Introduction: Non-suicidal self-injury (NSSI) constitutes a major health concern among youth. However, less is known about the useful ways to prevent NSSI. As such, the NSSI- Peer Education Program (NSSI-PEP) aims to intervene on the vulnerability factors that predispose to NSSI by applying a peer education approach. The NSSI-PEP is grounded on the psychoanalytic tradition's tenets, implementing modules targeting four crucial risk factors for NSSI: pubertal transformation, body image, self-esteem, and emotion regulation.Methods: Selected 8th grade students were trained to serve as peer educators and held a peer-education intervention for 6th and 7th grade students. Pre- and post-intervention assessments were conducted in order to evaluate the program's effectiveness.Results: Results revealed preliminary support for the program's feasibility, as students reported greater emotion regulation abilities (p = 0.038) and significant changes in self-esteem (p<0.001), personal alienation (p = 0.005), body image (p < 0.001), and maturity fear (p < 0.001). Also, NSSI-PEP was positively evaluated by participants.Discussion: Our pilot study provides preliminary empirical support for the NSSI-PEP, representing a promising way to address areas of vulnerability for NSSI onset. Findings may also help current policies to promote targeted preventive activities and produce sizable benefits to society. Non-suicidal self-injury (NSSI) is a clinical condition that refers to the socially unacceptable and intentional destruction of one's body tissue in the absence of suicidal intent . Common Although there is a paucity of research among youth under 12, findings suggest an increasing prevalence in early adolescence, with first episodes occurring at age 11 or younger . This isDespite the lack of immediate lethality, NSSI constitutes a major public health problem as self-injurers are at higher risk for attempting suicide , and advSuch adverse consequences are of particular interest given that the majority of youth who self-injure do not seek professional help  and are Despite increased awareness that NSSI represents an impairing behavior impacting adolescents' functioning and taxing on parents, developing evidence-based prevention programs for youth is still limited. To the best of our knowledge, to date exist only two school-based prevention programs for NSSI: The Signs of Self-Injury  and theAlthough both programs revealed that the NSSI rate was unchanged after module implementation, results are quite nascent and row, suggesting that more work needs to be done to develop an effective program for preventing NSSI. Aside from NSSI-specific programs, several prevention programs focus on youth mental health and suicide prevention, such as the Youth Aware of Mental Health program. That is a school-based universal intervention for adolescents implemented in the Saving and Empowering Young Lives in Europe (SEYLE) study  to raiseThe practices guidelines for prevention suggest that an optimal way of prevention program planning consists of identifying the factors contributing to the occurrence of the target behavior . As a rePE is an interactive approach indicating a “peer-to-peer education” relying on an informational exchange between credible, trusted peers and those being “educated” . During PE programs can be delivered in formal and informal settings, such as schools, clinics, and community centers . HoweverSince the onset of NSSI is quite early, middle-school students may be the target population for a school-based prevention program based on the PE approach to avert the problem behavior and avoid potential pathways to suicide attempts.Adolescence is a rapid growth and development phase in physical and psychological domains , which aIn the psychoanalytic perspective, the developmental function of adolescence involves integrating the infant fantasies in the new muscular and sexual mature body–allowing now the acting-out–through several changes and adjustments . The traThe body is the central object in NSSI . HoweverDrawing from these assumptions, we have designed a theoretical-driven program–NSSI-PEP–to effect empirically selected psychological factors that contribute to the development of NSSI among youth, working on risk reduction and the enhancement of protective factors. The program aims to target the vulnerabilities factors that-both theoretically and empirically–have been associated with NSSI among youth: pubertal transformation, body image, self-esteem, and emotion regulation –42. MoreRapid physical, endocrinological and psychosocial changes associated with puberty increase the relevance of body experienced during adolescence and leads youth to greater concerns about body image . ResearcAs the body is the focal point of adolescence developmental processes, it is not surprising that adolescents struggle with self-esteem. Although general self-esteem is relatively stable, it becomes increasingly domain-specific over the life course, as individuals encounter new roles and situations  and lifeSelf-esteem has demonstrated a deep relationship with NSSI, as it tends to be deficient in self-injuring individuals who show lower scores than those not engaged in NSSI . NegativEmotion dysregulation is a transdiagnostic factor common to many psychopathologies, such as binge eating , and hasThe PEP-NSSI is an interactive, participatory, and empowering approach based on the assumption that intervening early on NSSI vulnerability factors could prevent youth from engaging in NSSI. Thus, the PEP-NSSI aims to: a) intervene early to reduce the risk for NSSI among youth while enhancing protective factors through improving emotion regulation abilities, feelings of self-esteem, and building a positive relationship with own body image; b) conduct an initial evaluation of the effectiveness and feasibility of the NSSI-PEP program; c) gather helpful suggestion for the development of evidence-based prevention programs and improve the effectiveness of social policies for the promotion of healthy behaviors for adolescents. Thus, we hypothesized that the program would enhance emotion regulation abilities, improve self-esteem, and develop a positive body image.The PEP-NSSI was a pilot uncontrolled feasibility study using a nonrandomized design and involved a middle school in Southern Italy. The program aimed to increase students' knowledge, skills, and behaviors and enhance psychological characteristics  that pose vulnerabilities to NSSI among youth. See After the school headmaster agreed to participate, the NSSI-PEP was implemented in the school setting and integrated into the school day. Due to the restrictions introduced in response to the COVID-19 pandemic, all the activities (peers' formation and PEP intervention) were conducted online, using a digital platform (Google Meet). It occurred at two consequent stages. Peer educators were selected and trained to acquire the knowledge and skills required to lead PE to younger students in the first stage. In the second stage, research participants received a PE intervention over 5 weeks. Also, they were screened at baseline and after PEP completion. Participants were informed of the importance of attending each intervention's sessions.All procedures were reviewed and approved by the Ethics Board of the Department of Psychology-University of Campania “Luigi Vanvitelli.” The study was conducted in accordance with the principles of the Declaration of Helsinki . The stuParticipants were selected based on their willingness to participate in group meeting times and activities.Students were excluded for: (1) reporting current NSSI; (2) having lost at least one PE session.M = 12.71; SD = 0.488) confirm their commitment to the program. The peer educators' group was selected in order to be broadly representative of the student body.Once the school agreed to participate, the program was advertised within the school network–detailing participation requirements and the application process. Eight-grade students had the opportunity to apply to become peer educators. Program advisors delivered an informational meeting. Each aspirant provided a consent form signed by parents. All applicants were invited to participate in a group interview to evaluate their skills and capabilities of serving as peers. Afterwards, a team of selected school staff were asked to rate each student evaluating reliability, leadership, attendance, and ability to carry out the meetings. Eleven peers were selected, but eight  through a 3 week session, utilizing group activities . Also, as peers have to answer questions clearly and correctly, they needed to have an overall knowledge of the subjects, such as puberty and developmental change. Facilitation techniques as active listening and presentation skills were acquired during the training session to strengthen students' capacity as effective peer educators. Communication methods and tools were acquired through discussion and role plays, creating a safe and welcoming environment that allows for an empathetic climate. Program advisors and peers refined and co-created activities within the modules to tailor the PEP to students' needs. Also, involving peers in the decision-making process promotes participation in acquiring skills necessary to implement the program.During all the training weeks, peer educators could contact program advisors if they needed.All 6th- and 7th-grade students were invited to participate through school network announcements. An alphanumeric code was assigned to each students who provided assent and parental consent forms. Students were asked to complete a questionnaire booklet in two assessment sessions: baseline (T0) and 1-week post-intervention (T1). The test administration took place during regular school hours, using an online platform (SurveyMonkey), requiring about 40 min to complete. Instructions for each questionnaire were provided, and research assistants were presented at all times.Peer educators conducted the NSSI-PEP intervention sessions for 5 weeks (2-h sessions per week during school hours). The weekly meetings were centered around the four-core module of the program: (1) self-esteem, (2) body image, (3) pubertal body changes, and (4) emotion regulation. Peers selected the specific weekly topic and activities and conducted the meeting utilizing focus groups, group activities , and video. All the sessions culminated with an opportunity