Navegantes, who are specially-trained bilingual Community Health Workers (CHW), as key team members who improve the ability of the clinic to provide care for and improve the health status of a large population of uninsured Spanish-speaking patients in Providence, Rhode Island. Given the growing demand for CHWs at the clinic and in the broader healthcare sector in the state, CEHC developed the Advanced Navegante Training Program (ANTP). The ANTP prepares community members to become certified CHWs who are equipped to provide patient navigation and lifestyle coaching as well as professional medical interpretation services. The ANTP is developed and taught by CEHC Navegantes who themselves are bilingual and bicultural peers of trainees as well as the population that CEHC serves. Upon graduation, ANTP trainees have been able to attain higher-paying and fulfilling careers in a range of healthcare and other community settings. The ANTP offers a low-cost, community-based model for training CHWs who are uniquely prepared to promote health and well-being among medically underserved patients.Clínica Esperanza/Hope Clinic (CEHC) employs  Community health workers (CHW) are in high demand in the healthcare and non-profit industries. The US Department of Labor recently projected that health educator and community health jobs will increase by 16% from 2016 to 2026 , education systems, and local Health Equity Zones .Navegantes were trained to help with measuring blood pressure, checking basic laboratories such as blood sugar and cholesterol, and connected the clinic volunteers to members of communities that were hard hit during the 2008 recession.Clínica Esperanza/Hope Clinic (CEHC) is a free healthcare clinic in West Providence, Rhode Island that serves a population of over 3,000 uninsured, low-income Spanish-speaking immigrants. Recognizing that patients would benefit from the guidance of bilingual and bicultural healthcare navigators and community health workers, CEHC instituted this role at the time of its founding in 2007. At that time, the clinic was entirely run by volunteers and operated out of a church basement. Community members who took on the role of Navegantes continued to play a major role in the operation of CEHC as its services grew and it moved to a new, permanent location in 2010. Their participation in local health fairs attracted new uninsured patients to the clinic, as Navegantes helped foster trust and visibility of CEHC services in the community. Over the past 10 years, the Navegantes have engaged in a wide variety of health-promoting activities in the community, such as conducting community health needs assessments and door-to-door Census education, participating in active outreach and special health education programs at local community centers, and representing CEHC at city, state, and regional meetings.The Navegantes also continue to fulfill multiple roles in the daily clinical operations of CEHC. CEHC is staffed with a team of Navegantes  during all operating clinical hours to provide patient navigation, social service referrals, and peer-to-peer healthy lifestyle education. One Navegante each day is assigned to provide medical interpretation services. The Navegantes are also responsible for providing group session on healthy lifestyles including the CEHC's own Vida Sana lifestyle program and the Diabetes Prevention Program (DPP), funded by the Rhode Island Department of Health (RI DOH) (The (RI DOH) , 6.Navegantes and developed the Advanced Navegante Training Program (ANTP). The goal of the program is to expand the number of formally trained and certified bilingual and bicultural CHWs that are particularly well-equipped to care for the Spanish-speaking immigrant populations. From the advent of this program, the curricular and logistical planning has been spearheaded by staff Navegantes, with the support of project managers and administrators at CEHC.In 2012, as opportunities for bilingual and bicultural CHWs in RI continued to expand, CEHC recognized the opportunity to formally train and hire new Navegantes who know best how to serve this community. The goal of the ANTP is to build a workforce that will empower CHW to become advocates for improving access to healthcare for their community. Here, we describe practical components and lessons learned from developing and offering a community-based CHW training program at a volunteer-run free clinic.In addition to developing a workforce to meeting critical community health needs, the ANTP is also designed to empower individuals with the skills needed to attain rewarding and higher paying jobs. The ANTP has been organized and taught by current CEHC recruits and trains one to two cohorts of 12–15 participants in the ANTP per year. Each year before the ANTP begins, information is distributed to community members through partner organizations and social media posts. In collaboration with community partners, CEHC acts as the central recruitment agency and identifies potential participants through a variety of methods, including emailing listservs connected to healthcare job seekers, posting flyers at job fairs and outreach events, sponsoring ads on Facebook, and notifying our patient population about the training opportunity.Navegante graduates who spread awareness about the opportunity within their social networks. Many of these individuals have obtained jobs in local healthcare offices and community-based organizations, so they have made connections with other individuals who are interested in advancing their careers. Since the focus of the ANTP is to train members of the community who can provide culturally appropriate care to patients with similar life experiences, using local networks to recruit participants has proven to be an effective method of recruitment.Participants are also recruited by word of mouth through prior Navegantes and offered an interview if they meet the following criteria:  a healthcare setting, but do not currently have the knowledge and/or skills to carry out their desired roles. Usually there are more interested candidates than space in the program allows, resulting in a waiting list almost as long as the number enrolled. In these cases, the selection process is based on the applicant's interest in and dedication to the training, their relevant qualities skills  and their demonstrated ability to perform well in an intensive classroom setting.Navegantes), assisting patients and interpreting for clinicians. A list of the topics and skills covered in the ANTP is provided in The Advanced Navegante Training program (ANTP) is an intensive 10-weeks didactic program followed by an experiential learning internship. Classes are held during evenings and on weekends to accommodate participants' work schedules. Classroom learning takes place during 1–2-h sessions on weeknights, and 3–4-h sessions on the weekends. It is supplemented by at least 80 h of clinic-based experiential learning, where ANTP trainees can work with their mentors  by a certified medical interpretation educator. Participants learn about the health care interpreting profession and receive formal training in language and communication, professional ethics, health care systems, culture, medical interpreting protocols, message conversion, modes of interpretation, cultural brokering, mental health, HIPAA, job readiness , professionalism, and customer service. The course also reviews basic medical conditions and medical terminology that interpreters may encounter on the job.Navegantes. In this way, the Navegantes can experience the impact of healthy lifestyle training themselves, helping them learn the techniques to be effective at teaching it to others. In addition, the material covered in Vida Sana reinforces information presented to trainees during the didactic portion of the program. This iterative training process prepares participants to successfully conduct health coaching and facilitate the Vida Sana class to future cohorts. Upon graduation, participants receive a certificate of completion to facilitate the Vida Sana/Healthy Life program as a Lifestyle Coach at CEHC.A major role for CHWs is to provide health coaching and lead classes on healthy lifestyles. ANTP participants receive training in two types of lifestyle classes. The first is the Vida Sana/Healthy Life program, which is a unique social group-based course that was created and implemented by CEHC staff , 9. VidaThe Diabetes Prevention Program (DPP) is an evidence-based lifestyle change program through the CDC. The DPP Lifestyle Coach training is provided to ANTP participants by the RI DOH. In the DPP, trained lifestyle coaches lead group classes to help participants at risk for diabetes to improve their food choices, increase physical activity, and learn coping skills to maintain weight loss and healthy lifestyle changes to prevent the development of diabetes .Navegante, qualifying these individuals for employment opportunities at local clinics and hospitals, and in programs such as the Health Equity Zone programs funded by the RI DOH.Upon completion of ANTP, participants receive a certification to facilitate both the DPP and Vida Sana as a In addition to the CHW certification they earn, participants in ANTP graduate with other marketable skills that serve the needs of the employers who are in need of highly trained patient advocates. These include First Aid/CPR Certification and Human Subjects Research Training through the Collaborative Institutional Training Initiative website.Participants in the ANTP are required to complete and regular