A key challenge to providing care for newborn infants in low- and middle-income countries (LMICs) is the lack of timely diagnostic testing due to weak local infrastructures such as laboratory capacity and imaging technologies. To address this challenge, low-cost diagnostic testing that does not require extensive laboratory processing or costly storage procedures has been prioritised. One such example is the shipping of newborn dried blood spot (DBS) samples to international centres where screening for metabolic disorders can be conducted.DBS samples are used as a source of metabolites for newborn screening in many places around the world . These sIn newborn screening, the stability of DBS samples facilitates the shipment of blood for specialised analysis offsite from the location of birth. DBS cards are typically prepared from small drops of blood, dried at room temperature, and can remain stable at room temperature for at least one week. These properties also make DBS-derived samples desirable for screening initiatives in LMICs. Collection and analysis of international DBS have provided an opportunity to test the feasibility of deriving population-level gestational age estimates and identifying and initiating treatment of participants with rare but treatable diseases .The potential exists to use these samples for remote newborn screening and potentially other screening and diagnostic efforts. However, logistical challenges to this approach need to be examined. We describe the feasibility of international DBS sample collection for newborn screening analysis from the perspective of sample collection, shipping, and analysis turn-around times for samples collected in Bangladesh, Kenya, and Zambia and analysed in Ontario, Canada. We also consider the future opportunities for this approach.We aimed to evaluate the use of a gestational age algorithm based on metabolic data from DBS samples collected in Kenya, Zambia, Zimbabwe, and Bangladesh. This project was a partnership between the Ontario Hospital Research Institute (OHRI), Newborn Screening Ontario (NSO), the Department of Pediatrics at the Stanford University School of Medicine, the Child Health Research Foundation in Mirzapur (Bangladesh), the Kenya Medical Research Institute (KEMRI) in Kisumu (Kenya), and the University of Zambia, Lusaka in collaboration with the University of North Carolina, Chapel Hill.A detailed procedure manual was developed and staff at international partner sites were trained in person on the proper collection, storage, and shipping of cord and heel prick DBS samples. Pregnant women were enrolled during their first antenatal care visit or at childbirth. Cord and heel prick blood samples were collected from newborns and spotted on DBS cards, air dried at room temperature and stored up to a week before shipping to NSO. Upon receipt, the samples were visually assessed for quality and considered unsatisfactory if there was insufficient blood, serum rings, or if the sample was clotted, layered, or otherwise overtly damaged. A detailed study protocol can be found here .NSO screens for over thirty priority diseases using immunoassays, enzyme assays, high performance chromatography, liquid chromatography-mass spectrometry (LC-MS/MS), Flow Injection Analysis Tandem Mass Spectrometry (FIA-MS/MS), and quantitative real time PCR (qPCR) ,11. SampReal-time notification of inborn metabolism errors was made for conditions that would benefit from immediate and accessible treatment at the partner sites. Metabolite integrity, potential for confirmatory testing, and availability of effective interventions were all taken into consideration in determining the feasible management of screen positive results, and our approach and rationale have been described in detail elsewhere ,9,13. BaOf the 4731 samples received, only three samples were completely excluded (0.04%) from analysis and 58 (1.2%) underwent partial analysis. The most common reason for incomplete analysis was insufficient quantity of blood to fill out the sample circles on the DBS card.Cord samples were ideally collected within 30 minutes of delivery of the placenta and heel prick samples were collected 24-72 hours after birth or as late as possible, but before early hospital discharge. Most cord samples were collected within 30 minutes of birth, and most heel prick samples were collected before 24 hours due to hospital discharge occurring before then  to promptly identify the level of a substance in the sample and produce a screening result within 1-2 days. Samples were analysed for priority conditions within 4 days of receipt at NSO. Our experience suggests that remote population-based screening using shipped DBS samples under carefully controlled collection and shipping conditions is feasible. On average, samples arrived within 6 days of shipping and priority analysis occurred within 4 days of receipt at NSO or within 2 (Bangladesh) to 3 weeks  of birth  sites for analyte measurement.This platform could also be expanded to screen for additional congenital metabolic and genetic disorders. We have already demonstrated the feasibility of international screening of hemoglobinopathies, MCADD, and congenital hypothyroidism , which wThe use of DBS is particularly advantageous as sample collection is affordable, only requiring a lancet and blood spot card; furthermore, training for sample collection is minimal. DBS cards are ideal for shipping as they are relatively stable at room temperature for short-term storage , are affWith the current workflow, real-time reporting of gestational age estimates is not possible, due to the lag time required for molecular testing to occur (mean range of 32-43 days after birth in these cohorts) and generation of these estimates. Population estimates of gestational age can be obtained, however, and provide valuable information on preterm birth rates and inform global funding initiatives. Further research could evaluate the use of an algorithm based exclusively on biochemical test results, or prioritise key molecular testing markers  critical for gestational age estimates and thus allow for quicker gestational age reporting which could potentially inform infant care.We describe a viable program for the analysis of international DBS samples for gestational age estimates and newborn screening initiatives. This program could serve as a model for future international initiatives and could be further developed for other DBS testing initiatives. Future research should evaluate the possibility of real-time reporting of gestational age estimates back to the study site with modified algorithms. Further implementation of an expanded set of screen positive results back to international sites would also improve the cost-effectiveness of this programme.


Multisectoral and public–private partnerships are critical in building the necessary infrastructure, policy, and political will to ameliorate health inequity. A focus on health equity by researchers, practitioners, and decision-makers prioritizes action to address the systematic, avoidable, and unjust differences in health status across population groups sustained over time and generations that are beyond the control of individuals. Health equity requires a collective process in shaping the health and wellbeing of the communities in which we live, learn, work, play, and grow. This paper explores multisectoral leaders’ understanding of the social, environmental, and economic conditions that produce and sustain health inequity in northern Arizona, a geographically expansive, largely rural, and culturally diverse region.Data are drawn from the Southwest Health Equity Research Collaborative’s Regional Health Equity Survey (RHES). The RHES is a community-engaged, cross-sectional online survey comprised of 31 close-ended and 17 open-ended questions. Created to assess cross-sectoral regional and collective capacity to address health inequity and inform multisectoral action for improving community health, the RHES targeted leaders representing five rural northern Arizona counties and 13 sectors. Select open-ended questions were analyzed using an a priori coding scheme and emergent coding with thematic analysis.Although leaders were provided the definition and asked to describe the root causes of inequities, the majority of leaders described social determinants of health (SDoH). When leaders described root causes of health inequity, they articulated systemic factors affecting their communities, describing discrimination and unequal allocation of power and resources. Most leaders described the SDoH by discussing compounding factors of poverty, transportation, housing, and rurality among others, that together exacerbate inequity. Leaders also identified specific strategies to address SDoH and advance health equity in their communities, ranging from providing direct services to activating partnerships across organizations and sectors in advocacy for policy change.Our findings indicate that community leaders in the northern Arizona region acknowledge the importance of multisectoral collaborations in improving health equity for the populations that they serve. However, a common understanding of health equity remains to be widely established, which is essential for conducting effective multisectoral work to advance health equity.The online version contains supplementary material available at 10.1186/s12889-022-13279-6. In the last decade, public health researchers and practitioners have shifted from identifying health disparities to tackling the economic, social, and environmental root causes of health inequity , 2. ThisCommunities in Action: Pathways to Health Equity “The primary social conditions that impact the (housing and homeless) community I serve seem to be systemic racism and systemic poverty, which are, of course, inextricably related.” “Many unincorporated townships passing laws stating the outright ban of “box stores” and other affordable/accessible services. Past policies around land distribution and land use disproportionately impacting Native communities. Infrastructure, or lack thereof, favoring higher income brackets and more able-bodied peoples: lack of sidewalks, elevators, handicap access, specialized services, etc. Classism affecting poor families, and especially families of color with childcare and early education opportunities being too expensive for most to afford. Free or reduced-price options fill up quickly with wait times being years long.” Some of the participants discussed the role discrimination plays in health and economic inequities in their communities. A few mentioned the type of