for participants to reflect on the experience. Peer educators worked interactively with younger students during the PE sessions, while program advisors supervised the activities and were available if needed. Participants completed a socio-demographic sheet asking for information about sex, age, and family composition.The Difficulties in Emotion Regulation Scale  is a seThe Body Dissatisfaction scale of the Eating Disorder Inventory-3  consistThe Low Self-Esteem scale of EDI-3  consistsThe Personal Alienation scale of EDI-3  consistsThe Maturity Fear scale of EDI-3  consistsAt T0, NSSI was assessed using a single-item question: “Have you ever engaged in self-injury without an intent to die?” (yes/no). At T1, an altered version of the item was administered the item “Have you engaged in self-injury without an intent to die since the previous survey?" (yes/no).ad-hoc questionnaire assessing program implementation .The NSSI-PEP protocol adherence was assessed through the documentation provided by program advisors. For each meeting, program advisors documented the data, number of participants, module's activities, and the general trend of the meeting. The program's acceptability and feasibility were evaluated through an t-test was used to examine the differences from baseline (T0) to post-intervention (T1) across outcome variables. Cohen's d was used as the measure of effect size. According to Cohen's rule of thumb . At post-intervention (T1) 65 students  participated. A total of 58  6th- and 7th-grade students completed both baseline and post-intervention assessment. Reasons for exclusion were extracurricular activities in conflict with scheduled modules (n = 3), being absent during data collection , and having lost at least one PE session (n = 3). All participants reported being of Italian nationality. More than 80% (n = 61) fell into the lower- to upper-middle socioeconomic class.At baseline (T0), the sample consisted of 68 students aged between 11 and 13 years old  = 2.126, p = 0.038, d = 0.27], with less difficulties in acceptance of one's emotions , and greater access to effective emotion regulation strategies . At post-test, students showed greater self-esteem , and lower scores  on personal alienation , body dissatisfaction , and fear maturity .The paired Although comparisons on other dimensions of emotion regulation did not reach statistical significance, the mean scores from pre- to post-intervention demonstrated a change in the expected direction  indicated that the meeting's number was adequate and did not interfere with school commitments. About three-quarters of the sample (74.3%) indicated that NSSI-PEP's activities were very comprehensive and pleasant. More than 80% of students would like further to deepen the program's content with peer educators. Overall, the program was evaluated positively . No negative aspects/difficulties emerged.This pilot study examined the effectiveness and feasibility of a school-based prevention program (NSSI-PEP) focusing on vulnerability factors for NSSI, implementing a peer education approach.The program arises from practical and theoretical assumptions supporting the information-sharing intervention approach's demonstrable ineffectiveness . Availabvia the body  can be potentially effective in preventing NSSI among youth.Whilst peer educators, as someone “in the know,” effectively delivered PE intervention, there are significant challenges we have encountered in implementing the training. First, three selected peers decided to give up the program, as they perceived the PE needs exceeding their capability. Second, striking balance between empowerment and training took time, investment, and ongoing support. Lastly, although the online delivery of the training was cost-effective and easily accessible, the virtual environment limited the students-to-student and student-to-adult interactions and made it more difficult to develop connections and work with study's constructs, such as body image. In order to address these shortcomings, the PE should be in presence to foster and maintenance empathetic relationships with participants and maximize the effectiveness of the training.Cumulatively, implementing a preventive strategy addressing the underlying mechanisms of NSSI has a leading role in transforming the traditional preventive model. In this sense, a remarkable starting point concerns the use of a peer education approach: the NSSI-PEP is grounded in the belief that young people gain more from an experience when they are actively involved. Thus, the PE approach provides the opportunities to belong and experience a supportive relationship (for both peers and target group) to develop and practice new skills and improve self-efficacy.The program presents many strengths. First of all, it has a robust theoretical background that meets the empirical findings collected within the NSSI literature. Second, it addresses preadolescence, the age range with a greater risk of self-injurious behaviors and aims to prevent these behaviors using an innovative methodology. Findings suggest an urge for early prevention as youngsters engaging in NSSI usually do not seek help , with juAnother strength is focusing on NSSI risk factors to reduce youngsters' chances of engaging in self-injurious behaviors. However, even though researchers suggest addressing vulnerability factors within preventive interventions , to our However, the study also has several challenges and limitations. First, participation in the intervention is quite time-consuming for the school. Second, to test the generalizability of the intervention, the program will need to be extended to a greater diversity of school implementing longer and more frequent follow-ups. Third, we were not able to enroll a second school to act as a control group. Thus, further studies need to implement a randomized control trial design including a control group. Fourth, we have only two time-points limiting the conclusions about the data. A refinement of PEP is needed to increment assessment point and involve a larger number of participants. Fifth, samples' selection (peer educators and students) is prone to volunteer bias and may limit the generalizability of the results.Despite these limitations, our pilot study suggests that NSSI-PEP represents a promising prevention program to integrate into school systems to enhance protective factors and resilience among youth. Also, such encouraging results shed new light on the relevance of implementing a program based on the underlying mechanisms that drive the complex processes of pubertal development. Clinicians and practitioners would be provided with a novel approach not only to fighting NSSI but also to developing positive, sustainable health behaviors in youth and promote psychological well-being and a healthy lifestyle over time, producing sizable and sustained benefits to society.The raw data supporting the conclusions of this article are available from the corresponding author, SC, upon reasonable request.The studies involving human participants were reviewed and approved by Department of Psychology, University of Campania Luigi Vanvitelli. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.SC and PC designed the study. SC wrote the protocol. AC and LB conducted the study's activities. CA reviewed the literature and provided summaries of previous research studies. AC conducted the statistical analysis. SC and AC wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.This research was supported by V:ALERE 2020 (VAnviteLli pEr la RicErca)-University of Campania Luigi Vanvitelli [Legislative Decree No. 475 of 9 July 2020]. The funding source had no role in the design and conduct of the study, collection, management, analysis, interpretation of the data, preparation, review or approval of the manuscript, and decision to submit the manuscript for publication.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.


Objective: We investigated use and clinical outcomes in a digital musculoskeletal (MSK) program, by generation.Method: This longitudinal study uses retrospective data collected online or by app. The study included adults with 12 or more weeks of pain who took part in a digital MSK program. We compared Gen Z and Millennials, Gen X, working age Baby Boomers, and retiree age Baby Boomer and Silent Generation. Program use outcomes were program start, program completion, and number of exercises, educational articles, and messages to coaches. Clinical outcomes were changes in pain, depression, and anxiety from baseline to 12 weeks. We calculated descriptive statistics and conducted adjusted regression models.Results: Odds of starting the program were significantly higher for Gen Xers (OR: 1.12) and working age Baby Boomers (OR: 1.37) vs. Gen Zers and Millennials. Compared to Gen Zers and Millennials, we observed significantly higher odds of program completion among Gen Xers (OR: 1.62), working age Baby Boomers (OR: 2.24), and retirees (OR: 2.36). Compared to Gen Zers and Millennials, retirees had 19 more exercise sessions (IRR: 1.69), accessed 11 more articles (IRR: 1.84), and sent 4 more messages to coaches (IRR: 1.26). Compared to Gen Z and Millennials, we observed no significant differences in change in pain for Gen Xers, working age Baby Boomers, or retirees.Conclusions: Adults from multiple generations took part in a digital MSK program. Findings suggest that older generations used a digital MSK program more than younger generations, but had similar pain outcomes. Chronic musculoskeletal (MSK) pain is a leading cause of disability and cost in the United States, especially among older adults. Prevalence and incidence rates in the United States of osteoarthritis, back and neck pain, and other MSK disorders are among the highest in the world . In 2018To prevent and manage MSK pain and associated comorbidities, clinical guidelines recommend evidence-based exercises, education, and additional supports , 10. RevDigital health approaches can facilitate access to these types of conservative therapies by providing interactive tools, connecting users with health teams and offering choices for how, when, and where to access care . A meta-We must ensure that digital MSK programs meet the needs of a growing older adult population with MSK conditions. But, to date, no studies have examined whether the use and effectiveness of digital MSK programs differs by