Though the utilization of traditional medicine has been proposed for modern drug research and development (R&D), limited research has discussed its feasible paths. In this commentary, we summarized key factors for new drug R&D under limited resources by reviewing China’s discovery of artemisinin, and raised suggestions to utilize traditional medicines in low- and middle-income countries (LMICs).We suggested that systematic utilization of traditional medicine, outstanding synergy of research units at all levels and timely information-sharing mechanism should be achieved to establish a comprehensive and efficient R&D system, especially under low-resource settings. In the case of artemisinin discovery, Chinese scientists integrated documented traditional medicine experiences and modern approaches to develop drug candidates timely. Due to limited R&D resources, China adopted a collaborative way, motivating nearly all domestic research units at different levels, to develop antimalarial products. Moreover, the excellent synergy among all units through efficient information-sharing mechanisms greatly avoided work repetition and accelerated the R&D process.Traditional medicines inspires drug discoveries in LMICs, while a comprehensive and efficient R&D system could accelerate its R&D process and save investment. The discovery of artemisinin in China gave a reliable pattern to promote sustainable development of traditional medicines and a good example to realize R&D of traditional medicine under low-resource settings. Traditional medicines were developed on the basis of indigenous experiences from different cultures within a local environment . It has With the growing consensus about the tremendous potential of traditional medicine to advance human health, a systematic and adaptive R&D model should be established to guide the process in LMICs. Evidence showed that many LMICs, including Vietnam, India, Turkey, Mexico, Tanzania and so on, possessed abundant traditional medicine resources, but the R&D of traditional medicine in most countries were in early stage due to social and economic restrictions . Some scIn China, traditional medicines have been valued by researchers from both public and private sectors and has inspired plenty modern drug discoveries, which set good examples for integrating modern sciences and traditional medicines . SeveralThe aim of this study was to raise suggestions to accelerate new drug R&D from traditional medicine under low-resource settings. This study took the successful discovery of artemisinin as an example and determine key factors to promote the vitality of traditional medicine in LMICs.Like other LMICs, China started new drug R&D under low-resource settings. China discovered artemisinin not only based on valuable experiential wisdom of TCM, but also relied on a government-led R&D pattern. Based on the accumulated experience from TCM and productive synergy among multiple departments, China discovered the amazing effectiveness of artemisinin as a novel cure against malaria. Three key factors towards success are still inspiring nowadays, including scientific utilization of traditional medicine, comprehensive synergy of all research units and efficient information-sharing mechanism.In pharmaceutical industry, the drug discovery process was acknowledged as expensive, risky and inefficient. Under the surveillance of national drug regulatory agency and WHO, all new drug R&D should stick to standard drug development and approval process, including preclinical studies and 3 phases of investigational clinical trials . HoweverArtemisia annua Linn, raw material of artemisinin) were selected for further research. Qinghao has been used for more than 2,000 years in China and its antimalarial effects was first recorded about 1,600 years ago in Ge Hong’s “A Handbook of Prescriptions for Emergencies” [Plasmodium berghei.With profound knowledge of traditional medicine, Chinese scientists screened over 40,000 herbs and compounds from TCM books and collected folk remedies. After concluding the current evidence, 10 key herbs including Qinghao  was established to take charge of research plan implementation and collaboration among regions and departments. The National 523 Office was composed of six sectors, including the State Scientific and Technological Commission, the General Logistics Department of Chinese People's Liberation Army, Science, Technology and Industry Commission for National Defense, Ministry of Health, Ministry of Chemical Industry, and the Chinese Academy of Sciences. Each sector would designate focal points to be responsible for communication with National 523 Offices and implementation of all tasks in their subordinate units in a timely manner. Dozens of research institutions were organized by National 523 Office and Provincial 523 offices, including scientific research centers, medical colleges, and pharmaceutical manufacturing facilities.Traditional medicine was viewed as one of the research paths and a public private partnership was established to promote its development and industrialization. To overcome the challenge of producing artemisinin, the National 523 Office arranged for additional cooperation among institutions, medical colleges, and private enterprises . In the During the process, government departments collected research information from all sectors and served the whole industry chain by providing clear division and guidance. This government-led and mission driven R&D pattern could be used to establish a comprehensive and efficient R&D system for resource limited settings. This collaboration system has also been seen during the COVID-19 period domestically and globally to accelerate the R&D process.A productive collaboration system would not only rely on the commitment of government, but also build on efficient information-sharing mechanisms to promote synergy. Cross-region collaboration needed regular communications to avoid work repetition and share recent breakthroughs. China’s research on artemisinin set a good example in the 1970s. After Youyou Tu reported the discovery of Qinghao, China’s National 523 Office and professional groups attached great importance and promoted the information sharing among all research units and adjusted research directions. The information exchange among provinces ensured that all research centers progressed based on the latest breakthroughs and the synergy raised the efficiency of all researches.Nowadays, with the development of communication technologies, information and progress could be exchanged online instead of by offline meetings, which was much more time-saving and convenient. With the help of emerging communication tools, LMICs could establish a more effective information-sharing mechanisms to promote R&D collaborations.The discovery of artemisinin not only contributed to the reduction of malaria mortality globally, but also set an example for R&D of traditional medicine under low-resource settings in LMICs. Through collecting related records, screening promising candidates and identifying active ingredients, researchers could take advantage of ancestors’ wisdom in traditional medicine and explore new drugs. However, new drug development required multidisciplinary talents and massive financial support. Under low-resource conditions, China achieved outstanding innovative development of antimalarial drugs, which was greatly attributed to systematic utilization of traditional medicine, outstanding synergy of research units at all levels and timely information-sharing mechanism. To promote comprehensive and sustainable development of traditional medicine, LMICs should identify weaknesses in research resources and develop adaptive drug R&D pattern based on China’s experience of discovering artemisinin. The following recommendations should be valued when concrete executive strategies on drug R&D were generated: strengthening the utilization of traditional medicine by systematic review and in-depth interview; building R&D pipeline for targeted drug candidate by modern methods; exerting the leading role of government by integrating multidisciplinary research units and establishing information-sharing mechanism.


Maximising access to testing by targeting more than one infection is effective in identifying new infections in settings or populations. Within the EU funded Joint Action INTEGRATE, this paper examined the feasibility and impact of expanding integrated testing for HIV, hepatitis C (HCV), chlamydia, gonorrhoea and/or syphilis in four community-based pilots through targeted interventions in Croatia, Italy and Poland and the Spring European Testing Week since community settings are key in detecting new infections and reaching key populations.Pilots led by local INTEGRATE partners prioritised testing for other infections or key populations. The Croatian pilot expanded testing for men who have sex with men to syphilis, chlamydia and gonorrhoea. Italian partners implemented a HIV and HCV testing/information event at a migrant centre. A second Italian pilot tested migrants for HIV and HCV through outreach and a low-threshold service for people who use drugs. Polish partners tested for HIV, HCV and syphilis among people who inject drugs in unstable housing via a mobile van. Pilots monitored the number of individuals tested for each infection and reactive results.The pilot Spring European Testing Week from 18 to 25 May 2018 was an INTEGRATE-driven initiative to create more testing awareness and opportunities throughout Europe.The Croatian pilot found a high prevalence for each syphilis, chlamydia and gonorrhoea respectively, 2.1%, 12.4% and 6.7%. The Italian migrant centre pilot found low proportions who were previously tested for HIV (24%) or HCV (11%) and the second Italian pilot found an HCV prevalence of 6.2%, with low proportions previously tested for HIV (33%) or HCV (31%). The Polish pilot found rates of being previously tested for HIV, HCV and syphilis at 39%, 37%, and 38%, respectively. Results from the Spring European Testing Week pilot showed it was acceptable with increased integrated testing, from 50% in 2018 to 71% in 2019 in participants.Results show that integrated testing is feasible and effective in community settings, in reaching key populations and minimising missed testing opportunities, and the pilots made feasible because of the European collaboration and funding. For sustainability and expansion of integrated community testing