Atypical variants of the hepatic artery are common and pose a technical challenge for normothermic machine perfusion (NMP). The transplant surgeon has three options when confronted with hepatic arterial variation in a liver graft to be subjected to NMP: to perform arterial reconstruction (i) prior, (ii) during, or (iii) following NMP.Herein, we report our experience and technical considerations with pre-NMP reconstruction. Out of 52 livers, 9 had an atypical hepatic artery (HA): 3 replaced right HA, 3 replaced left HA, 1 accessory left HA, 1 accessory left and right HA, and 1 replaced left and right HA.Reconstruction was conducted during back-table preparation. A single vascular conduit was created in all grafts to allow single arterial cannulation for NMP, necessitating only one arterial anastomosis within the recipient. All grafts were subjected to NMP and subsequently successfully transplanted.Our approach is being advocated for as it preserves the ability to alter the reconstruction in case of problems resulting from the reconstruction itself, thereby allowing functional evaluation of the reconstruction prior transplantation, permitting simultaneous reperfusion in the recipient, and providing the shortest possible duration for vascular reconstruction once the graft is rewarming non-perfused within the recipient. In addition, in light of the frequency of technically demanding reconstructions with very small vessels, we consider our technique beneficial as the procedure can be performed under ideal conditions at the back-table. Normothermic machine perfusion (NMP) is a rapidly evolving technology in the field of liver transplants, allowing preservation and assessment of grafts prior to transplantation . CurrentArterial perfusion is ideally conducted via single vessel cannulation, and thus, atypical arterial anatomy poses a technical challenge for NMP. Additionally, it is preferable to perform only one singular arterial anastomosis in the recipient, instead of having several separate arterial anastomoses in-between donor and recipient vessels. The transplant surgeon has three options when confronted with hepatic arterial variation in a liver graft to be subjected to NMP: to perform arterial reconstruction (i) prior, (ii) during, or (iii) following NMP. The latter is to be done on a back-table or the recipient with the graft in situ. Pre-NMP reconstruction will prolong cold ischemia time (CIT); reconstruction during NMP will impair first arterial reperfusion; while post-NMP reconstruction will prolong the time for proper arterial perfusion in the recipient and may be more difficult as the graft is already in the recipient. Nevertheless, this option may be valuable for perfect trimming, especially with respect to arterial length.Although aberrant arterial anatomy is frequent  and presWe retrospectively reviewed our prospectively collected NMP database for cases between October 2019 and April 2021 at the Department of General, Visceral and Transplant Surgery, University Hospital Münster, Germany. The study was conducted according to the ethical principles of the Declaration of Helsinki. The approval of the local Ethics Committee was obtained . Prior to the analysis, all data were de-identified, and all participating patients provided their written consent for the routine recording of clinical data.). Aberrant HA anatomy was categorized according to Michels’ [The inclusion criterion was a full liver allograft with any form of anatomical HA variation. Standard hepatic arterial anatomy (type I according to Michel’s classification) was defined as a single common hepatic artery (CHA) proceeding from the celiac trunk, giving rise to the gastroduodenal artery (GDA), right gastric artery (RGA), and lastly, proper left (LHA) and right (RHA) HA Fig. . AberranMichels’  and HiatMichels’  classifiSurgical reconstruction of the arterial tree followed two main principles in all cases: (i) creating a single vascular conduit enabling single vessel cannulation for NMP (and aiming for only one single anastomosis in the recipient) and (ii) mandatory reconstruction of all vessels, irrespective of whether accessory or replaced.Reconstruction was performed prior NMP, during back-table preparation using microvascular techniques and surgical loupes. The utilization of an operating microscope was never necessary. Prior to reconstruction, the aortic Carrel patch encompassing the origin of both the superior mesenteric artery  and the celiac trunk with its branches were meticulously dissected, enabling a clear classification of variants. Reconstruction was mainly conducted with a continuous 7–0 or 8–0 Prolene suture. For lumina, smaller than 3 mm interrupted sutures were applied. Using temporary stenting (5F irrigation cannula) across the anastomotic site facilitated secure suture placement. The vascular anastomosis was mainly end-to-side. An end-to-end reconstruction onto the GDA was performed in one case. To avoid any form of kinking, the length of reconstructed vessels was kept to an absolute minimum, and all anastomoses were conducted at the origin of the GDA or distal to it. Thus, accessory hepatic arteries (aHAs) were reconstructed using the origin of the GDA or RGA, while replaced hepatic arteries (rHAs) were reconstructed directly on the respective HA arising from the celiac trunk.Post-static cold storage NMP, as defined by Karangwa et al. , was conGraft implantation was performed using the modified piggyback technique (Belghiti) with end-to-side cavo-caval anastomosis and temporary portocaval shunting. The arterial anastomosis was performed using end-to-end anastomosis at the level of the bifurcation of the proper HA or GDA. Intraoperative patency of the reconstructed arterial tree as well as the main anastomosis (graft-to-recipient) was confirmed through Doppler ultrasound (US) and intraoperative flow measurements.Our post-operative standard procedure included Doppler US following skin closure and every 12 h within the first 5 days, as well as once daily afterward; no other post-operative imaging was obtained without indication. However, all patients received a CT scan within the first year of transplant (66 ± 165 days). The use of anticoagulation was not determined by arterial reconstruction, and patients received anti-platelet therapy only when indicated by the leading transplant surgeon.t-test. For categorical variables, the Fisher’s exact test was used. One-year patient survival, death-censored graft, and overall graft survival were estimated by Kaplan–Meier methodology. A value of p < 0.05 was considered statistically significant.All data were analyzed with Graph Pad Prism . Continuous variables are presented as mean values ± standard deviation (SD), and statistical significance between groups was analyzed using the unpaired Student’s ); while this variant is not included in Michel’s classification, it was later included in the simplified Hiatt classification (Hiatt’s type IV). As this variant is characterized by the absence of a CHA and a GDA arising directly from the celiac trunk, the rRHA was reconstructed end-to-end to the GDA, while the rLHA was reconstructed end-to-site to the origin of the RGA  subjected to NMP during the study period Fig. . Althougp = 0.374), weight-adjusted portal vein flow , lactate concentration  or pH .To analyze whether arterial reconstruction prior NMP had any effect on the perfusion itself, we assessed functional metabolic as well as flow parameters (after 4 h of perfusion) between the nine reconstructed grafts and 43 livers without arterial reconstruction subjected to NMP during the study period. No differences were found with respect to weight-adjusted HA flow . In three cases, hemodynamic instability of the recipients necessitated primary portal vein reperfusion. Intraoperative Doppler US and flow measurements revealed regular values, and no HA thrombosis or bleeding at the site of reconstruction was observed. Following reperfusion in the recipient, no additional reconstruction or altering of the pre-NMP reconstruction was necessary. No anastomosis needed to be redone or refashioned. A total of six patients (67%) received post-operative platelet anti-aggregating, which was continued for the first six post-surgical weeks. Post-operative Doppler US conducted during the first 5 days revealed a regular (0.5–0.8) arterial resistive index  in all cases but one. One patient presented with a high-resistance flow with a normal systolic phase and a continuous but decreased diastolic flow (RI 0.86) on post-operative day 2 in a singular measurement. However, all subsequent examinations showed normal indices and no further intervention was required. None of the cases developed late HA thrombosis or stenosis. All cases demonstrated full arterial patency proven by post-operative CT scans. Figure p = 0.728). The 90-day graft and patient survival was 100% , one must consider that during the time of reconstruction, not only is the respective replaced artery closed but it may also be required to temporarily close the remaining proper HA, creating an additional phase of warm ischemia without arterial inflow. Additionally, reconstruction of very small and fragile accessory arteries maybe time consuming, which also subjects the graft to warm ischemia. However, the impact of a temporarily impaired arterial perfusion on the vulnerable biliary tree remains unclear as the OrganOx metra device provides supraphysiologic oxygenation of the portal venous blood . In agreement with this, Nasralla et al. found no biliary complications in patients with arterial reconstruction during NMP .Second, pre-NMP reconstruction and not post-NMP distinguishes itself by its ability to perform simultaneous reperfusion, which has been shown to be associated with superior long-term outcome . Third, There are numerous practical lessons derived from our study: even complex reconstructions  are technically feasible and suitable prior to NMP. In addition, no arterial or venous autograft or allograft, or vascular prostheses were needed for reconstruction. However, meticulous hemostasis must be employed to avoid bleeding of the reconstruction during the red blood cell-based perfusion in the absence of platelets and clotting factors. Moreover, it is difficult to visually control the patency of a reconstructed artery, as the OrganOx metra device provides supraphysiologic oxygenated portal venous blood. Thus, even in a case of a closed artery, the respective lobe remains homogeneously marbled and appears visually intact. Therefore, it is advocated to use Doppler US and flow measurements in case of doubt.Some surgeons advocate using only the celiac trunk including the LGA when faced with an aLHA, thereby avoiding the need for reconstruction, especially when the aLHA is rather small. However, we strongly advocate the reconstruction of these vessels  to omit any vessel redundancy. The length of the reconstructed vessels should be kept to an absolute minimum to avoid kinking during NMP and in the recipient thereafter. With respect to this, the frequently described reconstruction onto the SMA was completely avoided by carrying out anastomoses only to the GDA branch or distal to it. Therefore, we routinely used the RGA and have not encountered a scenario in which this vessel was absent or too small. Additionally, in our experience, even very small accessory arteries are safe for reconstruction and NMP allows us to further evaluate their patency.While others have declined grafts with aberrant arterial anatomy for NMP or to avoid difficult reconstruction, we, on the contrary, emphasize on the utilization of NMP in cases of complex arterial reconstruction. By employing NMP, one can test the reconstruction under physiological flow conditions, thereby shifting potential reconstruction hazards  from the recipient to the perfusion device. This is especially true for small accessory arteries. In addition, the absence of platelets and clotting factors during NMP seems to guarantee sufficient hemostasis after graft reperfusion in the recipient. It is important to state that we advocate our approach of pre-NMP reconstruction for all grafts, including marginal grafts, despite their known vulnerability to CIT. In our cohort, a total of four grafts (44.4%) were from extended criteria donors: one donor had a donor risk index (DRI) > 2, two liver grafts revealed a macrovesicular steatosis ≥ 30% and one graft had a CIT ≥ 10 h. However, even for marginal grafts for which reduction of CIT is critical, we believe that the above-mentioned benefits of pre-NMP reconstruction outweigh the additional CIT as a reconstruction, even a complex one, can be completed in under 30 min.Although our approach inevitably prolongs CIT by 10–30 min, it reduces the surgical difficulty of in vivo reconstruction and eliminates inadequate arterial graft perfusion during NMP. Since clinicians are frequently confronted with aberrant HAs, our data  demonstrates that even complex arterial reconstructions are technically feasible and no contraindication for successful NMP and subsequent transplantation.