generation. Studies have shown that older generations use general technology and digital health technology, but to a lesser extent compared to younger generations –20. FurtIn summary, gaps remain in our understanding about digital MSK program use and outcomes between generations. Thus, we sought to address two objectives. Our primary objective was to examine differences in digital MSK program use between generations. Our secondary objective was to examine differences in digital MSK program outcomes between generations. Better understanding about program use and outcomes by generation will allow us to make program improvements that meet the various needs and desires of a range of users.We conducted a longitudinal study using retrospective data collected from participants of a digital MSK program.The digital MSK program was offered as a benefit to employees and dependents of participating employers. We recruited through email, workplace posters or presentations, and mailings. Those interested in the program registered online by creating a member profile and completing a baseline questionnaire.After registering, we reviewed the baseline questionnaires to ensure that participants met the following program criteria: age 18 or older; pain in the low back, knee, shoulder, hip, or neck; baseline visual analog scale (VAS) pain score >0; pain lasted for at least 12 weeks; and member covered by employer's health plan. Exclusion criteria were signs of fracture, joint instability, infection, cancer, and cauda equina syndrome.All accepted participants received tablet computers with a program app and wearable motion sensors . These materials enabled members to receive technology-guided exercise therapy sessions, coaching, and education for chronic pain. To facilitate exercise sessions, animations and videos within the app demonstrated how to perform light-intensity stretching and strengthening exercises. The app and sensors displayed body position of the participant in real-time while completing exercises and indicated to participants whether they were within the appropriate range of movement.In addition, a personal health coach communicated with participants via text message, email, or in-app messaging. The program offered participants unlimited text and email messages and up to three phone calls with coaches. Participants could also take part in discussion forums with 20–30 other participants. Finally, participants received educational resources covering their condition and treatment options, as well as behavior change topics, such as catastrophizing, coping methods, and fear avoidance.Overall, participants were encouraged to complete at least three sensor-guided exercise sessions per week, read at least two education papers per week, and log symptoms twice per week. Participants were also encouraged to engage in at least three aerobic exercise activities per week.In addition to meeting program criteria, this study applied the following inclusion criteria: registered between February 2017 and April 2020 and 12 or more weeks had passed from the time of registration, had registered for only one pathway , had complete baseline data, and provided informed consent through waiver of written documentation.Data were collected online or through the program app at baseline during registration and 12 weeks later.We organized variables around Andersen's model of health service use  Supplem. The modThe predisposing factor of participant generation was the independent variable of interest and defined as Gen Z or Millenial (born between 1981 and 1999), Gen X (born between 1965 and 1980), working age Baby Boomer (born before 1964 and under age 65), and retiree age Baby Boomer or Silent Generation (age 65 or older) . The ratFor our primary study objective about digital MSK program use, we focused on five service use outcomes: program start ; program completion ; total exercise sessions by program week 12; total education articles read by program week 12; and total number of member-initiated messages to coaches by program week 12.For our secondary study objective about digital MSK program outcomes, we focused on three measures captured for each individual participant. Change in pain was pain scores at baseline minus pain scores at 12 weeks. Baseline and 12 weeks pain scores were based on responses to the question “Over the past 24 h, how bad was your [back/knee/shoulder/hip/neck] pain?” from 0 (none) to 100 (worst imaginable) presented on a horizontal visual analog scale. We also examined change in depression or anxiety by 12 weeks among the subgroup with moderate or severe depression or anxiety at baseline. Change in anxiety (no/yes) was defined as reported moderate or severe anxiety at baseline and reported no moderate or severe anxiety at 12 weeks. Moderate or severe anxiety was a score of 10 or higher on the Generalized Anxiety Disorder 7-item scale (GAD-7). Change in depression (no/yes) was defined as reported moderate or severe depression at baseline and reported no moderate or severe depression at 12 weeks. Moderate or severe depression was a score of 10 or higher on the Patient Health Questionnaire 9-item scale (PHQ-9). The GAD-7 and the PHQ-9 with cutoffs at 10 points have been shown to have acceptable performance for identifying anxiety and depression .Covariates included contextual , predisposing , and need  factors.To characterize the population, we conducted descriptive analyses  for predisposing and need factors, by generation. We examined differences using chi-square tests for categorical variables and one-way ANOVA for continuous variables. We conducted unadjusted and adjusted regression analyses, per protocol. For the primary objective, logistic regression was conducted for binary outcomes, including program start and completion. Generalized linear models (Poisson regression) was used among program starters for outcome variables representing counts, including total number of exercise sessions, articles and messages. Models were adjusted for contextual , predisposing , and need  factors.For the secondary objective, linear regression was conducted for the continuous change in pain outcome. Models were adjusted for contextual , predisposing , and need  factors. Logistic regression was conducted for binary outcomes, including change in anxiety and depression by week 12. This model controlled for contextual , predisposing , and need  factors. All analyses were performed using STATA statistical computing software.The study was approved by the Western Institutional Review Board and complied with all ethical regulations.The digital MSK program registered 13,535 Gen Zers or Millennials , 16,982 Gen Xers , 9,262 working age Baby Boomers , and 1,462 retiree age Baby Boomers or Silent Generation members . We examined 5 digital MSK program use outcomes: program start, program completion, and total number of exercise sessions, educational articles, and coach messages. Generation was significantly associated with number of exercise sessions, educational articles, and coaches messages among those who started the program. Compared to Gen Z and Millennials, the retiree age generation had an average of 19 more exercise sessions , accessed 11 more articles , and sent 4 more messages to coaches  by week 12 .Average pain scores decreased 27.13 points for Gen Z and Millennials, 28.21 points for Gen X, 27.28 points for working age Baby Boomers, and 25.60 points for retiree age Baby Boomer and Silent Generation. Compared to Gen Z and Millennials, we observed no statistically significant differences in change in pain for Gen Xers, working age Baby Boomers, or the retiree age generation in adjusted models .Compared to baseline, 79.28% of Gen Zers and Millennials were no longer reporting moderate to severe anxiety at 12 weeks vs. 81.16% of Gen Xers, 87.82% of working age Baby Boomers, and 91.36% of retiree age Baby Boomers and Silent Generation adults. Compared to Gen Zers and Millennials, working age Baby Boomers  and retiree age Baby Boomers and Silent Generation  had significantly higher odds of anxiety improvement in adjusted models. We detected no significant differences in odds between Gen Xers compared to younger generations .Compared to baseline, 78.39% of Gen Zers and Millennials were no longer reporting moderate to severe depression at 12 weeks vs. 77.76% of Gen Xers, 81.14% of working age Baby Boomers, and 85.51% of retiree age Baby Boomers and Silent Generation adults. Compared to Gen Zers and Millennials, working age Baby Boomers  had significantly higher odds of symptom improvement in adjusted models. We detected no significant differences in odds between Gen Xers or retiree age generations compared to younger generations .This study focused on two objectives. The first objective examined digital MSK program use between generations. Between 86 and 90% of the four generations started the program  after registering.We found that 83% of the retiree age generation completed the program, which exceeded the relatively high completion rates of younger generations (range: 67–82%). In our study, older generations also had more exercise, articles, and messages to coaches compared to younger adults.Past research suggests some reasons for the increased digital MSK program use among older generations that we observed. First, age interacts with attitude about digital health technology to influence adoption. In paying more attention to their MSK pain, older generations may be more likely than younger adults to use the digital MSK program . Second,The second study objective examined change in clinical outcomes among digital MSK program participants, by generation. We did not detect significant differences in changes in pain when comparing older generations to Gen Zers and Millennials. This is in contrast with previous research showing that the benefits of exercise on pain are often more pronounced among younger adults . When viWe also found that older generation was associated with higher odds of anxiety improvement at 12 weeks compared to Gen Zers and Millennials. Previous reviews have shown the effect of 3–12 week exercise programs on improving anxiety, but have found no moderating effect of age . The reaOur study participants may not be representative of older adults generally as the study only includes people who opted into a digital MSK program. First, a previous study of a nationally representative