across Europe, local government investment in legislation, financial and structural support are crucial. Integrated testing (testing for more than one infection) for HIV, hepatitis B (HBV) and C (HCV) virus and sexually transmitted infections (STIs) has been identified and supported by global and European organisations, including the European Commission, the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO) –4 as an INTEGRATE  is an EuIn Croatia, there is a national response strategy for HIV, however, strategic guidance is lacking for both the detection of HBV, HCV and testing by trained lay providers. Current legislation is also punitive against certain vulnerable groups, and key populations report widespread discrimination and stigma in the formal health care system , 7.In Italy, although national testing policies for HIV, HBV and HCV are comprehensive and promote widespread accessibility , 9, in pIn Poland, the national HIV response strategy has a strong partnership between the government and community network , howeverAdditionally, as another method of expanding integrated testing opportunities, INTEGRATE, in collaboration with the European Testing Week (ETW) initiative and the European Liver Patients’ Association, piloted a Spring-version of European Testing Week (SETW) which took place 18–25 May 2018. Since 2015, ETW occurs annually during the last week of November as a HIV/HBV/HCV testing awareness campaign, encouraging partners in civil society, health care, and policy institutions in the WHO European Region to unite to promote awareness of and increase coverage of HIV, HBV, and HCV testing. The SETW was piloted to assess the feasibility of implementing ETW twice a year during a different season, its impact on increasing integrated activities for HIV/HBV/HCV and reaching key populations. This article will present results from the pilot SETW and four pilot activities to describe the impact of expanding testing accessibility.All partners routinely perform testing and assessed their client’s needs to determine the most relevant activities to implement in the pilots including infections to test, groups to target, duration of the activity, selection criteria and recruitment strategies. Universally, individuals aged ≥ 18 years were included in the pilots and consent to test was obtained according to local EC/IRB regulation.The INTEGRATE partner, Croatian association for HIV and viral hepatitis (HUHIV), routinely tests for HIV and HCV for MSM through their Checkpoint in Zagreb. For the pilot, the test offer for MSM was expanded to include syphilis, chlamydia and gonorrhoea. All clients seen were offered additional testing upon risk assessment. HUHIV obtained additional funding from the local government and received donated chlamydia/gonorrhoea tests. It was implemented in collaboration with the Clinic of Infectious Diseases ‘Fran Mihaljevic’ who processed the results and provided staff training.Italian INTEGRATE partners, Associazione della Croce Rossa Italiana (CRI) and Fondazione Villa Maraini (FVM), collaborated to conduct a 1-day testing/informative session at a migrant centre managed by CRI in Rome about HIV/HCV  and substance abuse. Two preparatory meetings were held with centre staff to define the intervention. Participants were recruited to the informative session by centre staff and informative leaflets translated in English, Arabic, French, Turkish and Urdu prior to the event. The session was translated by cultural mediators in French, Arabic and Turkish. After the session, voluntary free testing was offered to all clients at the centre. After providing informed consent, clients responded to a risk-behaviour questionnaire interview, available only in Italian and English. Attendance to the informative session was not mandatory to access testing.FVM also routinely offers combined testing for HIV and HCV for PWUD, MSM, sex workers and other key groups, both in its medical centre for PWUDs  and in an outreach street unit. For the second pilot, FVM conducted targeted testing for migrants in these two settings. To initiate testing, FVM staff informed potential clients on the importance of getting tested and provided informed consent forms and the risk-behaviour questionnaires in English, Romanian or Arabic.INTEGRATE partner, National AIDS Centre (NAC) in Poland in cooperation with the Foundation for Social Education (FES), a community-based non-governmental organisation (NGO), piloted a mobile service which provided integrated testing for HIV, HCV and syphilis targeting PWID experiencing homelessness in addition to harm reduction, medical care and social support services. The mobile van travelled to four vacant properties in Warsaw and recruited participants via convenience sampling, respondent driven sampling (RDS) and/or street recruitment. All who were interested in any of the other services were offered testing.Across all pilots, monitoring was measured by a basic set of indicators including at minimum: the infection tested, the total number of individuals tested for each infection during the pilot and number of reactive results. These indicators were selected as they were universally collected across all pilots and all partners were able to collect this data. Optional indicators included the number of individuals with a known positive status who were tested and the number of individuals who were previously tested within the past 12 months. All pilots collected anonymised data which was submitted in an aggregated format via an online form on REDCap, Excel or a report.All pilots are established testing sites and no specific ethical approval was required for the additional pilot testing activities. Aggregated data on testing collected for this article contained no personal identifiers and the client surveys were conducted anonymously.To participate in the SETW, interested organisations sign-up on the ETW website with the intention to take action to organise their own local, national or regional activities to increase HIV/HBV/HCV testing awareness and access. There is no minimum requirement to participate and organisations volunteer their time to organise activities in their community.At the completion of ETW, all participants are invited to complete an online evaluation which measures the types of activities, targeted key groups, details on activities, satisfaction with ETW and challenges. Organisations who conducted testing are invited to submit aggregated data on people tested, reactive results and linkage to care via an Excel form. For this article, a comparison was performed between post-ETW data from November 2017 with SETW data from 2018 and 2019 to evaluate the impact of conducting ETW during Spring.For pilot partners who expanded existing services to include integrated testing for other infections Table , there wAt the CRI/FVM-hosted testing/informative event at the migrant centre in Rome, 26 clients attended the session, while 64 clients were tested for both HIV and HCV with no reactive results. Data from the risk assessment questionnaire, showed low rates of clients that previously tested for HIV (24%) and for HCV (11%).Through FVM’s pilot in their low threshold centre and street outreach, 250 individuals were tested for HIV and 242 for HCV. No new cases of HIV were detected, while an HCV prevalence of 6.2% was found. Regarding having previously tested within the past year, the reported rates were low for both HIV (33%) and HCV (31%). Those who received a reactive result were linked to the Infectious Diseases Clinic of Policlinico Tor Vergata in Rome.In Poland, 101 clients were tested via the mobile van, which found an HCV prevalence of 6.6% for new infections and no new detection of HIV or syphilis. Regarding previous testing in the past year, the found rates were low for HIV (39%), HCV (37%) and syphilis (38%). Clients who received a reactive result were directed to specialised clinics. Since the clients were anonymous, there was no possibility for follow-up of linkage to care.The number of organisations participating in the pilot SETW in 2018 and in 2019 was 104 and 136, with response rates to the survey of 32% and 36%, respectively . Both testing and survey data collection was also limited, and recruitment was primarily conducted through convenience sampling with small overall sample sizes. However, the aim was to assess feasibility and potential benefit of implementing integrated interventions in the real world that are relevant to national testing strategies.The data from Spring ETW is also limited. Although all ETW participants are asked to complete the online survey, it captures only a small percentage of the activities being organised. Furthermore, not all participants conduct testing activities and of those who do, some are unable to provide data or feedback. The survey is also provided in English which can be a barrier for completion. Lastly, the survey length can act as a barrier since respondents may not have allotted time to complete.This article shows that integrated testing outside of traditional health care settings is a feasible and an effective method to increase testing coverage and meet the needs of key populations who experience a disproportionate burden of HIV, HBV, HCV and STIs. The article found low rates of those previously tested within the past year among key populations and found that expanding integrated testing offer in community and outreach settings creates more opportunities to test for multiple infections with the potential of minimising extra costs due to utilising existing structures. National testing strategies should support the scale-up of integrated testing to maximise all opportunities of contact to provide people-centred care, minimise missed opportunities for testing and ensure that more people are aware of their status. The pilots emphasise the need for clear provision in national testing strategies to legislatively and financially support integrated testing in community settings and allowance of trained lay providers to provide testing to maintain sustainability and minimise reliance on time-limited funding. Community representatives should contribute to the development of these strategies to ensure effectiveness and sustainability and local cooperation between all service providers including policy makers, health care providers, laboratories and community-based services is crucial for the success of integrated testing programmes and securing linkage to care.


