IntroductionThe Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) is a three-part series of examinations similar to the United States Medical Licensing Examination (USMLE) that osteopathic medical students must pass for medical licensure. Osteopathic students are not required to take the USMLE, but during the residency admission process, many emergency medicine (EM) residency programs will not consider osteopathic applicants who only take the COMLEX-USA. Therefore, we examined program-level characteristics between programs that accept the COMLEX-USA alone for osteopathic applicants and those that prefer the USMLE using free, publicly available online databases and residency program websites.MethodsEmergency Medicine Residents’ Association (EMRA) Match was the primary database used; however, missing exam preferences were supplemented from Fellowship and Residency Electronic Interactive Database Access (FREIDA) and individual program websites. Program characteristics were compared between EM residencies that accept the COMLEX-USA and those that prefer the USMLE using the Chi-square test for categorical variables and the Mann-Whitney test for interval variables.ResultsTwo hundred sixty of the 278 EM programs in the dataset were included in the analyses. One hundred and seven programs reported preferring the USMLE, while 151 reported accepting the COMLEX-USA alone. Programs differed by the educational environment of the primary training site (p <0.001), number of Standardized Letter(s) of Evaluation (SLOE) needed for an interview (p = 0.042), emergency department (ED) shift length (p = 0.021), former American Osteopathic Association accreditation (p <0.001), percentage of osteopathic residents (p <0.001), annual ED volume (p = 0.001), number of intern positions (p <0.001), and number of elective weeks (p = 0.028).ConclusionEM residency programs that reported accepting the COMLEX-USA alone for osteopathic applicants differed from those that prefer the USMLE. Therefore, osteopathic medical students interested in EM should consider these differences when deciding whether to take the USMLE. The training pathway for students enrolled at osteopathic medical schools to match into residency and obtain a license to practice medicine independently is similar to that of students enrolled at allopathic medical schools, with the exception that osteopathic trainees are required to pass all levels of the three-part Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) . The COMNevertheless, the USMLE is a high-stakes series of exams with a significant time and financial commitment to the osteopathic applicant. It often requires additional study as the USMLE and COMLEX-USA are not identical, and some applicants may be at risk of failing one or both by diverting time and effort from focusing on just the COMLEX-USA. Therefore, only 60.7% of osteopathic seniors in the 2020 match reported taking the USMLE Step 1 .While the proportion of osteopathic applicants who recently matched into EM without the USMLE was about 75% , not comStudy designEmergency Medicine Residents’ Association (EMRA) Match is an interactive, collaborative, and filterable catalog that allows medical students applying to EM residencies to search for programs using various parameters, including whether a residency program accepts the COMLEX-USA alone for osteopathic applicants or prefers the USMLE ,14. ResiData collectionThe EMRA Match data was downloaded on August 9, 2021. The dataset was augmented to include whether a program has had prior accreditation by the AOA . US CensStudy populationWe studied factors unique to US EM residency training programs from pre-existing, publicly available online databases and individual program websites ,15.Outcome measuresThe two cohorts of EM residency programs, those that accept COMLEX-USA alone for osteopathic applicants and those that prefer the USMLE, were compared across multiple variables. Variables included geographic region, the educational environment of the primary training site , whether the program has a USMLE Step 1 minimum score, whether the program accepts applicants with USMLE Step 1 failures, whether the program allows moonlighting, the number of Standardized Letter(s) of Evaluation (SLOE) need for an interview, program length , emergency department (ED) shift length, ED shifts per month, former AOA accreditation, the percentage of osteopathic residents, annual ED volume, percent of intern rotations that are off service, number of intern positions, number of elective weeks, and number of critical care weeks.Data analysisThe Chi-square test was used to compare categorical variables. Comparisons between continuous variables were made using the Mann-Whitney test since all continuous variables were non-parametric as determined by the Shapiro test. The Chi-square test for trend in proportions was used to test for the significance of the trend. A p-value <0.05 was considered significant. Missing data for each program characteristic was reported for all variables and included as a factor for categorical variable comparisons. The EMRA Match dataset was downloaded as a Microsoft® Excel®  file, and analyses were performed with RStudio® .Of the 278 EM programs in the EMRA Match dataset, 108 had missing exam preferences. Exam preference was added for 62 programs from FREIDA and 28 programs from their individual websites, leaving 260 for analysis. One hundred fifty-one programs were classified as accepting COMLEX-USA alone, while 107 programs were classified as preferring the USMLE , number of SLOE(s) needed for an interview (p = 0.042), ED shift length (p = 0.021), former AOA accreditation (p <0.001), percentage of osteopathic residents (p <0.001), annual ED volume (p = 0.001), number of intern positions (p <0.001), and number of elective weeks (p = 0.028)  Figure .After the Single Accreditation System transition, there are differences in program-level characteristics between EM residency programs that accept the COMLEX-USA alone for osteopathic applicants and those that prefer the USMLE. For example, community sites were more common among programs that accepted the COMLEX-USA alone compared to programs that preferred the USMLE for osteopathic applicants, 53.6% vs. 27.1%, respectively  . Other vAlso, an increasing percentage of osteopathic residents per program was associated with an increasing percentage of programs accepting the COMLEX-USA alone for osteopathic applicants Figure . ConceptFormer AOA accreditation may also explain some of these differences. For instance, while the ACGME requires a minimum of 18 residents total, the AOA required only 16, which may explain the association between accepting COMLEX-USA and programs with fewer intern positions ,21. AlthLimitationsFirst, like all retrospective analyses, we can only assume correlation and not causation. Second, the information contained in EMRA Match, FREIDA, and program websites may be subject to reporting bias which may impact program-level responses. Last, we did not consider osteopathic recognition, an ACGME-accredited residency program status indicating dedication to the education of osteopathic principles and practice .EM residency programs that reported accepting the COMLEX-USA alone for osteopathic applicants differed from those that prefer the USMLE. Therefore, osteopathic applicants should consider these differences when deciding whether to take the USMLE.


Antimicrobial resistance is a major public health threat internationally but, particularly in Colombia. High and increasing rates of carbapenemases are challenging. Implementing antimicrobial stewardship programs (AMSs) in a large, academic, public network hospitals in Bogotá, Colombia.will help curb inappropriate antibiotic use. Adherence to AMS Program 2020. Subred Integrada de Servicios de Salud Sur Occidente E.S.E Bogotá, Colombia.Impact of an Antimicrobial Use Optimization Program in the First Year of Pandemic 2020 in a Large, Academic, Public Network Hospitals in Bogota ColombiaAMS was established in April 2020 consisting of an administrative champion, Infectious Diseases staff, nurse, General Physician, microbiologist, and pharmacists. Antimicrobial stewardship program interventions included postprescriptive audit and establishment of institutional guidelines. The AMS tracked appropriate drug selection including loading dose, maintenance dose, frequency, route, duration of therapy, de-escalation, and compliance with AMS recommendations. Defined daily dose (DDD) of drugs and health economics evaluations of antimicrobials (April-December 2020). Recommendations are placed in the electronic medical record as a progress note.From April to December 2020, 1013 patients were evaluated by means of a prospective methodology. Unnecessary 689 days of hospitalization and 4420 days of antibiotic therapy were avoided. Among the top antibiotics discontinued were piperacillin tazobactam for the months of July, August, November and December, while for September and October was meropenem. The intensive care unit was the most frequently intervened service (52%), followed by hospitalization (43%) and the emergency department (5%).Over the course of the year, there was significant adherence to the program, with 100% in July, followed by 93.3% in April, 87% in December, 86.6% in May and June, 83% in November, 80% in September, 73.3% in August and 57% in October. The AMS program was able to save &47.409US in antibiotics and &55.529US in hospitalization, and 11% decrease in nephrotoxicity events , which also saved additionally & 23.503 US for a total of an estimated cost saving for the network public hospitals of & 126.441 US by 2020.Implementation of a multidisciplinary antibiotic stewardship program in this academic, large, academic, public network hospitals in Bogotá, Colombia demonstrated feasibility and economic benefits even in a Covid19 pandemic situation.All Authors: No reported disclosures


Background: Childhood trauma would negatively affect pregnant women's mental health and would have intergenerational repercussions. However, there is a paucity of prenatal interventions specifically designed for women exposed to childhood trauma. The study aims to evaluate the acceptability of STEP, a manualized group intervention designed for pregnant women having experienced early life adversity.Methods: The acceptability of STEP was assessed in four phases. In Phase 1, six experts evaluated whether the program activities were pertinent and trauma sensitive. In Phase 2, three parents read the intervention manuals and evaluated whether they considered each session relevant, interesting, and clear. In Phase 3, the program was briefly presented by phone to 309 pregnant women from the community. Women were inquired about their interest in the program, and the reasons for their lack of interest were assessed. In Phase 4, 30 pregnant women exposed to childhood trauma participated in the program and completed anonymous satisfaction questionnaires after each session. Psychological distress was also measured before and after the program.Results: All activities were rated by independent experts as highly pertinent, adequate, and sufficiently safe to be offered to pregnant women. Parents who read through the intervention manuals also considered that the sessions were relevant, clear, and interesting. About half of the pregnant women from the community showed interest in the program. Participants reported very high levels of satisfaction and a significant decrease in psychological distress during the program.Conclusions: Our findings show a high level of convergence among various indicators of program acceptability. Childhood trauma (here defined as abuse or neglect before 18 years old) is frequent in pregnant women from the community . Having Survivor's Mom Companion (SMC) is a self-study psychoeducational program aiming to provide information about how trauma can affect childbearing and mothering, and to teach skills to improve emotion regulation, the management of PTSD symptoms and to reduce interpersonal reactivity  sustain maternal well-being during pregnancy and the years following delivery, (b) support maternal bonding and healthy