sample of older adults found that older adults are less likely to use health information technology vs. younger adults . In contWe examine generational differences in digital MSK program use and outcomes, but generation is a proxy for knowledge, skills, attitudes, and motivations that influence engagement . Future We use a behavior-based definition of program use that consists of program completion and number of exercises, articles accessed, and coach messages. But these measures may not reflect the “depth” of interaction with the digital MSK program as the measures do not capture affective and cognitive engagement . Future This study likely omitted important system, predisposing, and enabling factors that influence both program use and health outcomes. For example, the program does not collect predisposing factors such as education or income or enabling factors such as internet access. Further, this prevents us from comparing our study sample to the general adult population to assess generalizability of findings.This is an observational study that included consecutive program participants meeting inclusion criteria. The large sample sizes in this study may have resulted in detection of spurious relationships between generation and outcomes. In addition, we cannot establish the program's causal effect on pain improvements. However, the results provide evidence about program applicability in the real world with a wide range of ages.Findings from our study confirm that older generations actively use a digital MSK program that involves app and sensor-guided exercise, app-based education, and remote health coaches. On average, older generations interact with a digital MSK program more than younger counterparts and may experience similar improvements in health outcomes. A digital MSK program holds promise for the growing population of older adults with chronic MSK pain.grace.wang@hingehealth.com.The datasets presented in this article are not readily available because requests for proprietary data will be considered on a case by case basis. Requests to access the datasets should be directed to Grace Wang, The studies involving human participants were reviewed and approved by WCG, Western Institutional Review Board (20160949). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.GW and JK contributed to conception and design of the study. GW organized the data. GW, MY, and JB contributed to the statistical analysis. GW wrote the first draft of the manuscript. All authors contributed to manuscript revisions, read, and approved the submitted version.GW and JK are employed by and have equity interest in Hinge Health, Inc. JB and MY received consulting fees from Hinge Health, Inc.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The COVID-19 pandemic has led to the cancellation of away rotations and other experiences fundamental to orthopaedic surgery residency application. Limited information is available on the experiences of applicants and program directors (PDs) during the COVID-19 pandemic residency application cycle. This study aimed to evaluate the current perspectives of applicants and PDs regarding the orthopaedic surgery residency application process.This was a cross-sectional study using 2 independent but similar surveys that addressed multiple aspects of the application process during the COVID-19 pandemic, including perceived effect of virtual experiences. Between February and March 2021, the surveys were distributed to orthopaedic surgery applicants and orthopaedic residency PDs.In total, 113 applicants (20.1%) and 29 PDs (19.6%) completed the survey. Applicants applied to 97.6 programs and received 13.3 interviews. They participated in 2.4 virtual away rotations. In total, 79.3% of programs reported offering some form of virtual opportunity, including virtual away rotations (24.0%), virtual happy hours (64.0%), and virtual conferences (64.0%). Programs offering virtual away rotations hosted 46.8 rotators and only invited back 54.5% for an interview. Applicants were most concerned about the lack of away rotations, the interview, and networking during this cycle, and 51% reported less confidence in matching. The most important factors for influencing applicant rank lists were perceived happiness of residents, resident camaraderie, and geographic location. However, residency program social events were not well replicated in a virtual setting.The COVID-19 pandemic presented new challenges for applicants and PDs. Applicants had less clinical exposure and received less interview invites after virtual away rotations. Despite applying to more programs, applicants received fewer interviews than in previous years. The virtual experiences adopted in this cycle did not adequately replicate the social factors that applicants found most important when ranking a program. Even during the COVID-19 pandemic, PDs most highly valued away rotation performance, clinical rotation performance, and board examination scores when offering interviews. Studies have shown that a strong performance on these away rotations is considered one of the most important criteria to successfully match into a residency program.4Orthopaedic surgery continues to be one of the most sought-after medical residencies, requiring some of the highest United States Medical Licensing Examination (USMLE) step 1 scores, number of research experiences, and class rank of any specialty.5 Orthopaedic residency programs across the United States supported these guidelines and canceled commitments to host in-person away rotations and interviews. The loss of these experiences introduced gaps in both program directors' (PD) assessment of applicants and applicants' evaluations of prospective programs.However, in response to the COVID-19 pandemic, cancellation of away rotations, in-person interviews, and other experiences fundamental to the orthopaedic surgery application process were enforced by medical schools following a statement by the Association of American Medical Colleges.To compensate for this, programs rushed to produce novel virtual experiences, such as virtual away rotations, interviews, and social experiences. However, implementation of such program experiences varied among institutions. Some offered highly structured experiences, including virtual grand rounds, didactics, and journal clubs, whereas others only offered virtual open house sessions. It is unclear how valuable these experiences have been for applicants and PDs, and if they have adequately replicated their in-person counterparts.7 However, there is limited information regarding the experiences of applicants and PDs during the COVID-19 pandemic residency application cycle. The unique challenges posed in the current cycle and the constantly evolving medical landscape warrant assessment. The primary goal of this study was to evaluate the current perspectives of applicants and PDs regarding the orthopaedic surgery residency application process during the COVID-19 pandemic.Previous studies have evaluated multiple aspects of the orthopaedic surgery residency application process.This was a cross-sectional survey study of applicants and PDs in orthopaedic surgery. The applicant cohort included all fourth-year medical student applicants to our institution's orthopaedic surgery residency program. All applicant e-mails were acquired from the Electronic Residency Application Service. The PD cohort included all PDs of Accreditation Council for Graduate Medical Education–accredited orthopaedic surgery residency programs. All PD e-mails were acquired through the publicly available data on the Accreditation Council for Graduate Medical Education website.http://links.lww.com/JG9/A161, and Appendix 2, http://links.lww.com/JG9/A162, respectively. Between February 21 and March 15, 2021, the anonymous surveys were distributed to our acquired e-mail lists. Applicants who completed the survey were offered a chance to win one of 10 $50 Amazon gift cards. E-mail reminders were sent to applicants and PDs who had not yet completed the survey for a total of three cycles scheduled 5 days apart. One final e-mail was sent to both applicants and PDs on March 13th with a modification to ask for their assistance in adequately powering the study. The survey was closed just before match results on March 15th to minimize respondent bias.We designed two related anonymous surveys intended to capture the perspectives of applicants and PDs on multiple aspects of the orthopaedic surgery residency application process. The full contents of the applicant and PD surveys are given in Appendix 1, t-test and chi-square test were used for statistical analysis of continuous and categorical variables, respectively. Significance was established at a P value of <0.05.Survey responses were collected and analyzed using R Statistical Software . Continuous data were reported as mean and standard deviation, and categorical data were reported as percent of total group. Categorical Likert style response data were assigned numerical values (from 1 to 5) and reported as weighted averages. The Student The survey was successfully sent to a total of 562 applicant and 148 PD e-mails. In total, 113 applicants (20.1% response rate) and 29 PDs (19.6% response rate) completed the survey.Applicants who responded to the survey were 27.9 ± 3.0 years old, with 69.1% identifying as male and 30.0% identifying as female. The geographic distribution of applicant responses was 53.6% northeast, 20.9% south, 20.0% midwest, and 5.5% west. In total, 80% of respondents stated that their medical school had an associated orthopaedic residency program. The average step 1 score was 246.3 ± 15.0. Applicants spent an average of 10.2 ± 4.9 weeks on in-person orthopaedic services. They applied to 97.6 ± 34.7 programs and received interviews at 13.3 ± 9.1 programs. In total, 53.2% of applicants participated in virtual away rotations. This group participated in 2.4 ± 2.1 virtual away rotations and received interviews at 1.6 ± 1.5 programs where they performed a virtual away rotation.Table Table P = 0.550). They conducted 52.1 ± 31.5 interviews this year as compared with 52.0 ± 29.4 interviews in a typical year (P = 0.986). Programs required 2.8 ± 0.39 letters of recommendation (LOR) this year as compared with 2.9 ± 0.59 in a typical year (P = 0.412).The geographic distribution of PD responses was 31.0% northeast, 31.0% midwest, 24.1% south, and 