experience of many people with diabetes [Our findings are in agreement with other studies  that fouA dual aim of this study was to explore whether the program be adapted to support family members. Most participants praised the support they received from their families, and identified parents and partners as key supports for people with diabetes, with parents being particularly impacted by management issues and associated stress related to their child’s T1DM, consistent with other findings . This reParticipant experiences regarding family members also highlight a continuing clinical gap. The literature notes that family members are often impacted by their loved one’s T1DM, but their experiences are often not addressed routinely. This study therefore provides specific suggestions for how the program could address the needs of family members, including supportive counselling, education, and involvement in selected program sessions.Finally, the suggestions regarding extended follow-up could assist in reinforcing learning from the program, whilst the potential for group discussion could serve as an important psychosocial support system for those with T1DM. Suggestions to involve family members and health professionals in sessions could also assist in wider education for the support networks of people with diabetes. As a result, those participating in the MINDS OHP could be more empowered and supported to take responsibility of their health and control of their T1DM, with the likely long-term benefits to overall health and quality of life.Strengths of this study include the use of qualitative research methods which are becoming more recognized and valued in diabetes behavioural research , 16, 19.The small sample size may be perceived as a limitation, though we have justified it as sufficient for this type of study.This study provides pointers for future research, including potential adaptation of the program to incorporate families and carers, and exploring the specific impact of T1DM upon adolescents and how MINDS OHP could address this population more overtly. Other suggestions for future research include increasing involvement of diabetes educators in program conception and facilitation. By doing so, MINDS OHP could be offered as a routine component of a holistic package delivered early after the diagnosis of T1DM, ideally in primary diabetes care. This could include the program being introduced to newly-diagnosed T1DM patients by their general practitioner, probably with input from a diabetes educator and practice nurse to review and monitor progress.The MINDS OHP was generally well received as a psychoeducational intervention for individuals with T1DM. However, findings from this study highlight gaps, including the failure to address more overtly the needs of family members and adolescents, particularly early on. It is recommended that bridging this gap will contribute to improved development, reach and impact of the program. Consideration should be given to the inclusion of the program in the clinical management of diabetes, preferably in primary care.Additional file 1.Interview Guide. The Mental Health IN DiabeteS Optimal Health Program (MINDS OHP) Interview Guide.


With increasingly tough graduated driver licensing laws in all Australian States and Territories, driver licensing support programs are recognised as being important to support Aboriginal and Torres Strait Islander peoples to obtain a driver licence. Such programs appear to improve licensing attainment rates, but few studies have examined the broader impact that these programs can have. This research aims to 1) examine the impact of a New South Wales (NSW) based driver licensing support program (Driving Change) on client employment outcomes; 2) assess the influence of geographical area of program delivery on driver licence attainment.Driving Change was delivered from February 2013 to August 2016 in 4 urban and 7 regional Aboriginal communities of NSW. Clients were followed-up at 6 months or more following contact with the program as part of routine program operations. Descriptive statistics and regression models were used to analyse data.From 933 clients contacted 254 agreed to provide feedback, a response rate of 27%. Those that responded were mostly female (57%), aged 24 years and under (72%), unemployed (85%) with secondary education or less (71%) and from a regional area (74%).p = 0.011) of reporting a new job or change in job than those who did not attain a licence. Clients from regional areas were more likely  to gain an independent licence than those from urban areas. There was no difference in employment outcomes  for clients from urban compared to regional areas.Adjusted logistic regression indicated that clients who achieved an independent licence were more likely (OR: 2.5, 95% CI: 1.22–5.24, The Driving Change program appears to be effective in improving employment outcomes for those who gained a licence. Clients from regional areas were more likely to gain a licence compared to those in urban settings, and were predominantly young and unemployed, often a hard to reach cohort. Future licensing programs being delivered in regional areas need integrated pathways into employment opportunities to provide holistic services that address the social and economic challenges faced by Aboriginal and Torres Strait Islander Australians. Australia has a vast land mass. With its population widely spread across major cities and regional and remote towns, access to public or private transport is necessary for everyday life. Where there is an inability to access public or private transportation individuals experience transport disadvantage. In regional and remote towns of Australia compared to major cities there are fewer public transportations options, therefore having a valid driver licence and access to private transport is essential for mobility, social inclusion and participation in critical activities such as employment , 2. ThesCulturally relevant driver licensing programs have been delivered with increasing frequency over the past 10 years to support Aboriginal and Torres Strait Islander peoples to obtain a driver licence, however very few of these programs have been evaluated , 7. The Employment is a strong social determinant for improving Aboriginal and Torres Strait Islander people’s health outcomes , 15 and In summary, a high proportion of Aboriginal and Torres Strait Islander peoples reside in regional and remote areas , where tDriving Change was a culturally relevant, end-to-end driver licensing program that provided support to Aboriginal and Torres Strait Islander peoples to navigate through the NSW Government’s graduated licensing system and obtain a driver licence.Informed development of this culturally relevant program was underpinned by extensive community consultation, and formative evaluation , 21. ThiThe program was delivered from February 2013 to August 2016 widely across the State of NSW in 11 Aboriginal communities of: Kempsey, Taree, Raymond Terrace, Redfern, Campbelltown, Shell harbour, Dubbo, Dareton, Condobolin, Griffith and Wagga Wagga . The proThis study is a quantitative analysis of post program client interview data.Data was collected as a part of the program’s quality assurance processes; clients who attended the program were systematically followed up between June 2014 – August 2016.Upon initial contact with the program, baseline client data collected contained information on gender , age (16–24 and 25+ years), employment status , education  and community of program delivery, as well as reasons clients were accessing the program and expectations.