BackgroundEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a diagnostic procedure that allows clinicians to stage lung cancer by sampling lymph nodes in the mediastinum. EBUS-TBNA is recommended as a first step prior to mediastinoscopy for lung cancer mediastinal staging. This procedure has greatly aided pulmonologists in diagnosing mediastinal pathologies with substantial progress. In this study, our aim is to analyze how cell blocks affect the diagnostic yield of mediastinal and hilar lymphadenopathy using an EBUS cytology needle.MethodsThis retrospective study was conducted at King Abdulaziz University Hospital between May 2021 and September 2021. Patients with mediastinal and hilar lymphadenopathy in the absence of known or suspected primary lung cancer were included. The EBUS procedure was performed using a flexible bronchoscope equipped with a working channel suitable for transbronchial needle aspiration under direct ultrasound guidance. Data were recorded using Microsoft Excel and analyzed using Statistical Package for the Social Sciences (SPSS) v. 26.0 . Diagnostic accuracy measures were determined, and a p-value of 0.05 was established as the final threshold for statistical significance.ResultsThe total number of patients in our study was 151. The sensitivity for cytology specimens, histology specimens, and a combined evaluation for the full group of patients was 77.14%, 83.33%, and 87.5%, respectively, with a negative predictive value of 27.22%, 25%, and 21.42%. The diagnostic accuracy for cytology specimens, histology specimens, and a combined evaluation was 71.42%, 76.19%, and 80%, respectively.ConclusionOur study found that the combined examination of specimens for both cytology and histology in the diagnosis of lung cancer, sarcoidosis, and tuberculosis resulted in a higher diagnostic yield compared to cytological assessment alone using EBUS-TBNA. Conventionally, a variety of techniques have been available for mediastinal staging, including mediastinoscopy, blind transbronchial needle, and video-assisted thoracoscopy. However, in 2002, endobronchial ultrasound combined with transbronchial needle aspiration (EBUS-TBNA) was introduced. It uses ultrasound and bronchoscopy to visualize the airway wall and nearby structures and provides real-time guidance for sampling mediastinal and hilar lymph nodes and tumors . EBUS-TBIt has been shown that minimally invasive treatments such as EBUS-TBNA can yield high diagnostic value for lung cancer. Additionally, EBUS-TBNA has been utilized in diagnosing metastases from various solid tumors, sarcoidosis, tuberculosis, and lymphoma -5. RecenAdditional diagnostic tests can be performed by processing EBUS-TBNA material into a cell block preparation (CB). Combining CB with smear preparation has been shown to increase EBUS-TBNA diagnostic yield, and its routine application for the diagnosis of lung cancer has been endorsed by numerous medical associations. However, CB preparations are rarely employed in EBUS-TBNA samples, and little is known about their role in the diagnostic process -10.Most of the initial studies or trials have used highly preselected patient populations, which has resulted in high diagnostic accuracy. While the use of EBUS-TBNA has been well studied in the literature, there is a growing interest in evaluating the diagnostic utility of this modality in unselected patient populations , as wellPopulationThis retrospective study was conducted at King Abdulaziz University Hospital from May 2021 to September 2021. The study included patients with mediastinal and hilar lymphadenopathy without known or suspected primary lung cancer. Data collection commenced after the hospital institutional review board committee had given its approval.EBUS-TBNA techniqueThe EBUS procedure was performed using a flexible bronchoscope  equipped with a working channel suitable for TBNA under direct ultrasound guidance and a distal probe that could do linear parallel scans of the mediastinal and peribronchial tissues. Topical lidocaine spray and intravenous midazolam were administered to provide local anesthetic and conscious sedation, respectively, in accordance with established standards. To perform EBUS-TBNA, a special 22-G TBNA needle  was used. The internal stylet was used to clean the needle's tip after it had been inserted into the mass. Most passes were carried out using a 20-mL VacLoc syringe . The needle was moved from the bronchoscope channel to the tracheal lumen under ultrasound guidance to reach the node or mass, and was then propelled out of the sheath and implanted into the tracheal or bronchial wall. The needle was pushed forward and back while maintaining negative pressure with a syringe at the catheter's proximal end to release the suction before the needle was removed from the target structure.Lymph node aspirates were smeared onto glass slides, air-dried, and clotted on filter paper. The specimens were then immediately placed in 10% formalin for further laboratory processing to generate cell blocks. No on-site rapid cytology was performed. EBUS-TBNA is considered diagnostic in cases of sarcoidosis or lung cancer if clear and definitive histological and cytological samples of the lymph tissues are obtained. In addition, other diagnoses such as TB were included if found during our investigation. If the procedure failed to provide a definite diagnosis and presented normal lymphoid tissue, it was considered non-diagnostic. All obtained glass slides were examined by a cytology screener and reviewed by two board-certified pathologists.Statistical analysisA Microsoft Excel sheet was used to prepare the data sheet to record all data, including demographic characteristics such as name, age, gender, ID, date of procedure, and nationality, as well as indications for performing EBUS, such as lung cancer, sarcoidosis, tuberculosis, and others. The lymph node station was also recorded in the datasheet. The Statistical Package for the Social Sciences (SPSS) v. 26.0  was used to analyze the data. The results were presented as frequencies and percentages or means ± standard deviation. A Kruskal-Wallis test was used for comparing data in more than two groups, and a Wilcoxon signed-rank test was used for pairwise comparisons. Diagnostic specificity, sensitivity, negative predictive value (NPV), positive predictive value (PPV), and accuracy were determined using accepted definitions. A positive predictive value was defined as the likelihood that a subject with a positive test result will have the disease of interest, whereas a negative predictive value was defined as the likelihood that a subject with a negative test result will not have the disease. Specificity was defined as the probability of receiving a negative test result in a person without the disease, while sensitivity was defined as the probability of receiving a positive test result in a subject with the condition. Diagnostic accuracy was defined as the percentage of subjects that were correctly classified out of all subjects. A p-value of 0.05 was established as the final threshold for statistical significance.Out of the 151 patients who underwent EBUS-TBNA, 101 (66.89%) were male, and the overall mean age of the patients was 52.46 years (range 15-83 years). The EBUS-TBNA evaluation was performed on patients suspected of having lung cancer , lymphoma , sarcoidosis , and tuberculosis (TB)  , six cases of histological cell blocks (4.38%), and 89 cases with a combined evaluation (64.96%). The combined evaluation of histology and cytology specimens resulted in the highest rate of positive results and the lowest rate of non-diagnostic results  of 27.22%, 25%, and 21.42%. The diagnostic accuracy was 71.42%, 76.19%, and 80%, respectively . Similarly, for the diagnoses of sarcoidosis and TB, the sensitivity for the combined evaluation was significantly higher when compared with the cytological and histological evaluations separately (P=<0.001 for each). A significant difference was observed in the sensitivity of diagnosing lung cancer, sarcoidosis, and TB in the cytology evaluation (P=<0.001). The sensitivity of cytology specimens for sarcoidosis was higher when compared with lung cancer and TB. A higher negative predictive value was detected in the cytological evaluation of the sarcoidosis group compared to others. Higher accuracy was found in diagnosing sarcoidosis and TB in their histological evaluation. No cases of lung cancer were diagnosed using histological evaluation, and thus no true negative findings were found. As a result, there was no negative predictive value in the histological evaluation of sarcoidosis and TB. A significant difference was observed in the sensitivity of diagnosing lung cancer, sarcoidosis, and TB in the combined evaluation of both cytological and histological specimens (P=0.032). There was also a significant difference observed in the accuracy of different diagnoses in the combined evaluation of cytology and histology (P=0.041). However, no significant difference was found in the negative predictive value of lung cancer, sarcoidosis, and TB in the combined evaluation Table .The results of this study confirmed that adding cell block evaluation to cytological assessment in samples obtained by EBUS-TBNA improves diagnostic sensitivity. The sensitivity of EBUS-TBNA was found to be 77.14% for cytology specimens, 83.33% for histology specimens, and 87.5% for combined evaluation. The negative predictive value for the same specimens was 27.22%, 25%, and 21.42%, respectively. The diagnostic accuracy was found to be 71.42% for cytology specimens, 76.19% for histology specimens, and 80% for combined evaluation. Compared to Žemaitis et al.'s retrospective study, our results show higher sensitivity percentages . Their sAccording to multiple studies, the diagnostic utility of EBUS-TBNA heavily relies on the technique and expertise of the performing bronchoscopist. The representativeness of EBUS-TBNA samples has improved over time as bronchoscopists' skills have enhanced. Learning and maintaining this approach requires significant effort. Another factor that could impact the sensitivity of EBUS-TBNA is the method used to select patients for the procedure. A meta-analysis showed that trials that included patients based on a positive CT or PET scan result had a higher sensitivity  -17.Our results showed that out of the 151 patients who underwent EBUS-TBNA, 47 were diagnosed with lung cancer (31.1%), 24 with sarcoidosis (15.9%), 23 with tuberculosis (15.2%), ten with lymphoma (6.6%), and three with metastatic adenocarcinoma (2%). A retrospective study conducted in 2012 on 129 patient samples found that lung cancer was detected in 81% of cases, extrapulmonary carcinoma in 10%, sarcoidosis in 4%, lymphoma in 2.7%, and tuberculosis in 0.9% of cases . The stuPulmonologists and surgeons are convinced that EBUS-TBNA is superior to standard TBNA and an appropriate alternative to mediastinoscopy in lung cancer patients, and the lung cancer care landscape is changing accordingly. Oncologists are more interested in acquiring tissue to obtain relevant samples for personalized care of patients with advanced lung cancer. EBUS-TBNA has proven to be a reliable method in this regard. Many oncologists acknowledge the advantages of EBUS-TBNA because it allows for the sampling of many tumor metastatic areas, which is crucial as tumor heterogeneity becomes more apparent . EBUS-TBThe information obtained from EBUS-TBNA cytology samples may not always be sufficient. Additional tissue may need to be obtained, which can be accomplished by converting the collected material into cell blocks. Immunohistochemical labeling and histological diagnosis can then be performed. New treatments for lung cancer have been introduced with varying degrees of success and toxicity, requiring an accurate classification based on pathology. Therefore, cell blocks can be recommended to aid in the diagnosis of lung cancer as they can contribute up to 47.9% of aspirates obtained through EBUS-TBNA and up to 37.6% for definitive diagnosis. A study has shown that the diagnostic yield of EBUS-TBNA was enhanced from 72.9% to 80% in 26.4% of patients , 22. In The study has several limitations that should be considered when interpreting the results. The sample size was relatively small, which could limit the generalizability of the findings. Furthermore, the results could have been variable based on different laboratory methods and references used. The retrospective design could introduce bias, and the lack of blinding may have affected the accuracy of the analysis. The study was conducted at a single center, which may limit the generalizability of the findings to other healthcare settings. The study did not compare the diagnostic yield of EBUS-TBNA to other diagnostic methods, which could provide more information on the overall accuracy of the procedure. Finally, the experience level of the clinicians performing EBUS-TBNA may affect the diagnostic yield of the procedure.For evaluating mediastinal and hilar adenopathy, the EBUS-TBNA test remains the gold standard. The approach has been refined since its inception to eliminate unnecessary steps, reduce procedure time, and increase diagnostic yield. Our study found that the combined evaluation of cytology and histology specimens in the diagnosis of lung cancer, sarcoidosis, and tuberculosis demonstrated that EBUS-TBNA had a higher diagnostic yield.


