VA-ECHO  provides live, synchronous, continuing education accredited, case-based learning. Sessions deliver up-to-date, evidence-based, practice-relevant, Veteran-focused learning to healthcare team members. The primary goal of VA-ECHO is to increase Veterans' access to high quality care by improving knowledge and skills among VA care providers. Utilizing the RE-AIM framework, descriptive statistics for 23 VA-ECHO programs regarding program effectiveness, adoption, implementation, and maintenance during a five-year period (2018–2022) are reported. VA-ECHO offered 1,462 sessions and 157,238 contact hours, engaging 17,642 participants from 837 VA-based sites . Effectiveness includes information on number and diversity of programs, as well as reported impact on participants' practice. Adoption includes descriptive statistics, including comparison of growth and change compared to prior years. Implementation describes change in the program over time, including the number of specialties offered, and types of continuing education offered. Maintenance includes a narrative regarding sustainability. The discussion focuses on implementation and maintenance strategies the program has used to address participant and VA needs within the RE-AIM framework, including adjustments to the program, iterative qualitative improvement, sustainment strategies, and opportunities for future evaluation. VeteranOur VA-ECHO program, first implemented in the Northwest Veterans Integrated Service Network (VISN) 20 region, initially focused on five complex chronic conditions: human immunodeficiency virus, suspected lung cancer, chronic hepatitis C, heart failure, and chronic kidney disease . Over thVA-ECHO offers live, synchronous, continuing education (CE) accredited, case-based learning focusing on evidence-based practice. VA-ECHO facilitates connections between VA specialty care and non-specialty care across large geographic areas, utilizing video-teleconferencing combined with interactive case review. Clinical cases may be integrated within the didactic or presented at the conclusion of the didactic content. Cases are de-identified. Relevant clinical information including diagnostic imaging and laboratory values are presented to the audience. Most programs use the chat function and live polling (multiple choice questions or open-ended questions) to generate engagement from the audience. Some programs have utilized role-play to demonstrate specific skills . When appropriate, the coordinators distribute additional resources  to learners via email. They may also provide answers to questions that were not answered during the question and answer portion. In some sessions, multidisciplinary panel discussions are utilized. Session duration is 1–1.25 hours. Some programs offer multi-session events, providing 4–6 hours of content per day for 1 to 2 days. Handouts and recordings are available on internal VA SharePoint sites. Sessions are hosted by registered nurse (RN) coordinators and, when possible, utilize regular clinician moderators to introduce the speaker(s), monitor the live chat and relay questions from the audience to the speakers. The specific educational platform utilized has evolved over the years, but during this evaluation period VA-ECHO utilized Microsoft Lync, Skype for Business, and, most recently, Adobe Connect.Our team previously published an analysis of participation patterns from 2012 through 2018, using similar definitions and methods . Supplem2.We employed the RE-AIM framework to describe the program's offerings between January 2018 and December 2022. Our team consulted with the ORH Center for Evaluation of Enterprise-Wide Initiatives (CEEWI) on applying RE-AIM. CEEWI, which represents a collaboration between ORH and VA's Quality Enhancement Research Initiative (QUERI) “supports the ORH's mission by focusing on the implementation, sustainment, and expansion of effective programs to improve the health and well-being of rural Veterans” .The participant cohort in this analysis includes individuals who attended at least one session during the evaluation period. This included healthcare trainees and participants not affiliated with VA. Attendance and completion of brief post session evaluations are optional. The primary incentive for participation is no-cost continuing education (CE) credit. The types of continuing education credit offered for a given session are based on session content, anticipated audience, and available resources. During this evaluation period, 17 forms of CE credit were available See .Obtaining CE credit is optional. To obtain CE credit, participants are required to use VA's national online Talent Management System to register for sessions in advance and complete an additional post session evaluation. Some types of CE require additional steps. Our program tracks participants regardless of their intent to earn CE credits or their subsequent completion of these additional steps. With limited exceptions, only VA affiliated participants are eligible to earn CE.Individuals receiving salary support from VA-ECHO totaling more than 10 h per week (or 25% of full time) were excluded from the analysis. This includes program RN coordinators, and program support, management, and leadership. Medical directors, who receive 0%–20% salary support, are included as participants. They do not receive support specifically for their attendance at sessions, and there are no explicit requirements for them to attend sessions. Faculty are also included in the analysis and do not receive financial support unless they also serve as a medical director.2.1.We determine participant characteristics primarily through self-report upon initial registration with the program. Participants are asked to provide information including their site, discipline, and clinical specialty when first attending a session offered by our program or when requesting invitations to the sessions. In some cases, we used reputable online sources, including VA-based or academic affiliate faculty directories, or the National Provider Identifier Database (NPID) to address omissions or discrepancies in our data set. For this analysis, we utilized most recently known information for a given participant. Participants were assigned to clinical discipline categories based on the National Uniform Claim Committee (NUCC) provider taxonomy  and to a2.2.Several strategies for tracking attendance were utilized during the evaluation period, depending upon educational platforms utilized. Attendance data and evaluation results are maintained in a custom VA Research Electronic Data Capture (REDCap) based project supported by the VA Information Resource Center. We previously utilized a custom MS Access database . Quality2.3.Responses to brief post session evaluations are collected using internal VA SharePoint and MS Forms and are voluntary. Evaluations are identifiable to permit quality improvement . Respondents are aware that their responses are identifiable, however their names are not shared with planning committees or faculty. Evaluations from non-VA participants are not obtained except in very limited circumstances and are excluded in this analysis.2.4.VA-ECHO, including iterative evaluation, was approved before implementation as a non-research  initiative. We have secured written verification of non-research status at regular intervals, most recently from the VA Puget Sound Director of Human Research Protection Program and the VA Puget Sound Director of Quality, Safety, and Values. As a designated quality improvement (non-research) project, informed consent is waived and not required.3.3.1.reach element of RE-AIM are not included for this analysis, in accordance with guidance from CEEWI. VA-ECHO intends to evaluate reach only for sub-projects focused on implementation of specific skills among a limited cohort of care providers whose patient panel characteristics can be described.As the goal of our initiative is to improve Veterans' access to high quality care by offering educational development to VA care providers, metrics for the 3.2.The number and diversity of specialty programs offered and the reported impact on participants' practice are the best measures we have of the effect of VA-ECHO on Veterans' access to high quality care.3.2.1.In response to learning needs and emerging clinical issues , the number of specialty programs offered increased from 12 to 22 during the evaluation period . The numIn total, 1,462 sessions were offered during the evaluation period . SessionVA-ECHO offered 39 sessions not specifically affiliated with an existing VA-ECHO program to meet additional learning needs. These included six Veterans Health sessions (sponsored and developed by Pulmonary VA-ECHO); four sessions focusing on virtual care skills, including tele-supervision of trainees during COVID-19 (sponsored and developed by Sleep VA-ECHO); and 29 Chief of Medicine Grand Rounds sessions . These sessions are included in our analysis .The COVID-19 pandemic resulted in increased demand for virtual learning across the organization. In response, VA-ECHO increased the types of CE offered, the capacity in any given session and the overall scope of offerings while maintaining interactive learning and audience engagement. Furthermore, VA-ECHO focused on more deliberate collaboration with national stakeholders to maintain consistent messaging related to pandemic care.3.2.2.VA-ECHO utilizes brief, standardized post-session evaluations which are optional and identifiable. Evaluation results substantiate that session content is relevant to participant practice (90% or higher) and the majority (76%) anticipate practice change as a result of participation . Evaluat3.3.3.3.1.During the evaluation period, VA-ECHO supported 23 different clinical specialty programs : Acute C3.3.2.During the evaluation period, VA-ECHO provided 158,502 contact hours to 17,642 unique participants, 97%  of whom were VA-based . Contact3.3.3.n = 1,284) worked in rural, highly rural, or insular island settings. The vast majority of VA-based participants (93%) were affiliated with a VA-based medical center or clinic.We analyzed VA-based participant characteristics . Of the Participants represent a wide range of clinical disciplines  and clinical specialties . Approximately 9% of participants were healthcare trainees and were categorized as such as opposed to a specific clinical discipline or specialty. The most frequently represented disciplines were behavioral health and social service providers (18% of participants), pharmacy service providers (17%), registered nurses (16%), physicians (11%), rehabilitation and restorative care providers (7%), and advanced practice nurses (5%). Behavioral health and social service providers were predominantly social workers  and psychologists .The most frequently represented clinical specialties were specialty medicine (13%), pharmacy (13%), primary care (12%), mental and behavioral health (10%), social work (9%), and physical medicine and rehabilitation (7%). Among specialty medicine, a wide range of specialties were represented including pulmonary (excluding sleep medicine) , followed by neurology (7%), pain, cardiology, nephrology, and infectious disease (6% each). Of note, pulmonary  providers were highly engaged in the initial COVID-19 VA-ECHO program, which was focused on acute and critical care which contributes to their high level of representation. Overall, the distribution of represented