Vaccine hesitancy (VH) and the global decline of vaccine coverage are a major global health threat, and novel approaches for increasing vaccine confidence and uptake are urgently needed. ‘Nudging’, defined as altering the environmental context in which a decision is made or a certain behaviour is enacted, has shown promising results in several health promotion strategies. We present a comprehensive synthesis of evidence regarding the value and impact of nudges to address VH.We conducted a systematic review to determine if nudging can mitigate VH and improve vaccine uptake. Our search strategy used Medical Subject Headings (MeSH) and non-MeSH terms to identify articles related to nudging and vaccination in nine research databases. 15 177 titles were extracted and assessed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The final list of included articles was evaluated using the Mixed Methods Appraisal Tool and the Grading of Recommendations, Assessment, Development and Evaluations framework.Identified interventions are presented according to a framework for behaviour change, MINDSPACE. Articles (n=48) from 10 primarily high-income countries were included in the review. Nudging-based interventions identified include using reminders and recall, changing the way information is framed and delivered to an intended audience, changing the messenger delivering information, invoking social norms and emotional affect , and offering incentives or changing defaults. The most promising evidence exists for nudges that offer incentives to parents and healthcare workers, that make information more salient or that use trusted messengers to deliver information. The effectiveness of nudging interventions and the direction of the effect varies substantially by context. Evidence for some approaches is mixed, highlighting a need for further research, including how successful interventions can be adapted across settings.Nudging-based interventions show potential to increase vaccine confidence and uptake, but further evidence is needed for the development of clear recommendations. The ongoing COVID-19 pandemic increases the urgency of undertaking nudging-focused research.CRD42020185817. Nudging interventions addressing vaccine hesitancy primarily stem from high-income countries. Little information is available from low- and middle-income countries, many of which are currently facing declining public confidence in vaccines and pointed interest in potential interventions.Nudges that entail changing vaccine defaults (opt-out), giving incentives, and providing reminders and recalls  have proven efficacious in some settings, are considered viable options when communicating vaccination schedules, and could bolster intention to vaccinate.An in-depth understanding of the complexity of the target population is highly recommended to ensure the acceptability and effectiveness of nudging interventions.In light of the COVID-19 pandemic and public discourse around risks and chances of novel vaccines, exploring new pathways for interventions, including nudges, that foster vaccine trust and confidence is required. This review provides a comprehensive starting point for such research.Vaccines have a tremendous impact on disease control and are one of the world’s leading public health achievements, responsible for the eradication of smallpox, the prevention of lifelong disabilities, and major reductions in childhood morbidity and mortality.5–7Vaccines have become a source of anxiety among many families and individuals globally due to scientifically unfounded fears that they can cause autism and other health problems, and other concerns about vaccine safety.15 16The degree of decline in vaccination varies between and within countries, but its potential to overrun health systems due to outbreaks of vaccine-preventable diseases is most acute in low- and middle-income countries (LMICs),18Several health promotion approaches have been proposed and tested to address VH, including video-based vaccine promotion and educational messages in the form of anecdotes, storybooks, and mobile applications.In contrast to changing attitudes, another stream of health intervention research emphasises ‘nudging’ or changing the environmental context in which a decision is made or behaviour is enacted.33 34To date, a systematic evaluation of nudging’s efficacy, feasibility, and acceptability in terms of how it affects vaccine knowledge and awareness, intentions and behaviours is lacking. To address this gap, we conducted a systematic review mapping existing evidence regarding nudges’ acceptability, feasibility, and effectiveness in increasing knowledge, intentions, and behaviours (including uptake) related to vaccines. This review aims to contribute to the literature on nudging interventions in this field, to inform policy discussions, and to provide insights around whether and to what degree nudging can affect vaccination decision making.We employed a systematic literature review methodology36We searched the International Prospective Register of Systematic Reviews (PROSPERO) and Cochrane database for protocols matching this study’s title, aim, and objectives, or for any previously published primary research and reviews on the subject matter. Both databases had no ongoing or published systematic review about nudging in promoting childhood and adolescent vaccine uptake. We registered a protocol for this review on PROSPERO (registration ID: CRD42020185817).‘behavioral control’, ‘decision making’, ‘vaccination’, and ‘vaccines’, as well as the following non-MeSH terms: ‘behavioral intervention’, ‘behavioral strategy’, ‘nudge’ and ‘nudging’, using Boolean operators ‘AND’, ‘OR’ and ‘NOT’ to combine keywords for the final search strings  discussed the key words and core concepts. Further, to avoid missing studies that did not directly draw on nudging literature but whose interventions aligned with the selection criteria, we included Medical Subject Headings (MeSH):  strings . We excl10.1136/bmjgh-2021-006237.supp1Supplementary dataThe two lead authors pilot tested the final search strings in two research databases (PubMed and Science Direct) to identify potential problems. We searched nine platforms on both commercial and non-commercial databases to ensure that we captured academic and grey literature . JL indeMDCR and JL conducted data extraction and validation of included studies. Results from all search strings were initially tabulated per database, including duplicates between strings and between databases. All relevant papers collected were stored in a citation manager  and Microsoft Excel .Titles and abstracts of papers were screened by MDCR and JL based on predefined eligibility criteria . InitialWe excluded systematic review articles that were captured during the full-text screening, but we manually screened all references listed in these systematic reviews to ensure that no relevant articles were missed during the initial search. In cases of discrepancies, JW served as a third reviewer and articles were discussed until consensus was reached.The final set of included studies underwent independent quality assessment by MDCR and JL. The assessment was carried out on study level, focusing on study designs and whether study aims and objectives were achieved, adequately reported and synthesised. The Mixed Methods Appraisal Tool (MMAT) V.2018 facilitated the process.39 40Data collected from the included studies were synthesised and summarised. Relevant data were extracted using a predesigned and piloted evidence summary tool, with categories based on the aims and objectives of the study and additional information on themes emerging during analysis. JL and MDCR piloted the extraction form using five randomly selected studies from all study design groups within the final list of included studies; this process found consistency across the results.We prepared descriptive summaries, followed by presentation of results in a tabulated format . We followed the MINDSPACE frameworkWe performed a mixed integrative and interpretative synthesis of the findings from included studies, structured around the type of nudging employed, ways the intervention was implemented and any measure of impact of the intervention.We performed all searches from 15 May 2020 to 31 May 2021 and identified 15 177 articles . After rVaccine (n=8), Pediatrics (n=3), PLoS One (n=3), and The American Journal of Public Health (n=2).Key characteristics of the 48 included studies such as study population, sample size and outcome measures are detailed in According to the MMAT-based scoring , all incAccording to the GRADE scoring of the 28 RCTs included in the review , nine stDrawing on the MINDSPACE framework and the nudging literature,Nearly half of the included studies (21 of 48) used different ways of salient messaging  to capture attention and directly relate it to the target population’s personal experiences to promote vaccination behaviours.A qualitative study in the UK assessed the feasibility and acceptability of a personalised ‘celebration card’ (codesigned with parents/caregivers) to accompany the child’s vaccination record, alongside an information leaflet preceding the vaccination schedule.46An RCT in Australia evaluated the use of individualised letters  and pamphlets  among Aboriginal Australians.52In Bangladesh, an RCT demonstrated that the use of an application called ‘mTika’ to automatically generate reminder messages for mothers in hard-to-reach rural and urban areas was effective in improving vaccination coverage.56 57Automatic notifications were found to be more successful among vaccine providers. Duvall,59Also, in the USA, findings from an RCT compared the impact of mailing postcards  with practice-based reminders (HCWs delivered the postcards).Haemophilus influenzae type b (Hib) and pneumococcal conjugate (PCV13) vaccine uptake, the findings revealed an increase in parents’ perception of the benefits of vaccines, viewing vaccines as a component of motherhood.63 65An RCT conducted in Japan used a stepwise vaccination education programme with a focus on salient messaging for mothers, which entailed delivery of educational leaflets. The messaging approach began before giving birth until 3–4 days postpartum and 1 month after delivery to assess the infant vaccination uptake.Based on an RCT conducted in Israel, an invitation (‘getting early shot to increase vaccine effectiveness’) combined with traditional information approaches about stock (‘vaccine is more likely to run out of stock’), benefits (‘early shot carries monetary benefits’) and costs (‘early shot is free while the late costs a fee’) is effective compared with the intentions of getting influenza shots late.66Five studies used incentives as a mechanism to motivate behaviour change. Recognising that the cost of vaccines is a key barrier to uptake in China, a cross-sectional survey compared a free policy and non-free policy of influenza vaccination among parents of young children and found that influenza vaccination coverage was higher with the free policy (34.2%) compared with the non-free policy (3.1%).69In rural India, an RCT evaluated vaccination campaigns with and without incentives.70Setting defaults has also been used with regard to vaccination-related patient–provider communication. A cross-sectional study in the USA used participatory (built on the principle of shared decision making) and presumptive (presupposing those parents would decide to vaccinate their child the same day) approaches to increase vaccination acceptance. The presumptive format was associated with an increase in parental vaccine acceptance but also with reduced satisfaction in the clinical experience, while the participatory format showed the opposite pattern.72A survey in the UK investigated the use of defaults to increase catch-up vaccines  on measles, mumps and rubella (MMR) among members of the general population (62% of whom are parents with children).An RCT in the USA presented parents with a hypothetical scenario of moving to a new state where their adolescent son is starting at a new school.74Two studies focused their nudging intervention on changing the messenger assigned with communicating vaccine-related health information.75A non-RCT in Ireland