development in offspring, and (c) contribute to interrupting intergenerational cycles of childhood maltreatment. STEP reaches these goals by equipping participants with knowledge regarding childhood trauma, a better understanding of the impact of trauma on their current functioning, abilities to regulate emotions in stressful situations, interactions with other women having experienced adversity, and connections with existing resources in the community. STEP consists of eight or nine sessions of 2-h, is manualized and is designed to be offered by two facilitators to groups of four to six pregnant women. The program was originally conceived to be offered face-to-face, but has been offered online during the COVID-19 pandemic. The intervention is considered a “trauma-informed accompaniment program” during which facilitators share information, animate reflective activities, facilitate exchanges, and focus on the participants' experience in the “here and now.” The program is mainly based on the paradigm of trauma and violence-informed practices  and on mBecoming a Mother,” aims to explore and normalize the emotions experienced by the participants in the course of their pregnancy and to support the use of healthy emotion regulation strategies. The second section, entitled “A Look at My Own History,” aims to support mentalization of trauma by discussing the nature of trauma and its impact; by validating the participants' feelings as understandable responses to trauma; by supporting a reflection on positive and harsh experiences with significant others and the ways both types of experiences have influenced current mental states and behaviors; and by identifying how participants coped with trauma. The last section, entitled “Looking Ahead,” aims to explore participants' needs and strengths, to present available resources to support resilience and to provide the opportunity to envision positive and challenging moments with the child.STEP is divided into three sections. The first section, entitled “The current study aims to evaluate the acceptability of STEP by assessing whether its specific contents and activities are coherent with the experience of pregnant women exposed to childhood trauma. We did so by (1) evaluating whether the activities of the program are trauma-informed and appropriate according to experts and parents; (2) evaluating the level of interest in the program in a community sample of pregnant women; (3) providing preliminary data on the short-term changes in psychological distress in women participating in STEP; and (4) exploring the mothers' participation experience in the program.The acceptability of STEP was assessed in four successive phases see . In PhasEvaluation of the acceptability of STEP was measured throughout four successive phases. In Phase 1, all program activities were presented to the panel of independent experts during a full day of a face-to-face meeting. After the presentation of each activity, experts were required to evaluate whether it was pertinent and trauma-sensitive using a 10-point Likert scale ranging from 1  to 10 . In Phase 2, three parents from our target population read the intervention manuals and evaluated whether they considered each session relevant, interesting, and clear, using a 3-point scale . They also used a voice recorder to record all their comments as they occurred while reading the manuals. This was successively used by the team to refine the program, but this qualitative information is not reported in the current manuscript. In Phase 3, after a brief presentation of the program, the pregnant women who did not wish to participate in STEP were asked to choose one of the following 5 reasons for their refusal: (a) not feeling the need, (b) being unavailable, (c) being held back by the group format, (d) not wanting to think about past traumas, (e) or other reasons. Finally, in Phase 4, the pregnant women who participated in the program anonymously reported on their appreciation of each session, right after the sessions. They were invited to indicate to what extent they considered the session (a) useful and (b) emotionally challenging, and whether they (c) learned things, (d) had significant insights, and (e) were motivated to participate in the next sessions, using 5-point Likert scale ranging from 1  to 5 . At the end of the program, five questions were added to evaluate whether they observed positive changes in the way they felt about themselves, their past and motherhood; considered having learned helpful things throughout the program; and identified particular strengths they had as mothers.Participants were considered eligible for the program if they had experienced trauma, according to the Childhood Trauma Questionnaire  and theChanges in psychological distress was measured with the French version of the Kessler Psychological Distress Scale (K10) , 29 admiResults of the consultation process with six independent experts (Phase 1) confirmed that all activities were pertinent, adequate and trauma-informed . Indeed,In Phase 2, all parents confirmed the relevance of the program and its activities. The core seven sessions of STEP  were all rated as relevant , clear  and interesting .In Phase 3, 52.75% of pregnant women were interested in participating in the program. Reasons for refusal were: not feeling the need (49.32%), being unavailable (21.92%), being held back by the group format (12.33%) or not wanting to think about past traumas (0.68%). The remaining participants (15.75%) did not provide a motive. Of the 163 interested participants, 89 (54.60%) reported significant childhood adversity. In sum, our data suggest that around 28.8% of pregnant women from the community would be interested, engaged and eligible for the program.t-test showed significant improvements in terms of psychological distress between the beginning of the program  and the post-intervention assessment at the end of pregnancy , t(25) = 7.78, p = < 0.001  and the Comité d'éthique de la recherche avec des êtres humains de l'Université du Québec à Trois-Rivières (CER-16-226-10). The patients/participants provided their written informed consent to participate in this study.NB, CD-M, and RL conceptualized and designed the study, supervised material preparation and supervised data collection. JG-B performed and coordinated data collection and analyses. NB wrote the first draft of the manuscript. CL, CD-M, and TS revised and reviewed the manuscript for important intellectual content. All authors contributed to data interpretation, commented on previous versions of the manuscript, read, and approved the final manuscript.The research leading to these results received funding from the Public Health Agency of Canada (Grant No. 1617-HQ-000015) and the Canada Research Chairs (Grant No. 950-232739).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The web-based BeUpstanding program supports desk workers to sit less and move more. Successfully translated from a research-delivered intervention, BeUpstanding has gone through iterative development and evaluation phases in preparation for wide-scale implementation. In the third planned “early-adopters” phase (01/09/2017–11/06/2019), the program was made freely-available online. An integrated delivery and evaluation platform was also developed to enable workplace champions to run and evaluate the intervention within their work team independent of researcher support. Using the RE-AIM  framework, this study reports on the extent to which the program and processes were “fit-for-purpose” for a national implementation trial across the indicators of uptake (reach and adoption), implementation and engagement, and effectiveness for behaviour change.Data were collected via the online surveys embedded in the program and through program access analytics. Descriptive data (with linearized variance for the clustered staff-level data) and results from mixed models (repeated data and clustering for pre-post changes) are reported.n = 69, 51.1%) had low engagement (1 day toolkit usage) and few  were highly engaged (> 1 day toolkit usage and surveyed staff). Although only 18 users (7 organisations) performed the pre- and post-program staff evaluations , pre-post changes showed the program effectively reduced workplace sitting by − 9.0% .Despite purposeful limited promotion, uptake was good, with 182 Australian users initially registering  and 135 (from 113 organisations) then completing the sign-up process. Recruitment reached users across Australia and in 16 of 19 Australian industries. Implementation was inconsistent and limited, with signed-up users completing 0 to 14 of the program’s 14 steps and only 7 (5.2%) completing all seven core steps. Many champions . Conducting a planned early adopters phase and a comprehensive evaluation according to RE-AIM helped highlight necessary program improvements to make it more suitable for wide-scale implementation and evaluation.ACTRN12617000682347. Date registered: 12/05/2017.Australian and New Zealand Clinic Trials Registry The online version contains supplementary material available at 10.1186/s12889-021-11993-1. High levels of sitting are associated with morbidity and premature mortality, with adults who are also physically inactive at the greatest risk , 2. The Stand Up Australia program of research [The BeUpstanding™ program and accompanying BeUpstanding Champion Toolkit  were devresearch  and was research . Detailsresearch , but in Designing for dissemination often requires an iterative process of development and adaptation to ensure the resulting product is suitable for implementation in ‘real-world’ contexts , 15. HowStand Up Australia [Phase 1 involved the initial development of the ‘BeUpstanding Champion Toolkit’ and formation of research-government partnerships . In thisustralia  to sometIn Phase 2, a beta (test) version of the BeUpstanding program was evaluated, with the findings demonstrating that the “train-the-champion” approach used within the program was highly acceptable, feasible to implement, and effective in reducing self-reporting workplace sitting time , 22. TheThe updated website and toolkit went live in a “soft-launch” on September 1st, 2017 and was provided freely accessible to workplaces across Australia, but without support from the research team and with only limited promotion through the established research-government partnership avenues. The purpose of this phase (Phase 3) was to test the new onboarding and recruitment channels and the new integrated delivery and evaluation platform. The ultimate goal of this phase was to inform further optimisation of the program prior to its’ evaluation in the context of a national implementation trial (Phase 4 ). ParticThis current study focuses on Australian early adopters, reporting the extent to which the program was working as intended according to the RE-AIM framework . SpecifiThe study uses a hybrid implementation-effectiveness design, focusing here on a quantitative description of the reach, adoption, implementation and engagement of the BeUpstanding toolkit (early adpopters version) with effectiveness evaluated via a single-group pretest-posttest design . There wn = 7) were considered core  with the other half considered optional depending on the needs of the team and organisational requirements. The core elements spanned the ‘Plan, Do, Review’ phases and included: the staff pre- and post-program surveys; the pre- and post-program workplace audit; staff education and consultation on team strategies to sit less and move more; and, promotion of program messages and team strategies through emails and posters. The end-user journey through the sign-up process through to the toolkit, and how this integrates with the front-end boarding pages and the back-end technology platform accessed by the researchers, is shown in Fig. The aim of the BeUpstanding program is to create a more dynamic workplace through raising awareness of the benefits of sitting less and moving more and creating a supportive culture for change , 13. In Data were collected through the BeUpstanding toolkit through the implementation platform underpinning the BeUpstanding program . Data weIndicators of adoption