Racism and racial discrimination are fundamental causes and determinants of health and health inequalities globally, with children and adolescents particularly vulnerable. Racial discrimination is a common stressor in the lives of many children and adolescents, with growing evidence of negative associations between racial discrimination and multiple domains of child and adolescent health. Addressing racism and racial discrimination must be core public health priorities, even more so among children and young people.Schools are key settings in the lives of children and adolescents and become increasingly more important to identity formation. School communities, teachers and peers greatly influence children and adolescents’ beliefs about race and difference. Schools are therefore key sites for the delivery of population-based programs to reduce racism and promote proactive bystander behaviour and healthy resistance to racism among all children and adolescents as well as among the adults.N = 645; 52% female; 6% Indigenous, 10% Middle Eastern, African, Latinx or Pacific Islander, 21% Asian, 52% Anglo/European). Focus groups with students and interviews with staff collected qualitative data about their experiences of the program and their views about the program’s perceived need, implementation, impacts and suggested improvements.This study examines the feasibility and acceptability of the ‘Speak Out Against Racism (SOAR)’ program, a whole of school, multi-level, multi-strategy program that aimed to promote effective bystander responses to racism and racial discrimination in primary schools. A mixed-methods, quasi-experimental design was used. Students in Years 5 and 6 (10–12 years) across six schools completed surveys pre- and post- intervention (Quantitative data showed student prosocial skills and teacher inter-racial climate improved in intervention schools compared to comparison schools. Qualitative data highlighted teacher attitudinal and behaviour change regarding racism, and student reduced interpersonal racial discrimination, improved peer prosocial norms, commitment to anti-racism, knowledge of proactive bystander responses and confidence and self-efficacy to intervene to address racism.This study provides quantitative evidence of the potential of the SOAR program to improve the prosocial skills of students and their perceptions of the inter-racial school climate provided by their teachers. This program also provided qualitative evidence of the potential to promote teacher and student attitudinal and behavioural change. Further refinement and testing of the program in a large scale implementation trial is recommended.The online version contains supplementary material available at 10.1186/s12889-021-11469-2. Racism and racial discrimination are fundamental causes and determinants of health and health inequalities globally , 2. ChilRacial discrimination is a common stressor in the lives of many children and adolescents, with growing empirical evidence of negative associations between racial discrimination and multiple domains of child and adolescent health , 11–13. The importance of teaching children and adolescents to recognise and reject racism and racial discrimination is also supported by developmental science research that shows childhood and adolescence are foundational to the development of prosocial and intergroup attitudes, beliefs and behaviours as well as to identity formation –29. HoweSchools are key settings in the lives of children and adolescents and become increasingly more important to identity formation as they develop and function outside of the family unit . School While there is strong theoretical and empirical support for population-level school-based programs that counter racism and promote proactive responses to it, empirically tested programs are required. There remains an ongoing need for such programs to be evaluated rigorously, including their effectiveness in changing attitudes, beliefs and behaviours over time , 41, 45,Racial discrimination and bullying are related but conceptually distinct factors in the lives of children and adolescents , 50, 51.Best practice guidance for the development and evaluation of complex interventions, defined as interventions with several interacting components, recommends that they are developed using best available evidence and appropriate theory and then tested using a carefully phased approach starting with a series of pilot studies . Pilot sThe SOAR program was designed to be a whole of school, multi-level, multi-strategy program that aimed to promote effective bystander responses to racism and racial discrimination in primary schools. Specifically, it aimed to increase knowledge and practical skills for proactive bystander responses to racism and racial discrimination and to improve peer social norms and the school climate regarding racism and racial discrimination. SOAR drew on a multifaceted theoretical background, spanning theory and evidence on anti-racism, anti-bullying, prejudice reduction, child socio-cognitive development and social conflict in schools. This included evidence that the most effective programs are those that are: multi-level, considering stigmatised and non-stigmatised groups across intrapersonal, interpersonal, and systemic levels and include all students, those who experience racism as well as those who do not , 31, 53;Teacher training and development: 2 days of face-to-face training were provided for classroom teachers delivering the SOAR curriculum and classroom materials as well as any other interested school staff. These training workshops were presented by research staff from the Australian National University  together with staff from a service provider working with schools to support students of refugee backgrounds. New South Wales (NSW) Department of Education staff attended the NSW training and development workshops. After the training workshops, coaching sessions were delivered via phone or online throughout the program to enable staff to debrief with the research team and troubleshoot any issues. Curriculum and classroom materials: the SOAR classroom materials constituted an eight-week unit of work that included suggested activities and questions. The framework for this unit of work and classroom materials were developed by the research team , then workshopped and refined prior to implementation with classroom teachers and school support staff who had experience working with children from culturally, racially and religiously diverse communities, and reviewed by education department staff. These activities were facilitated in-class by classroom teachers, and culminated in the development of a class charter on pro-active anti-racist bystander action. Student support and development: the pedagogical approach of the SOAR program had a strong focus on students as experts and engaged learners throughout. This was foundational to the classroom materials and culminated in ‘Team SOAR’ student-led sessions for the second half of the program. ‘Team SOAR’ was a team of student influencers selected by teachers and classmates at the end of the eight-week unit of work to continue to promote the principles of SOAR. They held student-led meetings to develop materials and activities for their peers and the wider school community. Parent and community involvement: Team SOAR students developed activities to engage with parents and the wider community, and to communicate SOAR principles more broadly. School policies and guidelines: An audit tool was provided to support school leadership to review policies and guidelines regarding racism and racial discrimination and to develop a plan for future action in this area. Monitoring and reporting of racial discrimination: Schools were provided with the opportunity for school-level reports on survey data and the audit tool encouraged schools to review their monitoring and reporting systems, policies and guidelines.SOAR spanned six mutually reinforcing elements: teacher training and development; curriculum and classroom materials; student support and development; parent and community involvement; school policies and guidelines; and monitoring and reporting of racial discrimination. A mixed-methods, quasi-experimental design was used to evaluate the SOAR program pilot. Quantitative data collection examined program effects via student surveys pre- and post- intervention and also enabled exploration of the appropriateness of these survey measures to evaluation of this program. The primary outcomes of the student survey were: student reported bystander responses, self-efficacy to intervene, peer pro-social norms, and perceived school climate. Secondary outcomes were: student social and emotional wellbeing, school connectedness, sleep, and experiences of racial discrimination. Quantitative longitudinal measures of change were collected via student questionnaires administered at baseline and follow up. Qualitative data included interviews and focus group discussions exploring experiences of school students and staff participating in the program and student and staff views regarding perceived need for the program, program implementation, program impacts and suggested improvements. The study was pre-registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000880347).To recruit schools, emails describing the SOAR program were sent in late 2017 to primary schools in two Australian states  and Victoria) and information about the study was disseminated via community and education networks. This information described the goals and content of SOAR and included details about how to join the study. Four volunteer schools (two in NSW and two in Victoria) agreed to participate in the study as intervention schools. Two volunteer schools in NSW agreed to participate as comparison schools. A further volunteer school in Victoria initially agreed to participate in the study as an intervention school but withdrew after classroom teachers became aware of the time commitment involved. Data from this school is not included in this present study. All students in Years 5 and 6 (ages 10–12 years) in each of the six participating schools were invited to participate in the study. Ethics approval was obtained from the Australian National University and from each state government education department, with permission obtained from each participating school principal and staff member alongside parent consent and student assent.n = 4664) across NSW and Victoria  said, it like gets people to have more confident in their self and like just speak out and like just sort of have like an opinion and like tell them what’s actually happening .it’s like that’s kind of made me come out of my shell and like made me more confident and more like – I feel more like brave, probably. Like I will start putting my hand up even when they’ll probably – like say maths or something .Students discussed how the program had increased their understandings and awareness of racism and its expressions, including concepts such as stereotypes.Student: It’s a fantastic program that should be used in each school and it’s great for like children to learn about and learn about all the