key: cord-282265-8pfbzach authors: yu, christiaan; teh, bing mei; aung, ar kar title: covid‐19 significantly affects specialty training date: 2020-08-22 journal: intern med j doi: 10.1111/imj.14975 sha: doc_id: 282265 cord_uid: 8pfbzach nan the complexities of modern medicine have made specialisation of patient care an inevitable necessity. in australia, individual medical colleges are responsible for selection, accreditation, overall supervision and supporting the wellbeing of trainees. progression through training is based on work-based assessments and examinations. specialist training must fulfil highly stringent requirements over a minimum of 4-6 years to gain mastery of knowledge, skills and professional attributes. the unprecedented coronavirus disease 2019 (covid-19) pandemic has severely disrupted this streamlined process of specialisation. selection into training and entry/exit examinations has been cancelled due to social gathering laws and perceived risks to patients and practitioners. re-deployment away from usual training roles and suspension of all nonessential procedures and surgeries have limited trainees' specialty knowledge and skill acquisition, interrupting progression through training. postponement of conferences and workshops has further affected professional development and networking opportunities. these changes have tremendous implications to the strained medical workforce, in turn, affecting trainees' psychological well-being. a paradigm shift from the traditional models of specialty training is needed to address the challenges presented by this unrelenting outbreak. while temporary solutions, such as rescheduling exams, waiver for certain training requirements and training time extension may help alleviate anxiety, novel models of training, assessment and support need to be developed. the main impact of covid-19 is upon procedurebased specialties where reduced volume of work threatens acquisition of procedural competency. in addition, certain procedural techniques have been significantly modified to enhance personal safety. for instance, aerosol-generating procedures, such as bronchoscopies, are now performed with level 3 (enhanced) personal protective equipment. 1 general anaesthesia and closedcircuit ventilation are currently recommended for most airway procedures. 2 for non-procedural specialities, there is also added complexity in initial assessment and management of patients under droplet/airborne precautions. trainees now need to learn how to navigate through these barriers. with most planes grounded, pilots are using flight simulators to maintain their skills. in formula 1, the real-world racing has been replaced with virtual grand prix. in medicine, simulation training has been shown to improve procedural skills, clinical approach and situational awareness. 3 simulator tools include mannequins, interactive participants, such as 'mock patients' or virtual reality software. procedures can be performed in a safe virtual environment, technical skills assessed against pre-specified benchmarks, and instantaneous feedback provided. 4 in the united states, a web-based laparoscopic surgery module and standardised virtual hands-on training component has been made mandatory for all surgical residents. 5 virtual interactive cases may also offer a validated form of clinical experience to non-procedural specialty trainees. 6 balancing the fidelity, realism and cost effectiveness of virtual training programmes against the limitations placed by covid-19 would be integral to future training models. further research should focus on integrating simulation-based medical training programmes into current curriculums to reflect college requirements. this global crisis has presented us with an invaluable opportunity to experience a generalist role in parallel to speciality medicine as a result of crossdisciplinary exposure to clinical care, public health, epidemiology and healthcare systems. through this journey, we all can further develop professionalism and humanitarianism. training and simulation for patient safety simulation in cardiothoracic surgical training: where do we stand? beta test results of a new system assessing competence in laparoscopic surgery credentialing and certifying with simulation key: cord-282176-537vim4n authors: algiraigri, ali h. title: postgraduate medical training and covid-19 pandemic: should we stop, freeze, or continue? date: 2020-05-19 journal: nan doi: 10.1016/j.hpe.2020.04.002 sha: doc_id: 282176 cord_uid: 537vim4n abstract while many countries in the world are going through a state of lockdown to limit the spread of coronavirus disease 2019 (covid-19) [1], such a state may affect postgraduate medical training (pgmt) adversely in different aspects. these include a decreased number of clinical cases related to the specialty, staff shortage, cancelation of educational conferences, and difficulties conducting formal in-training and licensing examinations. trainees, program directors, licensing bodies, and other stakeholders are in a difficult situation regarding what to do next. such a situation raises several critical questions related to the training that we tried to address here. while many countries in the world are going through a state of lockdown to limit the spread of coronavirus disease 2019 (covid-19) [1] , such a state may affect postgraduate medical training (pgmt) adversely in different aspects. these include a decreased number of clinical cases related to the specialty, staff shortage, cancelation of educational conferences, and difficulties conducting formal in-training and licensing examinations. trainees, program directors, licensing bodies, and other stakeholders are in a difficult situation regarding what to do next. such a situation raises several critical questions related to the training that we tried to address here. the simple answer is no. medical trainees (residents or fellows) are the backbone/driving force for most, if not all, of the large hospitals. indeed, expanding the programs may appear reasonable to increase the workforce during such a critical time. they are like "soldiers in a war," where you depend on them for survival. during the lockdown state, should the actual training be postponed or frozen? physicians and physicians-in-training are the frontline workers defending and helping sick patients during such crises. promoting and graduating qualified physicians are highly needed during such time, more than at any time ever. however, there is a delicate balance between continuing graduating physicians and maintaining/ensuring the quality of graduating doctors. slight modification or shoveling some of the rotations to different allocations can be done to accommodate the current situation and educational needs. yes, some medical or surgical specialties will be affected by the current lockdown more so than other specialties. professional educators should think outside the box about different ways of accommodating the trainees' educational needs. for instance, clinical research rotation can be utilized during such time for the profoundly affected specialties. centers across the region or the country should share their educational activities to ease the situation for each other. teleconference activities across many centers should expand more to involve most, if not all, the centers in the region or country. sharing patients' clinical presentation and management will increase the exposure to cases and getting a different perspective from different professionals. utilizing various educational tools are warranted to compensate for some of the weakness during such a period. for instance, some programs will suffer from low exposure to specific clinical cases or activities, like elective surgical procedures and so on. such weakness can be mitigated by utilizing simulation activities. program directors and trainees may wonder how the assessments and exams will look like during such a critical period and whether some exams can be waived or cancelled. generally, there are standard tools that have been used to assess knowledge acquisition and competencies in medical practices. these include, and are not limited to, multiple-choice questions (mcq), in-training evaluation reports (iter), objective structured clinical examination (osce), logbook or portfolio, and others [2] . licensing examinations usually include all of the above-mentioned methods and take place in a predefined location that trainees may need to travel to in order to complete such exams. besides, a gathering is usually extensive, which may not be permissible during such lockdown status. however, within these lockdowns, we need to rethink how to do things differently, while maintaining high quality of the assessment tools. with an existing plethora of online technology like zoom, cisco webex, and many others, such exams like osce can be done remotely without the need for travel and a large gathering of trainees and examiners. further details can be reviewed in table 1 . finally, a take-home " table" that summarised the current challenges due to covid-19 lockdown state and some suggested solutions can be summarised in table 2 . director-general's opening remarks at the media briefing on covid-19 -25 the canmeds assessment tools handbook: an introductory guide to assessment methods for the canmeds competencies. royal college of physicians and surgeons of canada the author declares no conflicts of interest. no funding was received for this study. key: cord-285639-1vf7ot1r authors: tait, s.; mclean, r.; gopinath, b. title: covid 19 and training in the ukcorrespondence date: 2020-05-01 journal: int j surg doi: 10.1016/j.ijsu.2020.04.061 sha: doc_id: 285639 cord_uid: 1vf7ot1r nan the covid 19 pandemic has caused major disruption to training in all aspects of medicine and surgery. trainees from all specialities have felt the impact; with medical students being expedited onto foundation programmes [1] . unfortunately, with the current crisis, performing surgical procedures poses a major risk to our own health and the health of our patients. the current priority for us is to maintain an effective surgical workforce and effectively cover emergency surgery [2] . as such, most elective operating has been suspended since march 2020. this, alongside the potential for trainees being redeployed to support their critical care, medical and emergency medicine colleagues, has severely reduced the access trainees have to training opportunities. whilst we are eager to assist our colleagues in such an unprecedented situation it cannot be ignored this will have an impact on our training. currently trainees are still expected to achieve their arcp outcomes which includes operative numbers for core and registrar level trainees. operation numbers have been an integral part of achieving surgical competency [3] as an indication for their surgical experience. in our district general we have 10 trainees (ct1-st8). on reviewing operative numbers, there was a reduction of operative numbers to 20% of normal, amongst trainees comparing the month before and after lockdown came into effect in late march. furthermore, looking at both elective and emergency operating, there has been a decline in numbers since january. in our trust in january 2020, 294 general surgical elective operations were performed. this dropped to 109 in march and in the month since lockdown (23/03/2020), has decreased further to 26. over the same period in emergency surgery; in january 2020 97 operations were performed, in march 2020 75 and since lockdown 27. it is likely the case in all trusts across the uk and the steady decline since january will have a knock on effect come july arcp. this is a difficult time for surgical training both now and in the near future. current fears surround the impact on arcp outcomes for trainees with the potential for training to be extended so that competencies can be met. at present, the royal colleges and the four statutory education bodies [4] and the 15 speciality associations have released a statement in regards to training and indicative operative numbers; the current situation will take into account in regards to progression, but what that means in real terms is still unclear at present. what form this impact will take will be revealed fully over the next few months. a few other factors will also have a great impact on training outcomes; exams have been delayed [5] with implications for progression for future st3 applications and those looking to attain certificate of completion of training (cct). mandatory courses are now postponed with implications not only for those whose courses have been cancelled but a knock on effect to those who require access to these mandatory courses in the next couple of years as the back log is cleared. the st3 application for surgical training has changed vastly from a face to face approach to a self-assessment form [4] ; generating concerns that this approach may not be reflective of a trainee's true aptitude and competence and applying further pressure to a normally stressful time; application to higher level (st3 training). this is an anxious time being a national emergency and trainees are already struggling with fears about their own personal safety and that of their families. with the confounding factors of meeting arcp requirements, changes to st3 surgical application process, delays in exams and courses and the knock-on effect on progression, this is a difficult and dark time for surgical training. the long-term effects of which we are likely going to be feeling for the next few years. with these anxieties in mind, the joint committee on surgical training (jcst) [4] has arranged access to psychological support for trainees in this difficult and uncertain time. they are also reviewing the impact on surgical training and the arcp process. in the near future the shape of training during this pandemic should hopefully be clearer. no ethical approval required. none. s. tait: visualisation, investigation, original draft preparation. r mclean: conceptualisation, supervision. b gopinath: supervision, writing-reviewing and editing. 1. name of the registry: not applicable 2. unique identifying number or registration id: not applicable 3. hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable what early registration means for eligible final year students requested to start work in the nhs early due to covid-19 updated intercollegiate general surgery guidance covid-19 the intercollegiate surgical curriculum covid-19 and trainee progression in 2020 (update ii joint policy from the royal surgical colleges gopinath university hospital of north tees key: cord-331844-trjxt9qk authors: de berker, henry t; bressington, morgan j; mayo, isaac m; rose, anna; honeyman, calum title: surgical training during the covid-19 pandemic: challenges and opportunities for junior trainees date: 2020-08-13 journal: journal of plastic, reconstructive & aesthetic surgery doi: 10.1016/j.bjps.2020.08.014 sha: doc_id: 331844 cord_uid: trjxt9qk summary in this piece of correspondence, the authors set out the challenges and opportunities presented by the sars-cov-2 (covid-19) pandemic to junior surgical trainees embarking on a career in plastic surgery. the sars-cov-2 (covid-19) pandemic has resulted in an unprecedented disruption of surgical services and training around the world. 1 however, faced with significant pressure and evolving challenges, many surgeons have united in an impressive, proactive response leading to the rapid reorganisation of services and significant innovation. 2 junior doctors embarking on surgical training in august face uncertainty, a markedly different training landscape, and justifiable concerns about their ongoing professional development. current core surgical trainees have lost almost four months of training time due to redeployment and may feel poorly equipped to transition into their chosen specialties next year. however, this article highlights the many excellent training opportunities that still exist that should adequately bridge the gap until a more recognisable model of training resumes. core surgical trainees starting in august, and those returning to their posts after redeployment, face new rota patterns and the ever-present concern of a 'second wave' causing further disruption to training. furthermore, there is restricted access to theatre due to ppe shortages, consultant-driven operating, and staffing limitations imposed on general anaesthetic lists. undoubtedly, the current climate is putting significant pressure on a cohort that has already been under considerable strain in recent months. in addition to changes in working practises, trainees have seen exams, conferences, courses and teaching programmes cancelled across the united kingdom. furthermore, disruption to laboratories and clinical trials may limit progress for trainees looking to pursue an integrated academic pathway in the future. however, although the surgical training landscape has changed, seemingly overnight, many excellent training opportunities exist that will be invaluable to any surgical trainee interested in a career in plastic surgery. also, as trainees reflect on their experiences of redeployment, many will have gained skills that will serve them well in their future careers. the majority of non-urgent plastic surgery elective work has been suspended for the foreseeable future. this includes microsurgical breast reconstruction, which will likely have a detrimental effect on competency attainment for senior trainees approaching completion of training. however, there is still a substantial throughput of burns, trauma and skin cancer operating, all of which form the essential foundation of any successful registrar application. 3 much of the trauma and skin cancer work is performed under local anaesthetic, often away from main theatres and, as such, fewer restrictions apply. now, more than ever, trainees must work together to share ward commitments and on-call bleeps in order to maximise opportunities to attend these invaluable lists, and engage with trainers to set specific learning objectives for each case. trainees and consultants should convene regularly, to continually improve departmental training opportunities. furthermore, with a greater consultant presence in theatre, there are opportunities for trainees to obtain one-to-one training on index procedures that may not have been possible previously. in addition to maximising exposure in theatre, there are a number of innovative ways to learn outside of the workplace. low-cost tendon repair simulation on pigs' trotters, home microsurgery training platforms, and freely available simulation programmes (e.g. touch surgery) can all help to develop essential skills in plastic surgery. 4 in addition, courses such as the duke and penn flap courses, are being run virtually and free-ofcharge; an opportunity to learn from internationally-renowned trainers without the substantial cost of attending in person. many departments are moving their teaching online, with a huge expansion of reconstructive webinars released since lockdown began. 5 although many of these are pitched to higher level trainees, there are also resources that are ideal for core surgical trainees aiming to get to grips with the specialty, including the excellent 'plastic surgery covered' series from the plastic surgery trainees association (plasta). rapid reorganisation of surgical services has created many new pathways that are ideal for audit, quality improvement and research projects. conferences have also moved to virtual platforms which will reduce the cost of attending, and thus remove barriers to presenting work and learning from others. many deaneries now support study leave requests to attend virtual conferences and courses. redeployment in itself can also be a time of personal and professional development. the trainee redeployed to the emergency department may gain increased independence in basic wound care and the assessment and management of hand injuries, bites and other minor trauma. in addition, the non-technical skills required to adapt quickly to an unfamiliar environment, remain up-to-date in a rapidly changing clinical crisis, communicate effectively with a new team, and navigate fraught interactions with patients and their relatives will serve any future surgeon well. aside from surgical training, trainee morale is justifiably low at present. however, for current and future core surgical trainees, there are numerous possibilities for professional development, training and innovation. despite considerable challenges, covid-19 has brought with it an inventive and flexible approach to training; we hope this will continue as attention returns to training safe and confident surgeons of the future. none asit and the 15 speciality associations joint letter to surgical trainees on covid-19: the implications for surgical trainees in the delivery of care and training a1154437013a/asit_the_15_speciality_associations_letter_to_surgical_trainees_covid19.pdf covid-19 the great disruptor the effect of the ongoing covid-19 nationwide lockdown on plastic surgery trauma caseload? virtual surgical training during covid-19 webinars in plastic and reconstructive surgery training -a review of the current landscape during the covid-19 pandemic key: cord-318527-6dbat1cf authors: van der meulen, matthijs; kleineberg, nina n.; schreier, david r.; garcía-azorin, david; di lorenzo, francesco title: covid-19 and neurological training in europe: from early challenges to future perspectives date: 2020-09-24 journal: neurol sci doi: 10.1007/s10072-020-04723-9 sha: doc_id: 318527 cord_uid: 6dbat1cf the worldwide sars-cov-2 pandemic is dramatically affecting health systems with consequences also for neurological residency training. here we report early experiences and challenges that european neurologists and residents faced. the breadth of the pandemic and the social restrictions induced substantial modifications in both inpatient and outpatient clinical care and academic activities as well, adversely affecting our residency training. on the other hand we see also opportunities, such as gaining more clinical and professional skills. all these drastic and sudden changes lead us to reconsider some educational aspects of our training program that need to be improved in order to better prepare the neurologists of the future to manage unexpected and large emergency situations like the one we are living in these days. a reconsideration of the neurological training program could be beneficial to guarantee high standard level of the residency training in this period and beyond. the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is causing a pandemic of coronavirus disease 2019 (covid-19) and is dramatically challenging the medical workforce and healthcare systems. the sudden need for capacities to accept the huge number of infected patients and the greater exposure of healthcare workers to the virus [1] has altered the normal organization of hospitals [2] . although neurologists are not the designated professionals working in the frontline of this emergency, the devastating breadth of the pandemic is causing profound modifications in the routine practice of neurological patient care and as a result of the neurological residency training. the situation differs between countries and even between hospitals within one country; the rapid largescale spread and the severe restrictions regarding social life changes are diffusely affecting the neurological residency training. since future covid seasonal outbreaks are forecasted [3] , we aim to highlight the challenges faced by residents during the "early period" and their consequences on the training, in order to envision future opportunities to guarantee high standard level of residency training in this period and beyond. national and international courses and conferences are canceled or have been replaced with virtual conferences or digital platforms (for small group lessons). although opportunities for online education exist, technical and interactive boundaries are still too prominent to replace physical presence. bedside teaching is deeply reduced: neurology departments have canceled almost all elective hospitalization, a golden source for residents to fully study and manage many chronic neurological disorders. additionally, outpatient visits are strongly reduced. apart from case emergencies, most outpatient appointments for new referrals were postponed. therefore, physical examination cannot be performed while it is fundamental for patients' diagnosis and management. follow-up visits for chronic conditions were performed via telemedicine [3] , challenging with elderly and those with cognitive impairments. "learner positions" normally embarked as inner training rotations within the neurology department were stopped to reduce personnel contacts as a potential spread of the coronavirus. another consequence is the strong reduction of performed neurophysiological examinations. clinical neurophysiology is a fundamental part of the neurological curriculum and its rotation to focus on performance and interpretation of all investigations. the reduction of the abovementioned activities resulted in a paradoxical lower demand for medical staff. consequently, some residents were sent home to be "stand by." conversely, in the more affected areas, part of the workers stay at home preventively in case some get infected. in the most affected areas, the increasing number of covid-19 patients and the lack of medical staff (infected or quarantined) induced profound changes to the workforce management [2] . in north italy and spain, bed capacity has been reserved for medical emergencies, and neurologists (including residents) have been reallocated to internal medicine or intensive care units (icu) wards forming multidisciplinary teams [4] . such measures have also been applied in less affected regions as a precaution, to prepare for a possible scenario in which more workforce is needed. for residents' support, many hospitals are offering freely accessible webinars and online courses regarding the use of a ventilator machine, general knowledge on internal medicine, and pulmonology. in spain a handbook on neuro-covid-19 has been rapidly produced by the national neurological society [5] . however, learning via online courses cannot replace structured bedside teaching, which might lead to overstrained residents, not ready to embark on their new duty. furthermore, we are experiencing also that the physical isolation of admitted patients, not allowed to welcome visitors, is strongly affecting their moral. this demands additional mental support and care to the patients and to their relatives, which has to be provided by residents who are usually not sufficiently trained for. finally, the current situation is also compromising research and clinical trials. most of the research projects have been interrupted, and the few ongoing trials need peculiar care. even though the current situation is far from ideal for patient care and neurology training, it also offers opportunities. neurology residents who are currently working on the icu or covid wards will gain intensive experience in emergency care and internal medicine, strengthening the coherence within the healthcare system beyond disciplines and professions. this crisis also yields the development of technological and strategic skills, such as advancing in telemedicine, new teaching, and meeting platforms. these skills as health advocates and collaborators are also advised by the canadian model for medical training [6] . we cannot oversee the entire impact of this pandemic yet, but we must conclude that this sudden disease outbreak has hit the health systems hard, and lessons should be learned for future challenges. since many (aspiring) neurologists are needed in such an extraordinary situation, neurology training programs might benefit from some structural modifications. in most, but not all european countries, a rotation to internal medicine is mandatory [7] ; neurology residents are usually not sufficiently trained to manage critically ill patients on icus. so, more allocated time for internal and emergency medicine in neurology training programs might be beneficial. psychological support and communication skills are important aspects of our profession and should therefore also be incorporated in our training. telemedicine and digital technology represent a valid alternative in the future to consult patients who are struggling to reach the hospital [8] . indeed, healthcare systems are planning to use digital technology more broadly: in 2020 we have a wide range of technologic support (virtual clinics, e-learning platforms, telemedicine consultations, artificial intelligence-based triage systems) [9] that can be used to enhance public health strategies and educational activities. this aspect fits well with chronic neurological diseases, and a specific training on the use, advantages, and disadvantages of digital technology should be encouraged. for this year residents' cohort, we recommend that missed rotations should be recovered. the covid-19 pandemic severely and diffusely affects neurological residency training. despite the situation and the neurological training programs in europe differ widely, the problems faced by residents in this pandemic are similar. it also leads to new opportunities, to broaden our overall medical skills and to develop new strategies on how to remotely treat patients. in order to be prepared for future outbreaks, there is an urge to reconsider some aspects of training programs. we think that considering all these aspects would sensitize the national and international institutions to improve and adhere to standards of neurological training across borders. ethical approval none. code availability not applicable. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. early lessons from the frontline of the 2019-ncov outbreak critical care utilization for the covid-19 outbreak in lombardy, italy: early experience and forecast during an emergency response projecting the transmission dynamics of sars-cov-2 through the postpandemic period on being a neurologist in italy at the time of the covid-19 outbreak 2020) covid-19 handbook for neurologists collaboration, communication, management, and advocacy: teaching surgeons new skills through the canmeds project differences in neurology residency training programmes across europe -a survey among the residents and research fellow section of the european academy of neurology national representatives telemedicine in neurology: telemedicine work group of the american academy of neurology update digital triage for people with multiple sclerosis in the age of covid-19 pandemic publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-274448-lzxhtnfi authors: chua, alfredo; mendoza, marvin jonne; ando, mark; planilla, cyril jonas; fernando, gracieux; strebel, heinrik martin jude; ignacio, jorge title: changing the landscape of medical oncology training at the national university hospital in the philippines during the coronavirus disease 2019 (covid-19) pandemic date: 2020-06-05 journal: j cancer educ doi: 10.1007/s13187-020-01786-2 sha: doc_id: 274448 cord_uid: lzxhtnfi serving as one of the few training institutions of medical oncology in the philippines, the university of the philippines-philippine general hospital was faced with challenges brought by the coronavirus 2019 disease (covid-19) pandemic. with the dismantling of routines and practices in the hospital, training activities such as daily rounds, conferences, and examinations were temporarily put on hold. recognizing that the strength of any clinical training program is its wealth of patients, the immediate resumption of patient services, albeit limited at first, had been instrumental in ensuring the continuation of training in our institution. opportunistic teaching-learning strategies between the faculty and fellows were devised. innovative approaches to learning such as the use of online meeting platforms for division conferences, webinars, examinations, and other learning activities were initiated. emphasis was given on the important considerations in the management of cancer patients during the covid-19 pandemic. the emotional and psychological well-being of the faculty and fellows during this crisis were considered and a mental health assessment was conducted prior to the resumption of training activities. the university of the philippines-philippine general hospital, division of medical oncology serves as one of the few training institutions in the philippines for internists pursuing further subspecialty training in medical oncology. the division has 12 to 14 fellows for its 2-year training program. they alternately rotate in different in-patient services with daily outpatient clinics. they also attend multidisciplinary team meetings to discuss cases and develop treatment plans. didactics include bimonthly journal reports and examinations which serve as formative evaluations. in all these training activities, they are continuously guided by the faculty. furthermore, the philippine society of medical oncology (psmo) designates topics to each training institution for monthly round-table discussions tackling interesting cases with dilemmas in management. attendance in webinars, grand rounds, and other continuing medical education (cme) activities are likewise encouraged. in addition, they also produce research outputs intended for presentation and publication. the covid-19 pandemic has dismantled routines and practices in hospitals worldwide. the philippine general hospital has been delegated as a covid-19 referral center, with subsequent conversion of various areas for covid-19 patients. there was cessation of non-essential services, including elective admissions for oncologic treatment. all efforts, manpower, and resources were focused in addressing the covid-19 crisis [1] . fellows and consultants were called to augment the workforce and serve as front liners. with these constraints, most training activities were temporarily put on hold. in this paper, we discuss the challenges faced by the division of medical oncology at the national university hospital of the philippines in terms of subspecialty training and how it has adapted to these difficult predicaments. one of the challenges in training during this pandemic was ensuring the safe entry of newly accepted fellows into the training program. planning a smooth transition as they familiarize themselves with the day-to-day activities of an oncology fellow-in-training was difficult given that the entire healthcare system was overhauled. because of the enhanced community quarantine (ecq), new fellows coming from the provinces had difficulty in domestic travel with limited options in accommodation within the capital. the learning environment has not been ideal because of the limited encounters with patients. the cancer institute was temporarily closed, and upon resumption of services last april 1, 2020, there was a significant reduction in the number of patients seen daily from the usual 150 to 200 patients, to a maximum of 25 patients only. clinic-based learning became a challenge. daily rounds were fewer because admissions were limited to covid-19 patients. this imposed pressure to the new fellows who needed to quickly adjust to the new responsibilities while rotating at the covid-19 areas. training activities such as monthly round-table discussions, journal reporting, and examinations have also been affected. conferences such as the psmo midyear convention were also postponed. all healthcare professionals were subjected to a plethora of thoughts and emotions-more than the usual they need to face on a normal day. feelings of anxiety, fear, uncertainty, isolation, and burnout were common. others may feel vindicated that it is their duty to serve the people in this pandemic. others may have reservations given the high rate of infection among healthcare workers [1] . changing the landscape and adapting to the "new normal" a change in the learning paradigm must be sought to adapt to the new architecture the pandemic has brought. at the core of any clinical training program is the wealth of patients walking through its doors, carrying different clinical scenarios, and presenting as opportunities for learning. with the ecq and the temporary closure of the cancer institute, the medical oncology training program was essentially put on hold starting the second week of march. during this time, planning for alternative strategies through weekly online meetings was done. the resumption of patient services, albeit limited at first, has been instrumental in ensuring the continuation of training. prioritizing the safety of both patients and healthcare providers, continuation of cancer care amidst the covid-19 pandemic has been the overall goal [2] [3] [4] . strict safety precautions like patient prioritization, screening protocols, and social distancing measures were observed allowing the slow but safe resumption of services. patients not needing urgent care who can be managed remotely were attended to through teleconsultations [5] . eventually, multidisciplinary clinics resumed, and conferences were scheduled via an online meeting platform. there was a need to devise opportunistic teaching-learning strategies between the faculty and fellows. the aphorism, "every patient is a learning opportunity," has never been truer. taking advantage of the limited number of patients, bedside rounds were continued if possible. several consultants were assigned per week to go to the clinics and wards to teach. a buddy system between the faculty and fellows was started, with the consultant and senior fellow guiding the junior fellow during the first weeks of training. a practical guide on the basic principles of oncology care and chemotherapy was also provided. the emotional and psychological well-being of the faculty and fellows was also factored into planning [4, 6] . another important step was assessing the mental health of the faculty and fellows before resuming training activities. in cooperation with the department of psychiatry and behavioral medicine, a program was created, and separate virtual meetings with the first-and second-year fellows, and consultants were conducted. these served as a processing of their psychosocial reactions to the pandemic and an assessment of their readiness to proceed and transition back to the training activities. coping strategies and potential problems that could impede with their readiness were also explored. the radical limitation imposed by this crisis paved the way for other innovative approaches to learning. during the time of temporary closure, suggested reading assignments were given. attendance in psmo-led webinars and online activities were encouraged providing avenues for academic discussions and learning. the bimonthly journal reports were resumed in may 2020 via an online platform. instead of giving an actual written test, examinations were sent online. to further reinforce learning and compensate for the limited number of patients, monthly case presentations and discussions were started. cases were presented virtually and important points in management were discussed. an online platform allowed fellows who were relegated to other areas or in self-isolation or quarantine, to still learn whether by attending live or by accessing the recorded sessions [5] . during discussions, emphasis was given on the important considerations in the management of cancer patients during the covid-19 pandemic. cancer patients are more susceptible to infections brought about by their disease and the immunosuppressive effects of treatment [3] . balancing the need for chemotherapy and the risk of contracting the infection is complicated [6] . whether to initiate, continue, or delay cancer treatment must be carefully planned. guidance from the faculty in making these clinical decisions is important. multidisciplinary team meetings were also helpful in making these decisions. aside from the temporary interruption of ongoing clinical trials, the pandemic presented opportunities for research. topics relating to cancer care during the pandemic were pursued. these include describing the profile of cancer patients with covid-19, exploring the psychological impact to cancer patients, and looking at the oncologic outcomes of patients whose treatments were affected. table 1 summarizes the challenges during the covid-19 pandemic vis-à-vis the adaptations done to address these challenges. the covid-19 pandemic has brought changes of great impact to our society. the training of medical oncologists around the world is no exception. the landscape of medical oncology training worldwide has already changed. the combination of effective traditional and innovative teaching-learning strategies is expected to become the new paradigm. institutions should adapt to safeguard the training of soon-to-be medical oncologists. with good leadership, strategic planning, and collaboration, challenges can become opportunities despite the uncertainty of these trying times. the landscape may have changed but the goal of maintaining the quality of training will always remain. double trouble: challenges of cancer care in the philippines during the covid-19 pandemic managing covid-19 in the oncology clinic and avoiding the distraction effect cancer care during the spread of coronavirus disease 2019 (covid-19) in italy: young oncologists' perspective managing cancer care during the covid-19 pandemic: agility and collaboration toward a common goal adapting the educational environment for cardiovascular fellows-in-training during the covid-19 pandemic cancer guidelines during the covid-19 pandemic publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations code availability (software application or custom code) not applicable. conflicts of interest the authors declare that they have no conflict of interest. key: cord-264958-dbqit3vu authors: pervez, anum; mccurdie, fiona; poon, daniel title: the pursuit of radiology training in times of a pandemic date: 2020-09-07 journal: bjr open doi: 10.1259/bjro.20200039 sha: doc_id: 264958 cord_uid: dbqit3vu the coronavirus-19 (covid-19) pandemic has been the greatest challenge faced by the national health service (nhs) in its lifetime. the crisis has seen the disruption of many long-held institutions, most critically of which is specialty training. in this article, we discuss the impact of the pandemic on radiology training in the uk. we explore the methods that have been used to combat these difficulties and suggest workable solutions. as technology platforms become ever more integral to our daily clinical routines, we discuss how these offer a new approach to training. we argue that, of all the medical disciplines, radiologists are best placed to design and implement technology-based training, and lead other specialties in doing so. whilst the upheaval of traditional approaches to education is a challenge, we propose that this departure from the norm offers exciting opportunities for improvement. on december 31st 2019, the world health organisation was informed of a cluster of pneumonia cases in wuhan, china. as of august 19th, 2020, over 22.1 million cases have been recorded worldwide, with more than 781,000 deaths. 1 the novel coronavirus, covid-19, has halted the world in its tracks. for healthcare workers in the uk, and across the globe, personal and professional roles have had to rapidly change. with redeployment of staff, changes to service provision and social distancing, daily activities have been re-prioritised, at the expense of specialty training. whilst we look with trepidation to the coming winter, and await the threatened 'second peak' , it is an important moment to take stock. we reflect on the impact covid-19 has had on radiology training and explore how to move forward, seeking opportunities for improvement in this time of crisis. to explore the impact of covid-19 on training, we break it down into three phases ( figure 1 ) and discuss the different challenges faced at each point in time: phase i: initial response as the magnitude of the covid-19 pandemic became increasingly apparent, and hospitals issued major incident warnings, radiology departments across the country had to reconfigure the delivery of their services to match new, unprecedented demands.this put an emphasis on prompt reporting, clearing of backlogs and redistribution of the general workload. training in this phase came to a complete standstill. all upcoming frcr (fellow of the royal college of radiologists) examinations were cancelled, rotations were paused and trainees were redeployed to intensive care, emergency departments and medical wards. the london school of training reported around two-thirds of st1 and st2 clinical radiology trainees had been redeployed, with a variable number of st3s. these trainees went entirely without training during this period, which for some lasted months. for those trainees left behind, new rotas were designed to ensure demand for services could be met, whilst also limiting the numbers travelling to and spending 'nonessential' time at work. as routine outpatient work stopped, the volume and range of reporting opportunities plummeted. this particularly impacted practical training in modalities such as ultrasound, fluoroscopy and interventional radiology. another challenge, not unique to radiology trainees, was the increasing rates of staff illness. symptomatic staff members, or those living with symptomatic individuals, required adequate time off in self-isolation. likewise those who fell into the high-risk category needed to shield for prolonged periods. during this phase, there was little infrastructure in place to access reporting remotely, participate in virtual tutorials or attend multidisciplinary meetings (mdms) and https:// doi. org/ 10. 1259/ bjro. 20200039 the coronavirus-19 (covid-19) pandemic has been the greatest challenge faced by the national health service (nhs) in its lifetime. the crisis has seen the disruption of many long-held institutions, most critically of which is specialty training. in this article, we discuss the impact of the pandemic on radiology training in the uk. we explore the methods that have been used to combat these difficulties and suggest workable solutions. as technology platforms become ever more integral to our daily clinical routines, we discuss how these offer a new approach to training. we argue that, of all the medical disciplines, radiologists are best placed to design and implement technology-based training, and lead other specialties in doing so. whilst the upheaval of traditional approaches to education is a challenge, we propose that this departure from the norm offers exciting opportunities for improvement. hence this cohort of trainees were completely without any realtime interaction with the specialty. phase ii: early recovery several months on from the initial lockdown, we are now in the early recovery phase, grappling with the consequences of the initial phase and its impact on training. social distancing measures and a displaced workforce have meant that face-toface teaching, both in formalised tutorials and during chance work-place encounters, have near-vanished. this has led to a loss of real-time feedback and limited the fostering of the traineetrainer relationship, both of which are crucial to trainee development and their academic support. 3 service demands, in the wake of the initial phase, have changed the volume and nature of work. as more routine services are reintroduced, and the backlog is surmounted, shift patterns have been adjusted to allow for extra out of hours lists to be implemented. this has meant that trainees spend more time providing acute services, limiting supervised training sessions. as we look ahead to the next phase, future recovery, we consider this disruption to training and what impact it will have on the workforce. there is not a clear solution as to how to reclaim lost training time without extending length of training. this is particularly challenging for those senior trainees approaching their completion of certificate of training (cct) and those who have been unable to progress due to delayed frcr exams. according to the 2019 clinical radiology uk workforce census, there are a total of 1,636 specialty trainees. pre-covid, we were understaffed by 1,876 radiologists (33% of the workforce needed), which was due to rise to 3,331 (43%) by 2024. 4 the rcr has stated that it is working with the gmc, national training organisation and heads of schools to minimise disruption to trainee progression, 5 although there is no doubt that an already stretched workforce is about to be stretched further. covid-19 has thrown many aspects of training into question, and as yet there feels to be very little in the way of answers. whilst this is unsettling, it should be seen as an opportunity for improvement. traditionally, radiology training has been delivered through case-based teaching, through reporting sessions and didactic lectures. 6, 7 the pandemic has initiated a paradigm shift away from the classroom and towards a digital, remotely accessible learning environment. radiology, of all the medical disciplines, is best placed to welcome and drive such a shift. radiology practice is already technology-centric, our patients are mostly encountered on a computer screen and the archives of our work are stored as an electronic resource. we are extremely well-suited to shifting classroom, case-based approaches to an entirely digital process. moreover, we would be suited to taking a leadership role in setting up and implementing these systems for our clinical colleagues. whilst unable to offer a simple solution to this very complex problem, here we share some reflections on what we consider to have worked well in our department, and suggest how this could pave the way to more robust methods of training: "mute your mic" there has been an explosion in video-conferencing platforms during the pandemic. the new 'normal' seems to be a constant deluge of meeting links and malfunctioning (or unmuted) microphones. whilst these frustrations are unavoidable, there is tremendous scope for such platforms in training. choice of which to use is likely designed, in part, by the local it policy's approval, bjr|open opinion: radiology training in a pandemic but consideration should be made as to which one to use for the specific needs of training. one of the serious pitfalls of videoconference teaching is the lack of attendee engagement. we have found that there are excellent features that promote interactive learning, such as the 'share control' function in microsoft teams (washington), which allows the presenter to hand over control of their screen to a trainee, who can then scroll through images. the chat function, available on all platforms, should be utilised with a nominated attendee monitoring the chat activity whilst the presenter focuses on teaching. another strategy to encourage participation is the use of quiz-based platforms such as kahoot! (norway) and poll everywhere (san francisco) which promote active engagement whilst introducing a competitive element to the session, if desired. it is worth noting although that these do require pre-preparation by the trainer. another frustration arises with loading large datasets which slow transmission and lead to jolting or blurred images. simple alterations can improve this, for example when using pacs to present cases, choosing the thicker slice images, which allows a smoother image transfer. choice of which screen to 'share' also impacts image quality, with split or single, portrait screens leading to smaller, blurrier images on the trainee's screen. like so many aspects of modern life -netflix, next day delivery, uber -we expect to have what we need available on hand straight away. whilst formalised sessions are crucial to training, an on-demand learning platform is an excellent addition. this allows those who have missed training to 'catch up' in their own personal time. we are already accustomed to some great national online elearning platforms, such as the rcr's r-iti (radiology-integrated training initiative) modules, 8 but these should be offered at a local level. teaching files, a staple in radiology training, have traditionally allowed trainees to gain exposure by reviewing a wide range number of normal and abnormal cases. 9,10 as discussed, loss of training time and change to service provision have led to a lack of depth and breadth of training. with some simple organisation, these collections of cases can be collected and disseminated across the trainee body to be utilised by trainees at will, or as an adjunct to a specific teaching session and hence engender a 'flipped classroom approach' . 11 these can also be employed as a self-audit, where trainees report and then subsequently mark themselves against the positive and negative findings or formalised into assessments. covid-19 has irrevocably changed the face of radiology training. despite ongoing disruption, we should exploit this as an opportunity for meaningful change. there is ample scope to continue to deliver high standards of training with the utilisation of new technological platforms and the repurposing of existing ones. we argue that, as radiologists, we are best suited to maximise these new opportunities and lead the way in updating and improving specialty training in the uk. ukcovid-19: epidemiology, virology and clinical features available from: available for commercial use with no permission required. url: pixabay teaching remotely: educating radiology trainees at the workstation in the covid-19 era the royal college of radiologists. clinical radiology uk workforce census the royal college of radiologists training and coronavirus (covid-19 virtual learning during the covid-19 pandemic: a disruptive technology in graduate medical education radiology education: a glimpse into the future the royal college of radiologistsradiology-integrated training initiative radiology teaching files: an assessment of their role and desired features based on a national survey creating teaching files flipped classroom improves student learning in health professions education: a meta-analysis the authors would like thank all the trainers at guy's and st thomas's hospital radiology department who have continued to provide teaching in these difficult times. key: cord-258475-hj7fverf authors: ahmad, karam; bhattacharyya, rahul; gupte, chinmay title: using cognitive task analysis to train orthopaedic surgeons is it time to think differently?a systematic review date: 2020-09-23 journal: ann med surg (lond) doi: 10.1016/j.amsu.2020.09.031 sha: doc_id: 258475 cord_uid: hj7fverf background: working time restraints; senior led care; and a reduction in ‘out of hours’ operating has resulted in less operating time for orthopaedic trainees in the united kingdom. therefore, there has been an attempt to overcome these challenges by implementing novel techniques. cognitive task analysis (cta) focuses on the mental steps required to complete complex procedures. it has been used in training athletes and in general surgery but is new to orthopaedic training. aims: to undertake a systematic review to analyse if cta is beneficial to train novice surgeons in common orthopaedic and trauma procedures. materials and methods: a systematic review was performed evaluating cta in trauma and orthopaedic surgery on medline and embase. search terms used were: cognitive task’, ‘mental rehearsal’ and ‘orthop*‘. 33 studies were originally identified. duplicate studies were excluded (11). articles not relating to orthopaedic surgery were excluded (15). the cta research ranking scale was used to evaluate the impact of the studies included. results: 7 studies were identified as appropriate for inclusion. 264 participants. 178 m, 86f. all studies showed objective or subjective benefits from cta in orthopaedic training when compared to traditional methods. the majority of the participants highlighted high subjective satisfaction with the use of the cta tools and reported that they proved to be excellent adjuncts to the traditional apprenticeship model. conclusion: cta learning tools have demonstrated significant objective and subjective benefits in trauma and orthopaedic training. it is cost effective, easily accessible and allows repeated practice which is key in simulation training. a systematic review. 3 4 abstract: 5 6 background: working time restraints; senior led care; and a reduction in 'out of hours ' 7 operating has resulted in less operating time for orthopaedic trainees in the united kingdom. 8 therefore, there has been an attempt to overcome these challenges by implementing novel 9 techniques. cognitive task analysis (cta) focuses on the mental steps required to complete 10 complex procedures. it has been used in training athletes and in general surgery but is new to 11 orthopaedic training. were excluded (11) . articles not relating to orthopaedic surgery were excluded (15) . the 20 cta research ranking scale was used to evaluate the impact of the studies included. repeated practice which is key in simulation training. 31 despite changes to orthopaedic training it is well established that current trainees have 36 significantly less theatre training time as compared to their predecessors [1] . the shift from 37 time-based to competency-based training has worsened the current situation [1] . in an attempt 38 to counter both a reduction in theatre time for trainees and a rising demand for skilled 39 surgeons, the development of simulation as an adjunct to the apprenticeship system has aided 40 trainees to achieve their required training needs. 41 42 simulation is 'a method or technique that is employed to produce an experience without 43 going through the real event' [2] . it occurs in a safe environment and has been shown to 44 the intervention group were taught using the cta tool and the control group were given a 119 standard operative manual. the students were scored on mcqs and how effectively manual 120 steps were completed using finger swipes on the smartscreen. 121 122 bhattacharyya et al [18] carried out a randomised control trial to evaluate the effectiveness of 123 cta in knee arthroscopy. the cognitive task tool was developed and designed using the scores were given for decision making, swipe interactions, and time taken to complete steps. 149 percentage total scores were calculated. 150 151 sugand et al [23] attempted to validate touch surgery tm for intramedullary femoral nailing 152 (ifn). as per sugand's previous study [22] , the procedure was divided into four modules. 153 real-time objective performance data was obtained and stored from the participants primary 154 attempt. this was used to assess construct validity. a post-study questionnaire using the 155 likert scale was used to assess face and content validity. the study on cta and aa-tha by logishetty at al [19] found cognitively trained 170 participants were on average 35% faster, made 69% fewer errors in instrument selection, and 171 required 92% fewer prompts. they also were more accurate with acetabular cup orientation. 172 both studies by sugand et al [22, 23] [20] rated content validity, quality of graphics, 182 ease of use, and usefulness to surgery preparation as very high. bhattacharyya et al [17, 18] , 183 found that participants agreed the cognitive task analysis learning tool was a useful training 184 adjunct to learning in the operating room. over 90% of participants found to tool easy to use 185 and enjoyed using it. levin et al [21] found that 10/14 participants believed using cta 186 improved baseline understanding, 9/14 believed learning was accelerated and 8/14 felt the 187 procedure was easier to learn as a result of this. 188 all participants in the aa-tha study by logishetty et al [19] found the cta tool useful to 189 understand key technical steps, decision making processes, highlighting errors, and easy to 190 use. 34/35 enjoyed using the tool. 191 when validating touch surgery™ for intramedullary femoral nailing, sugand et al [23] 192 found that both junior and senior cohorts rated the face validity, quality of graphics, 193 willingness to use the app, usefulness for preoperative rehearsal as good or very good. 194 experts also rated the content validity as good. the use of cta within orthopaedic training is relatively novel. 6/6 studies show objective 198 benefits when using cta (one study did not use objective assessment). they suggest cta 199 enhances performance and efficiency in orthopaedic training. in the randomised controlled 200 trials by bhattacharyya et al [17, 18] and logishetty et al [19] trainees can progress faster through the initial phase of the sigmoid learning curve [24] . 211 this, a concept of mathematical psychology, follows the learner from unfamiliarity to 212 mastery of a skill. initially progress is slow, however with intentional practice, traction is 213 gained, and one enters the stage of 'hypergrowth' (where learning is exponential) and then 214 subsequent mastery [24] . the aim of cta is to propel the novice learner into hypergrowth 215 prior to getting sustained theatre experience, thereby improving efficiency of their operating 216 theatre training time. furthermore, this enhances patient safety as trainees are more equipped 217 with knowledge on the technical skills and potential errors before they perform a procedure 218 for the first time on patients [17, 19] . 219 220 by undertaking cta procedures, the trainee is enabled to progress through unconscious 221 incompetence, conscious incompetence and potentially reach the stage of conscious 222 competence. they, therefore, enter the learning process on patients at a higher point on the 223 broadwell learning curve [25] . 224 studies have estimated that 70% of vital steps can be missed out when taught by experts [13] . 2. all participants agreed the tool made the procedure easy to understand. the multimodality approach was beneficial and that it was beneficial to use the tool prior to operating. 10/11 participants agreed that the tool was easy to use and 9/11 enjoyed using the tool. yes yes 9 full-text articles assessed for eligibility (n = 7) full-text articles excluded, with reasons (n = 0) studies included in qualitative synthesis (n = 7) studies included in quantitative synthesis (meta-analysis) (n =7 ) no time to train the surgeons simulation in medical education training and simulation for patient safety demonstration of high-fidelity simulation team training for emergency medicine teaching surgical skills-changes in the wind surgical skills simulation in trauma and orthopaedic training arthroscopy skills development with a surgical simulator: a comparative study in orthopaedic surgery residents improving residency training in arthroscopic knee surgery with use of a virtual-reality simulator. a randomized blinded study improving resident performance in knee arthroscopy: a prospective value assessment of simulators and cadaveric skills laboratories testing basic competency in knee arthroscopy using a virtual reality simulator: exploring validity and reliability current and future use of surgical skills training laboratories in orthopaedic resident education: a national survey simulation in surgical training: prospective cohort study of access, attitudes and experiences of surgical trainees in the uk and ireland cognitive task analysis: bringing olympic athlete style training to surgical education teaching and measuring surgical techniques: the technical evaluation of competence phases of meaningful learning patterns of regional brain activation associated with different forms of motor learning trauma simulation training: a randomized controlled trial -evaluating the effectiveness of the imperial femoral intramedullary nailing cognitive task analysis (ifincta) tool knee arthroscopy simulation: a randomized controlled trial evaluating the effectiveness of the imperial knee arthroscopy cognitive task analysis (ikacta) tool a multicenter randomized controlled trial evaluating the effectiveness of cognitive training for anterior approach total hip arthroplasty a mobile-based surgical simulation application: a comparative analysis of efficacy using a carpal tunnel release module pre-course cognitive training using a smartphone application in orthopaedic intern surgical skills "boot camps training effect of using touch surgery™ for intramedullary femoral nailing validating touch surgery™: a cognitive task simulation and rehearsal app for intramedullary femoral nailing throw your life a curve teaching for learning (xvi). the gospel guardian changes to training have resulted in less theatre time for orthopaedic trainees cognitive task analysis (cta) focuses on understanding technical steps and the cognitive decision making required for each phase of a procedure the registry: research registry 2. unique identifying number or registration id hyperlink to your specific registration the following information is required for submission. please note that failure to respond to these questions/statements will mean your submission will be returned. if you have nothing to declare in any of these categories then this should be stated. all authors must disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding.none. all sources of funding should be declared as an acknowledgement at the end of the text. authors should declare the role of study sponsors, if any, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. if the study sponsors had no such involvement, the authors should so state. research studies involving patients require ethical approval. please state whether approval has been given, name the relevant ethics committee and the state the reference number for their judgement.none required.j o u r n a l p r e -p r o o f consent studies on patients or volunteers require ethics committee approval and fully informed written consent which should be documented in the paper.authors must obtain written and signed consent to publish a case report from the patient (or, where applicable, the patient's guardian or next of kin) prior to submission. we ask authors to confirm as part of the submission process that such consent has been obtained, and the manuscript must include a statement to this effect in a consent section at the end of the manuscript, as follows: "written informed consent was obtained from the patient for publication of this case report and accompanying images. a copy of the written consent is available for review by the editor-in-chief of this journal on request".patients have a right to privacy. patients' and volunteers' names, initials, or hospital numbers should not be used. images of patients or volunteers should not be used unless the information is essential for scientific purposes and explicit permission has been given as part of the consent. if such consent is made subject to any conditions, the editor in chief must be made aware of all such conditions. even where consent has been given, identifying details should be omitted if they are not essential. if identifying characteristics are altered to protect anonymity, such as in genetic pedigrees, authors should provide assurance that alterations do not distort scientific meaning and editors should so note. please specify the contribution of each author to the paper, e.g. study concept or design, data collection, data analysis or interpretation, writing the paper, others, who have contributed in other ways should be listed as contributors. in accordance with the declaration of helsinki 2013, all research involving human participants has to be registered in a publicly accessible database. please enter the name of the registry and the unique identifying number (uin) of your study. key: cord-319859-6mt34av6 authors: zhou, min; yuan, fei; zhao, xiaolong; xi, fanjie; wen, xianxiu; zeng, li; zeng, wenbo; wu, haiyan; zeng, hui; zhao, ziyu title: research on the individualized short‐term training model of nurses in emergency isolation wards during the outbreak of covid‐19 date: 2020-08-04 journal: nurs open doi: 10.1002/nop2.580 sha: doc_id: 319859 cord_uid: 6mt34av6 aim: to explore an effective personalized training model for nurses working in emergency isolation wards of covid‐19 in a short period. design: this study is a longitudinal study from 24 january 2020 to 28 february 2020. methods: there are 71 nursing staff working in the emergency isolation wards of sichuan provincial people's hospital that participated in this study. the questionnaires were conducted with likert scale. the operation assessment teachers have received standardized training. the self‐rating anxiety scale (sas) and self‐rating depression scale (sds) were applied to assess the mental state of nurses. results: after short‐term training, these nurses can handle the emergency tasks in a timely manner. the pass rate of nurse theory and operation assessment is 100%. the 111 suspected patients admitted to the emergency isolation ward have been scientifically diagnosed and treated, the three confirmed patients have received appropriate treatment. no nurses have been infected. conclusions: in this study, the personalized emergency training mode was feasible in the emergency isolation ward during the covid‐19 epidemic, which rapidly improved the rescue ability of nurses and effectively avoid the occurrence of cross‐infection. this mode can provide a valuable reference for the emergency training of nurses in the future. transmission routes (national health commission of china). covid-19 broke out in wuhan in december 2019, and then, the epidemic spread globally (who, 2020) . the whole world should pay attention to how to deal with the outbreak (kickbusch & leung, 2020) . to stop the spread of the epidemic as soon as possible, all of provinces and cities in china have taken strong measures. although various industries have resumed production in china, the current international covid-19 epidemic is still grim. under this circumstance, how to control the epidemic situation and prevent the recurrence of the covid-19 epidemic is worthy of attention (wu, guo, & chao, 2020) . through literature review, there are many studies on covid-19 in various countries; however, there are few reports about the training content of the nurses in the emergency isolation ward. our training methods follows the model: training → assessment → feedback → evaluation → retraining → reassessment. hopefully, this study could provide theoretical basis for training nurses under emergency assistance of covid-19 and we also hope to work with nursing colleagues around the world with an open attitude to save more patients. the sichuan provincial people's hospital has temporarily established an emergency isolation ward during the outbreak of covid-19. to seek efficient nursing training mode under the epidemic situation and improve the nurses' knowledge reserve on emergency handling and control capabilities, a combination of on-site training and online training was implemented to provide covid-19 related knowledge on nursing operation skills and hospital infections to the nursing team in a short term. the medical department, the infection control department and the nursing department trained the nursing staff through online social media (wechat or oa system) and on-site training. the nursing operations are mainly conducted through onsite training. all nursing staff need to pass the assessment before they start to work in the emergency isolation ward. the electronic questionnaire was filled in after the nursing staff worked in the ward for 2 weeks to assess the nurses' need for training. then, targeted training was conducted and the training results were evaluated by trainers. to control the spread of the epidemic, cut-off the route of transmission and protect susceptible cases effectively, sichuan provincial people's hospital reconstructed emergency isolation ward within three days. there are 32 open beds in this ward. by the end of 28 february (2020), a total of 111 suspected patients were treated in the emergency isolation ward, including three patients who were diagnosed with covid-19. they are mainly middle-aged and elderly patients. during the preparation of the emergency isolation ward, the nursing department established the logistics team, professional team and management team immediately. the logistics team is responsible for participating in ward reconstruction and material preparation; the professional team is responsible for personnel training and supervision; and the management team is responsible for nursing staff management, including communication and coordination among various departments. firstly, the management team established a human resource database for emergency isolation ward. all nurses in the hospital are encouraged to apply online to the human resources database. then, 71 nurses were selected by the nursing department from the human resources database. to avoid excessive fatigue, the selected nurses are divided into three echelons and work in turns on a flexible schedule. nursing positions included clinical nurses, supervisors, trainers and head nurses. the training process adopts training → assessment → feedback → evaluation → retraining → reassessment. a scenario drill is added in the first operation training section. the training forms and content are shown in table 1 . the forms are including online training and on-site training. the training contents include basic diagnosis, hospital infection, operation and psychological support. previous studies have already shown that nursing staff working in the emergency isolation wards might face tremendous psychological pressures (oh et al., 2017) . the anxiety self-rating scale (sas) and depression self-rating scale (sds) were implemented by head nurses to evaluate the psychological status of nursing staff. psychologists provide psychological support and guidance to medical staff based on individual circumstances, including online and on-site psychological counselling (zhou, 2020) . in addition, experts from the psychological workshop were invited to perform mindfulness decompression. psychological intervention based on mindfulness meditation has become an increasingly obvious part of the healthcare field (demarzo, cebolla, & garcia-campayo, 2015) . evaluation indicators include the following: nurses' grasp of training content, choice of training methods and improvement of psychological conditions before and after training. a self-made online questionnaire "nursing staff emergency training mode approval feedback questionnaire" was used to access nursing staff's feedback on the emergency isolation ward's training mode. the questionnaire is divided into four parts and 20 items which mainly includes basic information, feedback on theory, operation training methods and content. in order to evaluate the degree of recognition, the training content evaluation is divided into three angles: text, graphics and video. the knowledge level of the covid-19 is based on the national health and health commission's diagnosis and treatment plan and the hospital's sense prevention and control requirements, including theory and operation. the "nursing staff covid-19 emergency training theory assessment test questions" is prepared for online assessment. the operation technology is on-site assessment. then, comparing the pre-training and post-training, nursing theory and operation score are proportional to the degree of knowledge mastery. the improvement of nursing staff's psychological construction level before and after the training adopts zung's (1971) self-rating anxiety scale (sras) and zung's (1965) self-rating depression scale (srds). zung's sras and srds consist of 20 questions, each of which has answers in likert scale format from levels 1-4. the original score is converted to 100 points and psychological evaluation of the nursing staff is performed. the higher the score, the greater the degree of anxiety and depression. comparison was made before and after training. statistical analysis was performed by spss13.0 software. normal continuous variables were expressed as mean ± standard deviation, non-normal continuous variables were expressed as median values (interquartile range) and categorical variables were expressed as percentages. the comparison between groups was based on whether they met the normal distribution using the mann-whitney u test or t test and the categorical variables used the chi-square test or fisher's exact test. before and after the training, paired t test is mainly used; p < .05 was considered statistically significant. the study was previously explained to the head nurse of the selected hospital, with official permission. the purpose of the study was explained to all study participants, and their informed consent was subsequently obtained. all answers are confidential and used for this study only. basic information of nursing staff. it is shown in table 2 and there were also nine staff whose working experience was under 5 years (12.68%). there were 36 internal nurses, accounting for 50.7%, 23 surgical nurses, accounting for 32.39% and six paediatric and obstetrics nurses, accounting for 8.45%. the mean age of nurses was 31.31 (sd 4.85), their working years ranged from 2 to 20 years. through the scale survey of nurses' degree of recognition of training methods, the results have shown that theoretical training, environmental and process training using online and offline combination (online + on-site training) method is better statistical significance (p = .042, p = .002); while the operation training adopts on-site and on-site + network training methods, the difference is not significant. (p = .081; table 3 ). nursing staff recognized and evaluated the training content in the form of questionnaires in terms of text, graphics and video. it is indicated that the operation training content with partial text and video was better (p = .042, p = .040). there is no difference in the training effect of the three types of network training content, theoretical training, environment and process training (table 4) . compared with pre-training and post-training, the improvement of the covid-19 theory knowledge, operation skills and psychological conditions was significantly improved by paired t test, the mean value is >0 and the p value is <.01. the sas score decreased after training, with statistical difference (p = .019). the difference in sds before and after training was not statistically significant, with a pvalue equal to .306 (table 5) . this study has shown that compared with the pre-training, the difin terms of the degree of recognition of the training content, the results of this study have shown that the order of online training scoring is as follows: online video, online text and online graphics. it illustrates that dynamic visualization training works best. and dynamic visualization training, such as animation and video, has been proved as a particularly effective teaching programme (bernay & betrancourt, 2016; betrancourt & tversky, 2000; marcus, cleary, wong, & ayres, 2013) . regarding the selection of training methods, the results of the study have revealed that the on-site training method is effective for the nursing staff to improve their ability in emergencies, and the combination of network and on-site training methods is the best. supported by research, the comparison between online and faceto-face training, well-designed online training shows more advantages in terms of time efficiency and memory effect (kalyuga, 2007 ; ta b l e 5 before and after training, the nursing staff improved the covid-19 theory knowledge, operation skills and psychological conditions kalyuga & sweller, 2005) , which is consistent with the results of this study. but it is less effective at changing behaviours (aspegren, 1999; mansouri & lockyer, 2007) and face-to-face training seems to be more effective than online training. the reason for analysis may be related to the knowledge and skills provided by online training, and the on-site training can improve the self-confidence of nursing staff. the psychological status of nursing staff before and after working in the emergency isolation ward. the results of this study showed that the sas score of nursing staff after standardized training was lower than before training (p < .05). it indicates that through training and psychological intervention (mindfulness, group) related to the covid-19, the nurses in the emergency ward can be guided to scientifically treat the infection and control of the covid-19, thereby reducing the level of anxiety. the sds level did not change much before and after, one of the possible reasons could be the short-term trainees did not reach the level of depression. however, although the training involves psychological aspect, the need for psychological support is repeatedly mentioned in the questionnaire, indicating that when the medical staff first contacted the patient at the beginning of the outbreak and faced a large number of patients (suwantarat & apisarnthanarack, 2015) , the nurse's level of occupational stress is increasing. (wheeler, 1997) . due to the short-term emergency training and the high risk of infection, it is a huge challenge work for nursing staff. the survey shows that psychological problems are repeatedly mentioned, indicating that nurses have a greater need for psychological support, which seemingly suggests that future psychological support for front-line nurses needs to be strengthened in many ways (zhou, 2020) . selecting the nursing staff of the emergency ward of a hospital may have certain geographical restrictions, or the sample size may not be large enough. more samples from different regions can be researched in the future. the theory of planned behaviour holds that past experience is one of the determinants of a person's beliefs (ajzen, 1991; oh et al., 2017) . the planned selection of experienced nursing staff to participate in the rescue incident is more conducive to the rescue work. this training did not involve the problems of personnel's previous rescue experience. in future emergency rescue work, it is preferable to choose personnel with rescue experience in the human resources database. emergency training of nursing staff is crucial on preventing the spread of the covid-19 epidemic effectively and ensuring the operation of emergency isolation ward orderly. the training content of this study is based on the covid-19 theory operating materials of the chinese health commission and the us guidelines for disease prevention. the training form is a combination of online and offline. in order to form the best training content and provide an optimized training model for the next epidemic prevention and control, the effectiveness of the training form was analysed. at the same time, this study pays particular attention to the psychological problems of nursing staff. carrying out the prevention and intervention of psychological problems to the nursing staff in a timely manner will ensure the staff positively faces the epidemic situation. in short, the value of nursing staff in the prevention and control of the covid-19 epidemic cannot be replaced. how to ensure the safety of nursing staff and patients through training is a significant issue that worth to be discussed. the theory of planned behavior children & disasters: pediatric disaster preparedness and response topical collection children & disasters: educational tools beme guide no. 2: teaching and learning communication skills in medicine-a review with quality grading of articles does animation enhance learning? a meta-analysis effects of computer animation on users' performance: a review emergency preparedness and response: resources for emergency response professionals exploration of preparations for constructing emergency-oriented hospitals under covid-19 pandemic a42) disaster nurses in developing countries: strengthening disaster nurses' competencies through training and disaster drills expertise reversal effect and its implications for learner-tailored instruction rapid dynamic assessment of expertise to improve the efficiency of adaptive e-learning response to the emerging novel coronavirus outbreak a meta-analysis of continuing medical education effectiveness should hand actions be observed when learning hand motor skills from instructional animations? a systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education announcement of the national health and health commission of the people's republic of china exploring nursing intention, stress and professionalism in response to infectious disease emergencies: the experience of local public hospital nurses during the 2015 mers outbreak in south korea risks to healthcare workers with emerging diseases: lessons from mers-cov, ebola, sars and avian flu face-to-face instruction combined with online resources improves retention of clinical skills among undergraduate nursing students office of the assistant secretary for preparedness and response office of the assistant secretary for preparedness and response a review of nurse occupational stress reasearch: 1 director-general's opening remarks at the media briefing on covid-19-9 formulation and implementation of standardized training program on nosocomial infection prevention and control in covid-19 general hospital construction of nursing emergency training system for covid-19 psychological intervention and self-help manual for 11 groups of patients with pneumonia a self rating depression scale a rating instrument for anxiety disorder research on the individualized short-term training model of nurses in emergency isolation wards during the outbreak of covid-19 key: cord-261512-eoqrqnl4 authors: sneyd, j.robert; mathoulin, sophie e.; o'sullivan, ellen p.; so, vincent c.; roberts, fiona r.; paul, aaron a.; cortinez, luis i.; ampofo, russell s.; miller, caitlynn j.; balkisson, maxine a. title: the impact of the covid-19 pandemic on anaesthesia trainees and their training date: 2020-07-23 journal: br j anaesth doi: 10.1016/j.bja.2020.07.011 sha: doc_id: 261512 cord_uid: eoqrqnl4 covid-19 (sars-cov2) has dislocated clinical services and postgraduate training. to better understand and to document these impacts, we contacted anaesthesia trainees and trainers across six continents and collated their experiences during the pandemic. all aspects of training programmes have been affected. trainees report that reduced case-load, sub-specialty experience and supervised procedures are impairing learning. cancelled educational activities, postponed exams and altered rotations threaten progression through training. job prospects and international opportunities are downgraded. work related anxieties about provision of personal protective equipment, and risks to self and to colleagues are superimposed on concerns for family and friends and domestic disruption. these seismic changes have had consequences for wellbeing and mental health. in response, anaesthetists have developed innovations in teaching and trainee support. new technologies support trainer-trainee interactions, with a focus on e-learning. national training bodies and medical regulators that specify training and oversee assessment of trainees and their progression have provided flexibility in their requirements. within anaesthesia departments, support transcends grades and job titles with lessons for the future. attention to wellness, awareness of mental health issues and multimodal support can attenuate but not eliminate trainee distress. anaesthesia trainees are our current inspiration, our future colleagues and our replacements. training in anaesthesia and intensive care, with a degree of overlap that varies on a country by country basis, has evolved from a time-serving apprenticeship to structured programs with bespoke models of learning, reflection and assessment. the pandemic crisis prioritises critical care for those covid-19 patients who have been most profoundly affected, and hospitals, staffing, and working practices have been radically adjusted to accommodate this. recent experience with elective surgery suggests the impact of covid-19 may extend far beyond an icu capacity and staffing problem 1 with as yet unknown implications for training. selection into the speciality, placements, workplace-based assessments, examinations, and career progression have all been disrupted. america, and australia. contributors were identified as current or recent council members of the partner organisations and through personal contacts. they were asked to describe the impacts of the pandemic on themselves and their colleagues including: change of case mix, altered experiential learning opportunities, senior staff taking the lead on procedures, deferral or cancellation of teaching, workplace based assessments and exams, impacted rotations, anxiety and mental health. local, national and international innovations in practice and support were identified. we present a (necessarily) selective overview of the impact of covid-19 on anaesthesia training through the lens of our partner bodies and contacts on six continents. this small sample is not comprehensive but does allow a partial snapshot of the pandemic's impact. from these contributions and the outputs of public bodies we have identified recurrent themes that we present with reference to the uk system supplemented by notes from other countries. trainees in other specialties are also impacted by the pandemic. we attempt to identify and learn from their experiences 2 as well as our own and to look ahead. finally, we recognise a duty to document contemporary experiences and present the individual vernacular contributions online (supplementary appendix 1). guidance on social distancing has prevented face-to-face interviews. in the uk, training posts are allocated by competitive national recruitment. trainees compete again to progress into year three of training. these processes have continued without interviews on the basis of portfolio self-scores, precipitating concerns of unfairness. successful applicants now have their training number and will be monitored by enhanced review during training. however, those unsuccessful feel they have only been able to present half of themselves and perhaps in different times their story would have been different. continuing recruitment allows scheduled rotations and progression through training. when each contact with a patient becomes a potential health risk, supervised procedures performed by a trainee may seem unnecessary. aerosol generating procedures such as bag and mask ventilation, tracheal intubation and tracheostomy appear to carry the greatest risks 3 and there is understandable pressure for the most experienced practitioner to perform the procedure swiftly and efficiently. this diminishes the experience gained by the trainee and the opportunity to be signed off for a workplace-based assessment. mindful of patient safety, initial anaesthesia training typically focuses on a limited range of techniques learned whilst caring for low-risk patients. in houston, the introductory month is highly structured with emphasis on bag and mask ventilation and direct laryngoscopy. this has been replaced by two weeks of simulation then a fortnight to learn intubation using a videolaryngoscope and extubation under deep anaesthesia to avoid coughing and droplet exposure. out of theatre rotations to surgery, medicine and the blood-bank were cancelled. in hong kong, rapid or modified rapid sequence induction with videolaryngoscopy has become universal to avoid bag and mask ventilation. use of laryngeal masks is minimised. some hospitals have set up airway management teams, which intubate and extubate most of the general anaesthesia patients, limiting staff exposure but excluding junior trainees. other cases are diverted to regional techniques, with patients continuing to wear surgical facemasks whilst in-theatre. in chile, some centres chose to keep firstyear trainees away from clinical activity, prioritizing their safety. this group promoted theoretical teaching, especially online. inequalities in resource were recognised with the provision of internet scholarships and laptops for trainees and teachers. however, trainees asked to be included in the clinical work and are now being reincorporated. worldwide, most elective surgery was halted and the few cases undertaken prioritise cancer procedures, emergencies and obstetrics. accordingly, the less complex workload comprising the basis of early anaesthesia training has become scarce. uk trainees report lost opportunities for solo lists. only senior trainees have access to emergency procedures and usually at night or the weekend. worldwide shortages of personal protective equipment (ppe) have compromised safety and induced anxiety. in some south african hospitals these shortages precipitated poor practice. since activating covid-19 protocols has implications for the amount ppe used and where the patient will be managed, labelling of a patient as a covid-19 suspect becomes contentious. protective n95 mask respirators must be reused (if not directly contaminated) for at least one week before replacement. inadequate ppe. this received a swift trade union response but remains a threat. by contrast, in houston every anaesthetist has a fresh (re-sterilised) n95 or fitted p100 mask daily. training in full ppe challenges communication between trainee and trainer. in plymouth, weekly trainee meetings have increased in importance. combining on-site with remote access increases participation and enables issues to be raised and dealt with in a timely manner. socially distanced tutorials can be accessed in person or virtually and saved for access on demand. this flexibility can be a positive and permanent development. the experience across the different academic institutions in south africa is far from uniform. examination preparation and structured teaching were drastically reduced and, in some instances, fell away completely. some universities have embraced the virtual platforms to give tutorials and webinars to postgraduate students and have managed to keep to a regular schedule from the start of the lockdown. these are usually attended after normal work hours and have shown a high level of dedication and professionalism from teachers and registrars. other institutions have offered little teaching once the university closed, highlighting discrepancies in training across the country. this crisis may well usher in the next revolution in postgraduate education with online teaching becoming the new normal. anaesthesia is a craft (hands-on) speciality and on-line study may be a poor substitute for part-task simulators and supervised procedures performed on patients. loss of training opportunities also impacts surgical disciplines. 4, 5 reconfiguring obstetric anaesthesia training in singapore involved experimentation, some failures and some compromises. 6 us directors of pain programmes have developed detailed guidance on adapting training. 7, 8 many countries have redeployed non-anaesthesia trainees to icu, an unsettling and challenging time for those affected. 9 in dublin, anaesthesia trainees supported redeployed peers from surgery and psychiatry introducing them to icu in a safe and controlled manner. on a positive note, reduced time in theatre has focussed the minds of both trainees and trainers since every moment counts. training objectives are identified for each list and both parties are more engaged than previously. medical regulators and national training bodies specify learning outcomes and the curricula to deliver them, in increasing detail. inevitably (and properly) training programs focus on using trainees time well to route them through the curriculum with progressive completion of assessments and "time served" requirements. this inevitably diminishes flexibility whilst arguably increasing the quality and efficiency of training. the pandemic has disrupted the structure and content of curriculum compliant training programmes. social distancing and logistics have impacted the assessments whose completion permit progression and evidence the completion of training. adjustments to lessen the impact to medical training are being agreed and implemented very quickly. nevertheless, concerns remain that changes in exams and recruitment may tip trainees into other specialties or leaving the profession altogether. temporary flexibility within the uk anaesthesia curriculum facilitates progress within training. specifically, progression that is exam success dependent will not be automatically halted, with the expectation that the exam is successfully completed at a future sitting. patient safety considerations preclude complete omission of mandatory components although they may be rescheduled. control of progression by annual review of competency progression (arcp) panels will continue, using new covid-19 specific learning outcomes to incorporate experiences and learning from the disrupted workplace into training. 10 south african training programmes have opted to continue the rotation of trainees to different departments and hospitals, a decision supported by a survey of registrars. whether these rotations will need to be supplemented with extra time is yet to be determined. the impact of the pandemic on trainees adds to existing challenges to morale, mental and physical health. 12 professional and personal pressures in the workplace coincide with derangement of private lives. loss of personal support due to social distancing measures has left many doctors struggling to juggle childcare and work commitments. finances have become stretched with households dropping to a single income. difficult clinical decisions and compromises in care may generate moral injury. 13 trainees have expressed heightened anxiety at home and at work. anaesthetists have responded with innovation and adaptation using measures shown to be effective in previous viral epidemics. 14 other specialties 15 are also reporting impacts on the mental health of staff with trainees more affected than faculty. 16 internationally, anaesthesia departments have recognised these stressors and responded. 16a training on stress recognition, peer support and access to resources is variably implemented but universally understood. 17 uk undergraduate programmes are all to some degree 'integrated' with exposure to patients in all years and often within weeks of starting. the total or near total withdrawal of clinical placements turned the clock back with a focus on basic science and self-directed learning. 19 problem-based learning groups function well by video-link but the context-setting patient encounters with which they might have been bracketed have disappeared. the set-piece lecture may be a dinosaur to educationalists, but it is easy to provide remotely. innovative small-group techniques are harder to replicate if they depend on anatomical models, surface anatomy or part-task simulation. the greatest impact is undoubtedly on senior students who should be concentrating on maximising clinical encounters, building consultant and diagnostic skills, and progressively integrating into clinical teams as they prepare for the transition from student to care-providing trainee. temporary arrangements whereby patient contact is minimal or non-existent are not sustainable and feel inconsistent with the production of patient-focussed and clinically skilled medical graduates. 19a looking ahead, exclusion of medical students from the operating rooms may impair recruitment to the specialty even if a temporary fillip is provided by current media exposure. for hong kong medical students, all patient contact has been suspended. didactic components of the program have been moved and grouped together, with all teaching material, including lectures and small-group discussions, delivered on-line. clinical components were moved to later in the program. if patient examination is required in the medical school exam, patients would be tested for sars-cov-2 and wear n95 masks. final year medical students are expected to graduate as scheduled. covid-19 will not go away any time soon and therefore the new balance between service provision and training needs to be agreed in a sensitive way to avoid further frustration amongst trainees. adaptations to these circumstances have delivered new forms of teaching and supervision and the pandemic has provided a brutal laboratory to test them. video-calls, electronic learning and computer-based exams are probably here to stay. so too is the video-aryngoscope whose promotion from fall-back option to instrument of choice 20 has been accelerated. variation in national responses and possibly unknown epidemiological factors have produced dramatically different covid-19 burdens on health services. in australia, case numbers remained low and elective surgery escalated until recently. new zealand had no active cases and all restrictions were removed. other countries remain greatly disrupted with the pandemic worsening. in consequence the impacts on trainees are increasingly heterogenous. our ability to work effectively in teams and to support each other through crises was already well developed 21 but has been pre-eminent of late. as one trainee commented "this sense of community is a welcome silver lining and will be paramount in helping our health service transition smoothly out of crisis mode into the new normal". trainees and their supervisors have made pastoral and professional innovations and their departments have the opportunity to make them permanent. they are improvements just as important as teleconferences and videolaryngoscopes. mitigating the risks of surgery during the covid-19 pandemic. the lancet training disrupted: practical tips for supporting competency-based medical education during the covid-19 pandemic risks to healthcare workers following tracheal intubation of patients with covid-19: a prospective international multicentre cohort study how are orthopaedic surgery residencies responding to the covid-19 pandemic? an assessment of resident experiences in cities of major virus outbreak slowdown of urology residents' learning curve during the covid-19 emergency resilience of the restructured obstetric anaesthesia training program during the covid-19 outbreak in singapore maintaining high quality multidisciplinary pain medicine fellowship programs: part i: innovations in pain fellows' education, research, applicant selection process, wellness and acgme implementation during the covid-19 pandemic maintaining high quality multidisciplinary pain medicine fellowship programs: part ii: innovations in clinical care workflow, clinical supervision, job satisfaction and postgraduation mentorship for pain fellows during the covid-19 pandemic the impact of despecialisation and redeployment on surgical training in the midst of the covid-19 pandemic guidance and principles for managing extensions to training during covid-19. 