presented 72 parents of young girls with a one-page summary describing risks of an HPV infection. Parents were then randomly assigned to either receive a gain-framed message (describing the benefits of getting the vaccine) or a loss-framed message (describing the risks of not getting the vaccine).76In the USA, a mixed-methods study investigated the effects of different ways of framing vaccine-related information on HPV vaccine intentions among three cultural groups  .78In China, a study examined women’s (aged 18–45 years old) intention to vaccinate their children (and future children) with HPV vaccines using three types of messages: (1) gain-framed , (2) loss-framed , and (3) narrative (participants were presented with a story of a young mother related to HPV and HPV vaccine).81Employing a different framing approach in the USA, an RCT demonstrated that framing vaccine benefits on an individual level (the vaccine recipient) significantly increased vaccination intentions compared with the same information being framed in terms of societal benefits.83Three studies highlighted the use of social norms  in existing social networks  to shape their knowledge and intention to vaccinate.84On the other hand, a mixed-methods study in Australia concluded that using a values-based approach can in fact polarise vaccination attitudes and therefore be counterproductive.85Six studies employed dramatic narratives and graphics in the context of vaccine messaging. A non-RCT in the USA found that using pictures of patients with vaccine-preventable diseases could improve parental perception about vaccines and vaccine schedule adherence.88radionovela (a dramatic story broadcast on the radio) of a young girl’s journey of hearing about and ultimately receiving the HPV vaccine improved knowledge and attitudes about vaccines among US Hispanic parents or guardians of young children.90An RCT in the USA found that a vaccination-related In the USA, Nyhan and colleaguesA variety of outcome measures were used to assess the effect of nudging interventions. The most frequent were vaccination uptake, intention to vaccinate, parental knowledge and attitudes towards childhood vaccinations, and vaccination acceptability and satisfaction. To better illustrate the results across approaches, we plotted the results on a matrix (‘harvest plot’In a majority of studies assessing how participants perceived a given nudging intervention (10 of 16), participants reported that the approach was acceptable, feasible and satisfactory. In 6 of the 10 studies that assessed vaccination knowledge and awareness, the nudge of providing incentives, saliency of information, framing messages, encouraging emotional affect and changing the messenger were reported to have a positive effect. Among the 19 studies that looked at vaccination uptake as the primary outcome of interest, 12 studies found statistically significant increases in vaccination coverage compared with control groups. Roughly half (12 of 21 studies) showed a positive effect on vaccination intention among study participants.This systematic review is an up-to-date synthesis of available evidence on how nudging affects intentions and behaviours related to vaccines and vaccine uptake, thus providing important guidance related to the ongoing COVID-19 pandemic and beyond. We identify a number of nudging approaches, including some codeveloped by scientists, community members and HCWs, several of which have shown promising results in changing vaccination attitudes or behaviours. Arguably, the most promising evidence in terms of vaccine uptake exists for nudging interventions that make available information more salient, offer incentives to parents and HCWs, and change defaults. While some studies seem to be efficacious in increasing vaccine uptake, only five included studies were designed within a controlled experimental setting.24Some of the identified nudging interventions are driven by emotional appeals using salient messages, with evidence showing they could increase vaccination intentions and uptake.Several studies showed evidence of the role of the ‘antivaxxers’ movement in the sudden decline of vaccine confidence and uptake of childhood vaccinations.91Several LMICs are currently experiencing sudden declines of vaccine confidence,107Several studies highlighted ethical concerns, including that nudging restricts individual freedom of choice109–111Health systems in general and vaccination challenges in particular are complex and generally not resolved through single interventions at the family or individual levels alone. Instead, multipronged approaches including communities, hospitals or points of care, and policymakers are needed and essential.VH is an urgent public health problem not only in the context of already existing vaccines with well-established efficacy and safety, but also with regard to novel vaccines, where limited uptake by the population could have disastrous implications.In light of our review, we present the following recommendations. For policymakers aiming at introducing VH interventions in their respective settings, we want to highlight the promising results of nudging-based interventions, particularly with regard to making available information salient, offering incentives, and changing defaults or the messenger. However, policymakers should be aware of the limited number of large-scale RCTs and the mixed evidence regarding the efficacy of the same nudge in different settings, especially with regard to LMICs. We therefore discourage transferring nudging interventions one-to-one to drastically different settings. Instead, a detailed understanding of the complexity of the target population, as well as comprehensive design research, is highly recommended to ensure the acceptability and effectiveness of the nudging intervention in the particular setting. Additionally, policymakers should look beyond vaccine recipients as intervention targets and consider broadening the scope to also include medical professionals and other stakeholders, and be aware of the risks of certain nudging interventions  that may increase public doubt and provide additional arguments for antivaccination groups.9 93With regard to future research, the gaps in terms of study design, sample size calculation and risk of biases highlight opportunities for more rigorous research to gauge the broader applicability of the nudging approach. Our results underscore that a relatively small number of studies have drawn on the concept of nudging regarding vaccination uptake, but promising results and the complexity of the concept, especially its applicability to different settings, call for further research. We also highlight a number of nudges which, to the best of our knowledge, have not yet been applied to VH but have shown promising results in other health promotion contexts, meriting further research. Furthermore, there is exceptionally limited information from LMICs informing this discourse, and qualitative research exploring acceptability regarding nudging interventions, both among policymakers and the general community, is similarly limited. The potential value and impact of nudging, and how nudges can profit from rigorous adaptation and acceptance from the community members are then paramount. We therefore urge scholars to consider these angles of investigation for future research.The key strength of this systematic review is the rigorous search and identification of eligible studies across several databases using extensive search strings, overseen by a biomedical librarian (JL). The use of an iterative process at the outset of literature extraction ensured that we systematically considered all behavioural interventions and improved our chances of capturing nudging interventions. Nevertheless, some factors limit the generalisability of our results. The current small number of studies and the high variability with regard to quality, methods, measurement of VH, and outcomes across studies do not allow for a meaningful meta-analysis to ascertain its primary effects on vaccination uptake. The fact that most studies (46 of 48) took place in higher-income settings also conditions the interpretation of our findings, given the demonstrated variability of effects according to context. Also, we restricted this review to studies published since 2008, when the term nudging emerged.Nudging takes different forms and is delivered via different interventions. Early evidence suggests nudging may be a feasible and promising approach to increase public confidence in vaccines. Nudges targeting the vaccine recipients close to the decision whether or not to vaccinate  show the most promise. However, nudges targeting providers to facilitate vaccination uptake among their clients  and therefore addressing VH from another angle are also valuable to consider and explore further. Successful public health programmes designed to increase vaccination uptake require context-specific adaptations to address target groups’ specific concerns and the understandings of vaccine-hesitant individuals. Further research, specifically in relation to nudging interventions in LMICs, is required.10.1136/bmjgh-2021-006237.supp2Supplementary data


The intervertebral disc (IVD) is the fibrocartilaginous joint located between each vertebral body that confers flexibility and weight bearing capabilities to the spine. The IVD plays an important role in absorbing shock and stress applied to the spine, which helps to protect not only the vertebral bones, but also the brain and the rest of the central nervous system. Degeneration of the IVD is correlated with back pain, which can be debilitating and severely affects quality of life. Indeed, back pain results in substantial socioeconomic losses and healthcare costs globally each year, with about 85% of the world population experiencing back pain at some point in their lifetimes. Currently, therapeutic strategies for treating IVD degeneration are limited, and as such, there is great interest in advancing treatments for back pain. Ideally, treatments for back pain would restore native structure and thereby function to the degenerated IVD. However, the complex developmental origin and tissue composition of the IVD along with the avascular nature of the mature disc makes regeneration of the IVD a uniquely challenging task. Investigators across the field of IVD research have been working to elucidate the mechanisms behind the formation of this multifaceted structure, which may identify new therapeutic targets and inform development of novel regenerative strategies. This review summarizes current knowledge base on IVD development, degeneration, and regenerative strategies taken from traditional genetic approaches and omics studies and discusses the future landscape of investigations in IVD research and advancement of clinical therapies. The intervertebral disc (IVD) is a fibrocartilaginous structure that connects the vertebral bodies in the spine. The IVD is composed of three substructures: 1) the proteoglycan-rich central region referred to as the nucleus pulposus (NP), 2) the fibrocartilaginous peripheral region referred to as the annulus fibrosus (AF), and 3) the superior and inferior cartilaginous endplates (CEP) . The maiThe IVD is particularly prone to impaired repair leading to permanent damage. The IVD, which is the largest avascular organ in the body, has low cell density, low nutrient flow, and a low oxygen environment, creating a particularly harsh microenvironment for the resident cells . Thus, tin vivo tissue regeneration by combining tissue engineering using biomimetic scaffolds, targeted drug delivery for endogenous cell activation and differentiation, and exogenous cell implantation , annulus fibrosus (AF), and two endplates of hyaline cartilage on the superior and inferior sides of the disc referred to as the cartilaginous endplates (CEP) . Like moThe IVD is primarily composed of extracellular matrix (ECM) molecules, including multiple types of collagens and proteoglycans  Figure . The proThe main function of the NP, the inner core of the IVD, is to resist compression of the spine and to redistribute the applied load to the spine . The heaThe main cell types in the NP are categorized as notochordal and