Antimicrobial resistance (AMR) is a critical global health threat with a disproportionate impact on low-income and middle-income countries (LMICs) due to their higher burden of infections, reduced laboratory surveillance infrastructure and fewer regulations governing antimicrobial use among humans or animals. While there have been increasing descriptions of AMR within many LMICs in WHO’s Western Pacific and South East Asian regions, there remains a paucity of data from Pacific Island countries and territories (PICTs). The PICTs represent 22 predominantly middle-income countries and territories with a combined population of 12 million people and 20 official languages, spread over hundreds of separate islands spanning an area corresponding to more than 15% of the earth’s surface. Our paper outlines the present state of the evidence regarding AMR in PICTs—discussing the present estimates of AMR and their accompanying limitations, important drivers of AMR, as well as outlining key priorities and potential solutions for tackling AMR in this region. Significant areas for action include developing National Action Plans, strengthening laboratory surveillance systems and educational activities targeted at both healthcare workers and the wider community. Ensuring adequate funding for AMR activities in PICTs is challenging given competing health and environmental priorities, in this context global or regional funding initiatives such as the Fleming Fund can play a key role. There is a paucity of antimicrobial resistance (AMR) data from Pacific Island countries and territories (PICTs), especially for pathogens deemed ‘critical’ by WHO.Important potential drivers of AMR in PICTs include antimicrobial selection pressure in humans and animals, healthcare transmission of AMR pathogens, poor community understanding of AMR and increasing population movement and travel.excess, without jeopardising antimicrobial access for those who need them.In addressing AMR, a challenge for PICTs is trying to curtail antimicrobial Key priorities for PICTs responding to AMR should include developing National Action Plans, strengthening laboratory surveillance systems and educational activities targeted at both healthcare workers and the wider community.Providing funding for AMR can be difficult for PICTs in the setting of multiple competing health and environmental priorities; global or regional funding initiatives can play an important role.The emergence of antimicrobial resistance (AMR) represents a growing health threat that could undo decades of medical progress. Previously innocuous infectious or routine surgical procedures, such as Caesarean sections, may become life-threatening events in a ‘postantibiotic era.’3The Pacific Island countries and territories (PICTs) consist of 22 members of the Secretariat of the Pacific Community, with the omissions of Australia, New Zealand, USA and France . All are6The impact of AMR has been well described in other countries from the WHO Western Pacific Region10Escherichia coli resistant to third-generation cephalosporins was 0% in Kiribati (n=72), 12% in Fiji (n=2895), 24% in  and 77% in Micronesia (n=158).10The existing knowledge of AMR in PICTs was summarised in a recent systematic scoping review identifying 65 relevant studies published since 1950.Klebsiella pneumoniae surveillance isolates from a Fiji hospital were resistant to carbapenems.To date, carbapenem resistance—one of the most challenging and concerning examples of AMR—appears to be uncommon. For example, less than 1% of 2175 Accurately defining the magnitude of the problem of AMR in PICTs using existing literature has many challenges . First, Box 1Limited volume of dataSmall number of published studies.Small number of tested isolates.Acinetobacter baumannii).Paucity of surveillance data especially notable for some ‘critical’ bug/drug combinations  or subgroups .access to antimicrobial susceptibility testing.Under-representation of populations with limited or absent Limited quality of dataMany PICT laboratories lack rigorous quality assurance processes.Many PICT laboratories face shortages of necessary equipment or trained staff.Subsequent potential for AMR to be missed or misclassified.Long-term successful AMR surveillance in PICTs is possible, however, requires significant resources, infrastructure, capacity building and support. One example is the WHO Gonococcal Antimicrobial Surveillance Programme, active in certain PICTs for over 25 ye ars.17From the global literature, we have extrapolated some of the main drivers that are likely to influence the development and spread of AMR in the Pacific. Under the headings below we have provided context and highlighted the existing state of knowledge in PICTs. A schematic representation of drivers of AMR and potential solutions is presented in Antimicrobial use can exert selective pressure on micro-organisms, promoting the development and persistence of AMR isolates. Human antimicrobial consumption continues to rise globally, driven mostly by increases among LMICs.23Campylobacter carriage among 97% of chicken neck-skins at the point of slaughter. Of concern 47% of isolates were resistant to ciprofloxacin, an important antimicrobial regularly used in humans.26Use of antimicrobials in animals can also contribute to AMR. Animals may be given antimicrobials not only to treat existing infections, but also for prophylaxis, metaphylaxis (treating an entire group after a subset develop symptoms or disease) or growth promotion. There is little data on rates of antimicrobial use in animals in PICTs. Only five PICTs are member countries of the World Organisation for Animal Health (OIE), and the OIE’s annual report on regional antimicrobial use in animals provides aggregated data only, not country-level data.AMR acquisition can occur not only due to antimicrobial selective pressure, but also the direct transfer of multidrug-resistant organisms (MDROs) between humans, animals or the environment. This is a particular concern in healthcare settings, where high volumes of antimicrobials are used, infections are more likely to be due to MDROs and organisms can easily spread from patient to patient either directly or via healthcare workers and hospital equipment. Healthcare-associated infections are at least twice as common in LMICs than in high-income settings.Poor community knowledge about the purpose of antimicrobials, and the risks of AMR, can drive inappropriate demand for these products. Similarly, unnecessary prescribing of antimicrobials—for instance, for syndromes that are predominantly viral in aetiology—also contributes to excessive antimicrobial use. A survey of 112 Samoans living in New Zealand demonstrated common misconceptions around the role of antimicrobials: over 80% believed they could treat common colds, and very few (8%) were aware of the concept of AMR.32Traditionally, PICTs experienced low volumes of airline traffic due to their geographical dispersion, small populations and high costs of fuel and parts. However, the recent emergence of low-cost carriers has led to greater capacity on existing airline routes and the introduction of new routes.Another potential transmission source of AMR for PICTs is medical tourism.AMR is an important global health threat to which PICTs are particularly vulnerable. Globally, the danger of AMR has been recognised and efforts made to mobilise a response. The WHO’s ‘Global Action Plan on AMR’ is the internationally agreed framework for action.The Global Action Plan calls on countries to develop National Action Plans (NAPs) that are aligned with the global strategy but take into account local resources, national priorities and local governance arrangements.Regular and reliable surveillance should be the cornerstone of any AMR response. It provides an accurate understanding of AMR prevalence and changes over time, permitting the development of targeted AMR policies informed by local data. However, as highlighted earlier, AMR surveillance in PICTs can be variable, hindered by a lack of trained staff or consistent access to the necessary equipment and materials. Currently data are often recorded in hard copy, and cannot rapidly be linked to a centralised system or other facilities. PICTs should aim to develop their national laboratory infrastructure so that AST can be reliably performed on WHO Priority PathogensCorrect selection of antimicrobials by healthcare providers is also important to reduce AMR. Such stewardship is assisted by targeted education of healthcare workers, and developing standard treatment guidelines.Antimicrobial prescribing can also be optimised by rapidly differentiating between bacterial infections and other febrile illnesses. Studies from LMICs in South East Asia have demonstrated modest reductions in antimicrobial use with point-of-care testing for C-reactive proteinAwareness campaigns can help reduce unnecessary demand for antimicrobials, especially in the outpatient setting.excess should not concurrently deny antimicrobial access to those patients who require them.Lastly, when considering stewardship initiatives in PICTs, it is essential to recognise that more deaths currently occur in LMICs due to inadequate access to antimicrobials, rather than AMR.Allocating adequate funding towards AMR in PICTs is challenging. Competing national budget priorities—for instance, the rapid increase in non-communicable diseases,Globally, there has been a significant increase in funding for AMR research and initiatives in LMICs, most prominently through the Fleming Fund.47The small size and relative isolation of PICTs can be advantageous when monitoring antimicrobial consumption: there is little parallel importation of medicines, and national coverage of dispensaries is easier to achieve. Presently, many PICTs monitor their stockpiles and movements of medicines using software such as mSupply,49There is scope for this existing digital data to be analysed and presented as a proxy for antimicrobial consumption: providing accurate, real-time data down to the level of individual regions or clinics. In addition to the ability to contribute data to WHO’s Global Programme on Surveillance of Antimicrobial ConsumptionRates of both AMR and antimicrobial consumption are rising globally, especially within LMICs. Such increases are likely being replicated within PICTs, which face similar challenges including high rates of infectious diseases, low community knowledge around antimicrobials and AMR, and limited laboratory surveillance capacity. However, precise estimates of AMR prevalence within humans, and especially within animals, are hindered by a scarcity of data.WHO has taken a leading role in coordinating a global response to AMR, most notably through its Global Action Plan. Within PICTs, we suggest that addressing AMR should initially focus on: (1) optimising governance and cross-sectoral collaboration through the establishment of NAPs, (2) optimising surveillance through strengthening laboratory capacity and (3) optimising antimicrobial awareness through community education activities and provision of standard treatment guidelines for clinicians. Additionally, we believe PICTs have the potential to rapidly develop advanced surveillance systems for antimicrobial consumption in humans by building on existing IT infrastructure and improving laboratory systems. While providing reliable funding for AMR activities may be challenging for PICTs in the setting of multiple competing health and environmental priorities, global or regional funding initiatives can play an important role. Technical and financial support for sustainable collaborations and international partnerships with organisations with established AMR surveillance systems can help reduce the barriers faced by PICTs.