“Whether the client had a change in licence type as a result of the program”“Whether since joining the program the client has had a change in work, and if yes to specify employment change (‘unemployed and now employed’ or ‘change jobs’)”As part of routine program operations, clients were contacted by phone 6 months or more after their initial contact with the program and invited to participate in answering a set of open-ended post-program questions to ascertain: the levels of satisfaction with the program, services and support accessed; licensing outcomes; additional program outcomes reported for employment, education, family responsibilities and/or social inclusion. The specific outcomes of interest for analysis were:The 11 communities where the program was delivered were stratified as urban areas or regional areas - regional areas encompassed inner regional, outer regional, remote and very remote. Stratification of communities as urban  or regional  was in accordance with the classification of the Australian Bureau of Statistics Remoteness of Areas .Descriptive statistics (frequency and percentage distributions) were performed to determine respondents’ characteristics.a) The association between licensing attainment and self-reported improvement in employment outcomes; b) Adjustment for age, gender and carer responsibilities; these were considered important as younger clients were more likely to be engaged in educational commitments, with females and carers more likely to have family priorities impacting on employment outcomes.a) The association between geographical area on licensing attainment outcomes; b) Adjustment for literacy, household licensing status, level of contact with the program, age group and level of needs; as these variables influence the ability of a client to successfully obtain a licence.a) The association between geographical area and self-reported improvement in employment opportunities; b) Adjustment for age, gender and carer responsibilities; as these variables were considered to impact most on employment outcomes.Logistic regression models were used to estimate odds ratio of:All methods were carried out in accordance with the relevant guidelines and regulations, and all experimental protocols were approved by the Aboriginal Health and Medical Research Council Human Ethics Committee of New South Wales (Eth: 964/13). Informed consent was obtained from all subjects and/or their legal guardian(s). Data was analysed using Statistical Analysis System (SAS) version 9.4 .n = 254) and non-respondents (n = 679) – a higher proportion of respondents were employed (15% versus 9%) and tertiary educated (29% versus 20%) than non-respondents. Of the respondents, those reported gaining a job/or having a change in job proportionally were more often male, under the age of 24 years, secondary educated or less and resided in regional areas  to reporting gaining a job/or having a change in job. After adjustments were made for potential confounders  the relationship still held with clients being more likely  to report gaining a job/or having a change in job. For licensing attainment by geographical area, clients participating in the program from regional areas were more likely  to obtain an independent licence than those from urban areas. After adjustments were made for potential confounders  the relationship held with clients participating in the program from regional areas being more likely  to obtain an independent licence than those from urban areas. There were no differences in clients reporting having gained a job/or having a change in job between urban or regional areas , including after adjusting for age, gender and carer responsibilities .Regression analyses highlighted in Table p = 0.011) to report gaining a job or having a change in jobs. Respondents from regional areas were more likely  to obtain a driver licence than those participating in the program from urban areas.This study showed the direct impact that driver licensing programs can have on improving employment outcomes for Aboriginal and Torres Strait Islander clients and highlighted the influence that geographical area of program delivery has on licence attainment. We found that respondents who obtained a driver licence as a result of participation in the Driving Change program were more likely  2018 indicated where Aboriginal and Torres Strait Islander young people are likely to complete secondary education and unlikely to face other identified obstacles (such as access to birth certificates), driver licence programs could constitute an elective in the school curriculum . This dop < 0.001) to obtain an independent licence than clients from urban areas. Recent evidence shows licensing programs are being delivered in regional communities with increased frequency [The Driving Change program was delivered within both urban and regional settings, with sites chosen for program delivery based upon: communities need, engagement, and support of program; the population of Aboriginal and Torres Strait Islander residents; and socioeconomic status of the area. Research shows employment rates in urban areas for Aboriginal and Torres Strait Islander peoples who are tertiary educated are comparable, if not higher, than that of equivalently qualified non-Indigenous Australians , 13. Wherequency . These rState and Territory governments enhance and commit to current government driver education programs, so as to extend the geographic reach of the program and the consistency of service in certain areas...’ [A key strength of this program leading to translation of outcomes, has been through direct Government collaboration where stakeholders from both Transport for NSW Centre for Road Safety (TfNSW CRS) and Roads and Maritime Services  and representatives from a range of other key agencies formed members of the steering committee, which met quarterly. This allowed the program to be refined via input as it was implemented and importantly also allowed program outcomes and learnings to be fed directly back to government agencies with responsibility for the delivery of such services. This informed development and funding of a disadvantaged Driver Licensing Access Program which delivers services across the State , with Tfreas...’ . OpportuA strength in program data was the inclusion of questions specifically related to employment outcomes which allowed for the programs impact on employment to be directly assessed. Historically no studies have reported licensing programs to deliberately include employment data and outcomes as an evaluable program component . UnderstA limitation in program data was the homogeneity in those who participated in providing feedback, as most respondents were secondary educated (or a current secondary student) between the ages of 16–24 years. However, this may not be limited to post program analysis, as respondents’ characteristics were representative of the characteristic of those who did not respondent.Driver licensing programs appear to be effective in improving employment outcomes for Aboriginal and Torres Strait Islander clients who obtain a driver licence, and those in regional areas are more likely to obtain a driver licence than those participating in urban areas. Future licensing programs need to consider mechanisms for facilitating employment opportunities post program for clients who successfully obtain a driver licence. Developing such pathways will provide holistic and integrated services to address the social needs of Aboriginal and Torres Strait Islander Australians.