races and the bullying that’s happening everywhere.Student: Yeah, I agree, it should be taken to other schools because if it’s happening a lot in other schools well then they’d be able to learn about it and realise that it’s not okay .Stereotype like I heard people like talking about stereotypes but I never really knew what it meant until we were talking about different types of stereotypes .This increased awareness of racism in the world was described as an inspiration to anti-racism action among students and a commitment to acceptance of difference and the right to fair treatment for all.It was really helpful like I definitely learnt a lot and I think it – there’s a lot of stuff that I kind of heard about that I didn’t – like I hadn’t really heard of before like things that are going on in our world that aren’t really okay and it kind of inspired me to want to do something about it .Student: I think I've learned that it’s not okay to be bullied or, yeah, to be bullied just because you eat a different food to someone else or you have a different colour of skin or what you wear to someone else, we should all be treated the same because we’re all humans.Student: I definitely think it’s very important because like as she said we are all humans and we all have rights to be ourselves and to be okay with that and nobody should be able to take it away. It’s a really great and comforting program for those that have a different ethnicity or race to know that they're being supported by the people .Student: That it’s okay to be different.Student: Yeah.Student: Yeah, and that everyone is different in their own ways that they can’t change what they are.Student: And if everyone was the same it would be so boring .Time management is the thing, and to do it justice you can’t just do just a little bit here and a little bit there .…we don’t really kind of look into racism that much because as you’re probably aware the teaching curriculum is extremely overloaded. These poor teachers are just flat out and I’m not saying that as a sympathy-type thing, I’m saying that to be a realist. The amount of work that’s on these teachers is full-on .The need for school leadership support for the program was also reinforced by teachers as a key success factor.But the executive needs to be supportive of the whole school yes, so if you have someone that’s appreciative of the program and feels, well, there’s value behind it, if the people at the top see value in it then it’s easier to share with staff .Suggested improvements for the program were: translating materials into languages other than English to support engagement from students who were from refugee or newly arrived immigrant backgrounds, providing refresher lesson materials to continue the ongoing presence and sustainability of the program in schools, further exploring ways to increase parent and community involvement, and greater support for connection between participating schools.An already crowded curriculum and demands on teacher workload were commonly discussed as limitations to program implementation.This study provides quantitative evidence of the potential of the SOAR program to improve the prosocial skills of primary school students and their perceptions of the inter-racial school climate provided by their teachers, and critically, to not cause harm. It also provides qualitative evidence of the SOAR program’s potential to promote teacher attitudinal and behaviour change regarding racism, to reduce interpersonal racial discrimination, and to improve peer prosocial norms, awareness of racism and commitment to anti-racism, knowledge of proactive bystander responses and confidence and self-efficacy to intervene to address racism among primary school students. Study findings address critical gaps in the current empirical evidence regarding population-level school-based programs to counter racism and promote proactive responses to it. The urgent need for robust empirical evidence supporting such programs, including their effectiveness in changing attitudes, beliefs and behaviours over time , 41, 45,The SOAR program is a whole of school, multi-level, multi-strategy program that moved beyond generic bystander bullying programs to specifically target racism. While there are several theoretically sound, rigorously evaluated interventions shown to be effective at promoting prosocial bystander action in response to bullying and in reducing bullying behaviours –49 and aStudy findings highlighted a number of areas for improvement in the intervention design. Suggestions for development and refinement of the program need to be taken into consideration for future implementation. These include exploring how best to resource the program within already high teacher workloads and existing curriculum content, for example providing additional funding to support teachers to participate in the program and backfill their other duties, releasing teachers from other commitments or linking the program more directly to existing curriculum content and deliverables, maximising school leadership engagement and support, supporting teachers to provide refresher lessons for students after the program’s completion, enabling translation into languages other than English and cultural adaptation more broadly, and enhancing parent and community involvement within participating schools, as well as collaboration between schools. Further qualitative and co-design work with school staff and with parents and community members to develop and refine the intervention and its implementation to ensure it is contextually appropriate and feasible is an important future step. Despite these identified improvements, overall the study findings are promising and a larger implementation trial of the program is recommended using methods such as a stepped-wedge cluster randomised trial . Such a In interpreting quantitative findings from this present study, it is important to note that baseline levels of outcome measures across groups were all at relatively positive levels before the intervention commenced, meaning that further improvement on these already positive levels was difficult to achieve. Assistant scores were particularly close to the lowest score possible, with defender scores showing a little more, but not a lot of, room for improvement. Overall, bystander response scores and reported racial discrimination scores were more positive than the state population levels reported using the same measures . There wQualitative findings identified student and teacher reported increases in primary school students’ self-efficacy to reduce interpersonal racial discrimination and to improve peer prosocial norms, as well as awareness of racism and commitment to anti-racism, knowledge of proactive bystander responses and confidence and self-efficacy to intervene to address racism. Using more specific and sensitive measures of these constructs in future implementation studies would be important to capture these changes not presently identified in the quantitative data from this study. Collection of quantitative data from teachers, including regarding their attitudes and knowledge regarding racism is also recommended for future implementation studies. Qualitative data regarding student and teacher experiences of the program remain important to future work, with further attention to data collection regarding the audit tool also needed, as this was not discussed by participants in this current study. Greater attention to collection of implementation data drawing on implementation science methods would also be helpful.This study provides quantitative evidence of the potential of the SOAR program to improve the prosocial skills of primary school students and their perceptions of the inter-racial school climate provided by their teachers. It also provides qualitative evidence of the SOAR program’s potential to promote teacher attitudinal and behaviour change regarding racism, and to reduce interpersonal racial discrimination, and to improve peer prosocial norms, awareness of racism and commitment to anti-racism, knowledge of proactive bystander responses and confidence and self-efficacy to intervene to address racism among primary school students. Further refinement and testing of the program in a large scale implementation trial is recommended. Addressing racism and racial discrimination must a core public health priority, even more so among children and young people. Developing, implementing and evaluating rigorous programs to counter racism and to teach all children and young people to recognise and reject racism are vitally important human rights and health equity goals for societies as a whole.Additional file 1.


Background: Well-performing physician reflects the success of the residency program in selecting the best candidates for training. This study aimed to evaluate the selection criteria, mainly the United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge (CK) results and applicants’ status as international or locally trained applicants, used by the medical education department and the internal medicine residency program in Hamad Medical Corporation in Qatar to predict the residents’ performance during their training.Methods: A retrospective chart review was performed for three batches of graduates who started residency training in 2011, 2012, and 2013. Each group completed 4 years of training. The USMLE Step 2 CK status of the applicant, in-training exam (ITE) scores, formative evaluation scores, Arab Board written and clinical exams pass rate, and other indicators were analyzed. Statistical analysis included chi squares and independent t-test to identify associations. Multivariable analyses were conducted using logistic and linear regressions to test for adjusted associations.p < 0.001) over the 4 years of training and among the international compared with locally trained applicants (p < 0.001). The rate of passing part 1 and 2 written exam of the Arab Board was higher in international than in local applicants, whereas clinical Arab Board exam and formative evaluation were not associated with any criteria.Results: The study included 118  internal medicine residents. The ITE score correlated positively with the USMLE Step 2 CK score (r = 0.621, r = 0.587, r = 0.576, r = 0.571, Conclusions: Higher USMLE Step 2 CK score correlated with better performance on ITE but not with other performance indicators, whereas international applicants did better in both ITE and Arab Board written exam than local applicants. These variables may provide reasonable predictors of well-performing physicians. Although no universally agreed upon selection criteria can predict ideal candidates, most programs depend on standardized examination scores such as the United States Medical Licensing Examination (USMLE) Step 1 and Step 2 Clinical Knowledge (CK), in addition to personal interviews to decide whether an applicant can be offered a resident position.2 Its score was not originally intended to be used in the residency acceptance process. However, it is considered by many program directors as an important factor in prioritizing applicants, even though studies have shown conflicting results