Juvenile idiopathic arthritis (JIA) is a heterogeneous disease, the signs and symptoms of which can be summarised with use of composite disease activity measures, including the clinical Juvenile Arthritis Disease Activity Score (cJADAS). However, clusters of children and young people might experience different global patterns in their signs and symptoms of disease, which might run in parallel or diverge over time. We aimed to identify such clusters in the 3 years after a diagnosis of JIA. The identification of these clusters would allow for a greater understanding of disease progression in JIA, including how physician-reported and patient-reported outcomes relate to each other over the JIA disease course.In this multicentre prospective longitudinal study, we included children and young people recruited before Jan 1, 2015, to the Childhood Arthritis Prospective Study (CAPS), a UK multicentre inception cohort. Participants without a cJADAS score were excluded. To assess groups of children and young people with similar disease patterns in active joint count, physician's global assessment, and patient or parental global evaluation, we used latent profile analysis at initial presentation to paediatric rheumatology and multivariate group-based trajectory models for the following 3 years. Optimal models were selected on the basis of a combination of model fit, clinical plausibility, and model parsimony.Between Jan 1, 2001, and Dec 31, 2014, 1423 children and young people with JIA were recruited to CAPS, 239 of whom were excluded, resulting in a final study population of 1184 children and young people. We identified five clusters at baseline and six trajectory groups using longitudinal follow-up data. Disease course was not well predicted from clusters at baseline; however, in both cross-sectional and longitudinal analyses, substantial proportions of children and young people had high patient or parent global scores despite low or improving joint counts and physician global scores. Participants in these groups were older, and a higher proportion of them had enthesitis-related JIA and lower socioeconomic status, compared with those in other groups.Almost one in four children and young people with JIA in our study reported persistent, high patient or parent global scores despite having low or improving active joint counts and physician's global scores. Distinct patient subgroups defined by disease manifestation or trajectories of progression could help to better personalise health-care services and treatment plans for individuals with JIA.Medical Research Council, Versus Arthritis, Great Ormond Street Hospital Children's Charity, Olivia's Vision, and National Institute for Health Research. Juvenile idiopathic arthritis (JIA) is a heterogeneous condition with onset in childhood or early adolescence and common disease features that include joint swelling and pain.3Key outcomes for individuals with JIA are included in a core outcome set and are incorporated into the juvenile arthritis disease activity score (JADAS) and clinical JADAS (cJADAS),Evidence before this studyTraditionally, outcomes in chronic disease research, such as those used in juvenile idiopathic arthritis (JIA), have focused on changes either in single disease measures or in composite outcomes over time. This does not allow an understanding of how individual measures change in relation to each other. Because most measures represent unique aspects of disease, one cannot assume that they change in parallel. Novel unsupervised machine learning methods offer the opportunity to find so-called latent clusters of outcomes over time, facilitating a greater understanding of disease progression than is possible with a traditional dichotomy of improved or not improved. We searched MEDLINE and Embase from April 1, 1974, to Jan 1, 2019, for studies published in English of JIA (MeSH “juvenile arthritis”) using the search strings . Published studies have identified clusters of children and young people that differ in single aspects of disease over time. We did not find studies that used longitudinal multivariate approaches to understand how core clinical outcomes in patients with JIA progress in relation to each other after diagnosis.Added value of this studyOur work reports global longitudinal patterns of disease in children and young people with JIA, extending knowledge of the heterogeneity in disease course beyond the existing International League of Associations for Rheumatology paradigm. Additionally, studies have repeatedly shown that patient-reported outcomes do not correlate well with physician-reported outcomes. Our study shows that there are multiple clusters among children and young people with JIA who have different patterns in these outcomes over time, and that these patterns sometimes diverge. In doing so, we provide a foundation for reassessment of how JIA disease measures are used to capture disease course and clinical outcomes.Implications of all the available evidenceThese data show that although disease severity at onset of JIA is important across several JIA core outcomes, it does not entirely predict future disease course, particularly for those who have persistently poor wellbeing despite improvement in clinically detected arthritis. These children and young people have a large, unmet need for early identification and personalised management plans, because disease in these individuals is often difficult to manage with anti-rheumatic therapies alone. Our study also shows that novel unsupervised machine learning methods applied to traditional epidemiological data represent an exciting step toward stratified management for children and young people with JIA, as new avenues for biomarker discovery and further understanding of disease mechanisms become available within this heterogeneous disease.To further personalise medicine in JIA, it is important to understand the global patterns of disease, including how signs and symptoms of disease manifest at diagnosis, and how they unfold thereafter. Novel unsupervised machine learning methods are able to sort through heterogeneous real-world data and group individuals into previously unrecognised latent classes, in which shared disease patterns are identified among multiple signs and symptoms, either at a single time point  or longitudinally over time.To identify potential distinct groups within children and young people with JIA, several methods have been applied. Traditionally, consensus-based techniques have been used to develop JIA classification criteria.The aim of this analysis was to use unsupervised machine learning approaches to identify unique clusters of children and young people with JIA, both at first presentation to paediatric rheumatology and during a 3-year follow-up. To our knowledge, ours is the first analysis to use cross-sectional and longitudinal multivariate approaches that include data across multiple core clinical outcomes.The study population was comprised of children and young people recruited for the Childhood Arthritis Prospective Study (CAPS), a UK multicentre inception cohort of patients with childhood-onset arthritis. CAPS began recruitment in 2001 and had recruited over 1700 participants by Jan 1, 2019. Ethical approval for the cohort was gained from the Northwest Multicentre Ethics Committee ; written informed consent was provided by the parents or guardians, and assent was provided from children and young people, where appropriate.Children and young people with a physician's diagnosis of JIA were selected for analysis if they were recruited before Jan 1, 2015, to allow for at least 3 years of follow-up. If no cJADAS score could be calculated at any point, they were excluded.Data were collected at initial presentation to paediatric rheumatology (baseline) and annually thereafter. Between 2001 and 2010, data were also collected 6 months after baseline. Data at each timepoint included demographics, disease features including International League of Associations for Rheumatology (ILAR) category, disease activity, and medication data; these were extracted from medical records by study nurses. For this analysis, ILAR categories were assigned using data recorded 1 year after baseline; if this was missing, the closest ILAR category recorded on either side of 1 year was used, with preference given for the baseline value. Additionally, participants were asked to complete the Childhood Health Assessment Questionnaire (CHAQ), which incorporates two 100 mm visual analogue scales (VAS) for pain and patient or parent global evaluation of wellbeing. Parents or guardians of participants younger than 11 years completed these questionnaires; the option to self-complete was available for young people aged 11 years or older.An index of multiple deprivation ranking was assigned to all children and young people on the basis of their residence (postcode) at the time of study registration; these rankings were based on the English indices of deprivation, the Welsh index of multiple deprivation, and the Scottish index of multiple deprivation.The outcome measures used for the primary analysis were the components of the cJADAS with an active joint count up to ten (cJADAS 10): active joint count, physician's global assessment of disease activity, and patient or parent global evaluation of wellbeing. Components of cJADAS 10 were chosen in preference to JADAS because the cJADAS 10 does not require erythrocyte sedimentation rate, which is often not measured routinely in children with JIA in the UK.We used two clustering approaches to explore latent classes in patients with JIA: a cross-sectional analysis at baseline and a longitudinal analysis from baseline to 3 years of follow-up. Longitudinal clustering was undertaken independently of baseline clustering, with no inheritance of classes between the two methods. Class assignment at baseline versus in trajectories over 3 years were then compared graphically by use of a chord diagram, which illustrates the mapping between the two resulting sets of classes or clusters.Latent profile analysis  identified subgroups of children and young people on the basis of shared cJADAS 10 components at baseline. Latent profile analysis was applied with STATA 15 package gsem. Each individual was exclusively assigned to a cluster for which the highest posterior probability of group membership was obtained. Models used Poisson (for active joint count) and normal  distributions. We selected the optimal number of groups (out of ten) on the basis of the Bayesian information criteria (BIC), selecting that which resulted in the lowest BIC.Group-based trajectory models We selected an optimal model through a combination of statistical fit, clinical plausibility, and parsimony. Initially, models were excluded if they had a group representing less than 1% of the cohort, a mean posterior probability for any group membership lower than 70%, or relative entropy lower than 0·5.2 and Fisher's exact test and continuous variables with Kruskal-Wallis statistics for longitudinal models.We examined characteristics of children and young people such as demographic, clinical, and psychosocial factors at initial presentation for clusters within the latent classes at baseline and the trajectory groups using descriptive and univariable statistics. Additionally, pain (10 cm VAS) and functional ability (CHAQ scores) were compared with component trajectories in the optimal model, as these variables have previously been found to explain variation in wellbeing scores in both individuals with JIAWe undertook no imputation of missing data. As a maximum-likelihood-based