Background: There is an urgent need for culturally tailored diabetes self-management education to improve health outcomes in African Americans, especially given the disproportionate prevalence of diabetes and medication non-adherence. Stakeholder engagement can guide and enrich the development of these interventions by integrating content directly addressing barriers to African Americans’ adherence with existing community-based diabetes self-management education programs. The aim of this study is to explore stakeholder perspectives on a novel culturally tailored diabetes self-management program for African Americans. Methods: Thirteen semi-structured individual interviews were conducted in a large Midwestern U.S. city with healthcare professionals and organizational leaders serving African American communities and/or providing diabetes education. Transcripts were analyzed using directed content analysis with the Consolidated Framework for Implementation Research and inductive content analysis. Results: Five overarching themes were identified: (1) fulfill needs among stakeholders, (2) creating a supportive and trusting environment to address distrust, (3) building relationships and empowering peers, (4) logistical organization barriers to program implementation and (5) challenges to program acceptance by participants. Conclusion: Stakeholders delineated how the new culturally tailored diabetes self-management program aligned with the needs of African American patients. Perceived challenges and corresponding strategies to address barriers to participation were identified to inform program implementation and sustainability. Diabetes is a leading cause of death in the United States, accounting for over 100,000 deaths annually. Diabetes affects 37.3 million Americans and is a condition that continues to rapidly rise in prevalence, requiring complex management to avoid complications that contribute substantially to increased healthcare costs . FurtherThere are stark disparities indicating disproportionately higher medication nonadherence among non-Hispanic Blacks or African Americans (AAs) ,4,5, whiTo directly address barriers to medication adherence among AAs with type 2 diabetes, our team developed and implemented a theory-driven novel program called Peers Supporting Health Literacy, Self-Efficacy, Self-Advocacy and Adherence (Peers LEAD) ,15,16. ITherefore, we developed a novel culturally tailored diabetes self-management education (DSME) for AAs called Peers’ Experience in Communicating and Engaging in Healthy Living (Peers EXCEL) by combining Peers LEAD with an existing community-based DSME program, Healthy Living with Diabetes (HLWD). The American Diabetes Association strongly endorses diabetes self-management education (DSME) , which hOur long-term goal is to implement Peers EXCEL and evaluate its impact on medication adherence and glycemic control among AAs. The 2022 National Standards for DSME specify that healthcare professional and organizational perspectives need to be included in developing DSME programs since such input has proven effective in improving health outcomes, increasing patient participation, and promoting the sustainability of DSME programs ,22,23. TWe developed Peers EXCEL by combining Peers LEAD, a peer supported program for AAs focused on diabetes medication adherence, with Healthy Living with Diabetes (HLWD), a community-based DSME program, which is readily available in a Midwestern state.In the Peers LEAD program, AAs who have type 2 diabetes and are adherent to their medications (Peer Ambassadors) are paired with AAs with type 2 diabetes who are nonadherent (Peer Buddies). The peer support includes, but is not limited to, initial in-person and phone follow-ups, addressing misperceptions of medicines and diabetes, sharing experiences in managing diabetes and medications, discussions on medication management strategies and proactive support of self-advocacy in patient-provider interactions.HLWD is an evidence-based program which addresses several aspects of diabetes care including diet, exercise, and medications. This program is 6-weeks long, with workshops hosted for 2.5 h weekly. Although HLWD includes a 20-min activity on medications, it does not effectively address the main barriers related to medication nonadherence among AAs.Peers EXCEL is a program that integrates Peers LEAD with HLWD content, by adding two group sessions in weeks 1 and 2 led by a pharmacist and healthcare provider to address African American beliefs and misperceptions about medicines and diabetes. The program is intended for individuals who self-identify as AA who have been diagnosed with type 2 diabetes for more than 1 year and self-reported being prescribed one oral or injectable diabetes medication. As well, the program is intended for buddies who: (1) Self-reported nonadherence on the Adherence to Refills and Medications Scale for Diabetes (ARMS-D) scale and (2) Most recent HbA1c is higher than 7.6% at baseline screening. And for ambassadors, we will include AAs who self-report adherence on the ARMS-D scale. This is followed by 6 weeks of HLWD diabetes self-management content which will be led by two AA HLWD-trained group leaders, in addition to peer support focused on specific topics related to addressing health beliefs, family role in self-management, provider communication about medicines, and maintaining cultural experiences in diabetes self-management. Resources including a program book and referral to community health workers about participants’ needs on social determinants of health will be provided. We used descriptive qualitative methodology to investigate perceptions regarding Peers EXCEL from healthcare providers and organizational leaders who are key stakeholders in implementing the intervention. Individual semi-structured interviews were conducted virtually via a web-based platform in a large Midwestern City from December 2020 to October 2021. Semi-structured interview guides were developed and informed by the Consolidated Framework for Implementation Research (CFIR) to identify strategies that could support and facilitate implementation of Peers EXCEL. Three domains in the CFIR model were selected: (1) intervention characteristics , (2) outer setting , and (3) inner settings  and adapted for the two separate groups of participants based on the domains most relevant to their roles, responsibilities, and tasks in implementing the proposed intervention.The study was determined by the PI’s University Institutional Review Board to be exempt because it only involved interview procedures. We used snowball sampling, a type of convenience sampling, and collaborated with community partners, including recruitment by word of mouth, to invite healthcare professionals and organizational leaders to participate in the interviews. The eligibility criterion for the healthcare professionals was having had experience treating or serving patients with diabetes, preferably patients from the African American community. The eligibility criteria for organizational leaders were either having had experience hosting HLWD in the past or representing an organization serving the African American community that was identified by the research team as a potential host for Peers EXCEL in the future. Interviewers were research assistants who had been trained by the PI in conducting qualitative interviews, which involved reviewing literature on appropriate interviewing techniques, reviewing the interview guide in detail, and role-playing an interview with the PI to demonstrate mastery of interview skills. Research team members reviewed the purpose, format, and length of the interview to assure participants about confidentiality issues and voluntary participation in the study to obtain verbal informed consent. Each interview lasted up to 60 min and was audio-recorded and transcribed verbatim by a professional transcriptionist. Sample interview questions are provided in Both directed content analysis using the Consolidated Framework for Implementation Research (CFIR) and inductive content analysis were used to identify facilitators and barriers to program implementation . We sougTwo trained research members used NVivo 10  to analyze the qualitative transcript independently. First, in the process of open coding, research members read the transcript line-by-line to develop a codebook with codes and themes. Second, axial coding was used to compare existing themes with new themes and add the new concepts until data saturation . Last, pA total of 13 interviews were conducted with seven healthcare professionals and six organizational leaders . Seven hOur analysis identified five major themes related to the implementation of Peers EXCEL: (1) fulfill needs among stakeholders (2) creating a supportive and trusting environment to address distrust, (3) building relationships and empowering peers (4) logistical organization barriers to program implementation and (5) challenges to program acceptance by participants. The advantages of Peers EXCEL perceived by stakeholders well-aligned with the missions of their organizations. Capacity to provide diabetes education to anyone despite barriers to address health inequity is recognized as a shared goal for both healthcare and local organizations.“[HLWD] is really open to anyone in our community. So, we don’t limit it to just those who get care at [this specific health system]. I think it’s really important to get them that education if they can’t afford it, they don’t have access.”—PHS 4Peers EXCEL also fills the existing gaps that organizations were lacking. The advantages of utilizing existing partnerships and leveraging new partnerships with healthcare and local organizations were recurring themes elicited from both healthcare professionals and organizational leaders. Healthcare professionals recognized that partnering with a program like Peers EXCEL would complement clinical care and fill important knowledge gaps resulting from cultural barriers in diabetes self-management topics like diet and exercise. Healthcare professionals generally perceived limited time and fragmented care are barriers to achieving comprehensive care. Additional programs like Peers EXCEL not only dives into long-term lifestyle changes but take advantage of a team-based care approach to ensure holistic care for patients with diabetes.Sites with experience leading HLWD shared many advantages for future implementation of Peers EXCEL. These advantages included having a location and availability, supporting training, having the resources to provide food and transportation for program meetings using HLWD infrastructures. In addition, partnering with other community organizations not only add flexibilities to support the program but help overcome barriers to participant access to DSME.“Our location was centrally located in the community. We had an open-door policy with our residents. We were able to provide all the ingredients of a successful workshop…So definitely making sure that we offer multiple times for participants is one of the things and making sure that a snack or a meal of some sort is provided is the other…coordinating transportation is not necessarily the primary focus.”—PHS 1The importance of peer support was emphasized for creating a space in which participants could feel comfortable having conversations about their health. Stakeholders perceived a strong benefit from Peers EXCEL in facilitating trust and creating a safe space for participants. Stakeholders also believed that listening to and learning from peers would help patients relate to each other’s experiences, which would add additional value to the knowledge provided from healthcare professionals. Peer support was also described as an opportunity for patients to voice their concerns to others who care and who have first-hand knowledge of possible solutions to address challenges.