Trainees in graduate medical education are affected by burnout at disproportionate rates. Trainees experience tremendous growth in clinical skills and reasoning, however little time is dedicated to metacognition to process their experiences or deliberate identity formation to create individualized definitions of success and wellbeing. The purpose of this study was to understand the perspectives and experiences of trainees who participated in a 6-month, web-based, group coaching program for women residents in training.Better Together Physician Coaching is a six-month, self-paced, online, asynchronous, coaching program with multiple components including live coaching calls, unlimited written coaching, and self-study modules. Semi-structured interviews of seventeen participants of Better Together from twelve GME programs within a single institution in Colorado were conducted from May to June of 2021. All identified as women and had participated in a 6-month coaching program. Both inductive and deductive methods were used in collecting and analyzing the data with an aim to understand learners’ perceptions of the coaching program, including “how and why” the coaching program affected training experiences and wellbeing.Three main themes emerged as benefits to the coaching program from the data: 1) practicing metacognition as a tool for healthy coping 2) building a sense of community, and 3) the value of a customizable experience.Female trainees who participated in a group coaching program expressed that they found value in learning how to cope with stressors through metacognition-focused coaching. They also described that building a community and being able to customize the experience were positive aspects of the program.ClinicalTrials.gov Identifier: NCT05280964. Date of registration: March 15th 2022. Retrospectively registered. URL of trial registry record.The online version contains supplementary material available at 10.1186/s12909-022-03729-5. Burnout adversely affects physicians through higher rates of depression, suicidal ideation and substance abuse than the general population –3. PhysiThe stress of the COVID-19 pandemic has added urgency to address this crisis . ResidenVarious approaches to positively impact trainee wellbeing have been explored, including fostering reflective capacity through writing, and teaching mindful practices and resilient responses to challenging interactions . One proMost previously described coaching interventions use variably trained coaches, and 1:1 in-person sessions which are logistically challenging and costly to incorporate and scale within GME programs –20. A leBuilding upon previously described evidence-based coaching interventions and metacognitive and adult-learning theory-informed coaching tools, two physician life coaches (AM and TF) created Better Together Physician Coaching (BT), a web-based, group-coaching program housed on a members-only website and piloted it among 101 female trainees during 2021 . During Following the 6-month pilot RCT, our team conducted a qualitative study with BT participants to increase understanding of learners’ perceptions, including “how and why” the coaching program affected their experiences and wellbeing.Female-identifying, GME trainees at the University of Colorado (CU), a tertiary care center with academic, county, Veterans Administration, and community healthcare facilities were eligible for inclusion in BT. We used purposive convenience sampling to recruit participants. All residents who completed BT were invited via email to participate in a one-hour interview with one of two interviewers  within 1 month after the BT intervention ended. All interviews were completed by July 27th, 2021. Participation was voluntary and compensated with a $75 gift card.This qualitative study was designed prospectively to complement the quantitative analysis in the overarching sequential mixed methodology used to study the BT intervention. Our quantitative analysis was completed prior to our qualitative analysis . We deciClinicalTrials.gov on 03/15/2022, Identifier: NCT05280964.This was a qualitative descriptive study of resident physician participants in BT using a mixed deductive and inductive analysis  was used to report our findings ..The program created space to practice self-compassion. Some trainees shared:“...that grace that’s granted when you ask yourself … “What would be enough?“ I think just hearing that phrase, “what would be enough for you to say that you’ve done enough for today or to have met this goal and realizing that it didn’t have to be 100% but to still be acceptable to myself” (Participant 4).Throughout the interviews, trainees reported experiences of imposter syndrome in tandem with the experience of perfectionism. Through BT, trainees learned to re-evaluate their expectations for themselves. Many trainees shared that this reframing allowed them to remember that they are growing and learning, as in the following quote:“[Because of the program] I just allowed myself to be imperfect sometimes, and now I … don’t even like saying ‘imperfect’. I don’t like focusing on the things I may have thought were bad before at all … I’ve really shifted my mindset to say anything that maybe had a poor outcome or wasn’t what I wanted is all just a growth period for me” (Participant 5).Relationships in and out of the workplace impacted trainee wellbeing. Trainees shared that challenging work relationships made it harder to learn, make decisions, or have difficult conversations. Participants reported that applying what they learned in the coaching program enabled them to improve both professional and personal relationships:“It helped with my overall life in regards to my relationship with my boyfriend and … with my parents..” (Participant 11).Inductive findings from the interviews revealed the overall theme of community building which included the sub-themes of a sense of community and shared experiences with other participants. While the BT coaching program caters to individual preferences and needs, participants felt that the program built rapport, trust, and belonging. Hearing each other’s experiences offered a sense of validation and normalization that participants had not previously experienced. The trainees described feeling less isolated through these shared experiences. Whether they attended the calls or not, they felt the connection with their peers that gathered virtually and shared a safe space together:“Other people can understand me. [They] were able to vocalize a lot of things that I was thinking” (Participant 9).“We all kind of came together to support each other. You’re not alone. So I think that was one of the huge strengths was that we could comment for each other and support each other too.” (Participant 11).BT was created for trainees to be customizable, accessible, and user-friendly. Participants appreciated this and frequently described that it met their individual needs and expectations. Specifically, they valued: the multiple modalities in which they could engage with the program, the ability to self-pace the coaching program materials, and the option to have anonymity.“...It’s nice being able to have a format that you can ask it at any time and then also having a written response so that you can go back to it if you need to” (Participant 8).The most common aspect of the program that participants enjoyed was the multiple modalities available for coaching. These options made the experience customizable to individual schedules, needs, personalities, and learning styles. Some shared:“I thought they were very brief and to the point, so I could break up stuff into small chunks and I would learn about it. And then I can take some time to either reflect about what they were talking about or just go right to the worksheet” (Participant 7).The participants commented that they appreciated the self-paced, asynchronous, flexible, and anonymous attributes of the program. When discussing time commitment for the program, the participants felt that BT allowed them to engage in which parts made the most sense for them. Many agreed that they could not manage engaging with all modalities simultaneously, but that engaging with those that fit their independent needs was impactful. One participant shared this about the self-study webinars and worksheets:Finally, the option of anonymity was appreciated in the live coaching and written ask-for-coaching modalities. While the live coaching calls were not anonymous for the person being coached, the other participants on the call could remain anonymous.“So, I really liked that they had an anonymous Ask-for-Coaching [forum], or an ability to set up just a one-time meeting with them on their own. I thought that was great” (Participant 9).In this qualitative study, we describe perspectives of participants in a novel web-based, group coaching program that was developed to promote trainee wellness. We found that providing a tool for metacognition (the CTFAR model) supported wellbeing. In addition, participants described a sense of community not otherwise experienced in training. Finally, participants appreciated the multiple modalities for coaching that allowed for a customizable experience accommodating learners with variable schedules and learning preferences.Professional coaching is relatively new in academic medicine and has been shown to improve burnout and wellbeing among physicians and trainees , 19, 20.First, participants reported that learning and applying the CTFAR model for metacognition (thinking about one’s thinking) allowed them to gain insight, choice, and control over their training experience. These findings are consistent with available literature on burnout mitigation , 33, andThis study also provides insight into the potential role for group-coaching as a wellbeing intervention for physician trainees. Group coaching has been shown to support professional identity formation, and management of healthy work/life balance for junior physicians . Our stuFinally, participants reported that the multi-modal and asynchronous structure of BT was a major benefit. Our modalities included live group coaching, anonymous written coaching, and self-study modules, which has not previously been described in the literature. Participants described engaging with BT when they had the availability and interest, which is unique compared to other wellness interventions which take place at a specific time and place, require 1:1 coordination, and may or may not be convenient for a resident schedule. Participants could engage as little or as much in any of the three modalities as they wished, allowing them to use BT based on their individual learning styles, schedules, and preferences. Resident trainees have little agency or autonomy over their schedules and day-to-day workload, and BT offered both brief on-the-spot reflection (using the website resources on-demand) or deeper self-inquiry  depending on the time and needs of the trainee.why these program characteristics work: highlighting the experience of the trainees and demonstrating how coaching tools are useful in their personal and professional lives. Our study adds to the growing body of evidence recognizing coaching as an important tool for promotion of physician wellbeing. Our findings also suggest that the group coaching format was a positive factor which may help to normalize experiences and create community while also mitigating logistical challenges of 1:1 coaching interventions.Some of the facets of BT such as deliberate mindfulness and reflection and fostering of self-compassion have been described as best practices in wellbeing interventions for physicians , 35. OurThis was a single institution study of a coaching intervention for GME trainees who identify as female. Inclusion of women in this program was intentional, as this population is more impacted by burnout. The participants were representative of the demographics of female GME trainees at our institution, which are majority white, heterosexual, and cis-gender. As a result, these findings are not generalizable to trainees at other institutions that differ from our sample.Both AM and TF are internal medicine physicians in the institution in which this study was completed. It is possible that their positions impacted recruitment of participants through a social desirability bias which may have encouraged trainees to volunteer (or not) for this study.Finally, the changing nature of the COVID-19 pandemic may affect the context in which our data can be applied. Also, it is important to note the barriers to participating in BT: some participants reported busy trainee schedules , as an obstacle. Others noted feelings of isolation or lack of accountability in this self-paced program and reported a preference of more structure. Further, some participants shared feedback for the program such as, use of a different technology platform, tagging online material with keywords, having more worksheet examples, and having a structured coaching sign up. It is possible that the additional stress and social isolation for trainees created by the pandemic amplified both the need for and the effect of the coaching program.A physician-led group coaching program teaching metacognition enabled participants to reflect on and reframe beliefs around their work and professional lives to promote wellbeing. The community created by the program allowed for processing of burnout, growth of self-compassion, development of skills to address impostor syndrome and perfectionism, and improvement in relationships, all in a community that normalized the challenges. Having a customizable experience with multiple modalities for participation allowed participants with complex and irregular schedules and varying learning and communication preferences to benefit from the program. Group coaching may offer a meaningful and highly scalable strategy to mitigate burnout, foster community, and provide an accessible and customizable experience for trainee physicians.Additional file 1. Appendix.Additional file 2. Study Protocol.Additional file 3. Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist.