discrimination, for example, based on race, sex, or class. Often, participants discussed discrimination and racism at both institutional and systemic levels and included perspectives on the deleterious effects of past and current policies perceived to be discriminatory, as articulated here:“The root cause here is the same as it is anywhere - unequal distribution of money, opportunity and power. How that shows up in my community is: Essential services provided in population hubs where cost of living is too high for those who most need services. Virtually no public transportation, wage disparity, lack of entry level employment opportunities, social and geographic isolation, technology vacuums outside of population hubs - although about 95% of the population owns a smart phone, data services for their use is too expensive, or there is spotty/no service in many of the outlying rural areas. Very limited affordable housing. The most "affordable" housing is the furthest from services/food/socialization. Yavapai (county) has been identified as a mental health desert. Yavapai (county) has been identified as a food desert. Limited access to quality medical specialists. Not enough medical providers. Very limited services for families with children with special needs.”Some participants described unequal allocation of power and resources. Most leaders who identified this phenomenon as a root cause of health inequity in their community gave robust explanations, providing examples of how this unequal allocation manifests as a complex interlocking of systems of power. Many leaders went on to describe how this contributes to inequity across SDoH and places specific communities, especially communities of color and people living in poverty, at a direct disadvantage. A regional director that identified as multisectoral and serves families with young children and higher risk populations identified root causes of health inequity and resulting effects as:Approximately 75% of responses were categorized by the a priori definition of the SDoH. Guided by the SDoH specific code definition, we further categorized the types of SDoH leaders perceived as impacting the health of the community they serve. Based on these SDoH definitions, the predominant SDoH described by multisectoral leaders included economic opportunity, access to care, social and cultural cohesion, educational opportunity, transportation, housing, community safety, social justice, quality affordable food, environmental quality, and community design. These themes are summarized in Table In our analysis, two themes emerged beyond the a priori SDoH, including geographic location and local political context.Given the rurality of northern Arizona, it was no surprise that many leaders identified rurality as a cause of inequity in their community. Participants talked about rural, remote, or isolated areas and a lack of connection as a function of rurality. For instance, rurality was considered to compound a lack of or limited access to various services and resources, such as limited healthcare services often due to long distances to travel to care, lack of affordable housing, with the most affordable housing being in more rural and isolated areas, and unfunded and underperforming schools. A few participants who discussed rurality noted the disparities between rural and urban areas in their communities, observing that rural areas experienced greater challenges compared to urban areas due to limited access to essential social services and goods.“The disparity between rural and urban areas in the county. Lack of infrastructure: broadband, available land for private use, water, and other support utilities. These conditions negatively affect opportunities for economic development and mobility, and access to health.” “Economic disparity in rural communities across the region, combined with isolation from needed services . Additionally, rural Arizona's political attitudes of self-reliance, does not provide adequate support for needy populations.” A number of participants voiced their thoughts on how politics play a role in health inequities. Topics commonly mentioned related to politics were lack of trust and confidence in the government, political leadership that historically and currently does not represent the community’s diversity and needs, and perceived unfair tax systems.“Historic and continued lack of representation at the local and county level being anything other than white, male dominated.” “Rural area with low education standards, underfunded and underperforming schools, and lack of economic opportunities. General apathy towards education, along with a desire to live ‘off the grid’ and away from real or perceived government intervention. Perception that taxes and government interventions are already too high.” n = 130) of participants identified key strategies they considered essential in addressing health inequities in their local communities and society as a whole. Leaders described strategies that fell into ten broad categories, including 1) build community knowledge and capacity; 2) develop economic and workforce infrastructure; 3) activate collaboration and partnerships; 4) establish referral and resource systems; 5) provide direct services; 6) ensure flexible, fair, and equitable access; 7) conduct community outreach and engagement; 8) engage in advocacy and policy change; 9) be culturally and community responsive; and 10) utilize evidence-based practices  Program which aims to “develop and strengthen the research infrastructure necessary to conduct state-of-the-art biomedical research and foster the next generation of researchers from underrepresented populations,” our Southwest Health Equity Research Collaborative (SHERC) leveraged the RHES to inform the focus of our Center’s community engagement and investment in research infrastructure. By engaging multisectoral leaders across our region, we as a university partner are now in a better position to understand from a SDoH and health equity frame the community-identified research issues and solutions that our Center could mobilize to address as a regional research partner. As a result of the RHES, several local new community partnerships have been formed to engage community voices on the topic of health equity. In one project, we are pursuing a photovoice methodology to understand community perceptions on COVID-19 health inequity in a northern Arizona county. In another, we are employing a collective impact model aimed at enhancing the children's health system in a different regional county.As an RCMI, we have taken intentional steps to structure our internal research grant opportunities to support the strategies to address the root causes of health equity outlined in Table Based on standard procedures used in qualitative research studies, purposive sampling methods were used to recruit multisectoral leaders from the northern Arizona region , 35. WhiData adequacy in qualitative research is determined by both the appropriateness of sample size and sample composition . Using aWe also acknowledge the lack of racial and ethnic diversity in our respondents. Still, we are uncertain if this is a limitation of our recruitment strategy or a true reflection of the lack of diversity among leadership in northern Arizona. In an effort to obtain a sample representative of county leadership, we engaged county champions and members of the CAC in the development of participant lists. We presented survey results back to champions to interpret this lack of diversity in the sample, which is not representative of the racial and ethnic composition of the counties and communities served. Generally, this lack of diversity was interpreted as a true reflection of the composition of the leadership and an opportunity to critically reflect on how to improve racial and ethnic diversity and community representation within these leadership positions.Moreover, the lack of diversity in our sample aligns with recent studies that found that the US public health workforce employed at local, state, and federal health departments is largely non-Hispanic white . UnderreWith a completion rate above 60% and participation across all sectors and counties of interest, including many sectors not typically included in equity work, we are confident that the outcomes of the RHES capture the perspectives of multisectoral leadership in the northern Arizona region. This research was completed prior to the COVID-19 pandemic, which has potentially created more awareness about health equity for those in sectors outside of the health services or public health sectors. Additional assessment post COVID-19 of health equity among multisectoral representatives is necessary.Numerous health inequities and their drivers were identified by community leaders from different sectors in the northern Arizona region. Discrimination and disproportionate allocation of power and resources were listed as common root causes of health inequity. Many of the respondents also recognized the link between the SDoH and the existing health inequities. A majority of responses (75%) were categorized as SDoH across sectors, where leaders often described complex synergies between the various factors and systems impacting the communities they serve. Community leaders in the northern Arizona region acknowledge the importance of multisectoral partnerships and collaborations in improving health equity for their communities but a common understanding of health inequities remains to be widely established and is essential for conducting effective multisectoral work. This baseline assessment will serve as the basis for a productive dialogue about the various and unique contributions that each sector can activate to influence and strengthen health equity in our region.Additional file 1. NAU-SHERC Regional Health Equity Survey, Data Collection Instrument. Description of data: Online survey instrument used to collect data for the Regional Health Equity Survey