technique, group-based trajectory modelling is somewhat robust to potential bias caused by missing data, as long as they are missing at random.0=0·4) for active joint count and from a censored normal distribution with bounds at 0 and 10 by use of the STATA gentrun package for physician and parental global scores. Trajectories were evaluated after adding 1%, 2·5%, 5%, 10%, and 25% additional noise to the dataset.We did a secondary analysis to evaluate the sensitivity of the longitudinal trajectory model to random noise added to the dataset. Random noise was taken from a zero-inflated Poisson distribution , and a higher proportion of participants with rheumatoid factor-negative polyarthritis , had a higher proportion of white participants (1044 [90%] of 1166 773 (65%) of 1184 participants were female and 411 (35%) were male, and 594 (50%) of 1179 with available ILAR category data had oligoarthritis . Median The optimal model identified five distinct classes of children and young people at baseline  were frequently classed within the low-remission (278 [50%]), low-low (179 [32%]), and low-persistent (63 [11%]) trajectory groups. Those from the all-high (182 participants) and high active joint count (189 participants) baseline clusters tended to be classed within the high-low , high-low-high  and high-persistent  groups. The largest proportions of participants in the high patient or parent global group at baseline (161 participants) were classed within the low-persistent (57 [35%]) and low-remission (45 [28%]) trajectory groups .Figure 4The signs and symptoms of JIA are diverse and can change over the course of disease, due to treatment effects and evolution of the underlying condition. Our study identified six clusters of children and young people with JIA who had different patterns across three core outcome variables in the 3 years after initial presentation to paediatric rheumatology. In four of these groups, the three components of cJADAS followed similar patterns to each other. In the two other groups, slow improvements in active joint counts and physician's global scores were coupled with persistent poor patient or parent wellbeing scores. When using information from baseline alone, five clusters of children and young people with JIA were identified; these overlapped to some degree, but not completely, with the six trajectory-based subgroups identified over follow-up. Therefore, disease severity at onset is important but is not entirely predictive of future disease state, which will also be influenced by interventions.The classification criteria for JIA have been consensus-based and have largely focused on joint counts and extra-articular features in the early phase of disease.Our study reports six unique clusters of disease outcome over time. Multiple clusters of active joint counts were reported in a multicentre, retrospective cohort of 659 young people with JIA in Canada.vs 4–6% in the other groups). Extra-articular features, such as enthesitis, are not captured in active joint counts, and these children and young people might have high related levels of inflammatory pain. Additionally, there might be substantial overlap between painful non-inflammatory conditions, such as fibromyalgia, and enthesitis,To our knowledge, this was the first study to examine how the cJADAS 10 components track in relation to each other over time. The modelling of multiple measures of disease allowed for the identification of groups in which these scores diverged over time, which might have been less obvious if only the composite score had been used. Groups that had persistent poor wellbeing scores despite improving joint counts and physician global scores were difficult to distinguish from groups in which outcomes progressed in parallel to their initial presentation to paediatric rheumatology. Disease features at initial presentation were similar between groups that had low numbers of active joint counts at baseline and those that had high numbers of active joints, regardless of wellbeing trajectories. The greater representation of participants with enthesitis-related JIA in both persistent groups was a distinguishing disease feature (11% and 13% in persistent groups Our study benefitted from being set within one of the largest inception cohorts of children and young people with JIA globally. CAPS collects a wide range of information from both medical records and patient-completed questionnaires over time. This allowed for a detailed, longitudinal analysis of the cJADAS 10 components and the additional exploration of multiple factors, measured at initial presentation to paediatric rheumatology, that characterised group membership, such as demographic, clinical, and psychosocial characteristics. The inception nature of the cohort, together with models that could incorporate missing data, allowed for the inclusion of most of the cohort, minimising selection bias through both left-censorship and drop-out. Additionally, informative drop-out in CAPS allowed for the exploration of bias through data potentially missing not-at-random.Our study assessed trajectories of disease from the point of initial presentation to paediatric rheumatology. All children and young people were treated within the same health-care system, but individual responses to treatment were not modelled. Some therapies might have been prescribed before initial presentation to paediatric rheumatology. Therefore, these trajectories do not necessarily reflect patterns from disease onset and are useful to understand progression from the point of first contact with paediatric rheumatology. The trajectories presented are means based on an approximately annual follow-up within the first 3 years after initial presentation to paediatric rheumatology. The JIA disease course might have increased variability over time with more frequent capture of disease measures. Additionally, modelling a higher active joint, such as in cJADAS 71, rather than cJADAS 10 would not be expected to produce additional trajectory groups but might have raised the initial mean joint counts for high-low, high-low-high, and high-persistent groups. Finally, the follow-up was limited to 3 years in this study, on the basis of the observation of greatest changes in disease over the first year after diagnosis,Using the components of cJADAS, six distinct trajectories were observed for children and young people with JIA in the 3 years after initial presentation to paediatric rheumatology, with low disease activity and remission being common but not universal. Disease trajectories were not predicted entirely by ILAR category or disease manifestations at diagnosis. Importantly, in a fifth of children and young people, a divergence was observed between improving joint counts but persistently high scores for wellbeing, whose pain and function scores mirrored those of wellbeing over time. Understanding the biological and sociological mechanisms underpinning groups of children and young people within different clusters has the potential to improve disease management plans for a more personalised approach to treatment for individuals with JIA.online.Information regarding applying for access to CAPS data can be found


Growing concerns over ethical issues in mentoring in medicine and surgery have hindered efforts to reinitiate mentoring for Palliative Care (PC) physicians following the easing of COVID-19 restrictions. Ranging from the misappropriation of mentee’s work to bullying, ethical issues in mentoring are attributed to poor understanding and structuring of mentoring programs, underlining the need for a consistent approach to mentoring practices.Given diverse practices across different settings and the employ of various methodologies, a novel approach to narrative reviews (NR)s is proposed to summarize, interpret, and critique prevailing data on novice mentoring. To overcome prevailing concerns surrounding the reproducibility and transparency of narrative reviews, the Systematic Evidenced Based Approach (SEBA) adopts a structured approach to searching and summarizing the included articles and employed concurrent content and thematic analysis that was overseen by a team of experts.A total of 18 915 abstracts were reviewed, 62 full text articles evaluated and 41 articles included. Ten themes/categories were ascertained identified including Nature; Stakeholders; Relationship; Approach; Environment; Benefits; Barriers; Assessments; Theories and Definitions.By compiling and scrutinizing prevailing practice it is possible to appreciate the notion of the mentoring ecosystem which sees each mentee, mentor, and host organization brings with them their own microenvironment that contains their respective goals, abilities, and contextual considerations. Built around competency based mentoring stages, it is possible to advance a flexible yet consistent novice mentoring framework. At the heart of concerns amongst administrators, program designers, and curriculum advisor as well as some mentors and mentees are growing concerns over reports of ethical issues in mentoring.To address this lacuna and better inform the structuring of mentoring programs, review of novice mentoring data is required. However such an endeavor must acknowledge the fact that prevailing data involves a variety of methodologies and practices and does not often consider mentoring’s evolving nature that requires a longitudinal perspective of mentoring nor its context specific nature that limits comparisons of mentoring data across different research, clinical, academic, practice and healthcare settings, and mentoring goals. Scrutiny of novice mentoring is also limited by poorly defined terms and the mistaken intermixing of mentoring and educational approaches such as peer, near-peer, group, leadership, patient, family, and e-mentoring as well as advising, sponsoring, role modeling, tutoring, coaching, supervising, and networking which have their own distinct approaches and roles in medical education. Such conflation of terms and practices also compromises structured search processes which relies on clearly defined terms to guide the search process. In addition many review fail to consider the socially constructed aspect of mentoring nor the need to include longitudinal mentoring experiences and perspectives of mentees, mentors, and other stakeholders that are often captured in gray literature. These considerations and the need for a multidimensional socioculturally informed perspective of mentoring from the viewpoint of mentees, mentors, the host organization, and other stakeholders also underline the need for a constructivist approach and the use of a relativist lens.1518 we will seek to study prevailing novice mentoring data in IM and extrapolate these findings to PC.In the face of data suggesting that mentoring can be extrapolated from accounts of novice mentoring in Internal Medicine (IM),19 and the hidden systems that drive the mentoring process2028 across different research traditions.27 An NR is also better equipped to contend with data from gray literature and forward a better understanding of why21 and how mentoring’s socioculturally informed processes evolve and affect stakeholders and their mentoring relationships.252937With use of systematic and scoping reviews limited by poorly defined mentoring terms that will compromise structured searches, a narrative review (NR) is proposed given its ability to delve into the underlying38 whilst its relativist lens allows for the collation of historically, socioculturally, ideologically, and contextually influenced views, experiences and accounts of mentees, mentors, and host organizations (henceforth stakeholders).To address concerns that NRs lack transparency, accountability, and structure in the synthesis of narratives, we adopt Krishna’s novel methodology called Systematic Evidenced Based Approach (SEBA). Built upon a constructivist perspective, a SEBA guided NR (henceforth NR in SEBA) is able to map complex topics from multiple angles3941 This enhances the accountability of the search process.Guided through each stage of the synthesis of an NR in SEBA by an expert team comprised of medical librarians from the Yong Loo Lin School of Medicine (YLLSoM) at the National University of Singapore and the National Cancer Centre Singapore (NCCS), and local educational experts and clinicians at the NCCS, the Palliative Care Institute Liverpool, YLLSoM, and Duke-NUS Medical School, and guided by the principles of interpretivist analysis, the research team immerse and chart their review, and analysis of the qualitative data. Team discussions and expert guidance ensured that the data was pieced together in a meaningful, transparent, and reproducible manner.Outlined in what is known of novice mentoring in Internal Medicine (henceforth IM)?” In order to inform the design, structure, and oversight of novice mentoring programs, the secondary research questions were determined to be “what are the key characteristics of novice mentoring in IM?” and “what processes contribute to their success?”Ensuring a systematic approach to the synthesis of NRs in SEBA, the expert and research team established the overall goals of the NR and the population, context, and concept to be evaluated. The research question was determined to be “43 This is outlined in A Population Intervention Comparison Outcome Study Design (PICOS) format was adopted to guide the research process.Supplemental Appendix 1.Ten members of the research team carried out independent searches of 7 bibliographic databases  and gray literature databases  between 17 December 2019 and 17 January 2020. Focus on mentoring in IM rather than PC was in acknowledgement of a dearth of mentoring data in PC and evidence that extrapolation of data from IM and PC is possible. The PubMed Search Terms and Strategy may be found in 44 approach to “negotiated consensual validation” was used to achieve consensus on the final list of titles to be reviewed. The research team then independently reviewed each full-text article from this final list, created individual lists for inclusion, held team discussions online and arrived at a consensus on the final list of full-text articles to be included in the NR in SEBA. To circumnavigate the limitations caused by poorly delineated mentoring terms, the research teams reviewed the references of the included articles and snowballing their findings to reduce the chance of omitting relevant articles.Using an abstract screening tool, each member of the research team independently reviewed the titles and abstracts found in each database and drew up a list of titles to be reviewed. Comparing these individual lists via online meetings, Sambunjak et al’s45 approach to thematic analysis whilst the second team employed Hsieh and Shannon’s46 approach to directed content analysis. Used to enhance the trustworthiness of the results, concurrent thematic and content analysis is the hallmark of the Split Approach The third team summarized and tabulated the included articles, keeping with recommendations drawn from Wong et al’s38 RAMESES publication standards: meta-narrative reviews and Popay et al’s47 “Guidance on the conduct of narrative synthesis in systematic reviews.” The tabulated summaries serve to ensure that key aspects of the included articles are not lost. They are presented in Supplemental Appendix 2.Dividing into 3 teams, the researchers simultaneously reviewed the included full-text articles. The first team adopted Braun and Clarke’s4850 These codes were then organized into themes deemed to best represent the whole data set.51 Each member independently reviewed and refined their themes with negotiated consensual validation used to establish a final list of themes.52A reiterative step-by-step thematic analysis was carried and this saw codes constructed from the “surface” meaning of the articles.53Directed content analysis was employed to enhance validity of the themes identified and addressed the relative failure of Braun and Clarke’s approach in resolving contradictory data.54 reviewers drew codes from Krishna et al’s17 “Mentoring stages: A study of undergraduate mentoring in palliative medicine in Singapore,” the first clinically evidenced account of novice mentoring in Palliative Medicine. Deductive category application was employed to identify any relevant data not captured by existing codes and subsequently assigned a new code.55 Each member independently reviewed and refined their codes with negotiated consensual validation used to establish a final “code book.”Identifying and operationalizing a priori coding categories,The jigsaw perspective brings together complementary data and is especially important in ensuring that critical aspects are not lost in the “funneling” process that follows. This “funneling” process saw the themes and categories identified in the independent analyses compared and combined to present a holistic perspective of novice mentoring thus facilitating its effective analysis and interpretation.As part of the reiterative process, the findings were discussed with the expert team and concerns were raised over the influence of gray literature on the results as they were neither peer reviewed nor clearly evidence based. This saw the research team differentiating gray literature such as correspondence, letters, editorials, and perspective pieces extracted from academic databases from data driven and research based peer reviewed articles. Both were thematically analyzed independently and the themes derived from the gray literature were found to be in agreement with themes from the peer-reviewed literature.In total, there were 10 themes/categories revealed through Braun and Clarke’s and Hsieh and Shannon’s approach. As extensive overlaps were observed, they will be presented and discussed together.Supplemental Appendix 3. The following themes/categories pertaining to novice mentoring was discerned: (1) Definitions, (2) Nature, (3) Stakeholders, (4) Relationship, (5) Approach, (6) Environment, (7) Benefits, (8) Barriers, (9) Assessments, and (10) Theories.A total of 18 915 abstracts were reviewed, 62 full-text articles evaluated and 41 articles included. This is outlined in the PRISMA Flowchart in 56 definition which dominates prevailing practice characterizes novice mentoring as “an evolving relationship between an experienced clinician and junior clinicians and/or students that is focused upon creating personalised and enduring mutually beneficial mentoring relationships.”Wesley et al’sHowever 5 other considerations were highlighted:(a) the host organization’s role in the mentoring relationship.(b) the host organization’s role in nurturing the mentoring environment through the establishment of clear codes of conduct and provision of support for consistent, longitudinal and holistic assessments, matching processes, and training programs.(c) the presence of mentoring stages in a structured mentoring process.(d) the need to balance between a consistent mentoring approach, compliance with codes of practice, and flexibility so as to accommodate for evolving needs, goals, and expectations of stakeholders.(e) novice mentoring’s evolving, goal-sensitive, context-specific, mentee-, mentor-, organizational- and relational-dependent nature and thus implication on research and support.As briefly outlined in the final consideration above, novice mentoring possesses critical characteristics further elaborated in 58 These mentee- and mentor-specific traits are delineated in Supplemental Appendices 4 and 5 but may be broadly categorized into personal and professional characteristics.By virtue of their intrinsic involvement, stakeholders also naturally influence the mentoring process and their outcomes. This underscores the gravity of the matching process in ensuring that would-be mentees and mentors possess desirable traits that complement one another and the overall goals of the program.17 Indeed, the host organization, oft forgotten as a pivotal stakeholder, plays a crucial role in overseeing, supporting and assessing various facets of the mentoring program—including mentor training, mentee briefing, the matching process, mentoring relationship, mentoring approach, and mentoring environment.60In addition, their ability to fulfil their respective roles and responsibilities foregrounds the importance of longitudinal training, assessment and support.58 argue that mentoring relationships are shaped by shared values and beliefs between mentees and mentors, their success hinged on the presence of quality and reciprocal interactions between all stakeholders, including the host organization.58 The mentoring relationship has notable bearings on the professional identity formation of mentees and the motivations of mentors in seeking out avenues to groom them. Indeed the success of the overall mentoring program in realizing its mentoring goals is said to pivot upon the nurturing of lasting and personalized mentoring relationships.60Qiao Ting Low et al60Most mentoring programs adopt either a formal or informal mentoring approach. Formal mentoring offers a more rigorous structure to the matching process and provides clearer specifications with regards to goals, learning objectives, roles and responsibilities, codes of conduct, standards of practice, and the type and duration of interactions expected.revolves around the idea of apprenticeship in medicine”57 and sees more ad-hoc influence by learners, tutors, and the host organization.60 Whilst it proffers a more collegial environment which facilitates open communication beneficial toward the development of stronger ties between mentees and mentors, the lack of protected time and poor oversight, transparency, and support from the host threaten the viability of informal mentoring processes.Conversely, informal mentoring “Indeed regardless of which mentoring approach is used, for its full efficacy it should be sensitive to the personal, academic, research, professional, social, and emotional considerations of individual stakeholders involved. This is paramount as mentee and mentor knowledge, experience, preferences, needs, and limitations affect their availability and commitment toward developing the mentoring relationship. Whilst acceptable practice parameters must be adhered to, the importance of a flexible mentoring approach is underpinned here.60 suggest that the mentoring environment has 2 interwoven features, the mentoring structure and mentoring culture.Hee et althe framework that shapes the learning approach.” It includes logistical considerations such as the provision of protected time; the location, frequency, and duration of mentoring, tutorial, and feedback sessions; and the presence of confidential avenues for raising concerns directly to the host organization. The mentoring structure lays the foundation for the provision of streamlined professional and personal support to mentees and mentors alike.The mentoring structure is defined as “the norms, values, beliefs, practices and support moulding the socioemotional environment in which learning occurs.” These include permissible topics and sanctioned behaviors during the mentoring process. It is informed by the stakeholders, the formal mentoring structure and the informal curriculum. The latter referring