on the reliability of USMLE scores in predicting a resident's performance.5USMLE is part of the official requirement to gain medical licensure to practice medicine in the United States.7 whereas others have focused on in-training exam (ITE) results or passing the American board exam of a specific specialty.10 The Accreditation Council for Graduate Medical Education (ACGME) defined the milestones of residents’ evaluation to measure their performance in six competencies: medical knowledge, patient care, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills.11 Brittany et al. demonstrated a positive correlation between structured interviews, USMLE Step 1 and 2 results, and residents’ performance in ACGME competencies in 14 US residency programs.12 The internal medicine residency program at Hamad Medical Corporation (HMC) in Qatar is an ACGME-International (ACGME-I)-accredited academic program since 2013. Fifty medical graduates from different universities, ethnicities, and national backgrounds are matched annually in our program, which are selected from more than 300 annual applicants. Taking into account the wide diversity in candidates’ medical background and the differences in their academic transcript, the resident selection criteria depend largely on standardized examination scores such as the USMLE Step 2 CK, besides giving priority to graduates who completed the internship training at HMC.Resident performance has been assessed differently in various studies. Some studies have concentrated on clinical and communication skills,However, whether the USMLE-CK or any other criterion correlates well with the resident's performance in the internal medicine residency program in our institution or any other ACGME-I-accredited institutions has never been explored.In this retrospective study, we aimed to explore the reliability of the selection criteria, mainly USMLE Step 2, used by the internal medicine and medical education departments at HMC in predicting the performance of residents.This study is a retrospective chart review of electronic and paper-based internal medicine residents’ files from 3 intake years  each consists of 4 years of training in HMC, Qatar. We tested the association of the selection criteria including USMLE Step 2 CK, being local applicants  with a residency permit, or undertaking the internship in HMC with the residents’ performance measured by score on formative evaluations, passing Arab Board Part 1 and Part 2 written exams from the first attempt, and the ITE scores.Sample characteristics were summarized using frequency distributions for categorical variables and mean and standard deviation for continuous variables. Chi-squares and independent t-tests were used as appropriate to identify crude associations. Multivariable analyses were conducted using logistic and linear regressions to test for adjusted associations. Crude and adjusted odds ratios (OR) and beta (ß) coefficients were reported along with the respective 95% confidence intervals (CI). Significance was identified at the 5% level. All analyses were conducted using IBM-SPSS 24.0 .A total of 118 locally trained (who had a residency permit or completed their internship in Qatar) and international applicants joined the internal medicine residency program between 2011 and 2013. Moreover, 88 (75%) residents completed the training period, whereas the remaining 30 (25%) residents left the program at different levels of training  to join the residency programs in the United States. The program is a hybrid of an ACGME-I accredited program and an Arab Board program. The training period spanned for 4 years: 3 years to complete the ACGME curriculum and another 1 year as required by the Arab Board program with an exit exam for Arab Board certification.The medical education department of HMC (main training institution) mandates certain requirements for applicants for them to be shortlisted for interview with the internal medicine program director. These include medical school certificate, English language proficiency test , USMLE Step 2, evidence of the lack of a career gap, in addition to any other extracurricular activities and scholarly activity. Of these criteria, USMLE has been considered the most important criterion to select candidates for the program based on a score of >230 (out of 300) for international applicants and >208 (out of 300) for locally trained applicants.Residents’ performance during their training program was assessed across different domains/outcomes that included (i) ITE, which is a standardized multiple-choice question exam validated by the American Board of Internal Medicine (ABIM) score of each residency year; (ii) the cumulative score of the formative evaluation, which was adapted from that of ACGME and performed by the teaching faculty at the end of each rotation; the score is based on rating from 1 to 5 (where 1 is unsatisfactory and 5 is outstanding) and included the six competency domains of the ACGME; (iii) Arab Board (part 1 and 2) written exam result as pass or fail from the first attempt; and (iv) Arab Board Clinical Exam result as pass or fail from the first attempt.The study was considered as service evaluation by the HMC Institutional Review Board (IRB) and exempted from IRB approval (MRC-01-20-887). All analyses were conducted on de-identified database.A total of 118 applicants were included in the study; 94 (79%) were men and 24 (21%) were women. From these applicants, 81 (69%) were international applicants, whereas 37 (31%) were locally trained applicants .(a) ITE    ITE scores over the 4 years of residency showed a positive correlation with USMLE Step 2 score and other variables.   Higher ITE scores were seen in international applicants than in those who had a residency permit status in Qatar  and those who had their internship completed in Qatar.p = 0.008), PGY3 (p = 0.006), and PGY4 (p = 0.004). However, after adjustment for confounders, only the USMLE score remained significant at a beta (β) coefficient that ranged between 0.06 and 0.10 across the 4 years of ITE. The median USMLE score for local applicants was 215 compared with 234 for international applicants (p < 0.001).   The ITE score was higher in male graduates than in female graduates with a mean value ranging between 59% and 76% and between 55% and 69%, respectively, across the 4 years of training. This difference was significant for postgraduate year (PGY)2 ((b) Formative Evaluation p = 0.051)   None of the variables, including USMLE score, were associated with the residents’ evaluation by the teaching faculty. However, the formative evaluation showed marginally significant association with local applicants ((c) Arab Board Written Exam  and 5p = 0.037) and part 2  written exams. Moreover, having an internship in Qatar was negatively correlated with passing the Arab Board 2 written exam . Male graduates were more likely to pass the second part of the exam (p = 0.046). However, none of these associations remained significant in the multivariable analyses.   A negative correlation was shown between being a local applicant at the time of application and passing the Arab Board part 1  Arab Board Clinical Exam p = 0.086). Residents who passed the Arab Board part 1 were six times  more likely to pass the Arab Board Clinical Exam than do their counterparts .   None of the variables, including the USMLE score, were significantly associated with the passing of Arab Board Clinical Exam. However, results of Arab Board part 1 were borderline significant in predicting the result of the Arab Board Clinical Exam  included more than 40,000 participants, and USMLE Step 1 was found to have the strongest association with the examination-based outcomes, such as ITE scores over different subspecialty programs, not only internal medicine, whereas USMLE Step 2 showed weaker association.21 Studies performed in orthopedic residency programs have also demonstrated a correlation between USMLE Step 1 and Step 2 and the orthopedic ITE.22 By contrast, our study showed that USMLE Step 2 was not a good predictor of the resident performance as captured by the composite score of the formative evaluation in all six ACGME competency domains, although there was a tendency for positive correlation among local applicants compared with international applicants (p = 0.051), which is not fully explained because international applicants have higher USMLE scores than local applicants. Thus, it may be attributed either to chance or to the subjective nature of the evaluation by the faculty. Not enough data are available to assess such association in internal medicine programs. However, USMLE Step 2 showed a positive association with the evaluation performance by program directors of surgical programs.23 Moreover, our study showed no correlation between USMLE score and other variables, particularly the Arab Board written exam (parts 1 and 2) despite being a knowledge exam. This finding may be related to the lack of score gradient similar to ITE and is based on the pass/fail criteria or possibly because of the small sample size where an effect may not have reached significance. The Arab Board Clinical Exam, which is an exit exam for the Arab Board and tests the clinical skills of history taking and physical examination in addition to clinical judgment, did not correlate with any of the criteria studied including the USMLE-CK. This finding needs to be taken cautiously because the exam is not well standardized and lacks validity evidence.In a meta-analysis, Kenny et al. showed a significant inverse relationship between USMLE Step 2 CK and in-hospital mortality from myocardial infarction or heart failure, emphasizing that the content of USMLE Step 2 CK may provide the foundation for safe and competent practice of medicine by graduating residents in such programs.24 In another study, Cuddy et al. found a positive correlation between higher USMLE Step 2 CK scores and lower odds of having a disciplinary action from a US state medical board.25 These observations highlight the fact that USMLE-CK might be a reasonable test to predict safe and competent practice.Depending on USMLE scores to predict the performance of residents in terms of clinical judgment, procedural skills, communication and other non-cognitive skills is not well supported by evidence. However, Norcini Our study also revealed that international applicants did better than local ones in terms of the Arab Board written exam pass rate and ITE exam scores.To the best of our knowledge, this is the first study conducted in an ACGME-I accredited program. The study included only an internal medicine residency program with a reasonable number of candidates enrolled. Our program is unique in that it is a mix of ACGME-I program and Arab Board program with a total of 4 years of training. Moreover, the study population was composed of graduates from diverse international schools and national origins.Our results might be subject to attrition bias because 25% of the residents left the program during the residency period for further training in the USA.Selection bias might have been introduced while shortlisting local and international applicants, because local applicants with lower USMLE Step 2 score were more likely to be accepted than international applicants.The cut-off score for the USMLE of 230 is arbitrary and was selected by the program to indicate high scores versus low scores.The Arab Board written (both parts) and clinical exams have dichotomous result: either pass or fail, lacking the score gradient. The performance of residents as a predictor of future competent physician is not only dependent on medical knowledge but also on the composite of the six competency domains.To our knowledge, this study is the first in our institution and region to investigate the process of selecting residents for training program and highlighting the limitation of our selection criteria in recruiting internal medicine residents and thereby predicting the performance of residents during the training program that will ultimately shape the capacity and performance of future physician. In conclusion, the USMLE Step 2 score is probably not a robust tool in most of the outcome measures except for the cognitive knowledge tested by the ITE. International applicants showed better performance in cognitive tests than locally trained applicants. Further study is needed to determine the best combination of criteria that will predict competent internal medicine residents and future practicing physicians.The authors are grateful for the support provided by the Biomedical Research Program and the Biostatistics, Epidemiology, and Biomathematics Research Core, both at Weill Cornell Medicine-Qatar. The statements made herein are solely the responsibility of the authors.The authors do not have competing interest in relation to this paper.None


