Poor early-life nutrition is a major barrier to good health and cognitive development, and is a global health priority. Alive & Thrive (A&T) was a multi-pronged initiative to improve infant and young child feeding behaviors. It aimed to achieve at-scale child health and nutrition improvements via a comprehensive approach that included nutrition counseling by health workers, policy change, social mobilization and mass media activities. This study evaluated the sustainability of activities introduced during A&T implementation (2009–2014) in Bangladesh and Vietnam.This was a mixed methods study that used a quasi-experimental design. Quantitative data  were collected in 2017; and analysis compared outcomes  in former A&T intervention areas versus areas that did not receive the full A&T intervention. Additionally, we conducted interviews and focus groups with 218 stakeholders to explore their impressions about the determinants of sustainability, based on a multi-level conceptual framework.After program conclusion, stakeholders perceive declines in mass media campaigns, policy and advocacy activities, and social mobilization activities – but counseling activities were institutionalized and continued in both countries. Quantitative data show a persisting modest intervention effect: health workers in intervention areas had significantly higher child feeding knowledge, and in Bangladesh greater self-efficacy and job satisfaction, compared to their counterparts who did not receive the full package of A&T activities. While elements of the program were integrated into routine services, stakeholders noted dilution of the program focus due to competing priorities. Qualitative data suggest that some elements, such as training, monitoring, and evaluation, which were seen as essential to A&T’s success, have declined in frequency, quality, coverage, or were eliminated altogether.The inclusion of multiple activities in A&T and efforts to integrate the program into existing institutions were seen as crucial to its success but also made it difficult to sustain, particularly given unstable financial support and human resource constraints. Future complex programs should carefully plan for institutionalization in advance of the program by cultivating champions across the health system, and designing unique and complementary roles for all stakeholders including donors. The first thousand days of life are critical for child nutrition, growth and health outcomes –4 – yet Sustainability is a critical issue: after a period of rapid growth, global health development assistance has slowed and is showing signs of stagnation if not decline . Scholaractivities undertaken during A&T ongoing in Bangladesh and Vietnam, 2 years after the end of external program funding? (2) What were stakeholders’ impressions about determinants of the sustainability of the A&T model and activities?This study aims to add to this literature by using a theory-driven empirical approach to evaluate the sustainability of activities implemented during the A&T project period (2009–2014) in Bangladesh and Vietnam, by asking: (1) To what extent were The overall objective of A&T in Bangladesh and Vietnam was to demonstrate a large-scale model for achieving IYCF improvements in the participating countries. The exact A&T interventions in each country differed based on extensive formative research and dialogue with partners, but were informed by a common implementation framework and included four main components (and specific activities within each): advocacy, interpersonal communication and community mobilization, mass communication, and strategic use of data , 31. TabSustainability strategies were a key aspect of A&T program design , 35. TheA recent review identified five different types of definitions of sustainability: those that focus on continuation of activities, on continuation of benefits, on capacity building, on adaptations, and on cost recovery . Some deDeterminants of sustainability are factors that influence the continuation of program services beyond the initial period. We posit that these determinants – sometimes also called “capacity for sustainability”  have started saying that they will sell micronutrient powder rather than demonstrate IYCF … When I ask the reason, they mentioned that they got 200 taka incentives for [IYCF] activities before, but now they get nothing” ““It is practical to be demotivated if you are not receiving any money for work. The [workers] get incentives from various other programs including tuberculosis DOTS , ANC and PNC services, etc.” In the past, mothers came easily. The program was new and attractive, and they got a gift after the session. Now there is no gift, and it is no longer a new program, so it is somewhat difficult” “Interviewees noted cutbacks in counseling frequency due to budget reductions, and particularly mentioned limited or a lack of incentives for health workers to conduct IYCF counseling; competing priorities, especially activities that are income-generating; and waning interest from caregivers in Vietnam.“We conduct only an annual training about how to weigh and measure babies and children … Some of the [A&T-] trained staff have retired and their replacements have not been trained due to budget limitations. The district has no budget for training and the province does not conduct it.” “Now refresher trainings include all issues, including essential health care, nutrition, tuberculosis … whereas during [A&T], we conducted a full-day refresher training, from 9 am until 4 pm, every quarter during the year, only about IYCF counseling, demonstration, problems they faced during IYCF counseling and their solutions” Strong IYCF training was widely identified as a major achievement of A&T – but training efforts have substantially decreased, in terms of frequency, type  and mechanisms for ongoing education and support.We also investigated the persistence of health worker capacity to implement the activities post-A&T: knowledge, self-efficacy, and job satisfaction. Despite reductions in training, in both countries IYCF knowledge scores remained significantly higher among health workers in intervention areas versus workers in comparison areas  Table .Table 3It is a time-consuming process. Now, instead of half an hour, they only spend 10 minutes. So the practice is not done properly. Sometimes they use mobile phones for counseling on IYCF, rather than directly demonstrating.” “We do not follow the 8 topics as in the protocol, since it will take too long and women cannot stay so long. They ask for what they need, and we answer. We can also add a little information about nutrition. If we followed the protocol, it would be very difficult to conduct counseling” “However, these high knowledge scores did not translate into better counseling: when counseling sessions were observed, workers in intervention areas of both countries performed on average only 36–46% of all recommended activities Appendix . StakehoDuring [A&T], the monitoring system was effective: one monitor worked for two upazilas [sub-districts], and monitored field activities by rotation, collecting monthly progress reports, and randomly observing workers’ IYCF counseling activities. Later we discussed their findings and feedback during the refresher trainings. But post-[A&T], these activities are being supervised by a general monitoring team focused on overall health and nutrition activities, not specific to IYCF” “No one supervises the counseling session anymore or reviews the monitoring book of client counseling” “Changes to monitoring, such as cuts in supportive supervision and quality improvement feedback mechanisms, were also noted as a factor affecting counseling. Stakeholders were very enthusiastic about monitoring during A&T, but cited subsequent deterioration in the degree of specificity  and in feedback mechanisms.Health workers in intervention areas of Bangladesh nonetheless reported significantly higher job satisfaction (86%) and self-efficacy (93%) scores than workers in comparison areas (scores of 83 and 85% respectively) Table . These rGovernment should be the first changer in mainstreaming or implementing the IYCF activities nationwide” “In order to integrate the program into the existing system in a sustainable manner, it should be start with the national level. If not, it is difficult for the provincial level to implement and integrate without guidance from the national level” “Alive & Thrive was a comprehensive approach with the engagement of government stakeholders, which made the initiative acceptable by all levels of stakeholders.” “Qualitative data provided insights into specific determinants of sustainability highlighted in the study’s conceptual framework. Respondents from both countries felt that the government should take a leadership role for sustaining IYCF activities; and stakeholders in Vietnam spoke about the importance of involving all levels of the government, noting the important role of the national government in promoting these efforts.The modality was good, but who has so much money?... If anyone wants to replicate this in another country without funding from Bill and Melinda Gates Foundation, nobody will able to do it in the same way” ““During the [A&T] dissemination workshop, they presented the scaling-up plan and the proposed budget … But we waited and waited, and no funding came.” There were, however, concerns about the requisite financial resources for sustaining program activities.I am concerned about how we can continue to provide counseling. In my opinion, if the Ministry of Health advised the government that nutrition and nutrition counseling should be paid by the health insurance, sustainability will be feasible.” ““In the last two years, the National Nutrition Program budget has been cut significantly. In some provinces, the budget is only 10% of what was planned.” Stakeholders in Vietnam were concerned about the sustainability implications of unreliable public sector fund allocation for IYCF, increasing privatization of the health sector, and of omitting IYCF counseling from the national health insurance program.