Kerria. Lac is commercially cultivated in southeastern Asian countries, including China (Kerria yunnanensis), India (K. lacca), Thailand (K. chinensis), and Myanmar . It is non-toxic, insulating, moisture-resistant, adhesive, tasteless, and has a smooth texture. Lac has been historically employed to finish a small number of products, but it is currently used in various fields. In this review, we mainly focus on the importance of lac genes that are responsible for lac secretion. In addition, information gaps, potential future research directions, and areas that require further research are highlighted.Since ancient times, people have used insects, such as scale insects , honey bees (honey and wax), and silkworms (silk), to make natural products in many ways. Lac is the only natural raw material derived from insects, being obtained from several species of the genus In the current era, products made from organic materials enjoy a privileged position because of their inherent safety. The eco-friendly properties of natural lac resins have increased their demand in many industries. It is secreted by sucking insects  and comprises three major components, viz., resin, dye, and wax. Lac insects are generally bivoltine in nature and are distributed in tropical and sub-tropical regions with complex multi-trophic habitats. Because of their sedentary habits, lac insects are more vulnerable to predators, parasitoids, squirrels, and rats, leading to a more than 50% reduction in production yield. To increase lac production, advanced-level molecular research is required to figure out the mechanism behind lac synthesis and secretion to improve lac yield and quality. The present review highlights metamorphosis, sexual dimorphism, multi-trophic habitat, host plants, and natural enemies of lac insects, lac composition, and applications, emphasizing the role of microbes, potential lac genes, and lac synthesis mechanisms in enhancing lac quality and production. The information provided here might be useful for lac researchers and for stakeholders aiming to make their products more eco-friendly. Lac is a combination of natural resins produced by scale insects . At firsLac insects are members of the family Kerriidae (Hemiptera), also known as scale insects, which produce a resinous material that forms a hard scale test over their bodies ,13. ThisKerria can produce true lac ..SchleichFicus religiosa), ber (Ziziphus mauritiana), litchi (Litchi chinensis), kikar (Acacia nilotica), and sirin (Albizia spp.) are known as major host plants of lac insects [Acacia nilotica, A. catechu, Samanea saman, Butea monosperma, and Ziziphus mauritiana are common lac host plants in Bangladesh [Dalbergia assamica, D. szemaoensis, D. obtusifolia, Ficus altissima, F. racemosa, and Pueraria tonkinensis [Indian wild ber serves as a host plant for lac insects in different agro-climatic zones of Punjab, India . In Indi insects ,88,89, wngladesh . The varkinensis ,91.K. chinensis, K. fici, K. lacca, K. pusana, K. maduraiensis, K. destructor, and K. canalis, are known to feed on the rain tree host plant Samanea saman with slight to severe levels of lac encrustation [K. destructor has been reported to kill large rain trees [Seven species, including ustation . Neverthin trees  via repeAprostocetus (Tetrastichus) purpureus (Cameron), Tachardiaephagus tachardiae (Howard), and Parechthrodryinus clavicornis (Cameron) [Eublemma amabilis Moore (white moth), Pseudohypatopa pulverea Meyr (black moth), and Chrysopa sp. (green lace wing) [Chrysopa lacciperda and C. madestes are most prevalent and cause significant mortality in lac insects [Lac crop losses are higher than agricultural crop losses . Lac pesCameron) . Howeverce wing) ,16, whicce wing) ,95. In t insects ,92. Duri insects  observed insects .Pseudohypatopa pulverea and Eublemma amabilis can be achieved by the use of the biopesticide Bacillus thuringiensis Berliner in the field. Two ant predators (Solenopsis geminata and Camponotus compressus) have been evaluated for control of lac predators via attacking the pupae and larvae of P. pulverea and E. amabilis. Several egg parasitoids have been used for the management of lac predators such as Telenomus remus, Trichogrammatoidea bactrae, Trichogramma brasiliensis, T. pretiosum, and T. chilonis. Pests can be controlled by applying systemic insecticides that are safe for lac nymphs and effective against predators. A combination of the above components may reduce the pest population and increase lac yield [The best way to protect crops from pests is to follow preventive measures such as (a) selecting mature, healthy, and brood lac free of parasitoids and predators for crop inoculation (b) after 2–3 weeks of inoculation, removing sticks with no brood lac  (c) scraac yield ,20,27.In view of the biosafety of natural products, this review highlights detailed information, including the life stages, distribution, and interaction of lac insects; their applications and composition and the lac genes involved in lac synthesis; and microbial diversity, host plants, and natural enemies of lac insects. The factors contributing to yield reduction during lac crop cultivation are highlighted, as well as how they might be improved. Lac insects are attacked by vertebrate and invertebrate pests, resulting in yield losses of up to 50%. This loss can be reduced through timely and effective management. Earlier investigations identified a few genes that may be responsible for lac production, and at least four to five common genes that need to be verified through gene knockout or gene silencing techniques. Until now, there has been no information about indigenous associations involved in lac production. Further investigations are required to determine the role of native microbes in the female lac insect, as this is one of the most important factors in lac yield because commercial lac is obtained solely from female lac insects. In addition, the response of native microbes already present in lac insects and the lac resins on trees during the introduction of identified candidate microbes from different parts of lac insects could be investigated. Advanced omics research  could help us to identify the mechanisms and pathways of lac synthesis, which would enhance lac yield.


CMS uses the Overall Hospital Quality Star Rating program to stratify hospitals based on specific quality criteria . “STARS patients” experience more readmissions, longer LOS and often have more complex discharge plans. During the second surge of COVID we implemented a program to increase hospice referrals through early identification and implementation of goals of care (GOC) conversations.Electronic Medical Records reviewed for STARS patients from pre- (1/2019-7/2020) and post (3/2021–2/2022) program implementation. Location: 2 community-based hospitals. Data collected: demographics, hospital outcomes, discharge disposition. Data compared with Student’s t tests and Chi square.459 patients, 177 pre-program and 282 post-program were included. Groups were similar in age (83.0 vs 83.6), LACE score (13.0 vs 12.8), principal diagnoses , and mortality (3.5 vs. 4.0%). LOS increased 4.9 days vs. 6.1 days (p < 0.01), readmission rates unchanged: 12.6% vs 13.0% (p=0.90). GOC conversations increased, 48.6% to 75.0% (p < 0.01), DNR from 24% to 44% (p < 0.01), and comfort measures from 0.5% to 5% (p < 0.01). Hospice referrals increased from 0.5% to 11.2% (p < 0.01). Discussion: Early identification of STARS patients increased GOC conversations, DNR, comfort measures and hospice referral. Patients across time periods were similar in age, LACE and admitting diagnoses. LOS increased by a day, likely reflecting time needed to arrange discharge disposition. Increased hospice at end-of-life is associated with better quality care and patient/family satisfaction. This program may be adapted to larger, academic medical centers within the health system.