disciplines and specialties remains consistent among both rural and urban participants.3.3.4.n = 6,482)] demonstrated “high” or “very high” participation, attending 5 or more sessions. Approximately one quarter of participants  attended 2–4 sessions (defined as “intermediate participation”) and over one third  attended a single session (defined as “low participation”).Individual participants attended 1–622 sessions  . Over onn = 10,064) and another 24%  attending 2–3 of the 23 specialties offered. A minority (8%) attended sessions in more than 5 specialties.Extent of specialty focus varied, with 61% of participants attending one specialty exclusively  included broadening planning committee memberships, expanding CE offerings, actively incorporating evaluation feedback from non-primary care attendees, utilizing VA-based national communication tools, employing micromarketing to engage specific groups of learners, adding specialty programs relevant to broader audiences , and engaging with national partners and programs. Facilitating broad engagement predated the COVID-19 pandemic. As a result, when the COVID-19 pandemic occurred, VA-ECHO had an established framework for offering regular, live, multidisciplinary learning opportunities that were scalable and relevant to a very broad audience. In an effort to meet organizational needs, VA-ECHO adapted to permit larger and more diverse audiences as compared to the original Project ECHO model. In recognition of the value of case-based learning, we actively track case presentations , and havTo ensure consistently high-quality offerings, VA-ECHO established standard operating procedures for regular activities including data collection and communication with participants and faculty. VA-ECHO attempts to use the best available educational platform combined with standardization to ensure both consistency across programs and the ability for RN coordinators to support one another without difficulty. RN coordinators and medical directors regularly share challenges and best practices with one another. Each coordinator supports 3–4 programs, further promoting standardization and adoption of best practices across programs.Specific strategies which support efficiency and optimal resource utilization include a standard program staffing model based on complexity and session frequency. We establish an RN coordinator—medical director dyad (or triad) for each program. RN coordinators manage the day-to-day program needs, including those which require clinical expertise, without placing excessive burden on medical directors. After a formal orientation period, RN coordinators are expected to complete CE applications, lead planning committees, independently identify needed gaps in curriculum and potential faculty, and analyze and present evaluation and needs assessments results. VA-ECHO provides salary support for program medical directors , who may be physicians, nurse practitioners, social workers, etc. Medical directors are charged with developing a vision for their program and partnering with the RN coordinator to implement that vision. VA-ECHO enjoys exceptionally high retention of both coordinators as well as medical directors for many reasons, including support of professional development  and allowing each program autonomy with respect to session frequency, areas of focus, type of CE, new projects and innovations .3.5.The sustainability of VA-ECHO relies on maintaining strong relationships with key stakeholders and funders, as well as with program medical directors and faculty. VA-ECHO relies on funding from several VA-based national offices and programs. Funding agreements require annual renewal to maintain continued funding. Maintaining robust data allows VA-ECHO to demonstrate impact and value to current and potential future funders. Providing standardized reports, including evaluation results and detailed information about attendance patterns, demonstrates organizational stewardship to stakeholders.VA-ECHO's adaptability is another key component to sustainability. Stakeholders, including but not limited to funders, value the ability of the program to quickly offer high quality CE accredited educational offerings on emerging topics  and enterprise level priorities. This also ensures continued audience engagement. VA-ECHO proactively identifies and quickly offers content relevant to national initiatives  and tracks internal metrics. This allows the program to present data on initiatives to key stakeholders and has proven valuable when cultivating partnerships. The strategy demonstrates awareness of leadership priorities while also communicating the relevance of these priorities to the field in real time.In an effort to maintain program sustainability and establish partnerships with national programs and offices, VA-ECHO has begun to support some national teams with their regular Community of Practice calls . While these differ from learning sessions with didactic content and case-based learning, they generally serve the same audience and integrate well with planned curriculum. VA-ECHO provides high quality, low friction offerings by employing standardized processes, facilitating CE accreditation when appropriate and providing attendance data, which have not always been available to these national teams in the past.Lastly, VA-ECHO recognizes the importance of valuing all members of the healthcare team. We welcome any individual who contributes to care delivery for Veterans, regardless of role or clinical background. During COVID-19, we observed increased proportion of non-clinical attendees and executive leadership, who were either suddenly engaged in direct healthcare delivery at a level not previously experienced, or who had personal questions related to COVID-19 and/or their own wellness and resilience. VA-ECHO provides program planning committees with detailed analysis on their participants, including rurality, specialty, and discipline  . During In many respects, the overall patterns of participation are similar to the prior analysis despite expansion with respect to number of specialty programs. Consistent with our previous analysis, approximately one third of participants attended only a single session, and two thirds engaged with a single specialty program over a five year period .The overall increase in diversity with respect to participant specialty and discipline reflects our continued efforts to offer content relevant to all members of the healthcare team. We provide live educational forums where we strive to ensure all healthcare team members are on equal footing, as members of planning committees, faculty, and audience. Evaluation comments reflect interest and increased understanding of the role of the interdisciplinary colleagues, and the specific VA services that they support, offer, and/or promote.VA-ECHO has diverged from Arora's original Project ECHO model. Both programs utilize a didactic component, however Project ECHO focuses on real time clinical case review, while VA-ECHO as implemented by our team incorporates case-based learning into presentations but is not generally able to facilitate real time clinical case review. The original Project ECHO model targeted an audience of community-based primary care providers from a specific geographical area. VA-ECHO adapted to meet the needs of VA-based audiences to further de-monopolization of  knowledge. As VA-ECHO continues to evolve, we anticipate engaging increasingly diverse audiences across the nation and expanding into new specialty areas with the ultimate goal of supporting delivery of the highest quality of care to Veterans.4.1.There are limitations with our data related to the longitudinal nature of the project and the change over time in program scale and audience diversity. We initially developed processes around sessions with fewer participants  from more narrow range of disciplines and specialties . The amount of detail we collect for certain types of participants  has changed over time. In addition, we have used multiple educational platforms to provide sessions during this evaluation period, each of which has limitations which directly impact attendance data. Furthermore, there is no up-to-date, centralized source of participant demographics available for our team. Changes in participant characteristics  are certainly underrecognized. In addition, participants are assigned one primary site, discipline, and specialty when in many cases, participants work at multiple sites, have more than one discipline  or specialty , or serve multiple roles in their organization .There are also limitations with the evaluation data. Because evaluations are identifiable, this may influence the likelihood of response and the response itself. Recall bias is another concern since participants have a week from the end of each session to respond to the evaluation.Other more general limitations with our analysis include potential discrepancy between recorded attendance and actual engagement with session content. In an effort to engage all levels of participants and provide learning opportunities with minimal barriers to entry, we have chosen to not utilize pre- and post-knowledge assessments unless required by accreditation bodies.4.2.Ongoing participation with VA-ECHO and Project ECHO programs results in reported improvements in clinical content mastery including higher self-reported knowledge and competencies, self-efficacy, improved patient access to specialty care and useful inpatient care and treatment , 13. FutMore sophisticated analysis of participation patterns may yield some additional insight about the VA-ECHO audience and better inform curriculum development. Focusing on participants who have been engaged with a single specialty over a period of years and changes to their knowledge, skills, and confidence is another area of potential interest. Ideally, VA-ECHO would directly correlate participation with improved patient outcomes, however that has proven quite difficult for a variety of reasons, including the expansion into new content and audiences.We are also interested in the effect of participation on participants, medical directors and faculty, including recruitment, retention, and overall job satisfaction. Based on program evaluations, many participants, faculty, and planning committee members report that participating in VA-ECHO and interacting with colleagues throughout the nation results in overall sense of being part of a larger community in support of shared mission and vision for excellence in Veteran healthcare delivery.Further evaluation about how individual program design influences participation and the benefits is warranted. VA-ECHO supports heterogeneity among programs, however this limits comparison between programs. Alternatively, it may provide an opportunity to examine the impact of program differences including frequency of sessions, utilization of clinician moderators, formats for case-based learning etc.5.VA-ECHO has flourished over the last decade due to the continued support of local, regional and national programs and leadership who support the de-monopolization of knowledge, ongoing professional development and multidisciplinary learning environments. As VA-ECHO continues to evolve, we anticipate engaging increasingly diverse audiences across the nation and expanding into new specialty areas with the ultimate goal of supporting delivery of the highest quality of care to Veterans.