“With the peer support, they can get into more specific issues if they are really having troubles with maintaining their diet or maintaining their medications… they would have someone that they can voice their concerns to plus someone who would be there that can give them pointers on how to get around it. Just having the classes alone, you might get that, but a more one-on-one would, give that extra level of support.”—HCP 6 (Pharmacist)In addition to supporting participants with a safe place to talk about concerns, stakeholders also valued that Peers EXCEL provides additional opportunities and more time to engage with healthcare professionals about disease-related content. Topics such as diabetes perceptions, myths about medicines, and diabetes management ideas were perceived as helpful discussions which may not be covered in-depth by current diabetes self-management education class contents for AAs.“I do think that [Peers LEAD] was able to let the participant have more of a voice, exploring their perceptions and their ideas related to how they handle their diabetes. I think that is very, very good …. I know the other program has more structured sessions, which sometimes the timeline gets to be a little bit short for really letting people really understand those areas. So I think that maybe having that peer support in between could help reinforce some of those concepts that might not be able to be put in the actual class sessions….”—HCP 2 (Nutritionist)Healthcare professionals perceived the idea of utilizing peer support seems to help participants connect and motivate each other. In terms of peer discussion, the shared experiences of eating style within communities could be incorporated into program contents and provides options or opinions to address it. Along with the shared benefits of peer support, sites with experience leading HLWD perceived Peers EXCEL as an opportunity for patients to build relationships with their peers and reduce social isolation among AAs living with diabetes.“In HLWD, they share their struggles, they really feel connected to others in the class. They’re not in this battle alone. They have others they can reach out to that know what it’s like to live with diabetes”—PHS 4Stakeholders described that patients in Peer EXCEL may increase their level of engagement with their diabetes management as a result of connecting with peers who can provide social and emotional support, and enhance motivation to improve their health, especially in building diabetes self-management skills.“I think it’s going to help a lot with self-management, and eventually that gets reflected into an A1c... Really, it’s about adapting a healthier lifestyle, which is more important than just an A1c., it’s going to help with patient engagement. And that is one of the first steps in improving diabetes care.”—HCP 7 (Provider)“We recognize it’s important that individuals that want to have better management of their lives learn from their peers and individuals that can resonate with their story.”—PHS 1Several concerns were shared about a lack of organizational resources or capacity to successfully support a program like Peers EXCEL. In particular, important tasks such as patient recruitment, session set-up, and food coordination would require more staff than they currently have available.“The position of the coordinator role is not a state-mandated service at this time, and so it’s unlikely that more resources will be allocated to that position, and there is no capacity for that coordinator to increase time and do more programs than what we already have.”—PHS-3Stakeholders also shared concerns about scheduling challenges their organization would face in providing sufficient flexibility and timing of meetings that would allow Peers EXCEL participants to commit to attend the entire length of the 8-week program.“...in general, it’s time, work schedule. You know, some people are working the second shift or third shift. These are the barriers that they may not participate in the program.”—HCP 6 (Pharmacist)Additional logistical barriers were noted for participants, in addition to recruitment difficulties stemming from a lack of participant trust, lack of awareness of programs and relatively low numbers of AAs living in parts of the Midwest.“It would be really nice if we could reach out to our African American community in [a city in Midwest], our surrounding areas, and ask them what they’re comfortable with… Are you comfortable coming in to take a class inside the healthcare setting, or would you rather have it within your community?”—PHS 4Organizational leaders demonstrated the importance of promoting affordability of participating in the program. To enhance commitment to continued participation, leaders also proposed the ideas of adding a small monetary fee. Some logistical components that were considered important for participants included providing a snack or meal during the meetings, in addition to offering transportation to attend the program sessions.“...a lot of my patients do have difficulty getting transportation. So I think that might be a barrier.”—HCP 3 (Pharmacist)Another important barrier to program participation by AAs included a lack of trust in those leading the Peers EXCEL program, particularly when implemented in communities without a large AA population. Furthermore, they discussed that it can be difficult to attract adequate numbers of participants in those communities and would require additional outreach efforts to increase awareness of the program in AA communities. Stakeholders mentioned this could be possible through program ambassadors, healthcare providers, and diabetes educators, in addition to identifying spaces where AAs would prefer to gather to participate in the program.“[Patients] may be more willing to come if they really trust the people that’s involved in it. So, who’s leading the program, how the outreach is, those can either enhance or can be barriers to participation. But if someone that you know and trust asks you to do it, you’re more apt to do it.”—HCP 2 (Nutritionist)“It would be really nice if we could reach out to our African American community in (a Mid- Western County), our surrounding areas, and ask them what they’re comfortable with… Are you comfortable coming in to take a class inside the healthcare setting, or would you rather have it within your community?”—PHS 44. DiscussionOur study explored perspectives from key stakeholders regarding implementation of a novel culturally tailored diabetes self-management program for the AA community, Peers EXCEL, using the CFIR framework. When focusing on the CFIR domains of intervention characteristics , (2) outer setting , and (3) inner settings , we identified five major themes, including (1) partnering with local organizations, (2) creating a supportive and trusting environment, (3) building relationships and empowering peers (4) logistical barriers to program implementation and (5) challenges to program acceptance. We plan to use these themes to help pilot the feasibility and acceptability of Peers EXCEL and inform successful Peers EXCEL program implementation and sustainability.To successfully translate evidence into practice, we used stakeholder engagement to provide input on the Peers EXCEL program. Stakeholder engagement, including experts in clinical, organizational, and behavioral diabetes care, has been recognized as a standard in developing programs to ensure effective DSME program delivery . ConsistStakeholders also reported the perceived benefits of having peer support as being complementary to the care provided by healthcare professionals. While healthcare professionals may provide the clinical expertise to properly address diabetes management, especially around the initial diagnosis, there is substantial evidence that peer support plays a valuable role in long term diabetes management since most healthcare providers are not equipped with the time or skills to provide comprehensive behavioral and psychosocial support . In our Our findings also highlighted the value that stakeholders placed on Peers EXCEL as a resource to provide culturally tailored content for AA patients to empower themselves in diabetes self-management. Peers EXCEL program may help reduce the barriers AA communities face in accessing diabetes self-management information, building connections with peers, as well as addressing mistrust about the healthcare system. This finding is consistent with prior studies ,32,33,34Building Peer Support Programs to Manage Chronic Disease: Seven Models for Success, which noted various costs associated with peer-based support programs like Peers EXCEL. Though community stakeholders highlighted several anticipated challenges with program’s implementation, they also described possible strategies for overcoming these barriers, including building connections with healthcare providers and AA community to increase awareness [Despite the many perceived benefits of Peers EXCEL, stakeholders also expressed concern regarding several logistical challenges for implementation. For example, recruiting AAs to participate in the program could be difficult due to stakeholders’ perceived differences in education, fear of the unknown, less access to care  and lackwareness .There were some limitations of our study. Participants were recruited through convenience and snowball sampling in one Midwestern state in the U.S. However, our participants were in communities with or without African Americans as the majority racial and ethnic group. Findings from this study could counterbalance the prospective issues of recruitment for future program implementation. To enhance the diversity of our responses, we purposefully sampled organizational leaders with prior experience in leading the HLWD DSME program including those without such prior experience, but with whom we plan future collaborations to lead Peers EXCEL. However, future studies may include broadening to include stakeholder perspectives across additional healthcare systems, in addition to AA patients’ prior to implementation to ensure that interventions are aligned with the needs of the community. While many of the stakeholders did not personally identify as AA, all had extensive experiences serving AA patients in their practice or organization and had valuable perspectives to guide our future implementation of Peers EXCEL within the context of their organizations. This study also implicates that more culturally tailored contents of long-term lifestyle change are needed in the current healthcare systems to achieve a comprehensive care for underserved/marginalized communities.We identified major themes using key stakeholders’ perspectives related to facilitators, barriers, and strategies to be used in the implementation of a culturally tailored diabetes self-management program for AAs. Healthcare professionals and organizational leaders believed that the Peers EXCEL program would complement clinical care and could contribute to reducing health disparities by providing peer support in address barriers to diabetes medication adherence, diet, and lifestyle management. Peer support was viewed as having the ability to create a safe, open environment to facilitate trust-building and improve diabetes self-management among AAs. Potential strategies were identified to overcome logistical barriers to participation and enhance recruitment. Findings from this qualitative study will inform the pilot feasibility and acceptability of implementation of this culturally tailored diabetes self-management program for AAs living with diabetes.