Introduction: The roles and responsibilities of the administrative staff supporting required clinical medical student experiences have evolved. In 2004, the Association of American Medical Colleges Central Group on Educational Affairs (CGEA) offered for the first time the Clerkship Administrator Certificate Program. This program requires the completion of a series of workshops and a project and results in a certificate. Research related to long-term outcomes of professional development programs such as this is limited. The purpose of our study was to explore the impact this professional development program had on the careers of participants.Methods: We conducted a survey of those who completed the qualifying workshops from 2010 to 2018. The survey was based on program content, including questions to explore the self-described impact on their careers. Categorical and scaled data were summarized using descriptive statistics. The realistic evaluation framework was used to guide inductive and deductive content analysis, allowing respondent interpretations and context to define outcomes.Results: Out of 244 invitations, 50 (20.5%) responded. Of the respondents, 40 still work in medical education. Scaled responses (strongly disagree to strongly agree) were positive. The individual's motivation, departmental climate, and other contextual factors  impacted workshop participants’ ability to complete the certificate program. Those who completed certification noted various forms of recognition locally, ranging from special recognition by the chair, raises, and promotions. Additionally, participants felt more confident and accomplished in their careers.Conclusions: Although positively rated, the success of this program had differential outcomes depending on participant contexts. Unintended results for participants completing the program resulted in promotions. Applying the realistic evaluation framework provided insights to improve the program. For the past 20 years, the role of the administrative staff in supporting the required clinical medical student experiences has evolved . The fifTo offer professional development for clerkship administrators, the Central Group on Educational Affairs (CGEA) of the Association of American Medical Colleges began offering a certificate program in 2003. The CGEA Clerkship Administrator Certificate Program (CACP) was delivered for the first time in 2004. The CGEA is an organization for medical educators from all disciplines as well as across the continuum of medical education. A series of three workshops are presented in one setting. Since then the program has been delivered regularly at the CGEA as well as at the Council on Medical Student Education in Pediatrics (COMSEP), Association of Directors of Medical Student Educators in Psychiatry (ADMSEP), and multiple medical schools. We recently published an overview of this program .Programs such as CACP are of value to both participants and institutions due to their structure. Planners developed the program to ensure core content was completed in a four-hour session, which minimized travel expenses and time away for clerkship administrators. Although there have been many individuals who have participated in the program, it is still unclear what impact the program has had on participants. Part of the challenge in studying programs such as CACP stems from understanding the individual motivations, departmental cultures, and contextualized social situations of the participants. We, therefore, sought to explore the impact of CACP using a survey to obtain both quantitative and qualitative responses. The richness of responses led us to apply Pawson and Tilley’s realistic evaluation framework  to betteThe realistic evaluation seeks to identify what works for whom in what circumstances -8. The fThe purpose of this project was two-fold. We first wanted to obtain long-term feedback on aspects of the certificate program content. For this, we asked specific questions related to the content of the certificate program. Second, we wanted to determine how to improve content and expectations for future participants using the realistic evaluation framework. We used open-ended questions on the survey to construct these findings.SampleAll individuals who participated in the workshops for the CACP from 2010 to 2018 were invited to complete the survey. Although we had contact information from when individuals completed the program, we verified email addresses by searching institutional websites or internet search engines.SurveyThe survey evaluated the CACP content. Additional questions were asked related to the perceived impact of the program, both personally and professionally. The authors developed the questions that included Likert scales and open-ended questions. We invited input from colleagues to read the survey for clarity, making edits to questions where recommended. The survey had 13 questions and is available as a supplemental electronic file. The survey was created using QualtricsTM . The anonymous link was sent with two reminders at week two and week four after the initial invitation.The University of North Carolina Institutional Review Board reviewed and approved this study as an exempt (UNC IRB No. 20-0846).AnalysisCategorical and scaled items on the survey were summarized using descriptive statistics. Summaries were conducted using IBM SPSS, Inc. v. 26 .The realistic evaluation framework was used in our study in an interpretivist fashion . CraftinParticipants attending the Clerkship Administrator Certificate Program workshops from 2010 to 2018 (n=249) were eligible to complete the survey. Of those, two were deceased and two did not have verifiable email addresses, leaving a total sample of 245 participants. We received 50 (20.5%) completed surveys.Of the respondents, 45 (90%) continue to work in medical education in some capacity. Participants hailed from many disciplines or departments when they completed the workshops. However, pediatrics was represented more than all other disciplines, followed distantly by psychiatry Table . The greThirty-six (72%) respondents completed the program requirements for certification. Of these, 33 applied their project to the clerkship and 26 undertook additional projects. Twelve submitted their project as a poster presentation at a regional or national meeting. Three submitted their final project to a peer-review journal.A set of CMOs developed by the authors is detailed below and summarized in Figure The first CMO labeled “germane” was built on the premise that clerkship administrators recognize their role as a leader in medical education. The activities in the workshops  provided the mechanisms for participants to apply during the program. We hypothesized the outcome of "germane" context and mechanisms would be applied in their work. Based on the level of agreement from the survey Table , 44  useful insight for best practices in managing clerkships, (ii) an opportunity to network and learn from others and (iii) an opportunity to conduct some research in the area.” - Family Medicine“It strengthened my confidence in my role and allowed me to be a stronger voice on campus, which has resulted in my being asked to join committees and a task force representing all clerkship coordinators on campus.” - The goal of every professional development program is that participants find utility in the sessions, which was labeled “applicable.” Gaining specific communication skills to address challenging situations is something clerkship administrators face daily. The activities in this workshop allowed participants to practice skills using a variety of case scenarios. The outcome was their ability to approach challenging conversations with more confidence. The following quote is indicative of others about this particular CMO.Psychiatry“I feel that the program really gave me the skills to address difficult situations and find the best way to approach people that I may disagree with or have different personality types. This goes for both personal and professional life.” - “This program helped me in my current role as an Administrative and HR Manager. I can better assess personalities and gained knowledge and tools to better help my team move forward and have continued success.” - PsychiatryThe requirement for participants to complete a project assumed participants had baseline skills to complete a quality improvement initiative. During the program, examples of projects previous participants had completed were explained to participants. They were also encouraged to partner with their director to obtain mentoring to facilitate the successful completion of a project. During the sessions, ideas were generated and participants seemed motivated to initiate their projects. Thus, our anticipated outcome was that participants felt a sense of “agency” and that they would complete the project and thereby receive their certificate. However, results were mixed based on the survey. For some, they had no trouble completing the project requirement.OB/GYN“It was actually fun to come up with a project. I have millions of ideas all the time for student education research.”- Family Medicine“The project required by the program challenged me to "dig deeper" and view the clerkship from new angles.”- Completing a project was required to have completed the program and receive a certificate. For some respondents, completing the project seemed to be of low importance or that current work duties were too time-consuming.Pediatrics“Carving out time to develop the project. I am both the Student Coordinator and Medical Education Office for our Children's hospital. Currently working with approximately 500 student rotations per academic year.” - Finally, the goal orientation for participating in the program was unknown. Although attending the workshops gave a sense of recognition, our anticipated outcome was that this recognition and support from developing a network of colleagues would be present locally. Some participants indicated recognition within their department as well as from the school. Specifically, 12 respondents indicated they received a promotion and/or raise after completing the program.Pediatrics“I was given a raise and title change. I am now the Program Manager for a new undergraduate program in the same department.” - Internal Medicine“I received a promotion and a raise as well as public acknowledgment from my Chair.” - Pediatrics“…very positively impacted [me] because of the networking with other administrators nationally and gaining an understanding of the various issues involved in clerkship administration. Having that broader perspective helped me understand where I am within my institution.” - For some participants, their completion of the certificate program was not given any recognition locally.Pediatrics“Until I received this survey, I forgot I even participated almost 10 years ago. If completing the project had been prioritized by my director, I think the program would have been more impactful.” - Pediatrics“…was told by upper management that ‘anyone can go to a conference and get a certificate’. [They] totally disregarded the effort I put into the project ... It was truly heartbreaking.” - The results of our survey indicated that the certificate program was a positive experience for all of the respondents. One of the goals of CACP was for clerkship administrators to invest in this role as a career. Completing the project was our proxy measure of them embracing this concept. Of the respondents, 72% completed the certificate program in its entirety and more than half went on to undertake more projects. Additionally, “goal orientation” from the realistic evaluation analysis indicated the programmatic intent was successful.Applying the realistic evaluation framework to the survey data allowed us to better understand contextual issues faced by participants . ResultsProject completion was mixed. Although many indicated confidence in undertaking a project, some faced barriers upon returning to their home institution. The project was initially promoted as more of an educational research project, which some participants noted their director was not interested in pursuing. We have now deliberately incorporated formal discussions at the end of the workshops to address how to go about doing a quality improvement project and how to collect information to demonstrate change. Additional resources are being added to the program website for additional guidance.The mixed response for certificate completion highlights the importance of networking that began as part of the workshops. Respondents noted how impactful it was for them to meet others doing similar work. Offering follow-up networking sessions may promote developing a community of practice amongst the participants -12. FaciAlthough it is made clear that completing this program is intended for personal growth, some participants indicated they were disappointed that they were not given more formal recognition locally for completing the certificate program. However, since many of the individuals completing the program attend conferences there could be a way to identify that they completed the certificate program on their name badges. For upcoming sessions, we will intentionally ask everyone why they are participating in the workshops. This will then allow us to further test our hypothesis that they feel local support for involvement in continuing professional development.A limitation of this report is the lack of follow-up data regarding the long-term impact of this program on job satisfaction or continuing professional development of the participants. Although the impact has been noticeable through the presence of past participants who regularly attend ADMSEP, CGEA, or COMSEP meetings, the true magnitude has not been investigated. A future endeavor is to conduct follow-up studies with participants to inquire what sort of catalyst effect the certificate program has had on them. Additionally, it would be interesting to question clerkship directors for those who complete and do not complete the project requirement to better understand the goal orientation of participants. Professional development opportunities for medical student education administrative staff is important. The impact of such programs has not been studied to date. Based on responses from participants of CACP, most completed the requirements of the program and more than half pursued additional projects. Using this data to make changes for future sessions, we will further explore the hypotheses generated from our realistic evaluation findings.