exams in order to progress through the course. The CHW training component includes four quizzes and one final exam, while the medical interpreter training includes a pre-test, midterm, and final exam. Other components, including Vida Sana, include quizzes to assess participant understanding and readiness to continue.As part of ANTP, participants are required to complete an additional 80 h of on-site training at CEHC, for which participants receive a stipend (funded through the RI Department of Labor and Training). Since the majority of the participants either work full-time or work more than one job, these hours are very flexible , and they have an entire year after graduation from the didactic phase to complete the additional 80 h.Navegantes, who have a unique and broad set of duties and roles at CEHC. Navegante duties include administrative/clerical work, social service and healthcare navigation, medical interpreting, facilitating lifestyle classes, and more. If the ANTP trainees are also certified Medical Assistants (as many are), they can also perform Medical Assistant duties during CEHC clinics, such as taking vitals, administering point of care testing, urinalysis, vaccines, etc.During this experiential learning component, ANTP trainees shadow the staff In some cases, ANTP trainees are offered employment at organizations outside CEHC before completing the experiential component of their training. In these cases, trainees are able to receive state CHW certification after completing the requisite number of hours at their new job.Upon completing each of the requirements and passing each of the assessments, the participants are eligible to receive official certifications as a RI DOH Community Health Worker, a Professional Medical Interpreter, a DPP and Vida Sana Lifestyle Coach, and a First Aid/CPR provider.In Rhode Island, participants can receive formal CHW certification upon successful completion of both the classroom portion of ANTP, as well as 1,000 h and/or 6 months of work as a CHW . TraineeThe ANTP is provided free of cost to participants. For the first several years, ANTP was entirely supported by grant funding from local philanthropic organizations, including the Textron Foundation. In 2019, CEHC provided a partnership with the RI Department of Labor and Training (DLT) which established a renewable mechanism for funding for ANTP. DLT funding has allowed CEHC to expand the program from one to two cohorts per year  as well as providing additional funding for direct participant stipends.Navegante during their internship, assistance with career placement, and networking opportunities. The cost per participant also includes operational expenses associated with running the program like honoraria for presenters from The Warren Alpert Medical School of Brown University and local hospital systems including Lifespan and Care New England, as well as salaries for the Navegante leaders.The total cost to train each participant is about $7,500, which includes the cost of the RI CHW certificate ($125), the National Medical Interpreter Exam ($450), medical equipment ($125), and CPR certification ($75), and a stipend for the experiential learning component ($500). In addition to these direct costs that are covered for participants, they receive one-on-one mentoring with a senior ANTP is based on a strong community collaboration of organizations that provide various components of the training, spread the word for recruitment, facilitate job placement after graduation, and more. These organizations span many different industries, from small non-profits, social service agencies, universities, state agencies, to large healthcare systems.ANTP is offered on site at a free clinic that serves uninsured patients, many of whom are Spanish-speaking immigrants. In addition to providing valuable job training and improving employment outcomes for participants, the ANTP responds to the critical need for culturally competent and linguistically appropriate health care for medically underserved members of the Rhode Island community.Navegantes from each of the graduating classes to work at CEHC depending on funding and staffing needs.Since 2012, CEHC has trained over 100 bilingual and bicultural community members in the ANTP . Of ANTPThrough this training, low- to moderate-income level participants gain access to more rewarding and higher paying jobs in the growing sector of employers hiring CHWs and patient advocates in the healthcare industry. On average, CHWs earn $21.91 per hour in Rhode Island, more than the minimum wage in Rhode Island ($11.50 per hour) . With thMost graduates are now certified CHWs and engaging in fulfilling, higher-paying employment at CEHC and other community-based organizations and healthcare systems. These cohorts of ANTP graduates have been empowered and equipped with the tools to help community members overcome the many cultural and linguistic barriers that arise within our healthcare system, leading to long lasting, positive effects on the health of all members of the community in Rhode Island.During the ANTP graduation, participants often share powerful testimonials of their experience with this program and their gratitude for the opportunity. Some excerpts can be found in Navegantes are peers of the current trainees and have shared personal and professional experiences, improving the pedagogical and practical efficacy of the program, and  and the unfunded requirement for additional on-site training was a significant barrier to success. However, CEHC's recent partnership with the RI DLT has allowed for a significantly larger budget for these additional components of the training, covering both these certification costs and stipends for the experiential learning components as well as providing continuity in funding for CEHC as the parent organization.Navegante course leaders have also noted that it is also more difficult to recreate this atmosphere and keep the attention of the participants in a virtual format. However, the online format did allow for two cohorts of ANTP trainees to successfully graduate despite the COVID-19 pandemic. It also allowed more flexibility for those who may not have otherwise been able to participate, including trainees who worked in evening hours and those with children.In early spring 2020, the ANTP was moved to a virtual format due to the COVID-19 pandemic. There have been some significant challenges associated with transferring this program online. For example, some trainees lacked the necessary technology (such as a computer and reliable WiFi connection) to participate in the online classes, but CEHC staff were able to work with trainees to find other options  to ensure their ability to participate. In addition, the nature of the ANTP typically lends itself to a very dynamic classroom atmosphere with interactive activities and discussions. The comradery among trainees that naturally develops among the trainees in the classroom has also been more difficult to achieve in a virtual format. The One central implementation strategy to the ANTP is its integration within the greater parent organization of CEHC. Designing this program under the umbrella of CEHC's work as a free clinic provides the opportunity to leverage the existing infrastructure and staffing, which helps to minimize overhead and operational costs. Importantly, one of the major roles of full-time CHWs at CEHC is to coordinate and lead the entire ANTP with the support of the clinic's existing resources. It also allows graduates to benefit from the existing partnership network of CEHC for job placement. An additional advantage of this model is that CEHC is able to fulfill staffing needs by hiring several new ANTP participants for part- or full-time positions upon graduation.Another important aspect of the ANTP is making the work of CHWs at the center of all components of the program. The peer-led model enhances the warm social atmosphere and community among participants that is developed throughout the program. In this way, the program remains true to its core values of bridging the cultural and language gap that often exists within our healthcare and social service systems.An important next step of this program is to scale up and adapt the program for other community organizations within Rhode Island and beyond. Given the flexibility of its design, the ANTP is thought to be highly adaptable to other settings and could be recreated in many places around the country.CHWs are in high demand in healthcare and non-profit industries. ANTP is a relatively low-cost, sustainable and community-based job training model that uniquely prepares graduates to work in a variety of settings. By providing them with the tools they need to become CHWs, participants have access to higher-paying and fulfilling jobs, as we also build a growing team of knowledgeable, passionate advocates who promote community health for the medically underserved.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.MM and KB wrote the first draft of the manuscript. CE, BV, and DR were involved in the initial development and implementation of the ANTP, provided the logistical information, and details that were used to write the manuscript. ML and ADG oversaw the program's implementation and wrote sections of the manuscript. All authors helped to revise, read, and approved the submitted version of the manuscript.ADG was employed by the company EpiVax, Inc., which was not involved in this work financially or otherwise. The remaining 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.