Participation in psychosocial enrichment activities, such as music and arts programming, have shown potential to delay or reduce functional decline - without adverse effects that can be associated with pharmaceuticals. The performing-arts programming described in this community case study was inspired by a community music program called B-Sharp Music Wellness, located in Phoenix, Arizona, which involved small groups of musicians who provided symphony performances for people with dementia. Our community programming sought to engage people with dementia and their informal care partner  in existing performing-arts programs in their local community, providing social hours and season tickets for either symphony, dance , or non-musical theater performances. This case study describes the program history and design, including outcomes and lessons learned from the program evaluation of the last full season (2018–19) and partial season (2019–20), when the program was halted due to the COVID-19 pandemic. Program outcomes suggest strategies for, and benefits of, design for performing-arts programs as psychosocial interventions in other communities. For somFor PWDs and CPs, treatment options are limited to sparse choices in non-pharmacological interventions that can require additional coordination, transportation, or fear of stigma for the PWD or CP . Most phvia this multiyear community engaged case study in hopes that others interested in implementing similar programs can learn from our efforts.The B/C-Sharp community-based performing-arts program sought to address many of the current limitations in traditional pharmacological and non-pharmacological interventions. The program intentionally involved CPs, not only to enhance the PWDs’ experiences, but also to enhance CP QOL. Programming took place at a community performing-arts center, capitalizing on a normalized social environment that was dementia-friendly. The program also explored benefits of the dyad-focused intervention across a variety of outcome measures spanning biological, psychological, and cognitive health, providing insights regarding strengths and weaknesses of each outcome measure and enhancing our understanding of how CPs can best be included in future programs. The goal of this manuscript is to outline elements of the B/C-Sharp program as well as detail the evolution of our research approach and lessons learned 2.B/C-Sharp began in fall 2015 with a symphony experience. With support from the National Endowment for the Arts, programming expanded in 2018 to include dance and theater as alternative programs and to compare participant perceptions between the three programs. All three programs were offered until March 2020, when B/C-Sharp was halted due to the COVID-19 pandemic. A goal ofB/C-Sharp was to better understand lifestyle or environmental factors benefiting cognitive health and wellbeing in healthy aging and in PWD. This paper focuses on program design, procedures, evaluation methods, and outcomes of the 2018–19 season and partial 2019–20 season. Program evaluation included the “gold standard” measurement (paper and pencil cognitive testing) that is used in traditional pharmacological studies and clinical trials involving older adults to evaluate whether a community-based non-pharmacological intervention could also lead to improved changes in cognition with participants with neurocognitive decline . These f2.1.B/C-Sharp took place at a performing-arts center in a community of approximately 170,000 individuals . The cen2.2.Participants were recruited from senior centers, senior housing communities, churches, local nonprofits, and related organizations, with the goal of recruiting 15 dyads each for the new dance and theater programs.M = 2013). CPs were 40–91 years old, and healthy controls were 61–81 years old.All project elements received institutional review board approval with participants providing written informed consent. A total of 208 unique participants  enrolled in the program from 2018 to2020, including 34 dyads for dance and 30 dyads for theater. Dyads included 56 spousal/partner, 16 parent/child, 3 friends, 2 professional caregivers, and 1 sibling relationship. Dyad relationships were unknown for participants who began the program prior to 2018. Cognitively healthy controls, added in the 2019–20 season, were not required to participate in dyads. PWD were aged 55–95 years, with 58 having formal ADRD diagnoses. Dates of diagnosis ranged from 1994 to 2018 . Cognitive performance for PWDs and healthy controls were measured with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), a gold standard in the assessment of cognitive decline for its domain specificity, short duration, and high test–retest reliability through the use of parallel testing forms  provided information ng forms . The RBAAssessments were also conducted during the social hour before and after each performance, with follow-up CP telephone interviews one-week post-performance . Pre- anOther measures included wearable activity trackers and direct observations. Participants wore Fitbit activity trackers to measure heart rate, activity rate, and sleep patterns before, during, and after attending a performing-arts event. Direct observations were conducted by trained graduate students and recorded in detailed field notes for five events during the 2018–19 season . See Tab3.3.1.an emphasis on mixed-methods program evaluation, with qualitative data yielding the most valuable information, coordination and collaboration with CPs, and the community-driven nature of this program.Across 2018–2020, key B/C-Sharp elements established its overall success, leading to important findings related to improved dyad QOL as well as implications about community-based psychosocial programming. These included 3.1.1.via enjoyable processes, successfully generating valuable insights into dyads’ program experiences.Throughout the program evaluation process, qualitative components (interviews and observations) most successfully engaged participants and generated valuable findings as CPs could actively facilitate these methods with PWDs. Furthermore, social hour/performance observations and CP interviews were often part of the “fun” of B/C-Sharp whereas PWDs found the RBANS stressful, making it harder to incentivize completion. Thus, we obtained qualitative data more easily 3.1.2.As the program developed and its complexity increased, it became clear that program success depended upon engaging CPs and showing them the value of participation. Efforts to introduce new evaluation procedures without first consulting CPs could result in implementation challenges, inconsistent data, and less effective programming. When CPs were excited about programming, they engaged with methods more consistently. For example, when feedback highlighted that symphony attendance could be difficult due to the late start times, our team created programming options with matinee  or shorter performances . Similarly, the introduction of saliva sampling was embraced by CPs and, in turn, PWDs, as the team made special materials to explain the collection process, its purpose, and why it mattered. Saliva sampling experienced high participation, which we largely attribute to our collaboration with CPs.3.1.3.From its onset, B/C-Sharp was driven by a strong community-university partnership. Prior to program recruitment, the research team secured ticket donations for season performances from the local symphony, dance troupe, theater troupe, and performing-arts center. Community collaborators assisted with other aspects of the program. A local nonprofit functioned as the financial hub for donations and provided snacks for symphony performances. Other area nonprofits collaborated on recruitment and program enrollment. Ultimately, B/C-Sharp thrived because it was supported by multiple community organizations in addition to the interdisciplinary research team .3.2.quantitative data procedures, difficulties enrolling and sustaining participation, and overall program complexity.While B/C-Sharp had numerous successful components, it was not without challenges, which centered on 3.2.1.The primary quantitative evaluation outcome was cognitive performance as measured by the RBANS . Partici3.2.2.Partway through the program, we sought to introduce activity tracking before, during, and after programming. As cognition and QOL can be improved with additional exercise and sleep quality, we explored what role physiological changes played in program outcome measures. A small number of dyads were invited to wear Fitbits to track movement and sleep quality for approximately 5 days before a program event through approximately 5 days afterward. Through the pilot program, it became clear that using Fitbits would not be feasible. Too many PWDs found the Fitbits distracting or annoying, often removing and losing them. For CPs, remembering to keep Fitbits charged, keeping track of their own Fitbit and their partners’, and managing the additional research appointments needed to download Fitbit data was too challenging. Thus, this procedure was abandoned.3.2.3.Some quantitative data difficulties involved the broader challenge of engaging a difficult-to-reach population. Across B/C-Sharp, missing data became a significant problem as individuals skipped performances, declined to participate in testing due to frustration or fatigue, or dropped out because of ADRD progression or other circumstances. Even for participants who persisted in B/C-Sharp across multiple years, missing data made it difficult to draw meaningful inferences. Program sample sizes were often too small to adequately power the more sophisticated analyses needed to account for the myriad factors that influence changes in cognitive performance or QOL over the duration of a nine-month program.3.2.4.A final challenge was program complexity. Coordinating multiple community-based programs with different evaluation components could overwhelm participants. Even seemingly simple tasks (like completing intake surveys) often resulted in incomplete data because these procedures interrupted event social time (a key benefit of program participation) and felt less meaningful to CPs. Additionally, the barrage of data collection procedures meant that dyads sometimes picked and chose which they wanted to do at any given event—further complicating the data collection process.3.3.positivity, engagement, social interactions and relationships, and overall improved wellbeing and QOL due to program participation.Despite program challenges, we were able to draw upon qualitative data to assess behavioral, sociological, and QOL impacts of B/C-Sharp programming. In total, 47 interviews  were analyzed, and observational data from five events  was assessed. We used inductive analysis and visualizations using the NVIVO software program to identify themes . Key ben3.3.1.