We have compared PRAME staining to FISH testing results in 83 difficult to classify melanocytic neoplasms which showed spitzoid histologic features. A relatively low sensitivity of 29.6% and high specificity of 76.8% is seen with PRAME staining as compared to genomic testing with fluorescence in situ hybridization. This study highlights the limitations of PRAME staining in spitzoid neoplasms.PRAME  is a gene first identified in melanoma. It has been proposed as a useful marker to differentiate melanoma from benign melanocytic neoplasms. Recently genomic testing using fluorescence  In the in-situ hybridization (FISH) genomic testing in spitzoid and other difficult melanocytic neoplasms has been shown to have a sensitivity of up to 97.6% and a specificity of 72.7%  for 15 minutes and detected using the Leica Bond III system with red chromogen . p16 staining was also performed in 21 of the cases.2.1.The staining pattern for PRAME antibody was investigated in non-malignant and difficult to diagnose melanocytic lesions, predominately those with spitzoid features including nests of epithelioid or spindle cell melanocytes, clefting around nests of melanocytes and epidermal hyperplasia. We correlated and compared PRAME results with previously obtained FISH analyses, as well as with staining in nodular melanoma and normal skin as positive and negative controls, respectively.Investigators were blinded to the corresponding FISH results of each sample when quantifying the percentage of melanocytes staining positively for PRAME. The number of PRAME positive staining melanocytes in a square millimeter were counted in each sample by two independent researchers and then classified into a five-part scale based on the precedent set by Lezcano et al. . SamplesIndividuals whose PRAME results were 0 or 1+ were classified as PRAME negative, as in 2.2.™ Melanoma FISH analysis performed by NeoGenomics, which included the genes RREB1 (6p25), cMYC (8q24), CDKN2A (p16)/CEN9, and CCND1 (11q13). The high stringency cutoff for a positive result with this test is >29% for any probe, whereas the low stringency cutoffs for “borderline positive” results are less than 29% of cells with RREB (6p25) gain but greater than 16%, cMYC (8q24) gain in greater than 10%, CDKN2A (p16)/CEN9 homozygous deletion in greater than 10%, and CCND1 (11q13) gain in greater than 19% of cells. Negative results are defined as RREB (6p25) <16%, cMYC (8q24) <10%, CDKN2A (p16)/CEN9 < 10%, and CCND1 (11q13) <19%. Gerami et al. have found the high stringency cutoffs to be 94% sensitive and 98% specific in differentiating between benign and malignant melanocytic neoplasms, but only 70% sensitive in spitzoid neoplasms .3.Eighty-three spitzoid and atypical compound neoplasms were ultimately included in this study. Twenty-seven were ultimately categorized as malignant by FISH. Patient ages ranged from 2–79 with a mean age of 33.2 and a median age of 30.0.The body-site distribution of the samples was as follows: 21.7% from the head and face, 22.9% from the trunk, 30.1% from the upper extremity (including shoulder), and 25.3% from the lower extremity.p16 staining was performed in 21 cases, with loss of p16 observed in two cases which were diagnosed as melanoma. These two cases showed 0 and 1+ PRAME staining but received FISH staining over the high stringency cut off values for malignancy. In the cases in which p16 expression was retained there were 7 melanomas and 12 Spitz or atypical Spitz nevi.FISH for melanoma had been previously performed in every case, and PRAME IHC was performed on all cases.Of the 83 samples, 56 were FISH negative, and 27 were FISH positive. The distribution with respect to PRAME is summarized in In this dataset, the sensitivity of PRAME for malignant lesions is 29.6%, with a 95% confidence limit of 13.8 to 50.2%, as demonstrated in The specificity of PRAME for malignant lesions is 76.8% with a confidence limit of 63.6–87.0%. Estimated specificity is near the level that indicates usefulness, but the confidence limit is wide, again indicating lack of precision.In our dataset, a subgroup analysis was performed looking at the differences in specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) when the threshold for positivity was adjuste, as in 4.in-situ hybridization (FISH) utilizing probes for genes RREB1 (6p25), cMYC (8q24), CDKN2A (p16)/CEN9, and CCND1 (11q13) has been shown to be sensitive and specific for differentiating Spitz nevi from spitzoid appearing melanoma. Our study looked predominately at spitzoid melanocytic neoplasms in young adults which are a common diagnostic dilemma.Immunohistochemical stains including HMB-45, Mart-1, Ki-67, and p16 are commonly utilized in the diagnosis of difficult melanocytic lesions. PRAME  is a cancer testis antigen found to be overexpressed in melanoma. In large studies approximately 90% of primary melanomas showed nuclear PRAME staining while 98% of nevi are negative . O’ConnoThe risk of false negatives must be taken into account when determining the threshold for “diffusely positive.” As missing the diagnosis of melanoma is a very grave risk, we would recommend erring on the side of caution and utilizing a lower threshold for the percentage of PRAME positive cells considered as a positive test. However, in our study set, even by lowering our positivity threshold to PRAME 2+, we recaptured only 1 of the 20 samples that were identified as false negatives by FISH analysis; 8 of these FISH positive samples were quantified as PRAME 1+ and 11 did not stain for PRAME whatsoever, as in A screening test should have a higher sensitivity than that which we found in our study; had PRAME been used as a screening test to determine which cases warranted the more costly and time-consuming genetic testing in our study, only 8 out of the 27 or 29.6% of cases ultimately diagnosed as malignant after genetic testing would have been identified.Despite the relatively small sample size of this study, there were 20 cases which would be classified as negative for PRAME on the 0–4+ scale but which were FISH positive, and ultimately were diagnosed as malignant, raising concern for the safety of utilizing PRAME immunohistochemistry as a screening test.5.in situ hybridization have been utilized as diagnostic aids. In our study we sought to evaluate whether PRAME staining correlated with FISH results. We have concluded that PRAME immunohistochemistry does not show good correlation with FISH results in spitzoid melanocytic neoplasms, and ultimately, our study did not confirm its relevance as a screening tool. We also suggest, in line with Raghavan et al. that a lower threshold percentage of PRAME positive staining melanocytes might be utilized to increase the sensitivity of PRAME as a potential screening test. The lack of consensus in the literature on the appropriate percentage of positively staining melanocytes required for a lesion to be considered “diffusely positive” can also make it difficult to interpret the significance of this test between studies, although the majority follow the precedent set by Lezcano et al. However, the smaller sample size is a limitation of this study.The differential diagnosis of spitzoid melanocytic neoplasms can be difficult. Ancillary testing including immunostaining for p16 and PRAME as well as fluorescence Although Lezcano et al. concluded that PRAME immunohistochemistry may still have use as an ancillary test as it is largely positive in melanomas and negative in benign lesions, our study showed some lack of concordance with FISH testing. We recommend that PRAME staining be interpreted in combination with other immunohistochemical results. Further study of the use of PRAME immunohistochemistry in these difficult to diagnose melanocytic neoplasms, particularly spitzoid neoplasms, is still warranted, particularly in the setting of larger datasets.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by Wayne State University Institutional Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. The human samples used in this study were acquired from a by-product of routine care or industry. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and institutional requirements.EW: Data curation, Investigation, Project administration, Writing – original draft, Writing – review & editing. DM: Investigation, Writing – original draft, Writing – review & editing, Conceptualization, Data curation, Methodology, Project administration, Supervision. SU: Investigation, Writing – original draft, Writing – review & editing, Funding acquisition. RS: Data curation, Formal analysis, Methodology, Software, Writing – review & editing. JA: Data curation, Formal analysis, Methodology, Software, Writing – review & editing.