Moving Stories, which combines mental health literacy training for depression with contact with someone with lived experience both in the digital and nondigital world.Depressive symptoms are highly prevalent among adolescents in Western countries. However, although treatment for depressive symptoms is available, many adolescents do not seek help when they need it. Important barriers to help-seeking among adolescents include low mental health literacy and high stigma. Therefore, we have developed a game-based school program, Moving Stories, using a cluster randomized controlled trial.The aim of this study is to conduct a first test of the effectiveness of the newly developed game-based program, Moving Stories program, whereas the other half were in the control group, where no intervention was provided. The adolescents filled out digital questionnaires at 4 time points, with questions on mental health literacy, stigma, depressive symptoms, and the program itself . Using R , we ran linear mixed-effects models for all continuous outcome variables and generalized linear mixed-effects models for all binary outcome variables.A total of 185 adolescents participated, divided over 10 classes from 4 schools. Half of the classes were randomly selected to follow the Moving Stories group improved after the program in personal stigma . Effects on personal stigma lasted over time . Most adolescents in the Moving Stories group participated in the introduction  and contact session , played the game for 4 or 5 days , and indicated that they would recommend the game to their peers .Compared with the control group, participants in the Moving Stories as a stigma reduction program. With changes in the program to improve its effects on mental health literacy, Moving Stories could be implemented in schools to improve help-seeking in adolescents and reduce the negative consequences and burden of depressive symptoms.The results of this study show the potential of Dutch Trial Register NTR7033; https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7033RR2-10.2196/11255 Depressive symptoms are highly prevalent among adolescents in Western countries -3 and inMoving Stories, that targets mental health literacy and stigma on depression  was a friend, I would help him/her.” Specific first aid skills were assessed by asking whether the participant would perform each action on a list of 12 helpful and harmful first aid actions . The scoω was between 0.67 and 0.74 for all 4 time points.Beliefs about help were assessed by asking whether a specific person would make the person’s situation in the vignette “better”; “not better”, “not worse”; or “worse.” A score for beliefs about appropriate help was calculated by adding up the number of selected adult sources  deemed to be helpful (better) . The valω between 0.78 and 0.82), (2) help-seeking intentions toward informal sources , and (3) help-seeking intentions toward formal sources . Higher scores indicated higher intentions.Help-seeking intentions were measured using the General Help-Seeking Questionnaire, which has good internal consistency and excellent test–retest reliability . Averageω was between 0.62 and 0.67 for personal stigma, between 0.74 and 0.83 for perceived stigma, and between 0.84 and 0.87 for social distance. Higher scores for personal and perceived stigma indicated higher stigma, whereas higher scores for social distance indicated lower stigma.Stigma was measured with 3 scales. Both personal and perceived stigma was measured using the Dutch Depression Stigma Scale ,71, wheryes or maybe, they were then asked whether they offered the other person their help. If so, or if they were unsure, they were asked what they did out of the 12 actions and the open-ended option mentioned in the First Aid Intentions and Skills section [First aid behavior was measured by asking whether the participant has had contact with someone who has experienced a problem similar to the one seen in the vignette ever (before the program) or within the past 3 months (at 3- and 6-month follow-ups). If the participant answered  section .yes or not sure, they were asked whether someone had helped them with this problem in the past 3 months and who this person was. Multiple answers could be provided.Help-seeking behavior was assessed by asking whether the participants themselves had experienced a problem similar to the situation in the vignette. If they responded with Depressive symptoms were assessed with the Children’s Depression Inventory ,74. The Moving Stories and, if so, whether they had played it. If they indicated that they had played it, they were asked on what platform they had done so.To check for possible contamination effects because of the within-school randomization, participants in the control group were asked at the 6-month follow-up whether they had heard of the game Moving Stories with 7 items. To distinguish between the different components of the program and the study , the participants were also asked which of the components they would recommend to a friend if they had the opportunity to participate in the study over the following year.After the program, participants in the intervention group were asked to evaluate the program Moving Stories between classes. By including random effects, we knew that the differences between the experimental group and the control group would not be biased by differences between the classes. Therefore, the random effects structure benefited the interpretation in this 2-group design. When random effect variances were estimated as 0 in one of our models, we simplified the random effect structure of the model by first omitting random correlations and, if necessary, the random intercept for class. As recommended for confirmatory hypothesis testing, the random slope for our predictor of interest  was never omitted [Z scores. The significance of the coefficients was tested using t tests (2-tailed), with correction of the df based on the Satterthwaite approximation. A chi-square test was used to test if the condition had an effect on whether adolescents had provided help to someone in their network with a mental health problem. We reported the estimate, 95% CI, and 2-tailed t test results with P<.05 for the linear mixed-effects models and the odds ratio, 95% CI, and Z test results with P<.05 for the generalized linear mixed-effects models. The other results can be found in Data preparation and descriptive analyses were performed using SPSS Statistics  . All oth omitted . Time waJMIR Research Protocols [All materials have been made publicly available via Open Science Framework . The desrotocols . DeviatiA total of 185 adolescents participated, with an age range of 12 to 15 years . Of the 185 participants, 101 (54.6%) were boys, and 179 (96.8%) were born in the Netherlands. The educational levels of the classes were either only preparatory secondary vocational education or preparatory secondary vocational education including higher general secondary education  and preuniversity education . Approximately 91.9% (170/185) of the adolescents indicated that they played video games and did so for an average of 8.48 (SD 7.26) hours per week.183=2.47; P=.01) and had higher depressive symptoms  and a lower educational level  than the adolescents who finished the final questionnaire.Dropout at postprogram measurements  and the 3-month follow-up was low . At the 6-month follow-up, approximately 89.7% (166/185) of the adolescents finished the questionnaire (10% dropout). There were no significant differences in study condition, gender, country of birth, and gaming behavior and frequency among adolescents who dropped out at the 6-month follow-up and adolescents who finished the final questionnaire. However, the adolescents who did not finish the final questionnaire were significantly older , whether the adolescents generally played video games , and number of hours playing video games . In the experimental group, 66% (65/99) of the participants were male, whereas in the control group, 42% (36/86) were male. Significantly more adolescents in the experimental group indicated that they played video games, and they did so more hours a week than those in the control group. We included gaming frequency (standardized) and gender as covariates in all models. 182.35=−2.09; P=.04) and more social distance toward peers with depression . Moreover, the experimental group deemed more adults to be helpful than the control group .Differences were found between the experimental and control groups in terms of gender ; therefore, we did not conduct any analyses on the social anxiety vignette.b=−0.20, 95% CI −0.35 to −0.05; t169.28=−2.61; P=.01). Contrary to our secondary hypothesis, the experimental group had a decrease in first aid confidence from the preprogram measurement to the 6-month follow-up , whereas this effect was not found in the control group.No effects of condition were found at the postprogram measurement and 3-month follow-up for first aid confidence. Participation in the experimental group predicted changes over time in first aid confidence from the preprogram measurement to the 6-month follow-up compared with the control group  and from preprogram measurements to the 3-month follow-up . At the postprogram measurements and 3-month follow-up, in line with our primary hypotheses, personal stigma decreased significantly in the experimental group , whereas this was not the case for the control group. No effects of condition on perceived stigma and social distance were found at postprogram measurement and the 3- and 6-month follow-ups, and the effects on personal stigma did not last at the 6-month follow-up.Participation in the experimental group, compared with the control group, was related to changes over time in personal stigma from pre- to postprogram measurements  indicated having offered help. At the 3-month follow-up, this was 89% (31/35 participants), and at the 6-month follow-up, it was 67% (24/36 participants).There were no significant differences at the 3- and 6-month follow-ups between the experimental and control conditions on whether adolescents had a personal experience with a mental health problem. At preprogram measurements, 17.3% (32/185) of the participants indicated whether they ever had a mental health problem (or did not know for sure). At the 3-month follow-up, 10.9% (19/174) of the participants indicated having had a mental health problem in the previous 3 months (or did not know for sure), whereas at the 6-month follow-up, this was 5.4% (9/166) of the participants. None of the adolescents at the 3- and 6-month follow-ups mentioned that they had not been helped.Participation in the experimental group was not related to changes in depressive symptoms over time.Moving Stories. None of them indicated they had played the game.In the control group, at the 6-month follow-up, 3% (2/80) of the adolescents indicated that they had heard of Most of the adolescents in the experimental group participated in the introduction and contact sessions . During the playing days, 49% (49/99) of the adolescents played the game for 5 days, 34% (34/99) played it for 4 days, 14% (14/99) played it for 3 days, and 3% (3/99) played it for ≤2 days.Moving Stories positively at the postprogram measurements. When asked whether they would recommend elements of the study and program to a friend, 92% (90/98) of the adolescents indicated they would recommend the game, 66% (65/98) indicated they would recommend the contact session, and 79% (77/98) indicated they would recommend the research element. Of the 98 adolescents, 75 (77%) understood the game, 67 (68%) thought they had learned something from it, and 74 (76%) were interested in how