Additionally, the first order kinetics fit well to describe APEs degradation at pH 3.0 to 9.0, Na+, and K+ conditions. Our results suggest the potential application of Asta-loaded Pickering emulsion in food systems as a fortified additive.Astaxanthin loaded Pickering emulsion with zein/sodium alginate (SA) as a stabilizer (named as APEs) was developed, and its structure and stability were characterized. The encapsulation efficiency of astaxanthin (Asta) in APEs was up to 86.7 ± 3.8%, with a mean particle size of 4.763 μm. Freeze-dried APEs showed particles stacked together under scanning electronic microscope; whereas dispersed spherical nanoparticles were observed in APEs dilution under transmission electron microscope images. Confocal laser scanning microscope images indicated that zein particles loaded with Asta were aggregated with SA coating. X-ray diffraction patterns and Fourier transform infrared spectra results showed that intermolecular hydrogen bonding, electrostatic attraction and hydrophobic effect were involved in APEs formation. APEs demonstrated non-Newtonian shear-thinning behavior and fit well to the Cross model. Compared to bare Asta extract, APEs maintained high Asta retention and antioxidant activity when heated from 50 to 10 °C. APEs showed different stability at pH (3.0–11.0) and Na As the people of the world become more aware of health, consumers pay more and more attention to the safety, nutrition and bioavailability of food they intake. In particular, there is a great interest in the development of functional foods fortified with one or more health-promoting ingredients, such as vitamins, minerals, or natural nutraceuticals . Among tAn emulsion-based system is one of the most attractive carriers for environment sensitive or weak bio-accessibility components by constructing different emulsion structures to regulate the release of active compounds under different conditions . In receAs a safe food grade material recognized by Food and Drug Administration (FDA), zein is commonly used as a delivery carrier for hydrophobic active compounds due to its high hydrophobicity . In PickTo our knowledge, the information of Asta-loaded Pickering emulsion stabilized with zein (protein) and SA (polysaccharide) as composite stabilizer is limited. In this study, a Pickering emulsion was developed with zein and SA as surface-active colloidal particles to encapsulate hydrophobic Asta extract derived from Penaeus sinensis by-products. The property of Asta-loaded zein/SA Pickering emulsion (named as APEs) was measured, and the intermolecular interaction of APEs was analyzed. For further potential application of APEs, we focused on its stability under heating, different pH and metal ions treatments. In addition, the degradation kinetics of Asta in APEs at different pH buffers and metal ions solutions were described or discussed. Our results will provide valuable information for preparation of Asta-loaded Pickering emulsion stabilized with zein/SA complex and suggest its potential application conditions.The appearances of PEs (Pickering emulsion stabilized with zein/SA and no Asta loading) and APEs were uniform and stable. Further, a slight red color was observed for APEs due to Asta being entrapped A1,A2. PEUnder scanning electronic microscope (SEM) observation, PE powders were in spherical shapes with smooth surfaces B1. CompaAfter being diluted with distilled water, most of the particles in PEs and APEs were spherical nanoparticles in the transmission electron microscope (TEM) images C1,C2, anConfocal laser scanning microscope (CLSM) is usually used to observe the distribution of oil droplets and proteins in emulsions. In a typical CLSM diagram, the part with red color represents protein stained by fast green, while the green color represents the oil droplets stained by Nile red . As showAsta standard showed strong characteristic peaks at 11.0°, 13.5°, 14.2°, 15.0°, 16.4°, 18.5°, 20.7°, and 25.1° A, sugges−1 (–OH), 3032.39 cm−1 (=C–H stretching), 3000–2800 cm−1 (C–H stretching), 1073.19 cm−1 (telescopic vibration of C–O), and 967.91 cm−1 (C=C stretching). Furthermore, the characteristic bands including 1652.58 cm−1 assigned to C=O stretching vibration band of the six-membered ring and 1551.50 cm−1 related to its conjugated structure [−1 assigned to the amide A (NH–stretching coupled with hydrogen bonding), 3066.36 and 2961.47 cm−1 assigned to the amide B (antisymmetric and symmetric stretching of C–H), 1668.27, 1534.93, and 1253.02 cm−1 associated with the corresponding amide I (C–O stretching vibrations), amide II (C–N stretching vibrations and N–H bending), and amide III (N–H and C–N in-plane bending of bound amide or –CH2 groups of glycine) [The changes of spectral position of the characteristic bands can be reflected in FTIR, which contributes to monitor the intermolecular interactions among the components of complexes ,24. The tructure , were deglycine) ,27.−1 shifted from 3296.72 cm−1 attributed to the stretching vibration of the O–H in hydrogen bonding [−1 shifted from 1668.27 cm−1 associated with the C=O stretching vibrations in electrostatic interaction [−1 in PEs was red-shifted to 2925.58 cm−1 in APEs, proving C–H antisymmetric stretch mode associated with hydrophobic interaction induced by Asta incorporation. Similar results were found in our previous studies [Compared with zein, almost all of characteristic peaks in PEs occurred in shifts. For example, the peak at 3272.51 cm bonding , and theeraction . Obviousη), storage modulus (G′), and the loss modulus (G′′), could provide important information for emulsion stability and droplet–droplet interactions, and therefore suggest their potential applications [The rheological properties of emulsion samples, such as apparent viscosity , the infinite shear viscosity (η∞), and the characteristic time (α) were found to increase in APEs as compared to those in PEs. The rate index (n) was closed to 2/3, which proved that PEs and APEs were water-soluble polymers. The apparent viscosity data of APEs and PEs fit well to the Cross model (R2 > 0.98) (w/v) exhibited non-Newtonian shear-thinning behavior and the flow curves could be well described by the Cross model [As shown in  > 0.98) , suggestss model . In thisG′) and loss modulus (G′′) of APEs were similar at low frequencies. Similar results were found for the PEs. At lower angular frequency, the polymer chains of SA could have more time to relax to a more favorable state through the slip of the entanglement point of SA chains [G′ and G′′ values in APEs or PEs observed at a lower angular frequency. The G′′ values were found to increase for APEs or PEs when the angular frequency increased; whereas decreased G′ values were detected with the increase of angular frequency for APEs or PEs. At higher angular frequencies, the dynamic mechanical loss tangent (G′′/G′) of APEs or PEs aqueous solutions increased dramatically (>1), indicating its predominant viscous behavior. In addition, the tendency of G′′ values of APEs and PEs to approach each other at high frequency suggested the existence of similar microstructures.The viscoelastic behaviors of APEs and PEs at angular frequencies ranging from 100 to 0.1 rad/s were evaluated by undertaking dynamic oscillatory measurements. As was shown in A chains , therebyA chains . This coSmaller droplets were observed to aggregate in APEs with temperature increases A. The inThe addition of hydrophobic Asta in PEs system contributed to adsorb more zein molecules and to form a denser cross-linking structure with SA (as shown in p < 0.05)  C, becausp < 0.05). It was noted that the heated APEs at 50 °C to 100 °C showed a stable ability on scavenging DPPH and hydroxyl radicals (p > 0.05)  D,E. The +, K+, Ca2+, Cu2+, and Fe2+), APEs demonstrated a different visual appearance  of polysaccharide–proteins ,39. In tpearance A,B. Whenpearance A. A simi+ or K+ conditions. Alkali metal ions have hydration, which can reduce the electrostatic interaction between alkali metal ions and the surface of latex particles. Therefore, the aggregation degree of latex particles is reduced, resulting in higher stability [2+ or Cu2+ addition  of SA to form ionic bridges between different chains [2+ is the “egg box model”. In this model, the G-blocks of SA can form three-dimensional arranged cavities, in which Ca2+ ions could crosslink the anionic alginate, like eggs in cardboard egg boxes, and finally fabricate an anionic biopolymer network [2+ induced alginate gelation [2+ to crosslink zein and SA [2+ to zein-propylene glycol alginate resulted in a more compact alginate gel [2+ or Cu2+, the binding capacity of Fe2+ to SA molecules is weak, and it is not easy to form an integral gel network [2+ ions indicated increases of droplet–droplet interaction, which might be ascribed to the total number of anionic groups in SA chains dramatically decreasing in the presence of Fe2+ ions. As a result, some zein-coated oil droplets were released from SA network layer and further coalesced through hydrophobic interaction.As for the coexisting stability with metal ions, APEs remained a uniform dispersion in either Natability . Howeveraddition B. In thet chains . The mos network . Analogogelation . The affgelation . Similarn and SA . The binnate gel . Compare network ,46. The p < 0.05). Zein particles were to be expected to highly positive charged at pH ranged from 3.0 to 5.0 due to the isoelectric point of zein is around pH 6.2 [To investigate the stability mechanism of APEs under different pH values and metal ions, the changes of zeta-potential and PDI of APEs were further determined in d pH 6.2 . IncreaspI, the alginate and zein molecules were negatively charged. Consequently, the ability of SA layer to wrap zein particles decreased, resulting in the release of some zein particles from the SA network structure and further aggregation through hydrophobicity . Therefore, the electrostatic interaction between the positive charge region of zein and negatively charged SA was weakened, and finally resulted in droplets precipitation (insert photos in 2+ conditions (2+ and negatively charged SA molecules.In the presence of Na of APEs D. Howevenditions  might be+ and K+ conditions (ambient temperature of 25 °C), the total Asta retention of APEs was further measured in To evaluate the storage stability of APEs at pH 3.0 to 9.0, NaCompared to the bare Asta extract, APEs had higher total Asta retention rate, though the Asta degradation of APEs increased with incubation time increases. Furthermore, APEs