“[The National Institute of Nutrition] is lonely now in the fight … A&T was independent so could link multi-disciplinary partners well.” Partnership, including with civil society, and wide stakeholder buy-in were seen as important for sustainability – but stakeholders in both countries worried such efforts struggled without A&T as a coalescing force.Staff were changed and retired, but the program did not monitor this closely to train new staff” “If one [worker] dropped out, we had to distribute her registers among 8-10 others to manage the regular household visit. This increasing workload causes more dropouts.” “Turnover of human resources, at both leadership and implementation levels, was mentioned as a major sustainability challenge in both countries.Sometimes the government appoints a senior person in such designation which requires long experience in the field of nutrition, whereas the person might not have any exposure of nutrition related works” “The head of [facility A], an active and very good manager of the A&T model, retired – and her replacement does not know much about the activities. In [facility B], the head and the nurse who were trained by A&T have been moved to another facility, and the newcomers do not know about A&T” “Some respondents also mentioned low IYCF knowledge among new leadership as a challenge – and there were concerns about the continuity and long-term commitment of champions and loss of institutional knowledge due to high turnover.The multi-pronged design of A&T was seen as key to its success, but stakeholders were concerned about sustaining this – particularly because the varied activities require expertise, support and leadership from different implementing agencies. For example, stakeholders felt as though different groups would best implement interpersonal communication versus mass media efforts, and were concerned that this fragmentation may add coordination challenges and undermine sustainability.Stakeholders also discussed the importance of adaptations – including to training and interpersonal communication IYCF counseling materials – which have occurred during and subsequent to the program period. This flexibility was seen as a key strength of the model and important for integration and sustainability. A more problematic adaptation has been a broadening of scope since the end of A&T: improvements on specific IYCF indicators was seen as evidence of success in both countries, but stakeholders felt as though these have been diluted, and that stakeholders are less familiar with the specific goals. In both countries, this shift was attributed to competing priorities and the introduction of new programs and initiatives.A summary of qualitative findings in each country, mapped to the theoretical constructs of sustainability, is presented in Table This sustainability evaluation examined ongoing implementation of Alive & Thrive program activities in Bangladesh and Vietnam more than two years after external funding ceased. We found that many activities specifically aimed at promoting IYCF counseling with caregivers had continued in each country, thus expanding the reach of IYCF counseling services beyond the original program beneficiaries. In Bangladesh, the government successfully incorporated IYCF counseling and household visits into routine health programs. In Vietnam, although the national government was less heavily involved in the program, several provincial governments expanded the IYCF social franchises into new areas, and IYCF counseling is now included in the standard postnatal package for mothers.The results also demonstrate the significant enduring capacity of health workers based on increases in intervention sites compared to comparison sites for health worker IYCF knowledge, self-efficacy, and job satisfaction. These knowledge scores were very similar to the results found in the A&T endline evaluations  despite stakeholders’ perception that these were impactful during the initial project period. Consistent with other sustainability frameworks that point to the importance of a “champion” with a strong commitment to the program , 26, 55,This study also identified declines in IYCF-specific budgets in both countries post-A&T. Both public and private sources of financing were perceived to have limitations: allocations of public sector funds can be unreliable, while private sector support may come with new restrictions or different priorities. These funding challenges have caused the sunsetting of entire program categories, alteration (and in some cases narrowing) of target geographies and/or populations, and cuts to activities including health worker IYCF counseling training, and monitoring and evaluation. An examination of changes in funding allocation and sources (private and public) is important for understanding program sustainability  as diffeThis study adds to a growing global literature about sustainability , 57–60 wSome additional limitations should also be noted. First, these methods were not designed to assess causality. The study was also not designed or powered to compare findings across the two study countries. Additionally, the health worker sample in each country is very different – both in terms of background/cadre as well as sample size (due to sample selection strategies which differed by country to reflect A&T program structure). On the latter point, it should likewise be noted that the relatively small number of health workers surveyed in Vietnam may have limited our ability to find statistically significant differences between intervention and comparison area groups. Second, response bias may have affected some of these results: health workers may over- or under-state job satisfaction or self-efficacy, and there may have been social desirability bias for qualitative respondents. We tried to minimize these biases by using data collection teams unaffiliated with A&T program implementation, but it impossible to eliminate all such reporting bias. Similarly, the service observation scores may be biased upward due to a Hawthorne effect, or downward if the research assistants faced challenges in accurately documenting all aspects of an IYCF counseling session. Finally, all interviews and focus groups were conducted in each country’s local language, and full translations were beyond the scope of this project so separate research teams conducted the qualitative analyses. We implemented multiple quality assurance mechanisms to minimize potential bias by extensively discussing the codebooks and preliminary results, as well as assessing inter-rater reliability on a subset of translated transcripts.This research examined the sustainability of a comprehensive set of interventions that were designed and implemented with an explicit sustainability plan. The results suggest that while some program activities have been institutionalized and continue to be implemented after the end of the project, there have been substantial attenuations in implementation of certain activities . Despite this, some program benefits persist including strengthened capacity of health workers in intervention areas. The findings of this study also show that, while many earlier lessons from the field of sustainability research are still valid, there are some nuances that require additional consideration. For example, earlier literature emphasizes the importance of integration of activities into existing institutions. This study found that integration, if not accompanied by mechanisms to maintain program or activity fidelity, may lead to deterioration. The potential benefits of integration should therefore be considered within this context, and the trade-offs between institutionalization and the dimensions of sustainability may vary across activities and contexts. Furthermore, neither robust results nor thorough integration guarantees a continuation of funding, and the search for future funding introduces new challenges for sustainability. It was also found that champions were important during implementation, but strategies should be developed for identifying, cultivating and maintaining champions despite high turnover to ensure a program’s sustainability. Future sustainability studies should explore whether programs are diluted, subsumed or transformed due to adaptations such as discontinuation of activities over time . It is lAdditional file 1: Appendices.


There has been increased demand for greater public accountability and transparency of private sector-led global health partnership programs. This study critically reviews and pilot tests the World Health Organization (WHO) medicine program checklist as a framework for public reporting and assessing of programs.We reviewed each question on the WHO checklist for clarity and usability. Next, we pilot tested the subset of checklist questions focused on program assessment. We extracted and analyzed publicly available information on one randomly selected program from each of the 20 largest research-based biopharmaceutical companies. For each program, we assessed whether publicly available information allowed for an assessment of each relevant question in the checklist.Checklist questions fit in four main categories: [1] national health and development plans, needs, capacity, laws and policies; [2] financial, performance, and public accountability; [3] risk management and mitigation strategies; and [4] long-term sustainability. Nearly all (21 of 22) questions in the checklist require information best provided by companies; one question requires information best provided by governments.Programs frequently reported on the public health needs of their programs (100%), program objectives and activities (100%) and the actual or expected program outputs (95%). There was less information on program alignment with country plans and capacity (50%), detailed program monitoring and evaluation plan (20%), risks mitigation strategies (5%), program needs assessment (5%), and additional resources required from or contributed by government (0%).The WHO checklist of key considerations for evaluating proposals for access to medicine programs could be a useful framework for public reporting of program information as most of checklist questions ask for data that should be available to those leading the program. Further revisions of the WHO checklist will help refine it to improve clarity and content validity. The number and scope of public health programs implemented by biopharmaceutical companies to promote access to care and medicines for people in low- and middle-income countries has increased in recent years . This inMany programs implemented by biopharmaceutical companies seem to appreciate the importance of public transparency and accountability by hosting a website and publishing annual reports; however, these usually contain little information on program governance, needs assessment and alignment with country plans and capacity, detailed program plan, program impact and sustainability plans . When prIn 2017, the World Health Organization (WHO) published a checklist of key considerations that governments should consider when evaluating proposals for access to medicine programs from medicines and medical device companies (hereafter referred to as the "WHO checklist") . The motAlthough the WHO checklist was developed to provide a uniform framework through which programs can provide information to governments, it could also serve as a useful framework for public reporting of program information in the absence of any other reporting framework. It is important that the public is not only informed of the programs successes and lessons learned as is currently the case but has access to the evidence and assumptions used to inform program planning such as needs assessment documents, detailed program plan, monitoring and evaluation plan, sustainability plans and potential conflict of interest .The objective of this study is to test the feasibility of using the WHO checklist to assess key considerations for evaluating proposals for access to medicine programs as a framework for reporting program information. The WHO checklist was designed to assess information submitted to government by companies and from our perspective all such program information should be in the public sphere to ensure accountability and transparency . Based oFor the purpose of this study we defined access programs led by medicines and medical device companies as those that