Lisa would be doing in 6 months. Fewer adolescents rated the contact session positively ; however, 53% (52/98) of the adolescents indicated that they had learned something from it. Approximately 40% (39/98) indicated that they would play the game a second time to get a better score. In terms of stigmatizing attitudes toward Lisa, 23% (23/98) of the adolescents indicated that they would not hang out with Lisa in daily life, whereas the others were neutral or positive toward her.The adolescents in the experimental group rated Moving Stories [The goal of this cluster randomized controlled trial was to test the effects of the newly developed game-based school program  Stories  on mentaMoving Stories program reduced personal stigma over time compared with participation in the control condition. These results are in line with previous research showing that contact with someone with lived experience can reduce stigma [Moving Stories program seemed to be similarly effective, at least in terms of immediate effects. However, improvements in personal stigma did not continue beyond 3 months, and the effects could be a result of regression to the mean [We found that participation in the e stigma . Interacthe mean . These rthe mean -86.Moving Stories group were less confident about providing help at the 6-month follow-up compared with adolescents in the control group; however, there were no group differences at the 3-month follow-up or after the program. The adolescents in the Moving Stories group may have felt less confident after 6 months about remembering and applying the helpful skills taught in the Moving Stories program, whereas the adolescents in the control group had no knowledge of whether specific skills were helpful or harmful. Indeed, we did not find any effects on first aid skills. It could be that, for confidence to increase, a strong and longer-lasting knowledge improvement would be needed.Contrary to our secondary hypothesis, we found that adolescents in the Moving Stories program was not sufficient to improve mental health literacy. Other mental health literacy programs have incorporated didactic sessions in which facts about depression and first aid skills are explained. The Moving Stories program did not include didactic sessions but was focused on learning by doing [Moving Stories could combine the learning by doing in the video game with the didactic sessions from other programs to improve its effectiveness. This might be especially beneficial for a younger, less-experienced group of adolescents. Finally, it could also be that we did not have sufficient power to show effects in a Dutch context. We based our power analysis on an Australian study; however, the contexts of the 2 countries might have differed too much. Future studies in a Dutch context with Moving Stories, or any other mental health literacy program, should start with a lower expected effect size.No group differences were found for symptom recognition, first aid intentions, beliefs about the helpfulness of adults in general, help-seeking intentions in general, or toward informal and formal sources specifically. We did not find group differences in perceived stigma, social distance, or providing and seeking help. The null results in our study are not in line with previous work, as other mental health literacy programs have been found to be effective in improving mental health literacy, specifically in terms of knowledge ,44,47. Aby doing . It is pMoving Stories was well-received by the adolescents, and adherence to the full program was high. This is as important as the stigma results, as both digital and nondigital mental health programs often suffer from engagement problems [Moving Stories program does not have the same entertainment goals as the video games adolescents play today, adolescents in our study were still engaged by the game and interested in the content of both the game and the contact session.Finally, the process evaluation showed that problems . If we wThis study used a rigorous design to test the effects of a new mental health literacy program. Most studies on the effects of health literacy programs do not include a control group, and very few studies test the effects over a longer period -42. Anotfeeling very bad, they themselves and their parents would be contacted by the research team. To avoid such a call, the adolescents could have chosen not to fill out later questionnaires.A limitation of our study was the difference between dropouts and completers at the 6-month follow-up. Age and education level differences in attrition were mostly because of a class that received the questionnaire right before the Christmas break and therefore received fewer reminders. Compared with the other classes, adolescents in this class had a higher mean age and lower educational level. However, this particular class did not explain the attrition differences found in depressive symptoms. Adolescents with depressive symptoms may have been less comfortable with answering questions about their mental state and therefore did not fill in subsequent questionnaires -91. In ateen Mental Health First Aid [A second limitation was the relatively low reliability of some of the outcome measures . These outcomes should be interpreted with caution. In general, low psychometric quality is found for mental health literacy measures  and, to irst Aid ). Althouirst Aid .Moving Stories program because of small subsamples and differences at baseline in the quality of the provided help between the 2 conditions. If we are interested in studying whether adolescents show appropriate and effective behavioral responses when coming into contact with a friend with depressive symptoms after participation in a mental health literacy program, long-term follow-ups with larger samples are needed to allow for the occurrence of such an event. Moreover, assessing reaching out for help next to assessing receiving help would provide even more useful information.Finally, we were unable to explore the behavioral effects of the Moving Stories program specifically and mental health literacy programs in general. One recommendation is to compare the effects of a mental health literacy program between younger and older adolescents. The original idea of Moving Stories was to teach adolescents first aid skills and help-seeking behavior before most mental health problems occurred. However, it could be that a mental health literacy program is more effective when students have experienced mental health problems themselves or in their social environment, which is more likely when they are older. Another recommendation is to tailor mental health programs to the preferences of the users. This becomes a more feasible option when digital tools are used and might improve their effectiveness [Moving Stories, we could create a male or nonbinary version of Lisa and increase the number of first aid and dialog options in the game. Then, the game could be tailored to the preferences of a user but also to their knowledge and experience level. Finally, although many programs, both for mental health literacy and stigma, include the presence of a person with lived experience, the organization of these sessions on a large scale has proven to be difficult. Other options could be to include video material of people with lived experience while a school mental health professional leads a discussion. An added benefit is that the students participating in these discussion sessions are immediately in contact with someone who can provide help if they need it.On the basis of the results of this study, we have several recommendations for future directions of the tiveness . For exaMoving Stories program could be effective in reducing personal stigma regarding depression in adolescents, although the effects were small. Moreover, the program was well-received and well-adhered to, something that can be difficult to achieve with young adolescents. In its current form, the Moving Stories program had no effect on mental health literacy components, perceived stigma, or social distance. Our results suggest that a larger sample might be needed to show the effects on a Dutch adolescent population. Nevertheless, the stigma results and positive evaluations may be a good stepping stone for further iterations of the program. Combining the program with didactic elements from other programs and scheduling regular follow-up conversations in the classroom might improve these results. Moreover, tailoring the video game to each individual player’s preferences and skill level could further increase its effects. With better results and after showing its effectiveness in studies with larger sample sizes, the program could be implemented in schools to improve help-seeking in adolescents and reduce the negative consequences and burden of depressive symptoms.The results of this clustered randomized controlled trial seem to show that the


The Stanford Biodesign program was first introduced in Japan in 2015 at three national universities to develop medical technology innovation and its talent. This study aimed to (1) show the outcomes of leadership talent development, (2) indicate the educational results of the program, and (3) objectively analyze the ways in which the program executed in Japan, effectively promoted entrepreneurship orientation and the origination of new businesses. The latter is especially relevant as Japan has low entrepreneurial awareness and new business entry rates compared to the United States and Europe. Herein, fellows were subjected to questionnaires, interviews, and a survey based on academic papers, extant literature, and treatises issued by the Nihon Biodesign Gakkai (Academic Society of Japan Biodesign). Overall program performance showed notable results, despite indicating a need to improve business-related programs and team learning which is greatly influenced by Japanese culture. An externship program, planned and developed in Japan, was most inspiring and served to expose participants to role models. Comparing Japan Biodesign education elements to factors of general entrepreneurship promotion in Japan, sampled and organized from relevant White Papers, proved its educational effectiveness in entrepreneurship promotion from an objective viewpoint. Within the 4-year timeframe, the results indicated that leadership talent was indeed developed. Medical device innovation should progress through the stages of establishing new ventures, followed by contriving medical devices with novel, impactful value. This study revealed that Japan Biodesign education provides a platform for achieving these goals, despite the challenging Japanese new business environment. In 2015, the Stanford Biodesign program –6.A unique feature of the Biodesign program is its “Needs Start” innovation process that comprises the major steps, “Identify,” “Invent,” and “Implement” and starts with finding and screening unmet medical needs. Overall, the education offered in this curriculum consists of three elements, namely, medical device and business-related programs, and a design thinking approach, which supports the processes of the former two. Compared to the US and Europe, entrepreneurial awareness and activity are quite low in Japan, and very few new ventures arise. Thus, externships were established for, and incorporated into, the Japan Biodesign education program.This study aimed to analyze the degree to which Biodesign education in Japan has contributed to developing leadership talent and determine how to rate the overall education program given the remaining issues. Moreover, its effectiveness in spurring on an entrepreneurial orientation that could lead to new ventures and