showed different properties for Asta degradation under the tested pH values A–D. UndepI 6.2 [pI = 6.2) could induce zein particles aggregation to a certain extent, as well as zein coated droplets aggregated at alkaline condition through hydrophobicity. Obviously, the aggregation of zein coated particles was not conducive to the stability of Asta during APEs storage.The disassociation of -COOH groups of SA responded to pH change will determine its emulsifying ability . In thispI 6.2 , the dropI 6.2 . In addi+ or K+ conditions  than those at pH 9.0, Na+ and K+ conditions (>0.60) indicated relatively higher stability of APEs under acidic or neutral environments.According to the nditions . Similar1/2t, it could be seen that the retention rate of Asta at pH 3.0 (2.070 ± 0.059 day) or pH 7.0 (2.200 ± 0.286 day) was more than three times higher as compared to that at pH 9.0 (0.681 ± 0.033 day). Under extreme alkalis conditions, the cis/trans isomerization of Asta double bonds, functional group changes and de-esterification [P. rhodozyma showed the highest stability at pH 4 [By comparing the fication  could befication , which w at pH 4 . Our resFreeze-dried Asta extracts (30.94% of free Asta and 69.06% of Asta esters) derived from Penaeus sinensis by-products were prepared following a protocol performed in our laboratory ,56. Freev/v) under stirring. After uniform blending, the mixture was evaporated under vacuum (40 °C) to remove off ethanol completely, followed by deionized water addition to restore original volume, thus fabricating Asta loaded zein colloid particles. The Asta-loaded zein colloid was mixed with 2 wt% SA solution at a ratio of 1:1 (v/v). After completely stirring, the pH of mixture was adjusted to 4.0 using 5 wt% of citric acid solution, homogenized for 2 min under 12,000 rpm, and then kept at 4 °C for 36 h in dark. The generated sediments were collected and lyophilized . The freeze-dried APEs were dissolved in deionized water at 10:1 (m/v) for further analysis. Meanwhile, the Pickering emulsion without Asta loading was prepared under the same conditions, named as PEs.APEs were prepared referenced a facile anti-solvent procedure with further modifications . BrieflyThe encapsulation efficiency (EE) of Asta in APEs was defined as the total amount of Asta as compared to the amount of surface Asta determined, and expressed in a percentage.v/v), treated under sonication  in ice-water bath for 20 min, and centrifuged at 3000× g for 5 min at 4 °C . The supernatant was collected and measured the absorbance at 477 nm by a 1510 micro-plate reader . For surface Asta extraction, the freeze-dried APEs powders were directly vortexed with the organic solvent for 1 min instead of sonication treatment. A calibration curve of Asta was obtained by measuring a series Asta standard concentration ranging from 0 to 10 μg/mL at 477 nm (R2 = 0.9926). The Asta content of extraction was calculated as described in Equation (2).Total Asta of APEs was extracted as follows: 20 mg of freeze-dried APEs were blended with 2 mL of organic solvent  before and after treatments.Asta stability of APEs under different conditions was expressed as Asta retention rate as calculated in Equation (3).All of samples were diluted 30 times with deionized water, and agitated well to prevent multiple scattering effects. Then, the mean particle diameter (z-average), particle charge  and PDI of samples were determined using Zeta-sizer Nano-ZS90  with a detection range from 0.3 nm to 5 μm. All measurements were performed in triplicate at 25 °C.The emulsion was photographed after preparation or treated under different conditions. Emulsion sample (50 μL) was dropped on a clear glass slide with a coverslip and observed under an optical microscope  magnified by a 40× objective lens.The microscopic surface properties of freeze-dried APEs and PEs were observed by SEM . APEs and PEs were diluted with distilled water. Then, 2 μL of emulsions were dripped on copper net and dried naturally. After negatively stained with 2% phosphotungstic acid for 15 min and remove off extra liquid, the morphology of diluted emulsion was observed under TEM .v/v). The stained sample was placed on a concave confocal microscope slide and observed images using a 20× magnification lens at excitation wavelength of 633 nm for fast green FCF and 488 nm for Nile Red, respectively.The microstructure of APEs was observed by confocal laser scanning microscopy (LECIA TCS SP5) referenced with the method of Liang et al. (2020) , with slη) and shear stress (τ) were recorded as a function of shear rate (γ) from 0.1 to 100 (s−1). The experimental data of APEs flow curves were analyzed using the Cross model. Additionally, PEs were used for comparison.η, 0η and ∞η represent the viscosity (Pa·s) at any specific shear rate (γ), the zero-shear viscosity, and the infinite shear viscosity, respectively. α and n represent the characteristic time (s) and the rate index, respectively. For dynamic viscoelastic measurements, the angular frequency (ω) was set from 0.1 to 100 rad/s within the linear viscoelastic range of samples. The storage modulus (G′) and loss modulus (G′′) of samples were continuously determined under 1% fixed strain during the test.The rheological property of APEs was evaluated according to the method described by Liang et al. (2020)  at 25 °CXRD patter of freeze-dried APEs was determined using an X-ray diffractometer  equipped with Cu Kα radiation monochromatic filter  in the range of 5–90° at a scanning rate of 0.02°/s. Meanwhile, freeze dried PEs, zein and Asta standard were used for comparisons.−1 wavelength at a resolution of 4 cm−1 and 32 scans per minute. FTIR spectra of PEs, zein and Asta were used for comparisons.Freeze-dried APEs were grinded with dried KBr powders, and recorded on a Nicolet 670 spectrometer  from 400 to 4000 cmv/v) to extract the total Asta as described in The solution of APEs (10 mg/mL in distilled water) was heated at 50 °C, 60 °C, 70 °C, 80 °C, 90 °C and 100 °C for 30 min in water bath, respectively. Then, 1 mL of thermal treated APEs were blended with 1.3 mL of organic solvent , respectively. After blending, the visual appearances of the samples were recorded with photographs. Meanwhile, the zeta potential and PDI of samples after diluted suitable times were determined.APEs’ solutions (10 mg/mL in distilled water) were blended with the same volume of 0.2 mol/L phosphate buffer  or the same volume of 100 mM metal ions ; r represented the Asta retention rate at different time t (%); k represented the constant of degradation rate; t represented time (day). A plot of Asta retention rate (r − r0) versus time was constructed. The slope of the straight line (k) and the correlation coefficient (R) were obtained from the trend line of the plot.Asta degradation in APEs under different pH and metal ions conditions were analyzed using zero-, first- and second order models referenced the method described by Sun, Ma, Ye, Kakuda and Meng (2010) .(6)Zerok value and correlation coefficient (R) in first order model were determined through a plot of ln (r/r0) versus t in Equation (9).In first-order model, based on Equations (7) and (8), was obtained by taking logarithms on both sides, and then rearranged into Equation (9). The t in Equation (10) was constructed to obtain the k value and correlation coefficient (R).In second-order model, a plot of ® software 19.0  to present significant differences among the mean values at the p ≤ 0.05Data were expressed as mean ± standard deviation. One-way variance (ANOVA) and Tukey’s test were analyzed using SPSS+ and K+ conditions. APEs demonstrated higher Asta retention during storage at pH 3.0 to 7.0, and dramatically degraded under Alkaline or Na+ and K+ conditions when stored up to 6 days at ambient temperature. The SA network layer outside zein particles should provide an important protective structure for Asta retention of APEs under acidic and neutral conditions. Our results will provide important information for Asta loaded Pickering emulsion stabilized with zein and SA, and suggest potential application of APEs as an antioxidant additive in mild heating foods. However, further studies should be conducted, such as the storage stability of lyophilized APEs, appropriate addition and sensory attributes to foods, and adsorption properties in vivo in actual food products.The prepared APEs showed a double cross-linked structure with a SA layer outside zein particles. After heat treatment at 50 °C to 100 °C for 30 min, APEs still maintained high antioxidant activity on scavenging DPPH and hydroxyl radicals. Homogenous emulsions were observed for APEs under pH 3.0 to 7.0, Na


Mage = 15.27, SDage = 1.60), with 53.1% British and 64.1% non-White. Path analysis revealed that only perceptions of inclusivity for own social identity group  at T1 were associated with T2 STEM youth program belonging. There was a significant indirect effect of T1 perceptions of inclusivity for one’s own social identity groups on T3 perceptions of program career preparation via T2 program belonging. This study highlights that, over time, perceptions of inclusivity around youth’s own social identity groups  are related to a sense of youth program belonging, which in turn is later associated with perceptions of program career preparation.Little research has examined the associations between perceived inclusivity within informal science learning sites, youth program belonging and perceptions of program career preparation. This study explored relations between these factors at three timepoints . Participants were a diverse sample of 209 adolescents participating in STEM youth programs within informal science learning sites situated in the United States and United Kingdom (70% females:  Globally, there is a substantial shortage of people entering the Science, Technology, Engineering and Math (STEM) workforce, with the number of skilled STEM graduates not meeting the demand for STEM workers  had an indirect effect on later career aspirations in math among 12th grade adolescents  rather than a more generic sense that ‘all’ are welcome. This proposition is supported by Social Identity Theory , and specific inclusivity. Specific inclusivity can be divided into two dimensions: inclusivity for youth’s own social identity groups  and inclusivity for other social identity groups .Little research has examined the associations between perceived inclusivity within informal science learning sites, youth program belonging and perceptions of program career preparation. This study addresses two research questions. First, drawing on Social Cognitive Career Theory  were included in the study.n = 209) completed the follow-up survey 3 months after the program started (T2). Participants were aged from 10 to 20 years old at T1 assessment ; 8 participants did not report their age. The sample (69.9% girls and 30.1% boys) was racially and ethnically diverse, with 111 participants (53.1%) from the UK  and 98 participants (46.9%) from the US . Three (1.4%) participants did not report their race or ethnicity. Females and the majority of the non-White ethnic minoritized groups were considered as underrepresented in STEM in the UK . 