Background and Aim: Studies on hematological parameters in the differential diagnosis of idiopathic granulomatous mastitis (IGM) and breast cancer (BC) are limited. This study investigated whether preoperative fibrinogen and hematological indexes can be used in the differential diagnosis of patients with IGM and early-onset BC. Methods: Fifty patients with BC, 55 patients with IGM, and 50 healthy volunteer women were included in the study. Results: There was a statistically significant difference between the IGM and the BC with respect to fibrinogen, fibrinogen/albumin (Fib/Alb) ratio, C-reactive protein (CRP), white blood cells (WBC), neutrophils, neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), and monocyte values. When fibrinogen (p < 0.001), the Fib/Alb ratio (p < 0.001), CRP (p < 0.001), WBC (p < 0.001), neutrophil (p < 0.001), NLR (p < 0.001), monocyte (p = 0.008), and 2-hour sedimentation rate (p < 0.001) were compared between the groups, the highest levels were found in the IGM group. There was a negative relationship between CRP and albumin, and a positive relationship was observed between CRP and WBC, NLR, PLR, and 2-h sedimentation rate. CRP had the highest sensitivity (95%), whereas the Fib/Alb ratio (86%) had the highest specificity. Patients with recurrent IGM had increased fibrinogen, Fib/Alb, CRP, neutrophils, NLR, and 2-h erythrocyte sedimentation rate (ESR) and decreased lymphocyte levels compared to non-recurrent patients. Conclusions: Preoperative CRP, albumin, fibrinogen, Fib/Alb, WBC, neutrophil, NLR, monocyte, and 2-h ESR have considerable potential to be early and sensitive biomarkers of IGM caused by inflammation compared to BC. These parameters also have a significant effect on the recurrence of the disease, suggesting their potential as a practical guide for the differential diagnosis of BC from IGM. Idiopathic granulomatous mastitis (IGM) is a rare, chronic inflammatory breast lesion of unknown etiology that clinically and radiologically mimics breast cancer . IGM, whBC is the second most commonly diagnosed cancer worldwide, behind lung cancer . The IntNLR and fibrinogen levels, which are among the new indicators of systemic inflammation, have been associated with the prognosis of tumors such as gastric cancer , colon cStudies on hematological parameters in the differential diagnosis of IGM and BC are limited . The curThe study was approved by the Ethics Committee of the Cerrahpasa Faculty of Medicine . Fifty patients with solid tumors who were followed by a diagnosis of BC in the general surgery outpatient clinic of Cerrahpasa Medical Faculty, 55 patients diagnosed with IGM, and 50 healthy volunteer women with similar demographic characteristics were included in the study. Women over the age of 18, whose microbiological culture samples were confirmed to be sterile and found to have cancer and IGM in the histopathological evaluation, were included in the study. We excluded women who received chemotherapy or radiotherapy and were diagnosed with old or new BC or IGM, with another history of malignancy , and were pregnant or lactating. In addition, according to core needle biopsy taken from the suspicious lesion in the breast or pathological examination of the tissue taken from the abscess wall, patients with tuberculosis capable of granulomatosis reaction, infection such as fungal and parasitic reactions, sarcoidosis, Wegener granulomatosis, and non-infectious agents such as foreign bodies were excluded from the study.g. Plasma and serum were transferred to Eppendorf tubes and was studied immediately.Venous blood samples were collected from control subjects and patients with BC and IGM after 12 h of fasting. The samples were centrifuged for 15 min at 3000× Demographic data , biochemical parameters, cancer antigens (Carcinoembryonic antigen (CEA), CA 19-9, CA 15-3, CA-125), and pathology reports were obtained from the subjects’ medical records.Biochemical parameters were measured on an Olympus AU 800 analyzer by enzymatic methods using commercial kits  at the Central Biochemistry Laboratory of Cerrahpasa Medical Faculty. Tumor markers were measured by immunometric assay using an IMMULITE 2000 .p values were used to conduct the post-hoc test after the Kruskal–Wallis test. The Mann–Whitney U Test was used to compare two independent groups. Spearman’s correlation was used to show an association between two continuous variables. Receiver operating characteristic (ROC) curve analysis was performed to determine the sensitivity and specificity values of biochemical and hematological indexes that can be used to define BC and IGM. The statistical significance level was set at p < 0.05.SPSS 21 for Windows was used to conduct the statistical analyses. The Kolmogorov–Smirnov test was used for normal distribution. The Kruskal–Wallis test was used to compare data of three independent groups; adjusted The demographic characteristics and tumor markers of the study groups are shown in p < 0.01). The two-hour erythrocyte sedimentation rate (2-h ESR) was significantly higher in the IGM group compared to the control (p < 0.01). A comparison of fibrinogen (p < 0.001), the fibrinogen/albumin (Fib/Alb) ratio (p < 0.001), C-reactive protein (CRP) (p < 0.001), white blood cells (WBC) (p < 0.001), neutrophil (p < 0.001), NLR (p < 0.001), monocyte (p = 0.008), and 2-h ESR (p < 0.001) within the groups revealed the highest levels in the IGM group.As shown in Correlation analysis of the biochemical variables of the IGM group is shown in The recurrence rate of IGM was 20% at 2 years of follow-up. Biochemical laboratory findings and hematological indexes of patients with non-recurrent and recurrent IGM are shown in IGM continues to be an important problem for both surgeons and patients due to the difficulty in the diagnosis and treatment of the disease, as well as acute and chronic exacerbations and long-term effects on quality of life. The prognosis of IGM is not as clear as its treatment. IGM may be misdiagnosed as breast cancer.BC is still a worldwide public health dilemma. It is the most common female malignancy in the world and the primary cause of mortality due to cancer in women. Early diagnosis provides the best survival rate; thus, novel diagnostic markers are essential for reducing mortality and morbidity. Inflammatory factors such as the preoperative CRP, interleukin (IL)-6 and -8, and tumor necrosis factor-α are associated with BC prognosis ,26,27. TIn our study, there was a statistically significant difference between the IGM and the BC with respect to fibrinogen, Fib/Alb, CRP, WBC, neutrophil, NLR, PLR, and monocyte values. Some of these variables are components of IGM (WBC and CRP) and are, therefore, not surprising. More importantly, there was a negative relationship between CRP and albumin and a positive relationship between CRP and WBC, NLR, PLR, and