are designed and co-financed by pharmaceutical companies and that they take responsibility and credit for them . Depending on the industry-led program it could be implemented in collaboration with the government, other pharmaceutical companies or NGOs. The program can be philanthropic or has shared business and social goals.We used a two-stage process in conducting this study. In the first stage, we reviewed each question on the WHO checklist for clarity and took note of double- or multi-barreled questions (questions that had two or more concepts in a single question). We also critically reviewed the checklist to determine which questions require information best provided by companies versus government when using the checklist as a framework for public reporting of program information. We then described each question on the checklist and provided examples of program information that may or may not be good responses to each question on the checklist.In the second stage, we extracted and analyzed publicly available information of 20 biopharmaceutical industry led programs, with one program randomly selected from each of the 20 largest research-based pharmaceutical companies . Our proFor the programs selected, two researchers independently searched online for program information and reviewed program webpages, press releases, reports, and peer reviewed articles. They also reviewed program information reported in the IFPMA Health Partnerships Directory , Access Access Observatory is a public reporting platform with the aim to improve access to disease prevention and treatment services in low- and middle-income countries, including those designed and implemented by public and non-profit organizations. The Access Observatory was created in 2017 to report and evaluate the Access Accelerated programs .For each program, the researchers independently noted which of the program’s publicly available information responds to the questions on the WHO checklist. We considered programs that provided information on any of the constructs in the double- or multi-barreled questions on the WHO checklist, as having responded to that question. Furthermore, we interpreted the question “Due diligence on industry partner has been conducted” in Section 3 on Strong Risk Management and Mitigation Strategies to mean that companies have provided information on how they assessed and selected their funding or implementing partners. In our analysis, we combined the following two questions in the WHO checklist, “The initiative can be implemented under existing legislation and it adheres to national regulations, procurement procedures, treatment guidelines, and standards of care, quality and safety requirements, remuneration scales and hiring practices” and “The program is suitable for the existing infrastructure, capacity, environment and local context”. Only if both statements applied, did we check this combined item.The researchers met to reach a consensus if there was any disparity in the information they independently extracted. Thereafter, we calculated the proportion of programs with publicly available information on each of the questions on the checklist.The WHO checklist has four domains and 23 questions of key considerations to be taken into account by companies when providing information on access to medicine programs. Based on our analysis, information on 22 out of 23 questions could easily be provided by company programs when using the checklist as a framework for public reporting of program information. Governments are in a better position to provide information on one of the questions “There is sufficient support for the program amongst political parties, unions, and civil society organizations”. Two of the remaining 22 questions were combined into one, leaving 21 in the final checklist. Six of the questions (27%) contained two or more related constructs in one question  , described how their programs serve a public health need  and how their programs align with health strategic plans and general development agenda . Only a few programs reported on how their programs are suitable for existing infrastructure, capacity, environment and local context . One program (a HIV screening and linkage to care program) reported on how needs assessment was used to inform program design. None of the programs provided information on additional government resources required for their programs and none provided information on how and/or why their programs divert or do not divert resources away from other public health priorities.For the national health and development plans, needs, capacity, laws and policies domain, programs clearly stated their program objectives , program performance targets or outputs , parties responsible for overseeing and monitoring the programs  and the roles and responsibilities of all identified stakeholders . There was limited information on the financial resources budgeted or used for the project  and the process for monitoring and evaluation – data collection, processing, and validation .For the financial, performance, and public accountability domain, programs provided information on how the programs will be implemented  identified the risks and has risk mitigation strategies and one program reported on how their partners were selected (a HIV screening and linkage to care program). None of the programs reported identifying potential conflicts of interest.For the transitioning plan for long-term sustainability domain, more than half of the programs reported on a strategy or designed their programs in such a way as to ensure sustainability of health gains (55%) while 35% of programs were part of existing government program or will be integrated into the health system. None of the programs reported developing a clear transition plan for when the program ends.There is increased demand for greater public accountability and transparency of global health partnership programs. The WHO checklist was developed as a framework to assess key considerations for evaluating proposals for access to medicine programs. To our knowledge this is the first time the checklist has been pilot tested to study its feasibility as a framework for public reporting of program information..Our study contributes to existing knowledge in several aspects. First, our results demonstrate the usefulness of the checklist in systematically assessing programs. Most of checklist questions ask for information that should be available to those leading or reporting about the program. Setting standards in industry-led social program reporting is relevant to increase transparency and enable accountability . AlthougSecond, the piloting of the checklist showed the existing gaps in the public reporting of program information and the areas on which companies might need to focus more attention. We used publicly available program data because from our perspective, program information that companies submit to government should be in the public sphere to ensure accountability and transparency. In general, most programs were clear on the public health needs of their programs, program objectives and activities and the actual or expected program outputs. However, there was little information on additional resources required from or contributed by government and other stakeholders; program needs assessment, program alignment with country plans and capacity, detailed program monitoring and evaluation plan, risks mitigation strategies and sustainability plans. This finding agrees with an earlier observation of public-private partnerships by Buse et al.  SpecificMoreover, companies are currently reporting their program objectives and the public health needs that their programs meet. However, there is paucity of reporting program needs assessments, as many of the programs were silent on how or whether the needs assessment influenced program design. Conducting a needs assessment before the start of a program is invaluable as it helps organizations to use their limited resources to help communities in the most efficient ways . It is nFurthermore, apart from one donation program, all the programs clearly reported on how they are implementing their programs. The reason for the lack of information on the donation program, which is part of a Ministry of Health Pharmaceutical Assistance Program, is not clear. In addition, all programs, except for one new program that is still in the need’s assessment stage, reported their performance target or program output. However, it appears programs are behind in setting up systems for program evaluation, as there is paucity of information on the process for program monitoring and evaluation. This might not be limited to programs in this study, as earlier studies of access to medicine programs have shown few independent and rigorous evaluations of program impact .The transitioning plans for long-term sustainability domain has three questions, which appears to follow Shediac-Rizkallah and Bone three indicators of sustainability . It measThere are some areas in which the WHO checklist could be strengthened. We noted that the WHO checklist does not ask any question on how programs address social inequity. Information on how public-private partnerships have affected health equity is scarce and programs ability to address social inequity should be an important consideration in access programs . Social and the general development agenda” could be two separate questions, [Finally, double or multi-barreled questions can make respondents uncertain on how to respond to such questions , 31. Oneestions,  “The proThere are some limitations to the findings of this study. First, most of the programs in this study are in low- and middle-income countries and the findings in this study might not be applicable to programs in high-income countries. Secondly, large research-based pharmaceutical companies implemented the programs in this study and the findings might not be applicable to programs implemented by smaller pharmaceutical companies. Furthermore, we could only assess publicly available program information and could not assess whether companies had other program information requested in the WHO checklist that were not publicly available. Currently, most companies instead of independent third parties are providing data on their access programs. Third party verification of such program information could enhance its veracity but is currently not practiced in financial reporting as well as in many other private sector reporting activities.The WHO checklist provides a useful tool for assessing pharmaceutical industry led programs as most of checklist questions ask for information that should be available to those leading the program. Further revisions of the WHO checklist will help in refining it to improve clarity and content validity. The pilot testing of the checklist showed the existing gaps in the public reporting of program information such as paucity of information on additional resources required from or contributed by government and other stakeholders, program needs assessment, program alignment with country plans and capacity, detailed program monitoring and evaluation plan, risks mitigation strategies and sustainability plans.Additional file 1. List of programs used to evaluate checklist.