and reach (uptake) were the number of toolkit users (champions) and the organisations and workers (team members) they collectively represent, as well as their characteristics. Of particular importance was ensuring diverse recruitment geographically and across industries and sectors. Key partner-identified sectors were blue collar, small business, and government/public sectors as well as teams from regional/remote locations and call-centre workplaces. Additionally reported elements were organisation size, and characteristics of champions  and their work teams as perceived by the champions  and as reported by staff . Steps that could not be verified were treated as performed if the champion reported doing the step. Steps that could be verified  were only considered performed if a completed survey was acquired through the toolkit. Because a champion could have sent out staff surveys without receiving any completed responses, the pre- and post-program staff survey steps were considered completed if the champion reported having done that step, or at least one staff survey was acquired, with a very minimal requirement that the staff member had filled in the anonymous identifier questions at the beginning of the survey. Champions could perform steps in any order (and skip steps). Accordingly, champion progress through the phases was classified by the most advanced step performed. Champion engagement was considered in terms of their usage of the toolkit — all logins and all resource downloads (while logged in) – and evidence staff had been engaged (through the user or another user from their combined team performing pre- and/or post-program staff surveys). Three categories of engagement were created: 1) low: did not access the toolkit beyond the day they unlocked it; 2) moderate: repeat toolkit usage (> 1 day) but did not survey staff; and, 3) high: repeated toolkit usage (> 1 day) and surveyed staff.The primary effectiveness outcome was self-reported percentage of the workday spent sitting, collected in the pre- and post-program staff surveys using the Occupational Sitting and Physical Activity Questionnaire . This The quality of the data collection in Phase 3 was evaluated according to the RE-AIM framework  to detern = 208) who were from Australian workplaces (n = 182) and who completed the profile survey required to unlock the toolkit’s features (n = 135 users from n = 113 organisations). Data were extracted from the toolkit (07 May 2021). Adoption and reach were reported using descriptive statistics, considering biases in participation and retention via logistic regression or mixed logistic regression models accounting for staff nested in clusters (combined teams). Implementation was described per user and per combined team (treating everything done as soon as the first user from the group had done it). Engagement was described overall and plotted over time according to the program phase the champion was currently in. For effectiveness, changes in outcomes between pre- and post-program assessments were analysed using mixed models with random intercepts for cluster (combined team) and participant (repeated measures), and a fixed effects of time (pre / post). Staff members could only reliably be linked to an organisation’s combined team, not the specific champion, because users sometimes surveyed the staff members of a different champion. Only organisations that obtained both pre- and post-program staff surveys were included in the effectiveness analyses, using responses from staff members who provided data at the pre- and/or post-program surveys. A sensitivity analysis adjusted for staff characteristics that were imbalanced between pre- and post-program survey response groups. Analyses were performed in STATA v 16.0 . Significance was set at p < 0.05 (two-tailed). Clustering was accounted for using linearized variance estimation (descriptive statistics) or mixed models.Analyses focus on legitimate toolkit users who signed up during the early adopters phase  and word of mouth , with some reporting recruitment through presentations (n = 15) and assorted other means (n = 23), with n = 1 not providing referral information.The uptake of the program was nationwide, with the 182 valid Australian users signing up coming from all Australian states and territories. A further 26 international users signed up, with sign-ups from the United Kingdom (13), various European locations (6), the United States (4), Canada (1), Fiji (1), and Vietnam (1). In total 135 valid Australian users from 113 organisations unlocked the toolkit by completing the champion profile survey. These users collectively claimed a total of 23,154 workers in their teams. Users who registered  were mostly from Queensland , Western Australia , New South Wales , Victoria , and South Australia  while a small number were from Australian Capital Territory , Northern Territory , and Tasmania . Referral into the BeUpstanding program was primarily through wide-reach promotional avenues  and organisations  were from the government / public sector, collectively representing > 10,000 team members. Similarly, champions of regional/remote teams  reported > 10,000 team members, while the call centre , blue collar  and especially small business  sector teams reported representing smaller numbers of workers. Organisations (n = 113) showed an approximately even mix of champion-reported sizes, with 23 (20.4%) reported as small (< 20 employees), 31 (27.4%) as medium (20–199 employees), 35 (31.0%) as large (200–1999 employees), and 24 (21.2%) as very large (≥2000 employees).Penetration into each industry and sector is shown in Table n = 135) were largely but not wholly the user group for which the toolkit was designed, namely workplace champions delivering the intervention to teams of workers who are highly sedentary while doing desk-based work. Users (‘champions’) were mostly female (74.8%) with a mean age of 41.6 years (SD = 11.1). There were 110 (81%) champions who reported at least one form of experience relevant to delivering BeUpstanding: an occupational health and safety role within their organisation (67%); prior training in workplace health promotion (64%); and/or previous experience in delivering a health promotion program (50%). Most self-identified as employees (48.9%) or middle management (41.5%) rather than senior management (9.6%). Six toolkit users (4.4%) reported a team size of zero, suggesting that they were not intending to act as program champions to a specific team, either at all or at the time of filling in the champion profile survey. The remaining 129 champions reported team sizes varying widely from 2 to 8600. Collectively, of the 135 Australian teams, 109 (80.7%) would meet some basic screening criteria to participate in the implementation trial (team size ≥5 and desk-basked work). Nearly all users (88.1%) indicated their teams mostly did primarily desk-based work, and most (78.5%) indicated the majority or more had job roles involving high amounts of sitting. In support of the champion’s perceptions, the staff also reported workplace sitting that on average (M ± SD) was high (73.4 ± 20.2% of their workday), and notably much higher than their levels of desired sitting (43.1 ± 19.7% of their workday).Table p = 0.018), suggesting an underrepresentation of older workers in the post-program survey, but there were no large or significant (p < 0.05) difference between pre- and post-program surveys in other sociodemographic attributes or desired behaviours.There was some evidence of bias in participation in the evaluation. The group who went on to complete the evaluation had staff with significantly lower levels of moving and higher levels of desired moving Table . They alTable Champion toolkit usage spanned a timeframe as short as a single day to use that was still ongoing at the data census (> 300 days since unlocking toolkit). In total, 69 champions (51.1%) used the toolkit for a single day only and were considered low engagement, and 59 52.1%) of combined teams had only low engagement champions. Figure .1% of coAdditional File p = 0.3859) with average changes ranging between approximately 1% below and 1% above the overall mean change of 9%  partner promotional activities, informational boarding pages, and sign-up form worked sufficiently well to recruit diverse work teams (according to geography and industry). Furthermore, based on the data collected, the majority (81%) of those unlocking the toolkit would meet the basic screening criteria to participate in the implementation trial, suggesting the recruitment channels were appropriate. Importantly, the program was adopted by work teams across all five target sectors identified by the national regulators and state-based partners as being ‘at need’. Of note is that call centres, blue collar and small business teams were generally comprised of comparatively small team sizes, indicating that over sampling of these groups, as well as targeted recruitment, may be necessary to ensure adequate representation of these priority groups. It was identified that not all users were champions, and some users were working as part of a larger group rather than individually with a team. Team size, ranging from 0 to 8600, appears to be measured inaccurately, leading to difficulty in gauging reach and response rates accurately without direct contact of researchers with staff, as well as casting some doubt that the ‘team’ about whom the champion reported information are in fact the people who will go on to receive the BeUpstanding intervention. To address these limitations, functionality was added prior to Phase 4 to identify different roles of toolkit usage  and to link related users, while team size was added to the report display in the online survey portals and users were given the ability to modify this information. Additionally, research staff now proactively monitor multiple registrations from the same organisation and, for those participating in the implementation trial, check and confirm the team size.There was wide variation in program implementation and the extent to which users engaged with the toolkit and associated resources, with only a small number of toolkit users (< 10%) implementing and engaging with the program as intended. Specifically, despite the toolkit following a step-by-step process, most users did not complete the steps in order over the recommended 2–3 month program period and approximately half of users only logged on for single day. Similarly, despite being ‘flagged’ as important, core components were not completed systematically. Critically, data for some of these core elements, including the strategies that the work team participatively chose to sit less and move more, were not being captured. Intervention fidelity is a common issue facing evidence-informed programs in practice  and can Engagement with the evaluation components was mixed, with relatively good completion of the pre-program workplace audit by the user > 50%), but poor distribution of the staff surveys, with less than 7% having both pre- and post-program staff data. The findings confirmed the effectiveness of the program , with an average reduction in self-reported workplace sitting time of 43 min per workday. This change is line with findings reported from both the pilot study of BeUpstanding  and a me0%, but pThe deliberate inclusion of this early adopters phase, with associated soft launch, into the planned translation of the BeUpstanding program is a key strength as piloting the protocol in a “real-world” context provides an opportunity to refine research methods prior to wide-spread promotion . This stIn conclusion, findings from this early adopters phase provided important practice-based evidence on the extent to which the BeUpstanding program was working as intended and whether the data collection procedures were fit-for-purpose for a national implementation trial. They highlight the importance of this phase in the translation process and provide an example of how the learnings can be used for iterative improvement to maximise the success of research to practice.Additional file 1.Additional file 2.Additional file 3.Additional file 4.