In 2008, the government of Tanzania adopted a competency-based education and training (CBET) system to improve medical training. Yet there are still frequent observations of competency deficits among graduates, suggesting that the goal has not sufficiently been met. This study was designed to assess the underlying context of competency deficits in the health workforce in Tanzania and to provide recommendations for improvement.A cross-sectional study using document analysis and focus groups was carried out in 13 training institutions that provided a diploma course in clinical medicine. The research team assessed availability and adequacy of instructors, physical resources and the process and systemic factors that impact curriculum implementation outcomes.Six (46%) institutions had 75% or more of their teaching staff not trained in curriculum delivery and instructional methods. Seven (54%) institutions had lower instructor-students ratio than recommended (1:25). Overall, the full-time instructors in all institutions constituted only 44% of the teaching staff. Although all institutions had an adequate number of classrooms, the rooms were of small size with dilapidated walls, and had inadequate number of desks/ seats for students. Clinical skills laboratories existed in 11 (85%) institutions, but the majority were of small size, and were not fully equipped as per guidelines and were rarely used. Libraries were available in 12 (92%) institutions but five had seating capacities of 10% or less of the available students. Participants of focus group discussion in the majority of the institutions reported inadequate time allocated for practice and support from the clinical instructors at the practicum sites. Six (46%) institutions had no functioning governing/advisory boards and five (38%) lacked quality assurance policies and implementation plans.Currently, health-training institutions in Tanzania are ill-equipped to produce competent clinicians because of major gaps in the structural, process and systemic components. These findings call for major investment to facilitate production of a competent health workforce. Inadequate training background is a root cause of competency deficits of the health workforce , 2. StudThe determinants of the competence of graduates from HTIs can be classified into structural, process and systemic components , 13. In At the time of designing the study there were 157 registered HTIs  in a projected Tanzanian population of 60 million, which offered various training programs for health workers. Of these, 26 (17%) were technical clinical medicine training institutions. Of the training institutions for clinical medicine, 20 (77%) were public. A cross-sectional study with quantitative and qualitative data collection methods was conducted in 2018. We used the STROBE cross sectional checklist when writing our report .HTIs were stratified based on geographical locations . In Tanzania there are eight health zones: Eastern, Western, Lake, Central, South-Western, Northern, Southern Highland and Southern zones. This was followed by stratifying the HTIs based on ownership . Purposeful sampling was performed to ensure that all zones and a few available private and public–private HTIs were represented in this study to get a representative picture of the underlying context. Thirteen HTIs that implemented the competency-based education and training (CBET) curriculum for clinical medicine for at least 3 years were selected for the study. The sample size thus constituted 50% of the HTIs providing an ordinary diploma in clinical medicine in Tanzania. The distribution included six public institutions, five faith-based organizations (FBO), one public–private partnership and one private institution.The scope of assessment included the human resources, infrastructure and learning resources, governance and administration, and curriculum implementation at the HTIs. Assessment of human resources included the number and categories of full-time and part-time teaching staff based on the national guidelines , the numInfrastructure and learning resources included the number of students, programs at each institution, existence of classrooms, library, computer laboratory, skills laboratory, reliable power supply, availability and quality of classroom furniture, teaching/facilitating equipment and gadgets and existence of reliable internet connectivity. While the number of students was accessed from the principals’ offices, infrastructure and learning resources were verified by the research team.For the governance and administration the team assessed the existence and functioning of the governing or advisory board verified by documented proceedings, organogram and lines of responsibilities. The existence of institutional policies including the quality assurance policy and implementation plan, regulations, procedures and strategies to guide implementation of the planned objectives were also assessed and verified.Curriculum implementation: instructional methods and assessment were assessed by verifying the existence or availability of an implementation plan , module delivery plans, oversight mechanism, practical log book; academic committee and examination oversight, assessment plans for all modules, evidence on utilization of assessment plans, examination regulations, reports prepared by examination setters, moderators, and markers, procedures for declaring examination results board’s approval of examination results and external examiner’s reports.One focus group (FG) for discussion was conducted in each training institution. Each group was made of 8 students in second and third year of studies including at least two student leaders. Second and third year students were purposively selected because they were believed to have the potential to provide rich, relevant and diverse data pertinent to the research question. A moderator and research assistant guided the discussion, took notes and recorded the discussion. The discussion focused on the adequacy and availability of essential equipment and infrastructure to support teaching and learning processes; adequacy of faculty; commitments of the teaching staff and clinical instructors to the teaching role; capacity and effectiveness of the practicum site; and mechanisms in place for the assessment of teaching and learning processes. Participants were encouraged to openly convey their viewpoints using questions and prompts. Each thematic area was discussed until no new relevant information was being obtained from any participant. Focus group discussions lasted for around 40 min.All quantitative data, derived from document analysis and direct information provided to the research team were entered directly into Microsoft excel for analysis. Results were presented in terms of instructor-students ratio, staff disposition, existence and equipment of the instruction rooms, applied clinical laboratories, skills laboratories and information resource centres. These parameters were compared with the national standards which were developed in conformity with the National Council for Technical Education (NACTE) accreditation standards and the Ministry of Health for HTIs , 15. QuaAll health-training institutions provided an ordinary diploma in clinical medicine, nine community health program, two pharmaceutical sciences, five nursing & midwifery and four medical laboratory sciences. The number of students taking an ordinary diploma course in clinical medicine per institution ranged from 62 to 430. Public institutions tended to have fewer educational programs than the faith-based organizations Table . Almost “The number of instructors is inadequate taking into consideration the number of subjects and educational programs offered in this college. One instructor teaches all clinical officers’ classes from first to third year.” .“Instructors are very few, until now there are only two doctors who are not available at the college most of the time … we are compelled to rely on ourselves, we take our learning modules and read ourselves, we browse the internet and go to the hospital and ask questions whenever we do not get support from the college.” .Overall, full-time instructors constituted only 44% of the teaching staff across all institutions. The proportion of full-time instructors was less than one third of the teaching staff in four (31%) institutions. The overall employees' turnover for the three-year period (2016—2018) was 26%. The rate was as high as 46% in four training institutions. The main reason for leaving their jobs in the private and FBO institutions was related to new employment in the public sector while in public institutions reasons were either transfer or retirement. HTIs were affected by inadequate staff numbers, regular absenteeism and inadequate commitments of the teaching staff.. Some institutions hired very inexperienced staff like doctors still in the internship training program. Even in the institutions where the number was considered to be adequate, instructors were commonly not available, for various reasons including government assignments elsewhere.The majority of the training institutions hired part-time teachers from the teaching hospitals to bridge the gaps. Those teachers could not properly address these gaps, because they were usually heavily occupied with their primary responsibilities in their work places, particularly with attending patients“The walls of the classrooms have cracks and the ceiling fans do not function at all because they are very old … students are at risk of accidents when they are in the classrooms” .“Class sessions (lectures) are conducted in shifts, one after the other, because the number of desks and seats are inadequate.” .All institutions had an adequate number of classrooms for the clinical medicine program but these were usually not well equipped. Ten institutions (77%) had a shortage of complete sets of chairs & desks in the classrooms. Almost one third (31%) of the institutions had serious deficits in sets of chairs and desks in the classrooms ranging from 35 to 68%. Classrooms in the majority of the training institutions were of small size, lacked electricity, and had cracks and old paint coming off the walls, an inadequate number of desks and seats (chairs).“Although the classrooms are available, the number and size are inadequate when compared with the available number of students for all programs.” .“(…) Classrooms are inadequate, our college has many students … chairs and desks are greatly inadequate to the extent that students are compelled to keep chairs otherwise they do not get anywhere to sit during the lectures.” . Similar statements were also given by FG participants at HTI 13.Quite often teachers postponed lecture-sessions for reasons related to inadequate number of classrooms and/ or teaching aids like projectors till when another teacher finishes a session for the other class.“A clinical laboratory exists, but it is very small. We are compelled to work in groups of 10 to 15 while the class has ninety students”, .