The stroke induced by ischemia of brain remains high incidence and death rate. The study wanted to confirm the effects of Quaking 6 (QKI 6) on the protection role in neurons of rat model of cerebral ischemia/reperfusion injury (CIRI).The rat model with CIRI induced by middle cerebral artery occlusion was well established and rat neurons were isolated to characterize the effects of QKI 6 mediated by sirtuin 1 (SIRT1) on synthesis of triglyceride in neuron and neuronal apoptosis via activation of SIRT1‐peroxisome proliferater‐activated receptor (PPAR)γ‐ peroxisome proliferator‐activated receptor coactivator (PGC)‐1α signaling pathway.The expression levels of SIRT1 or QKI 6, and acetylation level of QKI 6 were decreased in neurons of rat model with CIRI. QKI 6 deacetylated and mediated by SIRT1 that contributed to suppressing the progression of neuronal apoptosis in rat through promoting synthesis of triglyceride in vivo and in vitro via SIRT1‐PPARγ‐PGC‐1α signaling pathway, then inhibiting CIRI.Our results demonstrated SIRT1 deacetylates QKI 6, the RNA‐binding protein, that affects significantly the synthesis of triglyceride in neurons of CIRI rat model. Moreover, it activated transcription factor peroxisome proliferator‐activated receptorγ coactivator‐1α (PGC‐1α) through post‐transcriptional regulation of the expression of PPARγ, and further enhanced synthesis of triglyceride, thereby restrained the progression of neural apoptosis and CIRI. Our results demonstrated SIRT1 deacetylates QKI 6, the RNA‐binding protein, that affects significantly the synthesis of triglyceride in neurons of CIRI rat model. Moreover, it activated transcription factor PGC‐1α through post‐transcriptional regulation of the expression of PPARγ, and further enhanced synthesis of triglyceride, thereby restrained the progression of neural apoptosis and CIRI. Therefore, ischemic stroke affects community economy and health  provide the spectrum of bio‐functions by deacetylating cellular proteins at the post‐translational level  has different bio‐functions in relation to the stability  model subsequently combined with reperfusion . Based on previous methods from Oka et al. , cerebra2.2All animals were obtained from Department of Laboratory Animal Science, College of Basic Medical Science, Fourth Military Medical University . All animal experiments were performed according to the guidelines for the Care and Use of Laboratory Animals established by the Chinese Association for Laboratory Animal Science and approved by the Animal Ethics Committee of Fourth Military Medical University, China. At the end, the mice were over‐anesthetized by increasing the amount of inhaled anesthesia, 0.5 ml/min isoflurane until breathing, and the heartbeat stopped. There was no pain in the entire process. Animal carcasses were handed over to the management department for unified treatment approach.2.3In our work, ischemia was induced with oxygen/glucose deprivation (OGD) , respectively. Meanwhile, the effect of SIRT1 in the protective role caused by QKI 6 was assessed with SRT1720  and Niacinamide , CIRI was used with DMSO. Then, cell viability was determined for these cultured neurons with regular medium under normoxia after OGD treatment for another 24 h.2.5The neuronal injury was quantity evaluated based on LDH activity assay , respectively.2.9http://sourceforge.net/p/ka‐predictor).The modified sites of acetylation in QKI6 were predicted with the KA‐predictor, which was an online tool  Vector System . The infection controls were Ad‐GFP.11 and 2.0 × 1011 pfu/ml, respectively.Adenovirus‐bacterial recombination system (AdEasy) was used, including pGEM‐3ZF (+) and pAdEasy‐1 pShuttle‐SYN, which was all expression vectors labeled using GFP. The total RNA extracted from cells of rat brain neurons was used for gene amplification of QKI 6, and then it was cloned into vectors based on rat QKI 6 (AF142419.1) sequence in GeneBank. Moreover, the sequence of primer at upward was 5′‐atgcttagtctcagcagcctccgcc‐3′, and the sequence of primer at downward was 5′‐gaccgagccgccaccggcaactaa‐3′. QKI 6 was cloned from primary cultured cortical neurons. The evaluation for concentration of virus and viral vectors titer was performed, and then viral stocks were detected on the replication competent viruses with potential contamination. The concentrations of virus were measured at A260 Hardy, . The tit2.11Followed without or with SRT1720 (50 ng/ml), the neurons treated with OGD were followed with treatment of either scrambled or SIRT1 siRNA. The siRNAs of scrambled sequence and SIRT1 siRNA sequence were as follows: scrambled siRNA: 5′‐ACUUUGCUGUAACCCUGUAdTdT‐3′ (sense), 5′‐UACAGGGUUACAGCAAAGUdTdT‐3′ (antisense); SIRT1 siRNA: 5′‐CCUACGCCACCAAUUUCGU‐3′ (sense), 5′‐ACGAAAUUGGUGGCGUAGG‐3′ (antisense).2.12The total protein of primary cultured cortical neurons induced by OGD was extracted, and then mixed with acetyl lysine antibody and incubated overnight at 4°C. The washed sediments were eluted and mixed with the elution buffer. After centrifugation, the immunoprecipitation (IP) products were assessed using western blot assay with the primary antibody of QKI 6 to determine the content of QKI 6 in the IP products.2.132 until unconscious and anesthesia was maintained with 1.25% urethane in 100% O2 at a flow rate of 1 L min−1. At first, a nylon filament was inserted in the right carotid artery . After 2 h of advanced occlusion, it was taken out, then blood flow was resupplied with enough reperfusion. The sham rats did not undergo the occlusions but surgery of MCA. After MACO and reperfusion, rat was sacrificed by decollation, and brains tissues and infarct volume were collected.Our experiment was approved by Institutional Animal Care and Use Committee of Fourth Military Medical University. The SD rats  obtained from Beijing Experimental Animal Center  were used in our experiment. In standard cages, these rats fed with water and food were housed at 22 ± 2°C in a cycle of light/dark (12 h/12 h). Ischemic stroke was induced by MCAO with subsequent reperfusion  sham, (2) model (CIRI), (3) rat with CIRI and treated with Ad‐QKI 6 (Ad‐QKI 6 group), or (4) empty adenovirus vectors (Ad group). The group of (2) CIRI, (3) Ad‐QKI 6, and (4) Ad were injected with saline, recombinant adenovirus with QKI 6 or saline + adenovirus (empty vector) through the right lateral ventricle for 3 days before ischemia, respectively. The site of injection is based on the brain stereotactic atlas for rats . Then, protein was electrophoresized with SDS‐PAGE gel (12%), further transferred onto polyvinylidene difluoride membranes. TBS containing nonfat milk was used to block the membranes, then it was incubated with SIRT1 antibodies , QKI 6 , PGC‐1α , PPARγ, or anti‐cleaved caspase‐3 , and β‐actin mouse mAb , respectively. Then, those were further incubated using the HRP (horseradish peroxidase)‐conjugated second antibodies . In the end, the image of blots was obtained using the electrochemiluminescence detection system.2.17The pentobarbital was used terminally to anesthetize the MCAO model after recovery period; brains were made into 2‐mm thick coronal sections and sliced from the frontal pole after transcardial perfusion with saline. Then, the sections were fixed with 4% formalin and stained with TTC. The area of infarction in each section was analyzed using the software of SigmaScan Pro 5. The signals of GFP were directly obtained using fluorescence microscope of Olympus BX51. The GFP fluorescent cells in each five view fields selected randomly were counted from 100 random cells. The transfection efficiency was calculated and analyzed using GraphPad Prism 5.0 and Image‐ProPlus 6.0.2.18The system of score with modification was used to evaluate neurological functional deficit in the MCAO model after recovery period. Neurological deficit score (NDS) of 0%–10% was considered normal, and 100% was considered maximum deficit.2.19The tissues of brain in MCAO model were first sectioned, and then the volume of infarction area was valued with TTC method. The captured image was obtained using fluorescence microscope Olympus BX51 . In each slice, the infarction area was assessed using image analysis software SigmaScan Pro V5.0 and Photoshop 7.0.2.20At 24 h following MCAO, after fixing with 4% formalin, the brain tissue sections were stained with TUNEL. Five fields of view in the brain tissues sections from contralateral hemisphere were selected randomly. Subsequently, the TUNEL‐stained cells were counted, while the digital photograph was observed from slide of brain tissue. In the end, the obtained NDS and apoptotic index were calculated automatically with GraphPad Prism 5.0.2.21t‐test for comparison of two groups and one‐way analysis of variance (ANOVA) with Kruskal‐Wallis post hoc tests for multiple group comparisons were performed. p < .05 was statistically different with significance.The continuous variables with normally distribute were indicated with mean ± SD (standard deviation). The analysis of statistics was conducted with GraphPad Prism (version 5.0). Student's 33.1p < .001).At first, the protective effects of QKI 6 on OGD‐induced death of neurons were determined. The results of MTT experiment indicated that the viability of neurons after treatment with OGD obviously decreased, and the survived cortical neurons were approximately 55%. However, when neurons were pretreated for 48 h with QKI 6 protein  before exposure to OGD (24 h), the viability assay demonstrated that neurons treated with QKI 6 were remarkably better than control neurons with dose dependence (p < .01) Figure . FurtherMoreover, the protective roles of QKI 6 in apoptosis induced by OGD were evaluated with caspase‐3 activity and terminal‐deoxynucleotidyl transferase mediated nick end labeling (TUNEL) assays. The activity of caspase‐3 obviously increased in cultured cortical neurons treated with OGD Figure . Meanwhi3.2Furthermore, the TGs Figure  and chol3.3The acetylation level of QKI 6 increased in primary cultured cortical neurons induced by OGD, but it was reversed by SRT1720 Figure . Additio3.4To evaluate the ability of neuronal SIRT1 to maintain lipid homeostasis, the agonist (SRT1720) and inhibitor (Niacinamide) of SIRT1 were used in this study. Furthermore, adenovirus‐mediated gene repletion of SIRT1 was employed in rat primary neurons, and siRNA of SIRT1 was used to interfere SIRT1 expression.Furthermore, in primary neurons, SRT1720 upregulated SIRT1 expression, meanwhile expression of QKI 6, PGC‐1α, and PPARγ also increased. However, the SIRT1 expression level was reduced by Niacinamide, which also induced downregulation of QKI 6, PGC‐1α, and PPARγ Figure . But, SR3.5n = 12) was determined, which decreased to 80%–90% of the baseline level in the core area  and the Ad group (61.80 ± 7.54%) (p < .01), respectively.After MCAO, the blood flow of these animal models , respectively. The final ordinary pathway of caspase‐dependent apoptosis, caspase‐3 activity of neuron, neuronal apoptosis induced by ischemic was further examined after transfection with QKI 6 gene to identify its specific role. The caspase‐3 activation in brains induced by ischemia/reperfusion reduced remarkably after treatment with QKI 6 gene , respectively. Overexpression of QKI 6 gene played a potential protective role against secondary brain damage of cerebral cortex induced by transient cerebral ischemia after MCAO; additionally, it may restore neurological/behavioral impairment.Transient cerebral ischemia damage could reduce the neurological score Figure  at 24 h The results of western blot assay demonstrated that the expression level of SIRT1, QKI 6, PPARγ, and PGC‐1α decreased in model rat, but it was reversed by QKI 6 Figure . However4RNA‐binding protein‐mediated posttranscriptional regulation is rarely studied in neuronal metabolism. STAR family member QKI is an RNA‐binding protein that produces multiple isoforms in human body and shows various expression patterns in several kinds of tissue cells  was used to predict the acetylation modification site of QKI 6. Therefore, SIRT1 was predicted that it may acetylate QKI 6. We found that the acetylation level of QKI 6 increased in primary cultured cortical neurons induced by OGD, but it was reversed by SRT1720 (the activator of SIRT1). Additionally, the acetylation level of QKI 6 increased in primary cultured cortical neurons induced by OGD, but it was reversed by SRT1720. Additionally, the increasing acetylation level of QKI 6 was induced by inhibitor of SIRT1 (Niacinamide), but the QKI 6 acetylation decreased in primary cultured cortical neurons treated with OGD+SRT1720. Furthermore, the increasing acetylation level of QKI 6 was induced by siRNA of SIRT1, but the QKI 6 acetylation decreased in primary cultured cortical neurons treated with Ad‐SIRT1. These results confirmed the protein interaction between SIRT1 and QKI 6, and its level in the SRT1720 group was higher than in primary cultured cortical neurons induced by OGD.Further investigation had been conducted to confirm the molecular mechanism of QKI 6. The online local tool of KA predictor  and inhibitor (Niacinamide) of SIRT1 were used in this study. Furthermore, adenovirus‐mediated gene repletion of SIRT1 was employed in rat primary neurons, and siRNA of SIRT1 was used to suppress SIRT1 expression. These experiments identified that in primary neurons, SIRT1 mediates the synthesis of TGs in the OGD model, which is associated with the QKI 6 and the PPARγ/PGC‐1α signaling pathway.Besides, the MCAO‐induced CIRI rat model was well established and used to characterize the effects of QKI 6 mediated by SIRT1 on synthesis of triglyceride in neuron and neuronal apoptosis via activation of SIRT1‐PPARγ‐PGC‐1α signaling pathway. It demonstrated that overexpression of QKI 6 with recombinant adenovirus protected against transient cerebral ischemia‐induced by secondary brain injury, and reversed postischemic neuronal apoptosis and behavioral impairments induced by secondary brain damage in transient cerebral ischemia via PPARγ/PGC‐1 α signaling pathway.5Our results demonstrated SIRT1 deacetylates QKI 6, the RNA‐binding protein, that affects significantly the synthesis of triglyceride in neurons of CIRI rat model. Moreover, it activated transcription factor PGC‐1α through posttranscriptional regulation of the expression of PPARγ, and further enhanced synthesis of triglyceride, thereby restrained the progression of neural apoptosis and CIRI.The authors declare that they have no conflict of interest.National Natural Science Foundation of China; Grant Number: 81771469; Shanxi Province Social Development Science and Technology Attack Project; Grant Number: 2016SF‐132; Logistics Research Program of Chinese People's Liberation Army; Grant Number: CJN14J005; Science and Technology Project of Louyang, Henan Province, China; Grant Number: 1603002A‐13.Rui Liu and Hongzeng Li contributed to the conception of the study. Rui Liu, Jingyuan Deng and Qunqiang Wu contributed significantly to analysis and manuscript preparation; Chunhua Liao, Qun Xiao, and Qi Chang performed the data analyses and wrote the manuscript; Rui Liu and Qi Chang helped perform the analysis with constructive discussions.Our experiments were performed according to Guidelines for use of Laboratory Animals in Fourth Military Medical University .https://publons.com/publon/10.1002/brb3.2271.The peer review history for this article is available at


We read with interest the article by Blancafort et al. reporting the rationale and process of the “AMICOPE” study , which aThis strategy shares many principles and key actions with our +AGIL Barcelona program, which started in 2016 and is still ongoing in one Barcelona’s primary care area (Spain) ,5. As inIt has been demonstrated that frailty represents an ideal target for preventive interventions against adverse events, especially incident disability. +AGIL Barcelona is based on a community detection strategy by primary healthcare and a comprehensive geriatric assessment conducted by a multidisciplinary team . The resulting intervention is tailored to the needs and priorities of the individual and may include up to 10 weekly sessions of adapted physical group exercise complemented by the use of an App for physical activity (ViviFrail©), nutritional recommendations (based on the Mediterranean diet) and specific actions on other different needs .The +AGIL project intervention strategy is very similar to what was adopted in AMICOPE, although there are some differences in the approach. For example, the design of AMICOPE seems quite selective in the inclusion of participants because it apparently excludes older adults with cognitive impairment or sensorial deficits . +AGIL Barcelona was designed to be more adaptable to the needs of older adults and primary care staff and includes a possibly more heterogeneous population. Interestingly, the preliminary results of +AGIL Barcelona have shown a beneficial impact of the program across different degrees of frailty, suggesting that the intervention is very customizable . On the The results of the co-creation process, which started from the review of the best available evidence on this topic, represented the basis of +AGIL Barcelona and were published in 2018 . This fiThe +AGIL Barcelona program is a nationally well-known research-implementation program supported by a national and international dissemination strategy and was also benchmarked with other relevant research in this field conducted at a local level . The pro


Aim of the study was to enrol a group of individuals with schizophrenia in a long-term moderate-intensity physical activity program and to evaluate its effects on their cognitive functions and cardiovascular risk factors. An additional aim of the study was the comparison of the adherence to the physical activity program before and during the COVID-19 pandemic.2 peak and walking speed were assessed at baseline and at the end of the program. All participants were evaluated on blood pressure and anthropometric variable. Cognitive functions were assessed with the Screen for Cognitive Impairment in Psychiatry (SCIP) and with the Frontal Assessment Battery (FAB) questionnaires.Forty sedentary patients diagnosed with schizophrenia (mean age 46.4 ± 9.6) followed by the Public Mental Health Department of Ferrara were included in the study. 28 of them followed a 1-year walking program consisting of two guided walking sessions/week, while 12 maintained their sedentary lifestyle and followed the usual Cognitive Rehabilitation program. To the participants following the walking program VOppc2 0.35 for SCIP and 0.26 for FAB), with a positive correlation between SCIP score and the number of sessions attended , evident in the patients attending to at least 75 of the 100 walking sessions. Walking speed and VO2peak increased significantly and a decrease of body weight, BMI, systolic and diastolic blood pressure was also observed. The adherence to the walking program registered during Covid-19 period did not differ from that observed before the pandemic. The 12 CG (Control Group) patients maintaining the sedentary lifestyle did not display improvements of cognitive functions.The 20 participants completing the walking program displayed significant improvements in cognitive functions . Schizophrenia is a common and expensive public health problem. Individuals affected by schizophrenia experience severe and chronic levels of disability that derive from acute psychotic symptoms, as well as from cognitive impairments . MoreoveRecently, adults with a schizophrenia disorder were associated to an increased risk also for the new Coronavirus disease COVID-19) mortality  mortalit. The COVAccording to the World Health Organisation, at least 60% of the general population does not follow the minimum guideline for health-related physical activity . It becoThe World Health Organization (WHO) and the European Mental Health Action Plan 2013–2020 , 15 acknPeople with mental illnesses tend to engage in less physical activity programmes than the rest of the population and experience a range of barriers to the engagement in PA such as pain, side effects of medications and negative symptoms –15.As indicated by recent meta-analyses, while no difference in PA is detected relying on self-reported measures , 17–21, A meta-analysis of ten studies recently suggests that aerobic exercise might improve cognitive functions in people with schizophrenia . AerobicIf such findings were confirmed, they would be clinically relevant especially considering that few interventions are available to address the cognitive impairments associated with schizophrenia , 26. MorThis was a 1-year pilot study of guided walking program compared to a usual cognitive rehabilitation program.Sixty-seven sedentary participants with schizophrenia (aged from 25 to 70) referring to the Public Mental Health Department of Ferrara were recruited from December 2017 to December 2018. Follow up evaluations were completed in December 2019 but the walking program continues.This study has been retrospectively registered on ISRCTN as non-randomized trial (n. ISRCTN14763786).In order to be recruited, patients had to be diagnosed with schizophrenia since at least one-year and on antipsychotic medications and with the same therapeutic regimen for at least three months before enrolment. In addition, they had to be free of symptomatic peripheral arterial occlusive disease and cardiovascular, pulmonary, neurological, metabolic, and orthopaedic disorders that could interfere with the walking activity.The eligible