“[It was] Good. Excellent, always is. I just enjoy the process, I enjoy thinking about it, I enjoy going there, I enjoy whatever degree of socializing can happen. I like it at all!” Feelings of positivity were associated with several program aspects: going out for a special event with a loved one, the performance itself, seeing and interacting with others, and a positive change in mood.Dyads used words like “enjoy,” “love,” “great,” “wonderful,” and other positive terms like “memorable” and “meaningful” to describe how they felt about the program. For example, a multi-year symphony CP articulated her consistently positive experiences: “It’s fun! You never know what’s going to happen.” Observations noted that researchers used humor to reduce anxiety during cognitive assessments and saliva collection, and many participants described that the saliva collection was fun due to the joking around during collection.Participants described how B/C-Sharp created a fun, safe space for dyads to have an evening out without overemphasizing the role of dementia in their lives. Direct observations noted a joyful atmosphere during the social hour, with participants smiling and joking. Participants also noted that the research team created a positive atmosphere, welcoming them warmly and making small talk. As a symphony CP described: “It does make him happier to do something like this and go back to things he did when he was well. It’s a big relief for both of us, because life is really stressful because of his disease. This is a really nice getaway just to see him smile and have a good time. These kinds of things make him very happy.”Often dyads were motivated to participate because they had attended performing-arts programs together prior to the challenges of dementia. As one (dance) participant explained: “[…] The best part was probably just being out for the evening. I think it’s just the socialization and getting to participate in something.” Participants described enjoying socializing with others experiencing dementia, interacting with the research team (including student researchers), and connecting with the larger community.For many participants, engaging in a social activity was a strong motivation for program participation. A symphony CP explained: “I just do not know how to explain. I mean she was just in a really more upbeat temperament when I took her home. I think she was a little scared when we first went because it was something she had never done before.” Although most CPs described improved mood due to program activities, the research component caused stress for some, because it revealed how PWDs struggled with tasks that previously would have been simple. This was occasionally reflected in mood scales and observations noted a few participants appeared upset about quantitative assessments, typically RBANS. Usually a poor mood did not last, as one symphony CP observed: “… it’s almost like she forgot about the testing by the end of [the evening]. She was just amazed about the ability of the musicians […] She was very impressed at their talent.” CPs explained their mood was sometimes lower after the event in anticipation of returning to the daily challenges of living with dementia.Participation across all programs was associated with improved mood per interview, mood scale, and observational data. As a symphony CP shared: 3.3.2.“She was fully engaged and engrossed in the play and noticed other people around. She not only engaged with me and also the person seated on her other side […] she did not know her prior to the performance.”Participant engagement was high for all programs, with only two participants describing low engagement (one symphony PWD and one theater CP). Interview and observational data illustrated how PWDs were more alert during programming than they were with similar activities . CPs and researcher-observers reported PWDs watching performers intently, clapping hands and/or singing along, commenting about aspects of the performance, looking to other audience members for reactions, reading the program, and reminiscing after the performance. A theater CP explained: 3.3.3.“Well, these days, we are at a point where I am definitely the caregiver. There were moments where I wasn’t in the role, which was nice […] it felt like an actual partnership” (symphony CP). Many CPs described holding hands during the performance and reminiscing together afterwards.Nearly all CPs said B/C-Sharp improved their relationship with their PWD, with only two CPs noting no changes. Several CPs explained that B/C-Sharp helped them feel more connected with their partner, describing participation as a “date night” and reprieve from caregiving: “It’s hard—we are not a couple anymore like we used to be, so people do not include us anymore in those types of activities sometimes.” Nearly all CPs described joy in connecting with others through the program. Observational data underscored dyads’ interactions, including conversations about the challenges of dementia and around shared interests, hobbies, etc. As a dance CP described: “It wasn’t what we were expecting. We enjoyed getting out and being among other people. We both enjoyed it.”B/C-Sharp also helped dyads create new relationships and allowed them to reconnect with acquaintances. Many CPs described becoming more isolated after their partner began exhibiting dementia symptoms, whereas B/C-Sharp helped them feel like a part of the community. A dance CP explained 3.3.4.“Memory—he kept bringing it up. We talked about it all the way home, and the next day, he brought it up without even having the program in front of him. He brought it up without me mentioning it and said how great it was and what a different performance it was” (dance CP).Many CPs described their surprise at what their partner could recall about B/C-Sharp events and how much they discussed their experiences together: 3.3.5.“[…] It’s just a great way to spend an afternoon, otherwise we would have just watched a football game on television, or she would have taken a nap.” Several participants explained that B/C-Sharp gave them confidence to do more activities, and a few noted that it helped them understand the importance of staying active: “[…] One of the things I learned the last year is how important it is to stay in the world. If something comes around, we do it” (symphony CP).Many CPs noted that B/C-Sharp renewed their interest in activities they used to do prior to their partner’s ADRD. A dance CP shared that he appreciated how the program changed their routine: 3.4.setting afforded social interactions, learning, and arts engagement; setting facilitated positivity and escapism; and spatial configuration created some challenges.In addition to documenting B/C-Sharp’s effects on wellbeing, we sought to understand the role of the program’s enriched environments . Analysis of observational and interview data revealed three themes: 3.4.1.The pre-performance social setting afforded opportunities for social connection. Observations noted that lines formed at the entrance to the event space as participants greeted researchers and each other. The refreshments and community table were hubs for social activities, enabling new participants to easily join conversations. Observers noted that participants moved between tables, forming and reforming small groups. Notably, observers did not record participants engaged in solitary activities (like browsing their phone) during social hours. Interviews also underscored the importance of the social space for connecting with others, as some CPs noted that socialization was more difficult on the few occasions where participants outnumbered the available seating.The event space layout also enabled communication between participants and researchers, facilitating informal learning. The ticket and saliva collection tables were located near the front of the room, with researchers stationed at those tables engaging with participants and within earshot of those at the refreshment area. Participants shared that they felt comfortable chatting with both faculty and student researchers. Observations noted many participant-researcher conversations sharing research findings and available community resources.Data revealed the role of others in the audience as a part of the B/C-Sharp experience. Observers recorded how participants would visually connect with other audience members during performances as a form of nonverbal communication, validating their emotional experience. They also chatted with study participants and other patrons during intermission and after the event, “checking in” to see if they had similar reactions. Many CPs cited this type of interaction as a program benefit and described how their PWDs initiated conversations about the performance with strangers, something they did not typically do.3.4.2.Observers noted the social atmosphere started out calm, with increased energy as the performance approached. Before walking to the performance, participants clustered together, talking in excited tones. This atmosphere of building anticipation created an engaging experience, with some specifically noting that in their interviews. During performances, participants were observed responding with emotion appropriate to the performance, including excitement , surprise (raising eyebrows and looking around at others), and calm/relaxation (closing eyes). Observers noted that PWD showed signs of high engagement during performances and looked to other patrons to gauge their responses.3.4.3.In interviews, CPs sometimes described issues related to physical obstacles. The most significant involved transportation and parking challenges. Some participants relied on a “Dial-a-Ride” service and were frustrated that they had to leave early to meet their pick-up window or were anxious that they might miss a ride. For those who drove, the number and location of parking spaces was difficult, as significant walking was required to get between parking, the social event space, and the performance space. Distance to the restrooms was also a challenge. Another common issue was the number and location of wheelchair seating in the performance halls. On a few occasions, CPs were unable to sit with their PWD who needed to remain in a wheelchair. The third significant theme related to challenges had to do with the timing of performances (mainly in the evening), with concerns their PWD would get tired or be at risk of “sunsetting behavior” that would not be conducive to enjoying an evening out.4.Our project’s aim was to co-design and evaluate performing-arts psychosocial programming for PWDs and CPs. Specifically, we explored whether performing arts could affect wellbeing for PWDs and CPs. Cognitive testing, while not statistically significant, showed a clear trend in improvement on total cognitive score and, more importantly suggested that brief neuropsychological testing is feasible in the context of arts-based, on-location settings. Qualitative data revealed that B/C-Sharp improved mood, memory, social relationships, and overall QOL. Our findings suggest that whichever types of performing-arts programming participants prefer (and find engaging) will likely prove the most beneficial for them. Additionally, architecture plays a role in psychosocial programming for PWD, including the need to go beyond universal design guidelines to create more inclusive spaces. Throughout our analyses, we identified clear successes and challenges in this complex, community-engaged program featuring a difficult-to-reach population. We now discuss the implications of our findings and recommendations for implementing similar programs in other communities.4.1.Our findings suggest that community performing-arts programming can improve PWD and CP sense of wellbeing and QOL by helping them experience “returning to normal” as a couple and engaging in a fun social experience without overemphasizing the role of dementia in their lives. B/C-Sharp also helped participants strengthen and expand their relationships. This is notable, as PWD and CPs’ networks often shrink post-ADRD diagnosis , and sma4.2.and create barriers. Due to the passage of the Americans with Disabilities Act of 1990, U.S. buildings are constructed to universal design building codes. However, disability researchers argue that universal design is insufficient, suggesting instead an inclusive design approach. Our findings suggest that the physical environment can both enhance performing-arts programming 4.3.connecting with and collaborating alongside CPs. Throughout B/C-Sharp, we found CPs invaluable to the co-design and evaluation process. When CPs valued procedures, they participated eagerly and successfully persuaded PWDs to participate. For example, CPs helped us understand that methods that felt too “medical” detracted from the B/C-Sharp experience. As such, we worked with CPs to identify measures that would accomplish evaluation aims without removing the special-ness