69.8% of participants demonstrated interests in STEM-related career orientations. Specifically, 59.8% of participants reported Participants were recruited from six informal science learning sites (three from the US and three from the UK). The UK sites include a biomedical and cell biology science education center (37.3%), a science museum (10.5%), and a medical heritage museum (4.3%). The US sites included an aquarium (23.9%), a zoo (14.8%), and a children’s museum (8.1%). Two participants did not report at which site they participated in the STEM education program. Young people serve as youth educators and are trained to interact with visitors, including welcoming visitors to the sites, engaging them in STEM issues and concepts centered around exhibits or animals and facilitating learning at special events or activities at the sites . All the sites have the mission to be inclusive and aim to recruit diverse youth and engage them in STEM to inspire future generations of STEM workers. In addition to increasing young people’s STEM knowledge and equipping them with key soft skills  they provide career advice and support, with the goal of empowering their pursuit of a STEM career and fueling their motivation for STEM as future area of work . None of the youth programs had any time limit, and participants could participate as long as they wish.Participants were from an Institutional Review Board-approved longitudinal study conducted by a joint research team from the University of Exeter and North Carolina State University. Parents were provided with information about the study prior to their children starting the program. After receiving consent from the participants’ parents, the research team sent a Qualtrics survey to the participants’ email. For those completing the survey, low-value electronic gift cards were sent out as an expression of gratitude.The longitudinal study was conducted across different time points. The first time point (T1) was the beginning of the program, and the research teams sent the survey out before program activities commenced, but while participants were completing training or orientation. All participants completed the survey within the first month of their program. The second time point (T2) was around 3 months after the start of the program. The third time point (T3) was twelve months after joining the program. The surveys sent at T1 and T3 were the same, and the survey at T2 was different from T1 and T3. The T2 measures were brief and meant to check in on how they were feeling about their participation in the program but did not include the same items at T1 and T3. Participants were asked to complete a smaller bank of measures at T2, focused explicitly on feelings of belonging. This decision was made to reduce participant burden.own ethnic/cultural group and other ethnic/cultural groups) on a six-point scale . Two items assessing the perceptions of inclusivity related to ethnic cultural groups were used: “How welcoming or not welcoming is X [the site you participated in STEM education program] for your ethnic/cultural group?” and “How welcoming or not welcoming is X [the site you participated in STEM education program] for other ethnic/cultural group?”. There are two items assessing the perceptions of inclusivity related to gender: “How welcoming or not welcoming is X [the site you participated in STEM education program] for girls?” and “How welcoming or not welcoming is X [the site you participated in STEM education program] for boys?” The total score of the four items is considered as general inclusivity .Four items assessing inclusivity were adapted from previous research . The score of inclusivity for other social identity groups was calculated by the total score of the item assessing inclusivity for other gender and the item assessing the inclusivity for other ethnic groups . Inclusivity was not assessed at T2.For the specific inclusivity, the items related to gender were recoded according to participants’ gender. The score of inclusivity for own social identity groups was calculated by the total score of the item assessing inclusivity for own ethnic/cultural group and the item assessing inclusivity for own gender (αT2 = 0.94). The eight items measured participants’ belonging within their program and their comfort with and connection to their leader and peers in the program  based on a 10-point scale . Belonging was assessed at T2.Eight items adapted from the institutional belonging scale . This item was assessed at T1 and T3, but not T2.One item  was used to ask participants to rate their program in terms of their future career preparation on a 6-point scale (1 = n = 110) answered all items across three time points. Around 36% of participants had missing data at one-time point and around 6% of participants had missing data at two time points.Missing data analysis was conducted in STATA 17. First, a frequency analysis was conducted to confirm the percentage of missingness for each variable , followed by further descriptive analysis to identify the patterns of missing data (Table S2). The mean percentage of missingness at T1, T2, and T3 is 4.8%, 18.1%, and 33.4%, respectively. As shown in Table S2, only around 53% of participants . For variables at T2 and T3, t-tests were run to investigate if the missingness depended on variables at T1. Results are presented in the supplementary materials (Table S3 and Table S4). In summary, missingness at T1 was not associated with gender, ethnicity, and site. For T2, although missingness did not depend on the variables at T1, the missingness was associated with country and site. As for T3, similar to T2, missingness was not associated with the variables at T1, but the missingness was associated with some demographic variables .From the missing data analysis, it can be concluded that the distribution of the data is not normal (Table S1), and the missingness of the data is not missing completely at random (MCAR). The missingness is not ignorable and should be addressed for analyses.MPLUS 8.4  estimation was conducted to examine the hypotheses using MPLUS 8.4 , the values of root mean square error of approximation , standardised root mean square residual , comparative fit index  and Tucker-Lewis index  following standard recommendations  on T3 perceived career preparation. Hypothesis 2 would be supported if there was a significant coefficient from T1 inclusivity  to T2 program belonging. Hypothesis 3 would be supported if there was a significant path from T2 belonging to T3 perceived career preparation. Hypothesis 4 would be supported if there is a significant indirect effect of T1 inclusivity on T3 perceived career preparation via T2 belonging.χ2(9) = 24.03, CFI = 0.82, TLI = 0.64, RMSEA = 0.09, SRMR = 0.06. Because the fit was not acceptable, the results were not interpreted further.The model fit of the path model was not acceptable (computed using the mean of 10 imputed databases): χ2(15) = 32.98, CFI = 0.95, TLI = 0.90, RMSEA = 0.08, SRMR = 0.06.The model fit of the path model for specific inclusivity Fig.  was acceThe correlation matrix can be found in Table β = 0.08, SE = 0.04, p = 0.04, supporting Hypothesis 4. There was a significant indirect effect from perceptions of program career preparation at T1 on perceptions of program career preparation at T3 through program belonging, β = 0.07, SE = 0.03, p = 0.04.The results can be seen in Fig. Despite the importance of social environment on youth career development highlighted by Social Cognitive Career Theory  when they began their informal program (T1) were positively associated with a sense of STEM youth program belonging (T2), and this belonging was related to participants’ perceptions of how well the program prepared them for their future career (T3). Findings suggest that only inclusivity for one’s own social identity groups at the beginning of the program was related to participants’ perceptions of program career preparation after one year via belonging, but this mediation pathway did not hold for the inclusivity for other social identity groups. The model for general inclusivity  was a poor fit for the data, indicating that specific types of inclusivity may be more central than general inclusivity at informal science learning sites.The finding of a positive association between perceptions of site inclusivity and program belonging supports Social Cognitive Theory Bandura, , since iTwo conceptualizations of inclusivity were explored. First, there was a general inclusivity conceptualization in line with previous theory  perception of site inclusivity than when they were first beginning a program at the site, as they will have a lot more observations on which to base their perceptions by T3. This may explain why inclusivity was not related at T1 and T3. Future research should examine the psychometric properties of site inclusivity, for example, testing the factor structure of inclusivity. In the current study, an existing measure of inclusivity  were associated with T2 belonging . This finding should be interpreted in the context of a STEM youth program that aims to equip youth with the necessary knowledge and skills for education and career development. If participants found the program helpful in career development, they could be more likely to have a higher level of program belonging. This suggests that the association between belonging and career development may be bi-directional. This should be tested in future studies using a more rigorous cross-lagged panel design with additional time points.The findings further extend the formal science education literature by showing the association between inclusivity and perceptions of career preparation within informal science learning contexts . Cross-lagged panel analysis could be conducted to provide longitudinal evidence of the association between belonging and career development. Future studies should use repeated measures to further test this association. Additionally, future research should explore additional factors that may play a role in these associations. Given the design, this study is not a longitudinal study. It is critical to examine the change in the variables over time to establish longitudinal evidence, which while not the focus of the present work, can be an important future direction.Research has not examined some potentially important environmental factors in career preparation during the critical developmental period of adolescence. These factors include youth perceptions of inclusivity within an informal science learning environment and the psychological sense of belonging to a youth program within such an environment. This is despite the fact that Social Cognitive Career Theory (Lent et al., Supplementary Tables


Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure, fatal infectious complications have been reported. However, adequate preventive strategies have not been determined. We aimed to investigate the effect of chlorhexidine mouthrinse on the prevention of microbial contamination during EBUS-TBNA.In this single-center, assessor-blinded, parallel-group randomized controlled trial, we randomly assigned adult participants undergoing EBUS-TBNA using a convex probe to gargle for 1 minute with 100 mL of 0.12% chlorhexidine gluconate before EBUS-TBNA or to receive usual care (no chlorhexidine mouthrinse). Aspiration needle wash samples were collected immediately after completion of EBUS-TBNA by instilling sterile saline into the used needle. The primary outcome was colony forming unit (CFU) counts per mL of needle wash samples in aerobic cultures. Secondary outcomes were CFU counts per mL of needle wash samples in anaerobic cultures, fever within 24 hours after EBUS-TBNA, and infectious complications within 4 weeks after EBUS-TBNA.n = 51) or usual care (n = 55). The median CFU counts of needle wash samples in aerobic cultures were not significantly different in the two groups . There were no significant differences between the groups regarding secondary outcomes, including median CFU counts in anaerobic cultures (P = 0.41) and fever within 24 hours after EBUS-TBNA . There were no infectious complications within 4 weeks in both groups.From January 2021 to June 2021, 106 patients received either chlorhexidine mouthrinse (Chlorhexidine mouthrinse did not reduce CFU counts in needle wash samples of EBUS-TBNA.NCT04718922. Registered on 22/01/2021.ClinicalTrials.gov, The online version contains supplementary material available at 10.1186/s12885-022-10442-5. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the standard procedure for the diagnosis of mediastinal and hilar lymphadenopathy as well as the staging of lung cancer . EBUS-TBDespite concerns about serious infectious complications associated with EBUS-TBNA, there are no established strategies to prevent such complications following this procedure. We hypothesized that oral hygiene care is important in preventing infectious complications during the procedure because previous studies have suggested that oropharyngeal commensal bacteria can contaminate the working channel of an EBUS bronchoscope and thus can be inoculated into the target lesion by a contaminated aspiration needle , 14. MorThis single-center, assessor-blinded, parallel-group RCT was performed from January 2021 to June 2021 at Seoul National University Hospital in South Korea. Adults (≥19 years old) who were hospitalized for EBUS-TBNA using a convex probe were randomly assigned to either the chlorhexidine mouthrinse group or the control group at a 1:1 ratio. Simple randomization was performed by a web-based randomization system developed and administered by the Medical Research Collaborating Center of the Seoul National University Hospital. A more detailed study protocol was published elsewhere . Key excA detailed description of the procedures was published previously . In brieAn EBUS bronchoscope with a convex probe  was used for EBUS-TBNA and was inserted orally. Following mediastinal evaluation using EBUS-TBNA was performed at the designated lymph nodes (LNs) or masses with a dedicated 22-gauge aspiration needle . At the bronchoscopist’s discretion, replacement of the aspiration needle with a new one, transesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA), or rapid on-site evaluation of aspirates could be performed. Prescription of prophylactic antibiotics after EBUS-TBNA was also allowed as determined by the bronchoscopist or care provider.As soon as EBUS-TBNA was completed, a needle wash sample was obtained by injecting 5 mL of sterile saline into the used needle. This sampling method has been described previously , 15. If The primary outcome was colony forming unit (CFU) counts per milliliter of aspiration needle wash samples in aerobic culture. The secondary outcomes were CFU counts per milliliter of the needle wash samples in anaerobic culture, fever within 24 hours following EBUS-TBNA, and infectious complications within 4 weeks after EBUS-TBNA. If two or more needle wash samples were present in a patient, the average of CFU counts on each agar plate was considered as an outcome measure. Fever was defined as a body temperature of 37.8 °C or higher. Infectious complications were defined as mediastinal adenitis, mediastinal abscess, mediastinitis, pneumonia, lung abscess, empyema, pericarditis, and sepsis.The sample size was estimated using the results obtained from an RCT of 100 patients who underwent gastroscopy with or without chlorhexidine mouthrinse  because U test. We also estimated 95% CIs for median differences of CFU counts between the groups based on 1000 bootstrap replications and the percent method [P values of less than 0.05 were considered statistically significant. All analyses were performed with R version 4.1.1.Data were analyzed according to the randomized allocation, excluding patients who withdrew consent or did not undergo EBUS-TBNA. Categorical variables are presented as counts and percentages. Continuous variables are presented as means with SD or median with interquartile range. CFU counts were analyzed by Mann–Whitney t method . SecondaOf 128 patients assessed for eligibility, 112 were randomly assigned to either the chlorhexidine mouthrinse group or the usual care group. After randomization and allocation, six patients were excluded from the study for reasons of withdrawal of informed consent in one, cancellation of scheduled EBUS following successful endobronchial biopsy in four, and no targeting lesions found by EBUS or EUS-B in one . The proportion of patients with LNs with heterogeneous echogenicity on ultrasound was not significantly different between the two groups . More than 80% of the patients underwent conventional flexible bronchoscopy before EBUS-TBNA and less than 10% underwent EUS-B-FNA. In the majority of patients, the number of insertions of EBUS bronchoscope was one and the number of aspiration needles used per patient was one. About one-third of patients were prescribed prophylactic antibiotics after EBUS-TBNA.Table P = 0.01). The proportion of those with heterogeneous echogenicity on ultrasound was significantly higher in the chlorhexidine mouthrinse group . Cytopathology examinations revealed that 24.5 and 17.9% of the LNs or masses were malignant in the chlorhexidine group and usual care group, respectively. The diagnostic accuracy of EBUS-TBNA in detecting nodal metastasis was 91%  and fever within 24 h after EBUS-TBNA . Infectious complications within 4 weeks after EBUS-TBNA did not occur during the course of this study. We performed a sensitivity analysis of 95 patients who underwent EBUS-TBNA with one aspiration needle, whereby the median CFU counts in aerobic and anaerobic culture were not different between the two groups . Table Streptococcus was the most common in both groups.Oropharyngeal commensal bacteria were identified in 20 39.2%) of 51 patients in the chlorhexidine mouthrinse group and in 27 (49.1%) of 55 patients in the usual care group, which was not significantly different (9.2% of 5In this RCT investigating the effect of chlorhexidine mouthrinse on the prevention of microbial contamination during EBUS-TBNA, chlorhexidine mouthrinse did not reduce CFU counts of aspiration needle wash samples. Results of sensitivity and subgroup analyses were consistent with this finding. The incidence of fever within 24 hours following EBUS-TBNA was not different between the groups. Infectious complications within 4 weeks after the procedure were not observed.Previous studies have suggested that postprocedural infection is attributed to contamination of aspiration needles with oropharyngeal commensal bacteria during EBUS-TBNA , 19. ConP = 0.03; Table Potential risk factors for infectious complication after EBUS-TBNA include target lesions with necrotic, cystic, or avascular features and the performance of EUS-B-FNA , 19, 21.Streptococcus was the most abundant in both groups. Oropharyngeal commensal bacteria such as the genera Streptococcus, Actinomyces, Gemella, and Prevotella were frequently reported as pathogens, and genus Streptococcus was identified as the pathogen in 14 of 29 cases of mediastinal infectious complications after EBUS-TBNA [Although infectious complications were not observed in this study, we found that bacteria identified from needle wash samples were consistent with common causative bacteria of infectious complications after EBUS-TBNA. In this study, oropharyngeal commensal bacteria were found in 39.2% of patients in the chlorhexidine mouthrinse group and in 49.1% of patients in the usual care group, and the genus Bacteria that are not generally considered oropharyngeal commensal bacteria were identified in half of the patients in both groups. This could be explained in three ways. First, they could be transitory species in the oropharynx. Second, they could shift from transitory species to colonizers in the oropharynx according to oral health and immune status . As immuOur study had several limitations. First, as the sample size was estimated on the basis of an RCT in patients undergoing gastroscopy with or without chlorhexidine mouthrinse , it was In conclusion, chlorhexidine mouthrinse did not reduce CFU counts of needle wash samples of EBUS-TBNA, nor did it affect the incidence of fever following EBUS-TBNA. Large-scale studies are needed to further validate these findings.Additional file 1.