chondrocyte-like large vacuolated cells . NP cellScx)+/SRY-related HMG-box (Sox)9+ progenitors that are originally unorganized but eventually align into the lamellar pattern as determined by actin stress fiber networks , Brachyury (T), and Notochord homolog (Noto) are all proven to be essential for regulating the development of the notochord (Shh) and hepatocyte nuclear factor (HNF)-3β  is important for successful differentiation and survival of notochordal cells , Shh, smoothened (Smo), Sox5/Sox6, and TSC Complex Subunit 1 (TSC1) were essential for NP development  and transforming growth factor (TGF)-β1 are known to play vital roles (Pax) 1 and Pax9 deletions can also affect the sclerotome cell proliferation, leading to a lack of vertebral bodies, proximal portions of the ribs, and IVD , TSC1, and Wnt/βcat are required for AF formation  is a cell-mediated response to the functional and structural failure of the disc . Disc deCOL1A1, COL9A2, COL11A1, Aggrecan, and IL-1 may play a role in disc degeneration , and physical therapy . If therThere are a variety of percutaneous procedures that can be classified into three categories: annuloplasty, percutaneous disc decompression, and endoscopic percutaneous discectomy. Annuloplasties are procedures aimed at repairing the disc annulus . IntradiDespite the theoretical benefits of these treatments and their extensive use, it appears that they have little clinical advantage over sham procedures . One cliOther percutaneous procedures targeting herniation and discogenic pain include endoscopic discectomy and disc decompression that includes laser discectomy, plasma discectomy, and mechanical disc decompression . EndoscoChemonucleolysis is a form of non-surgical treatment for discogenic pain and herniated discs , which iAs conservative therapy and percutaneous procedures are quite palliative in nature and may restrict functionality, surgery is utilized to help alleviate discogenic pain and with the hope of providing better mobility and function. Surgical treatments may include IVD excision, spinal fusion, or artificial disc replacement . Spinal Despite hundreds of thousands of individuals receiving spinal fusion surgery annually, there are various factors that bring into question the clinical significance and efficacy of the procedure. A study observed that for nonradicular back pain, fusion surgery was no more effective than intensive rehabilitation . An analAs spinal fusion surgery may limit mobility, artificial discs or cervical disc replacement (CDR) devices have emerged as an alternative as they preserve range of motion . As of 2in vitro tissue culture setting prior to use for treatment. However, as autologous stem cells are not always available for harvesting dependent on disease severity and presence of comorbidities in patients, some trials are exploring the use of allogeneic cells. This requires additional testing for immunologic and inflammatory responses, potential transmittable diseases, as well as additional consenting steps from the donors prior to implantation. The ethical and legal considerations for stem cell treatments and clinical trials are also dependent on each individual country’s healthcare and biomedical legislations, further complicating widespread implementation of cell-based therapeutics  line using CRISPR/Cas9-mediated genome editing that was verified by comparing them to two human NP cell transcriptome datasets . MSCs can be derived from robust sources like the bone marrow and adipose tissue, even from adult donors, and escapes much of the ethical and safety scrutiny that ESCs undergo in cell-based therapeutics development . Animal Recent advances in polymer and chemical engineering have led to the rapid development of synthetic and 3D printed bioimplants and hydrogels . RecentlThe advent of many omics techniques such as whole-transcriptomic sequencing (RNA-Seq), proteomics, and metabolomics have revolutionized our understanding of IVD development by allowing researchers to generate global profiles of gene expression and molecular level changes that are occurring at different time points during IVD formation. Omics studies have added much depth to our knowledge of processes involved in IVD development and helped to identify disc specific makers, as well as led to a better understanding of pathways involved in the maintenance and homeostasis of healthy tissue and degenerative changes that occur in IVD pathology. Some of the major omics investigations are discussed in this section and summarized in the omics tables .Pax1 and Pax9 positively regulate many genes associated with cartilage formation and activate expression of chondrogenic genes during early IVD differentiation  was shown to suppress hypertrophic differentiation of chondrocytes in conjunction with Sox9 since they regulate similar pathways in the same tissues  were upregulated in the same developmental window, providing insights into gene families required for patterning, ECM synthesis, and maintenance of the NP.NP cells . Using RCD24, stathmin-2 (STMN2), and reticulon 1 (RTN1), and implicated genes involved in inhibition of vascularization and inflammation as important master regulators of notochordal cell gene expression (FOXM1) and lysine demethylase 4E expression (KDM4E) were identified as signature gene markers for the AF and NP respectively. Furthermore, a membranome-based approach on immortalized NP and AF cell lines established from adolescent healthy disc tissue yielded various membrane-associated markers in the AF and NP  assay, where the cells were first quantified using a population average then assessed using single-cell analysis. They were able to detect differences between the NP, AF, and transition zone in between the NP and AF. Furthermore, the center region of the NP exhibits additional heterogeneity as indicated by the presence of a distinctive set of transcripts that are involved in cell pluripotency (Sox2 and Oct4) and the development of the notochord (Noto and T) and axial skeleton (Shh and Gli3).While bulk RNA-Seq has provided key insights into global gene expression profile changes that occur during the development of the IVD, it is important to account for the significant cellular heterogeneity that is present in fully formed IVD. Thus, single cell analyses such as single cell RNA-Seq (scRNA-Seq) can deconvolute some of these differences that may be lost when averaging the entire cellular population, especially at later time points . Kraus ein situ hybridization of adult bovine coccygeal IVDs identified 10 novel biomarkers, and further scRNA analysis of bovine calf coccygeal IVDs revealed 27 NP specific genes, 24 AF specific genes, and various cell population clusters (Transcriptomics has also been used to identify biomarkers and potential therapeutic targets for IDD. One study analyzed the rat IVD transcriptome using scRNA-Seq and established a comprehensive single-cell gene expression map as well as potential new genetic markers for IVD and multi-functional stem cells . Due to clusters  (biomarkclusters . scRNA aclusters . Analysiclusters . RNA-Seqclusters . Degenerclusters .Proteomics is used to identify and quantify proteins in a cell, tissue, or organism and to understand the structure and functions of these proteins . Using pNotably, Tam et al. were able to establish a spatiotemporal proteomics atlas of human intervertebral discs, DIPPER, through various measurement types including label-free proteomics, transcriptomics, and SILAC to degradome . Two cadKRT8, KRT18, KRT19, CA12, FOXA2, and NOG stayed consistent regardless of donor age or degeneration (Both transcriptomic and proteomic profiles of the developing disc have established the unique origin of the NP in mouse and human samples. However, the substantial structural changes that occur in the development of the IVD and the inherent heterogeneity of the fully formed NP, including the differences in cell population between mouse and human samples have made distinctly defining the ultimate mature NP cell profile a difficult task. In a recent study in adult human NP cells, Richardson et al. focused specifically on measuring putative notochordal and NP cell markers and found expression levels of previously identified novel NP and notochordal markers such as neration . AdditioIn addition to well-established transcriptomic and proteomic studies, other types of large-scale omics investigations are gaining momentum in IVD research as technologies become further refined, particularly in important mouse model studies . MatrisoMetabolomics is the utilization of advanced analysis techniques to identify and characterize metabolites from cells and tissues . MetabolThe IVD is an indispensable structure in the spine. The three substructures within the IVD work in concert to provide both mechanical support and biological function in the spinal column. The aggregated efforts of many labs over several years have established a solid framework for our understanding of the IVD. As a field, we have made great strides into elucidating many mechanisms that drive IVD development as well as mechanical and biological stresses that lead to IDD and related pathogenesis. While many early genetic and lineage tracing investigations laid the critical foundation for this field, advancements in omics techniques in more recent years have provided global overviews into early embryonic development, the genetic and molecular profile of a healthy IVD vs. a degenerated IVD, and importantly, new strategies in diagnostics and potential disc regeneration therapies.The complexity of the IVD, in development, composition, and function, makes this unique structure a particularly difficult one to fully understand. As the majority of the human population globally will be afflicted by disc degeneration and associated pain and other complications in their lifetimes, it is critically important to establish thorough and comprehensive molecular profiles of the IVD at various stages of development and disease. With the application of advancing omics technologies to both animal models and human samples, we already have an unprecedented and detailed view of many aspects of the IVD. While animal models are by no means a perfect replication of the human disc due to differences in IVD size, cell turnover, and biomechanical load, they have served as important starting points for developmental and degenerative studies as well as preclinical studies for therapeutics. Although human patient studies are difficult to achieve in large sample sizes, the ability to compare human data to large sets of animal data allows investigators to more readily establish validity of and relevance within their findings.The ideal outcome for future regenerative therapies is to be able to fully replace any damaged and diseased tissue with a substitute that has the capability to restore physiological function throughout the remainder of the patient’s lifetime. The best way to achieve this goal is to recapitulate the composition of the native tissue as closely as possible. Considering that organs and tissues in the body are in their healthiest state at the earliest points following completion of development and that the ultimate objective is to replicate native functional tissue, a key ingredient that is necessary to make significant progress towards building successful IVD regenerative strategies is a fully elucidated genetic and molecular profile of IVD development. Although multiple approaches to regenerative therapeutics have been under investigation for several years, we are still missing a comprehensive methodology that combines cellular gene expression, molecular signaling, and the ECM structure to construct native tissue-like replacements. Building on genetic and omics studies that have been completed thus far, in combination with multi-omics approaches, which allow for both temporal and spatial deconvolution of gene, protein, and other biomolecule expression at unprecedented resolution, we are well on our way to building a comprehensive profile of many aspects of the IVD. Taken together, these data will be crucial in furthering our understanding of development, maintenance, and pathology of the IVD, and will inform novel diagnostic and therapeutic advances in the future.