We aimed to test early feasibility, acceptability, and signals of improvement after the 8-week individually delivered asynchronous, web-based mind-body program (NF-Web) modeled after the synchronous group-based live video program .n = 14, cohort 2 n = 14) completed baseline and posttest .Two cohorts  completed baseline  and posttests . Video lesson (58.0%) and homework (70.9%) completion were fair to good. Satisfaction , credibility , and expectancy  were good to excellent. Participation was associated with statistically significant pre-to-post positive changes in quality of life  and emotional distress . Pain intensity and interference did not improve significantly (p > 0.05) after participation.Enrolled participants  was feasible.•Participation was associated with pre/post QoL and emotional distress improvements.•Psychosocial web-programs for rare illnesses may be useful and warrant attention. The three NF types are biomedically district disorders, with individuals experiencing varying degrees of physical symptoms burden, including disabling and disfiguring cutaneous tumors, gait issues, and learning disabilities in NF1, hearing loss and tinnitus in NF2, and chronic pain in schwannomatosis  . UnfortuVery few NF-specific psychosocial treatment options exist and there are limited mental health providers trained to deliver these treatments . To addrDespite this program's success, we quickly learned about important barriers that prevented individuals from participating in live video groups. In fact, roughly 1/3 participants expressing interest in the live video program trial program could not participate due to specific barriers  includinNF-Web,” adapted directly from the live video, group-based 3RP-NF resiliency program ). Taken together, these initial findings are promising – specifically that NF-Web is a feasible and acceptable program for adults with NF and could be a potential treatment option in the future, especially for participants who cannot or prefer not to participate in the live video trial.This is the first study to examine early feasibility, acceptability, and signals of improvement of an individually delivered asynchronous web-based treatment based on the 3RP-NF for adults with NF. NF-Web met all a priori feasibility  benchmarks (Fair to Excellent [>50%]) similar to our prior small sample psychosocial trials ,19,20,28Within-group improvements in secondary outcomes, including QoL and emotional distress, were consistent with our previous feasibility trials in NF and suggest that NF-Web demonstrates signals of improvement for psychosocial outcomes ,29. ThesOur study limitations included a small sample size, no comparison group, a mostly homogeneous sample , and a lack of power to compare findings by demographics . These limitations are similar to other pilot studies , includiAdditionally, given the similarity of NF-Web to online courses with videos, homework assignments, and quizzes, a possible limitation may be that participants who do not prefer this medium for learning and skill acquisition may have been detoured from participating. Anecdotal accounts from this sample (exit interviews) suggest that those choosing to participate in NF-Web did not experience these aspects of the program as deterrent, however when considering this program for a wider audience other program methods may be explored. Relatedly, our sample had a relatively high number of patients with learning disabilities which may impact the generalizability of these findings.Despite using multiple modalities , future studies may benefit from inquiring how one's learning disabilities and/or differences impact their participation in technology-based interventions. Also, the GCPS was used for assessing pain intensity, which deviates from the Response Evaluation in Neurofibromatosis and Schwannomatosis (REiNS)-recommended measures. Last, we did not systematically measure engagement in the NF-Web program during the 8 weeks as part of this study. With the social support aspect being the most notable difference between the two programs (live video and web-based), future studies will attempt to examine how key aspects of the NF-Web program  can facilitate engagement and how other methods of participation  can be encouraged. Despite these limitations, our study strengths included early feasibility testing a novel web-based program for an underserved population which appeared to increase enrollment, participation, accessibility, as well as retention throughout the study course.4.2Web-based programs are valuable for individuals who prefer to learn skills on their own timeline, have barriers to live video participation, and who may also have apprehensions about interacting with others during treatment. Although these do not impact other important reasons for limited participation , offering multiple program types in various modalities, we can increase accessibility to psychosocial care and make these kinds of programs sustainable in a time of limited mental health resources across the world. Long-term, multiple forms of the same evidence-based treatment can complement one another and can even supplement one another if needed .4.3Overall, NF-Web demonstrates early feasibility and acceptability for participants who are looking for a point of entry into these psychosocial interventions who may not be ready to commit to the live video or in-person group options. Having a web-version of this program provides more support to this underserved and in-need population of adults with rare illnesses. Clinicians can work with patients to decide which treatment modality fits their needs best and address barriers they may experiences when seeking psychosocial care. The next phases of this study will work to address the above limitations and plan to include a comparison group to examine between group effects for NF-Web.All authors declare that they have no conflicts of interest or competing interests related to this manuscript.NF Northeast, NF Midwest, Texas Neurofibromatosis Foundation, and the 10.13039/100001545Children's Tumor Foundation.Dr. Ethan Lester was directly supported by foundation grants-in-aid (early career) from All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.Informed consent was obtained from all individual participants included in the study.Description of authors' contribution to the work:Lester: Conceptualization, Data curation, Formal analysis, Funding aquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing - original draft, Writing - review and editing.Fishbein: Project administration, Writing - original draft, Writing - review and editing.Peterson: Writing - original draft, Writing - review and editing.Vranceanu: Writing - original draft, Writing - review and editing, Methodology, Supervision.


Health care workers (HCWs) are at heightened risk of adverse mental health events (AMHEs) and burnout with resultant impact on health care staffing, outcomes, and costs. We piloted a telehealth-enabled mental health screening and support platform among HCWs in the intensive care unit (ICU) setting at a tertiary care center.A survey consisting of validated screening tools was electronically disseminated to a potential cohort of 178 ICU HCWs. Participants were given real-time feedback on their results and those at risk were provided invitations to meet with resiliency clinicians. Participants were further invited to engage in a 3-month longitudinal assessment of their well-being through repeat surveys and a weekly text-based check-in coupled with self-help tips. Programmatic engagement was evaluated and associations between at-risk scores and engagement were assessed. Qualitative input regarding programmatic uptake and acceptance was gathered through key informant interviews.Fifty (28%) HCWs participated in the program. Half of the participants identified as female, and most participants were white (74%) and under the age of 50 years (93%). Nurses (38%), physicians-in-training (24%), and faculty-level physicians (20%) engaged most frequently. There were 19 (38%) requests for an appointment with a resiliency clinician. The incidence of clinically significant symptoms of AMHEs and burnout was high but not clearly associated with engagement. Additional programmatic tailoring was encouraged by key informants while time was identified as a barrier to program engagement.A telehealth-enabled platform is a feasible approach to screening at-risk HCWs for AMHEs and can facilitate engagement with support services. Thus, programs that can identify HCW distress from AMHEs in real-time and provide them timely access to support services are sorely needed.Concerns over personal safety, moral distress from patients dying without family present, staffing, and resource shortages, and uncertainty around frequently shifting guidance have contributed to alarming strain on health care systems.17 In addition to interventions centered on social support, positive attitude, training/education, and protective behaviors, utilization of telehealth to facilitate access to mental health services has been proposed as a potentially effective strategy.18 Telepsychiatry has been employed to expand the reach of mental health care for years and experienced broad uptake during the COVID-19 pandemic.19–24Prior efforts to mitigate AMHEs and promote wellness among HCWs have failed to identify a consensus approach.24 More recently, efforts to deliver mental health services to HCWs have increasingly utilized telehealth, particularly in the context of the pandemic.26Telehealth has also been successfully leveraged as part of screening and treatment programs targeted to trauma survivors in need of support for PTSD and other psychiatric sequelae.We sought to incorporate these emerging trends into an institutional effort to address HCW AMHEs by leveraging the substantial telehealth capabilities and expertise available at the Medical University of South Carolina (MUSC), a federally designated Telehealth Center of Excellence (HRSA U66RH31458). We designed a telehealth-enabled, automated screening, and support platform intended to (1) provide receptive HCW screening for AMHEs with real-time tailored feedback, (2) offer HCW's timely access to support services through telehealth, and (3) perform longitudinal check-ins with wellness tips.27–30 Herein, we report the findings of this pilot program to aid future efforts to provide needed support to HCWs.A pilot feasibility evaluation was performed to assess uptake and engagement of the program and to elicit feedback for program refinement. HCWs in the intensive care unit (ICU) setting were targeted in the pilot program as they were anticipated to have the highest need for AMHE support.This study was performed at MUSC, a quaternary care academic medical center in the southeastern United States. This study was determined to be quality improvement by the MUSC institutional review board and exempted from review. HCWs in two, predominantly medical, ICUs were selected for the pilot study based on perceived unmet needs in the context of the COVID-19 pandemic and resultant staffing shortages. The HCW cohort consisted of registered nurses (RNs), respiratory therapists (RTs), patient care technologists (PCTs), pharmacists, advanced practice providers (APPs), and physicians including internal medicine residents, pulmonary and critical care fellows, and pulmonary and critical care faculty with a potential cohort size of 178.DSM-5 (PCL-5); the Patient-Reported Outcomes Measurement Information System ; the Oldenburg Burnout Inventory (OBI); the alcohol use disorders identification test (AUDIT-C); and the 10-item Connor–Davidson Resilience Scale.31–45A multidisciplinary team comprising clinical and behavioral psychologists, critical care faculty, and fellows reviewed relevant literature and selected complete or subdomains of validated tools to screen for AMHEs including the 9-item patient