“Although our college has a clinical skills laboratory, we do not use it, and the mannequins are not used at all”, .One institution had no clinical skills laboratory. Only one institution had a clinical skills laboratory with complete sets of basic equipment for the surgery, paediatrics, internal medicine and obstetrics/gynaecology sub-sections. Other institutions had incomplete sets of basic equipment in one or more of these sub-sections Table . The FG Eleven (85%) institutions had a library with a fairly adequate number of relevant books for the clinical medicine program, ranging from 201 to 60,000 books Table . Five inBased on the FG participants’ opinions the information resource centres were generally small in size, short of relevant books for the program of clinical medicine and inadequately used because were usually opened during the class hours only. Because of the limited number of librarians in most institutions, libraries were opened only during the class hours, making it difficult for students to use them. In addition, students were often not allowed to borrow relevant books because of their scarcity.“There is a computer laboratory with several computers, but only five of them are functioning … For that reason students use their own computers.” .Although computer laboratories were available in more than three quarters (77%) of the HTIs, the majority were small with an inadequate number of functioning computers and lacked internet connectivity.All practicum sites  had departments for general surgery, obstetrics & gynaecology, paediatrics and internal medicine. Ten (77%) institutions also had sites for surgical specialties . Overall, FG participants from the majority of the institutions reported that the practice sites were sufficient for teaching and learning purposes and that students were encouraged by their teachers to go there. However, they also reported some shortfalls, including inadequate essential supplies like gloves, too brief rotations and inadequate support from the clinical instructors. Some hospitals required the HTI to supply gloves for students to use when assisting and performing clinical procedures. The HTIs however supplied very few gloves, which limited students' opportunities to assist and perform an adequate number of procedures.Six 46%) HTIs did not have functioning governing or advisory boards  institutions, they were reported to be small in size, with a shortage of prescribed books for the program of clinical medicine and only opened during class hours. In view of these findings, the current libraries do not adequately serve their roles in supporting teaching and learning. Libraries serve crucial roles in learning by supporting appropriate accessibility and utilization of relevant information and providing learning resources for teachers and students . If the Teaching hospitals play a crucial role in building and strengthening clinical competencies of medical students. They enable students to apply, in real patients’ setting, the specific knowledge and skills learned in the classroom and skills laboratories. To provide adequate experience to students, teaching hospitals must have appropriate and adequate facilities and supportive clinical instructors. Competent and committed clinical instructors play crucial roles in enhancing students’ learning in clinical settings through guiding, modelling, directing, and evaluating student learning. They assist students to integrate theory and practice, promote both professional ethical competence and technical capabilities . The briAs has been reported in other studies, our investigation indicates that education in clinical settings competes with patient care, mostly to the disadvantage of the training of clinical skills and competencies , 30. CliAccording to NACTE accreditation standards, Governing and Advisory Boards are key organs responsible for the quality and integrity of the training institution. The absence of these organs in 46% of the institutions leads to sub-optimal educational monitoring and control systems in the management of institutions. Governing and Advisory Boards, should, among others,1) monitor the overall performance of the training institution to ensure that institutional vision and mission are achieved; 2) ensure that institutional practices are consistent with the national regulatory bodies’ guidelines and standards; and 3) ensure that training institutions have functional quality assurance mechanisms. Based on our findings, we suggest that all training institutions form these organs to strengthen the institutional integrity and improve quality assurance.The quality assurance policy and implementation plan describe the quality management systems in place that ensure quality of the educational program being delivered. Quality assurance at the training institution encompasses the quality of training and learning activities, availability of appropriate information resources, facilities and functional equipment as well as financial control and sustainability . The absFocus group discussions only involved students. Further studies should also involve other key stakeholders including instructors, HTI management, owners of the HTIs and regulatory authorities .This study has provided a snapshot illustrating the gaps of the infrastructure, human resources, information and learning resources, the process and systemic components in training institutions, which offer clinical medicine program in Tanzania. Generally, these findings suggest that a substantial proportion of raining institutions offering the diploma in clinical medicine in their current state, are ill-equipped to produce competent clinicians. These findings call for major investment to address the gaps in order to produce a competent health workforce. They also suggest need for regulatory bodies to strengthen monitoring and evaluation of HTIs to ensure compliance with the standards.


Different models have been developed to address inequities across the cancer care continuum. However, there remains a scarcity of best practices on understanding and responding to the burden of cancer in a defined catchment area.As such, the National Cancer Institute (NCI) recently provided a framework to maximize the impact on cancer burden, including a greater focus on community outreach and engagement. In this paper, we describe how Cedars Sinai Cancer (CSC), a health system that serves one of the most diverse counties in the US, implemented the framework to define its catchment area, characterize its population, identify high risk priority groups, and make decisions to address health disparities.We provide a review of the methods used to assess socio-ecological levels of influence. Data were reviewed from numerous national, statewide, and county sources and supplemented by locally administered questionnaires, heat maps, and community profile summaries to gain more localized snapshots of cancer disparities in Los Angeles County. Lastly, feedback was solicited from external peer groups, community stakeholders, and key decision-makers, and the proposed catchment area was aligned with the State’s Cancer Plan and the NCI Catchment Area and Community Outreach and Engagement Mandate.The selected CSC catchment area meets NCI criteria and has potential to demonstrate impact both at the population level and within specialty populations. As a result, strategies are being developed to organize community outreach and engagement, as well as research across basic, clinical, and population sciences to guide cancer control and prevention efforts.To maintain a high level of cultural inclusion and sensitivity, multiple layers of data are needed to understand localized pictures of cancer disparities and underlying causes. Community engagement remains essential to implementing policy, best practice, and translational science for broader impact.The clinical and translation work conducted at any cancer center requires an understanding of the determinants of health that contribute to the differences in cancer incidence and mortality among different groups. The NCI-aligned approach that we highlight is critical to support the design of future cancer control strategies that address and possibly reduce local health inequities. Health disparities exist based on social, economic, and environmental factors, including gender, race, ethnicity, gender identity, sexual orientation, age, disability, geographic location, and socioeconomic status . Many diThe National Cancer Institute (NCI) now requires cancer centers to define their catchment area with geographical boundaries, and address cancer burden and inequities within that region through research and community outreach and engagement . To suppThe structure provided by these guidelines is essential when considering the vast diversity of municipal regions of the United States, such as Los Angeles, California, which is home to roughly 10 million people . The CouBelow we highlight the series of steps taken to define, characterize, respond to, and engage the population in our cancer center catchment area.Decisions were made regarding the catchment area based on geographic considerations, peer review to meet NCI criteria, and having a population size for which we could feasibly demonstrate measurable impact of our community outreach and engagement (COE) activities and COE-facilitated research. Our COE efforts focus on adherence to cancer screening guidelines and major behavioral and lifestyle factors, such as physical activity and tobacco use, and dissemination of the latest, most accurate cancer information. When considering the geographic area, we followed NCI metrics and County data. NCI requires clear geographic boundaries; a population of >4,000,000; greater than 80% of cancer patients residing within catchment area; and that the area is within 60 miles of the medical facility (CSC) to maximize clinical impact . These mWe presented the areas that met the NCI metrics to internal committees at CSC, external advisors, community outreach coordinators, and key decision-makers to ensure that we were aligned with the State’s Cancer Plan and the NCI Catchment Area and Community Outreach and Engagement Mandate. Ultimately, CSC determined its catchment area to encompass service planning areas: Antelope Valley, San Fernando Valley, Metro, West, South Bay  to characterize national trends in cancer incidence and mortality and assess selected behavioral risk factors for populations of interest in our catchment area. Next, we reviewed statewide data from the California Cancer Registry and the California Health Interview Survey (CHIS). CHIS is the nation’s largest state health survey and is conducted by the UCLA Center for Health Policy Research. At the time, the CHIS data cycle did not include comprehensive cancer screening questions; however, we have now partnered with CHIS