Point-of-care ultrasound (POCUS) is becoming widely adopted with increasing accessibility of courses. Little is known about the optimal design of the introductory course or longitudinal training programs targeting hospitalists that are critical to success.Hospitalists at four academic sites participated in a two-day introductory course and a longitudinal phase comprising clinical POCUS practice, clip uploading with online feedback, hands-on teaching, and monthly ultrasound conferences. Assessments were performed immediately before and after the two-day course and after 1 year.p < 0.001) and decreased slightly at 1 year . After the two-day introductory course, the median score for hands-on image acquisition skills, the principal metric of participant success, was 75%. After 1 year, scores were similar (median score 74%). Confidence increased from baseline to post two-day course  to Very confident (4), p < 0.001), and remained unchanged after 1 year (2.73). Course elements correlating with a passing score on the final hands-on test included number of clip uploads , attendance at hands-on sessions , and attendance at monthly conferences .Knowledge increased from baseline to post two-day course (median score 58 and 85%, respectively, The I-ScaN POCUS training program increased hospitalist knowledge, skill and confidence with maintained skill and confidence after 1 year. Uploading clips and attending hands-on teaching sessions were most correlative with participant success. Point-of-care ultrasound (POCUS) is becoming widely adopted across the field of hospital medicine after becoming well established in fields with competency overlap such as Emergency Medicine and Pulmonary and Critical Care Medicine , 2. The A 2013 survey of internal medicine program directors found that POCUS was considered valuable for diagnostic and procedural use and many residency programs had either adopted formal curricula or had planned to . A similHowever, the training of faculty has emerged as a key barrier to adoption into hospitalist groups , 13–15. We sought to address concerns of educational durability as we developed and implemented the Integrated Sonography Course at NYU (I-ScaN), a longitudinal POCUS training program for hospitalist faculty. We describe the design, implementation and 1-year outcomes of an observational cohort study of the I-ScaN program.The NYU Department of Medicine encompasses four teaching hospitals, NYU Langone Health (Tisch/Kimmel and Brooklyn campuses), Health + Hospitals/Bellevue, and the VA New York Harbor Health Care System/Manhattan. Each campus has a unique structure of teaching and non-teaching services and populations served. All physicians who were identified by their directors as core hospitalists, generally defined as those faculty who spend the majority of their clinical time on the inpatient teaching service, were invited to participate. Fifty percent (23/46) of the physicians who were asked accepted the invitation to participate.I-ScaN is a faculty development program with the goal of developing a cohort of physicians proficient in POCUS who will foster a culture of ultrasound use across the institution through routine clinical practice of POCUS and who will have the ability to supervise and educate the residents and students in turn. The program consists of four elements: 1. Introductory course including didactics, image interpretation and hands-on instruction; 2. Supervised practice with patients; 3. Competency assessment; 4. Skill maintenance and quality assurance . I-ScaN I-ScaN began with a period of self-study upon program registration, where participants were referred to relevant chapters from a POCUS textbook,  online vFollowing the two-day course, participants began the longitudinal portion of the program. An ultra-portable ultrasound device with the ability to upload ultrasound clips to a HIPAA-compliant website was provided to the faculty on each inpatient teaching service. Participants also had access to traditional cart-based ultrasound machines at each hospital. Participants were advised to scan patients daily when on service and upload all clips, anonymized to avoid sharing protected health information, to secure servers allowing comments and expert review. For each uploaded clip, participants were asked to provide the anatomic site and a clinical interpretation. The clips were reviewed by an expert (HS) who provided online feedback on both of these domains. Participants used these clips to create a personal portfolio in accordance with national standards set by SHM .Hands-on teaching sessions were led by local experts, primarily Pulmonary and Critical Care Medicine faculty, with a 1: 3 teacher to participant ratio. Sessions typically lasted one hour with the entire time spent at the bedside scanning a patient known to one of the participants. Each of the four hospitals arranged these sessions according to participant and teacher availability with the aim for weekly supervised scanning.Ultrasound conference, led by the course director (HS), was held monthly with remote viewing capability. Conferences allowed for a participant to present saved clips and a brief lecture to their peer group. Presenters and topics were rotated each month.We sought to assess participant outcomes at multiple levels of Miller’s Pyramid: basic ultrasound knowledge, application of this knowledge to patient care, demonstration of the technical skills of image acquisition, and integration of these new skills into everyday situations . The timAttendance was recorded for monthly conferences, including those who joined remotely, and at hands-on teaching sessions at each site. Total number of uploaded clips was recorded for each participant.We assessed participants’ knowledge of basic ultrasound knowledge, image interpretation, and clinical integration using a novel 20-item online test developed for this program. The same test was administered prior to beginning the program, at the conclusion of the two-day course and again after 1 year. The test was given three times to first measure the impact of the two-day course and then to assess for durability or decay of knowledge over the year.We evaluated participants’ POCUS skills using a hands-on test on human models that was proctored by faculty from the Pulmonary and Critical Care Medicine division. Skills were evaluated by the proctors, using a checklist adapted from the CHEST Certificate of Completion program . The hanWe assessed participant confidence in image acquisition and clinical integration using a retrospective pre- post- survey at the completion of the two-day course and again after 1 year . ResponsWe also examined participants’ barriers to using POCUS. The barrier survey was developed from pilot interviews to address reasons participants may not adopt various aspects of POCUS .Participants completed a questionnaire regarding overall satisfaction with the program and individual elements.Successful completion of the I-ScaN program required three components: 1) Achieving a score of ≥80% on the final knowledge test 2) Receiving a score of ≥80% on the hands-on test and 3) Submitting an image portfolio based on SHM guidance . PassingPre- and post- two-day knowledge scores (Cronbach’s α = .68–.74) and confidence in ultrasound use (Cronbach’s α = .79–.84) were summarized. Scores from knowledge were reported as percentages and confidence scores reported on a 1–4-point scale. Differences between pre- and post-values for two-day course variables were assessed by using 2-sample paired Wilcoxon signed rank tests with a 95% confidence level. Data were reported as median and interquartile range for two-day and year end assessments (Table Hands-on assessment was conducted at the end of two-days (Cronbach’s α = .84) and at the end of the program (Cronbach’s α = .93). Scores were summarized. At the end of the program, knowledge (Cronbach’s α = .74) and confidence (Cronbach’s α = .91) were reassessed and compared to post-two-days scores. Hands-on and knowledge scores were summarized and reported as percentages, while confidence scores are reported on a 1–4-point scale. Differences between two-days and end of program were assessed by using 2-sample paired Wilcoxon signed rank tests with a 95% confidence level. Data were reported as median and interquartile range for two-day and year end assessments  reported prior ultrasound training, with a range of 2–80 h (median of 4 h); 3 reported more than 5 h of prior training. Three reported active clinical use of POCUS though none of them had more than 5 h of prior training. The group averaged 4.5 years of clinical practice (range = 1–13 years). Only the nineteen hospitalists who completed the assessments at the one-year mark are included in the subsequent analysis .Approximately 1 year after the introductory course and at the time of the final hands-on test, participants had uploaded a total of 2787 clips , one had completed the image portfolio. At the time of writing four participants have satisfied all course elements.p < 0.001). Knowledge scores fell slightly at 1 year . There was no change in POCUS skills as measured by the hands-on test from immediately after the two-day course to one-year . Confidence ratings increased from 1.5 pre- to 3.1 post-course  and were 2.73 at one-year .Participant assessment scores from before and after the two-day course are presented in Table p < 0.001), while correlation between the post-two-day knowledge and hands-on tests was only moderate . Participant confidence at 1 year positively correlated with hands on performance at 1 year , however confidence post two-day course did not correlate with hands on performance after the two-day course. There was a correlation between passing the one-year hands-on test with the number of clip uploads , attending hands-on teaching sessions , and with attendance at monthly conferences .Correlation between course components and the hands-on test is presented in Table At one-year, 13/19 (68%) of participants strongly agreed or agreed that they felt confident using POCUS to make clinical decisions. Two (11%) reported using POCUS daily, 7 (37%) every 2–3 days, 1 (5%) weekly, and 9 (47%) “only with the right patient”. Lack of time during the workday was reported by 68% as the principal barrier to clinical use of POCUS. Scanning in front of house staff was reported infrequently as a deterrent (21% agreed or strongly agreed).In responding to the prompt that “POCUS takes too much time”, participants perceived vascular studies to be the most time consuming and lung to be the least . Planning to obtain a scheduled formal study was reported as a deterrent to performing POCUS for 21% of participants for cardiac views and 53% of participants for vascular views. Only 5–11% of participants reported not performing POCUS due to the physical exam alone being sufficient to make diagnoses across views.Participants agreed or strongly agreed that the ultra-portable device, when compared to a traditional machine, poses less of a barrier regarding device access (16 and 53%), ability to carry/transport (5 and 79%), ease of uploading (26 and 74%), and labeling recorded images (53 and 63%).At one-year, participants rated I-ScaN with an overall score of 4.6/5. Individual course elements were rated as follows: two-day course 3. 9, hands-on sessions 3. 9, and monthly conferences 3.4 .I-ScaN found that a two-day introductory course was effective at improving hands-on skill, knowledge and confidence, without a decline in hands-on skill following a longitudinal year-long curriculum. The critical portion of successful POCUS skill and knowledge acquisition lies in the longitudinal phase of the curriculum. Participants reported that lack of time was the principal barrier to adoption of POCUS.Limited experience exists for the ideal POCUS training program for hospitalists. Maw and colleagues described a 10-week pilot program resulting in immediate improvements in ultrasound acquisition and interpretation though long-term outcomes were not studied . The autThe sample sizes are too small to determine which program elements led to participant success, though similar to the results of the CHAMP program, we found that skill retention on the hands-on test correlated with attendance at monthly conferences, hands-on teaching sessions and image uploading. We believe that incorporation of scanning into clinical workflow immediately after the course along with routine direct supervision are the key elements that result in participant success in POCUS.Participant confidence in using POCUS at 1 year correlated with their performance on the hands-on test at 1 year but not at the conclusion of the two-day course. These findings suggest that participants developed an awareness of their strengths and weaknesses over time as they progressed along the Dunning-Kruger curve . ProvideA strength of our study is the comprehensive data collection for all assessments and surveys of all 19 participants, save a single confidence assessment, representing a diverse faculty across 4 distinct practice settings, including those both highly and minimally engaged during the longitudinal portion of the curriculum. The studies reviewed above either report short-term results or only the highly-engaged fraction of the total cohort of long-term participants.A recent survey of Internal Medicine faculty addressing barriers to POCUS adoption found that while the majority of respondents held a favorable view of POUCS, the most commonly cited barriers included the need for more training (79%), lack of a handheld ultrasound device (78%), lack of direct supervision (65%), and lack of an expert to review uploaded clips (53%) . I-ScaN Though not specifically addressed on our survey, we believe the low completion rate of the image portfolio was due to the time required to practice, the knowledge gap in how to upload clips, and the lack of an incentive given that successful completion of I-ScaN was voluntary and only required for those who wanted to teach in the program or be allowed by local leadership to use POCUS in clinical care. We have subsequently included uploading of scans as a standard practice during hands-on teaching sessions to address this barrier. We anticipate that uploading of clips and portfolio completion by hospitalists will be commonplace once standards and expectations are set similarly to those found in fields such as Emergency Medicine.Study limitations include a relatively small sample size encompassing a single cohort of participants, as is common in faculty development programs. The small sample size limits our ability to predict why some individual participants succeeded while others did not. Additionally, while we developed this program to foster a culture of POCUS by training core inpatient teaching faculty, we did not evaluate whether faculty did in-fact teach POCUS to others.Despite ongoing encouragement and assessment of barriers throughout the longitudinal portion of the course, we found wide variance in faculty participation in program elements and practice patterns. Participants rated all elements of I-ScaN highly, reinforcing that it is the time spent between course elements that predicts durable gains. Getting participants to the bedside following an introductory course to practice on patients and upload clips for feedback will yield the greatest results.I-ScaN demonstrates that POCUS skill development learned after a two-day introductory course can be achieved through a longitudinal mentored program consisting of access to ultrasound devices, hands-on teaching sessions, and monthly case conferences. The lowered costs of ultra-portable ultrasound devices and availability of a growing population of instructors will facilitate the expected growth of hospitalists learning POCUS.