ESR.Systemic inflammation and infection can promote thrombosis by increasing the serum levels of fibrinogen, leukocytes, coagulation factors, and cytokines, and by altering the metabolism and function of certain cells, monocytes, and macrophages . AlthougCRP, a member of the pentraxin family and a marker of inflammation, constitutes the prototype of acute phase proteins. CRP is a major acute phase reactant in humans, with an acute and rapid rise in response to infection and tissue damage. In response to all types of tissue damage and infection, the human body activates various mechanisms to correct this damage. The most important of these mechanisms is the acute phase response. In addition to radiological data and breast biopsy, circulating CRP levels may be non-invasive biomarkers that can help differentiate IGM from BC. CRP levels were found to be highest in the IGM group in the current study. A positive correlation was also found between 1-h ESR, 2-h ESR, WBC NLR, and PLR and CRP in IGM. ROC analysis results in the IGM group showed that the cut-off values for the best sensitivity and specificity for CRP were > 3.625 . This is consistent with the results of our other study  and thosn = 7) and without (n = 52) recurrence and found that NLR was significantly higher in patients with a recurrence, but they did not perform a ROC analysis to support their observations. In our study, according to the ROC analysis for the BC and IGM groups, the sensitivity (65%) and specificity (74%) of the NLR were found to be low. According to the results of the ROC analysis, NLR might not be a good biomarker for differentiating BC and IGM. The reason for the low sensitivity and specificity may be due to the different inflammation statuses of cancer patients. The routine collection of the CBC in clinical practice is simple and cost-effective to the patient, making the NLR a highly promising indicator for monitoring the systemic inflammatory status of IGM.Chronic inflammation is thought to be a predisposing factor for cancer formation by initiating the carcinogenesis process . ChangesSurgical treatment of IGM is controversial due to delays in wound healing, high local recurrence rates, and poor cosmetic results. In a study by Yau et al. , surgicaThe study has several limitations. Genomic whole exome or targeted exome sequencing of samples from IGM lesions and breast cancer patients could have been beneficial in identifying the difference. However, due to economic reasons, we could not perform sequencing. Most of these markers are acute phase reactants and we have aimed to check these acute phase reactants during the most acute time when these patients were newly diagnosed. Both diseases are progressive; however, we have taken samples from the patients at the time of the diagnosis at their first admission. In addition, in the results the cut off values for both diseases show a statistically significant difference. This constitutes a limitation for our study, and it would be reasonable to compare the severity of these diseases and markers according to the stage.If inflammation is treated or self-limiting, acute phase protein levels return to normal levels within days to weeks. Therefore, acute phase proteins such as albumin, fibrinogen, and CRP can be used as markers in monitoring the treatment of IGM, which is an inflammatory disease. However, breast biopsy is the gold standard for the differential diagnosis of IGM, and is also widely used in other situations. The diagnosis of IGM is not yet supported by any serum marker. CRP, fibrinogen, and complete blood count used in daily practice, which are cheap, easy, and non-invasive, can be useful in guiding follow-up and treatment. These parameters also play a significant role in the recurrence of the disease. The relatively low number of cases in both groups is another limitation of our study. Nevertheless, our findings provide important insights for larger studies that will examine IGM patients’ responses to treatment and the effects of inflammation-induced changes in these responses.


The purpose of this study was to survey current orthopaedic department chairs at ACGME-accredited orthopaedic surgery programs in the United States to determine whether department chairs valued the importance of formal leadership training and, if so, to understand the leadership development opportunities available along with the benefits of these program for their orthopaedic faculty.An anonymous online, voluntary, self-administered questionnaire containing 27 questions was distributed to current orthopaedic department chairs at ACGME-accredited orthopaedic surgery programs in the United States.Thirty-eight responses were received for a response rate of 27.1%. Twenty-three of 38 (60.5%) department chairs believed leadership training is very important for their orthopaedic faculty. Thirty-six of 38 (94.7%) department chairs did not believe that all their current faculty have strong leadership skills. Twenty-eight of 38 (73.6%) respondents have specific training programs for leadership development at their institution.Most department chairs (92.1%) viewed leadership training for their orthopaedic faculty as either important or very important. Seventy-four percent of orthopaedic surgery department chairs surveyed indicated that they had a leadership development program in place, with 59.1% being developed within the past 10 years. Benefits of these programs included improved listening and communication skills and management of staff. The skills necessary to be a competent and successful leader require systematic training and include persuasive communication, negotiation, financial decision making, team building, and conflict resolution.4With medicine constantly evolving, establishing strong management and leaderships capabilities is critical for hospitals, especially academic medical centers.7 For example, Drexel University College of Medicine created the Executive Leadership in Academic Medicine program to provide women in medicine and other healthcare fields with extensive coaching, networking, and mentoring opportunities to place more women in senior leadership positions.9 Similarly, the University of Michigan created a leadership development program specifically aimed at meeting the leadership goals and motivations of their surgical faculty.10 Finally, the Pediatric Leaders Advancing Health Equity program at the University of California, San Francisco, integrates leadership training alongside clinical training of pediatric residents to lead advances in health equity for children.11To address the increased needs for developing leadership skills among physicians, academic medical centers and medical schools have invested significant resources to create leadership development programs.12 found that several leadership development programs for orthopaedic