2020 conference of postgraduate medical deans of the united kingdom residency and fellowship program accreditation: effects of the novel coronavirus (covid-19) pandemic the royal college of anaesthetists l. a report on the welfare, morale and experiences of anaesthetists in training: the need to listen limiting moral injury in healthcare professionals during the covid-19 pandemic occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis well-being and education of urology residents during the covid-19 pandemic: results of an american national survey mental health among otolaryngology resident and attending physicians during the covid-19 pandemic: national study. head and neck trial under fire: one new york city residency program's redesign for the covid-19 surge covid-19 preparedness within the surgical, obstetric and anesthetic ecosystem in sub saharan africa response of chinese anesthesiologists to the covid-19 outbreak covid-19: novel pandemic, novel generation of medical students universal videolaryngoscopy: a structured approach to conversion to videolaryngoscopy for all intubations in an anaesthetic and intensive care department leadership and teamwork in anesthesia-making use of human factors to improve clinical performance key: cord-003749-3uivy27w authors: witkowska-piłaszewicz, olga; bąska, piotr; czopowicz, michał; żmigrodzka, magdalena; szczepaniak, jarosław; szarska, ewa; winnicka, anna; cywińska, anna title: changes in serum amyloid a (saa) concentration in arabian endurance horses during first training season date: 2019-06-08 journal: animals (basel) doi: 10.3390/ani9060330 sha: doc_id: 3749 cord_uid: 3uivy27w sport training leads to adaptation to physical effort that is reflected by the changes in blood parameters. in equine endurance athletes, blood testing is accepted as a support in training, however, only the changes before versus after exercise in creatine phosphokinase activity (cpk) and basic blood parameters are usually measured. this study is the first longitudinal investigation of the changes in routinely measured blood parameters and, additionally, serum amyloid a (saa), during seven months, in arabian horses introduced to endurance training and competing in events for young horses. it has been determined that cpk, aspartate aminotransferase (ast), packed cell volume (pcv), hemoglobin concentration, red blood cell count (rbc), and concentration of total serum protein (tsp) slightly increased after training sessions and competitions in similar manner. the increase in white blood cell (wbc) count was higher after competitions and saa increased only after competitions. total protein concentration was the only parameter that increased with training during a 7-month program. saa indicated only in the case of heavy effort, and, it thus may be helpful in the monitoring of training in young horses. in an optimal program, its concentration should not increase after a training session but only after heavy effort, which should not be repeated too often. optimal training is crucial for animal welfare in order to produce exercise adaptation but also to maintain good health in a horse. the analysis of change in routine blood parameters is used for the evaluation of training progress, as well as general health, but does not provide the information necessary for estimating subclinical disorders that may worsen with effort and result in interruption of trainings or even termination of sport career. therefore, additional parameters, such as serum amyloid a (saa), have been considered. the aim of this longitudinal study was to investigate the changes in saa concentration in arabian endurance horses during their first training season, with special regard to the relationship between saa concentration and the time and type of effort (training versus competition). our study indicates that, in the horses, the measurements of saa concentration together with commonly accepted parameters give additional insight into health control of the horse. endurance riding is an equestrian sport, involving completing the distances from 40 km to 160 km, depending on the age and sport level of horses, confirmed by previous finishing competitions required by the regulations. all distances are divided into loops, 20 km to 40 km each, with a time check and obligatory veterinary inspection (vet gate), in order to detect if the horses are fit to continue the ride. horses with irregular gait or metabolic abnormalities are eliminated from competitions. horses can reach the highest sport level (160 km competitions) after several years of training and competing at shorter distances since the career of endurance horses spans many years. not only the time of finishing the ride, but mostly points granted on the veterinary health check, matter for the final score. therefore, careful regular evaluation of health condition of endurance horses is crucial. while during the competition it is based solely on physical examination performed by a veterinarian, during training it is supported by periodical monitoring of blood parameters. in endurance horses, creatine phosphokinase activity (cpk) poses the most important functional measurement and, additionally, aspartate aminotransferase (ast), packed cell volume (pcv), hemoglobin concentration (hgb), red blood cell count (rbc), and concentration of total serum protein (tsp), glucose, phosphorus, and potassium [1, 2] are commonly determined. the analysis of change in these parameters over time provides information on metabolic alterations associated with training progress, however, it does not allow to detect developing disorders at the subclinical stage [3] . therefore, additional parameters characterizing the acute phase response (apr) have been considered [4] [5] [6] . typical apr that occurs in inflammation involves marked increases in the concentrations of pro-inflammatory cytokines and acute phase proteins (apps), such as saa, which is the major app in horses [7] [8] [9] , c-reactive protein, and haptoglobin. a similar reaction has been described in humans [10, 11] and animals [12, 13] after strenuous endurance events, however, certain differences between disease-induced and exercise-induced apr exist. in horses, the latter is characterized only by the increases in the concentrations of some cytokines [14] and saa, with other apps remaining unchanged [12] . such reactions may also occur during training [15] , but its role is yet to be clarified. therefore, the aim of this longitudinal study was to investigate the changes in saa concentration in arabian endurance horses during their first training season, with special regard to the relationship between saa concentration and the time and type of effort (training versus competition). eight privately-owned, healthy, 6-7 years old, previously untrained arabian horses (two mares and six geldings) that were starting their endurance training and sport carrier were enrolled in this study. the horses were housed in two stables in similar conditions, fed, and trained according to similar protocols. all exercises were provided under similar terrain conditions. the training involved daily sessions with the exercise-load depending on the horse's condition and increasing with time; altogether the horses covered about 250 km per month, and the sessions with high exercise-load were performed every 14-20 days. beginning with third month of training, the horses were introduced to endurance competitions at limited distance. the animals were monitored for the whole training season (the first training season in their carrier) and examined before and after training sessions selected for the study-the ones with high exercise-load (25-28 km, speed 14-15 km/h) and before and after finishing the competitions (42-45 km, speed 14-16 km/h). standard clinical examination performed before and after each training session included in the study revealed no clinical symptoms of disease. the study covered seven months and included five training sessions and three competitions, so the maximal number of examinations for individual horse was eight; however, horses entered a different number of competitions. blood samples were collected before and within one h after the training sessions or competitions during seven months of training. all samples were obtained during standard veterinary diagnostic procedures; thus, according polish law, the approval by local commission for ethics in animal experiments was not required. all blood samples were acquired by a jugular venipuncture using a bd vacutainer system into k2-edta tubes for hematological tests and plain tubes for serum analyses. edta blood samples were kept at + 4 • c and examined within 5 h for hematological parameters: white blood cell (wbc) count, pcv, hemoglobin concentration, and rbc in an automated analyzer calibrated for equine species (abc vet, horiba abx). the dry tubes were centrifuged (4380× g, 5 min), and serum free from any apparent hemolysis was aspirated for further analyses. ast and cpk activity were determined using automated clinical biochemistry analyzer (miura one, ise. s.r.l., albuccione, italy). tsp concentration was measured by refractometer technique (reichert rhino vet 360, munich, germany). for all measurements, pointe scientific (canton, usa) reagents, standards, calibrators, and controls were used. saa concentrations were measured using immunoenzymatic commercial assay (phase saa assay, tridelta ltd., maynooth, ireland). sample dilution was 1:1000 instead of 1:2000, recommended by the manufacturer's protocol, and the results were appropriately recalculated. the assay, including the dilution, was previously validated for determination of saa concentrations in horses [12] . the absorbance was measured by multiscan reader (labsystem, helsinki, finland) using a genesis v 3.00 software program. to avoid the influence of hemoconcentration, saa concentration was adjusted by tsp, according to the formula: saa is the saa concentration, tsp 0 is the tsp level before exertion, and tsp 1 is the total serum protein level after exertion. numerical variables were presented as the arithmetic mean ± standard deviation (sd) or median and interquartile range (iqr), unless normally distributed. the range was reported in all cases. the influence of two different types of effort (training and competition) on blood parameters was assessed using the hierarchical linear model controlling for potential confounding factors: the individual effect of a horse (included since horses were examined a different number of times), the number of efforts the horse had undergone before, and the time of blood collection (before and after the effort). the interaction between the time of blood collection and the type of effort was entered in the last step of developing the model and retained only when significant. otherwise standardized regression coefficients (β) and p-values for the model without interaction were interpreted. pairwise comparisons were performed only when a given factor (i.e., number of efforts, time of blood collection, or type of effort) proved significant in the hierarchical model on measurements averaged for an individual horse with respect to these factors, which proved insignificant in the hierarchical model. the paired-sample student's t-test, or the wilcoxon signed rank test and sign test in the case of non-normally distributed variables, were used in pairwise comparisons. a significance level (α) was set at 0.05. statistical analysis was performed in ibm spss statistics 24 (microsoft, new york, ny, usa) and tibco statistica 13.3.0 (tibco software inc., palo alto, ca, usa). in all horses hematological and serum biochemical parameters determined before the physical effort fell within relevant reference intervals [2] . during the 7-month training season, tsp was the only blood parameter that significantly increased, while the rest remained unaffected by the number of efforts the horse had undergone ( table 1) . the significant interaction between type of effort and time of blood collection was observed only for wbc and saa adj (table 1 )-they significantly increased after competition, whereas remained unchanged after training (table 2, figure 1 ). the highest individual saa concentrations after competition reached 10.6 mg/l. all remaining hematological (rbc, hgb, pcv) and serum biochemical parameters (cpk, ast, tsp) slightly rose both after training and competition (table 3) . table 3 . other hematological and serum biochemical parameters before and after the effort (training and competition). this is the first study presenting the changes in blood parameters of endurance horses monitored during 7 months in their first training season. as expected, the parameters routinely measured in the monitoring of endurance training (cpk, ast, rbc, hgb, and pcv) slightly increased likewise after the training and competitions. cpk and ast activities are commonly used in horses as the indicators of any kind of muscle fatigue or damage. after strenuous exercise, they increase from four-to 35-fold and from two-to six-fold, respectively [16] . in muscle damage, they are markedly elevated [16, 17] and clinical sings, such as lameness, occur. exercise-induced elevations in cpk activity may be attenuated by conditioning [16] but do not provide information on the magnitude of muscle damage [17] . in our study, cpk and ast activities were elevated significantly but only slightly less than two-fold, regardless of the type of effort. rbc, hgb, and pcv values are routinely examined in sport horses. in our study, the differences between resting and post-exercise measurements were similar during training and competition. exercise-induced hematological changes result from spleen contraction and the decrease in plasma volume [18] . the latter is also likely to account for the post-exercise increase of tsp. moreover, basal tsp concentration was the only parameter measured in our study that increased along with training process. it has been hypothesized that in human during training, plasma total osmolar and albumin contents increase to maintain constant during plasma volume expansion due to training-induced hypervolemia [19] , which is consistent with our findings in horses. however, although another study observed no increase of tsp concentration after training season, this could be due to the fact that this study was almost two-fold shorter and involved different training regimens for each horse [20] . it has been hypothesized that, in inexperienced horses, physical effort during training, particularly a heavy one, induces a reaction similar to apr [15] . several theories explaining the causes of exercise-induced apr have been proposed, however, mostly in regard to extreme effort during competitions or overtraining [21] [22] [23] . one of these hypotheses is that a high load of training produces muscle and/or skeletal and/or joint injuries, including microinjuries, which stimulate circulating monocytes and other cells to produce pro-inflammatory cytokines, such as tumor necrosis factor α (tnf-α), interleukin 1 (il-1), and interleukin 6 (il-6) [14, 22] . another widely accepted theory is that apr results from glycogen depletion in working muscles, which in turn results in il-6 release [10, 24] . il-6 promotes pleiotropic effects, i.e., hepatic glycogenolysis and lipolysis, but also stimulates the production of apps, including saa in the liver [5, 7, 9] . exercise-induced apr in horses has been postulated to result from an acute challenge to muscle metabolism, rather than muscle damage; however, definitive evidence is still lacking [25] . in our study, an increase of saa concentration (up to 16-fold) was observed after competitions but not during training and never reached high values. even the highest individual saa concentrations after competition were still relatively low (max. 10.62 mg/l), compared with those reported in horses with acute inflammation in the course of bacterial or viral infections, where saa concentration exceeds 100 mg/l [26, 27] . in the case of exercise-induced apr, as described earlier, the highest (10-fold or more) increases in saa concentration have been reported in endurance horses that completed the longest (120-160 km) distances [12] , whereas after a moderate distance ride or strenuous training in inexperienced horses was slighter but still significant, resulting in an observed two to four-fold elevation of saa concentration [15] . the unique feature of this response was that saa levels tended to increase proportionally to the covered distance [28] . our results imply that training sessions do not trigger the increase in saa concentration when the workload is optimal to produce adaptation and maintain good health. moderate increases of saa after competitions indicated a heavier challenge, particularly when the distance covered two training sessions. however, the increases were not high enough to indicate pathology but, rather, the physiological response to the relatively high workload, given that the horses were in their first training season. our previous study revealed that, in horses trained for the longest distances, saa concentrations did not rise after moderate distance, i.e., up to 60 km long rides [12] ; however, when the resting saa concentration exceeded 1 mg/l, the horse was likely not to complete a long distance (i.e., 120 and 160 km) endurance competition [21] . it has also been suggested that in young, inexperienced endurance horses, saa concentrations at rest are higher [15] , which is consistent with the findings of our present study. these facts suggest that saa concentrations at rest may decrease with training due to adaptational muscular remodeling in young animals and then increase only in the response to the heaviest efforts or pathology. our study indicates that such phenomena do not occur in the first training season, so it probably requires a longer training process. another parameter that increased significantly only after competition was wbc. higher wbc values are likely to be a combined result of hemoconcentration and the release of neutrophil marginal and splenic pool triggered by adrenaline, noradrenaline, and cortisol [29] . we enrolled in the study young (6-7 years old), healthy endurance arabian horses to minimize the influence of potential confounding factors, such as aging and disease [30] , but individual differences among horses still posed limitations of the study. our study indicates that, in the horses that begin their endurance carrier, the measurements of saa concentration, together with commonly accepted parameters, give additional insight into the training process. in contrast to routine measurements, which rise in a similar manner regardless of the type of the effort, the increase in saa concentration only indicated an excessive stress-load after heavy effort, which should not be repeated too often. thus, in unexperienced horses in the beginning of their carrier, the moderate increases in saa level indicate heavy effort, while higher increases can alert the veterinarian to the onset of different diseases, even without clear clinical signs. the authors declare no conflict of interest. total serum protein level after exertion tsp 0 total serum protein level before exertion tnf-α tumor necrosis factor α wbc white blood cell count the cardiovascular system exercise testing in the field clinical pathology in the racing horse: the role of clinical pathology in assessing fitness and performance in the racehorse acute phase response in animals: a review 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in haematocrit alterations during incremental treadmill exercise in horses exercise training-induced hypervolemia: role of plasma albumin, renin, and vasopressin haematological and plasma biochemical parameters in endurance horses during training serum amyloid a level as a potential indicator of the status of endurance horses muscle damage is linked to cytokine changes following a 160-km race cytokine hypothesis of overtraining: a physiological adaptation to excessive stress? interleukin-6 is a novel factor mediating glucose homeostasis in skeletal muscle contraction exercise-induced increases in inflammatory cytokines in muscle and blood of horses evaluation of serum amyloid a and surfactant protein d in sera for identification of horses with bacterial pneumonia experimental inoculation of equine coronavirus into japanese draft horses post-ride inflammatory markers in endurance horses alterations in blood, sweat, urine and muscle composition during prolonged exercise in the horse frequent participation in high volume exercise throughout life is associated with a more differentiated adaptive immune response this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-291366-d5d9l0xr authors: eirale, cristiano; bisciotti, giannicola; corsini, alessandro; baudot, christophe; saillant, gerard; chalabi, hakim title: medical recommendations for home-confined footballers’ training during the covid-19 pandemic: from evidence to practical application date: 2020-04-10 journal: biol sport doi: 10.5114/biolsport.2020.94348 sha: doc_id: 291366 cord_uid: d5d9l0xr in early 2020, the world is facing a global emergency called covid-19. many professional footballers around the world are home confined. the maintenance of physical capacity is a fundamental requirement for the athlete, so the training sessions must be adapted to this unique situation. specific recommendations must be followed concerning the type of training, its intensity, the precautions that have to be followed to avoid the possibility of contagion, and the restrictions in accordance with the presence of any symptoms. this article analyses the available scientific evidence in order to recommend a practical approach. in early 2020, the world is facing a global emergency called covid-19 (coronavirus disease 2019). many governments have requested the population to stay home unless necessary for proven reasons. professional footballers have found themselves in a unique situation in which they were not only obliged to stop their professional activity but also to be confined in their houses. the maintenance of physical capacity is a fundamental requirement for the athlete. specifically, for team sports athletes, maintaining a good level both of aerobic power and muscle strength is a fundamental prerequisite to preserve performance unchanged. the training physiological adaptation is a reversible process. indeed, most aspects of physiological adaptation are lost during a prolonged period of inactivity [1] . the rate of loss is different for each physical capacity, being higher for endurance and strength endurance rather than speed and maximum strength. there is generally accepted to be an overall loss up to 10% of fitness for each week of total inactivity [2] . in professional football the annual season is subdivided into three periods: the pre-competition period (pre-season period), the competition period and the transition period (off-season) [3] . in professional football, the transition period rarely lasts more than one month [4] . in this period, there is an important reduction, or even a medical recommendations for home-confined footballers' training during the covid-19 pandemic: from evidence to practical application authors: cristiano eirale 1 , giannicola bisciotti 1,2 , alessandro corsini 3 , christophe baudot 1 , gerard saillant 1 , hakim chalabi 1,2 1 paris saint germain fc, france 2 aspetar sports and orthopedics hospital-doha, qatar 3 internazionale milano fc, italy abstract: in early 2020, the world is facing a global emergency called covid-19. many professional footballers around the world are home confined. the maintenance of physical capacity is a fundamental requirement for the athlete, so the training sessions must be adapted to this unique situation. specific recommendations must be followed concerning the type of training, its intensity, the precautions that have to be followed to avoid the possibility of contagion, and the restrictions in accordance with the presence of any symptoms. this article analyses the available scientific evidence in order to recommend a practical approach. there is no previous off-season period characterized by confinement. in any case, it is obvious that the level of fitness that players will done individually and keeping the distance from other people imposed by the current health regulations. it is highly advisable to carry out the training in places not frequented by other people, preferring the times in which there is little flow of people. it is important to remember that the droplets containing covid-19 travel a distance of 1.8 metres in the air and the average life of covid-19 is 2.7 hours in the air, 13 hours on steel and 16 hours on polypropylene [31] . furthermore, currently there is no scientific evidence regarding wearing protective masks in public spaces for asymptomatic persons [32] . for these reasons, it is highly inadvisable to perform any form of physical activity in public or private gyms frequented by several people. on the other hand, since there is a consensus in several countries to restrict social gathering, including gyms and meeting places, and to limit population movements [32] , this recommendation may also be superfluous. indeed, there are some sport activities such as yoga, tai ji quan, and qigong that can be preferred in this specific period and should be proposed to the population as a valid alternative to more popular sports [26] . moreover, some alternative training methods such as software-generated partners should be proposed in order to maintain motivation [33] . suspension of high-intensity aerobic activity for 20 days or greater results in a significant decrease in vo2max [34, 35] . this obviously can be a problem for a team sports athlete [36] ; therefore, cardio training should be commenced as soon as possible. however, in compliance with the principle of maximal caution [27] , it is highly recommended to observe the following rules: i. the duration of the cardio training sessions should not exceed 60 minutes [37] . it would be advisable to carry out two sessions of no more than 30 minutes during the day [38] . if the solution of two sessions is adopted, the latter must be interspersed with a recovery of at least three hours. it is very important to carry out suitable rehydration between the two training sessions [39] . ii. the intensity of the effort should be limited to 80% of the maximum heart rate, corresponding to approximately 75-80% of the subject's maximum aerobic speed (i.e. the speed at which vo2max is reached) [40] . iii. the cardio training can be performed both in the form of continuous running [41] and intermittent [42] or interval training [43] , if the intensity of the effort indicated above is respected. strength training involves the use of equipment that usually is in public or private gyms. however, for the reasons of possible contagiousness explained above, attending public gyms is not recom-present when returning to normal training is closely linked to the following factors: i. whether the player has contracted covid-19 or not and, in case of contagion, if he/she shows any sequelae; ii. the duration of the detraining period and the confinement; iii. the level of physical activity that the player maintained during the detraining period. therefore, in accordance with the above points, it is extremely important that: -at the time of resuming sports activity, a battery of tests allowing objective evaluation of the player's physical condition is performed; -there is a suitable pre-competition period with a training programme including both aerobic training and strength conditioning activities [10, 12] . indeed, physical activity may influence the response and the effectiveness of the immune system [13] [14] [15] [16] [17] [18] . there is quite strong evidence that intense endurance sport activities, such as running, cycling, rowing or swimming, produce significant leukocytosis caused by an increase in numbers of b and t lymphocytes, neutrophils and nk cells in the systemic circulation [19, 20] . furthermore, acute severe exercise inducing an oxidative state results an acceleration of neutrophil apoptosis [21] . therefore, at the end of demanding physical activity there is a drastic drop in circulating lymphocytes with consequent loss of efficiency of the immune system [17] . in exercise immunology a central dogma is that a strenuous exercise bout or a period of intense exercise impairs the effectiveness of the immune system leading to an "open window" of infection risk [22] . the concept that any kind of strenuous exercise can be considered 'immunosuppressive' has recently been challenged and the concept of an "open window" has been questioned [23, 24] . however, the evidence provided for confuting the "open window" concept is not yet sufficiently convincing [25] . thus, further relevant studies will be needed in the future. therefore, considering both the high and dramatic specificity of the current pandemic period and the absence of evidence concerning sport activity during the covid-19 pandemic [26] , the training rules mentioned below are mainly based on the principle of "maximal caution" [27] . excessively intense training can weaken the immune system [22] and increase the risk of being contaminated by covid-19 or of developing a serious form of it affecting the heart [28] , the lung [29] , the liver, the kidneys and the immune system [30] . for these reasons, we recommend avoiding intense training during the epidemic period. in countries where there are no limitations for outdoor sporting activities, outdoor running training is possible. the training must be biology of sport, vol. 37 no2, 2020 205 medical recommendations for home-confined footballers' training during the covid-19 pandemic mended. in the absence of suitable equipment, strength training can be carried out at home with elastic resistance [45] or body weight exercises, for example pull-ups, push-ups, sit-ups, dips, nordic hamstring exercise, etc [46, 47] . the strength training should respect the following rules: i. the duration of the strength training sessions should not exceed 60 minutes [37, 48] . ii. the use of maximum loads and exercises conducted at full muscle exhaustion (regardless of the load used) is not recommended [37, 49] . indeed, the lactate production typical of strength exercise conducted at complete muscle exhaustion promotes lymphocyte apoptosis [50] . iii. during cross-fit sessions the intensity of the effort should be limited to 80% of the maximum heart rate [40] . two weekly strength training sessions respecting the above-mentioned points are sufficient to maintain the strength characteristics in a well-trained athlete [51] . in any case, we do not recommend strength training to be carried out at maximal levels as there is evidence of a reduction of up to 15% of isometric strength in infected subjects who do not fully recover until a month after the illness [52] . since in athletes the infection by coronavirus is often asymptomatic, athletes may potentially suffer from this kind of strength reduction even without a confirmed diagnosis of covid infection, and therefore it is safer to train at submaximal levels. stretching exercise sufficient to maintain or to develop the range of motion should be included in the training sessions. the stretching exercises should involve the major muscle groups and be performed in a minimum of 2-3 sessions per week. furthermore, stretching sessions should include both static and dynamic exercise [53] . fever is a normal physiological reaction of the body to an illness or immune stimulus assisting the immune system with mounting a response [54] . in case of fever, any type of physical activity must be suspended [55] . there is evidence from animals that strenuous exercise during an ongoing febrile infection can be dangerous, leading to an increased rate of complications and lethality [56] . moreover, dehydration can contribute to hyperthermia [57] . in cases of febrile infections with systemic symptoms, recommendations on resuming physical activity vary from recommencement of sport activity once fever has resolved to waiting until 14 days after the symptom's resolution [56, 58] . moreover, the proximity with others during sport activity performed with an active pulmonary covid 19 infection may potentially lead to spreading of the virus. despite the lack of direct evidence of that, considering the method of transmission [44] , it cannot be excluded. in addition, in case of absence of fever, it is necessary to avoid taking paracetamol as a preventive measure. indeed, the effect of paracetamol could mask the onset of viral infection [59] . some papers suggest a link between nsaids and both respiratory and cardiovascular adverse effects in several settings, but so far there is no evidence explicitly concerning covid-19. waiting for more robust evidence, we suggest a cautionary approach in their use [60] . use of corticosteroids is also not advised because they increase the risk of infection, including viral infections [61] . for these reasons, we do not recommend any kind of training in case of fever following a covid infection and, due to the lack of evidence, the principle of maximal prudence should be followed upon return to sport. the day will come (we all hope soon) when covid-19 will be only a memory. looking forward to that day, as a final recommendation, we encourage the football medicine community both to apply maximal caution on the decision when to restart sport activity and to adopt a specific protocol to check for cardiological, pulmonary and, in general, systemic sequelae of covid-19 in the athletes [27] . since the geographical distribution of covid-19 is unequal and the evolution of the pandemic is different in each country, the return to activity and the consequent programme of prevention should be tailored to each situation [62] . moreover, the return to normal activity will have to be progressive and programmed. it is highly recommended that players return to sporting activity progressively, applying [63] : i) a preliminary phase normally performed during the confinement phase, during which the player restarts the training at home, with the training schedules sent and checked remotely by the club staff; ii. an individual training phase in which a few club staff members may assist the player during the pitch or gym training. during this phase, it is recommended that a maximum of two players can train on the pitch at the same time, keeping a safe distance between them; iii. a group training phase, with a maximum of 8 players at a time; iv. a collective training phase with full resumption of training for the whole group. furthermore, during the aforementioned phases, it will be necessary to respect a series of rigorous medical and hygienic-sanitary rules [63] . to date, there is no scientific evidence to demonstrate an ability of the pneumococcal vaccine (or any other vaccination) to protect against coronavirus infection. finally, at return to play there will probably be a congested period with 2-3 games every 7 days, after a period of detraining. since both match congested periods [64] and activity load variation [65] have been associated with an increased risk of injury, attention should be paid to organizing for each player a tailored schedule of training and matches in order to avoid sudden variation of the load. this will also safe training. last, but certainly not least, the international medical community should rapidly establish a specific clinical protocol aimed at checking the athletes' medical status and physical fitness after the pandemic period caused by covid-19. therefore further studies are recommended in order to establish the evidence behind these protocols. all authors declare having no conflict of interest be necessary in order to avoid potential exercise-induced depression of the immune system [66] [67] [68] . the effect of a 4-week training regimen on body fat and aerobic capacity of professional soccer players during the transition period immune system adaptation in elite athletes exercise and the immune system clinical implications of exercise immunology exercise and the immune system: implications for elite athletes and the general 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conferences in intensive care medicine: ventilator-associated lung injury in ards special feature for the olympics: effects of exercise on the immunesystem: infections and exercise in high-performance athletes hydration and the human brain, heart and skeletal muscles long-term exercise training selectively alters serum cytokines involved in fever china coronavirus: six questions scientists are asking non-steroidal anti-inflammatory drugs and covid-19 the association between systemic glucocorticoid therapy and the risk of infection in patients with rheumatoid arthritis: systematic review and meta-analyses injury & illness epidemiology in soccer -effects of global geographical differences -a call for standardized & consistent research studies laliga protocol regarding the resumption of training across laliga clubs muscle injury rate in professional football is higher in matches played within 5 days since the previous match: a 14-year prospective study with more than 130 000 match observations the acute:chonic workload ratio in relation to injury risk in professional soccer training load, immune system, upper respiratory symptoms and performance in well-trained cyclists throughout a competitive season effect of exercise on the level of immunoglobulin a in saliva siga response and incidence of upper respiratory tract infections during intensified training in youth basketball players key: cord-279891-v71rysnw authors: karampekos, george; gkolfakis, paraskevas; tziatzios, georgios; apostolopoulos, pericles; vlachogiannakos, jiannis; thomopoulos, konstantinos; protopapas, andreas; kofokotsios, alexandros; oikonomou, michalis; mela, maria; samonakis, dimitrios; christodoulou, dimitrios; triantafyllou, konstantinos title: differences between fellows and fellowship program directors in their perception of the impact of the covid-19 pandemic on gastroenterology training: results from a nationwide survey in greece date: 2020-10-12 journal: ann gastroenterol doi: 10.20524/aog.2020.0546 sha: doc_id: 279891 cord_uid: v71rysnw background: lockdown measures applied during the sars-cov-2 outbreak caused a significant disturbance to hospital routine. we assessed trainees’ and fellowship directors’ perceptions regarding the impact of the pandemic on gastroenterology fellowship training. methods: a web-based survey was anonymously disseminated to all greek gastroenterology fellows and fellowship program directors. participants completed electronically a questionnaire comprised of 5 domains that assessed participants’ perception of: 1) overall impact on training; 2) impact on training in gastroenterology-specific fields (endoscopy, inflammatory bowel disease, hepatology); 3) impact on different aspects of endoscopy training; 4) impact on academic training; and 5) training perspectives for the post-pandemic era. results: a total of 77/128 fellows (60.1%) and 18/28 fellowship program directors (64.3%) responded. more fellows reported that the covid-19 pandemic would have an adverse impact on fellowship training compared to their fellowship program directors (81.8% vs. 55.6%, p=0.038). this concern was mainly focused on endoscopy training (83.1% vs. 27.8%, p<0.001), with no difference regarding training in gastroenterology’s other specific fields. the difference was consistent for technical skills (79.2% vs. 38.9%, p=0.001), and for the performance of basic diagnostic (70.1% vs. 22.2%, p<0.001) and emergency (48.1% vs. 11.1%, p=0.004) procedures. fellows and fellowship program directors identified the unknown timeframe of measure implementation and the postponement of scheduled endoscopic procedures as the main factors that negatively affected training. extension of the fellowship training program was deemed the optimal option by fellows for addressing the training decrement in the post-pandemic era, while fellowship program directors favored an increase in workload. conclusion: fellows and their fellowship program directors do not share the same concerns about the impact of covid-19 pandemic on training programs and they propose different measures to remedy its effects. presence [1] . countries more affected by the pandemic have allocated their staff, including those in training, to the service of units dealing with covid-19 patients [2] . greece, while having only a moderate disease burden that never exceeded the healthcare system's capacity, has postponed nearly all elective medical and surgical procedures since march 23, 2020. many of the hospitals that served as gastroenterology training centers acted as tertiary referential centers for covid-19 patients. in other countries this measure led to a re-allocation of gastroenterology fellows to other clinics, with a detrimental impact on their training [3] . in view of the controlled restart of elective activities, the governing board of the hellenic society of gastroenterology (hsg) decided to perform a survey to assess the perceptions of fellows and their fellowship program directors on the effects of the lockdown on gastroenterology training. this was a cross-sectional web-based survey carried out in greece in may 2020. the survey was distributed nationwide to all gastroenterology fellows (n=128) and fellowship program directors (n=28). based on the available literature [3] [4] [5] [6] [7] , a team of researchers (pg, gt, dc and kt) with previous experience in questionnaire construction designed 2 similar survey instruments for fellows and fellowship program directors. each instrument consisted of 2 sections: demographics and professional characteristics, and the main core of the questionnaire. in both questionnaires, the latter section consisted of the same 20 questions, classified into 5 distinctive domains, assessing participants' perception of the effect of the covid-19 outbreak on: 1) the overall impact on training; 2) the impact on training in gastroenterology-specific fields (endoscopy, inflammatory bowel disease, hepatology); 3) the impact on different aspects of endoscopy training; 4) the impact on academic training; and 5) perspectives regarding training in the post-pandemic era. finally, fellows were asked about the number of diagnostic endoscopiesesophagogastroduodenoscopy and colonoscopy-they had performed monthly, before and during the lockdown. the questionnaire with the 20 questions answered by both groups is presented in supplementary table 1 . the final versions of both questionnaires were approved by the governing board of the hsg. we used the commercially available version of the web-based survey program "google forms" to develop this survey. the survey was distributed using the official hsg databases, by sending individualized e-mail invitations with the link to complete the survey, along with a cover letter explaining its purposes. duplicate participation was prevented by the electronic survey program itself, since only a single response per user was possible. the first call was sent out on may 1, 2020, 6 weeks after the implication of the national lockdown, and a reminder was sent 2 weeks later. responses were automatically recorded in the system and entered into a software database (microsoft excel; microsoft corp., redmond, wa, usa), while remaining anonymous to study investigators. the purpose was to assess greek fellows' and fellowship program directors' perceptions regarding the impact of the covid-19 outbreak on gastroenterology training. while the survey focused mainly on endoscopy training, it also assessed overall gastroenterology training and other specific fields of gastroenterology (inflammatory bowel disease and hepatology). quantitative data were expressed as mean ± standard deviation (sd) or median (interquartile range [iqr]) depending on their distribution. categorical data were represented as number (%). the kolmogorov-smirnov statistic was used to assess the distribution of quantitative data for normality. we used nonparametrical tests to analyze categorical and non-continuous quantitative variables. for the purposes of the analysis "negative" and "very negative" answers were classified as negative, while "positive" and "very positive" answers were grouped as positive. all calculations were performed using the software statistical program statistical packages for social sciences (spss) version 25.0 (chicago, illinois, usa), with a p-value <0.05 considered as significant for all statistical assessments. the study's protocol was approved by the governing board of the hsg. participation was voluntary and anonymous. survey completion did not require registration of unique physician identifiers. all participants were informed about the confidentiality of the data collected, as well as the voluntary nature of the survey. a total of 77 of 128 fellows and 18 of 28 fellowship program directors completed the survey (response rates 64.3% and 60.1%, respectively). among fellows, 32 (41.6%) of them were in the 2 first years of the fellowship. the monthly diagnostic endoscopy volume performed by fellows during the covid-19 outbreak significantly decreased compared to that prior to the pandemic: median: 10 (iqr 2.5-20) vs. 50 (iqr 30-75), p<0.001. as far as fellowship program directors are concerned, they had practiced gastroenterology for 25.8±5 years and had served for 9.8±6 years as fellowship program directors. the demographic characteristics of the participants are shown in table 1 . the majority of fellows conveyed that the covid-19 pandemic would exert a negative impact on their training in gastroenterology overall, while fellowship program directors retained a more conservative attitude: 63 (81.8%) vs. 10 (55.6%), p=0.038, table 2 , questions 1-8. supplementary table 2 summarizes the distribution of answers among both respondent groups according to their baseline demographic characteristics. regarding the overall impact of covid-10 pandemic on gastroenterology training, no difference was detected among fellows (p≥0.205) and program directors (p≥0.188) according to their main demographic characteristics. significantly more trainees in departments with more than 7 fellows expressed their concerns that the lack of protective equipment in the context of the covid-19 pandemic might affect their training compared to departments with <7 fellows (94.7% vs. 65.5%; p=0.029). overall, there were no significant differences between fellows and program directors regarding factors potentially associated with a negative impact on training (p=0.274; fig. 1a ). both groups agreed that the unknown timeframe of measure implementation (87.0% and 83.3%), the cancellation of scheduled endoscopic procedures (83.1% and 66.7%), the reduction of endoscopies performed by fellows (62.3% and 44.4%), the redeployment of fellows in a covid-19 treating department (20.8% and 22.2%) and the reduction of training time in the outpatient clinic (10.4% and 27.8%) were the main factors that could negatively affect fellows' training ( fig. 1a) . however, more fellows than fellowship program directors identified the lack of time due to potential involvement with covid-19 patients, as well as the lack of protective equipment, as additional contributors that negatively affected training: 60 (77.9%) vs. 9 (50%), p=0.036, and 56 (72.7%) vs. 6 (33.3%), p=0.003, respectively. significantly more fellows than fellowship program directors expressed concerns about the negative impact of the pandemic on acquiring/maintaining endoscopy competence: 64 (83.1%) vs. 5 (27.8%), p<0.001. although numerically different, none of the differences between the 2 groups regarding the other specific fields of gastroenterology training were significant (72.7% vs. 55.6%, p=0.167 for training in general gastroenterology, 64.9% vs. 44.4%, p=0.192 for training in inflammatory bowel diseases, and 62.3% vs. 44.4%, p=0.243 for hepatology training, respectively). the rates of negative, neutral and positive answers for each group are given in table 2 , questions 9-12. significantly more fellows than fellowship program directors expected a negative impact of covid-19 outbreak on achieving competence and maintenance of technical skills in endoscopy: 61 (79.2%) vs. 7 (38.9%), p=0.001. this difference between the two groups was also consistent as regards achieving competence in the performance of basic diagnostic and emergency procedures: 54 (70.1%) vs. 4 (22.2%), p<0.001, and 37 (48.1%) vs. 2 (11.1%), p=0.004, respectively. the difference regarding the impact on the cognitive domain of fellows' endoscopy competence did not reach significance: 52 (67.51%) vs. 8 (44.4%), p=0.14, table 2 , questions 13-17. interestingly, statistically significantly more fellows ≤30 years old considered that the covid-19 pandemic would negatively affect their training, in acquiring or maintaining competence in the performance of basic diagnostic endoscopic procedures, compared to their older colleagues: 100% vs. 61.7%; p=0.013 (supplementary table 2 ). as shown in table 2 (questions 18-19) , there was no significant difference among fellows and their program directors regarding the potential impact of the covid-19 pandemic on academic training. interestingly, in both groups half or more of the participants considered that the pandemic would have either a positive or no impact on the fellows' scientific [47 (61%) and 10 (55.6%) for fellows and fellowship program directors, respectively] and academic [44 (57.1%) and 9 (50%), respectively] training. there was a significant difference between fellows and fellowship program directors regarding the optimal way to balance the training decrement in the post-pandemic era. almost half (49.4%) of the fellows proposed prolongation of the training period, while almost half of the program directors (44.4%) favored an increase in the daily workload (p=0.019; fig. 1b ). other options, such as redeployment in another gastroenterology department or participation in online courses were not deemed beneficial by either fellows or fellowship program directors (fig. 1b) . sars-cov-2 outbreak resulted in an unprecedented disruption of gastroenterology specialty training worldwide [8] [9] [10] [11] . the results of this first web-based nationwide survey present valuable data regarding trainees' our survey highlighted the fundamental concern of greek gastroenterology fellows about the overall negative impact on training exerted by the covid-19 pandemic. this newly encountered phenomenon has been at the focal point of other researchers worldwide. while our data were under analysis, 3 similar survey studies were published. specifically, one international study, involving 770 trainees from 63 countries [8] , reported that the pandemic led to restrictions in endoscopic volumes (99%; iqr 85-100% reduction in all procedures) and endoscopy training, with high rates of anxiety and burnout, while a second questionnaire distributed to members of the italian young gastroenterologist and endoscopist association and some european representatives, not including greece [9] , underlined the significant impact of the covid-19 outbreak on gastroenterologists' clinical activity. siau et al [11] , in a survey across the united kingdom (uk), noted a significant reduction in monthly endoscopy volume (p<0.001). it should be noted, however, that each of the abovementioned studies aimed at a different primary outcome and used its own, uniquely designed questionnaire, while the educational characteristics of the participants were not uniform, rendering direct comparisons to our results difficult. it is perhaps even more interesting that, in our study, fellowship program directors believed that a break of some weeks within a 4-year training program might be ultimately associated with only a small decrement in fellows' overall abilities [12] . this is corroborated by the fact that lack of time due to potential involvement with covid-19 patients, as well as the shortage of protective equipment, were identified only by fellows as major contributors that negatively affected the quality of training. a reduction in the volume of endoscopies has been a common finding among all studies that investigated this issue [8] [9] [10] [11] . procedural volume has been inextricably linked to procedural competence [4, 13] ; however, whether the same finding applies to the era of the covid-19 outbreak remains to be seen, since such implications at present time with the pandemic still underway are yet to be defined. similarly to their european colleagues [9] , study participants recognized that deployment in a covid-19 treating department and a reduction in outpatient clinic activities as factors with an adverse impact on training. our study presents for the first time a handful of interesting observations derived from the participants' perspectives of the impact the covid-19 outbreak will have on training in different fields of gastroenterology. although statistical significance was not always reached, the proportion of fellows expressing concerns about the negative impact of the pandemic on endoscopy competence, as well on other specific fields of gastroenterology, surpassed that of the fellowship program directors. for all aspects of endoscopy (technical, diagnostic, emergency), fellows anticipated a statistically significant negative impact on their training, compared to their directors. although short-term training breaks cause minimum disruption to fellows' training [12] , one cannot exclude that a prolonged period of covid-19 measures, together with existing evidence for high rates of anxiety and burnout among gastroenterology fellows [14] , may affect trainees' perception about the impact of the pandemic on their endoscopic skills. on the other hand, directors showed fewer concerns about this matter, perhaps knowing that endoscopic competence needs a significant amount of time and procedural volume to be achieved; thus, the disruption would only be temporary and would not be able to influence training in its entirety. most of the fellows proposed prolongation of the fellowship training program, while fellowship program directors favored an increase in the daily workload. training program prolongation could indeed be a potential measure; however, it is not without concerns (anxiety and burnout) for fellows, as was recently shown in a survey among uk gastroenterology trainees [11] . however, one should not forget that the uk and greek healthcare systems are not directly comparable, since the two countries have not been equally affected by the pandemic. on the other hand, an increased workload further results not only in physical and emotional exhaustion, but also in fellows' perception of inadequate training [14] . gastroenterology fellows ask for modifications of existing guidelines on training [11] , with reforming of training curricula and rearranging of training activities among institutions [15, 16] . although limited, respondents had a positive attitude towards medical education delivery through online teaching and webinars. however, these methods might never replace the "traditional" methods of teaching and endoscopy performance in realworld circumstances. this study had the following strengths. first, it is the first nationwide report to assess the perceptions of trainees and trainers regarding the impact of the covid-19 outbreak on greek gastroenterology fellows' training. second, the examination of fellows' as well as fellowship program directors' perspectives on this important issue is considered a study asset. finally, an equivalent response rate was achieved to those reported previously in similar studies [8, 9] . limitations of this survey include the possibility of results being susceptible to recall and self-report bias, as with all studies of this particular type. moreover, there is no validated instrument or questions; however, the questionnaire was designed based on the existing literature. another limitation associated with the study's cross-sectional character might be considered the fact that these results just reflect a snapshot taken during the acceleration phase of covid-19. although a response rate of 60% could be considered as satisfactory, the fact that 40% of those initially invited did not return the questionnaire cannot not be overlooked. finally, it should be underlined that the covid-19 pandemic and its impact on education represent a dynamic process. accordingly, conclusions should be viewed in the light that they may just reflect temporary and ephemeral opinions of the study's participants. to conclude, greek gastroenterology fellows are convinced that the covid-19 outbreak will have a negative impact on their training, while training program directors are less concerned. accurately identifying training gaps will assist local and international scientific societies to pursue new measures in order to address the educational needs of fellows during and after the covid-19 pandemic. what is already known: • covid-19 has affected endoscopy services provision worldwide • the impact on greek gastroenterology fellows' training has not been evaluated what the new findings are: • fellows and their fellowship program directors do not share the same concerns about the impact of the covid-19 pandemic on training, and they propose different measures than their directors to remedy this situation • the major concern of greek gastroenterology fellows is training in endoscopy assessing participants' perspective regarding the potential impact of the coronavirus (covid-19) outbreak on training please answer the following questions by choosing the most appropriate answer q1 do you think that the covid-19 pandemic will affect your/your fellows' training in gastroenterology, overall? asge's assessment of competency in endoscopy evaluation tools for colonoscopy and egd impact of the covid-19 pandemic on interventional cardiology fellowship training in the new york metropolitan area: a perspective from the united states epicenter a nationwide survey of training satisfaction and employment prospects among greek gastroenterology fellows during the economic recession naspghan training committee covid-19 survey working group. impact of covid-19 on pediatric gastroenterology fellow training in north america impact of covid-19 on endoscopy trainees: an international survey impact of covid-19 outbreak on clinical practice and training of young gastroenterologists: a european survey. dig liver dis the impact of covid-19 on endoscopic training the impact of covid-19 on gastrointestinal endoscopy training in the united kingdom do breaks in gastroenterology fellow endoscopy training result in a decrement in competency in colonoscopy? status of competency-based medical education in endoscopy training: a nationwide survey of us acgme-accredited gastroenterology training programs factors associated with residents' satisfaction with their training as specialists covid-19 and endoscopy training restarting gastrointestinal endoscopy in the deceleration and early recovery phases of covid-19 pandemic: guidance from the british society of gastroenterology covid-19) outbreak: what the department of endoscopy should know the challenges of "continuing medical education" in a pandemic era covid-19 pandemic through the lens of a gastroenterology fellow: looking for the silver lining the authors would like to thank all participants for their contribution to the study. key: cord-326582-qmavade5 authors: owens, michael d.; lloyd, michael l.; brady, tyler m.; gross, robin title: assessment of the angolan (cherrt) mobile laboratory curriculum for disaster and pandemic response date: 2020-04-13 journal: west j emerg med doi: 10.5811/westjem.2020.4.47385 sha: doc_id: 326582 cord_uid: qmavade5 introduction: as of april 5, 2020, the world health organization reported over one million confirmed cases and more than 62,000 confirmed coronavirus (covid-19) deaths affecting 204 countries/regions. the lack of covid-19 testing capacity threatens the ability of both the united states (us) and low middle income countries (lmic) to respond to this growing threat, the purpose of this study was to assess the effectiveness through participant self-assessment of a rapid response team (rrt) mobile laboratory curriculum methods: we conducted a pre and post survey for the purpose of a process improvement assessment in angola, involving 32 individuals. the survey was performed before and after a 14-day training workshop held in luanda, angola, in december 2019. a paired t-test was used to identify any significant change on six 7-point likert scale questions with α< 0.05 (95% confidence interval). results: all six of the questions – 1) “i feel confident managing a real laboratory sample test for ebola or other highly contagious sample;” 2) “i feel safe working in the lab environment during a real scenario;” 3) “i feel as if i can appropriately manage a potentially highly contagious laboratory sample;” 4)“i feel that i can interpret a positive or negative sample during a suspected contagious outbreak;” 5) “i understand basic biobubble/mobile laboratory concepts and procedures;” and 6) “i understand polymerase chain reaction (pcr) principles” – showed statistical significant change pre and post training. additionally, the final two questions – “i can more effectively perform my role/position because of the training i received during this course;” and “this training was valuable” – received high scores on the likert scale. conclusion: this angolan rrt mobile laboratory training curriculum provides the nation of angola with the confidence to rapidly respond and test at the national level a highly infectious contagion in the region and perform on-scene diagnostics. this mobile rrt laboratory provides a mobile and rapid diagnostic resource when epidemic/pandemic resource allocation may need to be prioritized based on confirmed disease prevalence. as of april 5, 2020, the world health organization (who) reported 1,133,758 confirmed cases and 62,784 confirmed coronavirus (covid-19) deaths affecting 204 countries/regions. 1 it is recognized that the lack of covid-19 testing capacity what was the research question? we conducted an assessment of a mobile lab curriculum for disaster and pandemic response based on current models. what was the major finding of the study? this curriculum provided the angola community health emergency rapid response team with the confidence to respond to a disaster/pandemic at the national level. how does this improve population health? rapid and accurate diagnostic confirmation of a public health emergency of international concern using a mobile lab improves response and mitigates further spread of a contagion. threatens the ability of both the united states (us) and low middle income countries (lmic) to respond to this growing threat. 2 for comparison, the 2014 ebola epidemic in western africa (liberia, sierra leone, guinea, and nigeria) infected tens of thousands of individuals and claimed more than 11,000 lives, with a case fatality rate of approximately 60%. 3, 4 there is growing evidence that this current outbreak is more widespread than reported due to the lack of laboratory capacity and resources. 5 this parallels the experiences identified in "after action reports" and lessons learned during the 2014 western africa ebola epidemic. however, covid-19 is now a pandemic affecting multiple lmics and the us whose current laboratory capacity is limited. 2 a mobile laboratory (biobubble, inc., fort collins, co) using genexpert (cepheid inc, sunnyvale, ca) technology to conduct reverse transcription polymerase chain reaction (rt-pcr) was deployed during the 2014 west africa ebola outbreak and again in the 2017 democratic republic of congo (drc) ebola outbreak. 6 this field-deployable diagnostic tool provided results in as little as 90 minutes. rt-pcr is a laboratory technique combining reverse transcription of ribonucleic acid to deoxyribonucleic acid (dna) and the amplification of diseasespecific dna targets using the polymerase chain reaction (pcr). in acute respiratory infections, rt-pcr is used to detect viruses from respiratory secretions. the use of this technology to develop a simple, rapid, and robust detection capability with minimal training and lab experience or infrastructure has been demonstrated during previous international health emergencies such as severe acute respiratory syndrome (sars). 5 on march 21, 2020, it was reported that the us federal drug administration approved the first rapid point-of-care covid-19 test capable of delivering results in under an hour. 7 this test kit involves taking a nasopharyngeal swab and can be done in an office, clinic, or a mobile lab in about 45 minutes. administering the test does not require any specialty training other than what was provided within the curriculum, and the lab is capable of running 24 hours a day/seven days a week. this current global outbreak presents challenges to local, regional, and national medical communities to mitigate the current pandemic. a global response involving logistical, epidemiological, public health, and medical interventions may slow and contain the further spread of this contagion. employing a mobile lab with biocontainment capability and a rapid, automated diagnostic test in regions where on-site diagnostics may be of benefit allows for a focused response and resource distribution by rapidly identifying positive cases. one of the mitigation and response strategies learned during the 2014 ebola epidemic includes rapid response teams that are trained, prepared, and mobilized immediately when a suspect case is identified. a strategy of rapid isolation and treatment of ebola using the liberia ministry of health and social welfare (mohsw), supported by the us centers for disease control and prevention (cdc), who, and other agencies in liberia began to respond systematically to suspected cases in remote areas in august 2014. 3 this rapid response concept, when instituted in later outbreaks, was one of the factors that helped contain the ebola virus disease (evd) outbreak in the drc in may 2017. teams that are competently and confidently trained in rt-pcr, personal protective equipment (ppe) protocols, and mobile laboratory capabilities provide a valuable resource by confirming cases quickly and efficiently. follow-up interventions are then deployed in a manner such that treatment, isolation/quarantine efforts, and other response and mitigation efforts are more effective and focused. the nation of angola, due to its proximity to evd-endemic areas and its own experiences with marburg and 2017 yellow fever epidemics, created a community health emergency rapid response team (cherrt) sponsored by the national military and ministry of health (moh). these angolan rrt members were trained for two weeks in december 2019 by the us navy and experts from the national institutes of health (nih). the first week of training included tabletop scenarios, individual breakout sessions, didactic lectures, hands-on training with equipment and ppe, and patient scenarios. the second week of training focused on rt-pcr, laboratory techniques, diagnostics, and use of the mobile lab and rapid diagnostic on-site testing. a pre-and post-training survey was completed by the participants, to include self-assessments of their perceived ability to perform rt-pcr diagnostics and work with the mobile lab. owens et al. the purpose of this study was to assess the effectiveness through participant self-assessment of a rrt mobile lab curriculum based on the who ebola virus disease consolidated preparedness checklist, revision 1 8 and the mobile lab training curriculum developed by the nih. using a pre-post confidential questionnaire with eight 7-point scale likert questions and an open-ended comments section, we assessed the impact of the training curriculum on each participant's self-perceived ability to perform his/her duties. this pre-post study was conducted in luanda, angola. a conference room providing space for presentations, breakout sessions, and simulation were used during the two weeks of training in the hospital. three native portuguese speakers provided direct interpretation when needed during the two weeks of training. all educational materials including presentations were translated by native portuguese speakers prior to the event. the planning team from the angolan military and us navy met prior to the event and used previous curriculums to establish the training topics, activities, and schedule for this specific program. a survey was provided to the 32 study participants before the initiation of training and immediately upon completion of the training. the pre-event survey included six likert-scale questions assessing the individuals' perceived ability to work and manage a real sample in a contagious environment and interpret the results. the post-survey questionnaire included these same six questions, two additional likert-scale questions assessing the overall effectiveness of the training, and a ninth open-ended question requesting comments for needed additional training. the study design used sqire 2.0 guidelines for quality improvement reporting. 9 the study received a waiver from the institutional review board. a total of 32 angolan classroom participants completed the course and the surveys. chosen by the forças armadas angolanas (faa) and the angolan moh, the participants were a mixture of civilian and military physicians, nurses, social workers, and lab technicians. this program was sponsored by the us africa command (us africom). a pre-course survey was provided to the 32 study participants before the initiation of training and immediately upon completion of the training. the pre-intervention survey included six likert-scale questions assessing their perceived ability to handle and manage a real sample in a contagious environment, and independently interpret the results. the first week's training (december 2-6, 2019) covered topics and training that the planning teams identified as high-yield prior to the training to include public health, disaster response, donning/doffing of ppe, and patient and ebola treatment unit protocols. the second week of training (december 9-13, 2019) focused on lab concepts that included the following: basic lab skills; lab safety, setup and use of the mobile lab; and rt-pcr skills. the majority of the participants had little to no prior experience with this equipment prior to the cherrt training. the post-intervention questionnaire included the same six pre-intervention questions, two additional likert-scale questions assessing the overall effectiveness of the training, and a final ninth question requesting comments for needed additional training ( table 1) . the primary outcome was the calculated change in the six likert-scored questions asked before and after the training assessing self-perceived competence and ability to perform their respective duties on the team. these six questions were provided on an anonymous form in portuguese using a 7-point likert scale ranging from "1," designated as strongly disagree, to "7," designated as strongly agree. translators were available in portuguese to assist with questions on the survey. the participants were instructed to circle one number from one to seven for each of the likert-scale questions. each participant was given a unique identifier allowing for anonymity and pairing analysis. the survey abstractors were not blinded to the study hypothesis. secondary outcomes included the two additional likert-scale questions assessing overall effectiveness of the training and a final, open-ended comment section eliciting recommendations for additional training that the respondent felt was needed or desired. the two additional post-intervention questions used the same 7-point likert scale as the pre-intervention assessment, allowing for consistency. the completed survey data was entered into microsoft office excel 2007 (microsoft corp, redmond, wa). we calculated means and standard deviations (sd) for each of the six pre-and post-intervention questions that were repeated on the surveys for comparison, and the two questions that were only asked on the post-intervention questionnaire. the comments elicited from the final question were translated into english by a professional translator identified by the us armed forces team. using the unique identifiers, we compared the six repeated pre-and postself-assessment questions using a paired t-test. means, sds, 95% confidence intervals (ci), and two-tailed p values were calculated for each of the six questions. we also calculated means and sds for the two unique post-intervention questions regarding participants' assessment of the training program. a total of 32 pre-intervention and 27 post-intervention questionnaires were completed. five individuals did not participate during the last day of the program that included ceremonial activities and completion of the survey. these five individuals were considered lost to follow-up. the pre-and postintervention surveys were paired using the unique identifiers. assessment of cherrt mobile lab curriculum for disaster and pandemic response all six of the questions -1) "i feel confident managing a real laboratory sample test for ebola or other highly contagious sample" (95% ci, -3.53 to -1.65; p=<0.0001); 2) "i feel safe working in the lab environment during a real scenario" (95% ci, -3.64 to -1.59; p=<0.0001); 3) "i feel as if i can appropriately manage a potentially highly contagious laboratory sample" (95% ci, -3.90 to -2.17; p=<0.0001); 4) "i feel that i can interpret a positive or negative sample during a suspected contagious outbreak" (95% ci, -2.12 to -0.40; p=0.006), 5) "i understand basic biobubble/mobile laboratory concepts and procedures"(95% ci, -4.69 to -0.79; p=<0.0001); and 6) "i understand pcr principles" (95% ci, -3.17 to -1.31; p=<0.0001) -showed statistically significant change pre and post training ( table 1 ). the course participants scored highly on the final two post-training questions -"i can more effectively perform my role/position because of the training i received during this course" (6.74), and "this training was valuable" (7.00). the participants were provided a final open-ended question: "what additional training is needed or desired?" comments from this question included requests for more hands-on time, epidemiology, prehospital and general patient transport, additional disease review, more frequent training for skill and knowledge maintenance, additional statistics on disease impact, and organizational communication. as of march 5, 2020, who reported 1,133,758 confirmed cases and 62,784 confirmed coronavirus (covid-19) deaths affecting 204 countries/regions. 1 drawing parallels to the west african ebola outbreak in 2014 that infected over 20,000 individuals resulting in approximately 11,000 deaths, 4,9 the ebola outbreak provides many lessons for future epidemics/ pandemics, such as the current covid-19 outbreak. these lessons learned include a need for increased surveillance, more effective ecological health interventions, expanded prediction modeling and improved risk communication, as well as improved diagnostic tools, medications and vaccines, and local and global response. 10 interventions created and employed around the world to respond to highly infectious disease outbreaks include rrts and a mobile lab for rapid, on-scene diagnostics. the angolan rrt is trained to respond to an infection of public concern as well as larger concepts of disaster response and management that will help contain the spread of any potentially infectious disease outbreak. the nation of angola with the assistance of the us armed forces identified 32 individuals of various specialties with a focus on lab personnel for this annual cherrt training. the who evd consolidated preparedness checklist, revision 1, 8 identifies 11 key components requiring minimal resources, and was used as a baseline for the training competencies. these competencies were supplemented with protocols, checklists, standard operating procedures (sop), and instructor experiences. the team's training on these concepts as assessed by the pre-and post-course intervention showed statistically significant changes in all six categories. these scores of self-perceived improved abilities, knowledge, and confidence provide evidence that this type of training improves personnel's perception in the team's ability to respond based on the training experience. for covid-19, as of march 2020 the lab capacity in the question pre-course mean ± sd (n = 32) post-course mean ± sd (n =27) p-value us did not meet the need for diagnostics testing even after the entry of commercial lab companies such as laboratory corporation of america holdings and quest diagnostic. 11 improving lab capacity is important in assessing the extent of the outbreak in the us as well as in lmics on the continent of africa, which has limited diagnostic resources. the mobile lab is one such resource that is readily deployable, cost effective, and provides a safe containment platform for rapid on-scene diagnostic capabilities. the sampling and testing methods are not dependent on shipping the samples to a reference lab, thus speeding up diagnostic turnaround in lmics or regions of the world that lack such labs. the current pandemic has identified an additional gap with regard to labs. it seems that even when labs are available, they can be quickly overwhelmed by the increased number of samples. this proposed model could be easily implemented with confidence and minimal training based on accepted protocols and past experience. working in highly contagious and volatile environments requires confidence in one's abilities as well as knowledge of the situation and environment (situational awareness). this confidence translates to an awareness of the environment inside a soft-walled lab with biocontainment capability, reducing the risk of cross-contamination of samples and/or spillage. formal training based on lessons learned, consensus protocols and checklists, and provider experience provide a foundation for adequately trained teams that can effectively intervene and contain a global outbreak. a long-term follow-up of the participants' abilities, as well as an assessment of each future activation, may further strengthen the perceived benefits of this training curriculum. the pre and post assessments, survey statements, participants' comments, and national/regional priorities provide the material for continued adjustments on curriculum development and implementation. there are several limitations to this study. first, we often had to use materials translated from english to portuguese. native portuguese speakers from the us armed forces were used for translation of instructional materials, surveys, and presentations when needed for clarification. additionally, some of the participants took part in prior disaster training and/or ebola workshops three years prior to this intervention. this earlier training was provided by the lead instructor; therefore, some program participants already had some baseline knowledge of the presented material. to that extent, in preparation for the final workshop, the rrt conducted some of its own training prior to the engagement. the survey focused on the specific training event; however, prior training or lab experience by some individuals could potentially have contributed to the relatively higher scores on the pre-intervention questions that did not achieve significance. the team was hand-picked by the moh and the military, allowing for potential selection bias for better trained and educated personnel. additionally, the survey abstractors were not blinded to the study hypothesis. the assessments are based on self-reported competence and ability after the training and simulations and do not reflect actual events. finally, this study's limitations include those inherent to any pre-and postintervention survey methodology. this angolan cherrt training curriculum based on who guidelines, after action reports, a nih standard mobile lab curriculum, and internationally accepted standard operating procedures, provides the nation of angola with the confidence to rapidly respond at the national level to a highly infectious contagion in the region and perform onsite mobile lab diagnostics. this mobile rrt laboratory provides a potential rapid diagnostic resource when epidemic/pandemic resource allocation may need to be prioritized based on confirmed disease prevalence. exclusive: u.s. coronavirus testing threatened by shortage of critical lab materials update: ebola virus disease epidemic -west africa lessons from the ebola outbreak: action items for emerging infectious disease preparedness and response detection of 2019 novel coronavirus (2019-ncov) by real-time rt-pcr new technology allows for rapid diagnosis of ebola in the democratic republic of congo. world health organization npr: the coronavirus crises world health organization preparedness_14_eng.pdf?sequence=1. accessed squire 2.0 (standards for quality improvement reporting excellence): revised publication guidelines from a detailed consensus process world health organization. who declares an end to the ebola outbreak in the democratic republic of congo despite entry of large private labs, coronavirus tests remain scarce in u key: cord-256960-57syyb9n authors: girardi, michele; casolo, andrea; nuccio, stefano; gattoni, chiara; capelli, carlo title: detraining effects prevention: a new rising challenge for athletes date: 2020-10-15 journal: front physiol doi: 10.3389/fphys.2020.588784 sha: doc_id: 256960 cord_uid: 57syyb9n nan the newly discovered coronavirus (sars-cov-2) has caused an infectious disease of pandemic proportion called coronavirus 2019 disease . the absence of an effective vaccine for the covid-19 disease has led many national and international authorities to take some prompt strict measurements to reduce the risk of infection, including closing non-essential activities and forcing individuals to stay at home. accordingly, several sport events have been canceled and/or postponed and, hundreds of thousands of amateur and professional athletes worldwide have abruptly been forced to train at home. as a consequence, athletes had to face an unprecedented and relatively long-term reduction or cessation in their training routine along with a substantial cutting of their physical daily activities. such changes may result in a significant decay of the quantity and worsening of the quality of training stimuli, making athletes exposed to some potential levels of detraining (i.e., "partial or complete loss of training-induced anatomical, physiological and performance adaptations"; mujika and padilla, 2000b) and to increased risks of injury. thus, sport scientists, coaches and exercise physiologists worldwide had to deal with a novel challenge consisting in how to minimize potential detraining effects induced by home confinement. detraining prevention can be defined as a set of physical training strategies aimed at limiting and/or counteracting detraining effects. the prevention of detraining processes is a fairly new concept, which so far has mainly been addressed in the field of occupational physiology. for instance, a large body of literature has focused on understanding strategies used to counteract detraining processes associated with prolonged exposure to microgravity in astronauts (hargens et al., 2013; hackney et al., 2015) . some studies have also investigated the effects of reduced training stimuli on physical performance in athletes (neufer, 1989; rietjens et al., 2001; garcía-pallarés et al., 2009 ormsbee and arciero, 2012; joo, 2018) . however, these are limited and controversial and they can only provide indirect information on detraining prevention strategies. for example, whereas 21 days of training-stimuli reduction (continuous and intermittent endurance training, 3 days/week) seem to counteract detraining effects (rietjens et al., 2001) , impairments on endurance performance, resting metabolic rate, body weight and composition have been found following 35-42 days of light-moderate exercise (<6.0 mets, 3 days/week) (ormsbee and arciero, 2012) . moreover, the training strategies used in these studies are often non-compatible with homebased-training settings as athletes might not have easy access to specific tools/equipment and sport facilities. yet, the most effective training frequency, volume and intensity as well as exercise modalities to use for preventing detraining are still unknown. therefore, considering the lack of a covid-19 vaccine and the possibility that similar home-confinement scenarios would present again, identifying the most effective strategies to minimize detraining effects represents a current priority. to help with this purpose, this brief report illustrates the potential morphological, physiological and functional changes induced by home-confinement. additionally, specific issues associated with injured athletes have also been discussed. to identify an optimal detraining prevention strategy, it is important to determine the main detraining-induced morphological, physiological, and functional adaptations. training cessation leads to changes in vo 2max during both short-(≤4 weeks) and long-term (≥4 weeks) periods (mujika and padilla, 2000a,b) . reductions in vo 2max seem to be progressive and proportional to individuals' fitness level (mujika and padilla, 2000a,b) . however, although the vo 2max magnitude is often considered an indirect marker of endurance capacity, its changes may not directly be correlated to endurance performance alterations. for example, it has been found that expansions in blood volume can partially reestablish vo 2max losses following a period of training cessation; nonetheless, this manipulation was not able to compensate for endurance performance decrements . moreover, 4 weeks of training cessation have been shown to decrease performance during a time to exhaustion test (tte) without affecting vo 2max in well-trained endurance athletes (madsen et al., 1993; pedlar et al., 2018) . impairments in endurance performance have also been found during 12-35 days of training cessation in both running and cycling incremental tests houmard et al., 1992 houmard et al., , 1993 , a yo-yo intermittent-test (joo, 2018) , a 3,000-m running time trial (pereira et al., 2016 ) and a cycling tte (madsen et al., 1993) . at the muscle level, the relatively short half-life of mitochondrial proteins (∼1 week) (hood, 2001 ) may cause decrements in mitochondrial function and capacity after a short period of training cessation. in line with this, decrements in muscle oxidative capacity (coyle et al., 1985; gjøvaag and dahl, 2008) and reductions in mitochondrial enzyme activities (coyle et al., 1985; wibom et al., 1992) have been found after few days/weeks of training cessation. non-systematic changes have been observed in glycolytic enzymes quantity and activity (mujika and padilla, 2001) whereas, reductions in muscle capillary density have been reported after 4-8 weeks of training cessation (klausen et al., 1981) . training stimuli cessation and the consequent decline in plasma volume, which may occur after 2 days of inactivity (thompson et al., 1984; cullinane et al., 1986) , lead to a reduced cardiac preload, which in turn triggers a series of rapid morphological and functional cardiac remodeling (martin et al., 1986; spence et al., 2011; pedlar et al., 2018) . in line with this, impairments in maximal cardiac output (q max ) have been found after 12 days of inactivity due to a 10% decrement in exercise stroke volume and 4% increment in maximal heart rate (coyle et al., 1984) . similar results have also been observed following a period of training cessation and headdown tilt bed rest during both maximal (coyle et al., 1984; pedlar et al., 2018) and submaximal exercise capelli et al., 2008) . such reductions in q max are critical as they may highly contribute in declining the maximal oxygen delivery capacity. training cessation can also markedly affect the volitional force-generating capacity of human skeletal muscles, which is the result of an interplay of neural and morphological factors including muscle cross-sectional area, muscle architecture, muscle fiber type, tendon properties and neural drive to the spinal-motor pool (bosquet et al., 2013) . it has been reported that all these physiological factors involved in volitional forcegeneration mechanisms can be affected by 8-12 weeks of training cessation, with maximal muscle force decrements predominantly caused by neural alterations in the initial weeks of training cessation and by morphological ones when the period of inactivity exceeds several weeks (bosquet et al., 2013) . for instance, a significant decline in maximal isometric force (∼7.5%) in subjects accustomed to strength training has been found after 8 weeks of training stoppage. interestingly, this force decrement was coupled with decreases (∼5-12%) in maximal electromyographic activity reflecting a precocious reduction of muscle activation (häkkinen and komi, 1983) . in another study from the same group, marked declines in strength performance (∼12%) were accompanied by a reduction in the ft/st muscle fiber area ratio (from 1.11 to 1.04), likely as a result of a tendency toward higher oxidative muscle fiber populations, as well as by a reduction of muscle mass after 8 weeks of training cessation, i.e., muscle atrophy (häkkinen et al., 1981) . longer periods of detraining (12 weeks) were also accompanied by substantial decreases of the mean muscle fiber areas of both fiber types (häkkinen et al., 1985) . in line with these studies, muscle atrophy and other detraininginduced morphological changes in muscle fiber distribution and architecture (coyle, 1988) and/or ft cross-sectional area (bangsbo and mizuno, 1988; allen, 1989; amigó et al., 1998) have been consistently reported in more recent investigations for athletes of different disciplines such as endurance runners, cyclists, soccer and rugby players, following 3-8 weeks of training cessation. conversely, despite novel evidences have arisen from bed rest studies showing that chronic inactivity induces muscle denervation and damage to the neuromuscular junction (narici et al., 2020) , the understanding of trainingcessation-induced neural changes, particularly at the single motor unit level is still limited. moreover, prolonged exposure to mechanical unloading may also cause impairments in tendon structures and properties (frizziero et al., 2016) as well as at the soft-tissue level (e.g., articular capsule, cartilage, ligaments, synovium). specifically, compromised tendon reactions to a load application (frizziero et al., 2016; paoli and musumeci, 2020) and a dramatic decrement in cartilage lubrication and nutrition (castrogiovanni et al., 2019) in response to inactivity have been recently documented. taken together, the rate at which these morphological and physiological remodeling adaptations occur underlines the importance of movement and exercise to preserve not only the integrity of the muscles, but also of the neural circuits upstream, tendons and joint structures in situations of reduced-training stimuli and mechanical unloading, such as the covid-19 home confinement. regaining a pre-detraining status is also essential for athletes. as effective training programs do, reconditioning training programs also need to match training principles (garber et al., 2011) . the time required to recover pre-detraining neuromuscular and cardiorespiratory levels may highly vary among athletes on the base of several factors, including time of training stimuli cessation or reduction, amount of individual detraining-induced effects, individual fitness levels and sportspecific requirements. for instance, following 20 days of bed rest, vo 2max , q max , blood plasma volume and heart volume values were recovered after a reconditioning training program ranging from few days to 55 days, where longer periods seem to be required for trained compared to untrained individuals (saltin et al., 1968) . while cardiovascular values may recover in few days (saltin et al., 1968) , longer training periods might be required to regain pre-detraining levels of muscle oxidative capacity and function (skattebo et al., 2020) . due to the heterogeneity effects of detraining and training, it is extremely important to perform a battery of sport-specific tests aimed at evaluating the individual detraining status for planning an effective and safer return to sport activities. sports-specific tests should also be performed to check the efficacy of the reconditioning training program. importantly, all the stakeholders (e.g., coaches, athletes and medical staff) need to be involved for planning effective and safer reconditioning training programs before, during and after the process itself. a particular case that undoubtedly needs to be considered is the injured athlete in both early and latest rehabilitation and reconditioning stages. in such specific population, the focus of a detraining prevention program shifts from the pursuit of counteracting detraining effects, to the pursuit of finding the best home-based recovery strategy. indeed, in addition to the potential morphological and physiological detraining effects due to the covid-19 home confinement, injured athletes might also struggle against detrimental effects associated with the injury itself and with a potential insufficient and/or inappropriate home-based rehabilitation and reconditioning. although no clear evidence has been provided on this topic, the scientific community suggests insufficient and/or inappropriate rehabilitation and reconditioning stimuli as the main determinants of injury recurrence (kyritsis et al., 2016) . this is particularly relevant for those athletes who suffered from musculoskeletal injuries and needed to readapt either damaged soft-tissues or muscles to loading through a proper neuromuscular rehabilitation. injured athletes at their very early stages of rehabilitation may need special attention. the unpredicted closure of sport therapy clinics worldwide could indeed have prevented athletes from optimally tackle the initial impairments related to a musculoskeletal injury. for instance, athletes with reconstructed anterior cruciate ligament would experience an initial inflammatory process on the knee with related pain and swelling, which in turn would cause a substantial inhibition of the quadriceps muscle and an associated dramatic deficit in muscle strength (rice and mcnair, 2010) . with the aim of reducing pain and re-establishing knee joint homeostasis, clinicians and health professionals typically strive to fix these issues immediately after surgery and thereby to ensure a progressive joint loading and muscles strength reconditioning in the following stages (dingenen and gokeler, 2017) . the impossibility to go through these fundamental steps and the absence of adequate professional support, may delay the recovery process and cause long-term problems (e.g., impaired quadriceps function, neuromechanical alterations and compensation strategies) which, in turn, may prevent athletes from returning to their pre-injury physical conditions, and increase the risk of a second knee injury (hewett et al., 2013) . similarly, also injured athletes in the latest rehabilitation phases would delay their return to sport. this happens because of the impossibility to provide adequate training stimuli aimed at re-gaining sport-specific fitness levels (buckthorpe, 2019) . for all these reasons, the adoption of proper home-based training protocols is pivotal to avoid a delayed or unsafe return to sport. however, recommending potential detraining prevention strategies for injured athletes is extremely challenging as they may vary according to the type and time of injury, individual responses to injury and different external factors (e.g., home setting and equipment availability). the covid-19 pandemic and the consequent forced home confinement have risen a new challenge in the field of sport and exercise sciences, which consists in how to limit and counteract detraining effects among athletes. training cessation has been shown to negatively affect physical human performance, but very little is known about the effects of training stimuli reduction. moreover, exceptional situations such as in the case of the covid-19 enforced quarantine might lead to inadequate rehabilitation and reconditioning programs in injured athletes, which in turn might be translated in a delayed and/or unsafe return to sport. however, researchers have never considered the need of investigating detraining effects prevention yet. considering the current lack of a covid-19 vaccine, the strict rules that several countries worldwide are still adopting to stop this pandemic, and the possibility that similar extreme situations would present again, future research in this field is certainly required. mg, ac, sn, cg, and cc contributed to conception and design of the study. mg wrote the first draft of the manuscript. ac, sn, and cg wrote sections of the manuscript. all authors approved the final version of the manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. all persons designated as authors qualify for authorship, and all those who qualify for authorship are listed. we acknowledge the support of the open access publishing fund of the university of verona. physiological and metabolic changes with six weeks detraining effect of summer intermission on skeletal muscle of adolescent soccer players morphological and metabolic alterations in soccer players with detraining and retraining and their relation to performance effect of training cessation on muscular performance: a meta-analysis. scand optimising the late-stage rehabilitation and return-tosport training and testing process after acl reconstruction metabolic and cardiovascular responses during sub-maximal exercise in humans after 14 days of head-down tilt bed rest and inactivity moderate physical activity as a prevention method for knee osteoarthritis and the role of synoviocytes as biological key detraining and retention of training-induced adaptations, " in resource manual for guidelines for exercise testing and prescription effects of 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optimizing human performance in space changes in isometric force-and relaxation-time, electromyographic and muscle fibre characteristics of human skeletal muscle during strength training and detraining electromyographic changes during strength training and detraining effect of combined concentric and eccentric strength training and detraining on force-time, muscle fiber and metabolic characteristics of leg extensor muscles space physiology vi: exercise, artificial gravity, and countermeasure development for prolonged space flight current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction invited review: contractile activity-induced mitochondrial biogenesis in skeletal muscle effect of short-term training cessation on performance measures in distance runners training cessation does not alter glut-4 protein levels in human skeletal muscle the effects of short term detraining and retraining on physical fitness in elite soccer players adaptive changes in work capacity, skeletal muscle capillarization and enzyme levels during training and detraining likelihood of acl graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture effects of detraining on endurance capacity and metabolic changes during prolonged exhaustive exercise effects of physical deconditioning after intense endurance training on left ventricular dimensions and stroke volume detraining: loss of training-induced physiological and performance adaptations detraining: loss of training-induced physiological and performance adaptations muscular characteristics of detraining in humans impact of sedentarism due to the covid-19 home confinement on neuromuscular, cardiovascular and metabolic health: physiological and pathophysiological implications and recommendations for physical and nutritional countermeasures the effect of detraining and reduced training on the physiological adaptations to aerobic exercise training detraining increases body fat and weight and decreases vo 2peak and metabolic rate elite athletes and covid-19 lockdown: future health concerns for an entire sector cardiovascular response to prescribed detraining among recreational athletes the impact of detraining on cardiac autonomic function and specific endurance and muscle power performances of high-level endurance runners quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives a reduction in training volume and intensity for 21 days does not impair performance in cyclists response to exercise after bed rest and after training increased oxygen extraction and mitochondrial protein expression after small muscle mass endurance training. scand a prospective randomised longitudinal mri study of left ventricular adaptation to endurance and resistance exercise training in humans the effects of caloric restriction or exercise cessation on the serum lipid and lipoprotein concentrations of endurance athletes adaptation of mitochondrial atp production in human skeletal muscle to endurance training and detraining 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.copyright © 2020 girardi, casolo, nuccio, gattoni and capelli. this is an openaccess article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-030600-0o7xafqz authors: fonseka, t; ellis, r; salem, h; brennan, pa; terry, t title: the effects of covid-19 on training within urology: lessons learned in virtual learning, human factors, non-technical skills and reflective practice date: 2020-08-17 journal: j clin urol doi: 10.1177/2051415820950109 sha: doc_id: 30600 cord_uid: 0o7xafqz the covid-19 pandemic has changed training and recruitment in urology in unprecedented ways. as efforts are made to ensure trainees can continue to progress, lessons can be learned to improve training and urological practice even after the acute phase of the pandemic is over. novel methods of education through virtual learning have burgeoned amidst the social distancing the pandemic has brought. the importance of training in human factors and non-technical skills has also been brought to the fore while operating under the constraints of personal protective equipment and working in new teams and unfamiliar environments. this paper critically appraises the available evidence of how urological training has been affected by covid-19 and the lessons we have learned and continue to learn going forward. level of evidence: not applicable. covid-19 has had a profound effect globally as well as on uk health services, with urology being no exception. service delivery has required extensive re-configuration with large-scale cancellation of elective operating and a vast reduction in face-to-face clinics. the pandemic has caused uncertainty amongst trainees, with considerable changes being made to training and national recruitment as well as the membership (mrcs) and fellowship (frcs) of the royal college of surgeons examinations required to progress in surgery and to gain a certificate of completion of training (cct). however, amongst the challenges this pandemic has caused, lessons have been and continue to be learned for the benefit of urological training. certainly, virtual learning has come to the fore in ways never seen previously. furthermore, operating in the challenging environment of covid-19 has also highlighted the impact of human factors (hf) and non-technical skills training, especially in reducing medical error. in this paper we critically appraise the current available evidence on changes to training and recruitment within urology during the pandemic and the effects this has had on the workforce. we discuss the value of virtual learning, the importance of hf, non-technical skills training and reflective practice. for those already in urology training the abrupt reduction in elective operating and outpatient clinics has drastically limited training opportunities within the specialty. amparore et al. 1 have described italian urology trainees experiencing similar on-call responsibilities but noted a significant reduction in exposure to outpatient visits, diagnostic procedures and surgery including endoscopic, open and minimally invasive procedures. during the pandemic the proportion of trainees who experienced severe reduction (>40%) or complete suppression (>80%) of exposure ranged from 41.1% to 81.2% for clinical activity and from 44.2% to 62.1% for surgical activity. at our institution the experience has been similar, with the vast majority of outpatient appointments converted to telephone clinics, mostly conducted by consultants. all elective operations were initially postponed unless considered high priority, such as obstructing stone disease or certain high-grade cancers. much of the emergency operating has also been conducted by consultants rather than registrars so as to minimise time in theatre, as per guidance issued by the royal college of surgeons (rcs). this has understandably caused considerable impairment to training. given the recent curriculum changes towards a more competencybased system, it is conceivable that the reduction in operating opportunities may result in training extensions for some trainees. however, one advantage of this new curriculum is that if a trainee has already met the required competencies, they are unlikely to be delayed in achieving their cct despite the reduction in elective work. with the large-scale changes to operative and clinical practice, one may argue that managing patients within the covid-19 pandemic can also present new and unforeseen training opportunities; for example, the ability to learn skills in crisis management, healthcare management and leadership skills. this has potential to result in more wellrounded trainees who have developed in a range of different aspects of practice. yet, there is no denying that many trainees would have experienced difficulty in achieving expected competencies at annual review of competency progression (arcp). accordingly, the joint committee on surgical training (jcst) have responded by creating a 'no fault' outcome to arcp, known as 'outcome 10', 2 whereby trainees who have been unable to meet training level requirements can have their training extended or be permitted to progress despite not all competencies being achieved in time. for example, for core trainees under normal circumstances achieving mrcs is a pre-requisite to gaining a place on st3 training. yet due to covid-19, the mrcs part b exam has not been conducted and therefore core trainees who have gained a place on st3 training but have been unable to achieve mrcs can still be allowed to continue to st3 and sit the mrcs part b exam when it is next available. in this way arcp outcomes have been adapted to account for the changes in competencies. for junior doctors applying to uk urology training through national selection, the face-to-face interview component of the recruitment process has been removed completely, with applicants scored solely on online self-assessment. 3 applicants go through a series of questions online pertaining to different areas of practice including quality improvement projects, presentations, publications, courses, teaching experience, surgical logbook, prizes and leadership roles, and score themselves in each category. therefore, as there is no face-to-face interview, be it in person or virtually, there is no formal way of assessing key components such as communication, technical operative skills, and portfolio review. there is little evidence of the validity of using solely self-assessment as a selection method and the limitations of self-assessment have been well documented. 4 only time will tell the impact of removing the interview process from national selection. recent studies have validated the use of alternative selection methods including mrcs pass scores, which may reduce the need for face-to-face aspects of selection in future years. 5 core surgical trainees will undoubtedly experience difficulties in gaining exposure to emergency and elective urology over the next few months due to reduced clinical activity and the redeployment of many to staff wards occupied mostly by patients with covid-19. with such disruption to core training programmes this gap in experience and opportunity may need to be taken into account in future st3 national selection processes in order to ensure a fair and non-discriminatory process. foundation doctors may find themselves in a similar position when applying for run-through st1 posts next year with little experience or exposure to urology. at medical student level, almost all clinical attachments have been cancelled, which will likely have profound effects on recruitment to urology in the future. 6 urology is a unique specialty that is often under-represented in medical school curricula; in the usa only 5% of medical schools have a mandatory urology rotation. it is possible that without urology exposure, students will be less inclined to choose it as their preferred specialty, which could further adversely affect competition rates at national selection, which have been steadily declining in recent years. 7 before the pandemic there was arguably already a relative lack of undergraduate training in urology, 8, 9 with many junior doctors feeling a lack of confidence in performing basic urological clinical skills such as catheterisation. [10] [11] [12] the current reduction in exposure to urology at medical student level may exacerbate this lack in training. delaying recruitment and allowing students time to complete urology placements may be the best way forward. remote training opportunities provided by royal colleges and medical associations should be taken advantage of by students and prospective surgeons. these opportunities may have unforeseen benefits, such as reducing the exorbitant costs of mandatory face-to-face training courses, potentially widening access to surgical training programmes. 13 telemedicine and the use of technology can be of great benefit in maintaining training during a pandemic. in the usa, vargo et al. 14 have created a structured framework through the use of virtual learning to continue urology training despite lower surgical volumes and the inability to have face-to-face meetings during the pandemic. the team used online platforms to provide an educational activity for each week day. these activities included discussing american urological association updates, holding a virtual journal club, having a guest virtual lecture, discussing interesting cases and going over a chapter of campbell's urology textbook. 15 the authors found this framework worked well to provide an element of normalcy in a time of great uncertainty for trainees while maintaining mental sharpness. simulation training can also be beneficial at a time when hands-on training is limited. urology has been a leading specialty in the use of simulation devices, particularly for education in minimally invasive surgery. 16 a range of simulation models exist even for use at home, such as with the lower fidelity box trainers. 17 though many are still in the experimental stage requiring more robust validity studies to demonstrate transferability of skills, box trainers are relatively simple to create at home and, in conjunction with virtual learning platforms, could be incorporated into a curriculum. 18 especially for the more senior trainees who would not want to lose operative skills gained through years of practice, simulation can help maintain these competencies for progression towards cct. 19 the jcst have published a statement discussing the importance of continuing professional development throughout the covid-19 crisis. 20 opportunities for training and development are abundant as the medical community continues to learn how to manage patients with covid-19. table 1 summarises key online resources related to health and wellbeing, personal protective equipment (ppe) and adapting practice during the covid-19 pandemic. royal colleges are providing free webinars to all healthcare professionals on a weekly basis sharing knowledge, discussing new evidence regarding covid-19, changes to services, and revision of intensive care principles, physiology and pharmacotherapy. [21] [22] [23] [24] novel techniques for remote teaching such as videoconferencing are being utilised by such organisations as the baus section of trainees and the royal society of medicine urology section to minimise the interruption to our training. these resources have been made free to trainees, and include mock viva examination questions to help with preparation for the urology frcs examinations. from this crisis has emerged a new way of training tomorrow's surgeons and sharing experience that hopefully will continue after the nationwide lockdown has ended. with videoconferencing technology so readily available, we feel that geographical barriers to learning should become a thing of the past. as a workforce we are becoming more aware of the impact of hf in medical error. 25 while we cannot compare aviation with medicine, many lessons have been learned from the airline industry and others who have implemented hf awareness and training, following the realisation that 70% of fatal plane crashes were due to human error, not technical faults. a large recently published systematic review and meta-analysis of 337,000 patients found that one in every 20 hospital admissions resulted in a medical error, 26 with the majority occurring in either surgery or prescribing. 27, 28 one in 300 of these results in death. 29 with such high stakes we have a duty to minimise risks as much as possible for our patients. we spend years honing clinical and technical skills in surgery to improve our patient outcomes, but often very little time is spent identifying and addressing the causes of human error. the covid-19 crisis has seen urologists working in unfamiliar environments and having to make decisions that differ to normal treatment pathways, adding to the already stressful task of providing a safe and effective urology service. guidance has been issued by the general medical council (gmc) with regards to making these decisions, though it is near impossible to alleviate the anxiety that clinicians may experience in working outside of their normal comfort zone. 30 the gmc's statement also highlights the need for the profession to look after themselves, enabling clinicians to care for patients. 30 many clinicians will be working longer hours and more irregular shift patterns, often in full ppe. as a result, it has never been more important to recognise the need for regular work breaks and recovery days, enabling clinicians to remain well fed, rested and hydrated to reduce the risk of medical errors. 31 it is important to appreciate the contribution of personal factors to poor decision making in such a stressful environment, which can include being hungry, angry, late or tired (halt). 32 remembering the mnemonic and stopping, even for a short break, when either individuals or teams experience one or more of these personal factors can make such a difference to personal performance and wellbeing. tiredness and fatigue play a significant role in poor cognitive functioning and decision making. 33 this issue was addressed in the new junior doctors' contract, 34 with stipulations made regarding the minimum number of hours off duty following on-call shifts. despite the increase in workload due to covid-19, nhs trusts are making every effort to ensure clinicians have adequate time off to prevent tiredness and burnout. resources have been made available to promote wellbeing for clinicians within trusts and nationwide as we start to recognise the frequency and impact of burnout in doctors. 35 stress and emotional factors often play a role in our decision-making ability, prompting the promotion of resilience training for clinicians. 36, 37 an appreciation for the impact of hf in medical error has been brought into sharp highlight by covid-19. working in an unfamiliar and stressful environment undoubtedly increases the risk of medical error. the efforts made nationwide to look after the medical profession have been considerable, and we must aim to continue to focus on the health and wellbeing of colleagues after this crisis abates in order to reduce error and workforce attrition. the rcs is being proactive in this regard. at the time of writing (30 april 2020), all emergency operations are being undertaken with the operating team table 1 . key resources to guide practice in the covid-19 era. online resources • stay connected to friends and family. • take regular breaks from your phone and computer to avoid information overload. • do not forget the importance of regular sleep, healthy eating and staying hydrated. • turn to supervisors and colleagues as it may help to share thoughts and listen to colleagues having similar experiences. • do not feel pressured to work when unwell. speak with occupational health for advice. wearing full ppe. this includes a fitted ffp2/3 facemask, visor, gown and gloves. 38 many will have experienced how uncomfortable and unfamiliar this protective equipment is to wear, especially when operating for long periods of time. it significantly reduces one's situational awareness in theatre by blocking out sounds, reducing hearing as well as peripheral vision. in figure 1 the clinician pictured opted for a surgical hood instead of more widely available face visors in an effort to reduce glare when performing a ureteroscopy and laser fragmentation of ureteric calculi. the effect full ppe has on both verbal and non-verbal communication between theatre members is profound. an awareness of the impact of these is crucial to the prevention of medical error. 39 to aid clinicians in the recognition and prevention of such errors the non-technical skills for surgeons (notss) course 40 has been made freely available to access online by the royal college of surgeons of edinburgh. 41 we believe that non-technical skills are crucial in the prevention of surgical error especially while operating at such a challenging time, and that this course should be mandatory for all surgeons, regardless of grade and experience. working amidst the covid-19 crisis has seen the flattening of hierarchies within the workforce. this has resulted in a deepened appreciation for colleagues and the expertise that each individual can bring to a team. this crisis has highlighted the ability of the nhs workforce to work as a team united in the pursuit of best patient care and the reduction of medical errors. we have a duty to patients to continue working as a cohesive multi-disciplinary team after the covid-19 crisis abates, continually striving to improve patient outcomes and reduce medical error. 42, 43 reflective practice reflective practice (rp) is a critical component for developing expertise in surgeons and trainees, with the aim of promoting excellence in patient care. rp is a conscious effort, using a structured framework, to think about an experience or an event to develop insights, and where necessary affect transitional or transformational changes using a novel paradigm. the simplest rp framework is the driscoll model, 44 which is based on three self-aimed questions: 'what?', 'so what?' and 'now what?'. 'what?' is a rich description of self-awareness of an experience. 'so what?' is an evaluation and analysis of the description of the experience, and 'now what?' is the exit synthesis action plan which may generate a novel way of managing the initial experience with the intention of improving patient care. such reflective cycles may be iterative as new information becomes available. at our institution one-third of the urology registrars were re-deployed to work in critical care, and engaging in rp has certainly been found to be beneficial in developing practice going forward. using the 'journal entry' section on the intercollegiate surgical curriculum programme (iscp) online portfolio, the registrars who were redeployed have been able to reflect on the skills and knowledge they have gained through working in a different specialty. rp has enabled them to consolidate learning and how they can apply their experience in critical care to their future practice in urology. this has aided development in training at a time when formal face-to-face training can be scarce, and the authors perceive engaging in rp in this way has helped them use experiences in redeployment to progress towards becoming more well-rounded urologists. rp also has a major role in making complex decisions in the face of covid-19 regarding service adaptations, scope of practice, end-of-life care and protecting the workforce. these decisions are considered by multi-professional teams, but rp for individual surgeons and trainees increases self-awareness through being more open minded, being in the moment, using active listening and receiving real-time feedback. these benefits translate into better team working and improvements in patient care during the covid-19 pandemic. all surgeons should be regular reflective practitioners, either in the moment or on action, and crystallise outcomes in writing (journals, diaries, twitter, blogs, e-portfolio) or in formal conversation with colleagues, else the new learning may be lost. it is not surprising that rp is a mandatory part of appraisal, revalidation and arcp. the covid-19 pandemic has seen considerable change in training opportunities in urology with uncertain effects on specialty recruitment. yet despite the setbacks in training this has caused, we have seen a flourishing of novel concepts in the field of virtual learning in medicine. the importance of hf in surgery and nontechnical skills has been brought to the fore in unprecedented ways, and resources have been made widely available to improve in these areas of practice. rp is important for individual surgeons and trainees to manage their new experiences with covid-19. this global pandemic has undoubtedly changed the way we learn and practise urology, and it is our hope that these lessons will continue to be built upon long after this acute crisis is over. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. none required. not applicable. contributorship tf and hs conceived the idea. tf searched the literature and drafted the first version of the article. re, hs, pb and tt reviewed and edited the article. all authors reviewed and were in agreement with the final version submitted. impact of the covid-19 pandemic on urology residency training in italy surgery specific management of arcps during covid-19 covid-19 and trainee progression in 2020 (update i) unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments impact of performance in a mandatory postgraduate surgical examination on selection into specialty training covid-19 and the urology match: perspectives and a call to action is there a need for an undergraduate urological curriculum? 