innovation was evaluated, and the type of factual results produced across the 4-year long terms—from program inception in 2015–2019—are determined. The outcomes of this study provide suggestions for directing medical device innovation education in Japan.A main objective of Biodesign education is the development of leadership talent. In 2015, the Japan Biodesign Program was introduced to three universities, Tohoku University, University of Tokyo, and Osaka University. The results of a questionnaire survey conducted in 2019 by the Nihon Biodesign Gakkai (Academic Society of Japan Biodesign)  on 41 feLeaders were defined as people who: (1) decided to start new businesses upon consideration of personal risks, (2) assumed project leader positions because of recognition of their Biodesign experience and took charge of planning, and (3) rose to positions closer to the CEO within organizational layers (promotion was excluded). The research period extended from completion of the program through March 2021. Forty-one individuals were interviewed by phone between April and June 2020, and their responses were analyzed according to the stated definition.A questionnaire-based survey was conducted from August to September 2019; the effective response rate was 100%, and responses were sent to the faculty of Nihon Biodesign Gakkai. In total, 41 fellows from the four terms included in this study responded and evaluated each program subject. A 5-point scale was used to evaluate the main subjects using question responses: strongly agree = 5, somewhat agree = 4, agree = 3, somewhat disagree = 2, and disagree = 1.One of the evaluation subjects was the Team Approach, which is an important factor in design thinking. A team with maximum four members was formed at each university. Where possible, effort was made to select group members with diversity in mind, combining individuals from medicine, engineering, and business sectors, and of both sexes. However, certain challenges arose, including that fewer fellows were available than anticipated, and the number of women was overwhelmingly small . Since medical device development requires knowledge of both medicine and engineering, there was a need for at least one team member to be from the medical and engineering field. Over the 4-year period, 12 teams (3 universities × 4 years) were formed, and fortunately, members with medicine and engineering backgrounds joined each team. The degree to which the fellows recognized and understood the importance of the team approach to the overall program was evaluated.To promote team performance, a Team Learning program was introduced from the second term onward. A specialist came onboard and started mentoring the teams by providing lectures and guidance four times a year. The concept was to ensure the psychological safety of members so they could function as a team . The keyAn externship program was incorporated into the Japan Biodesign education curriculum. The program entailed sending fellows to ventures or incubators in Silicon Valley for 2–4 weeks to gain hands-on experience while learning in an actual medical device start-up setting. This was done against the backdrop of Japan’s low level of entrepreneurial awareness and limited number of new ventures, compared to the US and Europe. Naturally, this translates into a low absolute number of ventures in Japan, whether in the medical device field or otherwise. Accordingly, a rating system that listed nine items—including externships—was used, allowing fellows to choose their three most preferred programs, to examine the results.A questionnaire-based survey was conducted, to which 41 fellows responded. Then, changes in the entrepreneurial orientation of fellows before enrollment and after completion of the program, were examined.Using the 2011 , 2014 1, and 201For a meaningful comparison, the factors that promote entrepreneurship were examined and chosen as follows: all factors related to “motive, purpose, and opportunity” for promoting entrepreneurship stated in these White Papers were listed, followed by the exclusion of factors unrelated to Biodesign education. For example, “self-realization” depends on an individual’s personal thoughts or determination, and “personal discretion” is excluded because starting one’s own business requires using personal discretion. As shown in Table Factual results, such as the number of start-ups and patent applications, subsidies, and venture capital (VC) investment, were surveyed by interviewing all fellows from August 2019 to March 2021.Originally, 48 places were available, and 42 individuals accepted into the program, of which 41 ultimately completed it (85.4% fulfillment rate = 41 fellows/48 places). The mean age of participants was 33.0 years, and the male/female ratio, 83:17. Figure Table The questionnaire items shown in Table In evaluating the overall program, Question 1 (“Were you satisfied with enrollment of Biodesign?”) scored 4.80 on average, and follow-up Question 3 (“Would you recommend the program to others?”), received a high average score of 4.22. Question 2 (“Would you continue with the program if possible?”) may have been meaningless for graduates who had already left the program two or more years earlier. Question 4 (“Did you learn the process of Needs Start?”), which relates to a feature of design thinking, scored 4.71, whereas Questions 6 (“Did you learn team learning?”) and 7 (“Did you learn design thinking?”) scored 4.17 and 4.36, respectively, which were all high average scores. However, Question 5 (“Did you learn about business?”) scored a relatively low score of 3.73. The proportion of participants who responded with “strongly agree” and “agree” is presented in the right-hand column; this did not differ notably from the average value on the 5-point scale, suggesting a need for improvement in education related to business.The variable, “Significance of team approach”, achieved a score of 4.78, at an effective response rate of 100%  answered “Yes” when asked whether they “Wanted to start a business” before enrollment. Of these, 43.8% were doctors, compared to only 17.0% company employees  based on the study of the literature, relevant hypotheses, and intellectual property (IP) possibilities while building simple prototypes. These activities encompassed the “Use of specialized skills and knowledge ” and “Commercialization of ideas.” Business plans were formulated covering research and development (R&D), proof of concept, regulatory path, distribution, and marketing, whereafter commercial possibilities were explored. Overall, the program addressed the factors of “Contribute to society ,” “Use specialized skills and knowledge,” and “Commercialize one’s ideas.”Concerning “role models”  and “Friends and associates who have the same mind and may become business partners,” the questionnaire results related to “Externship” are addressed first. Table Next, we studied “Friends and associates of the same desire and of the potential business partners” Teams worked together throughout all processes, resulting in development of a network between team members, alumni, faculties, and lecturers, which later proved to be a valuable asset. This corresponds to the second most preferred answer in Table A comparison between general factors for entrepreneurship promotion and the Japan Biodesign program is shown in Table Table A reasonable number of fellows were recruited over the 4-year period, with an overall fulfillment rate of 85.4%. As the name “Biodesign” was unfortunately not known in the early years of this program being presented in Japan, recruitment efforts were needed to continually make potential fellows aware of the program. An increase in applicants would result in a positive cycle, enabling us to attract higher talent with passion, which would result in successful innovation and leader development. The recruiting activity is a major issue in Biodesign education in Japan. As for leadership talent, it may be important to periodically verify the status over a certain period.Based on the questionnaire results, the overall program was highly rated by the fellows. As shown in Table Major changes were observed in the fellows’ entrepreneurial orientation before enrollment and upon course completion, indicating that the program was very effective in this respect. Prior to enrollment, 12 of 41 people (29.3%) wanted to start a business, and the number changed to 30 individuals (73.2%) after completion of the program. When excluding company employees, the number of participants who wanted to start a business increased by 52.2% from 10 (43.5%) pre-enrollment to 22 (95.7%) post-graduation. Thus, most of the fellows in this category developed a stronger entrepreneurial orientation.To better understand the situation regarding entrepreneurship and new ventures in Japan, we investigated some statistics. As described by an international comparison in the 2017 White Paper on Small and Medium Enterprises in Japan , the newAs shown in Table As shown in Fig. The ideas and business proposals fellows developed were examined not only by the faculties but also by the director of Stanford Biodesign. They examined the patent situation (14 IP submissions by six companies) and how innovative the medical technology they proposed was. After the faculties and the director agreed to the business proposals, the fellows were able to graduate the Biodesign course. This process is essential to make sure that their proposals are innovative and worth pursuing.Out of 12, ten members are medical or dental doctors while two have engineering background. Each start-up has at least one doctor (CEO or non-CEO). Four companies have CEO of doctors. It is speculated that they have strong desire or mission mind that they would be able to help patients and medical professionals around the world by innovating medical technologies.As shown in Table This report was based on assessment across four terms only, whereas more definite evaluation of the development of leadership talent and entrepreneurship as outcomes of education would require longer-term tracking. Continued surveys in the coming years would be most desirable in this regard. Moreover, the presumed lack of education programs for medical device innovation in Japan, prevented comparison with other programs. Similarly, we could not find academically comparable data from overseas organizations, except for Stanford University. By establishing future collaboration with other universities, both in Japan and overseas, the surveys could yield broader data from which meaningful comparisons can be drawn, which is highly desirable.Although it was suggested that team learning- and business-related educational aspects require improvement, the Japan Biodesign education initiative—with its self-devised externship program—shows definite positive results regarding medical device innovation. While the general situation in Japan reflects limited entrepreneurial awareness and a low new business entry rate, most fellows (95.7%) of Biodesign Japan, excluding company employees, wanted to start a new business. Since the program properly addresses general entrepreneurship factors, it objectively indicates the effectiveness of education in promoting entrepreneurship orientation and provides a platform for setting up a new business, followed by innovation.With continued education on innovation and development of leadership talent, more human resources and talent will become available in the field of medical device innovation, which would result in creating an ecosystem of medical technologies and thus a favorable cycle of talent, innovation, industry, and ultimately, positive contribution to global healthcare.