participants provided written informed consent and were subdivided to the Guided Walking Program (WG) or to the Cognitive Rehabilitation Program (CG) with an allocation of 2:1 .The Italian version of the Screen for Cognitive Impairment in Psychiatry (SCIP)  and the The SCIP is a brief screening tool designed for evaluating immediate and delayed verbal learning, working memory, verbal fluency and processing speed.The FAB consists of six subtests exploring conceptualization, mental flexibility, motor programming and sensitivity to interference, inhibitory control and environmental autonomy.These tests proved to be reliable in identifying the cognitive impairments associated with schizophrenia.Arterial blood pressure was determined in the seated position after three minutes of rest, using a validated automatic sphygmomanometer (Omron M3) and averaging the values of three successive determinations taken with two-minute intervals. Participants were instructed not to carry out any physical activity in the 12 h before this evaluation. Participants presenting with a systolic blood pressure above 130 mmHg were enrolled following the authorization of the family doctors.Height and weight were measured, and BMI was calculated. Waist circumference was measured using standard procedures .Values for both groups are reported in Table 2peak was indirectly determined using the 1-km walking test (1 k-WT) previously described [VOescribed . Five miescribed . Heart rescribed .All measurements were carried out at baseline and after 1-year, at the end of the walking program.Two walking sessions were organized each week and guided by exercise physiologists. The walking sessions were carried out outdoors on flat ground. Their duration varied from 45 to 60 min and the distance covered ranged from 4 to 6 km.Some increments of walking speed and duration occurred within the first months: they were not forced but chosen spontaneously by the participants.To motivate participants and enhance compliance, monthly meeting on the importance of regular physical activity were held.Participants allocated in the control group were enrolled in a 1-year program of usual cognitive rehabilitation followed by the Psychiatric Rehabilitation Centre of the Healthcare District of Ferrara, Italy. Specialized psychiatric therapists conducted this program with groups of 5–10 participants, based on a Cognitive Remediation model. Each session consisted in welcoming participants, reviewing tasks that were conducted in the last meeting, and assignment of new pen-and-pencil cognitive and metacognitive tasks. Tasks included games and exercises , as well as discussions aimed at improving short- and long-term memory (e.g. repeating sequences of words and numbers), executive functions, social cognition, with progressive adaptation of task difficulty. The total number of sessions was 50 for a duration of 12 months.2peak, walking speed and SCIP score) and their relative changes are expressed as mean ± standard deviation. The normal distribution was assessed with the Kolmogorov–Smirnov test. Differences between baseline and study-end values were analyzed using paired samples Student’s t-tests. The Wilcoxon test was used to assess differences in baseline values of the SCIP score between the WG and the CG. Further, we explored the relationship between adherence (number of attended sessions) and cognitive changes using Pearson correlation, followed by non-linear regression analysis, including a quadratic term. A stepwise multivariate regression analysis was used to assess whether age, gender, number of walking sessions attended and change in weight, BMI, walking speed and VO2peak were related to changes of SCIP total scores after 1-year of guided walking.The assessed variables  for pre-post differences in each group test scores, as well as the dppc2 sensu Morris [As measures of the effect size, we report the values of the Standardized Mean Difference .Given the exploratory nature of the study, the level of statistical significance was set at Twenty-seven participants were excluded for ineligibility and eight declined to participate.Twenty-eight participants with schizophrenia were included in the guided walking group while twelve followed the usual Cognitive Rehabilitation program.The baseline characteristics of the participants are reported in Table No differences in age, gender, anthropometric characteristics, arterial blood pressure values and cognitive function level were found at baseline within the groups.2peak was 28.3 ± 6.9 ml/kg/min: the average walking speed was 4.8 ± 0.5 km/h.Of the cardiovascular risk factors considered, smoking (63.4%) and being overweight with a BMI above 25 (87.8%) were extremely common. One participant had type 2 diabetes, while seven had hypertension with a systolic blood pressure above 130 mmHg. The baseline SCIP total score was 64.9 ± 11.3 while the FAB score was 14.8 ± 1.2. Estimated VOAlso in this group, smoking (75%) was extremely common. The SCIP total score was 68.1 ± 13.2 and the FAB score was 15.1 ± 2.6.Eight participants left the walking program within the first six months after enrolment, for insufficient motivation (n = 4), change of town (n = 1) and change of daytime activity (n = 3) and were excluded from the analyses. Age, anthropometric and functional variables of the dropouts were not significantly different from those of the patients completing the study.Twenty participants  completed the project. Their drug therapy did not change during this period. No participant suffered injuries or experienced side effects during the program.The 1-year program encompassed 100 walking sessions (averaging two sessions per week). Session duration and distance were increased progressively up to 60–70 min and to five kilometres during the first four months, while they were kept constant thereafter.Participation in the walking program of completers ranged from 21 to 93 sessions (mean of 67.8 SD: 20.6) of the 100 that were organized.P < 0.001) and FAB (P < 0.001) was evident  and not with age, gender and nor to changes in body weight, BMI, VO2peak and walking speed. The relationship between the number of walking sessions attended and the improvement of the SCIP score is presented in Fig. 2 = 0.86 (P < 0.001) adjusted for age and gender.Multiple regression analyses revealed that the increase in SCIP total score was associated with the number of walking sessions attended  that were organized. After 1-year the total score of SCIP and FAB did not change significantly  of 0.35 for SCIP and 0.26 for FAB  especially when one considers the overall low levels of adherence of individuals with schizophrenia to several psychosocial programmes or drug treatments previously studied .These considerations lead us to believe that their engagement to the project was favored by the presence of exercise physiologists supervising the activity and by the fact that walking session has been carried out in-group. Such characteristics have been previously associated with a greater adherence to guided exercise programs in depressed patients .Moreover, the guided walking program proposed proved to be a feasible activity even during the restrictions due to the COVID-19 pandemic where all other physical activities were suspended, and the gyms closed. People who previously attended other sports activities, suspended due to the pandemic, chose to follow the walking groups in order to continue to be physically active.Although the cognitive program was less demanding in terms of weekly e engagement than the guided walking project, the adherence rate recorded by the individuals with schizophrenia allocated to this program was of 53%, in line with the percentages reported in the literature .At baseline, the SCIP score of the subjects with schizophrenia enrolled in the study were well below Italian normal values (86.0 ± 7.0) reported by Belvederi Murri et al. , 42 withAt baseline, the SCIP and FAB scores documented in the individuals enrolled in the WG e CG groups were superimposable. The scores, both for SCIP and FAB questionnaires, significantly increased only in the individuals following the walking program.The relevant observation of this study is the significant correlation between walking sessions attended and improvement in cognitive functions (detected through the SCIP questionnaire): the improvement was documented only in the participants entering at least 1.5 sessions per week Fig. . Similar2peak assessed by the 1-km walking test [2peak determination also in individuals with schizophrenia, considering also its feasibility on the 500 and 200 m. [Cardiovascular diseases and diabetes represent the highest proportion of all natural causes of death in populations with severe mental illnesses. The 1-year guided walking program has been followed by an improvements in cardiovascular function as indicated by the increase of VOing test . This evd 200 m. , 45 Thesd 200 m. –32and ind 200 m. , 47.Walking activity, guided by exercise physiologists and performed in group can be considered an effective strategy to counteract the sedentary behaviour of individuals with schizophrenia, with a consequent improvement of their cardiovascular function and reduction of their mortality rate and, last but not least, an increment of the rate of their social inclusion.The main finding of this study is the improvement in cognitive functions documented in the participants completing the walking program with a significant correlation between the improvement and the number of walking sessions attended, evident only in the patients who attended to at least 1.5 sessions/week.It can be hypothesized that walking programs guided by exercise physiologists and performed in-group may be effective in counteracting the sedentary behaviour of individuals with schizophrenia and may lead to the improvement of their cardiovascular function, to a reduction of their mortality rate and increment the rate of their social inclusion.The maintenance of regular physical activity even during the COVID-19 pandemic may have helped the individuals with schizophrenia to preserve the cognitive and functional improvements obtained following the 1-year guided walking program.Walking as (it) a simple and economic activity, does not requiring special equipment and can be practiced while maintaining the social distancing required by the current health emergency.In order to confirm the results obtained including the anthropometric amelioration, a study with a larger population is in program.A study with a larger population is in program in order to verify the possibility to translate these preliminary positive results into a clinical significance. Future studies should also investigate the correlation between walking and every subdomain of cognitive questionnaire.