Patient experience is an important component of quality and patient centered health care not fully explored in physical therapy.This article addresses (1) concept of patient experience, (2) importance of capturing the patient experience, (3) measures to capture patient experience and whether these measures exhibit psychometrically sound measurement properties, (4) relationship between patient experience and clinical effectiveness outcomes, and (5) clinical applications of patient experience measures in the outpatient physical therapy setting, including suggestions for future studies.Employing patient experience measures into physical therapy practice may be an important key to improve clinical effectiveness outcomes and provide excellent patient-centered care delivery. An area of continued research should be focused on demonstrating the generalizability and measurement properties of patient reported experience measures for the musculoskeletal outpatient physical therapy population focusing first on the most common musculoskeletal conditions such as cervical, low back, and shoulder pain. Improving quality of care is an important focus for physical therapists. Quality of care can be evaluated based on inter-related domains of clinical effectiveness, safety, and patient experience. These related domains allow for improvements to be made in one area while addressing another. For example, addressing areas having been determined to need improvement through the information provided by a measure of patient experience could also potentially result in improvements to either of the two domains . While aOur view is that employing patient experience measures into physical therapy practice to objectively account for the patients’ perceptions of their health and experiences across various components is an important key to improve clinical effectiveness outcomes and provide excellent patient-centered care delivery. In this article, we discuss the (1) concept of patient experience, (2) importance of capturing the patient experience, (3) measures to capture patient experience and whether these measures exhibit psychometrically sound measurement properties, (4) relationship between patient experience and clinical effectiveness outcomes, and (5) clinical applications of patient experience measures in the outpatient physical therapy setting, including suggestions for future studies.Patient experience involves the sum of all interactions that patients have with the healthcare system, including their care from health plans, healthcare providers, and staff in inpatient and outpatient settings. It is shaped by an organization’s culture, that influence patient perceptions across the continuum of care . At its The overall quality of healthcare experience is intimately tied to the patient’s experience . While iMeasuring patient experience is unique from measuring patient outcomes and can be done with patient reported experience measures (PREMs). Unlike the commonly known patient reported outcome measure (PROMs), PREMs look at the patients experience with the healthcare system while receiving care, and objectively measure their experiences rather than simply subjective reports of satisfaction or outcomes . While PPREMs are questionnaires or surveys that can be used as a marker of healthcare quality based on the patient's perspective . PREMs cThere are a number of PREMs available for use in both the inpatient and outpatient settings and for specific medical conditions. The decision of which one to use in clinical practice should take the questionnaires’, measurement properties into consideration. Table The importance of the utilization of PREMs in relation to clinical outcomes is evident by the correlation between these two measures, with one example of such instance demonstrated through the improvement in outcome scores for individuals undergoing hip, knee, and hernia repairs , 4, 6, 8A few common relational aspects of patient experience that presented in past studies were patient-therapist interactions and interpersonal skills , 4. SomeBy making it a point to address aspects of patient experience that are valued by the patient, we may improve the overall patient experience, the quality of care and patient outcomes, but measuring these values in a validated questionnaire has been a challenge in an outpatient physical therapy world. Some different PREMs have been developed that each have their own strengths and weaknesses Table . The Pic


The authors conducted a scoping review to investigate the structure, content, and potential impact of post-residency medical education fellowships. The authors searched eight databases to identify English-language articles describing longitudinal, post-residency medical fellowships that both focused on medical education and described the structure and content of the curriculum. The authors summarized the findings of each article and, for those articles that included a program evaluation, assessed the potential impact of the program via the Kirkpatrick’s Four-Level Training Evaluation Model and the Medical Education Research Study Quality Instrument. Nine articles, describing a total of ten post-residency medical education fellowships, met inclusion criteria. Half of the programs were dedicated medical education fellowships and half were medical education tracks within a subspecialty fellowship. The content and educational strategies varied, with no two programs having the same curriculum. Most programs most focused on teaching skills, adult learning theory, curricular development, and medical education research/scholarship. Most programs used project-based learning, workshops, and faculty mentorship as educational strategies. Six of the articles included an evaluation of their program(s), all of which suggested positive changes, at least at the level of fellow behavior (Kirkpatrick level 3), and designs limited the strength of any conclusions drawn. This scoping review highlights the variation among medical education fellowships and the need for common curricular components, as well as program evaluation, across and within these fellowships. Additional assessment at higher levels of trainee outcomes will help guide the creation and revision of medical education fellowships, and inform the development of a core curriculum shared across programs. Such a core curriculum could then serve as the foundation for a certification program, by which a medical educator’s expertise could be recognized, thus elevating medical education to the stature it deserves within the academic mission. Clinician educators are active in a variety of roles, including teaching, curriculum design and assessment, education scholarship, innovation, and leadership ,2. Most Medical schools first created medical education fellowships in the late 1970s with the goals of improving faculty members’ teaching skills, advancing academic research, and transforming physicians into clinician educators . These fMedical education fellowships provide fellows protected time – before faculty appointment – to acquire the foundational knowledge and skills in medical education necessary to excel professionally. At the 2012 Academic Emergency Medicine Consensus Conference on Education Research, education leaders met to determine optimal training for education scholars and after an in-depth needs assessment, proposed a post-residency medical education fellowship prior to faculty appointment . ProposeThe number of medical education fellowship programs increased significantly since they were first implemented, as the number of graduating medical students and the demand for skilled teachers to train the future generation of doctors also grew . The benCurrent literature supports the importance and benefits of medical education fellowships . HoweverFollowing the Joanna Briggs Institute guidelines  for condWe transferred titles and/or abstracts of identified articles to Covidence  for furtTwo team members assigned Kirkpatrick’s Four Levels of Training Evaluation to each article based on the outcomes that were reported The Kirkpatrick model assesses programmatic effects or effectiveness, with 4 levels of outcomes including participant’s reaction (Level 1), participant’s learning (Level 2), change in behavior (Level 3), and program results (Level 4) . The quaOur initial database search identified 2645 article from the databases. After removal of duplicates, a total of 2385 articles remained. We excluded 2137 articles after screening of title and abstracts, leaving 248 articles for full-text review. After full-text review, we determined that nine articles , for a tThe structure and funding of the fellowships is summarized in The specific curricular content areas and educational strategies varied for each fellowship, though there were some similarities between fellowships. We summarized the curricular content and education strategies of each fellowship in Six of the articles about these fellowships reported on the assessment of learner outcomes, as shown in Four studies reported outcomes that we categorized as Kirkpatrick level 3, indicating a change at the level of participant behavior, with fellows assuming clinician educator roles after fellowship as the most common ,21,23. TThe goal of this review was to investigate the structure and content of post-residency medical education fellowships described in the literature. We found that medical education fellowships vary in terms of structure, curricula, instructional methods, and evaluation. Most are small, based at one institution, and offered through one department. This diversity of structure may be due to the diverse values and needs of the institution and/or department in which they reside.While we found no standard curricular content among medical education fellowships, a few commonalities did emerge, and we recommend the following best practices based on the findings of this review when creating a post-residency medical education fellowship. Institutions should consider their own needs and resources when creating the structure of the fellowship. For instance, if a robust department-based fellowship exists and a need for additional education training is identified, the department may choose to add a medical education track to the existing fellowship rather than create an independent medical education fellowship. Funding opportunities may also determine the structure of the fellowships. We recommend institutions draw on curricular commonalities of existing fellowships, including teaching skills, curriculum development, adult learning theory, medical education research/scholarship, and career development, as well as make scholarship and projects a focus, as this was the most commonly identified benefit. We advise programs to consider opportunities for evaluation, especially at higher levels such as change in behavior or patient outcomes, and outcomes that should be evaluated to continue to secure funding.In the national survey by Thompson et al, (2011) which focused on faculty development programs, less than half of programs allow fellows to participate . Most stThis review has inherent limitations, including the ability to only capture the subset of medical education fellowships that have reported on their programs’ structure and content. In addition, because most fellowships are small in number, newer fellowships may not have an adequate sample size for evaluation or sufficient data for publication. Another limitation, which may also be a strength, is that we only included medical education fellowships and medical education tracks of clinical specialty-based fellowships. This is a limitation in the sense that other related and relevant programs – such as faculty development programs – are not be identified; however, it is a strength that this review focuses on programs designed for participants who have just finished their residency training. Additionally, some articles included descriptions and evaluations of both medical education fellowships and faculty development programs at the same institution without distinguishing which content was included in which type of program.Our review confirmed that medical education fellowships confer both institutional and individual benefits, as has been described previously in the literature ,5,7–10.