13.8% west. The average number of residents per year at these programs was 4.8 ± 3.3. This year, programs received an average of 530.6 ± 233.5 applications as compared with a typical year where they received 493.8 ± 229.4 applications , virtual happy hours (64.0%), virtual conferences (64.0%), and other (16.0%). The other category included virtual town halls, question and answer sessions, and videos about the program. Programs offering virtual away rotations hosted 46.8 ± 43.6 rotators and only invited back 54.5% rotators for an interview.Table Table 9 In addition, applicants had 10.2 weeks of in-person orthopaedic clinical time compared with 15.5 weeks in previous years, which decreased exposure to the field and its procedures.2 Furthermore, the in-person exposure this year was limited to a single institution, compared with multiple institutions in previous years. This reduction in exposure can be attributed to the cancellation of away rotations this year. This is concerning because Huntington et al10 found that an applicant's impression of a program after the away rotation played a major role in determining their rank list.COVID-19 pandemic has undeniably affected the orthopaedic surgery residency application process for both applicants and programs. The unique challenges posed by this cycle made many applicants feel less confident in matching. These fears were not without merit because applicants applied to more programs (97.6 versus 74.9) but received fewer interviews than in previous cycles (13.3 versus 17).4 For applicants, away rotations typically allow them to showcase their skills, gain LORs, and network at training sites aside from their home institution.4 O'Donnell et al2 previously found that the most important variable for applicants when selecting away rotations was their desire to match that program. This desire was met in previous cycles, with 80% of rotating students receiving an interview invitation. However, this year, programs only extended interview invites to 50% of their virtual away rotators. It is likely that PDs did not feel that they could adequately evaluate students in the virtual setting, translating to fewer interview invites.With away rotations and interviews being transitioned to virtual settings, both applicants and PDs were forced to hastily adapt to the new challenges presented. Our results found that many programs attempted some form of virtual opportunity to fill this gap. However, none of these events or opportunities played a major role in influencing applicants' rank list. Virtual interviews similarly missed the mark, with applicants and PDs overwhelmingly preferring in-person interviews. The lack of in-person away rotations due to COVID-19 pandemic affected the rank list for 82% of applicants. Historically, away rotations have been critical for both applicants and PDs. For PDs, away rotations present an opportunity to evaluate applicants' on work ethic, team fit, and clinical aptitude.11 Although board scores and research experience were ranked highly by both applicants and PDs in our study, the AOA status was not ranked highly by either. Despite its lower perceived importance, the AOA status likely correlates with the number of interviews received because AOA induction considers the totality of academic achievement, research, education, leadership, humanism, and service; all considered to be the characteristics of a successful orthopaedic resident.12Multiple factors affect whether an applicant will receive an interview invite. Historically, factors most strongly correlated with increased interview invites were Alpha Omega Alpha (AOA) status, board scores, and research productivity.13 found a strong association between the location applicants matched for residency and where the applicants previously lived or attended school. In addition, Schrock et al14 found that a higher proportion of matched applicants come from top 40 NIH-funded schools. Although these studies are based on matched applicants, applicants may use this information when gauging the likelihood of receiving an interview. These associations may explain why applicants think connections and school reputation are important for receiving an interview. Furthermore, applicants underestimated the importance of performance on away rotations for receiving an interview. This may provide another explanation for why virtual away rotations resulted in less interview invites compared with previous cycles (55% versus 80%).Our survey also underscored differences between applicants and PDs regarding factors considered important in the residency application process. Applicants tended to overvalue having connections to a residency's institution, reputation of their medical school, and LORs. Evidence supporting most of these perceptions exists. Cox et al15 Before this year, away rotations allowed students to become immersed within the institution's culture for four weeks, providing first-hand insight into resident camaraderie and contentment with the program. In addition, for students who did not complete an away rotation at the institution, programs typically hosted resident social events during the interview day, allowing the applicants to spend time with residents in an informal setting. Because these programs transitioned virtually, it may have been more difficult for applicants to confidently evaluate these factors. Although most applicants reported participating in virtual events outside of the interview, they did not play a large role in informing their rank list. This is unsurprising because PDs found that the virtual preinterview/postinterview social events were the least well-replicated events. Our findings should be considered when developing future virtual program-applicant events. One suggestion noted by Kenigsberg et al16 was limiting virtual resident-applicant experiences to 3 to 4 person groups to foster more meaningful interactions.Applicants reported that the most important factors when forming their rank lists were perceived resident happiness and camaraderie. This finding is consistent with previous years because the 2019 National Residency Match Program applicant survey and a study by Huntington et al. found that students applying to orthopaedic surgery listed perceived happiness and resident camaraderie among the most important factors when creating their rank list.17 similarly reported that only 5% of PDs across various specialties altered applicant ranking after a letter of intent. The lack of merit for a letter of intent may be due to applicants notifying multiple programs that the program is being placed in the first ranking position. Grimm et al17 also supported this notion, reporting that 53% of PDs experienced at least one incident of applicants falsely claiming that they are ranking the program as their first choice yearly. National Residency Match Program states in their participation agreement “Both applicants and programs may express their interest in each other; however, they shall not solicit verbal or written statements implying a commitment.”18A letter of intent is an unsolicited letter from an applicant to a residency program mentioning the intention to list the program first on their rank order list. Of applicants who completed our survey, 66% reported sending a letter of intent to the program that they ranked first. However, 93% of PDs reported that letters of intent did not affect their ranking of applicants. A recent survey by Grimm et al19 We also agree with Kenigsberg et al16 that virtual experiences should limit the number of students paired with residents to allow for more meaningful interactions. This may allow students to better gauge the social aspects/personality of the program while allowing residents to adequately gauge if rotating students would be a good fit for the program. Although there is likely no way to perfectly recreate in-person social experiences virtually, they can still provide added insight into the daily proceedings and educational style of a residency program.If the virtual format persists, programs should consider pairing rotating students with resident mentors. Others have shown success adopting similar measures, allowing students to work alongside residents during telemedicine visits and putting together case presentations.20 Furthermore, PDs only represent part of the selection committee and may not entirely reflect how applicants are ultimately evaluated. Finally, our survey captured information primarily regarding applicant and PD perspectives and may not have reflected how either of these groups acted.We are aware of a few limitations with our study. First, our study had a low response rate for both surveys. There may also be a risk for selection bias because the responses represent those of applicants of a single institution. However, our geographic breakdown reflected current national trends because most resident training occurs in the northeast.In conclusion, the COVID-19 pandemic presented new challenges for applicants and PDs, forcing an early adoption of virtual experiences. However, these programs left much to be desired. Applicants had less clinical exposure and received fewer interview invites after virtual away rotations. Despite applying to more programs, applicants received fewer interviews than in previous years. The virtual experiences adopted this cycle did not adequately replicate the social factors that applicants found most important when ranking a program. Even during the COVID-19 pandemic, PDs most highly valued away rotation performance, clinical rotation performance, and board examination scores when offering interviews. The findings of our study should be considered when developing future virtual and in-person orthopaedic residency opportunities.