The last two decades have seen a shift in former Soviet countries from highly specialized to more family medicine-focused systems. Medical education has slowly adjusted to these reforms, although the region is still at risk to have a chronic shortage of family doctors. This paper presents the evaluation of a new post-graduate family medicine program in Tajikistan, focused on competency-based training. The findings are relevant for policy makers, international organizations and practitioners participating in similar medical education reform programs.We employed a quasi-experimental control group design and compared intervention residents, control group residents with traditional training, and 1st year residents with no training in two outcomes, clinical knowledge and competencies. We employed two objective measures, a written multiple-choice question test (MCQT) and an Objective Structured Clinical Examination (OSCE), respectively. We report reliability and validity of the measures along with ANOVA, planned contrasts and effect size estimates to examine differences across groups.We found statistically significant differences in both clinical knowledge and competencies between intervention and control groups. We also detected a large intervention effect size. Participants in the intervention outperformed control group participants in the two measures. Our analysis suggests that intervention and control group participants are comparable in terms of initial knowledge and competencies, strengthening the argument that the intervention caused the improvement in the program outcomes.Receiving tailored training and structured opportunities to practice knowledge and competencies in clinical settings have a positive effect on the education of family medicine doctors in Tajikistan. Our results support curriculum reform and investment in medical education in the form of longer and supervised on-the-job preparation designed to be more in line with international standards. We discuss suggestions for future studies and potential requirements to inform replicability in other countries.Family medicine is well recognized as central to health systems throughout the world, but high quality residency training lags behind in some countries. Our study showed that investing in family medicine residency programs and structured training is effective in increasing critical clinical competencies. We encourage promoting comprehensive post graduate family medicine doctor training so that the goals of a family medicine centered health system are attainable. To achieve universal health coverage and contribute to healthy populations, well-performing health systems, offering highest quality of care, are critical. After its independence in 1991, Tajikistan transitioned from a highly specialized health care system to a system based on family medicine (FM) [The focus on medical education reform, to ensure a supply of well-trained family medicine (FM) doctors, has been among the main health reform priorities of the Ministry of Health and Social Protection of the Population of the Republic of Tajikistan’s (MoHSP) 2010–2020 Strategy .Tajikistan, with support of the European Union, the World Health Organization (WHO) and the Swiss Agency for Development and Cooperation (SDC) has invested into improving and scaling up FM in the country through various activities, albeit the country still faces a shortage of FM doctors , 5. UntiIn 2013, the MEP, in close collaboration with a variety of stakeholders (for details see ) developst year Ordinator-FDs” in previous publications) [The evaluation focused on what could be objectively measured, and compared levels of clinical knowledge and competencies between newly graduated two-year PUST program participants  and the one-year conventional Internatura program  for the specialization of FDs. Further, it assessed increment by comparing the graduated PUST residents with those who newly entered the PUST program  .Literature focusing on medical education reform of family medicine  reform) in Central Asia and neighboring countries is limited. Publications mostly exist in the form of government reports and decrees. Few documents outlining the reform in Kyrgyzstan , 13; UzbPeer-reviewed literature on aspects of medical education reform related to FM in former Soviet countries – including Eastern Europe and Central Asia - appears almost non-existent. Only very few peer-reviewed publications from Tajikistan are available, describing the medical education reform overall , 8; the The conventional one-year Internatura residency program, which is the traditional way of training since the Soviet era, attaches a graduate to a medical doctor at a primary healthcare centre. The FM doctor has not received formal training by a tutor and the graduate gains work experiences independently without a structured training schedule or established accountability system. No theoretical teaching is offered and the new graduates learn by themselves based on trial and error and by gradually acquiring work experience; residents can participate in conferences or seminars on their own expenses, which are however not part of the planned training program.In comparison to the Internatura residency program, the PUST residency program in FM provides a structured approach and focuses strongly on training of clinical competence: It consists of 80% of practical work under clinical supervision by trained tutors, and 20% of lectures and teaching per week.The PUST residency program in FM aims to provide a structured approach to the training of clinical knowledge and clinical competencies, with an emphasis on the latter. The program consists of 20 % of lectures and teaching per week and 80 % of practical work under clinical supervision.For the practical clinical training, each resident is assigned to a tutor, who is an experienced FM doctor working at a rural health center or a CTB. The Post Graduate Medical Institute (PGMI) and MEP staff provide regular short refresher courses to tutors. Tutors and residents are visited on a monthly basis for monitoring by teachers from PGMI and RCFM. Graduates have their own list of patients and work under expert supervision. The PGMI delivers the training provided to all residents enrolled in the program. Further, the program includes capacity building of Faculty at the Tajik State Medical University on how to use Objective Structured Clinical Examination (OSCE)/In-Training Evaluation Report (ITER) to assess the clinical competency progress. In addition, to assure the continuous medical education (CME) and professional development of these newly educated FM doctors, an annual conference for students was introduced. Moreover, peer groups for newly graduated FM doctors were established, providing the opportunity for them to remain connected and keep to up to date – examining clinical issues encountered in practice and reviewing the evidence in a group discussion and reflection.So far, the peer-reviewed literature focusing on the outcomes of medical education reform in former Soviet countries is very scarce. For Tajikistan only two peer-reviewed publications exist so far, focusing specifically on the reformation of the medical education of FM doctors in Tajikistan and as outlined above. This is the first paper comparing the conventional and the reformed new FM specialization programs as part of the medical education reform process in Tajikistan, assessing the differences in levels of clinical knowledge and competencies between residents. Results demonstrate the success of the medical education reform efforts related to the FM residency program. With international donors currently funding similar initiatives of medical education reform in the region , results of this evaluation are of interest to policy makers, donors and implementers in countries, with similar attention to family medicine and reform plans.This article will 1. Compare the overall clinical knowledge and competencies level between participants in the conventional (Internatura) and reformed (PUST) family medicine specialization programs; and will 2. Identify specific clinical training domains in which the reformed FM PUST program may produce greater effect compared to the traditional FM specialization program.N = 26), 2) graduated Internatura residents (N = 8) and 3) 1st year PUST residents (N = 20). All three groups are comprised of graduated medical students specializing or having newly specialized in family medicine. Participants in Group 1 received training under the PUST program; participants in Group 2 participated in the Internatura program, and participants in Group 3 were recently graduated medical students who newly entered the PUST program with no on-the-job training so far. Therefore, our target group (intervention) is group 1 while groups 2 and 3 serve as control groups. Each group was evaluated once, but due to the nature of the groups and the timing of the evaluation, the meaning of these evaluations differs across groups. While graduated PUST residents and graduated Internatura residents were evaluated after the specialization training , 1st year PUST residents were evaluated before completing the training (as in a pretest).The evaluation employed a quasi-experimental design featuring three groups: 1) graduated PUST residents  and control groups (Groups 2 and 3). A positive difference between Group 1 versus Group 2 and between Group 1 versus Group 3 would both suggest intervention effect, given that other conditions for inferring causality are met.In our study, random assignment to intervention condition was unfeasible due to logistic and budget constraints. However, comparison of the two control groups (pre-intervention and post-intervention) help cast light on initial differences that could confound the intervention effect with selection. No differences between these two untreated groups would support group comparability. We thoroughly address this and other design limitations for sustaining causal claims in the discussion section.The two program outcomes in the evaluation were clinical knowledge and competencies. The instruments comprised of a written multiple-choice question test (MCQT), focusing on the clinical knowledge of participants; followed by an Objective Structured Clinical Examination (OSCE) approach  focusingInstruments were developed based on nationally defined standards and competencies of a FM doctor  in combiThe multiple-choice questions were developed based on recommendations by the Yale Center for Teaching and Learning , the UniFor the OSCE, a total of five scenarios were developed with a focus on history taking and anamnesis aiming to assess attitudes and practices; three tracer diseases and lab results, aiming to assess examination, management and communication skills. Scenarios were drawn from internationally existing OSCES for FM doctors and adapted to the Tajik context. In addition, instructions and templates for examiners and simulators were developed.MCQT and OSCE draft versions were shared with an international and national expert group for feedback; MCQT were reviewed by an expert panel for content relevancy and coverage  to proviThe purpose of the psychometric analysis prior to conducting further analysis was to examine the metric properties of items and scales in the MCQT and OSCE. Item properties include difficulty and discrimination, and scale properties