Four clinicians were also interviewed to determine program barriers. Qualitative analyses aggregated participant feedback to identify compliments, changes, and concerns about BERT and critical feedback was immediately implemented prior to initial testing. BERT was rooted in cognitive-behavioral practices and informed by the Gross model of emotion regulation. The 5-week program was then examined in a college sample (N = 42) to evaluate implementation , reach (enrollment and completion demographics comparable to the population in which recruitment took place), and efficacy (positive change in emotion regulation pre- to post-program). Of the recruited participants, 36 remained in the study where 27 completed at least 80% of program content. Repeated-measures ANOVAs exhibited significant improvements in emotion regulation, psychological distress, and negative affectivity, suggesting promising initial efficacy. Initial data provide support for feasibility and a future randomized control trial. BERT has potential significance for promoting healthy development as its brief electronic format reduced barriers and the program development process incorporated stakeholder feedback at multiple levels to inform better implementation and dissemination.Mental wellness is a critical component of healthy development in emerging adulthood and serves to protect against stress and promote resilience against psychopathology. Emotion regulation is a key mechanism for effective prevention because of its role in socio-emotional competence and its transdiagnostic significance for psychopathology. In this feasibility study, a brief, time and cost-effective emotion regulation training program for emerging adults (BERT) was developed and tested using the RE-AIM framework. Importantly, building interventions within the context of an implementation framework, such as the RE-AIM framework, enhances the chances that an intervention will be able to scale out and scale up. First, the brainwriting premortem method was utilized to refine program content, conducting focus groups a priori to identify potential program failures prior to program implementation. Undergraduate students ( Mental wellness is a critical piece of healthy development in emerging adulthood, a time when youth transition from adolescence to adulthood , 2. For Most college students are emerging adults [18-26 years of age] and are likely to experience violence, accidents, and substance use as well as psychological distress based on the collegiate schedule . WiIn emerging adulthood, optimal ER relates to college transitions through social competence, self-control, and academic achievement . ER is aThe Gross  model ofMental health is often divided into mental illness and wellness, though these are better conceptualized as ends of a spectrum than dichotomous categories . ConsideDeveloping prevention programs requires careful consideration of program delivery, engagement, and reception by the intended audience . Online Ensuring appropriate Implementation, Reach, and Efficacy requires actively engaging the target population and testing the program for intended and unintended consequences, eliciting feedback at multiple levels. Brief ER programs have yet to be developed for emerging adults; therefore, this study takes careful steps to produce an effective and sustainable practical program. After initial content development, scalability was enhanced by acquiring expert and target population feedback. Incorporating feedback from the onset helps ensure that the program will be adopted and well-received. This framework is consistent with participatory action research, integrating reflection and participant input while seeking to reduce inequity and appropriately engage target populations .Intervention efforts are shifting to brief and electronic formats to combat costs and address growing needs for treatment –43. ElecThe overall goal of this project was to systematically develop an online brief emotion regulation training (BERT) program designed to improve ER for emerging adults. Since BERT is a novel ER intervention delivered entirely online, this study aims to examine BERT's initial feasibility in preparation for a future randomized controlled trial. Additionally, it aimed to conduct preliminary tests of its Implementation, Reach and Efficacy. This study focused on the creation of BERT utilizing the brainwriting premortem method to refine program content to prepare for initial testing. The program was then tested in a college sample to evaluate implementation in delivering program content, reach to the recruited population, and preliminary efficacy through improved ER. This study was approved by the university institutional review board (IRB#20-018).To develop program content and design, the first author coordinated a team of data scientists, interaction and user experience designers, psychologists, and public health experts. The design team was mindful of guidelines for online design to meet standards of the 1990 Americans with Disabilities Act to ensure broad accessibility. The following sections outline the design of the BERT program and its four primary components: Emotion Regulation Orientation (ERO), Emotion Regulation Training (ERT), Self-Monitoring (SM), and Ecological Momentary Assessment (EMA) based on the Gross model .Participants completed an interactive 30-min online ERO at baseline describing the Gross  model ofFollowing the ERO, participants began the 5-week ERT. Each week, the ERT used short activities to break down a single ER strategy typically taught in one therapy session. Monday provided psychoeducation, Tuesday applied the strategy to daily life, Wednesday aimed to increase knowledge of the strategy, and Thursday's activity enhanced flexible implementation of these strategies , in addition to ~25 min of measurement per week. Altogether, the full treatment dose was ~6.75 h of intervention.a priori identification of program failures , trans male (n = 1)], heterosexual , queer (n = 1), lesbian (n = 1)], and white . All were full-time students and were in their 2nd (n = 2), 3rd (n = 2), 4th (n = 7), or 5+ year (n = 1), with 2 transfer students. In addition, four white women clinicians from early- to mid-career were interviewed of whom two had doctorates in clinical psychology (PhD) and two were licensed clinical social workers (LCSW). All had experience working with emerging adults. Undergraduates and clinicians were all compensated with $10 Amazon gift cards for their participation.Participants included 12 undergraduate students from three universities across four focus groups that took place between June and August 2020. The sample was predominantly female . Missing midpoint values were replaced by carrying forward initial survey values, providing a conservative estimate assuming no change. Two participants who completed BERT did not complete the final survey, with an additional participant missing parts of the survey. Little's MCAR Test was performed [p = 0.944] and missing final values for these 3 participants were replaced by carrying forward midpoint survey values, or initial survey values if they did not complete the midpoint survey. The overall attrition rate was 11.8%. Participants initiated BERT if they completed the ERO prior to the first week of the ERT (34 of the 42 participants) and completed BERT if they completed program content through Week 5 (n = 30), though 2 completers did not complete the final survey  platform included collaborative efforts between the grant team and five undergraduate students to ensure the program was delivered with fidelity. Approximately 1–2 h per day were required by team members to oversee the data collection process, send program content, and manage email reminders.p < 0.00; see n = 13) and non-Hispanic White students  were not significantly different than expected based on university demographics . Thus, the success of Reach was mixed, with representation adequate by race/ethnicity, but not ideal by gender.Females were represented in the study at a significantly higher rate (86%) than in the university , gender [p = 0.28], or first year status [p = 0.90]. These results support the Reach of BERT. To explore the data, separate logistic regressions were conducted to examine whether there were study variable differences between participants who completed the initial survey and continued to BERT compared with those who did not initiate BERT. There were no significant differences based on age [p = 0.17], BASE-6 [p = 0.72], DERS subscales [p = 0.82], or ERQ subscales [p = 0.75], mDES scales , applicability to daily life , keeping up with program demands , engagement , understanding wording , or recommending the program to others . A similar t-test could not be conducted to test for gender differences because too few men completed BERT. The absence of differential attitudes based on ethnic/racial identity suggests no barriers to Reach.Independent samples F = 9.07; p < 0.000; partial η η2 = 0.24; power = 0.97], consistent with hypotheses. Based on the Bonferroni-corrected alpha, no significant change was noted for the subscales: limited access to emotion regulation strategies ; non-acceptance of emotional responses ; difficulty engaging in goal-directed behavior ; impulse control difficulties ; lack of emotional awareness  = 0.14; p = 0.870; partial η2 = 0.01; power = 0.07]; lack of emotional clarity .As the Bonferroni correction was utilized, the corrected alpha for the DERS was 0.007 and for the ERQ was 0.025. Repeated measures ANOVA showed overall difficulties with emotion regulation  significantly decreased from baseline to follow-up , consistent with hypotheses, but there was not power to detect a similar statistically significant reduction in emotion suppression over time .On the ERQ, cognitive reappraisal skills significantly improved from baseline to follow-up . Additionally, the predicted cutoff score for this measure is 19  = 0.02; p = 0.882; partial η2 = 0.00; power = 0.05]. There was a significant decrease in negative affect over time .As the Bonferroni correction was utilized, the alpha for the mDES was 0.025. Changes in mDES total positive and negative affect scores were examined between baseline and follow-up with a repeated-measures ANOVA to determine broader changes in affectivity following BERT engagement. There was no change from baseline to follow-up in positive affect [The COVID-19 pandemic caused a range of interference in students' lives as evidenced by scores on the PCTQ, CIQ, and CEQ see . When coAn online Brief Emotion Regulation Training (BERT) program was developed and evaluated within the RE-AIM framework  to ensurBERT's strength is as a brief and intensive online intervention that does not require the presence of a clinician. Taking a transdiagnostic and preventive lens, BERT focuses on ER as an underlying mechanism impacting a wide range of psychopathology in emerging adulthood. Additionally, BERT is sensitive to a health equity framework , attemptIncorporating stakeholders to identify changes and concerns early in BERT's development provided invaluable input for developing a sensitive and targeted treatment program. Pragmatically, the brainwriting premortem simplified qualitative data collection, as participants shared and responded to ideas in writing. Many suggested changes were already in the program, but critical observations by participants were incorporated prior to pilot launch, including steps for behavior change, types of coping, windows of completion, sensitive language, and general clarity. Further BERT development will integrate ancillary premortem and initial feedback to enhance the applicability of program content.Promising initial results supported BERT's utility. Recruitment showed initial interest in BERT, though ~1/3 of students screened did not continue to the initial survey, roughly consistent with dropout rates in studies of smartphone apps for depression . Most paImplementation was supported from participants' engagement, low attrition once initiating BERT, and favorable attitudes. However, there were time costs, technological errors, and known technological limitations that posed barriers to implementation and retention. Relying on Qualtrics and GAS instead of mobile apps limited the program design, preventing use of SMS and push notifications that could have simplified content access and reduced implementation team time cost. Personalizing program reminders and having participants choose their notification preferences  would improve accessibility and reduce confusion. Moreover, participants all had to begin the program at the same time, which could have constrained Reach due to delayed initiation or period-specific life circumstances.Engagement measures including attrition (12%) and mean content completion (92%) compare favorably with app- or smartphone-based interventions for health behaviors and disease management , 81–83. This study sought to examine initial efficacy to determine whether further randomized controlled trials are indicated. Initial Efficacy of BERT was promising as there was improvement in DERS total and ERQ cognitive reappraisal scores. No significant changes were seen in DERS subscale scores which may reflect low power due to the small sample size or broad, rather than targeted, change in ER. Still, BERT shows significant improvements in overall ER and cognitive reappraisal, suggesting that foundational ER skills are increasing even if participants are not recognizing or reporting an increase in specific ER components. Interestingly, the mDES exhibited significant reductions in negative emotion but no significant change in positive emotion; this may have been limited by higher reports of positive emotion at baseline. Decreases in negative affectivity could result from increased regulation or management of negative emotional states. Unfortunately, a virtual platform does not allow for in the moment clinical judgment. Future research could expand measurement to include emotionally salient tasks, changes in risk-taking, and executive functioning tasks to better understand how BERT impacts specific ER components or skills.Psychological distress also saw significant reductions, a powerful result in the context of a cascading “mental health pandemic” resulting from the isolating effects of social distancing and quarantining during COVID-19 . It is iAn unavoidable limitation was conducting this work during the COVID-19 pandemic., which significantly impacted general mental health and wellbeing . As indiDespite strong recruitment efforts, only 42 participants enrolled in BERT, limiting statistical power. The small, somewhat homogenous, sample also raises generalizability concerns about findings. Additionally, since this program is designed as a preventive intervention it is difficult to disentangle potential adverse effects, though none were observed during this study. Occasional technological errors in content delivery may have also impacted observed results, though statistically more likely to have biased effect estimates downward than upward. Since BERT was not yet fully automated, manual email reminders were sent to keep participants on track. Occasionally, difficulties in loading the participant homepage impacted data collection, making it impossible to know if participants were 100% compliant with program content. Replicating testing of BERT with a larger and more diverse sample and with fully automated program delivery are thus important next steps. This stage of program development focused primarily on implementation and feasibility, thus excluding a control group comparison to maximize statistical power. Future work will benefit from a waitlist control design.Overall, results are promising for transdiagnostic treatment approaches to prevention like BERT. Approaching treatment development with the end in mind allows for critical examination of shortcomings and growth areas of BERT. While the online format lends itself to better fidelity, technological barriers still impeded implementation. By identifying and addressing dissemination barriers, BERT can be adapted to facilitate widespread program uptake. BERT takes an upstream approach to addressing a key mechanism underlying multiple forms of psychopathology, allowing it to effectively prevent a range of negative outcomes while promoting wellbeing. BERT can be widely disseminated because it is cost-effective, adaptable, and does not require significant clinician burden. BERT has great potential as a cost-effective tool to promote regulation and mitigate distress in emerging adulthood. Accessibility by individuals with disabilities was emphasized throughout the design process. Future development aims to test BERT with more ethnoracial and gender identity diverse samples to ensure an equitable program. When unmanaged, poor ER can manifest in deleterious ways  with a host of negative associated consequences . ProactiThe 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 Virginia Tech Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.AG came up with the intellectual property and BERT intervention as well as the primary manuscript drafts, which was supervised by LC and JD. SH provided consultation regarding implementation science. The data bridge team including AB, NP, MS, and TE assisted in the development of the technological components of BERT and assisted with data collection. All authors assisted with editing drafts of the manuscript. All authors contributed to the article and approved the submitted version.This project was funded by the Southern Regional Education Board Dissertation Award, the Thomas H. Ollendick Ph.D. and Mary Catherine Haley Ollendick Graduate Fellowship in Clinical Child Psychology, and the Institute for Creativity, Arts, and Technology (ICAT) at Virginia Tech SEAD Grant. Open access publishing fees were supported by the Virginia Tech Open Access Subvention Fund.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.