This study focused on the trends in antiosteoporosis drug preferences and compared the incidence of fractures between patients treated orally and those who were exposed to an awareness campaign and assigned to intravenous/subcutaneous treatment.  Our hospital registry included 1,716 osteoporotic women who were over 65 years of age without preexisting vertebral and nonvertebral fractures over 1 year before this study, with bone mineral density (BMD) < −2.5 standard deviation (SD) and fracture assessment tool (FRAX) score > 20%, who were given 1,337 oral and 379 intravenous/subcutaneous prescriptions to treat their osteoporosis. Self-administered surveys  collected data on trends of preferences among nine drugs and fracture prevention using relative risk reduction (RRR).  The number of patients taking oral prescriptions decreased gradually from 2012 to 2016, while the number of patients treated with intravenous and subcutaneous injections increased. The incidence of fracture was lower in patients receiving intravenous and subcutaneous injections than in patients taking oral medications.  These findings indicate a decrease in oral prescriptions for osteoporosis treatment and that treatment for osteoporosis using intravenous or subcutaneous injections of antiosteoporosis drugs is more effective for preventing fractures. Osteoporosis has been recognized as a major disease of older adults, especially women who often suffer from fractures due to fragility . Recentln = 673, intravenous: n = 42), risedronate , minodronate , ibandronate (intravenous: n = 129), selective estrogen modulator , teriparatide , and denosumab (subcutaneous: n = 33). The patients were divided into two groups according to the route of drug administration: an oral group and intravenous or subcutaneous (IV/SC) group. Moreover, the IV/SC group was classified into two groups: IV bisphosphonate  and the anabolic group (teriparatide and denosumab). All eligible patients were over 65 years of age, and the average of the follow-up period for this trial was around 2 years. For the surveillance study, subjects were asked to identify fractures they had experienced during this treatment for any of the specified locations: the clavicle, upper arm, wrist, spine, rib, hip, pelvis, upper leg, and lower leg. This study was conducted according to the Helsinki Declaration, and the medical ethics committee of Akita University Graduate School of Medicine approved this study .A retrospective cohort of patients treated as outpatients for osteoporosis and fractures between 2012 and 2016 at Igarashi Memorial Hospital was examined. Patients for the cohort were selected based on the standard for the diagnosis of osteoporosis: both T score of BMD < −2.5 SD and FRAX in MOF > 20%. DXA was performed by using the DTX-200, Datex DSM, Courtaboeuf Cedex, France. A total of 1716 patients were provided awareness program that, based on their preferences from either oral prescription or intravenous/subcutaneous administration after the usage of these several kinds of antiosteoporotic drugs, including their risks, benefits, and costs associated with treatments which were paid by insurance, was explained. Patients were excluded if they were cognitively impaired, had other illness, had previous treatment of osteoporosis, or had a previous fracture within 1 year. The antiosteoporosis drugs prescribed in this trial were alendronate . The RRR was based on the comparison with oral alendronate, which was the most prescribed drug (n = 672).Data for age, BMD of the forearm, FRAX, previous history of treatment for osteoporosis, adherence to treatment, and fracture rate were evaluated. Information on demographic characteristics of the subjects, osteoporotic condition, and outcomes of fractures was extracted from each clinical report and tabulated in Microsoft Excel spreadsheets. For each of the dependent variables, several explanatory variables including duration of treatment, number of patients, age, sex, age, body mass index (BMI), and previous history of medications were examined. Statistical analysis was performed using Microsoft Office Excel and the Statcel 3 program . Each subject was analyzed by the unpaired The accumulated number of patients was 1337 on oral prescriptions and 379 in the IV/SC group. The IV/SC group had significantly older age, higher FRAX score, and a significantly lower incidence of fracture than the oral group. There were no significant differences between the groups in BMI, BMD, and past history of medications . The numThe IV/SC group showed a higher rate of adherence to treatment than the oral group .Both bone resorption and bone formation markers also showed almost same results which have already been reported by Japanese clinical trial phase 3 in every IV/SC and oral groups. These results imply that all medications were effective during this treatment period on the basis of restriction of bone turnover marker and anabolic window Figures –5.The number of incidence of adverse events in each drug is shown in Incidence of fracture .The oral group had a significantly higher incidence of fracture than the IV/SC group, which had a high RRR, and the anabolic group appeared to prevent fractures the most in patients with osteoporosis .n = 672) showed that teriparatide and denosumab had the strongest fracture prevention effect (A comparison of the fracture rate between the IV/SC group and the major oral drug (alendronate, n effect .The number of oral medications has been decreasing in tandem with the increase in the number of intravenous and subcutaneous medications for osteoporosis in the USA , like thNext, the trends in prevention of osteoporotic fracture were investigated for the several kinds of therapies. The data analysis shown below found that, in the IV/SC group, especially the greatest preventive effect was seen with teriparatide, followed by denosumab, ibandronate, and alendronate in order.Although there were a few reports comparing BMD and fracture rates among several kinds of drugs in the treatment of osteoporosis –12, our Although this study has multiple methodological limitations including heterogeneity in the comparing groups and types of awareness program, the former drug used anabolic vs. antiresorptive that compared between new off-labeled drug treatment and the present mainstream treatment of osteoporosis. That implies for the testimony of effectiveness whether new anabolic drug treatment is more effective against the present antiresorptive drug treatment or not. The latter, although this awareness program was based on the patient's preferences, may be focused on the injectable groups rather than oral antiresorptive groups due to the patient's family assistance. Therefore, the distribution of these treatments would lead to being inadequate and heterogenous.Finally, we have some bias, including the number, duration, and patient's choice of medication because zoledronic acid and romosozumab, which have strong fracture prevention effects, could not be used because they were introduced to the Japanese market recently –32. FurtIn summary, these results showed a decrease in the number of oral prescription drugs for osteoporosis treatment, and intravenous and subcutaneous treatment for osteoporosis was more effective in fracture prevention.The trends in treatment for osteoporosis were examined, and the fracture rates were compared among nine osteoporosis drugs. The results showed that the number of patients given oral prescription decreased gradually from 2012 to 2016, while the number of intravenous and subcutaneous injections increased, and the fracture rate was relatively low in the intravenous and subcutaneous injection patients compared to the oral prescription patients.


BackgroundSimulation is used in critical care for skill development, formative assessment, and interprofessional team performance. Healthcare educators need to balance the relatively high cost to deliver simulation education with the potential impact on healthcare quality. It is unclear how to prioritize simulation in critical care education, especially considering interprofessional needs across adult and pediatric populations. The objective of this study was to prioritize topics for critical care educators developing simulation-based educational interventions.MethodologyA modified Delphi process was used to identify and prioritize critical care topics taught using simulation. We disseminated a multi-institutional survey to understand critical care simulation topics using a three-round modified Delphi technique. An expert panel was recruited based on their expertise with simulation-based education through the Society for Simulation in Healthcare and the Society of Critical Care Medicine lists. Critical care topics originated using content derived from multiple critical care board examination contents. Additional content for a critical care simulation-based curriculum was generated.ResultsConsensus and prioritization were achieved in three rounds, with 52 simulation experts participating. The first Delphi round surveyed priority topics in critical care content and generated additional topics for inclusion in round two. The second Delphi round added the content with the highest-ranked items from round one to generate a set of simulation-based topic priorities. The third Delphi round asked participants to determine the importance of each priority item taught via simulation compared to other modalities for clinical education. This round yielded 106 topics over four domains categorized into (1) Diagnosis and Management of Clinical Problems, (2) Procedural Skills, (3) Teamwork and Communication Skills, and (4) General Knowledge and Knowledge of Technical Adjuncts.ConclusionsThe modified Delphi survey revealed a prioritized, consensus-based list of topics and domains for critical care educators to focus on when creating a simulation-based critical care curriculum. Future work will focus on developing specific simulation-based critical care curricula. Simulation-based medical education (SBME) is widely accepted as an effective method to teach interprofessional and interdisciplinary team communication skills, technical skills, high-stakes rare events, and integrative case-based demonstration of higher-level skills . HealthcEvidence supports using SBME to teach numerous domains of critical care, spanning across multiple medical specialties and healthcare professions -4. EducaDespite the evidence of its importance, there is no current widespread standardized curriculum or guidance on critical care simulation content for educators. Although several disciplines have developed guidelines for teaching critical care topics, none have exclusively prioritized the role of a simulation-based curriculum for this level of intensive care training ,15. TherDesign and Delphi processA modified Delphi was used to develop consensus around SBME priorities and present a list of content to guide future simulation-based educational priorities such as generating a standard critical care simulation curriculum -16. The Identification of simulation education experts for Delphi panelThe research team was composed of interprofessional members of the Society of Critical Care Medicine (SCCM) Research Section, Simulation Education Research Subcommittee. Simulation education experts were identified through the purposeful sampling of publicly available lists of simulation centers to identify experts in critical care simulation education for this panel. Representatives of accredited simulation centers available through the American Board of Anesthesiology and Society for Simulation in Healthcare were approached, along with members of the SCCM Education Research Committee. We defined “critical care simulation educator” as someone who uses any modality of technology-enhanced simulation to educate learners, utilizing evidence-based strategies directed at