to opportunistic and idiosyncratic instruction-giving, including the transmission of values and beliefs that underlie prevailing actions and practices of mentors and the host.The mentoring culture on the other hand refers to “The diverse benefits of mentoring to mentees are highlighted in 60Although not commonly addressed, benefits to mentors may be personal and or professional. Personal benefits include the chance to share their knowledge and experience leading to satisfaction, joy, fulfilment, and pride when witnessing the success of their mentees. It also reportedly encourages professional growth, improved job performance, accelerated research productivity and promotions, and provides opportunities to forge new liaisons with collaborators.16 These hinder the fostering of fruitful mentee-mentor relationships.Barriers to effective mentoring include a lack of protected time, availability of mentors and difficulties in balancing disparate needs, goals, and expectations of the stakeholders involved.60 No validated tool to assess mentoring experiences or their outcomes as presently available.Traditionally under the purview of the host organization, assessments and evaluations of the mentoring process remain poorly studied.61 there are no prevailing theories that comprehensively capture all its components.Despite recent efforts to forward a theory of mentoring,62 and the STORIES  statement. In addressing its primary and secondary research questions, this NR in SEBA builds on the 10 themes/categories identified to map and discuss prevailing data on novice mentoring.The narrative produced was guided by the Best Evidence Medical Education (BEME) Collaboration guideyet maintain a consistent mentoring approach that exists within the confines of codes, standards of practice, and program expectations.With the new findings, novice mentoring may be characterized as the process of creating personalized, enduring, and mutually beneficial mentoring relationships between stakeholders. Its success necessitates the guidance of a mentoring structure that is able to balance demands for flexibility in accommodating for evolving mentoring needs, goals, circumstances of stakeholders, and the mentoring environment To support novice mentoring’s dynamic, entwined, evolving, adaptable, context-specific, goal-sensitive, mentee-, mentor-, host organization-, mentoring environment-, mentoring approach-, and mentoring relationship-dependent nature, the host organization must oversee, assess, and support the mentees, mentors, matching process, mentoring relationship, mentoring approach, and mentoring environment.This definition will help to focus the course and content of this NR in SEBA.6388 yet flexibility697389103 within the mentoring program. By spearheading the program, the host organization is deeply involved in formalizing the mentoring approach and its structure. It establishes mentee and mentor roles, responsibilities, and expectations;104 practice standards and codes of conduct;105 and the milestones of each mentoring stage.96 Albeit under the aegis of the mentoring program as a whole, guidelines established by the host steer mentees and mentors as they set their specific goals,107 objectives,106 and timelines.Recent reviews suggest that the host organization plays a critical role in ensuring consistency88 is enhanced by flexible accommodations to their particular setting, goals, needs, and capabilities. Understanding the host organization’s role in the mentoring process and in operationalizing the mentoring structure it has adopted underlines the influence of the mentoring culture and introduces the notion of mentoring dynamics.Whilst a consistent and transparent program imbues confidence in the mentoring relationship, the mentee’s and mentor’s sense of autonomy, connectivity, and advocacy of the program108 which enables the host to instil and influence mentoring and education philosophies as well as goals and values of the program.109 The mentoring culture consequences recruitment and retention of stakeholders110112 and informs stakeholders of characteristics desired of them.Mentoring dynamics refer to the quality of interactions between stakeholders. It is critical to the development of mentoring relationships is influenced by particularly influenced by the mentoring cultureThe notion that each stakeholder influences the mentoring dynamic raises the idea of a mentoring ecosystem with each stakeholder bringing with them individual “micro-environment.” For mentees and mentors, their micro-environment consists of internal and external factors. Internal factors account for individual characteristics, availabilities, abilities, motivations, and goals. These are impacted by external factors such as particular sociocultural, curricular, personal, academic, clinical, professional, ethical, and research factors; prevailing geopolitical, care and educational financing as well as healthcare and educational systems. Changes in these factors affect their micro-environment and influences their ability to productively participate in the mentoring process.The host organization’s microenvironment is more complex. Despite nurturing the program’s mentoring environment, the host organization’s micro-environment does not on its own shape it. Instead the host organization’s “micro-environment” which is informed by internal and external factors including the mentoring structure, the nature and dynamics of interactions between stakeholders and the informal, formal and hidden curricula shape the program’s own mentoring environment.The mentee’s and mentor’s micro-environment are influenced by the program’s mentoring environment as early as the recruitment stage where participation is contemplated. At the matching stage where mentees are introduced to potential mentors, their micro-environment begin to intermingle. Within this “meso-environment,” elements within the mentee’s micro-environment affect the mentor’s ability to function within the mentoring program and vice versa.The mentoring relationship begins with the mentee’s and mentor’s formal agreement to enter into a mentoring relationship with each other under the aegis of the mentoring program. With this, the mentee’s and mentor’s meso-environment fuse with the host’s microenvironment as well as the program’s mentoring environment to form the macro-environment.This macro-environment sees the mentor and mentee influenced by wider factors affecting the mentoring program and host organization. The macro-environment will change as the stakeholders’ micro-environment interact with one another and as the mentoring relationship moves through the mentoring stages. Thus the evolution of the mentoring micro-, meso-, and macro-environments is directed and heavily influenced by the overarching mentoring structure and its constituents. This gives rise to the idea of a mentoring ecosystem which comprises of these dynamic elements and interactions. How micro-, meso-, and macro-environments form under the aegis of the mentoring structure also uncovers the novel role of competency based mentoring stages.17 posit clear mentoring stages in the form of recruitment; aligning of expectations; the matching process; pre-mentoring meetings and training processes; and the subsequent mentoring relationship. For more targeted support and efficacious mentoring outcomes, it was suggested that each stage contain specific competencies to be met by the mentees in order for the mentoring relationship to advance. Not only do these competency based stages shed light as to how micro-, meso-, and macro-environments interact and respond to rigorous mentoring structures but it also further explains the importance of balancing between such need for consistency and demands for flexibility.The more traditional view of mentoring relationships is that it begins with and is sustained by a “fit for purpose” match that brings mentees and mentors with complementary interests and goals together. A newer perspective however sees the development of mentoring relationships occur in stages. To create a stable, effective and nurturing environment, Krishna et alIn order to conceptualize these dynamic elements and interactions within the mentoring ecosystem, 17 (As PC programs wrangle with concerns about structural issues in mentoring programs that may predispose ethical issues and abuse, we forward a mentoring framework built around the mentoring stages posited by Krishna et al17 . Advanci38 In addition although use of Levac et al’s113 adaptation of Arksey and O’Malley’s114 methodological framework to conduct a systematic scoping review rather than “traditional” scoping reviews115 was used to enhance transparency and reproducibility of the NR and use of broad search terms, the presence of papers drawn from a common stable raises concerns about inherent biases and the omission of critical papers. These factors stifle efforts to deepen understanding of a complex process116 despite use of the Split Approach and involvement of expert teams. However, the expert team concurred on the narrative presented and believed that it would be useful for various parties interested in designing, assessing, supporting, and expanding novice mentoring programs.Whilst NRs attempt to build on linked papers, the lack of data on novice mentoring and the common root from which they stem from hinders efforts to create a “coherent paradigm.”Conceiving mentoring as a flexible process within structured mentoring stages helps explain the process of balance and underlines the ability of the mentoring structure to personalize mentoring processes and contend with evolving mentoring dynamics across different stages without compromising mentoring standards and breaching codes of practice. Perhaps more importantly having the competencies and the standards of practice of the specific stage agreed upon by the stakeholders makes for more timely, personalized, appropriate, specific assessments of the mentoring dynamics, relationship, and progress. Moving forward, future studies must also consider the impact of PC’s multidisciplinary practice and the impact of multiple stakeholders in the mentoring process and enhance the structuring of the mentoring process accordingly. Assessments of mentoring processes and mentor training must be the focus of coming studies if mentoring in PC is to regain its place in PC education.Click here for additional data file.Supplemental material, Appendices_xyz46891a36bb924 for Enhancing Mentoring in Palliative Care: An Evidence Based Mentoring Framework by Lalit Kumar Radha Krishna, Lorraine Hui En Tan, Yun Ting Ong, Kuang Teck Tay, Jia Min Hee, Min Chiam, Elisha Wan Ying Chia, Krish Sheri, Xiu Hui Tan, Yao Hao Teo, Cheryl Shumin Kow, Stephen Mason and Ying Pin Toh in Journal of Medical Education and Curricular Development