Proteomics and metabolomics were used to reveal the significant molecular networks. The bioinformation analysis was validated by administering peroxisome proliferator activator receptor-γ (PPARγ) antagonist and agonist via perfusion circuit in the air-ventilated NMP. Results showed that air-ventilated NMP conferred a better functional recovery and a less inflammatory response in the rat DCD liver; integrated proteomics and metabolomics analysis indicated that intrahepatic docosapentaenoic acid downregulation and upregulation of cytochrome P450 2E1 (CYP2E1) expression and activity were associated with DCD liver functional recovery with air-ventilated NMP; PPARγ antagonist worsened liver function under air-oxygenated NMP whereas PPARγ agonist played the opposite role. In conclusion, air-ventilated NMP confers a better liver function from DCD rats through the DAP-PPARγ-CYP2E1 axis; CYP2E1 activity provides a biomarker of liver functional recovery from DCD.The optimal oxygen concentration is unclear for normothermic machine perfusion (NMP) of livers from donation after circulatory death (DCD). Our purposes were to investigate the effect of air-ventilated NMP on the DCD liver, analyze the underlying mechanism and select the targets to predict liver functional recovery with NMP. NMP was performed using the NMP system with either air ventilation or oxygen ventilation for 2 h in the rat liver following warm ischemia and cold-storage preservation.  Thus, NMP has theoretical advantages over static cold storage (SCS) in benefiting liver transplantation by utilization of DCD donors. Animal transplant models and clinical data have suggested that the use of NMP might improve organ utilization and posttransplant outcomes3. However, few sensitive parameters have been developed to predict liver functional recovery from DCD liver with NMP. The reason is partly due to that the mechanisms underlying the benefits of NMP are not completely understood.Normothermic machine perfusion (NMP) could deliver oxygen and recreate the physiological environment of oxygenation and cellular metabolism. This might minimize liver ischemia followed by reperfusion injury, help to estimate liver graft functionality and benefit functional recovery before graft implantation, especially for organs from donation after circulatory death (DCD)5. Initial dysfunction in mitochondria and endoplasmic reticulum from warm ischemia from DCD may induce a lower threshold of reperfusion injury in liver grafts compared with donors after brain death6. Our previous study demonstrated that endoplasmic reticulum stress is highly activated during liver NMP from DCD rats, and that administration of acting transcript factor 6 agonist under NMP could improve liver function7.The most commonly used approach for applying NMP in clinics is the replacement of cold preservation prior to graft implantation. Experimental models have demonstrated that warm and cold liver ischemia followed by reperfusion injury, that is named ischemia–reperfusion injury, is characterized by oxidative tissue injury and activation of the inflammatory immune response either in situ at implantation or during NMP8. Application of hypothermic machine perfusion (HMP) 100% oxygen for kidney grafts from DCD resulted in a better function compared to HMP with no oxygen or air9. So far, it remains unclear what oxygen concentration is optimal for NMP.Constant oxygenation during machine perfusion is of special interest in the context of graft functional recovery. Oxygen in the perfusate may help the fast recovery of mitochondrial function following liver cold preservation. Meanwhile, the availability of oxygen, especially at high concentrations of oxygen may foster formation of reactive oxygen species (ROS). This is of even greater concern under re-oxygenation conditions where the perfusion ROS-mediated injury occurs. This ROS-mediated injury potentially restricts organ function after transplantation. Against this background, different concentrations of oxygen draw attention to yield the positive effects of active oxygenation while avoiding adverse effects7. Through our pilot experiment based on the established rat model7, arterial oxygen-ventilated NMP system could create an oxygen pressure of over 400 mmHg in the artery (PaO2 > 400 mmHg), which agrees with the most reported NMP systems4, whereas arterial air-ventilated NMP could produce near-to-physiological oxygenation (PaO2 = 90~200 mmHg). Thus, our primary purpose in the current study was to compare the effect of air-ventilated NMP with oxygen-ventilated NMP on liver function from DCD rats before implantation. Based on the findings, the further purpose was to investigate the mechanism of liver functional recovery using an arterial air-ventilated NMP system on liver function through an integrative proteomics and metabolomics analysis, and select the suitable target to predict liver functional recovery from DCD liver with NMP.Our previous study demonstrated the arterial oxygen-ventilated NMP system could improve function of DCD liver using the rat modelThe animal experiment was approved by the Animal Ethics Committee of Zhengzhou University, Zhengzhou, China (No.2019-KY-019). All methods were carried out in accordance with relevant guidelines and regulations along with the ARRIVE  guidelines statement. The Sprague–Dawley male rats weighing 320–350 g were purchased from Beijing Vital River Laboratory Animal Technology Co., Ltd. . All rats were housed under specific pathogen-free conditions at room temperature with a 12/12 h light/dark cycle, and were allowed free access to chow and water before surgical procedures.3, we designed the experimental groups (Table 2: 90~200 mmHg) and hyperoxygenation (PaO2 > 400 mm Hg) of the perfusate on liver graft: ① Group control (n = 6), healthy livers without ischemia; ② Group hyperoxygenated NMP (n = 6), DCD livers exposed to 30 min of in situ warm ischemia and 8 h cold ischemia preservation followed by 2 h NMP with oxygen ventilation; and ③ Group air-oxygenated NMP (n = 6), DCD livers exposed to 30 min of in situ warm ischemia and 8 h cold ischemia preservation followed by 2 h NMP with air ventilation.Based on the accepted concept that oxygenated NMP would benefit functional recovery of liver graftps Table  to compa11.In the next step, in order to evaluate the effect of the selected targets on liver functional recovery from the above step, three more groups were designed: ④ Group Dimethylsulfoxide , DCD livers exposed to 30 min of in situ warm ischemia and 8 h cold ischemia preservation followed by 2 h air-oxygenated NMP with DMSO in the perfusate; ⑤ Group Rosiglitazone (n = 4), DCD livers exposed to 30 min of in situ warm ischemia and 8 h cold ischemia preservation followed by 2 h air-oxygenated NMP with the peroxisome proliferator activator receptor-γ (PPARγ)-specific agonist Rosiglitazone in the perfusate; and ⑥Group GW9662 (n = 4), DCD livers exposed to 30 min of in situ warm ischemia and 8 h cold ischemia preservation followed by 2 h air-oxygenated NMP with the PPARγ-specific antagonist GW9662 in the perfusate  and gassed with air or 100% oxygen through a hollow fiber dialyzer . The oxygen concentration was adjusted to the blood gas value by oxygenator. The liver perfusion system was modified from the perfusion system12, and the same perfusion medium was used for two consecutive liver perfusions of 2 h each, supplemented with 4–5 ml circuit solutions after each perfusion to replenish the necessary loss.The liver perfusion had perfusate comprised of rat red blood cells that recirculated through both hepatic artery and portal vein of liver grafts by means of a peristaltic pump . The perfusion medium, with the total volume of 36 mL, contained 24 ml whole heparinized blood supplemented with 10% sodium