of the performing-arts experience. We advocate including CPs as valued participants and co-designers. CPs are highly knowledgeable about challenges and how PWDs respond to different circumstances; valuing their expertise builds capacity for better research and increases participant buy-in.Throughout this project, we learned valuable lessons for those developing similar programming. The first lesson includes selecting and implementing evaluation measures carefully. Throughout B/C-Sharp, we collected numerous forms of data to document program outcomes: short- and long-term cognitive performance (RBANS), mood, QOL, saliva samples, post-performance interviews, and observational data. Our intention was to have a thorough account of B/C-Sharp outcomes; the result was a patchwork collection of measures. Thus, we recommend choosing a few measures with dyads in mind (in collaboration with CPs) to ensure a more complete dataset toward more conclusive findings.A second lesson includes strike a balance between participant desires and research needs. Throughout B/C-Sharp, dyads could be skeptical of procedures core to addressing research questions. Acknowledging these concerns while underscoring the measures’ value was essential. This involved communicating clearly and often with stakeholders about research goals and the value of participation. Creating a sense of value in participants  was key. As such, investigators should not automatically abandon measures met with hesitance from participants, instead working collaboratively with them to communicate their value, increase buy-in, and, if need be, identify alternatives.A final lesson learned is to 4.4.Despite its compelling findings, this project had limitations. First, participants were drawn from a community sample, resulting in a homogenous participant pool . Additionally, asking dyads to participate in an intervention over several months was challenging. ADRD progression can be unpredictable , making Given the significant burdens resulting from ADRD, there is a critical need to identify effective non-pharmacological, psychosocial interventions promoting cognitive health and wellbeing. Despite its limitations, our program points to how performing arts might lead this new research frontier. Contributions from B/C-Sharp include its innovative design and important findings. First, our approach was translational, informed by basic science, clinicians, and community agencies. Second, our approach was comprehensive, with interventions intentionally designed as integrated, community-based experiences that took advantage of the rich programming already available. Finally, our team developed an inventory of protocols for measuring physiological responses, social engagement, QOL, program experiences, and cognitive function that captured rich  outcomes helping us better understand key components in effective therapeutic applications of community performing-arts programming.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Colorado State University Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.LM, MF, and DD contributed to the program design and evaluation and to the manuscript creation, including concept, organization, writing, and editing. LM created Figures 1 and 2 and organized Table 1, with input from MF and DD. All authors contributed to the article and approved the submitted version.This project was supported by an award from the Research: Art Works program at the National Endowment for the Arts: grant# 1809975-38-18, along with funding from the Catalyst for Innovative Partnerships grant program through the Office of the Vice President for Research at Colorado State University and by the Columbine Health Systems Center for Healthy Aging (Pilot Funding for Innovative Research in Aging). Additional support was provided by the Fort Collins Symphony, Canyon Concert Ballet, Open Stage Theater, Fort Collins Lincoln Center, Banner Health, Community Foundation of Northern Colorado, Home State/Guaranty Bank, International Neuroscience Network Foundation, Kaiser Permanente, Rotary Club of Loveland, Sage Benefit Advisors, and individual community donors.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.


Smear microscopy has remained the initial diagnostic test for presumptive tuberculosis (TB) patients in health facilities without the World Health Organization (WHO) recommended rapid diagnostic tools. In the Uganda TB laboratory network, the technique remains the only tool to monitor response to treatment among drug susceptible TB patients, with the country currently having over 1,600 microscopy TB testing units. It has been evidenced that acid-fast bacilli (AFB) microscopy’s yield highly depends on the staining technique and reading ability of the laboratory personnel. For the quality of TB testing in the country, the TB control program set up a Randomized Blinded Rechecking (RBRC) program in 2008 to monitor the testing performance of laboratories to continuously improve the reliability and efficiency of results. This is the first study to determine the effectiveness and impact of the RBRC program on the performance of the participating laboratories in Uganda.This was a retrospective cross-sectional study based on a record review of the RBRC’s annual results compilations between January 2008 and December 2017.Between January 2008 and December 2017, a total of 265,523 smears were re-checked during the RBRC program. The number of enrolled laboratories in the RBRC program rose from 660 to 2008 to 1,406 in 2017. The RBRC program resulted in a statistically significant reduction in microscopy errors, with false positives decreasing from 12.8% to 2008 to 7.6% in 2017, false positive errors decreasing from 10 to 6.3%, false negative errors decreasing from 2.9 to 0.7%, quantification errors decreasing from 6.0 to 1.8%, and the overall sensitivity of smear microscopy compared to the controllers increased with statistical significance from 93 to 97%.The study reveals an overall significant error reduction and an improved sensitivity of smear microscopy upon continuous implementation of the RBRC program in an AFB microscopy TB laboratory network. Implementation of a RBRC program is crucial and essential to maintaining a reliable TB laboratory service that can facilitate accurate diagnosis and offset the disadvantages of using smear microscopy. Tuberculosis (TB) is an old scourge that has remained captain among infectious diseases. Studies of human skeletons reveal that this public health menace has affected humans for thousands of years , 2. It iDespite the significant advancement in TB diagnostic and monitoring tools, classical smear microscopy remains the most common and economical method to detect pulmonary TB. The test of 135 years directly identifies Acid-Fast Bacilli (AFB) in Ziehl-Neelsen (ZN) sputum under a microscope . This isTo maintain a reliable laboratory service that can facilitate accurate diagnosis and offset the disadvantages of using smear microscopy, a well-functioning quality assurance (QA) system is essential to ensure that information generated by the laboratory is accurate, reliable and reproducible . ExternaThe International Union Against Tuberculosis and Lung Disease (IUATLD)/ World Health Organization (WHO) recommended three EQA Programs for any Tuberculosis Laboratory Network . FirstlyIn 2002, with the support of IUATLD, WHO, Japan Anti-Tuberculosis Association (JATA), Koninklijke Nederlandse Chemische Vereeniging (KNCV), Centers for Disease Control and Prevention (CDC) and Association of Public Health Laboratories (APHL), a 14-member workgroup developed the multi-sponsored EQA guidelines which recommend Lot Quality Assurance Sampling (LQAS) for RBRC . Lot QuaIn Uganda, all TB laboratories follow the WHO guidelines and grading system of microscopic diagnosis for all AFB smear microscopy readings  therefore samples 10 slides per lab per quarter using a simple random sampling method (for the first slide to be picked) where slides are selected using the laboratory register and not directly from the slide box. The subsequent selection of slides is done serially following a calculated interval given as the quotient of the total number of slides processed in the register divided by 10 (the sample size per quarter). The details of each slide are recorded on a sampling form, including the unique identifier and peripheral results. The DTLS then gives the randomly sampled AFB smears to the District Laboratory Focal Person (DLFP), who is the first-level controller. The DTLS ensures that the DLFP has no access to the participating lab results; only a list of slide identification numbers and slides are given to the DLFP , 11. ShoThe smears are then blindly re-examined by the DLFP using the same microscopy technique as used in the peripheral laboratories. The DTLS then sends all the first-controlled smears  to the Regional External Quality Assurance (REQA) Coordinator who is the second-level controller at National Tuberculosis Reference Laboratory (NTRL) as in Fig. Slides with discrepant results between the peripheral and first controller are re-examined by the REQA Coordinator using the same microscopy technique as used in the peripheral laboratories to exclude the presence of AFB with the highest possible probability and this result is considered the ‘gold standard’. The coordinator then compiles all results, identifying the types of errors and their origin (laboratory or first controller) as shown in Table Since 2002 when IUATLD published the guidebook of EQA for AFB microscopy, little research on the evaluation of the new LQAS RBRC EQA system’s impact and implementation barriers in TB microscopic laboratories has been conducted in resource-limited countries . Even thAn efficient strengthened RBRC EQA system is an essential tool to the country’s TB control program with a role to monitor the testing performance of individual microscopy laboratories to continuously improve the reliability and efficiency of the microscopy TB results , 13, 20.This was a cross-sectional retrospective study. Quarterly AFB smear microscopy data and the corresponding EQA reading results collected from all the microscopy TB laboratories enrolled on RBRC EQA program between the first quarter of 2008 and the fourth quarter of 2017 were extracted from the NTRL AFB smear microscopy EQA databases. Database entries were verified against the paper-based archived RBRC sampling forms and reports at the National Tuberculosis Reference Laboratory (NTRL) of Uganda.The data used in this study was retrieved from the several compilations made at the various district/regional levels from 2008 to 2017 for a ten-year review.The results of the EQA randomized blinded re-checking system were evaluated based on the proportion of high false-positive (HFP), high false-negative (HFN), low false-positive (LFP), low false-negative (LFN), and quantification errors (QE). HFN; this is an error declared for a negative result of the laboratory and/or first controller versus a clearly positive result  by a second controller. HFP; this is an error declared for a positive result of the laboratory and/or first controller versus a clearly negative result by a second controller. LFN; this is an error declared for a negative result of the laboratory and/or first controller versus a scanty result by a second controller. LFP; this is an error declared for a scanty positive result of the laboratory and/or first controller versus a clearly negative result by a second controller. QE; this is an error declared when there is more than 2 steps difference in quantification of positive results between the laboratory and/or first controller by the second controller.P values less than 0.05 were considered to be statistically significant. Results were explained using absolute numbers and/or percentages. The frequencies/percentages of the different test results were extracted and presented in both tabular and graphical formats.Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to demonstrate the AFB smear reading performance of the participating laboratories relative to the final EQA re-checking (by the second controller) results as explained elsewhere . RelativBetween 2008 and 2017, the laboratories enrolled for the EQA program increased from 660 to 1405, respectively. The numbers of laboratories enrolled and those rechecked during the random blinded rechecking program steadily increased over time  and highest in 2016 35,021), see Fig. 5,021, seThe proportion of slides with scanty numbers of AFB bacilli, defined as the presence of 1–9 AFB in 100 fields, was highest in 2008 (8%) and decreased to 4% in 2016, though after that it slightly increased by 2% in 2017 Table . This deThe percentage of laboratories that accurately reported at least 85% of their negative slides was 64% in 2008; which progressively rose between 2009 (52%) and 2011 (88%); and following 2012, there was just a minor increase from 81% 2013) to 87% (2017). Furthermore, the proportion of laboratories that reported slides with at least one false negative steadily decreased from 12% to 2008 to 3% in 2017 (Table  to 87% (The percentage of errors identified decreased while the diagnostic accuracy parameters increased with more years of participation in the RBRC EQA program for the laboratories (660) that were enrolled on the EQA program throughout the 10 years of analysis, see Table Sensitivity and specificity of the smear readings (random blinded rechecking) as an EQA program increased over the years from 90% to 97% in 2008 to 93% and 99% in 2017 for the entire network, respectively. The corresponding positive predictive values also increased from 88 to 95% while the negative predictive values were found to increase from 97% to d 99% in 2008 and 2017, respectively. It can be realized that similar trends were observed for all the 4 validity parameters even within the subset of the 660 laboratories with complete follow-up (Table Mycobacteriumtuberculosis (MTB) mainly in developing countries at peripheral testing sites without molecular WHO-recommended Rapid Diagnostic (mWRD) tools such as GeneXpert. The method serves as a GeneXpert substitute that is less expensive while simultaneously being useful for drug-sensitive tuberculosis treatment monitoring. In this study, we have demonstrated the effectiveness and impact of the RBRC program on the performance of the participating laboratories. Recent field studies that have been authored have shown how much these improved EQA program evaluations can actually affect a country’s ability to meet core competencies like those related to the detection of events with global public health significance while also fostering vivid confidence in the advancement of diagnostic network services in Africa [Sputum smear microscopy continues to play a significant role in the diagnosis of n Africa .The high frequency of HFN at the beginning of the EQA program in 2008 compared to the lowest observed at the end of the study in 2017 could be attributed to a number of factors including; poorly maintained microscopes, inexperienced smear readers, and inadequate training. Additionally, poor quality of staining technique and the lack of internal quality control have been reported to cause such errors , 25.The Ugandan National TB Reference Laboratory (NTRL) evaluated the network of TB microscopy laboratories prior to the launch of the EQA program, taking into account the kind of equipment, human resources that were available, and their competency . The conThough the initial values for sensitivity (90%) and specificity (97) were high for the randomized blinded rechecking in 2008, these significantly increased over the ten years of implementation to 93% and 99%, respectively. According to the international standards, the ultimate values for sensitivity and specificity as determined in this study are unarguably high .The positive and negative predictive value (s) increased with more years of participation in the EQA program given that these correspond with the decreased frequency of high false positives and false negatives. Additionally, the continued participation in the program potentially consolidated the competencies of AFB smear readers at the diagnostic sites over the years, explaining the gradual drop in the error trends within our study period. We recently demonstrated that continued participation in external quality assurance programs improves tuberculosis testing accuracy of laboratories .The RBRC program, in general, had a favorable impact on the national TB laboratory microscopy network, increasing the sensitivity and specificity of the use of microscopes for accurate tuberculosis diagnosis. The rechecking program presented in this paper was simultaneously accelerated by; intensive support supervisions, the establishment of laboratory quality management system (LQMS), the availability of sufficient resources that compelled laboratories to ensure enough supplies in order to achieve quality testing, improved identification and management of nonconformities within the microscopy sections (path of workflow), preventive action practice, and continuous quality improvement. These efforts, the majority of which have been asserted elsewhere , ultimatOur experience in implementing the RBRC has allowed us to appreciate how affordable it is when compared to other EQA methods such as proficiency testing and on-site supervisions, in terms of intensive planning that requires time, resources and capacity building needs among others. This is stated with the background that microscopy as a diagnostic method in itself is simple, widely available at diagnostic sites , inexpenOur study commends that the RBRC EQA program is effective and its continuous implementation commensurate with reduced errors, high sensitivity, and specificity of the laboratories employing smear microscopy, as this is evidenced by the increased improvement rates. These findings are reasonable enough to deem RBRC as an essential component of the EQA program. The need to evaluate the impact of the RBRC program after decentralization must be advocated so as to ascertain the effectiveness of the move on AFB External Quality Assurance of smear microscopy.


This article was migrated. The article was marked as recommended.First-year medical students are at risk for burnout despite resources available to help them manage stress. In 2015, a structured peer-mentorship program was created at our institution for incoming medical students (M1s) by second-year medical students (M2s) with a goal of reducing risk factors for burnout; a secondary goal was to improve the mentoring skills of M2s. Over the course of the year, we surveyed M1s about their anxiety, prioritization skills, and work-life balance; M2s from the previous year’s unstructured peer-mentorship program served as a control group. 164 M1s and 164 M2s participated in this program. Among M1s, a structured peer-mentorship program significantly reduced anxiety levels (p=<0.01), improved prioritization skills (p=<0.01), and facilitated greater awareness of the importance of striving to maintain work-life balance (p=<0.01). M2s felt neutral-to-agreeable in their ability to provide guidance, refer students for help, and remain invested in their mentees. A structured peer-mentorship program, therefore, may reduce anxiety, improve prioritization skills, and emphasize the importance of work-life balance among M1s, elements that have been associated with reduced rates of burnout. Furthermore, this program can augment the professional development of M2s by motivating them to maintain longitudinal mentoring relationships with underclassmen. The medical school environment poses unique challenges to students regarding work-life balance, career exploration, and acquiring clinical skills and knowledge . These cA study of nearly 4,300 students at seven medical schools found a 50% burnout rate, suggesting that many students could benefit from additional support .Burnout can be attributed to several factors, including increased anxiety, poor prioritization skills, and work-life imbalance . AnecdotOur institution had a longstanding peer-mentoring program  designed to facilitate interactions between second-year medical students (M2s or “big sibs”) and first-year medical students (M1s or “little sibs”). This program was unstructured, denoting no formal requirement for sibs to meet or direct responsibility for the big sib to mentor his or her little sib. Feedback about the program was mixed. While some of the sib pairings resulted in longitudinal mentoring relationships, many sib relationships did not persist beyond the first month of school. This observation could be attributed in part to increased academic demands from M2s and reluctance of M1s to seek advice from their big sib.In 2015, we implemented a structured peer-mentorship program designed to promote greater interaction between sibs throughout the academic year and enhance mentoring. Our goal was to improve the transition to medical school for M1s by reducing burnout risk as assessed through their anxiety, prioritization skills, and importance for maintaining a work-life balance. A secondary goal was to improve the mentoring skills of M2s.Program DesignOur peer mentorship program was structured as follows: incoming M1 students were randomly assigned into one of four societies by the medical school administration. A society represents a community of students across all years of training intended to facilitate interclass mentoring sessions and social events. Student leaders in the societies paired each M1 with an M2 based on similar undergraduate institutions and degree backgrounds. Student participation was required unless exempted by their society’s faculty mentor. Throughout the academic year, M2s received emails every four to six weeks containing talking points that prompted them to interact with their little sib as shown inEach module was paired with a talking point focused on predictable challenges and career guidance between siblings. These talking points were included in the email prompts received by the M2s to discuss with their little sib. These talking points were formulated by an ad hoc committee of students and faculty focused on addressing times of predictable stress in the M1 academic year. Students were encouraged to interact in person. Other alternative modes of acceptable communication between siblings included texting, calling, emailing, FaceTiming, and Skyping.This student-directed initiative was designed to encourage M2s to remain engaged with their little sib and provide a greater number of M1s with the opportunity to have a meaningful mentoring relationship with an upperclassman. Of note, M2s did not receive any mentoring training prior to the initiation of the structured peer-mentorship program.Study Design and Data AnalysisThis was a prospective longitudinal study of M1s and M2s at Northwestern University Feinberg School of Medicine (FSM) in Chicago, IL, USA. Incoming M1s were the experimental group, participating in the new structured peer-mentorship program; M2s, having participated in an unstructured peer-mentorship program as M1s the year before, served as the control group.The study population included all M1s and M2s enrolled at FSM with a big or little sib, respectively. Students were not included if they did not participate in the peer-mentorship program. Approval of this study was exempted by the Northwestern University Institutional Review Board.During the academic year, M1s and M2s were evaluated with voluntary, anonymous Google surveys using a 5-point Likert scale  according to the timeline provided inEach letter in the timeline in The M1 year was split into two blocks in order to achieve a midpoint and final assessment of the program by M1s. During these program assessments, we surveyed M1s on their number