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doctors will stop at nothing to provide care in this crisis our job is to support them impact of hydration and nutrition on personal performance in the clinical workplace using the halt model in an exploratory quality improvement initiative to reduce medication errors sleep: its importance and the effects of deprivation on surgeons and other healthcare professionals bma. agreed new contract deal for junior doctors in england resilience, burnout and coping mechanisms in uk doctors: a crosssectional study stress training for the surgical resident the impact of stress on surgical performance: a systematic review of the literature updated intercollegiate general surgery guidance on covid-19 operating during the covid-19 pandemic: how to reduce medical error advances in patient safety -nontechnical skills in surgery technical skills for surgeons (notss) teamwork in healthcare: key discoveries enabling safer, high-quality care 24-karat or fool's gold? consequences of real team and co-acting group membership in healthcare organizations reflective practice for practise -a framework of structured reflection for clinical areas not applicable. key: cord-308409-0n2ysgsa authors: pawlak, katarzyna m.; kral, jan; khan, rishad; amin, sunil; bilal, mohammad; lui, rashid n.; sandhu, dalbir s.; hashim, almoutaz; bollipo, steven; charabaty, aline; de-madaria, enrique; rodríguez-parra, andrés felipe; sánchez-luna, sergio a.; żorniak, michał; walsh, catharine m.; grover, samir c.; siau, keith title: impact of covid-19 on endoscopy trainees: an international survey date: 2020-06-11 journal: gastrointest endosc doi: 10.1016/j.gie.2020.06.010 sha: doc_id: 308409 cord_uid: 0n2ysgsa nan the coronavirus disease 2019 (covid-19) pandemic has had a profound impact on the provision of gi endoscopy services worldwide, with the radical curtailment of elective procedures to restrict disease transmission. 1 consequently, multiple gastroenterology and endoscopy societies have published rigorous recommendations on triaging endoscopy procedures, appropriate use of personal protective equipment (ppe) and postprocedure decontamination for gi endoscopy during the pandemic. [2] [3] [4] [5] surveys from italy and north america have reported over 75% reductions in procedure numbers in many centers. 6, 7 as institutions attempt to limit periendoscopic exposure to covid-19 and conserve ppe, this will inevitably impact trainee engagement in hands-on endoscopy procedures. the covid-19 pandemic creates challenges for endoscopy trainees for several reasons. for trainees who are in direct contact with patients, providing clinical care during a pandemic can evoke fear and anxiety regarding personal safety and viral transmission. 8, 9 trainees also face social isolation due to restricted contact with their families and friends. 10 these concerns can be further exacerbated by inconsistency in scheduling, both due to trainees being quarantined and redeployment to other services. 11 finally, trainees may be concerned about delays in competency acquisition and future job security. novice endoscopists must become proficient in a range of diagnostic and therapeutic modalities during a training period, often of finite duration. as it remains unclear when endoscopy units will fully resume regular activities, endoscopists-in-training may be concerned about attaining and maintaining competence in procedural skills. additionally, trainee exposure to inpatient and ambulatory gi patients may be significantly reduced if institutions are limiting contact between consulting services and inpatients and cancelling non-essential office visits. shortages of ppe could worsen these issues because trainees may be the first to be excluded when there is inadequate ppe. despite these issues, there are no published data on the impact of the covid-19 on endoscopy training and trainee well-being. therefore, in this international survey, we aimed to assess the impact of the covid-19 pandemic on endoscopy trainees, including procedure numbers, barriers to training, and the physical and emotional well-being of trainees. we also aimed to explore variation in this impact internationally. a 37-item survey (appendix 1) was developed through consensus by an international group of representatives from 10 countries with expertise in endoscopy training and education. the survey was conducted using the surveymonkey platform (svmk inc, san mateo, calif, usa) and was structured into the following domains: 1) demographics, including age, gender, country of training and specialization; 2) monthly endoscopy volumes before and during covid-19; 3) training and availability of personal protective equipment (ppe); 4) impact on physical, mental and emotional well-being. the primary outcome studied was the percentage reduction in the monthly volume of hands-on endoscopy procedures performed by trainees as a result of covid-19. this was studied using 2 methods: (1) as a comparison over two 30-day periods before and during the covid-19 pandemic, and (2) as a categorical variable according to trainee indication of an overall reduction in procedure volume. endoscopy procedures studied comprised esophagogastroduodenoscopy (egd), colonoscopy, eus, ercp, and upper gastrointestinal bleed hemostasis (included within the egd numbers), for supervised, unsupervised and total numbers. secondary outcomes comprised: 1) barriers to hands-on training and the impact on residual training opportunities; 2) changes to institutional case volume 3) trainee concerns regarding competency development and prolongation of training; 4) anxiety, assessed using the generalized anxiety disorder-7 (gad-7) scale, 12 and rates of burnout, measured using the single item burnout scale. 13 for each outcome, analyses were compared across continents to denote international variation in survey responses. at the beginning of april 2020, the endotrain survey was distributed to trainees both directly and indirectly via program directors, trainee representatives, and to representatives within national and international societies (supplementary table 1 ). the survey was open for three weeks from april 11 to may 2, 2020. all continuous variables were subjected to normality assessment (shapiro-wilk) and presented as medians with interquartile ranges (iqrs) or means and standard error (se) as appropriate. for each procedure, trainees who did not indicate any procedures in a given modality over the 2 comparison periods were excluded from analyses to identify active trainees for each procedure category. pairwise comparisons of procedural numbers were performed at trainee-level between pre-covid-19 and covid-19 periods using wilcoxon signed-rank tests. nonparametric data across procedure types and continents were compared using kruskal-wallis, followed by dunn's test for pairwise comparisons. continuous variables were compared across continents using one-way analysis of variance (anova). categorical data were compared using the pearson chi-square test. binary logistic regression analysis was performed for univariable and multivariable analysis of factors associated with anxiety in endoscopy trainees. the gad-7 outcomes were stratified into 2 groups by composite score: <5 and ≥5 (indicating at least mild anxiety). a forward stepwise approach to factor selection was used and outcomes presented as odds ratios (or) and 95% confidence intervals (95% ci). statistical analyses were performed using spss v26 (arkmont, ny, usa: ibm corp) and prism v8 (san diego, calif, usa: graphpad corp), with p<0.05 considered statistically significant. in total, 1199 respondents participated in the international training survey. after excluding incomplete responses (n=429, 35.8%), 770 trainees from 63 countries within six continents (supplementary table 2 and supplementary fig. 1) were included for analysis. trainee characteristics and the differences across continents are presented in table 1 overall, 770 trainees (93.8%) reported a reduction in their monthly endoscopy case volume attributable to covid-19. by procedure type, the differences in estimated monthly volumes before and during covid-19 are presented in figure 1 , with significant (p<0.0001) decrements over the two 30-day periods. across all modalities (figure 2) , the median percentage reduction in procedural volume was 99% (iqr 85%-100%). this did not vary significantly by trainee specialty (p=0.658), or whether procedures were performed under supervision or independently (p=0.614), but varied by procedure type (p<0.001). on subgroup analysis, percentage reductions were greater for colonoscopy (median 100%, iqr 88%-100%) compared with ercp (median 100%, iqr 60%-100%; p=0.003) and upper gastrointestinal bleeding (ugib) procedures (median 100%, iqr 50%-100%; p<0.001). this outcome also varied across continents (p<0.001), with significantly greater percentage reductions observed in europe (median 100%, iqr 91%-100%) and north america (median 99%, iqr 88%-100%) compared to asia (median 87%, iqr 75%-97%) and south america (median 91%, iqr 70%-100%). of the 770 (93.8%) trainees who reported a reduction in endoscopy procedural volumes during the covid-19 study period, the reasons cited included: changes to institutional policy to exclude trainees from procedures (79.9%); lack of cases (58.3%); shortage of available ppe (28.8%); redeployment to another clinical area (24.0%); and personal reasons (10.2%). access to endoscopy training remained accessible on an ad hoc basis to 60.5% (n=466) of trainees, with rates varying internationally ( table 2) . of these, 36.1% (n=168) could perform endoscopy on patients at low risk or negative for covid-19, and 7.9% (n=37) on unsupervised procedures only. 46.7% (n=359) reported access to ad hoc emergency cases and 15.4% (n=119) to intensive care unit (icu) cases. only 6.2% (n=29) reported no restrictions on their endoscopy privileges. reductions in institutional endoscopy case volume due to covid-19 were reported by 98.2% of trainees, with 73.5% of trainees reporting a decrease of ≥50% and 3.6% reporting the cancellation of all endoscopy activity. regarding ppe, 73.7% (n=520) received training on the use of ppe for covid-19 patients. 50.5% (n=356) received training specific to managing covid-19 in their endoscopy unit. this was mainly delivered through face-to-face teaching (34.0%, n=121), virtual teaching (22.4%, n=80), or written communication (43.5%, n=155). the level of ppe used within the endoscopy unit was felt to be adequate in 67.6% (n=476), but this varied internationally (p<0.001) ( table 2) . 47.0% (n=331) believed that a lack of ppe was contributory to reductions in institutional endoscopy case volume. endoscopy-specific practice guidelines on ppe use were available for 89.2% (628) of respondents. ppe policy within the endoscopy unit was predominantly directed by national guidelines (47.4%), individual unit/hospital policy (33.0%), or international guidelines (19.6%). trainees were asked to rate their level of concern regarding the impact of covid-19 on the outcome of their endoscopy training (table 3; figure 4 ). concerns with competency development were raised by 90.1% (n=629) of trainees across continents (p=0.844). concerns regarding the need to prolong specialty training to reach the required competency were raised by 71.9% (n=502) of respondents. this concern varied internationally (p<0.001), with the lowest proportion of concerned trainees in north america (49.5%). in total, 68.9% (n=472) of trainees believed that existing national/international guidelines should be modified to better support endoscopy training during the covid-19 pandemic. concerns of acquiring covid-19 were expressed by 79.3% of trainees (figure 4) . in total, 23.9% (n=168) reported taking time off work for covid-19 related reasons; 76.8% (n=129) took time off for themselves and the remaining 23.4% (n=39) for a household member. of trainees affected, 14 .7% (n=19) tested positive, 52.7% (n=68) negative, 30.2% (n=39) were not tested, and 2.3% (n=3) preferred not to answer. anxiety and burnout were assessed in 695 trainees ( table 3 ). the following anxiety levels were reported according to gad-7 criteria: no anxiety (47.6%, n=331), mild (33.2%, n=231), moderate (14.2%, n=99) and severe anxiety (7.8%, n=54). on multivariable analysis ( table 4) to our knowledge, this is the first study to comprehensively evaluate the impact of covid-19 on endoscopy trainees. survey responses from 770 trainees across 63 countries indicate that covid-19 has had a profound adverse effect on endoscopy volume worldwide, with reductions in training opportunities for the majority of trainees (93.8%), and a drastic median reduction in case volume of 99% (iqr, 85%-100%). this has raised concerns among trainees in regard to competency development (90%) and the potential need to prolong training to achieve endoscopic competence (72%). these concerns were among the cited factors leading to covid-19 associated anxiety (52.4%) and burnout (18.8%) among trainees. these results highlight the urgent call to action for institutions, training programs, gi societies, and accreditation councils to address the 2 overarching issues identified: (1) reductions in endoscopic training opportunities and (2) the emotional welfare of trainees. the emphasis on minimum endoscopy procedure numbers as a competence safeguard is ubiquitous across international training settings. 14 these serve to indicate readiness for certification, credentialing, and program completion. although training in all procedures was disrupted by covid-19, the decrement was most pronounced for colonoscopy and less so for emergency procedures (ercp and gi bleeding). this is important as colonoscopy is regarded as a core endoscopic skill. over 50% of trainees estimated a reduction in institutional endoscopy volumes of 75% or more, in line with international recommendations to curb elective procedures. however, the exclusion of trainees was another major barrier, with ppe shortages and redeployment being contributory. the significant impact of covid-19 has raised doubts among trainees over whether endoscopic competence in various procedures is realistically achievable within the duration of their training, with a substantial proportion expressing concerns that training will need to be prolonged. addressing these issues could potentially have disruptive implications at many levels: restructuring of training curricula and schedules, redistribution of endoscopy cases between junior and senior trainees, delays in entering the workforce, financial strain and negative effects on trainees' mental well-being. indeed, relatively little has been published on the physical and mental well-being of endoscopy trainees, even before covid-19. from our survey, covid19 affected trainees beyond reductions in endoscopy training opportunities: 79.3% had concerns of acquiring covid-19 and a significant proportion of trainees had to take time off work for covid-19 related reasons. inadequate ppe was raised as a concern by a third of respondents and was independently associated with increased anxiety. overall, 52.4% of trainees met criteria for at least mild generalized anxiety, with 22.0% reaching a threshold score of ≥10, which has 89% sensitivity and 82% specificity for clinically significant anxiety. 12, 15 predictors of anxiety included female gender (consistent with population-based studies), 16 concerns regarding prolongation of training, inadequate ppe, and a lack of emotional and mental health support. anxiety levels positively correlated with burnout which was identified in 18.8% of trainees. burnout is a consequence of unmitigated chronic stress which requires urgent intervention as it can lead to emotional exhaustion, depersonalization, negativity and impaired professional performance, 17 including suboptimal medical care and medical error. 18, 19 the association between the availability of emotional support and lower anxiety levels suggests that training programs should strongly consider implementing support strategies to proactively address anxiety and burnout in trainees and promote their wellbeing. formalized interventions to improve trainee well-being, such as group stress management and resiliency training (smart) may also play a positive role in improving job satisfaction and well-being. 16, 21, 22 there is additional need for attending gastroenterologists to proactively engage with trainees to discuss their learning gaps and career development and devise individualized curricula. internationally, there was significant heterogeneity in survey responses for both primary and secondary outcomes (tables 1-3) . these may be partially explained by locoregional differences in severity and the phase of the covid-19 pandemic during the survey period. nearly 50% of respondents were from the united states, united kingdom, and spain, which were in the acceleration to plateau phase in the 30 days leading up to the survey. 23 this is likely to account for the reductions in exposure to endoscopy training, institutional caseloads, uptake of ppe and time off work from covid-19. it is possible that, as covid-19 caseloads subside, training opportunities will slowly resume, although trainee exposure is still likely to be impacted due to prolonged turnaround times for decontamination and our study has several limitations. surveys are vulnerable to bias and misinterpretation inherently. data validation was performed by excluding respondents who provided incomplete responses of primary outcome data, did not indicate a training modality, and where endoscopy numbers performed each month in a given modality exceeded 100. it was also not possible to estimate the response rate as the survey was disseminated through multiple national and international societies and organizations. not all countries and specialties were represented which might affect the generalizability of findings. next, our data provide a snapshot of training in time and was not matched to regional differences in pandemic activity. our completion rate was limited at 65%, with a further dropout rate of 11% for completing all survey questions. contributory factors include the length of the survey, complexity of individual questions, and dissemination only in english, which may have affected comprehension. additional data, such as unit-level information and lifetime procedure counts were not collected. finally, baseline data for anxiety and burnout could not be retrospectively captured in a valid manner and therefore, the high rates of anxiety cannot be directly attributed to covid-19 alone. the effects of covid-19 are projected to persist until at least 2022. 24 as such, an urgent review of endoscopy training is warranted to adapt accordingly and provide direction. in our survey, 68.9% of respondents indicated that guidelines should be modified to support training. training programs should openly recognize that minimum procedural numbers may not be achievable in some countries and adopt mitigation strategies. first, emphasis should shift toward maximizing gains from evidence-based, hands-off training interventions. for beginners, simulation-based training can be used to develop technical skills, 25, 26 nontechnical skills, 27 and accelerate time to achievement of competence. 28 although simulation training requires performance feedback to be optimally effective, 29 selfassessment with benchmark videos and computerized feedback are viable alternatives. 30, 31 for all trainees, cognitive competencies can be developed through distance education using educational resources, webinars, and open access social media education, such as structured conversations on twitter. 32 all 3 major american gi societies have high-quality, expert-led, endoscopy training videos; notably the american society for gastrointestinal endoscopy (asge) with its catalogue of education materials in gi leap, its online learning platform. 32, 33 second, determination of competence should rely less on attaining minimum numbers and more on the use of objective and validated methods of competency assessment. this is best achieved through the use of objective performance tools with strong validity evidence, such as ace (assessment of competency in endoscopy), 34 dops (direct observation of procedural skills), [35] [36] [37] and giecat (gastrointestinal endoscopy competency assessment tool), 38 which can allow trainers to target feedback provision in a formative manner, and to benchmark global competence for summative sign-off. 35 despite these measures, it may be necessary for some trainees to extend their endoscopy training. 39 additionally, it will be important for institutions and private practices to ensure that new faculty are closely mentored to promote continued skills development. with meaningful application of evidence-based training paradigms, the gi community can mitigate the ongoing impact of covid-19 on trainees and ensure that they achieve the cognitive, technical, and integrative competencies needed for independent endoscopic practice. the recent literature on the impact of covid-19 on trainees stems from individual experiences and expert opinion. 10, 33 our trainee-centered survey has now quantified the impact of covid-19 on procedural volumes and on the well-being of endoscopy trainees, and shown how this varies internationally across different continents. as countries engage in collaborative endeavors to tackle the global impact of covid-19, it is hoped that our findings will help to inform future strategies to mitigate the impact of the pandemic on endoscopy training. in this article, we aimed to assess the impact of covid-19 on procedural volumes and the emotional well-being of endoscopy trainees worldwide. our study showed that the covid-19 pandemic has led to drastic reductions in endoscopic volumes and restrictions on endoscopy training, with detrimental effects on trainee well-being, including high rates of anxiety and burnout among trainees worldwide. therefore, existing curricular requirements and delivery of endoscopy training should be urgently reviewed and adapted to support the educational and emotional needs of trainees during the covid-19 pandemic. covid-19) outbreak: what the department of endoscopy should know overview of guidance for endoscopy during the coronavirus disease 2019 pandemic practice of endoscopy during covid-19 pandemic: position statements of the asian pacific society for digestive endoscopy (apsde-covid statements) aga institute rapid recommendations for gastrointestinal procedures during the covid-19 pandemic esge and esgena position statement on gastrointestinal endoscopy and the covid-19 pandemic endoscopy units and the covid-19 outbreak: a multi-center experience from italy changes in gastroenterology and endoscopy practices in response to the covid-19 pandemic: results from a north american survey the impact of severe acute respiratory syndrome on medical house staff: a qualitative study covid-19 and the digestive system covid-19 pandemic through the lens of a gastroenterology fellow: looking for the silver lining adapting a gi fellowship to a pandemic: novel approaches to accommodating a novel virus a brief measure for assessing generalized anxiety disorder: the gad-7 using a single item to measure burnout in primary care staff: a psychometric evaluation training in endoscopy psychometric properties of the generalized anxiety disorder scale-7 (gad-7) in outpatients with anxiety and mood disorders generalized anxiety disorder prevalence of burnout among physicians: a systematic review physician burnout: contributors, consequences and solutions medical student and resident burnout: a review of causes, effects, and prevention supporting the health care workforce during the covid-19 global epidemic smart-r: a prospective cohort study of a resilience curriculum for residents by residents intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial johns hopkins coronavirus resource center projecting the transmission dynamics of sars-cov-2 through the postpandemic period impact of a simulation training curriculum on technical and nontechnical skills in colonoscopy: a randomized trial progressive learning in endoscopy simulation training improves clinical performance: a blinded randomized trial a non-technical skills curriculum incorporating simulationbased training improves performance in colonoscopy among novice endoscopists: a randomized controlled trial impact of a simulation-based induction programme in gastroscopy on trainee outcomes and learning curves the impact of constructive feedback on training in gastrointestinal endoscopy using high-fidelity virtual-reality simulation: a randomised controlled trial influence of video-based feedback on self-assessment accuracy of endoscopic skills: a randomized controlled trial computerized feedback during colonoscopy training leads to improved performance: a randomized trial society for gastrointestinal endoscopy: guidance for trainees during the covid-19 pandemic how to maximize trainee education during the covid-19 pandemic: perspectives from around the world asge's assessment of competency in endoscopy evaluation tools for colonoscopy and egd colonoscopy direct observation of procedural skills assessment tool for evaluating competency development during training ercp assessment tool: evidence of validity and competency development during training direct observation of procedural skills (dops) assessment in diagnostic gastroscopy: nationwide evidence of validity and competency development during training in-training gastrointestinal endoscopy competency assessment tools: types of tools, validation and impact variation in exposure to endoscopic haemostasis for acute upper gastrointestinal bleeding during uk gastroenterology training key: cord-318813-eiazlhi4 authors: trembley, lauren l.; tobias, adam z.; schillo, gwendolyn; von foerster, nicholas; singer, jordan; pavelka, samantha l.; phrampus, paul title: a multidisciplinary intubation algorithm for suspected covid-19 patients in the emergency department date: 2020-06-03 journal: west j emerg med doi: 10.5811/westjem.2020.5.47835 sha: doc_id: 318813 cord_uid: eiazlhi4 introduction: intubation of patients suspected of having coronavirus disease 2019 (covid-19) is considered to be a high-risk procedure due to the aerosolization of viral particles. in an effort to minimize the risk of exposure and optimize patient care, we sought to develop, test, provide training, and implement a standardized algorithm for intubating these high-risk patients at our institution. methods: we developed an initial intubation algorithm, incorporating strategic use of equipment and incorporating emerging best practices. by combining simulation-based training sessions and rapid-cycle improvement methodology with physicians, nurses, and respiratory therapists, and incorporating their feedback into the development, we were able to optimize the process prior to implementation. training sessions also enabled the participants to practice the algorithm as a team. upon completion of each training session, participants were invited to complete a brief online survey about their overall experience. results: an algorithm and training system vetted by simulation and actual practice were developed. a training video and dissemination package were made available for other emergency departments to adopt. survey results were overall positive, with 97.92% of participants feeling confident in their role in the intubation process, and many participants citing the usefulness of the multidisciplinary approach to the training. conclusion: a multidisciplinary, team-based approach to the development and training of a standardized intubation algorithm combining simulation and rapid-cycle improvement methodology is a useful, effective process to respond to rapidly evolving clinical information and experiences during a global pandemic. what do we already know about this issue? the coronavirus disease 2019 pandemic has forced healthcare providers to make adaptations to the procedure of intubation to minimize exposure risk. what was the research question? we sought to develop, test, and implement a standardized intubation algorithm for suspected covid-19 patients. what was the major finding of the study? a simulation-vetted algorithm and training system were developed and disseminated across our healthcare system. our standardized approach to intubation minimizes exposure risk, increases the quality of patient care, and can easily be adapted at other institutions. airway management with endotracheal intubation is a high-risk and time-sensitive medical task. it is standard practice in emergency medicine training programs to teach a systematic approach to airway management, often enlisting the use of checklists or algorithms. 3 the multimodal training focuses on motor skills, assessment skills, and decisionmaking. however, it is uncommon to introduce education simultaneously with a systematic evaluation of iterative process changes associated with what is normally considered routine airway management care. evaluating necessary process changes that included the complexity involved with standardizing airway, communications, and team-based skills in order to minimize aerosolization of highly infectious viral particles during intubation proved challenging. early data from china estimate that 3.2% of confirmed coronavirus disease 2019 (covid-19) cases developed severe disease requiring endotracheal intubation and positive pressure ventilation at some point in their clinical course. 4 due to the potential for aerosolization of patient secretions during this invasive procedure, endotracheal intubation is recognized to be a high-risk procedure in terms of potential exposure and transmission to healthcare providers. 5 as more cases emerged in the united states, process recommendations regarding intubation were made by various groups. [6] [7] [8] [9] major themes of these recommendations include the use of an n95 respirator or powered air-purifying respirator (papr) as part of personal protective equipment (ppe) by all members of the healthcare team with direct patient contact during the procedure. environmental considerations include the recommended utilization of a negative pressure isolation room for the procedure when possible, as well as minimizing risk by having the fewest number of providers with direct patient contact. procedural recommendations included having the most experienced provider perform the intubation using video laryngoscopy, rapid sequence induction (rsi), and avoiding the use of non-invasive positive pressure ventilation and bag-valve-mask ventilation (bvm). while these recommendations provide general guidance and strategies for intubating patients with either confirmed or suspected covid-19, there is still a need to incorporate these changes at the local level. the risk of aerosolization of viral particles during the procedure requires adaptations to standard airway management algorithms and procedures, based on resources available. without experience and training with these new methods, and without an established protocol for their implementation, there is potential for suboptimal patient care and increased risk of exposure to the healthcare team. therefore, training healthcare providers on the new changes will help to avoid uncertainty and confusion, reduce risks of healthcare provider infection, and lead to increased first-pass success for the intubation procedure. to implement such change, there is a need to develop and implement a stepwise process for intubation of high-risk covid-19 patients that incorporates the newly published recommendations. changes to existing emergency department (ed) airway management routines require a multidisciplinary approach, attention to detail, and a rapid-cycle improvement process to guide the development of a new algorithm. each cycle of testing and training needs to inform necessary changes to the developing algorithm based on the successes and identified areas that did not perform optimally. simulation has previously been identified as a successful tool to educate and serve as a useful framework to evaluate system change to clinical processes, 10,11 as well as teamwork and systemsrelated training in critical care environments. 12 simulation has also been described by our institution and others as a useful modality for rapid development of necessary curriculum and process validation during pandemic preparedness. [13] [14] [15] the primary goal of this project was to develop and implement a standard process for intubation of all patients with suspicion for covid-19 for the ed at our institution, employing a multidisciplinary approach using simulation and a rapid-cycle improvement methodology. we designed our revised approach to incorporate the emerging best practices including 1) minimization of exposure risk to aerosolized patient secretions; 2) optimization of the strategic use of equipment; 3) maximization of first-pass intubation success, 4) enhanced teamwork, communications and patient safety principles; and 5) incorporation of quick access to backup, emergency equipment in case of a difficult airway. trembley et al. our primary outcome was to conduct training sessions, develop a modified airway algorithm that had been tested for functional use, and create a deployable training package for dissemination across the eds of our health system. our algorithm development process was developed around a four-member team that included a physician (dr), two registered nurses (rn1 and rn2), and a respiratory therapist (rt). three members of the team (dr, rn2, and rt) would participate in the actual procedure while rn1 would serve as logistics support outside the zone of potential contamination. a fifth person, a patient care technician (pct), could assist rn1 as needed if available. the first step in development of our procedural algorithm was to compile a list of standard equipment needed for intubations of infected or suspected covid-19 patients. we first identified the minimum standard equipment and medications that would need to be prepared to enter the procedural area. the equipment is prepared on a standard bedside tray and minimized to prevent confusion and unnecessary contamination or equipment waste. the equipment to be prepared on the tray was organized into a bag labeled "inside bag" to indicate the contents were to go into the procedure room. inside items included standard intubating equipment, listed in figure 1 . a second bag, designated as the "outside bag," contained items that were to be staged immediately outside the room in which the procedure was to occur and contained what would be historically considered backup equipment for difficult airways. outside items consisted of a cricothyrotomy kit, i-gel (intersurgical, berkshire uk), and gum elastic bougie. the i-gel was selected as the primary rescue device mainly due to its ease of insertion compared to other supraglottic devices. the outside bag is designed to remain outside of the room with the belief that it would be uncommonly needed and could remain unopened to avoid unnecessary equipment waste. a third bag, designated the "vent bag," contains items needed to initially confirm tube placement and would be carried into the treatment area along with the ventilator, and then assembled by the rt. equipment in this bag included bvm, viral filter, peep (positive end expiratory pressure) valve, and colorimetric carbon dioxide (co2) detector. these bags were attached to each ventilator to ensure easy access and availability. the bags of equipment were pre-assembled and stored in the designated treatment area in our ed for intubating patients suspicious of covid-19, ensuring that they were readily available and easy to access. the initiation of our procedure is triggered when the physician decides that a patient's clinical condition requires intubation. the core management team for the patient is quickly established and the dr, rt, and rn2 don appropriate ppe. simultaneously, rn1 begins following a checklist to accomplish step 1 in our procedure ( figure 1 ). step 1 focuses on preparing medications for rapid sequence induction (rsi) and post-intubation sedation, verifying that "inside items" are present, preparing the endotracheal tube (ett) selected by the physician, and anticipating any additional procedures to be completed after intubation, such as central line placement. once step 1 is completed, the dr, rn2, and rt proceed inside the room. the dr is responsible for transporting the video laryngoscope and blades and setting up the equipment. the "inside items" (that had been prepared by rn1) are rolled in by rn2, and the ventilator and vent bag are transported in and set up by the rt. our final idealized placement of equipment and providers is in figure 2 . the rn2 then reads the pre-intubation checklist, which begins step 2 ( figure 3 ). the checklist serves as a time-out to ensure necessary equipment is present and functioning. after the initial checklist is completed, rn2 then reads the script (figure 3) , which serves as a reminder to the team about the backup plan and equipment that is immediately available, should intubation prove difficult. the dr then performs the intubation. to minimize aerosolization of secretions, pre-oxygenation is delivered by face mask oxygen at 10-12 liters (l) per minute (min) with an additional 5-6 l/min of oxygen delivered via nasal training, refinement and implementation upon completion of the initial version of the intubation algorithm, we partnered with the winter institute for simulation, education and research (wiser) to conduct simulation-based training sessions. wiser is the simulation institute of the university of pittsburgh and the upmc health system and is accredited by the society for simulation in healthcare in the areas of teaching/education, assessment, research, and systems design. the simulation training sessions were strategically designed to teach a refresher of airway management as modified for the pandemic, but also to study our new processes, incorporating the necessary teamwork and communications to allow for rapid optimization. in addition to standard simulation-based training, we employed the plan-do-study-act (pdsa) rapid-cycle improvement process to evaluate the need for refinements of our process changes as well as our educational content. we held seven days of multiple one-hour sessions for multidisciplinary training, deliberate practice, and process refinement. participation was voluntary. drs were recruited via email and could select a convenient time over the available training days. rns and rts were recruited from those working in the department, as identified by nursing and rt leadership as the most convenient way to maximize both availability and participation. the training sessions were conducted in situ within our ed. primary goals of the training sessions were to have participants practice their roles associated with the new process while working as a team, to recognize some difficulties associated with ppe that may not be routinely used, and to recognize the effectiveness of checklist and standardized processes. the secondary goal of the training sessions was to identify process changes that could be implemented successfully, as well as those requiring revisions or removal from the redesigned intubation process. participants were allowed to practice as many times as desired, using actual equipment and an intubating mannequin. following each training session, a debriefing was held to help to ensure participant understanding of the material as well as to solicit their professional input into the redesigned system. based on the observations and feedback of participants comprising the core team, numerous changes were made over a short period of time to enhance the algorithm. by the fourth day of training and study, there were no major changes identified for the algorithm and it was then trialed in our department. upon completion of the training session, participants were invited to complete an online (surveymonkey), seven-question survey focusing on reaction (appendix a). the course evaluation was approved by our institution's institutional review board (approval #pro13040395). the link to the survey was emailed to participants. the survey consisted of basic information including role (physician, rt, rn), and prior use of papr for intubation, followed by four 5-point likert-scale items (scored from strongly disagree to cannula, which remains in place upon removal of face mask. this method provides apneic oxygenation, reducing the potential need for bvm or positive pressure ventilations. if the intubation is successful the bvm, pre-fitted with a viral filter and a co 2 detector, is connected and up to five shallow breaths are given to confirm tube placement with the colorimetric device. the bvm is then disconnected, and the dr quickly covers the disconnected ett with his or her thumb while the patient is hooked up to the vent circuit. the rt then holds the ett while the dr places an orogastric or nasogastric tube. the dr then holds the tube while the rt places the tubeholder and secures the ett. once the tube has been secured, rn2 will then read the script (figure 3 ), prompting the dr to place any additional lines or other invasive procedures before doffing ppe. this ensures that all lines will be placed prior to radiograph confirmation, attempting to minimize exposure to radiology technicians and conserve ppe. the pre-identified, post-intubation sedation plan will then be implemented. in the event of a difficult airway or failed first attempt, we incorporated an early activation of a backup plan (that is appropriate for the given facility) into our algorithm. thus, if the dr requests the outside bag, rn1 would also call for additional help. if the airway proved difficult and intubation is not successful within a reasonable time, or if the patient decompensated, we encouraged placement of the i-gel backup device and ventilation through the i-gel until additional resources arrived. this is based upon previous studies demonstrating the i-gel to be the quickest device to be used to secure the airway while wearing ppe. 16 the dr also has the option to perform a cricothyrotomy if clinically indicated. trembley et al. selected either "agree" or "strongly agree" to the item, "prior to taking this course, i felt confident with my role in the intubation process of high-risk covid patients." however, after completing the course, 95.74% selected either "agree" or "strongly agree" to the item, "after completing this course, i feel confident with my role in the intubation process of high-risk covid patients." further, 97.92% selected either "agree" or "strongly agree" to the item "i would recommend this course to other healthcare providers." most participants (93.75%) also felt that the course enhanced their team communication skills (question 6). we received 18 responses for the open-ended item, with feedback overall positive. many of the responses highlighted the usefulness of the training overall, expressing gratitude for the dedicated time to physically practice. one major theme, however, was the effectiveness of the multidisciplinary, teambased approach, which was highlighted by the following comments: very educational. there was a lot of open discussion and suggestions were bounced back and forth which was nice. this was high yield, manageable length, and extremely team based. i'm glad we were able to do it within the clinical setting in which we work. areas of improvement suggested from the open-ended feedback included using different scenarios to allow for more practice and providing a finalized list of the algorithm for those who participated early in the course before the final changes were implemented, the latter of which was satisfied with the online materials distributed across the health system. what is unique to our algorithm and training sessions is that we combined training with evaluation and iterative practice improvement into a rapid cycle re-design of traditional airway practices. we incorporated multidisciplinary practice and were able to incorporate the suggestions of practicing professionals near-real time for system optimization. through the first four sessions, we made multiple revisions to the algorithm. examples of major revisions included methods for covering the tube after the intubation while the ventilator circuit was being attached. a number of other revisions were also made, addressing specific placement of equipment in the room and adding equipment to the "inside items" (marker for labeling rsi medications), as suggested by nurses. finally, different methods of communication between the team inside strongly agree with a neutral option) to assess the educational objectives of the session. finally, there was one final, opentext item asking for any additional feedback or suggestions. to increase response rates, we sent another email five days later as a reminder to participants. two intubations of real patients were carried out using the new system by two of us on the core team. (pp and gs). a post-procedural multidisciplinary debriefing was held and resulted in several more changes to the algorithm. the algorithm underwent a total of 17 iterations of substantial change. following the live patient validation and subsequent adjustments, an online video training overview was created and bundled with a package of pdfs to create print materials. this allowed for dissemination across our health system to facilitate rapid implementation at facilities that had a perceived need for such a systematic change. a total of 54 participants completed the training course over the initial seven sessions. we received 48 total responses (19 drs, 28 rns, and one rt), for a response rate of 88.8%. survey results were largely positive. specifically, there was a positive improvement in level of confidence with one's role in the intubation process. prior to the course, only 32.33% multidisciplinary intubation algorithm for suspected covid-19 patients the room and the nurse and pct outside the room were also tested, with the final decision to use readily available baby monitors. the original solution of using spectralink phones was found to be unsuccessful during the first of the trials involving an actual patient. although we did want to standardize the intubation process for patients with suspicion for covid-19 as much as possible, the algorithm still allows some room for incorporating individual physician clinical decisionmaking. recognizing different physician preferences in medications for rsi as well as post-intubation sedation, for example, we did not mandate the exact drug regimen in our algorithm. selection of ett size, method of backup plan, and placement of central or arterial line access were similarly addressed. due to different approaches to management of a patient's respiratory status, especially within the setting of rapidly evolving understanding of covid-19 and its optimal management, we did not feel as though any criteria for intubation would follow a "one size fits all" mentality and should instead be considered on a case-by-case basis. therefore, our algorithm begins after the need for intubation has been established. our focus was on optimization of the process once the clinical decision to intubate was made. we recognize that there have been many other proposed methods for minimizing the aerosolization of viral particles during intubation, in addition to other preferences for intubation techniques and use of backup devices. some institutions have even incorporated specific intubation teams that intubate all high-risk patients in the hospital. we recognize that these are all acceptable strategies for addressing the common problem. we believe that the adoption of any one system is based upon the resources, experiences, and situations that are unique to the individual ed. while we designed the details of our algorithm based on the resources available at our institution and what we determined to be the most feasible through feedback received during our training sessions, we tried to identify and include flexibility in areas we thought would have the most implementation variability. therefore, our revised airway process recommendations could be easily adapted for use at other eds. the basic structure and overall process are easily transferable, while specific materials and details could be adapted based on availability and preferences at other institutions. implementation of our streamlined process could have profound effects on efficiency of patient care, patient safety, and safety of the healthcare team. lastly, our extensive process validation that included simulation training sessions along with debriefings after our first two experiences with actual patients allowed for the development of materials to facilitate deployment of our recommended new approach to airway management to the 19 eds across our health system that see over 400,000 patients per year. in addition to our asynchronous training and print materials, we will be conducting train-the-trainer sessions in collaboration with wiser to help local champions adopt our methods for their institution efficiently and effectively. one limitation of our work is the inability to evaluate our algorithm in a large number of actual patients. the formidable challenges imposed upon the delivery of healthcare during the pandemic combined with the need to maximize the safety of healthcare providers necessitated a rapid roll-out of our revised processes based on our findings from our rapid-cycle improvement methodology. however, we do intend to collect further feedback from real-time use. another limitation to our report is that the analysis of our training sessions is limited to kirkpatrick level 1 reaction data. given the demands of our team during the pandemic, combined with the changing details of our training sessions based on the iterative feedback, a more formal assessment was not feasible. future studies could address a more formal effectiveness of the training program, focusing on team-based, nontechnical skills acquisition. a formal review of patient outcomes associated with the new airway management recommendations after implementation in the ed would also be appropriate. a multidisciplinary, team-based approach to the development and training of a standardized intubation algorithm combining simulation and a rapid-cycle improvement methodology is a useful, effective process to respond to rapidly evolving clinical information and experiences during a global pandemic. world health organization. coronavirus disease (covid-19) pandemic aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 prompting with electronic checklist improves clinician performance in medical emergencies: a high-fidelity simulation study clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review the covid-19 intubation and ventilation pathway (civp); a commentary interim clinical guidance for management of patients with confirmed coronavirus disease (covid-19) recommendations for endotracheal intubation of covid-19 patients intubation and ventilation amid the covid-19 outbreak: wuhan's experience design thinking-informed simulation: an innovative framework to test, evaluate, and modify new clinical infrastructure the study of factors affecting human and systems performance in healthcare using simulation the effect of a simulationbased training intervention on the performance of established critical care unit teams simulation as a tool to facilitate practice changes in teams taking care of patients under investigation for ebola virus disease in spain rapid development and deployment of ebola readiness training across an academic health system: the critical role of simulation education, consulting, and systems integration simulation-based training of extracorporeal membrane oxygenation during h1n1 influenza pandemic: the italian experience emergency airway management in a simulation of highly contagious isolated patients: both isolation strategy and device type matter key: cord-312232-ktlrc5gx authors: comfort, alison b.; rao, lavanya; goodman, suzan; barney, angela; glymph, angela; schroeder, rosalyn; mcculloch, charles; harper, cynthia c. title: improving capacity at school-based health centers to offer adolescents counseling and access to comprehensive contraceptive services date: 2020-07-28 journal: j pediatr adolesc gynecol doi: 10.1016/j.jpag.2020.07.010 sha: doc_id: 312232 cord_uid: ktlrc5gx abstract study objectives many pediatric providers serving adolescents are not trained to offer comprehensive contraceptive services, including intrauterine devices (iuds) and implants, despite high safety and satisfaction among adolescents. this study assessed an initiative to train providers at school-based health centers (sbhcs) to offer students the full range of contraceptive methods. design surveys were administered at baseline pre-training and at follow-up three months post-training. data were analyzed using generalized estimating equations for clustered data to examine clinical practice changes. setting eleven contraceptive trainings across the us from 2016-2019 participants two hundred-sixty providers from 158 sbhcs serving 135,800 students interventions on-site training to strengthen patient-centered counseling and equip practitioners to integrate iuds and implants into contraceptive services. main outcome measures the outcomes included counseling experience on iuds and implants, knowledge of patient eligibility, and clinician method skills. results at follow-up, providers were significantly more likely to report having enough experience to counsel on iuds (adjusted odds ratio [aor]: 4.08; 95% confidence interval [ci], 2.62—6.36]) and implants (aor: 3.06; 95% ci, 2.05 – 4.57). provider knowledge about patient eligibility for iuds, including for adolescents, increased (p<0.001). providers were more likely to offer same-visit iud (aor: 2.10; 95% ci, 1.41 – 3.12) and implant services (aor: 1.66; 95% ci, 1.44 – 1.91). clinicians’ skills with contraceptive devices improved, including for a newly available low-cost iud (aor:2.21; 95% ci, 1.45-3.36). conclusions offering an evidence-based training is a promising approach to increase counseling and access to comprehensive contraceptive services at sbhcs. providing adolescents with access to comprehensive contraceptive services can empower them to select their preferred method if they want to prevent pregnancy. many pediatric providers serving adolescents are not trained to offer patients a full range of contraceptives, including iuds and the implant, 1,2 despite high safety and acceptability for these methods among adolescents 3, 4 and high satisfaction and continuation rates. [5] [6] [7] national survey data of contraceptive providers show that many providers hesitate to offer the iud to adolescents due to providers' outdated views on patient eligibility. 8, 9 primary care providers, as compared to obstetricians and gynecologists, are less likely to have received training in iuds and implants. 10 the american college of obstetricians and gynecologists and the american academy of pediatrics both recommend that providers include these contraceptive methods in contraceptive counseling for adolescents, alongside other reversible methods. 11, 12 the centers for disease control and prevention also state that iuds and implants are appropriate for adolescent and nulliparous women. 13 however, knowledge of contraceptives is incomplete among adolescents, and particularly low for the iud and implant. 14 access barriers represent one among several factors which may limit adolescents' ability to use their contraceptive method of choice. 15 other barriers to access that may be exacerbated for adolescents include high upfront costs and waiting periods where patients are asked to return for multiple clinic visits to obtain these methods. 16, 17 access to comprehensive services for adolescents is especially challenging during a time when there is emphasis in federal policies to support abstinence-only education and to restrict contraceptive funding for adolescent health education. 18 adolescence is an important time to learn accurate reproductive health information. in 2017, 40% of adolescents aged 15-19 reported having had sexual intercourse, with 20% of students by 9 th grade having had sexual intercourse compared to more than half of students (57%) by 12 th grade. 19 one promising approach to increase adolescent contraceptive education, counseling and access to services is through school-based health centers (sbhcs). indeed, a systematic review of studies on the impact of providing reproductive health services through sbhcs on adolescents' sexual and reproductive health identified some positive effects on condom use and hormonal contraceptive use among the more rigorous evaluations. 20 however, sbhcs vary in terms of the reproductive and sexual health services they offer, which can include contraceptive counseling, pregnancy testing, vaccination against the human papillomavirus, and on-site diagnosis and treatment of stis. 21 however, currently less than 40% of sbhcs nationwide provide contraceptive methods onsite, 22 and fewer still offer implants (6%) and iuds (5% ) onsite. [21] [22] while half of all sbhcs are prohibited from dispensing contraceptives, most commonly due to school district policy, there are many schools with potential to offer high-quality care. 21 training providers at sbhcs on patient-centered counseling and full contraceptive services could be an effective strategy to ensure adolescents have access to their method of choice. offering contraceptive counseling and services on school campuses could be helpful for adolescents who wish to prevent pregnancy and/or stis. notably, a majority of adolescents and young adults report that they trust a clinician or a health care provider for birth control information. 23 in addition, sbhcs are considered a highly effective strategy for providing preventive and comprehensive health services to young people, especially for those who are uninsured, low-income, or underserved by other health care settings. 20, 22 sbhcs often represent the first point of contact with the health care system for many adolescents. 24 providing health services, including contraception through sbhcs, can increase access to comprehensive and non-stigmatizing health services for adolescents, provide links between schools and communities, and reduce transportation costs. 20 furthermore, in light of the covid-19 pandemic, there are increasing concerns about ensuring access to contraceptive services 25 especially for adolescents who may have limited privacy for telehealth services from home. sbhcs may become even more important in delivering health services, 26 in prior research, we developed and tested a provider contraceptive training intervention in a cluster randomized-controlled trial among adolescents and young adults. 28 the trial demonstrated significant effects of the training on provider knowledge and clinical practice change. specifically, we saw increased counseling on the full range of methods and greater capacity to offer patients iuds and implants, without compromising patient autonomy in contraceptive decision-making, or other contraceptive and sti prevention outcomes. 28 adolescents, along with young adults, were more likely to know about and choose iuds and implants after being counseled on the full range of contraceptive methods. 4 providers demonstrated sustained improvements one year post-training in knowledge, attitudes and practice. 29 following the randomized trial, we adapted and scaled the provider training intervention to different practice settings, including sbhcs, in an implementation science phase. as part of the scale-up, we drew on a leading theory in clinical practice change, the diffusion of innovation, 30 by starting with the experts in specialized care or 'early adopters', and expanding out to the 'early majority' or those providers willing to adopt evidence-based practice changes. following the principles of implementation science research, 30 we adapted the training to the needs of the practice setting, which in this study were sbhcs interested in strengthening their contraceptive services. specifically, the training we offered to sbhcs focused on patient-centered counseling for adolescents. the intervention addressed adolescents' access to the full range of contraceptive methods, helping overcome barriers on the provider side, including a lack of training in counseling and provision of iuds and implants. this study evaluates the scaling of the provider training intervention to sbhcs to test whether it contributed to enhanced provider capacity to provide full contraceptive services. our study assessed the effect of an evidence-based provider training on contraceptive counseling and access to the full range of contraceptive services including iuds and implants on providers' knowledge, skills, counseling and provision practices ( figure 1 ). we implemented the training throughout the u.s. among providers and health educators at sbhcs and local community referral clinics. a total of 11 trainings were implemented between 2016 and 2019, with 260 health care providers trained from 158 sbhcs that served approximately 135,800 students across albuquerque, chicago, los angeles, minneapolis, new york, portland, san francisco bay area, seattle, and washington d.c. this sbhc sample was part of a larger implementation science initiative among a variety of practice settings. 31 we offered the training to sbhcs meeting the following conditions: they were open to learning new skills and techniques, following our theoretical framework; they were part of networks of sbhcs interested in contraceptive care; and they had the support of their school systems. 30 most of the sites provided contraceptives on-site. data available from 2017 onwards showed that 68% offered iuds and implants on-site. the training was offered to providers and staff at sbhcs with patient care responsibility; these included physicians, nurse practitioners, and counselors/health educators, as well as support staff, such as medical assistants and social workers. for cost efficiency, the trainings typically included several sbhcs operating within a geographic area, through public health departments and/or school districts. to measure training impact on provider knowledge and clinical practice change, we collected data from providers on socio-demographic characteristics, provider type, and contraceptive knowledge, counseling and provision practices. we collected baseline data prior to the training and follow-up data 3 months after the training. the provider training, a continuing education-accredited course from the university of california, san francisco school of medicine, involved an on-site training to equip participants to use patient-centered counseling, and provide the full range of contraceptive methods, including condoms for sti prevention. the training adopted an all-staff approach to ensure clinic-wide changes in culture and practices, which is particularly important in high turnover settings and low resource clinics. the trainings also included local referral clinics in order to strengthen the sbhcs' referral networks, because not all sbhcs were able to offer contraceptive devices on-site. the course was informed by a rights and equity framework 32 focusing on ethical issues specific to iuds and implants, with discussions on the importance of upholding patients' reproductive autonomy, issues around coercion and provider bias, and the importance of method removal upon patient request. the training also covered updated evidence on all methods, including medical eligibility for iuds and implants. clinicians were offered a hands-on practicum to practice iud placement and removal with uterine models, while health educators and other staff were offered an interactive contraceptive counseling session. an important component of the training was to address clinic flow and systems issues including reimbursement to be able to offer same-day services, and the strengthening of referral networks to promote the continuum of care. 15 this evaluation was approved by the university of california, san francisco institutional review board. we evaluated the quality of the training using data from the formal continuing medical education (cme) course evaluation. we assessed training quality, educational content, and faculty quality, with responses on a 5-point likert scale (poor, fair, good, very good, excellent). we asked whether issues of cultural and linguistic competency in diverse populations were adequately addressed (yes/no) and whether attendees intended to change their practice (not at all, unlikely, somewhat likely, highly likely, definitely likely). study outcomes included provider knowledge, counseling skills, and provision practices at follow-up. we assessed provider knowledge with a 6-item scale that has been validated and adapted from prior research. 8 to measure changes in provider counseling skills, we collected data from participants on whether they felt they had enough experience to counsel on iuds and implants (strongly agree, agree, disagree, strongly disagree). we created dichotomized variables that take a value of 1 if the provider "strongly agrees" or "agrees" and 0 for "disagrees" or "strongly disagrees". we assessed changes in clinic practice by asking whether the clinic offered same-day services, as an access measure. 33 among clinicians, we assessed whether they had acquired the skills to feel comfortable inserting an iud (including levonorgestrel devices, mirena®, skyla®, liletta®, and the copper iud) and the implant (nexplanon®). we used likert scales (strongly agree, agree, disagree, strongly disagree) and coded the outcome 1 for "strongly agrees" or "agrees" and 0 for "disagrees" or "strongly disagrees". we included a covariate for provider type (clinician/non-clinician) and year of training. the analytic sample included all clinic staff who received the training and had patient care responsibilities (n=260). to examine training impact on clinical practice outcomes, we used a repeated cross-sections approach, including data from all providers completing a baseline or follow-up survey. 34 this approach is the most appropriate for the study design, allowing us to account for differences in clinical practice pre-and post-training, and for any staff turnover. we used generalized estimating equations (gee) to assess changes in study outcomes from baseline to follow-up. we used multivariable regressions to assess changes in provider knowledge, counseling skills and provision practices, adjusting for provider type (clinicians versus non-clinician) and training year. observations were clustered by training and within health centers, as trainings were hosted by an organizing agency and included all affiliated sbhcs. we used gee to account for correlation within trainings and by extension within clinics. for the continuous outcome, the provider knowledge scale, we used an identity link with a gaussian distribution. for dichotomous outcomes for counseling and provision skills, we used a logit link with a binomial distribution. we used cluster robust standard errors at the training level. we used the stata option "nmp" to adjust the standard errors for the number of predictors in the model given the relatively small number of trainings (n=11). we conducted an attrition analysis to assess whether there were differences in key baseline characteristics, including age, gender, race, provider type (clinician), and level of education, between respondents and non-respondents at follow-up. analyses were conducted in stata 16 (stata corp, college station, tx), and significance levels reported at p ≤ 0.05. among the 260 clinic staff participating in the trainings, 238 (92%) completed the baseline survey. the response rate at follow-up was 67% (173/260). results from the attrition analysis showed that there were no significant differences in characteristics between respondents and non-respondents at followup for age, gender, race/ethnicity, or educational level. however, we found that clinicians were less likely to respond at follow-up compared to non-clinicians. the sample of participants trained included the full care team: 10% were physicians, 9% physician assistants, 32% nurse practitioners, 5% registered nurses, 7% medical assistants, 14% counselors/health educators and 7% social workers (table 1) . on average, the clinic staff were 38 years old and 93% identified as female. about half identified as white (54%), 14% as black, 11% as hispanic/latinx, 9% as asian/pacific islander, and 12% as other race/ethnicity. the majority of participants (72%) had a graduate or professional degree. almost all (96%) believed that students should have access to the full range of contraceptive methods through sbhcs (figure 2) . likewise, almost all sbhc providers (95%) reported routinely counseling on condom use, both at baseline and follow-up. almost all clinic staff (81%) believed that students had misperceptions about birth control and only about a third believed that students were knowledgeable about iuds (30%) and implants (34%). participant had high ratings of overall quality of the training intervention, the faculty, and educational content (4.5, 4.6, and 4.5 respectively out of a scale of 1 to 5). ninety-one percent reported that issues of cultural and linguistic competency in diverse populations were adequately addressed in the course, and 97% reported an intention to change practice. provider knowledge about the range of patients who are eligible for iuds increased significantly. the knowledge scale measuring patient eligibility for iuds, including adolescents and nulliparous women, increased from 0.85 at baseline to 0.91 at follow-up (p ≤ 0.001) ( table 2 ). this evaluation identified significant improvements among providers at sbhcs in knowledge, counseling skills and provision practices, with increased capacity to offer adolescents interested in iuds or the implant with these methods. the training improved knowledge about these methods and led providers to feel experienced in counseling on these methods. among the clinicians, the hands-on training practicum also led them to feel more comfortable providing different methods. in particular, there were substantial increases in skills providing the newly available low-cost levonorgestrel iud, liletta®, from 16% of clinicians at baseline to 27% at follow-up reporting they felt comfortable providing this method. the training also led providers to be more likely to offer same-day iud and implant services upon patient request, a component to improving access to these methods. these results showed that this training intervention can be scaled and adapted to different health provider contexts, specifically sbhcs. these positive impacts within sbhcs highlight that the training intervention is an effective way to enable providers that serve adolescents to integrate iuds and implants into their counseling and contraceptive services. adolescents are increasingly more likely to use a contraceptive method at last intercourse. 35 the most common methods used by sexually active women aged 15-19 is condoms (55%), followed by the pill (27%), and withdrawal (26%). in contrast, only 7% of sexually active women ages 15-19 have used the intrauterine device (iud) and subdermal implant. 36 however, method choice is not necessarily a reliable measure of adolescents' preference because it assumes that the method was freely chosen over other methods without considering barriers to access. 37 studies on method preference among adolescents find that while there are relatively low rates of use of long-acting reversible contraceptives, up to 61-69% of adolescents would prefer using these methods. 3 increasing access to preferred methods is an important component of contraceptive care that respects patient reproductive autonomy. 37 barriers to contraceptive access may play an especially important role in limiting adolescents' ability to access the full range of contraceptive methods and choose their preferred method. 38 emphasizing patient preferences and voluntary method choice is essential for all age groups, including adolescents. it is also important to highlight that the training focuses on counseling about iuds and implants together with condoms, given potential concerns with sti rates. our randomized controlled trial confirmed that the training intervention did not compromise condom use nor did it result in increased sti rates, 39 in contrast to concerns about increasing access to iuds and implants among young people. 40 while our results highlight that the provider training was effective in improving sbhc providers' knowledge, counseling skills and provision practices, there remain significant challenges in working with sbhcs to ensure adolescents' access to comprehensive services. since so many sbhcs face limitations in offering contraceptive services as a result of restrictions at the state, school district, and school level, 21 training referral clinics is also relevant, as was done in our intervention. while sbhcs reach an important adolescent population, youth-friendly clinics outside of schools remain essential points of care, especially in regions where contraceptive services available at sbhcs are restricted. our evaluation focuses on specific provider-related barriers to access for contraceptive services. sameday provision and provider competency are important aspects of access that our intervention targets. nonetheless, there is also a need to more broadly address other aspects of the continuum of contraceptive care, from community outreach and trust building to follow-up support and identifying interventions that address structural and social contexts. 15 while our sample included trainings across different regional contexts in the us, it comprised sites supportive of contraceptive education and access, with most providing contraceptives on-site. implementing the intervention with sbhcs across different geographic regions and school districts requires substantial programmatic effort, as each district has its own requirements and permissions. the sample size for this study was relatively small to measure intervention impact for the clinician-only measures. we cannot rule out external factors that may account for the changes measured in this implementation science scale up to a new practice setting. nevertheless, the results were similar to the data in our randomized trial showing clinical practice changes. 29 this study reflects the counseling practices and clinician skills at the sbhc itself, but we did not collect data on referrals. although sbhcs often provide referrals for contraceptive services off-site, referrals do not guarantee that adolescents will follow through on referrals, either due to confidentiality concerns, transportation issues, costs, or capacity to schedule a visit amidst other competing priorities. 22 understanding changes in referral patterns after the training, however, could help us to understand the impact of the intervention on sbhcs that work in restrictive environments. this study demonstrated the impact of adapting a provider training intervention post-randomized trial to the context of sbhcs. our findings highlighted that offering provider training to sbhcs is an effective way to improve adolescents' access to full contraceptive services. this is especially important in the current policy environment, which is increasingly restrictive of contraceptive services and sexual education for adolescents, 18 and with access to clinic services further challenged by the covid-19 pandemic. 25 these results show that this provider training is an effective approach that can be scaled and replicated across sbhcs to enable adolescents to have access to the full range of contraceptive methods. the authors do not have any conflicts of interest to disclose. meeting the contraceptive needs of teens and young adults: youth-friendly and long-acting reversible contraceptive services in u.s. family planning facilities factors associated with provision of long-acting reversible contraception among adolescent health care providers acceptance of long-acting reversible contraceptive methods by adolescent participants in the contraceptive choice project long-acting reversible contraception counseling and use for older adolescents and nulliparous women satisfaction with the intrauterine device insertion procedure among adolescent and young adult women continuation and satisfaction of reversible contraception three-year continuation of reversible contraception challenges in translating evidence to practice: the provision of intrauterine contraception counseling and provision of long-acting reversible contraception in the us: national survey of nurse practitioners evidence-based iud practice: family physicians and obstetrician-gynecologists acog committee opinion: adolescents and long-acting reversible contraception: implants and intrauterine devices mmwr recomm rep attitudes and beliefs about the intrauterine device among teenagers and young women beyond same-day long-acting reversible contraceptive access: a person-centered framework for advancing high-quality, equitable contraceptive care a missed opportunity for care: two-visit iud insertion protocols inhibit placement long-acting reversible contraception for adolescents and young adults: patient and provider perspectives the trump administration and the abandonment of teen pregnancy prevention programs youth risk behavior surveillance -united states a systematic review of the role of school-based healthcare in adolescent sexual, reproductive, and mental health school-based health alliance census report meeting the sexual and reproductive health needs of adolescents in school-based health centers the fog zone: how misperceptions, magical thinking, and ambivalence put young adults at risk for unplanned pregnancy. 2009, national campaign to prevent teen and unplanned pregnancy school-based health centers in an era of health care reform: building on history in the response to covid-19, we can't forget health system commitments to contraception and family planning school-based health centers can deliver care to vulnerable populations during covid-19 pandemic school-based health alliance. strategies to continue providing care during school closures reductions in pregnancy rates in the usa with longacting reversible contraception: a cluster randomised trial training contraceptive providers to offer intrauterine devices and implants in contraceptive care: a cluster randomized trial disseminating innovations in health care bringing a contraceptive training to scale nationally: implementation science of an intervention across blue and red states california family planning health care providers' challenges to same-day long-acting reversible contraception provision regression methods in biostatistics: linear, logistic, survival, and repeated measures models youth risk behavior surveillance -united states changing patterns of contraceptive use and the decline in rates of pregnancy and birth among us adolescents challenging unintended pregnancy as an indicator of reproductive autonomy unmet demand for short-acting hormonal and long-acting reversible contraception among community college students in texas the impact of an iud and implant intervention on dual method use among young women: results from a cluster randomized trial long-acting reversible contraception and condom use among female us high school students: implications for sexually transmitted infection prevention this scale has 6-items asking providers if they would consider a patient eligible for an iud if: nulliparous, adolescent, immediately post-abortion, hiv positive, or with a history of sti or pid in the last 2 years robust standard errors clustered at training level. coef= coefficient, aor=adjusted odds ratio, ci = confidence interval. models adjusted for provider type and training year we would like to thank participants in our training intervention, including collaborating organizations such as peer health exchange which helped bring together sbhcs. we would also like to acknowledge our expert clinician and health educator teams and staff, including connie folse, nina pine, maya blum, janelli vallin, lauren coy, and caitlin quade. we are grateful to the jpb foundation for supporting this work (grant number 1088). key: cord-288933-q3b0r5ig authors: bushell, mary; frost, jane; deeks, louise; kosari, sam; hussain, zahid; naunton, mark title: evaluation of vaccination training in pharmacy curriculum: preparing students for workforce needs date: 2020-08-20 journal: pharmacy (basel) doi: 10.3390/pharmacy8030151 sha: doc_id: 288933 cord_uid: q3b0r5ig background: to introduce and evaluate a university vaccination training program, preparing final year bachelor of pharmacy (bpharm) and master of pharmacy (mpharm) students to administer vaccinations to children and adults in community pharmacy and offsite (mobile and outreach) settings. methods: final year bpharm and mpharm students were trained to administer intramuscular vaccinations to adults and children. the education program embedded in pharmacy degree curriculum was congruent with the requirements of the australian national immunisation education framework. the training used a mix of pedagogies including online learning; interactive lectures; and simulation, which included augmented reality and role play. all pharmacy students completing the program in 2019 were required to carry out preand post-knowledge assessments. student skill of vaccination was assessed using an objective structured clinical assessment rubric. students were invited to complete pre and post questionnaires on confidence. the post questionnaire incorporated student evaluation of learning experience questions. results: in both cohorts, student vaccination knowledge increased significantly after the completion of the vaccination training program; pre-intervention and post-intervention mean knowledge score (sd) of bpharm and mpharm were (14.3 ± 2.7 vs. 22.7 ± 3.3; p < 0.001) and (15.7 ± 2.9 vs. 21.4 ± 3.2; p < 0.001) respectively. there was no difference between the bpharm and mpharm in the overall knowledge test scores, (p = 0.81; p = 0.95) pre and post scores respectively. using the osca rubric, all students (n = 52) were identified as competent in the skill of injection and could administer an im deltoid injection to a child and adult mannequin. students agreed that the training increased their self-confidence to administer injections to both children and adults. students found value in the use of mixed reality to enhance student understanding of the anatomy of injection sites. conclusion: the developed vaccination training program improved both student knowledge and confidence. pharmacy students who complete such training should be able to administer vaccinations to children and adults, improving workforce capability. mixed reality in the education of pharmacy students can be used to improve student satisfaction and enhance learning. vaccination and injection skills training has been taught in some australian pharmacy degree curriculums since 2013 [1] . indeed, training was being taught in pharmacy schools before pharmacists were administering vaccinations in the practice setting [1, 2] . the rationale for this was that both the profession and pharmacy schools were anticipating regulation change to expand the scope of practice to enable pharmacist-administered vaccination [1] . teaching and upskilling pharmacy students to vaccinate would enable a work-ready graduate. in 2014, queensland became the first jurisdiction, outside a pilot program, to modify regulations to enable pharmacists to vaccinate [3] . since then, regulations across all australian states and territories have been modified to allow appropriately trained pharmacists to administer vaccinations to adults and more recently children aged 10 and over [4] [5] [6] [7] [8] . many pharmacy students across australia have now completed vaccination training embedded within their university degree; however, until march 2019, training was not formally recognized. that is, students would complete university vaccination training, and then, once registered (provisionally or fully, dependent on jurisdictional regulation), complete training delivered by an external provider (e.g., pharmaceutical society of australia or pharmacy guild of australia) to be certified competent to vaccinate [9, 10] . this resulted in duplication of training for many early career pharmacists and an inherent lag time between original knowledge and skills development and administration of vaccines in the practice setting. in march 2019, the australian pharmacy council (apc), the body responsible for the accreditation of pharmacy education in australia and new zealand, published the standards for the accreditation of programs to support pharmacist administration of vaccines version 1.1 [11] . the apc amended the standard to enable pharmacy students enrolled in an accredited pharmacy degree program, to complete a vaccination training program delivered either within the degree program curriculum or via an external provider, during their period of study [11] . this change enabled universities to train and certify students to vaccinate. however, authorization to administer vaccinations is determined by state and territory legislation; at the time of writing, regulations preclude pharmacy student vaccinations in all australian states and territories. however, the move by the apc to recognize vaccination training embedded in pharmacy degrees removes duplicity of vaccination training and enables students to be ready to vaccinate once they register. the scope of practice of the australian pharmacist vaccinator is constantly evolving to include more vaccinations and expand the age groups that pharmacists can vaccinate to. the eligible age of patients that pharmacists can vaccinate varies across jurisdictions. interestingly, even within a state or territory, the eligible age to vaccinate differs between vaccines. from may 2020, appropriately trained pharmacists across all states and territories can administer the influenza vaccine to children aged 10 and over [5, 6, 8, 12] . in most jurisdictions, pharmacists can administer measles-mumps-rubella (mmr) and whooping cough (dtpa) to individuals 16 and over. while in victoria, pharmacists can administer the mmr and dtpa vaccines to people aged 15 years and over [7] . there is a clear trend to lower the age limit eligibility and increase the type of pharmacist-administered vaccinations, improving accessibility and vaccine uptake. more recently, regulation has been modified to enable pharmacists to administer vaccines outside the pharmacy setting via both mobile and outreach services [7] . therefore, it is appropriate that pharmacy students are trained and certified competent to deliver a vaccination service to both children (aged 10 and up) and adults. to date, most australian pharmacy schools have integrated vaccination training into undergraduate and postgraduate pharmacy degrees, with a focus on administering vaccinations to adults [2, 13] . the vaccination training program developed by the authors and evaluated in this paper, used the learning outcomes for the national immunization education framework for health professionals [14] . this paper describes and evaluates the teaching and learning of vaccination training embedded in the pharmacy curriculum at the university of canberra. a vaccination training program (vtp) was developed in line with the national immunization education framework for health professionals (the framework) [14] . this framework was designed to facilitate the development of nationally consistent, quality education programs for australian health professionals, who are not medical practitioners, who want to be recognized as competent to administer vaccinations within their scope of practice. the university vtp adopted the core learning objectives and outcomes from the framework, and then the teaching team adapted them to be pharmacy specific. to do this, the standards and guidelines specific to pharmacy (professional practice standards, practice guidelines for the provision of immunization services within pharmacy) [15, 16] were considered and integrated where appropriate. vaccination training has been embedded in the bachelor and master of pharmacy degrees at the university of canberra since 2016. the training, co delivered by pharmacists, pharmacy and nursing academics (all authorized immunizers), focused on teaching the knowledge and skills to administer vaccinations to adults. in 2019, to ensure that teaching and learning is congruent with contemporary pharmacy practice, this training was expanded to include content and skills assessment of injections to children. as the pharmacist vaccinators did not have, at that point, experience administering vaccinations to children, a nurse practitioner qualified to provide immunizations, delivered the content, theory, skills training, and assessment related to children. pharmacists work as part of a broader health care team. the developed vaccination training program was taught via an interprofessional teaching team, which included pharmacist and nurse vaccinators. with reference to and consistent with the literature on pharmacy student vaccination training, there were a variety of educational pedagogies used to promote understanding and skill competency [13] . teaching included both face-to-face (internal) and non-face-to-face learning opportunities and delivery of content. see table 1 . students were given access to the online non-face-to-face content at semester commencement. this learning material could be completed by students in an asynchronous fashion prior to the intensive workshops. the face-to face content was delivered over four intensive whole day sessions. students were taught the knowledge and skills to administer both im and subcutaneous (sc) vaccinations and how to appropriately manage anaphylaxis. to simulate environments and prepare students for real experience, the training program used the following: role-plays, mannequins, standardized patients, and mixed reality. students had to role play and administer vaccinations to both a pediatric and adult low fidelity mannequin. a mixed reality simulation technique using the microsoft hololens head-mounted devices along with the gigxr applications holohuman and holopatient were used in the face -to-face delivery. the two applications were used to augment the students understanding of anatomy and physiology and to view a simulated patient who was portraying symptoms of anaphylaxis. holohuman is an anatomy application that allows a student to gain a spatial understanding of anatomy and walk through the holographic body. as the student walks through the holographic image, layers of virtual anatomy peel away to reveal the underlying structures. this provided students with a unique way of identifying landmarks (i.e., deltoid muscle) for intramuscular (im) vaccination. it was used to enable students to visualize the shoulder (synovial) joint and to recognize why a shoulder injury related to vaccine administration (sirva) would occur if given too high. mixed reality has the power to engage the learner in a variety of interactive ways, which until this point have not been possible. students skill competency was assessed using an objective structured skills assessment (osca). see appendix a. an authorized immunizer assessed student skill competency to administer a vaccination to both an adult and child mannequin and provided feedback at the end of the assessment. students completed identical pre-and post-knowledge assessments on the content taught on the topic of vaccination. thirty questions assessed understanding of the topics taught. there were questions that assessed knowledge of the national immunization schedule, immunological principles of vaccination, vaccine preventable diseases, the different types of vaccines and how they elicit an immune response, current legislation and regulations related to pharmacist administered vaccination, vaccine cold chain, how to appropriately administer vaccines, documenting the vaccination service, and managing anaphylaxis. to enable matching of the pre-and post-vaccination knowledge tests, while enabling students to be deidentified, students had to provide an answer to questions, such as who was their first teacher and the day of the month they were born, on both the pre and post-tests. all students completing the vaccination training, embedded in the unit pharmacy practice 4, were invited to participate in the evaluation of the training program by completing a hard copy questionnaire at the completion of the training. participating in the evaluation questionnaire was voluntary and no payment or other incentive was provided. the questionnaire was developed by the authors of this paper. questionnaires were face validated by pharmacy and nursing academics, all authorized vaccinators. each evaluation questionnaire included 19 questions that required students to rate their level of agreement on 5-point likert scale (strongly agree to strongly disagree) and two free text questions. one question asked what the student liked about the vaccination training, the other how the vaccination training could be improved. descriptive statistics were conducted. free text responses were analyzed to identify repeating themes. all subjects gave their informed consent for inclusion before they participated in the study. the study was conducted in accordance with the declaration of helsinki, and the project was approved by the human research ethics committee of the university of canberra (hrec17-138). in total, in 2019, 52 students completed the vaccination training. of this, 34 (65.4%) were enrolled in the final year of bpharm and 18 (34.6%) were enrolled in the final year of the m pharm degree. see table 2 . when combined, 19/52 (36.5%) had a current first aid certificate, 12/52 (23.1%) had a current mental health first aid certificate, and 48/52 (92.3%) were currently working in a pharmacy. see table 3 . there was no association between working in pharmacy, having a current first aid certificate and/or mental health first aid certificate and the mean knowledge score of the pre-test. the only statistically significant finding was that students who held a first aid certificate performed better than students who did not have a first aid certificate on the post-knowledge test (p = 0.014). the mean pre-intervention knowledge score for the cohort was 14/30, while the post intervention knowledge score was 22/30. the difference in mean vaccination knowledge scores pre and post educational intervention was better (p < 0.001) with a large effect size (cohens d = 0.75). see table 2 . the results show that there was no statistically significant difference between the scores for the knowledge assessment between bachelor and master cohorts. bpharm students mean score pre-educational intervention was 15/30, and for master of pharmacy students it was 16/30. the mean score post-intervention was 23/30 for b.pharm students, and 21/30 for m.pharm students (p = 0.95). using the osca rubric, all students (mpharm and bpharm) completing the training program were identified as competent in the skill of injection. all students (n = 52) scored a yes against the 25 criteria of the osca rubric (appendix a). all students could administer an im deltoid injection to a child and adult mannequin. all students (n = 52, 100%) either agreed (16/52, 31%) or strongly agreed (36/52, 69%) that the vaccination training enhanced their knowledge of vaccination. all students (n = 52, 100%) either agreed (6/52, 11%) or strongly agreed (46/52, 89%) that the practical session of administering a vaccine was useful/beneficial. all students (n = 52, 100%) either agreed (9/52, 17%) or strongly agreed (43/52, 83%) that the practical session increased their confidence to administer vaccinations. when asked 'i feel confident that i know the correct vaccination technique for both adults and children', one student (1.9%) responded neutral, 29/52 (58%) agreed and 22/52 (42%) strongly agreed. students voiced value in having the content delivered by an interprofessional teaching team, which included pharmacists and nurses. a sample of students provided simple but positive comments like: "good teaching team" pharmacy student a. students were both satisfied and valued the integration of mixed reality in the vaccination training. students voiced that it helped with the understanding of certain concepts, for example, shoulder injury related to vaccine administration (sirva). from the feedback evaluation form: "walking into the holohuman was really neat. i liked that the layers of the human peeled away and it felt like i looking inside a human layer by layer. it helped my understanding not only of anatomy but the importance of making sure when administering an injection, i administer it in the right spot." pharmacy student b. students' knowledge significantly increased post the educational intervention vaccination training. there was no difference between bpharm and mpharm student knowledge pre or post education intervention. this indicates that delivery of the training program in the final year of both degrees enables comparable understanding of the content and skills taught and a work ready graduate. one finding was that students who had completed a first aid certificate, had higher post vaccination training knowledge scores. this finding is interesting as students did not have a higher mean pre knowledge test score. one possible reason for this is that students complete first aid training as adjunct training, that is, while it is recommended, it is not compulsory for students to complete. students have gone above expectation to complete the training and have demonstrated commitment to continuing education. this attitude to study may be extrapolated to their commitment to the vaccination training and the larger unit in which the training is embedded. many recent studies have shown that an individual's grit, perseverance and passion for long term goals is associated with higher academic grades [17, 18] . the training employed a range of teaching pedagogies to promote student understanding, skill competency and confidence. simulation is a learner-centred educational pedagogy that facilitates learning by exposing the learner to a situation which is based on or mimics a real-life event. simulation includes a broad range of activities. the use of simulation as an educational tool enables experiential learning and constructivism. it provides students with an opportunity to create their own meaning and co-construct knowledge in a safe environment, taking knowledge learnt from the lectures to application of the skill. consistent with the literature, this teaching evaluation shows that student's value and like to learn using simulation when being taught medical skills, such as vaccination [19] . students learnt how to administer both an im vaccination to a child and adult low fidelity mannequin. a recent study showed that the use of high-fidelity simulation mannequins as a teaching tool resulted in lower or equal student performance of clinical skills when compared to low-fidelity simulation mannequins [20] . the use of the different low fidelity mannequins enabled students to learn how to best position themselves to administer the vaccination safely at a 90-degree angle. students were educated to be seated when administering a vaccine to a seated individual. using appropriately sized mannequins showed students why vaccinations given by a standing immunizer to a seated individual are linked with increased risk of being administered too high. using the different mannequins provided students with a safe environment to problem-solve and learn prior to practicing in the professional setting [21] . mixed reality (mr) is an emerging technology in health care education [22] . consistent with previous studies exploring student acceptability, students enjoyed and valued the integration of this teaching tool in the vaccination training [23] . to correctly identify the im deltoid injection site, pharmacy students were taught to use anatomical markers. they were taught to create a 'triangle' over the individuals' deltoid with their fingers, the centre of which the injection is administered. they were educated to locate the acromion process (shoulder tip) and place their index finger (or first finger) along it. then to place the second and third finger down underneath the index finger (the third finger becomes the base of the triangle). the fourth finger is then opened to create a 'side' of the triangle. in the middle (not the top or the bottom) of the triangle, the injection should be made. using mr enabled students to peel away the body to see these important anatomical markers, contextualizing and providing insight as to why the content was taught and the potential outcomes of incorrect vaccine administration. students using the mixed reality anatomical software could visually see, using the 3d animation, that vaccines that are administered too low can be injected into the radial nerve, while vaccines that that are given too far to the side can cause damage to the axillary nerve. this highlights the importance of administering the vaccination into the correct area. role play enabled the students to step through the process of delivering the vaccination service and encouraged both peer learning and formative feedback. using role play, students learnt to communicate appropriate, evidence-based information about benefits and the potential risks of vaccination and obtain valid consent. the active learning approach is widely used in higher education and allows learning across cognitive, psychomotor, and affective domains [24] . pharmacists work as part of a broader health care team. one strength of the vaccination training program was that it used an interprofessional teaching team. in doing so, students were provided with an opportunity for interprofessional learning and practice. this strengthened program delivery and enabled students to see the value of interprofessional collaborative practice, which will continue in the practice setting [25] . while both internationally and nationally there are only a small number of studies published on the delivery and evaluation of pharmacy vaccination training in pharmacy schools, the results of this study are consistent with other published evaluations [2, 26] . across the studies, students' value gaining new knowledge and skills and report confidence to administer vaccinations on completion of training [2, 13, 26] . consistent with this study, the two australian studies that outline the development of a pharmacy vtp also used national pharmacy standards to inform material [2, 26] . in contrast, where this study reports adopting the learning outcomes from the national immunization education framework for health professionals, the other studies did not. this makes direct comparison between the training programs difficult. there are currently varied approaches to when vaccination training is embedded in degree programs. there are pharmacy schools that embed vaccination training in the earlier years of the curriculum, to enable students to see themselves as future 'clinical' health professionals [26, 27] . in the published studies, students report satisfaction and skill acquisition. they also report enabling students to see that they will be touching patients as part of their future professional role when providing care [28] . given pharmacy students in australia, can now complete a university vaccination training program and, when jurisdictional regulation allows, vaccinate without needing to complete additional training by an accredited external provider, the best year level to embed vaccination training should be further researched. in doing so, an evidence-based and consistent decision can be made about the best year level to introduce the training. further, to date, research in australia has not directly compared the delivery, skill acquisition, confidence, and competence of students across different university vaccination training programs, this too should be further explored. students, like authorized immunizers, completed vaccination training that is congruent with the national immunization education framework for health professionals and demonstrated competency. there is a case for jurisdictional regulations to be modified to enable pharmacy student-administered vaccinations. international research demonstrates that pharmacy students, under the supervision of a credentialled vaccinator, can administer vaccines safely [28, 29] . the application of skill acquisition in the clinical setting improves students' self-confidence [27, 30] . having pharmacy students ready to vaccinate on placement would enable a more work-ready graduate and a critical workforce that can be used to promote vaccination uptake. this skill is likely to be of greater use particularly in times when vaccination demand is high, for example a pandemic. if and when the covid-19 vaccine is available, mass immunization is likely to be needed in a relatively short period of time to mitigate the spread of the disease and enable international borders to reopen. pharmacy students could be used to improve workforce capability in australia. the vaccination training program described in this paper was embedded in the final year of mpharm and bpharm curriculum and enabled the same skill competency and knowledge acquisition across cohorts. the training program incorporated a suit of teaching methods, including mixed reality, which had high student acceptability. aligning with the changed scope of practice for australian pharmacists, pharmacy students learnt how to administer vaccinations to both adults and children. international research demonstrates that pharmacy students, under the supervision of a credentialled vaccinator, can administer vaccines safely. given student competency and readiness after completing vaccination training, there is a case for jurisdictional regulations to be modified to enable pharmacy student-administered vaccinations in australia. case for pharmacist administered vaccinations in australia current research: incorporating vaccine administration in pharmacy curriculum: preparing students for emerging roles australia's first pharmacist immunisation pilot-who did pharmacists inject? act government. medicines, poisons and therapeutic goods (vaccinations by pharmacists) direction poisons and therapeutic goods regulation queensland government. health (drugs and poisons) regulation 1996, drug therapy protocol-pharmacist vaccination program victorian pharmacist-administered vaccination program expansion communique northern territory government. qualifications prescribed for pharmacist to supply and administer schedule 4 vaccine. in department of health; northern territory government evaluation of a vaccination training program for pharmacy graduands in australia current research: a shot in the arm: pharmacist-administered influenza vaccine in new south wales standards for the accreditation of programs to support pharmacist administration of vaccines version 1.1 pharmacist-led immunisation in the northern territory: results from the pilot study development and design of injection skills and vaccination training program targeted for australian undergraduate pharmacy students national immunisation education framework for health professionals practice guidelines for the provision of immunisation services within pharmacy national competency standards framework grit: perseverance and passion for long-term goals building grit: the longitudinal pathways between mindset, commitment, grit, and academic outcomes the history of medical simulation high-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students a brief history of the development of mannequin simulators for clinical education and training virtual reality in pharmacy: opportunities for clinical exploring the application of mixed reality in nurse education exploring the potential of role play in higher education: development of a typology and teacher guidelines interprofessional collaborative practice for medication safety: nursing, pharmacy, and medical graduates' experiences and perspectives managing vaccine-associated anaphylaxis in the pharmacy an introductory pharmacy practice experience emphasizing student-administered vaccinations integration of first-and second-year introductory pharmacy practice experiences introductory and advanced pharmacy practice experiences within campus-based influenza clinics a literature review of the impact of pharmacy students in immunization initiatives the authors would like to thank louise mcclean for helping to assess students. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. pharmacy 2020, 8, 151 appendix a table a1 . osce: administration of medication by intra-muscular injection (imi). demonstrates: the ability to administer imi into the deltoid muscle. assessor question: where would you find information regarding the drug class, action and side effects of this drug? key: cord-328315-idel6l11 authors: mellor, nicholas; horton, hetty; luke, david; meadows, jon; chatterjee, arunangsu; gale, thomas title: experience of using simulation technology and analytics during the ebola crisis to empower frontline health workers and improve the integrity of public health systems date: 2016-12-31 journal: procedia engineering doi: 10.1016/j.proeng.2016.08.062 sha: doc_id: 328315 cord_uid: idel6l11 abstract the ebola outbreak highlighted the challenge of health security and particularly of how best to give frontline workers the knowledge, confidence and competence to respond effectively. the goal was to develop a tool to improve infection prevention and control through local capacity building within the context of an emergency response. the research showed that digital technology could be a powerful ‘force multiplier’ allowing much greater access to high fidelity training during an outbreak and keeping it current as protocols evolved or new safety critical steps were identified. tailoring training to the local context was crucial to its relevance and accessibility. this initiative used a novel approach to the development of the training tool – ebuddi. it used agile development to co-create the tool with active participation of local communities. a further pilot showed how it could be extended to meet the longer term needs of triage training and ensure better quality assurance. in the longer term it may have the potential to improve compliance with international health regulations, be adapted for future emergencies, and contribute to global health security. the recent ebola outbreak highlighted four key areas of concern in health security. firstly, it focused attention on the importance of infection prevention and control (ipc) competence and compliance amongst frontline workers in a region as large and remote as west africa. secondly, training needed to be accessible to a wide range of people be they working in healthcare and the laboratory sectors or burial teams and maintenance staff -all with large variations in skills, knowledge and education levels [1] . these workers, whether they were professionals or volunteers, needed access to training to keep themselves, their patients, colleagues and families safe. thirdly, community engagement was vital in controlling the outbreak. finally, the need to be prepared for novel and new pathogens such as middle east respiratory syndrome coronavirus (mers-cov), severe acute respiratory syndrome coronavirus (sars-cov) and other strains showing resistance to anti-microbials. ebola was not a one off -there will be constant challenges of this nature, requiring healthcare systems to be more resilient, watchful and responsive than ever before. there are important messages to learn about health security from the ebola response, both in the west african region and globally. even highly trained international health workers lacked skills in the use of personal protective equipment (ppe) which lead to high profile cases of infection. these observations imply a problem with how such epidemics are handled and without a change in attitude and approach; similar issues could resurface in the next outbreak, as illustrated by the challenge of dealing with the endemic lassa fever in the same region [2] . in his article, 'the next epidemic -lessons from ebola', bill gates emphasised the need for better and faster training for health personnel to confront and contain an epidemic quickly [3] . he is not the only figure to draw attention to training on a global stage. multiple reviews reflect lessons learnt from community empowerment and giving the frontline the tools, knowledge and competences to contain the outbreak [4, 5] . this a lesson for all countries as highlighted by the efn report on eu health professionals' perceptions of preparedness for ebola and infectious diseases of high consequence (idhc) 'we are not prepared unless we are all prepared' [6] . in addition there was the recognition of the importance of innovation and finding smarter ways of responding, but most initiatives struggled to realise their full potential [7, 8, 9] . simulated training can 'bring learning alive' and increase engagement levels [10] . it encourages teamwork, in particular the role of the buddy, which is vital in situations where ppe is required. the digital nature facilitates a network-based approach to distribution allowing tight version control and replication across communities, districts, countries and potentially continents [11, 12] . it helps shift training from a classroom based, didactic style delivered by an international expert to a more peer based, personalised approach that overcomes some of the constraints inherent with a centralised, cascade based approach to rolling out new training. this article presents a model that could transform ipc training. it blends traditional training with tablets to create a technologyenhanced approach that aims to improve patient and health worker safety. the system, known as ebuddi, has been prototyped in west africa and has the potential to improve quality, accessibility, scalability and legacy of training [10, 13] . this novel approach has attracted international attention and it could be used to improve health systems resilience and outbreak response worldwide. creating the ebuddi prototype was a collaborative approach between organisations with frontline operational capacity and specialists in medical education, training and agile software development. the masanga mentor ebola initiative (mmei) comprised the masanga hospital in sierra leone, the mentor initiative and experts from merlin's lassa fever programme. plymouth university peninsula schools of medicine and dentistry (pupsmd) were involved throughout providing input based on pedagogical principles and best practice in virtual learning and distributed simulation. the core concepts were based on national guidelines and ipc curriculum developed by the liberian ministry of health in association with the who and cdc. these were applied to pedagogical mechanics from game based learning and used agile development to interpret them with graphical user interface (gui), animation and language [13] . initial prototypes were built from videos with who expert trainers and photos of the healthcare settings, and evolved through co-creation and agile development. co-creation by experts and frontline trainers produced an authentic module that engaged the audience more than passive illustrations portrayed in textbooks or demonstrations by international experts alone. agile development meant that frontline trainers and healthcare workers could feedback to the international development team and see their involvement included in subsequent builds. initially the development involved input from diaspora groups able to meet directly with the development team in london. however as communications links were put in place with operational training teams on the ground, input to the development team could be provided directly from those in the frontline -ensuring even greater authenticity and relevance of the training material to the safety critical steps. fig.1 illustrates this continuous loop of communications between the in-field metrics and international development teams exchanging module iterations with data to improve technical performance and learning impact. the quicker this feedback was incorporated, the more impact it had on subsequent suggestions as trainers were encouraged to see the value of their ideas, encouraging bottom up innovation. open innovation and collaboration make digital approaches to learning more accessible and affordable. for such technologybased initiatives, insights such as the principles for digital development act as 'living guidelines that can help development practitioners integrate established best practices into technology-enabled programs' [13] . considering an open approach to technology-enabled international development would encourage a free flow of ideas that permeate organizational boundaries, not waste public resources unlocking code and duplicating work. the principles guide strategies for leveraging and contributing to broader resources and knowledge to give greater impact. with these guidelines, we can make a more concerted effort to institutionalise the many hard lessons learned in the use of information and communication technologies in development projects [14] . the field trials comprised quantitative and qualitative studies to investigate the value of ebuddi. they introduced the concept of ipc and ppe, as well as the effectiveness of trainers, to healthcare workers both during the acute phase of the emergency and the subsequent transition into restoring essential healthcare. the training tool was developed by immerse learning, pupsmd and total monkery, and a team of experts led by jon meadows. fieldwork was conducted by masanga hospital and the mentor initiative; supported by expertise at pupsmd. the training team comprised ipc specialists within the mentor initiative who, during the course of the studies, visited over one hundred health facilities. the majority of these facilities were private health clinics and health centres, in addition to three hospitals and one ebola treatment unit (etu). facilities covered both urban and rural areas. close to five hundred healthcare workers were introduced to the tool during the study. the fieldwork comprised four main phases: phase 1: introducing the concept. early prototypes developed by immerse learning were introduced to healthcare workers in sierra leone. feedback confirmed that the tool was relevant and appropriate for training healthcare workers and supported the model which incorporated training in both english and local language. phase 2: testing potential. conducted in health facilities in liberia to test the potential of the program. small groups used ebuddi and gave informal feedback and first impressions. it was tested as a standalone tool where participants used the module on a laptop for approximately one hour, independent of scheduled training, and evaluated confidence levels before and after. phase 3: testing efficacy. the study used rapid and agile feedback mechanisms to accelerate development and prioritize local input. each participant evaluated their confidence with ipc practices and then was assessed on their competence at donning and doffing enhanced ppe. ebuddi was used to reinforce the practical experience and then the participant was reassessed on their practical skills. quantitative data collection identified trends and performances. phase 4: operational value. this phase focused on how best to apply ebuddi in different contexts -targeting end users with a range of resources and abilities. field trials integrated ebuddi into scheduled group ipc training, focusing on ppe training. the program was used alongside practical demonstrations and skill stations, continuously adapting to meet changing resources. the studies gave a real insight into the concept of ebuddi -how it might be best used in the field and its potential as a teaching tool to support traditional training methods. there were many positive attitudes across the different stakeholders shown in fig.2 , although the multiplicity of stakeholders meant that building a coherent base of support was often a slow process given their different perspectives and priorities when it came to training. the initial feedback was encouraging and people enjoyed the concept. however, most users had minimal experience with laptop technology and initially required constant guidance from the trainer on how to operate the module, especially on the first run. the unfamiliarity of the target audience with computers meant that many users struggled to use a mouse. this contrasted with their confident use of smartphone technology and touch screen interfaces. west africa has seen technology leapfrog from minimal use of social media and connectivity to rapid adoption of to smartphones and use of tablets, without following the evolutionary path through desktops and laptops. this meant that agencies outside the region often underestimated the utility of digital tools or were constrained by the belief that custom low cost hardware would be necessary to ensure the broadest possible update of such tools. introducing tablets enhanced trainee engagement as well as gui intuitiveness. with the ever-increasing prevalence of smart phones, a touch screen interaface was found to be more and more accessible. this shifted the study focus from laptops to android based tablets due to their size, relatively low power consumption and usability. the intuitiveness of the module and the familiarity of the graphics were important. unknown objects in the background distracted users from the key messages from the program, so the study worked alongside liberian trainers to design a setting that was familiar to end users. including local voiceover (language and dialect) increased understanding. software developers focused on making the module as intuitive and graphical as possible, recognising that some target users are illiterate, let alone computer literate. initial wariness to foreign schemes pervaded the communities throughout the emergency response but this authenticity, as well as trust in the local training teams, helped overcome this challenge. the close involvement of sierra leonean and liberian experts ensured a more authentic tone and familiar setting to the content being developed. testing ran concurrent to software development. daily updates facilitated rapid feedback direct to developers, made possible through digital communications and the adaptability of the simulation environment compared with video based training materials. it was important to value and input suggestions from frontline trainers, and agile development allowed this to happen quickly. once trainers could see their suggestions incorporated into new versions, it encouraged further feedback and a sense of co-creation -a virtuous circle of engagement. however, this process was not without its challenges -from the most basic access to sufficient connectivity for conference calling, through to information management and prioritisation of development recommendations. a key lesson learned was the need to communicate clearly to the front line healthcare workers about what development would be enhanced for the next app release. their expectation of instant and specific modifications from their personal recommendations grew quickly and at times to an unrealistic level. the training had to be flexible and adapt to changing resources, including time constraints, staff availability, limited equipment and power management. the advantage of ebuddi was that as modules were developed they could be added as additional posters in the simulated clinic, as shown in fig. 4 . in the end, this would allow trainers to pick and choose the topics they needed according to their local priorities. the initial ebuddi module evolved to respond to the changing training needs in liberia. its teaching responded to changes in the national guidelines that shifted focus from specific ebola material to generic ipc in health facilities -from the 'keep safe keep serving' curriculum to the 'sqs' curriculum [15, 16] . the liberia specific module developed is currently being adapted for training in standard precautions and ipc in sierra leone to build resilience post ebola as part of the icare project, funded by the department for international development uk. agile development has enabled the core modules to be adapted to this changing focus. this was a good indication of how the program could adapt to new material, something that the modular approach helped significantly. the studies demonstrated the value of near peer learning when introducing new concepts. collaboration and teamwork were important and emphasised in the conversations during the introduction of the blended approach to learning. this immediate feedback identified areas where training needed to be reinforced to avoid common or dangerous mistakes. some unexpected findings came out of the fieldwork combining digital technology with peer learning in austere environments. in one example a nurse, who was confident with ipc was struggling to use a tablet. she was helped by a nurse aid who was more computer literate yet did not know much ipc. this collaborative approach to learning between the trainees was insightful and very encouraging to watch. inbuilt data collection was trialled in the latter stages of the fieldwork. the module introduced a personalised user record that tracked which topics had been covered and the scores achieved in each competency. users liked to know their scores and progress through the module and so the data collected could be used for personal feedback as well as wider progress tracking. it could facilitate targeted coaching to individuals and also more novel outreach functionality, for example, if a key module was overlooked, it would be flagged and the coordinator could remind the trainer responsible for that facility. the field trials in west africa tested the ebuddi prototype and explored its potential in different and challenging environments. it began to address some of key concerns in health security raised from the lessons learnt from the ebola response -focusing on improving outcomes in skill improvement not just outputs of number of health workers trained. the importance of ipc in such outbreaks is undeniable. frontline workers need frequent, high quality training that is accessible to all and independent of location and education level. it needs to adapt to changing resources such as available equipment and how to respond to shortages, introduction of new equipment, procedural change and learning from incidents that might have resulted when critical safety steps have not been fully understood. the training needs to adhere to local policies and protocols. this is captured in the ebuddi development process by a compliance document that details local guidance and captures key learning, critical steps and evaluation points. the field trials showcased the potential of ebuddi to augment existing ipc training in liberia, which has contributed to the success of stopping the outbreak. true behavior change of health care workers is difficult to ensure as adherence to standard protocols can wane quickly when the acute threat of infection is deemed to have reduced. the second key concern is that everyone must have access to required knowledge and skills to work with confidence and competence, a philosophy enshrined in the efn report 'we are not prepared unless we are all prepared' [6] . ebuddi seemed to increase the confidence of healthcare workers in the short term, although the long term benefits require further research. a key finding from the fieldwork was that the graphics needed to be familiar to the trainee -including the design of the health facility, equipment available and surrounding landscape (rural or urban). the addition of a local soundscape further increases the immersive nature of the learning experience. increased usability of the module developed from feedback, engaged a wide audience regardless of skills, knowledge or education levels. community engagement is vital in controlling an outbreak such as ebola. the co-creation model of ebuddi empowers frontline workers and trainers to give valued feedback and critically be able to see their input in the module. this ensured authenticity and buy in to any subsequent development. the avatar characteristics can be changed to reflect an appropriate mix of gender, ethnicity and culturally appropriate clothing. this gives the module great potential to relate to different communities and demographics, and recognise the importance of highlighting the key role women play in the response by highlighting this in the simulation exercises [17] . preparedness for fresh outbreaks from existing pathogens such as ebola or lassa fever or emerging pathogens such as middle east respiratory syndrome (mers) is important. this is where the agile development of ebuddi can really rise to the challenge as it has the potential to respond quickly and accurately to an outbreak with international experts co-creating training with local community actors. using analytics and data to collect information and statistics can be used to identify trends, gaps through automated monitoring, and evaluation of an outbreak much faster and at higher integrity than before. ebuddi could ensure frontline health workers have the right kind of training in time, acting as an aid to programme management of resources, as well as provide direct support to health trainers carrying out each session. there was scepticism whether such research could be carried out during an emergency. some frontline agencies saw a technology-based approach as an additional complication, cost factor or constraint in training programmes. however, the mmei partnership illustrated the capacity of small organisations or alliances to be more responsive and innovate more easily than larger, more bureaucratic organisations -although they often face challenges in getting support from donor agencies who often prefer to support well established implementing partners with whom they have an existing relationship [9] . in the field of health research the main focus has been on therapies, vaccines and equipment where there are good precedents of public private sector partnerships leading to tangible products. there are fewer precedents in the digital field possibly leading to less appreciation in the emergency sector of how significant such technology could be in re-imagining capacity building. the business sector has already seen how digital simulation technology can be delivered on multiple platforms where laptops, tablets and mobile phones could all provide an opportunity to teach and train; and the growing trend for people to bring their own device (byod) to the training session. every crisis is an opportunity to innovate, build on lessons learnt and share new sights and better practices more widely. the importance of doing this was recognised in the european summit meeting on lessons learnt from the ebola response which concluded that successful innovations from the recent ebola response need to be built on to create 'a smarter, more scalable and sustainable' response capability in the future [18] . the wilton park meeting (2015) on empowering frontline health workers concluded: 'this is a moment in time. the last 15 years have seen a revolution in ict and mobile technologies. ebola shone a spotlight on the ineffectiveness of past health systems strengthening efforts; there is growing evidence that ict and mobile are a vital part of the solution to build resilient health systems.' [19] . the field trails demonstrated that it was possible to innovate in an emergency response setting. it had many challenges and it was important to reduce the burden of the technology where possible. nonetheless, the benefits of the analytics and the inbuilt monitoring and evaluation could, in the long run, make the data collection process much less burdensome. ebuddi was designed to provide a legacy to the ebola outbreak -an expert training aid with the potential to be adapted as practice, protocols and equipment evolved. right from the start it aimed to improve the emergency response and to leave a legacy that would help to ensure a higher standard of training after the emergency was over. the transition from a conventional training model to a blended or technology enhanced model is often difficult, but if this path can be successfully navigated then mmei's research demonstrated many benefits of using digital technology for training in an outbreak response. these include using a standardised training format to promote key safety protocols and the ability to detect lack of knowledge and skills through analytics embedded in the tool. the use of tablet devices proved transformational compared with early trials that used laptop computers -in particular the usability of the interface, their intuitiveness and lower power consumption. bringing together the expertise and resources for an effective blended learning programme required a breadth of skills and investment beyond any single organisation. the mmei partnership not only was able to draw together such competences but also benefit from the insight and expertise of a wide range of volunteers from a wide range of specialities, sectors and countries around the world keen to contribute to the fight against ebola. ebuddi could assist a coherent approach to evaluating outbreak response competences such as the standards for outbreak response set by the international health regulations (ihr) [20] . the ihr represents the agreement between 196 countries including all who member states to work together for global health security and stipulates that each country needs a human resource development plan to address the gaps existing between the knowledge and skills required to comply with ihr requirements and the knowledge and skills available in the workforce. currently compliance with ihr is often difficult to assess. longer term, the ebuddi model could be adapted to other regions and public health contexts where there is a need to boost local understanding of infection, prevention and control as well as personal and patient safety. the adaption process would require alterations across three areas -protocol adherence, graphical interface and avatar characteristics. the architecture of the code underlying the module has been built in a way which allows continual development. the advanced analytics could enable real-time tracking and monitoring of the training impact. it could be used to improve training in real time, offering quality assurance to trainers and project managers on the ground through automatic monitoring and evaluation, thereby improving the integrity of the public health training programme. the analytics may be presented on an individual basis, of a training group, within a community, district, national or international level. on a wider stage, data provides a greater level of transparency for donors and other sponsoring agencies. analytics will ensure continuous improvement, building the evidence base to support future deployment as well as being a catalyst to continuing innovation. as the tool matures, ebuddi may be able to provide high quality training in hard to reach places, recognising the physical constraints of movement during a public health crisis, geographical inaccessibility, or the threat of insecurity. the study has shown ebuddi could enhance conventional approaches to local capacity building by improving training effectiveness, increasing cost efficiency when scaled and enabling an agile response to changing priorities. ebola -what went wrong? london. the lancet global health blog lassa fever update the next epidemic -lessons from ebola. usa a community-engaged infection prevention and control approach to ebola. health promotion international community-centered responses to ebola in urban liberia: the view from below we are not prepared unless we are all prepared' eu health professionals' perceptions of preparedness for ebola and infectious diseases of high consequence one year into the ebola epidemic. world health organisation case study: innovations in emergency disease responses. centre for research in innovation management (centrim) what we've learned about fighting ebola virtual learning and distributed simulation (v-lads) for preparing healthcare workers at peripheral health units to protect themselves against ebola virus disease (evd) in west africa advancing today's training and tomorrow's outbreak preparedness: the importance of innovation a networked approach to improving the resilience of communities confronted by the threat of ebola. london. the lancet global health blog health worker focused distributed simulation for improving capability of health systems in liberia. simulation in healthcare digital development principles working group. the principles for digital development ebola virus disease (evd) infection prevention and control standard operating procedures (sop) for health clinics, health centers and hospitals liberia ministry of health ipc task force the psychosocial aspects of a deadly epidemic -women in the ebola crisis: response and recommendations from un women conference: lessons learned for public health from the ebola outbreak in west africa -how to improve preparedness and response in the eu for future outbreaks re)building health systems in west africa: what role for ict and mobile technologies? (wp1409) strengthening health security by implementing the international health regulations. geneva. world health organisation the authors are grateful to the following partners, contributors and organisations for their continued help and support through this programme: the telegraph christmas appeal, richard allan, geoff eaton, elton gbollie, dr simon mardel, dr jurre van kesteren, dr bart waalewijn, dr austin hunt, richard scott and the ipc team in the the mentor initiative -liberia programme. key: cord-252129-hlqr5jby authors: bisciotti, gian nicola; eirale, cristiano; corsini, alessandro; baudot, christophe; saillant, gerard; chalabi, hakim title: return to football training and competition after lockdown caused by the covid-19 pandemic: medical recommendations date: 2020-06-25 journal: biol sport doi: 10.5114/biolsport.2020.96652 sha: doc_id: 252129 cord_uid: hlqr5jby the lockdown caused by the covid-19 pandemic represents a great unknown regarding the physiological changes induced in elite football players. although it will differ from country to country, the return to sport for professional football players will follow a forced lockdown never experienced and longer than the normal annual season break. moreover, in addition to an obvious decrease in performance, the lockdown will possibly lead to an increase of the injury risk. in fact, preseason is always a period with a specific football injury epidemiology, with an increase in the incidence and prevalence of overuse injuries. therefore, it seems appropriate to recommend that specific training and injury prevention programmes be developed, with careful load monitoring. training sessions should include specific aerobic, resistance, speed and flexibility training programmes. the aerobic, resistance and speed training should respect some specific phases based on the progressiveness of the training load and the consequent physiological adaptation response. these different phases, based on the current evidence found in the literature, are described in their practical details. moreover, injury prevention exercises should be incorporated, especially focusing on overuse injuries such as tendon and muscle lesions. the aim of this paper is to provide practical recommendations for the preparation of training sessions for professional footballers returning to sport after the lockdown. in december of 2019, an outbreak of a severe acute respiratory syndrome caused by covid 19, starting in the chinese hubei province of wuhan, quickly disseminated to the rest of world. this led to a quarantine enforced progressively by most affected countries. therefore, from february 2020 onwards, all major sport events were cancelled or postponed, and leagues suspended. in most of the countries, athletes were confined and obliged to train at home, with all the consequent logistic restrictions but especially with the health incertitude linked to the pandemic. during that period, sport medicine professionals were called to provide advice on the home confined sport activity [1, 2] and on the activity restarting [3] . due to the lack of knowledge about covid-19, all the recommendations are for the moment difficult; therefore the principle of "maximal caution" has been evoked [3] . although it will differ from country to country, the return to sport for professional football players will follow a forced lockdown never experienced and longer than the normal annual return to football training and competition after lockdown caused by the covid-19 pandemic: medical recommendations crease in haemoglobin content. these physiological changes cause a decrease in muscle capillarization and a loss of efficiency of the body temperature regulation mechanisms [13, 14] . if the detraining period lasts longer than four weeks, in addition to a further decrease in vo 2 max, a reduction in arterial-venous oxygen difference is observed, which, in turn, implies a change in maximal oxygen delivery to the skeletal muscles and a decrease in haemoglobin content [13, 14] . furthermore, after a detraining period longer than one month, a decrease in skeletal muscle oxidative enzyme activity is observed [13, 14] . this important mismatch of the aerobic system, both from the central and the peripheral point of view, requires attention to some important points during the re-training phase. it has been recommended that the re-training could start only after the player has undergone the post-covid-19 pre-competition medical assessment [3] . based on these profound physiological changes, both central and peripheral, of the aerobic system, the training period should be based on a careful choice of intensity, volume and type of training. for this reason, we suggest that aerobic training be based on three different phases, characterized by a different type of work in order to stimulate the aerobic and anaerobic system with i.e. the minimum speed corresponding to the vo 2 max) interspersed with running phases performed at active recovery speed (50-60% of vo 2 max) [15] . the total duration of the training sessions should not be less than 20 minutes [16] . after this first period of basic adaptation, a second period based on intermittent training of increasing intensity (from 100 to 115% of the mas) should follow. therefore, in this second phase the physiological demand shifts from a purely aerobic mechanism to a mixed aerobic-anaerobic mechanism, with a greater progressive involvement of the lactacid anaerobic system [17] . the recommended types of interval training are 30"/30", 20"/20" and 10"/10" (and related variations). the recommended intensity are from 100% of the mas (for 30"/30") to 115% of the mas (for 10"/10"). the total durations of the recommended series range from 10 minutes (for 30"/30") to 6 minutes (10"/10"). the total volume of the training should involve at least 3 sets of intermittent training per session. furthermore, at the beginning the recovery should be passive, while in a second time the recovery should be active, i.e. carried out at a running speed equal to about 50-60% of the mas [17, 18] . finally, high intensity ball exercises should only be performed in a third period following the first two adaptation periods mentioned above. the human muscle fibres are classified by several methods including histochemical methods, the speed of twitch contraction, the fatigability, the dominant fibre enzymatic pathway and the isoform expression of the myosin heavy chain (myhc) [19] [20] [21] [22] . the myhc isoform expression it is the most used classification method. the professional footballers returning to sport after the lockdown, without denying the importance of the individual approach. detraining is a physiological effect well known in the literature. the term detraining means the partial or complete loss of previous physiological adaptation to physical exertion caused by a period of training interruption [5] . in general, a few weeks of inactivity or lower level activity are sufficient for the decline of physiological capabilities, unless specific programmes of training are carried out [6] . detraining causes changes of body mass and composition, a loss of efficiency of neuromuscular and cardiovascular systems and, consequently, a loss in strength, speed, flexibility and endurance and an increase of the risk of injury [7] . during the traditional season, the detraining experience occurs at the end of the league competition or because of an injury or illness. these detraining situations are common and are not comparable to the situation caused by the confinement due to the covid-19 pandemic, despite the home training performed [1] . due to the inactivity during the season break, preseason is always a period with a specific football injury epidemiology, with an increase of overuse injuries' incidence and prevalence. [8] . moreover, there is evidence of a preventive effect of training during preseason on in-season injuries [9] . the return to sport after a lockdown period can be even more impacting because of 3 main reasons: a) the lockdown does not correspond to the classic off-season period due to all the physiological and psychological constrictions related to confinement. b) the next preseason will probably differ from normal. indeed, in some countries it will possibly correspond to a congested period, with a potential increase of injuries [10] . c) in the case of a congested period, the acute versus chronic workload ratio, estimated to be a risk factor of injuries [11] , will be elevated with a consequent increase of injury risk. for these reasons, we may speculate that the incidence of injuries at the return to play may be impacting. moreover, the lack of possibility of performing an adequate preseason-training programme, and the long period of detraining, may expose the footballers to more injuries during the regular season. therefore, it seems appropriate to recommend that specific training and injury prevention programmes be developed, with careful load monitoring. the reduction in aerobic performance occurs after stopping intense aerobic exercise for a few weeks [12] . a period of 2-4 weeks of detraining causes a quick initial decrease in vo 2 max followed over the longer term by a decrease of blood volume together with a de-biology of sport, vol. 37 no3, 2020 315 return to football training and competition after lockdown human skeletal muscle shows three different types myhc: type i, type iia and type iix. the so-called "pure fibres" express a single myhc isoform, while the so-called "hybrid fibres" show co-expression of multiple myhc isoforms [22] . in agreement with this classification method, the human skeletal muscle fibres are subdivided into three different categories. the type i fibres (also called slow twitch fibres) have slow contraction and predominantly oxidative metabolism. the type iib and iix fibres (also called fast twitch fibres) have fast contraction and predominantly glycolytic metabolism. the human skeletal muscle fibres show high plasticity that is correlated with mechanical stimulation (i.e. training and de-training) [23, 24] , hormonal influence [25] and aging [26] . physical exercise, and consequently the de-training phenomenon, may induce change in muscle fibres' transition. indeed, chronic muscle stimulation causes an increase of cytosolic free ca2+ [27] . ppp3ca (also called calcineurin), a protein with phosphatase activity controlled by intracellular calcium, has a main role in fibre type gene regulation. calcitonin up-regulation increases type i fibre gene activity, whereas calcitonin inhibition increases type ii fibre gene activity [28] . resistance training involving high intensity contractions is able to increase muscle mass inducing hypertrophy. since the long detraining period caused by lockdown due to the covid-19 pandemic may have caused both a loss of muscle mass (atrophy) and a decrease or a loss of the fast fibres' particular characteristics, we suggest organizing the resistance training in two periods. the first period, which should be composed of at least 10 training sessions, should be focused on the recovery of muscle hypertrophy. the external load adopted for the training in this period should be between 70 and 75% of the maximal load and the series should be composed of 8-10 repetitions. the rhythm of execution should be slow and controlled [29, 30] . it is important to remember the relationship between strength and hypertrophy. indeed a period of 8-12 weeks causes a loss of muscle mass (on average 0.6% per day starting from 15 days of inactivity) [31] . this loss of muscle mass is the cause of a contextual loss of muscle strength ranging between 7 and 12% [31] . for this reason, the recovery of muscle mass is the first important step on which to base the resistance training [32] . the second period should be based on selective stimulation of the fast twitch fibres. indeed, several studies have shown a decrease in fast twitch fibres after a detraining period in footballers, swimmers and weightlifters [14, 33] . during this second training period, the external load should be between 50 and 85% of the maximal load [34] . the executive rhythm should be at maximum speed (i.e. maximal power output) and the series must be stopped when the execution speed (or power production if the training is monitored) decreases over an established limit. it is possible to maintain this type of training also during the in-season period [35] . furthermore, as a final but not least important recommendation, we suggest the inclusion (starting from the second period) of exercises based on eccentric contraction in the resistance training plan. indeed, ec-centric exercises are particularly effective both for the prevention of muscle injuries and for the increase in maximal strength [36] . there is evidence that 4 weeks of detraining in a soccer player population cause an increase in the time of 20 and 30 m sprint and in the performance of an agility test [37] . considering both these data and that a long detraining period, such as that caused by the covid-19 pandemic, can result in a decrease in the number of fast twitch fibres [14, 33] , it is reasonable to expect a noticeable loss of athletic speed skills. since several studies have shown a close relationship between maximal speed values and muscle power values [38] [39] [40] , we suggest structuring the speed training in three phases as follows: the first phase should be focused on exercises allowing maximal power production of the lower limb. the exercises may be of general or specific type. the general exercises (leg press, squat, squat jump) should respect the same rules already specified for the second period of resistance training. the specific exercises consist of sprint with tow, uphill-sprint, etc; in the other term the specific exercises are based on different types of sprint. it is important to underline that this training period should be preceded by an initial period of resistance training focused on the recovery of muscle hypertrophy [41] . a second phase based on plyometric training [42, 43] . in soccer the ability to perform sprinting, kicking, changing of direction, jumping and in general rapid action is paramount to optimize the performance [44] . a large number of soccer specific movements are constituted by a rapid stretch-shortening cycle (i.e. a succession of quick eccentric and concentric phases) [45] . plyometric training is able to improve exercise performance involving the stretch-shortening cycle of a muscle-tendon unit [45] . for this reason, plyometric training may be considered a correct and useful method to develop explosive strength [42, 43, 46] . a third phase based on repeated sprint ability training [47] . interspersed by short recovery [48] . the repeated sprint ability is the capability to perform the best possible sprint performance during a series of short sprints, whose duration is  10 seconds, separated by a short period ( 60 seconds) of recovery [49] . therefore, repeated sprint ability requires a "physiological mix" between power production (i.e. the sprint speed) and endurance (i.e. the recovery between the sprints) [50] . more precisely, repeated sprint ability is based on a complex relationship between metabolic aspects, such as oxidative capacity, phosphocreatine recovery and h+ buffering, and neural factors such as muscle activation and a neuromuscular recruitment strategy [47] . to date, in the literature several studies have reported the importance of a specific training programme focused on repeated sprint ability improvement in soccer [47] [48] [49] [50] [51] . following the national football league lockdown (march 11th to july 25th, 2011) [65] . there is evidence of the deleterious effect of detraining on the lower limb tendon biological characteristics [66] . indeed, the rate of tendon collagen synthesis decreases over time during a period of disuse or detraining [66] . some authors showed that, after a period of 23 days of unilateral lower leg suspension at the patellar tendon level, it is possible to observe a fall in the rates of myofibrillar protein synthesis, a decrease in tendon collagen synthesis and a decrease in focal adhesion kinase (fak) phosphorylation [66] . other studies show that a period of detraining causes important modification in collagen type i and iii synthesis, collagen organization, tendon vascularity and proteoglycan content [67] [68] [69] [70] . this sequence of biological and structural alterations causes a decrease in the tendon mechanical resistance that is particularly evident at the achilles and patellar tendon level. for these reasons, we suggest that the sport activity should be restarted with caution after a long detraining period, to avoid an increase of tendon pathology and/ or tendon injuries caused by the modification in tendon metabolism induced by detraining [68, 69] . another important point to underline is that in the literature there exists evidence on the increasing risk of development of achilles tendinopathies or rupture for subjects belonging to blood group o [71] [72] [73] [74] . indeed, subjects belonging to blood group o show much higher n-acetylgalactosamine transferase activity than in subjects belonging to groups a and b [71] . this increased n-acetylgalactosamine transferase activity would result in an increase in type iii collagen and in a consequent imbalance in the ratio type i collagen / type iii collagen. since type iii collagen shows less resistance to mechanical stress compared to type i collagen [75] , its abnormal collagen iii proliferation may expose subjects to tendinopathy or spontaneous tendon rupture [73, [76] [77] [78] . for this reason, players belonging to blood group o may have increased injury risk. insufficient neuromuscular control during dynamic movements may be a major injury risk factor [79] [80] [81] . poor neuromuscular control may cause motion asymmetry and inefficient movement strategies following muscle or joint injuries [82] . indeed, especially during the rehabilitation period following muscle or joint injury a symmetrical lower limb motion and an appropriate movement pattern are necessary both to reduce re-injury risk and to improve the athletic performance. furthermore, even in a healthy athlete, a loss of neuromuscular control may expose the subject to deleterious load that he is not able to control [83, 84] . the drop in muscle strength during immobilisation is more important than the loss of muscle volume; moreover, it occurs faster. for this reason, muscle strength is influenced not only by the cross sectional area and the characteristics of the muscle itself but also by neural mechanisms, especially during the first phase of immobilisation [60] . to our knowledge, in the literature there are no studies focused on the loss of efficiency of the neuromuscular system after a long flexibility flexibility is the capacity to reach an optimal joint range of motion. it depends on several factors linked to different anatomical structures such as bone, the muscle-tendon unit and connective tissue [52] . some authors report a decrease in flexibility after 8 weeks of detraining [52] . stretching is a hotly debated topic in the literature. many studies have highlighted the possible negative effect of static stretching on dynamic performance [53, 54] . however, there are also some studies that show no negative effects of static stretching on dynamic performance. it is likely that stretching of short duration (lasting up to 30 seconds) inserted in a warm-up session may not have a negative effect on the subsequent dynamic performance, especially in a highly trained population [55] . on the other hand, dynamic stretching does not show a negative effect on dynamic performance. indeed, dynamic stretching seems to have a positive effect on the neuromuscular system, providing a performance enhancement [55] . however, it should be stressed that static and dynamic stretching probably have two different application rationales. regular practice of static stretching is able to increase the joint range of motion (rom). to have an optimal rom is an important factor for acquisition of the benefits associated with flexibility in particular sport activities [56] . on the other hand, dynamic stretching shows its optimal application in the warm-up [57] . indeed, an optimal warmup should be structured by sub-maximal aerobic activity, dynamic stretching and sport specific dynamic exercises [55] . for these reasons, we suggest early introduction in the training plan of stretching exercises involving the major muscle groups, performed both in static and dynamic conditions [56] . there is evidence that muscle performance is maintained for up to 4 weeks of inactivity, but in elite athletes the eccentric strength and sport-specific power may decrease remarkably [58] . hwang et al. [59] stated that the period is even shorter (2 weeks). inactivity leads to a reduction of fibres' cross sectional area (atrophy) [60] but also to a change of their composition [61] . indeed, fast type fibres (type ii) may undergo a transformation into slow type fibres (type i). this modification further affects muscle performance especially in terms of strength [61] and speed. this importantly impacts footballers, due to the physiological demands of the game that requires fast accelerations and high speed. for this reason, at the return to play, muscle testing should be performed, especially focusing on the research of eventual atrophy and loss of strength and speed. in the case of atrophy, we recommend complementing the training programme with specific exercises. finally, it is important to remember that the socalled "multicomponent prevention programmes" seem more effective than the "single-component prevention programmes" especially in joint injury prevention [62] [63] [64] some authors have reported an increase in achilles tendon injuries biology of sport, vol. 37 no3, 2020 317 return to football training and competition after lockdown detraining period such as that imposed by the covid-19 pandemic. it is however reasonable to suppose that a lack of specific stimuli for such a prolonged period may have deleterious effects on the neuromuscular system, exposing the players both to a greater injury risk and a decrease in performance. therefore, we recommend executing single-leg exercises in dynamic movements, reaction to unforeseen functional circumstances, proper landing, leg and foot positioning, as well as improving resistance to neuromuscular fatigue, proprioception, muscle activation, and inter-joint coordination [85] . the lockdown caused by the covid-19 pandemic represents an unknown factor regarding the physiological changes induced in elite athletes. indeed, except for the national football league lockdown, to find a similar suspension of sporting activity we have to go back to the times of the second world war. therefore, there are no evidence-based strategies for the return to sport activity. for this reason, without denying the importance of serious and correct sharing of information, the latter must be carefully checked before being put into practice. it is therefore obvious that further studies are warranted on the subject. the problems we will have to face are manifold: the loss of performance, the increase of injury risk and the consequences of important systemic changes. all this will also be further complicated by the fact that we will have an extreme need for a return to normality in an extremely short time. for all these reasons, to date, the only certainty is that it will be a very demanding challenge for everyone. medical recommendations for home-confined footballers' training during the covid-19 pandemic: from evidence to practical application the covid-19 pandemic: how to maintain a healthy immune system during the quarantinea multidisciplinary approach with special focus on athletes football cannot restart soon during the covid-19 emergency! a critical perspective from the italian experience and a call for action sharing information is probably more helpful than providing generic training recommendations on return to play after covid-19 home confinement effects of short-term in-season break detraining on repeated sprint ability and intermittent endurance according to initial performance of soccer player concurrent training and detraining: brief review on the effect of exercise intensities effect of training on muscular performance: a meta-analysis the football association medical research programme: an audit of injuries in professional football-analysis of preseason injuries br time before return to play for the most common injuries in professional football: a 16-year follow-up of the uefa elite club injury study the impact of short periods of match congestion on injury risk and patterns in 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lower-extremity plyometric training data concerning the effect of plyometric training on jump performance in soccer players: a meta-analysis. data brief physiological and metabolic responses of repeated-sprint activities: specific to field-based team sports repeated sprint ability -part i: factors contributing to fatigue neural and muscular adjustments following repeated running sprints intermittent endurance and repeated sprint ability in soccer players seasonal variation in physiological fitness of a semiprofessional soccer team negative effect of static stretching restored when combined with a sport specific warm-up component the acute effects of static stretching on the sprint performance of collegiate men in the 60-and 100-m dash after a dynamic warm-up a review of the acute effects of static and dynamic stretching on performance lo stretching una vision critica acute effects of a static vs. a dynamic stretching warm-up on repeated-sprint performance in female handball players muscular characteristics of detraining in humans resistance training-induced elevations in muscular strength in trained men are maintained after 2 weeks of detraining and not differentially affected by whey protein supplementation physiological and biochemical effects of immobilization on muscle muscular characteristics of detraining in humans prevention of non-contact anterior cruciate ligament injuries in soccer players. part 1: mechanisms of injury and underlying risk factors prevention of non-contact anterior cruciate ligament injuries in soccer players. part 2: a review of prevention programs aimed to modify risk factors and to reduce injury rates acl injury in football: a literature overview of the prevention programs did the nfl lockout expose the achilles heel of competitive sports? the temporal responses of protein synthesis, gene expression and cell signaling in human quadriceps muscle and patellar tendon disuse time course of changes in the human achilles tendon properties and metabolism during training and detraining in vivo time course of changes in muscle and tendon properties during strength training and detraining hyaluronic acid injections protectpatellar tendon from detrainingassociated damage the role of detraining in tendon mechanobiology abo blood groups and musculoskeletal injuries abo blood group and achilles tendon rupture abo blood groups and achilles tendon rupture in the grampian region of scotland abo blood groups and achilles tendon injury subcutaneous rupture of the achilles tendon: basic science and some aspects of clinical practice distrubution of blood groups in patientswith tendon rupture. an analysis of 832 cases basic science of tendons tenocytes from ruptured and tendinopathic achilles tendons produce greater quantities of type iii collagen than tenocytes from normal achilles tendons: an in vitro model of human tendon healing biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction effect of the 11+ injury prevention programme on fundamental movement patterns in soccer players deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiological study horsley i task based rehabilitation protocol for elite athletes following anterior cruciate ligament reconstruction: a clinical commentary maximum number of repetitions, total weight lifted and neuromuscular fatigue in individuals with different training backgrounds biomechanical and neuromuscular characteristics of male athletes: implications for the development of anterior cruciate ligament injury prevention programs all authors declare having no conflict of interest. key: cord-316879-nbkvd0le authors: ashcroft, james; byrne, matthew h v; brennan, peter a; davies, richard justin title: preparing medical students for a pandemic: a systematic review of student disaster training programmes date: 2020-06-09 journal: postgrad med j doi: 10.1136/postgradmedj-2020-137906 sha: doc_id: 316879 cord_uid: nbkvd0le objective: to identify pandemic and disaster medicine-themed training programmes aimed at medical students and to assess whether these interventions had an effect on objective measures of disaster preparedness and clinical outcomes. to suggest a training approach that can be used to train medical students for the current covid-19 pandemic. results: 23 studies met inclusion criteria assessing knowledge (n=18, 78.3%), attitude (n=14, 60.9%) or skill (n=10, 43.5%) following medical student disaster training. no studies assessed clinical improvement. the length of studies ranged from 1 day to 28 days, and the median length of training was 2 days (iqr=1–14). overall, medical student disaster training programmes improved student disaster and pandemic preparedness and resulted in improved attitude, knowledge and skills. 18 studies used pretest and post-test measures which demonstrated an improvement in all outcomes from all studies. conclusions: implementing disaster training programmes for medical students improves preparedness, knowledge and skills that are important for medical students during times of pandemic. if medical students are recruited to assist in the covid-19 pandemic, there needs to be a specific training programme for them. this review demonstrates that medical students undergoing appropriate training could play an essential role in pandemic management and suggests a course and assessment structure for medical student covid-19 training. registration: the search strategy was not registered on prospero—the international prospective register of systematic reviews—to prevent unnecessary delay. global disasters, such as a pandemics or warfare, are events that cause a major disruption to health and social care, industry and economy, and community and education. 1 disasters on this scale result in substantial loss of life, and an immeasurable burden is placed on healthcare services to deliver core medical care. 1 disaster healthcare provision requires a collaborative approach that uses the expertise and skills of as many people as possible. much of what is formally taught in medical school is around the knowledge, skills and behaviours required of a physician for patients at the bedside. 2 however, the broad training medical students receive could be applied to disaster scenarios especially if supported with adjunct specialist training. the current medical student curriculum already covers a wide range of specialties, and some may argue it is stretched. however, the rising incidence of worldwide disasters and the impact of the current coronavirus (covid-19) pandemic has justified the need for disaster preparation training in medical students. 1 in some respects, students with disaster training may be better suited to assist in both clinical and non-clinical roles in disaster scenarios than redeployment of senior physicians with super-specialist skills and knowledge. curricula using multidisciplinary methods of simulation and human factors training have been proposed for implementation by the usa (association of american medical colleges 3 ) and europe (government of the federal republic of germany 4 computer science applied to medical practice, italy 5 ). however, at present, it is recognised that there is a brief or non-existent exposure to disaster training within current medical training curricula across the world, which may leave students unprepared for an intimidating and unfamiliar setting if assisting in the healthcare workforce. 1 the current covid-19 pandemic is rapidly driving the need for healthcare workers in the uk. 6 on 24 march 2020, the uk health secretary, matt hancock announced plans to introduce medical students as volunteers to the nhs in order to assist in this pandemic. 7 in response, the british medical association and medical schools council issued clear advice regarding medical students joining the uk healthcare workforce including ensuring correct induction, training and supervision. 8 the aim of this study was to systematically review disaster training courses for medical students. we describe the educational structure and methodology employed, and evaluate both preparedness for disaster medicine and learning outcomes to inform the development of covid-19-specific training programmes. we adhered to prisma (preferred reporting items for systematic reviews and meta-analyses) guidelines and recommendations for systematic reviews of observational studies. 9 we searched embase, medline and cochrane central from 1996 for all articles published until 19 march 2020 evaluating training that medical students receive to prepare them for pandemics and disasters, with no language restriction. we identified 1289 articles, which we then screened for inclusion. the search was conducted using the following medical search headings: 'coronavirus', 'covid-19', 'sars virus', 'disasters', 'natural disaster', 'major catastrophe', 'mass casualties', 'crisis event', 'extreme weather', 'disease outbreaks', 'infectious disease transmission', 'epidemics', 'pandemics', 'mass drug administration', 'warfare', 'biohazard release', 'chemical hazard release', 'radioactive hazard release', 'radiation exposure', 'radiation injuries', 'hazardous', 'waste', 'chemical water pollution', 'radioactive water pollution', 'medical students', 'medical schools', 'education' with terms exploded as appropriate. the search strategy was not registered on prospero-the international prospective register of systematic reviews-to prevent unnecessary delay. we selected randomised controlled trials, case-control studies and cohort studies that measured medical student training outcomes in the context of pandemics and disasters. studies were selected only if they contained a detailed report of the training implementation and used objective precourse and/or postcourse assessments related to medical student knowledge, attitude, skills or clinical care outcomes. importantly, if medical student outcomes were grouped with other healthcare students or professionals and not reported separately, the study was excluded. we excluded non-english language articles in order to ensure data quality, logistical training process evaluations, literature reviews, case reports, clinical trial proposals, conference abstracts, editorials, letters and articles evaluating non-medical student populations only. pandemic infections that may be secondary issues to a disaster, but were not the primary cause, were also excluded, for example, hiv, dengue, malaria; situations where medical students were unlikely to be required to volunteer en masse, for example, active shooter situations; and interventions that were not in a disaster setting, for example, basic life support and routine clinical infection control procedures were excluded. duplicates were removed and two reviewers (ja and mhvb) independently screened titles and abstracts using rayyan, an online software to aid blinded abstract screening. 10 any discrepancies were resolved by consensus. of the 1289 citations screened, we identified 65 articles for full text and reference review, of which 23 final studies met the inclusion criteria for data synthesis (figure 1). two reviewers (ja and mhvb) independently extracted relevant information from each training report using standardised data extraction proforma in keeping with best evidence medical education recommendations and one author with medical training expertise (rjd) reviewed all extracted data. 11 we recorded administrative information including authorship, institution and year of publication; training-related data including details and duration of intervention, participants and teaching methods; and quantitative and qualitative outcome measures. 11 the quality of training intervention and risk of bias in reporting of results was assessed using the robins-1 for non-randomised controlled trials. 12 meta-analysis was not performed on the training outcomes assessed due to the wide heterogeneity in training interventions and reporting of results. descriptive analysis was performed instead. interventions were assessed against kirkpatrick criteria and kirkpatrick's levels were assigned: impact on learners' satisfaction (level 1), changes in learners' attitudes (level 2a), measures of learners' knowledge and skills (level 2b), change in learners' behaviour (level 3), changes to clinical processes/organisational practice (level 4a) and benefits to patients (level 4b). 11 twenty-three studies met the inclusion criteria, and their characteristics are displayed in table 1. the majority of studies (n=18, 78.3%) were from the usa, and other countries were germany (n=1), israel (n=1), italy (n=1), saudi arabia (n=1) and south korea (n=1). five studies (21.7%) involved a multidisciplinary cohort and reported outcomes for other healthcare students and professionals, as well as outcomes for medical students individually without pooling of results. the course structures and learning objectives were grouped into three categories: broad concepts in disaster medicine (n=12, 52.2%), trauma or haemorrhage mass casualty management (n=8, 34.8%), or influenza pandemic management, airborne viral management or personal protection (n=3, 13%). the length of studies ranged from single day teaching to 4-week boot camps, and the median length of training was 2 days (iqr=1-14). the majority of training interventions used traditional didactic lectures with simulative or experiential teaching methods, with 12 courses (52.2%) containing lectures and simulation. of the simulation experiences, four courses (17.4%) contained outdoor actor-based mass casualty simulation. multimedia approaches were used in eight courses (34.8%) as an adjunct to training, often precourse, in order to efficiently provide material to attendees. problem-based learning or casebased learning was used as a predominant feature in five courses (21.7%) in a classroom setting with or without other teaching methods. no courses involved only didactic teaching methods, all 23 included studies were prospective cohort studies measuring the impact of their training intervention postcourse evaluation, with 18 using precourse evaluation for comparison as displayed in table 2. the majority used subjective assessments of knowledge or preparedness in disaster medicine (n=20, 87.0%) with nine studies (39.1%) using objective measures. there was a wide range in number of medical students attending the courses, with the median number of participants being 61 (iqr 24-123). however, five studies did not clearly describe their medical student population, either omitting total number of participants or seniority of students. only two studies 13 14 reported data that assessed longitudinal learning beyond the year of course implementation. common limitations of study design included training being limited to a single institution, studies which were excluded due to being randomised controlled trials evaluating the efficacy of different teaching methods or simulation technology, or studies excluded due to reporting medical student outcomes pooled with outcomes of other healthcare student or professionals. of the studies included in this review, 18 studies in total measured precourse and postcourse outcomes. of these 18 studies, knowledge was measured in 16 (88.9%), of which 10 undertook objective knowledge measurements, making this the most measured outcome. however, none of the subjective or objective measures of knowledge were previously described or undertaken with validated measures. a total of four studies measured attitude-either preparedness for disaster (n=2) or confidence in approaching a disaster (n=2) by precourse and postcourse assessment. disaster medicine skills were subjectively measured in four studies and objectively measured in two, one being pass rates in personal protective equipment fitting and the second being accuracy of disaster triage. in these studies, validated measures were used to create scores or pass rates. of the five studies inviting a multi-disciplinary participant group, none trainee satisfaction was assessed in 13 (56.5%) studies and most commonly assessed using likert type scales. medical students were asked to rate the overall quality of the courses in addition to whether they would recommend courses to colleagues for disaster preparedness. course satisfaction was generally very high and appeared to be enhanced by multimodal approaches to curriculum design including the incorporation of simulation and technology. 15 however, one group discussion and interactive activity-based study did report mixed reviews with postcourse overall ratings of positive (33%), undecided (13%) and negative (54%). this is reflective of overburdening medical students with work, with one student stating, "this was way more work than it should have been. i would rather have an hour lecture on the flu than do all that group stuff. this was just frustrating to have at the end of the year when finals are right around the corner". 16 attitudes and perceptions of knowledge in medical students were assessed in 10 studies (43.5%). attitudes were broadly assessed as level 2a following courses measuring either a simple change such as interest in disaster medicine, a measurement of a medical student's willingness to volunteer in or preparedness to practice disaster medicine, or by mapping trainee responses to learning objectives. level 2b was measured by a total of 20 studies (87.0%) which assessed medical student knowledge or skill acquisition, with 18 assessing knowledge and 11 assessing skills, either alone or in combination. in courses training students in mass casualty scenarios, discrete and measurable skills were easily assessed including tourniquet application and triage skills. 15 17 as behavioural change is a difficult area to measure in nonpracticing medical students, only one study was deemed to adequately assess behavioural change. this study assessed confidence and perceived stress handling emergencies once the medical students had graduated 1.5 years following the course. 13 no studies investigated the impact of disaster training on clinical performance (level 4a) or organisational delivery of care (level 4b). all included studies were cohort studies and risk of bias was assessed using robins-1 (figure 2). 12 risk of bias was low to goolsby, 15 2014, university of the health sciences, usa postcourse questionnaire assessing perceived confidence at assessment and procedures in a combat casualty situation and perceived preparedness at managing combat casualties. the majority of students feel more confident and better prepared to assess and perform procedures in a combat casualty situation after course. the majority of students preferred the high-fidelity simulation to their normal learning environment. attitude, skill 1 to 2a ingrassia, 29 2014 crimedim, italy precourse and postcourse examination assessing disaster medicine knowledge. triage accuracy was measured in a disaster simulation assessed by an examiner. there was a significant improvement in knowledge of disaster medicine after course from 40% to 83% (p<0.01), and a significant improvement in triage accuracy in the disaster medicine simulation after course from 45% to 78% (p<0.01). the majority of students felt that disaster medicine should be part of their curriculum and evaluated the course highly. knowledge and assess learning of the didactic material immediately before the 90 min case-based lecture, and the posttest immediately after the lectures. the 2009 class could take their pretest via an e-learning tool up to several days before the class, and the post-test was available online for 3 weeks after completion of the course. over a 2-year assessment period the first year cohort's post-test knowledge scored improved from 3.8/10 (below average to average) compared with 7.6/10 (average to above average) and the second year's post-test scores improved from 2.5/5 (average) before and 3.8/5 (above average). in the first year cohort he average overall rating for the experience was 4.9/5, and 100% of the respondents recommended the class for next year's students allowing it to continue. knowledge, attitude 1 to 2b scott, 41 2012, medical university of south carolina, usa participants undertook precourse and postcourse assessment developed to meet learning objectives of the course. selfassessment of personal capability and comfort to handle a disaster and multiple choice questions of knowledge and subjective skill were undertaken. most (70%) of the trainees considered their emergency preparedness knowledge and skill as average or below average before the training experience. after the curriculum, 100% of trainees considered their emergency preparedness knowledge and skill above average, and 90% would recommend the course to other healthcare workers. knowledge, skill 1 to 2b scott, 14 2013, medical university of south carolina, usa participants undertook an online precourse and postcourse assessment developed to meet the learning objectives and competencies of the course in addition to giving post-test feedback on the implementation of the course. in discrete knowledge, subjective knowledge and skills all participants demonstrated significant improvements in their postcourse test results when compared with pre-test. course evaluation was performed, and it was found that students would recommend this course (median 92.5%), whether the course was feasible (median 82.5%) and overall evaluation (94.5%). knowledge, skill 1 to 2b silenas, 16 2008, the texas a&m college of medicine, usa students answered likert type scales to assess the extent to which the objectives and understanding of key concepts had been accomplished. written and verbal comments from the students and facilitators about their experience were gathered. sixty-six medical students completed the knowledge test before and again 4 days after the avian influenza exercise. the lowest scores for knowledge were best and all tested knowledge areas except one (endemic influenza as a public health issue) decreased postcourse. the course received mixed ratings which overall were positive (33%), undecided (13%) and negative (54%). knowledge. knowledge, skill 2b table 3 continued figure 2 individual risk of bias for non-randomised control trials determined by robins-1. overall risk of bias for non-randomised control trials determined by robins-1. critical ( figure 3 ). confounding bias was serious overall as many studies did not present pretest control data. there was critical overall bias in the selection of participants as courses were often not open to all students, for example, self-selected recruitment from student emergency medicine interest groups. classification bias and bias due to deviation from intended interventions was low. a single study had a classification bias because they did not adequately describe their educational intervention-as all other studies had low bias, this domain was classified as having low overall bias. overall missing data bias was moderate as three studies had some form of missing data and were not able to adjust for this in their analysis. measurement of outcomes had serious bias overall, as many questionnaire evaluations were subjective without any objective measures. selection and report of results had serious bias overall. while some studies did note ethical approval there was no priori registration of the results and some studies had limited reporting of results. this systematic review identified approaches used to train medical students in disaster medicine in order to suggest training approaches for medical students in the current covid-19 pandemic. we identified 23 studies published between 1996 and march 2020. overall, medical student disaster training programmes improved student disaster and pandemic preparedness and resulted in improved attitude, knowledge and skills. there was an improvement in all studies that measured precourse and postcourse outcomes. we found that all interventions ranging from simple classroombased interactive discussion to complex multimodal simulative experiences resulted in improved knowledge, skill and attitudes towards participation in disaster medicine. the main outcomes of the courses reviewed were subjective; however, there was evidence to suggest that disaster medicine training does improve objective knowledge and can teach skills which can be used by medical students, relevant to a pandemic. the majority of courses were just 1 day in duration, indicating that short courses can still be impactful. the courses identified in this review required expert faculty or high-fidelity equipment and were implemented alongside an already busy medical school curriculum. these barriers prevented the majority of courses in this review from reaching longitudinal integration into medical school training. however, this may be overcome in the current covid-19 pandemic by collaboration and coordination, particularly when many medical students have had their studies either postponed or converted to telemedicine/online teaching. the main limitations of this review are related to study design, as the majority of studies were single centre and often focused on very specific aspects of disaster medicine. the overall reporting of both participant factors and outcome factors was generally poor, and the educational methodology was very heterogeneous-this was represented by critical risk of bias in selection of participants, and serious risk of bias in measurement of outcomes. this bias inevitably weakens the strength of the conclusions drawn, but given that all studies demonstrated a positive benefit, it can still be concluded that there will be benefit to students who undertake disaster preparedness courses. another limitation was the kirkpatrick levels that were evaluated. only one study evaluated change in behaviour (level 3) and no studies evaluated change in clinical performance (level 4a) or organisational patient benefit (level 4b). furthermore, only three studies focused solely on pandemic influenza, airborne viral management or personal protective equipment (n=3, 13%), and only a single study assessed resuscitation in a disaster setting. this is of particular importance for the covid-19 pandemic, where respiratory personal protective equipment is a necessity and there are specific resuscitation guidelines. 18 clinical impact and clinical utility must be taken into account when making suggestions for training during the covid-19 pandemic. although medical students working during the covid-19 pandemic will likely be deployed to non-infectious areas of work, there is no guarantee that medical students will not be exposed to the virus. 19 furthermore, a strain will be placed on healthcare services and contingency care may need to be provided in place of a traditional care service. 20 here, students may be essential in ► medical students could play a crucial role in the sars-cov-2 healthcare response. ► disaster medicine programmes using multimodal techniques improve knowledge, skills and attitudes which are imperative for medical practice in a pandemic. ► training programmes incorporating previously successful techniques could ensure the successful integration of disaster training into global medical school curricula. ► do disaster training programmes aimed at medical students demonstrate direct patient benefit? ► can disaster training programmes improve the integration of medical students into the healthcare workforce during the sars-cov-2 pandemic? ► how can disaster training programmes be adapted to manage future pandemics? preserving the resilience of hospitals and community healthcare systems. 20 there will ultimately be more pressure on medical students to work than previous cohorts and this review suggests that disaster medicine training as a part of medical school's curriculum is not common practice. therefore, medical students may require a very different set of competencies than those acquired during medical school. unsurprisingly, some final year medical students do not feel ready to start as a newly qualified doctor, due to worries they are not well prepared for clinical placements, or feeling under prepared for covid-19. 21 moreover, the medical schools council have advised that medical students from any year should not take on roles that will impact on their studies. 8 this review suggests that early mobilisation of medical students into the workforce could be accompanied by disaster medicine training. all courses reviewed in this study were positively evaluated by medical students, and if a similar programme was offered to current medical students, it would likely be well received improving willingness and preparedness to work in the healthcare service. this is of particular importance as medical students are already being asked to join the workforce as volunteers, or to graduate early in order to join healthcare systems as physicians. there is great concern that students who give assistance during a disaster without training are at an increased risk of both harm to themselves and psychological consequences. 22 there is therefore a need to create novel courses to teach medical students pandemic skills in these unprecedented circumstances. this review suggests that the most beneficial medical student disaster medicine courses should consist of mixed modalities of didactic sessions, case-studies, practical hands on training and simulation experiences. these training methods could be used to train medical students in covid-19 specific knowledge and skills and prepare them for clinical practice. table 4 shows a proposed covid-19 course and assessment based on the findings of this systematic review. the course structure includes the variety of elements found in other studies. didactic lectures on covid-19 could be delivered in a lecture hall with social distancing measures in place, or perhaps more appropriately as a distance learning component consisting of video, podcast and computer activities. practical activities could include fitting of respiratory personal equipment as well as donning and doffing. the simulated element could consist of a patient with covid-19 who requires cardiopulmonary resuscitation. in resource-limited scenarios, this could be undertaken using computer-based tutorials or video tutorials. as new doctors and medical students may have a substantial volume of information to learn in addition to this course, handouts and online refresher courses should be offered. the proposed assessment aims to cover all kirkpatrick levels and criteria. it is also important to teach and train human factors awareness, particularly in relation to team dynamics, lowering authority gradients and empowering anyone to speak up if concerned. 23 maintaining both individual and team situational awareness is also important during any clinical duty, and even more so during a crisis setting. 23 it may be useful to incorporate a credentialing process for medical students undergoing disaster training, thereby allowing students to demonstrate a background of competency and separating this cohort from unskilled volunteers when aiding a disaster medicine response. 24 the successful implementation of these suggested disaster training techniques will require the encouragement of people-centred training, the development of peer-learning, coordination and funding of training systems, and regular disaster preparedness exercises of multimodality format. 25 the covid-19 pandemic has caused unprecedented disruption to healthcare services in peacetime. medical students may play a crucial role in the healthcare response. there is an imminent demand for educational interventions to train medical students to better assist in this response. the disaster medicine courses reviewed in this article improved knowledge, skills and attitudes through multimodal techniques and were well received original research by learners. although no studies in this review demonstrated direct patient benefit, the courses increased student preparedness and similar courses should be implemented prior to medical students joining the healthcare workforce during the covid-19 pandemic. future courses should note the methodological and longitudinal flaws demonstrated in previous studies so that direct patient benefit can be demonstrated in the covid-19 pandemic. future work should be undertaken to ensure the successful integration of disaster training into global medical school curricula. twitter james ashcroft @jamesashcroftmd, matthew h v byrne @mhvbyrne, peter a brennan @brennansurgeon and richard justin davies @jdcamcolorectal contributors ja and rjd undertook conceptualisation of this article. ja and mhvb undertook data collection, analysed the data, and drafted and revised the manuscript. rjd and pb undertook critical review of all data collection and analysis and guided critical revisions. rjd approved final manuscript for submission. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. the importance of evidence-based disaster planning achieving good medical practice training future physicians about weapons of mass destruction: report of the expert panel on bioterrorism education for medical students code of federal regulation 8. nouvelle of german medical licensure act. fed law gaz i nationwide program of education for undergraduates in the field of disaster medicine: development of a core curriculum centered on blended learning and simulation tools clinical features of patients infected with 2019 novel coronavirus in wuhan, china the guardian. matt hancock calls for 25000 volunteers to help the nhs. guard medical schools council. medical student volunteers in the nhs preferred reporting items for systematic reviews and meta-analyses: the prisma statement rayyan-a web and mobile app for systematic reviews conducting a best evidence systematic review. part 1: from idea to data coding. beme guide no robins-i: a tool for assessing risk of bias in non-randomised studies of interventions evaluation of a new community-based curriculum in disaster medicine for undergraduates competency in chaos: lifesaving performance of care providers utilizing a competency-based, multi-actor emergency preparedness training curriculum new wide area virtual environment (wave) medical education developing disaster preparedness competence: an experiential learning exercise for multiprofessional education stop the bleed training empowers learners to act to prevent unnecessary hemorrhagic death resuscitation council uk. adult advanced life support for covid 19 patients, 2020. 19 uk foundation programme. allocations to interim f1 posts refining surge capacity: conventional, contingency, and crisis capacity covid-19-medical students face disruption and uncertainty why medical students should be trained in disaster management: our experience of the kashmir earthquake improving patient safety: we need to reduce hierarchy and empower junior doctors to speak up willingness of health care personnel to work in a disaster: an integrative review of the literature united nations office for disaster risk reduction. sendai framework for disaster risk reduction deployment and disaster medicine in an undergraduate teaching module planning and incorporating public health preparedness into the medical curriculum integrating the bleeding control basic course into medical school curriculum nationwide program of education for undergraduates in the field of disaster medicine: development of a core curriculum centered on blended learning and simulation tools a disaster medicine curriculum for medical students stop the bleed training empowers learners to act to prevent unnecessary hemorrhagic death training medical students in bag-valve-mask technique as an alternative to mechanical ventilation in a disaster surge setting herd immunity" in a civilian community through incorporation of "just-in-time using problem-based learning for pandemic preparedness the education and practice program for medical students with quantitative and qualitative fit test for respiratory protective equipment simulation training for in-flight medical emergencies improves provider knowledge and confidence a short medical school course on responding to bioterrorism and other disasters disaster preparedness medical school elective combating terror: a new paradigm in student trauma education disaster 101: a novel approach to disaster medicine training for health professionals high-fidelity multiactor emergency preparedness training for patient care providers teaching mass casualty triage skills using immersive three-dimensional virtual reality teaching mass casualty triage skills using iterative multimanikin simulations disaster training in 24 hours: evaluation of a novel medical student curriculum in disaster medicine competing interests none declared. provenance and peer review not commissioned; externally peer reviewed. this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. james ashcroft http:// orcid. org/ 0000-0003-2964-5032 matthew h v byrne http:// orcid. org/ 0000-0002-2414-352x key: cord-293041-7ndp05ru authors: xu, pengbo; wu, di; chen, yuqin; wang, ziwei; xiao, wei title: the effect of response inhibition training on risky decision-making task performance date: 2020-07-24 journal: front psychol doi: 10.3389/fpsyg.2020.01806 sha: doc_id: 293041 cord_uid: 7ndp05ru response inhibition is an important component of executive function and plays an indispensable role in decision-making and other advanced cognitive processes. at the same time, we need an effective way to improve decision-making in the face of complex and limited information. this study mainly explored the influence of response inhibition training on college students’ risky decision-making. the recruited students were randomly divided into the training group (n = 28) and the control group (n = 28). the training group engaged in go/nogo and stop-signal tasks for 2 weeks, while the control group was given the task of reading and summarizing popular science articles related to self-control. the stroop task and balloon analog risk task were used to evaluate the pretest and posttest performance in inhibitory control and risky decision-making tasks, respectively, for all subjects. the results showed that response inhibition training can be effectively transferred to interference control task performance. the results showed that both the reward acquired and adjusted balloon analog risk task score (adj bart) significantly improved compared to the pretest in the training group, while the control group showed no significant differences in the reward acquired and the adj bart between the pretest and the posttest. although response inhibition training increased risky behaviors in the balloon analog risk task, it substantially reduced overly conservative behaviors and participants gained more money. there are all kinds of risky decisions that we make in life. from daily shopping to financial investments, people always need to make choices with limited time and information resources. many studies have shown that people's decision-making is influenced by gender, individual characteristics, emotional states, cognitive abilities, irrelevant information, and so on (sun et al., 2015; stanovich, 2018; talukdar et al., 2018; weller et al., 2018) . however, little is known about whether a simple and an operational training method can effectively affect decision-making. in the dual-process theories of decision-making, system 1 processes are often automatic, fast, and easily affected by emotion, while system 2 processes are relatively slow and rational process, in which the most important function of system 2 is the successful override of system 1 (stanovich and west, 2008; evans and stanovich, 2013; stanovich, 2018) . moreover, the selection of alternative responses in the decision-making process also depends frontiers in psychology | www.frontiersin.org on the continuous effectiveness of regulatory control processes (moeller et al., 2001) . that is, to achieve better decision-making, it is necessary to continuously control their own dominant responses and irrelevant interference information, which is undoubtedly closely related to the ability of inhibitory control. the purpose of this paper is to determine whether primary cognitive training can effectively change high-level decisionmaking behavior. if the method of improving risky decisionmaking ability through primary cognitive training (such as inhibitory control) is proven and widely accepted, it will greatly advance the research process in the field of decision-making and will certainly provide a direction for future development. inhibitory control, one of the important components of executive function, is the ability to suppress irrelevant, interfering, incorrect or inappropriate goal-directed dominant responses, impulses, behavioral choices, and automatic behavioral habits (barkley, 1997; miyake et al., 2000; munakata et al., 2011; enge et al., 2014) . inhibitory control can be roughly divided into reaction inhibition and interference control; the former mainly focuses on the suppression of the dominant response, while the latter focuses on the suppression of irrelevant information. many studies have shown that inhibitory control plays an important role in verbal communication (bishop and norbury, 2005) , reading comprehension (wang and gathercole, 2015; potocki et al., 2017) , memory retrieval (depue et al., 2010; penolazzi et al., 2014) , and mathematical ability (gilmore et al., 2013) and is involved in other higher cognitive processes, such as problem-solving and decision-making (sakagami et al., 2006; shenoy and yu, 2011) . in addition, inhibitory control training can affect working memory and fluid intelligence (liu et al., 2015) , and there have already been some practical applications in controlling addictive behavior, losing weight, reducing diet consumption, and improving mental illness (houben, 2011; bartholdy et al., 2016) . therefore, inhibitory control can be considered a basic ability that people must have. the traditional view is that inhibitory control is an internal top-down execution process (aron et al., 2004 ). an increasing amount of research results shows that top-down implementation of frontal regions is not always necessary to inhibit control behaviors and the participation of these inhibitory regions can be automatically driven by specific stimuli (lenartowicz et al., 2011) . manuel et al. compared event-related potentials (erps) before and after auditory go/nogo task training and found decreased activity in the left parietal cortex (manuel et al., 2010) , suggesting that the repeated and stable association between the stimulus and inhibition response in the go/nogo task resulted in the gradual separation of top-down connectivity in the frontal lobe, thus facilitating rapid automatic inhibition. this is also the purpose of inhibitory control training, that is, training the slow thought suppression process into an automated, faster process. there are many disputes about whether there is a close relationship between performance in the inhibitory control task and the risky decision-making task. kertzman et al. (2018) used the performance on the go/nogo task, the matching familiar figures test (mfft), and the stroop task as indicator of inhibition ability and used the iowa task performance as an indicator of risk and found no direct correlation between the two (kertzman et al., 2018) . they suggested that although there is some overlap between inhibitory control and the cognitive processing of risky decision-making, they may represent two relatively independent abilities. this may have something to do with the limitations of the iowa gambling task itself. previous studies have demonstrated that short-term stop-signal task (sst) training can reduce risk-taking behavior in gambling tasks (verbruggen et al., 2012; stevens et al., 2015) . they designed a special training study and systematically studied the generalization model of promoting automatic inhibition and developing a top-down control inhibition training program. simply training people to control their exercise behavior induced them to make cautious and risk-averse decisions for at least 2 h and the effect was comparable to that found in previous studies that used transcranial direct current stimulation (tdcs) to control risk (fecteau et al., 2007) . the previous studies examined only immediate changes after training and the decision task selection typically included a single task. on the basis of previous studies, we chose the balloon analog risk task that has strong operability with initial results that are relatively stable and we appropriately increased the time interval between cognitive training and posttest decision-making task assessment. after excluding the immediate effects of training, we wanted to demonstrate that classic response inhibition training can also effectively change performance in this task. it can make the response suppression training more stable, more generalizable, and more convincing for improvements in risky decision-making. this paper proposes a hypothesis: classic response inhibition training can reduce risk behavior in the balloon simulation risk task, thereby resulting in more rewards. a total of 56 university students were randomly divided into a training group (18 men and 10 women; mean age = 19.54 years, sd = 1.20) and a control group (18 men and 10 women; mean age = 19.46 years, sd = 1.55). there was no significant difference in age between the two groups [t (54) = 0.193, p = 0.848]. subjects were included based on the following inclusion criteria: they were 18-22 years old, physically and mentally healthy, right-handed, with normal vision or correctedto-normal vision, and had not participated in other relevant psychological experiments. the exclusion criteria were as follows: neurological disorders, alcohol or other substance abuse or overdependence, mental illness, and treatment with any psychotropic substance. the training process in our experiment is all person-by-person training. under the condition of limited manpower and financial resources, the workload of these subjects is close to the maximum. however, post hoc power calculation is calculated by gpower 3.1.9.2 with a sample size of 56 participants, a significance level of 5% and an effect size of 0.2. the calculated power value is 0.95, proving that the sample size is sufficient. this research was approved and strictly implemented the recommendations of the local ethics committee. all subjects were given detailed experimental instructions and agreed to participate in the experiment. then, they signed the informed consent in accordance with the declaration of helsinki and were entitled to a certain payment after the experiment was completed. the training group adopted the go/nogo task and sst as training tasks that were presented using e-prime 3.0. all experiment started with a short practice phase to make sure that the subjects understood the rules of the task completely. all training tasks were completed in the laboratory over a total of 4 weeks. the two groups were assessed with the stroop task and the balloon analog risk task to evaluate the pretest and posttest performance on inhibitory control and risky decision-making tasks at weeks 1 and 4. in the intervening 2 weeks in the training group, two classic paradigms were simultaneously used and cross trained. the whole training schedule consisted of 30-min sessions, three times per week. during each training session, the two tasks alternated twice. in this study, two kinds of response inhibition training tasks were adopted. on the one hand, to increase the generalization effect of training, the inhibitory control ability was improved by automatic inhibition and top-down control inhibition (spierer et al., 2013) . on the other hand, with this kind of pure training, the more obvious the training boost will be and the more likely that the change in gambling task performance was due to improved inhibitory control. the control group read popular science articles related to self-control and were required to complete a task of summarizing the articles. the time and frequency for this task were consistent with the cognitive training of the training group. there were double triangles ("go") and single triangles ("nogo") used as stimuli in the task. the participants had to make a button-press response to the double triangle and inhibit their response to the single triangle. go and nogo stimuli were randomly presented in a 3:2 ratio. all stimuli were presented for 100 ms in the center of the screen with a 1,200 ms interstimulus interval. the experimental phase consisted of go stimuli of 240 trials and nogo stimuli of 160 trials. there was a pause at the halfway point of this task and the participants could take a break or press any key to continue the experiment. the optimal performance of the task is to minimize the response time and the number of errors (the sum of the number of omission errors and commission errors). the task is the classic response inhibition task paradigm that has been widely used and is also recognized as a method that reflects inhibitory control abilities in a relatively simple and pure way (congdon et al., 2012; wostmann et al., 2013; enge et al., 2014) . the participants were required to press the "f " or "j" key when the "f " or "j" letter (go signal), respectively, appeared, and during a relatively low proportion of trials (30%) with obvious red dots (stop signal) appearing after the go signal, to immediately suppress the impulse to press the button. the task consisted of 200 trials, including 120 no-stop stimuli and 60 stop stimuli. the center of the screen shows a fixation point (+) of 250 ms before all the stimuli appear, and there is a 1,000 ms interval after the button response. in the no-stop stimulus, the most presentation time of the go signal was 1,250 ms. if the subject does not press the button in time, the screen will show "too slow". in the stop stimulus, the stop signal will appear later than the go signal and the stimulus presentation time is still 1,250 ms at most. if the subject does not immediately suppress the key, there will also be an interval of 1,000 ms. the difference between this task and the go/nogo task is that each stop signal is preceded by a reaction impulse and the clever experimental design allows a measure of behavioral inhibition time (verbruggen and logan, 2009; verbruggen et al., 2019; i.e., stop-signal reaction time, ssrt). the tracking method was used to automatically adjust the time when the stop signal appeared (i.e., stop-signal delay, ssd) and the initial value was set at 250 ms. when the inhibition was successful, the ssd increased by 50 ms, while the inhibition failed, and the ssd decreased by 50 ms to ensure that the successful inhibition rate of the subjects was approximately equal to 50%. then, the ssrt value can be calculated (ssrt was equal to the average go reaction time minus the average ssd). the stroop task, which is commonly used for inhibitory control and relatively complicated in processing, was used to evaluate the ability of stimulus interference to inhibit or selectively focus on target-related stimuli (turner et al., 2017) . the participants were asked to select the corresponding key according to the four colors of red, blue, green, and yellow fonts. all stimuli were presented for 100 ms followed by fixation point (+) for 250 ms and there was a 1,000 ms interval after the subject responded. the task consisted of 160 trials. four colors and four fonts were randomly matched and presented (every font was matched with four different colors, so that the ratio of consistent trials to inconsistent trials was 1:3) and consistent and inconsistent response times (rt) were recorded. the conflict effect (incongruent trials rt -congruent trials rt) and conflict score (conflict effect/congruent trials rt) were calculated to evaluate the two groups before and after the inhibitory control ability training (maraver et al., 2016) . the balloon analog risk task was used to evaluate risky behaviors and is a decision-making task that can effectively simulate realistic risky behaviors that are relatively stable under laboratory conditions (lejuez et al., 2002) . the experimental programming of this task was based on computer programming (c++) prepared and rendered on the computer screen. the participants can make money by inflating the balloon with a click of the mouse (earning 2 yuan per inflation, which was included in the temporary account), but if the balloon bursts, they lose the money they made during the round (the temporary account). at the same time, the participants can choose to stop the pump at any time and the temporary account is transferred into the permanent account. each balloon is blown between 1 and 32 times and there is a predetermined explosion point (randomly set by the computer). the participants were asked to conduct 30 balloon trials to make money and were given the sum from their permanent accounts for the 30 balloon trials. the only way to make money is to stop the balloon before it explodes. the subjects were also told that the goal was to inflate the balloon as large as possible without exploding to maximize the benefit. the final benefit of each subject was recorded and average adjusted pumps (i.e., adj bart; adj bart = total number of unexploded balloon pumps/number of unexploded balloons) was calculated to measure the performance and impulsivity in the task. first, a curve was drawn between the performance in the two tasks in the training group and the training time. then, two independent sample t-tests were conducted on the pretest values of the stroop task and balloon analog risk task for the two groups and no significant difference was found between the two groups at pretest. because the experiment adopted a mixed design with between-and within-subjects factors, mixed-model anovas of 2 (control group and training group) × 2 (pretest and posttest) factors were used to evaluate the transfer effect of response inhibition training to stroop performance and its impact on balloon analog risk task performance. finally, we further analyzed the correlation between the initial threshold and the change amount of the training group. since both tasks were completed twice in one training session, we took the average of the two as the performance for that training session. repeated-measures anovas were conducted to compare the performance in the first session with that of the sixth session. as shown in figure 1 , both go rt and ssrt were gradually reduced from the first to the last training session in their respective tasks and the differences reached statistical significance [go rt: f (1,27) = 34.987, p < 0.001, η 2 = 0.564; ssrt: f (1,27) = 38.416, p < 0.001, η 2 = 0.587]. in the two tasks, the error rate did not significantly change from the first to the sixth training session [go/nogo task: f (1,27) = 3.057, p = 0.092, η 2 = 0.102; sst: f (1,27) = 0.028, p = 0.869, η 2 = 0.001; figure 2 ]. however, there was a downward trend in the go/nogo task, especially across the first four training sessions. the pretest conflict effect [t (54) figure 3 , we also found a significant time × group interaction effect [conflict effect: f (1,54) = 6.821, p = 0.012, η 2 = 0.112; conflict score: f (1,54) = 5.664, p = 0.021, η 2 = 0.095]. through simple effect analysis, two groups of effects were obtained. the conflict effect and conflict score in the training group after training were significantly lower (p < 0.001), while no significant difference between pretest and posttest performance was found in the control group [conflict effect: f (1,27) = 1.025, p = 0.320, η 2 = 0.037; conflict score: f (1,27) = 0.697, p = 0.411, η 2 = 0.025; table 1 ]. the inhibitory control ability in the training group was improved compared with that of the control group because of the training. frontiers in psychology | www.frontiersin.org 5 july 2020 | volume 11 | article 1806 as shown in figure 4 , there was no significant difference between the two groups in the pretest adj bart [t (54) we further analyzed the correlation between the initial threshold and the change in the training group and found a significant negative correlation (reward: r = −0.734, p < 0.001; adj bart: r = −0.620, p < 0.001; figure 5 ). the results indicated that adj bart and reward acquired by the training group after training significantly increased compared with that before training. moreover, the subjects with lower pretest indexes had a greater range of changes through training. from the results of the whole experiment, we not only improved the performance of the training task through 2 weeks of response inhibition training (go/nogo and stop-signal tasks), but also more importantly, we found the migration effect of training in the untrained stroop task and balloon analog risk task. the fact that inhibition control plays an important role in people's complex decision-making process has been verified. there was a gradual improvement in the performance of the training group in two classic response inhibition tasks. the error rate in the go/nogo task (the ratio of the sum of omission errors and commission errors) showed a downward trend over the first four training sessions and increased in the later sessions. moreover, it can be seen from the results of the last two training sessions that the task response decreased while the error rate increased. this may have been because the participants were too reactive, which sometimes led to a rebound in error rates. in the later sessions, there was a gradual balance between the reaction time and the error number, and finally, it tended to be stable. therefore, although the error rate during the last four training sessions showed a slight upward trend, the overall response time showed a downward trend and an obvious training effect could still be seen. the error rate in the sst refers to the proportion of errors in the go response, not the proportion of suppression failures. the low error rate during the first exposure may have been due to the relatively small allocation of cognitive resources in the process of inhibition. with the increase in the allocation of cognitive resources in the inhibition process, the accuracy of keystrokes is ignored and the error rate changes little or slightly increases. however, we can still see the improvement in task performance from the trend in the ssrt scores. there was a significant difference in the effect of the two kinds of training, and it was also found that the pursuit of reaction speed might lead to a decrease in accuracy in the later periods of training, and eventually, the two tended to stabilize. in addition, enge et al. also found that in the latter stage of training in the sst, ssd and mean go reaction time were simultaneously reduced, which would eventually lead to the reverse increase in ssrt (enge et al., 2014) . in this experiment, this phenomenon occurred in some subjects, but the overall trend was not found. lower conflict scores in the stroop task in the training group after training suggested that response inhibition training could be transferred to interference control. this also showed that the two classic response inhibition task training methods are effective. friedman and miyake used latent variable analysis to demonstrate that almost all inhibition tasks have a common inhibitory control mechanism (friedman and miyake, 2004) . although brydges et al. (2012) later used erp technology to show that the two tasks engaged two different cognitive components (brydges et al., 2012) , they were still closely related, and performance could be transferred (maraver et al., 2016) . from the adj bart in the balloon analog risk task, it can be concluded that the training of response inhibition led to an increase in the subjects' risky behaviors, which seems to contradict our hypothesis. however, at the same time, the reward acquired in the task increased after the training. according to the value gained by pumping up the balloon and the probability of explosion, the value of the first 16 rounds of pumping is greater than the value of the nonpumping rounds. it is not until the seventeenth turn that pumping up the balloon becomes irrational (lejuez et al., 2002) . therefore, from the perspective of profits obtained, the subjects were too conservative to avoid balloon explosion, thereby losing the chance to win more money before training. this also explained our increased risk-taking behavior and benefits after training. we therefore suggest that the key decision for balloon analog risk task is not to inflate (this is a continuous process) but to decide when to stop inflating and put the contents of the temporary account into the permanent account. only by making a rational decision to stop inflating (properly suppressing decisions that are too early or too late) can the maximal amount of reward be obtained. each inflation is actually equivalent to a go reaction, and it is the ability of response inhibition that is needed as the basis for the critical and appropriate stopping of inflation. the results of increasing risk-taking behaviors in this paper were inconsistent with those of the previous study (verbruggen et al., 2012) . although many gambling tasks are task paradigms for evaluating risky decision-making, different tasks represent different risky decision-making processes (buelow and blaine, 2015) . the stopping of inflation in the balloon analog risk task may be more related to the ability to response inhibition, which may also have contributed to the inconsistent results across different tasks. we further analyzed the significant negative correlation between the initial threshold and the change amount in the training group and found that the lower the initial value was, the more significant the improvement. this suggested, to some extent, that people with lower initial values were more likely to improve (schmaal et al., 2013) . therefore, we should probably focus more on the lower level of the population, where the limited training intensity could achieve a higher training effect. there are many other factors that affect inhibitory control training. it is widely recognized that emotion and motivation affect cognitive inhibition processes, higher decision-making processes, and other neural or psychological functions (padmala and pessoa, 2011; turner et al., 2018) . in the traditional sense, it is considered that subcortical structures, such as the amygdala, ventral striatum, and hypothalamus, are mainly responsible for processing emotions and behaviors, while cortical structures, such as the dorsolateral prefrontal cortex and anterior cingulate cortex, are responsible for activating cognitive control and higher executive functions (pessoa, 2008) . therefore, appropriate incentives and positive feedback will effectively improve the training effect of the subjects. in addition, some studies failed to achieve transfer effects of training (enge et al., 2014; zhao et al., 2015; kable et al., 2017) , which may be because the differences were not significant due to the insufficient number of subjects or the training time and intensity did not reach the threshold needed to transfer tasks (kable et al., 2017) . as shown in figure 4 , there were also some subjects with opposite results, but this pattern of results were mainly concentrated in those with higher starting values. if the primary group chosen were primarily high-level people, then grouplevel indifference would be inevitable. therefore, the initial level of grouping will also affect the training effect. the basis for improving decision-making through training in response inhibition is brain plasticity (i.e., a change in behavior and its underlying brain anatomy based on experience; spierer et al., 2013) . these changes can facilitate the acquisition of new skills, the improvement of acquired abilities, and the recovery of defective or impaired functions (kelly and garavan, 2005) . changes in behavior and brain plasticity induced by training have been demonstrated at different levels of executive function. research has shown that people's inhibitory control ability is closely related to the inferior frontal gyrus and dorsolateral prefrontal cortex (aron et al., 2004) . at the same time, these brain regions also play an important role in risky decision-making tasks (chiu et al., 2012) . during the training of the inhibitory control tasks, the corresponding brain regions will be repeatedly activated and the connections between the corresponding brain regions will be increased, which will inevitably affect the neural connections in the decisionmaking process. although there is no neuroscientific evidence, it is likely that this is one of the important reasons that response inhibition training changes subsequent performance in decision-making tasks. the results of the control group also showed that reading about self-control skills alone was not enough to improve the participants' inhibitory control skills, which also reflected the need for cognitive training of response inhibition. first, the selection range of the subjects was relatively limited, leading to limited generalization. second, the training time was short, and there was no long-term tracking due to the effect of novel coronavirus, so the duration of the transfer effect cannot be determined at present. third, the degree of improvement in the balloon analog risk task performance in the training group was relatively limited, which may also be related to shorter training time and lower intensity. fourth, as the training group needs to spend a lot of time in the whole training process, our subjects may be potentially inadequate. the problem of subject size is also a shortcoming of most cognitive training studies. because of this, slight differences in some experimental conditions may lead to different migration outcomes or no migration effects between many similar training studies. in addition, for the measurement of inhibitory control and risky decision-making, a variety of evaluation indicators should be used, such as questionnaires, behavioral observation, and imaging techniques such as erps and magnetic resonance imaging (mri), rather than cognitive task paradigms on computers. a single score from the inhibition task or risky decision-making task cannot represent the complex control processes that may be correlated with each other, so it is necessary to use multiple tasks to evaluate the inhibitory control ability and risky decision-making (dougherty et al., 2005) . this study confirms that classic response inhibition training can increase risk-taking behavior in the balloon analog risk task, improve their overly conservative behaviors, properly inhibit them to obtain more benefits, and substantially increase economic rationality. during the whole experiment, various experimental conditions were strictly controlled and the training and transfer effects were statistically significant. it is particularly important that compared with inhibiting the near transfer between control tasks, the risky decision-making task can be considered a far transfer (crespi et al., 2018) and this experiment is a good attempt at selecting a cognitive training far transfer task. research on the transfer effect of inhibitory control training to higher cognitive function and the tracking of training will also become the focus of future research in this field. however, at the same time, we must also make it clear that these higher cognitive processes are not just inhibitory control processes, and whether there is a more general, fundamental process is debatable. the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. the studies involving human participants were reviewed and approved by air force medical university. the patients/ participants provided their written informed consent to participate in this study. px completed the experiment and wrote it. dw and yc assisted the experiment and analyzed the data. zw provided technical guidance and site support. wx grasped the idea and financial support. all authors contributed to the article and approved the submitted version. inhibition and the right inferior frontal cortex behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of adhd a systematic review of the relationship between eating, weight and inhibitory control using the stop signal task executive functions in children with communication impairments, in relation to autistic symptomatology. 