citrate, 1% penicillin and streptomycin, and 12 ml circuit priming solution with 45% lactated Lexington, USA). Perfusate samples were taken from the portal vein cannula for measurements of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) using standard biochemical methods. The viability of the preserved livers was evaluated by changes in ALT (ΔALT = postperfusion ALT level – preperfusion ALT level) and AST (ΔAST = postperfusion AST level – preperfusion AST level) in the perfusate.Perfusate samples for blood gas analysis were withdrawn from the cannula placed in the hepatic artery at the three-way stopcock and analyzed using an automatic blood gas analyzer .Liver biopsies obtained from the perfused liver were immediately snap-frozen with liquid nitrogen and stored at − 80 °C for the further detection of PPARγ and cytochrome P450 2E1 (CYP2E1), fixed with 10% buffered formalin for further morphological evaluation by performing hematoxylin/eosin (HE) staining, and kept at 0~4 °C for assessment of superoxide dismutase (SOD) activity, malondialdehyde (MDA) level and CYP2E1 activity, and tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6) using an enzyme-linked immunosorbent assay  were performed as previously13. In brief, the peptides were enriched by prewashed antibody beads , followed by analysis with tandem-mass-tag labeling combined with LC–MS/MS on the tissue samples. The resulting MS/MS data were processed using the engine software MaxQuant  and uploaded to Proteomics identifications database (PRIDE) under the project accession number PXD028641. A differentially expressed protein was considered significant if P < 0.05 and FOLD > 1.2.Untargeted 14. Briefly, after the quality control, each specimen was introduced for GC-TOFMS analysis on a time-of-flight mass spectrometry (GC-TOF/MS) system (Pegasus) with an Agilent 7890B gas chromatograph . The raw data from GC-TOF/MS were processed with XploreMET 3.0, and each data set was converted to comparable data for further statistical analysis (P < 0.05 and FOLD > 1.5 as significant difference).Quantitative metabolomics was conducted on the XploreMET platform  according to the previously published methodThe ratio of two adjacent metabolites from a known metabolic relation network was calculated for the analysis of individual metabolic alterations. The Z-score heat map was applied for data visualization of the entire relationship. A multivariate regression model with the O2PLS method and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis were applied to integrate proteomics data with metabolomics data. Integrative analysis and coregulated pathways by Spearman correlation analysis were constructed to elucidate the impact of oxygen concentration on DCD liver with NMP. Cytoscape/MetScape-based analysis was used to visualize and interpret the interaction network between proteins and metabolites.15.Liver tissues were fixed in 4% paraformaldehyde in phosphate-buffered, embedded in paraffin wax, and stored at 4 °C. HE staining was performed, and histological analysis was evaluated according to Suzuki histological criteria by the pathologist as report before15. The PVDF membranes were cut prior to hybridization with target-specific antibodies  and the internal control, glyceraldehyde-3-phosphate dehydrogenase (GAPDH). Primary antibodies used were against PPARγ , CYP2E1 , and GAPDH . Immunoreactivities were visualized by secondary horseradish peroxidase-conjugated rabbit antibody , mouse antibody , and the ECL Western Blotting Substrate  according to the manufacturer's instruction of KPL Protein Detector Western Blot Kit . The full-length membranes and the original blots are illustrated in the supplemental file.Protein extracts of liver tissue were prepared and separated by SDS–polyacrylamide gel electrophoresis (SDS-PAGE), transferred to polyvinylidene difluoride (PVDF) membrane by electroblotting, and processed for Western blot analysis as previously described16.Based on the ratiometric fluorescent probes for selectively sensing activity of CYP2E1, liver S9 fraction was prepared from the perfused livers to detect levels of the P450-catalyzed drug metabolizing enzyme activitiesChina). Results were obtained using a Multiscan FC plate reader with SkanIt software .Detection of the SOD activity at 550 nm and quantification of MDA content were performed using a WST-8 assay kit and thiobarbituric acid assay according to the manufacturer's instructions  levels in the liver were measured according to the manufacturer's protocols .by using two-tailed unpaired Student’s test, and differences between more than two groups were analyzed by one-way analysis of variance (ANOVA), and Bonferroni test was used for a multiple comparison analysis. The statistical tests were employed by using SPSS version 21.0 . A probability level of less than 5% (P < 0.05) was considered statistically significant.Values are given as means with a standard deviation (SD). Differences between the two groups were analyzed The animal experiment was approved and supervised by the Animal Ethics Committee of Zhengzhou University, Zhengzhou, China (No.2019-KY-019).t = 13.307, P = 0.001). To compare the degree of liver recovery following air-ventilated NMP and oxygen-ventilated NMP, aminotransferases in perfusate, HE staining, SOD activity, MDA level and inflammation parameters of the perfused liver were investigated.Arterial oxygen pressures in oxygen-ventilated NMP and air-ventilated NMP were 576.3 ± 27.9 mmHg and 137.9 ± 17.6 mmHg with a significant difference  with a significant reduction following air-oxygenated NMP in comparison with that of hyperoxygenated NMP (0.750 ± 0.167 vs 1.583 ± 0.319)    with a significant difference following air-oxygenated NMP in comparison with that of hyperoxygenated NMP   with a significant reduction following air-oxygenated NMP in comparison with that of hyperoxygenated NMP   and CYP2E1 were enriched in the pathway of biosynthesis of unsaturated fatty acids . DPA expression in the air-oxygenated NMP was downregulated by gas chromatography-mass spectroscopy  with an increase in the air-oxygenated NMP in comparison with that of hyperoxygenated NMP . CYP2E1 activity of air-oxygenated NMP with 66.438 ± 4.215 pmol/min/mg protein was higher than that of oxygen-oxygenated NMP with 52.479 ± 2.115 pmol/min/mg protein , and showed no significant difference with control with 69.180 ± 3.686 pmol/min/mg protein  .To test the effect of PPARγ on DCD liver, administration of PPARγ agonist and antagonist in the perfusion circuit was employed in the air-oxygenated NMP system. In comparison with administration of DMSO and PPARγ agonist Rosiglitazone in the perfusion circuit, administration of PPARγ antagonist GW9962 worsened liver injury and inhibited functional recovery of DCD liver under NMP, as indicated by HE staining and Suzuki criteria score  and oxygen ventilation (PaO2 > 400 mmHg) on liver functional recovery in the rat DCD model7, the results demonstrated that air-ventilated NMP was associated with a superior liver morphological change, a better functional recovery and a less inflammatory response of the rat DCD liver with static cold preservation. The preclinical result of near-to-physiological oxygenated NMP offered a better way to expand clinical usage of the extended criteria donor liver.After we compared the effect of NMP with air ventilation -PPARγ-CYP2E1 axis might provide promising biomarkers and therapeutic targets, and thus predict and improve liver graft quality from DCD donors.The results of the present study showed that air-ventilated NMP can simulate a near-to-physical oxygen pressure through artery perfusion, and thus confer better liver functional recovery from DCD rats following ischemia–reperfusion injury. The integrative Supplementary Information.