of mentoring discussions between siblings, their reasoning for fewer than 3 mentoring discussions between siblings per block, and their descriptions of any conflicts between siblings (survey E). A mentoring discussion was defined as an in-person meeting between siblings. If sibling pairs were unable to meet in person, other communication methods were used but were not surveyed. Two or fewer mentoring discussions per block represented less than optimal participation in the structured peer-mentorship program.Prior to the initiation of the new structured peer-mentorship program, we surveyed M2s about their experience as M1s with the unstructured peer-mentoring program, focusing on anxiety, prioritization skills, and work-life balance (survey B). After one year in the structured program, we surveyed M2s on their mentoring skills by assessing their comfort in giving advice and guidance, motivation to help their sib, capabilities with referring sibs to additional resources, and identification of areas for growth in their little sib.At the beginning of the academic year, we assessed M1s to measure their anxiety and comfort level after being assigned to a big sib (survey A). At the end of the year, we surveyed them about their anxiety, prioritization skills, and importance of work-life balance (survey C).p < 0.05 was determined to be statistically significant. The total number of responses were recorded with the mean, median, and standard deviation calculated for each question asked in all surveys.Data from survey B was compared with the results from survey C using an unpaired student’s t-test whereA total of 164 M1s and 164 M2s participated in the structured peer-mentorship program. Only one M2 was excluded from the sibling program.The duration of the unstructured program was approximately 10 months (August 2014 - May 2015) compared to the structured program that lasted for 7 months (August 2015 - February 2016). The structured peer-mentorship program ended earlier than anticipated from the study design due to protected time included in the M2 curriculum for dedicated USMLE STEP 1 studying. Consequently, M2s did not receive email prompts to contact their little sib during the last three months of the M1 academic year. The response rates for each survey administered can be found inM1s responded to a two-question survey prior to arrival on campus for matriculation. This survey focused on reduction of anxiety and comfort level seeking advice related to transitioning to medical school. This data is shown inM1 responses were recorded based upon student agreement with (A) ease of anxiety and (B) development of comfort level in seeking advice from their assigned big sib. At the end of block 1, M1s responded to survey E, with over 33% (n = 37) of respondents reporting 4 or more mentoring discussions. The majority of M1s with less than 3 mentoring discussions responded that informal communication had replaced formal meetings or more than one mentoring session per module was unnecessary. Only one M1 reported significant conflict with their big sib. In block 2, a decreased number of M1s responded to survey E compared to block 1. A portion of M1s stated their big sib or themselves performed less outreach as one reason for less than 3 mentoring discussions. No sibling conflicts were reported during block 2. These results are presented inp = 0.0004, 0.001, and 0.004, respectively, in favor of M1s utilizing a structured peer-mentorship program.First-year medical students at our institution appear to have benefited from having a structured peer-mentoring program. Our data suggest that, compared to an unstructured peer-mentorship program, introducing guidance via talking points and prompting regular mentoring sessions significantly reduced anxiety, improved prioritization skills, and raised awareness of the importance of striving to maintain work-life balance-factors associated with a risk of burnout. To our knowledge, this study represents the first assessment of a structured peer-mentoring program aimed at reducing the burnout components in first-year medical students.These benefits may be attributed, in part, to a program that prompted M2s to reach out to M1s at times of predictable stress during the academic year, such as preparing for their first objective structured clinical examination (OSCE) or written examination. Over the academic year, students reported having multiple mentoring discussions between siblings, especially early in the year. The reduction in mentoring discussions later in the year may suggest that students had adjusted to school and anxiety levels had declined from the start of medical school. Additionally, the observed decline in discussions could further be explained by the absence of the M2s for their protected time to prepare for USMLE STEP 1. However, evidence of unprompted discussions between siblings was noted inOur results indicate that having a big sib reduced the anxiety of M1s. Interestingly, this benefit was notedeven beforestudents arrived at school or had met with their big sib. Additionally, having a big sib was associated with a willingness of M1s to seek advice about challenges related to transitioning to medical school. These observations emphasize the high levels of anxiety among incoming students and offer a readily available solution to alleviate it.A surprising finding was that, throughout the academic year, only one M1 reported a poor relationship with his or her big sib. The outcome of this conflict remains unknown from our data. There may have been other sub-optimal sibling pairings that were not captured in our data due to a response rate of 55% and 48% for blocks 1 and 2, respectively. It is also possible that student concern over exposing conflicts between siblings for review by their peers and faculty may have inhibited additional reporting of poor relationships.Finally, M2s also appeared to benefit from this program. Our data suggest that participating M2s were motivated to assist their mentees. For many M2s, this role may have been the first time they have functioned as mentors. This experience appears to have encouraged them to model constructive behavior, which may improve their performance later in the apprenticeship model of training (Stalmejjer, 2015;There are several limitations to this study. First, data obtained was from a single institution, limiting the generalizability of our findings. Our data is further limited by the use of non-validated surveys in assessing self-reported anxiety, prioritization skills, and work-life balance understanding in contrast to objective measurements of these variables. Second, our data is limited to a single, truncated year. While our findings were promising, additional data is needed to further support our findings and its reproducibility. As part of this study, a declining response rate may represent selection bias leading to a non-representative sample of M1s and M2s. Third, we surveyed M2s about their experiences as little sibs at the start of their second year of medical school. This delay in surveying M2s after completing their first year of medical school introduces the potential for recall bias in the control group.As this program evolves, we anticipate M1s who participated in a structured program may perform better as M2 mentors. These M2s may feel more confident when helping their little sibs address common challenges of the first year in medical school compared to M2s who had participated in an unstructured program. Subsequent iterations of the Sibs Program may also show even greater reductions in anxiety levels and improvements in prioritization skills and work-life balance. In addition, it would be helpful to collect data regarding the barriers to mentoring identified by M2s that could be used to develop strategies to improve their mentoring skills.Compared to an unstructured peer-mentoring program, a structured peer-mentoring program was associated with self-reported reductions in anxiety, improved prioritization skills, and greater awareness of the importance of striving for work-life balance among first-year medical students. These elements can ease the transition into medical school and are associated with reduced risk of burnout. Incoming medical students have positive associations with being assigned a peer mentor, and second-year medical students report that serving as a peer mentor motivated them to help mentees.•First-year medical students are at risk for burnout despite commonly available resources to help them manage stress.•Compared to an unstructured peer-mentoring program between first- and second-year medical students, a structured program was associated with self-reported reductions in anxiety, improved prioritization skills, and greater awareness of the importance of striving for work-life balance among first-year medical students.•Second-year medical students reported that serving as a peer-mentor motivated them to help their mentees and facilitated a sustained longitudinal mentorship.Gabriel A. Arenas is an alumnus of the Northwestern University Feinberg School of Medicine, where he earned his medical doctorate in 2018. He is currently an obstetrics and gynecology resident at the University of Chicago Medical Center interested in medical education and mentorship.Gregory E. Brisson is a clinical assistant professor of internal medicine at Northwestern Memorial Hospital. He is also the leader of the academic societies within the Northwestern University Feinberg School of Medicine. This review has been migrated. The reviewer awarded 4 stars out of 5 Thanks for the opportunity to review this article. This is an educational intervention study compared the two groups who underwent un structured and structured peer mentorship program and ti was concluded that the first-year medical students appear to have benefited from having a structured peer-mentoring program which is evident statistically by unpaired t test between M1 and M2 students mean values. Two queries / suggestions to the authors1. Was there any interim analysis conducted or any pre and post comparison for M1 students done in this study?2. Complete Study protocol can be added as a supplementary file to get more clear picture on – the study population, recruitment, follow up, outcome surveys and analysis. Thanks regards Dr. A. BalajiReviewer Expertise:NANo decision status is available This review has been migrated. The reviewer awarded 4 stars out of 5 I enjoyed reading this paper about the big sib mentoring program at the Northwestern University medical school and agree with the authors that peer mentoring is an effective approach to enhancing wellbeing among junior medical students.The abstract summarizes the program and results well.The introduction provides a good lead in to why the program was designed and the need for this study. The problem is stated, the gap in literature mentioned and the goals of the program are reasonably clear.Under methods, the program has been described well. I really like the approach where the students are placed into societies and the sibling program constructed within the society. This provides many opportunities for engagement and society faculty availability for guidance. The talking points are also well done to ensure that the siblings have a framework for their conversations.Tables 1 and 2 provide informative details about the structure of the program and evaluation time points.The results section only consists of graphs and tables without a concise summary of what the most important results were. A lot of data have been collected and I am not entirely sure all of them are necessary to inform readers about the impact of the program. I could have been convinced of its effectiveness with less data. I would have actually liked to have seen some narrative or open-ended comments which would have been really meaningful.Overall the paper is well written, well referenced and would be of interest to all educators designing peer mentoring programs for undergraduate or postgraduate trainees.Reviewer Expertise:NANo decision status is available