2: response inhibition dissociable components of cognitive control: an event-related potential (erp) study of response inhibition and interference suppression the assessment of risky decision making: a factor analysis of performance on the iowa gambling task, balloon analogue risk task, and columbia card task neural correlates of risky decision making in adolescents with and without traumatic brain injury using the balloon analog risk task measurement and reliability of response inhibition improving innovative decision-making: training-induced changes in fronto-parietal networks inhibitory control of memory retrieval and motor processing associated with the right lateral prefrontal cortex: evidence from deficits in individuals with adhd laboratory behavioral measures of 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right inferior frontal gyrus in the absence of inhibitory cues the effects of inhibitory control training for preschoolers on reasoning ability and neural activity brain dynamics underlying training-induced improvement in suppressing inappropriate action training on working memory and inhibitory control in young adults the unity and diversity of executive functions and their contributions to complex "frontal lobe" tasks: a latent variable analysis psychiatric aspects of impulsivity a unified framework for inhibitory control reward reduces conflict by enhancing attentional control and biasing visual cortical processing human memory retrieval and inhibitory control in the brain: beyond correlational evidence on the relationship between emotion and cognition linguistic and cognitive profiles of 8-to 15-year-old children with specific reading comprehension difficulties behavioral inhibition and prefrontal cortex in decision-making effects of modafinil on neural correlates of response inhibition in alcohol-dependent patients rational decision-making in inhibitory control training-induced behavioral and brain plasticity in inhibitory control miserliness in human cognition: the interaction of detection, override and mindware on the relative independence of thinking biases and cognitive ability how does response inhibition influence decision making when gambling? calm and smart? a selective review of meditation effects on decision making individual differences in decision making competence revealed by multivariate fmri response inhibition and impulsive decision-making in sexual offenders against children impulsivity and cluster b personality disorders proactive motor control reduces monetary risk taking in gambling a consensus guide to capturing the ability to inhibit actions and impulsive behaviors in the stop-signal task models of response inhibition in the stop-signal and stop-change paradigms interference control in children with reading difficulties accounting for individual differences in decision-making competence: personality and gender differences reliability and plasticity of response inhibition and interference control wesley says": a children's response inhibition playground training game yields preliminary evidence of transfer effects key: cord-313087-8ku61qox authors: raftery, philomena; ködmön, csaba; van der werf, marieke j.; nikolayevskyy, vladyslav title: european union training programme for tuberculosis laboratory experts: design, contribution and future direction date: 2020-05-11 journal: bmc health serv res doi: 10.1186/s12913-020-05240-3 sha: doc_id: 313087 cord_uid: 8ku61qox background: tuberculosis (tb) control programmes rely heavily on laboratories to support both clinical care and public health. qualified personnel with adequate technical and managerial skills comprise an integral component of any quality assured laboratory. training a new generation of tb laboratory specialists was identified as a critical priority in the european union /european economic area (eu/eea). a tailored training programme for tb reference laboratory professionals was developed and implemented within the european reference laboratory network for tuberculosis to increase the pool of technical experts available to step into leadership roles in the tb laboratory community. three cohorts of selected laboratory specialists participated in a series of trainings from 2009 to 2016. methods: we conducted an evaluation of the training programme using a structured questionnaire administered via the eusurvey website, with the aim of documenting the benefits and contribution as well as suggesting improvements and future direction of the programme. all graduated participants and all current erltb-net members were invited to participate in the online survey and descriptive quantitative analysis was performed. results: the evaluation found significant benefits for both the participants and the participants’ institutions, with improvements being reported in laboratory practices and management including implementation of new diagnostic techniques and career progression for participants. the training programme differed from other international and european initiatives in a number of important ways; the curriculum is unique in the scope and range of topics covered; the programme targets senior level professionals and future directors; cohorts were limited to 8–10 participants; and the programme involved a number of workshops (5–7) taking place over a two-year period. relationships and collaborations established between individuals and institutions were valued as an important success of the initiative. suggestions on how the impact of the programme could be enhanced included equipping participants to perform laboratory assessments in low-resource settings outside the eu, thus bolstering global tb control. conclusion: based on the findings presented the training programme has proved to be successful in developing leadership, expertise, partnerships and networks to support tb laboratories and has contributed significant benefits to strengthening european national reference laboratories in the fight against tb. tuberculosis (tb) causes the highest number of deaths due to an infectious disease in the world, is the leading killer of people living with hiv and is associated with major challenges related to antimicrobial resistance [1] . in 2019, an estimated 10 million people developed tb and 1.5 million died from the disease worldwide, including 251,000 deaths among persons living with hiv [2] . multidrug-resistant tb (mdr-tb) caused by bacilli resistant to at least two key antimicrobials (rifampicin and isoniazid) remains an emerging public health challenge globally [3, 4] . accurate results from tb diagnostics and drug susceptibility tests enable tb programmes to identify tb cases and select appropriate treatment. therefore, laboratories play a critical role in tb control both in supporting clinical care and public health activities: detecting active tb cases, monitoring treatment, contributing to outbreak investigations, contact tracing and surveillance activities [5] [6] [7] [8] [9] . laboratories are complex systems comprising many components including infrastructure, equipment and technologies. vital to their operation are the human resources and the systems that manage the processes and implement the standards to produce reliable, accurate and actionable results [10] . in addition, successful implementation of new and innovative diagnostic tests and technologies requires functional networks of laboratories with trained and motivated staff, robust quality management systems (qms) and safe working environments. to achieve and maintain resilient laboratory systems, special consideration needs to be given to training programmes for laboratory management and leadership, strengthening laboratory networks through partnerships and pooling of resources, and developing strategies to integrate laboratories' functions [10] . qualified personnel with relevant technical and managerial skills comprise an integral component of a quality assured laboratory and are essential for obtaining and retaining laboratory accreditation [11] . a lack of personnel with advanced technical skills has been reported in many settings as a major obstacle to performing complex laboratory tests [5] . existing tb laboratory training initiatives at the global and european level have predominantly focussed on technical issues, qms, planning and accreditation. the stop tb partnership's global laboratory initiative (gli) [12, 13] developed a training package for tb diagnostic network planning which is predominantly administered through an online portal. this does not provide dedicated in-person practical training, which is vital for development of leadership and management skills, as well as for gaining expertise in conducting assessment visits. another training offered by the european tb laboratory initiative (eli) offers regional workshops that bring together laboratory specialists from countries with high tb and mdr-tb rates to strengthen their technical capacity in tb and mdr-tb diagnosis and implementing biosafety measures [14] . while these initiatives support the implementation of the world health organization (who) end-tb strategy [15] they do not specifically target the needs of senior level staff and laboratory managers serving as tb laboratory specialists in the eu/eea. thus, training of a new cadre of mycobacterial laboratory specialists was identified as an urgent requirement in the eu tb laboratory network [5, 16] . in order to strengthen the development of medium and senior level professionals, an innovative training programme was developed and implemented within the european reference laboratory network for tuberculosis (erltb-net; erln-tb [before 2014]) from 2009 onwards [17] . the erltb-net training programme aimed to increase the pool of technical experts with advanced knowledge of tb diagnostic methods, available to take leadership roles in national tb laboratories, and to support national tb laboratory systems and the eu/ eea tb diagnostic community. the curriculum for the training programme was developed by a group of tb experts experienced in providing advanced level training based on needs identified through external quality assessment (eqa) rounds [11] and decisions made at erltb-net annual meetings. between 2009 and 2016, the programme was provided to 22 laboratory specialists divided into three cohorts. all participants were subjected to a rigorous selection process. trainees were first nominated by erltb-net laboratories who selected them based on specific criteria including their work experience, level of seniority in their current position as well as potential benefits for the supporting laboratory. as potential candidates they then had to submit a portfolio including a cv and motivation letter highlighting their relevant experience and suitability as a trainee. following shortlisting by the erltb-net senior selection panel, participants were interviewed to confirm suitability before being enrolled as trainees. the programme was delivered through a series of small (three to five per training cycle) and large workshops (two per training cycle) lasting 3 days each, with each training cycle spanning 2 years (see additional file 1 for details of the topics covered). small trainings were held at two erltb-net member supranational tb reference laboratories fully accredited to iso15189 standards located in the uk and italy. these were predominantly laboratory-based and included both demonstration, interactive lectures and hands-on components covering basics in tb laboratory diagnosis, molecular diagnostic methods, latent tb diagnosis, tb epidemiology and contact tracing, laboratory assessment and tb laboratory design. large trainings were combined with annual erltb-net meetings and provided opportunities for developing networks, leadership, management and training skills through direct involvement of trainees in the meeting organization, teaching and discussions. topics for large trainings included laboratory operations, tb policies and guidelines, laboratory financial management as well as emerging technologies in tb laboratory diagnosis. after completing the programme, graduates were involved in a variety of activities including workshops, taskforce visits, staff exchange visits and laboratory assessment visits. all trainings were delivered by recognised experts in tb laboratory management, laboratory diagnostics, epidemiology and public health comprising of erltb-net laboratory directors, senior staff members and external speakers from who, national public health bodies, and leading universities. following participant feedback from trainees of cohort one and two some modules and content were deemed less relevant or redundant for the target audience while other topics were incorporated into remaining modules so the course content was modified slightly. this demonstrated that participant feedback was incorporated at an early stage to improve the course and make it more relevant and impactful, otherwise training for all cohorts followed the same training curriculum developed as a part of erltb-net activities. the goal of this study was to evaluate the training programme by exploring the benefits experienced by the participants and their supporting institutions throughout the period 2009-2016. we aimed to document the impact of the training on participants' career development and the value of the training to the participants' institutions. in addition, we sought to identify gaps and limitations of the training programme and make recommendations for improvement, development and its future direction. two structured web-based questionnaires (see additional files 2 and 3) were developed and distributed using an online platform. the first questionnaire was designed for participants who had completed the programme and consisted of 34 questions designed to evaluate their individual experience with the training. the questionnaire included questions on the application process, the quality of the training programme, participation in visits to other countries and perceived personal benefits. the second questionnaire was sent to heads of all erltb-net member laboratories and consisted of 13 questions aimed at assessing the benefits of the programme from the perspective of the network members. an additional questionnaire (see additional file 4) was circulated to all persons who participated in the training programme following initial analysis to augment information on the benefits of the training and the types of missions trainees had participated in. applying the methodology developed by kilpatrick et al. to assess the perceived benefits of the training for the participants we compared initial expectations upon acceptance to the training programme to the level to which these expectations were met [18] . from a choice of 13 pre-defined answers (see additional file 2), participants were asked to choose the four most relevant. initial expectations were compared with the perceived principle gains or major self-reported achievements, to assess if the training programme allowed them to achieve additional skills versus original expectations. objective benefits were assessed using a set of questions addressing individual's career progression, process or system improvements, and new methodologies implemented in their home institutions. all individuals who had completed the programme between the years 2019-2016 (n = 22-1 deceased = 21) were invited to take part in the evaluation of the erltb-net training programme along with all current erltb-net members represented by heads of laboratories (n = 31). the survey questions were uploaded to the eusurvey (https://ec.europa.eu/eusurvey/) website, a web-based tool, in order to allow easy distribution, access and responses submission for all respondents with the option to remain anonymous. upon completion of data collection, which lasted two months, the responses were exported to microsoft excel (microsoft corporation, redmond, washington) spreadsheets for compilation of the data sets followed by descriptive quantitative analysis. response rates to the questionnaires were 85.7% (18/21 training participants) and 58.0% (18/31 heads of tb laboratories). of the 18 respondents to the participant questionnaire, five had been trained in cohort 1, seven in cohort 2 and six in cohort 3. the highest level of education at the time of application to the training was bachelor of science degree (bsc) 17%, master of science (msc) 33%, and doctor of philosophy (phd) 50%. seventy-two percent of the respondents were > 35 years old, 17% within the age range 31-35 years and 11% in the range 25-30 years old. the level of seniority at the time of application, judged as an individuals' position within their organisation, ranged between intermediate (39%) and senior level (61%). of the 18 participants, 15 (84%) were employed at a national reference laboratory (nrl) at the time of application while 2 (11%) were working at a supra-national reference laboratory (snrl) and one respondent worked at a clinical laboratory. the majority of applicants had some knowledge about the training programme prior to application, with 88% reporting that the institution in which they worked was a member of the network, and/or they had colleagues who had already participated in the training programme. all applicants reported that they were adequately supported by their home institution throughout the application process. the key expectations of the training programme included receiving scientific training, development of professional relationships and building managerial expertise (n = 13 respondents). the self-reported achievements of the training participants were generally in agreement with their expectations, with scientific training, development of professional relationships, managerial expertise, networking skills and participation in conferences being the achievements reported by most participants (fig. 1) . in all but one category (dedicated practical training), the principle gains reported surpassed the participants' initial expectations. in addition to what was expected from the training programme, participants learned to work in teams (18 respondents), to share expertise (17 respondents) and received scientific training in tb diagnostic and research methodologies (17 respondents). although categories "get more publications"; "get some editorial experience"; and "get a higher position" had not been selected as initial expectations by any participant, these were self-reported as achievements by five, five, and three participants, respectively. erltb-net members (n = 18) that had nominated staff to participate in the programme gave similar responses to those of the training participants regarding initial expectations (fig. 2) . the majority of the network members cited the following six reasons for supporting the application of their staff member: to get new experience, to get a scientific training, to get a dedicated practical training, to develop new professional relationships, to contribute to team work and sharing knowledge with new colleagues and peers and to learn new perspectives on management and organization of tb reference laboratories and national laboratory networks. all respondents reported that the erltb-net training empowered them to improve the diagnostic services in their institution, expanded their expertise in advanced tb diagnostics, and facilitated their career progression. of the 18 respondents, nine (50%) had progressed to a more senior position since completion of the training programme; seven had been promoted to a more senior position in the same institution, one had moved to a more senior position in a different public health institution in the same country and one had obtained a more senior position in an international public health organisation. nearly three quarters (72%) of respondents reported that they had established links with other institutions and initiated information sharing, expertise sharing and/or new projects through collaborations made during the training programme. following graduation, new methods, policies and practices had been introduced in all laboratories with many laboratories implementing more than one change (fig. 3) . changes ranged from improvements in methodologies, implementation of additional techniques such as liquid culture, liquid culture for drug-susceptibility testing (dst), molecular identification, molecular dst, interferon-gamma release assay (igra), epidemiological genotyping, next generation sequencing (ngs) and improvements to the qms, biosafety, training and diagnostic algorithms, guidelines and policies. laboratory directors were asked to grade (1-10) the perceived gains for their institution of having a staff member participating in the training programme. areas which respondents graded > 5 included: team work and sharing knowledge with new colleagues and peers, implementation of new practices, increased international visibility, participation in joint projects with other institution, new perspectives on tb laboratory organization and activity, implementing new methods/protocols and guidelines/policies and becoming members of national/ international organizations. building partnerships and collaborations between participating laboratories was considered a key benefit of the training and one which warranted further investment. "in my opinion there must be more focus on the twinning programmes between countries. also, relationships already established between labs should be further supported." (erltb-net member). ten of the 18 graduated training participants reported having taken part in one or more country and/or laboratory assessment missions. all of these were conducted at nrl's with the duration of missions varying from 1 to 3 days. the types of missions ranged from joint ecdc/ who-europe missions, erltb-net commissioned task force visits and exchanges, missions to regional laboratories and international who commissioned missions to laboratories in africa. participating in missions was seen by support experts as a key way for trainees to apply their knowledge in a tangible way. this was also highlighted as an important learning opportunity for those coming from more advanced laboratories on the diverse contextual challenges and resource limitations experienced in different countries across the region. "if funding would be available, it would be great to make. .. a mission available for each support expert during training... . you really grow as a person after such mission. at the same time you'll be very humble by seeing the difference in possibilities of various labs, due to aspects like economy, biosafety, burden of mdr-tb patients and so on." (newly trained support expert). of the 18 heads of tb laboratories participating in the network survey, five had hosted a mission by a training participant. outputs received following the mission included post-visit debriefing, written reports, lists of recommendations and support provided on implementation of recommendations. a high proportion (80%) of laboratories who had hosted a mission reported making changes or taking action based on the findings of the mission. members reinforced the point that newly trained support experts should be afforded the opportunity to participate in missions and that the training should be continued for additional cohorts. the majority of respondents (91.0-100% for different training events) felt that the training content was relevant and within the scope of the training program with overall satisfaction levels reaching 75.0-100% of participants. suggestions on how the training programme could be improved or optimised included making the programme longer and expanding it to cover additional topics including new technologies, addressing emerging problems like migration and its implications for tb diagnostic services, development of networking capabilities and expanding research and education opportunities (see additional file 5). "should look at how research collaborations can be built between countries and encourage snrl's to support further education of colleagues at nrl's" (newly trained support expert). sixty-eight percent of the erltb-net members were satisfied with the programme and recommended changes included: utilising existing collaborations and twin arrangements between the laboratories, concentrating on developing practical skills, support for research collaborations and implementation of online training (see additional file 6). some support experts suggested advocating for the training programme to be recognised by who so that support experts within the network could be called on as additional expertise to bolster global tb efforts. "training should allow support experts to perform assessments with who outside the european context in the developing world where the need is greatest" (newly trained support expert). an important recommendation which was highlighted by a number of training participants was that newly trained support experts should be involved more in leadership and management of the network activities and that opportunities to participate in the erltb-net annual meetings should be expanded. "i think younger experts should be encouraged to participate more in the activities of the management team decision and policy discussions and to broaden the core group beyond the more senior experts" (newly trained support expert). resilient laboratory systems are critical to support tb programmes, infectious disease diagnostics and public health systems. global health crises such as the current coronavirus disease 2019 (covid-19) pandemic and the 2014-16 west africa ebola outbreak highlight the importance of functional laboratory systems and diagnostic capabilities [19] [20] [21] [22] . unfortunately, laboratory systems and infrastructure have long been neglected and under-resourced in many settings. investment in training and upskilling of human resources should be considered a critical component of laboratory system strengthening. recognising this need in the eu region, the erltb-net set out a clear objective to invest in developing a cadre of future leaders within the tb diagnostic community. a tailored training programme for tb reference laboratory experts was developed and implemented within erltb-net to address the specific needs of the eu/eea member states [17] . the ultimate goal of the training programme was to increase the pool of technical experts available to step into leadership roles in national tb laboratories and in the eu/eea international tb diagnostic community. the course specifically targeted future leaders in tb diagnostics in the european region, therefore recruited those likely to take up management and leadership positions in tb laboratories within the eu, to achieve optimal impact. a total of 21 persons were trained within this programme in 2009-2016 and many of them subsequently took up leadership roles in tb laboratories. a high proportion of training participants reported having been promoted to more senior positions nationally and internationally following their graduation, indicating that the training program was beneficial for their career progression and fulfilling one of the fundamental objectives of the training programme. satisfaction with the training programme was generally high and self-reported achievements exceeded initial expectations in the vast majority of categories, indicating significant perceived benefits for the trainees. practical training was the only area where expectations were high but gains were relatively low (fig. 1) which could be explained by the fact that the advanced training covered various aspects of which hands on training was just one component. inclusion of multiple components spanning theory and practice, combined with leadership and management aspects, allowed trainees to gain a broader expertise which is demonstrated by significant gains in other areas. the course was offered to tb nrl's in the entire european region where the vast disparity in public health development, available resources and tb diagnostic capabilities is evident between laboratories in these countries. one of the significant objectives and benefits of the erltb-network is to act as a platform to coordinate capacity building of developing nrl's by other high-resource reference laboratories. our findings demonstrate the critical opportunities available for more advanced nrl's and snrl's in the european region to share their experiences and support development of those operating in low-resource contexts through missions and collaborations. furthermore, an important objective of this training programme was to harmonize diagnostic methodologies across the european region. various new methods, policies and practices have been implemented in participants' home institutions following graduation, achieving a key goal of the programme. recently mathys et al. [23] , demonstrated the value of networking activities in sharing expertise and developing methodologies that could be used to improve quality and laboratory performance within the erltb-net and beyond. reported benefits for the erltb-net further supported these findings indicating that the programme had a positive influence on the tb laboratory network at ground level. it is widely accepted that to help ensure that laboratories can effectively play their critical role in the detection, prevention and control of diseases, laboratory directors and senior laboratory managers require specialised training in leadership and management. to achieve this, in 2020, who expect to launch a new training programme the global laboratory leadership programme (gllp) which is anticipated to greatly contribute to the laboratory profession globally. however, the content and teaching modalities are still under development and it is unclear if the programme will be administered in person or through distance learning [24] . while there are currently a number of other training initiatives available to support capacity building of laboratory staff, the erltb-net training programme which has been running for more than a decade, differs from those available in a number of important ways [13, 14] . firstly, the training curriculum is unique in the scope and range of topics covered within the programme which includes education on tb policy and guidelines; management, leadership and organisation of tb laboratories; technical training on new methodologies, as well as qms and biosafety issues. secondly, the programme is pitched at a very high level, targeting future directors and senior level professionals in tb diagnostics in the european region, which has been identified as a critical need in the eu/eea area. the requirement for training of senior tb experts was further supported by the results of a recent survey (erltb-net, unpublished data) demonstrating that 32.0% and 61.3% of senior technicians and heads of national tb reference laboratories in eu/eea countries are approaching retirement age (50 years +) or are above retirement age. in countries that joined the eu in 2004 and later these proportions are even higher (42.1% and 63.6%, respectively). the recruitment process for this training involved careful selection of participants based on their long-term commitments, qualifications and nominations from host institutions, prioritising laboratory experts already working in nrls and snrls. thirdly, training cohorts are purposely limited in number with only eight to ten participants per cohort facilitating targeted training, fostering relationships and encouraging collaborations to be built over the period of the training. finally, the programme took place at a number of venues within the eu (uk and italy), with trainees participating in a number of small and large workshops spread over the two-year period. this longitudinal nature of training (as opposed to one off training offered by many initiatives) further facilitated network and relationship building, resulting in collaborations and partnerships developing, with many subsequent positive outcomes. a high proportion (80%) of laboratories who had hosted a visit by a support expert reported making changes or taking action based on the findings of the visit, demonstrating the usefulness of the exercise. the findings clearly showed that support experts were enthusiastic to contribute to and participate in missions. participating in missions was seen by support experts as a key way for trainees to galvanize and apply their learning, and to contribute to capacity building and harmonization of systems and practices across the european region. an important suggestion on how the impact of the programme could be enhanced was that graduated experts should also be trained in performing assessments beyond the european context in lowresource settings where the need is greatest, enabling the training programme to support global tb control. all of the respondents reported that they would recommend colleagues to apply for the training programme and made a number of important suggestions on how the programme could be improved which are being explored by the training coordinators for future cohorts. a notable suggestion was that the programme should be used to promote research collaborations between countries and encourage snrls to support further education of colleagues at nrls which would ultimately benefit the erltb-net. an additional suggestion included ensuring that trained experts are continually involved in the work of the network and in future training and meetings. evidence that this is already being implemented was visible at recent annual meetings where a number of graduated experts contributed in both organisational and teaching components. suggestions for future provision of online training courses, additional practical training and further supporting relationships and collaborations are also being explored. a number of limitations exist relating to the methodology of this study, including that the responses and therefore results and conclusions are based on selfreported participants' opinion. evaluations in the form of pre-and post-tests were not performed and results of post-training evaluations were not included in the analysis presented here. additionally, the information about expectations was collected retrospectively and not before the start of the training programme. we also highlight the low response rate to the erltb-network questionnaire (58%). in addition, we did not gather information on other training courses attended by the trainees which could have contributed to or augmented the benefits and career progression of trainees which we report here. based on the finding presented and discussed above we believe that the concept of the erltb-net training programme has proved to be successful in developing expertise, partnerships and networks to support tb laboratories in the eu/eea and has contributed significant benefits to european nrls in the fight against tb. this manuscript describes an important initiative with demonstrated successes of career progression, improvements in technical skills and competencies, development of collaborations and value added to the broader tb community. we propose that the training programme described here would be extremely beneficial if implemented within other regions outside the eu, for example in africa and asia, where tb prevalence is high and laboratory systems are weak and traditionally neglected. now more than ever, public health programmes would benefit from dedicated experts trained to lead and manage tb and infectious disease laboratories and this manuscript describes a potential framework for implementation. world health organization regional office for europe. tb in the who european region european centre for disease prevention and control/who regional office for europe. tuberculosis surveillance and monitoring in europe european centre for disease prevention and control/who regional office for europe. tuberculosis surveillance and monitoring in europe the added value of a european union tuberculosis reference laboratory network--analysis of the national reference laboratory activities. euro surveillance : bulletin europeen sur les maladies transmissibles = european communicable disease bulletin rapid diagnostics of tuberculosis and drug resistance in the industrialized world: clinical and public health benefits and barriers to implementation diagnosis of tuberculosis and drug resistance: what can new tools bring us? genotyping of mycobacterium tuberculosis: application in epidemiologic studies diversity and evolution of mycobacterium tuberculosis: moving to whole-genome-based approaches. cold spring harbor perspectives in medicine roles of laboratories and laboratory systems in effective tuberculosis programmes external quality assessment for tuberculosis diagnosis and drug resistance in the european union: a five year multicentre implementation study global laboratory initiative (gli) world health organization world health organization. the end tb strategy recommended standards for modern tuberculosis laboratory services in europe eight years of the eacvi's grant programme: existing developments, impact, and steps forward establishing ebola virus disease (evd) diagnostics using genexpert technology at a mobile laboratory in liberia: impact on outbreak response, case management and laboratory systems strengthening diagnostic preparedness for infectious disease outbreaks what ebola tells us about outbreak diagnostic readiness the laboratory diagnosis of covid-19 infection: current issues and challenges time-and-motion tool for the assessment of working time in tuberculosis laboratories: a multicentre study world health organization. global laboratory leadership programme publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements yen holicka provided support on communications with participants and on compilation of the data received from the survey. supplementary information accompanies this paper at https://doi.org/10. 1186/s12913-020-05240-3.additional file 1. details of the topics covered during each training course.additional file 2. questionnaire for erltb-net support experts.additional file 3. questionnaire on ertb-net support experts training programme benefits for the network and tb community as a whole.additional file 4. additional questionnaire on missions and benefits for the laboratories for erltb-network members and trained support experts.additional file 5. additional topics suggested by participants for inclusion in the training programme.additional file 6. proposals from erltb-net members to enhance the training programme.authors' contributions prdeveloped the study tools, analysed and interpreted the data collected, wrote the first version of the manuscript, revised draft versions, and prepared and submitted the final manuscript. vnprovided significant input to development of the study tools and reviewed and provided significant input to all versions of the manuscript. ck -provided input to development of the study tools and reviewed and provided input to all versions of the manuscript. mvdwprovided input to the study design and tools, reviewed and provided input to all versions of the manuscript. the author(s) read and approved the final manuscript. the study received funding from the european centre for disease control (ecdc; solna, sweden) under grant 2014/001. the funding body had no role in the design of the study, collection and data analysis; but, contributed to writing and critical reviewing of the manuscript. the datasets analysed as part of the current study are available from the corresponding author on reasonable request. ethical approval was not required for this study as it was an evaluation of a training programme. by participating in the survey, participants gave written consent for their contribution to be used as part of the evaluation. the study was an observational study with an aim of quality improvement where no private, sensitive, personal or health data was collected or analysed. names or surnames were not stored with the data and all identifiers were removed before data analysis and stored securely. the lead author did not have access to personal data. therefore, we declare that no personal information was collected or analysed and as such no ethics permission was required for this study. not applicable. the authors declare that they have no competing interests. key: cord-329388-defbarkz authors: keane, martin g.; wiegers, susan e. title: time (f)or competency date: 2020-08-03 journal: j am soc echocardiogr doi: 10.1016/j.echo.2020.05.029 sha: doc_id: 329388 cord_uid: defbarkz nan martin g. keane, md, fase, and susan e. wiegers, md, fase, philadelphia, pennsylvania seventy years ago, susan's 92-year-old father's first teaching job was in a one-room schoolhouse in fayetteville, maine. he recently came across the ''register'' that he was required to keep of his students' daily attendance. he explained that attending an adequate proportion of school days was the sole determinant of whether or not a child was promoted to the next grade. ''apparently, actual accomplishment was not considered,'' he laughed. indeed, time spent in training is an essential component of the development of skill and expertise-time in rank, time on service, and time devoted to learning and performing the skill in question. linked with time spent in training, appropriately robust experience to develop expertise requires repeated exposure to and performance of tasks essential to the skill over that time-amounts of consults/evaluations, accumulation of procedures, numbers of echocardiograms. it is important to recognize, however, that competency in the skill is the outcome of interest. time and numbers are merely surrogate markers. the core cardiovascular training statement (cocats 4)-task force 5-outlined the expected behaviors and work product for echocardiographers. 1 levels of training from most basic echocardiographic knowledge (level i) to most advanced knowledge suitable for an echocardiography lab director (level iii) are clearly defined by duration of echo-specific training as well as specified numbers of procedures (transthoracic, transesophageal, and stress echocardiography) performed by the trainee. the task force clearly recognized that competency-based evaluations and assessments of echocardiographic knowledge base are essential elements in the certification of skill. however, as lab/program directors responsible for the providing certification letters over many years, it has been our experience that the ''focus'' of the fellowship trainees (and sometimes of their mentors as well) is frequently geared toward meticulous documentation of ''time served'' and ''procedures performed,'' as evidence for the proverbial notches in their belts. suitable evaluation of the individual candidate's competency is potentially at risk for being overlooked. necessity is the mother of invention, however, and the ongoing covid-19 crisis may prove instrumental in shifting the focus of echocardiography training evaluation from time and numbers to consideration of alternative measures of skill. dr. jose madrazo rightly and extensively illustrates this important point in his letter in this issue of journal of the american society of echocardiography. 2 as with the johns hopkins program, training programs across the country are faced with significant decline in the volume of all forms of echocardiographic evaluation as clinical focus shifts toward the care of an overwhelming number of patients with covid-19. dr. madrazo notes that social distancing measures, so crucial to thwarting the spread of sars-cov2, additionally hamper opportunities for hands-on training as well as face-to-face mentoring and supervision between expert echocardiographer and trainee. he makes numerous worthwhile recommendations for alternative experiential and evaluative tactics. these must be considered for implementation in the certification process, especially during a pandemic that is here to stay for the foreseeable future. we applaud his recommendations and reiterate a need for a shift toward competency-based assessment. the recent 2019 american college of cardiology/american heart association/american society of echocardiography advanced training statement 3 focused on select competencies and echo procedure volumes for level iii advanced training. the document is unique in its greater focus on delineating strategies for the evaluation of competency, in addition to recommended numbers of advanced echo techniques and procedures performed. it recognized that the endorsed volumes for specific advanced echo techniques and procedural guidance to achieve level iii have been developed by the expert committee consensus, in consultation with echocardiography training authorities across the country. in all instances, these procedure volumes are noted to be recommendations only. they serve as recognition that diverse trainees develop competency at different levels of experience-some quickly, others requiring more procedural practice. perhaps it is an appropriate time for a similar shift toward competency-based assessment when certifying level i and level ii training as well. to that end, the advanced training document delineates several evaluation tools that can be utilized for robust competency documentation 3 : 1. examination 2. direct observation 3. procedure logbooks 4. simulation 5. conference presentation 6. multisource evaluation 7. echo lab quality improvement and quality assurance projects to supplement the procedural logbooks and decrease in face-toface direct observation of skills, alternative evaluation methods are readily available. we admit that faced with weaker trainees, it can be easier to recommend ''more studies'' rather than giving uncomfortable and negative feedback regarding their current level of accomplishment. as noted, 2 ''distant'' overreading of fellow-interpreted studies can be as valuable, or even more so, than direct observation. more conscious effort must be expended on the part of the expert mentor to virtually review all aspects of each study overread in order to provide the trainee with as comprehensive an assessment and education as occurs in side-by-side reading. whenever distancing norms permit, every effort should be expended to maintain direct supervision, with at least one or two trainees in direct contact with the mentor using proper personal protective equipment. in addition to evaluation of interpretive skills, it remains possible to evaluate the breadth and depth of trainee knowledge through participation in and presentation of didactic conferences. today's sophisticated video conferencing mechanisms allow for a remarkable level of interaction under difficult circumstances. we endorse additional novel video conference applications, including interactive case reviews and case series presented to the fellowship group. 3 finally, while formal national board of echocardiography board examination remains a final tool to assess knowledge base, allowing trainees more time and access to board review courses, board review questions, and seminars in both print and online format will only serve to enhance the comprehension and critical thinking of echocardiography-focused fellows. in terms of the performance of echocardiography techniquestransthoracic, transesophageal, and stress modalities-it is undeniable that frequent access to individual scanning of patients with a multitude of pathologies is essential. in the face of a relative dearth of clinical subjects, as well as concerns regarding prolonged interpersonal exposure and possible coronavirus transmission, programs (and certification authorities) must adapt, with utilization of simulators and other techniques focused on recognition of technical adequacy and pitfalls in acquisition of previously acquired study images. several simulation systems are available for purchase. these systems can often analyze probe position and angling in three-dimensional space far more effectively than with a human mentor. although the views and the simulator ''patient'' are idealized, fellows benefit tremendously from exposure to repeated simulator scanning to perfect their technique in all echocardiographic windows. pathologic cases can also be programmed, with appropriate clinical scenario and the opportunity for the operator to evaluate diverse pathologies in multiple views. both transthoracic and transesophageal performance are included on most simulators, and the trainee may be evaluated directly by a mentor or more remotely using extensive recording of probe motion and images obtained by the simulator. stress echo cases-using both practice sets 2 or via simulator-can be virtually ''performed'' and/or reviewed in similar fashion. ongoing participation in echo laboratory quality assurance projects, even when done on a remote basis, increases the sophistication of understanding of proper performance and application of echocardiographic techniques-essential for both level ii and level iii training. remote evaluation of clinical requests for echo examina-tions and application of appropriate use criteria principles further broaden a trainee's knowledge base. recognition of the appropriate application and mentored interpretation of an increased number of point-of-care ultrasound studies is an additional and unique skill that has been enhanced in the covid-19 pandemic. 2 furthermore, exposure to the echocardiographic findings of covid-19 patients and the unique clinical scenarios (such as elevation in biomarkers) that mandate at least a limited echocardiographic evaluation of the covid-19 patient will be an essential part of overall competency in the future. the covid-19 pandemic and the clinical exigencies that accompany it have merely magnified the difficulties with a time-based and numbers-/volume-based documentation of echocardiographic skill. the pandemic has conversely provided extensive opportunities for innovation and expansion of traditional educational and assessment strategies. most importantly, the desired outcome of true echocardiographic competence at all levels of training can be achieved despite the change in the training paradigms. cocats 4 task force 5: training in echocardiography new challenges and opportunities for echocardiographic education during the covid-19 pandemic: a call to focus on competency and pathology ase advanced training statement on echocardiography (revision of the 2003 acc/aha clinical competence statement on echocardiography) key: cord-267229-hdnzs9o6 authors: yang, dennis; wagh, mihir s.; draganov, peter v. title: the status of training in new technologies in advanced endoscopy: from defining competence to credentialing and privileging date: 2020-06-03 journal: gastrointest endosc doi: 10.1016/j.gie.2020.05.047 sha: doc_id: 267229 cord_uid: hdnzs9o6 abstract the landscape of advanced endoscopy continues to evolve as new technologies and techniques become available. although postgraduate advanced endoscopy fellowships have traditionally centered on ercp and diagnostic eus, the breadth of training has increased over the years in response to the ever-growing demand for therapeutic endoscopy. the increasing diversity and complexity of emerging endoscopic techniques accompanied by the shift in focus toward competency-based medical education requires innovative changes to the curriculum that will ensure adequate training yet without compromising best patient practices. the purpose of this review is to highlight the expansive array of advanced endoscopic procedures and the challenges of both defining and measuring competence during training. all authors are interventional endoscopists at their respective institutions performing these complex procedures, as well as training fellows in these techniques. we share our perspectives based on our experience navigating through these issues at our institutions and discuss strategies to standardize training and how to potentially incorporate these measures toward the process of credentialing and privileging in endoscopy. endoscopic stenting, deep enteroscopy, and more recently, "third space" endoscopy and endoscopic bariatric therapies (ebt). with the increasing complexity of these procedures and the inherent higher risk for adverse events, trainers and trainees alike face the daunting task of measuring and attaining competence in these various techniques within a relatively short period of time. however, because these fellowships are not formally accredited, there is little to no regulatory oversight on the structure of these programs, which has traditionally resulted in significant variability on how training is provided and assessed. traditionally, advanced endoscopy training has been based on an apprenticeship model with volume of cases commonly serving as a surrogate for competence. in this model, trainees learn through the observation and performance of procedures under supervision. initially, the minimum number of cases required to achieve competence in any given procedure was largely based on expert opinion. with time, multiple studies have attempted to identify and validate the minimal procedural number for competence, perhaps best illustrated with regard to ercp during advanced endoscopy training. early studies on ercp suggested that a threshold number as low as 35 was sufficient to achieve competency [1] . subsequent studies, using predefined target measures (ie, biliary cannulation success rate ≥80%, bile duct clearance of choledocholithiasis, successful placement of an endoprosthesis), showed that a threshold of 100 to 200 ercps was necessary for competency [2] [3] [4] . based on these studies, the american society of gastrointestinal endoscopy (asge) and national institutes of health consensus guidelines published in 2002 recommended that competence be assessed after 200 ercps [5, 6] . yet, subsequent publications have suggested different thresholds, with a study from mayo clinic recommending more than 350 ercps as the minimal procedural number for competency in patients with native papilla [7] . more recently, a systematic review published in 2015 reported that the threshold for competency, defined by high rate of successful selective duct cannulation, ranged from 79 to 300 ercps [8] . in aggregate, these findings illustrate how identifying a minimal procedural number can be rather elusive, and further highlights how using thresholds as the only endpoint in competence assessment is flawed. for one, most of these studies defined performance of a particular intervention (ie, biliary cannulation) as a maker for procedural competency. yet, interventions such as biliary cannulation, albeit a crucial step, only represents one of the many maneuvers that are commonly performed during ercp and may not be a good indicator of a trainee's global competence. secondly, we need to recognize that trainees have different educational background and learn skills at variable rates, thereby absolute thresholds have limited value in this regard. this is particularly evident nowadays when more and more physicians seeking additional training have been in practice for several years, many of whom already possess a background in advanced endoscopy. in addition, as we previously alluded, in the absence of any regulatory oversight, training programs vary significantly in terms of the educational experience provided. noteworthy, most faculty in these programs are deemed qualified to teach given their own expertise in the field (master-apprenticeship model); yet most of them lack any formal training in teaching endoscopy. the asge has published curricula for training in various advanced endoscopic procedures [9, 10] , but training and skills assessment remains variable across the country. furthermore, trainees with similar number of cases under their belt may not have the same level of readiness for independent practice due to factors beyond numbers. these may include trainee's degree of involvement during training (ie, extent of passive observation vs hands-on activity), diversity of case exposure, and level of difficulty associated with the training procedures. with these issues in mind, there has been an increasing effort in endoscopy training, and in medical education in general, to shift away from time-based training toward competencybased education [11] a primary mission of the american society for gastrointestinal endoscopy (asge) is to promote high-quality patient care by ensuring competence in gi endoscopy. the asge defines competence in endoscopy as "the minimum level of skill, knowledge, and/or expertise derived through training and experience that is required to safely and proficiently perform a task or procedure" [12] . this definition implies that competency involves a combination of both technical and cognitive skills. equally as important are the integrative skills needed to extract and interpret the information obtained from the procedure to guide patient management. noteworthy, although not clearly stated in the asge definition, competence in endoscopy implies that the trainee should be able to independently perform the procedure upon completion of training. although these concepts may appear self-explanatory, how to objectively measure competence during advanced endoscopy training remains controversial and challenging. the landscape of advanced endoscopy training continues to evolve as new technologies and techniques become available. the skill set and degree of training required for these novel endoscopic procedures will vary based on multiple factors, including but not limited to the complexity of the technique. in light of this fact, the asge has previously set forth guidelines to provide a framework on how to evaluate competence involving new and emerging technologies in gi endoscopy [12] . according to the asge, a "major skill" describes a new technique or procedure that involves a high level of complexity, interpretative ability, and/or new type of technology. as such, the development of major skills requires formal training under the supervision of a preceptor(s). competence in a major skill, as detailed by the asge, involves the following components: (1) understanding of the indications, benefits, risk and alternatives to the procedure; (2) ability to perform the procedure proficiently and safely; (3) identify and manage adverse events that may arise; (4) interpret endoscopic findings accurately; (5) incorporate these into the overall clinical evaluation of the patient; and (6) provide a comprehensive pre-and postprocedural plan [12, 13] . by the completion of training, the trainee is expected to have a degree of competence that allows them to perform the major skill at hand. based on these criteria, most advanced endoscopic procedures, such as eus, ercp, esd, and poem would constitute "major" skills requiring dedicated training (table 1) . conversely, the asge also recognizes that in some instances, endoscopic advances may represent minor extensions or minor refinements of established endoscopic procedures. this may include improvements or modifications of existing techniques familiar to the endoscopist (table 1) . as per the guidelines, acquisition of a "minor skill" can thereby be accomplished through limited education and practical exposure, which may involve didactic resources (ie, instructive videos, interactive tutorials) and short dedicated courses [12, 13] . we should emphasize that these definitions by the asge should only be used as a framework because ultimately, the extent of training necessary to achieve competence will largely fluctuate based on the endoscopist's background. for instance, although radiofrequency ablation (rfa) may represent a "minor" skill for an endoscopist with experience in the treatment of barrett's esophagus (be), this technique may constitute a "major" skill for a trainee with little to no background in ablative techniques and/or familiarity in the diagnostic evaluation of be. similarly, as discussed later, although some ebts may be considered "minor" skills (table 1) , these procedures should not be performed in-silo and most endoscopists may still require dedicated training to fully understand the role of these procedures within the multifaceted treatment of obesity. the practice of gi endoscopy is dynamic, and the breadth of procedures continues to increase. consequently, endoscopists are faced with the challenge of seeking and attaining proper training in these new technologies over the course of their career. in recent years, with the transition toward a competency-based training curriculum, we have witnessed the development and integration of standardized measurement tools that aim at providing both quantitative and qualitative assessment in endoscopic training [14] [15] [16] , however, with the expanding array of endoscopic techniques, both the challenge and focus is now shifting on how do we adequately measure competence among trainees in novel technologies. among these, "third space" and bariatric endoscopy have gained traction over recent years as budding subspecialties within the field of advanced endoscopy. "third space" endoscopy, also referred as submucosal endoscopy, is based on the concept that the deeper layers of the gi tract can be accessed via the submucosal space. with advances in endoscopic devices and refinement in techniques, we have witnessed the evolution of third space endoscopy from a vanguard concept to techniques in routine clinical use, including the widespread adoption and dissemination of procedures such as endoscopic submucosal dissection (esd) and peroral endoscopic myotomy (poem). introduced in japan as a minimally invasive alternative to surgery for the management of early gastric cancer. given its efficacy and safety in the hands of japanese experts, this technique has evolved and shifted to include lesions in the lower gi tract. the main advantage of esd over endoscopic mucosal resection (emr) is the ability to achieve en-bloc resection of lesions irrespective of size and thereby lower risk for local recurrence [17] . however, this procedure is associated with a steep learning curve and potential risk for serious adverse events. esd training in japan follows the traditional master-apprentice model. this template for therapeutic training has been very successful in japan, where trainees are highly subspecialized and undergo extensive cognitive and technical training under direct supervision. however, due to multiple factors, including the limited number of local esd experts and training opportunities, this model is not translatable to western countries. consequently, the transition of esd to the west has been slower than its uptake in asia [18] . in light of these issues, the european society of gastrointestinal endoscopy (esge) recently issued a position statement with recommendations for a core curriculum to achieve high quality training in esd [19] , clearly outlining that trainees should not perform complex endoscopic procedures in humans independently without having undergone sufficient training (ie, supervised cases by experts, structured focused fellowships). the primary aims of this curriculum included (1) the definition of skills and competence needed before esd training; (2) to develop a standardized core curriculum for esd practice through the establishment of minimum standards; (3) and to define a training program for endoscopists who want to start esd practice in their center. the esge recognizes that competence in esd requires an in-depth understanding of all the available modalities for appropriate lesion characterization and selection. hence, proficiency in advanced diagnostic techniques, including knowledge of endoscopic classification systems, are considered a requisite before esd training. given that esd is a technically complex procedure that requires precise endoscope control, prior emr skills are necessary to serve as a foundation for needed skills in advanced resection, including injection, hemostasis and management of adverse events. the core curriculum proposed by the esge guidelines parallels training pathways that have been previously suggested for esd training in the west [18, 20, 21] . as we have previously suggested [18, 20, 21] , live esd courses and meetings can serve as an initial venue for trainees to learn the basics on theoretical knowledge, techniques and esd devices. hands-on training on animal models is strongly recommended as this has been shown to improve esd outcomes and the skills needed for the management of adverse events [22, 23] . the esge recommends that trainees should perform at least 20 esd procedures in animal models before undertaking any human cases. after this, trainees should observe (20 cases) and assist (5 cases) experts on live human esd procedures before performing cases on carefully selected lesions under direct supervision (10 cases). according to this esge curriculum, trainees can then start esd in their own centers once they have fulfilled these requirements as confirmed by an "expert in esd" [19] . although these guidelines provide a potential framework for esd training, several logistical issues should be highlighted. for one, this model is difficult to adopt in the united states where cases are sporadic and may be far in between even in specialized centers. esd trainees are often full-time interventional endoscopists at their own institutions and may not be able to arrange travel arrangements in short notice. noteworthy, due to hospital policies, visiting trainees are often restricted to observing cases only, as they are not credentialed to actively "assist" in the care of patients. last, we need to recognize that these suggested guidelines are mainly based on expert opinion and that robust data substantiating these training recommendations are lacking. peroral endoscopic myotomy. peroral endoscopic myotomy (poem) is a minimally invasive endoscopic technique for the management of esophageal motility disorders initially developed approximately a decade ago [24] . since its introduction into clinical practice, poem has become widely accepted given its excellent short and mid-term outcomes and safety profile [25, 26] . however, as a modified natural orifice transluminal surgical procedure, training in poem presents several challenges. the procedure is technically complex and demands advanced endoscopic skills, knowledge of both intra-and extraluminal anatomy of the gi tract, and the ability to manage adverse events that may include pneumothorax and pneumoperitoneum. in spite of the rapid dissemination of this technique, there is very little published information regarding training in poem [27, 28] . in 2017, the japan gastroenterological endoscopy society (jges) launched a committee for poem to establish clinical guidelines to serve as a decisionmaking tool and to ensure minimum standards of practice [29] . the jges-sponsored clinical guideline introduces several recommendations regarding training and teaching programs for poem. similar to the esge positional statement on esd, this clinical guideline on poem recommends that initial skill acquisition should be met through training on animal models, including organ and live models, although a minimum threshold was not provided [29] . however, in a single center prospective study using both ex-vivo and live swine models, mastery, defined as the absence of intraprocedural adverse events and plateau in procedural time, was achieved by trainees after 26 cases [30] . subsequently, training progresses by observation of poem cases followed by proctoring of live human cases by an experienced operator, who can provide step-by-step supervision and guidance through the initial cases. the literature on the learning curve for poem is conflicting due to differences in definitions and heterogeneous training backgrounds. not surprisingly, there is a wide discrepancy in the learning curve plateau reported, ranging anywhere from 7 to 100 cases [31] [32] [33] [34] [35] , with many of these reporting data from animal models, or highlighting single-center or single-operator experiences, rather than studies designed to assess training and competency in poem. hence, similar to training in esd, these recommendations are based on expert opinion rather than formal training data. the obesity epidemic continues to rise in the united states and globally; yet, only 1% of eligible patients undergo conventional bariatric surgery [36] . more recently, endoscopic bariatric therapies (ebt) have emerged as an adjunctive endoscopic option to traditional surgical treatments for obesity, with multiple endoscopic devices and techniques demonstrating safety and efficacy in prospective randomized studies [37] . ebt encompasses a broad array of procedures including primary weight loss interventions and treatment of adverse events from bariatric surgery. similar to other emerging technologies, there is a paucity of data regarding training requirements in ebt. in 2015, the asge issued a position statement on ebt in clinical practice, recommending that endoscopists partaking in ebt should demonstrate competency in upper endoscopy and endoscopic hemostasis [38] . given the diversity of ebt procedures, the duration and type of training will vary, depending on the complexity of the particular intervention. the asge suggests that focused training via dedicated courses are potential settings to gain further expertise in certain aspects of ebt [38, 39] . many of these courses are sponsored and organized by industry, which plays a vital role in the training and education of these new devices. yet, moving forward, there is a need to introduce standardized criteria for the teaching and evaluation of these new techniques among the various courses, as to reduce variability in learning and potential for conflict of interest. conversely, ebts of greater complexity may require proctoring and a structured training program; albeit no specific recommendation regarding procedural thresholds are provided by the asge given the scarcity of data in this area. a few studies have attempted to define learning curves with endoscopic sleeve gastroplasty (esg), a gastric restrictive procedure commonly performed with endoscopic suturing [40] [41] [42] . however, threshold numbers to achieve "efficiency" varied greatly from 7 to 38 cases, due to the heterogeneous definitions and variable outcome measures across the studies. noteworthy, these data were based on endoscopists who had extensive prior experience with the endoscopic suturing device. overall, both the asge and the american society for metabolic and bariatric surgery (asmbs) emphasize that ebt should not be carried out in isolation and that endoscopists performing ebt should be part of a multidisciplinary comprehensive obesity program [38, 39] . as previously discussed, with the shift toward competency-based medical education (cbme), there is an increased emphasis on establishing an outcomes-based training curriculum; with the goals of reducing variation in the quality of endoscopy and to define standards within the field of advanced endoscopy that may help identify areas for quality improvement. although major strides have been made in the standardized assessment of ercp and eus training [43] [44] [45] , several challenges remain when attempting to implement a structured training program for emerging endoscopic procedures: 1. training the trainers. in the traditional "see one, do one, teach one" training model, teachers are identified based on their own expertise within a particular field of interest. these teachers then serve as mentors and are responsible of identifying when their students have fulfilled their training requirements. a national audit of colonoscopy performance in the united kingdom (uk) identified the numerous pitfalls of this informal and highly subjective teaching approach [46, 47] , which subsequently sparked the implementation of various strategies aimed at improving endoscopic training [15, 16] . one of the key issues identified included the importance of developing programs to "train the trainer" (ttt), based on the premise that simply acquiring the skill of performing an endoscopic procedure does not explicitly translate in an ability to be an effective endoscopy trainer [48] . since its implementation in the united kingdom in an effort to improve colonoscopy quality outcomes, these ttt programs have been applied in other countries with proven impact on endoscopic training [49] . the ttt model promotes standardization of training by (1) educating the trainer on how to effectively and efficiently teach endoscopy; and stresses the (2) need to develop a structured curriculum with pre-established learning objectives [48] . noteworthy, the adoption of this training program, designed to upskill endoscopists, should help build an effective trainer pool over time, which is paramount for the dissemination of novel endoscopic skills [50] . although hands-on practice on animal models has often been advocated as an integral component in endoscopy training, particularly in the acquisition of major skills [19] , animal laboratories are costly and not widely available. simulation-based training in gi endoscopy may be a valuable adjunct tool that can help trainees acquire new skills and accelerate learning curve in a low-risk environment [51, 52] . this may be particularly attractive for training in third-space endoscopy, given the already aforementioned lack of local "experts," training opportunities, and high stakes with these complex interventions. theoretically, with simulation-based training, learners should be able to repetitively perform the intended skills and adjust training to target specific skills or build upon existing competencies with no risk to patients. however, there is currently a scarcity of data examining the ability of simulators as tools to assess endoscopic skill. hence, although promising, additional studies on simulator-based assessment tools with predictive validity are necessary before we can determine its role as compared with the acquisition of technical and cognitive competency via standard endoscopic training [53] . similarly, real-time assessment and provision of data on trainee performance can be challenging depending on the available of local experts. more recently, indirect assessment methods, including video-recorded procedures, have been evaluated as an alternative to "live" assessment [54] . video recording allows careful review and debriefing of procedures after the training session, which may facilitate the exchange between mentor and trainee. with technological innovations and increasing broadband availability, video-based live instruction (during animal hands-on training, simulationbased sessions, or even human cases) may be a potential strategy for endoscopic education of highly specialized new techniques even with mentors in geographically distant locations [55] . this approach may become even more prominent due to the expected higher precautionary restrictions on travel and visiting endoscopists in light of the recent worldwide coronavirus (sars-cov-2) pandemic [56] . 3. standardization of training and assessment tools. trainees learn and acquire endoscopic skills at variable rates; thus, recommended minimum volume thresholds in silo cannot ensure competence. for example, with esd training, we cannot expect that the needs and requirements of an individual who just graduated from gi fellowship will be the same as that of a practicing endoscopist with extensive experience in emr already. hence, duration and intensity of training should be in part dictated by the trainee's background. given the complexity of some of these techniques, it is unrealistic to expect that all trainee can acquire these skills through the "standard" advanced endoscopy fellowship pathway. in recognition of this limitation, several advanced endoscopy training programs, have modified their curriculum as to meet the specific needs and expectations of the trainee. likewise, we need to acknowledge that many endoscopists seeking training in novel technologies do not necessarily do so through the formal advanced endoscopy fellowship pathway. given this heterogeneity, there is an urgent need to standardize training, especially given the paucity of data on learning curves for novel procedures and the numerous training pathway permutations [50] . in figure 1 , we outline the suggested steps to consider when developing a training curriculum for a novel endoscopic procedure. first, core skills for each novel procedure should be defined, which can be achieved by deconstructing the technique into a series of sequential steps. in the case of esd, these steps may include lesion assessment before resection, marking the margins of the lesion, mucosal incision, submucosal dissection, use of traction-countertraction during the procedure, elective closure and management of adverse events. the next step is to define quality metrics based on outcomes data and set these as benchmarks during training (ie, en-bloc resection and adverse event rates). for instance, the esge training curriculum for esd proposes a 90% en-bloc resection rate with <3% perforation rate as threshold targets [19] . once these core skills and target metrics are established, the next steps would involve the development and validation of an assessment tool followed by its adoption in formal competency-based training programs ( figure 1 ). again, it should be emphasized that these assessment tools must be procedure-specific based on the predefined outcome metrics, which is key in ensuring that endoscopists, irrespective of their training background, meet the expected quality benchmarks for clinical practice. lastly, post-training evaluation (ie, assessment of prospective case log with documentation of quality indicators) will be key in validating the efficacy of the assessment tools in establishing competency in terms of independent practice. 4. maintenance of skills/competence. the maintenance of endoscopic competence is equally as important as the skill acquisition process. many of these novel advanced endoscopic techniques, such as esd and poem, are complex and technically demanding. maintaining skills is highly dependent on case volume, which can be difficult to attain due to multiple factors, including low incidence of certain illnesses (ie, gastric cancer in the united states) or reimbursement issues (ie, esd, poem, ebt). as such, endoscopists should have a well thought out plan before undertaking training in new endoscopic skills. this initial plan should include prediction of future case volume at their own center as to ensure maintenance of skills, and perhaps even more importantly, to justify the need for training in this new skill in the first place. obtaining institutional endorsement on various fronts is key before starting training. for instance, institutional support at our institutions (university of florida and university of colorado), allowed us to make infrastructural adjustments to facilitate the introduction of poem and esd into our endoscopy unit, thereby easing the incorporation of these procedures into the schedule [57] . institutional support in terms of protected time to train in an animal laboratory is also highly desirable, as this can be a complementary strategy to maintain skills and avoid spaced training initially, when human cases are relatively low [19] . last, although beyond the scope of this review, it is important to recognize that many of these interventions do not have dedicated procedural terminology (cpt) codes. upfront discussion with stakeholders with regard to billing and coding is essential to ensure the necessary case volume to sustain newly acquired skill sets [57] . credentialing is the process in which an institution reviews an endoscopist's qualifications to determine if they meet the criteria to perform the endoscopic procedure in question. traditionally, preceptors have been responsible in establishing when a trainee has reached "an acceptable level of competency" and thereby provide written documentation of the successful completion of the training for future credentialing purposes [12, 13] . hospital credentialing committees then determine who will be granted privileges based on the supporting evidence. there are several issues worthy of discussion with regard to how this process is currently structured: 1. definition and assessment of competence. as we have previously discussed, defining competence remains a challenge in endoscopic training. the assessment of competence by tallying total number of procedures performed is not sufficient. although the performance of a minimum volume is a prerequisite for skill acquisition, it does not guarantee competence; herein lies the importance of establishing procedure specific benchmarks that can be used as concrete performance endpoints. continuous recording of performance data into accessible electronically generated centralized endoscopic databases would potentially allow third-parties (ie, hospital credentialing committees) to then identify and search for these target benchmarks [12] . 2. responsibility of establishing competency in endoscopy training. the current certification of competency in endoscopy is usually provided by a training program director. however, there are several limitations to this approach. for one, a trainee's performance is based on the subjective evaluation by his/her mentor, which, by itself, may introduce bias in the credentialing process. secondly, in the absence of standards and objective parameters, there is likely substantial variation among training directors on what may be considered an "acceptable level of competency." it is important to reiterate that competency should be procedure specific. hence, competence in a particular procedure does not necessarily translate into competence in a materially different one. last, as previously discussed, many endoscopists interested in acquiring new endoscopic skills do not undergo formal advanced endoscopy training and may do so through different training pathways. this poses a challenge in the absence of clear guidelines on how or who should be responsible in attesting to the competency of these individuals. in light of these concerns, the asge has previously issued a statement regarding the important role of proctoring in the process of endoscopic privileging [12, 13] . according to these guidelines, a proctor should be an endoscopist who is credentialed in the specific procedure being observed, has no physician or patient relationship, and reports directly to the institution's credentialing committee. the role of the proctor is to provide an unbiased evaluation of the endoscopist's competence on the procedure in question. however, similar to the issues regarding the lack of locally available experts, we presume that the pool of qualified proctors for emerging new technologies will also be scarce. videobased proctoring may be a viable strategy in the future. reliable, blinded video-based proctoring could potentially provide an unbiased assessment in the credentialing process [54, 55] . 3. responsibility for privileging, conflicts of interest, and the lack of uniform standards. there are no established national standards for granting endoscopic privileges. the current credentialing process in the united states requires each hospital and its credentialing committee to manage the process of granting privileges. it is the responsibility of each institution to develop and maintain their own guidelines regarding this process, which potentially introduces conflict of interest-hospital credentialing committees may be subject to external pressure from the applicants, their employers and even competitors [58] . many hospitals may be pressured to offer a broad range of endoscopic procedures due to economic incentives. similarly, the pursuit for endoscopic innovation and the distinction of being the "first" hospital to offer a novel procedure may unintentionally influence and circumvent the safeguard training and credentialing requirements necessary for such processes. in the case of many novel endoscopic techniques, trainees often use certificates of "attendance" from industry-sponsored courses to support their application. however, most of these "exposure" courses vary significantly in length, content, didactics and hands-on training. importantly, with a few exceptions for the acquisition of minor skills as previously discussed, most of these courses do not attest to the competence of the attendees. the ultimate solution would be the establishment of an independent board for endoscopic procedural credentialing that would remove conflicts of interest from hospital credentialing committees. requiring certification for endoscopic procedures by a national board would help oversee that endoscopic privileges are granted to hospitals that meet the established national consensus parameters in order to safeguard best patient practices and ensure uniformity of the process across all institutions. this step is particularly crucial in assuring the safe stepwise dissemination and adoption of new technologies in clinical practice. until then, criteria for endoscopic privileging could be established by national consensus standards developed by professional societies based on evidence and expert opinion, including experiences from centers across the world. these professional societies could also help identify and assign independent proctors, which would help limit any undue influence conclusion gi endoscopy is an exciting and continuously evolving field. the age-old dictum of "see one, do one, teach one" is dated with the increasing diversity of complexity of emerging endoscopic techniques and the shift toward competency-based medical education. minimal threshold numbers are an integral part of training; yet do not guarantee competence. of note, defining competence in endoscopy must be procedure specific, starting with the identification of core skills, and establishing quality metrics and benchmarks for a given technique. the development of validated procedure-specific assessment tools can then help in the evaluation of these predefined targets. training in novel emergent endoscopic techniques can be obtained through various pathways, and the integration of standard advanced fellowships and other resources, including simulation-based learning and video-based teaching, may further broaden and tailor the educational opportunities to a widely diverse trainee population. it cannot be overemphasized that short weekend courses and training in animal models does not necessarily qualify as a permit to start performing these newer endoscopic procedures in humans independently. lastly, establishing national consensus standards for endoscopic privileging are needed in order to reduce variation in endoscopy practice and ensure that all patients are optimally managed. figure 1 . flow diagram for the creation of a structured training curriculum for novel endoscopic procedures using esd as an example. *the esd assessment tool in the diagram is used to illustrate potential core skills that could be graded using a numerical score. this is not a complete list nor a validated tool. health and public policy committee, american college of physicians assessment of technical competence during ercp training quantitative assessment of procedural competence: a prospective study of training in endoscopic retrograde cholangiopancreatography 200 supervised procedures: the minimum threshold number for competency in performing endoscopic retrograde cholangiopancreatography methods of granting hospital privileges to perform gastrointestinal endsocopy nih state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ercp) for diagnosis and therapy establishing a true assessment of endoscopic competence in ercp during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy when trainees reach competency in performing ercp: a systematic review endoscopic retrograde cholangiopancreatography (ercp): core curriculum eus core curriculum the next gme accreditation system-rationale and benefits guidelines for privileging, credentialing, and proctoring to perform gi endoscopy methods of privileging for new technology in gastrointestinal endoscopy training in eus and ercp: standardizing methods to assess competence direct observation of procedural skills (dops) assessment in diagnostic gastroscopy: nationwide evidence of validity and competency development during training colonoscopy direct observation of procedural skills assessment tool for evaluating competency during training endoscopic submucosal dissection for barrett's esophagus and colorectal neoplasia how to master endoscopic submucosal dissection in the usa curriculum for endoscopic submucosal dissection training in europe: european society of gastrointestinal endoscopy (esge) position statement training for complex endoscopic procedures: how to incorporate endoscopic submucosal dissection skills in the west? training in endoscopic submucosal dissection learning colorectal endoscopic submucosal dissection: a prospective learning curve study using a novel ex vivo simulator training on an ex vivo animal model improves endoscopic skills: a randomized, single-blind study peroral endoscopic myotomy (poem) for esophageal achalasia peroral endoscopic myotomy: a meta-analysis safety and efficacy of poem for treatment of achalasia: a systematic review of the literature per-oral endoscopic myotomy white paper summary training pathways and competency assessment in peroral endoscopic myotomy (poem) clinical practice guidelines for peroral endoscopic myotomy the per oral endoscopic myotomy (poem) technique: how many preclinical procedures are needed to master it? analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (poem) learning curve for peroral endoscopic myotomy peroral endoscopic esophageal myotomy: defining the learning cuve the light at the end of the tunnel: a single-operator learning curve analysis for peroral endoscopic myotomy comprehensive evaluation of the learning curve for peroral endoscopic myotomy endoscopic bariatric therapies endosocpic bariatric and metabolic therapies: new and emerging technologies asge position statement on endoscopic bariatric therapies in clinical practice a pathway to endoscopic bariatric therapies endoscopic bariatric therapies for treating obesity: a learning curve for gastroenterologists endoscopic sleeve gastroplasty: the learning curve a single-operator learning curve analysis for the endoscopic sleeve gastroplasty variation in learning curves and competence for ercp among advanced endoscopy trainees by using cumulative sum analysis a prospective multicenter study evaluating learning curves and competence in endoscopic ultrasound and endoscopic retrograde cholangioapncreatography among advanced endoscopy trainees: the rapid assessment of trainee endoscopy skills (rates) study setting minimum standards for training in eus and ercp: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees the national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the uk quality improvements in endoscopy in england training the gastrointestinal endoscopy trainer leadership training to improve adenoma detection rate in screening colonoscopy: a randomized trial asge principles of endoscopic training virtual reality simulation training for health professions trainees in gastrointestinal endoscopy the learning curve for a colonoscopy simulator in the absence of any feedback: no feedback, no learning preservation and incorporation of valuable endoscopic innovations (pivi) on the use of endoscopy simulators for training and assessing skill a prospective comparison of live and videobased assessments of colonoscopy performance video-based performance assessment in endoscopy: moving beyond "see one, do one, teach one gastrointestinal endoscopy during the covid-19 pandemic: an updated review of guidelines and statements from international and national societies introducing poem in your institution: the blueprint for launching a new program in the endoscopy suite stricter national standards are required for credentialing of endoscopic-retrograde-cholangiopan-creatography in the united states table 1. sample classification of endoscopic procedures as either "major" or "minor" skills • radiofrequency ablation of be • endoscopic placement of intra-gastric balloons for weight loss • other-the-scope clip key: cord-275711-ejw3ausf authors: mon-lópez, daniel; de la rubia riaza, alfonso; hontoria galán, mónica; refoyo roman, ignacio title: the impact of covid-19 and the effect of psychological factors on training conditions of handball players date: 2020-09-05 journal: int j environ res public health doi: 10.3390/ijerph17186471 sha: doc_id: 275711 cord_uid: ejw3ausf the spread of covid-19 has altered sport in spain, forcing athletes to train at home. the objectives of the study were: (i) to compare training and recovery conditions before and during the isolation period in handball players according to gender and competitive level, and (ii) to analyse the impact of psychological factors during the isolation period. a total of 187 participants (66 women and 121 men) answered a google forms questionnaire about demographics, training, moods, emotional intelligence, and resilience sent using the snowball sampling technique. t-test and analysis of variance (anova) were used to compare sport level and gender differences. linear regressions were used to analyse the psychological influence on training. handball players reduced training intensity (in the whole sample; p = 0.44), training volume (especially in professional female handball players; p < 0.001), and sleep quality (especially in professional male handball players; p = 0.21) and increased sleep hours (especially in non-professional female players; p = 0.006) during the isolation period. furthermore, psychological factors affected all evaluated training and recovery conditions during the quarantine, except for sleep quantity. mood, emotional intelligence, and resilience have an influence on physical activity levels and recovery conditions. in addition, training components were modified under isolation conditions at p < 0.001. we conclude that the covid-19 isolation period caused reductions in training volume and intensity and decreased sleep quality. furthermore, psychological components have a significant impact on training and recovery conditions. currently, a virus called coronavirus 2 (sars-cov-2 or covid-19) has quickly spread to many countries around the world, causing an unexpected pandemic [1] . consequently, quarantine and isolation periods have been imposed on citizens. in spain, the lockdown started on 14 march, 2020 [2] . on the sporting fields, official competitions and trainings were postponed or suspended [3] . specifically, in handball, the last matches in spain were played on 7-8 march, 2020, and all handball players had to remain in their respective houses at least until 4 may, 2020 (almost eight weeks). during detraining periods (off-season), monitoring the external load of players (volume and intensity) is necessary to ensure the maintenance of fitness [4] . accordingly, technological devices such as heart rate monitors or global positioning systems (gps) can be used to quantify the training load jointly with individual questionnaires associated with the rating-of-perceived-exertion (rpe) scale [5] . drastic reductions in physical activity levels or cessation of training entail a decrease in the athlete's physiological and neuromuscular adaptations, and even increases the injury risk [1] . after a period of more than 3-4 weeks, this can result in negative effects on body composition, aerobic capacity (vo 2 max), repeated sprinting ability, and strength and power in the lower limbs of the body [6] . specifically, the physical activity reduction caused by covid-19 (eight weeks) could decrease strength by 8-12% and fast fibre areas by 15% as well as lower muscle electrical activity [7] . furthermore, other factors relevant to sport performance such as sleep quantity and quality, food/nutrition, hydration or mood could be affected by detraining periods [8, 9] . however, the effects caused by stopping training during the quarantine were different depending on the sport and the athlete's profile [10] . specifically in handball, the most important differences caused by a period of non-competition (off-season) were identified in jumping performance levels, shooting velocity, maximum concentric strength of the upper limbs, and the power of upper and lower limbs [11, 12] . moreover, isolation periods associated with a lack of training sessions and official competitions in a team sport might also have led to decreased communication between players and coaching staff, and to inadequate individual training conditions [13] . hence, isolation periods might have led players to a partial or total reversal of the adaptations produced by the training process or 'detraining' [7] . together, isolation and sporting inactivity periods tend to produce psychological disorders [14] . factors like quarantine duration, fears of infection, frustration, boredom, inadequate supplies, and inadequate information could be the most important 'stressors' leading to adverse mental effects [15] . however, the consequences derived from an isolation period do not have the same prevalence throughout the population. thus, young female students were the social group that suffered the most stress, anxiety, and depression during the covid-19 quarantine [16] . interestingly, physical exercise positively influenced mood [17] and the athletes' well-being [18] , even in those who were in a non-specific training, recovering from injury, or off-season period [4] . thus, the exercise load modified the subjective perception of well-being [19] and reductions in physical activity levels entailed an increase in the prevalence of the higher severity of depressive disorders [14] . in addition, variations in the strength levels registered after an off-season period in which a training programme had been implemented were related to psychological factors and self-perception [20] . another relevant psychological area for the athlete's performance is emotional intelligence (ie), which can be defined as the dynamic capacity to solve problems derived from the emotions of oneself and others [21] . thus, motivation towards training and physical activity are associated with higher ie values [22] . however, this factor could be negatively affected by sport inactivity periods due to low levels of interaction between the different participants in competition (coaches, players, coaching staff, opponents, etc.) [23] . accordingly, during isolation periods, the promotion and development of intrinsic motivation levels would become essential to decreasing anxiety and stress levels [21] . the covid-19 quarantine has had effects at different levels (physical, physiological, psychological, emotional) due to a change in the athletes' daily lives and training habits. the importance of this research lies in the need to know how the general state (physical, psychological, and emotional) of a handball player evolves over long periods of detraining in order to apply adequate strategies to return to physical activity. therefore, the objectives of this study were (i) to compare training components (intensity, volume, and recovery conditions) before and during the isolation period in handball players by gender and competitive level, and (ii) to analyse the impact of psychological factors (mood, emotional intelligence, and resilience) on training components during the isolation period. the research design corresponding to this study was non-experimental, cross-sectional, retrospective, and descriptive, based on conducting a survey through the google forms web platform (google llc, mountain view, ca, usa). the inclusion criteria were that all participants must be nationally federated handball players (royal spanish handball federation) during the 2019-2020 season. a total of 215 handball player questionnaires were collected. surveys of injured athletes (n = 12), athletes not resident in spain (n = 13), under 16 years old (n = 12), and players infected with covid-19 during the survey (n = 1) were excluded from the study. there were 187 handball players in the final sample (n = 121; 64.7% men and n = 66; 35.30% women). accordingly, the gender proportion in our study was almost identical to the spanish handball player population (64% men vs. 36% women) [24] . the men were 23.61 ± 6.19 years old and the women were 22.65 ± 4.62 years old and had been confined for 34.66 ± 3.33 days and 34.97 ± 3.12 days, respectively. in the last two years, 26 male and 18 female players had been called up by their national or autonomic teams. six men (5%) and one woman (1.5%) had recovered from covid-19 when they filled out the questionnaire. handball players were divided into two categories: professionals ('división de honor-asobal' and 'división de honor plata' for men and 'division de honor-guerreras iberdrola league' for women) and non-professionals (other national leagues). descriptive variables of playing position, sport level, mood states, emotional intelligence, and resilience variables are shown in table 1 . the first demographic and training questionnaire was adapted to handball from football [25] jointly by five studies and sport university teachers with wide academic (more than five years) and investigative experience in the sport field. later, the demographic questions were evaluated by two expert international handball coaches with more than 20 years' experience and their feedback was used by the researchers to develop the definitive version of the demographic questions. two external psychology experts assisted with adding the appropriate psychological tests for the study. the spanish validated versions of the profile of mood states (poms) [26] , the wong law emotional intelligence scale short form (wleis-s) [27] , and the brief resilience scale (brs-ii) [28] were used to measure mood state, emotional intelligence, and resilience, respectively. the study variables were distributed into three categories: demographic, training, and psychological variables. the demographic variables were (q1-q8): gender (male or female); age (years); place of residence (spain or another country); number of days confined (days); sport level (competition category); professional or non-professional classification according to two criteria ([1] 'level of dedication/remuneration': for professionals, there is a high percentage of sport contracts while non-professionals receive no remuneration for sport practice; [2] 'competition structure': professionals participate in competitions structured in one group at the national level, while non-professionals compete in categories divided by groups according to geographical and economic criteria and, therefore, do not exclusively take competitive performance factors into account); selected by the national team in the last two years (yes or no); playing position (goalkeeper, wing, lateral-back, centre-back or pivot); and personal experience with covid-19 (no experience, covid-19 infected, or covid-19 recovered). the [26] , emotional intelligence [27] , and resilience [28] showed excellent to acceptable reliabilities. notes: t-a = tension-anxiety; sea = self-emotion appraisal; oea = other's emotion appraisal; uoe = use of emotion; roe = regulation of emotion; brs = brief resilience scale; prof = professional players; n-prof = non-professional players. the final version of the survey was formatted into a google forms questionnaire (see supplementary materials file s1) and was sent via whatsapp to personal contacts and published on twitter using the snowball sampling technique [29] . snowball sampling is a method of gathering information to access specific groups of people. the researcher asks the first few samples, who are usually selected via convenience sampling. the existing study subjects recruit future subjects among their acquaintances. sampling continues until data saturation. this method is the most effective when the members of the population are not easily accessible [30] . one follow-up was sent to the whatsapp contacts to improve the response rate after five days. although we do not know the response rate, the final number of participants can be considered as a very representative dataset [31] . the questionnaire was available online for ten days starting on 16 april, 2020, just one month after the state of alarm was declared in spain [2] . these dates were selected due to the special situation of spain, which at that time had the second highest total number of cases of covid-19 infections [32] . the questionnaire was open and anonymous to verify the sincerity of the answers. an unlimited time to complete the survey was provided to all athletes. once the deadline for admitting surveys was closed, they were reviewed to remove contradictory responses (checking the congruence between the data provided by the players) or repeated (checking two or more submissions with the same responses in a short period of time), deleting one response from the database. all participants signed an informed consent form before completing the survey. this study was approved by the ethics committee of the polytechnic university of madrid. the data were described by arithmetic mean (m) and standard deviation (sd). the normal distribution of the variables was checked using the kolmogorov-smirnov and shapiro-wilk tests. paired sample t-tests were used to compare the pre-isolation and isolation periods and independent sample t-tests were performed to check gender differences [25] . when statistically significant differences were found, the effect size was estimated using cohen's d index (d) [33] , establishing two cut-off points: medium effect (0.30) and large effect (0.60). the confidence interval for the effect size was set at 95% and the percentage of change was calculated by (% = (m1 − m2/m1) × 100). the anova of two factors was used to analyse the differences between professionals and non-professionals, male and female, and the interaction of both [34] . to set the differences between groups, a post-hoc analysis was carried out using the bonferroni test. finally, two-step hierarchical regression was performed to analyse the relationships between the psychological and training variables. ibm spss statistics software (spss 25.0. ibm corp., armonk, ny, usa) was used for the mathematical calculations. the level of significance was set at p < 0.05. the analysis by gender showed differences in the psychological variables of depression (t (185) = −2.54; p = 0.012) and fatigue (t (185) = −2.02; p = 0.045) with lower values for women and higher values for men in vigour (t (185) = 2.18; p = 0.03), sea (t (185) = 2.23; p = 0.027) and roe (t (185) = 2.14; p = 0.034). moreover, a higher percentage of women in the sample played in higher categories than men p = 0.036. for the whole group, rpe, tdays, thours, and squality were reduced while shours increased (all p < 0.001). similar results were obtained when the analysis was carried out by gender. only the squality (p = 0.005) in men and tdays (p = 0.001) and squality (p = 0.001) in women presented different significant values (see table 2 ). result are summarised in table 3 . with regard to training conditions (volume and intensity), professional players had higher rpe values than non-professionals during confinement (f (1,183) = 4.09; p = 0.044) and trained more days than non-professionals before (f (1,183) = 51.58; p < 0.001) and during the isolation period (f (1,183) = 20.13; p < 0.001). additionally, women trained more days than men both before (f (1,183) = 5.17; p = 