In this review, we discuss mechanisms regulating ChREBP activity and highlight phenotypes and controversies in ChREBP gain- and loss-of-function genetic rodent models focused on the liver and pancreatic islets.Excessive sugar consumption is a contributor to the worldwide epidemic of cardiometabolic disease. Understanding mechanisms by which sugar is sensed and regulates metabolic processes may provide new opportunities to prevent and treat these epidemics. Carbohydrate Responsive-Element Binding Protein (ChREBP) is a sugar-sensing transcription factor that mediates genomic responses to changes in carbohydrate abundance in key metabolic tissues. Carbohydrate metabolites activate the canonical form of ChREBP, ChREBP-alpha, which stimulates production of a potent, constitutively active ChREBP isoform called ChREBP-beta. Carbohydrate metabolites and other metabolic signals may also regulate ChREBP activity  Thisvia the portal vein, these cellular nutrient-sensing mechanisms have further evolved to play key roles in the regulation of organ and systemic metabolism complementary to hormonal systems. Indeed, observations that high glucose levels in cell culture media regulated expression of glycolytic enzymes in isolated hepatocytes independently of insulin signaling led to the search for factors that mediated this cell autonomous metabolic regulation , as the key factor that is activated by carbohydrate metabolites and transactivates genomic programs including glycolytic and lipogenic genes involved in the response to dietary and circulating sugars , 13. ChRosophila , 15. ChRosophila , 17. Nevosophila . The abiosophila .https://hugeamp.org/region.html?chr=7&end=73088873&phenotype=TG&start=7295752, accessed September 10, 2020). These associations indicate an important role for ChREBP in regulating human metabolic physiology and health. Investigators studying ChREBP have gained some appreciation of molecular and physiological mechanisms by which ChREBP links carbohydrate sensing to circulating lipids (detailed below). However, its role in regulating the balance of the aforementioned phenotypes and their significance to human health remain far less clear.Common genetic variants in the ChREBP locus including putative missense variants in ChREBP associate at genome-wide significance with numerous physiological traits and cardiometabolic risk factors including height, waist-to-hip ratio, circulating triglycerides, circulating HDL and LDL cholesterol, T2D, circulating gamma-glutamyl transferase, plasma c-reactive protein, and serum urate as well as many other diverse metabolic traits at near genome-wide significance , 28, 29 Our knowledge of the tissue-specific transcriptional targets and associated cellular and physiological mechanisms by which ChREBP mediates its pleiotropic metabolic effects remains poorly defined. In this review, we will discuss both adaptive and maladaptive functions of ChREBP in metabolic physiology guided by results in tissue-specific genetic gain- and loss-of-function models. We will limit our discussion to the role of ChREBP in the liver and pancreatic beta cells. Important roles for ChREBP have also been established in the intestine and white and brown adipose tissue. These aspects have been reviewed elsewhere recently , 31. We via its effects on gene expression. As such, its activity is tightly regulated depending upon the status of carbohydrate fuel availability. The precise carbohydrate metabolites and the mechanisms by which these metabolites regulate ChREBP transcriptional activity remain controversial. An early model suggested that ChREBP transcriptional activity was primarily regulated by an effect of the pentose-phosphate metabolite, xylulose-5-phosphate, to activate a protein phosphatase and dephosphorylate ChREBP at cAMP-dependent protein kinase phosphorylation sites  is the prime candidate for this activity , in isolated hepatocytes independently of insulin signaling . As a rein vivo appears more responsive to sugars other than glucose  , which catalyzes fructose phosphorylation, the first step in fructose metabolism . This hin (GCKR) . As a ren (GCKR) . While gn (GCKR) . Altogetvia lipolysis in the adipose tissue, is also efficiently extracted by the liver and rapidly phosphorylated by glycerol kinase  , 71, 72.via pyruvate kinase overexpression   , 82. Mecet al.   . ChREBP is (DNL) , 85, 86.teatosis . In contteatosis , 82, 83.teatosis , 80, 87.teatosis .ChREBP activates lipogenesis and inhibits expression of the transcription factor PPAR-alpha, a master regulator of fatty acid oxidation , 90. ThiNAFLD appears to be largely a condition of disordered hepatic and systemic lipid metabolism . As ChREWe and others have demonstrated that ChREBP potently transactivates expression of the metabolic hormone FGF21, and FGF21 is under investigation as a therapeutic for treatment of NAFLD , 99, 100B) , another hepatokine that inhibits lipoprotein lipase , 115. ChWhile most investigation has focused on the role of ChREBP in regulating systemic lipid and carbohydrate metabolism, recent work also indicates that ChREBP integrates organismal carbohydrate status with amino acid metabolism . Adenovivia regulation of Txnip, could be a major mediator of glucotoxicity, and this might suggest that ChREBP activation is maladaptive in beta cells. Indeed, recent efforts have targeted beta cell Txnip inhibition to alleviate glucotoxicity and treat diabetes (ChREBP is expressed in pancreatic beta cells at levels that are comparable to those of ChREBP in the liver , 119. Sidiabetes , 127.et al. (While excessive beta cell ChREBP activation may be maladaptive, this leaves open the question as to what adaptive, physiological functions ChREBP might mediate in this cell type. Both major forms of diabetes result from insufficient beta cell mass, and therefore major research efforts are underway to identify pathways, interventions, small molecules, and other therapies to expand functional beta cell mass . Since get al.  tested tet al. , 118. Moet al. . Wollheiet al. . Thus, CThese initial observations were published before the discovery of distinct ChREBP isoforms. First described in the adipose and liver tissue, ChREBP-alpha and ChREBP-beta are also expressed in beta cells . Indeed,et al. (Gain-of-function experiments testing the effects of the two isoforms have been particularly revealing and may reconcile conflicting observations of ChREBP as a mediator of either adaptive expansion or maladaptive glucose toxicity. Adenoviral overexpression of ChREBP-alpha or doxycycline-mediated induction of ChREBP-alpha does not lead to apoptosis or an immediate decrease in glucose-stimulated insulin secretion , 130. Fuet al.  discoveret al. . In staret al. , 129. Tain vivo models are needed to resolve these differences and to test the effects of each isoform on the activity and stability of the other with respect to proliferation, apoptosis, and function in vivo.It is important to note that Shalev and colleagues demonstrated that ChREBP-beta overexpression decreases ChREBP-alpha abundance and postulated that the role of ChREBP-beta induction in diabetic or glucose-treated beta cells is to prevent ChREBP-alpha from mediating glucose toxicity in a feedback rather than feed-forward regulatory loop . HoweverIn aggregate, genetic gain- and loss-of-function models conclusively demonstrate that ChREBP plays both critical adaptive and maladaptive roles in the response to dietary and circulating sugars. The pleiotropic associations between common genetic variants in the ChREBP locus and diverse metabolic traits in human populations further confirm an important role for ChREBP in human metabolic physiology and health. Together, these studies indicate that further investigation into the function of ChREBP will provide a promising avenue to understand the harmful effects of excessive sugar consumption on cardiometabolic risk.What are the functions of the distinct ChREBP isoforms? Will isoform-specific studies help resolve the apparent discrepancies in the literature to date? To answer these questions, detailed mechanistic investigations with isoform-specific manipulation in each of the key metabolic tissues will be required. Genetic mouse models have only recently become available to begin to approach these isoform-specific questions.versus harmful effects? In any of the key metabolic tissues where ChREBP is expressed, it regulates the expression of one to two thousand gene targets (versus harmful metabolic effects is necessary to harness the potential of this system for novel diagnostic or therapeutic strategies. Efforts to prioritize ChREBP transcriptional targets that also harbor variants, which associate with metabolic traits in human populations, seem a promising avenue to advance this field.Which ChREBP transcriptional targets contribute to ChREBP’s beneficial  targets , 134. Thversus harmful effects. A detailed knowledge of how ChREBP impacts diverse metabolic traits and cardiometabolic outcomes will need to integrate molecular mechanistic studies performed in vitro and in animal models with physiological or population genetics approaches in humans. To harness this promise will require substantial investment of time and resources to generate novel reagents to test relevant hypotheses.The overarching goal guiding research in this field over the next decade will be to further understand the mechanisms mediating ChREBP’s beneficial The authors declare that they have no conflicts of interest with the contents of this article.