Eight were perfused applying urine recirculation (URC), four with replacement of urine (UR) using Ringer's lactate. The aim of our study was to investigate biomarkers , cells and cytokines in the perfusate in context with donor characteristics, perfusate hemodynamics and metabolic parameters. Cold ischemia time did not correlate with any of the markers. Perfusates of DBD kidneys had a significantly lower number of leukocytes after 6 h of NMP compared to DCD. Arterial flow, pH, NGAL and L-FABP correlated with donor creatinine and eGFR. Arterial flow was higher in kidneys with lower perfusate lactate. Perfusate TNF-α was higher in kidneys with lower arterial flow. The cytokines IL-1β and GM-CSF decreased during 6 h of NMP. Kidneys with more urine output had lower perfusate KIM-1 levels. Median and 6-h values of lactate, arterial flow, pH, NGAL, KIM-1, and L-FABP correlated with each other indicating a 6-h period being applicable for kidney viability assessment. The study results demonstrate a comparable cytokine and cell profile in perfusates with URC and UR. In conclusion, clinically available perfusate and hemodynamic parameters correlate well with donor characteristics and measured biomarkers in a discarded human NMP model.Kidney transplantation is the best renal-replacement option for most patients with end-stage renal disease. Normothermic machine preservation (NMP) of the kidney has been studied extensively during the last two decades and implemented in clinical trials. Biomarker research led to success in identifying molecules with diagnostic, predictive and therapeutic properties in chronic kidney disease. However, perfusate biomarkers and potential predictive mechanisms in NMP have not been identified yet. Twelve discarded human kidneys ( Improving the quality and duration of donor kidney preservation prior to transplant may increase utility and potentially improve outcomes. Machine perfusion is at the forefront of this field –4, but aThe kidney is equipped with a sophisticated immune compartment, hosting a plethora of non-hematopoetic cell types and a variety of both transient and resident leukocytes , 8. ThisOn these grounds, the aim of this study was to investigate if perfusion inflammatory profiles correlate with (i) donor factors, (ii) perfusion hemodynamics, (iii) the type of volume management, applying either urine recirculation (URC) or urine replacement (UR), and (iv) biomarkers of renal injury  in a blood-based perfusate of long-term NMP , 13 of dHuman kidney grafts, deemed not transplantable by all kidney transplant centers in the United Kingdom were included in this study. All organs were retrieved for the purpose of transplantation but discarded during post-procurement assessment. Donor and retrieval characteristics, kidney function parameter, and ischemia times were collected.After being sent to Oxford, perfusions were performed at the Institute of Biomedical Engineering, University of Oxford. The technique of NMP using discarded human kidneys was reported previously , 13. BriContinuous urine recirculation or urine replacement with Ringer's lactate was applied as reported previously , 14. RinNeutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and liver fatty acid-binding protein (L-FABP) levels in the perfusate samples were measured. Neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and liver-type fatty acid-binding protein (L-FABP) levels in the perfusate samples were measured by a quantitative sandwich enzyme immunoassay technique using NGAL and KIM-1 Quantikine ELISA kits  and Human FABP1/L-FABP ELISA Kit  according to manufacturers' instructions .A commercially available human 13-plex magnetic bead panel  was used, following the manufacturer's protocol. The plate was read using a Bio-Plex 200 system . Thirteen cytokines and chemokines were assessed: Interferon (IFN)-γ, Interleukin (IL)-1α, IL-1β, IL-1RA, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p40, IL-12p70, granulocyte macrophage colony-stimulating factor (GM-CSF), and tumor necrosis factor (TNF)-α (Samples of perfusate (4 ml) were collected into EDTA vacutainers, 0.4 ml dimethyl sulfoxide (DMSO) was added and well-mixed; 2 ml of this solution was then transferred into a cryogenic storage vial, moved to a CoolCell® Cell Freezing Container and stored in a −80°C freezer. Immunophenotyping of the human perfusate samples was performed on a BD LSR II flow cytometer . Leukocytes were identified and gated as CD45+ and their viability assessed using an eFluor™ 506 viability dye . Following this, a panel of antibodies was utilized to characterize T helper cells (CD3ε+CD4α+), cytotoxic T cells (CD3ε+CD8α+), double-positive T cells (CD3ε+CD4α+CD8α+), double-negative T cells (CD3ε+CD4α-CD8α-), γδ T cells (γδ+), B cells (CD3ε-CD21+), classical monocytes (CD14+CD163-), non-classical monocytes (CD14+CD163+), immature neutrophils (6D10+2B2-), mature neutrophils (6D10+2B2+), mature eosinophils/basophils (6D10-2B2+), and natural killer cells (CD335+). Cells were treated with red blood cell lysing solution , washed, and resuspended in 0.3 ml of staining buffer. A 20 ml quantity of e123count beads  was added and samples were analyzed for 3 min. All gating strategies and analysis were performed using FlowJo version 10.0.6  and five from donors after circulatory death (DCD), were perfused for a median (min-max) of 12.8 (6.1–24.1) h. Volume management was facilitated by replacement of the urine (UR) with Ringer's lactate in four  NMP kidneys, and urine recirculation (URC) was applied in eight  kidney perfusions.p = 0.05. Median (min-max) donor urine output prior to retrieval was 60 (10–350) ml/h. Median (min-max) donor serum creatinine and eGFR at the time point of retrieval were 64.5 (32–208) μmol/l and 81 (29–247) ml/min/1.73 m2.n = 3 URC kidneys 12 h, n = 1 URC kidney 18 h, n = 4 URC kidneys 24 h); median (IQR) NMP time of 21 (11.4) hours with URC vs. 7.2 (3) hours with UR , p = 0.01.The median  duration of NMP was 12.8  h. The median (min-max) hourly urine output during NMP was 54.4 (1.7–471.9) ml/h and the median arterial flow was 370.8 (100–787) ml/min. The median (min-max) perfusate lactate during NMP was 12.8 (4.4–20) mmol/l and the median (min-max) perfusate pH throughout the preservation period was 7.36 (7.16–7.62). A significantly longer NMP period could be achieved in kidneys with URC  perfused NMP kidneys for time points 30 min, hours 1 and 6 after NMP-start. There were significantly more T-cells, CD4+ and NKT-cells in the perfusate after 6 h of NMP compared to 30 min after NMP-start. The content of monocytes, the intermediate type, was also significantly higher at hour 6 compared to the early measurements after initiation of NMP (n = 8) or UR (n = 4); we compared the potential efflux of cells between these two groups, shown in n of NMP . Perfusap = 0.003, 95% CI of difference −21,204 to −2,633. p = 0.09. p = 0.02. There were less T cells , CD4+ and CD8+ T cells, in the perfusates of DBD kidneys after 6 h of NMP compared to DCD organs; 30,071  in DBD vs. 102,356  in DCD, p = 0.01.Perfusates of DBD kidneys had a significant lower number of leukocytes  after 6 h of NMP compared to DCD kidneys; 99,862  in DBD vs. 466,163  in DCD, Donor hypertension did not correlate with any of the perfusate markers measured.Estimated glomerular filtration rate (eGFR) of the kidney donors and their corresponding serum creatinine were related with changes of IFN-γ and IL-6 over 6 h NMP without reaching significance. Perfusate NGAL after 6 h of NMP was insignificantly higher in kidneys from a donor with higher serum creatinine at the time of retrieval.p-values are shown in p < 0.001 considered significant according to Bonferroni correction.Duration of CIT did not correlate with any of the biomarkers , neither with number of leukocytes nor with cytokines in the perfusate. The correlations coefficients (Spearman's rho) and associated Renal arterial flow in ml/min after 6 h of NMP correlated insignificantly with the CD8+ cell count. Overall, perfusates of kidneys with higher arterial flow had lower TNF-α levels. Kidneys from donors with higher eGFR at time of retrieval developed a significantly better arterial flow until hour 6 of NMP.p = 0.7) and donor age (p = 0.8) for NMP kidneys reaching higher or lower arterial flow than the median of 303.5 ml/min. Donor eGFR (p = 0.002) was higher and donor serum creatinine lower (p = 0.002) in NMP kidneys reaching a higher arterial flow than the median.p = 0.004, shown in p = 0.6, depicted in Arterial flow after 6 h of NMP and median arterial flow correlated inversely. Perfusate lactate measured at hour 6 after NMP start was significantly lower in NMP kidneys reaching an arterial flow higher than the median of 303.5 ml/min; p = 0.07) and a more physiological pH (p = 0.06) but significantly lower perfusate lactate levels (p = 0.004).Perfusate pH measured at hour 6 after NMP-start correlated significantly with median pH over time. There was a trend toward a more physiological pH and lower NGAL levels of kidney perfusates with higher arterial flow after 6 h of NMP. p = 0.7, shown in p-values are shown in p < 0.001 considered significant according to Bonferroni correction.NMP kidneys with higher arterial flow had non-significantly higher volume of hourly urine output; p = 0.01, shown in p = 0.6, displayed in The application of URC led to significantly longer periods of NMP; p-values are shown in p < 0.001 considered significant according to Bonferroni correction.The correlation coefficients (Spearman's rho) and associated p-values are shown in p < 0.001 considered significant according to Bonferroni correction.After application of the Bonferroni correction for multiple testing, there were no significant correlation of NGAL, KIM-1, and L-FABP with other parameters measured in the perfusate. There was a connection between NGAL levels after 6 h of NMP and the concentration of GM-CSF and its change over time, ΔGM-CSF, in the perfusate. The concentration of IL-1β was non significantly higher in perfusates with higher 6-h NGAL levels. Perfusates with higher KIM-1 levels after 6 h of NMP had a higher count of non-classical monocytes. Perfusates with higher L-FABP levels at hour 6 after NMP start had also non-significantly more macrophages in the perfusate. The correlations coefficients (Spearman's rho) and associated We herein report for the first time the results of measuring several biomarkers, including cytokines and leukocytes, in a normothermic human kidney perfusion model comparing a novel approach of urine recirculation (URC) to facilitate perfusate homeostasis and volume control , 13 withex-situ organ treatment to prevent detrimental effects for the organ recipient. Our data revealed that IL-1β was higher in perfusates with higher content of NGAL and KIM-1 which are well-known markers for impaired kidney function and, NGAL at least, available to be measured in the clinical routine (The Cambridge group of Clatworthy, Ferdinand et al. , reporte routine , 22–24.  