Nutraceuticals have gained immense importance in poultry science recently considering the nutritional and beneficial health effects of their constituents. Besides providing nutritional requirements to birds, nutraceuticals have beneficial pharmacological effects, for example, they help in establishing normal physiological health status, prevent diseases and thereby improve production performance. Nutraceuticals include amino acids, vitamins, minerals, enzymes, etc. which are important for preventing oxidative stress, regulating the immune response and maintaining normal physiological, biochemical and homeostatic mechanisms. Nutraceuticals help in supplying nutrients in balanced amounts for supporting the optimal growth performance in modern poultry flocks, and as a dietary supplement can reduce the use of antibiotics. The application of antibiotic growth enhancers in poultry leads to the propagation of antibiotic-resistant microbes and drug residues; therefore, they have been restricted in many countries. Thus, there is a demand for natural feed additives that lead to the same growth enhancement without affecting the health. Nutraceuticals substances have an essential role in the development of the animals’ normal physiological functions and in protecting them against infectious diseases. In this review, the uses of amino acids, vitamins and minerals as well as their mode of action in growth promotion and elevation of immune system are discussed. Amino acids play vital physiological roles in the body  must be provided in the diet for maximum performance. Out of these 10 essential amino acids, lysine and methionine are the first two limiting amino acids for broilers  and muscle accretion  needed for optimal poultry health. The use of these nutrients in sufficient quantities can improve animal health. Most vitamins cannot be synthesized by birds and must be provided by feed, however, the feed alone is not sufficient to cover vitamin requirements. Diets supplemented with vitamins play an important role in disease treatment and prevention; because vitamins allow an animal to use proteins and energy for health improvement, FCR, growth, and reproduction  is a biological antioxidant and contributes to the improvement of growth performance and physiological and immunological status of broiler chickens due to its ability to reduce lipid peroxidation and neutralize free radicals in both skeletal muscle and plasma  augmented carcass mass and decreased the content of the abdominal fat of broilers  homeostasis and cellular proliferation and differentiation (Holick 3) decreased the incidence of tibial dyschondroplasia 2D3) has an immunomodulatory property in chicken macrophages. Rodriguez-Lecompte et al. (3 or its derivative 25(OH)D3 above the recommended levels has a positive influence on the immune system particularly when dietary levels of calcium are low. Irrespective of form, the apparent total tract digestibility of calcium was higher in diets enriched with vitamin D. The apparent total tract digestibility of phosphorus was higher in 3,000 IU/kg feed of vitamin D2 compared to the other treatments. The utilization of calcium and phosphorus by laying birds can be enhanced by the addition of different sources of vitamin D in rations  in the diet led to higher proximal tarsometatarsus cancellous bone volumes of laying hens.Vitamin K regulates the production of some coagulation factors in the blood such as prothrombin and clotting factors  which are involved in stopping uncontrolled bleeding from wounds. Therefore, deficiency of this vitamin increases blood-clotting time leading to hemorrhagic diseases in organs and tissues. Also, vitamin K is important in relation to bone formation and re-modeling which may be due to the fact that osteocalcin (one of the main bone proteins) depends on vitamin K Weber . VitaminZhang et al.  conducteIn contrast to this, some researchers have investigated the effect of vitamin K deficient diet supplied to the laying hens for a time period of 28 weeks. Reduction in the concentration of skeletal/bone protein gamma-carboxyglutamic acid (Gla) and altered blood clotting was observed. But despite of the insufficient vitamin K level, no significant adverse effects on skeletal metabolism in laying hens, their growing progeny embryos and young chickens were noticed  increases disease resistance in birds by strengthening the immune system. It plays a significant role in the biosynthesis of corticosterone, a hormone that enhances energy supply during stress  stated that vitamin C increased performance and could improve carcass traits in birds reared under heat stress. Dietary vitamin C supplementation (200 mg/kg feed) provided protection against the risk of high stocking density and improved final BW, reduced mortality percentage and down-regulated HSP70 expression level in the liver  is actively and rapidly absorbed from the small intestine and then is transformed by phosphorylation into the active coenzyme – thiamin pyrophosphate that is involved in the oxidative decarboxylation of ketoglutaric acid and pyruvic acid  plays an important role in the metabolism of fatty acids, carbohydrates and amino acids and displays a critical function in the production of energy by the citric acid cycle  significantly augmented the hatchability percentage in Japanese quail  significantly increased BW at 28 days of age  and flavin mononucleotide (riboflavin-5′-phosphate). The coenzymes play major roles in the development, growth, cellular function and energy production and metabolism of steroids, fats, and drugs Rivlin . This vi3.6.4.12 belongs to a specific group of cobalt containing coronoids with biological activity in animals and humans. It is available commercially for addition to the feed as cyanocobalamin. It is an essential constituent of some enzyme systems that carry out a number of basic metabolic functions in the body  , potassium (K) and chloride (Cl)) and osmotic homeostasis  and phosphorus (P) are the most abundant elements in the body. This group also includes chloride (Cl), magnesium (Mg), potassium (K), sodium (Na) and sulphur (S). The required content of these elements in the diet is usually higher than 100 mg/kg feed  is a major element in poultry nutrition. It is an important component for mineralization of bones and shells, blood-clot formation and muscle contraction  and also act on immunity mediators such as thymus peptides, cytokines and enzymes  and cell-mediated immunity (assists in eliminating invading bacteria). It shows immunostimulating action and supports maintaining appropriate microbiological balance in the digestive tract  helps in transportation and storage of oxygen and enhances protein metabolism, energy supply and processes of anti‐oxidation and immunization inside the body  is an important trace nutrient for the maintenance of growth and health of humans and animals (Kieliszek and Błażejak 4.5.3)2) and iodine levels in the animal diet 2, KI, or iodized salt. Iodine is a very essential microelement in laying hens’ feeding, and has a strong impact on growth performance of birds  is a trace element with several biological functions. One of the most important is the proper functioning of the thyroid gland as iodine is a constituent of its hormones (triiodothyronine and thyronine) that play an essential role in regulation of metabolism, cellular oxidation and intermediary cell activity (Van Middlesworth 4.6.Chromium (Cr) plays an important role in poultry health and nutrition, as well as augments growth performance. It is a potent antioxidant and hypocholesteremic agent. Chromium is known to decrease cholesterol, increase high-density lipoprotein cholesterol and improve nutrient digestion (Haq et al. A summary of the implications and beneficial effects of different amino acids, vitamins and minerals as nutraceuticals in poultry is presented in 5.Various advanced delivery options are needed to be explored for efficient utilization of amino acids, minerals and vitamins in poultry feeding (Abd El-Hack et al. Amino acids are being used in different forms to achieve better results in terms of production performance. Nowadays, individual amino acids in pure forms are commercially available (Ravindran Minerals in typical poultry feed formulations are delivered mainly in the inorganic form, for example calcium as limestone, shell grit; calcium and phosphorus as dicalcium phosphate, defluorinated rock phosphate, bone meal; sodium as salt, sodium bicarbonate and trace minerals in the form of premixes (Ravindran A novel approach in poultry production is the application of nanoparticles, which can serve as a platform to incorporate nutrients into the body. They enable direct transportation of active compounds to target organs, avoiding their fast degradability and encourage several health benefits. Nanoparticles in poultry production include elements such as silver, selenium, copper, and gold (Gangadoo et al. Salmonella Enteritidis and necrotic enteritis infections in broiler chickens (Hernandez-Patlan et al. in vivo and in vitro performance (Jampilek et al. The dietary supplementation of cyanocobalamin showed no effect on feed intake, daily weight gain and feed conversion efficiency, but it improved hematological parameters including red and white blood cells and platelet counts (Ahmad et al. 6.Nutraceuticals could serve as functional food by providing various beneficial health impacts (Martirosyan and Singh Stephen DeFelice used the word nutraceuticals in 1989 for nutritional substances which can be consumed as pharmaceuticals too. Hasler  also staHemidesmus indicus and Vanilla planifolia due to their acetylcholinesterase inhibitory activity are suitable candidates for functional food production, which can be used in the treatment of neurological disorders (Kundu and Mitra It is documented that functional food containing acetylcholinesterase inhibitors along with potential antioxidants can be a treatment option against neurological disorders like Alzheimer’s disease and/or dementia. Phenolic compounds like 2-hydroxy-4-methoxybenzaldehyde and 4-hydroxy-3-methoxybenzaldehyde present in Spirulina platensis by supercritical fluid extraction, generated biofortified eggs with polyunsaturated fatty acids, including n-3 and n-6.Nutraceuticals can be employed to develop designer and functional food. Manipulation of nutraceuticals in the poultry diet can help in altering the composition of poultry products that can be adjusted to the demands and health requirements of consumers. Fatty acid or cholesterol, mineral, vitamin, and/or amino acid composition of eggs or meat can be modified by dietary nutraceuticals that will serve as a basis for producing designer and functional products, having beneficial health applications in addition to nutritional applications (Rajasekaran and Kalaivani Low cholesterol diets are preferred nowadays for numerous beneficial health effects. They may also modulate immune and inflammatory responses that can be helpful in various diseases (Ibrahim et al. 7.Nutraceuticals are proved to be beneficial in poultry production both for supporting nutritional requirements and having pharmacological benefits, thus providing healthy and disease free physiological state. Being natural components of poultry diet, nutraceuticals can overcome side effects and limitations of chemical drugs. The demand for using an alternative natural feed additive such as nutraceuticals is essential especially after preventing using of antibiotics in poultry feed as growth factors. Currently, nutraceuticals are applied for boosting poultry growth rate, preventing diseases, and modulating immunity. Conversely, applying nutraceuticals for disease treatments has yet to be verified. Common nutraceuticals including amino acids, minerals and vitamins are vital for life processes of poultry. Having a role in numerous physio-biochemical mechanisms these nutraceuticals are involved in various essential growth and developmental processes. Modification of mineral, vitamin and amino acid composition of eggs or meat can help in developing designer or functional foods that can have potential applications in disease prevention and treatment. Nutraceuticals can be used for covering the gap between increasing the world’s population and production of high quality and low-cost animal feed. However, further large-scale studies are required in order to use nutraceuticals in commercial poultry production.