Knowledge data was collected via self-reports two weeks prior and immediately after the Nutrition Module. Behavioural data on daily fruit and vegetable consumption was gathered via student passports  one week before and for four consecutive weeks after the Nutrition Module. Chi-Square Difference tests and t-Tests were conducted with a significance level set at p < 0.05. Across all 19 schools, knowledge of the daily recommended serves of fruit and vegetables improved significantly following participation in the program, aligning knowledge closer to the Australian dietary guidelines. Behavioural results for fruit consumption were favourable, with clear improvements reported. Increases in vegetable consumption were demonstrated in two of the eight schools. A discussion on the knowledge–action gap is provided, including recommendations for future iterations of the Healthy Eats program. One in four school children in Australia are overweight or obese. In response, the Healthy Eats program was developed, piloted, and delivered using a whole-of-school approach underpinned by the socio-ecological model to increase fruit and vegetable consumption among children aged 8–10 years in regional Queensland, Australia. This research presents an outcome evaluation of the Healthy Eats program using pre–post data collected throughout 2021  from 19 schools to assess whether changes occurred in students’ nutritional knowledge ( In Australia, about one in four 25%) children and adolescents aged 5–17 are overweight or obese. While overweight and obesity rates in Queensland reflect those of the country 5% childr. OverallInterventions that incorporate multifactorial approaches are needed to address the complexity of obesity and diet-related health problems ,8. SchooThe socio-ecological model accounts for the multifactorial nature of changing eating behaviour in school settings as it recognises the intrapersonal, interpersonal, organisational/settings, community, environment and political influences, and their interactions . Within Life Education Queensland (LEQ) developed, piloted, and delivered the Healthy Eats (HE) program using a socio-ecological lens . A formaFollowing formative research and design, a pilot program was launched. LEQ held consultations with 41 state schools across North Queensland, of which 20 agreed to participate in the pilot in 2019. Schools were identified based on the level of need, and to ensure diversity in the overall sample . Program components on an individual level included classroom nutrition education , and fruit and vegetable competition (to foster a positive eating environment and increase fruit and vegetable consumption). On an interpersonal level, families, friends and social networks were addressed via teacher and parental involvement . Measures taken on a school and community level included tuckshop menu audits, tuckshop resources, school breakfast program resources, school fruit and vegetable garden assistance, the collaboration of other key community organisations ) and the inclusion of Healthy Eats “Brain Breaks” to create consistent daily healthy eating habits. The evaluation of the pilot showed promising results, with more than 90% of students correctly identifying the recommended serves of fruit and vegetables, and more than two-thirds able to retain this knowledge ten weeks later. There was a 45% increase in schools with vegetable gardens, and a 50% increase in schools offering breakfast for children. Compliance with the Smart Choices minimum standard increased from 0% to 22% of tuckshops, and a further 17% achieved the highest possible rating . Following review and recommendations from pilot schools, the program was revised to include ‘Healthy Eats accreditation’ , and professional development modules for teaching staff. The revised Healthy Eats program was implemented on a broader scale to schools in Southeast Queensland in 2021. The goal of this paper was to present a student-focussed outcome evaluation of HE in schools in North Queensland, focussing on determining whether the main program components achieved their primary goal . Sharing results from the evaluation is vital to provide insights into program delivery and effectiveness, and unintended consequences, which inform improvement of future programs. The data used in this evaluation of the Healthy Eats Program were provided to Griffith University by Life Education Queensland (LEQ). The data were collected through self-reports, throughout 2021, which were administered by both teachers and Healthy Eats Educators in schools. Data were collected to assess the learning outcomes of the Nutrition Module (the Knowledge Survey) and to examine the behavioural outcomes of the program (data collected during the Passport Competition). Knowledge Survey data, in the form of knowledge of recommended serves for fruit and vegetables, and knowledge of how to make a healthy snack, were collected cross-sectionally in two stages: two weeks before the start of the module, followed by a post-session survey administered directly after the completion of the module. This research was approved by the researchers’ Human Research Ethics Committee (Ref: 2022/789).Behavioural data  were collected longitudinally in two parts: first, Passport Competition student passports  were given to students to record daily (Mon–Fri) serves of fruit and vegetable intake one week prior to the start of the Nutrition Module. After the Nutrition Module, students used Passport Competition student passports for four consecutive weeks to record daily (Mon–Fri) serves of fruit and vegetable intake. n = 933); post-program (n = 935)) from 19 schools  and other program-specific background data. Overall, for the Knowledge Survey, 1868 pre-post responses were collected  of 2.1 for each individual per day . Based oA series of statistical tests were used to analyse the effectiveness of the Healthy Eats program. To provide an overview of the Knowledge Survey sample, basic demographic analyses and means analyses were used, which included Chi-squared difference testing to test whether groups within the pre-post sample were different regarding age, gender, ethnicity, program participation, tuckshop, pathway and vegetable garden. Responses from the Knowledge Survey on knowledge of recommended daily fruit and vegetable servings was analysed using means analyses, Independent Sample t-Tests and One Sample t-Tests. Follow-up tests to assess group differences were conducted, which included one-way analyses of variance (ANOVAs) on gender and pathway  along with a series of Independent Sample t-Tests on ethnicity  vs. non-ATSI), program participation (first-timers vs. previously participated) and vegetable garden. To test for changes in knowledge of healthy food skills, responses to the open-ended questions asking participants to “Name a healthy snack/how to make a healthy lunchbox snack” were manually coded. The coding scheme was constructed to align with the goals of the program (fruit and vegetable consumption) while minimising the potential for researcher bias. In the first round of coding, ‘Snack name’ was coded as either whole fruits or whole vegetables—or mixed ingredients, in which case the snack was sent to the second round. In the second round, ‘Ingredients to make the snack’ was coded as having fruit ingredients, vegetable ingredients, both fruit and vegetable ingredients, or ‘Other foods’. The category ‘Other’ contains all responses that did not include whole fruits/vegetables. To test differences between the groups pre- and post-program, Chi-squared post-hoc tests based on adjusted standardised residuals  were conducted following Beasley and Schumacker . For Passport Competition data, which allowed for matching participants pre-post program, Paired Sample t-Tests in conjunction with One Sample t-Tests were employed on fruit and vegetable consumption. Following data entry and cleaning, descriptive and inferential statistics were estimated. Statistical analysis was conducted using IBM SPSS Statistics (Version 28) for Windows. To determine whether participation in HE resulted in changes in knowledge of recommended fruit and vegetable consumption, students’ responses to Questions from the pre-survey with Questions from the post-survey were compared, which asked students to indicate their knowledge on recommended fruit and vegetables serves per day using a five-point Likert-scale. p < 0.001). Before the program, students reported they should eat 3.55 serves of vegetables a day (on average). Post-program an average of 4.81 serves per day was evident, which is closer to Australian guidelines—also a significant change (t(1466) = −26.12, p < 0.001). This indicates that HE positively influenced students’ knowledge of the recommended serves of fruit and vegetables.The results reveal that before the HE program, 36.7% of students correctly identified the recommended number of daily fruit serves. Post-program, the number of students who correctly identified daily fruit serves increased to 93.4%. In a similar vein, the identification of the recommended number of vegetable serves per day increased from 32.1% (pre) to 93.0% (post). An Independent Sample t-Test conducted on combined data from all schools cf.  indicateOverall, the results show that all schools but three  showed a significant change in knowledge of recommended daily fruit serves following participation in the Healthy Eats program. Likewise, all schools but one (School K) observed a significant increase in knowledge of the recommended daily vegetable serves. To examine these changes in the context of the key lessons in the program, it was necessary to test if students’ knowledge was in accordance with the recommended daily serves of fruit and vegetables, at either timepoint. Consider two examples: the first being a school where the data show that students’ knowledge of vegetable serves improved and is now close to the recommended number, and the second being a school where the data show that students’ knowledge of vegetable serves also improved but is still some distance from the recommended number of serves. One Sample t-Tests were conducted to determine whether students’ knowledge of the recommended serves was (on average) aligned with dietary guidelines at either point—beforehand, meaning they did not need to change, or afterwards, meaning their knowledge was now accurate.When it comes to knowledge of the recommended amount of daily vegetable serves, To test for group differences in knowledge, a series of one-way analyses of variance (ANOVAs) and Independent Sample t-Tests were conducted cf. . Some diA comparison between pre-post data was undertaken for questions asking participants to “Name a healthy snack/how to make a healthy lunchbox