Brachytherapy (BT) was the first radiotherapeutic technique used to treat human disease and remains an essential modality in radiation oncology. A decline in the utilization of BT as a treatment modality has been observed and reported, which may impact training opportunities for medical physics residents. A survey of therapeutic medical physics residency program directors was performed as part of an assessment of the current state of BT training during residency.In March 2021, a survey consisting of 23 questions was designed by a working unit of the Brachytherapy Subcommittee of the American Association of Physicists in Medicine (AAPM) and approved for distribution by the Executive Committee of the AAPM. The survey was distributed to the directors of the Commission on Accreditation of Medical Physics Education Programs (CAMPEP)‐accredited therapeutic medical physics residency programs by the AAPM. The participant response was recorded anonymously in an online platform and then analyzed using MATLAB and Microsoft Excel software.The survey was distributed to the program directors of 110 residency programs. Over the course of 6 weeks, 72 directors accessed the survey online, and 55 fully completed the survey. Individual responses from the directors  were evaluated and analyzed. Nearly all participating programs (98%) utilize high dose rate BT treatments with 74% using low dose rate BT techniques. All programs treated gynecological sites using BT, and the next most common treatment sites were prostate (80%) and breast (53%). Overall, the residency program directors had a positive outlook toward BT as a radiotherapeutic treatment modality. Caseload and time limitations were identified as primary barriers to BT training by some programs.Based on the responses of the program directors, it was identified that the residency programs might benefit from additional resources such as virtual BT training, interinstitutional collaborations as well as resident fellowships. Programs might also benefit from additional guidance related to BT‐specific training requirements to help program directors attest Authorized Medical Physicist eligibility for graduating residents. Recently, there has been a decline in the utilization of BT as a treatment option.The Brachytherapy Subcommittee (BTSC) of the Therapy Physics Committee (TPC) under the Science Council of the AAPM pursued an investigation into the current state of residency training. A working unit was formed, comprising of two senior subcommittee members and two junior members. The unit proposed to evaluate the state of BT training through surveys of the trainers  and the trainees . This work presents the results of a survey that was distributed to the CAMPEP‐accredited residency program directors, with a goal to evaluate medical physics resident training in the areas of high dose rate (HDR), low dose rate (LDR), radiopharmaceutical, and electronic BT. Through this survey, the authors collected information about the various BT modalities used at different training programs: types and frequency of cases, distribution and frequency of treatment sites, typical workload/caseload per resident, and availability of adequate and diverse learning opportunities involving residents. Information regarding attestation of the training and experience requirements documented on the Nuclear Regulatory Commission (NRC) form 313A22.1The survey consisted of 23 questions of four types including multiple choice, select all that apply, five‐point scale, and free response. The questions were designed to collect information regarding six areas: (1) the types of modalities, radioactive sources, treatment sites, and dose calculation algorithms utilized at each program; (2) the average annual patient‐ and fraction‐based caseload at each program as well as the length of time residents spend training in BT; (3) AMP eligibility requirements as they relate to the training received during a residency program; (4) program directors’ views on BT as a treatment modality; (5) program directors’ views on the BT training received by residents both generally as well as specific to their own program; and (6) a free response question to identify additional thematic information not directly asked during the survey. A copy of the survey questions is provided in the Appendix. Marcrom et al.2.2The survey content was thoroughly vetted by the AAPM. The survey was first reviewed and approved by the BTSC before undergoing review by the TPC. The survey was then distributed to both the Professional and Education Councils for comments and approval. Following consideration and incorporation of feedback, the survey was presented to the Executive Committee (ExCom) of the AAPM by the Education Council. The survey was approved for distribution to the residency program directors by ExCom.2.3A link to the survey was distributed among the program directors according to the CAMPEP‐accredited therapy residency program list (March 2021).2.4Numerical results were analyzed using summary statistics with Microsoft Excel33.1Seventy‐two program directors responded to the survey out of 110 survey recipients. Fifty‐five program directors completed the full survey for an overall response rate of 65% and a completion rate of 50%. Surveys were considered “completed” if respondents electronically submitted the survey, even though they may not have answered all questions. All survey answers were included in the analysis independent of whether a program director completed the survey in full or in part. The average time spent on the survey by all respondents was 27 min. The average time required to complete the survey was slightly greater at 33 min.3.23.2.1Program directors were asked about the treatment sites, source types, treatment modalities, caseload for each modality, dose calculation algorithms, imaging modalities, and use of therapeutic radionuclides at their respective institutions. This information allowed evaluation of the breadth of procedures in which residents receive BT‐related training.The distribution of the utilization of BT for various treatment sites is presented in Figure A variety of BT sources are used by the survey participants for treatments. Individual respondents could select multiple sources for this question. The distribution of sources utilized for BT treatments by the programs is presented in Figure An overwhelming majority of respondents  use HDR Ir‐192‐based BT (98%). LDR BT was utilized by 74% of the respondents including I‐125 (71%) and Pd‐103 (47%).The results of the reported BT technique and treatment site distribution are presented in Figures In terms of caseload, as seen in Figure Most (98%) programs reported using the AAPM TG43 formalismAll but one program reported using computed tomography (CT) as an imaging modality for BT. Close to 80% of the programs reported using magnetic resonance imaging (79.6%) or ultrasound (77.8%) while performing BT procedures. Other imaging modalities frequently used included fluoroscopy (24.1%), digital radiography (18.5%), single‐photon emission computerized tomography (11.1%), and others (5.6%). Other modalities included PET, DYNA CT, and linac‐based kV imaging. Seventy‐four percent of the programs used three or more modalities for BT procedures.Approximately half (48%) of the programs reported residents receiving training in the use of therapeutic radionuclides. The list of radionuclides used is presented in Table 3.2.2Program directors were asked about the annual BT caseload at their institution in terms of patients treated as well as the number of fractions. Additionally, data were collected about the length of time residents spend training in BT in terms of months on a BT rotation as well as the number of training hours received.Twenty‐two percent of programs reported an annual caseload between 101 and 150 BT patients each year, with 21% of programs treating more than 300 patients each year using BT. Only three programs reported 50 or fewer cases per year.The plurality (31%) of programs reported performing more than 500 BT fractions each year with 21% of programs performing between 201 and 300 fractions each year. Twenty‐five percent of the directors reported 200 or fewer fractions treated per year (and no programs reported 50 or less).Most programs (66%) require residents to spend 3–4 months on a BT rotation. Five percent of programs reported not having a dedicated BT rotation. All programs that offer a dedicated BT rotation reported residents spending no fewer than 2 months training in BT. Fourteen percent of the programs reported residents spending more than 5 months for BT‐related training. The plurality (44%) of programs reported residents receiving between 300 and 500 hours of BT‐specific training.Fifty‐seven percent of the program directors reported attesting to AMP eligibility for their graduating residents, while 43% do not. When program directors were asked if their program would benefit from more structured guidelines for the number of cases required for a physicist to become an AMP, 42.6% of program directors responded in the affirmative and 14.8% replied in the negative. The remaining 42.6% were unsure if their program would benefit from more detailed guidelines.3.2.3Program directors were asked about the importance of BT as a treatment modality, whether they thought BT utilization will increase in the future, as well as their thoughts on the adequacy of the status of BT training.When asked about the importance of BT as a treatment modality in radiation oncology, 86% of program directors believed it was essential, 3% were neutral, and 11% were ambivalent.When asked about the future of BT utilization for treating cancer, most respondents (57%) believed there will be some degree of increase, while 39% of the respondents believed there would be no change, and 4% believed there will be a decrease in utilization.None of the program directors reported believing that the BT training was optional. A third of the directors believed that the training was adequate, 30% believed it requires some expansion, and 37.5% of the directors believed significant expansion was needed to the BT training.3.2.4Program directors were asked to provide their opinions on the preparedness of their residents at the end of the residency training program, the degree of support from radiation oncology colleagues in allowing medical physics residents to engage in BT procedures, and the level of independence achieved by residents for different BT tasks. Additionally, directors were asked if a BT fellowship would be beneficial to their residents, what the greatest hurdles are in providing BT training, and what resources would be needed to overcome these hurdles. Finally, programs were asked what percentage of their residents practice BT in their first postresidency position.The plurality (43.6%) of program directors believed CAMPEP‐accredited programs partially prepare residents to independently practice BT in their first postresidency position, with 36.4% of the directors perceiving their residents as more than partially prepared but not proficient. The results are shown in Figure When asked if radiation oncologists are generally supportive of medical physics residents being involved in BT procedures, most (59%) program directors believed radiation oncologists were encouraging, while 28.6%, 10.7%, and 1.8% of directors felt radiation oncologists were supportive, neutral, or unsupportive, respectively.Figure Most (87.3%) respondents believed their residents could benefit (34.6%) or could maybe benefit (52.7%) from a BT fellowship. Only 12.8% of program directors believed their residents would not benefit from such a fellowship.Approximately a third of program directors 32.1%) were unsure if graduates of their program practiced BT in their first postresidency position. The results are provided in Table .1% were 3.2.5The greatest hurdle identified by residency directors regarding resident training was caseload. This includes the lack of treatment options and/or variety of case types that are handled at various programs. The second largest reported barrier was regarding time constraints including both lack of time for daily activities and on a larger scale such as the residency duration itself. Some procedures and modalities would not occur during a trainee's BT rotation, which correlates with a lack of caseload. A resident's limited time commitment while balancing other clinical tasks was also noted.Many respondents recognized they could not affect a