Background: Good social climate and high work engagement are important factors affecting outcomes in healthcare settings. This study observed the effects of a program called Civility, Respect, and Engagement in the Workplace (CREW) on social climate and staff work engagement in a psychiatric ward of a Japanese hospital. Methods: The program comprised 18 sessions installed over six months, with each session lasting 30-min. Participation in the program was recommended to all staff members at the ward, including nurses, medical doctors, and others, but it was not mandatory. A serial cross-sectional study collected data at four time-points. Nurses (n = 17 to 22), medical doctors (n = 9 to 13), and others (n = 6 to 10) participated in each survey. The analysis of variance was used to evaluate the changes in the following dependent variables, the Essen climate evaluation schema (EssenCES), the CREW civility scale, and the Utrecht work engagement scale (UWES) over time. Result: We found no significant effects. The effect size (Cohen’s d) for EssenCES was 0.35 from baseline to post-installation for all staff members. Effect sizes for EssenCES for medical doctors and UWES for nurses were 0.79 and 0.56, respectively, from baseline to post-program. Conclusions: Differences in social climate and work engagement among Japanese healthcare workers between the baseline and post-installation of the CREW program were non-significant. The psychosocial work environment, comprising workplace social support and social climate , has beeSome interventions have been designed to improve workplace climate. It is known that effective interventions involve acting simultaneously at different levels, affecting the structure and organization of work and relations between workers. For example, different interventions were reported that improve the working conditions, including the structure, organization, and relationships between workers in psychiatric units .On the other hand, programs, such as Civility, Respect, and Engagement in the Workplace (CREW), focus on enhancing workers’ relationships and communication to improve the work environment. This organizational intervention program was first developed and used in Veterans Hospital Administration settings in the United States in 2005 . This prCivility, which describes respectful communication behaviors between people, is an essential concept of the CREW program and an important part of the organizational culture and positive psychological climate ,32,33,34This study aimed to evaluate the effects of a workplace program called Civility, Respect, and Engagement in the Workplace (CREW) on the social climate and work engagement in a psychiatric ward at a Japanese hospital. We hypothesized that the social climate and work engagement assessed by the staff members working in a Japanese hospital would be better after the CREW program installation compared to a time-point before the program was installed. The effect of the CREW program on work engagement has never been reported. This is the first study investigating the effects of the CREW program on social climate and work engagement among healthcare staff in a Japanese hospital.This pretest/posttest study administered a survey at four time-points to observe changes in hospital ward social climate and work engagement of all the staff members working in the ward before and after the CREW program installation at a psychiatric ward of a Japanese university teaching hospital. Approximately seventy staff members from moderately diverse professional backgrounds  participated in the study. The number of staff members and staff composition differed over time because of monthly personnel rotation. In other words, the staff members working in the ward at all four time-points were not constant and slightly changed. This was the first installation of the CREW and survey in Japan.The CREW program was installed over six months, and 18 sessions (3 sessions a month) were held in the ward. Sessions were held during working hours for about 30 min per session and were facilitated by the three ward nurses trained by the research team before installing the CREW program. Staff participation in the CREW program was not mandatory, but the session was announced during the morning conference, and CREW facilitators in the ward asked staff members working on the shift to participate in the CREW program. In each session, the CREW toolkit   and origThe outcomes of this study were social climate and the individual work engagement of all the staff members working in the ward assessed by the self-administered questionnaire survey. Because the CREW program was intended to change the workplace climate, we observed the effect on all staff members who worked in the ward that installed the CREW program. Therefore, the survey respondents were recruited from all staff members working in the ward regardless of their participation in the CREW program. Participation in the study was completely voluntary, and anonymity and confidentiality were assured. Questionnaires were provided at baseline , at the midpoint , after the last session of the CREW program as a post-program , and one month after the end of the CREW program as a follow-up . Over six months, staff members in the ward fluctuated over time. Study purposes and procedures were explained to all staff members. Questionnaires were distributed at the workplace through the sub-chiefs of the ward and collected in sealed envelopes via a collection box. The questionnaire included an assessment of the ward’s social climate, individual work engagement, and other demographic variables. The following surveys measured the social climate: the Essen climate evaluation schema (EssenCES) and the CREW civility scale (civility). Work engagement level was measured using the Utrecht work engagement scale (UWES).To assess the social climate at each time point, we used a subscale of the Japanese version of the EssenCES , originaTo assess the civility levels at each time point, we used the Japanese version of the CREW civility scale , which wWork engagement at each time point was assessed using the nine-item Japanese version of the Utrecht work engagement scale (UWES) , which wDemographic characteristics were also collected through the self-administered questionnaire. Items included age, gender, work-related characteristics, occupation, employment status (full-time job or part-time job), and years of experience on the job. Age was classified into five groups: 60 years old or older, 50–59 years old, 40–49 years old, 30–39 years old, and 20–29 years old. The occupation was classified into three groups: nurse, a medical doctor (psychiatrists and residents), and other . In addition, we provided a blank space where respondents could write comments related to the job or the CREW program.Levene’s test was conducted to assess baseline differences in nonparametric characteristics of staff members working in the ward in four time-points. One-way analysis of variance (ANOVA) was used to assess the differences in the outcome scores between time points. The level of significance was 0.05 (two-tailed). Means and standard deviations (SD) were reported for each outcome variable at baseline (T1), midpoint (T2), after the program (T3), and one-month follow-up (T4). Effect sizes (Cohen’s d)  were alsThe Ethical Committee of the University of Tokyo approved the aims and procedures of this study (No. 10560).To ensure all ethical standards were met, the subjects were informed in writing about the purpose and methods of this study and data storage and privacy protection methods. Respondents sealed the completed questionnaire in an envelope individually to maintain confidentiality. Staff members were also informed that the participation in the survey was voluntary, and nonparticipants would not be disadvantaged. Respondents indicated their consent by responding to the questionnaire.p > 0.05). The respondents’ descriptions by specific occupation across the four time-points are included in the At T1 of the data collection, 77 staff members belonged to the ward, and 47 staff members (61%) answered the self-administered questionnaire. Due to the staff rotation of the residents and nurses in the hospital, the staff members differed and changed over time and at each time point. Overall, 43 out of 74 (58%), 38 out of 74 (51%), and 36 out of 76 (47%) answered the questionnaires at T2, T3, and T4, respectively. Demographic characteristics for participants by each time point are presented in The average number of participants per CREW session was 9.7, and most participants were nurses, with an average number of 7.8 nurses per session. Besides nurses, other participants included medical doctors, psychiatric social workers, occupational therapists, clinical psychologists, and pharmacists.The effects of the CREW program on the social climate and work engagement for all staff members and by occupation are shown in The effect sizes on EssenCES were small for all staff members from baseline to T3. Among medical doctors, the effect sizes were large on both EssenCES and civility of 0.76 (95% CI: −0.12 to 1.64) and 0.79 (95% CI: −0.09 to 1.67), respectively, from baseline to T3. Among nurses, the effect sizes were medium on both EssenCES and UWES of 0.57 (95% CI: −0.10 to 1.24) and 0.56 (95% CI: −0.11 to 1.23), respectively from baseline to T3. In summary, the effects were non-significant regardless of the effect sizes.Some respondents commented on the social climate in the blank space provided, stating, for example, “Our workplace climate has become positive”, “Staff cooperation was strengthened in our ward”, “Felt the sense of unity among the staff”. Negative comments about the CREW program included, “It was tough to participate in CREW sessions during working hours because we are busy”.The purpose of this study was to examine the effects of the CREW program on the social climate and work engagement among psychiatric ward staff at a Japanese teaching hospital. The hypothesis was that social climate and work engagement assessed by the staff members working in a Japanese hospital would be better after the CREW program installation than the time-point before the program was installed.ANOVA results were not significant for all outcome variables. The effect size for the social climate assessed by EssenCES was small, and the effect sizes for the civility scale and work engagement were even smaller. The confidence intervals for all effect sizes included zero. This means that we cannot claim that social climate or work engagement, as assessed by the ward staff members before and after the CREW program installation in the ward, changed over time. Furthermore, in this study, the CREW program’s effects were not sustained one month after its installation at T4. In a previous study, the CREW program showed significant improvement in civility norms  and work-related outcomes  ,23,24, aIn this study, no changes were observed for several reasons. First, as mentioned in the participants’ comments, CREW sessions may have burdened busy healthcare staff, which could have curtailed the effect of the CREW program. Second, the number of participants other than nurses in the CREW program was modest, and the healthcare staff at the ward may not have been familiar with the CREW program. Third, social climate and work engagement baseline scores in this study were slightly higher compared to the scores reported for Japanese nurses. The mean of UWES was 2.2 (SD ± 1.0) for Japanese nurses  , and theIn terms of outcome results by occupation, although most of the participants in the CREW session were nurses, the effect sizes on the perceived civility and social climate in the ward were larger for medical doctors than for nurses. This result may suggest a crossover effect. Previous studies have indicated that climate change is often contagious in the most positive sense within the organization, likely causing a “civility spiral” ,23. TherTo the best of our knowledge, this study is the first to report the results of the installation of the CREW program in an Asian setting. We also reported participants’ comments to an open-ended question, supplementing the quantitative data. The study result can form the basis for further CREW study in Japan. Furthermore, evaluating the effects of the CREW program from the perspective of program session participants, including their perceptions of the program itself and its effect on the individual participants, appears useful for subsequent research, both qualitative and quantitative.Although we did not find significant score improvements, the CREW program was implemented for six months without interruption in the ward, and the participants’ comments revealed that the ward climate changed for the better, and they feel that the cooperation among the staff increased. In addition, after the study period, the nurse manager, who proposed the installation of the CREW program, retired; nevertheless, the CREW program session has been implemented in the ward on an ongoing basis, although less frequently . This suggests that the staff members in the ward believed that the program had some positive effect, and its implementation may be of value to staff members working in hospitals. The CREW program installed in the Japanese psychiatric ward in this study did not show the same effect as in the previous studies. However, larger studies are needed to evaluate the effectiveness of this program and other interventions that could effectively improve social climate change and work engagement in healthcare settings. Future studies could interview the ward staff and carefully investigate the elements of the CREW program that affect the Japanese psychiatric ward workers.This study has several limitations. First, the follow-up survey was conducted at the end of the fiscal year, which is an extremely busy period in healthcare settings, and the influence of this situation could not be verified. Second, survey response rates were 47 to 61 percent among the staff members working in the ward at each time point. It is possible that the staff who responded to the survey were supportive and showed a more positive attitude towards nonrespondents. Finally, the CREW program is intended to change the workplace climate. Thus, we intended to measure the CREW program’s effect on all staff members, who worked in the ward that installed the program, regardless of whether they participated in the CREW sessions, and we did not examine the effects on people who did not answer the survey. In addition, we did not investigate the participation status of respondents. Therefore, how exposure to the CREW program affected healthcare staff is unclear. In this pilot study, it might have been better to consider other ways to assess the social climate in the ward  and conduct an evaluation based on the participation status.This study did not demonstrate statistically significant differences in social climate and work engagement among healthcare workers between before and after the installation of the CREW program in a Japanese psychiatric ward. However, the effect size was small to large. Overall, this pilot study showed that installing the CREW program in a psychiatric ward at a single hospital was feasible and well-received. We believe that presenting the effect sizes of our study could inform further research on social climate and/or work engagement in workplaces. A larger study should be conducted in the future to evaluate the effect of this program.