routine . GM-CSF  routine . Whereas routine , 27, in The Cambridge group did not detect any differences between DBD and DCD organs in terms of inflammatory gene signature they described. The only difference we could observe between DBD and DCD organs was the significant higher number of leukocytes, CD4+ and CD8+ T-cells in DCD-perfusates after 6 h of NMP compared to DBD organs; independent of URC or UR. This finding could be representing the cessation of blood flow in DCD organs and warm ischemia time prior to the start of retrieval, as the donor leukocytes have still a “route out” in DBD kidneys. In future, it will be interesting to compare DBD kidneys not only with DCD ones, but also with kidneys procured after normothermic regional perfusion.ex-situ organ assessment, the 6-h values of lactate, renal arterial flow and pH correlated with their respective median values. NGAL, a biomarker we would define as a routinely available biomarker (The most relevant findings of our analyses were the clear connection of perfusate lactate, perfusate pH and urine output with several kidney function parameters in the donor as well as with published kidney injury markers as NGAL, KIM-1, and L-FABP . Perfusaiomarker , was alsex-situ NMP setting cannot be correlated with clinical study results yet, but different cytokine and immune cell patterns do offer an important target to invest more research, particularly in forthcoming clinical use of the NMP device. The downside of performing cell and cytokine analyses solely in the perfusate and not in the tissue or from any other components in the circuit, is a limitation of our investigation, is the missing answer to the question of where the immune cells were possibly migrating to.Our results, gained from an To summarize, clinically available perfusion parameters as perfusate lactate, pH and NGAL correlate well with donor characteristics, renal arterial flow, cytokines, immune cell changes, and KIM-1 in a discarded human NMP model. Potentially, lactate, pH and NGAL become a trinity to support decisions and fulfill the criteria to be diagnostic, predictive, and therapeutic biomarkers  in futurThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.AW designed the study, involved in the development of the perfusion device, performed the perfusions, collected and analysed the data, and wrote the manuscript. JS and JF performed the Luminex and FACS analyses. ML, JH, and RP were involved in data analyses, interpretation, and revision of the manuscript. CC and PF were instrumental for the study set-up, the development of the perfusion device, and revision of the manuscript. All authors contributed to the article and approved the submitted version.This research was supported by the Oxford Centre for Drug Delivery Devices under Programme Grant EP/L024012/1 from the UK's Engineering and Physical Sciences Research Council.PF and CC are co-founders of OrganOx R Limited, receive consultancy payments as non-executive medical and technical directors of OrganOx R Limited, and are shareholders. JF is the Chief Scientific Officer of the ex-vivo Research Center CIC, but receives no payments and has no shares and is an executive director of Perfusion Biotechnology Limited. 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The results of the Serbian national integrated West Nile virus (WNV) surveillance program conducted in 2018 and funded by the Serbian Veterinary Directorate are presented. The WNV surveillance program encompassed the entire territory of Serbia and was conducted by the veterinary service in collaboration with entomologists and ornithologists. The objective of the program was early detection of WNV circulation in the environment and timely reporting to the public health service and local authorities to increase clinical and mosquito control preparedness. The program was based on the detection of WNV presence in wild birds  and mosquitoes (virus vectors) and on serological testing of sentinel horses (WNV-specific IgM antibodies). The season 2018 was confirmed to be the season of the most intensive WNV circulation with the highest number and severity of human cases in Serbia ever reported. The most intense WNV circulation was observed in the northern and central parts of Serbia including Vojvodina Province, the Belgrade City area, and surrounding districts, where most positive samples were detected among sentinel animals, mosquitoes and wild birds. The majority of human cases were preceded by the detection of WNV circulation during the surveillance. The WNV surveillance program in 2018 showed satisfactory results in the capacity to indicate the spatial distribution of the risk for humans and sensitivity to early detection of WNV circulation in the environment. The West Nile virus (WNV) is a zoonotic neurovirulent mosquito-borne Flavivirus, which is maintained in nature in an enzootic transmission cycle between avian hosts and ornithophilic mosquito vectors. Besides birds as natural hosts, the virus occasionally infects other vertebrates including humans and horses, which are incidental, dead-end hosts. Unfortunately, in humans and horses, WNV may cause sporadic disease outbreaks that may result in fatal outcomes. WNV is nowadays considered one of the most widespread flaviviruses in the world and is endemic in Africa, Asia, Europe, the Middle East, Australia, and the Americas ,2. Until the beginning of the 1990s, WNV was essentially maintained in endemic cycles in Africa, India, the Middle East and Europe and only affected humans and horses sporadically with rare reports of encephalitis ,4. In EuBefore 2009, the WNV status in Serbia was mostly unknown and the virus presence remained unrecognized. The first confirmation of the presence of WNV circulation was obtained through the findings of 12% (42/349) WNV neutralizing antibody-positive horses sampled during 2009–2010 in the northern part of the country. WNV antibody-positive horses were found in 14 out of 28 municipalities studied, and spread over 200 km ,16. The The history of WNV infection among the human population in Serbia is mostly unknown and/or unrecognized, probably due to the low disease prevalence before 2012. The first serological studies conducted among the human population in Serbia revealed a low prevalence for WNV antibodies, being ≤ 8% from the early 1970s to 1990 . In 2012Except for the continuous surveillance of human cases in the frame of the human medicine data service that was established from 2012, official integrated program-based WNV surveillance did not exist in Serbia before 2014. Based on the obtained results and the anticipated intense circulation of WNV, which poses substantial risks for both public and animal health in Serbia, the Veterinary Directorate of the Ministry of Agriculture, Forestry and Water Management launched and funded a national integrated WNV surveillance program starting from 2014. The results of the surveillance program conducted during 2014 and 2015 showed the success of the program in the early detection of WNV in the environment, as well as some difficulties and shortcomings that have already been published . Each yeDetailed results of the WNV surveillance program in Serbia during 2018 and a comparison of the surveillance data of all three tested pillars  obtained during the WNV surveillance program with the human WNV-positive cases reported to the ECDC in 2018  are presBetween June and September 2018 in Serbia, positive serological responses, i.e., the presence of WNV IgM antibodies in horse blood sera, were detected in 1.75% (44/2511) of tested animals. Positive serological responses in horses were detected in all four testing months (June–September) with the highest prevalence in the period of most intense vector mosquitos’ activity. The first WNV IgM antibody-positive horse was detected on 30th June. The percentage of WNV IgM antibody-positive animals ranged per month of testing from 0.79% (5/630) in September to 2.78% (18/648) in July. The number of IgM antibody-positive horses and the number of districts in which the positive horses were detected per each month of testing are presented in Cx. pipiens mosquitoes were tested from June to August 2018 , and WNV was confirmed in 107 (12.65%) samples. The first WNV positive mosquito pool samples were detected on 19th June. The prevalence of WNV in mosquitoes increased after the first positive findings in June , while 15.05% (59/392) mosquito samples tested positive in July, and 10% (24/240) in August. Positive mosquito samples were detected in 13 out of the 25 districts (52%). The prevalence of WNV in mosquitoes and the number of positive districts per each month of testing are presented in During the surveillance of WNV presence in the environment, 846 pools of Falco tinnunculus)) was detected on 20th June in the South Bačka District. Among 79 samples of found dead wild birds, WNV was detected in 8 (10.13%) cases, and among 198 tested tracheal/pharyngeal swabs of 198 live-trapped wild birds, WNV was detected in 6.56% (13/198) samples. The presence of WNV was detected in tissues or tracheal/pharyngeal swab samples of carrion crows (Corvus corone), hooded crows (Corvus cornix), Eurasian magpies (Pica pica), common kestrels , Eurasian jay (Garrulus glandarius), common blackbird (Turdus merula), long-eared owl (Asio otus) and great tit (Parus major). All of them are resident birds in Serbia. The presence of WNV was not detected in any of 24 samples of shot carrion crows and Eurasian magpies (12 in July and 12 in September) in the West Bačka District. In total, WNV was detected in 6.98% (21/301) of tested wild birds. WNV positive wild birds were detected during each month of testing and were found in 9 out of the 25 districts of Serbia  on 20th June, and the first IgM antibody positive horse was detected on 30th June, both in the South Bačka District (Vojvodina Province). These results preceded the onset of the first human cases of West Nile disease (WND) in Serbia (detected on July 2nd in South Bačka and South Banat Districts) by 2 weeks (mosquitoes and wild bird’s data) or 2 days (IgM antibody positive horse). Positive findings in the frame of integrated WNV surveillance program preceded human infection at district level by detection of WNV presence in one, two or in all three tested pillars  in 12 out of 17 or 15 districts where human WNV infection was suspected or confirmed consequently. On a district level, the