health questionnaire ; the 7-item generalized anxiety disorder (GAD-7); the abridged 8-item post-traumatic stress disorder checklist for Additional detail regarding these tools are given in Once the initial screening questionnaire was finalized, six ICU stakeholders including three ICU RNs, one RT, and two physicians were invited to voluntarily beta test the survey to provide feedback on survey length, pertinence of questions to ICU HCWs, and likelihood to engage in the program. Feedback was obtained through a four-question survey and through qualitative field notes .Before distributing the assessment tool to the targeted cohort of ICU HCWs, we developed a process map of how the program would score and give feedback to participants . We utilIf a respondent exceeded the high-risk threshold on the PHQ-9, GAD-7, or PROMIS tools or exceeded the clinically significant threshold on any of the other tools, then they were categorized as high risk. Respondents received immediate tailored feedback regarding their risk category . Any resIf any respondent answered the PHQ-9 question: “Over the past 2 weeks, how often have you had thoughts that you would be better off dead or of hurting yourself in some way?” with any answer other than “not at all,” the platform immediately responded in two ways. First, the platform provided the participants with the telephone number to the national suicide hotline and recommended that they call 911 or go to the nearest emergency room if they were at risk for harming themselves. Second, the platform generated an alert e-mail to an MUSC resiliency clinician who then contacted the participant directly.47 through a Research Electronic Data Capture (REDCap™) survey link. Respondents were again given immediate tailored feedback feedback  based onIn addition, respondents of the weekly check-in were provided a stress relieving tip of the week  with a lFinally, all respondents of the initial screening who did not opt out of the program received the complete 61-question screening tool again at 30, 60, and 90 days of the program to assess longitudinal trends in AMHEs as well as willingness to engage in repeated assessments of well-being.After the screening tools and process map were finalized, they were built into REDCap surveys using branching logic statements to provide the tailored feedback. A field was included to capture respondents' cellular telephone numbers to facilitate text-based distribution of weekly check-ins. The comprehensive 71-item survey was distributed in June 2022 to the target population through e-mail list-serves  as an opTwilio, a third-party web service that integrates with REDCap, was utilized to provide personalized automated feedback after completion of the initial assessment and to disseminate the invitations to participate in the weekly check-in and weekly self-help tips and videos . RespondAfter conclusion of the study period, we sought qualitative feedback through a structured interview comprising open-ended questions authored by our multidisciplinary team to gauge participants' perceptions and critique regarding the multifaceted domains of our pilot program. All initial participants were invited to take part and up to three invitation e-mails were sent. Seven respondents were interviewed 1:1 either in person or using a videoconferencing platform in the presence of the interviewer and a second transcriber. All responses were transcribed independently by two team members for review, and an iterative approach to thematic analysis was utilized to recognize barriers to program uptake, positive or negative critique, and suggested improvements.Respondent demographics and screener response data are presented using descriptive statistics. Respondents were dichotomized as “more engaged” or “less engaged” with the monthly screener component of the platform if they completed ≥1 or 0 of the monthly longitudinal screeners, respectively. Similarly, respondents were dichotomized as “more engaged” or “less engaged” with the weekly check-in component of the platform if they completed ≥4 or <4 of the 12 available weekly check-ins, respectively.t-tests after the scores were found to be normally distributed. Chi square test was performed to test for associations between demographics and engagement subgrouping. All analyses were performed in SAS, version 9.4 .The scores on each domain of the baseline screener were compared between the more engaged and less engaged subgroups using two-sided Of the planned potential cohort of 178, 50 (28%) HCWs chose to participate in the program. Their demographics are displayed in From the 50 participants, there were 19 requests for an appointment with a resiliency clinician. To protect the privacy of participants, data were not captured regarding appointment attendance, clinical recommendations from, or impact of any appointments. Longitudinal engagement with the program was assessed based on willingness to participate in (1) serial assessments of the complete screening tool that were administered at days 30, 60, and 90 of the programs and (2) weekly check-ins delivered through text messaging.Twenty-two (44%) participants were classified as “more engaged” based on their participation with at least one of the serial screens, whereas 13 (26%) participants were deemed “more engaged” because of a willingness to participate in at least 4 weekly check-ins . AlthougScores from the baseline screening tool were used to estimate the prevalence of burnout and AMHEs among HCWs who were willing to engage with the program. For tools with more than one clinically significant threshold, any score above the milder threshold was considered potentially clinically significant. More than half of program participants exceeded clinically significant thresholds for burnout, resilience, and alcohol use . In addiIn univariate testing of AMHE scores and participation with the program, we found no associations between demographics or baseline scores in any domain and being engaged with the program (data not shown). There was insufficient power to assess longitudinal changes in scores and their potential relationship with baseline scores or engagement status (data not shown).After conclusion of the pilot program, we interviewed seven participants (six physicians and one APP) who volunteered to provide qualitative feedback regarding perceived strengths and weaknesses of the program as well as proposed refinements. We analyzed these interviews to identify motivators and detractors impacting ongoing engagement and utilization of services offered by the program. These are summarized with illustrative quotes in Several interviewees were hopeful that the program could be expanded to other HCWs but also recommended tailoring of both the longitudinal check-ins and the provided self-help tips based on which domains were clinically relevant on a participant's baseline screening.49HCWs experience high rates of AMHEs, an epidemic made worse by the COVID-19 pandemic crisis. However, health systems struggle with timely identification of these issues and, more importantly, with timely connection of affected HCWs with support. In this pilot program, we demonstrated that ICU HCWs had a high degree of willingness to participate in a telehealth-enabled program intended to screen for AMHEs, connect HCWs to support services, and provide self-help resources. We used an inclusive approach to targeting all ICU HCWs including RTs and PCTs due to the high impact of burnout across all disciplines as well as observed staff attrition among all ICU care team members.50 confirming an ongoing need for HCW support. Program participants also demonstrated a willingness to connect with resiliency support services and appreciated the program's ability to generate self-insight. However, despite these positive features, longitudinal engagement was modest that limited the ability to assess changes in AMHE prevalence over the course of the program.There were additional salient findings in this pilot program that suggest the potential value of this program. The participant population demonstrated a high prevalence of AMHEs, like previous reports24The telehealth-centered design of the platform provided several potential benefits that could translate into improved support for HCWs. First, incorporation of automated text links to assessments and self-help resources expanded the program's reach and offered greater convenience of completing assessments quickly and from anywhere. In addition, the platform's ability to provide real-time scoring feedback coupled with simultaneous access to the contact information for a resiliency clinician enhanced the likelihood that an at-risk participant sought needed support. This was suggested by our finding that 38% of participants requested an appointment with the MUSC Resiliency Program, an uptake rate nearly half of that observed among severe trauma survivors in an analogous program.Furthermore, offering these appointments virtually through telehealth provided a convenience whereby HCWs could schedule appointments with greater flexibility and anonymity that may have contributed to program uptake. Lastly, the platform's automated infrastructure offers both scalability and adaptability allowing for easy translation to other health systems.This pilot initiative also yielded important findings that can and will be used for programmatic refinement. Modest longitudinal engagement rates were observed that may limit the impact of the program on HCW well-being. Qualitative feedback from participants suggested several possible contributors to participant attrition. The combination of busy schedules with little spare time and the frequency of the program's check-ins were cited by multiple participants as a detractor. Furthermore, multiple participants commented that they would appreciate additional tailoring of the program to their individual needs including customization of their ongoing assessments and resources based on their initial screen results.This feedback suggests that even if the check-ins are very brief , weekly check-ins and monthly assessments may be too frequent for this population. However, enhancing the value of the longitudinal touches through customization could impact engagement.Although designed as a pilot program that was not intended to be definitive, we acknowledge that this evaluation has limitations. The modest longitudinal engagement rate impeded our ability to assess for changes in AMHEs and burnout over the duration of the program. Future iterations of the program will target larger HCW populations and will include feedback-guided refinements including participant-selected frequency of check-ins, tailored/customized check-ins, and participant-selected timing of the delivery of check-ins. It is possible that the prevalence of AMHEs observed here is confounded by selection bias as only HCWs willing to participate in the program were assessed.However, the goal of this pilot program was not to measure AMHEs and burnout rates among ICU clinicians, as this has been well established. Rather, our objective was to design and conduct a pilot feasibility evaluation of a proactive novel telehealth intervention to better meet ICU HCW specific needs. We acknowledge that this pilot program was confined to ICU clinicians who had provided a large volume of COVID-19-related care in the past 3 years and who worked in a single quaternary academic medical center. Thus, not all the findings of this pilot study may be generalizable.In conclusion, we have demonstrated in this pilot study that ICU-based HCWs are willing to participate in a telehealth-enabled program intended to identify those who are at risk and connect them with support. Future study will include program refinement to enhance participation and optimize longitudinal engagement that will allow for a more definitive assessment of the program's impact on HCW well-being.