The study demonstrated the feasibility of the MYmind program in the Chinese context. A larger trial with longer follow-up period is suggested to better examine the effect of mindfulness on adolescents with ASD and their parents.This study investigated the feasibility and preliminary effectiveness of a concurrent mindfulness program (MYmind) on Chinese adolescents with autism spectrum disorder and their parents in Hong Kong, China using a randomized controlled trial with a waitlist control group. Results showed the study had 80% compliance rate, 0% dropout rate, and 89% response rate. Between-group comparisons showed mindfulness had trend effects on parent’s rumination ( Studies have shown autism spectrum disorder (ASD) has an increasing prevalence in the last decade , social intervention, CBT, and medication are the most common treatments for adolescents with ASD. They are shown to have some positive impacts on social functioning, anxiety, and behavioural problems. However, there are certain limitations to each treatment. For example, ABA is intensive and requires long-term participation to optimize the outcomes. Also, most of the ABA effectiveness studies are conducted on young children with ASD, instead of adolescents with ASD , called the MYmind program, was developed for adolescents, who have ASD without having intellectual disability or borderline intelligence, and their parents. It consists of 9 weekly 1.5-h mindfulness-training sessions for adolescents and parents separately. There are several reasons to suggest the MYmind program has beneficial effects on adolescents with ASD. Firstly, in consideration of ASD symptoms, mindfulness involves focusing on the present moment, which includes moments of having interaction with others. It helps adolescents with ASD pay attention to social cues during interaction with others and give appropriate responses. Secondly, in consideration of executive function, mindfulness involves mind–body exercise, which allows adolescents with ASD to shift attention and monitor the interaction among mind, body, and behaviours, hence foster self-control of emotion and behaviour  10 to 18-year-old adolescent who was diagnosed with ASD by a psychologist or psychiatrist according to the Diagnostic and Statistical Manual of Mental Disorders DSM-V  and was registered in Chinese Clinical Trial Registry with a reference number of ChiCTR-IPR-17011233This study was a randomized controlled trial. Participating families were randomized into either (i) immediate MYmind program (6 to 12 children per group) or (ii) waitlist-control group, which they received the MYmind program 9 weeks later. The MYmind program was arranged in summer vacation. Pre-specified questionnaires were self-administrated by parents in both groups before and after the 9-week MYmind program  in a systematic order. And then, created a second column and generated random numbers using the RAND function. At last, sorted the second column filled with random numbers in ascending order, which produced a list of treatments in random order.Due to the study design, it was not possible to blind the participants and mindfulness instructors. However, the research assistants who collected and analysed the data were blinded from the treatment allocation.In Browne’s research , the recThe primary outcomes were feasibility and acceptability of the MBI (MYmind program) as measured by the following: (1) Recruitment rate; (2) Compliance rate reflected by the attendance rate of the nine mindfulness training sessions; (3) Retention rate reflected by the dropout rate and the response rate  of the MYmind group; (4) Program evaluation consisting of 4 questions reported on a 10-point scale: (a) easiness of the program contents , (b) helpfulness to parents , (c) helpfulness to adolescents , and (d) satisfaction of the program . To indicate the program was acceptable, all the questions had to achieve an average score of 5 or above.The Social Responsiveness Scale (SRS) is developed to identify the presence of autistic behaviours and the extent of social impairment of 4–18 years old children (Constantino and Gruber The Child Behaviour Checklist (CBCL) is widely used to identify problematic behaviours of children aged 6–18 years (CBCL/6-18)  is a 36-item questionnaire measuring parenting stress Abidin . Three sThe PS is a measure of dysfunctional parenting in discipline situations  I have felt cheerful and in good spirits, (2) I have felt calm and relaxed, (3) I have felt active and vigorous, (4) I woke up feeling fresh and rested, and (5) My daily life has been filled with things that interest me  as the within-subjects variable and group (MYmind group and waitlist control group) as the between-subjects variable, was used to detect the effects of time, group, and time x group interactions on each of the outcome measures with adjustment of parent’s age and education. The Holm–Bonferroni sequential correction was used to counteract the problem of multiple comparisons  years old (See Table SD = 0.7). The average age of the participating adolescents was 13.0 (SD = 2.3) years old, 76% of them were boys. The participating adolescents received their diagnoses 7.3 (SD = 4.3) years ago. The demographic characteristics of parents in both the MYmind group and the waitlist control group were balanced at baseline except MYmind group had an older age (49.1 (SD = 5.4) vs. 44.1 (5.5), p = 0.017) and higher educational level .The average age of parents was 46.0 (SD = 2.03) sessions, and adolescents attended 7.21 (SD = 1.87) sessions. The overall attendance rate was high, which was 80%. The reasons for session absence included adolescent or parent sickness and time clashes with personal activities. Adolescent’s attendance rate was higher than that of parent’s because sometimes other family members brought the adolescents to class instead of parents.There were 15 (78.9%) parents and 15 (78.9%) adolescents who attended at least 6 out of 9 sessions respectively. On average, parents attended 7.16 (SD = 1.64) out of 10 ; there were 9 (81.8%) parents who scored 5 or above. The average score of the perceived helpfulness to parents was 5.91 (SD = 2.21) out of 10 ; there were 9 (81.8%) parents who scored 5 or above. The average score of the perceived helpfulness to adolescents was 4.73 (SD = 2.24) out of 10 ; there were 6 (54.5%) parents who scored 5 or above. The average satisfaction score of the program was 6.55 (SD = 2.25) out of 10 ; there were 8 (72.7%) parents who scored 5 or above.The program evaluation results (N = 11) showed that the average score of the perceived degree of easiness of the program contents was 5.91  and therefore might have a lower level of stress, which was associated with improved social functioning and reduced internalizing problems  Only parents filled in the program evaluation. The inclusion of adolescents to fill in the program evaluation could obtain a comprehensive evaluation of the program. (3) The study did not collect any data about whether the adolescents and parents completed weekly homework practice. The lack of practice could be a reason contributing to insignificant results. (4) The reporting timelines of measurements  in the pre-assessment and the post-assessment were overlapped, which might have led to inaccurate results. A longer-term follow-up was suggested to better examine the effects of mindfulness training on adolescents with ASD and their parents. (5) Due to the study design, blinding of the participants and teachers was not possible, but the outcome assessors were blinded to the randomization.The study had a short follow-up duration; the long-term effects of mindfulness training on adolescents with ASD and their parents were unknown. Also, the study involved a small sample size, which might not be powered enough to detect differences between the MYmind group and the waitlist control group. A bigger sample size was required to accurately measure the effectiveness of mindfulness training on adolescents with ASD and their parents. Furthermore, the study had the following weaknesses: (1) Reliance on parent’s observation to report adolescent’s outcomes. In future studies, additional measures, such as clinical interview, naïve clinician reportDue to the increase in ASD prevalence, innovative interventions are needed to support families of children with ASD. This study is the first RCT to investigate the effectiveness of a mindfulness-based intervention (MYmind) on Chinese adolescents with ASD and their parents in Hong Kong, China. Results showed the MYmind program was feasible in the Chinese context. Although the secondary outcomes were not statistically significant, there were some notable findings in parent’s rumination, mindful parenting, parenting style, and parenting stress. Future study with larger sample size and longer follow-up period is suggested to better examine the effectiveness of mindfulness training on adolescents with ASD and their parents.