to include cancer screening questions in the next data cycle (2021-2022) and to oversample CSC’s catchment area populations of Latinx and Asians age 50+ to increase the number of participants in these groups. At the county level, we collated information from the Los Angeles County Cancer Surveillance Program and Los Angeles County Department of Public Health. Finally, we applied innovative geospatial mapping of these data to identify local hotspots for screenable cancers diagnosed at late stages with overlays of other relevant data  to better understand local cancer disparities (discussed below).We supplemented our secondary data collection with additional questionnaires to better understand barriers to adherence that individuals face with cancer preventionand early detection efforts. We focused on social and behavioral risk factors in different racial and ethnic pockets through the administration of culturally adapted questionnaires, as exemplified with the Cancer and Healthcare in Los Angeles Survey (CHILAS). The CHILAS survey was developed with input and feedback from large communities in the catchment area  to identify major factors that characterize and influence screening behavior, medical history, and health care access. To date, a total of 3,200 surveys have been completed. Of these, 381 surveys have been collected from the Korean community, yielding interesting results. For example, the top barriers for not getting screened were not having health insurance and not feeling sick, suggesting the importance of financial concerns and cultural considerations. Also, we observed that mammography rates among age-eligible women (N=216) were low at 37% (N=80), whereas colonoscopy rates among age-eligible participants (N=284) were higher at 64% (N=182), leading us to question: “What are the unique factors for low mammography screening in Korean women in Los Angeles County (that do not apply to colonoscopy)?”In the Filipinx community, upon review and feedback from our Filipinx community advisory board, the CHILAS survey was further adapted, and a recruitment strategy was implemented to form a Filipinx Cohort. A total of 1,492 surveys were collected from the Filipinx community in two waves. For screenable cancers, in contrast to Koreans, low adherence to colorectal cancer screening guidelines was identified. In waves 1 and 2, we found that 61% (386 out of 629) of age-eligible men and women had ever had an FOBT and/or colonoscopy, and in wave 2 where the question was updated to ask about most recent screening, only 44% (126 out 287) of age-eligible men and women are up to date with colorectal cancer screening (had FOBT within a year and/or had a colonoscopy within the last 10 years). This finding is consistent with the national trend of Filipinx Americans underutilizing life-saving screening tests for colorectal cancer, resulting in later stage of diagnosis and poorer survival . With thWith both primary and secondary data, we developed community profile summaries for several racial/ethnic/gender/sexual orientation minority groups. These profiles highlight noteworthy cancer trends, as well as other social determinates of health such as income, poverty, access to health care, mental health, and literacy. Further, we examined risk behaviors such as substance abuse, physical inactivity, and poor nutrition , melanoma mortality rates have declined by nearly 18% since 2014 in non-Latinx White (NLW) individuals –10. ThisData from the California Cancer Registry and other literature show that the melanoma burden is increasing in Latinx adults in California, who represent the largest ethnic group in the state, at 39% , and typIn summary, we used the following process to identify cancers and behaviors of primary, initial focus. 1) We considered publicly available data such as cancer registry data , with a focus on top five cancers and cancers with increasing incidence rates, such as liver cancer in Latinx and breast cancer in selected Asian populations. 2) We generated our own quantitative data from: a) conducting geospatial analyses of cancer registry data; b) conducting our own survey, CHILAS, described above; c) sexual and gender minority questionnaire; and d) the California Health Interview Survey (CHIS) described above. 3) We also conducted study-specific surveys when useful. 4) In addition, we continue to seek qualitative input from community advisory boards , townhall meetings, media events, and participation at community events, such as PRIDE events in greater LAC to identify issues of concern to them and to set priorities. 5) We considered strengths at Cedars-Sinai Medical Center (CSMC) that we may leverage to address specific disparities. 6) We aligned our efforts with the NCI Catchment Area and Community Outreach and Engagement Mandate and the State of California’s 5-Year Cancer Plan.Through partnerships with churches, community organizations, Federally Qualified Health Centers, non-profit organizations, and trained community navigators, our COE team has reached over 16,000 community members of Filipinx (18%), Latinx (20%), LGBTQ+ (25%), Korean (27%), and African American and other (10%) descent in our catchment area with science-based tailored cancer information in our newly defined catchment area. Based on pre/post workshop surveys, there was an 84% improvement in knowledge, behavior, and attitudes concerning cancer risk and prevention for all groups if a community member attended community outreach events, while reduction in barriers to cancer screening was most effective through navigator/promotora training. Knowledge of cancer risk and prevention was also shown to have improved more if there were physical events (33.3%), compared to virtual events (16.1%). With this feedback on our COE strategies, we have a more narrowed focus on a smaller set of cancers and behaviors and have built toward step 4 of NCI’s guidelines, addressing disparities, by developing culturally sensitive, sustainable, scalable, and exportable interventions. We are investing in areas where we believe we have the potential to make a difference in either incidence (long term), mortality, or survivorship experience.For the Korean breast cancer example, we started by noting the increasing incidence from cancer registry data, increased density of late-stage breast cancer in Koreatown , and low adherence to breast cancer screening guidelines from our CHILAS data. The grant-funded intervention we describe was facilitated by the CAB and utilizes capacity building among our community partners, training of navigators, and workshops and media events to increase awareness of this issue in the Korean community.For the melanoma example, we noted that melanoma mortality rates in the US are highest among older men and individuals of lower socioeconomic status. Our findings from our qualitative exploratory study have enriched existing data regarding inequities in lower SES Latinx and non-Latinx White (NLW) individuals and have been critical in designing current interventions that deliver more effective primary and secondary melanoma prevention for underserved populations across geographic regions. At the healthcare systems and health policy level, this work adds to infrastructure and models for collaboration, and is aligned with the Wipe Out Melanoma - California statewide initiative, which is increasing the number of research studies, clinical trials, educational campaigns, and opportunities for the community to engage in melanoma prevention and early detection.Key to step 4 in the NCI guidelines is the continued involvement of the population in setting a research agenda, and reaching out to the population through research, outreach, and education. The entire research portfolio developed as a result of the methods employed in this paper span across basic, clinical, and population science to guide cancer control and prevention efforts. Through further development of our community advisory boards, and a bidirectional relationship between community outreach and education and research, the populations in the catchment area are at the center of our endeavors. As part of an ongoing assessment process, community leaders representing populations with cancer disparities serve on four active community advisory boards:1) LGBTQ+ Community Advisory Board, 2) Filipinx Community Advisory Network, 3) Latinx Community Advisory Board, and 4) Korean American Community Advisory Board. Representatives from these advisory boards and networks comprise a larger 22 member Cedars-Sinai Cancer Community Advisory Board, which meets quarterly that helps to maintain engagement, guide research into policy implementation and standards of practice, and facilitate translational research across CSMC.An example of how we are guiding research into policy is through our collaboration withThe California Dialogue on Cancer and their Health Equity Taskforce. The CRCHE faculty and staff were instrumental in writing for the first time a section on LGBTQ+ and cancer. Given that there are no reliable cancer registry data stratified by sexual and gender minority status, the CRCHE has been engaged in advocacy efforts to help expand the California Cancer Registry’s data dictionary to include these important variables. The efforts are currently underway with support from the State’s Comprehensive Cancer Control Program which will ultimately impact Surveillance, Epidemiology and End Results (SEER) to become more inclusive of LGBTQ+ populations. This important effort will enable organizations and cancer centers to develop a standardized and coordinated cancer control and research agenda to better serve this population.For COE to inform and facilitate research in the other research programs, Cancer Biology (CB) and Experimental Therapeutics (ET), senior leadership at CRCHE work closely with the CSMC Executive Committee and Leadership Council, which includes other Associate Directors, program co-leaders, and program members where COE and catchment area topics are addressed on a regular basis. These meetings are exclusively focused on COE and the catchment area. An example that emerged from our meetings with ET is a community-based study of Nonalcoholic fatty liver disease (NAFLD) in the Latinx population that is currently a cross-sectional study of NAFLD prevalence that will facilitate a future, planned intervention trial. An example for CB is the initiative to use organoid models to address selected cancer disparities, such as breast cancer in transgender subjects with a focus on hormones and sex differences in bladder cancer.In this paper, we highlighted how CSC, through guidance from