Cancer Cell, Jana et al. uncover a phenomenon they call ‘transcriptional-translational conflict’ (TTC) where deletion of the ARID1A tumor suppressor elevated proliferation-associated transcripts, but up to 70% of upregulated mRNAs displayed no corresponding change in protein levels.1 The clinical implication of these findings is that patients with ARID1A-deficient bladder tumors may be susceptible to treatment with pharmacological inhibitors of protein synthesis.In a recent publication in 1 ARID1A is thought to be a tumor suppressor because its deletion upregulates transcription of oncogenic transcripts and promotes double stranded DNA (dsDNA) break repair, which results in tumor progression. However, knockout of ARID1A in mouse bladder urothelium did not increase the incidence of malignancies even though there was a deregulation of transcription resulting in an increase of cell cycle promoting mRNAs. Notably, this did not translate into an increase of cell cycle regulated proteins demonstrating a discordance between transcription and translation, which affected 70% of ARID1A transactivated mRNAs. The authors noticed that most of the transcripts subject to TTC had a high C/G content; previous reports support that high C/G content transcripts had a slower elongation rate,2 and they eventually concluded that this effect of ARID1A knockout on translation was due to a dampening of translation elongation caused by a decrease in active eEF2, a regulator of GTP-dependent ribosomal translocation.Oncogenes and tumor suppressors have well defined roles in cancer—oncogenes like MYC and PIK3CA promote tumor growth while tumor suppressors such as PTEN and p53 prevent it. However, these genes often do not follow their supposed roles—loss of PTEN can upregulate TP53, promoting senescence, while MYC overexpression cause apoptosis through enhanced expression of BIM, and PIK3CA induce cellular differentiation via SH3RF1, an AKT substrate. Jana et al. now show a similar conflict in AT-rich interactive domain-containing protein 1 A (ARID1A), a SWI/SNF nucleosome remodeler mutated in ~25% urothelial malignancies.3 RASGRP1 can initiate MAPK signaling; hence, a decrease in this signaling cascade culminated in activation of eEF2K, a highly conserved protein kinase that inactivates the eukaryotic elongation factor 2 (eEF2) via phosphorylation. Pharmachological targeting of EZH2, the catalytic component of PRC2, restored RASGRP1 protein levels and reduced eEF2 phosphorylation, thereby restoring protein synthesis rates.The root cause of this elongation defect was decreased expression of the Ras superfamily guanine nucleotide exchange factor (GEF) RASGRP1, a direct target of ARID1A. RASGRP1 reduction was caused by deletion of ARID1A resulting in increased abundance of H3K27me3, indicative of elevated levels of the polycomb repressive complex 2 (PRC2) that restricts transcription nitrosoamine (BBN)-induced tumors4 caused an increase in γH2AX cleaved caspase-3, and DNA damage, compared to similarly treated WT-mice, although carcinogen exposure was comparable. Both WT and ARID1Afl/fl mice developed the same number of tumors, however, ARID1Afl/fl tumors were smaller than their WT counterparts.ARID1A deletion compromised double strand DNA (dsDNA) break repair, excision repair, and repair of interstrand crosslinks, that significantly compromised DNA repair pathways and promoted genome instability. Protein levels of dsDNA repair genes, but not mRNA levels, were downregulated in ARID1Afl/fl tumors showed 4-fold increase in eEF2 levels, but eEF2 phosphorylation increased only twofold, thereby enhancing translational elongation. ARID1A deletion in established tumors resulted in faster proliferating lesions with upregulated pro-proliferative mRNAs and upregulation of transcripts shown to increase RNA translation. Thus, TTC allows the suppression of oncogenesis even when a tumor suppressor is lost, by preventing protein synthesis despite an increase in the expression of oncogenic transcripts.In vivo modeling using the ARID1A/eEF2K double knockout tested the effects of relieving ARID1A deletion-mediated translation elongation deficiency, while retaining ARID1A deletion-dependent transcriptional transactivation, thus divorcing the two effects. Organoids from the urothelium of ARID1A knockout mice had limited replication potential but those from the ARID1A/eEF2K double knockout animals exhibited uncontrolled growth and elevated protein levels of ARID1A targets. Hence reinstating proficient translational elongation while maintaining ARID1A driven transactivation of pro-proliferative transcripts unveiled the oncogenic properties of ARID1A loss. BBN-induced ARID1ACan inhibiting protein synthesis in cells deficient for ARID1A accentuate TTC to suppress tumorigenesis? The translational inhibitor homoharringtonine (HHT) was used to treat bladder cancer organoids that were either ARID1A deficient or proficient. While HHT had minimal effects on ARID1A proficient cells, ARID1A deficient cells were sensitive to it. This analysis was recapitulated in preclinical studies using bladder cancer PDX models with low, medium, and high levels of ARID1A protein expression. In vivo tumor sensitivity to HHT inversely correlated with ARID1A levels suggesting that in the absence of ARID1A, pharmacological targeting of translational elongation can be utilized to restore its tumor suppressive properties.5The fundamental changes caused by ARID1A deletion are fueled by chromatin remodeling which ultimately results in altered expression of multiple transcripts. While cell cycle associated transcripts are upregulated by ARID1A loss, repression of RASGRP1 due to enhanced assembly of PRC2 at its promoter results in decreased translational elongation. Therefore, ARID1A loss alone is not sufficient to drive transformation but can, in conjunction with an increase in translational elongation, augment tumorigenesis. Reinstating the translational elongation block by pharmacological intervention restores TTC to limit tumorigenesis. Restoration of the elongation blockade would also be predicted to reduce levels of DNA repair proteins, which would hinder DNA repair and promote genome instability. A reduction of BRCA2-dependent dsDNA repair could be another therapeutic opportunity since these cells would be predicted to have heightened sensitivity to PARP inhibitors.This tumor suppressive mechanism in urothelial carcinoma is unique. While ARID1A is a positive regulator of translation, other tumor suppressors such as p53, PTEN, APC and PDCD4 are negative regulators of mRNA translation. However, since ARID1A is deleted or mutated in other malignancies as well, ARID1A may have a similar role in these tumors. Since the ARID1A-dependent transcriptome is likely to differ in different cellular contexts, the details of ARID1A-dependent tumor suppression or activation may be cell type specific. This study underscores that identifying changes in translation elongation is an underexplored facet of transformation that has a potential for discovery of novel therapeutic vulnerabilities.