snack”. The results obtained post-program show considerable differences compared to pre-program see  below. p < 0.001; whole vegetables 6% before vs. 3% after, p < 0.001). This was due to substantially more children naming a snack made of several ingredients. Within these, fruit ingredients decreased , while vegetable ingredients increased , as did fruit and vegetable ingredients . Other (non-fruit or vegetable) ingredients decreased .Firstly, a greater number of healthy snacks was identified, which fall into the ‘Mixed ingredients’ category, representing 93% (vs. 66% pre-program) on average. Of these 93%, 32% included vegetable ingredients, (a 7% points increase compared to pre-program). Importantly, over half of the responses in ‘Mixed ingredients’ category included both fruits and vegetables, (an increase of 53%-points compared to pre-program). Fruit ingredients decreased post-program from 15% to 2%. Lastly, unhealthy foods made up 4% of ‘Other’, which compares favourably to the 24% of unhealthy foods identified pre-session. To test differences between the groups pre- and post-program, Chi-squared post-hoc tests based on adjusted standardised residuals  were conducted. The post-hoc tests revealed that the healthy lunchbox snacks named by children changed after the program. Firstly, the proportion/percentage of children naming whole fruits and whole vegetables decreased  and post-data (n = 521) were collected from the same students, therefore allowing pairwise testing. Before commencing the analysis, the data were screened for outliers. Based on the decision rules determined in Eight schools reported data for individual students during the Passport Competition, which were included in this analysis. Pre-  and was aligned to the recommended levels of two serves per day. Two of the eight schools increased vegetable consumption significantly (School F and L). Six schools observed no change in vegetable consumption . One-Sample t-Tests were used to examine whether students (on average) reported consumption approaching the recommendations that they have been acquiring knowledge about as part of the Healthy Eats program. It needs to be highlighted that ‘daily’ serves reported only consider children’s consumption at school (and not at home before or after school). Therefore, this is likely to be an underestimation of their daily consumption. This test shows that at most schools, children were meeting their recommended daily fruit intake at school. Even with increases and decreases in consumption  consumptFor completeness, the one-Sample t-Test was also performed for reported vegetable consumption see  below. AThe lack of significant change for some of the schools cf.  could beFor fruit, across all schools, more children reported increases in consumption. Increases in consumption were more often seen at School F, School H, School L, School P and School S—where consumption was mostly below two serves prior to the program, and at or above two serves afterwards. Decreases in consumption were more often seen at School I, School R and in particular School G following the program. Fruit consumption at these schools was above two serves prior to the program, and only marginally below two serves afterwards. For vegetables, across all schools, more children reported increases in consumption. Increases in consumption were more often seen at all schools (except School S and School G). Of note are School F, School I and School L, all of which posted strong positive changes in the number of vegetable serves consumed. There are not enough responses in each category  to perform a robust statistical analysis, but this table suggests that for fruit, changes in both directions resulted in children’s consumption becoming more aligned with the daily recommendations. For vegetable consumption, more children increased their consumption, but a large proportion reported decreases in consumption.The Healthy Eats Program, developed and delivered by Life Education Queensland (LEQ), aimed to empower students to make healthier food choices by developing and sustaining a whole-of-school approach. This outcome evaluation was undertaken to (1) assess the extent to which students have retained or changed knowledge about daily fruit and vegetable consumption recommendations and (2) explore whether students’ fruit and vegetable consumption improved after the program. Within most schools, knowledge of the daily recommended serves of fruit improved, aligning with Australian recommendations . KnowledThe program was more effective at aligning fruit consumption closer to recommended daily consumption levels than it was for vegetable consumption. It should be noted that increasing children’s consumption of vegetables is the most important goal of the program, recognising that less than 6% of Queensland students consume the recommended serves each day. Other studies have noted the difficulties associated with improving vegetable intake compared to fruit . While sThe positive knowledge changes without subsequent improvement in vegetable consumption resonate with the mixed body of evidence on school-based nutrition programs. For example, similar to the findings of the Healthy Eats program, Long and Stevens  found inThe reasons for the knowledge–action gap may be manifold. In the case of this program, ‘Daily’ serves reported only consider children’s consumption at school (and not at home before or after school). Therefore, this is likely to be an underestimation of their daily consumption. This is a substantial consideration given Australian children aged 9–11 consume a large proportion of their daily vegetable intake (close to 60%) during dinner . For fruNutrition knowledge (and by extension—nutrition literacy) is a broad concept, covering the knowledge, skills, and competence required to achieve nutritional health . Two comFurthermore, parents’ actions are a critical determinant of children’s fruit and vegetable consumption, through both role modelling of consumption  and as tFinally, longer exposure to program strategies are likely to be needed to create stronger effects on behaviour change , as wellOutcomes observed in the 2021 Healthy Eats program evaluation deliver support for the viability of the socio-ecological model as a framework that can be applied within social marketing programs that aim to promote healthy eating in school environments. In summary, the evaluation of the Healthy Eats program indicates there were increases in students’ knowledge of fruit and vegetable recommendations, which only partially translated into behavioural shifts. Opportunities to enhance program effects are evident from the outcome evaluation, which would be a fruitful area for further work. For example, Social Cognitive Theory (SCT)  has showThe findings of this evaluation should be considered in light of any limitations. In the Knowledge Survey, some questions were not always worded the same in both the pre- and post-surveys. This makes it difficult to make direct comparisons between the time points. Future data collections should consider how questions can be worded in age-appropriate ways, but not so that they increase the risk of social desirability bias or curtail the richness of the data and it should ensure that repeated measure designs are used. For the behavioural data (the passport data), an important limitation was the issue of outliers detected in the data set, which had the potential to distort trends in the data. To minimise the issue of outliers, statistical detection techniques were used to identify and discard serious outliers. Second, the issue of missing data, particularly in the analysis of the Passport Competition, meant that pre-post comparisons were not feasible for all schools. The current evaluation considered whether Healthy Eats program components  achieved intended changes in knowledge of recommended fruit and vegetable consumption and the degree that influencing student knowledge supported behavioural change. Future research is needed to evaluate and appreciate the outcomes and lasting impact derived from other components of the program . For example, a better understanding of how tuck-shop menu audits and vegetable gardens each contribute to initial and lasting behaviour change and behaviour maintenance consistent with recommended daily fruit and vegetable consumption guidelines are also needed to further enhance program improvement and future program implementation.The outcome evaluation of Healthy Eats Program, delivered by Life Education Queensland (LEQ), showed improved knowledge of the recommended daily number of fruit and vegetable serves following the program, and some improvements to fruit and vegetable consumption behaviour. Overall, this evaluation supports the effectiveness and importance of conducting classroom and school-based initiatives to increase healthy eating knowledge.


In this poster, researchers based at a Mid-Atlantic university campus provide an understanding of their evaluative steps informing an adaptation of the Diversity Circles program to include a multigenerational component, supporting diversity across the lifespan. Project methods and analysis have been informed by critical theoretical frameworks, including feminist gerontology, that illuminate the invisibility of age, even in the context of intersectional work. Pilot feedback from five participants from a condensed program in an Adult Development and Aging course informed the interview approach. Post-program semi-structured interviews, with program participants, including students and older adults (n=7), and community stakeholders (n=18), provided feedback on diversity needs at the campus and in the surrounding community, as well as on program content and experience and opportunity for further curriculum integration of concepts of age-friendliness, ageism, and age-awareness. Stakeholders interviewed included community practicum liaisons, university advising and student affairs staff, faculty and staff previously engaging in diversity-related activities, university administrators, university personnel attending to enrollment matters, and staff and faculty interested in student-centered curriculum design. Semi-structured interviews were chosen for data collection because of their capacity to provide saturated data from a small, purposeful sample. Focused codes emergent from the interviews included both a) suggestions for curriculum adaptation and modification as well as the value of existing content and b) issues of age-friendliness and ageism more generally. The research team looks toward incorporating suggestions within their findings in an expansion of the program on their campus, and disseminating findings for the benefit of other campuses’ programs.