Diversity remains low among US colleges faculty, with only 3% identifying as Black or Hispanic. Moreover, underrepresented racial minority faculty often face unique challenges and are less likely than their white counterparts to earn higher academic rank, tenure, and funding, especially those who study health equity. We developed a novel program for health-equity focused pre-docs and junior faculty. The Disparities Researchers Equalizing Access for Minorities (DREAM) Scholars is a 24-month career development program led by the Center for Clinical and Translational Science (CCTS) that provides pilot and travel funding, career development seminars, mentoring, and writing retreats. We report the outcomes of the first Scholar cohort (N = 10), pre-docs n = 6; assistant professors, n = 4; seven were Black, one Hispanic, two White, one who identified as non-binary. At the end of the program, Scholars coauthored 34 manuscripts, 9 abstracts and 8 grants. Semi-structured interviews revealed seven major program strengths: funding, support and sense of community, accountability, exposure to translational science, network expansion, and exposure to multidisciplinary peers. Scholars provided feedback useful for subsequent cohorts. The DREAM program provided accountability and fostered a sense of community, expanded professional networks and enhanced scholarly productivity. The program serves as a model for implementation throughout the CCTSs. Although the United States (US) population is becoming increasingly diverse, with 28% of the population identifying as non-White  diversitEven when underrepresented racial/ethnic minority (URM) scientists attain faculty appointments, they often face unique challenges, which results in their holding lower academic rank and having higher attrition –5. MoreoEvidence suggests that the barriers faced by URM faculty begin early in their academic career as pre-docs and a substantial amount of overlap exists between the academic experience of URM students and that of URM faculty ,11. GiveThe purpose of the DREAM Scholars program is to promote the career development of multidisciplinary pre-docs, post-docs, and junior faculty who are interested in conducting health equity research among special populations. Because of our desire to retain URM pre-docs as future faculty, we developed the DREAM Scholars program to support pre-docs, post-docs, and junior faculty. The DREAM Scholars originally started in the College of Nursing (CON) and served as an informal mentoring program for URM individuals. In 2018, the CCTS collaborated with the CON and Center for Health Equity Transformation to expand DREAM into a structured, multidisciplinary career development program. This article describes the processes used for cohort as one of the restructured DREAM Scholars, which occurred between September 2018 and May 2020.Applications from all individuals are accepted; however, to increase the institution-wide diversity of health equity scientists, we prioritized applicants who were URM in research. We used the NIH definition of URM, e.g. African American/Black, Hispanic American, Native American/Alaska Natives who maintain tribal affiliation or community attachment, Hawaiian Natives and natives of the US Pacific Islands; additionally, to align with the National Center for Advancing Translational Sciences definition of Integrated Special Populations (ISP), we include sexual/gender minorities in our underrepresented definition.We open the application period for 6 weeks and advertise the program on the CCTS webpage, list serves, and directly to campus-wide programs. Scholars are accepted after the submission of a competitive application packet that includes: 1) demographic data; (2) a letter of support from a primary mentor; (3) research plan focused on special populations; (4) career goals and objectives; (5) career development plan; and (6) applicant and mentor’s curriculum vitae. We select five applicants who display the highest potential for success as DREAM Scholars and five applicants with meritorious applications as DREAM Scholar Associates. Table  demograpThe DREAM program is directed by a CCTS Associate Director who also serves as the codirector of ISP. She is an NIH-funded health equity researcher from the CON. The CCTS Career Development Director supports the program. Additionally, during the Scholar application period, one of the applicants who was a part of the original CON Scholars received a notice of award for an NIH-K01, as such; she served as a peer mentor.Scholars met twice monthly for individual presentations and career development seminars. Each meeting lasted 1–1.5 hours and was held during the lunch hour; we suspended meetings during the summer. To ensure that the seminars addressed the unique needs of the Scholars, at the first meeting, we solicited the Scholars input regarding topics of interest. During the individual seminars, Scholars presented works in progress, e.g. dissertations, grants, abstracts and developed individual development plans. Faculty and staff from across campus presented the career development seminars. We structured the seminar topics into four major components as outlined in Fig. Over the 2-year program, the Scholars received $5000 in pilot funding and $3000 travel support. Scholar Associates (hereafter included in the discussion of Scholars) participate with all DREAM activities; however, they do not receive funding support.We utilized a mixed methods approach to evaluate the DREAM Scholars program. The main outcome metric for the program was scholarly productivity, measured by peer-reviewed publications, and other high quality scientific outcomes, including extramural grant submissions. Publication data were obtained from Scopus for the cohort during the 2-year period of program participation, and extramural grant data from the Office of Sponsored Programs. Additionally, near the end of the cohort’s term, we sought qualitative feedback from each Scholar to examine their experiences in the program and to identify opportunities to improve the program for subsequent cohorts. Firstly, DREAM leadership met with the CCTS Director of Evaluation to discuss the program components. We then developed a semi-structured interview guide that addressed all program aspects. The Director of Evaluation attended a Scholar meeting to meet the Scholars, to establish rapport, and to inform them of her purpose for contacting them. Subsequently, she contacted the Scholars to arrange individual 1-hour semi-structured confidential interviews. To allow the Scholars the freedom to speak candidly regarding the program, none of the DREAM Scholar leaders attended the interviews. The University {blind} Office of Research Integrity approved the qualitative research procedures. Following informed consent, the Director conducted the interviews in private spaces. All interviews were audio-recorded for transcription purposes and later transcribed and verified for accuracy by evaluation staff. The CCTS evaluation team used an iterative process to identify primary themes.The cohort included 10 Scholars, 6 were pre-docs, and 4 were assistant professors. No applications were received from post-docs. Seven were Black, one Hispanic, one White, and one who identified as non-binary. The Scholars were multidisciplinary and represented seven colleges. At the end of the 2-year program, all of the Scholars were retained. All of the Scholars had at least one peer-reviewed publication, and had collectively coauthored 34 manuscripts and 9 abstracts, obtained 8 extramural grants and acceptance into competitive national training programs. Moreover, they were recipients of numerous prestigious awards/honors.Seven of the 10 Scholars participated in the semi-structured interview. As outlined by Table One Scholar stated:“The majority of the people in the program coming from underrepresented, you know, backgrounds, it is, I think critical to be able to provide like solid, um, funding opportunities. Because we might not always have those kinds of resources otherwise. And so I think that was honestly one of the best aspects of the program. I got to go to a very expensive conference that, you know, was super pertinent to like my research, but I would not have been able to afford to go.”The funding facilitated exposure to additional opportunities:“…the funding to be able to get professional development opportunities and go to conferences has been amazing. Because then at those places I'm able to continue getting even more like access to resources and meeting people does like continue perpetuating, the, you know, professional development goals.”One Scholar stated:“…. But there’s just something about, you know, us kind of all working together for our common goals and then bringing different perspectives. It’s kinda like iron sharpens iron… it could happen, you know, in a different direction if you have… homogeneous groups. But there are always gonna be more blind spots with that group in my opinion than, you know, folks who have different lenses.”Another stated:there’s even more diversity within the group at different perspectives. And I think that seeing things done similarly but differently is really important because as I said, when you're stuck in your little silo of your college, things are typically done a certain way and you learn that way. So it’s nice to see that you can get to the same outcome.”“…Another:…it’s been great to be able to, like I said, get perspective from people who are interested in some of the same areas but who come at it from a completely different lens that’s been super informative ….”“Having a space with other URM scientists was a major theme that was mentioned by six of the Scholars. One Scholar stated:“… you also end up like meeting other researchers that also are minorities themselves, which is nice… it was great to go to a room and not be the only person of color or being part of the minority I guess…So I thought that’s something like unconsciously you, you've been always a minority. You kind of feel either you have to be the different person to other minority groups and talk for everyone or unconscious about it and not want to talk or seem more insecure…."