Brain metastases (BM) are the most frequent intracranial tumors, which may result in significant morbidity and mortality when the lesions involve the perirolandic region. Surgical intervention for BM in the perirolandic region is still under discussion even though prompt relief of mass effect and avoidance of necrosis together with brain edema may not be achieved by radiotherapy. More recently, several researchers attempt to evaluate the benefit of surgery for BM within this pivotal sensorimotor area. Nevertheless, data are sparse and optimal treatment paradigm is not yet widely described. Since the advance in intraoperative neuroimaging and neurophysiology, resection of BM in the perirolandic region has been proven to be safe and efficacious, sparing this eloquent area while retaining reasonably low morbidity rates. Although management of BM becomes much more tailored and multimodal, surgery remains the cornerstone and principles of resection as well as indications for surgery should be well defined. This is the first review concerning the characteristics of BM involving the perirolandic region and the current impact of surgical therapy for the lesions. Future perspectives of advanced neurosurgical techniques are also presented. The perirolandic region is essential for neurological functions, supporting motricity, and sensitivity of trunk and extremities , 2. NotaControversy exists regarding optimal treatment for patients with BM within the perirolandic region , 11–22. This review summarizes the impact of surgery on the multimodal management of BM in the perirolandic region. Close attention has been paid to the indications for surgery, the principles of resection, and the individualized surgical approaches. Future minimally invasive and multimodal therapies such as laser interstitial thermal therapy (LITT) are discussed, which may lead to new paradigm for management.The perirolandic region, also known as central lobe  or paracBM are the most common neoplasms in the central nervous system , with anBM have been estimated to occur as many as 10 times more frequently than primary brain tumors , 33, 34.i) well-demarcated border to surrounding white matter; ii) perivascular protrusion from main tumor mass; iii) diffuse infiltration of single cells into surrounding brain parenchyma  cannot promptly relieve the symptoms or even develop new deficits caused by mass effect, brain edema, or hydrocephalus; ii) cannot provide definite histological diagnosis which may facilitate the chemotherapy or targeted therapies; iii) has been generally limited to lesions which are less than 3cm in maximal diameter; iv) may cause symptomatic radiation necrosis with an incidence of 5%.Surgical intervention for BM in the perirolandic region has still been a matter of debate, since there may be a potential risk of new permanent neurological deficits during the postoperative period , 19, 26.The introduction of 5-ALA fluorescence-guided resection has significantly improved local tumor control for gliomas , 52. Recvia dissection of the precentral sulcus. Total removal of the tumor was achieved, while the patient showed improvement in the initial symptoms. The perirolandic lesion frequently causes critical displacement and distortion of the pyramidal tract or the thalamocortical radiations as being depicted by DTI  untod by DTI , 63. Furd by DTI , 65. Fold by DTI . The safd by DTI , 66. D’Ad by DTI  performeSince Penfeld and Boldrey first described brain stimulation techniques , intraopWith advances in neuroscience and technologies, surgery remains the cornerstone in BM treatment because of prompt relief of the mass effect and resultant clinical symptoms , 46, 73.The recursive partitioning analysis (RPA) classification provided by the Radiation Therapy Oncology Group (RTOG) is graded based on age, functional status characterized by the Karnofsky Performance Score (KPS), and control of systemic disease, which facilitates to select appropriate patients for surgical treatment . GuideliWith the advances in therapeutic options for systemic cancer and improvement of neurosurgical techniques as well as instruments, more patients with BM in the perirolandic region may benefit from aggressive surgical excision which could be performed in the following situations as depicted in The oncological idea that en bloc excision, defined as circumferential stripping of lesion along the brain-tumor interface without violation of its capsule may obtain local disease control and improve the survival time has been widely accepted , 35, 40.As previously described, BM might display an infiltrative growth pattern, extending towards surrounding brain parenchyma . TherefoRegarding BM at the sensorimotor strips, the central sulcus can be dissected to minimize brain retraction and contusion , 32, 76.Deep medial BM involving the paracentral lobule could be reached by different approaches. Since Spetzler et al.  first dePrevalence of BM involving the perirolandic region is increasing , 19. As BM in the perirolandic region may still carry a poor prognosis in spite of contemporary management and technical advances. Nevertheless, individualized and multimodal therapies have been identified as standard of care, and surgery still plays an important role as a cornerstone of therapy, which has been well accepted. More prospective randomized controlled studies are needed to determine if better local tumor control and improved overall survival could be achieved by more minimally invasive surgery.FZ, JK, and YZ conceived and designed the study. FZ and KH collected the data from the previous literature. FZ analyzed the data and drafted the article. FZ and JW contributed to financial support. JW final approved the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by the National Natural Science Foundation of China (No. 81701262) and the Beijing Hope Run Special Fund of Cancer Foundation of China (No. LC2017B13).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In undergraduate and postgraduate medical education, mentoring offerspersonalized training and plays a key role in continuing medical education andthe professional development of healthcare professionals. However, poorstructuring of the mentoring process has been attributed to failings of the hostorganization and, as such, we have conducted a scoping review on the role of thehost organization in mentoring programs. Guided by Levac et al’s methodologicalframework and a combination of thematic and content analysis, this scopingreview identifies their “defining” and secondary roles. Whilst the “defining”role of the host is to set standards, nurture, and oversee the mentoringprocesses and relationships, the secondary roles comprise of supporting patientcare and specific responsibilities toward the mentee, mentor, program, andorganization itself. Critically, striking a balance between structure andflexibility within the program is important to ensure consistency in thementoring approach whilst accounting for the changing needs and goals of thementees and mentors. Through the provision of personalized training,learning and support, mentoring facilitates “the process by which healthprofessionals keep updated to meet the needs of patients, the health service, andtheir own professional development.”2836 With 2 recentreviews31 attributing ethical issues such as bullying andmisappropriation of the mentee’s work to neglect on the part of the host, it iscritical to scrutinize their role in mentoring programs.3241However, lapses in support and oversight of the mentor-mentee matching process, thenurturing of relationships between the mentee, mentor and the host organization, andthe cultivation of a positive mentoring environment has hindered its fullpotential.120 Perhaps most significanthas been the failure of many reviews in acknowledging and contending with theimpact of mentoring’s evolving, entwined, context-specific, goal-sensitive,mentee-, mentor-, relationship-, and host-dependent nature.4249 This suggests that peer,near-peer, group, mosaic, network, leadership, patient, youth, family, ande-mentoring should not be mistakenly conflated nor intermixed withpreceptorship, supervision, role modeling, and networking which have their ownspecific approach and role in education and training.41 Acknowledging mentoring’s context specific nature, this review will focuson the role of the host in novice mentoring which is defined as the“dynamic, context-dependent, goal-sensitive, mutually beneficialrelationship between an experienced clinician and junior clinicians and/orundergraduates focused upon advancing the development of thementee.”50 Novice mentoring is the dominant form of mentoring in medicaleducation.5160A dearth of data on the role of the host in mentoring has been attributed to anumber of issues.the central sourcesand forms of evidence available” on host organzations.42 The flexible nature of a scoping review allows systematic extraction, synthesis,43 and summarizing44 of actionable and applicable information across a diverse range of studyformats and settings. This circumnavigates the limitations posed by mentoring’snature4550 and a paucity of articleson host organizations.5154A systematic scoping review was adopted to identify “55 adaptations of Arksey and O’Malley’s42 methodological framework for conducting scoping reviews was adopted tosystematically study the potential size, gaps, and scope of available literatureon host organizations in novice mentoring.5660 The PRISMA-P 2015checklist was used to develop the protocol for this study.61Levac et al’s“what is known aboutthe role of the host organization in novice mentoring—particularly inInternal Medicine and its subspecialties as delineated by the AmericanCollege of Physicians?”62 The secondary research question was then determined to be “whatwould make an effective host organization in these disciplines?”Narrowing this scoping review’s focus on novice mentoring in Internal Medicinewas largely determined by the amount of prevailing data already present in thefield of mentoring in undergraduate and postgraduate medical education. Thesequestions were designed on the PCC  elementsof the inclusion criteria64 and presented in a PICOSformat , and prevailing reviews of CPD practices, the 8-member researchteam determined the primary research question to be Sformat .66 The PubMed Search Strategymay be found in Supplemental Appendix A.A search on 7 bibliographic databases  was conductedbetween 24th April and 12th September 2018. A search of gray literatureinvolving GreyLit, OpenGrey, and Web of Science databases was carried outbetween 18th October 2018 and 17th December 2018. In order to update the searchso as to include articles published up to December 2019, a subsequent search ofall 10 databases was conducted between 30th December 2019 and 4th January 2020.Accounts of novice mentoring prior to the year 2000 were omitted given thepropensity of these articles to neglect clear descriptions of mentoring andconflate mentoring approaches.67 approach to “negotiated consensual validation.”Upon completion of the independent searches, each member of the research teamcompiled a list of titles and abstracts to be reviewed. They discussed theirfindings online and at weekly research team meetings, achieving consensus on thefinal list of titles and abstracts by using Sambunjak et al’s68 approach to thematic analysis was adopted in the absence of an apriori framework and a clear definition of the host in novice mentoring.Braun and Clarke’s70 As such, drawing upon theroles of medical education units set out by the “AMEE Education Guide no. 28:The development and role of departments of medical education,”71 2 independent reviewers who were not involved in the thematic analysisadopted Hsieh and Shannon’s72 approach to directed content analysis. This process involves“identifying and operationalizing a priori codingcategories”73 which aligns with the constructivist approach adopted in this scopingreview. This approach circumnavigates the wide range of research methodologiesemployed in the articles and prevents statistical pooling andanalysis.7477 Quantifying the data andtabulating the frequency by which the themes and categories emerge also aids asa proxy indicator of their significance.78In keeping with the reiterative process outlined in Levac et al’s sixth stage,consultations with key stakeholders saw the expert team note that the themesidentified were consistent with descriptions of medical education units whichoversee and support multiple education programs.79 81 to evaluate the quality of the quantitative and qualitative studies includedin this review.Whilst not commonly associated with systematic scoping reviews, quality assessmentswere deemed important to better influence and inform future practice. This sentimentwas shared by the expert team. Two authors thus carried out individual appraisalsusing the Medical Education Research Study Quality Instrument (MERSQI)82 and the STORIES  statement.83The narrative produced was guided by the Best Evidence Medical Education (BEME)Collaboration guideComparisons between the themes and categories identified using thematic and directedcontent analysis revealed significant consistencies.