the NCI catchment area framework, has aimed to address health disparities in historically underserved communities. The approach to research and population engagement (steps 2 and 3) has allowed us to work towards solutions that address disparities and aim to alleviate the cancer burden (step 4). Although we have not yet reached the stage of presenting catchment area-level results, our work has led to funded grants that are implementation science based and are presently in the implementation and evaluation phase. The next step currently underway is step 5, which focuses on the representation of the catchment area population in clinical trials. Inclusion of racial and ethnic minorities in cancer clinical trials is critical to increasing the generalizability and knowledge of the risks and benefits of new interventions; however, evidence points to low participation among racial/ethnic minority populations –27. in rEach cancer center faces its unique challenges in defining, characterizing, and addressing the needs in their catchment area population. We have found that there is not a ‘one size fits all’ approach, especially in regions such as Los Angeles County that have diverse populations with pockets of dense, ethnic enclaves. Approaches must aim to be sensitive and inclusive of all races, ethnicities, and sexual and gender identities, a goal achieved through continuous tailoring and community engagement. A consideration of multiple health domains and socio-ecological influence is required, as well as a continued and localized assessments of cancer needs and disparities coupled with understanding of racial/ethnic-specific and localized cancer-relevant social and behavioral risk factors; otherwise, trends can be missed, and disparities can widen. Our mixed-methods approach to implementing that framework set forward by the NCI, in concert with continued community outreach and education partnerships, provides a narrative for other cancer centers aiming to create a sustained population-level reduction of cancer burden for individuals and communities experiencing health disparities.The original contributions presented in the study are included in the article/LF, CS, RH, ZS contributed to conception and design of the study. LE, MC contributed to data curation and visualization. LF wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The late-stage breast cancer study is funded by California Breast Cancer Research Foundation (CBCRP) Award Number B27BB4290; the melanoma study is funded by Mary E. Brenneisen Fund at Stanford Medicine and in part, the National Center for Advancing Translational Sciences of the National Institutes of Health, Award Number UL1TR003142. Additionally, this manuscript is the result of work supported by resources at Cedars Sinai Cancer in Los Angeles, California.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Critical care ultrasonography (US) is widely used by intensivists managing critically ill patients to accurately and rapidly assess different clinical scenarios, which include pneumothorax, pleural effusion, pulmonary edema, hydronephrosis, hemoperitoneum, and deep vein thrombosis. Basic and advanced critical care ultrasonographic skills are routinely used to supplement physical examination of critically ill patients, to determine the etiology of critical illness and to guide subsequent therapy. European guidelines now recommend the use of US for a number of practical procedures commonly performed in critical care. Full training and competence acquisition are essential before significant therapeutic decisions are made based on the US assessment. However, there are no universally accepted learning pathways and methodological standards for the acquisition of these skills.Therefore, in this review, we aim to provide a methodological approach of the head to toe ultrasonographic evaluation of critically ill patients considering different districts and clinical applications. Critical care ultrasonography (US) is considered an essential tool for the initial evaluation and clinical management of critically ill patients admitted to the intensive care unit (ICU), combining simple protocols of US application, a prompt assessment of critical conditions and therapeutic decisions. As a matter of fact, critical care US is nowadays considered not only a diagnostic tool providing information about the source of critical illness but can also be a component of the patients’ physical exam. This approach expands the sensitivity and specificity of clinical examination and basic measurements and is oriented to the peculiarity of the single patient.The diffusion of critical care US has been slowed down over the last years because of technical issues (portability and availability of the machines), and lack of formal and standardized training programs. These gaps have been recently overcome by technical advances providing high-quality images at the bedside, and by the development of new guidelines for skills certification. Recently, a consensus of the European Society of Intensive Care (ESICM) provided a number or recommendations for the head to toe basic skills to be obtained by intensivists managing critically ill patients , and focAccording to that paper, the aim of this review is to provide a methodological approach of the US evaluation of different body districts and a critical reappraise of available training programs in the literature for the implementation of head to toe US in ICU.For the purpose of this review, we asked the contribution of ICU Italian physicians with recognized expertise in US use in the critical care setting. Criteria for panel selection included high scientific knowledge and production in the field of ultrasonography and recognized clinical expertise.We finally involved 12 experts, who were further divided in 5 subgroups, each one addressing different districts: brain, heart, thorax, abdomen, and vessels US. The experts were asked to summarize the methodological issues related to the application of US in the ICU, and to provide a review of the available training programs and studies aimed at providing competences for the application of US in critically ill patients.Brain ultrasound (BUS) is getting interest as bedside tool for intensivists and emergency physicians, with an important role in the early diagnosis and management of acute intracranial pathology . The useThe use of this technique has opened new possibility for the assessment of intracerebral pathophysiology, not only for neurocritical patients but also in general intensive care unit and emergency room settings .Clinical indications of TCCD currently include the evaluation of cerebral anatomy , as well as the assessment of cerebrovascular diseases. The analysis of the waveform obtained from the major intracranial vessels allows in fact the management of patients in different scenarios such as traumatic brain injury, subarachnoid hemorrhage, and neurological complications of general ICU patients such as cardiac arrest, sepsis, and respiratory failure .The evaluation of normal or altered cerebral anatomy. In particular, TCCD is able to assess the presence of intracranial hemorrhage, midline shift, hydrocephalus, and the need for external ventricular drain –10.The use as a confirmatory test in the assessment of brain death, which is determined as oscillatory reverse flow, systolic spikes, and absence of flow .Noninvasive and indirect evaluation of intracranial pressure (ICP) and cerebral perfusion pressure, based on different techniques obtained from the flow velocity waveform analysis , optic nAngiographic vasospasm and delayed cerebral ischemia are the most severe consequences in aneurysmal subarachnoid hemorrhage (aSAH) patients: in this context, TCCD ultrasonography has shown to be reliable even in comparison with digital subtraction angiography (DSA) in the detection of increased flow velocity in the middle cerebral artery .Cerebral autoregulation (CA) is the ability of the brain to maintain cerebral blood flow (CBF) constant despite changes in cerebral perfusion pressure: the flow velocity is directly correlated with CBF; therefore, TCD allows evaluation of both static and dynamic components of CA, including transient hyperemic response test, cuff test, and the Mx index, calculated as the correlation coefficient between flow velocity and arterial blood pressure , 17.Clinical applications of BUS include:BUS is generally performed using four specific insonation windows: transtemporal, transforaminal , submandibular and transorbital. A phased array 1.5–4 MHz low-frequency probe is used for the insonation of intracranial structures, while linear 7–15 MHz high frequency is used for ultrasound of optic nerve sheath.Training paths and skills certification for the use of BUS by intensivists are still matter of debate among Scientific Societies and experts. Currently, only the American Academy of Neurology advises for the routine use of TCD in the neurocritical care setting Lung ultrasound gained a leading position in critical care both as a diagnostic and a monitoring tool –20, faciAlthough a significant difference in probes performance could not be found in children , we suggBi-dimensional images can be associated to M-mode, particularly useful to confirm the presence/absence of lung sliding , thanks to its higher frame rate.Color Doppler is rarely used in lung ultrasound; it can help identifying shunt in consolidated lobes , althougAutomation has been proposed to facilitate the interpretation of lung ultrasound in the critically ill –37: it sA training curriculum of 25 supervised examinations resulted adequate to acquire basic skills in lung ultrasound ; howeverThe advent of portable ultrasound machines has revolutionized the clinical application of cardiac US, allowing physicians to assess cardiovascular complications at the patient’s bed. In particular, cardiac ultrasound with transesophageal echocardiography (TEE), first used in 1981, was moved from the necessity to evaluate the surgical result immediately and monitor the hemodynamic state of the patients with post-cardiotomy shock in terms of fluid and inotrope in the operating room . That leDeveloping and applying echocardiography within the critical care setting required another 10 years since the American College of Chest Physicians and La Société de Reanimation de Langue Française in 2009 published a consensus statement to describe how the use of ultrasound should be considered and described what type of skills should be mastered to reach competence. This paIn contrast, advanced CCE refers to a more comprehensive hemodynamic assessment that requires