“When I would talk about my research, when I made the decision to focus specifically on low income African Americans…people would tell me, well, why are you focusing on black people? … Why aren't you focusing on Appalachia?… So DREAM scholars provides me a space where I don't have to constantly justify (that)…”The Scholars viewed the program as an opportunity to expand professional networks among the Scholars and more broadly. One Scholar commented:“So I'm able to get outside of my department…. it’s great to have broader perspectives… (DREAM) connects you with other folks because they have networks that they, you know, will link you with. I would say it’s extremely valuable.”A nurse Scholar stated:“…and expanding my network here at the university, um, and the resources that are available to me becoming more aware of those… I could see myself working with (my peers) in the future. We have similar research interests. We're in the same vein, but they might be looking at it from a sociological point of view and I'm looking at it from a nursing point of view.”The pre-doc Scholars viewed being with Scholars of different stages as an opportunity to obtain peer mentoring and gain perspective for future roles. Scholars stated:“That’s a huge benefit, because even if it’s not relevant to you at this level, it’s probably going to be relevant to you in the future. So in a way you're kind of getting a glimpse of the future.”“…when I was in the process of like designing the study, I was able to meet with some of the junior faculty who were able to like give me lots of advice and guidance when thinking about developing a pilot study and kind of given me their perspective from their respective fields, which I feel like was helpful.”Scholars viewed the program as instrumental in increasing their accountability for scholarly development.“I like how it’s an external structure… having milestones that you're checked up on outside of your own department, it’s like that second person.”“I think having people there to review your work and telling people that I'm hoping to graduate here, I'm hoping to defend my oral qualifying exam on this day and that accountability that comes with vocalizing this to your peers and to other faculty.”Scholars indicated that the program provided knowledge of translational science that they otherwise would not have received. One Scholar stated:“I'm thinking more about like translational a lot more than I did before. So we've had a lot of like presentations and didactics about like translational science and like the process of getting, you know, your science into actual practice, um, and like communicating that to other fields. I think that that’s something that has definitely sparked to me starting to think about the way that I want to approach my research more so than I had done before doing the DREAM Scholars.”Another stated:“I think that this program more than anything else I've done on campus has probably exposed me to, uh, one like the translational side of science…being in this group has allowed me to see, you know, the clinical side of things. And I think that being in this environment has exposed me to that in ways that I probably wouldn't have been exposed to…”The Scholars offered helpful suggestions for strengthening future cohorts as well, see Table The Scholars suggested expanding the mentoring to include peer mentoring and strengthening the mentorship with their primary mentors. For instance, regarding peer mentoring one Scholar commented:“I think maybe have more formalized collaboration or mentorship process. It'd be nice… I think it would be cool to formalize like maybe pairing up a pre doc with one of the junior faculty or a postdoc and like working together on a project or like on a manuscript or something. I mean, that would be a cool aspect.”Although the Scholars were required to have a primary mentor throughout the program, many of them indicated that the mentor was not as involved as they would have liked. One Scholar stated:“So part of the process of applying (DREAM) is you have to identify someone to be your mentor, which is great, but then I've not seen any indication that there are checks and balances to make sure that your mentor is giving them mentorship. But I think as a formal process, I would like them to do more checks and balances probably because I've, my mentor relationship just exists on paper.”The Scholars indicated a desire for having an individual development plan at the outset of the program. One Scholar stated:“I think, yeah, the structure and timing could be, definitely be modified. …earlier this year with someone who had sent out an IDP, [individual development plan]… She uses this in other contexts, and I was like, Oh, you know, for the next iteration of this, this is something that people should have at the beginning.”The Scholars spoke of the need to increase racial/ethnic diversity among faculty and within the research portfolio. One Scholar stated:“… the experience with mentors that I've had here, outside of the DREAM program, have not been positive at all… I don't think people here, a lot of people, are comfortable even just, they're not comfortable talking about race, but just interacting with someone who’s different from them.”The Scholars spoke of barriers to expanding research efforts beyond Appalachia to reach racial/ethnic minority communities. One Scholar stated:“I submitted a letter of intent… and my work is primarily with African-Americans. Um, so yeah, it was quite discouraging to get feedback … asking for connections to a community that I had never referenced, um, in my letter of intent and so that kind of messages, um, frustrate me as a researcher. …. One of the things I didn't realize coming here was the limited research that was being done with African Americans, um, within the UK sort of research complex.”The first cohort of the DREAM Scholar program resulted in high retention and increased scholarship among the pre-docs and junior faculty members. The feedback provided important insight for future cohorts. High scholarly productivity among our Scholars are consistent with the findings of other structured programs  and is iOur program is unique in that it includes individuals at different career stages . Both thScholars expressed a sense of isolation and a feeling of lack of institutional value of health equity research outside of the program. This perspective speaks to the importance of developing institution-wide diversity and inclusivity efforts in concert with programs such as DREAM. In the fall of 2020, the University {blind} amplified institution-wide resources to advance health equity through the development of a research priority area focused on racial disparities and inequity across broad areas. The priority area will increase racial diversity at the University of Kentucky by strategic faculty recruitment, leveraging existing strengths to expand health equity research with special populations and forging new relationships.The DREAM Scholar program was successful in providing a structured career development program for URMs. However, limitations are that it was developed to address the unique needs of University {blind} health equity-focused pre-docs, post-docs, and junior faculty. Although their needs are likely similar to elsewhere, the resources, research, and training infrastructure available at a given institution may affect Scholar’s needs and require adaptations to the program components. Secondly, although our evaluation included 70% of our Scholars, our findings would have been strengthened by full participation. There was no difference in the background or level of program engagement of the three Scholars who did not participate in the evaluation, therefore, we are confident that the experiences of the included Scholars is reflective of the entire cohort. Additionally, the scholarly productivity of the DREAM Scholars was high, however, given that DREAM is a unique inaugural program, we have no historical controls or similar programs to serve as comparison. A program design that included a comparison cohort or historical control would strengthen the validity of the results. Future career development program developers should consider using a research design to rigorously test the effectiveness of the program. Lastly, we assessed the short-term effects of the program; in the future, we will develop evaluation metrics to assess long-term effects. Given the success of cohort one, it is imperative that the program is sustained, thus dedicated institutional commitment is necessary. To date, the {blind} Cancer Center and the Cardiovascular Research Priority Areas have provided funds to support two additional Scholars for cohort 2, thereby allowing for seven funded Scholars.In summary, the DREAM Scholar program not only promotes the career development of URM health equity investigators, but also optimizes their potential and promotes retention by fostering a sense of sense of community, belonging, and value for their health equity research. The program serves as a model for implementation throughout the CTSAs and may increase the applicant pool diversity for TL1 and KL2 programs.


Rupture of a popliteal artery aneurysm is an uncommon event in an uncommon disease. We present the case of an 88-year-old female with a ruptured popliteal artery aneurysm that was diagnosed by multidetector computed tomography and treated by an endovascular approach. An 88-year-old female, with arterial hypertension, was admitted to our hospital for onset of acute pain and swelling behind her left knee. There was no history of trauma. Physical examination revealed a palpable and pulsatile mass in the upper popliteal fossa. Left ankle brachial index was 0.8 . Multidetector computed tomography of left lower limb, on axial and sagittal volume rendering technique reconstruction, revealed a voluminous popliteal artery aneurysm  with partial aneurysm sac thrombosis and signs of contained rupture . She waIntraprocedural diagnostic digital subtraction angiography confirmed left popliteal artery aneurysm . The paPredischarge and follow-up ultrasound color Doppler confirmed thrombosis of the treated left popliteal aneurysm sac and stent lumen patency.Ruptured popliteal artery aneurysm is an uncommon event in an uncommon disease.