Woza Asibonisane Community Responses (CR) Programme was developed to prevent HIV infections and gender-based violence (GBV) within four provinces in South Africa. The Centre for Communication Impact (CCI) in collaboration with six partner non-governmental organizations (NGOs) implemented the programme, which was comprised of multiple types of group discussion and education activities organized and facilitated by each NGO. To date, little information exists on the cost of implementing such multi-objective, multi-activity, community-based programmes. To address this information gap, we estimated the annual cost of implementing the CR Programme for each NGO.The We used standard methods to estimate the costs for each NGO, which involved a package of multiple activities targeted to distinct subpopulations in specific locations. The primary sources of information came from the implementing organizations. Costs  are reported for each partner for one implementation year . In addition to total costs disaggregated by main input categories, a common metric--cost per participant intervention hour--is used to summarize costs across partners.Each activity included in the CR program involve organizing and bringing together a group of people from the target population to a location and then completing the curriculum for that activity. Activities were held in community settings . The annual cost per NGO varied substantially, from $260,302 to $740,413, as did scale based on estimated total participant hours, from 101,703 to 187,792 participant hours. The cost per participant hour varied from $2.8–$4.6, with NGO labor disaggregated into salaries for management and salaries for service delivery (providing the activity curriculum) contributing to the largest share of costs per participant hour.The cost of implementing any community-based program depends on: (1) what the program implements; (2) the resources used; and (3) unit costs for such resources. Reporting on costs alone, however, does not provide enough information to evaluate if the costs are ‘too high’ or ‘too low’ without a clearer understanding of the benefits produced by the program, and if the benefits would change if resources (and therefore costs) were changed. South Africa has one of the highest HIV prevalence rates 18.8%) in the world 8.8% in t–4.To avoid the attenuation of biomedical interventions, both structural and behavioral drivers of HIV also need to be addressed , 6. In SIn addition, there is a dearth of studies that report on the costs associated with delivering such activities . For pubWoza Asibonisane Community Responses (CR) Programme from 2014 to 2019, with funding from United States Agency for International Development (USAID). Each NGO provided an overall package of activities targeted at in-school youth (ages 15–19), out-of-school youth (ages 20–24) and adults . The overall objectives of the CR Programme were to prevent HIV infections and prevent gender-based violence (GBV) in targeted locations within four provinces  in South Africa. The primary objective of this analysis was to estimate the cost for each NGO providing the CR package of activities.The Centre for Communication Impact (CCI) worked with NGOs in different locations in South Africa to implement the The cost of implementing any program depends on: (a) who is implementing the package of activities and where; (b) the details of the package; and (c) the additional assumptions and information used to establish costs. We briefly discuss each below.Heaven’s Defense Force (HDF) – Gauteng;Isizinda Sempilo (ISO) – Gauteng;The Valley Trust (TVT) – KwaZulu-NatalDrama in AIDS Education (DramAidE) – KwaZulu-Natal;Project Support Association Southern Africa (PSASA) – Mpumalanga; andGrassroot Soccer (GRS) – Western Cape and Gauteng.The CR program was funded by USAID. CCI was the grant ‘prime recipient’, and then six NGOs implemented the program (package of activities) in specific locations within four provinces of South Africa. The six NGOs  were:Table S1 in Additional file Within each province, the NGO organized implementation activities within specific locations to target populations in informal settlements. For reference, Each NGO implemented a package of activities targeted to HIV and GBV prevention in specific populations. Table In Table Each activity listed in Table When disaggregated by target population and activity, each NGO implemented a package comprised of 13 activities. These 13 activities are considered a package (or combination intervention) because all could in principle jointly contribute to HIV and GBV prevention in the program locations and potentially elsewhere. For example, positive externalities could exist if, for example, a young man completing the One Man Can workshop in one location then influenced friends in other locations. For each activity in the package targeting specific subpopulations  are also briefly discussed.Throughout the analysis, key resources used by each NGO are identified even if the NGO incurred no direct cost for the resource. The two main categories of resources used, for which no financial cost was incurred, were: [1] venues for some activities; and [2] time required by the program participants. We stop short of imputing some additional value to these free inputs .We used a 5% real discount rate to annualize capital purchased . Based on the purchase price in the year of purchase, an annual equivalent cost based on a 5% real discount rate and an expected useful equipment life (5 years). This annual equivalent cost (AEC) is essentially an implicit annual fee to the program for using the equipment for 1 year. For equipment purchased before FY17, costs were inflation adjusted ‘up’ to 2017. For most NGOs, there were relatively few equipment items (mainly vehicles and computers) for which upfront costs needed to be annualized. Thus, the results are not sensitive to the choice of the discount rate or the useful life of equipment.All costs and results are reported in 2017 South African Rand (2017 ZAR) and U.S. dollars (USD). As mentioned above, equipment costs incurred before the implementation year (USG FY 17) were adjusted up to the implementation year using the annual consumer price index for South Africa as reported in the International Monetary Fund’s World Economic Outlook database [, a detailed example for one NGO (DramAidE) is provided.Different strategies or approaches can be used for evaluating costs based on the information available and purpose of the analysis. Terms such as a bottom-up approach, or a top-down approach, or an ingredients-based approach, or an expenditure-based approach are sometimes used to categorize the type of analysis used. A combination of these approaches was used in this analysis, but in general a combined expenditure- and ingredients-based approach was used . An ingr2Table While each NGO implemented the overall package of activities as outlined in Table Total costs ranged from a low of about R3.5 million $260,302) to R9.9 million . While total costs are provided in Table 60,302 toIn Table In Table In Table Table In Fig. Figure For each NGO, labor costs, either salary for management or salary for service delivery (the facilitators of the activities), were the major cost categories. The direct costs per participant hour for each activity, mainly refreshments, where the smallest share for all NGOs, followed by the aggregated headquarters-based costs.Based on cost per participant hour and total participant hours from Table Some possible differences across provinces are observed in Fig. Woza Asibonisane Community Responses (CR) Programme was implemented by six NGOs, working in separate locations in South Africa, to provide a package of activities targeted to multiple groups, with goals of reduction HIV and GBV risks. The overall structure of activities was similar for in-school youth (ages 15–19), out-of-school youth (ages 20–24), and adults (ages 25+): dialogues; short HIV prevention workshops (2 h); and more intensive workshops address gender-based violence (10-h workshops using SKILLZ or Stepping Stones curricula). To implement these activities, the NGOs needed to identify participants and locations (venues) for the activities. The NGO provided facilitators (trainers/educators) to implement the curriculum. Additional materials were provided to the facilitators  and participants (refreshments). The cost per participant hour varied from $2.36–$4.26.The Not surprisingly, for a program that largely uses staff to organize and provide activities, salary costs comprised the largest component of program costs for all partners. This is also the case in other community-based programs, such as the SASA! program in Uganda, where staff-related costs were 76% of total program costs  . Within A costing analysis cannot assess whether such costs are too large or too small without additional information on costs and effectiveness of multiple programs .To contextualize the costs calculated in our analysis, a recent review of the literature on the costs of HIV services in South Africa provides some useful information for understanding the costs of other types of HIV services . For exaUnfortunately, little published, peer-reviewed, information exists on the costs of implementing the activities included in the CR program for comparison purposes. The few studies that have been published focus on measuring the impact or benefits of their respective programs. An evaluation study of the Stepping Stones activity was published in 2008 . In thisThe current analysis is not without limitations. First, this analysis focuses on 1 year (October 2016 to September 2017). This was the fourth year of the CR Program, so the cost presented here are interpreted as a ‘typical’ program year. If the type of program was to be rolled out to new locations, additional costs for training staff would likely be needed. In addition, the question of free venues or venues requiring hiring should be assessed from the beginning.Second, this analysis relied mainly on the program budgets and scopes of work as the source documents for the analysis, combined with other information (expenditures on equipment purchased previously for the program) and discussions with the NGO staff. When budgets are organized with a structure that is not clearly related to program activities, a costing analysis must generally rely on program expenditures as the foundation for the analysis. In case of the CR Program NGO budgets, however, the budgets are presented with categories clearly linked to specific interventions in the program. As long as implementation did not deviate significantly from the scope of work (SOW) and budget, in which case the partner and CCI would have reported such changes to USAID for approval, then the budgets should track expenditures fairly closely.Thirdly, due to data availability limitations, participation and attrition rates, particularly for interventions that require multiple attendance, are unknown. For example, with cost per participant hour denoted as “c”, attrition denoted as “a” or lack of participation would be expected to increase costs per participant hour to c/(1-a). For example, as a rough estimate, if the program only provided 