are reliability and validity . The anaFollowing, we conducted EFA to examine the internal structure of the two scales  and subscales (OSCE). In our analysis, we were interested in testing how the data complied with the intended unidimensional structure of the two measures. Thus, we tested for unidimensionality forcing a one factor solution. The exploratory factor analysis was conducted utilizing maximum likelihood estimation with no rotation. The maximum likelihood factor analysis produces a factor solution accounting for the common variance among items excluding random error and unique item variance. We discovered heterogeneous factor loadings with a few items per scale exhibiting low or negative factor loadings. Initially, we retained items with factor loadings higher than 0.3. We then decided to keep items with factor loadings higher than 0.2 avoiding sacrificing content coverage and undermining content representation and validity.Table The reliability coefficient reported in our analysis is the Cronbach’s alpha internal consistency coefficient. All final scales and subscales reached acceptable reliabilities for research purposes (above 0.7 and closer to 1.0). In general, the psychometric analysis provided input for increasing the initial reliabilities. The most notable case pertains to the MCQT score with an initial Cronbach’s alpha coefficient of 0.40 and a final coefficient of 0.85.r = 0.5 (p < 0.001). The correlation coefficients among OSCE subscales ranged from − 0.08  and 0.76. These empirical results support the reliability and validity of the MCQT and OSCE scores for evaluation purposes.The final step in our psychometric analyses involved estimating the Pearson correlation coefficient among scales and subscales. The scoring for scales and subscales is expressed in percentage of correct response. We expected positive correlations across scales and subscales, specifically, a positive and moderate correlation between clinical knowledge (MCQT) and clinical competencies (OSCE), and positive correlations among OSCE subscales. Overall, the data conformed with our expectations. The correlation between MCQT and OSCE was All residents who newly entered the PUST program, and those who newly graduated in the PUST program or Internatura in 2018, were invited to participate. Recruitment of graduated Internatura residents proved challenging, with some who could not be reached, others who had left Tajikistan and some on maternity leave. Following the invitation, a total of 54 participants participated in the MCQT, and a total of 50 participants in the OSCE Table . Four paParticipants were invited by email and followed-up by phone in case of no response. The invitation email included information on the purpose and outcome of the evaluation; and it was emphasized that participation is voluntary, results will be fully encrypted and may be published, and participation can be withdrawn any time and prior to the start of participation without any consequences. With participation consent was automatically provided. This was reiterated again prior to the start of the MCQT. Participants were compensated for travel costs but did not receive further incentives. The evaluation had been included in the project’s workplan agreed between SDC and MoHSP. Ethical approval was received from the MoHSP .The evaluation took place between November and December 2018 at PGMI facilities. The MCQT was administered by three invigilators, who received a short training and written instructions to read out to participants to ensure a standardized process. Inclusion criteria of invigilators included no previous or current affiliation to any of the FM programs. Participants were allocated a number and randomly assigned to different rooms and seated separately. The overall written exam took 2.5 h.A total of four patient simulators were trained, based on individual scripts. OSCEs took place over 2 days and a total of 10 examiners were trained. Examiners came from medical institutions training Internatura and PUST residents. To reduce the Hawthorne effect, one examiner from each training institution were placed in one room, overseeing one scenario each. The grading was based on a template with a variety of pre-defined grading criteria; examiners were asked to compare grading results after each performance and come to a joint conclusion.p-value. P-values indicate if a statistical model  fits the data. Following expert recommendation on the use of statistical significance [We conducted a series of ANOVA to gather evidence about differences in the program outcomes across groups. The F statistic from ANOVA tests the null hypothesis of no difference. We report the F statistic and exact ificance , we repoificance . While aificance  proposesANOVA is a first step to explore group differences because the F statistic is not informative of where these differences are (if any). We conducted planned contrasts to examine differences between specific pairs of groups. We compare graduated PUST residents vs. graduated Internatura residents and graduated PUST residents vs. 1st year PUST residents to determine intervention effect. Additionally, we compared graduated Internatura residents with 1st year PUST residents to ascertain about pre-intervention group comparability. We present the difference between groups in the same metric of the original variables (percentage of correct answers) along with statistical significance.Table p = .0018). The effect size of the difference by accounts of the eta-square coefficient was rather large (eta-square = .22). The planned contrast shows that graduated PUST residents outperformed both graduated Internatura residents  = 8.45; p = .0054) and 1st year PUST residents  = 10.410; p = .002). Also, there was no statistically significant difference between graduated Internatura residents and 1st year PUST residents in their clinical knowledge  = .270; p = .608). Similarly, results from ANOVA suggest that differences in clinical competencies (OSCE) by group were statistically significant  = 9.80; p = 0.0003). The size of the effect was large (eta-square = .30). Planned contrast shows that graduated PUST residents outperformed both graduated Internatura residents  = 10.49; p = 0.0022) and 1st year PUST residents  = 14.85; p = .0004). There was no statistically significant difference in clinical competencies between graduated Internatura residents and 1st year PUST residents  = .45; p = .50).Results from ANOVA suggest that differences in clinical knowledge (MCQT) by group were statistically significant  = 7.17; Table Current graduates pursuing the family medicine specialty in Tajikistan undergo a conventional training comprised fundamentally of 1 year of on-site work experience (i.e. Internatura program). Our study evaluated a program for training in the specialty of family medicine that better adheres to international guidelines (i.e. PUST program) and comprises lectures and on-site clinical work under supervision. The two programs greatly differ in length and intensity of the training the future family medicine doctors receive. The two-year PUST residency program provides a structured approach and has put great attention on improving clinical competencies , under the guidance of a trained FM tutor. Aspects of clinical competencies training include all steps of patient care such as history taking, examination, diagnostic steps, interpretation of results, diagnosis and treatment, and follow-up.The results of the evaluation support the assumption that the PUST program contributes to an increase in clinical knowledge and competencies. Receiving theoretical training by skilled tutors, and being able to implement the knowledge in clinical practice, seems to be a successful approach. Likewise, results from the OSCE show that graduated PUST residents outperform graduated Internatura residents, as well as participants who newly entered the PUST program in overall clinical competencies. The PUST graduates perform significantly better in six criteria. As a whole, the results support that the PUST program is effective by a large margin than the current FM specialization training. In fact, the evaluation results showed that compared to the PUST training, the current Internatura program does not enable doctors to improve their clinical competence or raise their theoretical knowledge over and above what they learned at university.There were a few aspects in which we report unexpected results, particularly pertaining clinical competencies. The significant difference in providing the main diagnosis after interpretation of laboratory results (station 4) between graduated Internatura residents and 1st year PUST residents may be explained by the fact that newly graduated medical students have not been exposed to the disease indicated by the laboratory results to the same extent than have graduated Internatura residents. While general consultation and communication skills were included in the PUST training program, no formal training addressing specific communication with patients was included; it is therefore not surprising that no differences could be seen between the three groups. This finding demonstrates the need for PUST to introduce more practical training in communication scenarios.The credibility of our conclusions rests on several evaluation design features, and we believe that the methodology used in this evaluation may also be of wider interest for other programs. The main strength of the study is the utilization of two objective measures. Both the MCQT and OSCE were developed in-house following rigorous standards. The reliability and validity of the two measures comply with widely accepted quality criteria that it is fully accounted in the study.phishing and type I error [Another strength of this evaluation is the utilization of two control groups. An initial limitation of the study relates to the use of a quasi-experimental design and the expectation of inferring about program effect. The study compares three unmodified groups in a setting where random assignment of medical students to the different programs or stages within a program  is unfeasible. In theory, lack of random assignment prevents effectively ruling out initial differences across groups, increasing the chance of a confound between program effect and selection , 40. How I error . We alsoWe cannot guarantee the generalizability of our findings, as participation was voluntary, and not all group members attended to the full evaluation. We were not able to examine whether participants with MCQT or OSCE data were different than those with no data. Anecdotal evaluation evidence suggests that participants in the evaluation might not differ from those that were not part of the evaluation and that non-participation was due to chance . A future evaluation should cast light on the extent to which these findings also apply to future cohorts of PUST residents and different contexts.Detecting the effect of a medical educational reform is challenging because changes take time to have an observable effect on critical outcomes. Our findings are promissory because the size of the effect in knowledge and competencies is substantial. A first interesting follow-up issue pertains to the extent to which differences between Internatura graduates and PUST graduates include other outcomes besides clinical knowledge and competencies. Future