Nigeria has one of the highest burdens of maternal deaths globally, and hypertensive disorders of pregnancy (HDP) are the leading cause of maternal morbidity and mortality in the country. There is a significant implementation gap in utilizing evidence-based practices for the management of HDP in Nigeria. This study evaluated facilitators and barriers to implementing a home blood pressure monitoring program to improve management of HDP.From August 2022 to September 2022, we conducted 15 semi-structured, key informant interviews and 4 focus group discussions among patients, health care workers, and administrators at University of Abuja Teaching Hospital (UATH), a tertiary care centre in Nigeria. The study used the Consolidated Framework for Implementation Research to assess five domains: individual characteristics, inner and outer settings, intervention characteristics, and process of implementation. Audio files were transcribed, and data were analysed using a combination of inductive and deductive approaches. We also conducted 32 brief surveys on the participants to assess acceptability, appropriateness, and feasibility of a blood pressure monitoring program.n=22) including specialists in cardiology, obstetrics and gynaecology, maternal-foetal medicine, nurses/midwives and resident doctors as well as patients (n=10). Mean (SD) age was 39.5 (10.9), and 78% were female. Participants identified facilitators including the perceived simplicity of home blood pressure monitoring program, high burden of HDP, and availability of a multi-disciplinary team of healthcare professionals with expertise in HDP management. Barriers identified were cost, limited knowledge of HDP amongst patients, limited transportation networks, inconsistent management protocols, and inadequate manpower and facilities. Survey results indicated that between 81% and 88% of participants reported that a blood pressure monitoring program would be acceptable, 56%-72% reported that it would be appropriate, and 47%-69% reported that it would be feasible.The study sample consisted of healthcare workers (This study identified facilitators and barriers while highlighting key implementation strategies to leverage and effectively address these respectively to enable successful implementation of a home blood pressure monitoring program. It also demonstrated that a home blood pressure monitoring program was considered acceptable, appropriate and feasible among respondents interviewed at UATH. Nigeria has one of the highest burdens of maternal deaths worldwide, with an estimated 1047 deaths per 100,000 live births accounting for 29% of all maternal deaths globally [Hypertensive disorders of pregnancy  are the leading cause of maternal morbidity and mortality in Nigeria. A 2022 study of 76,563 women admitted for delivery in a nationwide network of referral level hospitals found that HDP accounted for 32% of maternal deaths . It is eEvidence-based strategies are being employed to reduce the impact of hypertensive disorders of pregnancy (HDP) in high-income countries, including postpartum blood pressure (BP) monitoring, elevated BP treatment, and comprehensive postpartum follow-up as suggested by the American College of Obstetricians and Gynaecologists and World Health Organization , 10. HowDespite the high burden of HDP in Nigeria and available evidence-based practices, there remains a significant knowledge-to-action gap in the utilization of these practices. Successful implementation of evidence-based practices requires consideration of factors such as the selection of appropriate and acceptable interventions, identification of barriers and facilitators, adaptation to local contexts, and evaluation of implementation success or failure . Thus, wThis was a qualitative study designed to understand the facilitators and barriers to optimal management of HDP at the University of Abuja Teaching Hospital (UATH), a tertiary care centre located in the Federal Capital Territory of Abuja, Nigeria. The hospital is a referral centre for pregnant patients in Abuja and neighbouring states.The study used the Consolidated Framework for Implementation Research (CFIR) to assess five key domains: intervention characteristics, individual characteristics, inner setting, outer setting, and implementation process. The research team, comprised of the principal investigator and 2 research assistants, conducted 15 in-depth in-person interviews and 4 focus group discussions with 3-6 participants each comprised of physicians, nurses, midwives, patients, and administrators from UATH, between August 2022 to September 2022. The sample was selected using a maximal variability sampling frame approach with additional participants recruited through a snowball approach to achieve thematic saturation. The study was approved by the Institutional Review Board at the Washington University in St. Louis and UATH Health Research Ethics Committee.Interviews were conducted by the principal investigator and 2 trained research assistants using a pre-designed interview guide that used CFIR to evaluate: individual characteristics, inner and outer settings, intervention characteristics, and process of implementation of a home BP monitoring program to optimize management of HDP in the hospital. All interviews were conducted in person, in English, audio recorded, and subsequently transcribed by an independent transcriber. Field notes were taken during the interview. Interview duration ranged from 10 minutes to 60 minutes.A combination of inductive and deductive approaches was used for the analysis while applying key stages of framework analysis, including data familiarization and systematic coding using the CFIR 2.0 to interpret and condense data into themes. Dedoose version 9.0.78 software was used for data analysis. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to present the findings of this study . To compAcceptability was defined as the perception among implementation stakeholders that a home BP monitoring program is agreeable, palatable, or satisfactory. Appropriateness was defined as the perceived fit, relevance, or compatibility of the home BP monitoring program at UATH and for postpartum patients with HDP. Feasibility was defined as the extent to which the home BP monitoring program can be successfully executed by patients with HDP at UATH. Descriptive statistics were used to summarize the participants characteristics and responses to survey questions.The study sample consisted of 32 individuals, comprising of healthcare workers  and patients, all from UATH Table . PhysiciWe report themes of the facilitators and barriers to implementing a home BP monitoring program in the management of HDP, as well as strategies to overcome these barriers. Participants' responses covered various constructs from the updated CFIR domains and are shown in Table Participants’ highlighted important facilitators that could be leveraged to ensure successful implementation of the home BP monitoring program. These include:Home BP monitoring is perceived as a simple intervention (innovation)“The blood pressure apparatus is relatively easy to use. Most of the patients that access care here have at least secondary level education. I think teaching them to use the home blood pressure monitor should not be too much of a challenge.” (Cardiology Registrar)Participants perceived home BP monitoring as a simple intervention and felt most patients would be able to perform despite low literacy levels in the population.“I believe that they would make use of that BP apparatus because if you look at the patients that are diabetic patients, they have their own glucometer, we teach them how to use it and they are making very good use if it, you understand.” Additionally, some participants compared home BP monitoring with self-monitoring of blood glucose using glucometers, a patient-level intervention currently utilized at UATH in the management of diabetes.“When you go home with this, the machine for high blood pressure, it’s very good because sometimes you feel like shivering or high blood pressure, you want to check it yourself, you feel like ah! Where will I go to? Maybe it’s night, it’s late. You cannot just go to the hospital at that moment. So, when you have it in the house, you can easily use it any time, any hour. So, no…me I’m saying like it’s one of the best things you people are bringing so far.” (Patient)Patients who were pregnant or postpartum expressed their motivation to participate in a home BP monitoring program. They viewed the intervention as being timely and believed that it would give them a greater sense of ownership in their care.2.The hospital has a high burden of hypertension disorders of pregnancy and participants perceive the intervention as appropriate, urgent and significant (inner setting and innovation)“I can tell you categorically that, those days they used to say that postpartum haemorrhage is the commonest cause of maternal morbidity and mortality. But I will tell you here, the commonest cause of maternal morbidity and mortality is hypertensive disorders.” (Consultant Obstetrician)Physicians and nurses expressed an urgent need to address HDP as it is a major cause of mortality among the pregnant patients that present to UATH. Physicians also noted UATH serves as a regional referral centre, making it an ideal setting to implement an intervention that can have wide reach in the community.“Blood pressure is very, very important during pregnancy because once your blood pressure is being monitored you will know whether your blood pressure is high or low, because high blood pressure is a bad thing during pregnancy which can eventually kill the baby and even the mother who is carrying the baby. So once the BP is being monitored, the doctor will know the medication to give the pregnant woman in order to lower or increase the BP so that there won’t be any complications during pregnancy.” (Patient)Patient participants felt that improving the management of hypertensive disorders of pregnancy (HDP) was crucial, as it can impact the outcomes for both mothers and their babies.3.University of Abuja Teaching Hospital is a tertiary care centre with a multi-disciplinary team of healthcare professionals who have the expertise to provide the necessary care for patients (inner setting)“We have a referral system here. So, when they (pregnant women) come to antenatal clinic and we find out that the blood pressure is still high, it’s still elevated, we now write a referral to the medical team, they would go there and receive the treatment. But for those that we would admit in the ward, and we are not able to control the blood pressure, we immediately invite the medical team to come in.” (Consultant Obstetrician)Participants believed that UATH has the necessary expertise to care for patients with HDP, due to the presence of a multi-disciplinary team comprised of obstetricians, maternal foetal medicine specialists and cardiologists.…(T)hey have enough doctors here, specialized doctors. Because if something is happening to you, they will rush you to this place. Even if you go to private hospitals, they are going to refer you here. So, instead of going and they refer you, it’s better you just come here straight.” (Patient)“Patient participants viewed the physicians and nurses as experts in their field, and reported that pregnant patients prefer to receive care at UATH over private hospitals because of the expertise available there.Furthermore, participants reported a high level of patient-provider trust which encourages participants to seek care at UATH and return for follow-up appointments. Participants believe that existing relationships with primary and secondary healthcare centres, along with community involvement, can be utilized to facilitate the success of the program.4.Protocols are commonly used for other conditions (implementation process)“I'm not sure if they have it in the labour ward or the obstetrician (mm-hmm), but I, I don't have a particular protocol that I follow.” (Family Medicine Consultant)Some physicians, nurses, and administrators commented on the use of protocols for managing certain medical conditions including HDP. However, the knowledge of the protocols and their use were inconsistent amongst the participants interviewed.