50% of intended participant hours, cost per participant hour would double. Because most of the NGOs costs are not related to such attrition, any possible savings from attrition , would be minor.Finally, cost per participant hour does not provide enough information to evaluate if the costs are ‘too high’ or ‘too low’ compared to other community-based HIV and GBV prevention programs as well as other types of HIV-related services. Also, it worth noting that our costing methodological approach focuses only on financial expenditure employing a mixture of bottom-up and top-down methods, based on program budgets with pre-determined line items which may not account for other indirect costs associated with delivering the program .There are a few possible ways to measure the benefits of the CR Program going forward. First, given that the CR program is designed for prevention of HIV and GBV, a part of the possible contribution of such community-based programs is to increase demand for HIV prevention services (as well as GBV services). Increasing demand for HIV testing, male circumcision, PrEP, early presentation for antenatal care when pregnant, complements these other HIV prevention activities. Measuring and documenting such outcomes is relatively feasible and a potentially important topic for future program M&E activities. Second, with direct behavior change to reduce HIV risks  among the program participants (and their non-participant partners), as well as reduced risks following additional biomedical interventions induced in part by the program, some cases of HIV are likely to be delayed or avoided over a lifetime. This of course is a key question that is unlikely to be directly answered by one or even a few studies. The impacts of this specific program or other similar programs on HIV transmission, are unlikely to be answered due in part to the complexity of the issues.Most studies to date have focused on the impact of community-based GBV programs, but none to date have looked at the cost of actually implementing these programs. Ideally, once additional information is reported on the multiple potential benefits of community-based programs such as the CR program, the cost and the benefits can be brought together and compared to other HIV and GBV prevention efforts.Woza Asibonisane Community Responses (CR) Programme. While community-based activities that address social and structural drivers of HIV may prevent new HIV infections and reduce sexual- and gender-based violence, it is however important to understand the costs associated with implementing such programmes for budgetary impact and planning purposes.This analysis has produced estimates of the range of costs that can be expected from implementing a package of demand-side prevention activities such as those of the Additional file 1. CR Programme implementation locations.Additional file 2. A detailed example of costing methods.Additional file 3. Summary cost profiles of implementing NGOs.


This study aimed to report the experience of diagnosis and treatment of one rare case of mediastinal lymph node tuberculous abscess (MLNTA) using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).An 18-year-old female patient was hospitalized in the Affiliated Hospital of Xuzhou Medical University in November 2017, due to intermittent left chest pain. She was suspected of infecting tuberculosis (TB) and thus received anti-TB treatment. Since April 1, 2018, she began to exhibit symptoms of chest distress. The patient was then admitted to Shanghai Pulmonary Hospital and continued receiving systemic anti-TB treatment during the whole course. On April 11, 2018, she received EBUS-TBNA to puncture pus and inject isoniazid. Simultaneously, the pus was sent for cytopathological and bacteriological examination, both supporting the diagnosis of TB in the patient. On April 24 and May 10, she received two times of EBUS-TBNA treatment. The symptoms of chest distress were relieved, but granulomatous neoplasm occurred at the EBUS-TBNA site on the trachea wall. The patient then received local clamp removal and cryotherapy on May 29 and Jul 19, respectively. Chest computed tomography (CT) reexamination on September 28 revealed that the MLNTA lesion had been completely absorbed, and electronic bronchoscopic reexamination on September 30 demonstrated that the granulomatous neoplasm on the trachea wall was entirely invisible.Using EBUS-TBNA to puncture and aspirate pus and inject drugs can be effectively used to diagnose and treat MLNTA, which provides a new, less invasive, safe and reliable method for diagnosis and treatment of MLNTA. Mycobacterium tuberculosis, is a worldwide major problem of public health [Tuberculosis (TB), a common chronic infectious disease caused by the bacillus c health . Particuc health . TB typic health . The medAbscesses are short of blood supply, which hampers the delivery of the administered drugs. As a result, systematic chemotherapy may not achieve satisfactory outcomes. Therefore, suitable adjunctive intervention therapy is essential to relieve the related symptoms and control the spread of abscess. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can determine the sites of lesions and vessels under the guiding of EBUS, accurately puncture to aspirate tissue specimens, pus, etc. and inject drugs in lesions . EBUS-TBAn 18-year-old female patient (school student) was hospitalized in the Affiliated Hospital of Xuzhou Medical University  in November 2017, due to intermittent left chest pain. Chest computed tomography (CT) showed left pleural effusion. Hydrothorax analysis demonstrated adenosine deaminase activity of 67 U/L and T cell test positive for TB infection, which suggested high possibility of TB infection. She thus received anti-TB treatment, including 0.3 g isoniazid (INH) , 0.6 g rifampicin (qd), 0.5 g pyrazinamide , and 0.75 g ethambutol (qd).On January 14, the patient was hospitalized again in the initial hospital for repeated fever. During the treatment, she was found enlargement of supraclavicular and mediastinal lymph nodes, hypoechoic nodules outside the envelope of the left external lobe of liver (suggestive of involvement of lymph nodes), splenomegaly, multiple hypoechoic area within spleen (suggestive of TB), and a small amount of pelvic effusion. On February 2, she received supraclavicular lymph node puncture for histological observation, which showed many neutrophils, lymphocytes and phagocytes and a few epithelioid cells. This indicated that the possibility of scrofula could not be excluded. Since April 1 she began to exhibit symptoms of chest distress. The chest CT reexamination on April 6 revealed patchy and nodular shadow with increased density in the right upper lung, enlarged lymph nodes in the mediastinum and right supraclavicular region, with uneven enhancement, and necrotic areas (liquefaction area) in the interior. Enlarged mediastinal lymph nodes obviously compressed to narrow the trachea. The main bronchus on both sides were clear, and no obvious effusion was observed in the thorax on both sides  for further treatment. After admission, the patient underwent physical examination: temperature 37 °C, pulse 80 times/min, respiration 18 times/min, and blood pressure 130/80 mmHg. She had a clear consciousness, without cyanosis in the mouth and lips, and had thick breath sound from both lungs, without obvious dry and wet rales. The heart rate was 80 times/min and heart rhythms were regular. Abdomen was smooth and soft, liver and spleen did not reach below costal, and pathological sign was (−). No edema was seen in both lower limbs. Blood gas analysis for pulmonary function on April 9, 2018 showed: pH 7.41, partial pressure of carbon dioxide 39.4 mmHg, oxygen partial pressure 108 mmHg↑, total hemoglobin 11.1 g/dL↓, oxygen saturation 99.2%, standard base excess 0.6 mmol/L, actual base excess 0.6 mmol/L, actual bicarbonate 24.7 mmol/L, standard bicarbonate 25.0 mmol/L, and alveolar artery oxygen partial pressure difference 0.0 mmHg ↓. Blood routine analysis on April 10, 2018 were as follows: hemoglobin 106.0 g/L↓, red blood cells 4.11*10The patient continued receiving systemic anti-TB treatment during the whole course, including 0.3 g INH , 0.6 g rifampicin (po/qd), 0.75 g ethambutol (po/qd), and 0.5 g pyrazinamide (po/tid). All the drugs were purchased from the Shanghai Sine Pharma . On April 11, she received EBUS- TBNA treatment, namely, EBUS examination, with the help of an ultrasonic tracheoscope  and the corresponding EU-C2000 ultrasound processing apparatus (Olympus), to observe the enlarged mediastinal lymph nodes at the Four Right group, followed by puncturing and aspirating all the pus (about 5 ml) from the abscess with a specific 21-G needle  , with the probe temperature of − 40 ~ − 75 °C. Chest CT reexamination on May 30 indicated the MLNTA lesion was obviously decreased Fig. . ElectroThis study was approved by the Ethics Committee of the Shanghai Pulmonary Hospital, Tongji University School of Medicine. Informed consent was obtained from the patient.EBUS-TBNA is a minimally invasive and safe procedure for the assessment of mediastinal lymphadenopathy –10. We sMycobacterium tuberculosis (TB-PCR) [Mediastinal TB is rare and a diagnostic challenge. EBUS-TBNA has been used to sample for analysis in the diagnosis of MLNTB in Chinese , 15, Ind(TB-PCR) . Until nMLNTAs, secondary to MLNTB, are not common. There are very few studies reporting the treatment for MLNTAs. For example, Zuo et al. used video-assisted thoracoscopic surgery  in combination with anti-TB chemotherapy for MLNTAs, leading to good recovery in patients but causing some complications  in some cases . In thisAlthough EBUS-TBNA has been successfully used for the diagnosis of mediastinal lymphadenopathy such as MLNTB –10, therIf granulomatous neoplasm is really a complication of EBUS-TBNA, we suppose that the treatment times, means of puncturing and aspirating of pus from abscess, the needle (a specific 21-G needle was used in this study) whereby puncturing and aspirating are performed, etc. may be related to the risk of granulomatous neoplasm, which needs to be optimized to decrease the risk of this complication.From our experience of one case of EBUS-TBNA for MLNTA, the indication could be initially supposed as follows: 1) patient exhibits symptoms of TB, 2) MLNTAs are detected in patient after imaging examination, which compress to narrow the trachea, 3) no significant improvement is observed in abscess after regular anti-TB treatment, and 4) lymph node lesions can be reached by EBUS. Of course, with more MLNTA patients receiving EBUS-TBNA in the future, the indication of the procedure will be further improved.Compared with VATS for MLNTAs , EBUS-TBA limitation of this study is that since the cases of using EBUS-TBNA in the diagnosis and treatment of MLNTAs are very scarce, only one case is reported in this study. Prospective studies with more cases are warranted to validate the diagnostic and treatment values of EBUS-TBNA for MLNTAs.This study suggests a new, effective, less invasive and safe method for diagnosis and treatment of MLNTAs by using EBUS-TBNA to puncture and aspirate pus for diagnosis and inject drugs for treatment.