studies could monitor on-the-job performance between these two types of FM doctors. A second relevant aspect not considered in our study pertain to impact on patients’ variables, for instance, quality of care, health-related quality of life or DALYs. A third issue is the effect on job conditions. For instance, does the better training impact on the employability and career progress of the graduated from FM specialty? Do PUST graduates show less attrition and mobility than Internatura graduates and does recognition of the FM specialty change as a result of a high quality training? An additional question relates to the broader goal of the FM reform: Does the improved training of FM doctors help attract more candidates to the FM specialty and reduce the shortage? Fourth, more research is required to understand how our specific implementation of the PUST program in the Tajik context is achieving better outcomes than the traditional Internatura. Despite the many positive findings, how can the PUST program be improved? Furthermore, is the effect homogeneous across participants, for instance, by gender or another policy-relevant variable?With the reformation of the family medicine specialty program we intended to showcase that longer specialty training closer to international standards is essential for quality education of doctors - even if 2 years is still considered too short in international comparison. However, there was an undercurrent of resistance to expanding the length of all specialty trainings due to concerns about cost implications. Our findings, and coherent with recent publications , 10, undTo develop and maintain a strong and sustainable primary health care system requires that a substantial part of graduating doctors go into primary care, and are supported with appropriate and high quality training to work as competent family doctors. The training of family medicine doctors is critical to ensure the success of health reforms offering the highest quality of care, the promotion of healthy populations, and in achieving universal health coverage.The demonstrated cost-effectiveness  and over


Despite major setbacks to its health infrastructure and health workforce capacity, Liberia began its first post-graduate training program for physicians in 2013. Specialty training in Internal Medicine, Pediatrics, General Surgery and Obstetrics and Gynecology were the four inaugural Residency programs that recruited graduates from the country's only medical school, A.M. Dogliotti College of Medicine. The Obstetrics and Gynecology residency program was designed to combat the rising maternal mortality and strengthen health systems to improve maternal care. The program adapted in the face of challenges posed by limited financial support, lack of specialist-faculty and general physician shortages and the Ebola virus outbreak. The manuscript discusses the challenges and successes of the program and demonstrates how the shortage of teaching faculty was addressed by developing a collaboration between local government and educational communities, a United States (US) academic institution and volunteers from the Global Health Service Partnership. Liberia suffered through 14 years of conflict and two civil wars from 1989 to 2003. During that time all health-related infrastructure including the only medical school was severely damaged. Loss of vital school facilities, and an acute shortage of teaching faculty who fled the country for fear of losing their lives, resulted in an almost complete cessation of the medical school that graduated only 17 students between 1999 and 2002  . The MinBy 2012 of the estimated 117 physicians registered by the Liberian Medical and Dental Council, only 51 were Liberian trained physicians; the majority were expatriates returning to help rebuild Liberia's health and medical education sectors. Most of the Liberian-trained physicians were employed in general practice, public health, or administrative positions; fewer than 15 were specialists . In 2013Under the leadership of then Deputy Minister of Health, Bernice Dahn, a Technical Working Group (TWG) of senior Liberian physicians convened in 2011 to set the parameters and establish realistic goals for developing the first specialty training programs in Liberia. Early collaborators to this program were the West African College of Physicians and Surgeons, the Ghana College of Physicians and Surgeons and the Ministry of Health of the Republic of Liberia.The TWG visited Ghana to tour the Ghana College of Physicians and Surgeons. The first collaborative meeting with representatives of the Ghana College was held in Ghana in mid 2012.Upon returning to Liberia and with the guidance from Ghana, the West African College of Physicians (WACP) and the West African College of Surgeons (WACS), the TWG drafted the First Act of the Liberian Residency training program . SpecialMount Sinai Hospital has had a longstanding relationship in Liberia in the field of women's health. In 2007 at the annual Clinton Global Initiative meeting in New York, key-note speaker President Ellen Sirleaf appealed for help to rebuild Liberia's health sector citing the country's lack of physicians. In 2008, twenty-eight health workers from the Mount Sinai System, among them three senior Ob/Gyn faculty were deployed to Monrovia and Bong County. The team introduced daily bedside rounds and assisted in outpatient and in-patientcare of patients. This began a long- term relationship in the field of maternal health at John F. Kennedy (JFK) Hospital in Monrovia and Phebe Hospital in Bong County. As plans to establish the post graduate program evolved, the Ministry of Health called upon Mount Sinai to assist with the development of the obstetrics and gynecology residency program. The Global Health Service Partnership (GHSP), a collaboration between the Peace Corp and SEED Global Health was established to provide health care and education in areas of the world with extreme shortages of healthcare providers . Given tThis manuscript explores the challenges and successes of this multi-institutional collaboration in the first 4-years of the residency training program in Obstetrics and Gynecology in Liberia, following the program from its inception in 2013 to the graduation of the first cohort in 2017.The residency program, originally proposed as a 4-year training program was changed to a 3-year program following the Ebola outbreak. A 9-month delay caused by the outbreak resulted in the first cohort completing their first year of training (PGY-1) over a 21-month period (September 2013-June 2015). The outbreak, and the urgency for maternal health specialists were some of the factors that influenced that change.JFK Hospital the largest tertiary hospital in the city of Monrovia was designated as the primary training site for the program. Redemption Hospital, the largest public hospital in the city of Monrovia was selected as the rotation site in the city, where residents covered day services only. Rotations at Phebe Hospital in Bong County and Jackson Doe Hospital in Nimba County were identified as the rural rotation sites.The process of accreditation for designating JFK Hospital as the primary training institution was conducted by an external team of evaluators from the West African College of Surgeons in conjunction with the Liberian College of Physicians and Surgeons at a site visit. Because of the urgent need for specialists in the country the hospital was given partial accreditation. The site reviewers granted authorization to start the training programs with specific recommendations made for upgrading the hospital to obtain full accreditation.Residency candidates were recruited from among graduates of the AM Dogliotti College of Medicine and non-specialized physicians practicing throughout Liberia. A selection examination was administered, and candidates were called for interviews based on scores. Five candidates were selected based on examination scores and interview performance. The maximum number of recruits was capped at 5 per year, to ensure that the pool of graduating physicians available to provide service throughout the country was not diluted. To avoid the risk of “brain drain” the first cohort of recruits included previously graduated physicians with long standing roots in Liberia, while subsequent cohorts gave more consideration to recent graduates from the AM Dogliotti College of Medicine . All canRecruitment of faculty was coordinated by the Liberian College of Physicians and Surgeons (LCPS). Liberian physicians who completed residency training in obstetrics and gynecology abroad, and Board-Certified physicians from Mount Sinai Medical Center were interviewed and offered employment through the LCPS. Volunteer candidates from the Peace Corp were interviewed and selected through an application process led jointly by the LCPS, the Global Health Service Partnership (GHSP) and Mount Sinai School of Medicine. The ratio of faculty to trainees was set at 1:3 following the guidelines of the West African Colleges of Physicians and Surgeons.The curriculum was based on a modification of the Ghanian curriculum, adapted to meet the needs of Liberia, and harmonized with the West African College curriculum . BecauseWritten examinations were given at mid-year and end of year. Residents who scored below 70% had an opportunity to meet with faculty to review overall topics that were problematic on the examination, and they were then allowed to repeat the examination. An assessment form was completed by faculty and the evaluation was based on residents' performance in patient care, medical knowledge, case presentations, clinical decision making, clinical skills, and surgical skills. In-person evaluations were conducted by faculty with each resident and included a review of the resident's case list and discussion based on their assessment forms. This was followed by a joint meeting with faculty and residents where residents could provide feed-back or discuss any issues that came up during their training that needed attention. To graduate, residents had to sit and pass both a written and an oral examination. Residents who failed the written examination were not allowed to sit the oral exams, until the next orals examinations were scheduled the following year, thus delaying their graduation. Oral examinations were conducted by an examiner from the West African College as the lead examiner. The external examiner reviewed each residents written examination prior to their orals, and then led the exam in collaboration with local faculty. The oral examinations were presented as an objective structured clinical examination (OSCE) that included simulations, interpretation of sonograms general knowledge and case management.Between 2013 and 2017 three cohorts matriculated into the residency training program . CandidaAt the start of the program there were 2.5 full time equivalents (FTEs) for 5 in coming residents (PGY-1). At the completion of the PGY1 year  there were 4 residents, one succumbing to Ebola. Post-Ebola PGY1 residents were moved to Bong County where the Ebola outbreak had declined. At the start of their second year of training, these residents remained in Bong County until completion of their PGY2 year. By the time the first cohort graduated in 2017 there were 3.5 FTEs and a total of 14 residents .Performance assessment was based on a modification of