quantitative evaluation of cardiovascular function (without or with TEE use). For example, in patients with shock, advanced assessment would refer to the quantification of left ventricular ejection fraction, evaluation of diastolic dysfunction and valvular diseases. In this context, color and spectral Doppler modes are applied with the aim to provide an appreciation of patho-physiological conditions.Considering that the transthoracic echocardiography (TTE) percentage of successful diagnostic exams in the ICU is approximately 50% vs over 90% in the elective cardiac lab, and also that an adequate TTE window is obtained in 36% as compared to 97% with TEE, even if the main focus for echocardiography in ICU remain training in TTE, it must be considered also the importance of achieving education in TEE as well .For training in CCE, an experts panel representing 13 Scientific Societies of Critical Care has recently determined the basic and advanced skills Fig. .Fig. 3LeSimilar echocardiography disciplines prove that the learning curve for basic CCE may flatten out after 30 supervised studies . The AmeDiaphragm ultrasound has been increasingly employed in daily clinical practice and research to assess diaphragmatic function both in and outside ICU , 51–57. As depicted in Fig. Normal values of diaphragmatic displacement, thickness, and thickening fraction along with the measurements indicative for diaphragmatic atrophy and dysfunction are reported in Table The ultrasound report should always include mechanical ventilator settings (including the applied pressure support and positive end expiratory pressure), patient positions , and previous comorbidities  because all these factors possibly affect the measurements of diaphragmatic muscle mass and function.In the absence of ultrasound experience, the learning curve for gaining sufficient skills to conduct a diaphragmatic ultrasound assessment for thickness and displacement in clinical practice requires at least 40 bilateral examinations, of which 20 under the expert supervision , even ifAs future perspectives, new ultrasound applications have been proposed in the assessment of diaphragmatic activity, i.e., diaphragmatic tissue Doppler analysis, diaphragmatic shear wave elastography, and diaphragmatic speckle tracking analysis, evaluating diaphragmatic excursion kinetics, stiffness, and strain, respectively, during respiratory cycle . The reaIn case of unexplained shock associated to abdominal pain or not, bedside ultrasound assessment of the abdomen should be performed to diagnose possible underlying conditions. Furthermore, bedside sonographic reassessment of worsening patients suffered from blunt trauma should be executed to visualize previously undetected free fluids or to monitor the evolution of already known small amount of free fluid. Finally, abdominal ultrasound should be part of a systematic sonographic assessment of septic patients for searching the source of sepsis.Despite significant evidence on the use of abdominal ultrasound in critical care , a strucRecently, a consensus statement from the ESICM  includedThe minimal requirements for optimal imaging acquisition and interpretation are reported in Table Studies have reported that different physicians from various subspecialties and different levels of training can be able to identify the aorta using ultrasound with enough degree of accuracy. Hoffmann et al. have found that also inexperienced sonographers might achieve acceptable performance with an appropriate training requiring > 25 proctored examinations needed to ensure competency . Nguyen No significant data have been published on how many examinations are needed per year to maintain proficiency in the setting of critical care.POCUS can be helpful in case of urosepsis, allowing to detect infected hydronephrosis Table  69]..69].When hydronephrosis is identified, both kidneys and the bladder should be evaluated . In factHigh value (> 0.77) of resistive index of the renal interlobar arteries assessed through pulse-wave color Doppler has been shown to predict adverse outcomes and renal failure progression in septic patients and after major or cardiac surgery .Regarding sonographic diagnosis of hydronephrosis, Sibley et al. have found that a learning curve consisting in 25 examinations at least may be enough to achieve proficiency . On the Training for evaluation of Doppler-derived renal resistivity index (RI) is not defined yet and requires further evidence.In patients with acute abdominal pain, unexplained shock or septic shock, abdominal ultrasound is useful to assess differential diagnosis and to define the need of further radiological exams to identify possible underlying conditions. However, in this context, abdominal ultrasound performed bedside by intensivists reaches its maximum effectiveness only if clinically driven.The presence of previously undetected abdominal free fluids in a symptomatic patient suggests acute abdomen needing further diagnostic exams and eventually surgery consultation .Increased echogenicity of the peritoneal stripe with multiple reverberation artifacts may be a sign of free intraperitoneal air due to perforation .A dilated small bowel loop with reduced or absent peristalsis, characterized by the “to-and-fro” movement of the intestinal content, also associated to gastric distension suggests bowel occlusion .In a context of sepsis or septic shock and jaundice associated to elevated liver function tests, sonographic appearance of the gallbladder characterized by thickened walls (> 3 mm) associated or not to fluid peripheral collections, gallbladder dilation (length > 4 cm), hydrops in conjunction with large gallbladder stones, and presence of biliary sludge or pus are signs of acute cholecystitis .No robust evidence is still available regarding training and learning curve for abdominal ultrasound performed in a critical care context by intensivists. Further studies are needed.Ultrasound for detection of free fluids in the acute traumatic abdomen is well known as clinical practice since part of focused assessment with sonography for trauma (FAST) examination recommended by the American College of Surgeons in the Advanced Trauma Life Support Course.After the first assessment in the Emergency Room, this kind of examination should be repeated also during ICU stay as a monitoring tool or in case of unexplained hemodynamic instability allowing to detect eventually previously undetected free fluids collection or an increase in already known small amount of free fluid.With the aim of establishing the competency in detecting intraperitoneal free fluids at FAST examination, 10 examinations might not be sufficient . The leaBowel dysfunction, associated to vomiting and abdominal distension may be common in the critically ill, especially in patients who underwent major abdominal surgery. Gastric ultrasound allows both a qualitative and quantitative assessment of the stomach allowing to rule out postoperative ileus and to define risk of aspiration , 78.When properly clinically driven, gastric ultrasound reaches high sensitivity (1.0), specificity (0.975), positive predictive value (0.976), and negative predictive value (1.0) .Arzola and coworkers have found that 33 supervised gastric scans are required to achieve a 95% accuracy in qualitative assessment of gastric content Finally, in septic shock, ultrasound allows to detect abscesses, necrotizing fasciitis, cellulitis, or thrombophlebitis as potential underlying source of sepsis with good accuracy , 82. BerThe global use of ultrasound is recommended to assist all steps of ultrasound vascular access device placement: (a) rational choice of appropriate vein and proper approach; (b) prevention of primary malposition; (c) ruling out of respiratory complications; (d) ruling out of late complications   Table 55.Table 5General curriculum for ultrasound-guided vascular access procedures should consist of didactic lectures or web-based teaching; laboratory training including simulation training; a clinical phase that includes both closely supervised and distant supervised learning. Following ESAIC guidelines, each trainee should observe and then perform, under supervision, 5 procedures of each kind of approach. Finally, perioperative use of ultrasound-guided for vascular access guidelines from European Society of Anesthesiology and Intensive care (ESAIC) suggests at least 30 US-guided procedures of any type in a 12-month period for completion of competency-based training, as personal learning curve In addition, compressive ultrasonography of common femoral vein at the groin, superficial femoral vein at the mid-thigh, and popliteal vein in the popliteal fossa allows to rule out deep vein thrombosis with good accuracy.Head to toe ultrasonography is becoming a fundamental skill for the bedside assessment of patients in the ICU Fig. .Fig. 5HeA standardized training program and certification is required to improve physician’s knowledge and patients care in these settings.


Materials, presenting research and review papers that focus on the wear and corrosion resistance of various materials, new scientific issues and their useful applications in wear and corrosion research and industrial sectors.“Wear and Corrosion Resistance Technology of Thin Film Materials” is a new and open Special Issue published in Over the last decade, wear and corrosion resistance technology has emerged as an exciting research field, offering perspectives on how to reduce the unit prices of products and their fabrication processes in industrial sectors and driving future research and developments (R & D).Wear and corrosion resistance technology is crucial for industrial applications, which include several scientific issues, such as surface protection ,2, the iThe Special Issues, entitled “Wear and Corrosion Resistance Technology of Thin Film Materials”, collates research that explores various wear and corrosion resistance technologies (development and applications), including studies on lubricants or friction, focusing on, but not necessarily limited to, the following themes: wear and corrosion resistance technologies in thin films; various materials for film coating technologies; metal alloys or carbon-based investigations of thin films; macroscopic or microscopic (micro/nano) composite films for wear and corrosion; and the development and applications of resistance technologies for thin film materials in various environments, such as semiconductor applications (LED/OLED), aerospace/automobile engineering, energy and environmental technology, medical/pharmaceutical industry, and the paper/cellulose industry.