(1) “Defining” and secondary roles83141 These papers suggest thatthe “defining” roles47 of the host include:An overwhelming majority of the included articles defined the host organization bythe roles they play in their respective mentoring programs.86140establishing and/or complying with overarching goals, clinical standards, andcurriculum requirements95135influencing,92122 and overseeing the mentoring program102107designing,90108110 and mentoringrelationships95102and nurturing the mentoring cultureeffective host, in particular, were determinedto be their ability to:Characteristics of an 142144provide consistent leadership142145proactively support mentor and mentee participation146cogently facilitate all mentoring processes146148proactively gather and revert feedback on the mentoring program and thementoring relationships within146and, finally, successfully initiate curricular reform to better meet theneeds of their participantsIn addition, the secondary roles of the host comprise of supporting patient care andspecific responsibilities toward the mentee, mentor, the overall program, and theorganization itself. These are outlined in (2) Balancing structure and flexibilityAlthough not a defining characteristic of the host organization, a key finding whichemerged in numerous papers was the need for the host to balance structure andflexibility within the program.9095123144 Rigorous oversight and thejust provision of support, in turn, influences the mentoring culture.151 It ensurestransparent communication of the program’s mentoring philosophy, mentoring approach,as well as the goals and values of the program.149 It also facilitatesrecruitment and retention of mentors through the provision of financialremuneration,150 opportunities for academic promotion,139 formalrecognition of their time and efforts,150 timely access to facilities,resources,144 research funding,154 and protectedtime.95154Establishing a mentoring structure serves to ensure fairness and consistency in thementoring approach and experience for all.47 within the mentoring program so as to adapt to the evolving mentee-, mentor-,host organization-, and relationship-dependent nature of each individual mentoring relationship.114 This is critical in enhancing the mentee’s sense of autonomy, connectivity,and advocacy.144 It is of note that flexibility is also encapsulated within theclinical standards and codes of conduct set out by prevailing hostorganizations.8692 As outlined in Yet, the host must also allow for flexibility116 with common values, goalsand views on education and clearly delineated roles and responsibilities 9092 who collaborate throughcoordinated lines of communication104, assessment, and reporting 104 in order to realize their“defining” and secondary roles. The “defining” roles of the host includeestablishing, nurturing, and overseeing mentoring relationships whilst ideallyoffering both structure and flexibility within the mentoring program.”86110In addressing its primary and secondary questions, this SSR characterizes the hostorganization as a “team of educators and administrators155 This will provide theprogram leaders with administrative, financial, and training support that will helpstreamline their response to the changing needs of the stakeholders and thementoring process.146 Such resources will ensure that codes of conduct, standards ofpractice, timelines, roles, and responsibilities to be adhered to by mentees,mentors and the educationalists and administrators designing and spearheading theprogram are clearly overseen.8692 A consistent framework is alsocritical in ensuring that mentoring takes place within reasonableboundaries.31 Establishing an implicit or contractual92131 agreement between menteesand mentors on the expectations of the mentoring program would minimize the risk ofmisdemeanors and breaches in ethical conduct.To realize their “defining” roles, the host should design and incorporate thementoring program as part of the formal curriculum.89149 Adaptations should be guidedby consistent evaluations of the mentee’s, mentor’s, and the host organization’schanging needs and goals. In the absence of a specific assessment tool, acombination of tools and assessors may be considered.110116124149153To ensure a flexible approach, the host must adopt adaptable, context sensitive, andstakeholder-specific assessment methods to provide mentees, mentors, and thementoring relationship with personalized, appropriate, specific, timely, holistic,accessible, and longitudinal support.The host should also work to establish an accessible and robust platform for mentorsand mentees to communicate freely and confidentially. Such a platform would alsoencourage mentors and mentees to attune themselves and respond to any changes duringthe course of their mentoring relationship. To facilitate this, they should beprovided with pre-mentoring workshops and longitudinal training programs to developtheir communication and online literacy skills. Such skills will help them tocircumnavigate obstacles such as conflicting schedules amidst urgent deadlines thatmay impede the progress of their mentoring projects.142144, holistic support for thematching,142145 and mentoringprocess146, personalized, specific and comprehensive feedback to allparticipants 146148 and thesuccessful development and execution of crucial curricular reform.146Overall, these considerations will provide the host with the opportunity to deliverconsistent, timely, appropriate, longitudinal leadershipToo narrow a picture of the host organization may have been sketched in this scopingreview given that it was explored in isolation from factors such as the dynamicnature of mentoring relationships, structures, environments, and even mentee-mentormatching processes. Concurrently, given the context-specific nature of the host andtheir roles in mentoring programs, conflation within the included articles ofdifferent healthcare, educational and CPD systems across different national andinternational contexts may prove to be problematic.These limitations are compounded by the scoping review’s focus on articles publishedor translated into English. As a result, much of the data comes from North Americaand Europe, potentially skewing perspectives and raising questions as to theapplicability of these findings in other healthcare settings. In addition, despiteusing the Endnote software to carry out independent searches and consolidation ofthe findings, relevant articles may have been unintentionally omitted.42 Levac et al,55 and Pham et al.157 As a result, we believe that the findings will help to inform the design andoversight of future mentoring programs. We also believe that this review may be ofinterest to educators and program designers in settings beyond the mentoringlandscape due to the potential applicability of the findings to other aspects ofmedical education.However, despite these limitations, this scoping review was carried out with therequired rigor and transparency advocated by Arksey and O’Malley,This scoping review evidences the critical role of the host in mentoring programs andhints at their applicability to undergraduate and postgraduate medical education.Riding on ever improving communication technology and advances in the disseminationof information, the increasing use of technology-enhanced mentoring platforms willalso see ever increasing demands for transparency and accountability. There is aneed to conduct closer evaluations of all intra and interprofessional mentoringinteractions to ensure that personal and professional boundaries are maintained withcodes of conduct and standards of practice strictly adhered to.Prospective studies should be conducted to better understand how balance betweenstructure and flexibility can be better struck to ensure maximum efficacy. However,it is only with the curation and validation of effective assessment tools accountingfor mentoring’s evolving nature that mentoring can realize its true potential in CPDprograms.(a) Mentoring’s role in CPD hinges on effective support and oversight by thehost organization. This may be facilitated through the development of aformal mentoring program that is overseen by the wider education andadministrative team.(b) Collaborative efforts between educators and administrators are requiredto ensure that a clear organizational structure is established with the aimof meeting the critical “defining” roles of the host. These comprise ofestablishing, nurturing, and overseeing the mentoring relationships whilstbalancing structure and flexibility within the program. This process must beguided by clear outcome measures, codes of conduct, standards of practice,and assessment points.(c) Members of the host must be trained, briefed, supported, and appraisedthroughout the mentoring program. Their roles, responsibilities and lines ofreporting should be clearly established.(d) Mentoring in CPD should be run as a longitudinal program that is in turnsupported by mentee and mentor training workshops.(e) Mentoring’s role in CPD is to facilitate personalized social, academic,and leadership development opportunities especially when used in conjunctionwith e-mentoring. However, the effectiveness of such an approach pivots uponthe host’s ability to assess and respond to the evolving needs of thementee, mentor and the mentoring relationship.Click here for additional data file.Supplemental material, Supplementary_material for The Pivotal Role of HostOrganizations in Enhancing Mentoring in Internal Medicine: A Scoping Review byElisha Wan Ying Chia, Kuang Teck Tay, Shiwei Xiao, Yao Hao Teo, Yun Ting Ong,Min Chiam, Ying Pin Toh, Stephen Mason, Annelissa Mien Chew Chin and Lalit KumarRadha Krishna in Journal of Medical Education and Curricular Development


Advancing our knowledge related to honoring nursing home resident preferences is a cornerstone of person-centered care (PCC). While there are multiple approaches to providing PCC, we focus on resident preferences as assessed via the Preferences for Everyday Living Inventory (PELI). The PELI is an evidenced-based, validated instrument that can be used to enhance the delivery of PCC. In this symposium, we explore the perspectives of a variety of stakeholders including nursing home residents, staff, and the impact of preference-based care on provider level regulatory outcomes. First, we present a comparative study of preference importance among n=317 African America and White nursing home residents that found more similarities than differences between the two groups. Second, a content analysis of the responses from n=196 interviews with nursing home residents details the barriers and facilitators connected to their levels of satisfaction with their preferences being fulfilled. Third, perspectives from n=27 direct care workers explore the concept of pervasive risk avoidance to the delivery of PCC. Fourth, systems-level practices, such as shift assignments and provider schedules are identified as barriers to successfully fulfilling resident preferences from the perspectives of n=19 staff within assisted living. Our final presentation utilizes a fixed-effects panel regression analysis with n=551 Ohio nursing home providers to explore the impact of PELI use on regulatory outcomes such as substantiated complaints and deficiency scores reported in the CMS Nursing Home Compare data. Discussant Dr. Kristi Williams will integrate findings, highlighting implications for policy, practice, and future directions. Research in Quality of Care Interest Group Sponsored Symposium.


The Older Americans Act (OAA) is the foremost federal law focused on the wellbeing of aging adults in the US. Since its conception 1965, the OAA has sought to optimize the lives of aging Americans, with emphasis on low-income adults, through programs that promote nutrition, transportation, support caregivers, offer employment, and combat elder abuse. This symposium will explore the modernization of the 2020 OAA, which was last reauthorized in 2016. Presentations 1 and 2 will focus on important updates to the definitions used throughout OAA (Title I). Presentation 3 will cover several noteworthy changes to improving grants for states and community programs on aging’s (Title II). Presentation 4 will provide additional context to amendments made to modernize activities for health, independence, and longevity (Title III) prioritize senior Community Service Employment Programs (Title IV) and enhance grants for Native Americans (Title V). Presentation 5 explores the modernizing allotments for vulnerable elder rights protection activities and other programs (Title IV) included changes in funding and home and community-based best practices and elder justice activities. Collectively, these presentations will provide an overview of the key changes in the reauthorization of the OAA. This work will allow GSA attendees to understand the specific efforts to modernization this critical legislation to better serve the aging US population.