the ACGME Obstetrics and Gynecology Milestones. All four graduating residents achieved comprehensive understanding of normal and abnormal, complex antepartum problems including management and recognition of diabetes, hypertension and pre-eclampsia. Residents self-reported confidence in managing obstetrical emergencies and intrapartum problems that covered a range of atypical conditions including, eclampsia, sepsis, malaria, HIV and non-communicable diseases in the patients with and without prior ante partum care, as well as performing inductions and delivery of breech and multiple gestations. They were able to supervise junior residents through primary, secondary Cesarean sections, communicating with midwives, families and hospital staff in a professional manner. Third year residents were adept at routine Gynecologic open procedures, while first, and second year residents achieved the milestones set by the program and felt they had supervision and guidance from their senior residents and faculty.Resident feedback highlighted lack of subspecialty exposure and clinical/surgical management of oncology, urogynecology and infertility patients, training in endoscopic procedures, vaginal surgery. They cited lack of multidisciplinary support for acutely ill patients requiring intensive care and shortage of supplies/equipment that limited their ability to practice evidence based medicine. Logistical feedback related to the lack of telecommunication services within the hospital necessitating use of their personal phones to address all emergencies. The lack of a cafeteria on campus necessitated residents going off campus for meals and affected their response time if called back for emergencies. All residents had strong positive feed-back regarding the learning experience gained at morning report, scheduled didactics and contact with faculty as well as the community experiences they gained at the rural hospitals.By the end of the 2016–2017 academic year, all four residents who matriculated in 2013 passed their written and oral examinations on their first attempt allowing them membership into the Liberian College of Physicians and Surgeons. Two residents passed their WACS primary examinations, and all five first year residents passed their final examinations allowing them to become second year residents.September 15, 2017, marked the graduation for residents from all four residency programs started in 2013. The residents who competed their training in Obstetrics and Gynecology were the first Liberian trained specialists to have graduated from an in-country program .Influenced in part by globalization, transnational health networks and advances in science and technology, medical specialization has increased in low- and middle-income countries over the last decade . SpecialThe curriculum and design of the residency programs in Liberia were guided by the tenants of the West African College of Physicians and the West African College of Surgeons. These sister organizations are the accrediting bodies of post graduate training in West Africa promoting education, research, and training in both surgical and non-surgical specialties , 20. TheThe first Global Health Service-volunteer completed 1 year and 6 months in Liberia working primarily at Phebe Hospital in Bong County and was succeeded by a second volunteer in 2018. The Global Health service volunteers additionally played an important role in preparing the graduating residents for their exit exams and participated in the ceremony honoring the first Liberian physicians to be trained as specialists in the country. The collaboration between the Liberian medical community, Mount Sinai and the Global Health Service Partnership resulted in an over 50% increase in specialists in the field of Obstetrics and Gynecology in Liberia beginning in 2017.Despite the success of the program, there were additional challenges facing the residency program that ranged from lack of infrastructure, shortage of supplies, and limited faculty. Basic infrastructural hurdles alluded to in the residents' feedback, were the lack of land-line communication throughout the hospital, lack of on-call rooms and cafeteria facilities for staff. This posed several problems including difficulty in reaching residents who left campus for meals or showers. Because candidates initially entering the program had not previously worked in the structured environment of a residency training program, it was initially challenging to introduce the concept of team-work and shared responsibility and accountability. However, as the program has now trained seven cohorts of residents, there has been a seamless transition that engages responsibility and accountability for the improvement of patient care.Because there was only one obstetrician at JFK Hospital prior to the residency program, most deliveries were performed by nurse midwives and the introduction of residents into the system initially created some tension. Historically, all first antepartum visits were seen and followed by nurse midwives, with physician involvement reserved for complications that occurred during labor or post-partum. Involving the midwives in conferences where patient management was discussed and having residents working as allies for the best patient outcomes, have gradually changed the dynamics, so that antepartum visits are now designated as high risk with resident involvement and midwives have become part of a larger team.Most of the graduated residents have made the decision to remain in academic medicine and help train and mentor the incoming residents. This portends well for improving health workforce capacity and sustainability. One of the residents who was admitted into the program in 2016, entered an IGCS supported 2-year fellowship program in gynecologic oncology at the Uganda Cancer Institute in Kampala after graduating in 2019, and is scheduled to return to Liberia in 2023.Establishing a local training program provided the opportunity to train more specialists than the country would have done if candidates were sent outside the countryTraining locally also prevented depletion of the few physicians left in the country providing health care.Establishment of the Liberian College of Physicians and Surgeons strengthened Liberian physicians' participation in the West African Colleges of Physicians and SurgeonsAnnual budgeting for faculty posed additional challenges at the end of an academic year and the beginning of the next one, causing delays in starting the academic year and uncertainty for retaining the same faculty members.Strong partnerships were built between the participating institutions.September 2017 marked the inaugural graduation of Liberian trained specialists. The Obstetrics and Gynecology residency faced major obstacles, but the program prevailed with the help of multi-institutional support. The graduation marked the beginning of a pipeline of specialists dedicated to improving maternal care in the country. In 2017, the World Bank, through the Ministry of Health funded a program with US Academic Partners that allowed hiring of sub-regional faculty to support training of residents in all four specialties. The Liberian training program today has expanded to include additional residency training in Family Practice, Psychiatry and Ophthalmology. All seven (7) residency programs have continued without interruption during the COVID-19 pandemic. Six cohorts of Ob-Gyn residents have since graduated increasing the number of Obstetrics and Gynecology specialists in the country.Initially, the programs were established as a 4-year residency that was based not at one hospital, but several hospitals throughout the country. This was to ensure that rural communities had access to specialists as part of a primary care team. Over the course of the first year however, it became clear that the infrastructure in most of the rural hospitals was not adequate to support training, and the program became centered at JFK Hospital in Monrovia. The duration of the program was also decreased from 4-years to 3 years because of the delay in the first year of training due to Ebola and the urgent need for specialists in the country.The Ebola virus outbreak was a catastrophic challenge to the program. The first confirmed case of Ebola was in Lofa County near the border with Guinea in March 2014. Sporadic cases occurred in rural areas through early May 2014 with little impact on the residency program. By late May however, a second wave of Ebola included the first documented case in Monrovia in a patient who had traveled through the city, changing the outbreak from a rural to an urban epidemic . During It was difficult to provide objective data demonstrating real time improvements due to the residency program. Liberia like most African countries has challenges in data collection, accuracy, and consistency. Based on data retrieved from “Morning Report,” the number of referrals, and the volume of patients attending JFK antepartum clinic, have shown a steady increase over the course of 3-years, indicating increasing trust from the surrounding communities. Another measure that has been demonstrated through Morning Report, reflects an almost 40% decrease in primary Cesarean section. Because JFK Hospital is a referral hospital many of the Cesarean sections performed were on patients who were sent as emergencies after hours or days of labor at home or in community settings. This accounted for an estimated 50–70% Cesarean section (C-section) rate. The noticeable decrease in C-section rates, reflects better communication with the community and earlier admission to the hospital as well as improved judgement and recognition of true emergencies by the resident staff. As the program continues to grow and the administrative assistance to support the residency programs increases, a focus should be on improving data collection as a means of improving decision making and impacting patient outcomes.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.AMB, MR, AB, LR, JM, JJ, VK, MB, SS, BJ, RM, and BD contributed to conception and design of the study. ML, AD, CM, SC, JS, EG, TN, and WL contributed to carrying out the study. All authors have contributed by drafting sections of the manuscript, editing, and approving the final version that is currently being submitted.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In 2015, the AGHE Program of Merit was expanded to implement a voluntary evaluation process for health professions programs that integrate gerontology/geriatrics competencies within their curriculum. These competencies augment students’ competence and confidence in the field of aging, preparing them to work with older adults and their care partners. All health professions and medical education programs are eligible to apply for the Program of Merit designation. This international process of evaluation: (1) Verifies program credibility and quality; (2) Informs campus administrators of global guidelines, expectations, and practice in aging for their health professions programs; (3) Assures quality graduates from POM designated programs; and (4) Clarifies for employers the knowledge and skills imparted to student graduates of POM designated health professions programs. Additionally, graduates from POM programs receive a certificate from AGHE stating the health profession program is a designated AGHE Program of Merit.