critical care practice objectives . We estaStudy data were collected and managed using REDCap electronic data capture tools co-hosted at the University of Pittsburgh and Stony Brook University. Surveys were distributed between December 2018 and June 2019. Responses were collected and de-identified for final data analysis. No limits on respondents were set a priori. Once panelists agreed to participate, a link to the first round of the survey was sent, along with detailed instructions on how to complete the Delphi surveys.The writing group consisted of 12 members, a diverse interprofessional and interdisciplinary group of simulation educators and facilitators from neurocritical care (2), pediatric critical care (5), emergency medicine-critical care (1), pediatric emergency medicine (1), critical care nurse practitioners (1), and critical care pharmacist (1).Survey design and iterative feedbackInitial first-round items were derived from blueprint content of critical care board examinations from the following specialties: the American Board of Internal Medicine, American Board of Surgery, American Board of Pediatrics, American Board of Emergency Medicine, and American Board of Anesthesiology. Descriptions of training program requirements in critical care medicine were reviewed to determine a list of topics for ranking in the survey. As all study team members were critical care simulation educators, a pilot test of the survey for readability, feasibility, and face validity was performed, and changes were made as needed. Experts were asked to prioritize each topic on a three-point Likert scale . Free text options to describe the current simulation curriculum and its associated objectives were included. At the end of the first round, unique free-text items were analyzed and included in the second round as potential additions to curricular content.Consensus was defined a priori as >80% agreement with “somewhat” or “most” important selected. Topics with a consensus of <80% were not included in the priority list for round two as they were thought to be unlikely to reach a consensus. Round two items were aggregated from round one, and potential topics for inclusion in a critical care simulation content outline were included in the final round of content generation. At the end of the second round, we selected the items from the list of consensus curriculum that achieved this threshold -18,21. FFor round three, items were again aggregated and then prioritized into three domains of content that were most important, somewhat important, or least important to include as SBME content. For each ranking, we asked participants to rate each topic using a three-point Likert scale (with options labeled 1 = best taught via simulation to 3 = should not be taught via simulation).To obtain a prioritized list of critical care content, we used the methods proposed by Altschuld and Thomas, where content is ranked and scored according to the frequency of occurrence for prioritization scoring . AccordiOutcome measuresThe primary outcomes of interest were ranked in order of importance of areas of critical care content. We defined “simulation education” as any modality of technology-enhanced  simulation, which is an educational tool with which the learner interacts to mimic an aspect of clinical care for the purpose of teaching or assessment in the delivery of critical care to adult or pediatric patients . The priConsensus was reached after round three, from which we developed a critical care simulation content outline. All recommended topics were mapped into four main learning domains: General Knowledge, Diagnosis and Management, Procedural Skills, and Teamwork and Communication; consensus was reported among all simulation specialists Figure .A total of 52 experts participated in the initial survey, 27 of whom completed all three rounds (52%). The majority of participants worked in critical care. There were 34 (65%) respondents who were physicians, followed by nurse practitioners n = 6, 12%), nurses , pharmacists , respiratory therapists , and other . Experts most commonly represented pediatrics  and emergency medicine . These experts reported working in 16 states across all geographical regions of the United States. Additional demographic data of the simulation experts are presented in Table 2%, nurseThe first round of the Delphi survey contained demographic information and 22 items focused on simulation, including free-text boxes for participants to add additional critical care curriculum content not previously captured. The second survey included 183 questions and with a completion rate of 69% (36/52). The third and final survey generated a list of 116 elements of ranked content and was returned with a completion rate of 75% (27/36).After the Delphi process, experts identified 106 items to be recommended for critical care content over four domains. Topics with a score of >60 were strongly prioritized in the four domains of General Knowledge and Knowledge of Technical Adjuncts, Diagnosis and Management, Procedural Skills, and Teamwork and Communication Skills, and are listed in Tables Topics with moderate priority are listed in Table Evaluation of the recommended topics yielded four major domains: Procedural Skills, Clinical Elements, Conceptual Elements, and Interpersonal Elements Figure .We developed simulation-based critical care education priorities through the consensus of simulation experts across all pediatric and adult critical care facets. In defining these domains and categories of core simulation-based critical care content, we hope to improve the prioritization of SBME within critical care. Identifying priority areas for simulation-based education may help stakeholders, including healthcare organizations, professional societies, and educational leadership, prioritize funding, budget allocations, faculty/staff support, research collaboratives, and program assessments. This content should aid training programs and simulation centers in evaluating learners and target learning needs specific to critical care medicine.Prior work using the Delphi process for content generation has been used to generate UME content for critical care  and pediA key finding of our study was a generally good agreement on the topics for critical care education across teamwork, communication, and procedural skills. While pathophysiology and diagnosis may differ across the age spectrum and between different medical and surgical subspecialties, often the basics of procedures and especially the skills necessary for effective communication during resuscitation events transcend specialties and professions. This suggests that combining interprofessional critical care simulation programs across subspecialties may benefit from optimizing resource utilization. We hope that this will ultimately facilitate a shift from training in silos to training together through interprofessional simulations. In doing so, we might better approximate how we might create better learning activities for critical care teams.Despite an underrepresentation of neurointensivist participation, neurological emergencies were identified as an area of high priority, potentially reflecting emerging awareness of the utility of SBME for teaching about neurological emergencies and technological advances that support creating such simulations. Intensivists, including pediatric, emergency medicine, and trauma critical care providers, have essential roles in the initial identification and management of acute neurological injury and thus may have ranked these topics higher.One of the main challenges of the widespread adoption of simulation education is insufficient faculty time and the limited ability to regularly pull trainees and interprofessional colleagues from clinical care responsibilities. Especially during the global coronavirus disease 2019 (COVID-19) pandemic, any disruption to the available pool of faculty and trainees available to provide bedside care is unlikely to be supported and may result in the cancellation of simulation courses altogether. By co-training learners from different specialties, no individual department is left with inadequate patient care coverage. Additionally, if course goals and objectives are uniform, faculty across different specialties could share the responsibility of teaching sessions. Finally, expanding the pool of potential learners and research subjects can further facilitate the performance of simulation education research. Additionally, the COVID-19 pandemic has shown the importance of cross-training healthcare providers who are not typically critical care providers for such surges. This priority list helps healthcare systems and simulation centers determine key objectives for rapid just-in-time training.Our work has several significant limitations, including a variable survey response rate and drop-off between rounds resulting in a small sample size of predominantly physicians and a higher ratio of pediatric-to-adult intensivists. Additionally, it is not possible to extrapolate if the opinions expressed by educators truly reflect learners’ needs. Third, our results may have been different had this study been performed after the onset of the COVID-19 pandemic.The Delphi method has inherent limitations within the process itself. The intention is to gather and obtain consensus based upon experts’ opinions and insight. It does not result in an evidence-based summary (a Delphi is performed precisely because of a lack of evidence within a specific area). Additionally, the final product is a list of statements that gained consensus but does not provide additional detail or depth to those answers. This study’s specific aims focused on overall expert opinion for which consensus was sought over a wide range of content, spanning multiple disciplines, several specialties, and age ranges, thus limiting the ability to obtain in-depth input for any specific subspecialty or pathology. However, the broad net that was cast in this project may also be seen as a strength as it increases the generalizability of the findings. Given the scope of the study, some of the topics listed by subspecialty boards were more detailed than others, leading to a wide range in the specificity of the topics included.The Delphi survey’s extensive and iterative nature could have led to potential survey fatigue and content bias. The composition of our expert panel may have been biased as well. Although we tried to mitigate this by broadly recruiting experts in the field through multiple lists, the final panel was somewhat self-selecting by answering our recruitment emails. Given that this Delphi process was conducted remotely, as opposed to in-person, bias from a smaller group of “influential” experts was less likely to have occurred. However, using a remote method without an in-person component may have also contributed to the relatively high attrition rate experienced. While we had a reasonably sized group, it is unclear from existing literature what the ideal size of an expert panel should be. A group should generally be large enough to propose new ideas and overcome attrition issues. A total of 30 members have been suggested as a reasonable target to attain these goals and align with our final survey round . FinallyIn conclusion, we defined priority areas in SBME curricula for critical care using a modified Delphi process. Healthcare systems and simulation centers should focus on these criteria when designing training curricula for critical care teams across medical professions and subspecialties and consider sharing resources between different groups of faculty and learners. As critical care practice changes with new medications, technology, and multispecialty teams, judicious use of simulation will help ensure timely and effective educational interventions that will also inform quality improvement and safety initiatives.