surgeons exist; however, the number of programs is not adequate to meet the demand. The purpose of this study was to survey current orthopaedic department chairs at ACGME-accredited orthopaedic surgery programs in the United States to determine whether department chairs valued the importance of formal leadership training and, if so, to understand the leadership development opportunities available along with the benefits of these program for their orthopaedic faculty.Although more and more programs are being developed, few studies have attempted to understand leadership development opportunities specifically for orthopaedic surgeons. Yayac et al.http://links.lww.com/JG9/A167).After obtaining approval from our Institutional Review Board (2019 to 1699), an anonymous 27-question online survey using Qualtrics  was distributed through e-mail to 148 department chairs at ACGME-accredited orthopaedic surgery programs in the United States. Follow-up e-mails were sent at 2 and 4 weeks after the initial e-mail to encourage more participation. Of the 148 e-mails sent, 8 were returned as undeliverable, leaving a total of 140 e-mails delivered to department chairs. Some questions only appeared based on a participant's response to a previous question  they recommend receive leadership training. Additional questions asked whether the chair's institution has a leadership development program in place for their faculty and, if so, do they believe it is beneficial.A total of 38 responses were received for a response rate of 27.1%. Most respondents  have been chairs of their orthopaedic department for 5 to 9 years, whereas 13 of 38 (34.2%) have been chairs for 0 to 4 years and 5 of 38 (13.2%) for 10 to 14 years. Twenty-four of 38 (63.2%) had more than 30 faculty members in their department, whereas 7 of 38 (18.4%) had between 21 and 25. Seventeen of 35 (48.6%) spent 41% to 60% of their time on nonclinical duties, whereas 9 of 35 (25.7%) spent between 61% and 80%, and 6 of 35 (17.1%) spent between 21% and 40%. Twelve of 35 (34.2%) of the chairs' institutions are located in the Northeast, 8 of 35 (22.9%) were located in the Midwest, 10 of 35 (28.6%) were located in the South, and 5 of 35 (14.3%) were located in the West. Most chairs  were aged between 56 and 60 years, whereas 5 of 35 (14.3%) were aged between 66 and 70 years and 4 of 35 (11.4%) between 41 and 45 years. Thirty-three of 35 (94.3%) respondents were men, whereas only 2 of 35 (5.7%) were women. Thirty-two of 35 (91.4%) department chairs were White/Caucasian.Twenty-three of 38 (61.0%) orthopaedic surgery department chairs believed leadership training was very important for their orthopaedic faculty, whereas 12 of 38 (31.6%) believed it was important. Only 1 of 38 (2.6%) believed leadership training was very unimportant. Most  of the department chairs did not believe that all their current faculty have strong leadership skills. Chairs recommended that Division Heads/Chiefs , Vice Chairs , Program Directors , and Associate Program Directors  receive leadership training. Sixteen of 33 (48.0%) chairs believed that all faculty should receive leadership training. When asked to rate leadership, conflict management, emotional intelligence/self-management, personnel management/team building, and business/financial skills based on order of importance, most respondents ranked emotional intelligence/self-management as the most important skill, followed by leadership, personnel management/team building, conflict management, and business/financial.Twenty-eight of 38 (74.0%) respondents have specific training programs for leadership development at their institution, whereas 10 of 38 (26.3%) did not. Examples of these programs included Physician Executive Leadership Program, Dean's Teaching Fellowship, and Faculty Leadership Institute. For respondents with leadership development programs at their institution, 13 of 22 (59.1%) of these programs were developed between 2010 and 2020. Nineteen of 25 (76.0%) chairs were actively involved in the development of their leadership programs, whereas 6 of 25 (24.0%) were not. These leadership development programs were not required for all orthopaedic faculty . Most  of these institutional leadership development programs are offered in-person, whereas 6 of 25 (24.0%) are both in-person and online, and 1 of 25 (4.0%) is online only. Twenty-one of 25 (84.0%) programs had both lecture/didactic and case discussion/interactive formats, whereas 3 of 25 (12.0%) had only a lecture/didactic format, and 1 of 25 (4.0%) had only a case discussion/interactive format. Twenty-one of 25 (84.0%) programs had external guest speakers, whereas 4 of 25 (16.0%) did not.Ten of 25 (40.0%) respondents have leadership development programs that meet once a month, 6 of 25 (12.0%) meet twice a month, 3 of 25 (12.0%) meet quarterly, and 3 of 25 (12.0%) meet yearly. The duration of these programs varied as 7 of 25 (28.0%) last between 12 and 15 months, 6 of 25 (24.0%) between 8 and 11 months, 6 of 25 (24.0%) between 0 and 3 months, and 4 of 25 (16.0%) between 4 and 7 months.Eleven of 25 (44.0%) orthopaedic surgery department chairs believed their institutional leadership development program was very beneficial for their faculty, 11 of 25 (44.0%) believed it was beneficial, and 3 of 25 (12.0%) were neutral. When asked to select all the benefits of their leadership development program, chairs chose improved management of staff and healthcare team , improved listening and communication skills , increased emotional intelligence , improved ability to succeed under pressure , improved teaching of residents and students , and improved productivity  , communication skills , conflict management , emotional intelligence , team building , work-life balance , financial/business skills , time management , networking , and public speaking  , promotion of participants , and evaluating faculty performance . Ten of 25 (40.0%) department chairs reported that the effect of the leadership development program was not measured. All participants of these leadership development programs were allowed to provide feedback regarding the programs.When asked to select other types of leadership programs that department chairs encourage their faculty to participate in, programs such as American Orthopaedic Association (AOA) Emerging Leaders Program , Association of American Medical Colleges Early Career Women Faculty Leadership Development Seminar , Specialty Society Leadership Training , and AOA North American Traveling Fellowship  were selected  was very interested, whereas 4 of 10 (40.0%) were interested, 4 of 10 (40.0%) were neutral, and 1 of 10 (10.0%) was uninterested. In addition, these respondents were asked why they do not have a leadership development program for their orthopaedic faculty. 2 of 9 (22.0%) believed it was too expensive to develop a program and 2 of 9 (22.2%) it was too time consuming. 