The process of cultural adaptation of internet-based cognitive behavioral therapy (ICBT) programs for bulimia nervosa (BN) have rarely been reported despite the potential influence of cultural adaptation of psychosocial interventions on therapeutic response.This study aimed to illustrate development process of an ICBT program for Japanese women with bulimia nervosa (BN).A mixed methods approach was used to assess cultural adaptation of the prototype of an original ICBT program by using the Cultural Relevance Questionnaire (CRQ). Five women with BN and seven clinicians were interviewed using the CRQ.Quantitative analyses were conducted to assess cultural adaptation of the prototype of the program and participants rated cultural adaptation as high. A qualitative analysis of the mixed method supported the culturally sensitive changes implemented.The results of this study show that a series of processes can make ICBT programs more culturally adapted. The effectiveness of cognitive behavioral therapy (CBT) for bulimia nervosa (BN) has been demonstrated in multiple clinical trials conducted mainly in Western countries . CBT is The process of cultural adaptation of CBT treatment manuals or protocols have been rarely documented, including for CBT for BN. A preliminary single-arm clinical trial conducted in Japan suggested the feasibility of CBT for women with BN . The resWhen providing CBT, differences between Japanese and Western cultures cannot be ignored. For example, Japanese culture tends to avoid assertions in communication and more ambiguous expressions are preferred . This inSeveral frameworks have been developed for the cultural adaptation of psychotherapies. Existing treatment manuals/protocols are generally used to develop intervention programs for communities with certain cultural characteristics –18. ThisThe Ecological Validity Model (EVM) is often used when cultural adaptations for CBT in a cultural community have been developed . PreviouThis paper describes the process of developing Internet-based CBT (ICBT) for BN adapted to Japanese culture. The development of the ICBT program was based on the FMAP approach. We evaluated aspects of EVM when reviewing the prototype of the ICBT program.The following three steps were used to develop an ICBT program that is culturally adapted for Japanese women: Phase (a) Develop a prototype of the original ICBT program; Phase (b) Verify the ecological validity of the prototype; Phase (c) Improve the ICBT program. The study describes the above steps and shows the process of developing the culturally adapted ICBT program.The first and second authors (SH and KM) designed this ICBT program so that the number of characters, linguistic expressions, concepts, symbols, metaphors, and dietary content would be familiar to Japanese patients. The team has experience of building ICBT programs for other mental disorders—anorexia nervosa  and obseThe treatment modules were influenced by previous studies included the following: psychoeducation and case-formulation –29; relaAs an adaptation/culturally relevant example, a linguistic form is chosen that is natural for Japanese and involves vague nuances in a tone that avoids assertions. For example, “In modern society, even if one leads a careful life in terms of diet, the nutritional value tends to be biased.” In another example, in the case of positive feedback, we used gratitude such as “good work (otsukaresama in Japanese)” and “You did your best (ganbarimashitane in Japanese)” rather than a direct emphasis on the actions they took. Regarding meals, Japanese convenience stores have introduced Japanese recipes. These can be followed even by people who are not good at cooking. Consequently, they do not need to hesitate about what to eat. In addition, in establishing eating habits, we introduce recipes using natto and udon, which are unique to Japan.We recruited women with BN who were University of Fukui Hospital patients as participants. They were diagnosed with BN by psychiatrists at the Hospital. They met the current or past diagnostic classification of BN based on the Diagnostic and Statistical Manual of Mental Disorders, 5th edition . We alsoTo assess the ecological validity of the ICBT program, we used the Cultural Relevance Questionnaire (CRQ), which is a self-report scale used to rate the cultural adaptation of treatment programs . CRQ canThe information given by participants as feedback regarding the ICBT program was analyzed, discussed, and incorporated into the second version of the ICBT program by the first and second author (SH and KM).We used SPSS Version 26  for statistical analyses. First, we reported descriptive statistics on the CRQ to assess the cultural fit of the entire ICBT program and each of its modules. Next, we conducted a qualitative analysis of the comments/opinions and impressions about the ICBT program. We responded to all comments from participants by discussing the revisions made.The ICBT program consisted of 12 treatment module and 1 assessment interview module See . This ICThe mean age of the five women with BN who participated in this study was 30.6 (SD = 11.4) years. Four had comorbid mental disorders . All participants with BN received pharmacotherapy . The clinicians included four psychiatrists, two clinical psychologists, and a nurse teacher with a total mean age of 36.1 (SD = 7.5) years. See For cultural adaptation measured by CRQ, all criteria  were at a high level in both groups. The means of functional, conceptual equivalence and linguistic equivalence for the entire module are as follows: 4.60 (SD = 0.37), 4.60 (SD = 0.55), 4.80 (SD = 0.45) for women with BN respectively; 4.76 (SD = 0.25), 4.86 (SD = 0.38), 4.43 (SD = 0.53) for clinicians. The mean and standard deviation of the CRQ suggest that the ICBT program is culturally fit enough to be accepted by women with BN and clinicians in Japan. There was no significant difference in total CRQ scores between the groups. See The main feedback from the participants was that some sentences were difficult to understand. Thus, we have changed some of the jargon in the prototype of this program to more general terms, in response to comments from participants. For example, “progressive muscle relaxation” was changed to “a method of loosening and relaxing muscles,” and “rumination” was changed to “rumination .” In addition, for the treatment model and cognitive behavioral techniques that were said to be “difficult to understand,” we implemented some videos or photographs of psychoeducation on the module in the ICBT program. The objective of this study was to develop an original ICBT program for the effective treatment of BN in Japan through a framework of cultural adaptation. An internet-based treatment program was constructed for women with BN to deliver evidence-proven cognitive-behavioral techniques. Five women with BN and seven clinicians evaluated the ICBT program prototype for cultural suitability. Participants provided feedback indicating that the cultural adaptation was consistently high and partially difficult to express linguistically. The developers made various improvements to the program in response to this feedback.This study created a prototype of the ICBT program, in which linguistic expressions, including Japanese food in the diet, and daily life including eating habits, were adapted to Japanese culture. The developers paid attention to the ecological validity of the ICBT program . The resn = 4 of 5) commented, “This is an appropriate amount of information.” Furthermore, as three out of five patients with BN commented “If there is more information than this, it is too much information.” Thus, we retained the amount of information as is. ICBT for BN is reported to have a relatively high dropout rate . Previous research reported that the average length of the written text for the session was 1,711–3,000 words , 49. Theout rate , 51. Theout rate . As showout rate .First, due to the small number of participants in this study, our findings may not represent the entire population with BN. Of the five patients in this study, four had relevant mental/addiction comorbidities, and all participants with BN received pharmacotherapy. Thus, the participants might be women with relatively serious BN cooperated. Another study is probably needed to determine whether our ICBT program is culturally adaptable to populations whose symptoms are not as severe. Further research is recommended to understand better whether cultural adaptation is beneficial for patients with BN. Second, the CRQ Japanese version as the assessment tool of cultural adaptation was not standardized. Third, this study did not include data on participants who had been exposed to the intervention, making it impossible to assess the effectiveness of the culturally adaptive ICBT program developed. In the near future, we will investigate the feasibility and effectiveness of our ICBT program in a randomized controlled trial.In conclusion, this study illustrates via a series of processes the development of a culturally adapted ICBT program. The ICBT program may be adequately adapted for Japanese patients. However, more research is needed on the feasibility and effectiveness of this program by conducting a pilot study, preferably as a prospective randomized controlled trial.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The protocol of this phase was approved by the Research Ethics Committee of the University of Fukui in November 2021 (No. 20210136). The patients/participants provided their written informed consent to participate in this study.Conceptualization and methodology: SH, KM, and GA. Formal analysis and funding acquisition: SH. Investigation: SH, KM, TI, RS, YH, HK, and YM. Project administration and writing—original draft: SH and KM. Supervision: YM and GA. Writing—review and editing: SH, KM, TI, RS, YH, HK, YM, and GA. All authors contributed to the article and approved the submitted version.This work was supported by the Grants-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (JSPS) .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.