Online interventions can be a cost-effective and efficient way to deliver programs to large numbers of people regardless of geographic location. However, attrition in web-based interventions is often an issue. Developing ways to keep participants engaged is important for ensuring validity and limiting potential biases. We developed a web-based dietary intervention as part of The My Food & Mood study which aimed to optimize ways to engage participants with low mood or depressive symptoms to promote dietary behavior change. Different versions of the My Food & Mood program were tested during optimization. Iterations were developed based on user feedback and usage analysis.The purpose of this study was to compare engagement and nonusage attrition across 4 program iterations—which differed by platform format, delivery mode, and activity type—to create an optimized version.Each program version contained modular videos with key activities with respect to implementing behavior change techniques of equivalent levels of required participation and length: version 1.0, desktop program and smartphone app; version 2.1, desktop or smartphone program; version 2.2, desktop program; and version 3.0, smartphone app. Adults with PHQ-8 scores of 5 or greater were recruited online and assigned to 1 of the 4 versions. Participants were asked to use the program for 8 weeks and complete measures at weeks 4 and 8. Engagement data were collected from the web-based platform system logs and customized reports. Cox regression survival analysis examined nonusage attrition and Kruskal-Wallis tests compared engagement across each cohort.P=.001) and greater proficiency with computers  reduced the risk of nonusage attrition. Computer confidence was associated with an increased risk of nonusage attrition.A total of 614 adults participated. Kruskal-Wallis tests showed significant differences across the 4 cohorts in all engagement measures. The smartphone app (version 3.0) had the greatest engagement as measured by weeks engaged, total usage time, total time key activities, number of active sessions, percentage of activities completed against protocol, goals completed, and percentage of videos watched. Cox regression multivariate survival analysis showed referral from a health practitioner (hazard ratio [HR] 0.344, My Food & Mood version 3.0, a dietary intervention delivered via smartphone app with self-monitoring tools for diet quality and mood monitoring, was the version with greatest engagement in a population with low mood or depression. The iterative design techniques employed and analysis of feedback from participants resulted in a program that achieved lower rates of nonusage attrition and higher rates of intensity of use. Depression is a common and debilitating mental illness that is estimated to affect 4.4% of the world’s population . There iNutritional psychiatry is an emerging field of research that could potentially provide such strategies. This field investigates the relationship between diet and mental health  and has A digital dietary intervention for people experiencing depressive symptoms has the potential to be large scale and attract people who may not seek treatment through traditional channels. There is a substantial body of evidence supporting digital delivery of psychological interventions for depression as an accessible and feasible way to reach this population -18. DigiHowever, despite the promise of these technologies, literature suggests that they have not yet been successfully harnessed to achieve meaningful and sustained health behavior change ,21. In oTraditionally, engagement in web-based interventions has been measured by content access measures, such as how many times a user logs into the intervention site or how many pages of intervention content are accessed ,31. WhilUnderstanding how participants use digital interventions has been identified as key to understanding the issues of limited uptake, engagement, adherence, and high attrition rates . AnalyziThe My Food and Mood study aimed to develop and optimize a digital  dietary intervention for people experiencing depressive  symptoms. From 2017 to 2019, the My Food & Mood study developed an initial version of the program (My Food & Mood Program version 1.0) guided by evidence from nutritional psychiatry, behavior change, expert input, and consumer input. Using principles of user-centered design, this study iteratively optimized the program based on qualitative feedback, self-report questionnaires, and analysis of both usage and intensity of use engagement measures. Each version of the program was trialed by a separate cohort of the target population. During the course of the optimization phase, 3 subsequent versions of the program  were produced and trialed. This study is an analysis of the quantitative engagement data collected during the My Food and Mood study.The primary aim was to analyze patterns of usage across all 4 cohorts of the My Food and Mood study to understand quantitative differences in engagement across each version and to determine which version of the program had the highest rates of user engagement and lowest rates of nonusage attrition. The secondary aim was to identify factors that predicted active usage and nonusage attrition across all cohorts.The My Food & Mood study was conducted from 2017 to 2019. The study design was guided by the Information Systems in Research framework . The stuParticipants were recruited by targeted email campaigns, online advertising, and social media posts. Campaign emails were sent to members of the Food & Mood Centre’s potential participants database and to members of the Community and Research Network run by Innovation in Mental and Physical Health and Clinical Treatment Strategic Research Centre Strategic Research Centre. The program was also advertised by Beyond Blue to members of Blue Voices, a community with lived experience who contribute to the development of mental health services, policy, and programs . TargeteScreening was performed online via the recruitment website . RecruitThe screening survey included demographic questions, questions about access and use of technology, and questions about dietary autonomy. Computer proficiency was evaluated using the Computer Proficiency Questionnaire (CPQ-12) , and scrIndividuals were eligible for the study if they were aged over 18 years and reported current depressive symptoms (PHQ-8 score ≥5). Individuals were excluded if they did not have access to the internet, a computer, or smartphone; had low computer literacy (CPQ-12 score <10 ); had limited English literacy; were not able to follow a different diet (no diet autonomy); and if there was risk of eating disorder (SCOFF score ≥2). In recruitment round 1, participants were excluded if they were not located in Australia or the United States. This additional criterion was due to the available versions of the diet recall tool that was used in this part of the trial. In recruitment round 2, individuals were also excluded if they already followed a high-quality diet (MEDAS score >11).All 4 versions of the program addressed the relationship between diet and mental health. Advice provided in version 1.0 was for a diet for good gut health; this focused on increasing fiber intake and decreasing discretionary food intake and was aligned to the Australian Dietary Guidelines . It inclVersion 1 was a 6-module web-based program and accompanying smartphone monitoring app. Each module contained an educational video and 6 reinforcement activities . The smartphone app enabled self-monitoring of diet and mood with simple graphical inputs and produced a graph of daily food and mood scores. Participants had 8 weeks to complete the 6 modules. Participants were advised to use the smartphone app daily from week 1.Version 2.1 was a web-based program that delivered the intervention content as 16 discrete short modules. The program was optimized for use on a desktop but could also be accessed on a smartphone. Each module contained a video explaining an aspect of the Mediterranean diet and an activity or a short quiz about the video content. The program also included a web-based activity to self-monitor diet. The videos were between 1.5 to 3 minutes in length. Participants could work through the videos and activities at their own pace over the 8-week period.My Food & Mood version 2.2 was a web-based–only program that delivered the intervention content in a week-by-week format. The program also included a web-based activity to self-monitor diet. The first 2 weeks presented the intervention video content as compiled modules. Modules 1 to 8 were presented in week 1 and modules 9 to 16 in week 2. The subsequent 6 weeks of the intervention presented recipes and goal setting activities.My Food & Mood Version 3.0 was a custom-built smartphone app. The intervention content was presented as links with the content divided as per version 2.2 . The app also contained self-monitoring tools for diet, mood, and lifestyle as well as tools for goal setting and food shopping. Participants could see their progress against the ModiMed Diet score  on the pconfident at all to confident and computer skill level was also self-rated on a Likert scale between never used to highly skilled.Participant characteristics were derived from the screening survey. BMI was calculated from self-reported height and weight. Socioeconomic index and remoteness area classification were coded from Australian Bureau of Statistics datasets ,45 for Ar=0.42 to 0.57; Parletta N, unpublished data). A combined baseline diet quality score (MEDAS Rescored) was calculated for both the MEDAS and SDQ responses; this included responses to overlapping questions from the 2 instruments. Diet quality question mapping and scoring is shown in Diet quality was measured at baseline, week 4, and week 8 using the validated MEDAS ,47 and tDepressive symptoms were measured at baseline, week 4, and week 8 using the PHQ-8. PHQ-8 is reliable and valid 8-item assessment of depressive symptoms with a score ranging from 0 to 24. PHQ-8 has been shown to be suited to self-reporting . Baselinweeks engaged: duration of program use in weeks calculated by subtracting the date and time of the last active session from the date and time of the first active session; (2) total usage time: calculated from the sum total time for all active sessions; (3) total time key activities: calculated from the sum total time of active sessions for key activities; (4) number of active sessions: total count of active sessions; (5) average time per session: mean total time of active sessions; (6) per protocol percentage: total number of completed key activities divided by total number of key activities; (7) goals completed: number of goals set and marked as complete; and (8) percentage videos watched: maximum duration watched for each video divided by video duration.Engagement was represented by duration, frequency, and intensity-of-use measures; 8 engagement measures were calculated from database entries, timestamped event logging from active sessions, and a custom script tracking the duration of videos watched. An active session was recorded any time the participant logged into the desktop app or opened the smartphone app and accessed content or made data entries. The measures were (1) nonusage attrition observed if there were less than 4 active sessions recorded over the 8-week period and if they had completed less than 90% of the key activities (per protocol percentage) for their program by their last active session. (These requirements were based on the optimization protocol and the number of sessions required to complete the key activities.) Participants who recorded more active sessions and had completed more than 90% of the key activities (per protocol percentage) were coded as nonusage attrition not observed.Weeks engaged, per protocol percentage, and number of active sessions were used as indicators of nonusage attrition. Participants were coded as An active participant was defined as a participant who used their allocated program. Use was determined as those who logged in to the desktop program at least once  or downloaded and logged into the smartphone app (version 1.0 and 3.0).The sample size required to detect an improvement in engagement, calculated from time required per activity, was based on the initial program design (My Food & Mood version 1.0). In this program, the 6 modules required 15 to 20 minutes engagement time. Assuming mean 90 (SD 25) minutes for engagement time, a sample size of 100 participants per cohort, and type I error of .05, the study had 80% power to detect 10 minutes or greater improvement in mean engagement time across each version of the program. This is equivalent to a moderate effect size of 0.4.H tests.Nonusage attrition rate across weeks engaged was analyzed using Cox regression multivariate survival analysis, with weeks engaged and the coded survival variable. Univariate analyses were conducted on baseline characteristic variables of interest to select covariates for the model. Selected characteristic variables were age, gender, recruitment