2 of 9 (22.2%) department chairs stated that developing a program is not a top priority, whereas 2 of 9 (22.2%) reported using external leadership development programs through the AOA as being sufficient.In recent years, leadership development programs have become more prominent in academic medical centers throughout the United States. Institutions may be investing more resources in leadership development opportunities for their orthopaedic surgery faculty because 74.0% of department chairs surveyed indicated that they had leadership development programs in place, with 59.1% being developed within the past 10 years. In addition, 80.0% of the department chairs provided funding for their faculty to travel and attend external conferences for leadership development. This is critical because only 5.0% of the respondents believed that all their orthopaedic surgery faculty have strong leadership skills.10 evaluated a leadership development program specifically designed for surgeons at the University of Michigan. The authors interviewed 21 surgical faculty who completed the program. Most surgeons reported improvements in their self-empowerment to lead, self-awareness, team-building skills, and business and leadership knowledge. The surgical faculty also reported that the program positively influenced their day-to-day work activities and long-term career development plans.10 Similarly, our study demonstrated that 92.1% of orthopaedic surgery department chairs believed leadership development was very important or important for their orthopaedic faculty. Moreover, 88.0% of chairs viewed their institutional leadership development programs as either very beneficial or beneficial. The leadership development program at the University of Michigan along with all of the institutional programs mentioned by department chairs in our study allowed feedback from program participants. With most of these leadership development programs being developed within the past 10 years, allowing participant feedback is critical to promote continued improvement of these programs.A recent study by Pradarelli et al.13 studied the effectiveness of the American Academy of Orthopaedic Surgeons Leadership Fellows Program (LFP). The authors compared graduates of this program with applicants who applied to this program but were rejected. They found that graduates of the American Academy of Orthopaedic Surgeons LFP reported significantly higher leadership competency in the areas of knowledge of theory (good knowledge of different leadership styles and aware of own leadership strengths and weaknesses) (P = 0.005), tolerance for demands of leadership (comfortable making unpopular decisions and taking responsibility for them) (P = 0.001), and leadership positioning (considerate of the ideas of others and integrated into the institution's decision-making process) (P = 0.008), whereas competencies such as environmental scanning  and conflict management trended toward significance . In addition, graduates of the LFP were markedly more likely to report holding a position of academic rank , holding a position of department or subspecialty chief, and/or were chair of a national committee in comparison with applicants who did not complete the program . Although this study showed the clear objective benefits of an external leadership program, it may be limiting to some physicians because of time constraints, distance, and/or finances.10 By contrast, with the onset of the COVID-19 pandemic, external leadership development programs may become more accessible because of the ability to communicate and teach virtually.15Although most orthopaedic surgery department chairs reported that their institution offered leadership development programs, many still encouraged their faculty to seek and attend external leadership programs such as the AOA Emerging Leaders Program, AOA APEX Leadership Program, and AOA Kellogg Leadership Series Table . A study16 surveyed and interviewed 10 internal medicine department chairs at medical schools in the United States and found, on average, 55% of the chairs' time was spent on administrative duties. Another study surveyed 73 chairs of the department of anesthesiology to gain insight into how they manage their department.17 The authors found that 39% of chairs' time was spent on administration, committee meetings, and managing people one-on-one, whereas only 31% was spent on clinical care. Thus, as one advances into leadership positions, gaining additional administrative and management skills is important to handle these duties. Institutions should emphasize the importance of leadership and professional development programs for their faculty to become more adept at managing the increased administrative workload because these programs address topics such as conflict management, team building, communication, and financial skills.Of interest, almost three quarters of the orthopaedic surgery department chairs spent between 41% and 80% of their time on nonclinical responsibilities, suggesting that as one advances into leadership positions, more time is spent outside of the clinic and operating room. Similarly, LobasThis study has several limitations. First, given the relatively low response rate of 27.1%, the results may not reflect the opinions of all orthopaedic surgery department chairs in the United States. Moreover, department chairs who are more enthusiastic about leadership development for their faculty may have been more likely to respond to the survey, leading to response bias. Finally, this is a survey study and, hence, is subjected to the inherent limitations of such a design, including recall bias. Future studies should determine whether leadership development programs should be tailored to individual specialties because different areas of medicine may require a distinct skillset to become a successful leader.


As the field evolved, so too, has the Gerontology and Geriatrics Curricular Standards and Guidelines in Higher Education. The 7th edition is focused on the integration of the highly vetted AGHE Gerontology Competencies for Undergraduate and Graduate Education. Through this work we establish a set of standards and guidelines that provides the foundation for excellence in gerontology and health professions education at various levels and across a range of programs in the US and globally. The document provide a model for institutions of higher education in the development of new programs, a basis for program assessment and evaluation, guidance for academic or institutional reviews in existing programs, and a platform for what constitutes a program of study in gerontology/geriatrics or health professions programs for students, the public, and employers. An overview of the development of the 7th edition and suggestions for its use will be provided.