“…(E)very day they come for antenatal, there are health talks that will make them aware. Every, anything they are going through pregnancy, there are health talks that will put them through. But unfortunately, some of these our mothers don't even go for health talk. They don't know. Something that can be prevented, because of ignorance they don't know they will have problems. So, I think if every woman will go for antenatal, it'll go a long way because they are informed and when you are informed, you'll be transformed.” (Midwife)In addition to protocols, there are ongoing educational talks in antenatal clinics on various conditions that can be leveraged on to improve management of HDP.5.Health insurance schemes can be leveraged on to improve access to postpartum care (outer setting)“(Patient pays) only 10%, however the insurance covers like 90%.” Available health insurance schemes can be leveraged to improve access to postpartum care. Participants noted that for patients on the National Health Insurance Scheme, they pay a fraction of the cost and that mitigates the financial barrier for attending clinics.6.Mobile technology is widely available and may facilitate implementation of home monitoring program and follow-up via telehealth (outer setting)“… I think quite a number of people do have Android phones now… Quite a good number, at least most of our patients.” (Cardiology Registrar)Participants noted that nearly all patients have access to a mobile phone. This will enable follow-up via phone calls and text messages, thereby reducing the number of participants who drop out.Participants noted that other technological advancements including availability of automated BP devices will simplify the process of implementing a home BP monitoring program.Participants’ identified key barriers that ought to be addressed to effectively implement and scale up a home BP monitoring program and these include:Limited knowledge of hypertensive disorders of pregnancy among patients and providers “…because most times we tend to lose these patients in follow-up. That’s one. Because most people don’t think hypertension is an issue until they come down with heart disease or heart failure.” (Midwife)Participants felt that there was inadequate knowledge and low awareness on HDP and its complications.Furthermore, overall low literacy levels in the community could pose a challenge for some patients to participate in programs that rely on text messaging because they may have difficulty understanding and using this form of communication.2.Pervasive socioeconomic challenges “Because from the top right down into the communities, starting from the government, you need to have them, have policies up there that can support this program. You need to have funding. You need to have, I mean you need to prepare, you have manpower. You need lots of things up there put in place.” (Family Medicine Consultant)Participants were concerned about the long-term sustainability of the program due to a lack of sustainable funding sources.“I think, uh, you should keep in mind the indigent patients. There are a lot of patients here that when we discharge them, they cannot go they will just be around because they cannot pay their bills. Some are there now, they are there.” Some patients may be unable to pay to attend antenatal care or postnatal care clinics and this may affect their ability to enrol and commit to the program. Other trepidations include costs of medication, and any treatment patients may need could impede retention in the program.3. Limited transportation networks affect follow-up and retention (outer setting)“Most of those, uh, patients that are in the village, even when they discharge them, we'll tell them: please come for your next appointment. We don't get to see them. It's when there's serious issues you will see them. Why didn't you come? "I thought I was fine". They don't used to come. Most times it's the educated ones that will even, we see, but those ones in the village is very, very difficult.” Some patients are referred from remote areas of the Federal Capital Territory at the time of delivery due to maternal or foetal complications requiring a higher level of care. Once they deliver, they may be less likely to return long distances for follow-up appointments due to a lack of transportation and resources. This could affect their willingness to participate in a program that requires them to return for follow-up visits.4.Inadequate manpower, equipment, and facilities (inner setting)Participants lamented on working conditions, highlighting that most hospital wards are understaffed and thus unable to take additional responsibilities. They expressed concerns about the challenges of introducing a new program that would require additional workload for the already burdened workforce.“Manpower number one. manpower, number one; I’m short…in fact the clinic is short-staffed. Secondly there is so much equipment that is not just there, you write drug for patient the, patient will have to go and buy from outside. It’s not all the drugs that are available at the pharmacy, you understand. They’re some things you need, in fact, some instruments are not there.” When asked about the barriers of implementing a program, a nurse manager stated:Physicians highlighted other concerns such as staff burnout, poor staff compensation leading to mass migration of healthcare workers to other countries as factors that could impact successful implementation of the program.Participants emphasized on inadequate equipment in the hospital, ranging from beds to BP monitors, and more advanced imaging equipment such as CT and MRI scanners. This diagnostic gap limits their ability to care for pregnant women effectively and may impact home BP monitoring program implementation.Although the hospital has instituted an electronic medical record system, there are some limitations include signal outage and gap in communication between the outpatient and inpatient records, which have not yet been digitized.5. Prevailing religious and sociocultural norms in the surrounding “…another problem we have majorly, our people are so religiously inclined…Medical advice is secondary. Some will tell you that they want to speak to their Imam, their religious leaders. You will be talking to a patient, and they will be calling their pastor or calling a religious leader to pray for them or to seek consent whether they should go ahead with the medical advice.” Participants stated that religious beliefs and practices amongst patients can affect enrolment and participation in the program.Some participants also reported that existing traditional beliefs in the community discourage participation in program. Other concurrent and competing family obligations can affect ability of the participants to remain engaged to the program.6.Cumbersome processes in hospital wards and clinics (implementation process)“For us in the tertiary health care centres, I think it’s the rigors of going from one place to the other. It’s so much, it’s so much, erm… how do I put it now? They have a lot of puddles to cross. You have to go get your file, you have to go pay consultation, you have to get a booking, you know…the movement round the hospital could be a little cumbersome. So, sometimes that…that affects them.” Patient-participants felt processes in the hospital are too cumbersome especially for pregnant or nursing mothers and involve mothers walking to multiple departments to complete investigations, payments, and appointments. This discourages mothers from attending follow-up appointments in clinics.completely agree to completely disagree. 81%-88% (completely agree) indicated that a home BP monitoring program would be acceptable, 56%-72% (completely agree) reported that it would be appropriate, and 47%-69% (completely agree) reported that it would be feasible at UATH. None of the participants disagreed with the notion that the program was acceptable, appropriate or feasible , its symptoms, normal and abnormal BP parameters, and potential complications. This approach was recognized by the National Partnership for Maternal Safety's Consensus Bundle and the World Health Organization as a critical aspect for improving maternal outcomes postpartum , 16. In A 2019 scoping review found low levels of knowledge among women and healthcare providers regarding cardiovascular complications following HDP in seven countries, including Nigeria . This reAnother strategy identified at the patient level to enhance health behaviour and address financial barriers in program enrolment and retention was the use of financial incentives. Although healthcare providers favoured cash payments, patients interviewed in this study preferred to receive essential items like diapers as incentives. Use of financial incentives has been widely supported in maternal health research as a means of improving health behaviour , 20. HowAt the provider level, educating healthcare workers on the proper diagnosis and management of HDP at both primary and secondary care facilities can improve early referral and treatment . In tertCommunity-level strategies encompass involving traditional and religious leaders as respected figures to disseminate information about health programs. Although these strategies are less well-researched, they may be effective methods for tailoring interventions to the local context. A study conducted in Malawi examined the role of traditional rulers in implementing national policies for maternal, new-born, and child health. The findings revealed that these leaders significantly facilitated the implementation process through community campaigns and encouraging women to deliver at healthcare facilities instead of home with traditional birth attendants . AnotherCumbersome processes within the hospital were identified as obstacles that could be tackled at the system level by adapting, tailoring, and standardizing HDP management protocols in the hospital. Other system-level strategies include increasing access to care through utilizing readily available mobile technology for follow-up appointments or providing community outreach clinics and home visits to patients in remote areas. According to a systematic review conducted in 2016, the use of mobile health interventions in low-income countries has been identified as a promising approach to enhance the accessibility and quality of obstetric healthcare services .The study focused on addressing the critical issue of managing hypertensive disorders of pregnancy (HDP) in Nigeria through the evaluation of a home BP monitoring program employing a comprehensive research approach by utilizing both qualitative and quantitative methods. Through semi-structured interviews, focus group discussions, and the use of the Consolidated Framework for Implementation Research, the study provides in-depth insights into the facilitators and barriers to implementation from various perspectives.The inclusion of a diverse range of participants, such as healthcare workers specializing in relevant fields and patients, strengthens the validity and applicability of the findings. This study contributes to the literature as it identified facilitators and barriers to implementing a home BP monitoring program specific to the Nigerian context. These findings can inform the development of tailored implementation strategies that address the identified barriers and capitalize on the facilitators, thus increasing the likelihood of successful program implementation. Furthermore, the study's quantitative assessment of acceptability, appropriateness, and feasibility provides valuable insights into stakeholders' perceptions and attitudes, enabling informed decision-making and resource allocation for future implementation efforts.Although this was the first qualitative study to assess the facilitators and barriers to the implementation of home BP monitoring program in the management of HDP in Nigeria, some limitations must be acknowledged. Despite using a maximal variability sampling method and additional sampling through a snowball approach to reach thematic saturation, there was a possibility of selection bias. The study also did not include interviews with policy makers, community leaders, or family members who could also play a role in the successful implementation of the program. This study’s findings may not be applicable to secondary care centres or other settings as it was conducted at a single tertiary care centre in the Federal Capital Territory.The current study demonstrated that a home BP monitoring program was considered acceptable, feasible, and appropriate among physicians, nurses, midwives, administrators and patient groups at UATH. We identified contextually-relevant implementation strategies to leverage facilitators and mitigate barriers that will increase the adoption, implementation, and long-term success of a home BP monitoring program for improved maternal cardiovascular outcomes.