The Virginia Geriatric Education Center (VGEC)’s Geriatrics Workforce Enhancement Program (GWEP) partners with two programs, Senior Strong at Eastern Virginia Medical School in Norfolk, VA and the Richmond Health and Wellness Program at Virginia Commonwealth University in Richmond VA to support their age-friendly initiatives. These programs enhance primary care for an older population experiencing adverse social determinants of health by providing screening around the 4Ms pillars of age-friendly healthcare and connecting participants with healthcare and community-based organizations. These programs offer a rich learning environment for interprofessional students. The VGEC GWEP strengthens these programs by developing faculty and student training in collaboration with the programs and facilitating program participation in the GWEP-CC Age-Friendly Action Community to develop and refine age-friendly practice workflows, referral pathways and documentation.


Biosphera, Sciencein3D, and Anatomage allow deeper exploration but are often costly, offered through restrictive licenses, or require expensive hardware. A new approach to teaching anatomy is to utilize virtual reality (VR) environments. The Virginia–Maryland College of Veterinary Medicine and University Libraries have partnered to create open education–licensed VR anatomical programs for students to freely download, access, and use. The first and most developed program is the canine model. After beta testing, this program was integrated into the first-year students' physical examination labs in fall 2019. The VR program enabled students to walk through the VR dog model to build their conceptual knowledge of the location of certain anatomical features and then apply that knowledge to live animals. This article briefly discusses the history, pedagogical goals, system requirements, and future plans of the VR program to further enrich student learning experiences.Traditionally, there are three primary ways to learn anatomy outside the classroom. Books provide foundational knowledge but are limited in terms of object manipulation for deeper exploration. Three-dimensional (3D) software programs produced by companies including  Traditional methods of teaching anatomy in a veterinary curriculum include using textbooks, live animals, and cadavers to build foundational knowledge. Three-dimensional (3D) software programs provide a platform for deeper examination of anatomical structures but are unable to deliver a fully immersive experience. The use of virtual reality (VR) provides a new type of learning environment.After a comprehensive curriculum change occurred in 2016 at the Virginia–Maryland College of Veterinary Medicine (VMCVM), faculty discovered students no longer possessed a conceptual picture of anatomy during lab sessions. The idea to use VR to bridge this knowledge gap was developed through a collaboration among faculty members in the VMCVM, School of Visual Arts, and University Libraries. The library provided a $3,000 Open Educational Resource (OER) grant to launch the project.Unreal Engine 4 because it supported the ability to manipulate and control the displayed levels of anatomy. Data derived from CT scans was sliced using Slic3r to create high-quality topology models for each anatomical structure. Models were exported into other 3D modeling programs for UV unwrapping, projection of a two-dimensional surface to a 3D model, to provide texture applications and re-topologize the graphics for better integration and rendering in Unreal Engine. Users were able to access the program in the VR environment through SteamVR.The project was developed using Because first-year students used live canines to develop their clinical skills, the dog was the first VR model to be developed. After beta testing, this program was integrated into the first-year students' physical examination labs in fall 2019. Although still under development, the VR program enabled students to walk through the VR dog model to build their conceptual knowledge of anatomical features and relationships. Students then applied that knowledge as they determined physiological markers from the program to use when palpating and examining the dogs.Students voluntarily shared their experiences and perceptions using VR as part of their learning environment. Prior to using VR in the first lab, 20% of respondents stated they had previous experience using a VR system and 26% were moderately familiar with anatomy. After the first lab, 40% indicated the VR program was very or extremely effective for learning anatomical features, 78% indicated the labeling was effective, and 83% stated they could transfer the anatomical locations from the VR dog model to the live dog. After the last lab, 57% of respondents stated a high or very high likelihood of continuing to use VR as a learning tool.Additional funding from other sources has been procured, and the library's role has evolved into a full partnership to continue advancing the VR dog model and to develop VR cow and horse models. Currently, the program works with Oculus Rift CV1 and HTC Vive VR headset and controllers, but developments are being made for additional wireless options like Oculus Quest. Because the equipment can be cost-prohibitive, the Veterinary Medicine Library provides training and access for students in the library. Another group is examining how the program will work in less expensive VR systems and eventually on smartphones. Additionally, work is being done to incorporate haptic technologies for the cow and horse models to further enhance the learning opportunities available through VR.Vet Med Library Information: Virtual Reality Anatomical Models.It is also important to note two philosophical goals that were implemented at the beginning of the project. The first is that all anatomical programs that are developed will be freely available for anyone to download, access, and use through an OER license. The second is to develop a community of users and contributors who can add files that will enable new models to be created, such as models that include common abnormalities; to support additional learning objectives at a significantly reduced cost; and to allow the new model to be shared with others. For more information and a video on how VR is currently being used by the first-year class, visit


Dental care utilization for low income pregnant women is met with challenges in the traditional dentist-centered model of care. County-level measures provide insights for policy and roles for stakeholders that extend beyond the dentist-patient relationship. We examined county-level data to generate hypotheses about factors that influence utilization of dental services in North Carolina’s Medicaid for Pregnant Women (MPW) program.County-level Medicaid utilization data for dental services for 2014–2016 were pooled to get mean county estimates of dental utilization in the MPW program. Descriptive statistics and multivariate regression models of dental utilization and county-level measures are presented. Data used were collected by NC Child and the Robert Wood Johnson Foundation’s County Health Rankings Reports. USDA Economic Research Service data were used to categorize counties in terms of Farming, Recreation, Persistent Poverty, and metro/non-metro status using Rural Urban Continuum Codes.Dental utilization ranged from 1–26% with a median of 8.5% across the 100 counties of North Carolina. Strong patterns linking utilization of dental services in the MPW program to contextual social measures of well-being emerged, specifically, increased reporting of child abuse and neglect, elevated infant mortality, poor quality of life, and worse ranking in years of potential life lost. Counties with persistent poverty had lower rates of dental utilization.Utilization of dental services in the MPW program is generally low. Patterns identify the potential for enhancing community-clinical linkages to improve birth outcomes and care coordination for pregnant women to enhance dental utilization in this population.Dental coverage in the Medicaid program in most states is administered separately from medical coverage. The separation of the funding mechanisms adds a further layer of complexity to care integration. Efforts to enhance dental care for pregnant women in the Medicaid program may benefit from policy that aligns incentives for care coordination within the community. Policy that extends the window of eligibility for dental benefits to 24 months after the birth of the child will help women complete the dental treatment that is needed. This also leverages the value of care coordination for community stakeholders from diverse child health sectors. The importance of oral health during pregnancy is often overlooked and this has been framed as a “call to action”. Signifi6The term Pregnancy Medical Home has been used to describe community-based care for pregnant women in North Carolina (NC). It has emerged as an effective model for care coordination among pregnant women who are covered by the NC Medicaid program , 10. It In NC, dental benefits are available for low income women who do not meet the standard income eligibility levels for Medicaid while they are pregnant through the Medicaid for Pregnant Women (MPW) program. The MPW program is designed to help low income pregnant women get access to health care by loosening the income requirements so that women with incomes as high as 185% of FPL are eligible. It is a program with unique challenges for women who do not have a usual source of care for dental services. The dental benefit for the pregnant woman in the MPW program ends when the baby is born.Value can arise from community-level systems and supports  that infCounty-level data for this study came from several sources. None of the sources had individual/personal identifiers. The dependent variable came from NC Medicaid claims filed for the MPW program in each of three fiscal years 2014–2016. County status was the place of residence of the recipient (rather than provider place of service). Dental service utilization represented any dental service that was filed as a claim under the MPW program in the NC Medicaid system.Independent variables were organized around Andersen’s Model for assessing health care utilization to include Predisposing Factors, Enabling Factors, Indicators of Need, and Health Services measures . PredispThe Rural Urban Continuum Code (RUCC) system was used to characterize metro and non-metro