0.024) and during the isolation period (f (1,183) = 7.23; p = 0.008). similar results were obtained with regard to the training hours, where professional players trained more hours than non-professionals before (f (1,183) = 69.59; p < 0.001) and during the isolation periods (f (1,183) = 25.27; p < 0.001) and women trained more hours than men both before (f (1,183) = 11.69; p = 0.001) and during the isolation periods (f (1,183) = 4.09; p = 0.017). furthermore, the interaction for gender and professional level variables was significant before (f (1,183) = 7.49; p = 0.007) and during the isolation period (f (1,183) = 12.95; p < 0.001). in relation to recovery (shours and squality), professional players slept more hours than non-professionals (f (1,183) = 20.47; p < 0.001) and had better sleep quality (f (1,183) = 7.66; p = 0.006) before the isolation period. moreover, the interaction for gender and professional level variables was only significant for the sleep hours before the isolation period (f (1,183) = 5.18; p = 0.017). for the rest of the comparisons, no significant effects were detected (p > 0.05). five two-step hierarchical regression analyses were performed using rpe, tdays, thours, shours, and squality as the criterion in each case. mood status (tension-anxiety, depression, anger, vigour, fatigue, and friendship) was entered at the first step while emotional intelligence (sea, oea, uoe, and roe) and resilience were entered at the second step (see table 4 ). according to the rpe criterion, the model was non-significant at step 1 (p > 0.05). at step 2, uoe and resilience were significant predictors (f (11,175) = 2.22, p = 0.02, r 2 = 0.12, β = 0.23 and β = −0.17, respectively). the ∆r 2 was significant from step 1 to step 2 (p = 0.015). based on the tdays criterion, depression, vigour, and fatigue were significant predictors (f (6,180) = 3.56, p < 0.001, r 2 = 0.11, β = 0.25; β = 0.24 and β = −0.28, respectively) at step 1. at step 2, depression and fatigue retained significance and uoe was a significant positive predictor (f (11,175) = 3.32, p < 0.001, r 2 = 0.17, β = 0.24). the ∆r 2 was significant from step 1 to step 2 (p = 0.018). in relation to the thours criterion, depression, vigour, and fatigue were significant predictors (f (6,180) = 3.56, p = 0.01, r 2 = 0.09, β = 0.25; β = 0.22 and β = −0.26, respectively) at step 1. at step 2, depression and fatigue retained significance and uoe was a significant positive predictor (f (11, 175) = 2.66, p < 0.001, r 2 = 0.14, β = 0.19). the ∆r 2 was not significant from step 1 to step 2 (p > 0.05). regarding the shours criterion, the model was not significant in step 1 or step 2 (p > 0.05). for the squality criterion, the model was non-significant at step 1 (p > 0.05), but at step 2, tension-anxiety was a significant predictor (f (11,175) = 2.11, p = 0.02, r 2 = 0.12, β = −0.25). the ∆r 2 was not significant from step 1 to step 2 (p > 0.05). this study is one of the first to analyse the impact of the isolation period caused by covid-19 on the training (intensity and volume) and recovery conditions (quantity and quality of sleep) of professional and non-professional handball players according to the influence of transitory psychological factors (moods) and personality trait (emotional intelligence and resilience). based on the results yielded: (i) training and recovery conditions of the handball players were modified during the isolation period, reducing the intensity-rpe (in the whole sample), volume-tdays and thours (especially in professional female handball players) and sleep quality-squality (especially in professional male handball players) and increasing sleep hours-shours (especially in non-professional female players); and (ii) the psychological factors analysed (mood, emotional intelligence, and resilience) had an impact on training and recovery conditions, except for sleep quantity, during the covid-19 lockdown. training levels during the isolation period decreased in both intensity (rpe, p < 0.001, d = −0.93 (−54.44%)) and volume (tdays, p < 0.001, d = −0.53 (−14.42%); thours, p < 0.001; d = −1.28 (−89.56%)) in the whole sample. this change could activate the reversibility principle in the players, producing anatomical, functional, and physiological maladjustments [3] . accordingly, the isolation period could cause negative effects like the reduction of cardiorespiratory capacity, deceleration of the metabolic process, a decrease in muscle activity and the process of energy generation, and a decrease in hormonal production [7] . in addition, other detrimental effects on performance such as collective tactical disorganisation or the lack of interaction between teammates could appear in team sports [13] . one possible factor for the decrease in training levels during quarantine could have been the lack of equipment or insufficient space to exercise. this fact implies that the intensity and specificity of the training could have been replaced by global exercises at a constant speed [20] . thus, the neuromuscular adaptations of the training process achieved before the isolation period have gradually disappeared, losing the technique and speed-power in the basic skills of a team sport [12] . furthermore, movement restrictions have caused a deterioration of the players' fitness due to the impossibility of applying for strength training programs, producing what is known as 'long-term atrophic decrease' [35] . however, the training load does not seem to have decreased in the same way among all the players, especially when considering the volume (days and hours of training). regarding the competition level, there was a greater training time reduction in professional handball players (tdays, p = 0.004; thours, p < 0.001) than in non-professionals (tdays, p > 0.05; thours, p > 0.05). similar results were found by skoufas et al. [36] , who demonstrated that athletes with a higher competitive level reduced their training volume more than others during the off-season or non-competitive periods due to the higher initial levels of physical activity. in addition, the lack of qualified staff (coaches, physical trainers, etc.) to guide the physical-sport activity and the absence of contact and interaction with teammates could also be explanatory causes [37] . this activity reduction could lead to an increase in the body fat percentage, a decrease in the lean mass percentage, a reduction in sprint ability, a decrease in the rate of production of muscular energy, and/or a reduction in aerobic capacity [13] . regarding gender, a greater reduction in training volume was observed in men (tdays, p < 0.001, d = −0.54 (−17.64%); thours, p < 0.001, d = −1.13 (−90.88%)) than in women (tdays, p = 0.003, d = −0.56 (−9.39%); thours, p < 0.001, d = −1.73 (−87.31%)). similar results by gender were detected in the study of giustino et al. [38] in which men reduced the amount of exercise and energy expenditure during the isolation period. furthermore, men preferred to do physical activity outdoors more frequently than women [39] . however, when gender and competitive level were considered together, the decrease in training volume was greater in professional female players (tdays, p < 0.001; thours, p < 0.001) than in professional male players (tdays, p = 0.021; thours, p > 0.05). this result could be biased by the presence of a greater number of women who participated in the professional handball category (46.97%) compared to the number of professional male handball players (38.02%). the physical activity levels in professional female handball players before the isolation period were higher and the reduction was greater. along this line, professional female athletes reduced their training volume more during quarantine (76%) than professional males (74%). less communication with coaches and teammates, poorer adaptation to physical activity planning, a deterioration of rest and recovery conditions, and the thought of restarting competition in the long-term could be some of the factors that explain the difference in training volume by gender [10] . from a psychological perspective, several factors seem to have mitigated the decrease in training intensity and volume during the isolation period. the psychological component that had the greatest impact on training conditions was the use of emotions-uoe (rpe, r 2 = 0.12, p = 0.01; tdays, r 2 = 0.17, p = 0.01; thours, r 2 = 0.14, p = 0.03). team sport players tend to manage and use their emotions more easily and frequently for different purposes, better adapting to the environment's conditions [21] . therefore, a greater skill in the uoe would have enabled handball players to maintain higher external load parameters during the isolation period. greater contact with other teammates and friends, the clear and simple design, and planning of workout routines for training and encouraging an exercise-prone mood seem to have facilitated the control and management of negative feelings interrupting, to a lesser extent, training conditions [10, 17] . interestingly, the present study yielded two surprising a priori results associated with moods and personality traits. the first connects, as opposed to other studies in different fields [22, 40] , a lower resilience (brs) with a higher training intensity (r 2 = 0.12, p = 0.046). difficulty and confusion in measuring perceived training intensity (rpe) in isolated situations could have caused a relatively lower effort record, associated with a higher degree of control and experience [19] . the second finding links higher levels of depression to a higher training volume (tdays, r 2 = 0.17, p = 0.01; thours, r 2 = 0.14, p = 0.01;). players seek relief from depression and anxiety symptoms in physical-sport activity, thanks to a high commitment to sport excellence and high levels of athletic identity [41] . in relation to the recovery of physical activity pre-and post-isolation, the whole sample presented an increase in quantity of sleep (shours, p < 0.001, d = 0.69 (10.20%)) and a decrease in quality of sleep (squality, p < 0.001, d = −0.34 (−15.20%)). considering the correlation between physical activity levels and mental well-being [18] , the limitation or cessation of exercise could cause a deterioration in sleep quality, which is closely associated with well-being. the factor with the greatest negative impact on sleep quality during the isolation period was tension-anxiety (r 2 = 0.12, p = 0.01). isolation conditions could lead to worries about the athlete's fitness and restarting competition. these could be the main precursor factors of psychological disorders during quarantine such as stress, depression, or irritability [1, 15] . however, other behaviours could have affected sleep quality during the isolation period such as nutritional changes and a sedentary lifestyle [10] . on one hand, a decrease in the consumption of foods rich in vitamin d and carbohydrates could have caused a worsening in the athlete's recovery capacity [3] . on the other hand, negative changes in lifestyle (lower levels of physical activity, higher use of technologies, higher consumption of alcohol and other addictions, etc.) could have caused an alteration in sleep quality and fatigue perception [37] . however, tension-anxiety levels were higher in professional male handball players. together, the need to keep an adequate physical condition (self-perception of the physical profile) [20] to compete at top levels ('liga asobal' and 'liga de division de honor plata') and the impossibility of training under appropriate conditions could have caused adverse mental health states [42] that did not allow for optimal rest conditions. accordingly, increases in fatigue and injury risk could lead to a decrease in the player's recovery capacity [43] . regarding sleep quantity, an increase in sleep hours during the isolation period was detected in handball players, especially in non-professional female players. this change could be associated with changes in lifestyle caused by mobility restrictions. the time spent lying in bed increased and waking time was delayed, thus increasing sleep hours [44] . the greater daily flexibility of schedules in the young population, similar to handball players, could have been an opportunity to develop sleep habits that are more closely linked to their endogenous body rhythms, favouring a greater number of sleep hours [8] . similar results were found in other sports. on a psychological and emotional level, clemente-suárez, et al. [45] detected, in olympic and paralympic athletes, a higher impact of the isolation period (psychological inflexibility) on professional players and on women due to greater experimentation with stressful situations. considering the training conditions in team sports, mon-lópez et al. [25] found how the frequency, duration, and intensity of training were reduced during the quarantine in football players in spain. in relation to rest conditions, pillay et al. [10] demonstrated the alteration of sleep patterns (reduction in sleep quality), which led to an increase in the level of fatigue and the rate of injuries in a study with 692 athletes from 15 different sports. therefore, it seems that the effects of isolation period have generally been perceived as negative by the athletes. due to the deterioration of the fitness in handball players caused by the quarantine, coaches, physical trainers, technical staff, sports institutions, and national and international sports federations should plan strategies and training programmes aimed at reducing the detraining effects according to the athlete's gender and competitive level to avoid potential adverse effects such as injuries. however, even with continuous and accurate player monitoring, there could be a certain degree of non-control of the variables analysed due to the implications of government laws connected to public health. thus, the impact of these variables on the player's fitness could undergo modifications external to sport training. based on the scientific evidence, specific exercises should be proposed to personalise the training and recovery process of athletes, especially in handball players. setting clear training objectives through simple training tools and resources; personalised definition of the training external load variables according to a holistic vision of the context and the sport experience of the player during the previous competitive period (injuries, minutes played, competitive experience, etc.) [13] ; organise a 'player support network' by the experts (coach, doctor, psychologist, nutritionist, etc.) through the use of technology (phone calls, video calls, email, etc.) to guarantee suitable physical and psychological levels for the return to competition; design an individualised home fitness training programme according to available space and equipment resources tailored to the athlete's characteristics and current needs [3] ; provide adequate recovery and rest methods (sleep and relaxation techniques, stretching, supplementation, etc.) [9] ; and daily monitoring of the athlete's well-being, physical state, recovery capacity and psychological state [19] . although this is one of the first studies on the effects of covid-19 on handball players, some limitations should be mentioned. the unprecedent social and sport context in which the research was carried out and the isolation situation were novel regarding the sport training process and additional data would be necessary. moreover, the final sample of the study was 187 players, which limited the statistical power and possibly resulted in a self-selection bias associated with the athlete's gender and level of competition. accordingly, the results should be considered with caution, especially due to the sample imbalance with a greater presence of professional female handball players. another important aspect was that to ensure the sincerity of the answers, the questionnaires were anonymous, which implied the impossibility of confirming the athletes' identities. future study designs could consider including more variables in relation to demographic characteristics (level of studies, place of residence, etc.), training and recovery conditions (available space, training machines, etc.), and mood (motivations, etc.) of the players. on the other hand, an improvement in the monitoring systems for the training quantity and quality would be desirable in order to draw more precise conclusions. furthermore, conducting a longitudinal study covering the pre-, during and post-isolation periods through various measurements could provide information on how such a long detraining period influences the habits of handball players. the covid-19 isolation period had significant adverse effects on the training and recovery conditions of handball players, leading to physical deconditioning and worsening sleep conditions. relevant training reductions in volume and intensity were detected, especially in women and professionals, while a decrease in sleep quality was identified in professional handball players, especially in men. the psychological components had a significant impact on training and recovery conditions during the isolation period. psychological traits associated with personality such as resilience or emotional intelligence (use of emotions-uoe) were modifying factors of the training intensity and volume, and moods, based on components such as fatigue, depression, and tension-anxiety had a greater impact on the rest and recovery conditions of the players as well as on the external load of training. the set model of mood and personality traits (emotional intelligence and resilience) was explanatory of the training and recovery conditions of handball players during the isolation period, especially on the physical activity levels associated with a reduction in the days and hours that players use for exercise. medical recommendations for home-confined footballers' training during the covid-19 pandemic: from evidence to practical application strategies and solutions for team sports athletes in isolation due to covid-19 the relationship between workloads, physical performance, injury and illness in adolescent male football players the relationships between internal and external measures of training load and intensity in team sports: a meta-analysis discrepancy between exercise performance, body composition, and sex steroid response after a six-week detraining period in professional soccer players detraining: loss of training-induced physiological and performance adaptations. part ii dealing with sleep problems during home confinement due to the covid-19 outbreak: practical recommendations from a task force of the european cbt-i academy brief ideas about evidence-based recovery in team sports nowhere to hide: the significant impact of coronavirus disease 2019 (covid-19) measures on elite and semi-elite south african athletes effects of an entire season on physical fitness in elite female handball players in-season resistance training and detraining in professional team handball players the transition period in soccer: a window of opportunity mental health in elite athletes: international olympic committee consensus statement the psychological impact of quarantine and how to reduce it: rapid review of the evidence immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china the impact of physical activity on psychological health during covid-19 pandemic in italy what do olympic shooters think about physical training factors and their performance? monitoring the athlete training response: subjective self-reported measures trump commonly used objective measures: a systematic review psychological correlates of performance in female athletes during a 12-week off-season strength and conditioning program emotional intelligence, motivational climate and levels of anxiety in athletes from different categories of sports: analysis through structural equations development of emotional intelligence through physical activity and sport practice. a systematic review positive personality-trait-like individual differences in athletes from individual-and team sports and in non-athletes how has covid-19 modified training and mood in professional and non-professional football players? versión breve en español del cuestionario poms para deportistas adultos y población general validation of the spanish version of the wong law emotional intelligence scale (wleis-s) reliability and validity of the brief resilience scale (brs) spanish version snowball sampling: using social networks to research non-heterosexual women snowball sampling: a purposeful method of sampling in qualitative research. strides dev dual-career through the elite university student-athletes' lenses: the international fisu-eas survey covid-19) situation report 83; world health organization statistical power analysis for the behavioral sciences detraining produces minimal changes in physical performance and hormonal variables in recreationally strength-trained men the effect of arm and forearm loading on the throwing velocity of novice handball players: influences during training and detraining traininginhome-home-based training during covid-19 (sars-cov2) pandemic: physical exercise and behavior-based approach physical activity levels and related energy expenditure during covid-19 quarantine among the sicilian active population: a cross-sectional online survey study gender and age differences in levels, types and locations of physical activity among older adults living in car-dependent neighborhoods physical activity is associated with grit and resilience in college students: is intensity the key to success? the experience of depression during the careers of elite male athletes depression is under-recognised in the sport setting: time for primary care sports medicine to be proactive and screen widely for depression symptoms recovery strategies in elite sport: focus on both quantity and quality of sleep impact of covid-19 lockdown on sleep quality in university students and administration staff modulators of the personal and professional threat perception of olympic athletes in the actual covid-19 crisis we wish to thank all handball players who completed the questionnaire. the authors declare no conflict of interest. key: cord-326657-zzvmj5qy authors: james, dr hannah k.; pattison, mr giles t.r. title: disruption to surgical training during covid-19 in the united states, united kingdom, canada and australasia: a rapid review of impact and mitigation efforts date: 2020-06-25 journal: j surg educ doi: 10.1016/j.jsurg.2020.06.020 sha: doc_id: 326657 cord_uid: zzvmj5qy the global covid-19 pandemic has the potential to lead to significant training disruptions affecting surgical residents across all specialties. there has been lively social media discussion about the impact of cancelled training activities under the twitter hashtag #notrainingtodaynosurgeonstomorrow. we present a rapid scoping review synthesising the current evidence of pandemic-related impact on surgical training in the united states, united kingdom, canada, australia and new zealand. we describe and compare strategies that have been put in place to mitigate disruption, and reflect on how the challenges of the pandemic may present the opportunity to improve on how we select, assess and train surgeons in the future. the covid-19 pandemic caused by the novel zoonotic coronavirus 'sars-cov-2' is currently wreaking medical(1), social (2) and economic (3) havoc across the globe. the published academic literature of the impact of covid-19 has justifiably concentrated on the global scientific and clinical efforts to address the many threats of the pandemic(4, 5) . no facet of healthcare systems have been untouched by the disruption and this includes postgraduate surgical training, the impact on which has received minimal attention so far. as surgical educators we are facing a uniquely challenging set of circumstances in delivering effective training, assessment and selection. healthcare and education systems share a complex interdependent relationship where a delicate balance exists between population needs, health-system demands for professionals and supply of qualified individuals from education programs (6) . as the output from our residency schemes are the future global surgical workforce, it is important to consider the effect of the pandemic on the training of postgraduate surgical residents both in the short and long term. selection into training, assessment and progression within residency schemes must continue to be robust despite the adverse circumstances, to ensure a continued supply of suitably competent surgeons. surgical training bodies have recently faced the considerable and unenviable challenge of having to rapidly mobilise the surgical resident workforce to augment the frontline clinical staffing response, whilst simultaneously safeguarding trainees and minimising disruption to established training systems. the impact of the pandemic has the potential to lead to significant training disruptions affecting all resident levels and surgical specialties. the aim of this review is to synthesise the current evidence of pandemic-related impact on surgical training internationally and describe strategies that have been put in place to mitigate disruption. a rapid scoping review was undertaken of the publically available published pandemic-related web literature from the surgical training bodies of five large english-speaking countries; united states(7), united kingdom(8-10), canada(11), australia and new zealand (australasia)(12). recent press releases, position statements and correspondence from the major training bodies were hand searched (last accessed 09 june 2020). a rapid review method was chosen to deliver a timely evidence synthesis within a quickly evolving situation. by mid-april 2020, three months after the director general of the world health organisation declared a public health emergency of international concern(13), most surgical training organisations had communicated or published their respective mitigation strategies. this time point in the pandemic was therefore considered optimum to deliver this review. the differences in resident numbers, pandemic epidemiology and status of elective surgical activity by country is summarised in table 1. the us has by far the largest number of active surgical residents (14) and also the largest covid-19 burden(15). non-urgent elective surgical activity, a key source of training opportunity for residents, has been entirely stopped in the uk for a minimum of three months (16) . the american college of surgeons (17) and ministry of health (18) has recommended reduction of elective surgical activity in the us and canada respectively, but this mandate is to be implemented regionally based on local healthcare need. australia and new zealand (19) , with the smallest covid-19 disease burden(15) of the included countries, is the first to reopen elective surgical services, in a phased manner from early may 2020. the current surgical training operational status and mitigation measures by country are presented against five key domains of activity; 1) recruitment and selection into residency programmes, 2) board examinations, 3) assessment, progression and certification within residency, 4) resident operating privileges and 5) didactics (table 2) . recruitment and selection are pressing ahead for the 2020 residency intake in all reviewed countries (20-23). in the us, residents may start their placements early without any fear of redress from contract breach(20). in the uk, the pandemic hit part way through the specialist training recruitment cycle, which forced training bodies to rapidly rewrite the rulebook on selection procedures(21). this has been streamlined to involve matching residents based solely on self-assessment scores submitted as part of the application, which is a minority part of the usual national interview-based selection process. canada will be conducting interviews by videoconference for second iteration interviews(20). australasia will be piloting currently undisclosed non face-toface recruitment methods for the 2021 residency selection process (23) . the 2020 us residency match was completed relatively uneventfully(20). (31) . in the uk(32) and australasia (23) , speciality training boards are considering issues of lost-training opportunity on a case-by-case basis. if training extensions are required, these will be non-punitive and the maximum time to complete training will be extended. no statements on resident operating privileges during the pandemic were found for any country. in the us, there is a recent report of an emergently reconfigured surgical residency program (33) , which has been skilfully designed to maximise training opportunity, including or time, and minimize risk to residents. the american board of surgery has said they will accept a 10% reduction in logbook numbers for the 2019-20 training year in recognition of the difficulties residents may have in accessing the or (29) . face-to-face didactics such as courses and conferences have been widely postponed across the included countries until at least september 2020 (23, 34) . curricular teaching provision is being made available using webinars or remote conferencing technology, and appears to be locally driven by individual training programmes. in the uk, the royal college of surgeons virtual learning environment resources have been made open access during the pandemic to facilitate e-learning (35) . the american college of surgeons has recommended that programmes document their didactic provision during the pandemic (36) . surgical residency in the included countries remains largely time based rather than competency based (37) , with the notable exception of canada(11) who have a thriving portfolio of competency based residency programmes (38) . assessment for progression in time-based models of training is highly dependent on exposure to, and performance of, a prescribed 'minimum indicative' number of surgical procedures during residency training(39). surgical residents may be particularly badly affected by pandemic related service reconfiguration as compared to their medical counterparts, as many of the required competencies for surgery can only be obtained in the elective setting. the widespread suspension of elective surgical services in the us, uk and canada, and a rumoured unofficial moratorium on residents operating during the pandemic will inevitably jeopardise the attainment of competencies required for progression within surgical training programmes. despite widespread assurance(21, 40) that surgical training bodies do not wish to penalise residents for situations beyond their control, training extensions will be inevitable in a prolonged epidemic scenario. clearly a balance needs to be struck between ensuring quality and maintaining progression without any imposed extensions being unduly burdensome. the introduction of a special covid-19 'no-fault' training extension outcome code for the annual review of competence progression assessment in the uk is a creative example of how the traditional stigma associated with training extensions can be avoided. it is anticipated that in the uk training extensions will be largely restricted to residents at critical progression points or at the very end of training(41). accreditation bodies will need to demonstrate flexibility in how they sign off residents who are at the end of their training but who have been denied the opportunity to sit board examinations in the conventional timeframe. whilst passing these exams continues to be a requirement for completing training in canada(22), local mechanisms can be invoked to provide graduating residents with provisional licenses until they can be given the opportunity to sit examinations. similarly, recruitment into residency has had to continue to ensure an uninterrupted supply of doctors. the pandemic has exposed weaknesses in the recruitment systems in the uk, who have become suddenly reliant on using self-assessment scores alone to appoint new residents(21). the predictive validity of self-assessment from previous recruitment rounds has not been formally examined or reported, which has led to concerns amongst prospective uk surgical residents that selection may be unconsciously biased. canada (42) has managed to set up remote-interviews for prospective residents, and fortunately the us(20) and australasian(23) resident recruitment rounds were largely complete before the onset of the pandemic and have hence been relatively unaffected. the principle challenges for surgical education bodies in a rapidly evolving pandemic are to safeguard residents whilst minimising disruption to training in the short term and to continue to recruit, assess and certify residents to ensure the supply of high-calibre surgeons in the long term. the collective response to these challenges by the main surgical training bodies in the us, uk, canada and australasia has been agile and resident-centred. positive change in the postgraduate surgical education community may result from this difficult time. perhaps the convenience of using webinar to deliver some aspects of didactic teaching in surgical residency will continue once life returns to normal. the pandemic has also exposed the continued reliance on time-based training, the weaknesses in existing recruitment systems and has brought the gift of opportunity to study the progress of the 'covid cohort' of residents. this is certainly fertile ground for training systems improvements once the pandemic is over. ten weeks to crush the curve the lancet c, amp, adolescent h. pandemic school closures: risks and opportunities. the lancet child & adolescent health responding to covid-19 -a once-in-a-century pandemic? health professionals for a new century: transforming education to strengthen health systems in an interdependent world the royal college of surgeons of edinburgh the royal college of physicians and surgeons of glasgow the royal college of physicians and surgeons in canada association of american medical colleges. report on residents table b3: number of active residents, by type of medical school, gme specialty, and sex covid-19: all non-urgent elective surgery is suspended for at least three months in england american college of surgeons covid-19: recommendations for management of elective surgical procedures 19 specialty recruitment plans 30 march 2020 %281%29.pdf. 22. update on the coronavirus outbreak and impact to the royal college. royal college of physicians and surgeons of canada statement 21 royal australasian college of surgeons covid-19 information hub: trainee update the american board of surgery: june general surgery certifying exam cancelled vascular surgery certifying examination cancelled american board of surgery covid-19 news releases. 2020 general surgery qualifying exam to be administered virtually american board of surgery: modifications to training requirements ubc pgme guidelines on resident redeployment. statement 17 jcst contingency plan for annual review of competence progression (arcp) emergency restructuring of a general surgery residency program during the coronavirus disease royal college of surgeons covid-19 information hub: courses the virtual learning environment of the royal college of surgeons accreditation council for graduate medical education covid-19 frequently asked questions time-versus competency-based residency training. plastic and reconstructive surgery competence by design launch schedule covid-19) has impacted on trainee progression racs trainees' association end-of-term survey statement by the joint committee on intercollegiate examinations on behalf of the surgical royal colleges 13 royal college of physicians and surgeons of canada virtual teaching resources (42) interviews being held remotely by videoconferencing.incoming residents due to start in july 2020 as planned aus/nz selection for 2021 entry to continue subject to further updates (23) selection for 2021 entry will be subject to alternative, non-face-toface mechanisms 2. board examinations us may general surgery qualifying exam to be delivered virtually (28) board eligibility to be extended for this exam diet and will not be counted as a missed exam opportunity. disrupted candidates to be given advance priority to schedule for 2021 uk all examinations cancelled until november 2020 (45) all cancelled bookings to be honoured at next available examination diet.guidance awaited on impact of cancelled exams on residency progression or appointability canada spring 2020 exams postponed until september 2020(22).oral exam not required for delayed spring 2020 cohort. failure at delayed exam will not exhaust a sitting attempt. test sites will be expanded so less travel is required. test sites will adhere to current social distancing and ppe protocols. aus/nz all examinations postponed until midseptember to end-november (27) candidates will be provided with a minimum of 3 months notice when a decision to reinstate exams has been made arcp priority given to trainees who need to revalidate or at a critical progression point. a more flexible approach to the available workplace based assessments will be taken. new 'outcome 10' metric for pandemic-related training extensions canada provincial regulatory authorities will invoke mechanisms to provide graduating residents with provisional/temporary/restricted licences to practice(22)residents will be credited for redeployment time.residents should not be required to extend training as a result of redeployment (31) aus/nz surgical logbooks and competency assessments should be used to judge progress against curricula (23) speciality training boards to consider issues of lost training opportunity in judging progress on a case-by-case basis. should an extension to training be required, the maximum time to complete training will also be extended (23) (23) webinar programme available from racs website (23) key: cord-159103-dbgs2ado authors: rieke, nicola; hancox, jonny; li, wenqi; milletari, fausto; roth, holger; albarqouni, shadi; bakas, spyridon; galtier, mathieu n.; landman, bennett; maier-hein, klaus; ourselin, sebastien; sheller, micah; summers, ronald m.; trask, andrew; xu, daguang; baust, maximilian; cardoso, m. jorge title: the future of digital health with federated learning date: 2020-03-18 journal: nan doi: nan sha: doc_id: 159103 cord_uid: dbgs2ado data-driven machine learning has emerged as a promising approach for building accurate and robust statistical models from medical data, which is collected in huge volumes by modern healthcare systems. existing medical data is not fully exploited by ml primarily because it sits in data silos and privacy concerns restrict access to this data. however, without access to sufficient data, ml will be prevented from reaching its full potential and, ultimately, from making the transition from research to clinical practice. this paper considers key factors contributing to this issue, explores how federated learning (fl) may provide a solution for the future of digital health and highlights the challenges and considerations that need to be addressed. research on artificial intelligence (ai) has enabled a variety of significant breakthroughs over the course of the last two decades. in digital healthcare, the introduction of powerful machine learning-based and particularly deep learning-based models [1] has led to disruptive innovations in radiology, pathology, genomics and many other fields. in order to capture the complexity of these applications, modern deep learning (dl) models feature a large number (e.g. millions) of parameters that are learned from and validated on medical datasets. sufficiently large corpora of curated data are thus required in order to obtain models that yield clinical-grade accuracy, whilst being safe, fair, equitable and generalising well to unseen data [2, 3, 4] . for example, training an automatic tumour detector and diagnostic tool in a supervised way requires a large annotated database that encompasses the full spectrum of possible anatomies, pathological patterns and types of input data. data like this is hard to obtain and curate. one of the main difficulties is that unlike other data, which may be shared and copied rather freely, health data is highly sensitive, subject to regulation and cannot be used for research without appropriate patient consent and ethical approval [5] . even if data anonymisation is sometimes proposed as a way to bypass these limitations, it is now wellunderstood that removing metadata such as patient name or date of birth is often not enough to preserve privacy [6] . imaging data suffers from the same issue -it is possible to reconstruct a patient's face from three-dimensional imaging data, such as computed tomography (ct) or magnetic resonance imaging (mri). also the human brain itself has been shown to be as unique as a fingerprint [7] , where subject identity, age and gender can be predicted and revealed [8] . another reason why data sharing is not systematic in healthcare is that medical data are potentially highly valuable and costly to acquire. collecting, curating and maintaining a quality dataset takes considerable time and effort. these datasets may have a significant business value and so are not given away lightly. in practice, openly sharing medical data is often restricted by data collectors themselves, who need fine-grained control over the access to the data they have gathered. federated learning (fl) [9, 10, 11] is a learning paradigm that seeks to address the problem of data governance and privacy by training algorithms collaboratively without exchanging the underlying datasets. the approach was originally developed in a different domain, but it recently gained traction for healthcare applications because it neatly addresses the problems that usually exist when trying to aggregate medical data. applied to digital health this means that fl enables insights to be gained collaboratively across institutions, e.g. in the form of a global or consensus model, without sharing the patient data. in particular, the strength of fl is that sensitive training data does not need to be moved beyond the firewalls of the institutions in which they reside. instead, the machine learning (ml) process occurs locally at each participating institution and only model characteristics (e.g. parameters, gradients etc.) are exchanged. once training has been completed, the trained consensus model benefits from the knowledge accumulated across all institutions. recent research has shown that this approach can achieve a performance that is comparable to a scenario where the data was co-located in a data lake and superior to the models that only see isolated singleinstitutional data [12, 13] . for this reason, we believe that a successful implementation of fl holds significant potential for enabling precision medicine at large scale. the scalability with respect to patient numbers included for model training would facilitate models that yield unbiased decisions, optimally reflect an individual's physiology, and are sensitive to rare diseases in a way that is respectful of governance and privacy concerns. whilst fl still requires rigorous technical consideration to ensure that the algorithm is proceeding optimally without compromising safety or patient privacy, it does have the potential to overcome the limitations of current approaches that require a single pool of centralised data. the aim of this paper is to provide context and detail for the community regarding the benefits and impact of fl for medical applications (section 2) as well as highlighting key considerations and challenges of implementing fl in the context of digital health (section 3). the medical fl use-case is inherently different from other domains, e.g. in terms of number of participants and data diversity, and while recent surveys investigate the research advances and open questions of fl [14, 11, 15] , we focus on what it actually means for digital health and what is needed to enable it. we envision a federated future for digital health and hope to inspire and raise awareness with this article for the community. ml and especially dl is becoming the de facto knowledge discovery approach in many industries, but successfully implementing data-driven applications requires that models are trained and evaluated on sufficiently large and diverse datasets. these medical datasets are difficult to curate (section 2.1). fl offers a way to counteract this data dilemma and its associated governance and privacy concerns by enabling collaborative learning without centralising the data (section 2.2). this learning paradigm, however, requires consideration from and offers benefits to the various stakeholders of the healthcare environment a parameter server distributes the model and each node trains a local model for several iterations, after which the updated models are returned to the parameter server for aggregation. this consensus model is then redistributed for subsequent iterations. (b) decentralised architecture via peer-to-peer: rather than using a parameter server, each node broadcasts its locally trained model to some or all of its peers and each node does its own aggregation. (c) hybrid architecture: federations can be composed into a hierarchy of hubs and spokes, which might represent regions, health authorities or countries. (section 2.3). all these points will be discussed in this section. data-driven approaches rely on datasets that truly represent the underlying data distribution of the problem to be solved. whilst the importance of comprehensive and encompassing databases is a well-known requirement to ensure generalisability, state-of-the-art algorithms are usually evaluated on carefully curated datasets, often originating from a small number of sources -if not a single source. this implies major challenges: pockets of isolated data can introduce sample bias in which demographic (e.g. gender, age etc.) or technical imbalances (e.g. acquisition protocol, equipment manufacturer) skew the predictions, adversely affecting the accuracy of pre-diction for certain groups or sites. the need for sufficiently large databases for ai training has spawned many initiatives seeking to pool data from multiple institutions. large initiatives have so far primarily focused on the idea of creating data lakes. these data lakes have been built with the aim of leveraging either the commercial value of the data, as exemplified by ibm's merge healthcare acquisition [16] , or as a resource for economic growth and scientific progress, with examples such as nhs scotland's national safe haven [17] , the french health data hub [18] and health data research uk [19] . substantial, albeit smaller, initiatives have also made data available to the general community such as the human connectome [20] , uk biobank [21] , the cancer imaging archive (tcia) [22] , nih cxr8 [23] , nih deeplesion [24] , the cancer genome atlas (tcga) [25] , the alzheimer's disease neu-roimaging initiative (adni) [26] , or as part of medical grand challenges 1 such as the camelyon challenge [27] , the multimodal brain tumor image segmentation benchmark (brats) [28] or the medical segmentation decathlon [29] . public data is usually task-or disease-specific and often released with varying degrees of license restrictions, sometimes limiting its exploitation. regardless of the approach, the availability of such data has the potential to catalyse scientific advances, stimulate technology start-ups and deliver improvements in healthcare. centralising or releasing data, however, poses not only regulatory and legal challenges related to ethics, privacy and data protection, but also technical ones -safely anonymising, controlling access, and transferring healthcare data is a non-trivial, and often impossible, task. as an example, anonymised data from the electronic health record can appear innocuous and gdpr/phi compliant, but just a few data elements may allow for patient reidentification [6] . the same applies to genomic data and medical images, with their high-dimensional nature making them as unique as one's fingerprint [7] . therefore, unless the anonymisation process destroys the fidelity of the data, likely rendering it useless, patient reidentification or information leakage cannot be ruled out. gated access, in which only approved users may access specific subsets of data, is often proposed as a putative solution to this issue. however, not only does this severely limit data availability, it is only practical for cases in which the consent granted by the data owners or patients is unconditional, since recalling data from those who may have had access to the data is practically unenforceable. the promise of fl is simple -to address privacy and governance challenges by allowing algorithms to learn from non co-located data. in a fl setting, each data controller not only defines their own governance processes and associated privacy considerations, but also, by not allowing data to move or to be copied, controls data access and the possibility to revoke it. so the potential of fl is to provide controlled, indirect access to large and comprehensive datasets needed for the development of ml algo-rithms, whilst respecting patient privacy and data governance. it should be noted that this includes both the training as well as the validation phase of the development. in this way, fl could create new opportunities, e.g. by allowing large-scale validation across the globe directly in the institutions, and enable novel research on, for example, rare diseases, where the incident rates are low and it is unlikely that a single institution has a dataset that is sufficient for ml approaches. moving the to-be-trained model to the data instead of collecting the data in a central location has another major advantage: the high-dimensional, storage-intense medical data does not have to be duplicated from local institutions in a centralised pool and duplicated again by every user that uses this data for local model training. in a fl setup, only the model is transferred to the local institutions and can scale naturally with a potentially growing global dataset without replicating the data or multiplying the data storage requirements. some of the promises of fl are implicit: a certain degree of privacy is provided since other fl participants never directly access the data from other institutions and only receive the resulting model parameters that are aggregated over several participants. and in a client-server architecture (see figure 1 ), in which a federated server manages the aggregation and distribution, the participating institutions can even remain unknown to each other. however, it has been shown that the models themselves can, under certain conditions, memorise information [30, 31, 32, 33] . therefore the fl setup can be further enhanced by privacy protections using mechanisms such as differential privacy [34, 35] or learning from encrypted data (c.f. sec. 3). and fl techniques are still a very active area of research [14] . all in all, a successful implementation of fl will represent a paradigm shift from centralised data warehouses or lakes, with a significant impact on the various stakeholders in the healthcare domain. if fl is indeed the answer to the challenge of healthcare ml at scale, then it is important to understand who the various stakeholders are in a fl ecosystem and what they have to consider in order to benefit from it. the aggregation may happen on one of the training nodes or a separate parameter server node, which would then redistribute the consensus model. b) peer to peer training: nodes broadcast their model updates to one or more nodes in the federation and each does its own aggregation. cyclic training happens when model updates are passed to a single neighbour one or more times, round-robin style. c) hybrid training: federations, perhaps in remote geographies, can be composed into a hierarchy and use different communication/aggregation strategies at each tier. in the illustrated case, three federations of varying size periodically share their models using a peer to peer approach. the consensus model is then redistributed to each federation and each node therein. clinicians are usually exposed to only a certain subgroup of the population based on the location and demographic environment of the hospital or practice they are working in. therefore, their decisions might be based on biased assumptions about the probability of certain diseases or their interconnection. by using ml-based systems, e.g. as a second reader, they can augment their own expertise with expert knowledge from other institutions, ensuring a consistency of diagnosis not attainable today. whilst this promise is generally true for any ml-based system, systems trained in a federated fashion are potentially able to yield even less biased decisions and higher sensitivity to rare cases as they are likely to have seen a more complete picture of the data distribution. in order to be an active part of or to benefit from the federation, however, demands some up-front effort such as compliance with agreements e.g. regarding the data structure, annotation and report protocol, which is necessary to ensure that the information is presented to collaborators in a commonly understood format. patients are usually relying on local hospitals and practices. establishing fl on a global scale could ensure higher quality of clinical decisions regardless of the location of the deployed system. for example, patients who need medical attention in remote areas could benefit from the same high-quality ml-aided diagnosis that are available in hospitals with a large number of cases. the same advantage applies to patients suffering from rare, or geographically uncommon, diseases, who are likely to have better outcomes if faster and more accurate diagnoses can be made. fl may also lower the hurdle for becoming a data donor, since patients can be reassured that the data remains with the institution and data access can be revoked. hospitals and practices can remain in full control and possession of their patient data with complete traceability of how the data is accessed. they can precisely control the purpose for which a given data sample is going to be used, limiting the risk of misuse when they work with third parties. however, participating in federated efforts will require investment in on-premise computing infrastructure or private-cloud service provision. the amount of necessary compute capabilities depends of course on whether a site is only participating in evaluation and testing efforts or also in training efforts. even relatively small institutions can participate, since enough of them will generate a valuable corpus and they will still benefit from collective models generated. one of the drawbacks is that fl strongly relies on the standardisation and homogenisation of the data formats so that predictive models can be trained and evaluated seamlessly. this involves significant standardisation efforts from data managers. researchers and ai developers who want to develop and evaluate novel algorithms stand to benefit from access to a potentially vast collection of real-world data. this will especially impact smaller research labs and start-ups, who would be able to directly develop their applications on healthcare data without the need to curate their own datasets. by introducing federated efforts, precious resources can be directed towards solving clinical needs and associated technical problems rather than relying on the limited supply of open datasets. at the same time, it will be necessary to conduct research on algorithmic strategies for federated training, e.g. how to combine models or updates efficiently, how to be robust to distribution shifts, etc., as highlighted in the technical survey papers [14, 11, 15] . and a fl-based development implies that the researcher or ai developer cannot investigate or visualise all of the data on which the model is trained. it is for example not possible to look at an individual failure case to understand why the current model performs poorly on it. healthcare providers in many countries are affected by the ongoing paradigm shift from volume-based, i.e. fee-for-service-based, to value-based healthcare. a value-based reimbursement structure is in turn strongly connected to the successful establishment of precision medicine. this is not about promoting more expensive individualised therapies but instead about achieving better outcomes sooner through more focused treatment, thereby reducing the costs for providers. by way of example, with sufficient data, ml approaches can learn to recognise cancer-subtypes or genotypic traits from radiology images that could indicate certain therapies and discount others. so, by providing exposure to large amounts of data, fl has the potential to increase the accuracy and robustness of healthcare ai, whilst reducing costs and improving patient outcomes, and is therefore vital to precision medicine. manufacturers of healthcare software and hardware could benefit from federated efforts and infrastructures for fl as well, since combining the learning from many devices and applications, without revealing anything patient-specific can facilitate the continuous improvement of ml-based systems. this potentially opens up a new source of data and revenue to manufacturers. however, hospitals may require significant upgrades to local compute, data storage, networking capabilities and associated software to enable such a use-case. note, however, that this change could be quite disruptive: fl could eventually impact the business models of providers, practices, hospitals and manufacturers affecting patient data ownership; and the regulatory frameworks surrounding continual and fl approaches are still under development. fl is perhaps best-known from the work of koneä�ná»³ et al. [36] , but various other definitions have been proposed in literature [14, 11, 15, 9] . these approaches can be realised via different communication architectures (see figure 1 ) and respective compute plans (see figure 2 ). the main goal of fl, however, remains the same: to combine knowledge learned from non co-located data, that resides within the participating entities, into a global model. whereas the initial application field mostly comprised mobile devices, participating entities in the case of healthcare could be institutions storing the data, e.g. hospitals, or medical devices itself, e.g. a ct scanner or even low-powered devices that are able to run computations locally. it is important to understand that this domainshift to the medical field implies different conditions and requirements. for example, in the case of the federated mobile device application, potentially millions of partici-pants could contribute, but it would be impossible to have the same scale of consortium in terms of participating hospitals. on the other hand medical institutions may rely on more sophisticated and powerful compute infrastructure with stable connectivity. another aspect is that the variation in terms of data type and defined tasks as well as acquisition protocol and standardisation in healthcare is significantly higher than pictures and messages seen in other domains. the participating entities have to agree on a collaboration protocol and the high-dimensional medical data, which is predominant in the field of digital health, poses challenges by requiring models with huge numbers of parameters. this may become an issue in scenarios where the available bandwidth for communication between participants is limited, since the model has to be transferred frequently. and even though data is never shared during fl, considerations about the security of the connections between sites as well as mitigation of data leakage risks through model parameters are necessary. in this section, we will discuss more in detail what fl is and how it differs from similar techniques as well as highlighting the key challenges and technical considerations that arise when applying fl in digital health. fl is a learning paradigm in which multiple parties train collaboratively without the need to exchange or centralise datasets. although various training strategies have been implemented to address specific tasks, a general formulation of fl can be formalised as follows: let l denote a global loss function obtained via a weighted combination of k local losses {l k } k k=1 , computed from private data x k residing at the individual involved parties: where w k > 0 denote the respective weight coefficients. it is important to note that the data x k is never shared among parties and remains private throughout learning. in practice, each participant typically obtains and refines the global consensus model by running a few rounds of optimisation on their local data and then shares the updated parameters with its peers, either directly or via a pa-rameter server. the more rounds of local training are performed without sharing updates or synchronisation, the less it is guaranteed that the actual procedure is minimising the equation (1) [9, 14] . the actual process used for aggregating parameters commonly depends on the fl network topology, as fl nodes might be segregated into sub-networks due to geographical or legal constraints (see figure 1 ). aggregation strategies can rely on a single aggregating node (hub and spokes models), or on multiple nodes without any centralisation. an example of this is peer-to-peer fl, where connections exist between all or a subset of the participants and model updates are shared only between directly-connected sites [37, 38] . an example of centralised fl aggregation with a client-server architecture is given in algorithm 1. note that aggregation strategies do not necessarily require information about the full model update; clients might choose to share only a subset of the model parameters for the sake of reducing communication overhead of redundant information, ensure better privacy preservation [10] or to produce multitask learning algorithms having only part of their parameters learned in a federated manner. a unifying framework enabling various training schemes may disentangle compute resources (data and servers) from the compute plan, as depicted in figure 2 . the latter defines the trajectory of a model across several partners, to be trained and evaluated on specific datasets. for more details regarding state-of-the-art of fl techniques, such as aggregation methods, optimisation or model compression, we refer the reader to the overview by kairouz et al. [14] . fl is rooted in older forms of collaborative learning where models are shared or compute is distributed [13, 40] . transfer learning, for example, is a well-established approach of model-sharing that makes it possible to tackle problems with deep neural networks that have millions of parameters, despite the lack of extensive, local datasets that are required for training from scratch: a model is first trained on a large dataset and then further optimised on the actual target data. the dataset used for the initial training does not necessarily come from the same domain or even the same type of data source as the target dataset. this type of transfer learning has shown better algorithm 1 example of a fl algorithm [12] in a clientserver architecture with aggregation via fedavg [39] . require: num federated rounds t 1: procedure aggregating 2: initialise global model: for t â�� 1 â· â· â· t do 4: for client k â�� 1 â· â· â· k do run in parallel end for 10: return w (t) 11: end procedure performance [41, 42] when compared to strategies where the model had been trained from scratch on the target data only, especially when the target dataset is comparably small. it should be noted that similar to a fl setup, the data is not necessarily co-located in this approach. for transfer learning, however, the models are usually shared acyclically, e.g. using a pre-trained model to finetune it on another task, without contributing to a collective knowledge-gain. and, unfortunately, deep learning models tend to "forget" [43, 44] . therefore after a few training iterations on the target dataset the initial information contained in the model is lost [45] . to adopt this approach into a form of collaborative learning in a fl setup with continuous learning from different institutions, the participants can share their model with a peer-to-peer architecture in a "round-robin" or parallel fashion and train in turn on their local data. this yields better results when the goal is to learn from diverse datasets. a client-server architecture in this scenario enables learning on multi-party data at the same time [13] , possibly even without forgetting [46] . there are also other collaborative learning strategies [47, 48] such as ensembling, a statistical strategy of combining multiple independently trained models or predictions into a consensus, or multi-task learning, a strategy to leverage shared representations for related tasks. these strategies are independent of the concept of fl, and can be used in combination with it. the second characteristic of fl -to distribute the compute -has been well studied in recent years [49, 50, 51] . nowadays, the training of the large-scale models is often executed on multiple devices and even multiple nodes [51] . in this way, the task can be parallelised and enables fast training, such as training a neural network on the extensive dataset of the imagenet project in 1 hour [50] or even in less than 80 seconds [52] . it should be noted that in these scenarios, the training is realised in a cluster environment, with centralised data and fast network communication. so, distributing the compute for training on several nodes is feasible and fl may benefit from the advances in this area. compared to these approaches, however, fl comes with a significant communication and synchronisation cost. in the fl setup, the compute resources are not as closely connected as in a cluster and every exchange may introduce a significant latency. therefore, it may not be suitable to synchronise after every batch, but to continue local training for several iterations before aggregation. we refer the reader to the survey by xu et al. [15] for an overview of the evolution of federated learning and the different concepts in the broader sense. despite the advantages of fl, there are challenges that need to be taken into account when establishing federated training efforts. in this section, we discuss five key aspects of fl that are of particular interest in the context of its application to digital health. in healthcare, we work with highly sensitive data that must be protected accordingly. therefore, some of the key considerations are the trade-offs, strategies and remaining risks regarding the privacy-preserving potential of fl. privacy vs. performance. although one of the main purposes of fl is to protect privacy by sharing model updates rather than data, fl does not solve all potential privacy issues and -similar to ml algorithms in generalwill always carry some risks. strict regulations and data governance policies make any leakage, or perceived risk of leakage, of private information unacceptable. these regulations may even differ between federations and a catch-all solution will likely never exist. consequently, it is important that potential adopters of fl are aware of potential risks and state-of-the-art options for mitigating them. privacy-preserving techniques for fl offer levels of protection that exceed today's current commercially available ml models [14] . however, there is a trade-off in terms of performance and these techniques may affect for example the accuracy of the final model [10] . furthermore future techniques and/or ancillary data could be used to compromise a model previously considered to be low-risk. level of trust. broadly speaking, participating parties can enter two types of fl collaboration: trusted -for fl consortia in which all parties are considered trustworthy and are bound by an enforceable collaboration agreement, we can eliminate many of the more nefarious motivations, such as deliberate attempts to extract sensitive information or to intentionally corrupt the model. this reduces the need for sophisticated countermeasures, falling back to the principles of standard collaborative research. non-trusted -in fl systems that operate on larger scales, it is impractical to establish an enforceable collaborative agreement that can guarantee that all of the parties are acting benignly. some may deliberately try to degrade performance, bring the system down or extract information from other parties. in such an environment, security strategies will be required to mitigate these risks such as, encryption of model submissions, secure authentication of all parties, traceability of actions, differential privacy, verification systems, execution integrity, model confidentiality and protections against adversarial attacks. information leakage. by definition, fl systems sidestep the need to share healthcare data among participating institutions. however, the shared information may still indirectly expose private data used for local training, for example by model inversion [53] of the model updates, the gradients themselves [54] or adversarial attacks [55, 56] . fl is different from traditional training insofar as the training process is exposed to multiple parties. as a result, the risk of leakage via reverse-engineering increases if adversaries can observe model changes over time, observe specific model updates (i.e. a single institution's update), or manipulate the model (e.g. induce additional memorisation by others through gradient-ascentstyle attacks). countermeasures, such as limiting the granularity of the shared model updates and to add specific noise to ensure differential privacy [34, 12, 57] may be needed and is still an active area of research [14] . medical data is particularly diverse -not only in terms of type, dimensionality and characteristics of medical data in general but also within a defined medical task, due to factors like acquisition protocol, brand of the medical device or local demographics. this poses a challenge for fl algorithms and strategies: one of the core assumptions of many current approaches is that the data is independent and identically distributed (iid) across the participants. initial results indicate that fl training on medical non-iid data is possible, even if the data is not uniformly distributed across the institutions [12, 13] . in general however, strategies such as fedavg [9] are prone to fail under these conditions [58, 59, 60] , in part defeating the very purpose of collaborative learning strategies. research addressing this problem includes for example fedprox [58] and part-data-sharing strategy [60] . another challenge is that data heterogeneity may lead to a situation in which the global solution may not be the optimal final local solution. the definition of model training optimality should therefore be agreed by all participants before training. as per all safety-critical applications, the reproducibility of a system is important for fl in healthcare. in contrast to training on centralised data, fl involves running multiparty computations in environments that exhibit complexities in terms of hardware, software and networks. the traceability requirement should be fulfilled to ensure that system events, data access history and training configuration changes, such as hyperparameter tuning, can be traced during the training processes. traceability can also be used to log the training history of a model and, in particular, to avoid the training dataset overlapping with the test dataset. in particular in non-trusted federations, traceability and accountability processes running in require execution integrity. after the training process reaches the mutually agreed model optimality criteria, it may also be helpful to measure the amount of contribution from each participant, such as computational resources consumed, quality of the local training data used for local training etc. the measurements could then be used to determine relevant compensation and establish a revenue model among the participants [61] . one implication of fl is that researchers are not able to investigate images upon which models are being trained. so, although each site will have access to its own raw data, federations may decide to provide some sort of secure intra-node viewing facility to cater for this need or perhaps even some utility for explainability and interpretability of the global model. however, the issue of interpretability within dl is still an open research question. unlike running large-scale fl amongst consumer devices, healthcare institutional participants are often equipped with better computational resources and reliable and higher throughput networks. these enable for example training of larger models with larger numbers of local training steps and sharing more model information between nodes. this unique characteristic of fl in healthcare consequently brings opportunities as well as challenges such as (1) how to ensure data integrity when communicating (e.g. creating redundant nodes); (2) how to design secure encryption methods to take advantage of the computational resources; (3) how to design appropriate node schedulers and make use of the distributed computational devices to reduce idle time. the administration of such a federation can be realised in different ways, each of which come with advantages and disadvantages. in high-trust situations, training may operate via some sort of 'honest broker' system, in which a trusted third party acts as the intermediary and facilitates access to data. this setup requires an independent entity to control the overall system which may not always be desirable, since it could involve an additional cost and procedural viscosity, but does have the advantage that the precise internal mechanisms can be abstracted away from the clients, making the system more agile and simpler to update. in a peer-to-peer system each site interacts directly with some or all of the other participants. in other words, there is no gatekeeper function, all protocols must be agreed up-front, which requires significant agreement efforts, and changes must be made in a synchronised fashion by all parties to avoid problems. and in a trustless-based architecture the platform operator may be cryptographically locked into being honest which creates significant computation overheads whilst securing the protocol. future efforts to apply artificial intelligence to healthcare tasks may strongly depend on collaborative strategies between multiple institutions rather than large centralised databases belonging to only one hospital or research laboratory. the ability to leverage fl to capture and integrate knowledge acquired and maintained by different institutions provides an opportunity to capture larger data variability and analyse patients across different demographics. moreover, fl is an opportunity to incorporate multiexpert annotation and multi-centre data acquired with different instruments and techniques. this collaborative effort requires, however, various agreements including definitions of scope, aim and technology which, since it is still novel, may incorporate several unknowns. in this context, large-scale initiatives such as the melloddy project 2 , the healthchain project 3 , the trustworthy federated data analytics (tfda) and the german cancer consortium's joint imaging platform (jip) 4 represent pioneering efforts to set the standards for safe, fair and innovative collaboration in healthcare research. ml, and particularly dl, has led to a wide range of innovations in the area of digital healthcare. as all ml methods benefit greatly from the ability to access data that approximates the true global distribution, fl is a promising approach to obtain powerful, accurate, safe, robust and unbiased models. by enabling multiple parties to train collaboratively without the need to exchange or centralise datasets, fl neatly addresses issues related to egress of sensitive medical data. as a consequence, it may open novel research and business avenues and has the potential to improve patient care globally. in this article, we have discussed the benefits and the considerations pertinent to fl within the healthcare field. not all technical questions have been answered yet and fl will certainly be an active research area throughout the next decade [14] . despite this, we truly believe that its potential impact on precision medicine and ultimately improving medical care is very promising. financial disclosure: author rms receives royalties from icad, scanmed, philips, and ping an. his lab has received research support from ping an and nvidia. author sa is supported by the prime programme of the german academic exchange service (daad) with funds from the german federal ministry of education and research (bmbf). author sb is supported by the national institutes of health (nih). author mng is supported by the healthchain (bpifrance) and melloddy 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collaborative deep learning multi-site fmri analysis using privacy-preserving federated learning and domain adaptation: abide results federated optimization in heterogeneous networks communication-efficient learning of deep networks from decentralized data federated learning with non-iid data data shapley: equitable valuation of data for machine learning key: cord-303861-qn8yifcd authors: wang, chongjian; wei, sheng; xiang, hao; xu, yihua; han, shenghong; mkangara, ommari baaliy; nie, shaofa title: evaluating the effectiveness of an emergency preparedness training programme for public health staff in china date: 2008-05-31 journal: public health doi: 10.1016/j.puhe.2007.08.006 sha: doc_id: 303861 cord_uid: qn8yifcd summary background the severe acute respiratory syndrome (sars) crisis of 2003 provided a new urgency in china in terms of preparing public health staff to respond effectively to public health emergencies. although the chinese government has already carried out a series of emergency education and training programmes to improve public health staff's capability of emergency preparedness, it remains unclear if these training programmes are effective and feasible. the purpose of this research was to evaluate an emergency preparedness training programme and to develop a participatory training approach for emergency response. methods seventy-six public health staff completed the emergency preparedness training programme. the effectiveness of the training was evaluated by questionnaire before training, immediately after training and 12 months after training (follow-up). additionally, semi-structured interviews were conducted throughout the training period. results the emergency preparedness training improved the knowledge levels and increased attitudinal and behavioural intention scores for emergency preparedness (p<0.01). the results at follow-up showed that the knowledge levels and attitudinal/behavioural intention scores of participants decreased slightly (p>0.05) compared with levels immediately after training (p<0.01). however, there was a significant increase compared with before training (p<0.01). moreover, more than 80% of participants reported that the training process and resources were scientific and feasible. conclusions the emergency preparedness training programme met its aims and objectives satisfactorily, and resulted in positive shifts in knowledge and attitudinal/behavioural intentions for public health staff. this suggests that this emergency training strategy was effective and feasible in improving the capability of emergency preparedness. summary background: the severe acute respiratory syndrome (sars) crisis of 2003 provided a new urgency in china in terms of preparing public health staff to respond effectively to public health emergencies. although the chinese government has already carried out a series of emergency education and training programmes to improve public health staff's capability of emergency preparedness, it remains unclear if these training programmes are effective and feasible. the purpose of this research was to evaluate an emergency preparedness training programme and to develop a participatory training approach for emergency response. methods: seventy-six public health staff completed the emergency preparedness training programme. the effectiveness of the training was evaluated by questionnaire before training, immediately after training and 12 months after training (follow-up). additionally, semi-structured interviews were conducted throughout the training period. results: the emergency preparedness training improved the knowledge levels and increased attitudinal and behavioural intention scores for emergency preparedness (po0.01). the results at follow-up showed that the knowledge levels and attitudinal/behavioural intention scores of participants decreased slightly (p40.05) compared with levels immediately after training (po0.01). however, there was a significant increase compared with before training (po0.01). moreover, more than 80% of participants reported that the training process and resources were scientific and feasible. since the 9/11 disaster, anthrax bioterrorism, 'mad cow' disease, severe acute respiratory syndrome (sars) and avian influenza outbreaks, public health emergencies have become an important threat to communities worldwide. managing these emergencies and the threats they pose is part of the longterm government development plans in many countries, and expensive resources are being invested into preventing and responding to public health emergencies. 1 in china, surge capacity is one of the most urgent problems regarding public health emergency response at the present time, 2 along with the lack of equipment and the low efficiency of the public health emergency information system. recognizing this, the chinese government carried out a series of emergency preparedness education and training programmes to improve the capability of public health staff to respond to emergencies nationwide. however, it remains unclear if these training programmes are feasible and effective in improving emergency preparedness. investigation has revealed that the emergency response of the public health sector was insufficient, especially the emergency preparedness of public health staff, such as not knowing the emergency response protocols and management procedures, and how to collect and analyse the relevant data during the sars outbreak. 2, 3 therefore, in order to change the current situation and improve the capability of public health staff in china to respond to emergencies, a pilot study was developed and supported by the ministry of health of the people's republic of china (moh) and the world health organization (who). the study was carried out by tongji medical college in hubei province from 2004 to 2006. the training was completed in 2005, and the follow-up survey was conducted 12 months later. like any other successful health education programme, the emergency preparedness training programme should be subjected to a process of continuous monitoring, control, evaluation and, if needed, relevant modifications. [4] [5] [6] [7] [8] the comprehensive evaluation of an emergency training preparedness programme should include its various aspects (contents, aims and objectives, training resources, methods, effects and impact), and it should also answer questions about the efficiency and impact of training on the participants. [9] [10] [11] this study highlighted the procedures used in the evaluation of an emergency preparedness training programme, and focused on its most important aspects: training resources; training process; and effectiveness of training (before training, immediately after training and 12 months later). seventy-eight trainees from the centers for disease control and prevention (cdc) in 18 cities in hubei participated in the emergency preparedness training programme in 2005. two participants did not complete their training and were not part of the evaluation (n ¼ 76). trainers were selected based on their expertise in the field of public health emergency response, related training programmes and their involvement in continuous consultations on health service programmes, both educational and promotional. trainers came from the moh, who, chinese cdc, health department of hubei province, fudan university, wuhan university and huazhong university of science and technology. the aims and objectives of training were designed carefully by educational and training experts with an intimate knowledge of the public health emergency response plan and the training programme, in consultation with public health personnel who did not participate in the training. the training programme was based on the us cdc's emergency preparedness core competencies for all public health workers. [12] [13] [14] in brief, the training consisted of: (1) the definition of public health emergency; (2) the public health workers' role during emergencies; (3) the responsibilities of local, province and government agencies during emergencies; (4) the role of the cdc during emergencies; (5) the cdc emergency response chain of command; (6) emergency communication strategies and use of special equipment; (7) emergency response protocols; and (8) management procedures, including the management of necessary supplies and equipment. the training contents and objectives were subjected to continuous monitoring and evaluation throughout the training period. various training methods were used, including case studies, workshops, tutorials, seminars, group discussions, role playing, drilling and fieldwork. formal lecturing was the least used method. the training centre was equipped with modern audiovisual aids designed for training purposes. as well as the training logistics, other facilities and general services, such as transportation and accommodation, were provided free of charge to the participants. individual basic information, knowledge levels, attitudes and behaviours regarding emergency preparedness were investigated by questionnaire, which was designed by experts in the field of training programmes and continuous consultation on emergency management. in order to assess the questionnaire, a pilot test was undertaken among other public health personnel who did not participate in the training, and modifications were made by experts based on the feedback. thirty questions assessed the participants' knowledge of public health emergency competencies, which consisted of basic public health science knowledge, emergency management knowledge and emergency analytical/assessment skills (10 questions). if the correct answer was given to these questions, the participant received one point, whereas incorrect answers received no points. eight items were designed to assess the staff's attitudinal and behavioural intentions related to the 'eight core competencies for public health services'. 15 each of the eight items asked respondents to rate their attitudinal and behavioural intentions, as well as the frequency of their use of each of the competencies. responses were rated on an ordinal scale (1 ¼ very low, 2 ¼ low, 3 ¼ middle, 4 ¼ high, 5 ¼ very high). participants completed the first measurement (pre-test, baseline) on the first day of training. the post-training measurement (post-test) was conducted at the end of the last day of training. for the follow-up test, the participants were mailed a copy of the survey, with a self-addressed return envelope, 12 months after the training had been completed. the training process and resources were subjected to continuous monitoring and evaluation by semi-structured interviews. the inclusion of the trainees in the evaluation process was extremely helpful in updating and modifying the programme. the items addressed in the semi-structured interviews were as follows: (1) the scientific methods offered; (2) the technical material presented; (3) the performance of the trainer; (4) the benefits derived by the participant; (5) the use of the audiovisual aids; (6) the strengths and weaknesses of the session; and (7) final critical comments and remarks. the forms were distributed at the end of each session to be completed anonymously by each participant. the forms were analysed immediately and the results were shown to the trainer who had conducted the session. if any defects were revealed, the necessary rectifications were made immediately. evaluation of workshops and fieldwork was carried out in a similar fashion. feedback of the results of the evaluation was given to the participants. most data were reported as scores. frequency and confidence scores were derived for each domain by participants' responses to the frequency questions and the self-efficacy questions. repeated-measures analysis of variance was used to test differences between pre-test, post-test and follow-up test. the data from semi-structured interviews were categorized independently by three authors using the triangulation method, and the individual results of the analysis were compared and discussed until consensus was reached. all results were expressed as mean7standard deviation. data were analysed by one-way analysis of variance using statistical package for the social sciences for windows, version 12.0 (spss. inc., chicago, il, usa). seventy-six of the study participants completed the entire training programme and represented public health staff from the cdc of 18 cities (97.44% response). most respondents were male (n ¼ 57, 75%) and over half (n ¼ 42, 55.26%) had earned a bachelor's or master's degree, of which one-sixth possessed masters of public health degrees. additionally, most participants (n ¼ 62, 81.58%) had more than 5 years of experience as public health staff. some trainees (n ¼ 50, 65.79%) had participated in inter-related training approximately 12-24 months previously. the results of reliability assessment showed that test-retest reliability and the internal consistency of questionnaires was accredited to some extent (test-retest reliability of pretraining ¼ 0.83, cronbach's alpha 40.61). the results of related analysis indicated that the construct validity of the questionnaire was of high quality (related coefficient fluctuated between 0.35 and 0.79, po0.05). 16, 17 knowledge levels the investigation revealed that knowledge levels of public health emergency preparedness were relatively low before training. after training, a significant increase in the mean knowledge scores was observed (pre-test: 19.7972.41; post-test: 24.4970.86; followup test: 24.2471.58) (po0.01). basic public health science knowledge and emergency management knowledge scores decreased slightly (p40.05), but the mean scores for emergency analytical/assessment skills were increased dramatically in the follow-up test compared with the post-test (po0.01). furthermore, there was a significant increase in overall knowledge scores between the follow-up test and the pre-test (po0.01) (fig. 1 ). descriptive statistics on attitudinal and behavioural intentions at pre-test, post-test and follow-up test are presented in table 1 . as mentioned above, the responses ranged from high (5) to low (1) . the results showed that participants reported a significant improvement in their attitudinal and behavioural intentions in all eight core competencies in the post-test compared with the pre-test. twelve months later, there were slight decreases in participants' attitudinal and behavioural intentions in some core competencies, but the mean score for emergency analytical/assessment skills was significantly increased compared with the post-test (4.35 vs 3.69), and mean scores for policy development/programme planning skills (2.94 vs 3.95) and financial planning and management skills (2.66 vs 3.47) were decreased compared with the posttest (po0.05). the results of the semi-structured interviews showed that most participants (n ¼ 73, 96.05%) thought that the training methods were excellent/very good, and the training contents were clear and easy to understand. the remaining participants (n ¼ 3, 3.95%) indicated that the training methods needed to be improved/further developed. however, all of the participants recognized that the training was innovative. analysis showed that 80.26% (n ¼ 61) of participants were satisfied with the trainers' performance, and 19.74% (n ¼ 15) of participants thought that the trainers' performance needed to improve. however, no participants indicated that resource personnel were incompetent. additionally, most participants (n ¼ 72, 94.74%) were very satisfied with the venue, training logistics and services, and only four participants (n ¼ 4, 5.26%) thought that logistics and services needed improvement. continuous medical education and training is a process of updating knowledge, developing skills, bringing about attitudinal and behavioural changes, and improving the capability of participants to perform their tasks efficiently and effectively. 18 effective training methods are key to the success of an emergency training programme. a number of studies have shown that the training methods recommended by the present study educators were effective because different participants learn by different training methods, and methods of active training are especially helpful for adult learning. [19] [20] [21] formal lecturing was the least used training method because trainees do not participate actively in the learning process and the outcome is inferior to methods of active learning. the results of the evaluation suggested that up-todate training of public health staff should focus on the development of effective training methods, and interactive training methods may help to increase the quality of training and improve retention of knowledge through immediate reinforcement of learning. 22, 23 furthermore, comprehensive evaluation and feedback about the training programme were of vital importance for the participants and trainers as it helped participants to identify their limitations while monitoring their performance during the training period. also, trainers tended to improve their performance as they were aware that it was being monitored and evaluated. feedback of the results of evaluation of the training sessions to the trainers was found to be helpful in rectifying the weaknesses of sessions. 24 in addition, the mean scores of emergency analytical/assessment skills increased rather than decreased by 12-month follow-up. this is similar to results found by qureshi et al. 14 for this type of phenomenon, one must consider the experience of the public health staff at the end of 2005. before the follow-up survey, the majority of trainees had participated in avian influenza emergency response activities, thus providing practice and increasing perceived relevance of the training. as such, this probably had a positive effect on the effectiveness of training. nevertheless, the increased overall knowledge score and the positive change in attitudinal and behavioural parameters suggested that training programmes on emergency preparedness resulted in gaining knowledge and shifts in attitude and behaviour. this study had a few potential limitations. the analysis was limited to staff who were primarily engaged in disease monitoring and control, and epidemiological investigations in the cdc. in addition, evaluations were based on changes over time without the use of a horizontal comparison group. thus, it was not possible to fully determine which changes were due to the emergency preparedness training programme and which were the result of other factors. these results, however, remained constant throughout, which provides support that these changes were due to the training programme. the effectiveness of any educational training programme depends on its continuous monitoring and evaluation, which should include appropriate and varied methods. moreover, trainers and trainees should be actively subjected to the process of monitoring and evaluation, which was helpful in monitoring their overall performance. immediate feedback with results analysis of the continuous monitoring and evaluation should be available to those involved so that necessary improvements can be made. the results of the evaluation suggested that the emergency training strategy was effective and feasible in improving the capability of public health staff to respond to an emergency. a preliminary framework to measure public health emergency response capacity evaluation of the performance of responding to public health emergency for the workforce in cdc in hubei report of the system construction on disease control and prevention. hubei measuring effectiveness of tqm training: an indian study emergency preparedness: one community's response the road map to preparedness: a competency-based approach to all-hazards emergency readiness training for the public health workforce primary health workers in northeast brazil evaluation of health impact assessment workshop. criteria for use in the evaluation of health impact assessments business and public health collaboration for emergency preparedness in georgia: a case study responsive evaluation of competencybased public health preparedness training programs emergency preparedness training for public health nurses: a pilot study emergency preparedness core competencies for all public health workers public health worker competencies for emergency response council on linkages between academia and public health practice. core competencies for public health professionals psychometric considerations in evaluating health-related quality of life measures psychometric theory training objectives, transfer, validation and evaluation: a srilankan study what matters most? predictors of student satisfaction in public health educational courses applying educational gaming to public health workforce emergency preparedness relative effectiveness of worker safety and health training methods emergency preparedness and bioterrorism response: development of an educational program for public health personnel evaluating health impact assessment evaluation study of the training programs for health personnel in al-qassim, saudi arabia the authors thank all of the participants and trainers for their hard work, and all of the coordinators for their support and help. in addition, the authors would like to thank c.k. lee for his critical reading of the manuscript. not required. world health organization. none declared. key: cord-321125-ok0o1wiy authors: hsu, peng-wei; fu, ren-huei; chang, yu-che title: comparing learning outcomes among postgraduate year trainee groups date: 2020-10-22 journal: biomed j doi: 10.1016/j.bj.2019.10.002 sha: doc_id: 321125 cord_uid: ok0o1wiy background: the objective of postgraduate year (pgy) training programs is to inculcate in medical graduates the expected levels of skills in patient care. this study compared the core clinical competencies of trainees who received pgy training at chang gung memorial hospital by attending the pilot training program in different groups. methods: we used six 10-min test stations for clinical performance evaluation, which comprised four and two test stations designed for objective structured clinical examination and procedural skill, respectively, to evaluate the learning outcomes of the trainees. the trainees were divided into three groups according to the training programs that they had attended. results: the aspects of clinical performance included history taking, physical examination, medical communication, logical thinking, and problem-solving abilities. the trainees who selected the surgery-based training program exhibited a higher performance at the station for aseptic surgical preparation than the other two groups (p = 0.0261). the trainees who selected the internal medical training program (p = 0.0020) exhibited a higher performance at the station for abdominal pain in children. conclusions: a well-designed postgraduate training program should develop trainees' competencies, particularly clinical operational skills. the results of this study may provide useful insight into methods for improving the design of training programs. additional investigation is necessary for understanding the effects of different programs on the clinical performance of trainees. we use structured objective structured clinical examinations (osces) to evaluate the core competencies and professional performance of pgy trainees in clinical practice. the reliability and validity analysis of the osces and statistical analysis were used to verify the results of the study. taiwan's medical education system change to 2-years post-graduate training gradually since year 2011. the pilot program was launched in year 2015 and there were no studies analyzing the outcomes. the results of present study provide valuable information that can be used to improve the design of medical training programs. previously, medical students in taiwan acquired clinical skills and cultivated patient care skills through knowledge-centered learning. they began clinical work in professional subdivisions immediately after graduating, consequently, an overall lack of abilities was perceived in general clinical medical care [1] . the united kingdom designed a postgraduate general education training system in 1951 [2] , and the united states developed the postgraduate year (pgy) comprehensive medical training course in 1970 [3] . both training programs were intended to solve the problem of the lack of comprehensive clinical care abilities among medical graduates. since then, advanced countries have established comprehensive medical training programs for 1 or 2 years to improve the patient care abilities, clinical skills, and physicianepatient communication skills of medical graduates. after the severe acute respiratory syndrome (sars) pandemic in 2003, the postgraduate training program for general medicine was implemented by the taiwanese government to address the need for improvement in the professional training provided to medical graduates. after detailed and rigorous planning, the taiwan joint commission on hospital accreditation developed a pgy training program to improve the abilities of medical graduates. the pgy trainees were expected to develop their skills and abilities in patient-centered care after completing general medical training, including medical knowledge, clinical skills, and professional attitudes. the pgy training program, which was a 3-month course, was launched in taiwan in 2003. in 2011, a 1-year training program was launched and will eventually be transformed into a 2-year course in 2019. finally, taiwan's medical education system will change from seven years of medical education plus one year of postgraduate training to 6-year medical education plus 2-years post-graduate training. it will be a big change in the medical education system. in the first year of the proposed 2-year training course, participants are expected to receive comprehensive medical training to enhance their overall skills in general medical care. currently, a 1-year training program is being implemented. in the second year, specialized training will be provided depending on the individual interests and requirements of the trainees. in august 2013, chang gung memorial hospital (cgmh) launched a pilot project for the second year pgy training program. objective structured clinical examination (osce), a useful tool, is usually used to assess the learning result of medical trainees. a well designed osce can be used to assess the core competencies in medical graduates. since there were no studies comparing the outcomes of different pilot training programs and core competence of the trainees, we thought that an effective assessment is necessary. therefore, the aim of our study is to evaluate the core competencies by welldesigned assessments. by using osce, this study compared the differences in the core clinical competencies of trainees who received pgy training at cgmh by attending the second year training courses in different groups. the results of this study will provide further understand about the impact of different education program on learning outcomes. we also expect that the quantitative and qualitative information in the learning resulted between the different training groups facilitate improvements in the design of the program and accurately assess the implementation of comprehensive medical training in taiwan. concerning about the research ethics, the study is approved by the institutional review board (irb no. 103-7377b). between august 2015 and july 2017, 134 pgy trainees completed the training program at cgmh one year after they graduated from the medical school. the trainees were assessed using six 10-min test stations designed for clinical performance evaluation in the last month of one-year training program. four stations were designed for osce and were related to internal medicine, surgery, obstetrics and gynecology, and pediatrics, whereas the remaining two stations were designed for assessing clinical skills. depending on the training program attended, the trainees were divided into the following three groups: program 1 was a conventional training program (currently provided in taiwan) designed for training in general medicine. the training program comprised 3 months of internal medicine training, 2 months of surgery training, 1 month of training in pediatrics, 1 month of obstetrics and gynecology, 1 month of an elective course, and 4 months of emergency department and community medical training. program 2 and program 3 was designed as a pilot project for the second year course of the 2-year training program. program 2 (surgical training program) was designed for training in surgery and the obstetrics and gynecology subspecialties. the program comprised 6 months of training on surgery and gynecology, 1 month of internal medicine training, 2 months of an elective course, and 3 months of emergency medicine and community medicine. program 3 (internal medicine training program) was designed for training in the internal medicine and the pediatrics subspecialties. the program comprised 6 months of training on internal medicine and pediatrics, 1 month of surgery training, 2 months of an elective course, and 3 months of training on emergency medicine and community medicine. twelve trainees, selected randomly from each group (n ¼ 36), participated in the clinical performance evaluation. there were 8 male and 4 female in the group 1 (conventional training program), 7 male and 5 female in the group 2 (surgical training program), and 7 male and 5 female in the group 3 (internal medicine training program). all the participating trainees were the post-graduate year-one residents. the criteria for passing or failing at each test station were determined using the angoff method. a 3-point likert scale was used to evaluate the result of each item on the checklist, which was defined as not completed (0), partially completed (1), and completed (2). the final score obtained at each test station was determined using the following formula: (score obtained/maximum obtainable score) â 100. the mean score was then calculated across all test stations. all the raters were qualified by the taiwan association of medical education and had completed the rater-training program. an unpaired t test, analysis of variance, and the wilcoxon rank sum test were used to analyze the data in spss version 19.0 (spss inc., chicago, il, usa). p < 0.05 indicated statistical significance. the examination topics designed for the assessment of learning outcomes in internal medicine, surgery, gynecology, and pediatrics were palpitations, burn injuries, uterine fibroids, and abdominal pain in children. several aspects of performance were evaluated at the different test stations. history taking, physical examination, and medical communication were evaluated at the surgery and internal medicine test stations. at the stations for gynecology and pediatrics, the clinical reasoning, problem-solving abilities, physical examination skills, and medical communication of the trainees were assessed. the reliability (cronbach's alpha coefficient, as known as cronbach's a) and validity (kendall's coefficient of concordance, as known as kendall's u) of the test stations were analyzed before the assessment [ table 1 ]. an example of the checklist of the test station (palpitation) was attached on table 2 . the test stations that were designed for the evaluation of clinical skills assessed the trainees' skills at aseptic surgical preparation and use of infection-protective clothing. the analysis and comparison results of trainee performance at individual test stations revealed that the trainees who selected the surgical training program exhibited a significantly higher performance (p ¼ 0.0261, wilcoxon rank sum test) at the test station for aseptic surgical preparation than the other two groups. the trainees who selected the internal medical training program exhibited a higher performance (p ¼ 0.0020, wilcoxon rank sum test) at the station for abdominal pain in children. the trainees' skills with burn injuries, uterine fibroids, palpitations, and the use of infectionprotective clothing did not differ significantly among the three groups [p ¼ 0.8090, 0.3829, 0.3855, and 0.6597, respectively, table 3 ]. the development of taiwan's comprehensive medical graduate training program can be divided into four stages. the training duration extended from 3 months to 6 months and eventually one year. the training program contents extended from general and community medicine to more comprehensive internal medicine and surgery training. other specialties such as emergency medicine, pediatrics, and obstetrics/gynecology were also added. the objective of this stage was to enable every medical graduate to develop sufficient comprehensive abilities in clinical care. immediately after 2019, this training program will enter the fourth stage, which is a 2-year training program. the first year of the training course will follow the third-stage program. after entering the second year of the program, trainees will be allowed to select a training system according to their interests. the trainees can then decide whether to become surgeons, physicians or other specialists. in august 2013, cgmh launched a pilot trial for the second year of the 2-year pgy training program. according to the rules of the accreditation council for graduate medical education (acgme), the pgy training program is expected to highlight and develop six core competencies in medical graduates [4] . the program uses various tools for the effective and credible assessment of trainee learning outcomes and for improving training program content by using the results of the assessment. these assessments include quantitative assessments (e.g. mini-clinical evaluation exercise (mini-cex), direct observation of procedural skills (dops), case-based discussion (cbd)) and qualitative, reflective writing sections (e.g. medical ethics and legislation report, medical care quality report and personal however, these assessments are all workplace-based assessments evaluated by individual clinical teachers. there were no standardized assessments to evaluate the pgy trainees' training program and outcomes. osces with standardized patients (sps) and checklists can be used to assess interpersonal communication skills as well as patient care. multiplechoice questions (mcq) and oral tests are useful tools for assessing medical knowledge, whereas osces and checklists effectively assess professionalism. osces, sps, checklists, and mcq tests can be used to assess trainees' abilities to learn and improve in practice. they are also useful for evaluating system-based practices [5] . considering their proven efficacy, mcq tests, osce with sps, and checklist were used to analyze the learning outcomes of the different training programs included in this study. mcq tests have been used for departmental or comprehensive exams to determine whether progress has been achieved or as a certification for learning outcomes [6e9]. osce with interactive situations involving sps can be tailored to meet specific educational goals, and students' performance can be reliably evaluated [10, 11] . according to the literature, if the number of sites and trainees is sufficiently high, then the reliability of the assessment is as high as 0.90 [12] . the specific skills that we assessed using osce were medical history taking, physical examination, interpersonal communication, technical skills, data interpretation, differential diagnosis, and treatment decisions. trainees' technical skills can be objectively and structurally assessed using an evaluation list that has been validated for its reliability and effectiveness [13, 14] . in this study, the cronbach's a for reliability is ranged from 0.851 to 0.968, the kendall's u