Faculty development for nurse and physician educators has a limited evidence base in high income countries, and very little research from low- and middle-income countries. Health professions educators in many global settings do not receive training on how to educate effectively.To pilot and assess a faculty development program aimed at nurse and physician educators at a teaching hospital in rural Haiti.We developed a program covering a total of 22 topics in health professions education, including applied learning theory as well as nurse and physician targeted topics. We assessed impact through participant assessment of personal growth, participant evaluation of the program, knowledge testing pre and post program, and structured observations of program participants providing teaching during the program.Nineteen out of 37 participants completed the program. While participant reviews were uniformly positive, a pre- and post-test on general educational topics showed no significant change, and the effort to institute observation and feedback of teaching did not succeed.Our project showcases some benefits of faculty development, while also demonstrating the challenges of instituting faculty development in situations where participants have limited time and resources. We suspect more benefits may emerge as the program evolves to fit the learners and setting. Human resources for health is a blanket term for the human elements necessary to a functional healthcare system, encapsulating initial training, subsequent deployment, and continuing professional development (CPD) for all health care providers 2. Well d5Low-resource settings amplify the challenges faced by CPD programs. The clinical demands on health care workers are higher, the gaps between provider knowledge and application are wider , the log9th century, with subsequent international ostracizing that heavily impeded its growth over the years [Our research here focuses on faculty development in Haiti, the first Black republic which formed out of a slave rebellion in the 19he years . Due in he years . An unpuhe years , and grahe years .The Haitian government and the non-governmental organization (NGO) Partners in Health opened a new teaching hospital in March 2013, Hôpital Universitaire de Mirebalais (HUM) , staffinTable 1). Members of the HUM educational leadership and instructors from the NGO EqualHealth arrived at the list of core topics in discussion after review of the literature and existing resources for the faculty development of educators.The Teach the Teacher pilot program consisted of didactic and observational components. The didactic portion constituted a series of 22 one-hour lectures and workshops covering core topics for clinical educators in nursing and medicine  , all sesTable 1). The profession-specific topics were chosen by the respective leadership of those professions. Each topic was taught twice during a given week in order to accommodate participants’ clinical schedules.The course spanned 6 weeks at HUM between December 2014 and February 2016, with 3 topics taught each week in roughly hour-long small group sessions. The majority of topics were meant for both physician and nurse participants, while a smaller number were targeted specifically at a particular profession . Observations were ranked with a score of (1) for not meeting criteria, (2) for needing continued improvement, and (3) for meeting goal criteria. After each observed session, participants were provided with standardized verbal and written feedback. The Teach the Teacher program aimed for each participant to have three or more observations over the program period. Observations occurred both during didactic weeks via visiting teachers and outside of them via project members who held administrative positions at HUM.Select physician and nurse faculty were invited to participate, with HUM leadership determining which faculty were best positioned to use further educational training. We intentionally combined nurses and physicians with intent to build interprofessional connections and model interprofessional education. The pre-established qualifications for a certificate at the end of the course were attendance of half of the sessions, completion of the pre- and post-tests, and undergoing at least three observations of educational activities.The program’s impact on participants’ knowledge, attitudes, and teaching practice was evaluated using a multimodal approach. A 29-question multiple-choice test of educational best practices based on course learning objectives was administered at the beginning and end of the program , and the comparison was analyzed using Student’s T-test. Qualitative surveys were collected after each individual session and upon the program’s completion to assess participants’ satisfaction with the course and the program’s perceived impact on their professional development. Direct observations of physicians during educational activities were also performed, with a rubric tool to standardize ratings across observers. Our intent was to compare the rubric performance of participants over the course of the year to see whether their individual or communal performance on rubric elements improved.The program materials were generated by volunteer nurses and physicians with EqualHealth, and refined in consultation with leaders from HUM. Sessions were largely taught by visiting NGO volunteers. HUM provided room and board for visiting volunteers , who covered their travel costs to Haiti. EqualHealth covered the approximately $100 necessary for printing course materials and purchasing flash drives containing the course documents for all participants.The study was reviewed by the Zanmi Lasante Research Committee (ZLRC ID#85) and considered to have exempt status as the data generated was produced for monitoring and evaluation of an educational program. We only show program level data throughout this paper to avoid identifying any specific participants.Twenty-six physician and eleven nurse HUM faculty members participated in at least two didactic sessions; these thirty-seven faculty members were considered our participants. Fifteen physicians  and four nurses  participated in at least half of the sessions open to them, which was pre-established as a minimum standard for certification. At least one member of each physician specialty achieved certification at the program’s completion. Nursing representation included two nurse-educators, one rehabilitation nurse and eight nurse managers. The physicians included three participants from emergency medicine, one from rehabilitation medicine, one from family medicine, six from internal medicine, five obstetrician/gynecologists, eight pediatricians and two surgeons.Thirty-three participants completed the pre-test. The average score from all participants was 57%. Twenty-two participants completed the post-test, with an average score of 63%. The pretest average for nurses was 54% (n = 10) and did not increase for the four nurses who completed the post-test. The physician pre-test average was 59% (n = 23) and increased to 66% (n = 16) (p = 0.08).Table 2 for results from selected individual sessions  and from the end-of-course feedback. Not all totals are identical as some participants left responses blank. Across the total of all sessions, 89% of participants agreed with the statement ‘This topic is important to becoming an excellent teacher’ and 87% agreed with that ‘This topic allowed me to better understand my role as a teacher’.The participant evaluation of the program included Likert items related to their role as a teacher. See Figure 1.There were 27 direct observations of participants conducting multidisciplinary clinical rounds , of an intended 78. Across disciplines the lowest score from observers was bedside teaching of patient examination  and the highest score across disciplines was for bedside teaching discussion . The average score for each criterion by department is presented in We piloted a faculty development program for nurses and physicians at a 300-bed teaching hospital in rural Haiti. While participants broadly lauded the overall program and individual sessions in their survey responses, our tests of knowledge retention did not show statistically significant improvement and our direct observation of teaching returned too few observations to ascertain whether there had been a significant change in behavior. We believe our project provides useful insights into structuring faculty development in a resource-deprived country such as Haiti. There are a range of larger projects that have addressed human resources for health, but many of these focus on training new providers or researchers, and not necessarily on developing the educators . A scatt20The implemented program had several positive results. We taught an array of topics key to education in nursing and medicine, and the participants routinely viewed the topics as pertinent and well-taught. We additionally assessed behavior change by performing observations of participants teaching, building off of a strong literature on peer observation programs; moving to assessment of behavior change is a potentially important step for faculty development programs globally 23, partiOur pilot had several limitations. Due to a short timeline between the decision to develop this program and implementation, the knowledge test was created before the individual session materials were fully completed, and as we received feedback from participants, the focus of what was taught evolved. As such, the final knowledge test did not consistently match the most emphasized teaching points, reducing the utility of our knowledge acquisition test. Since the participants were invited specifically due to their roles as educators, our participants were likely more interested in developing their teaching abilities than the overall faculty and were more likely to favorable rate these activities. Alternatively, as they were asked to join by supervisors, faculty may have felt compelled despite a lack of time or personal interest, which could relate to the overall low rate of completion. We did not survey those who did not complete the program for their barriers to completion, and this would have been useful information. Participants reported considerable limitations on their time between their direct clinical responsibilities, their time teaching trainees, and the administrative roles that most possessed. There was no protected time for these sessions, as distinct from much of the CPD these staff are exposed to, which occur as full-day events, often off site. This lack of time and support, familiar to health professional faculty throughout the world, often precluded faculty attendance, even when offering each session twice in a given week. Of note, the nursing staff reported more time pressure, which may relate to why fewer of them completed the program. Finally, the majority of the sessions were taught in English with French translation; this likely reduced the effectiveness of the education, especially given the complexity of the topics.The observation portion of the program designed to assess behavior change had two particular challenges. First, direct observation of faculty was novel to this environment, and ultimately few faculty were eager to undergo peer feedback. This may reflect a failure to successfully establish a safe learning environment, a foundational requirement for such programs, or insufficient time exploring this approach with faculty prior to implementing it given its novelty. Second, our peer observers were largely educational administrators for the hospital; this proved a scheduling challenge, as they were quite busy with existent educational, clinical, and administrative duties. Consequently, while we did obtain a number of observations, we fell short of our goal of having sufficient observations of each faculty member to assess for changes in their behavior.In summary, we implemented a pilot faculty development program in an academic Haitian hospital. Our sessions were well received by the nursing and physician participants, and the course curriculum generated was viewed by participants as relevant to their clinical educator roles. We met challenges in evaluating the program using standard pre and post-testing strategies and in retention of faculty through the entire program. The attempted introduction of direct observation of education highlighted the tension between existing responsibilities and adequate time for faculty development, as well as the challenges of implementing new educational approaches that involve critique of faculty. This program continues as a CPD activity organized by HUM leadership, with reported particular interest from the younger faculty. Health professional educator development in LMICs is an understudied topic that should have downstream benefits for a range of health system metrics and is a space where international partnerships and NGOs can play a useful role supporting LMIC institutions.The additional files for this article can be found as follows:10.5334/aogh.3512.s1Supplementary File 1.Rounds Evaluation Rubric in French and English.10.5334/aogh.3512.s2Supplementary File 2.Pre and post test in French and English.