In this analysis, we examined the effects of 3 months of participation in the BB program on the outcomes of children and adolescents with developmental difficulties . Parent-rated scores on the Brain Balance–Multidomain Developmental Survey (BB-MDS) were used to assess six areas at baseline and post-program: (1) negative emotionality; (2) reading/writing difficulties; (3) hyperactive/disruptive behavior; (4) academic disengagement; (5) motor/coordination problems; and (6) social communication problems. To estimate change from pre- to post-program, we calculated effect size (Cohen’s d) and the Reliable Change Index (RCI) for groups stratified by baseline severity. There was a very large effect size for the moderate/high severity (d = 1.63) and extreme severity (d = 2.08) groups, and a large effect size for the mild severity group (d = 0.87). The average percentage of participants who observed reliable change over all BB-MDS domains was 60.1% (RCICTT) for extreme severity, 46.6% (RCICTT) for moderate/high severity, and 21.1% (RCICTT) for baseline mild severity. In additional assessments of primitive reflexes and sensory motor activity, students demonstrated significantly diminished primitive reflexes from pre- to post-participation and significant improvements in sensory motor skills including fine motor skills, gait and aerobic ability, proprioception, rhythm and timing, and eye-gaze stability. Overall, these results demonstrate improvements in primitive reflex integration and sensory motor skills, as well as statistically significant reliable change in emotionality, reading/writing, behavior, academic engagement, motor skills, and social communication in BB participants from pre- to post-program, with the probability and degree of change increasing as the participants’ baseline severity increases. These results contribute to the growing literature on the need for evidence-based nonpharmacologic approaches to addressing developmental issues. Future research with well-controlled designs, longitudinal follow-up, implementation across settings, and participant groups in which diagnoses are known, will help to more fully characterize the effects of the BB program.The effects of comprehensive multimodal programs on developmental outcomes have not been well-studied. Emerging evidence suggests a possible role for the Brain Balance From infancy through adolescence, various domains of development  intersect, such that a deficit in one domain can negatively affect the development of another, and conversely, improvement in one area can positively influence the development of a different area . Interve® program) has been shown in recent studies to improve cognitive performance, attentional issues, and mental well-being in children and adolescents who tested below age-appropriate levels for attention and developmental functioning prior to program participation , recent studies have explored the effect of the Brain Balance program in youth with baseline attentional issues. Children and adolescent (aged 4–17 years) who participated in the Brain Balance program for 3 months experienced on average a decline in ADHD symptoms in parent-rated scores on the Brown Attention-Deficit Disorder Scales® . More thAdditional investigation on the program’s effects on cognition found that children and adolescents who participated in the Brain Balance program for 3 months showed significant overall improvements in cognitive performance, and improved performance on distinct tests of memory, reasoning, verbal ability, and concentration . A majorThe aim of this study was to retrospectively review data from parent-reported surveys on outcomes in six developmental areas of Brain Balance participants (aged 4–18 years) stratified by baseline severity. Symptom severity at baseline can influence intervention outcomes in children and has been recommended to be taken into consideration during treatment-related decision making . In thisMethods section for details on these assessments). Here, we show significant improvements in five areas of sensory motor skills and integration of eight different primitive reflexes following Brain Balance participation. Taken together, the results from parent-rated BB-MDS scores along with direct sensory motor assessments of students provide evidence of improvements in developmental outcomes of students who participate in the Brain Balance program.As sensory motor skills and primitive reflexes can provide additional valuable information about a child’s development , we alsoApproval for this retrospective data review was granted by an institutional review board (IRB) at Advarra , an independent organization accredited by the U.S. Office for Human Research Protections and the Association for the Accreditation of Human Research Protection Programs. The Advarra IRB determined that this retrospective data review met the requirements for exemption from IRB oversight, according to the Department of Health and Human Services regulations found at 45 CFR 46.104(d)(4). Informed parental consent was obtained for any participants prior to general enrollment in the Brain Balance program.M] = 9.91, Standard Deviation [SD] = 3.11); and 2,817 (69.7%) were male. These data have been previously used in an exploratory factor analysis to refine and validate the BB-MDS prior to its use here  provided complete cases and were included for the present study. All participants were between the ages of 4 and 18 years  ;Reading/writing problems  ;Academic disengagement  ;Hyperactive/disruptive  ;Motor/coordination problems  ;Social communication problems  .Before and after BB participation, students were assessed for primitive reflexes including the asymmetric tonic neck reflex, Landau reflex, Moro reflex, palmar reflex, rooting reflex, spinal galant reflex, symmetric tonic neck reflex, and tonic labyrinthine head reflex . PrimitiIn order to assess fine motor skills, students were timed on their completion of the Purdue Peg Board using 25 pegs with the dominant hand . To asseTo assess gait, we used the cross-crawl march  and jumpTraining Protocol section below. Following completion of the Brain Balance program, participants’ parents again completed the BB-MDS.Prior to enrolling in the Brain Balance program, prospective students were assessed at Brain Balance centers by trained technicians who had completed training in the centers’ protocols. Students who were eligible for enrollment in the Brain Balance program did not have any known genetic disorders and needed to demonstrate a developmental readiness for the program, as defined by the ability to engage with instructors and follow a one-step direction, to attempt the tasks requested, and to continue to work throughout the duration of the assessment. Re-direction and repetition of instructions both visually and verbally were allowed in the definition of readiness. Tasks were described to each student through verbal instructions as well as a physical demonstration of the task. In most instances, additional instructions beyond this initial explanation and demonstration were not needed. However, if a student did not understand the instructions, the assessor repeated the physical instructions, for example, demonstrating the placement of one peg in a pegboard at a time for the fine motor task. At the time of this assessment for students, parents completed the BB-MDS. Students who met the abovementioned inclusion criteria were then enrolled for participation in the Brain Balance program, as described in more detail in the Participants in the Brain Balance program attended three in-center sessions per week (for 3 months), with each session lasting 1 h (45 min of sensorimotor stimulation and 15 min of academic activities), along with other multimodal activities targeting various developmental areas (see the list below). All participants went through the same series of stations, which consisted of the following exercises and activities:Passive sensory stimulation in the form of tactile, olfactory, visual, and auditory stimulation ;Exercises targeting primitive and postural reflexes , which wCore muscle exercises ;Proprioceptive and balance training, using a rocker board and one-leg balance ;Gait exercises, using the cross-crawl march  and jumpVestibular exercises, including rotational, translational, and anterior-to-posterior movements;Fine motor activities, including the palmar grasp reflex to increase muscle strength and the Purdue Peg Board to improve dexterity and speed ;Rhythm and timing exercises, including whole-body coordination activities and use of the Interactive Metronome®, a training tool that combines the concept of a musical metronome with a computerized program that measures and improves rhythm and timing ;Activities that aim to enhance auditory and visual processing, as well as coordination and endurance of eye movements . More spWhile all participants engage with the same activity stations, each participant’s program is individualized based on their performance on the initial assessment in order to determine the appropriate starting level for each exercise. Each exercise/activity was progressive in nature and changed in duration, quantity, and complexity as the participants’ functional abilities improved over the course of the program. The criteria for making changes in the duration, quantity, and complexity of the program were based on a student achieving mastery of each level. We defined mastery as the student successfully completing the task over three consecutive sessions. For example, during the sensory stimulation component of the program, if a student cooperatively wears the tactile sensory gear for three consecutive sessions, tactile vibration will be increased to the higher increment of stronger vibration for the next session. Similarly, for fine motor tasks such as the Purdue Peg Board, once the student achieves mastery by reaching their current goal target for three consecutive sessions, the next session’s goal will be increased to place additional pegs into the pegboard holes in the same amount of time.The academic component of the 1-h session was based on the initial functional assessment and focused on improving literacy and listening skills. During the initial assessment, each student completes a reading fluency benchmark to determine the appropriate reading level. Students whose reading level is at a PreK- to third-grade level will engage in reading fluency and comprehension activities specific to their current level of ability. Students whose reading level is at a fourth-grade level or higher will engage in a listening comprehension curriculum in which the student listens to a passage and answers questions in either details or main idea topics. If a student is struggling to read at the appropriate grade level, they will listen to the passage while reading, with each word lighting up as it is being read, to engage both visual and auditory pathways simultaneously.In addition to the abovementioned in-center activities, parents were asked to assist their children in completing daily exercises at home and were also given nutritional guidance and support throughout the duration of the program. The home exercises consisted of 0–8 primitive reflexes (assigned if the primitive reflex was present at the time of assessment), physical fitness activities (push-ups and sit-ups), and eye strengthening exercises. To ensure consistency in parental implementation of the at-home portions of the program, parents received in-center training on how to perform the home exercises and were provided access to an online parent portal that included videos on each of the exercises as well as written instructions with photos. Any verbal and written instructions given to parents are provided in plain language that