for validity is from 0.807 to 0.871 [ table 1 ]. in the current study, to compare the performance of different groups of trainees under the same test conditions, we used the same assessment blueprint while designing the topics of assessment. for example, in the test stations for heart palpitations, burn injuries, uterine fibroids, and abdominal pain in children, the tests included medical history inquiry, physical examination, and medical communication. to assess the effectiveness of gynecology and pediatric learning, the physical examination skills, logical thinking, problem-solving abilities, and medical communication skills of the trainees were assessed. after data analysis, we found that the trainees who had attended program 3 exhibited a significantly higher performance at the test station for abdominal pain in children than the other groups (p ¼ 0.0020). however, the same results were not observed at the test station for palpitations (p ¼ 0.2207) and infection-protective clothing (p ¼ 0.6597). the trainees who had attended program 2 exhibited a significantly higher performance in aseptic surgical preparation than the other trainees (p ¼ 0.0261). however, they did not exhibit a higher performance than the other trainees did at the test stations for burn injuries (p ¼ 0.8090) and uterine fibroids (p ¼ 0.3829). the reason for these results may be related to the training plan arrangement and the design of the station. there is a lack of general medical training in the present pilot training program. training in pediatrics was limited in program 1 and program 2 (1 month in program 1 and not included in program 2). the clinical presentations of diseases in children differ from those in adults. these two factors caused the relatively low performance in pediatrics of the trainees who selected program 1 and 2. program 2 provided the trainees with more opportunities to enter the operating room to learn the related techniques than did program 1 and program 3; consequently, the trainees in program 2 exhibited a higher performance in preparation in a sterile operating room than the trainees in other programs. by contrast, trainees who selected programs 1 and 3 generally had fewer opportunities to wear infectionprotective clothing than those who selected program 2; therefore, the performance of the two groups is lower than did in program 2, although there was no significant statistical difference. further researches with osce stations containing similar assessment aspects and recruitment of more pgy participants are necessary to certify our assumptions. the results of this study show that highly specialized training may result in insufficient training for trainees in other fields (for example, in the pediatrics training in this study). therefore, in the 2-year training program, general medical training is necessary in the first year. it enables medical graduates to develop their general medical care abilities. specialized training in the second year can strengthen the trainees' technical skills and prepare them for specialized field training in the future. combining the first year of general medical training and the second year of specialist training, the trainees could access a comprehensive ability in clinical care. a limitation of the present study is the relatively low number of test stations and trainees involved in the clinical performance assessment process. however, the results provide valuable information that can be used to improve the design of training programs. united states and canada: a comparison of two systems the acgme competencies: substance or form? accreditation council for graduate medical education a core competence-based objective structured clinical examination (osce) in evaluation of clinical performance of postgraduate year-1 (pgy1) residents evaluating the effectiveness of a 2-year curriculum in a surgical skills center the structured oral examination as a method for assessing surgical residents assessing medical students' clinical sciences knowledge in france: a collaboration between the nbme and a consortium of french medical schools comparing the outcomes of different postgraduate year training programs in taiwan an experimental assessment carried out in an undergraduate general practice teaching course (osce examination) evaluation of a medical spanish elective for senior medical students: improving outcomes through osce assessments validation of an objective structured clinical examination in psychiatry does rating with a checklist improve the effect of e-learning for cognitive and practical skills in bariatric surgery? a rater-blinded, randomizedcontrolled trial the development and testing of a performance checklist to assess neonatal resuscitation megacode skill key: cord-209221-vjfmxsks authors: ishiguro, katsuhiko; ujihara, kazuya; sawada, ryohto; akita, hirotaka; kotera, masaaki title: data transfer approaches to improve seq-to-seq retrosynthesis date: 2020-10-02 journal: nan doi: nan sha: doc_id: 209221 cord_uid: vjfmxsks retrosynthesis is a problem to infer reactant compounds to synthesize a given product compound through chemical reactions. recent studies on retrosynthesis focus on proposing more sophisticated prediction models, but the dataset to feed the models also plays an essential role in achieving the best generalizing models. generally, a dataset that is best suited for a specific task tends to be small. in such a case, it is the standard solution to transfer knowledge from a large or clean dataset in the same domain. in this paper, we conduct a systematic and intensive examination of data transfer approaches on end-to-end generative models, in application to retrosynthesis. experimental results show that typical data transfer methods can improve test prediction scores of an off-the-shelf transformer baseline model. especially, the pre-training plus fine-tuning approach boosts the accuracy scores of the baseline, achieving the new state-of-the-art. in addition, we conduct a manual inspection for the erroneous prediction results. the inspection shows that the pre-training plus fine-tuning models can generate chemically appropriate or sensible proposals in almost all cases. retrosynthesis, first identified by corey & wipke (1969) , is a fundamental chemical problem to infer a set of reactant compounds that can be synthesized into a desired product compound through a series of chemical reactions. the search space of sets of compounds is innately huge. further, a product compound can be synthesized through different series of reactions from different reactant compound sets. such difficulties require the huge efforts of human chemical experts and the large knowledge base to build a retrosynthesis engine for years. thus, expectations of machine-learning (ml) based retrosynthesis engines is growing in recent years. the need for the retrosynthesis becomes intensive in these days along with the development of in silico (computational) chemical compound generations (jin et al., 2018; kusner et al., 2017) , which are also applied to new drug discovery for covid-19 (cantürk et al., 2020; chenthamarakshan et al., 2020) . these generation models can generate unseen compounds in computers but do not answer how to synthesize them in practical. retrosynthesis engines can help chemists and pharmacists fill this gap. practical retrosynthesis planning requires a strong model to learn inherent biases in the target dataset while keeping generalization performance to generate unseen (test) product compounds. the current trend is to focus on developing such a strong ml model architecture such as seq-to-seq models (liu et al., 2017; karpov et al., 2019) and graph-to-graphs models (shi et al., 2020; yan et al., 2020; somnath et al., 2020) , which achieve the state-of-the-art (sota) retrosynthesis accuracy. however, model architecture is not the only issue to consider. in the current deep neural network (dnn) era, the quantity (many samples) and the quality (less noisy, corrupted samples) of the available dataset often governs the final performance of the ml model. the problem is that there are only a few large and high-quality supervised training datasets that are available publicly. instead, only a small and/or a noisy dataset is usually available for the target application task. to cope with this problem, data transfer approaches are widely employed as ordinary research pipelines in computer vision (cv), natural language processing (nlp), and machine translation (mt) domains (kornblith xie et al., 2020; he et al., 2020; khan et al., 2019; sennrich et al., 2016) . a data transfer approach tries to transfer knowledge to help a difficult training on the small and/or noisy target dataset. that knowledge is imported from augmented dataset, which is usually a large or clean dataset in the same domain but does not share the same task or the same assumptions with the target dataset. such augmented datasets are beneficial if the quantity or the quality of the augmented dataset is superior compared to the target dataset. however, this data transfer approach is not still well investigated in the previous retrosynthesis studies as we explained above. in this paper, we conduct a systematic investigation of the effect of data transfer for the improvement of the retrosynthesis models. we examine three standard methods of data transfer: joint training, self-training, and pre-training plus fine-tuning. the result shows that every data transfer method can improve the test prediction accuracy of an off-the-shelf transformer retrosynthesis model. especially, a transformer with pre-training plus fine-tuning achieves comparable performance with, and in some cases better performance than, the sota models. in addition, we conducted an intensive manual inspection for the erroneous prediction results. this inspection clarifies the limitations of our approaches. but at the same time, it reveals that the pre-training plus fine-tuning model can generate chemically appropriate or sensible proposals more than 99% cases of top-1 predictions. computers are used to aid retrosynthesis design for decades, dating back to corey & wipke (1969) . however, it takes many years to see the rise of generalizable and scalable ml-based approaches, instead of rule-based approaches (e.g. chen & baldi (2009) ), which cannot extrapolate beyond the rules given, and first principle-based approaches (e.g. wang et al. (2014) , which suffer from prohibitively heavy computations. the most recent ml retrosynthesis employs deep neural network (dnn) for its main component (e.g. (wei et al., 2016) ). among them, liu et al. (2017) first introduced the lstm seq-to-seq model. their model handled the compounds with the smiles (weininger, 1988 )-format string representation, and the retrosynthesis problem was solved as the mt problem. later, karpov et al. (2019) replaced the lstm with the transformer (vaswani et al., 2017) , which is the current baseline seq-to-seq dnn, and achieves a good performance. recently, shi et al. (2020) introduced a graph-to-graphs approach. graph-to-graphs approach can treat the compounds as molecular graphs with help of graph neural networks. this approach well matches human experts' intuition and the very recent model (somnath et al., 2020) greatly improved the accuracy, outperforming the former state-of-the-art (sota) model based on the deep logic network . as seen, most efforts of ml-based retrosynthesis researches are dedicated to stronger dnn architectures. in this paper, we propose another approach to improve the sota of retrosynthesis, i.e., by transferring the knowledge of additional datasets that are not directly prepared for the users' target tasks. generally, the performances of the statistical ml model are dependent on the design of the model (variable dependencies) and the datasets. in the dataset side, the both of the quality (fewer noises in features, less mislabels or conflicting samples) and the quantity (many sample sizes, not-few and not-too-many numbers of class labels) of the training dataset are crucial. however, it is difficult, or practically impossible, to prepare a large dataset of high-quality samples for users' target tasks. to cope with this problem, data transfer techniques are widely employed as ordinary research pipelines in cv, nlp, and mt domains. pre-training is to train a model with some datasets prior to fine-tuning, which is further training with the target dataset. sometimes the pre-trained model is deployed as it is as a general-purpose baseline. one of the first major successes of data transfer for dnn is the supervised pre-training in cv. in that circumstance, pre-trained binaries of successful networks (krizhevsky et al., 2012; simonyan & zisserman, 2015; he et al., 2016) included in deep learning frameworks (e.g. caffe) played crucial roles in advancing other cv studies. today it is a common pipeline to employ the pre-trained model as a part of the larger and stronger networks (girshick et al., 2014; long et al., 2015; xiong et al., 2018; kornblith et al., 2019) . one distinct characteristic of the pre-training in the nlp domain is the large sizes in the dataset to feed and the train models. very large networks such as bert (devlin et al., 2018) and gpt-2 (radford et al., 2019) are trained with massive amounts of the corpus (dataset), which were unrealistically huge for most engineers and researchers to deal with, were distributed in binaries or parameters. these pre-trained models were incorporated in each developer's system and contributed to push limits of several nlp studies and applications (e.g. lan et al., 2020; yang et al., 2019) ). self-training, another data transfer method studied in this paper, has a longer history than the pretraining, back to the seminal work by scudder (1965) . in the self-training approach, we first train a base model with the labeled target dataset, which is often small but high-quality. then, a larger dataset that contains unlabeled or attached with low-quality noisy labels is relabeled by the base model. the relabeled dataset is used to augment the small target dataset to obtain a stronger model. the same technique is often referred to as pseudo labeling, one of the elemental techniques to boost performances in program competitions. recently self-training draws attention in several domains, such as cv (xie et al., 2020) , nlp (he et al., 2020) , and speech recognition (khan et al., 2019) . an advantage of self-training against the pre-training is that the self-training does not require the large labeled dataset thanks to the relabeling, even for the supervised task. this characteristic is employed in the mt application: it is difficult to collect qualified translation datasets (parallel corpus) for minor languages. thus the self-training (referred to as back translation) is intensively used to augment the pseudo parallel corpus (sennrich et al., 2016) . zoph et al. (2020) examined the data transfer pipeline and showed that the self-training is superior to the widely adopted pre-training in object recognition (segmentation) tasks. they studied the data transfer at discriminative models. in this paper, we focus to examine the effectiveness of the data transfer methods in sequence-to-sequence generative models. a few researchers in bioinformatics and chemoinformatics show interest in the data transfer approach to learn a universal numerical representation (embedding) of properties of the compounds that is informative enough to predict multiple quantities. honda et al. (2019) employed a transformer encoder-decoder to pre-train the intermediate representation of compounds and applied the pre-trained encoder for downstream tasks combining with a separate predictor network. li & fourches (2020) followed the masked prediction procedure of bert (devlin et al., 2018) for pre-training. wang et al. (2019) employed an lstm but reports that the pre-trained model performs well in some small datasets. compared to these previous studies, our study differs in the following two essential points. first, as we have explained earlier, we deal with data transfer for sequence-to-sequence generative models for retrosynthesis while these studies focus on discriminative models similar to (zoph et al., 2020) . second, these previous studies did not perform systematic comparisons of different transfer methods for the target tasks. in contrast, we perform systematic and intensive comparisons among transfer methods to find the best data transfer methods for retrosynthesis. there are two exceptions that study the transfer learning in generative models in chemoinformatics. pesciullesi et al. (2020) improved accuracy of synthesis prediction by applying the molecular transformer model to carbohydrate reactions using transfer learning. though apparently similar, the synthesis and the retrosynthesis belong to different classes of problems: a set of reactants yields a specific product compound while a product can be decomposed into multiple reactant sets. chen et al. (2019) proposed to pre-train a retrosynthesis model in a slightly different way. they synthesized a pre-training dataset by manipulating the target dataset randomly or using pre-defined rules and did not rely on the other large datasets. they reported such pre-training was still able to improve retrosynthesis accuracy, though the gains were not large. their problem setting was different from ours. we focused on the case where an additional huge dataset is available other than the target dataset to mitigate the quantity-and-quality problem. we will show that our approach can achieve much greater improvements in retrosynthesis accuracy. in this section, we first give a general formulation of ml-based retrosynthesis problem. then, we explain several data transfer methods using that formulation. retrosynthesis is a problem to map a product compound item x to an appropriate set y of reactant compounds (figure1). a sample for a retrosynthesis model is a pair (x, y) where x denotes a product, y denotes a set of reactants. a retrosynthesis model m is a (stochastic) mapping between x and y: conventionally formulated as a likelihood distribution p m (y|x; θ) with the parameters θ m . formulation of the likelihood determines the model characteristics. most previous studies focused on developing new sophisticated formulations e.g. seq-to-seq models (liu et al., 2017; karpov et al., 2019) and graph-to-graphs models (shi et al., 2020; somnath et al., 2020; yan et al., 2020) . in this paper, we simply set m a naive seq-to-seq transformer (vaswani et al., 2017) since we focus on the data transfer rather than the model architecture. now the model is fixed, so we omit m hereafter. under a seq-to-seq formulation of retrosynthesis, both of the product x and the set of reactants y are represented as strings (a sequence of characters). we adopt the standard string representation of chemical compounds, referred to as smiles (weininger, 1988) . basically any compound can be uniquely represented as a smiles format string. y consists of possibly multiple compounds. in such a case, we simply concatenate the multiple smiles strings into a longer string with delimiters. assume a dataset d is a set of reaction samples where the product and the reactants are represented as smiles strings. the ith sample of the dataset is indexed by i: a pair ( a training dataset d train is used to find good parameters θ m * that optimize an objective function, which is typically the maximum (log-)likelihood criterion: we usually implement the above maximum likelihood criterion as the minimization of the crossentropy loss l(d train ). we minimize the cross-entropy loss by an iterative parameter update algorithm such as stochastic gradient descent: the iterations are scheduled by validation scores computed on a validation dataset d val , and the learned model is evaluated by test scores computed on a test dataset d test . these three datasets should have no intersection samples. the standard setting of most of the previous retrosynthesis models followed a simple scenario. first, we prepare a dataset to which we want to fit the model. we refer to this dataset as a target dataset d t . the whole d t is split into three sub-datasets: a training set d t train , a validation set d t val , and a test set d t test . the single model training is: where the training procedure is scheduled by d t val and evaluated on d t test . in this setting, we have no dataset other than the target dataset, thus we do not (can not) conduct any data transfer. next, we consider another scenario where we are given an additional dataset other than the target dataset. we call this additional dataset as augment dataset d a . typically augment datasets have larger sample sizes than those of the target datasets. it is also usual that empirical distributions of p(y|x) can be different between d t and d a . still, we want to transfer some knowledge from d a to the model parameter to improve the test scores computed on the target test set d t test . one of the most simple ways of data transfer is joint training. we split d a into a training set d a tran , a validation set d a val , and a test set d a test . in the joint training, we optimize the parameters that satisfy the training objective on both d t train and d a train . in our setting, the model and the objective are shared among datasets, so we simply train on the concatenated training sets: the training process is scheduled by d t val and evaluated on d t test . the above formulation (eq.4) of the joint training is restrictive: only available when the domain of the data pair (x, y) are shared among the target dataset and the augment dataset. for example, in our cases, the canonicalization rule of the smiles compound string representation must be the same in x (y) of d t train and d a train . self-training is a well-known technique for data transfer, and it is also known as pseudo labeling. unlike the joint training, we can conduct the self-training even if the domain of y differs between d t train and d a train . we first conduct the single model training (using d t solely) and obtain θ * single . then, we decode all product of the augment dataset with the learned parameter θ * single . the generated pseudo labelsŷ is used to replace the reactants of the new augment training set. then we perform the joint training by concatenating d t train and the pseudo-labeled d a train . decoding with the single model trained by the target dataset will ease the difficulty of transferring knowledge due to the inconsistent p(y|x) between d t and d a . we can formulate the self-training as follows: the training process of eq.7 is scheduled by d t val and evaluated on d t test . in the joint training and the self-training, the final best parameter is computed via the training on the concatenated training sets d joint and d self . the sample sizes of these concatenated training sets can be large, resulting in slower training convergence. pre-training plus fine-tuning method handles this problem by training a model in advance with the augment dataset d a . the pre-trained model is simply loaded as the initial model, and is tuned to the smaller target dataset. the later fine-tuning finishes faster in general, beneficial for the cases when we have potentially multiple target datasets for deployments. the pre-training plus fine-tuning approach thus naturally requires two training phases. in the pretraining phase (the first phase), we preform a single model training solely on the augment dataset: where the training procedure is scheduled by d a val and evaluated on d a test . in the fine-tuning phase, we train the model with d t not from the scratch but from m θ * pretrain . where the training procedure is scheduled by d t val and evaluated on d t test . in this section, we first assess the effects of the several data transfer methods, compared with the transformer that is trained naively. after that, we show the comparisons with the most recent sota retrosynthesis models. most ml-based retrosynthesis studies adopt the uspto database, which is a collection of chemical reaction formulas automatically ocr-scanned from the us patent documents. the target dataset is the uspto-50k dataset, which contains curated 50k samples provided by lowe (2012) . this dataset serves as the standard benchmark in the retrosynthesis studies. the characteristic of this dataset is that all samples are classified in one of ten major reaction classes in advance (schneider et al., 2016) . this means the distribution of products and reactants are skewed. in this study, the reaction class information is only used to summarize the prediction results and is not used for filtering the dataset or for prediction. for data transfer, we prepare two augment datasets. since these two datasets are not filtered based on the reaction classes, their distributions of compounds are clearly different from that of the uspto-50k dataset. the first and the main augment dataset is referred to as uspto-full dataset, which contains 877k samples curated by lowe (2017) . the second augment dataset is referred to as uspto-mit dataset, which contains 479k samples curated by jin et al. (2017) . experimental results on uspto-mit is included in the appendix for sample sizes assessment. the three datasets have a number of shared reaction samples or noisy instances. for fairer evaluations, we need data cleansing beforehand. the details of the data cleansing are presented in the appendix. in order to give fair assessments of the effects of data transfer methods, we fix the architecture of the seq-to-seq model, namely the transformer vaswani et al. (2017) regardless of the transfer methods. we may obtain better results if we optimize the architecture for each transfer method. (2019), learning rates are scheduled in a cyclic manner with the warm-up iterations excepting the fine-tune training. in the fine-tuning, we find that a standard non-cyclic scheduler (klein et al., 2017) perform good, thus we adopt it in our experiments. we adopt the n-best accuracy score of the predicted results on the test set as the evaluation metric. we use k = 50 beam search to list and sort the predictions, and compute n = 1, 3, 5, 10, 20, 50-best accuracy scores, following the normal procedure in the literature. previous works somnath et al., 2020; yan et al., 2020) use the validation sets to exponentially decay the learning rate. instead, we use the validation set to choose and output a snapshot that records the best validation perplexity. all accuracy scores of our experiments are computed on these best val-score snapshots. full descriptions about the experimental procedure are presented in the appendix. table 1 shows the n-best accuracy scores over several data transfer methods. we use the uspto-50k dataset as the target dataset, and the cleansed uspto-full dataset as the augment dataset in this table. generally, all data transfer methods are successful in improving the n-best accuracy for all choices of n. among them, the pre-training plus fine-tuning method achieves the remarkable gains (more than 20 points for most n). this result is indeed beneficial for the researchers who conduct not computational experiments but actual synthesis experiments because it reduces the number of required experiment trials. in this study, we did not perform optimization of the model itself because our main goal was to confirm the effect of data transfer, but if necessary, we can perform optimization with the existing model immediately. it is interesting to compare this result with the previous study by zoph et al. (2020) , which examines the self-training and the pre-training plus fine-tuning in the image recognition tasks. their conclusion is that pre-training is less effective than the self-training to improve generalization performance. the authors explain this is because there is no universal representation (embedding) of generic images. in this study, which is not for image recognition but for retrosynthesis, we observe that the pre-training plus fine-tuning is evidently better than the self-training. perhaps the chemical compound strings may have a universal representation because of restrictions and patterns naturally imposed on the chemical compounds in nature. next, we compare our best data transfer model with the sota model of the retrosynthesis. as the figure shows, our best pre-training plus fine-tuning model performs as good as the latest sota model in the literature, which is built on a off-the-shelf simple transformer. moreover, our model exceeds the known best accuracy at n = 10 and n = 20. table 2 : n-best accuracy of retrosynthesis tasks on uspto-50k, comparing with the most recent sota models. bold faces indicate the best scores at the specific n-accuracy. all numbers of the compared models are borrowed from their original papers. n/a indicates the accuracy scores are not reported in the published papers. n-best accuracy (%) name model arch. n = 1 n = 3 n = 5 n = 10 n = 20 n = 50 gln (dai et al., none of the compared studies provided the standard deviations of the obtained accuracy scores. thus it is difficult to conclude definitively that one model is better than other models from this result. however, our model performed the best in n = 10, 20-best accuracy, which is preferable for those who conduct synthesis experiments, for many reasons. first, there is usually more than one correct answer for retrosynthesis analysis, even if it consists of only one-step reaction. second, the reaction with the highest score is not always the best in practice. thus, it is expected to output various solutions within a limited number (for example, 10) of answers rather than producing only one answer. in other words, a predictor that makes 10 good suggestions is pragmatically more highly valued than a predictor that makes only one suggestion that is considered the best. due to page limitation, we describe other additional analyses in appendixes. here we only summarize the main messages of these analyses. please find the appendix for the details. 1. additional experiments with smaller uspto-mit dataset shows that the sample size of the augment dataset clearly affects the generalization performance of the transferred models. 2. we find that the 1-best accuracy and n-best accuracy show quite different evolution curves against training iterations, especially for the single training model. such behaviors are not mentioned in the literature so far, possibly opening a new question for model training. this behavior is not observed in the pre-training plus fine-tuning, which is another advantage over other transfer methods. 3. we confirm that the pre-training plus fine-tuning improves the class-wise prediction accuracy for all 10 major reaction classes of uspto-50k. the augment dataset especially help prediction of difficult bond/ring formation reactions. 4. the manual inspection for the erroneous prediction results reveals that there are a few reactions that are still difficult to perform reasonable retrosynthesis prediction. 5. at the same time, the manual inspection results show that over 99% of top-1 predictions are chemically reasonable and appropriate hypotheses, even if the hypotheses do not include the exact "gold" reactant hypothesis. in this paper, we conducted a systematic investigation on the effect of data transfer for the improvement of the computational retrosynthesis system. the result proved that the most typical data transfer methods can improve the test prediction accuracy of a retrosynthesis model. especially, a transformer with pre-training plus fine-tuning updated the sota of the 10-and 20-best retrosynthesis accuracy. we also confirmed that the pre-training plus fine-tuning model can generate chemically appropriate or sensible proposals more than 99% cases of top-1 predictions through our manual inspections of the predictions. we only validated the simplest transfer techniques in this work. as future work, we are interested in applying more sophisticated transfer learning methods. for example, freezing a part of the nn during fine-tuning may be effective according to the results in cv domain. it is also interesting for the retrosynthesis community to apply the data transfer methods for graph-to-graphs models such as (somnath et al., 2020) . we observed that the uspto-full dataset is transferable to the uspto-50k dataset, which has a biased distribution of reaction types. to examine the transferability of the uspto-full dataset, we need to test the transfers to other retrosynthesis datasets, which are small, biased and collected for specific purposes. a.1 dataset most ml-based retrosynthesis studies adopt the uspto database, which is a collection of chemical reaction formulas automatically ocr-scanned from the us patent documents. we use the filtered subsets of the uspto database in this study. the target dataset is the uspto-50k dataset, which contains curated 50k samples provided by lowe (2012) . this dataset serves as the standard benchmark in the retrosynthesis studies. the dataset is split into 40k train, 5k validation, and 5k test sets following (liu et al., 2017) . the distinct characteristic of this dataset is that all 50k samples are classified in one of ten major reaction classes in advance (schneider et al., 2016) . this means the distribution of products and reactants are highly skewed. in this study, the reaction class information is only used to summarize the prediction results and is not used for filtering the dataset or for prediction. to perform data transfer, we prepare two augment datasets. since these two datasets are not filtered based on the reaction classes, their distributions of compounds are clearly different from that of the uspto-50k dataset. the first and the main augment dataset is referred to as uspto-full dataset, which is curated by lowe (2017) . the uspto-full dataset is split into 879k, 49k, and 49k samples for training, validation, and test sets, respectively. the second augment dataset is referred to as uspto-mit dataset, which is curated by jin et al. (2017) . the uspto-mit dataset is split into 409k, 30k, and 40k samples for training, validation, and test sets, respectively 1 . experimental results on this dataset are presented in the appendix for assessment of the sample sizes of augment datasets. the training sets of the augment datasets (uspto-full and uspto-mit) contain many reaction smiles samples that are incorporated in one of the subsets of the target dataset uspto-50k. such contaminated samples inhibit fair predictions, because of the duplicated training samples (duplicated samples given more weight than other samples) or the data leaks (if a test sample is included in the training set, the model can answer correctly by simply memorizing the sample without learning the features). thus, we remove all reaction samples from the training sets of the two augment datasets whose product smiles are included in any subsets of the target dataset. as a result, the uspto-mit training set is reduced to 384k samples. similarly, the uspto-full training set shrinks to 844k samples. we adopt a canonical smiles format throughout the experiments. however, there are multiple canonicalization rules in this field. in fact, we confirmed the canonicalization rules are not unified among the three datasets. non-unified canonicalizations may hinder effective training, and may also induce unexpected data leaks because the same compound with different smiles string cannot be detected. therefore we conducted unified canonicalization for all datasets using the rdkit tool (landrum & others, 2006 ) with a specific version. in order to give fair assessments of the effects of data transfer methods, we fix the architecture of the seq-to-seq model, namely the transformer vaswani et al. (2017) regardless of the transfer methods. this means the reported results are based on the sub-optimal transformer architecture; we may obtain better results if we optimize the architecture for each transfer method. the number of self-attention layers is set to 3, and the dimensions of the latent vectors are set to 500 in all layers. we adopt the positional encoding, which we find it essential to achieve good scores through preliminary experiments. we limit the maximum number of tokens (length of a sequence) up to 200 to avoid memory shortage of gpus. we use the off-the-shelf implementation of the transformer by opennmt-py 2 . table 3 : n-best accuracy of retrosynthesis tasks on uspto-50k, with different data-transfer training methods. augment dataset is the smaller uspto-mit. other details are the same with the table 1 . n-best accuracy (%) training method n = 1 n = 3 n = 5 n = 10 n = 20 n = 50 single model (no transfer) 35.3 ± 1.4 52.8 ± 1.4 58.9 ± 1.3 64.5 ± 1.2 68.8 ± 1.2 72.1 ± 1.3 joint training 38.4 ± 0.9 60.7 ± 0.5 67.8 ± 0.4 75.2 ± 0.3 80.4 ± 0.4 84.9 ± 0.3 self-training 41.2 ± 0.3 60.2 ± 0.4 66.2 ± 0.2 71.9 ± 0.3 75.5 ± 0.5 78.2 ± 0.5 pre-training + fine-tune 52.2 ± 0.4 73.1 ± 0.4 78.8 ± 0.4 83.7 ± 0.3 86.3 ± 0.3 88.2 ± 0.3 all models are optimized via adam (kingma & ba, 2015) . following the seminal paper of karpov et al. (2019) , learning rates are scheduled in a cyclic manner with the warm-up iterations excepting the fine-tune training. in the fine-tuning, we find that a standard non-cyclic scheduler (klein et al., 2017) performs good, thus we adopt it in our experiments. we adopt the n-best accuracy score of the predicted results on the test set as the evaluation metric. remember that a sample is a pair of the input product smiles string and the expected reactant smiles string. however, the provided reactant smiles is not necessarily the only correct answer. thus we predict the k-best possible predictions for each test input. if the expected reactant smiles is included in the best-n prediction, we assume the retrosynthesis model is successful in predicting the answer. we use k = 50 beam search to list and sort the predictions, and compute n = 1, 3, 5, 10, 20, 50-best accuracy scores, following the normal procedure in the literature. we note that there are possible choices of how to employ validation split samples. previous works somnath et al., 2020; yan et al., 2020) use the validation sets to exponentially decay the learning rate. however, we adopt the cyclic learning rate scheduler following the seminal transformerbased model (karpov et al., 2019) and we found it indeed effective in our experiments. therefore, we use the validation set to choose and output a snapshot that records the best validation perplexity. all accuracy scores of our experiments are computed on these best validation score snapshots. we do not employ any ensemble model for fair comparisons with the previous studies. table 3 shows the n-best accuracy scores over several data transfer methods, but this time we use the smaller uspto-mit dataset as the augment dataset in this table. our expectation is the gains of data transfer methods decreases with the smaller augment dataset. the joint training and the pre-training plus fine-tuning record worse scores compared to the uspto-full cases (table 1 . surprisingly, the gain of the self-training is not affected by the sample size of the augment dataset. we thoroughly trained several models with larger numbers of mini-batch iterations (or epochs), which has not been conducted in any previous studies. figure 2 consists of 4x3 panels, where the four rows correspond to four different transfer training methods: single model (no transfer), joint training, self-training, and pre-training plus fine-tuning 3 , and the three columns correspond to the three different metrics. the left column shows the perplexity on the training set. we observe all transfer training methods successfully decrease the training perplexity, namely, better fit for the training set. the middle and the right columns show the 1-best and the 20-best accuracy scores on the test set, respectively. the remarkable difference is observed among different models, especially between the single (1st row) and the self-training (3rd row) models. more importantly, this analysis clearly showed different behavior between 1-best and the n(> 1)-best accuracy curves in the single model. one may naturally expect and hypothesize that 1-best and the n(> 1)-best accuracy curves behave similarly: but no previous retrosynthesis studies have examined, or even discussed, this hypothesis. we showed in this study that the hypothesis does not hold for single model training on uspto-50k, which is the default training strategy in previous studies. this observation, that the 1-best and the n-best accuracy curves may be totally different, is important especially when trying to verify the top-n result experimentally (not in a computational experiment, but in an actual experiment that is both time-consuming and expensive). one possible reason for this difference between the 1-best and the n-best accuracy is the form of the objective function. the maximum likelihood of objective l updates the parameter θ so as to maximize the 1-best accuracy on the training set, not to maximize the n-best accuracy. it is also remarkable that the two curves of the pre-training plus fine-tuning (4th row) are not significantly different, but rather very similar. the trained model quickly hits the peaks of the 1-best and the 20-best accuracy around 10k iterations. after hitting the peaks, two curves decrease rapidly. the model gradually forgets the beneficial knowledge transferred from the augment dataset by keeping the training iterations, and the model will converge to the single train model after many iterations. thus it is important whether we can detect the peaks to early-stop the fine-tuning. in our experiments, the validation score monitoring are always successful in identifying this peak, yielding the good scores for all top-n accuracy in tables. 1,3. the fact that the two curves of the pre-training plus fine-tuning approach are very similar is another advantage for the data transfer in retrosynthesis. the joint training (2nd row) also shows the similar curves in test scores, but the pre-training plus fine-tuning approach is better in two aspects: final accuracy scores (table. 1) and necessary numbers of iterations (roughly between 70k and 250k iterations) required to achieve the best-val-score snapshot. it may seem strange that the 1,3,5-best accuracy scores of the single model are lower than those of the known results in (karpov et al., 2019) 4 . in our experiment, the best-val-score snapshots of the single model are always chosen from the earlier iterations (less than 10,000 iterations), resulting in low 1-best scores of the single model compared to the known results (karpov et al., 2019) . according to figure 2 . the 1-best accuracy exceeds the known score if we choose the snapshot of e.g. 140,000 iterations. however, the snapshot achieves worse 20-best accuracy compared to the best-val-score snapshot. next, we examine the predicted reactant smiles to see how the data transfer contributes to the improvement of the computational retrosynthesis prediction from the perspective of actual chemical experiment. we evaluate 428 test samples (x j , y j ) ∈ d t test whose 50-best predictionsŷ j s do not include the "gold" reactant smiles string y j . we note again that the gold reactant set y j is not the sole correct retrosynthesis prediction, but the current studies adopt this "hard" criterion. during the inspection, we realize that uspto-50k test dataset still contains a number of errors (mislabels) within the test set despite the curating efforts of the original authors (lowe, 2012) . therefore we exclude these mislabeled samples from this in-depth analysis. difficult to predict with a single training of a seq-to-seq model (liu et al., 2017) . the heterocycle formation reaction not only forms some new bonds but also aromatizes some atoms through a reaction, which changes many capital letters in smiles string to lowercase. therefore, it is expected that it will be difficult to learn atom-to-atom mapping with small training samples. figure 3 shows examples that fail in the single model but succeed in the transfer model. significant improvements are observed in the prediction of complicated reactions such as heterocyclic reactions (1st row), suggesting that pre-training plus fine-tuning with a large augment dataset enables to learn such large changes. deals-alder reaction (2nd row) is another example of complicated reactions, where two c-c bonds are formed as well as some atom and bond types change. in general, the single model is not good at generating the ring formation reactions and only returns odd answers, while the transferred model is able to return correct answers to such reactions. figure 3 : examples of being able to make predictions with pre-training and fine-tuning. the top-1 predictions for the single model are reasonable but the model does not predict reactants for constructing a ring. the 1st row (a) an example of heterocycle formation (rx 4). synthesis nsubstituted pyrrole from 1,4-diketone and alkylamine. single model does not correctly propose reactants built a pyrrole ring. the 2nd row (b) an example of c-c bond formation (rx 3). synthetic organic chemists easily come up with the diels-alder reaction when they see bicyclo[2.2.1]hept-2-ene ring system but single model does not predict any diels-alder reaction within the top-50. figure 4 shows difficult examples that could not be predicted correctly even by our best model. if there are multiple similar substituents in a compound, the transferred model sometimes chooses them wrong. in another case, our model fails to generate valid smiles string. this indicates that the augment dataset still does not contain a sufficient amount of reactions for polycyclic aromatic hydrocarbons. we need more data augmentation to prevent that from happening, but augmentation may be difficult to do as such chemical groups are rare. having confirmed the predicted results based on our expertise in synthetic organic chemistry, less than 0.5% of the top 1 reactions were found to be wrong, and less than 0.2% of the cases did not output any organically correct reactions at all. this is a difficulty of the evaluation of retrosynthesis: there are multiple reasonable (appropriate) hypotheses for reactant predictions, and the n-best accuracy does not perfectly match the problem. at the same time, it is surprising that our model achieves such high accuracy without using domain knowledge or graph representation of compounds. machine-learning driven drug repurposing for covid-19. arxiv learning to make generalizable and diverse predictions for retrosynthesis no electron left behind: a rule-based expert system to predict chemical reactions and reaction mechanisms cogmol: target-specific and selective drug design for covid-19 using deep generative models computer-assisted design of complex organic syntheses retrosynthesis prediction with conditional graph logic network pre-training of deep bidirectional transformers for language understanding. 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with molpmofit retrosynthetic reaction prediction using neural sequence-to-sequence models fully convolutional networks for semantic segmentation extraction of chemical structures and reactions from the literature chemical reactions from us patents (1976-sep2016 transfer learning enables the molecular transformer to predict regio-and stereoselective reactions on carbohydrates language models are unsupervised multitask learneres what's what: the (nearly) definitive guide to reaction role assignment probability of error of some adaptive pattern-recognition machines improving neural machine translation models with monolingual data a graph to graphs framework for retrosynthesis prediction very deep convolutional networks for large-scale image recognition learning graph models for template-free retrosynthesis attention is all you need discovering chemistry with an ab initio nanoreactor smiles-bert: large scale unsupervised pre-training for molecular property prediction neural networks for the prediction of organic chemistry reactions smiles, a chemical language and information system. 1. introduction to methodology and encoding rules self-training with noisy student improves imagenet classification towards good practices on building effective cnn baseline model for person re-identification xlnet: generalized autoregressive pretraining for language understanding rethinking pre-training and self-training key: cord-356288-zaspyveg authors: giroux, maria; funk, suzanne; karreman, erwin; kamencic, huse; bhargava, rashmi title: a randomized comparison of training programs using a pelvic model designed to enhance pelvic floor examination in patients presenting with chronic pelvic pain date: 2020-09-08 journal: int urogynecol j doi: 10.1007/s00192-020-04487-y sha: doc_id: 356288 cord_uid: zaspyveg introduction: pelvic floor myalgia is a common cause and contributor to chronic pelvic pain [neurourol urodyn 4:984–1008 (2017)]. the purpose of this study was to compare in-person versus video-based teaching methods of a comprehensive assessment of the pelvic floor musculature on a pelvic model. methods: a randomized controlled trial of 46 participants was conducted. the participants were randomized into two groups. both groups were taught by the same pelvic floor physiotherapist using two different teaching methods on a pelvic model. group 1 watched an instructional video, whereas group 2 had in-person training. both groups underwent preand post-training assessments consisting of a written examination and an objective structured clinical examination (osce). primary outcome measure was the change in participants’ preand post-training assessment scores. secondary outcome measures were perceived changes in both participants’ comfort level in performing pelvic floor examination and applicability of the training program to clinical practice. results: there was no statistically significant difference between the teaching methods in the degree of improvement of the participants’ mean written assessment scores (p = 0.58), osce scores (p = 0.15), and perceived comfort level (p = 0.19). participants’ mean preand post-assessment scores improved significantly (p < 0.001). participants reported the training program to be applicable towards their clinical practice. conclusions: this study demonstrates that learners’ assessment of pelvic floor musculature can be enhanced using varied teaching methods on a pelvic model. chronic pelvic pain is a complex multi-faceted problem that places a substantial burden on healthcare resources [1] . it is common and affects women of all ages and backgrounds. kavvadias et al. reported that 15-20% of women have chronic pelvic pain lasting for more than 1 year [2] . pelvic floor myalgia (pfm), defined as pain originating from the pelvic floor musculature, is an important and common cause or contributor to chronic pelvic pain [3] . in a 2011 prospective cross-sectional study by fitzgerald et al., 63% of patients with self-reported chronic pelvic pain examined by a physician and 73.7% of patients examined by a physiotherapist were found to have pfm [4] . pfm remains a frequently unrecognized and under-treated component of chronic pelvic pain [3] . palpation remains the best method of assessment for pfm [5] . nonetheless, a 2011 literature review of 69 articles by kavvadias et al. revealed that few gynecologists perform assessment of the pelvic floor musculature for the presence of myofascial pelvic pain and trigger points [4] . it is important for physicians to receive training in the comprehensive assessment of the pelvic floor musculature to identify a possible muscular cause or contribution to chronic pelvic pain and refer patients for appropriate treatment. a positive examination warrants an early referral to a pelvic floor physiotherapist. an untreated musculoskeletal component of chronic pelvic pain can result in persistent symptoms, central sensitization, subsequent patient visits to numerous health care providers, unnecessary laparoscopic surgery, psychological distress, and impaired quality of life [3] . simulation-based training is an integral component of medical education [6] . pelvic training models are useful tools for teaching the technique of pelvic examinations and enable learners to feel comfortable with pelvic examinations prior to patient contact [7] [8] [9] [10] . upon review of the literature, hands-on training was found to be superior to video-based training in teaching obstetrical emergencies and surgical skills [10] [11] [12] [13] [14] . nonetheless, the 2014 study by nilsson et al. found no significant differences in performance scores between training methods for teaching management of postpartum hemorrhage [15] . no previous studies were found that compared training methods for teaching the assessment of pelvic floor musculature in patients presenting with chronic pelvic pain. therefore, we designed a training program for medical students and physicians to enhance examination of pelvic floor musculature for patients presenting with chronic pelvic pain using a pelvic model. no patients were involved in the process of developing and validating the program. the objectives of the proposed training program were to identify pfm as a possible cause or contributor to chronic pelvic pain and to teach the examination of the pelvic floor musculature using a pelvic model. the purpose of this study was to compare video-based versus inperson teaching methods. we hypothesized that in-person teaching method would result in higher proficiency test scores. a randomized controlled trial was conducted between january 16 and november 19, 2018, at the department of obstetrics and gynecology at the university of saskatchewan in regina, saskatchewan, canada. this quality improvement study was reviewed and exempted by the university of saskatchewan research ethics board. forty-six participants were assessed for eligibility. inclusion criteria consisted of the following: ≥ 18 years of age, learners affiliated with the college of medicine at the university of saskatchewan (including medical students, resident physicians in family medicine and obstetrics and gynecology programs), staff family physicians, and obstetricians and gynecologists. informed consent was obtained from all 46 participants enrolled in the study. exclusion criteria consisted of participants with a physical limitation that prevented them from performing a pelvic examination. none of the participants dropped out from the study. figure 1 depicts the study flow diagram. participants were randomized to video (n = 23) and in-person (n = 23) groups. all participants underwent a consecutive 4hr training session that consisted of the following parts ( fig. 2 ): the written examination consisted of 13 multiple choice questions, 2 short answer questions, and fill in the blanks diagrams illustrating pelvic floor musculature (fig. 3) . the 10-min osce station was administered by two gynecologists and consisted of a comprehensive assessment of the pelvic floor musculature on a pelvic model. the maximum score for each test was 30 points. all participants viewed a 37-min video entitled "chronic pelvic pain and pelvic floor myalgia" and labeled diagrams of the pelvic floor anatomy to solidify their learning. the participants were randomized using ibm spss 22 software into video-based (n = 23) and in-person (n = 23) groups using stratified block randomization. participants were stratified based on the level of training: medical students, obstetrics and gynecology resident physicians, family medicine resident physicians, staff family physicians, and obstetricians and gynecologists. after randomization, participants were allocated to different rooms. group 1 viewed a 22-min instructional video of a pelvic floor physiotherapist demonstrating a comprehensive assessment of the pelvic floor musculature on a pelvic model (https://www.youtube.com/watch?v= b19x9avcugc). the same physiotherapist delivered identical content to group 2, but with an in-person demonstration. following the demonstration, group 2 participants were provided with immediate feedback as they assessed pelvic floor musculature on an identical pelvic model. participants were re-tested using exactly the same written examination and 10-min osce as in the pre-training assessment. the osce was administered by the same two gynecologists. the evaluators were blinded to participants' group assignments and were not present at the allocation and training. all materials tested were taught in the training program. during the training session, the use of internet and mobile devices was prohibited, and the participants were respectfully asked to refrain from discussing content learned during the session with each other. notes taken during the educational sessions could not be utilized during the post-training assessment. participant feedback was obtained at the end of the session. primary outcome measure was the change in participants' preand post-training assessment scores in the written examination and osce. secondary outcome measures were perceived changes in both participants' comfort level in performing pelvic floor examination and sense of applicability of the training program to clinical practice. secondary outcome measures were assessed using a 5-point likert-type scale. using a minimally important difference in osce and written assessment scores of 4.5 points (on a 30-point scale) [16] , a standard deviation of 5, alpha level of 0.05, and power of 0.80, a sample size of 21 participants per group was required to adequately power this study (two-tailed test). ibm spss statistics 22 software was used for statistical analysis. primary and secondary outcome measures were analyzed using mixed design analysis of variance (anova) including main effects for group and time (pre to post). differences in baseline characteristics between the two training groups were compared using independent t-tests for continuous variables and chi-square analyses or fisher's exact tests for categorical variables. any variables for which a significant difference in baseline scores between the two groups existed was accounted for by adding them as confounding variables to the main analyses to correct for their influence. table 1 demonstrates primary and secondary outcome measures organized by group assignments. there were no significant differences in baseline characteristics between groups (p > 0.05) except for the baseline (pre-intervention) scores (table 2) . even though participants were randomized into one of the two study groups, baseline osce scores were significantly higher in the in-person group (p = 0.04), while a similar difference approached significance for the written assessment scores (p = 0.07). the mean written assessment scores improved significantly before and after training for both in-person (p < 0.001) and video-based (p < 0.001) training groups. in the video group, the mean written assessment scores improved from 13.3 (95% ci: 11.5-15.1) to 24.3 (95% ci: 23.0-25.7). in the in-person group, the mean written assessment scores improved from 15.6 (95% ci: 13.8-17.4) to 24.8 (95% ci: 23.4-26.2) (fig. 4) . after including the baseline written assignment score as a confounding variable, there was no statistically significant difference in the degree of improvement in the mean written assessment scores between video and inperson groups (p = 0.58). the mean osce scores also improved significantly before and after training for both in-person (p < 0.001) and video-based (p < 0.001) training groups. in the video group, the mean osce scores improved from 11.7 (95% ci: 10.0-13.5) to 24.4 (95% ci: 23.1-25.7). in the inperson group, the mean written assessment scores improved from 14.3 (95% ci: 12.5-16.1) to 26.5 (95% ci: 25.2-27.8) (fig. 5) . after including the baseline osce score as a confounding variable, there was no statistically significant difference in the degree of improvement in the mean osce scores between the video and in-person groups (p = 0.15). the mean perceived comfort level improved significantly in both groups before and after training (p < 0.001). there was no statistically significant difference in the degree of improvement in perceived comfort level between the video and inperson groups (p = 0. 19) . no significant interaction effects were found after analysis of any of the primary or secondary outcome measures, indicating that improvements in scores from pre-to post-training did not significantly differ between the two groups. participants reported the training program to be applicable to their clinical practice. this study demonstrates no significant difference in the effectiveness between video-based and in-person training for teaching the assessment of the pelvic floor musculature to identify a possible muscular cause or contribution to chronic pelvic pain using a pelvic model. improvements in written assessment scores, osce scores, and perceived comfort level were comparable between the video-based and in-person groups, suggesting that video-based training may be an efficient and cost-effective means to teach concepts surrounding pelvic pain to medical learners and physicians. furthermore, video-based education can offer students several other advantages compared to more conventional means of training, including the ability to watch anytime, anywhere, to stop and rewind, and to refer back when needed [17] . the ability to effectively educate students on concepts regarding pelvic pain using video may, therefore, be highly applicable to future training of medical learners. there was no significant difference in the performance scores and degree of improvement in the perceived comfort level between training methods. although we hypothesized that the osce scores and perceived level of comfort in the in-person training group will be superior to video-based training, the results of this study disprove our hypothesis. the results of this study are different from several other studies that compared in-person versus video-based training. studies on microsurgery, vacuumassisted delivery, shoulder dystocia management, and breech vaginal delivery, showed that hands-on learning was more effective [10] [11] [12] [13] [14] . important to note, however, is that many of these skills involve complex tasks with a steep learning curve [13, 14] . tying surgical knots under a microscope, for instance, require meticulous practice, a high level of participant involvement and immediate feedback as well as a high degree of precision in movements, perceptual ability, and psychomotor skills [13] . the results of our study are more in line with a previous study on teaching the management for postpartum hemorrhage, a skill that, while challenging, does not involve the same level of manual dexterity that may be seen in microsurgery or the management of shoulder dystocia [15] . therefore, despite the detailed anatomic knowledge required for evaluating myofascial trigger points for pelvic pain, it may not require the same level of previous experience, perceptual skills, or participant involvement that are required in some of the other skills listed above, which makes it more applicable to video-based learning. other factors likely also contributing to the success of the video include the overall quality of the video and the use of mental practice. the video, similar to the in-person training session, included the use of two anatomy models in addition to the pelvic floor model and included minor text descriptions such as "pelvic floor muscle strength" and the "modified oxford scale for pelvic floor muscle strength," which could have helped students to stay organized in their approach to pelvic pain. such qualities have also been endorsed in the medical education literature, namely in dong and goh's 2015 study regarding "twelve tips for the effective use of videos in medical education." tip 7, in particular, suggests that integrating powerpoint slides, on-screen captions, and lecture images is effective because these types of information are processed in different parts of the brain [18] . another important aspect we noted regarding the video cohort, but not the in-person training session, was that we could see participants rehearsing the sequence of the pelvic floor examination out loud or writing out steps on a piece of paper prior to post-training assessment. mentally rehearsing steps of pelvic examination has been shown to facilitate skills acquisition and improve performance using a pelvic model and standardized patient [19] . when assessing the applicability of our study, it is key to make note of the type of video-based learning we used. a training video, rather than in-person pelvic floor physiotherapist, was used to demonstrate the assessment to standardize the teaching experience and avoid variation in the quality of the demonstration due to inter-and intra-individual variability [20] . nonetheless, we cannot rule out that a demonstration by a live pelvic floor physiotherapist may produce different results. in the in-person group, we used the same pelvic floor physiotherapist to demonstrate the assessment and provide immediate feedback on performance. this study has several limitations. the first limitation of this study is that learners were educated and assessed using a pelvic model, which feels different from palpating the pelvic floor musculature of a patient. furthermore, using a model places emphasis on technical skills, but the ability to communicate effectively and obtain informed consent are also required for clinical situations [7, 21] . other methods of teaching, including simulated patients and anesthetized patients, also have their downfalls. while teaching pelvic examination skills using standardized patients has a greater short-term improvement in clinical performance and decreases learner anxiety compared to manikin-based teaching, it is significantly more expensive, and evidence of long-term impact is lacking [21] [22] [23] . using anesthetized patients for practicing pelvic examinations can also be useful for teaching learners, but it requires informed consent and lacks patient feedback and is not endorsed by the sogc as the primary method of teaching pelvic examinations to medical learners [7] . further research is required to determine whether the skills gained from this training program are transferable to the examination of the pelvic floor musculature in a clinical setting. a second limitation is that the assessment instrument has not been validated. this imposes limitations on the overall applicability and generalizability of the study to other settings. a third limitation is that we used the same written examination and osce station before and after the intervention, which can result in test-enhanced learning. lastly, we did not measure retention rates after training. we cannot exclude that the training effect may decrease over time. due to lack of subsequent retesting, we cannot rule out that additional training sessions may be necessary for maintenance of long-term competency. data are lacking regarding when reinforcement of training may be required. another limitation of this study was that we did not perform a subgroup analysis to assess the effect of previous clinical experience with pelvic floor examination on the primary and secondary outcome measures. despite these limitations, all participants' perceived comfort level improved with training, and they found the training program can be implemented into their clinical practice. in the future, we aim to conduct a study that will compare the longterm knowledge retention between these two methods of teaching pelvic pain. these results will support whether video-based training can also produce long-term results. future studies should also seek to create validated assessment instruments that can be used to compare different methods of teaching that allow for greater generalizability. testing whether a combination of in-person and video-based training produces best results is also an important question to investigate. overall, our study supports the use of video-based training for pelvic floor myalgia and acknowledges its various strengths, including improved access to education and ability to disseminate knowledge worldwide and reach most rural and low-resource areas where in-person training may be less accessible [7] . the current pelvic floor myalgia workshop is also cost-effective, since the video is available online on the iuga fig. 5 mean osce scores before and after training in both groups (maximum score was 30) fig. 4 mean written assessment scores before and after training in both groups (maximum score was 30) academy, obgyn academy, and youtube websites (https://obgynacademy.com/chronic-pelvic-pain/). the authors also designed a "guide to the assessment of the pelvic floor musculature," which are cards with the anatomy of the pelvic floor and step-by-step instructions of the assessment. healthcare providers of all levels of expertise can use the video to acquire or maintain skills at their convenience using a mobile device. this is especially useful when in-person training is not feasible, such as during the covid-19 pandemic, thus creating effective online means of knowledge dissemination is particularly important. through this research the end goal is to disseminate knowledge to enhance care of women suffering from chronic pelvic pain through provider education. this study demonstrates that learners' assessment of pelvic floor musculature can be enhanced using varied teaching methods on a pelvic model. however, there was no statistically significant difference between video-based and in-person teaching methods in degree of improvement of participants' performance and perceived comfort level with examination of the pelvic floor musculature. participants reported the training program to be applicable towards their clinical practice. a standard for terminology in chronic pelvic pain syndromes: a report from the chronic pelvic pain working group of the international continence society pelvic pain in urogynecology. part 1: evaluation, definitions and diagnosis recognizing myofascial pelvic pain in the female patient with chronic pelvic pain pelvic floor muscle examination in female chronic pelvic pain myofascial pelvic pain high-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students pelvic examinations by medical students a randomized controlled trial of birth simulation for medical students realism and construct validity of novel pelvic models of common gynecologic conditions a randomized comparison of video demonstration versus hands-on training of medical students for vacuum delivery using objective structured assessment of technical skills (osats) objective structured assessment of technical skills evaluation of theoretical compared with hands-on training of shoulder dystocia management: a randomized controlled trial objective structured assessment of technical skills (osats) evaluation of theoretical versus hands-on training of vaginal breech delivery management: a randomized trial hands-on simulation versus traditional videolearning in teaching microsurgery technique the effect of bench model fidelity on endourological skills: a randomized controlled study comparing hands-on and video training for postpartum hemorrhage management measurement of health status. ascertaining the minimal clinically important difference control an evaluation of the "5 minute medicine" video podcast series compared to conventional medical resources for the internal medicine clerkship twelve tips for the effective use of videos in medical education demonstrating procedures with video the use of mental practice in pelvic examination instruction medical students learning the pelvic examination: comparison of outcome in terms of skills between a professional patient and a clinical patient model cost-effective analysis of teaching pelvic examination skills using gynaecology teaching associates (gtas) compared with manikin models (the ceat study) prior presentations: video (1) august 2019-international urogynecological association (iuga) academy-the training program selected as the monthly e-lecture. workshop: (1) march 2019-society of obstetricians and gynecologists of canada (sogc) west/central cme (lake louise, ab, canada) canadian society for the advancement of gynecologic excellence (cansage4) (ottawa, on, canada) international pelvic pain society (ipps) annual scientific meeting publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements we thank the dilawri simulation centre at the regina general hospital and marie-josée forget at total pelvic health for providing the pelvic models. conflict of interest the authors declare that they have no conflict of interest. key: cord-330666-puhijixa authors: carrico, ruth m.; coty, mary b.; goss, linda k.; lajoie, andrew s. title: changing health care worker behavior in relation to respiratory disease transmission with a novel training approach that uses biosimulation date: 2007-02-02 journal: am j infect control doi: 10.1016/j.ajic.2005.12.013 sha: doc_id: 330666 cord_uid: puhijixa background: this pilot study was conducted to determine whether supplementing standard classroom training methods regarding respiratory disease transmission with a visual demonstration could improve the use of personal protective equipment among emergency department nurses. methods: participants included 20 emergency department registered nurses randomized into 2 groups: control and intervention. the intervention group received supplemental training using the visual demonstration of respiratory particle dispersion. both groups were then observed throughout their work shifts as they provided care during january-march 2005. results: participants who received supplemental visual training correctly utilized personal protective equipment statistically more often than did participants who received only the standard classroom training. conclusion: supplementing the standard training methods with a visual demonstration can improve the use of personal protective equipment during care of patients exhibiting respiratory symptoms. health care personnel are at risk for exposure to a variety of infections during the routine performance of their job responsibilities. despite these risks, compliance with protective equipment has remained suboptimal. 1 the safety of emergency department (ed) personnel, often the first to encounter an ill patient, is an important area to target for improvement. the risk factors for those individuals include the emergent nature of the care provided and the unknown circumstances that initially led to the patient's utilization of health care. 2 despite the emphasis on standard precautions training for health care workers (hcws), the consistent use of personal protective equipment (ppe) remains poor. 3, 4 various descriptions and analyses of the 2002-2003 severe acute respiratory syndrome (sars) outbreak reported lack of basic preemptive infection prevention and control strategies. as the outbreak grew, attention was paid to use of protective equipment, including respiratory protection, as symptomatic patients were identified. the experiences of hcws confronted with suspected or confirmed sars cases revealed an often inadequate and incorrect use of ppe. 5, 6 a fundamental flaw in the preventive process seemed to involve failure to recognize quickly the key signs, symptoms, or risks that might have led to the early implementation of protective equipment. although there is little research concerning changing hcw behavior when providing care for patients with respiratory illness, there was some evidence from the sars outbreak that pointed toward the benefits of training programs and availability of adequate ppe. 7 the workplace practices identified as problematic during the sars epidemic mirror those identified by jagger et al at the international healthcare worker safety center of the university of virginia. jagger et al's work has focused on injuries and exposures involving blood and body fluid exposures among hcws. in 2001, as part of the epinet surveillance program, 8 a total of 463 blood-body-fluid exposures were reported from 49 participating health care facilities. of these exposures, over 13% occurred in the ed. less than 10% of the exposed hcws reported wearing appropriate eye protection, and fewer than 20% reported wearing some sort of mask or other facial barrier. 9 clearly, the need still exists for effective training techniques to promote the use of ppe as a way to minimize such workplace exposures. traditional infection prevention and control training for hcws has involved a review of the occupational safety and health administration (osha) bloodborne pathogens training, 10 as outlined in the current centers for disease control and prevention (cdc) isolation guidelines, 11 with emphasis on transmission-based precautions. when we conducted an informal telephone interview with infection control professionals (icps) from 10 us hospitals chosen at random, results indicated that this type of training involved a classroom setting (80%) and/or written handouts (20%). a pretest and posttest process typically assessed competency. none of the interviewed hospitals reported the consistent inclusion of an observational component in their training or subsequent assessments. much of the existing research and education involves exposures to bloodborne pathogens; very little involves respiratory pathogens. the research does, however, enforce the concepts of disease transmission and identifies the lack of consistent protective activities used by health care personnel. [1] [2] [3] [4] the risks involved in respiratory pathogen transmission have been included in the concept of ''cough etiquette'' outlined in the draft version of the impending cdc draft guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings, 2004. 12 it is important to identify innovative methods that will impact practice and result in procedural changes that will better protect the care provider. developing new methods that can change the behavior and increase the appropriate use of ppe is a challenge. this pilot study evaluated a novel training approach for hcws to use ppe when encountering patients who have known or suspected respiratory illnesses. the training approach involved the use of a human patient biosimulator to visually demonstrate respiratory disease transmission. the effectiveness of the visual demonstration was assessed by comparing the ppe-specific knowledge, attitudes, and skills of ed registered nurses (rns) who received the demonstration to those who only received the standard disease transmission training. the study hypotheses were as follows: (1) the standard disease transmission training will result in an increase in knowledge among rns, and (2) the additional use of a visual demonstration would result in significant improvement in appropriate ppe use among hcw beyond the improvement produced by the standard training methods. this pilot project involved the use of the patient biosimulator (medical education technologies, inc. [meti], sarasota, fl) to demonstrate particle dispersal during a cough. when the biosimulator ''coughed,'' fluorescent powder was dispersed into the air, allowing the study subject to visualize the impact to themselves and the environment. the study subjects were able to see the particles move directly from the patient to the air and contaminate the environment as well as the subject's physical person (fig 1) . the effectiveness of ppe was demonstrated using a black light that showed areas of fluorescent powder contamination and areas in which ppe provided a barrier, thereby preventing contamination. we used pre-/posttest knowledge assessments and observations of hcw-patient interactions to evaluate the impact of the visual demonstration of respiratory disease transmission on ppe use by hcws. the study was conducted during the peak of the 2005 influenza season (january to march) to ensure that the hcws could be observed interacting with the greatest number of patients with respiratory symptoms. the study was conducted at a university medical center in a large metropolitan city. training sessions and observations took place in the ed. initially, 22 rns were recruited into the study; 2 subjects withdrew from the study following job transfers. an effort was made to recruit an equal number of day shift (7 am to 7 pm) and night shift (7 pm to 7 am) nurses into the study. the university hospital institutional review board approved the study. eligible rns were identified by the ed nurse manager and were informed of the study during scheduled staff meetings and by posted flyers. eligible rns were those nurses who were employed by the hospital; therefore, mobile or per diem nurses were excluded. during the staff meetings, the investigators provided a brief overview of the study, answered questions, and determined staff members' willingness and eligibility to participate in the study. the rns who agreed to participate were provided with a consent form to sign. after the consent form was signed, all subjects were scheduled to attend classroom training. this training focused on mechanisms of disease transmission, standard precautions, and appropriate use of ppe. the 20 subjects were randomly assigned to either the intervention group or the control group. the intervention group received classroom training plus biosimulated visual training, and the control group received classroom training only. after group assignments were made, a colored sticker was placed on the subjects' identification badges to indicate participation in the study. observers with experience in the education and training of health care personnel were trained to recognize and evaluate the use of ppe by study participants during real patient interaction. the observers were blinded to the subjects' group assignment. a work schedule was provided to the observers to allow equal opportunity for evaluation on both shifts throughout the observation period. the study was designed to continue until a minimum of 10 patient-subject interactions were observed for each study participant or until the ed activity indicated that the presentation of symptomatic patients had declined to a point that observation opportunities were minimal. personal handheld computers were used for data entry by the observers. the investigators developed software, and training was provided to the observers. use of the handheld data collection device allowed the observers to collect and record information in an unobtrusive manner and minimize data entry errors. written scenarios and monitoring of real-time nursepatient interactions were observed in an effort to promote interrater reliability between the 2 observers. the 2 observers participated in specific education and evaluation sessions held prior to the study, during the study, and after completion of the study. sessions were held with both observers together as well as separately. scenarios were presented to determine the ability of each observer to identify the care setting (eg, triage, assessment) specific types of ppe (eg, mask vs n95 respirator), and symptoms exhibited by the patient (eg, temperature readings, cough, rhinitis). during all reviews, both observers consistently demonstrated 100% accuracy. data were collected at 3 points in time: (1) participants completed a knowledge assessment prior to the classroom training. the pretest phase included an assessment of subject's knowledge of respiratory pathogen transmission as well as standard precautions; (2) once classroom training was completed, the subjects retook the knowledge assessment; and (3) observations began after the posttest had occurred. observations of the subjects' use of ppe were made in the weeks immediately following the completion of training. a patient-subject interaction was considered appropriate for study inclusion if the observers noted that the patient exhibited respiratory symptoms (ie, cough and/or fever). if the patient-subject interaction was appropriate, the observers evaluated the subject's behavior with regard to ppe use. the observers also recorded the patient's symptoms, the time and location of the care, and the care that was being provided. type of care provided was coded as triage, physical assessment, invasive procedure, noninvasive procedure, and resuscitation event. knowledge related to respiratory pathogen transmission and standard precautions guidelines were measured by a questionnaire developed for this study. evaluations of the patient-subject interaction by the 2 trained observers included the date/time of observation, presenting diagnosis, procedure(s) performed during the observation episode, presence of respiratory symptoms, patient cooperation as related to each procedure, and a list of all ppe items used or worn by the observed hcw. the opportunity for the observer to make special comments that may impact the use of ppe (eg, if the patient is masked during the observation episode) was included in the data collection form. table 1 . the 2 groups were found to be similar on most demographic variables. the age range was 23 to 56 years with a mean age of 38 years. the 2 groups were primarily female (95%), with slightly less than half (48%) having a college or graduate degree (bachelor's degree or master's degree in nursing). both the intervention group and the control group completed standard classroom training designed to provide text-based information about disease transmission. the preclassroom training knowledge assessment indicated no difference between the intervention and control groups (t(19) = 1.11, p = .28). the average pretest score was .67 (sd = .12) for the control group and .62 (sd = .09) for the intervention group. the 2 groups also did not differ significantly on the postclassroom training assessment (t(19) = 1.22, p = .24). the average posttest score for the control group was .81 (sd = .17) and .72 (sd = .18) for the intervention group. combining the scores of both groups yielded a pretest score of .64 (sd = .11) and a posttest score of .76 (sd = .17). overall, both groups showed a a total of 114 observations were recorded: 56 for the control group and 58 for the intervention group. of these, 35 involved more than 1 observation on a single patient. in an effort to ensure independent observations, 1 observation was randomly selected from each patient to be included in the final data set. this was done to prevent multiple observations of a single patient for whom ppe was used or not used during each patient interaction. in the final dataset, there were 84 observations, with 42 in each group. cough, fever, rhinitis, and/or sneezing were considered conditions in which ppe was required. the intervention group did not differ significantly from the control group on the proportion of patients with symptoms requiring ppe use (86% vs 93%, respectively, [fisher exact test, p = .16]). table 2 shows the breakdown of protective equipment used by study participants stratified by group. interestingly, rns in both groups routinely elected to place masks on the patients instead of on themselves. a mask, used on the rn and/or the patient, was considered to be appropriate ppe when the patient condition included fever, cough, sneeze, and/or rhinitis. self-use of a mask did not differ between the control and intervention groups (fisher exact test, p = .60). although use of a mask on the patient occurred more frequently in the intervention group, it was not significant (fisher exact test, p = .08). upon analysis of data, the practice of nurses masking patients was an unexpected finding. it was then decided to aggregate self and patient mask use into a single dichotomous variable: ppe mask use. when use of ppe (self-use of mask and placement of mask on patient) was dichotomized into ''yes'' or ''no'' and was cross-tabulated with group assignment, analysis comparing use of ppe between control and intervention groups indicated that subjects who received the visual training demonstrated use of ppe more often (74% vs 53%, respectively). given the exploratory nature of the study and the unidirectional hypothesis that the visual demonstration would improve ppe use, statistical significance for this hypothesis was evaluated as a 1-tailed distribution test (a = .05). a fisher exact test was performed to determine whether the visual demonstration increased appropriate ppe use relative to the standard training alone. results are shown in table 3 and indicate that the standard training plus biosimulation significantly increased the use of ppe for patients with respiratory symptoms (p = .04). the literature that addresses ppe use among hcws continues to stress the need for education as a means of improving safety practices. [1] [2] [3] [4] [5] [6] [7] this study showed, however, that traditional education is not necessarily the sole or even key factor in improving ppe use. two basic components were addressed in this pilot project. the first involved the increase in knowledge regarding disease transmission using a traditional didactic training process. the second component investigated whether a biosimulated, visual demonstration of particulate transmission would result in increased ppe use. traditional classroom training did, indeed, make a significant difference in pre-and posttraining knowledge. the addition of a visual component to training emphasized the personal risk of the individual hcw. direct observations showed that the subjects trained using this visual approach appropriately used ppe more often than those subjects whose training did not include this visual component: 74% versus 53%, respectively. therefore, these results suggest that use of the biosimulator and visual training is an important new approach for learning in the health care setting. this type of learning allowed the hcw to see the impact of disease transmission as opposed to simply hearing about it through traditional didactic education. in addition, the components of this visual demonstration built on the principles of adult learning. teaching occurred within the context of work experience, thereby making the learning relevant to the individual. feedback from the subjects in the intervention group reinforced the value of the visual component of training. several staff commented that they recognized environmental or personal contamination when they could see the blood or other fluids they encounter during emergency procedures but admitted that their use of protective strategies, including ppe, was less than ideal. every subject trained in the intervention group remarked on the impact they felt the visual demonstration had on their individual practice. the major limitation of this pilot study was the small size of the sample. although many results demonstrated significance, the question remains whether or not the results are generalizable. repeating this study on a larger scale could help answer that question. the logistics involved in unobtrusively observing practice and working around nurses who were not involved in the study made planning and implementation a difficult task. another issue of concern was our inability to ascertain the influence of the organization on the use of safety practices, including use and selection of ppe. if this study were repeated and involved multiple sites, the culture of safety and its impact could be assessed. with the availability of inexpensive computer technology in recent years, simulation technology has blossomed, especially in the field of medicine, in which applications range from scientific modeling to clinical performance appraisal in the setting of crisis management. much of the initial work with human patient biosimulators, or use of a simulation ''dummy,'' has been done by anesthesiologists as part of their road toward medical error reduction. biosimulators are now used in university medical centers across the country to assist and improve the learning of residents, medical students, nursing students, and employed hcws. the benefits of simulation technology in medical training include improvements in cardiovascular examination skills, increased precision in surgical technical skills, and acquisition and retention of knowledge compared with traditional modes of teaching (eg, lectures). [13] [14] [15] [16] [17] [18] although there has been significant knowledge and experience gained through simulation in the area of medical education, there has been a lack of research concerning the use of simulation as a method of enhancing performance involving respiratory disease transmission. developing an improved model for training hcws that demonstrates a significant improvement in behavior regarding ppe use has the potential to protect the millions of hcws that currently practice in health care settings. reducing the respiratory exposures because of influenza and preventing the repeated scenarios identified during the sars 2003 global epidemic may also prevent the unnecessary illness/deaths of hcw because of inadequate or inappropriate use of respiratory ppe. successful demonstration of improvements could change the way hcw education is conducted throughout a variety of environments, not simply the ed. furthermore, this type of education could be used in other professional disciplines, including physician, therapist, and administrative training. epidemiology and prevention of blood and body fluid exposures among emergency department staff compliance with universal precautions among emergency department personnel: implications for prevention programs risks for exposure to and infection with hiv among health care providers in the emergency department variables influencing worker compliance with universal precautions in the emergency department lack of sars transmission among healthcare workers, united states investigation of a nosocomial outbreak of severe acute respiratory syndrome (sars) in toronto, canada the bc interdisciplinary respiratory protection study group. protecting health care workers from sars and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines occupational safety and health administration. occupational exposure to bloodborne pathogens: final rule. 29 cfr part 1910.1030 guideline for isolation precautions in hospitals. the hospital infection control practices advisory committee cdc cdc draft guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings patient safety and simulation-based medical education simulation technology for health care professional skills training assessment educating health professionals to respond to bioterrorism practical health care simulations recognizing biothreat diseases: realistic training using standardized patients and patient simulators the authors thank the observers, david walsh, bs, and jonathan carrico, bs, for their commitment to the project and attention to excellence and the hospital emergency department staff for their support and participation. the authors have made available to the readers a visual component to this article. readers may visit the following web site to see a brief video clip (there is no sound with this clip): http://www.louisville. edu/television/cough.asx key: cord-297734-rp7eoonp authors: bdaiwi, yamama; rayes, diana; sabouni, ammar; murad, lina; fouad, fouad; zakaria, waseem; hariri, mahmoud; ekzayez, abdelkarim; tarakji, ahmad; abbara, aula title: challenges of providing healthcare worker education and training in protracted conflict: a focus on non-government controlled areas in north west syria date: 2020-07-08 journal: confl health doi: 10.1186/s13031-020-00287-9 sha: doc_id: 297734 cord_uid: rp7eoonp without healthcare workers (hcws), health and humanitarian provision in syria cannot be sustained either now or in the post-conflict phase. the protracted conflict has led to the exodus of more than 70% of the healthcare workforce. those remaining work in dangerous conditions with insufficient resources and a healthcare system that has been decimated by protracted conflict. for many hcws, particularly those in non-government-controlled areas (ngcas) of syria, undergraduate education and postgraduate training has been interrupted with few opportunities to continue. in this manuscript, we explore initiatives present in north west syria at both undergraduate and postgraduate level for physician and non-physician hcws. conclusion: challenges to hcw education in north west syria can be broadly divided into 1. organisational (local healthcare leadership and governance, coordination and collaboration between stakeholders, competition between stakeholders and insufficient funding.) 2. programmatic (lack of accreditation or recognition of qualifications, insufficient physical space for teaching, exodus of faculty affecting teaching and training, prioritisation of physicians over non-physicians, informally trained healthcare workers.) 3. healthcare system related (politicisation of healthcare system, changing healthcare needs of the population, ongoing attacks on healthcare.) locally implementable strategies including dedicated funding are key to supporting retention of hcws and return during post-conflict reconstruction. health workforce planning during conflict and in the post-conflict phase is essential to ensuring sufficient supply of healthcare workers (hcws) of the right cadres and skills to meet the needs of the healthcare system [1] . the education and training of hcws is fundamental to this however it is often neglected or adversely affected by political instability and conflict, particularly those which are complex and protracted such as in syria. syria's conflict began with peaceful uprisings in march 2011 but by mid-2012 escalated into a conflict which has devastated its health system and eroded its healthcare workforce [2] . as of april 2020, more than 923 healthcare workers (hcws) have been killed (mostly by the government of syria and its allies) and more than 70% of hcws have been forced to flee due to violence [3] [4] [5] . this has left those who remain working in an understaffed and underfunded healthcare system which is increasingly fragmented and politicised due to the prolonged conflict. the insufficient numbers of senior faculty has affected training, leadership and governance [5, 6] leaving undergraduates and junior postgraduate staff with inadequate training or mentorship and under conditions which require them to work beyond their training or expertise [5, 6] . the political complexities and ongoing violence with the competing needs of health and humanitarian priorities has also affected healthcare workforce planning with potential consequences during post-conflict reconstruction [7] . healthcare needs of the population increase and change during protracted conflict due to violence, interruption of vaccination campaigns, effects on essential services and poor access to healthcare [2] . this occurs alongside the negative effects on the education and training of hcws which affect the quantity, skills, distribution and quality of hcws who enter the workforce [7, 8] . in syria, the conflict has exacerbated existing preconflict geographical inequalities in healthcare access; aleppo, homs, idlib, dera'a, rural damascus and deir ez-zor have the lowest numbers of doctors per population [9] . poor healthcare planning and ongoing violence have led to uncontrolled and largely unregulated expansion of private providers contributing to poorly planned, uneven distribution of health and medical services among geographical regions [10] . a population based survey that was performed in government and nongovernment controlled areas by the syrian centre for policy research noted that 31% of the population lived in areas where hcws were insufficient and 27% live in areas where hcws are completely absent [5] . there are no accurate estimates of the number, distribution and specialities of syrian hcws who remain in syria and population mobility is such that estimates are quickly out of date. in 2018, the world bank estimated the number of doctors per 1000 population in syria to be 0.3 with a significant decrease from 2010 when it was 1.5 [9] . for nurses and midwives, the estimated decrease between 2010 and 2018 is from 1.4 to 0.6 per 1000 population [9] . in north west syria, an area which has seen large scale population movements and increasing violence has an upper estimate of 1000 doctors (615 are hospitalists) for its 4.17 million population; there are up to 358 midwives, 1693 nurses and 709 community health workers [11] . it is important to note, however, that these estimates may be an overrepresentation of actual hcws that exist given the lack of official registration and risk of double-counting hcws who work in multiple facilities. healthcare workforce management in syria is challenged by the fragmented healthcare system which has different health and political leadership across the country [2, 8] . broadly, this includes areas under government control, north east syria (under de facto kurdish control), north west syria (under opposition control) and areas in northern syria which are under turkish control [12] . this affects national as well as regional healthcare workforce planning and affects the education and training of undergraduate hcws across the country but particularly those in areas outside of government control with some students who oppose the government in these areas intimidated or arrested [13, 14] . areas outside of government control are also affected by an absence of universities whose degrees are accredited or recognised by international bodies [15] . due to particular challenges arising in north west syria with regards to the healthcare system, healthcare workforce and the potential to highlight illustrative factors relevant to hcw education and training during conflict, we have focused on this area [16] . during the course of the conflict, this area has developed a complex healthcare system where syrian-led initiatives, syrian nongovernmental organisations (ngos,) international ngos and international organisations (e.g. who, un) have provided cross-border health and humanitarian care; this has been mostly coordinated through the who-led health cluster in gaziantep, turkey [17] . some of these organisations have also provided education or training to support the healthcare workforce on whom they draw on for staffing projects and healthcare facilities in north west syria [17] . as of may 2020, it describes an area which includes idlib, north west hama, northern aleppo and north eastern lattakia governorates [18] . this area has seen a further escalation of violence in february 2019 and then again between december 2019 and march 2020 when almost 1 million civilians were forcibly displaced from their homes, including many hcws [19] . access to undergraduate hcw education and postgraduate training differs across geographical parts of syria, particularly given the varying effects of the conflict across the country, the presence of an academic workforce, governing bodies, opportunities for continued training, accreditation, leadership, and specialization. data from inside syria is sparse as the situation has been rapidly changing with limited information about what undergraduate education or postgraduate training is available to hcws in different areas in syria. this is particularly the case for areas outside of government control, where volatile conditions and poor access for humanitarian agencies and researchers limits the ability to gather reliable, real-time information [5] . therefore, in this manuscript, we explore current initiatives present in the north west of syria at both the undergraduate and postgraduate level for physician and non-physician hcws and the challenges faced in providing undergraduate education and postgraduate training during the conflict. this is with the aim of exploring the current provisions of hcw education and training and providing some comparisons to other conflict or postconflict settings. we conducted a desk-based literature review of available academic and grey literature which explore the undergraduate education and postgraduate training of healthcare workers including both formal and informal initiatives. we searched the websites of ngos (non-governmental organisations) which are known to provide education opportunities to hcws. we supplemented this with brief interviews to solicit clarifications from relevant stakeholders based within syria and neighbouring countries to ensure that available material was up to date and to supplement what was found through the literature search. we also used notes from a meeting in gaziantep where syrian and international ngos met to discuss hcw education in the summer of 2018. the interviews were not conducted as a formal qualitative research study; as such ethics review was not indicated. for the purposes of this manuscript, the term nonphysician hcws is used to describe allied health professionals including physiotherapists, nurses, specialist nurses (e.g. neonatal, dialysis,) pharmacists, midwives, dentists, paramedics and emergency or anaesthetic technicians; the term physician hcw refers to doctors. we have used 'education' to refer to undergraduate education and 'training' to refer to postgraduate or speciality training for both physician and non-physician hcws. the activities of the main public sector, private sector, ngos and international organisations which support undergraduate and postgraduate hcw education and training are summarised in table 1 . before the conflict, syria had five public universities with faculties of medicine: damascus university, university of aleppo, al-baath university (homs), al-furat university (deir ez-zor), and tishreen university (latakia) [20] . (see fig. 1 ) studies were delivered in arabic. the structure of courses include basic medical sciences during the first 3 years with clinical modules in years 4 and 5 and clinical rotations in year 6 [21] . aleppo university was the main university in the north west and was the second largest university in syria. it had a number of faculties including medicine, pharmacy, dentistry and nursing. the university ran six hospitals in aleppo including aleppo university hospital, aleppo university cardiovascular surgical centre, surgical ambulance hospital, obstetrics and gynaecology hospital, oral and maxillofacial surgical centre and al-kindi hospital. universities and undergraduate students have not been spared the effects of the conflict. the university of aleppo was bombed on 15th january 2013, killing 82 people including students in an aerial attack [22] . al-kindi university hospital (affiliated to aleppo university) was destroyed by bombing [23] . the increased security threats, including bombardments, detention and torture, pushed many students to give up their studies and flee either out of the country or to ngcas. some of the most affected were those near the end of their degrees with little option to transfer to other universities inside syria given security concerns including the risk of arrest by the gos if they were thought to oppose the government or to have studied at 'opposition institutions.' [13, 14] for students and academic staff who remained in the ngcas, some were able to continue their studies/lecturing in underground classrooms but others had to suspend their studies/academic career and contribute to humanitarian and healthcare provision to civilians affected by the conflict [13, 24] . some were killed either during attacks on universities or during the course of the war [4] . as a result of the protracted conflict, targeting of healthcare and demand for trained hcws in north west syria, new faculties and institutes have been established in attempts to meet the education and training needs of physician and non-physician hcws. established facilities include three public faculties of medicine and three faculties of pharmacy at the free aleppo university (fau), idlib university and shahba university; the latter was established in dana to cover areas that are geographically far from idlib university's main campuses. there are six newly established healthcare institutes, three of which are still operating as of october 2019 (termanin institute, the medical sciences academy in qah, and idlib university institute) covering nursing and midwifery training, and three had been closed after repeated attacks (kafr sijneh institute, birnas institute, and maarat alnuman institute). (personal communication) none currently have official recognition or accreditation for their degrees. the demand from potential students and from potential employers has resulted in an economy around hcw education. this led to the founding of two private universities in north west syria: ebla university which was operating until 2018 but closed after repeated attacks and the north syria private university which is still operating. other private universities provide health-related degrees and established either before or after the conflict; some have continued to function while others have closes as they struggled to meet required standards set [25] . in this section, we discuss public universities, private universities and ngo-led undergraduate initiatives available in north west syria in more detail. the main public universities in the north west are the fau and the university of idlib. the fau was founded as an alternative to universities in gcas in december 2015 by the ministry of higher education of the syrian interim government and has since been contested in northeast idlib by the rival opposition government, the syrian salvation government [25, 26] . they provide degrees in a number of subjects including medicine, engineering and mathematics, however, there is no formal recognition or accreditation for these outside of ngcas [25] . it is estimated that there are 5200 students in the 2018/2019 academic year, enrolled with campuses across the ngcas. in the 2018/19 academic year, a second public university called shabha university (previously known as nahda university) was established; it is associated with the higher education council and has been established in buildings that previously belonged to the fau. it is in al-dana and has branches in sarmada and atareb [25] . the university of idlib is associated with the syrian salvation government and was formed in late 2017 [25] . it uses the infrastructure and the buildings which previously belonged to the idlib campus of the university of aleppo. it currently has 13,553 students across 16 faculties including faculties of medicine and dentistry; numbers increase to 15,000 students once the medical and dental students in maarat al-numan are included [25] . the faculty of medicine is listed in the world directory of medical education however it has yet to receive international recognition [27] . the war has contributed to the necessity for and a trade in the provision of private healthcare education and training in north west syria. however, these are often poorly regulated with little standardization or governance and have been more challenging for the local health directorates to regulate. they charge approximately 1000 usd per year and some provide options for distance-learning in addition to on-campus training. examples of some of these universities include: al-shamal private university which was set up with the merger of 'oxford university of syria' and the university of rumah; the 'oxford university of syria' was opened as a branch of the yemeni oxford university which is recognised by the yemeni ministry of education and the arab league [25] . other private universities include mari university (established in 2015 in mersin;) osmania university (established in istanbul in 2016, is a branch of the university of malaysia, and has recognition in yemen;) al-hayat university of medical sciences (established in maarat al-numaan in 2016 with disciplines in nursing, midwifery, physiotherapy and anaesthesiology.) [28] some of these universities faced internal administrative, financial and governance challenges which affected their credibility and caused some to close. in addition, the syrian salvation government has tried to enforce registration, permits and affiliation with it driving some private universities to close their doors [25] . iii. non-governmental organisation led undergraduate initiatives due to insufficient supply of hcws and increased demand as well as the recognised need to fill the gaps left by public and private universities, some diaspora ngos, often in conjunction with international organisations or universities have set up both undergraduate and postgraduate training initiatives to bridge gaps. these include undergraduate and postgraduate training, short courses, cme (continuous medical education), skillsbased training and is aimed at physician and nonphysician hcws. many educational and training opportunities have been created in response to the operational needs of the ngos as well as the health and humanitarian needs of the population. though ngos have provided in-service training in other conflict or postconflict settings [7] the extent to which this has been required to meet the needs in north west syria has been more extensive and more sustained. some international ngos e.g. medecins sans frontieres have recognised the need for structured training for its local hcws and have set up an academy for healthcare in 2017 to support hcws in areas where they work [29] . a full review of the courses provided by ngos is beyond the scope of this article, however some examples are given here. the syrian american medical society (sams,) a us-registered humanitarian organisation, continues to support two training programs for midwives at al salam obstetric centre in idlib. one is a 3-year training program where undergraduate enrolment occurs after high school and the other is an 18-month conversion course taken by qualified postgraduate nurses; there are currently 30 students in the former who will graduate in february 2021 [30] . they also support nursing education which started as 6-9 month courses in idlib, homs and deraa. in 2017, they received funding to develop a two-year undergraduate nursing program in termanin in idlib; there are currently 53 first-and second-year students in general nursing and 11 in public health. in december 2018, 46 students graduated from the sams nursing program [30] . most recently, a collaboration between sams and the idlib health directorate resulted in the successful examination of 38 student midwives in maarat al-nu'man and omar bin abdul-aziz in termanin [31] . a uk-registered ngo called hand in hand for aid and development trained 205 healthcare workers (doctors, nurses, nursing assistants, midwives) in 2017 as part of their livelihood program [28] . the syrian expatriate medical association (sema) provides training through its academy of health sciences [32] ; in 2018, sema trained 65 nurses, 43 paramedics and 20 physiotherapists through 2 year diplomas [32] . they also provide online lectures for the students. though these initiatives fill an important gap and can be responsive to local needs, the courses provided by ngos are not accredited or recognised outside the area however they do provide students with skills and opportunities to work with ngos in north west syria. these initiatives may be poorly coordinated, donor or ngo driven which could lead to duplication or gaps with little opportunity to standardise or provide quality assurance. this is being addressed by the local health directorates to ensure fair access to potential students and improved coordination. postgraduate speciality training for physicians is provided the ministry of higher education or the ministry of health however, in opposition areas, this would fall under the remit of the local health directorates. to fill this gap, syrian led initiatives have been established. the most prominent of these in north west syria is sboms (syrian board of medical specialties) which was set up mid-2015 with the aim of providing certification for the completion of speciality training after review of applicants' experience and success at standardised examinations. it is affiliated to the ministry of health of syrian interim government (sig) [18] and works in coordination with health directorates in idlib, aleppo, and hama to expand postgraduate and speciality opportunities for hcws inside syria, based on projected healthcare system needs. sboms was set up as an independent legal and financial identity but is yet to be registered. they have 23 scientific committees (consisting of specialists who remain in syria and expatriate syrian doctors in the diaspora) who provide support for post-graduate training, examination and certification in a number of specialties including internal medicine, general surgery, vascular surgery, paediatric surgery, orthopaedic surgery, urology, paediatrics, cardiothoracic, obstetrics and gynaecology, ent, ophthalmology, anaesthesia and intensive care, maxillofacial surgery, neurosurgery, and psychiatry. though sboms has initially focused on physicians, they plan to expand to non-physician postgraduate training. training is between 4 years (e.g. internal medicine, paediatrics) and 6 years (e.g. neurosurgery). so far, they have supported the training of 423 residents. in 2018, sboms successfully collaborated with the health directorates to support haematology and oncology specialty training for doctors in these governorates [33] . the need for short updates which are focused on building the capacity of hcws to meet the immediate needs of the population and the ngos' operational strategies has led predominantly syrian ngos to provide short updates for qualified hcws. some have been funded through private funds whereas others have been provided with funding from international ngos or international organisations. most of the training has been delivered by syrian expatriate ngos (predominantly sams, sema, uossm, hihaid, syria relief, syrian relief and development) either in syria (in training centers in idlib or bab al-hawa on the syria-turkey border,) in turkey (in gaziantep, reyhanli or yayladag) or via tele-education. courses provided range between 2 and 3 day updates on particular topics e.g. intensive care, general practice, microbiology, paediatrics to longer postgraduate courses which lead to certification; these include training for midwives, healthcare assistances, nurses, anaesthetic and dialysis technicians [32, 34] . other initiatives have utilised expatriate syrian experts or international trainers to deliver sessions or have developed collaborations for tele-education e.g. with yale university, the university of albany in the us, however many of these have not been sustained [35, 36] . other providers including who have focused on training syrian hcws in particular topics such as infection prevention and control, post-surgical infections and mental health gap action programme (mhgap) [37] . unfpa has supported a midwifery capacity building program began started a training-the-trainers program over 6 month periods during 2017 and 2018 with three sessions in gaziantep and coaching during and after, in addition to certificates issued by unfpa to accredit the trainees to be trainers in syria [38] . in september 2019, the idlib health directorate celebrated the conclusion of the unfpa reproductive health training program, awarding 100 female reproductive health trainees with certificates indicating the success of their training, supervised by the unfpa and the health cluster [39] . though numerous training courses for hcws have been held, there has been limited coordination, standardization or quality control for the training provided. idlib health directorate has tried to address this through the appointment of a focal point whose role is to coordinate and prioritize topics for training courses for hcws from idlib and to liaise with providers. (personal communication) training opportunities have also recently been hampered by the escalation of attacks in the north west since february 2019 as well as greater difficulties for syrian hcws to obtain turkish permits to cross the syrian-turkish border in order to attend training in southern turkey over the last 4 years [40] . the opening of training centres in idlib (one in 2017 and one in september 2019) may support further opportunities for the education of hcws however the entry of foreign experts to idlib via turkey will be limited given ongoing security concerns and border closures due to the ongoing covid-19 pandemic. as such, increasing use of tele-education is being put in place to deliver remote education. in syria, tele-education has been used with mixed success with challenges including logistics and cost, consistent expertise outside of syria, connectivity and, in the case of clinical skills, the benefits that in-person training would provide. blended modes of learning e.g. teleeducation with some in-person training or contact time if possible may be the best approach to ensure relevant theoretical and practical skills are introduced. given current insufficient numbers of educators among the healthcare workforce in north west syria, more efforts to capitalise on available technologies which support the education of hcws is needed. tele-education has been used in other conflict and post-conflict settings including iraq, gaza [41, 42] , bosnia and herzegovina [43] ; some of these have been collaborations with international universities e.g. mayo clinic, queen mary university in london and have usually focused on a single topic e.g. burns care, intensive care education. further work to provide sustained and evaluated courses is needed to meet the training needs of hcws in north west syria. despite the clear need for a skilled workforce of sufficient number and training to meet the current and future demands of north west syria's complex healthcare system, the provision of hcw education and training remains fragmented, politicised and uncoordinated. hcws continue to face numerous obstacles, including ongoing interruptions to education and training, lack of access to advanced specialty training and professional development opportunities of sufficient quality and which are accredited and recognised outside of the area. providing relevant opportunities can improve retention of hcws and may support return of those who have been forced to flee, promoting long-term peacebuilding efforts [44] . as such, focused and realistic strategies which include key stakeholders and which are led and coordinated by local governing bodies (health directorates) could improve opportunities for hcw education and training in north west syria. this could have positive consequences on the local healthcare system including the retention or return of hcws, and the overall reconstruction of the syrian healthcare system. challenges to hcw education in north west syria can be broadly divided into 1. organisational (local healthcare leadership and governance, coordination and collaboration between stakeholders, competition between stakeholders and insufficient funding.) 