change in patient‐load constraints and focused on alternatives such as virtual resources for resident training. This included access to a database of treatment scans and plans, online learning/lecture series, and simulation labs. Others suggested longer residency training. A common theme was a need for higher levels of support for BT procedures ranging from physician acknowledgment of physicist necessity to more space and patience from the staff.Some centers reported no concerns with caseload or time constraints. Interestingly, centers with large patient volumes (>300 cases per year) were equally likely to report concerns with time constraints and caseloads, indicating even large patient numbers alone are not a reliable solution for case and modality diversity.Several respondents expressed apathy or lack of ability to change their training opportunities as barriers to BT training. While this may reflect the inability of an individual to change practice patterns at their institution, some expressed the feeling that BT use was declining following the patterns of care described earlier.Several respondents indicated a desire to have detailed guidelines and caseloads like medical radiation oncologists when attesting to AMP license requirements. Another recurring theme was that of needed collaboration between various programs to afford residents with exposure to diverse caseloads, particularly those involving newer modalities and radiopharmaceutical administration.4One method to display a data‐driven look at strengths and weaknesses of a particular system is to perform a Strength, Weakness, Opportunities, and Threats (SWOT) analysis. In Table AAPM Report 249 characterizes the guidelines and essential curriculum for a residency in medical physics.According to AAPM report 249, the trainees should demonstrate an understanding in a variety of treatment sites including GYN, prostate, and soft tissue sarcomas, as well as optional sites such as the eye, and the liver. Training modalities included HDR, LDR, interstitial BT as well as optional modalities such as pulsed dose rate (PDR), electronic BT, and Y‐90 microsphere applications. Based on the information presented from responses to survey questions 1 and 6, the authors found that approximately 100% of centers treated GYN, 80% prostate, 45% ocular, 35% sarcoma, and only 12% were involved with electronic BT. About 40% of the programs reported using Y‐90, and 5% PDR.The greatest barrier to adequate resident training identified by the residency directors was caseload. This includes the lack of modalities and/or variety of case types that are handled at various programs. Programs that treated fewer than 150 patients a year were more than twice as likely to report issues than programs who treated greater than 150 patients per year. This result reaffirms the finding of Marcrom et al., which was reported for physician residents.On a larger scale, the disparity of time allotted for BT training varied from no formal training to more than 5 months with the average time being 3 months. Time constraints on the treatment team were also indicated by the respondents, for example, in having limited time to train the residents in these modalities, which may be partially due to the urgent nature and short timeframe of BT procedures.Regarding treatment planning and medical dosimetry, trainees are commonly required to perform a decay calculation and calculate the total dose delivered by a temporary and permanent implant as outlined by Report 249 recommendations. These are general and can be performed in a classroom setting. For specific plans, the report requires a treatment plan for a vaginal cylinder applicator, and inspection of Figure For the radiation safety requirements listed in Report 249, most requirements can be performed in the classroom or laboratory setting. These include performing source receipt procedures, source management activities, room surveys, regular inventories, leak checks for sealed sources, shielding calculations, and shielding surveys. Figure For source assays or calibrations, Report 249 requires discussion and performance of an assay for sealed sources. If possible, it also recommends assays for unsealed sources; however, as noted above, most programs will not be able to offer this experience to their trainees. Finally, the trainee is expected to discuss and perform verification of source strength and reconcile their measurements with the vendor's certificate.Finally, Report 249 has several items related to QA activities for trainees. These include demonstrating an understanding of and participating in periodic spot checks, safety procedures, and source exchange QA, including source calibration. In addition, there is a requirement to understand the comprehensive periodic QA of a remote afterloader. Considering that nearly all programs offer HDR Ir‐192 treatments, most of these items should be readily achievable for most clinics. Additional QA training topics include secondary dose calculations, treatment planning system QA, and acceptance testing for metrology equipment. These items are generally applicable and should be achievable at most training programs.Our survey indicated program directors are divided on whether to attest to AMP eligibility via NRC form 313A for residents at the completion of residency training. This could pose a challenge for graduates seeking employment at institutions offering BT services. This study included program directors reporting the amount of time residents spend receiving BT training in units of months, with some residents receiving as few as 2 months, while others received more than 5 months. Of note, form 313A for AMPs requires an accounting of training duration in units of years but does not clarify if the training must be specific to BT or general training inclusive of BT.There are differences in the requirements of form 313A for authorized user radiation oncologists (AU) compared with AMPs.Data collected during this study could be used to inform the types of BT treatments and the number of cases per treatment type that training centers could accommodate based on typical caseloads. Additional effort would be needed to identify ways for residents to receive additional training experiences if their program did not offer the minimum requirements. Potential solutions include virtual offerings, simulations,This work was limited to surveying CAMPEP‐accredited residency programs. The data as well as accompanying analysis about BT as a treatment option and its availability are thus representative of programs of a similar nature and may not be representative of all residency programs. Additionally, this survey reflects opinions and training activities reported by medical physics residency program directors during the spring of 2021, and the results may have been influenced by the SARS CoV‐2 pandemic‐related implications.5A professional society‐driven survey of medical physics residency program directors was performed to glean insight into the current state of training specific to the practice of BT. Based on the responses of the program directors, it was identified that residency programs might benefit from additional resources to support training such as simulations, fellowships, and external rotations in an era of declining utilization. In addition, responses demonstrated that, specific to the practice of BT, there was little commonality between programs due to the variety of sites, techniques, and modalities. This challenges uniformity of practice and training in accredited programs. Finally, program directors might benefit from additional guidance related to attesting AMP eligibility for graduating residents.All authors worked on all the aspects of the manuscript. Manik Aima and Samantha J. Simiele contributed equally to the publication and should be considered joint first authors. Two authors acted as more senior authors and two as more junior in a mentorship arrangement. The survey design, results, and written summary were all contributed to by all authors.The Chair of the BTSC Unit 72 has reviewed the required Conflict of Interest statement on file for each member of BTSC Unit 72 and determined that disclosure of potential Conflicts of Interest is an adequate management plan. The members of Unit 72 attest that they have no potential Conflicts of Interest related to the subject matter or materials presented in this document.


Furthermore, αSyn RT-QuIC reliably identified cases with LB pathology in the cortex (97% sensitivity) vs. cases with no LBs or LBs present only in the olfactory bulb (93% specificity). However, the sensitivity was low, only 50%, for cases with LB pathology restricted to the brainstem or amygdala, not affecting the allocortex or neocortex. In conclusion, αSyn RT-QuIC of CSF samples is highly sensitive and specific for identifying cases with clinicopathologically-defined Lewy body disorders and shows a lower sensitivity for non-standard LBD or asymptomatic LBD or in cases with modest LB pathology not affecting the cortex.Currently, there is a need for diagnostic markers in Lewy body disorders (LBD). α-synuclein (αSyn) RT-QuIC has emerged as a promising assay to detect misfolded αSyn in clinically or neuropathologically established patients with various synucleinopathies. In this study, αSyn RT-QuIC was used to analyze lumbar CSF in a clinical cohort from the Swedish BioFINDER study and postmortem ventricular CSF in a neuropathological cohort from the Arizona Study of Aging and Neurodegenerative Disorders/Brain and Body Donation Program (AZSAND/BBDP). The BioFINDER cohort included 64 PD/PDD, 15 MSA, 15 PSP, 47 controls and two controls who later converted to PD/DLB. The neuropathological cohort included 101 cases with different brain disorders, including LBD and controls. In the BioFINDER cohort αSyn RT-QuIC identified LBD  vs. controls with a sensitivity of 95% and a specificity of 83%. The two controls that converted to LBD were αSyn RT-QuIC positive. Within the AZSAND/BBDP cohort, αSyn RT-QuIC identified neuropathologically verified "standard LBD"  vs. no LB pathology (n = 53) with high sensitivity (100%) and specificity (94%). Only 57% were αSyn RT-QuIC positive in the subgroup with "non-standard" LBD The online version contains supplementary material available at 10.1186/s40478-022-01388-7. The clinical diagnosis of Parkinson’s disease (PD) can be difficult due to its heterogenous presentation and clinical overlap with atypical parkinsonian disorders, especially early in the disease course. Indeed, the diagnostic accuracy for PD has been found to be as low as 73.8% (67.8–79.6) by non-experts but only slightly better by movement disorders specialist with an accuracy of 79.6% (46–95.1) at the initial assessment, particularly when disease duration is less than 5 years . The difThere are to date no disease-modifying therapies available in PD. New disease-modifying therapies are likely to be most efficient early on in the disease process, before neuronal damage is irreversible . The lacAlthough results consistently have shown decreased levels of CSF unmodified α-synuclein (α-syn) in PD, but also PD with dementia (PDD), dementia with Lewy bodies (DLB), and MSA compared with controls, the reduction is modest, with a broad overlap with controls, and subsequently has failed to adequately discriminate between PD and controls , 51, 53,Ultrasensitive seed amplification assays are methods originally developed for the detection of misfolded prion proteins and prion-like proteins. Over the last several years αSyn RT-QuIC and related α-syn seed amplification assays have emerged as possible methods for detecting misfolded forms of synuclein in CSF, exploiting the prion-like propagation mechanism of pathological α-syn aggregates. Previous studies have shown a high sensitivity of > 92% for clinicopathologically verified Lewy body disorders (LBD), i.e. PD, PDD and DLB, compared to controls/non-synucleinopathies, and a specificity of > 95% , 27, 61.In this study we use a rapid αSyn RT-QuIC assay to test CSF samples from participants with clinically diagnosed PD, PDD, MSA, PSP and controls in the longitudinal Swedish BioFINDER study  and partwww.biofinder.se) [The study was performed at the Clinic of Neurology, Skåne University hospital, Sweden as part of the Swedish BioFINDER Study (nder.se) . The stunder.se) . Patientnder.se) . Patientnder.se) . Patientnder.se) . All conAll participants gave written informed consent before entering the study. The study procedure was