source, BMI, education, employment, computer skills, computer confidence, baseline mood, and diet quality. Cox regression multivariate survival analysis was repeated including only active participants. Intervention engagement was evaluated by comparing median engagement time and intensity of use outcomes  between the 4 cohorts using Kruskal-Wallis 2=12.295, P=.006) baseline PHQ-8 , and baseline MEDAS Rescored  across cohorts. Consort diagrams for each recruitment round are provided in A total of 614 adults were recruited online into the 4 cohorts at the 2 time points. Participants were predominantly female  and from Australia . Of those who supplied a valid Australian postcode , 79.3% (241/304) were from major cities, 20.1% (61/304) were from regional areas, and 0.7% (2/304) from remote areas. Most participants had a university education and lived in higher-ranked socioeconomic index areas. P=.001) and high computer skills . High computer confidence was a significant predictor of nonusage attrition . No other variables were significant predictors of nonusage attrition.Survival curves for each cohort from the Cox regression survival analysis are shown in P=.002); however; computer skills rated as highly skilled did not . In this model, age was also a significant predictor of active usage . Computer confidence rated as confident remained a significant predictor of nonusage attrition .When including only active participants, referral from a health practitioner remained a significant predictor of active usage across all versions of the intervention , we found that older adults were more likely to continue to use their allocated program. There were no relationships found between nonusage attrition and baseline depression symptoms or diet quality.Analysis of quantitative engagement measures showed that the optimization of the program resulted in the latest version of the program  being a more acceptable version compared to all other versions. Participants who used this version of the program completed more activities, spent more time using the app, completed more goals and watched more of the intervention video content. Version 3.0 required that participants log daily food and mood entries and also prompted them to do so. This more regular interaction did not increase participant burden but appeared to improve usage and engagement. This is contrary to evidence from the field that suggests continually requiring data entry from participants introduces burden that may gradually erode the intervention’s effectiveness . LiteratThe versions that directed intervention participation over the course of the 8 weeks (versions 2.2 and 3.0) had higher rates of engagement and completion of activities. These versions directed the users to complete the videos in the first 2 weeks and perform a series of behavior change activities in the following 6 weeks. This structured approach seemed to be preferred by participants. Even though this required all videos to be watched in the first 2 weeks, participants in cohorts 2.2 and 3.0 watched a greater percentage of the intervention videos compared to cohorts 1.0 and 2.1. The videos in version 1.0 were also of a longer format than and with different content to those in subsequent versions; however, the videos in version 2.1 were the same as those in version 2.2 and version 3.0. These results suggest that the structure and direction was more important for prompting engagement and completion than the length of the videos.There were also more active participants  for the version 3.0 program. This was despite the additional step required to access this version. Participants allocated to this version had to install the app to their smartphone prior to logging in, whereas participants using the desktop programs only needed to click a link to access their version. With ubiquitous use of mobile phones across the globe, this is a promising finding for the design and dissemination of dietary interventions.P=.047) when analysis nonusage attrition for active users. This result may be counterintuitive as there is a common assumption that younger users are more likely to engage with technology due to their higher levels of technology use [While many researchers have investigated predictors of adherence and attrition, there is little consensus as to which defining characteristics might predict active engagement with a digital intervention ,32. Anallogy use ; howeverWe found no relationship between baseline depressive symptoms and nonusage attrition and our subsequent feasibility analysis  showed tIn addition, there was also no relationship between nonusage and baseline diet quality, the primary outcome measure for the feasibility study. This finding shows participants with low diet quality and more opportunity for improvement could engage with the intervention as well as those with higher diet quality and less opportunity for improvement.One key finding from the analysis of nonusage attrition was that participants referred to the program by a health practitioner were more likely to use the program. There are two reasons why this may have been the case. Referral by health care practitioners may have increased the perceived credibility of the program, thereby encouraging usage. Second, participants referred by health practitioners may have been identified as well-suited to this form of adjunctive treatment. Increased engagement due to these informal referral channels is a positive finding and an important consideration for the design and dissemination of future interventions of this kind. In order to increase participation and reduce the risk on nonusage attrition in future trials and treatment programs, more formal referral and recruitment processes utilizing health practitioners should be employed.Participant’s with higher self-rated computer skills were more likely to remain actively using the program. However, if users rated their computer confidence as high, this was a significant predictor of nonusage attrition. These findings appear contradictory; we would expect confident users to encounter fewer barriers to navigating through or actively using an eHealth intervention. Participant characteristics across all cohorts showed there were much larger proportions of participants rated as confident compared to any other level. Given the common use of technology in modern society, and the limited range of options for this response the majority of participants rating themselves as confident is perhaps not surprising. It may be that additional nontechnical barriers limited progress of participants through the programs. Even if perceived confidence is high and participants are willing to engage, having inadequate skills may be one such barrier. In order to manage this, strategies to improve participants skill-level to improve nonusage attrition rates could be introduced in the initial program stages, especially focusing on the skills required to participate in the intervention.The nonusage attrition analysis highlights the need to address attrition in the early stage of digital interventions. A large percentage of participants across all cohorts did not use the intervention (pretreatment dropouts) or only used the intervention for a short period of time, with nonusage attrition curves across all cohorts showing significant drop in usage after 1 day or within the first week. Qualitative feedback was collected during the web-based programs and follow-up surveys 4 and 8 weeks after the program ; howeverThe screening survey ended with links and log-in information to directly access the program or download the required smartphone app. This was designed to be a seamless transition to starting the programs. Analysis of participant behavior at this final screen might aid the design of future interventions. An additional prompt, given prior to closing the browser for participants who do not click on the access links, similar to notifications used by marketing websites, might improve these access numbers. In addition, the access information was also sent to participants via email. Automating follow-up of click through rates on access information emails for those yet to access the program might also be an opportunity to prompt users to log-in.The strengths of this study include the quantitative data analysis of engagement across all participants, as these data were available for the entire cohort. Moreover, active engagement of people with lived experience, including members of Beyond Blue’s Blue Voices, informed the design of the program and produced an mHealth version that was able to be used by people experiencing differing severities of depression symptoms. The study design allowed multiple internet delivery parameters to be explored. Lastly, the study met its recruitment targets such that sufficient power to explore endpoints was available.Despite the strengths of this study, there were also limitations. The dietary advice changed between the first version and the subsequent versions of the program. The change in dietary advice to a more prescriptive Mediterranean diet resulted from relevance and rigor cycles and were defined by the Information Systems Research framework  that wasA large proportion of participants were based in Australia, which may limit global generalizability. In addition, we were unable to collect feedback from those who left the study without downloading the app. Without this feedback, it is difficult to address the reasons the different versions of the program were not able to capture their attention.The optimization study of the My Food & Mood program resulted in an mHealth version of a dietary intervention that had higher levels of usage and engagement than 3 previous versions of the intervention. More participants using this version completed more of the assigned activities and remained engaged, actively using the program for longer. These findings will inform and support the development of future large-scale trials aimed at further testing dietary interventions in depression.Analysis of nonusage attrition showed that referral by a health practitioner reduced the risk of nonusage attrition. In addition, nonusage was independent of participants’ depressive symptoms or diet quality. While several researchers have investigated predictors of adherence and attrition, there is little consensus in the literature of which characteristic might predict participants actively engaging with a digital intervention ,32. Our


Tracheobronchial injury in children is rare but can be highly fatal in severe cases. Therefore, prompt diagnosis and treatment are required. The appropriate treatment method depends on the extent and severity of the injury.An 8-year-old girl fell from the fifth floor and was transported to a local hospital. She had a tracheobronchial injury, went into cardiopulmonary arrest during transportation to our hospital. She was revived with cardiopulmonary resuscitation, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was commenced. Subsequently, we performed tracheobronchial reconstruction by inverted Barclay’s method for tracheobronchial injury. She was switched from VA-ECMO to venovenous (VV)-ECMO 4 days postoperatively, and VV-ECMO was eventually discontinued 27 days after the surgery. The patient was awake and weaned off the ventilator on postoperative day 58. She was discharged 97 days after the surgery.Tracheobronchial reconstruction by inverted Barclay’s method is the preferred surgical technique when other reconstruction techniques are expected to cause excessive tension on the anastomosis of the right main bronchus. Tracheal and bronchial injuries due to chest trauma in children are uncommon, but the fatality rate is reported to be 30%, with approximately half of those deaths occurring within the first hour after injury . TherefoAn 8-year-old girl fell from the fifth floor and was transported to a local hospital. She had a tracheobronchial injury Fig. , bilaterReports have described direct suturing of a tracheobronchial injury in children –5. In thRecently, it has been reported that covered self-expanding metallic stent (SEMS) implantation can be used to treat tracheobronchial injuries with high surgical risk . TreatmeIf direct suturing, pericardial patch, and covered SEMS are not suitable treatments for a tracheobronchial injury, reconstruction of the injured area is necessary. Before performing reconstruction, resection of the injured area is necessary, as reconstruction without resection may lead to postoperative suture failure and anastomotic stenosis owing to insufficient blood flow and bacterial contamination. Given these risks, we resected the injured area, though the injury was extensive. Reconstruction methods for tracheal bifurcation include the double-barreled, Barclay’s, inverted Barclay’s, and Grillo’s methods –10. TensThis report described an 8-year-old girl who survived a tracheobronchial injury after resection of the injured area and tracheobronchial reconstruction by inverted Barclay’s method. This reconstruction method may be effective when other methods are more likely to cause excessive tension on the anastomosis of the right main bronchus.