The emergence of COVID-19 exacerbated the existing epidemic of opioid use disorder (OUD) across the United States due to the disruption of in-person treatment and support services. Increased use of technology including telehealth and the development of new partnerships may facilitate coordinated treatment interventions that comprehensively address the health and well-being of individuals with OUD.The analysis of this pilot program aimed to determine the feasibility of delivering a COVID-19 telehealth care management program using SMS text messages for patients receiving OUD treatment.Eligible individuals were identified from a statewide opioid treatment program (OTP) network. Those who screened positive for COVID-19 symptoms were invited to connect to care management through a secure SMS text message that was compliant with Health Insurance Portability and Accountability Act standards. Care management monitoring for COVID-19 was provided for a period of up to 14 days. Monitoring services consisted of daily SMS text messages from the care manager inquiring about the participant’s physical health in relation to COVID-19 symptoms by confirming their temperature, if the participant was feeling worse since the prior day, and if the participant was experiencing symptoms such as coughing or shortness of breath. If COVID-19 symptoms worsened during this observation period, the care manager was instructed to refer participants to the hospital for acute care services. The feasibility of the telehealth care management intervention was assessed by the rates of adoption in terms of program enrollment, engagement as measured by the number of SMS text message responses per participant, and retention in terms of the number of days participants remained in the program.Between January and April 2021, OTP staff members referred 21 patients with COVID-19 symptoms, and 18 (82%) agreed to be contacted by a care manager. Participants ranged in age from 27 to 65 years and primarily identified as female  and White . The majority of participants were Medicaid recipients . There were no statistically significant differences in the demographic characteristics between those enrolled and not enrolled in the program. A total of 12 (67%) patients were enrolled in the program, with 2 (11%) opting out of SMS text message communication and choosing instead to speak with a care manager verbally by telephone. The remaining 10 participants answered a median of 7 (IQR 4-10) SMS text messages and were enrolled in the program for a median of 9 (IQR 7.5-12) days. No participants were referred for acute care services or hospitalized during program enrollment.These results demonstrate the feasibility of a novel telehealth intervention to monitor COVID-19 symptoms among OTP patients in treatment for OUD. Further research is needed to determine the applicability of this intervention to monitor patients with comorbid chronic conditions in addition to the acceptability among patients and providers using the SMS text messaging modality. Following the emergence of the pandemic in March 2020, drug overdoses spiked by 28.5% between April 2020 and April 2021 [When the COVID-19 As overdose deaths continue to increase, improving access to evidence-based treatment for opioid use disorder (OUD) is a key tertiary prevention strategy . This neTo address these concerns, experts recommend increased use of technology, including telehealth, and the development of new partnerships to facilitate coordinated treatment interventions that comprehensively address individual health and well-being ,11. WhilAn OTP network based in the state of Delaware recruited patients to participate in this telehealth care management program where eligible patients are invited to connect with a care manager to monitor their COVID-19 symptoms through daily SMS text messaging communications. The overall COVID-19 telehealth care management program has been in place since the beginning of the pandemic and provides COVID-19 resources and support to businesses and their employees. It consists of 10 care managers who are all licensed registered nurses. This study focuses on the feasibility of enrolling patients with OUD into this established telehealth program.OTP staff conducted universal COVID-19 symptom screenings for their patients during OTP appointments and referred patients with symptoms to community sites for a COVID-19 test to confirm diagnosis. The Delaware Department of Public Health reviewed and verified diagnostic test samples, and notified the testing facility if patients were positive for COVID-19.Eligible patients who screened positive for COVID-19 symptoms were invited by OTP staff to participate in the telehealth care management program. Eligibility criteria included patients 18 years or older; with confirmed COVID-19 symptoms; currently receiving OUD treatment; who owned a cell phone with SMS text messaging capabilities; and able to understand, speak, and read English.Beginning January 2021, OTP staff invited patients who met eligibility criteria to receive a SMS text message from a care manager using Twistle software . This enThis pilot program was conducted between January 11 and April 30, 2021. We assessed the feasibility of the program intervention by focusing on three process measures: (1) adoption, which was measured by the number of patients who were invited versus the number who agreed to participate and enrolled in the program; (2) engagement, as measured by the overall number of SMS text messages sent by participants; and (3) program retention, as measured by the number of days participants remained active in the program by continuing to respond to the daily SMS text messages. OTP staff provided a count of patients screened for COVID-19 symptoms and program referrals. The lead care manager tallied the number of patients who screened positive for COVID-19, received a SMS text message program invitation, were lost to follow-up or declined participation, and were enrolled in the program. They also reported the number of days participants were monitored and if any were referred for acute care services during the program. The Twistle data provided the number of messages sent by participants to care managers. Demographic data including age, sex, race, and insurance type were obtained from the electronic health record (EHR). An EHR review confirmed if participants were locally hospitalized while in the program.U and Fisher exact tests calculated differences in the demographic characteristics for age, sex, race, and insurance type between those enrolled and not enrolled in the program. Data were analyzed using Stata/SE version 16.1 (StataCorp).Descriptive statistics summarized the characteristics of patients approached to participate in the telehealth care management pilot program and process metrics for program enrollment. Mann-Whitney We received approval from the ChristianaCare Institutional Review Board (IRB00000480) to evaluate the feasibility of this program.Characteristics of patients enrolled in the program (n=12) and those not enrolled (n=6) are shown in Of the 12 individuals enrolled, 2 opted-out of SMS text message communication and instead spoke with the care manager verbally by telephone. The remaining 10 participants answered a median of 7 (IQR 4-10) messages. The median time in the program was 9 (IQR 7.5-12) days. Of the 12 participants, 10 were monitored for less than 14 days because of improvement in COVID-19 symptoms, and 2 were monitored for the maximum 14-day period. No participants were referred for acute care services or hospitalized while being monitored by the care manager.In this study, we assessed the feasibility of using SMS text messaging to manage COVID-19 symptoms of OTP patients receiving treatment for OUD. We evaluated the feasibility using three criteria: adoption measured by the ratio of enrolled participants over eligible patients, engagement measured by the number of participant responses to the care managers, and retention measured by the days participants remained in the program. Although a small number of individuals were eligible, the majority of those approached about the program agreed to be contacted and monitored by a care manager via SMS text message. Only a few then opted for verbal telephone communication as opposed to SMS text message communication. Our findings are consistent with the literature documenting the acceptability of SMS text message interventions among individuals seeking OUD treatment following emergency department discharge . AdherenTelehealth is considered safe and effective for a variety of conditions, and research has demonstrated its ability to manage health care needs while maintaining social distancing to reduce infectious disease transmission -17. CurrTelehealth care management through secure SMS text messaging is a promising tool that offers a convenient, private, and low-maintenance approach to promote patient engagement. SMS text messaging does not require broadband internet access, a smartphone data plan, or downloading a smartphone app, thereby avoiding barriers that exist for many individuals including those in rural areas . Though acceptability among patients and providers [Our study shows that OTP patients may be comfortable communicating through SMS text messages. Though 2 participants preferred to communicate verbally by phone, we believe SMS text messaging remains a feasible telehealth modality. Further research is needed to explore telehealth preferences including concerns related to privacy, security, and other potential barriers. This is consistent with a recent review identifying that only a limited number of studies to date have explored telehealth roviders . Consequroviders ,23.The small sample size of this pilot study limits the generalizability of our findings to the broader population of OTP patients. Because of the small sample size, we could not assess other feasibility criteria such as estimating the appropriate workload for the care manager or the referral rate to acute care. The program focused on patients from a single OTP network within Delaware, which restricts the validity of our findings to this local region. The feasibility of this program may vary depending on contextual factors such as geography. Fortunately, our OTP network included multiple community-based sites in urban, suburban, and rural settings throughout the state.This study identified the feasibility of a novel telehealth program intervention delivering COVID-19 care management services for OTP patients. Further research is needed to determine the impact of this intervention on managing other comorbid chronic conditions within this patient population, the association between telehealth outcomes and use of health care services, and telehealth acceptability among patients treated for OUD and providers to ensure engagement and sustainability of services through this evolving modality using SMS text messaging for telehealth purposes.


Clinical practice guidelines establish that occupational therapy (OT) services are indicated for people with early Parkinson's disease (PD). However, OT is uncommon compared to other rehabilitation services. This study describes the development and evaluation of a proactive, consultative OT program for people with early PD as a part of an integrated care approach.  The program was developed by an occupational therapist adapting practice guidelines for people with early PD. Retrospective program evaluation occurred at an outpatient rehabilitation clinic. The consultative OT program for early PD includes a 90-minute evaluation with instruction in self-management techniques, individually tailored exercises, and follow-up recommendations. The program was evaluated with the RE-AIM framework. Postprogram semistructured interviews provided patient-reported program effectiveness and satisfaction. n = 16, 69.6%) were within Hoehn and Yahr stages 1-2 and were seen within 3 years of PD diagnosis. Participants presented with deficits in hand strength (60.0 ± 23.4 pounds) and dexterity (right hand 30.0 ± 8.0 seconds) and reported complaints about basic and/or instrumental activities of daily living . Semistructured interviews (n = 16) revealed that most individuals (75%) reported high satisfaction. Of the 10 who recalled a home exercise program, 60% reported continued adherence. Consultative OT was delivered with fidelity in 22/23 individuals (96%). After one year, only two occupational therapists at one clinic had adopted the program, and the program is maintained in the organization.  