Haloarcula hispanica DSM 4426T and is closely related to His2 (Pleolipoviridae family). The viral genome is 16,133 bp long, with terminal inverted repeats of 599 bp. The predicted spike protein is only weakly similar (32% amino acid identity) to that of His2.Hardyhisp2 virus infects the halophilic archaeon  Haloarcula hispanica DSM 4426T and is closely related to His2 (Pleolipoviridae family). The viral genome is 16,133 bp long, with terminal inverted repeats of 599 bp. The predicted spike protein is only weakly similar (32% amino acid identity) to that of His2.Hardyhisp2 virus infects the halophilic archaeon  Haloarcula hispanica DSM 4426T. The isolation and plaque purification followed the methods described for halovirus His2 (de novo assembler tool within Geneious version 10.2.6 (Gammapleolipovirus genus (H. hispanica.Hardyhisp2 is a novel halovirus that is related to the gammapleolipovirus His2  and was rus His2 . A stockn 10.2.6 . This ann 10.2.6 . The Hisus genus . Annotatus genus  and BLASus genus  of the NMW557853. The associated BioProject, SRA, and BioSample accession numbers are PRJNA698715, SRR13683896, and SAMN17734765, respectively.This genome sequence has been deposited in GenBank with the accession number


N-methylpyridinium (NMP) were preliminary shown to promote glucose uptake and exert anti-adipogenic properties. Against this background, we aimed at characterizing the effects of trigonelline and NMP in inflamed and dysfunctional human adipocytes. Human Simpson-Golabi-Behmel syndrome (SGBS) adipocytes were treated with NMP or, for comparison, trigonelline, for 5 h before stimulation with tumor necrosis factor (TNF)-α. NMP at concentrations as low as 1 µmol/L reduced the stimulated expression of several pro-inflammatory mediators, including C-C Motif chemokine ligand (CCL)-2, C-X-C Motif chemokine ligand (CXCL)-10, and intercellular adhesion Molecule (ICAM)-1, but left the induction of prostaglandin G/H synthase (PTGS)2, interleukin (IL)-1β, and colony stimulating factor (CSF)1 unaffected. Furthermore, NMP restored the downregulated expression of adiponectin (ADIPOQ). These effects were functionally associated with downregulation of the adhesion of monocytes to inflamed adipocytes. Under the same conditions, NMP also reversed the TNF-α-mediated suppression of insulin-stimulated Ser473 Akt phosphorylation and attenuated the induction of TNF-α-stimulated lipolysis restoring cell fat content. In an attempt to preliminarily explore the underlying mechanisms of its action, we show that NMP restores the expression of the master regulator of adipocyte differentiation peroxisome proliferator-activated receptor (PPAR)γ and downregulates activation of the pro-inflammatory mitogen-activated protein jun N-terminal kinase (JNK). In conclusion, NMP reduces adipose dysfunction in pro-inflammatory activated adipocytes. These data suggest that bioactive NMP in coffee may improve the inflammatory and dysmetabolic milieu associated with obesity.Although coffee consumption has been historically associated with negative health outcomes, recent evidence suggests a lower risk of metabolic syndrome, obesity and diabetes among regular coffee drinkers. Among the plethora of minor organic compounds assessed as potential mediators of coffee health benefits, trigonelline and its pyrolysis product  The seriousness of the global epidemic of obesity and type 2 diabetes (T2D), now collectively referred to as “diabesity”, can no longer be questioned . UpdatedN-methylpyridinium (NMP) -2-deoxy-d-glucose (2-NBDG) was estimated as described in previous research [The uptake of the fluorescent glucose analog 2-[research . In brie6 cells/mL) were fluorescently labelled by incubation with calcein-AM (5 ng/mL) for 30–45 min, and washed twice in an RPMI medium. The suspended THP-1 cells were then added to the SGBS monolayers. After 1 h, the non-adhering cells were removed by gentle washing with DMEM-F12 and monolayers fixed with 1% paraformaldehyde. Images of SGBS and adherent calcein-labeled THP-1 cells were visualized and captured with a stereomicroscope , equipped with Nikon NIS-Elements D at 40× magnification.The fully differentiated SGBS cells were treated with NMP at the indicated concentrations for 5 h and then stimulated with 10 ng/mL TNF-α for a further 18 h. To examine how many monocytes attached to the cultured adipocytes, the THP-1 cells (10www.wwpdb.org) (accessed on 12 August 2021) with PDB IDs as follows: 5NHV for ERK2, 2H96 for JNK1, 6M9L for p38, and 3A1F for gp91phox. The predicted crystal structures of NOX4 were derived from AlphaFold Protein Structure Database  (accessed on 12 August 2021) with the following Uniprot (www.uniprot.org/) (accessed on 12 August 2021) ID: Q9NPH5. In order to prepare the proteins for the docking simulation, all the missing atoms were repaired. In addition, all the water molecules and the co-crystalized heteromolecules were removed, followed by the addition of polar hydrogen atoms and neutralization using Kollman united-atom charges. The dimensions of the grid box were 60 × 60 × 60 with a 0.500 Å distance between the points. During the docking procedure, the ligand was flexible and the protein was rigid. Autodock4 and Lamarckian genetic algorithms were used to dock 250 conformations. The best docked pose was saved and the results of the best poses for the proteins with NMP were analyzed using free energy of binding (ΔG) and the Inhibition Constant (Ki). A Protein-Ligand Interaction Profiler  and Discovery studio 2020 Visualizer were used to investigate the protein-ligand non-bonding interactions of the best poses. The docking calculations were conducted using Autodock Tools 1.5.6.Molecular docking is a computational modelling technique that allows the prediction of molecular interactions that hold together a protein and a ligand in the bound state . The cryp value of <0.05 was considered statistically significant.The results were expressed as means ± S.D. Student’s t-test was used to compare the means between the control group and the compound-treated group. Multiple comparisons were made using one-way analysis of variance (ANOVA). A The conversion of the water-soluble yellow dye MTT to insoluble purple formazan crystals by the action of mitochondrial reductases (MTT assay) was used to evaluate whether concentrations of NMP or TRIGO A,B, equip < 0.01). The exposure to NMP, at concentrations of 0.1 and 1 µmol/L, before TNF-α challenge, significantly ameliorated the downregulation of GLUT-4 mRNA (p < 0.05), whereas concentrations equal to or above 10 µmol/L, even while improving the downregulating effect exerted by TNF-α, were less effective. Under the same experimental conditions, cell exposure to TRIGO before cytokine-stimulation did not exert any gene-regulating effects (data not shown). For this reason, we decided to perform the following investigations, evaluating only the metabolic activities of NMP. From a functional point of view, the exposure of SGBS adipocytes to insulin increased the glucose uptake by 250% (p < 0.05). When the cells were exposed to TNF-α for a sufficiently long time (18 h) to induce insulin resistance [p < 0.05). However, when the cells were exposed to NMP before TNF-α challenge, the glucose uptake was significantly restored. Again, lower NMP concentrations exhibited stronger regulating effects (p < 0.05).The consolidated evidence ascribes a pivotal role to TNF-α in orchestrating obesity-related metabolic dysfunction as shown, in vitro, by the reduced uptake of glucose in hypertrophic adipocytes persistently exposed to TNF-α . To evalsistance , the insp < 0.05). When the cells were made insulin-resistant by exposure to 10 ng/mL of TNF-α for 18 h, the insulin-mediated Akt phosphorylation was decreased by 43% . However, the cells’ pre-treatment with increased concentrations of NMP significantly restored, by 42%, 27% and 16%, the insulin-mediated AKT phosphorylation . These data showed that NMP, especially at lower concentrations, improves insulin resistance counteracting the TNF-α-induced downregulation of GLUT-4 mRNA, the impairment of insulin-stimulated glucose uptake, and Akt activation.Ser(S)473Akt phosphorylation (and activation) represents a key event in insulin signaling, and is a commonly estimated target to explore the effects of drugs and bioactives in terms of insulin signalling pathway improvement . As showp < 0.05), which was also highlighted by the reduced lipid droplet density on the ORO photomicrographs (p < 0.05). We next investigated whether the TNF-α-mediated reduction in the lipid content of the cells was due, at least in part, to the deregulation of the expression of the genes associated with lipolysis. We observed that the cells’ exposure to TNF-α reduced the mRNA expression of ATGL) (p < 0.05), leaving unaffected the downregulated mRNA expression of the other lipolytic genes assessed (data not shown). In line with these results, TNF-α per se induced a significant increase in glycerol release (p < 0.05). Again, the cells’ pre-treatment with 0.1–10 µmol/L NMP prevented the TNF-α-mediated induction of glycerol release (p < 0.05).It is well known that inflamed insulin-resistant adipocytes are characterized by low lipogenic capacity and high lipolytic activity, which causes increased FFA release . In an arographs B. Pre-trof ATGL) A, as welUnder obesogenic conditions, hypertrophic adipocytes begin to secrete TNF-α, which in turn induces the expression of an array of adipokines able to attract circulating monocytes to the adipose depots, thus further fueling and worsening insulin resistance . The preIn an attempt to elucidate the molecular mechanisms through which NMP affects adipocyte physiology under adipogenic pro-inflammatory conditions, we preliminarily investigated the ability of NMP to interact with key molecular switches in adipocyte biology by performing a predictive computational analysis using a molecular docking approach . To thisUnder persistent obesogenic conditions, hypertrophic adipose cells prime local and systemic low-grade inflammatory states that may favor the development of preclinical metabolic dysfunction into overt T2D and related cardiovascular sequelae, especially in centrally obese subjects . In closDue to its neuromodulatory effects and its soft bitter taste, the consumption of coffee beverages has significantly increased over the last 150 years, to the point where it has become one of the most traded commodities in the world , many moHere, we report that, at concentrations equivalent to those attainable in vivo ,26 afterTo tentatively explore the underlying mechanisms of action, we showed that NMP reversed the inhibition of S473Akt and restored the expression of the master regulator of adipocyte differentiation and metabolism, PPARγ, possibly by downregulating the activation of JNK. The metabolic regulating effects of other coffee components, including caffeine, caffeic, clorogenic acids ,52, and In physiological conditions, insulin’s interaction with its receptor (IR) determines the autophosphorylation of its tyrosine residues that enable IR to attract and activate the IR substrate (IRS)-1, which, in turn, leads to the recruitment and activation of the catalytic subunit of PI3K. Once activated, PI3K converts phosphatidylinositol-4,5-bisphosphate (PIP2) to phosphatidylinositol-3,4,5-triphosphate (PIP3) within the plasma membrane. The interaction of Akt with PIP3 makes possible the activation of Akt by upstream kinases: the 3-phosphoinositide-dependent protein kinase-1 (PDK1) that phosphorylates Akt in Thr 308 , and the mammalian target of rapamycin complex 2 (mTORC2), DNA-dependent protein kinase (DNA-PK), and ataxia telangiectasia mutated kinase (ATM). This induces the full activity of Akt, phosphorylating it in Ser473 (regulatory domain) . Upon acWe observed that NMP was able to counter-regulate both the TNF-α-mediated downregulated expression of GLUT-4 and the inhibition of S473Akt phosphorylation, suggesting the potential ability of NMP to interfere with mechanisms upstream of IKK activation. In agreement with Ruan et al. , we alsoWe demonstrated, for the first time, that adipocyte exposure to NMP effectively improves insulin signaling while reducing monocytoid cell adhesion and related stigmata of inflammation, thus further allowing its qualification as an anti-inflammatory molecule. Moreover, taking all these findings together, we propose for NMP the potential to act as an anti-inflammatory and insulin-sensitizing bioactive molecule. This may explain and sustain, at least in part, the anti-diabetic and anti-obesity properties of coffee beverages ,17. A li