is short and simple, as education levels may vary among the participants’ parents.d = 0.05 is considered statistically significant, even with a stringent adjustment to correct for Type I error. We considered a multivariate analysis but chose not to use this approach as we wanted to consider change in each domain individually. Instead, we rely here on Cohen’s d and its associated 95% confidence intervals, and the percentage of participants that observed improvement as assessed by the Reliable Change Index (RCI) (CTT). The RCICTT is defined as:Due to the large sample size of the study, we did not rely on tests of statistical significance to determine whether scores differed from pre- to post-program, as a negligible effect size of ex (RCI) . Here, tRaw and PreRaw refer to simple summary scores of the pre- and post-program data, and SEPre refers to the standard error of measurement at pretest. The RCICTT assumes equal weighting of items, such that all items are equal contributors in the estimate of the latent trait CTT is the average of the individual SEs, which can vary across individuals, this may result in an SE that overestimates measurement precision in the middle of the distribution and underestimates measurement precision in the tails of the distribution , participants who obtained an RCI ≥ 1.96 were considered to have observed “deterioration,” and participants who obtained an RCI between −1.96 and 1.96 were considered to have experienced “no change,” as change was too small to be considered statistically significant . Age variables were calculated by subtracting the whole number of years that had passed since birth until the date the students were enrolled into the Brain Balance program. Students were placed into age groups 6–10, 11–13, and 14–17 years, and only students who had complete data from pre- and post-program were included in the analysis. Sensory motor activity levels were analyzed by creating a variable that represented the difference in levels between pre- and post-program data and was accomplished by subtracting pre-program levels from post-program levels.p value less than 0.05.Primitive reflex activity was analyzed by calculating the percentage change from pre- to post-program and was accomplished by utilizing the following formula: [(postprogram reflex – preprogram reflex) ÷ postprogram reflex × 100] and percentages were rounded to the nearest whole number. For both sensory motor and primitive reflex analyses, Wilcoxon Signed Rank Sum tests were performed because the pre- and post-program data are dependent and the data are not normally distributed. The Wilcoxon Signed Rank Sum test analyzes whether means by group differ and statistical significance may be achieved by observing a Multivariate analysis of variance (MANOVA) was performed to determine whether age or gender significantly affected outcomes collectively of dependent variables.2 ≤ 0.010). Test information functions (TIF) for all BB-MDS subscales were high across three standard deviations of All BB-MDS domains were considered appropriate for IRT analysis, as all subscales were considered to be unidimensional via Principal Axis Factoring  , an examof θ see . Internad and its associated 95% confidence intervals) can be found in d = 0.87); effect sizes ranged from moderate (d = 0.47 for Motor/Coordination problems) to very large (d = 1.13 for Hyperactive/Disruptive). For “moderate/high severity” participants (d = 1.63); all effect sizes ranged from d = 1.53 to d = 1.80, and for participants with “extreme severity” at baseline ; per RCIIRT, the average percentage was 15.8% (range = 2.3 to 22.9%). Among participants in the “moderate severity” range, the average percentage of participants who observed reliable change was 46.6% (range = 36.5 to 53.6%) per RCICTT; using RCIIRT, the average percentage was 43.9% (range = 26.9 to 37.3%). For participants in the “extremely severe” range, the average percentage of participants who observed reliable change was 60.1% per RCICTT (range = 50.9 to 72.3%) and 68% per RCIIRT (range = 60.0 to 80.7%). As anticipated, the probability of reliable change increased as baseline severity increased; RCICTT estimates suggest more favorable outcomes among Brain Balance participants with milder baseline symptoms than RCIIRT; conversely, RCIIRT suggests more favorable outcomes among Brain Balance participants with more severe baseline symptoms than RCICTT.Reliable change estimates can be found in p < 0.0001), while gender had no effect (Wilks’ Lambda p < 0.41). After excluding students that did not meet the inclusion criteria, there were 6,150 students included in the analysis: 627 students aged 6–10 years, 2,356 students aged 11–13 years, and 3,167 students aged 14–17 years. The total number of students assessed for eligibility was 68,244, with 59,975 students excluded for incomplete data and 2,119 excluded for not meeting the age requirement of 6 to 18 years old. p < 0.09).MANOVA showed that age significantly affected the outcome variables collectively , as shown in Primitive reflex metrics included assessments of Landau, symmetrical tonic neck reflex, tonic labyrinthine reflex (head up), tonic labyrinthine reflex (head down), asymmetrical tonic neck reflex, spinal galant, rooting, Moro, and palmer reflex. Across all age groups for the primitive reflex analysis, mean changes in percentage from 35.8 to 72.5% were observed and statistical significance was achieved across all metrics and all age groups  for Brain Balance participants in the extreme severity group. Taken together, these estimates suggest that Brain Balance participants begin to observe moderate to large effects with mild difficulties, and larger differences from pre- to post-program with increasing levels of severity.Although many studies on developmental outcomes often do not stratify children by degree of baseline severity, there are many that group participants by baseline diagnosis  and use RCI to evaluate changes in functioning from baseline to post-intervention. For example, previous studies have shown that children with an ADHD diagnosis who participate in non-pharmacologic behavioral interventions show varying degrees of reliable improvement from pre- to post-intervention in at least one area of behavioral or emotional functioning, with percentages of reliable change varying from 50 to 75% , to as lOur findings of pre- to post-program changes in two specific BB-MDS domains relating to academic functioning, namely, reading/writing difficulties and academic disengagement, could be attributed to the individualized support provided by the Brain Balance program’s academic component and/or to the program’s effects on cognitive performance and attentional functioning . In a prIn the present study, Brain Balance participants demonstrated a significant decrease in the level of primitive reflex activity, as indicated by tests of eight different primitive reflexes across age groups ranging from 6 to 17 years old. In previous studies, significantly higher levels of primitive reflex retention have been found in school-aged children with ADHD symptoms compared with typically developing peers . AtypicaBrain Balance participants also significantly improved in all five tests of sensory motor abilities examined, including fine motor skills, proprioception, gait and aerobic skills, rhythm and timing, and eye-gaze stability. The observed improvements across multiple sensory motor domains, together with primitive reflex integration, indicate that the Brain Balance program improves the functioning of proprioceptive and vestibular feedback mechanisms crucial for the voluntary control of complex movements and behaviors . TogetheThe results presented here derive from program participation in a center-based setting . The generalizability of the program’s outcomes is therefore limited until the results are demonstrated across other types of settings. Studies are currently underway to assess Brain Balance program outcomes in home- and school-based settings.Caution should also be taken in interpreting the evaluation of the Brain Balance program relative to other programs, as this study did not compare the program with other relevant interventions such as biofeedback or cognitive-behavioral training. The present study also did not include a control group. Future studies on the Brain Balance program will need to include direct comparisons with other interventions, as well as with a control group, in order to more accurately and fully evaluate the contribution of the Brain Balance program.Although participants in this study were stratified by baseline severity, the sample may have been fairly heterogeneous with respect to developmental diagnoses. Information about participants’ diagnoses was not available to us, as parental disclosure of private health information (including diagnoses) was not a prerequisite for enrollment. Notably, one recent study on attentional improvements after Brain Balance participation did include participants with ADHD diagnoses and known medication status . It is wRegarding the at-home portion of the Brain Balance program, parents are provided with nutritional guidance and recommendations at home. The at-home portion is a small part of the program, as most of the Brain Balance program in this study took place in-center and was run by technicians not needing parental involvement. However, to what degree families are applying these recommendations was not tracked in the present study, leading to potential variations among participants in implementation of the at-home portions of the program. Because of potential differences in education levels of our participants’ parents, any instructions to parents regarding the at-home exercises are given in plain language that is short and simple. Going forward, adherence to home-based recommendations is being probed by survey questions at the completion of the program.The present findings suggest that the Brain Balance program is helpful in improving childhood developmental outcomes, especially for more impaired participants who have the most to gain with respect to improvement in emotional, social, behavioral, motor, and academic functioning. These results contribute to the growing literature on the need for evidence-based nonpharmacologic interventions and programs for children and adolescents with developmental issues, in order to limit the total lifetime exposure to drug treatments. Future research with well-controlled designs, longitudinal follow-up, implementation across settings, and participant groups in which diagnoses are known, will help to more fully characterize the effects of holistic multimodal approaches on the outcomes of children and adolescents with developmental and attentional challenges.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The requirement of ethical approval was waived by Advarra for the studies involving humans because the Advarra IRB determined that this retrospective data review met the requirements for exemption from IRB oversight, according to the Department of Health and Human Services regulations found at 45 CFR 46.104(d)(4). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin because this study was approved as a retroactive study and met the requirements for exemption.This work was carried out in collaboration between both authors. RJ designed the study, provided the Brain Balance protocol, and contributed to the manuscript. JJ performed the analyses of the study, interpretation of the data, and manuscript writing. All authors contributed to the article and approved the submitted version.Author RJ was employed by Brain Balance Achievement Centres.The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The authors declare that this study received funding from Brain Balance Achievement Centres to JJ. The funder had the following involvement in the study: data collection.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.