In 2018, 23 individuals used OT out of 77 people with early PD who attended the proactive rehabilitation program. Most individuals ( Occupational therapists reached people in the early stages of PD when a specific program was tailored to evaluate and target their specific needs. Motor activity deficits noted in individuals with early PD support future scaling and sustainability efforts of OT within this population. Quality improvement suggestions are discussed for future implementation and clinical trials. Occupational performance, or engagement in life activities, is impacted by Parkinson's disease (PD) symptoms, including tremor, bradykinesia, weakness, poor dexterity, fatigue, gait impairment, apathy, depression, and cognitive deficit , 2. An iOccupational therapy traditionally addresses occupational performance and participation in activities of daily living (ADLs), including self-care, leisure, and work . OccupatSeveral CPG state that OT should be considered early after diagnosis with PD, to provide assessment, education on PD symptoms, and early intervention if ADL difficulties are present –5. InitiOur purpose is to describe the development and evaluation of a proactive, consultative OT program for individuals in the early stages of PD. We will describe the results of this retrospective program evaluation using the RE-AIM framework, a tool to aid measurement and understanding of evidence-based, implemented programs . RE-AIM In 2016, a proactive, consultative rehabilitation program was implemented for PwEP by physical therapists at the Shirley Ryan AbilityLab  . Althougn = 2). In total, 77 PwEP were referred to the proactive PD rehabilitation program, 23 of whom were seen in OT. Of the 77 individuals who utilized the program, 66 were contacted to participate in the program evaluation phone interviews . Of the 23 OT clients, 16 individuals agreed to participate in the interview . These individuals provided verbal consent for audio recording of the interview for program evaluation, future quality improvement efforts, and deidentified dissemination activities.Data were extracted from individuals if they were referred to the proactive PD rehabilitation program for any discipline in 2018 from the University's Movement Disorders Center or the SRAlab Interdisciplinary Parkinson's Disease and Movement Disorders Rehabilitation Screening Program. Individuals with a different movement disorder were excluded from analysis  in 2018. Data were extracted from the referring providers' note (neurologist or interdisciplinary clinic screening note) and OT documentation in the electronic medical record (EMR) and managed using a tool created in Research Electronic Data Capture software hosted at the University Clinical and Translational Sciences Institute , 22. ProReach was measured as the proportion of PwEP who accessed the OT program. Demographics, PD-specific characteristics, and OT evaluation measures are described. Demographics include age, gender, employment status, and insurer. PD-specific characteristics include time since diagnosis and PD severity reported using the Hoehn and Yahr (HY) scale . OT evalProgram effectiveness was measured using a phone survey and semi-structured interview 12–18 months after the initial evaluation (mean 15 months). Effectiveness was operationalized using the self-reported level of ADL function in everyday tasks after completing consultative OT by rating current status as “improved,” “maintained,” or “declined.” Program satisfaction was measured using a 10-point rating scale. PwEP were also asked if they recalled and continued to use their OT home exercise program (HEP) and other recommendations. The interview guide included multiple choice and open-ended questions, which are shared in the supplementary material . Fidelity measures include treatment information, education, and provision of an OT HEP supported by best practice recommendations .Maintenance of the program is described as the number of PwEP seen in the early OT program in 2020 based on administrative data, although the program evaluation focused on the first year of the program (2018).N (%) and continuous data as means ± standard deviations. We compared PwEP who received OT to the other recipients of the proactive rehabilitation program (PT and/or ST) using Chi-square tests for categorical data and t-tests for continuous data, after checking normality assumptions, at a significance level of 0.05.Demographics, OT assessment, and phone interview data are presented with descriptive statistics. The categorical outcome data were presented as p=0.0213). n = 20, 87.0%) were documented at a level of modified independence for at least one basic ADL. The top five reported problem areas were upper extremity dressing , eating , lower extremity dressing , bathing , and grooming . The two most frequently reported problems with instrumental ADLs were writing  and keyboarding .Of the 77 people seen in the proactive rehabilitation program during 2018, 23 PwEP (30%) were seen by OT. Out of 23, 22 were seen in combination with at least one other discipline . DemograSixteen of the 23 PwEP who engaged in the OT program completed interviews. Over a year after participation in the consultative model of OT, the level of function in everyday tasks was self-reported as “maintained” in 11 respondents (68.8%), “improved” in one (6.2%) respondent, and “declined” in four respondents (25.0%). Twelve (75.0%) respondents were highly satisfied with the OT program. Ten (62.5%) respondents were able to recall their HEP, but 4/10 stated that they no longer follow the exercises. Nine (56.3%) respondents recalled and described OT recommendations they had utilized, the most common being ADL tips, writing strategies, and computer keyboard modifications.Two occupational therapists conducted proactive evaluation and OT intervention sessions in 2018. All proactive OT sessions were conducted at a single site, even though the proactive PT program spread to two other affiliated outpatient clinics in the same timeframe. Six physicians (neurologists and physiatrists) referred PwEP to the OT program in 2018, out of 15 total referrers to all disciplines providing this consultative model.All PwEP in the OT program were within five years of diagnosis. Three OT delivery patterns were used: (1) 17 (74%) PwEP completed one 90-minute session with no additional follow-up, (2) five (22%) PwEP completed 1–3 additional follow-up visit(s), and (3) one (4%) individual had a restorative bout of OT with seven follow-up visits. Either all PwEP were recommended to attend a re-evaluation in 6–12 months to document functional status and monitor HEP, or the occupational therapist documented that the individual would contact their physician if further treatment was needed.The program was sustained for the duration of 2018 and continues to reach PwEP into 2022 with adaptations to the initial program. Adaptations have included new organizational leadership support of OT program champions and mentorship opportunities. In 2020, programmatic reach grew by 47% from 23 to 34 PwEP. Over time, adoption spread to 2 sites, 4 occupational therapists, and 11 referrers.This program evaluation offered insights into a novel opportunity for occupational therapists to reach individuals with early stage PD. Most individuals with early PD chose to engage in this consultative model of care with just one 90-minute session focused on assessment, education, and exercise prescription. People with early PD who attended this model of OT presented with impairments in dexterity and hand strength compared to the similarly aged healthy population. Additionally, 87% of PwEP reported difficulty with at least one ADL. The observed impairments in hand strength and dexterity may be related to the self-reported difficulty or slowness with ADLs, suggesting the need for greater use of OT interventions early after diagnosis . It is iAt this time, there is a lack of clarity around which treatments will best target the mild deficits noted in people with early PD. Foster and colleagues hypothesize that individuals in the early stages “may benefit greatly from interventions that promote the integration of self-management habits and other healthy performance patterns…into daily life” . Future In this described program, OT provided baseline functional assessments, individually tailored exercise programs and environmental modification recommendations, and basic and instrumental ADL management strategies. The occupational therapist recommended treatment of observed deficits. The majority of PwEP in the OT program (74%) required a low-dose delivery model, with only one 90-minute consultative session. This delivery model had high program satisfaction, suggesting good value without the need for a burdensome commitment. People in the early stages of PD may be more interested in this consultative model versus a more extensive approach for a variety of factors, such as the individual's mild disease severity, insurance, time, or cost. Additional research is needed to better understand the best delivery models and assessments of low-dose, consultative models of care .Improving reach, adoption, and effectiveness of OT for PwEP are opportunities for clinical and research improvement. We found OT to be the least common area of rehabilitation, which aligns with data from larger patient registries . SimilarAdditional opportunities to improve proactive OT delivery include exploration and application of OT interventions as they relate to employment and self-management. Our data suggest that our initial proactive OT program implementation focused on traditional areas of basic and instrumental ADLs. However, approximately 35% of PwEP in this program were working full or part time, and computer use strategies were a commonly recalled tip from participants. Proactive OT can tailor interventions to address employment, including the psychosocial implications of working with a chronic condition, work-related skills, and workplace productivity. Energy conservation techniques and self-management education may help manage symptoms to help PwEP stay in the workforce longer , 33. FurThe results of this program evaluation have limited generalizability. First, the sampling strategy for this single-site evaluation introduced recall and selection bias due to the small sample size, delayed follow-up, and lack of control. Second, the high level of variability in clinical documentation made it difficult to extract data from the EMR. Additional organizational support for OT-specific program development and facilitation could improve implementation fidelity in the future. Some documentation had evaluation items missing, which could be due to clinician time constraints or patient barriers, such as cognition or language. Third, our cohort was fully insured, primarily white, and English-speaking, which may limit generalizability to more diverse clinics. Lastly, the nature of a single consultative visit did not allow for follow-up assessments to document the clinical effectiveness of the proactive OT model beyond satisfaction. Future research should include regular follow-up assessments in order to compare the results of this intervention to other OT interventions.This OT program evaluation revealed that even individuals with early PD have key occupational performance and participation issues that can be addressed by occupational therapists. While the use of OT early after diagnosis was lower than other disciplines, satisfaction remained high for those who participated. Future quality improvement efforts, aided by programmatic support or implementation research funding, are recommended to improve the reach of this program.


Self-management can improve health status and reduce hospitals admissions in patients with chronic obstructive pulmonary disease (COPD). The aim of this mixed-methods study was to evaluate the implementation of the ‘Living well with COPD’ self-management program, a nation-wide effort by the Swiss Lung Associations and the Swiss society of pulmonary medicine.For the implementation evaluation we used qualitative  and quantitative  methods to assess indicators of the outcomes reach, dose, fidelity, acceptability and appropriateness of the program. To evaluate the effectiveness, we assessed exercise capacity (1-minute sit-to-stand test), disease specific quality of life (Chronic Respiratory Questionnaire CRQ), symptoms, health care utilisation and health behaviour including physical activity at baseline and at the end of the program (after 12 months).Seven Cantonal Lung Associations implemented the program into their services according to plan, conducted it 13 times during 1 year and included in total 122 COPD patients . The patients' attendance rate and the coaches' fidelity to the protocol were high . Overall, acceptance and satisfaction of all involved persons  was very high; they particularly acknowledged the meaningfulness of the program. Challenges were sustainable funding, integration of the coaches' additional workload and uncertainties regarding roles and responsibilities. After 14 month, the patients did not just avoid a decline in exercise capacity and health status but significantly improved in the 1-minute sit-to-stand test (23.9 vs. 27.1 repetitions) and in 3 of 4 CRQ subscales (with 0.2-0.5 units).The ‘Living well with COPD' program was successfully implemented despite a tight schedule and showed a remarkably positive impact of the COPD patients' health status. The insights of this study will support the broader multiplication of the program throughout Switzerland and also serves the international community since it is one of the first nation-wide implementations beyond study settings.


COPD is the third leading cause of death worldwide. Rural communities often face challenges to provide high quality chronic disease care for aging populations. Despite these longstanding challenges, there was an intention to improve the care setting by developing and fostering a shared vision for quality care, as evidenced by enhancing COPD screening and care. To ensure consistent and longitudinal patient access to high quality of care as well and ongoing physician recruitment and retention a new rural program was developed. Objective-In this presentation we will describe a new rural community based COPD program from conceptualization and development through to current functioning highlighting areas of innovation. Methods-A process evaluation guided by Moore et al.’s framework to assess program implementation, mechanisms of impact, and context was conducted. Qualitative thematic analysis was undertaken of stakeholder interviews conducted in 2021 (n=11) and document review  of key clinic documents dated back to pre-program development.We describe five phases of program development: Survive; Reorganize and Stabilize; Assess and Respond; Build and Refine; and Sustain and Share. Outreach and localizing resources improved access to the program. Acquiring secured physician compensation, capturing quality data, and improving patient and provider self-efficacy built the capacity of the system and stakeholders within it. Finally, relationships were forged through building an integrated facility, collaborative networking, and patient engagement. The key elements of program implementation were the resources required to ensure its operation, categorized as hardware, software, organizational, and human.