approved by the local ethics committee at Lund University Sweden and conducted according to the Helsinki Declaration.A thorough medical history was taken and the participants underwent extensive testing. Participants were examined by a physician experienced in movement disorders and a registered research nurse using, among other scales, the Unified Parkinson’s Disease Rating Scale (UPDRS) -3, the Hoehn & Yahr scale and the Mini Mental State Examination (MMSE) , 28, 37.CSF samples were obtained by lumbar puncture in the L3/L4 or L4/L5 interspace with patient non-fasting. The samples were collected in polypropylene tubes and gently mixed to avoid gradient effects.All samples were centrifuged within 30 min at + 4 °C at 2000 g for 10 min to remove cells and debris, and then stored in aliquots at − 80 °C pending biochemical analysis. The procedure followed the Alzheimer’s Association Flow Chart for CSF biomarkers .The neuropathology cohort consisted of neuropathologically classified participants (n = 101) from the Arizona Study of Aging and Neurodegenerative Disorders (AZSAND), an antemortem-postmortem donor cohort with dates of enrollment from 2007 to 2019. Autopsies were performed by the Banner Sun Health Research Institute Brain and Body Donation program (BBDP) .Neuropathological diagnosis of PD was based on a combination of established neuropathologic criteria , 11, 24 th and 10th cranial nerve nuclei, pons at the level of the locus ceruleus, amygdala, substantia nigra, transentorhinal area, cingulate gyrus at level just posterior to genu of corpus callosum, middle temporal gyrus, middle frontal gyrus, inferior parietal lobule) yielding a maximum score of 40. Neuronal perikaryal cytoplasmic staining, neurites and puncta were considered together, using the templates provided by the Dementia with Lewy Bodies Consortium [Cases were classified using the Unified Staging System for Lewy Body Disorders (USSLBD) i.e., cases with LBs present were classified into LB stages: I. Olfactory Bulb Only; IIa Brainstem Predominant; IIb Limbic Predominant; III Brainstem and Limbic; IV Neocortical . Lewy Bonsortium . The immnsortium .Cases were classified as having PD or DLB, or ILBD  in the case of controls without parkinsonism or dementia, when Lewy bodies were present on neuropathological examination but cases did not meet clinicopathological diagnostic criteria for either PD or DLB.PSP, CBD and MSA were diagnosed according to previously published criteria , 31, 36.Histopathological scoring was performed blinded to clinical and neuropathological diagnosis. Amyloid plaque and neurofibrillary tangle density were both graded and staged at standard sites in frontal, temporal and parietal lobes and hippocampal CA1 region and entorhinal region using a semi-quantitative score of 0–3 based on the CERAD templates, yielding a total score of 15 , 50. ImmPost mortem CSF was drawn from the lateral ventricles through the corpus callosum prior to removing the brain with precautions taken to minimize contamination. The CSF was then ejected into 15 mL disposable polyethylene tubes. CSF was centrifuged at 2,000 g for 10 min at 24 C and supernatants were aliquoted into 0.5 mL polyethylene microcentrifuge tubes and stored frozen at − 80 °C . Mean poWhereas the BioFINDER CSFs were collected from living patients by lumbar puncture, the AZSAND/BBDP CSFs were collected on autopsy from the brain ventricles. Overall comparisons of BioFINDER and AZSAND/BBDP CSFs from PD cases where all replicate reactions were positive indicated that the post-mortem CSFs had slightly higher (22%) mean total protein concentrations, , slightly lower 17%) mean RT-QuIC fluorescence maxima, and slightly longer (15%) mean times to threshold  was considered statistically significant. Sensitivity and specificity of the αSyn RT-QuIC results were calculated for diagnoses in the clinical BioFINDER cohort and between the presence/absence of any LB pathology, LB stage, LB density score, LB distribution and clinicopathological diagnosis in the AZSAND/BBDP cohort. Univariate associations between two continuous or ordinal variables were analyzed using Spearman ρ. SPSS  was used for statistical analyses and figures.There were no sex differences between the diagnostic groups and no significant difference between men and women in αSyn RT-QuIC results Table . There wIn the clinically diagnosed BioFINDER study, 94% of PD patients and 100% of PDD patients were αSyn RT-QuIC positive compared with 17% (8/47) of controls (not including those who later converted to LBD) and 33% (5/15) of PSP patients. Further, 33% of those with clinically diagnosed MSA (5/15) were αSyn RT-QuIC positive. Interestingly, both individuals who were included as controls but subsequently developed clinically diagnosed LBD (PD and DLB respectively) during follow up had positive αSyn RT-QuIC results.In this clinical cohort, αSyn RT-QuIC could discriminate between controls and non-demented PD with a sensitivity of 94% (47/50) and specificity of 83%. When including PD, PDD and individuals who later converted to PD, the sensitivity was slightly higher (95%). However, the three αSyn RT-QuIC negative cases had disease duration of ≤ 5 years yielding a sensitivity of 90% for cases with early PD (≤ 5 years), including those who later developed LBD, and 100% in cases with advanced PD, including PDD (> 5) years. Furthermore, αSyn RT-QuIC discriminated between LBD vs. MSA and PSP with a sensitivity of 95% and a specificity of 67%.There was no significant difference between men and women regarding CSF αSyn RT-QuIC results in this neuropathology-based cohort Table . As expeThe frequency of αSyn RT-QuIC positive cases in each LB stage are given in Fig. When comparing the CSF αSyn RT-QuIC results more directly to the distribution of LB pathology in the brain we found that 30/31 (97%) of cases with LB pathology in the cortex  were αSyn RT-QuIC positive Fig. . The oneWhen using the total LB density score , the αSyn RT-QuIC negative cases had significantly lower LB density compared with αSyn RT-QuIC positive cases (p < 0.001) Table . αSyn RTCSF αSyn RT-QuIC identified neuropathologically verified "standard LBD"  vs. no LB pathology n = 53) with high sensitivity (100%) and specificity (94%). αSyn RT-QuIC thus correctly identified all clinicopathologically confirmed cases with standard LBD. It is worth noting that all 4 cases with DLB also met criteria for AD. In cases with atypical parkinsonian syndromes, i.e. PSP (n = 5), CBS (n = 1) and MSA (n = 1), 6 out 7 were negative. The one αSyn RT-QuIC positive individual with an atypical parkinsonian syndrome had clinicopathological PSP with no evident LBs. It is also worth noting that the one case with neuropathologically confirmed MSA did not have any LB pathology and was αSyn RT-QuIC negative , only 57% cases were αSyn RT-QuIC positive Table  or higheThere were no significant differences in total amyloid-β plaque density score or total neurofibrillary tangle density score between αSyn RT-QuIC positive and negative cases. Further, there was no significant difference between the presence/absence of TDP-43 pathology between to αSyn RT-QuIC positive and negative cases Table .In this study we describe αSyn RT-QuIC testing of CSF from both a clinical cohort and a neuropathological cohort from a longitudinal clinicopathological study. Previous neuropathological studies with αSyn RT-QuIC of CSF have mainly investigated verified clinicopathological diagnoses with LBD vs. cases with no LBD, finding a high diagnostic accuracy in this setting , 14, 61,The diagnostic accuracy was very high for neuropathologically verified cases with standard LB disease vs. cases with no LBs at all with a sensitivity of 100% and a specificity of 94%, which is consistent with previous results , 27, 61.The presence of more than one pathology is prevalent in neurodegenerative disorders , 41, 59 st degree relatives of individuals with PD (mostly) or atypical parkinsonian disorders. There were, however, no significant differences in the proportions of αSyn RT-QuIC-positive and negative BioFINDER controls that had spouses or 1st degree relatives with LBD. None of the αSyn RT-QuIC positive controls had 1st degree relatives with LBD but one of the αSyn RT-QuIC positive controls that converted to LBD had a sibling with PD.In the clinical BioFINDER cohort, we found a high sensitivity (95%) for αSyn RT-QuIC in LBD. However, the specificity in the present study was 83%, which is lower compared to previous results , 61. OneIn our study, 33% of clinical MSA were αSyn RT-QuIC positive and 0/1 of the neuropathologically confirmed cases with verified MSA was αSyn RT-QuIC positive. This is in line with previous studies , 70. It Perhaps more surprising is our low specificity in PSP cases (67%) in the clinical BioFINDER cohort. In our hands, one of the positive PSP samples from the clinical cohort gave 4/4 and one 3/4 positive replicate wells and the others gave 3/8 positive replicate wells. In the 47 positive PD cases, 41 gave 4/4 positive replicate wells, four gave 3/4, one gave 3/8 and one 6/8. All 14 PDD gave 4/4 positive replicate wells. We did not observe any significant difference in the fluorescence intensity in PSP compared to the PD CSF samples. Clinical diagnoses are difficult and inherently uncertain, especially for atypical parkinsonian syndromes and it is possible that the low specificity in the present study may be due to clinical misdiagnoses. However, there were was no significant differences in disease duration, UPDRS motor score, Hoehn & Yahr score, age or sex (data not shown) between the αSyn RT-QuIC positive and negative PSP patients. The presence of multiple pathologies is relatively common in neurodegenerative disorders , 59 and Given the results in the present study with a very low diagnostic accuracy in cases with relatively low LB load in the neuropathological AZSAND/BBDP cohort , one could speculate that αSyn RT-QuIC analysis of post mortem ventricular CSF has a lower sensitivity for detecting LBD compared with in vivo lumbar CSF with a high sensitivity for clinical LBD. It has been stated that lumbar CSF has significant differences from ventricular CSF but this has been refuted in several articles , 35, 67.longitudinal studies are needed to clarify how early in the pre-symptomatic and prodromal phases individuals with early LBD convert to αSyn RT-QuIC positivity in CSF.Overall, CSF αSyn RT-QuIC has become a promising biomarker assay for the diagnosis of PD and DLB that may vastly improve the diagnostic work up in these patients, but may not greatly improve the detection of individuals at the very earliest stages of the disease. Still, several studies have shown a high sensitivity for αSyn seed amplification assays in prodromal cases , 61, 68.The possibility of accurate pre-symptomatic or prodromal diagnosis is especially relevant in coming trials on disease modifying therapies, as these are most likely to be effective if initiated early on in the disease course. αSyn RT-QuIC may be a useful test for at risk iRBD individuals in clinical drug trials to monitor the effect of disease modifying therapies initiated at an early stage.A limitation to the present study is the lack of neuropathological data in the clinical cohort. However, we also studied αSyn RT-QuIC in a neuropathological cohort which strengthens the results. Further, participants in the clinical cohort are followed over time to ascertain as certain a diagnosis as possible. Indeed, the three αSyn RT-QuIC negative individuals clinical PD diagnosis were followed for 2–5 years in the study, showing typical features for PD including Levo-dopa response but were nonetheless early PD with a disease duration of ≤ 5 years.In conclusion, the present study confirms that αSyn RT-QuIC has excellent sensitivity and specificity for cases with clinicopathologically verified LB disorders vs those with no LB pathological changes. However, the diagnostic accuracy was poor for cases with LB pathology restricted to non-cortical areas and having an overall low-to-intermediate LB brain load. Further studies are needed to investigate what factors influence αSyn RT-QuIC results in these cases with more limited LB pathological changes and determine at what timepoint in the pre-symptomatic or prodromal stages of LBD that the αSyn RT-QuIC result converts from sub-threshold to clear positivity.Additional file 1: Supplemental Fig. 1. Comparisons of BioFINDER and AZSAND/BBDP CSFs from PD cases where all replicate reactions were positive.