first positive data on WNV presence obtained in the surveillance program were detected from 2 months to a few days before the first human WND case. Contrary to that, the integrated WNV surveillance program was not successful in early warning before the first WNV infection in humans in 5 districts, which was either due to the delayed detection of WNV presence in horses, mosquitoes or wild birds (in two Districts) or to the absence of positive findings on WNV presence during the surveillance activity (in three Districts). The detailed data obtained per each district were presented in In line with the main goal of the integrated WNV surveillance program, that is, early detection of WNV circulation in the area, the presence of WNV in Serbia was detected as early as 19th June in mosquitoes, which was at the same time the first round of mosquito sampling in 2018. At that time, WNV presence was detected in mosquitoes from 4 districts, and after 2 or 3 days in the mosquitoes from additional 3 districts, out of 25 districts in Serbia. All of these 7 WNV positive districts represent the Vojvodina Province, the northern part of the country. By the end of June, in the rest of Serbia, only one more district (Raška) tested positive for the presence of WNV in mosquitoes. The first detection of WNV in wild birds was in the sample of tracheal/pharyngeal swab of the ill common kestrel  before the onset of the first reported/confirmed human case in most (12/17 or 12/15) of the districts where human WND cases were detected. This suggests the success of the program in 2018. However, some shortcomings of the surveillance program were observed, which will be discussed below.The main objective of the program was the early detection of WNV circulation in the country, followed by timely alerting of public health services and local authorities to increase both clinical and mosquito control preparedness. For those purposes, we developed the surveillance program considering different strategies previously used for WNV surveillance ,32,33,34Cx. pipiens  was tested since the results of all previous studies suggested that this species is the most competent WNV vector in Serbia as well as in the surrounding regions [Although highly susceptible, horses are less suitable for use as sentinel animals in areas where vaccination of the horse population against WNV is widely used. In Serbia, horses are not vaccinated against WNV, and therefore, they were included as sentinel animals in WNV surveillance like it was done in other WNV surveillance programs ,34. Hors regions ,17,38,39 regions ,39, exceThe WNV surveillance program revealed the highly intense circulation of WNV in Serbia during 2018, the same as it was confirmed in the whole region ,43,44,45The extraordinary intensive circulation of WNV was also confirmed through the number/percentage of positive findings. The obtained results showed that the presence of WNV IgM antibodies in horse blood sera was detected in 1.75% (44/2511) of tested animals in 13 (52%) out of the 25 districts in Serbia and during all four months of surveillance . Virus pIt should be emphasized that 2018 was also the year of the highest ever reported number and severity of human WNND cases in Serbia ,26,45. IThe majority of human cases were preceded by the detection of WNV in horses, wild birds, and mosquitoes , Table 1Dfa climates) with an average temperature in the warmest month of ≥22 °C, as well as by the presence of many slow water flows , swamp areas and small lakes that are the favourite habitats of many resident wild bird species, but also for shorter or longer stays of many migratory birds on their migration routes. It is highly probable that in the past, migratory birds have introduced WNV into the aforementioned areas, which also represent suitable breeding sites producing abundant populations of Cx. pipiens, the most competent virus vector [The districts of Vojvodina Province and the City of Belgrade have previously been identified as areas with high WNV circulation ,17,18,27s vector . Consequs vector ,47 additSatisfactory results obtained in 2018 are the consequence of the implementation of an integrated WNV surveillance program designed, validated and improved in close collaboration between veterinary service, ornithologists and entomologists based on the “One Health” strategy. Although the "One Health" principle is essential in the management of vector-borne and zoonotic diseases ,48,49, aAlthough the WNV surveillance program in 2018 proved very successful, we need to point out two major drawbacks. Previous years of virus circulation in the area were characterized by a high percentage of already seropositive horses, so the adequacy of the number of seronegative (sentinel) horses that can be used in the WNV surveillance program in the following years is questionable. This problem can be overcome by the inclusion of some other animal species as sentinel animals for indirect monitoring of WNV presence in the program, such as cattle and pigs that are mentioned in the literature as potential sentinel animals ,51. For Collaboration between veterinary and human health services as well as medical entomologists and ornithologists, and the coordination and management of data at both national and local levels, are the prerequisites for a successful program and essential in providing early warning and adequate protection of human and animal health. Based on the obtained results and anticipated continued intense circulation of WNV, further studies, especially those on the introduction of other animals species  as sentinel animals, usage of meteorological data  and studThe WNV national integrated surveillance program, established by the Veterinary Directorate of the Serbian Ministry of Agriculture, Forestry and Water Management, designed as both active and passive surveillance, has been conducted starting from the year 2014 . In the INgezim West Nile IgM from Ingenasa and ID Screen West Nile IgM Capture from IDVet) following the manufacturer’s instructions.During the 2018 season, the serology surveillance of horses was performed by detection of WNV IgM antibodies. The horses were sampled as described in Corvidae , raptors , common pheasants and songbirds, as well as birds that died in rehabilitation centres, zoos or bird breeding farms  being submitted for testing for the presence of WNV. The selected and collected wild bird species were previously confirmed as the bird species in which WNV has often been detected in previous years in this part of Europe [Dead wild birds found in the natural environment, particularly the resident species most susceptible to infection, e.g., from the order Passeriformes, mainly f Europe ,18,55. TCulex pipiens mosquitoes , previously indicated as the primary WNV vector species in this region [Cx. pipiens mosquitoes in the traps exceeded 300 individuals, 2 mosquito pool samples were tested per sampling site.Mosquitoes were sampled over 4 sampling periods, at approximately 2-week intervals from June to the end of August, by dry-ice baited traps without light (trap types NS2), operating overnight  in semi-urban and urban localities, as described in s region ,17, wereTissues from wild birds found dead and wild birds that were shot  during surveillance and tracheal/pharyngeal swabs of live-trapped wild birds, as well as mosquito pools, were tested for the presence of WNV RNA as described in g, and the supernatant was used for RNA extraction. Tracheal swabs from wild birds were immersed in 0.75 mL of sterile phosphate-buffered saline during the sampling, placed on ice packs during the transport to the lab, and after a reception in the lab, vortexed vigorously for 3 minutes. The supernatants were directly used for RNA extraction. The preparation of samples for molecular detection of WNV genomic RNA was performed as follows: Tissue samples  of wild birds in amounts of 0.2 g or up to 50 individual mosquitoes (one pool) were placed in 2 mL microtubes and homogenized in 1 mL sterile phosphate-buffered saline for 5 min using a TissueLyser LT  operating at 50 Hz. The homogenates were then centrifuged for 10 min at 2000× QIAamp cador Pathogen Mini Kit  and IndiSpin Pathogen Kit  according to the manufacturer’s instruction. One-step RT-qPCR was conducted using the commercial kits RNA UltraSense™ One-Step qRT-PCR System or SuperScript™ III Platinum™ One-Step qRT-PCR Kit  with the primers and probes that targeted the nucleocapsid protein C gene regions of WNV, as described by Linke et al. [Mosquito pools and bird samples  were tested for WNV RNA presence by TaqMan-based one-step reverse transcription real-time PCR (RT-qPCR) that amplified both lineage 1 and 2 strains. Viral RNA was extracted using the commercial kits  positive cases reported by the Serbian CDC   to the E


Older cancer survivors present with unique challenges that may impact quality of life and increase physical dysfunction if not properly managed. Regular physical activity (PA) can help mitigate these effects. Silver Sneakers (SS), a free exercise program available to Medicare beneficiaries, has more than 16,000 US locations. To understand capacity of SS to serve older adults in our mixed rural/urban catchment area of Central Pennsylvania, we 1) identified all registered SS program locations in our 28-county catchment area and; 2) conducted phone questionnaires with SS program staff. Approximately 18 gyms closed during the pandemic, leaving a sample of 121 participating gyms. We talked to 80 gyms (66% response rate) to understand member and programming characteristics, training of staff and program marketing. Geographic locations of SS were mixed – 39% in rural and 61% in urban counties; the majority (43%) were located in private gyms or YMCAs. The majority of gyms reported membership was equally mixed by gender and described ages of members as 65-80 years (94%). Program staff said that many members exercised several times per week with friends/family. Program staff also reported that social opportunities (35%) were a primary reason participants remained active in SS. Most (89%) of the facilities were still able to offer SS during the pandemic, with the majority (60%) adapting format to Zoom and other video platforms to conduct classes. Overall, SS programs offer a sustainable option to facilitate access to exercise programs and reduce barriers to PA among older adults in our catchment area.