In an analysis of risk evaluation and mitigation strategies for teratogenic drugs, Ameet Sarpatwari, Beatrice Brown and Aaron Kesselheim explore the variation in primary and secondary prevention measures. Teratogenicity is a common reason for the US Food and Drug Administration (FDA) to apply risk evaluation and mitigation strategies (REMS) to approved prescription drugs.Among the 11 REMS for 10 drugs we analyzed, we found considerable variation in which contraceptives were required, for whom, and when, as well as in the timing and frequency of mandated pregnancy testing, which was only partly explained by the drugs’ known teratogenic risks.Further study of the adequacy of REMS for drugs with teratogenic risks may be necessary to optimize their public health benefits.Since 2007, the US Food and Drug Administration (FDA) has required drug manufacturers to institute risk evaluation and mitigation strategies (REMS) for certain drugs with known safety problems to help ensure that the benefits of use outweigh the risks ,2. TheseRoe v. Wade in June 2022, [Among the most common reasons for a REMS is teratogenicity. In such circumstances, the REMS may include requirements for patients to use contraception (primary prevention) or undergo pregnancy testing (secondary prevention) . Studiesne 2022,  and withne 2022, .For our investigation, we first used the FDA’s REMS database to identify all drugs subject to REMS for teratogenic risks as of September 1, 2021 . For eacFor each REMS, we extracted information about the requirements for use of contraception (primary prevention), pregnancy testing (secondary prevention), and emergency contraception (secondary prevention) . For useOf 62 REMS, we identified 11 (18%) intended to minimize teratogenic risks. Seven applied to the generic and branded versions of drugs to prevent organ transplant rejection (mycophenolate) and to treat pulmonary hypertension , acne (isotretinoin), and multiple myeloma . The other 4 REMS applied only to the brand-name product Adempas , Pomalyst , Thalomid , and Qsymia . Pomalyst and generic pomalidomide each had their own REMS, which were very similar. The REMS for bosentan managed hepatotoxicity in addition to birth defects, and the REMS for mycophenolate and Qsymia had recommendations instead of requirements.The nature of the teratogenic risk varied for the 10 drugs covered by the REMS . Six druFor 4 drugs , human data supported the teratogenic risks. TERIS reported that 2 drugs  had a high magnitude of teratogenic risk and excellent quantity and quality of evidence. Mycophenolate had a moderate-to-high magnitude of risk and fair-to-good quantity and quality of evidence, while topiramate—one component of phentermine-topiramate—had a small magnitude of risk and fair-to-good quantity and quality of evidence. The remaining 6 drugs had an undetermined magnitude of risk, with quantity and quality of data ranging from none , to very limited , to limited . For 3 of these drugs, TERIS noted the potential for high teratogenicity because of their drug class  or mechanism of action (riociguat).Thus, most drugs with REMS for teratogenicity lacked human data on teratogenicity. Of these drugs, most also had low TERIS ratings for quantity and quality of data and an undetermined magnitude of risk.Five REMS  required the use of contraception by males and females, and 5 REMS  made no exceptions for abstinence from sexual activity. Five REMS  required contraception to be used at least 4 weeks before initiating treatment, and 10 REMS  required or recommended contraception use following drug discontinuation.Five REMS  required multiple methods of contraception, one of which was hormonal, unless the female had undergone tubal ligation ; neither intrauterine devices (IUDs) nor tubal sterilization alone were sufficient. Two REMS (for bosentan and mycophenolate) did not require or recommend an additional method of contraception with an IUD but did with a progesterone implant, while 5 REMS  listed unacceptable contraception methods, including progesterone-only mini-pills, the Progesterone T hormonal IUD, and female condoms.To promote compliance with these primary prevention requirements, 9 REMS  required patients and prescribers to sign attestations of understanding. However, only the REMS for isotretinoin required that prescribers and patients document the 2 methods of contraception being used.Overall, the REMS for isotretinoin, lenalidomide, pomalidomide, Pomalyst, and Thalomid had the most stringent primary prevention requirements. They mandated contraceptive use before treatment initiation and after treatment discontinuation, use of more than 1 form of contraception for all contraceptive methods, and use of hormonal methods of contraception absent tubal ligation.Every REMS required or recommended at least monthly pregnancy testing of all females of reproductive potential, without exceptions for abstinence, and every REMS except for Qsymia required or recommended lab-based pregnancy testing. Nine REMS  ensured compliance with the pregnancy testing requirement by making dispensing dependent upon a check by the prescriber and/or pharmacist for a negative test result. Five REMS  required multiple tests at various intervals before treatment initiation; 4 REMS  required weekly testing during the first month of treatment, and 4 REMS  required at least 1 pregnancy test after discontinuation of treatment.Seven REMS  required prescribers to discuss emergency contraception during counseling (this was only a recommendation for mycophenolate). Of these REMS, 4  further required the prescriber to provide the patient with literature about emergency contraception.Thus, as with the primary prevention requirements (with the exception of the REMS for isotretinoin)., the REMS for lenalidomide, pomalidomide, Pomalyst, and Thalomid had the most stringent secondary prevention requirements. These included more than 1 pregnancy test before treatment initiation and dissemination of a brochure on emergency contraception during counseling.Our analysis of 11 REMS for 10 teratogenic drugs reveals substantial variation as to which contraceptives were required, for whom, and when, as well as to the timing and frequency of mandated pregnancy testing. Some of this variation may be due to differences in the drugs and their activity. The REMS for isotretinoin, lenalidomide, pomalidomide, Pomalyst, and Thalomid, for example, required that males taking the drug agree to condom use during sex. Preclinical testing of these drugs had revealed possible drug transmission via blood or semen.The statutory factors that the FDA must consider when deciding to implement a REMS—“(1) the estimated size of the population likely to use the drug; (2) the seriousness of the indicated disease or condition; (3) the expected benefit of the drug; (4) the expected or actual duration of treatment; (5) the seriousness of any known or potential adverse events that may be related to the drug and the background incidence of such events in the target population; and (6) whether the drug is a new molecular entity” —may alsoOther REMS may not have gone far enough to prevent pregnancy. The REMS for Adempas, ambrisentan, bosentan, macitentan, mycophenolate, and Qsymia did not require that females begin contraceptives before treatment initiation. However, some methods of contraception permitted under these REMS, including combined oral contraceptives, may leave a gap between treatment initiation and full protection against pregnancy since they are not effective immediately. Additionally, the REMS for Adempas, bosentan, and Qsymia did not include counseling females on emergency contraception, which can help prevent fetal-embryo exposure in the case of contraceptive failures.It is important to consider how REMS requirements impact patient autonomy. For example, the REMS for isotretinoin, lenalidomide, pomalidomide, Pomalyst, and Thalomid required 2 methods of contraception for females regardless of which primary method was used, including an IUD. However, in routine clinical settings, females are counseled that a second method of birth control is not necessary for avoiding pregnancy following the insertion of an IUD or hormonal implant .Additionally, several REMS did not permit the use of 2 barrier methods of contraception and instead required at least 1 hormonal method or another invasive method, such as a nonhormonal IUD, tubal ligation, or partner’s vasectomy. Hormonal methods of contraception can have side effects, ranging from nausea, headache, irritability, and weight gain to more serious thromboembolic events . CertainREMS intended to minimize teratogenic risks must optimally balance risk minimization with patient autonomy. The FDA might consider allowing females of reproductive potential taking these drugs to comply with the contraception requirement without needing to use either hormonal or invasive nonhormonal methods. For example, such REMS could allow females to use 2 barrier nonhormonal methods or to agree to abstinence to ensure that females can access the drug in question even if they cannot use hormonal methods or are unwilling to for health or religious reasons. Some REMS, such as those for Adempas, ambrisentan, and bosentan, already allow for 2 barrier nonhormonal methods to be used, and others, including isotretinoin, lenalidomide, and Pomalyst, allow abstinence in lieu of other contraceptive methods. Any changes to REMS related to teratogenic risks should be followed up to ensure they do not increase pregnancies.For secondary prevention, the heightened frequency of testing before treatment initiation and during the first month of treatment for some REMS may pose cost and access issues for patients without meaningfully contributing to risk mitigation . In addiThere is substantial variation in primary and secondary prevention measures across REMS that intend to minimize teratogenic risks. Some of this variation may be explained by differences in the drug or statutory factors that the FDA is required to consider. To protect reproductive autonomy in an increasingly fraught political climate, the FDA can reexamine REMS for drugs with teratogenic risks to ensure their requirements are aligned with available evidence on safety.