TM Dx Target Test). The numbers of punctures and core tissues, as well as computed tomography (CT) and EBUS findings, were evaluated. The success rate of NGS was 83.3% (130/156). The cut-off value for the number of core tissues was 4, and the sensitivity and specificity for successful NGS were 73.8% and 61.5%, respectively. CT and EBUS findings were not associated with successful NGS. In logistic regression analysis, the number of core tissues (≥4) was the sole predictor of successful NGS. Bronchoscopists should obtain sufficient core tissues for successful NGS using EBUS-TBNA specimens.Next-generation sequencing (NGS) with specimens obtained through endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been used to identify cancer-related genes among patients with lung cancer. However, the reported success rates vary, and the clinical factors associated with successful NGS remain unclear. We retrospectively reviewed consecutive patients with non-small-cell lung cancer who underwent EBUS-TBNA for NGS (OncomineTM Dx Target Test). Using the receiver operating characteristic curve, we calculated the optimal numbers of punctures and core tissues for NGS and evaluated CT and EBUS findings suggestive of necrosis and vascular pattern within the lesion. The success rate of NGS was 83.3%. The cut-off value for the number of core tissues was 4, and the sensitivity and specificity of successful NGS were 73.8% and 61.5%, respectively. Logistic regression analysis revealed that the number of core tissues (≥4) was the sole predictor of successful NGS. CT and EBUS findings were not associated with successful NGS. Bronchoscopists should obtain sufficient core tissues for successful NGS using EBUS-TBNA specimens.The success rate of next-generation sequencing (NGS) with specimens obtained through endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) among patients with lung cancer as well as the related clinical factors remain unclear. We aimed to determine the optimal number of punctures and core tissues during EBUS-TBNA for NGS in patients with non-small-cell lung cancer (NSCLC) as well as the association of chest computed tomography (CT) and EBUS findings with successful NGS. We retrospectively reviewed 156 consecutive patients with NSCLC who underwent EBUS-TBNA for NGS (Oncomine EGFR), fusions of echinoderm microtubule-associated protein-like 4 and anaplastic lymphoma kinase (EML4/ALK), c-ros oncogene 1 (ROS1), and v-raf murine sarcoma viral oncogene homolog B1 (BRAF), improve prognosis better than conventional cytotoxic chemotherapy [Various molecular-targeted drugs for treating patients with advanced-stage non-small-cell lung cancer (NSCLC) that are tailored for specific driver gene mutations, including epidermal growth factor receptor gene  as an NGS-based companion diagnosis for NSCLC. Using as little as 10 ng of DNA or RNA, it can simultaneously evaluate 46 cancer-related genes [EGFR, EML4/ALK, ROS1, and BRAF. The ODxTT multi-companion diagnostics (CDx) system is a common NGS test covered by insurance in Japan. Compared with previous companion diagnostic tests, NGS requires tumor tissues with sufficient quantity and quality, including tumor content ratio and the number of tumor cells in the specimens. Moreover, recent studies have reported on the success rate of NGS using bronchoscopic specimens [In 2017, the US Food and Drug Administration approved the Oncomineed genes ,12,13,14pecimens ,17,18,19Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive and standardized technique for sampling from mediastinal and hilar lesions that can be bronchoscopically approached from airways . Two preFor EBUS-TBNA procedures, the American College of Chest Physicians’ (ACCP) guidelines suggest a minimum of three separate needle passes per target lesion for lesion diagnosis in patients with suspected lung cancer, as well as additional sampling for molecular analysis . HoweverBronchoscopists can routinely evaluate mediastinal and hilar target lesions using B-mode sonographic findings and color/power Doppler mode ultrasound images during EBUS-TBNA. Each sonographic finding allows differentiation between benign and malignant lesions ,26,27. SWe aimed to determine the optimal number of punctures and core tissues during EBUS-TBNA for NGS in patients with NSCLC, as well as whether chest CT and EBUS findings before and during EBUS-TBNA could predict the success of NGS (ODxTT multi-CDx system).This single-center retrospective study included patients with primary or recurrent NSCLC who underwent ODxTT multi-CDx system analysis using EBUS-TBNA specimens from July 2019 to October 2020 at the National Cancer Center Hospital, Tokyo, Japan. We obtained approval from the institutional review board of the National Cancer Center Hospital, Tokyo, Japan (No. 2018-090); moreover, all the participants provided written informed consent for EBUS-TBNA. EBUS-TBNA and ODxTT multi-CDx system were performed when clinically required rather than solely for this study.TM Pulmonary, Boston Scientific Corporation, Natick, MA, USA; EchoTip Ultra® or EchoTip ProCore®, Cook Medical, Bloomington, IN, USA) or a 25-G needle . Although 22-G needles were mainly used for EBUS-TBNA, 25-G needles were selected for cases that required systemic staging or for those in which the operator believed puncturing the tissue would be too difficult using a 22-G needle. Furthermore, a dedicated ultrasound processor  was used to evaluate B-mode findings and vascular pattern images with the color/power Doppler mode ultrasound at its maximum diameter. All procedures were performed under the supervision of two bronchoscopists with more than 10 years of experience.All patients underwent flexible bronchoscopy under moderate-to-deep sedation with intravenous anesthesia. EBUS-TBNA was performed using a convex probe ultrasound bronchoscope  and a 22-gauge (G) needle  with up to 30–50 strokes per puncture, if there was a lot of blood backflow, and lower negative pressure or using the slow-pull method for the subsequent passes. The specimen within the needle was pushed out with an air-filled syringe onto glass slides. The obtained core tissues on the slides were immediately fixed with 10% neutral-buffered formalin for 6–48 h and embedded in paraffin. The slide from which the core tissue was removed was pressed onto another glass slide, and the two slides were fixed with 95% alcohol and treated with Papanicolaou stain. When performing rapid on-site evaluation (ROSE), one of the slides was dry-fixed and stained with Diff-Quik stain. In all patients, the first pass at each lesion was performed using ROSE. The numbers of punctures and core tissues  were couThe ODxTT multi-CDx system can analyze mutations at hotspots in 46 cancer-related genes using DNA derived from tumor specimens, as well as fusions in 21 cancer-related genes using RNA derived from tumor specimens with amplicon sequencing .