counties . Codes rCounty Typology Codes identified counties with Persistent Poverty and the dominant economic driver in the county as Farming, Recreation, Manufacturing, Government, or Non-specialized . PersistAnalytic Approach.In this study we used both univariate and multivariate statistical techniques. The univariate descriptive measures make use of spatial visualization of the dental utilization rate with map procedure provided by SAS version 9.4, as well as basic descriptive statistics. We employed multivariate regression modeling to analyze the conditional impact of covariates on the dental utilization rate. The primary selection criteria for the best model was statistical significance of the coefficients and fit as measured by the r-square and adjusted r-square.Our primary dependent variable is percent utilization rate (PUR) defined as the proportion of eligible women in the MPW program who had a claim for any dental service. We used three years for our study, 2014–2016, which we combined into a single sample of 100 observations by calculating PUR as the ratio between total number of mother-births utilizing dental services and total number of eligible mother-births over the three-year period for a county. Use of a three-year summary value provided some stability to the data since some counties had fewer than 100 eligible women in a given year.We used Andersen’s Behavioral Model to frame variables related to health services utilization , where tDental utilization in the MPW program ranged from 1 percent to 26 percent with a median of 8.5 percent. A major focus of this study was to determine whether characterization of the context of rurality identifies differences in health utilization rates for dental services. Therefore, we began by presenting basic statistics in Table Figure In order to have a better understanding of RUCC we also present a map showing the spatial distribution of this classification in the state Fig. . We diviDescriptive statistics for variables used in our analysis are presented in Table In general, non-metro counties have a higher percent of counties classified as Farming/Recreational, classified as places with Persistent Poverty, more Child Abuse Reporting events, a higher Infant Mortality rate, worse rank for Length of Life among counties, and both a lower number of Dentists per population and a lower High School Graduation Rate.Our multivariate regression results are presented in Table The approach is validated by the fact that even though the R-square in full model is 0.488, the explained variation in the non-metro model is 0.618 versus metro with 0.390. Therefore, we conclude that metro versus non-metro areas may be influenced by two different processes, where non-metro populations have less random variation and thus any policy interventions based on our independent variables may be more effective.The variables for Pre-disposing factors (Group 1) have expected signs and magnitudes with notable differences between metro versus non-metro counties. Farming/Recreation classification only matters for the non-metro counties and same is true for the Persistent Poverty indicator (it is notable that in metro counties those coefficients are effectively zero). High School Graduation rate appears to have slightly more explanatory power in the metro counties.Factors that represent county-level need are measures of well-being that are relevant for the maternal-child population (Group 2). These factors present very interesting differences between two subpopulations. The variable Change in Abuse Reporting, which in combination with Abuse Reporting Past Year, provides an indication of how the dynamics of abuse reporting affects PUR while holding levels of Abuse Reporting the same. It only matters for the non-metro counties. The same is true for the Infant Mortality variables. On the other hand, Length of Life Ranking and Poor Mental Health Days appear to be important in both models.The indicators for Dental Health Services (Group 3) show that the impact of the Dentist per population variable appears to be larger in non-metro areas but since it is not statistically significant and the confidence intervals overlap, we cannot determine in which subpopulation it matters more. Whether a county has an FQHC that provides dental services has a similar positive impact in all three models.The non-metro model shows some strong relationships. Counties with dominant Farming/Recreation economies have a PUR that is higher by about 1.5 percentage points, compared to counties classified otherwise. Counties characterized by Persistent Poverty have PUR that is 4.3 percentages points lower than average which is relatively large since the mean PUR in our sample is about 9.3. A Dentist per population coefficient of 0.05 means that having one more dentist per 100,000 population improves PUR by about 0.05 percentage points. To put this into perspective, if one would double the number of dentists in a non-metro county of 150,000 population from 30 to 60 dentists (which seems unlikely) this would improve utilization by about 1 percentage point. The High School Graduation Rate coefficient is 0.20 which means that the improvement between the worst (68%) and the best county (92.5%) in North Carolina would amount to an improvement in PUR by about 5 percentage points- which is substantial.Utilization of dental services in the MPW program was low with a median of 8.5 percent of pregnant women having any dental service. There was a broad range across counties. The lowest utilization rate was 1 percent and the highest was 26 percent. Patterns in the dental utilization rate were different when counties were separated as non-metro versus metro areas. In the non-metro sample, community-level patterns were stronger which suggests that non-metro counties maybe influenced more directly from policy changes that leverage community-level factors. Since dental utilization is low statewide, statewide policy changes to improve dental utilization should focus on enhancing the dental benefit to make it easier to use. For example, a first step could be to extend the window of eligibility to 24 months after the birth of the child. Recent evidence shows that improving oral health in pregnant women will improve the child’s oral health . A 24-moSome of our findings are consistent with other studies that look at dental utilization by rural classifications. These include the lack of a strong relationship between number of dentists in a community and utilization of dental services. Supply and demand in Appalachia counties was not uniform and required spatial analysis techniques to understand utilization of dental services . PatternIn our data for North Carolina, dental service utilization was related to number dentists available, however, not in a consistently robust manner. Four counties with zero dentists had a wide range of dental service utilization and counties classified as most “rural”  had both the highest utilization and the lowest utilization of all counties statewide. Counties with Persistent Poverty had poor utilization and counties classified as Farming or Recreational  had better utilization, especially when comparisons included both metro and non-metro counties.Some of the associations observed may be artifacts or oddities in the county-level measures. These somewhat counter-intuitive observations may signal the existence of other unmeasured factors. For example, increased reporting of child abuse and neglect may reflect an increased awareness of its importance in a community and not necessarily an increase in the prevalence, simply better reporting . HoweverIt is interesting to speculate on the measures from the County Health Rankings file that were statistically important in the final model. Both Quality of Life and Length of Life measured at the county level over the period 2006–2012 for number of poor mental health days – a Quality of Life measure - and 2010–2012 for county ranking in number of years of potential life lost before age 75 – a Length of Life measure - represent time periods that precede the time period for the PUR variable in the model . Further research should explore whether this lag is meaningful in the dynamics of community social interactions around efforts to improve health outcomes in general and health outcomes for pregnant women specifically.Infant mortality has been identified as a marker for society’s need to address “access to health care, adequate nutrition, a healthy psychosocial and physical environment, and sufficient income to prevent the adverse consequences of poverty”. One hypPolicy initiatives at the state level may also explain these observed patterns, but more information is needed to go beyond what these contextual indicators highlight. Such policy initiatives include efforts that began in 2013 to implement the Essentials for Childhood Framework to reduce child maltreatment . Also, aEllis and Dietz (2017) have proposed a model for articulating how communities can actively participate in cross-sector efforts to support community resilience. The concept of community resilience  identifiIn the model , two keyCo-production provides an alternative economic framework for conceptualizing service delivery involving diverse stakeholders in the public sector . In healLimitations.As an ecologic study, observed patterns may not be present at the level of the individual. Independent variables are measured at various years, sometimes not even in the range 2014–2016. However, since each mother-birth dyad is independent of each other between years, even if it relates to the same woman, and most independent variables are relatively stable over the years, we anticipate that differences in period measurements would have only a small impact on our results. Our sample is only 100 counties and statistical power is limited. Nevertheless, our results should be treated as a first step toward a more definitive study.Predisposing factors among counties such as low high school graduation rates and having Persistent Poverty were associated with low dental service utilization by pregnant women on Medicaid. These factors may compound the effects of material and social disadvantage over time to create a culture of deprivation. Collective action around infant mortality and child well-being may improve dental utilization. A systems dynamic approach that engages community stakeholders across multiple sectors may help shift to a culture of health for low income families.