® 2.0 fluorometer (Thermo Fisher Scientific). Library preparation was performed using the ODxTT multi-CDx system, controls, and Ion PGM Dx Library Kit. Template preparation was performed using Ion One Touch Duo Dx and Ion One Touch Dx Template Supplies, and Ion PGM Dx Sequencing Kit was used for sequencing platform. Mutations among cancer-related genes were analyzed by the Torrent Suite Dx software (Thermo Fisher Scientific).ODxTT multi-CDx system was performed on 10–15 slides of 5 µm-thick sliced tissues prepared using formalin-fixed paraffin-embedded (FFPE) specimens containing core tissues obtained through EBUS-TBNA. DNA and RNA extractions were performed using the Ion Torrent Dx FFPE Sample Preparation Kit, which was included as part of the ODxTT multi-CDx system for the Applied Biosystems VRTi Dx (Thermo Fisher Scientific). The deparaffinized samples from FFPE specimens were lysed using protease and filter cartridges were used to separate DNA and RNA. DNA and RNA inputs were 10 ng each and were measured using the NanoDrop spectrophotometer (Thermo Fisher Scientific) and the QubitEGFR, EML4/ALK, ROS1, and BRAF) in Japan. Therefore, in this study, “success” was defined as cases where all four cancer-related genes  could be analyzed through NGS. “Failure” was defined as cases diagnosed as NSCLC (by pathologists) that did not undergo NGS due to insufficient tumor tissue as judged by the pathologists (tumor content ratio <30 % and the number of tumor cells per slide <5000 cells) [EGFR, EML4/ALK, ROS1, and BRAF) could not be analyzed.The ODxTT multi-CDx system is only approved for companion diagnostic testing for four cancer-related genes (0 cells) ,16,29 anThe B-mode findings and vascular pattern images were reviewed by two bronchoscopists with more than 10 years of experience who were blinded to the results of the pathological diagnoses.Based on a previously reported B-mode image classification ,27, imagAn independent cytologist and pathologist evaluated histological and cytological specimens. The final diagnosis of each lesion was based on the pathological evidence obtained from EBUS-TBNA or surgery.U test. Receiver operating characteristic curve (ROC) analysis and the Youden index (sensitivity + specificity − 1) were used to calculate the optimal cut-off values for the numbers of punctures and core tissues. The trend was examined using the Cochran–Armitage test with one-sided p-values. Furthermore, we performed a multivariable logistic regression analysis of the clinical factors that were shown to influence the success of NGS in the univariable analysis. Statistical analyses were performed using EZR [Data are presented as frequency, median (range), and percentage. Based on a two-sided hypothesis, between-group comparisons were performed using the Fisher’s exact test or Mann–Whitney sing EZR   and 26 (16.7%) patients, respectively . NGS wasp = 0.021) than the failure cases (p < 0.001) than the failure cases (re cases A. Using re cases B. Succesre cases C. Using re cases D.p = 0.028 and p < 0.001). Additionally, all eight patients for whom six core tissues were obtained through EBUS-TBNA had successful NGS.p < 0.001 and p = 0.004) could predict successful NGS. Needle size, performing systemic staging, necrotic CT findings, B-mode findings, and vascular pattern images were not associated with successful NGS. Logistic regression analysis revealed that the number of core tissues (≥4) was the only independent predictor of successful NGS with EBUS-TBNA specimens .This is the first study to show that the number of core tissues has the greatest contribution to the success rate of NGS (ODxTT multi-CDx system) using EBUS-TBNA specimens. The cut-off value for the number of core tissues required for successful NGS was 4. Moreover, the number of punctures and core tissues was positively correlated with the success rate of NGS. However, successful NGS could not be predicted by differences in the needle size, EBUS, and CT findings suggestive of necrosis or blood flow within the lesions.EGFR, v-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog (KRAS), and EML4/ALK) [ACCP guidelines regarding EBUS-TBNA procedures without ROSE suggest a minimum of three separate needle punctures per target lesion for diagnosing lesions in patients with suspected lung cancer, as well as additional sampling for molecular analysis . A retroML4/ALK) . AlthougML4/ALK) ,18. On tML4/ALK) . TherefoIn addition, the number of core tissues was a more predictive factor for successful NGS than the number of punctures. We previously reported that in 29.0–41.4% of single EBUS-TBNA specimens obtained using a 22-G needle, only blood, cartilage, or bronchial walls were obtained, which rendered them unsuitable for diagnosis . SimilarWe observed no differences in the success rate of NGS between EBUS-TBNA specimens obtained using 22- and 25-G needles, which is consistent with previous reports . 22-G neWe found that B-mode findings, vascular pattern images on EBUS, and necrotic findings on CT could not predict successful NGS using EBUS-TBNA specimens. However, these findings do not imply that EBUS-TBNA procedures suitable for NGS may be performed without considering findings suggestive of necrosis or/and abundant blood flow in the target lesions. Although EBUS-TBNA is generally a safe procedure with a low complication rate, there have been reports of EBUS-TBNA-related complications, including bleeding, infections, and pneumothorax ,37,38,39NGS panels vary according to institution and country. We used ODxTT, which is a relatively small-panel NGS testing method that can analyze 46 cancer-related genes ,11,12,13This study has some limitations. First, this was a single-center retrospective study with a relatively small sample size. Second, all procedures were not performed by the same bronchoscopist; therefore, EBUS-TBNA specimens may have been affected by the skill of the bronchoscopists. Third, previous studies ,16,17,18In conclusion, the number of core tissues was the most important contributing factor to the success of NGS (ODxTT multi-CDx system) using EBUS-TBNA specimens. The success rate was positively correlated with the number of punctures and core tissues. Bronchoscopists should perform a sufficient number of punctures and obtain ≥4 core tissues for successful NGS using EBUS-TBNA specimens.


Social connections are critical for healthy aging . Consistent findings in research for persons with dementia that live alone show that a natural support network is the gold-standard for success, as social capital enhances well-being. Therefore a community-based intervention was piloted as part of a national 'special populations grant' in partnership with the local Meals-on-Wheels program. Dementia care management provided by graduate social work interns sought to provide weekly supportive contacts. Quantitative data was collected at baseline and following the program through administration of standardized measurement tools for "thriving" and for "dementia quality of life." The sample to date (N=33) consists of a majority being white females (82.4%), with additional participants expected as the remaining enrolled complete the program. These early "completers" do not show significant changes in their specific "surviving to thriving" domains, yet they do report greater perceptions of quality in their life as a whole following the dementia care management intervention when comparing post data to their baseline . To date this intervention continues to be studied and suggests a positive impact is likely for older adults with dementia that live alone, as well as for the communities where they reside.