2. programmatic (lack of accreditation or recognition of qualifications, insufficient physical space for teaching, exodus of faculty affecting teaching and training, prioritisation of physicians over non-physicians, informally trained healthcare workers.) 3. healthcare system related (politicisation of healthcare system, changing healthcare needs of the population, ongoing attacks on healthcare.) similar challenges have been highlighted in other conflict affected contexts including iraq [45] and gaza [46] where politics, economics and inability to recruit educators have been noted. in gaza, an additional challenge highlighted is the disorganised post-graduate programs with limited continuing professional development; this has been cited to be a factor contributing to low morale among doctors [46] . figure 2 summarises key challenges in north west syria and their relationship to providers and recipients of hcw education. some of the key challenges are explored in more detail below. educational governance in north west syria has been challenging though public institutions and an increasing number of the ngo led initiatives have monitoring and evaluation programs in place [30, 32] . however, there remains a lack of oversight or a standardised approach with ngos often answerable to their funders to a greater extent than local governing bodies. for private led initiatives, regulation has proven particularly challenging [25] . idlib health directorate has led a number of initiatives to address issues surrounding educational governance and have developed a central database of the healthcare workforce including skill-mix and training gaps, coordinated capacity building initiatives across health facilities, identified physical spaces where training can occur and have supported programs which meet the needs of the healthcare workforce. sboms has taken a leading role in postgraduate training and certification (with support from diaspora syrian hcws) to provide standardisation to specialty training; for internal medicine postgraduate specialty training, a diaspora ngo (sams) provided a stipend and training for doctors as a financial incentive to allow them to work and provide much needed healthcare for the local population while training. however, similar initiatives and the work of sboms and the idlib health directorate are met with funding constraints which affect sustainability and planning. the funding shortfall for health and humanitarian provision to north west syria is large with very limited financial resources available for hcw education and training. for example, donor funds have been redirected from local health directorates to the who to implement and oversee hcw educational programs, weakening the role and influence of local health directorates [47] . this can partly be addressed by a dedicated funding stream for hcw education and training and for funders to allow some project funds to be allocated to education and training. though undergraduate degree programs are provided in north west syria, they are unrecognised outside of the local area and the programs do not have accreditation. a number of attempts have been made to address this however none have so far been successful; this may present challenges for the graduates. a similar challenge occurred during the balkan conflict with the consequences for the hcw both during and after the conflict [48] . after 1989, many albanians lost their jobs leaving them without insurance; as a result, albanian health professionals set up a parallel primary healthcare system. albanian doctors and nurses, who were unable to study in their own language in pristina university were trained through this parallel health system during the 1990s [48] . however, though the 600 doctors and 1200 nurses who graduated from this system may have had sufficient theoretical knowledge (clinical training was harder to obtain), this mode of training left a generation of albanian doctors and nurses with unrecognised qualifications, subsequently affecting their ability to work [48] . as such, a similar scenario in north west syria, could leave thousands of hcws in north west syria with certificates or degrees which are not recognised outside of the region limited their career prospects; this could affect retention of hcws who may seek opportunities elsewhere though, conversely, it may support the retention of some hcws who are unable to leave the local healthcare system as a result. a group of hcws who have received little attention are those who have gained training in healthcare informally. these may be students who left their degrees due to the conflict but continued to work in hospitals or clinics or those who began providing healthcare to injured civilians and gained 'on the job' training particularly where there were shortages of trained hcws. they are disadvantaged even compared to those whose degrees or qualifications are unrecognised or unaccredited. due to the protracted nature of the conflict, many, particularly those who are wanted by the government, may have left syria to complete their studies elsewhere but others may have continued to work in the local health system gaining experience and attending courses providing by syrian ngos. according to uossm 2015's hospital surveillance, 36% of the 696 nurses working in the north west fell into this category and there is concern as to what their role will be post-conflict as they have not participated in recognised training programs [49] . however, with the role of newly established institutes, the idlib health directorate reports that this percentage is declining. (personal communication.) one of the roles of sboms has been to review this 'on the job' training in collaboration with the health directorates in north west syria with a view to identifying those who can receive credit for this. physicians in syria are highly respected and are often community leaders; during the course of the syrian conflict, many have established health or humanitarian ngos or taken leadership positions. this, together with the more standardised pathways for physician training, may have contributed to greater opportunities for physician compared to non-physicians hcws in north west syria. subsequently, the insufficient numbers of hcws in the area, have led to the recognition that increased focus on non-physicians hcws or on skill substitution (the transfer of tasks normally performed by doctors to other health professionals with different skills or levels of training) as potential solutions [50] . skill substitution (formerly task shifting) has been discussed by the who and world medical association for some years and has an important future role in both high-and low-income countries as well as in humanitarian crises to reduce costs and meet the needs of the population [50] . in north west syria, skill substitution has already occurred in some contexts; for example, specialised dialysis nurses had been taking the roles of renal specialists to oversee the estimated 500 dialysis patients managed by syrian diaspora ngos in the north west; this was done with the support of the single remaining renal physician and a team of expatriate renal physicians providing training and advice. (personal communication) however, as yet, the acceptability of skill substitution to syrian patients amongst syrian hcws as one of the solutions has not been fully explored. this is particularly the case as proposed models which may be suited to other conflict affected settings, may not be as acceptable to the local population in syria due to the heavily medicalised and specialist model of the health system before the war [10] . locally acceptable solutions are therefore urgently required given the massive skill and number shortage of hcws which is likely to persist for some years [7, 44] . local and international political developments have a number of effects on hcw education and training. syria's health system is increasingly fragmented and politicised; in north west syria, there are shifts in groups who control the area and their influence over local institutions [26] . for example, when the syrian salvation government took control of idlib and parts of the western countryside of aleppo, it insisted that local educational institutions be affiliated to it; this led some institutions to close and others to relocate. classes were interrupted and students staged sit-ins and called for politics to remain separate from education [26] . (see fig. 3 ). political influences are noted in other conflict affected contexts in gaza, iraq and the balkans [46, 48] . hcws also face challenges crossing check points to attend training, examinations or to participate in educational activities in government controlled areas; reports of questioning and arbitrary arrests are widespread [14] . any affiliation with a ngca institution has been considered criminal by the government of syria. as such, when the government of syria reclaimed aleppo, students burned their books and study materials to avoid being linked to one of the opposition-led universities which would result in arrest [14] . students and faculty in government controlled areas would be stopped at university fig. 3 free aleppo university graffiti in arabic which reads 'keep education separate from politics' and is dated 8th january 2018. photo credit to free aleppo university or hospital checkpoints, questioned and sometimes arrested without charge. these individuals were arrested by security forces that had set up offices within university campuses, hospitals, or by appointed student members of the syrian student union. the offices of the student union were sometimes used as temporary detention centres for arrested students and faculty, and there have been documented instances of arrested hcw student and faculty being tortured in these offices before being taken to security force centres. some of those arrested later died under torture [51] . the response to hcw education and training in north west syria has seen an important shift in the humanitarian system whereby local and diaspora led initiatives including from ngos have identified critical gaps in hcw education and training and sought to meet them [30, 32, 34] . though this has occurred in other conflict affected settings e.g. gaza, iraq, balkans, the extent to which these organisations have responded to the needs in north west syria and their sustained attempts to meet critical gaps and to replace previous educational institutions and accreditation bodies has been more extensive than seen in previous conflicts [41, 42, 48] . this may represent a shift change in the humanitarian system whereby hcw education (with regulation/ certification/ accreditation) is prioritised alongside other key sectoral needs, particularly for complex and protracted crises such as syria. this could draw on the experience of international organisations or ngos e.g. medicins sans frontieres [29] with lessons learned in syria informing these discussions. while this manuscript focuses on north west syria, students in faculties of medicine or other health sciences in other areas of syria, including government-controlled areas have also suffered the effects of the conflict. students in government-controlled areas who could safely remain were able to complete their studies with a change in the regulations. students were allowed to fail up to 6 or even 8 classes of the 12 required [13] . students from al-baath, aleppo and al-furat could attend classes at safer campuses with thousands of students able to transfer to damascus or latakia universities. after the national hospital of homs was destroyed, agreements were made to allow students to take clinical placements at private hospitals. due to these exceptions, standardized final examinations were introduced for medicine, dentistry, pharmaceutical studies and nursing (as well as informatics engineering.) [13, 21] 1. syria's protracted conflict has decimated its health system and led to a profound shortage of healthcare workers of sufficient number and skills, exacerbating pre-existing geographical inequalities. 2. both physician and non-physician healthcare worker undergraduate and post-graduate training has been affected across the whole of syria but the impact has been greatest in areas outside of government controlled, particularly in north west syria. 3. free aleppo university and idlib university and shabha university are the main public universities which provide undergraduate medical and pharmacy education in north west syria however they lack sufficient funds and faculty to support quality and sustainability. 4. there has been an unregulated growth in the number of private universities which provide undergraduate physician and nonphysician healthcare worker education. 5. unusually in a humanitarian response, non-governmental organisations have stepped in to provide some undergraduate courses as well as shorter, postgraduate continuous medical education opportunities for healthcare workers however this has been uncoordinated and unsustained. 6. there remains a gap in post-graduate physician training though organisations like the syrian board of medical specialties provide some opportunities though they are affected by poor funding and insufficient numbers of faculty with the specialties required. 7. challenges can be broadly divided into 1. organisational 2. programmatic and 3. healthcare system related 1. develop a locally driven healthcare worker education strategy for north west syria which is developed in close collaboration with key local and international stakeholders and which could lead to the formation of a consortium focused on healthcare worker education. 2. ensure dedicated funding streams for healthcare worker education which are multi-year and accessed through the consortium is the ideal but may be not be feasible; however, allowing funding as part of grants could allow dedicated funds for healthcare worker education. 3. develop relevant governance and regulatory structures which standardise the minimum quality of public and private educational establishments which deliver healthcare worker education. 4. develop strategic partnerships with international institutions which could support accredited and recognized courses for physician and non-physician healthcare workers in north west syria. this could be supported with more developed tele-education interventions. 5. increase focus on non-physician healthcare workers and skill substitution (task shifting) is required to ensure a healthcare workforce of sufficient skill and specialty to meet gaps. 6. conduct regular reviews of initiatives which have or have not been effective (e.g. quality, cost) in providing physician and non-physician healthcare worker education is needed to inform future initiatives. 7. continue to advocate for the protection of all health workers and healthcare provision in conflict, which is essential for the continuation of work and training without fear of attack. there are important topics which influence any discussion around the training of hcws in syria which have not been explored in this manuscript. these include the changing health needs of syria's population where there is a high burden of non-communicable diseases, conflict-related disability and a traumatised population [52]; the severe psychosocial stresses experienced by the hcws both first-hand and as secondary trauma [44, 52, 53] ; and the weaponization and destruction of healthcare in syria [5, 54, 55] which affects hcws' ability to focus on their own education and training needs. table 2 summarizes some of the key messages from this manuscript together with broad recommendations for the future. these recommendations need to be developed further with on the ground actors to ensure they are locally practicable and, given resource constraints, prioritized. challenges faced in delivering hcw education and training will affect the numbers, skills and distribution of hcws in north west syria both now and in the postconflict phase. improved coordination by all stakeholders with a medium and longer-term strategy that is implementable in the current context is needed. this requires sufficient and sustained investment from multilateral organizations, such as the un, and international donors. the situation in north west syria shares some similarities but also important differences in terms of hcw education and training during conflict. as such, lessons can be learned from the syrian context with opportunities to support earlier adoption of innovations e.g. tele-education, skill-substitution for both ongoing and future conflict-affected contexts and ensure robust leadership and governance. the need for this has been further underlined by the covid-19 pandemic which has highlighted the need for a robust healthcare workforce and healthcare systems which can effectively meet the needs of the response. lastly, we highlight that efforts in education and training for hcws without protection as stipulated under international humanitarian law are futile. world health organization. guide to health workforce development in post-conflict environments. world health organization health workers and the weaponisation of health care in syria: a preliminary inquiry for the lancet -american university of beirut commission on syria medical personnel are targeted in syria a map of attacks on health care in syria. physicians for human rights. the destruction of hospitals -a strategic component in regime military offensives health workers and the weaponisation of health care in syria: a preliminary inquiry for the lancet american university of beirut commission on syria. heal policy 2516 www strengthening human resources for health: integration of refugees into host community health systems human resource management in postconflict health systems: 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un officials urge unity in security council | un news humanitarian catastrophe for civilians in northwest syria geneva foundation for medical education and research. medical schools, governments, ministries, medical associations : syria specialty preference and intentions to study abroad of syrian medical students during the crisis this is what it looks like when syria bombs a university -the atlantic aleppo's largest hospital in rebel-held area is "destroyed" | world news | sky news syria's lost generation of doctors universities of north syria: future hindered by crises -enab baladi a power struggle over education emerges between rival opposition governments in idlib province -syria direct. https:// syriadirect.org/news/a-power-struggle-over-education-emerges-betweenrival-opposition-governments-in-idlib-province world directory of medical schools child and adolescent health in northwestern syria: findings from healthy-syria 2017 study conducting a colliculum exam for students of midwifery institutes | idlib health directorate specialties-sboms-announces-the-general-rating-of-students-foradmission-to-blood-and-tumors-specialties in the midst of war, future syrian doctors trained with help from yale faculty, students | yale school of public health ualbany online science courses for refugee syria medical students training creates more support for vulnerable people in syria accessed 22 quality midwifery care in the midst of crisis: midwifery capacity building strategy for northern syria the conclusion of the activity of medical education center to train reproductive health providers. | idlib health directorate accessed 23 london calling gaza: the role of international collaborations in the globalisation of postgraduate burn care education using tele-education to train civilian physicians in an area of active conflict: certifying iraqi physicians in pediatric advanced life support from the united states impact of weekly case-based teleeducation on quality of care in a limited resource medical intensive care unit protecting healthcare in syria impact of conflict on medical education: a cross-sectional survey of students and institutions in iraq medical education in palestine losing their last refuge inside idlib's humanitarian nightmare a case study of health sector reform in kosovo wma resolution on task shifting from the medical profession -wma qualitative accounts from syrian health professionals regarding violations of the right to health, including the use of chemical weapons, in opposition-held syria international failure in northwest syria: humanitarian health catastrophe demands action publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations thank you to dr. abdullah suleiman terkawi (syrian expatriate medical association, us) and the syrian health professionals in syria and turkey who contributed valuable information. authors' contributions aa conceptualised, wrote the first draft and revised subsequent drafts. yb, as, dr conducted searches and interviews with key stakeholders. yb, dr, as, ae, lm revised and made significant contributions to subsequent drafts. ff, wk, mh, ae, tk revised drafts, contributed information and clarifications. no funding was sought directly for this work however as is partly funded by the academic foundation program of hull york medical school; the salaries of ff and ae are partially funded through the uk research and innovation gcrf research for health in conflict in the middle east and north africa (r4hc-mena) project; developing capability, partnerships and research in the middle and north africa es/p010962/1. wz is employed by sboms (syrian board of medical specialties) and receives a salary. dr is partly funded by elrha/ research for health in humanitarian crisis. there is no extra available data other than that which is quoted and referenced in the text.ethics approval and consent to participate no ethics approval or consent was required for this work. all authors have reviewed and provide consent for publication. author details key: cord-340930-5cavkdde authors: cheung, victor kai-lam; so, eric hang-kwong; ng, george wing-yiu; so, cc sze-sze; hung, jeff leung-kit; chia, nam-hung title: investigating effects of healthcare simulation on personal strengths and organizational impacts for healthcare workers during covid-19 pandemic: a cross-sectional study date: 2020-07-16 journal: integr med res doi: 10.1016/j.imr.2020.100476 sha: doc_id: 340930 cord_uid: 5cavkdde introduction: this cross-sectional study aimed at evaluating impacts of healthcare simulation training, either in-situ or lab-based, on personal strengths of healthcare workers (hcws) and organizational outcomes during the covid-19 pandemic. methods: covid-19 taskforce was established to formulate standardized scenario-based simulation training materials in late-january 2020. post-training questionnaires made up of 5-point likert scales were distributed to all participants to evaluate their personal strengths, in terms of i) assertiveness, ii) mental preparedness, iii) self-efficacy, iv) internal locus of control, and v) internal locus of responsibility. independent sample t-tests were used to analyze between-group difference in “in-situ” and “lab-based” group; and one-sample t-tests were used to compare change in personal strengths with reference point of 3 (neutral). kirkpatrick’s model served as the analytical framework for overall training effects. results: between 05 february and 18 march 2020, 101 sessions of simulation training were conducted in “in-situ” at either accident & emergency department (20, 20%) or intensive care unit (15, 14%) and “lab-based” for isolation (30, 30%) and general wards (36, 36%). 1,415 hospital staff members, including 1,167 nurses (82%), 163 doctors (12%) and 85 patient care assistants (6%), were trained. all domains of personal strengths were scored 4.24 or above and statistically significantly increased when comparing with reference population (p < .001). however, no significant differences between in-situ and lab-based simulation were found (p > .05), for all domains of personal strengths. conclusion: healthcare simulation training enhanced healthcare workers’ personal strengths critical to operational and clinical outcomes during the covid-19 pandemic. 2 1. introduction a novel coronavirus (aka "covid-19" or "sars-cov-2"), initially emerged in wuhan hubei province in december 2019. at the end of the year, the wuhan municipal health commission reported that 27 unknown pneumonia cases had exposure to the huanan seafood wholesales market. on 20 january 2020, prof. zhong nanshan, head of the health commission, affirmed that two pneumonia cases in gongdong were infected through human-to-human transmission. on 23 january 2020, the first imported case from the mainland china was admitted to queen elizabeth hospital (qeh) in hong kong special administrative region (hksar). flashbacks of severe acute respiratory syndrome (sars) were still vivid. hksar occupied over 1-fifth of sars cases (1755/8096), with 0.77 increased risk ratio of case fatality rate (cfr) among 29 countries in 2003. 1, 2 of 386 local healthcare workers (hcws) infected, 3 public and 2 private hospital medical officers, 1 nurse and 3 healthcare assistants have sacrificed their lives to safeguard public safety of hong kong during the epidemic. 3, 4 in the concurrent battle with covid-19, local hcws' safety and health conditions, physically and mentally, have been taken into consideration. except more stringent infection control measures within hospital compounds, simulation training could be a hope for filling the knowledge gap and safeguarding psychological health and safety of hcws. 5-9 healthcare simulation training replicates any clinical scenarios in a safe environment, bridging between immersive experience, acquired skills, and insights from the training and clinical practice. 5 not only had technical (e.g., cognitive and psychomotor skills in donning and doffing procedures of personal protective equipment (ppe) in designated clean and dirty zone with buddy system) and non-technical skills (e.g., teamwork, leadership and communication among hcws) enhanced, 7, 8, 10 simulation training, either "lab-based" in simulation training center or "in-situ" in genuine clinical environment with highest environmental fidelity, could strengthen personal qualities critical in healthcare industries. 3, 6, 10, 11 li and colleagues, 12 through a recent british medical journal (bmj) editorial paper, highlighted escalating needs of exploring simulation training effects on healthcare providers themselves rather than existing findings over-emphasizing scientific values of clinical, epidemiological, and laboratory characteristics, infection and transmission dynamics, and effect of pharmacological interventions. through the lens of positive psychology, we explored specific personal strengths of hcws associated with personal, organizational, and community safety, including: (1) assertiveness ---speak-up behavior, 13 (2) mental preparedness ---psychological capacity to response in high risk conditions towards resilience, 14 (3) self-efficacy ---capacity to execute task-oriented behavior with self-confidence, 15 (4) internal locus of control ---belief of clinical outcomes influenced by their action, not by chance 16 (5) internal locus of responsibility ---self-motivated morality for patient care. 17 this crisis served as a precious opportunity for our center to explore i) whether in-situ simulation would j o u r n a l p r e -p r o o f 3 outweigh lab-based simulation in rating of personal strengths and ii) how simulation training brought prosperity to the society in hong kong. recommendations regarding effective management approach of simulation training will be discussed as a wrap-up of this article. multi-disciplinary simulation and skills centre (mdssc), based in qeh, has been continuously improving quality and safety of hospital service through healthcare simulation. fully accredited by the society of simulation in healthcare (ssih), our center is dedicated to facilitating innovations and exploring new frontiers in simulation-based learning and research. back in the late-january 2020, covid-19 taskforce was established under the leadership of high management and well-rounded support from administrative and clinical departments for the strategic direction and curriculum design on infection control training. the aim of this taskforce was to, through simulation training, unify and standardize hospital-wide practice and procedures to minimize contamination by and exposure to highly contagious covid-19 pathogens during high risk procedures, such as aerosol generating procedure (agp) and endotracheal intubation. after a trial finalizing training materials and scenario setting, the first training class titled "infectious disease practice drill and refresher training (novel coronavirus)" was organized in early february 2020 (see supplement 1). to comply with infection control guidelines of hospital authority, healthcare workers (hcws) in high-risk areas for suspected or confirmed cases of covid-19 was required to attend this training. target participants included anesthesiologists, accident and emergency (a&e) physicians and nurses, intensivists, medical physicians, surgeons, nurses and healthcare assistants from isolation wards, a&e, intensive care unit (icu), and general surgical and medical wards. any projects initiated by high management of hospital authority for education purposes are waived from ethical approval by the research ethics committee (rec) of the hospital authority in hong kong. therefore, ethical approval was not required for this study. in line with the mdssc standard operation procedures (sop), all participants were required to complete a written informed consent on confidentiality issues and use of data, including but not limited to course evaluation, questionnaire, formal and informal feedback in written or verbal format, formative or summative assessment approved by respective steering committee, and audio-visual recording, for internal audit, education and research purposes prior to commencement of training sessions. by the end of training sessions, one set of validated questionnaires was distributed to each participant to evaluate training effect. 18 each item was measured on a 5-point likert scale ranging from 1 "strongly disagree" to 5 "strongly agree". the questionnaire, with excellent inter-item reliability (cronbach's α = .96), was categorized into 5 domains of personal strengths: i) assertiveness, ii) mental preparedness, iii) self-efficacy, iv) j o u r n a l p r e -p r o o f 4 internal locus of control, and v) internal locus of responsibility. to examine the study hypothesis, participants were stratified into two groups: i) in-situ and ii) lab-based. independent sample t-tests were used for between-group comparison of population means of different pairs of personal strengths. one-sample t-tests were used to compare overall score of personal strengths with reference point of 3 for the general population of hcws. all levels of alpha were set at .05 (two-tailed). the data were analyzed using ibm spss statistics (version 25.0, ibm corp., 2017). kirkpatrick's model has been widely adopted to evaluate training processes and effects at different levels in healthcare and business setting. 19 with further advancement by philips, 20 of 101 sessions carried out from 05 february 2020 to 18 march 2020, 1-third of simulation classes was held in-situ at respective departments (naed = 20; nicu = 14) and 2-thirds was operated in our simulation lab (nisolation_ward = 30; ngeneral_ward = 36). within this period under intense time and resources constraint, 1,415 hospital staff members, including 1,167 nurses (82%), 163 doctors (12%) and 85 patient care assistants (6%), were trained (see table 1 ). retrieved from training record, we acknowledged that participants were largely satisfied with the training program and learning objectives were met (see fig. 1 on volunteer basis, 1,200 out of 1,415 participants completed the questionnaire (response rate = 85%). all domains of personal strengths, in terms of assertiveness, mental preparedness, self-efficacy, internal locus of control and responsibility, were scored 4.24 or above out of 5 (excellent). equal variance assumptions were examined and confirmed (p>.05, for all domains) by levene's tests before data processing with t-tests. regarding between-group comparison of in-situ and lab-based results, no significant differences were found (p>.05) for all domains. to compare participants' post-training scores with reference point, statistically significant differences were found (p<.001) for all domains (see table 2 ). figure 1 in summary, this cross-sectional study showed that covid-19 specific healthcare simulation training programs, both in-situ and lab-based, enhanced personal strengths of hcws, in terms of assertiveness, mental preparedness, self-efficacy, internal locus of control and internal locus of responsibility, to a large extent. since there were lacking in scientific investigation into relevant aspects of covid-19 for the time being, we expand our discussion to clinical and organization impacts and strategic management approaches we used aligned with evidence-based medicine. the lessons we learned from sars strengthened hcws' resilience and preparedness of the covid-19 pandemic. dr. nguyen and colleagues 21 from massachusetts general hospital and harvard medical school reported that multivariate-adjusted hazard ratio (ahr) of covid-19 was 11.5 times higher in hcws in the uk; increased 4.45 times than those in the usa; and additively increased by 400% for those managing confirmed patients of covid-19. 21 as of 10 june 2020, no hcw was infected with covid-19; 1,054 out of 1,107 infected patients were discharged from local public hospitals in hong kong. such magnificent figures reflected painstaking efforts of all stakeholders in local healthcare industry during the unprecedented crisis. assertiveness is one of the non-technical elements in crew resources management (crm) which has been embedded into our scenario-based training. 7, 8, 10 the training provided participants with immersive experience in revisiting proper donning/ doffing procedures of ppe and team-based management of agp with clear role delineation. throughout the training, "speak-up" culture formed in error-provoking environment could literally speed up participants' learning process, resulting in readiness and self-confidence to handle suspected and confirmed cases of covid-19 in clinical setting. 5, 8 uncertainty of the pathogens and fear of infection and death were detrimental to occupational health conditions of hcws. 6, 14, 21 in addition to placebo-effect, debriefing sessions helped hcws consolidate their understanding of the pathogens and pertaining practice with "take-home message" as trump card for maximizing hcws' sense of control and responsibility for patient care in the covid-19 pandemic. 8 effective management strategies and validation of training materials are essential drivers of successful healthcare simulation training programs: (1) doctor-nurse ratio ≤ 1:5, addressing that nurses had greater training needs and were relatively prone to stress and fatigue 22 (2) prioritizing training needs by" high-risk area first" policy (isolation ward first, general ward the next) icu staff, in-situ simulation could achieve the highest degree of environmental fidelity and provide optimal flexibility for trainers and trainees based on their availability. 23 for training of general ward and isolation ward, simulation training center would be much more appropriate for a balance between risk of infection control and occupancy of clinical operation. there was no evidence showing that levels of fidelity in simulation matter in this study. regardless of training setting (in-situ or lab-based simulation), observers involved in scenario-based simulation and subsequent debriefing sessions have gained insights from the scenario and enhanced personal strengths as much as their counterparts who participated directly in the scenarios. 5, 8 moreover, all training materials were reviewed by the taskforce members in multidisciplinary manner; in particular specialists from intensive care team (ict) and quality & safety (q&s) department, to ensure that all training components were aligned with hospital policy, algorithm for standard workflow, and international standards of practice (cdc guideline 24 ; aha bls guideline regarding covid-19 for a&e basic life support training 25 ). the study showed promising evidence of how incorporating scenario-based simulation into infection control measures enhanced skills and knowledge acquisition and personal strengths of hcws. strengthened assertiveness on team collaboration, mental preparedness, self-efficacy under limited resources, internal locus of control and responsibility on designated clinical duty would probably lead to satisfactory clinical and organization outcomes. limited empirical studies in related areas have necessitated researchers further investigating inter-factorial association and their long-term impacts on organization across healthcare disciplines. we expect that person-centered principles and strategic approaches we recommend can be translational worldwide, expediting the return to normalcy in near future. summary of probable sars cases with onset of illness from epidemiology of sars in the 2003 hong kong epidemic factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 chronology of the sars epidemic in hong kong the use of simulation to prepare and improve responses to infectious disease outbreaks like covid-19: practical tips and resources from norway, denmark, and the uk psychological symptoms among frontline healthcare workers during covid-19 outbreak in wuhan covid-19: using simulation and technology-enhanced learning to negotiate and adapt to the ongoing challenges in uk healthcare education anaesthesia simulation training during coronavirus pandemic: an 8 precautions for operating room team members during the covid-19 pandemic a comparative epidemiologic analysis of sars in hong kong, beijing and taiwan preparing and responding to 2019 novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in china evaluating the impact of an assertiveness communication training programme for japanese nursing students: a quasi-experimental study psychological preparedness for the covid-19 pandemic, perspectives from india health-specific self-efficacy scales locus of control and covid-19: the benefits of shifting our internal narrative in times of crisis individual differences and intelligence reinforcing assessment quality with professional standards in sim-training center of public hospital kirkpatrick's four levels of training evaluation return on investment in training and performance improvement programs risk of covid-19 among frontline healthcare workers psychological responses to the sars outbreak in healthcare students in hong kong preparedness for covid-19: in situ simulation to enhance infection control systems in the intensive care unit interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings we would like to express our gratitude to the hospital authority head office (haho) and queen elizabeth hospital (qeh) high management for their operational support to our simulation training; qeh quality & safety (q&s) department for their initiation for workforce establishment; infection control teams the authors declared no conflict of interest. the data of this study are available from the corresponding author on reasonable request. pca 10 (4) key: cord-341720-qwdjb7vk authors: jukic, igor; calleja-gonzález, julio; cos, francesc; cuzzolin, francesco; olmo, jesús; terrados, nicolas; njaradi, nenad; sassi, roberto; requena, bernardo; milanovic, luka; krakan, ivan; chatzichristos, kostas; alcaraz, pedro e. title: strategies and solutions for team sports athletes in isolation due to covid-19 date: 2020-04-24 journal: sports (basel) doi: 10.3390/sports8040056 sha: doc_id: 341720 cord_uid: qwdjb7vk in december of 2019, there was an outbreak of a severe acute respiratory syndrome caused by the coronavirus 2 (sars-cov-2 or covid-19) in china. the virus rapidly spread into the whole world causing an unprecedented pandemic and forcing governments to impose a global quarantine, entering an extreme unknown situation. the organizational consequences of quarantine/isolation are: absence of organized training and competition, lack of communication among athletes and coaches, inability to move freely, lack of adequate sunlight exposure, inappropriate training conditions. based on the current scientific, we strongly recommend encouraging the athlete to reset their mindset to understand quarantine as an opportunity for development, organizing appropriate guidance, educating and encourage athletes to apply appropriate preventive behavior and hygiene measures to promote immunity and ensuring good living isolation conditions. the athlete’s living space should be equipped with cardio and resistance training equipment (portable bicycle or rowing ergometer). some forms of body mass resistance circuit-based training could promote aerobic adaptation. sports skills training should be organized based on the athlete’s needs. personalized conditioning training should be carried out with emphasis on neuromuscular performance. athletes should also be educated about nutrition (vitamin d and proteins) and hydration. strategies should be developed to control body composition. mental fatigue should be anticipated and mental controlled. adequate methods of recovery should be provided. daily monitoring should be established. this is an ideal situation in which to rethink personal life, understanding the situation, that can be promoted in these difficult times that affect practically the whole world. in december of 2019, there was an outbreak of a severe acute respiratory syndrome caused by the coronavirus 2 (sars-cov-2 or covid19) in wuhan, hubei province, china. the virus rapidly spread across the country and then into the whole world [1] , causing an unprecedented pandemic [2], forcing governments to impose an almost global quarantine. at the beginning of 2020 (january-march), the whole world, including the world of sports, entered an extreme and unknown situation [2], where, gradually, all sports competitions were postponed and any organized training or practice was banned [3] . the health of the athletes, coaches and spectators became a priority. the major local and international competitions, such as the european football championship and the olympic games in tokyo, were postponed for a year. this unusual global crisis has caused a major organizational, financial and social disruption to athletes, coaches, clubs and sports federations. all teams have allowed their athletes to return home, where they are in mandatory home isolation following government guidelines. isolation, of course, does not allow athletes to follow their usual training and competition schedule. regardless of duration, isolation could have a significant impact on the physical and mental state of an athlete. however, to the best of our knowledge, no previous evidence on this particular topic has been published. the organizational consequences of quarantine/isolation are: absence of organized training and competition, lack of adequate communication between athletes and coaches, inability to move freely, lack of adequate sunlight exposure, inappropriate training conditions [4, 5] . staying in quarantine can have negative effects, not only on most physiological systems, but also in the players' lives. for example, isolation at home can lead to poor and inappropriate nutrition, poor quality of sleep, addictions, loneliness, just to name a few negative lifestyle changes. the physiological adverse effects of isolation include an increase in body fat content and a decrease in muscle mass, impaired immunity, loss of mental sharpness and toughness, insomnia and depression [4, 6] . all of these consequences can have both a short-and long-term negative effect on the athletes' physical fitness and competitive performance. although it is difficult to predict the duration of the global covid-19 crisis at this time, it is possible to predict the loss of training-induced adaptation [7] [8] [9] [10] [11] . therefore, first, it is extremely important to identify these effects and to understand the mechanisms and effects on all physiological systems, as well as their impact on athletic performance. second, but no less important, it's important to provide practical recommendations to coaches and athletes to reduce the unwanted consequences of the forced quarantine. the principle of training reversibility states that stop or markedly reduce training induces a partial or complete reversal of the previous developed adaptations, thus compromising athletic performance [12] . the reversibility principle is also known as detraining. the concept of detraining refers to the total or partial loss of the training-induced adaptation achieved through training [10] . although athletes experience transition periods throughout their sports careers, usually coinciding with the end of their competition period, illness, injury, or other factors, the loss of physical activity is not comparable to the restriction that the current "stay at home" confinement represents. however, detraining is one of the biggest negative consequences of the forced quarantine. detraining affects different physiological systems (e.g., neuromuscular, cardiovascular, respiratory or muscle-skeletal) and their corresponding physical capacities (e.g., strength and power, endurance, speed or flexibility). although some investigations have concluded that neural changes are long-lasting and did not affect the elements of h-reflex pathways [13] , there is strong evidence to think the opposite. for example, it was reported that neuromuscular performance was impaired in top-level male kayakers after 5 weeks of either reduced training or complete training cessation [14] . a recent systematic review [15] revealed that the concurrent (ct) training-induced gains may be compromised with a short-term detraining period (2-4 weeks), leading to a return to baseline values. the authors also explained that a 4-week period of training cessation after ct with different resistances or aerobic training loads compromised training-induced gains in young men. they concluded that, despite scarce evidence, it seemed that regardless of the intensity of the previous endurance and resistance training during ct, only 2-4 weeks of training cessation can cause a significant and marked loss of performance. to date, the most used ct method is resistance circuit-based training (rcbt) [16] . rcbt is an effective training method for the concurrent development of maximum oxygen consumption (vo 2max ) and one repetition maximum (1-rm) bench press in healthy adults, independent of participant and load characteristics, as shown in the authors' review and meta-analysis [16] . therefore, some forms of home-based rcbt could easily be performed with simple equipment at home and promote both neuromuscular and metabolic adaptations, thus minimizing neuromuscular detraining effects [17] . reductions in maximal and submaximal exercise performance occur within weeks after the cessation of training. these losses in aerobic performance decline cardiovascular function and muscle metabolic potential. specifically, significant reductions in vo 2max have been described within 2 to 4 weeks of detraining [18] . the detraining effects were mainly: (1) an initial rapid decline in vo 2max ; (2) decrease in blood volume; (3) changes in cardiac hypertrophy; (4) decrease in the total hemoglobin content; (5) decreased skeletal muscle capillarization; and (6) disruption of temperature regulation. when absence of training continued beyond 2 to 4 weeks [18] , the detraining effects became more severe. this results in: (1) further declines in vo 2max ; (2) reductions in maximal arterial-venous (mixed) oxygen difference; (3) changes in maximal oxygen delivery, which may result from decreases in total hemoglobin content and/or maximal muscle blood flow and vascular conductance; (4) declines in skeletal muscle oxidative enzyme activity; and (5) reductions in submaximal exercise performance, which may be related to changes in the mean transit time of blood flow through the active muscle and/or the thermoregulatory response (i.e., degree of thermal strain) to exercise. therefore, athletes must incorporate some type of endurance exercise their daily routine to try and reverse some of the aforementioned effects of detraining. flexibility is the ability to move a joint through its optimal range of motion. the ability to move a joint without restriction or pain depends on the condition of different structures, such as bone, muscle, and connective tissue. it also depends on the muscle's ability to produce an adequate amount of force [19] . decreases in flexibility have been reported after 8 weeks of detraining [20] . given that the current isolation period could be longer than a month, it is recommended to incorporate exercises to maintain and improve flexibility. for example, neurodynamic treatments [21] or tai chi, ioga or thai chi may be a useful therapy for vestibular rehabilitation, improving dynamic balance control and flexibility [22] . short-term detraining may specifically affect eccentric strength and the size of the type ii (ft: fast twitch) muscle fibers [23] . it has been suggested that performing eccentric muscle actions during training is essential to promote greater and longer-lasting neural adaptations to training [24] and that speed-strength is better maintained during periods of reduced training if previously the focus of training was on power development [25] . loturco et al. [26] concluded that it may be important for coaches to include plyometric training, even in detraining periods, in order to avoid possible impairments in the stretch-shortening function [26] . this simple advice could help in maintaining/improving all the neuromuscular indices relevant to athletes' performance and could constitute the basis of an ideal detraining strategy in sports like track and field [26] . reduced or complete absence of strength training can cause loss of muscle mass. muscle atrophy results from an imbalance between protein degradation and synthesis in favor of the former [27] . when inactivity exceeds 4 weeks, there is a transition of ft fibers into type i (st: slow twitch), especially in sports, characterized by explosive actions, with the ft being more vulnerable to periods of inactivity than the st type [28] . although when training periods do not exceed two weeks, the changes in the distribution of muscle fibers are not noticeable in long distance runners or in strength and power athletes [10] , after the first 15 days, there is a decrease in the transverse fibrillar area of approximately 0.6% per day [29] . this decrease in muscle size translates to a 7% and 12% reduction in strength and team sports athletes, after a period of inactivity ranging from 8 to 12 weeks. a decrease in ft fiber content has been observed in footballers and weightlifters [30] and a decrease in the ability to apply force to the water in swimmers [18] . similarly, some fibrillar conversion of fta fibers to ftx fibers has been observed in long-distance runners and cyclists [10] . periods of prolonged inactivity negatively affect the anti-gravitational muscle groups and the posterior extensor muscle chain [31] . in general, inactivity affects different muscles and muscle chains depending on whether they are tonic or phasic, causing muscle shortening and/or hypertonia or laxity and/or hypotonia depending on the muscle type (figure 1 ). these imbalances can be the onset or worsening of pathologies such as groin pain [32] . other authors hypothesized that inactivity also caused a decrease in collagen synthesis in the human tendon, with progressive decreases in collagen synthesis being recorded between 10 and 21 days of complete inactivity [33] . periods of prolonged inactivity negatively affect the anti-gravitational muscle groups and the posterior extensor muscle chain [31] . in general, inactivity affects different muscles and muscle chains depending on whether they are tonic or phasic, causing muscle shortening and/or hypertonia or laxity and/or hypotonia depending on the muscle type (figure 1 ). these imbalances can be the onset or worsening of pathologies such as groin pain [32] . other authors hypothesized that inactivity also caused a decrease in collagen synthesis in the human tendon, with progressive decreases in collagen synthesis being recorded between 10 and 21 days of complete inactivity [33] . fundamental characteristics of the tonic and phasic muscles, as well as the main physiological adaptations to pathology or inactivity. characteristics and habitual response of the tonic and phasic muscles (cos and cos, 1999) . reducation in activity results in a reduced energy expenditure, which consequently requires a reduction in energy intake to prevent unwanted body fat gains. in terms of an absolute amount of protein per day, when increasing protein to 2.3 g/kg, body mass reduces muscle loss during periods of reduce caloric intake [34] . thus, athletes may benefit from increasing their protein intake to counter the immobilization-induced anabolic resistance, as well as to attenuate the associated losses in muscle mass [35] . it is accepted that when reducing energy intake, macronutrients should not be cut evenly, as maintaining a high-protein intake will be essential to attenuate loss in lean muscle mass. for instance, leucine consumption, which is a key and critical amino acid for stimulating the cell signaling pathways that control muscle protein synthesis, should be emphasized in the protein sources consumed [36] . a major consideration when training athletes in home isolation is compliance, especially regarding the intensity and volume of exercise. it is difficult to monitor and ensure that the load that athletes use at home is appropriate to maintain physical fitness and performance at the required level. for recreational and ordinary people in isolation, maintaining an acceptable level of physical fitness is possible with moderate exercise [37] , but high-level athletes need precise exercise prescription. maintaining a high level of physical and mental fitness requires relatively high loads of submaximal and maximal intensity exercise [38] . because of the lack of appropriate space (e.g., a football field) and the subsequent inability to perform sport-specific and/or high-intensity exercises, such as sprints, athletes returning to sport after the quarantine must be aware of an increased chance of injury. reducation in activity results in a reduced energy expenditure, which consequently requires a reduction in energy intake to prevent unwanted body fat gains. in terms of an absolute amount of protein per day, when increasing protein to 2.3 g/kg, body mass reduces muscle loss during periods of reduce caloric intake [34] . thus, athletes may benefit from increasing their protein intake to counter the immobilization-induced anabolic resistance, as well as to attenuate the associated losses in muscle mass [35] . it is accepted that when reducing energy intake, macronutrients should not be cut evenly, as maintaining a high-protein intake will be essential to attenuate loss in lean muscle mass. for instance, leucine consumption, which is a key and critical amino acid for stimulating the cell signaling pathways that control muscle protein synthesis, should be emphasized in the protein sources consumed [36] . a major consideration when training athletes in home isolation is compliance, especially regarding the intensity and volume of exercise. it is difficult to monitor and ensure that the load that athletes use at home is appropriate to maintain physical fitness and performance at the required level. for recreational and ordinary people in isolation, maintaining an acceptable level of physical fitness is possible with moderate exercise [37] , but high-level athletes need precise exercise prescription. maintaining a high level of physical and mental fitness requires relatively high loads of submaximal and maximal intensity exercise [38] . because of the lack of appropriate space (e.g., a football field) and the subsequent inability to perform sport-specific and/or high-intensity exercises, such as sprints, athletes returning to sport after the quarantine must be aware of an increased chance of injury. therefore, sport governing bodies must offer appropriate time to the athletes and teams to prepare for high-level competition. lack of competition poses an additional problem to teams and athletes, because it is through competitions that athletes can best maintain their physical fitness and sport form. competing activities in many sports with a congested competition schedule [39] is also a key factor which is an important developmental stimulus [40] . in addition, preparatory, control and official competitions are an important tool to establish and maintain optimal performance [41] . consequently, the absence of competition has a negative impact on athlete's performance and peak sports form. in spite of everything, some positive effects of isolation should also be kept in mind. in such conditions, the athlete can fully recover from all stresses, injuries and previously accumulated loads (overreaching and overtraining). for example, in team sports there are very few situations in the regular annual calendar in which a player can have a prolonged period of complete recovery from specific training and competition demands. only off-season/transition periods can offer some opportunity for rest [42] . isolation and the absence of intensive specific training and competition enable both complete cellular recovery and the avoidance of common daily mental stress. this is also an opportunity to implement developmental programs of certain physical abilities for which an athlete in team sports does not have enough time under the regular periodization regimen [43] . off-season/transition periods like this exceptional situation are also a rare opportunity to have enough time for extensive injury prevention and individual athletic development work. that work prepares athletes for a rushed pre-re-season, including high-intensity work in wide spaces, and good performance with low injury risk, when the competitions resume. a very similar situation occurs after an athlete suffers a serious injury. those athletes who use rehabilitation as an opportunity for athletic development generally return to competition in a better shape for the rest of the season, which consequently positively affects their future career [44] . in other words, this isolation is an opportunity for both a complete physiological and mental reset as well as for the athlete's integral development. all the previously mentioned training and recovery programs should be strictly personalized [45] . based on the current scientific and practical evidence, we strongly recommend the following points: -encourage, provoke and motivate the athlete to reset their mindset and use this break as an opportunity for personal development [44] ; -organize appropriate guidance and support to athletes by experts (sports coach, strength and conditioning coach, nutritionist, doctor, psychologist) by using technology (video call, e-mail, telephone, text messages); -educate and encourage athletes to apply appropriate preventive behavior and hygiene measures to promote immunity and protect their own health and the health of the people in their immediate environment [6] ; -ensure good living conditions in isolation (space, equipment, food, telecommunications). if possible, the athlete's living space should be equipped with cardio equipment (treadmill, bicycles, rowing ergometer, etc.), resistance training equipment (dumbbells, elastic bands, abdominal wheels, medicine balls, etc.) and other equipment for frequent use (mats, foam rollers, self-massagers, etc.). if not, some forms of body mass resistance circuit-based training could promote (or maintain) neuromuscular and aerobic adaptations [6] ; -organize alternative sports skills training (kinesthetic ball training in a small space, visualization, virtual reality technical aids, video analysis, theoretical training) based on the athlete's deficits and needs; -organize personalized strength and conditioning training at home with available space and material resources that are tailored to the athlete's individual characteristics and current needs [45] . focus on neuromuscular plyometrics (i.e., vertical and horizontal jumping) and eccentric training (i.e., elastic bands), to maintain some key adaptations related to the stretch-shortening cycle, strength and power performance. adaptations of the stabilizer muscles as an indispensable element and facilitator of the efficient sensorimotor action of any act is also extremely important [46, 47] ; -educate the athlete about nutrition, supplementation (especially vitamin d, zinc and proteins) and hydration in isolation conditions, and about strategies to control body mass and body composition [5, 36, 48, 49] . it is important to consume food to fight off viral infections, thus advising against lower carbohydrate/intermittent fasting approaches is likely important [50] ; -organize mental fatigue monitoring and mental training (mental self-help techniques and/or the support of a psychologist by telecommunication) [51] ; -provide adequate methods of recovery (supplementation, sleep, breathing and meditation exercises, self-massage, myofascial relaxation, stretching, low back heat, etc.) [52] ; -use forms of self-assessment (heart rate monitoring, hearth rate variability, hearth rate recovery, orthostatic test, simple movement functional tests, simple vo2max tests, etc.) that an athlete can use on a daily basis and share data with a strength and conditioning coach [53] ; -establish daily monitoring of the athlete's health, wellness, physical fitness, recovery [54] and workload by using technology (phone, applications, e-mail, text message) [55] ; -even though many athletes are not currently injured, the time off is similar to the time off after an injury [56] ; -finally, muscle memory is important to educate athletes, given that any losses are rapidly regained. this should quell some anxiety [57] . to conclude, an athlete's life in isolation due to a covid-19 crisis and imposed quarantine should have another, positive meaning. this is an ideal situation to rethink and reorganize one's personal life and value system. humility, gratitude, understanding of the global situation, empathy for other people, family values, attitude towards knowledge, spirituality, and helping the needy are just some of the values that can be promoted and truly lived in difficult times that affect practically the whole world. as athletes are often role models, in this challenging time they should take responsibility and promote "good values". thus, they can contribute to building better societies and better people and promote better human behavior. covid-19): a perspective from china football cannot restart soon during the covid-19 emergency. a critical perspective from the italian experience and a call for action coronavirus disease (covid-19): the need to maintain regular physical activity while taking precautions vitamin d and the athlete: current perspectives and new challenges covid-19 epidemic: exercise or not to exercise; that is the question! asian in endurance training: science and practice effect of training 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team sport performance: new perspectives brief ideas about evidence-based recovery in team sports the development of a personalized training framework: implementation of emerging technologies for performance evidence-based post-exercise recovery strategies in rugby: a narrative review monitoring the athlete training response: subjective self-reported measures trump commonly used objective measures: a systematic review nutritional support for exercise-induced injuries muscle memory and a new cellular model for muscle atrophy and hypertrophy this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no funding sources. the authors declare no conflict of interest. key: cord-325916-t8feni6a authors: gorozidis, georgios s.; tzioumakis, yannis s.; krommidas, charalambos; papaioannou, athanasios g. title: facebook group petcon (physical education teacher collaborative network). an innovative approach to pe teacher in-service training: a self-determination theory perspective date: 2020-08-20 journal: teach teach educ doi: 10.1016/j.tate.2020.103184 sha: doc_id: 325916 cord_uid: t8feni6a the purpose of the study was the evaluation of a teacher in-service training program, namely “pe.t.co.n.“, an online community of practice via facebook groups. drawing from self-determination theory (sdt), the program aimed at satisfying teachers’ autonomy, competence, and relatedness needs and facilitating their autonomous motivation. pre-post measurements showed significant improvements in key variables that can determine training success. preliminary quantitative group insights supported by qualitative data revealed enhanced participatory dynamics in terms of members’ interaction. findings suggest that pe.t.co.n. is a promising, innovative approach to teacher training. implications are discussed in light of sdt. traditional teacher (and pe teacher) training has been frequently criticized as inadequate and ineffective (e.g., borko, 2004; hardman & marshall, 2008) . on the other hand, communities of practice (cop) may serve as an effective alternative for inservice pe teachers' professional development (e.g., deglau & o'sullivan, 2006; yoon & armour, 2017) and there has been a call for a shift from traditional provision of teacher training to supportive and collaborative "learning partnerships" (wenger-traynor, 2014) such as teacher learning communities (lieberman & miller, 2011) . unfortunately, such collaborative-interactive groups of pe teachers rarely exist. a more contemporary, innovative approach to conventional teacher cop, is to develop online cop which is a very promising perspective in effectively enhancing teacher learning and practical knowledge (baran & cagiltay, 2010; jonassen, howland, marra, & crismond, 2008) . in this line, recent research evidence with samples of pre-service and in-service teachers supports the beneficial role of social networks, such as facebook, for educational purposes and teacher training/professional development (bissessar, 2014; rutherford, 2010; çevik, çelik, & haş laman, 2014) . a key factor for teacher successful in-service training is their motivation to participate in learning situations (gorozidis & papaioannou, 2014; shulman & shulman, 2004; van eekelen, vermunt, & boshuizen, 2006) . recent research in the greek context shows that pe teachers who decide to participate in optional or mandatory in-service training present high levels of self-determination and take part mostly for autonomous rather than for controlled reasons (gorozidis & papaioannou, 2014 . according to self-determination theorization (sdt; , educators would be autonomously motivated when working and training conditions actively contribute to the fulfillment of their innate psychological needs for autonomy (sense of volition/ choice), competence (sense of efficacy/efficiency on what they do) and belongingness/relatedness (sense of being accepted group member). thus, it is expected that the creation of such conditions through online cop, which are teacher initiated, self-regulated and supportive for cooperative social learning, would satisfy teacher needs for autonomy, competence and relatedness thus enhancing their autonomous motivation towards training/learning. research has shown that it is common practice, for teacher training, both in greece and internationally, one or two day seminars, following a top-down approach, organized by relevant stakeholders. this practice is not facilitative to further develop teacher everyday practices. therefore, current teacher professional development programs are often described as poor, inadequate and insufficient by researchers and educators (e.g., garet, porter, desimone, birman, & yoon, 2001; karagiorgi & symeou, 2008; villegas-reimers, 2003) . in response to this shortcoming, findings from recent research indicated that successful professional development may occur if based on collaborative professional learning (hargreaves, 2001) , where teachers collaborate, learn from each other, discuss and exchange opinions regarding their teaching. this particular kind of learning process seems to occur through professional learning communities, discourse or communities of practice, or teacher networks (cochran-smith & lytle, 1999; deglau & o'sullivan, 2006; lieberman & miller, 1999; putnam & borko, 2000) . these networks or teacher action-learning cop draw from a social-constructivism perspective by vygotsky (1978) , lave and wenger (1991) , and wenger (1998) , that posit that learning is defined as a social-cultural outcome and is a result of social participation, interaction, and collaboration. therefore, these communities are often acknowledged as informal, structured communities that are formed by individuals with common professional pursuits during their leisure time (wenger, 1998) . in the present research the aforementioned theories serve as a starting point for the development of a teacher collaborative learning environment namely physical education teacher collaborative network (pe.t.co.n.) which was designed and implemented online as a social learning group via facebook. a current form of teacher networks or learning communities are online group networks which are commonly created and operated within popular social networks (e.g., facebook, twitter) (e.g., xing & gao, 2018) . social researchers suggest that using social networking as a means for developing and operating cop has a wide range of benefits for the teachers and it may eventually lead to the advancement of their teaching practices (duncan-howell, 2010; lieberman & pointer mace, 2010; ranieri, manca, & fini, 2012) . overall, there is a positive attitude towards this direction among teachers (davis, 2015) . the potential significance of using such e-communities is high as teachers have the opportunity to get involved in cooperative and interactive activities from diverse locations at minimal cost. further, such communities offer potential advantages for the participant teachers as they could adapt their interaction with the e-community at their own pace, according to their habits and daily needs. these e-communities seem promising as this approach integrates successful elements of previous effective interventions such as flexibility, accessibility, collaboration with and support from colleagues without the limiting effects of potential common setbacks as time, location, absence from work and participation costs (armour & yelling, 2004 , 2007 . in recent years, there has been a growing interest in the development and use of social networking by the teacher communities in favor of their professional development. recent research findings suggest that such means provide teachers with useful and effective tools to achieve enhanced professional development and learning (bissessar, 2014; kelly & antonio, 2016; maci a & garcía, 2016; rehm & notten, 2016) . however, studies regarding the reasons that lead teachers' participation and sustainability of such e-communities and interactive networks, are still lacking (hur & brush, 2009; ranieri et al., 2012) . a further challenge in the present study, is that digital learning environments seem very diverse from the traditional continuing professional development context and the daily practice of inservice pe teachers whose teaching and learning reality, normally takes place in a physical environment with practical tasks and activities, which is far less demanding in terms of technological competencies and skills compared to normal school classes (of other teacher specializations). thus, taking also into consideration the growing popularity of online learning and social networks, and the relatively scarce theoretically driven empirical research in the particular context, it is of great importance to test research hypotheses based on contemporary socio-cognitive theories (such as sdt) and to examine their applicability in this type of learning contexts/environments. as participation in cop is generally voluntarily and the nature of online training creates minimal social pressure (sproull & kiesler, 1991) , participants have the freedom to withdraw at any given time. this stresses the fact that creating a highly motivating e-learning environment is pivotal for challenging participants to engage actively in the training process and reduce withdrawal rates. having this in mind, the present online training was designed and delivered, in an unobtrusive manner emphasizing the fact that teacher participation in the group, learning tasks and the training process would be self-paced, self-regulated and volitional. although traditional learning processes have been applied in elearning environments (margaryan, bianco, & littlejohn, 2015) , there is a gap in literature as to how design effective learning strategies that ensure active and sustained participation in cop and to set the stage for a framework that considers jointly e-learning environments and autonomous learning. in the present research, facebook was chosen due to its constantly growing global popularity (wilberding & wells, 2019) which also applies in the greek context. researchers suggest that the social network facebook can be used for educational purposes, because it has the potential, as an informal teaching tool, to promote learning outcomes (fewkes, mccabe, 2012; greenhow & lewin, 2015; prescott, stodart, becket, & wilson, 2015; yu, tian, vogel, & kwok, 2010) . despite, several constraints (e.g., privacysecurity issues, file sharing limitations), researchers suggested that facebook group function has pedagogical, social and technological affordances (e.g., sharing ideas and resources, communicating, collaborating, easiness of use) making it a useful medium to supplement learning (kop, fournier, & mak, 2011; manca & ranieri, 2013; o'bannon, beard, & britt, 2013; wang, woo, quek, yang, & liu, 2012) . based on sdt and facebook groups characteristics, we surmised that this form of social learning, may satisfy teachers' basic psychological needs for autonomy, competence, and relatedness and facilitate their autonomous motivation and learning. for instance, facebook participation is self-initiated, provides individuals with the required autonomy, facilitates communication with the colleagues-"friends" they choose to interact with, and therefore making the use of the platform self-regulated and fun (quan-haase, young, 2010; sheldon, 2008) . additionally, user familiarity with facebook interface might reduce the risk of technological frustration, and consequently attrition, for participants with low levels of digital skills (manca & ranieri, 2013) , thus increasing active participation. this condition may also facilitate their competence need satisfaction during participation in online training procedures via facebook groups. in addition, findings from relevant studies suggest that educators' professional development through social networking promotes a sense of belonging according to the group members (davis, 2015) . above that, educators seem to highly appreciate the knowledge acquired informally due to cooperation and interaction with colleagues, because the acquired knowledge can be applied in everyday professional settings and therefore, to improve their abilities and professional skills (armour & yelling, 2007) . furthermore, facebook has corresponding applications for mobile operating systems (e.g., android, ios), making it feasible for participants to "carry" the training with them, in their pocket, at all times. this feature provides participants with the possibility to participate conveniently whenever/wherever they choose. if these assumptions are correct then teacher training via facebook groups (or other/future social networks with similar features) might be a response to the challenge of designing effective online cop, with the aim to motivate and actively engage participants through completion, as from what we know from massive open online courses (moocs) literature, attrition rates in elearning environments are very high (jordan, 2015; martin, kelly, & terry, 2018) . according to sdt, the reasons why individuals are involved in an activity determine the type of their motivation, which may be autonomous, controlled or they may be amotivated (deci & ryan, 1985) . when autonomously motivated, the behavior emanates from ones' self, accompanied with feelings of enjoyment, interest and satisfaction and not because of externally imposed rewards and contingencies. but, on the other hand, when one is controlled motivated, behaviors are performed out of expectations for tangible rewards, prizes, social approval, to avoid punishment or feelings of guilt or shame . more than 30 years of empirical evidence have shown that the more self-determined forms of motivation have greater positive impact on behavior in various life domains . additionally, according to sdt, individuals have innate psychological needs (for autonomy, competence and relatedness) to fulfill. an environment that provides support and fulfillment of those needs enhances one's self-determined motivation, personal growth, development and well-being . theoretical advancements within sdt have proposed in contrast to need satisfaction, that some contexts not only lead to low need fulfillment but they actively thwart needs satisfaction resulting in needs frustration (e.g., chen, et al., 2015) . recent reviews have shown that needs frustration in diverse contexts lead to maladaptive motivational outcomes and decreased well-being, or even psychopathology (vansteenkiste & ryan, 2013) . following sdt definitions of basic psychological needs (see chen et al., 2015; , for the specific context of teacher continuous training, autonomy need satisfaction corresponds to the volitional participation in a given program and selfendorsement of involvement with any given task, whilst autonomy frustration refers to the mandatory-coerced undertaking of training accompanied by feelings of pressure and control. competence need satisfaction represents experiencing mastery over the training environment by utilizing and developing skills and expertise, whereas competence frustration denotes experiencing failure and/or ineffectiveness when interacting with training environment, tasks and educational materials. relatedness need satisfaction concerns the sense of belongingness of a teacher with colleagues and/or instructors in the training accompanied by feelings of closeness, genuine connection and personal value, whilst relatedness frustration connotes experiencing of social alienation/ distance, isolation, exclusion or even rejection by educators and/or fellow teachers in the training. relevant literature has consistently shown that participant motivation is a prerequisite for any learning process, and that applies equally to teachers as well as to learners. motivation is defined as the force that drives the initiation, direction, intensity and maintenance of a certain behavior (maehr & braskamp, 1986) . research results from the educational context indicate that teachers' strong volition to learn plays a pivotal role in effective learning outcomes (van eekelen et al., 2006) . furthermore, the major determinant of teacher participation in training as well as the adoption and application of educational innovations is their quality of motivation, that is, their autonomous motivation which is directed by their learning goals (cave & mulloy, 2010; gorozidis & papaioannou, 2014 lam, cheng, & choy, 2010) . this evidence is highly significant for educational systems (e.g., greece, netherlands, denmark, sweden, norway, ireland, turkey) where participation in continuous professional teacher training is not a statutory obligation, and teachers' engagement in retraining is voluntary, depending on their discretion (european commission/ eacea/eurydice, 2018). for instance, in greece, where this study was conducted, external incentives (monetary or ongoing license requirements) for in-service training are absent and teachers can choose whether they would engage/participate in any provided learning event. in such contexts, sdt framework might reveal important internal motives and corresponding strategies/practices for the promotion of teachers' autonomous participation in continuous training. accordingly, the examination of teacher cognition within motivational processes is vital in terms of their effective involvement in cop that are implemented through social networking. however, to the authors' best knowledge, there is a scarcity of publications in relevant literature (e.g., zhang & liu, 2019). drawing from social-constructivism, the overall purpose of the present study was to investigate whether specific sdt principles have applicability and can be effective in a real-life situation such as teachers' on-line training cop context. more specifically, based on these sdt principles, the pe.t.co.n. methodology was designed (as described below), and evaluated as an in-service training protocol/ procedure. furthermore, a secondary aim, in terms of cop implementation, was to identify and highlight the strong features and weaknesses of this novel theory-driven approach to teacher in-service training, namely pe.t.co.n., in order to inform future researchers, policy makers, and authorities interested to develop effective online professional training. the overarching research question guiding this study was, whether an online cop (via facebook groups), which is designed according to sdt principles, can be an effective means of professional training of pe teachers. following these purposes, the next research questions with corresponding hypotheses were formulated: 1) rq1: can pe.t.co.n. training promote optimal motivational processes of its members? (i.e., nurture/foster basic psychological needs satisfaction, enhance members' autonomous motivation and satisfaction with training?) 2) rq2: can pe.t.co.n. participation enhance teachers' self-efficacy on specific core subjects of the training? hypothesis 2 (h2): pe.t.co.n. social learning experience will improve teachers' self-efficacy to promote students' pa outside of school. 3) rq3: what are the pros and cons of this novel approach and how can it further improve? after an open call, in the greek context, that was distributed via online channels (i.e., emails, facebook), 132 in-service greek pe teachers responded voluntarily to participate in an innovative online training program namely pe.t.co.n. this recruitment process included posting an invitation on our facebook profile page in public view (which was shared to others via facebook by 30 individuals in their profiles), posting to six facebook groups for pe, sports and exercise professionals (with about 12,000 membersduplicates included) and sending 230 e-mails to potential participants (in-service pe teachers) that were mainly obtained from previous university trainings and congresses as they had expressed their interest in participating in future trainings. it is also noted that the degree, to which information regarding pe.t.co.n. was further disseminated via social media and other means is unknown to authors. candidates were invited to fill-in an e-application/consent form in order to participate in the online training and research via facebook groups feature, while confidentiality was emphasized. to ensure teachers' anonymity when responding to electronic questionnaires/quizzes, each member of the private/secret group was provided a unique 5-digit code from the corresponding university ethics board, to use it for accessing the e-forms. these codes were further used by the authors to anonymously match subsequent data. although 132 members initially accepted the invitation, provided consent and registered to the group, six members remained in previewing mode and did not participate in the process at all, and another 10 members were excluded from further analyses as they did not engage with the training at all. thus, the final pool of active group members consisted of 120 individuals, that is, 116 pe teachers, plus 4 academics (3 researchers-pe teachers and 1 university professor). next, we present preliminary data i.e., "group insights" measurements (facebook feature) from the total number of engaged participants that exhibited at least a minimum level of interaction with the training material and group members (n ¼ 116), and quantitative-qualitative results from a smaller number of teachers (n ¼ 63; 54% response rate) who were responded to electronic questionnaires at three time points (see table 1 for demographics). these participants, held a bachelor degree from departments of physical education and sport science of various greek universities, and had been working at the time of the study at public schools which were distributed geographically throughout greece. given the small number of p.e.t.co.n. participants and the voluntary nature of the study, the sample represents a wide range of cases (patton, 2002) regarding samples' demographics i.e., age, experience, school level, geographical distribution (table 1) . the respondents can be considered as information rich participants since they had personally experienced the training under investigation/ evaluation (patton, 1990 ). the pivotal aim of the present training was to educate pe teachers on the promotion of students' pa outside school settings. the literature on physical education domain has underlined the significance of a positive pe environment, aiming to increase the quantity and quality of physical activity, and pe teachers are recognized as playing a pivotal role in the quality of engagement in such settings (e.g., duda, papaioannou, appleton, quested, & krommidas, 2014) . therefore, providing pe teachers with the knowledge and means to create positive physical activity environments may in turn lead to increased youth pa and quality of life. with this in mind, a panel of pe experts (consisted of six university faculty members), developed a training program consisting of 12 modules that focused on the promotion of students' pa outside school settings (see table 2 for details), aiming to reach who global guidelines on pa for health for children and youth aged 5e17 (i.e., students should accumulate at least 60 min of moderate-to vigorousintensity physical activity daily) (who, 2018). according to recent world health organization (who) physical activity for health report, insufficient physical activity is the leading risk factor for premature death and non-communicable diseases. unfortunately, 81 percent of youth (aged 11e17 years) in a global scale do not meet the recommended guidelines for daily physical activity (who, 2018) . therefore, a progressive increase in physical activity levels is a leading priority, as apart from obvious physical and psychosocial benefits, increased levels of youth physical activity may lead to the adoption of healthy behaviors and to higher academic performance at school. a secret/private group namely pe.t.co.n. was created in facebook, as a social learning group and pe teachers facebook friends who had filled in the application/consent form, were invited to participate in this training group. the training program included in total 16 modules of different topics, consisting of general information, instructions, educational material, knowledge quizzes, questionnaires, and a structured set of educational activities. the whole program comprised of 4 informative-introductoryexplanatory units (a-d; table 2 ) plus 12 learning/instructional thematic units (1e12; table 2 ). each thematic module was assigned to a specific pe related topic (see table 2 ), aiming to promote students' out-of-school pa. each topic lasted for a two-week period before the new learning module was introduced. however, it remained open and available for comments and discussion for the entire time of the training, providing time to members to go back and forth and to interact with their colleagues and the educational material in a self-paced manner. every unit was initiated with a prompt which was posted from the group administrators to trigger discussions between members. after 3e4 days, another question/ prompt was posted for the same topic, to continue interaction and sharing of ideas, and so forth (each unit consisted of 3e4 learning posts; table 2 ). after a 12-day period that members have been commenting and reacting to the learning posts, administrators posted a pdf file with a collection of educational material (text, hyperlinks, images, videos), presenting scientific information related to the topic discussed. administrators during each module encouraged group members to interact with each other (e.g., to comment administrators posts as well as to comment posts from other group members). in order to overcome facebook limitation in terms of personal data protection and privacy, facebook group privacy settings were set to "private" and "hidden", meaning that only group-members could search and find group participants and see what has been posted. in addition, membership approval was not available to the trainees and only administrators could approve new group memberships upon request. furthermore, confidentiality was emphasized during the recruitment phase as well as in the "group rules" section (see table 3 , rule 3). as pe.t.co.n. drew from sdt, we followed specific strategies to ensure that this informal training allowed participants to experience greater basic psychological need satisfaction (i.e., autonomy, competence and relatedness) as, according to theory, these needs are essential to sustain self-determined motivation. pe.t.co.n. was purposefully structured as to provide participants, via educational activities, a meaningful rationale so that they could find value or personal significance and meaning in these activities. in a similar vein, the organization of pe.t.co.n. aimed at minimizing coercion as it attempted to engage teachers in the activities in a self-paced manner, as there were no strict or narrow time frame for the completion of quizzes and learning tasks/posts, thus limiting task imposition. further, tasks were designed in a manner that did not stimulate reward contingencies but rather reflecting intrinsic interest for the activity. questions, prompts, and interactions between participants aimed at stimulating a high degree of engagement and potentially increase immersion and presence at these educational activities. additionally, to support group members' autonomy, on the last two units, administrators asked for their input. specifically, on unit 11, group members were asked to propose a broad thematic subject that according to their opinion, would probably have a great impact on the project's goal. after a vote-activity among members, it was decided that adding a unit about outdoor/alternative activities, would nicely complement previous units. finally, as a concluding task, group's members were encouraged to provide their input and contribute in creating an educational guide collaboratively (in a form of a voting poll), according to the previous 11 educational units. this would describe the successive steps that would enable pe teachers to be the most effective in creating such an environment that would facilitate the increase of pe students' out of school pa. discussions during courses were open and with no rigid restrictions regarding the topic discussed. everyone was invited to provide input and have a say on the topic discussed regardless of his or her experience and teaching background. administrators attempted to establish trust using an open and sincere communication with the online participants. all opinions were accepted and respected, and in general, an online social climate based on reciprocity, inclusiveness, acceptance and respect was encouraged during interactions. also, affective expressions such as exclamation marks and reaction buttons ("likes" or heart signs) were used by all participants to express a high degree of acceptance and agreement to posts but these reactions also imply a warm emotional context that potentially can have a motivationally supportive effect within online learning contexts (scogin & stuessy, 2015) . administrators throughout the informal training course, attempted to offer an educational context that provided clear competence support by giving attention (feedback) to all participants' posts, by responding or by posting reactions ("likes" or heart signs depending the degree to which administrators agreed with the participants' posts). further, the facebook platform was selected to apply the training modules as most participants were familiar with the user's interface and they had already developed digital skills to meet the demands and the requirements of their participation in the training format. in addition, facebook "social learning" group type features "units" section/tab, which has a special function allowing administrators to choose the order and organization of posts, making possible to create posts in a hierarchical structure on a timeline. this way, learning-posts and educational material were presented in a sequential manner making it easier for participants to find them. also, we enabled a feature that provides members with an indication of personal progress/completions (see image1). furthermore, participants, were challenged to refine their digital skills (e.g., searching information regarding pe.t.co.n. modules via web and scientific databases) as to build upon their previous knowledge and extend to new topics and subjects relevant to their expertise. before conducting this study, approval from the university's ethics committee was obtained. in the beginning of the training process, one week after the official initiation of the group, the first online psychometric questionnaire (t1) became available for all the group members (october 2018) and remained open for responding for a 10-day period. upon the completion of the first phase of teachers' training (t2), the second online questionnaire was distributed in order to collect participants' opinions/views regarding the pe.t.co.n. project so far (januaryefebruary 2019). the same procedure was repeated/followed upon the completion of the last phase (t3) of the e-training (june 2019). in order to respond to our research questions, we collected quantitative data and we complemented them with qualitative data. the basic criterion to collect our data was to sample teachers already participating in this informal e-training program, which was designed according to sdt propositions. to ensure data collection of high quality, a screening item for inattention check was included in the e-surveys (i.e., "i read the instructions carefully. to show that you are reading these instructions, please leave this question blank.") (maniaci & rogge, 2014) . furthermore, survey completion times of less than 5 min were considered insufficient. in total, 3 cases failed the screening question and 2 cases completed the questionnaire in insufficient time, therefore, their data were excluded from further analysis. in order to establish prolonged engagement with the context of the study, the first author served as participant observer (kept notes) during the entire e-training process, having the dual role of moderator/administrator and group-member. in addition, the second author monitored also the process by serving as group administrator along with the other members of the research group. researchers' observations and notes together with the collected data used later on, as different sources for data triangulation (patton, 1990 (patton, , 2002 . moreover, in order to build rapport, the researchers engaged in informal chats via messenger app and/or emails, with group members whenever they had any query or they needed further assistance. we targeted specific quantitative variables in two time points t1/t2 and t3 that could provide us with useful information to answer research questions 1 and 2. (a) "teacher basic needs satisfaction/frustration", can inform us whether the training virtual environment can promote or thwart teacher needs for autonomy, relatedness and competence. (b) "teacher autonomous motivation to participate in pe.t.co.n. training", can inform us whether pe.t.co.n. training unit 12 e teacher guide co-creation for students' pa promotion let's co-create an educational guide!!! step 1 -best practice 1 (poll) step 2 -best practice 2 (poll) step 3 -best practice 3 (poll) step 4 -best practice 4 (poll) step 5 we're all in this together to create a welcoming environment. let's treat everyone with respect. healthy debates are natural, but kindness is required. 4 respect everyone's privacy. being part of this group requires mutual trust. authentic, expressive discussions make groups great, but may also be sensitive and private. what's shared in the group should stay in the group. 5 no promotions or spam messages. give more than you take to this group. self-promotion, spam and irrelevant links aren't allowed image 1. pe.t.co.n. short guide about units and personal progress/completion bar. participation tends to increase or diminish teachers' selfdetermined motivation to take part in this training. (c) "teacher self-efficacy to promote students' self-regulation in out-of-school pa". teachers self-efficacy is considered a key variable on the implementation of innovative teaching practices in pe and the effectiveness of teaching (gorozidis & papaioannou, 2011) . thus, any increase or decrease in teachers' self-efficacy as a result of pe.t.co.n. training, would be of great importance for the promotion/achievement of pe.t.co.n. main goals. (d) "teacher internal satisfaction with training", can inform us of the level of participants' satisfaction with the training. (e) "teacher intention to recommend pe.t.co.n. to their colleagues" can provide us with information on the degree to which teachers had positive (or negative) perceptions about pe.t.co.n. training. (f) "facebook group insights" was an objective measure that we used to monitor members' active engagement throughout the entire duration of the training. by making use of the "facebook group insights" feature, we were able to check in detail, the numbers of participants (active group members), completions of learning posts and member's engagement (posts, comments and reactions e.g., "likes"). we collected qualitative data that could provide us with useful information to answer research q3 and to complement and triangulate quantitative data (patton, 1990 (patton, , 2002 corresponding on research q1 and q2. thus, participants were invited to express personal beliefs and opinions regarding pe.t.co.n. functioning (in open-ended questions) in two-time points (t2-t3), in order to gain an insight into better understanding their needs and the effectiveness of the pe.t.co.n. strengths and weaknesses of the implementation. in addition, to complement these data, we kept notes of members' spontaneous-sporadic comments relevant to training procedure throughout the process, that were made either in public view as comments or in person via messenger chat or emails. krommidas, & papaioannou, 2020) , which was adapted for the specific context. this 7-point likert type scale (1/strongly disagree-7/strongly agree) comprises three subscales with 3 items each, reflecting teachers' basic needs satisfaction. following the stem, "in pe.t.co.n. training …" participants responded in items as "i feel/felt completely free to make my own decisions" (autonomy satisfaction), "i feel/felt highly effective at what i do/did" (competence satisfaction), "i feel/felt very close and connected with other people (within pe.t.co.n.)" (relatedness satisfaction). this newly tested scale for the greek context, in a study with pre-service pe teachers produced valid and reliable results (gorozidis, tzioumakis, krommidas, & papaioannou, 2020) . accordingly, in the present study, confirmatory factor analyses results supported the construct and test-retest validity of the 9-item 3-correlated factors model, producing acceptable goodness of fit indices (pre/post: tli ¼ 0.910/1.00, cfi ¼ 0.940/1.00, rmsea ¼ 0.083/.000, c 2 ¼ 34.19/21.41, df ¼ 24, c 2 /df ¼ 1.43/0.9). in addition, cronbach's alpha for each t1-t3 subscale was over 0.73 (see table 4 ). (ii) teacher basic needs (relatedness) frustration scale (t1 -t3) pe teacher basic needs frustration was measured by basic needs frustration scale (nsfs; longo et al., 2016; krommidas, gorozidis, tzioumakis, & papaioannou, 2019) , which was adapted for the specific context. similar to the previous scale, pe teachers responded to items such as "in pe.t.co.n. training …" "sometimes, i feel a bit rejected by others" (relatedness frustration). this scale in a study with pre-service pe teachers produced valid and reliable results (krommidas, gorozidis, tzioumakis, & papaioannou, 2019) , however, in the present study, confirmatory factor analyses results did not support the construct validity of the 9-item 3-correlated factors model. thus, we decided to omit autonomous and competence frustration items and to retain only relatedness frustration items which presented high internal consistency. cronbach's alpha for relatedness frustration subscale t1-t3 was above 0.81 (see table 4 ). dowson, 2008) . following the general stem "why do you/have you participate/participated in the pe.t.co.n. training?" teachers responded to items as, "because i like doing it" (intrinsic), "because i consider pe.t.co.n. important for the academic success of my students" (identified). answers were given on a 7-point likert type scale ranging from 1 (does not correspond at all) to 7 (corresponds completely). according to sdt, intrinsic and identified regulation share common features (e.g., choice, internal locus of causality) therefore, they can be merged to formulate an autonomous motivation variable (see vansteenkiste, simons, lens, sheldon, & deci, 2004) . thus, for the purposes of the present study, two autonomous motivation variables were constructed (pre and post), by combining together, intrinsic and identified items of each time point. cronbach's alphas for this scale was 0.85 and 0.89, for t1-t3 respectively. (c) teachers' self-efficacy to promote students' self-regulation in out of school pa (t1 -t3) teachers' self-efficacy was measured with self-efficacy in promoting students' exercise self-regulation (gorozidis & papaioannou, 2011) scale. the instrument consists four items. following the general stem "in your school, how confident are you that you can help all your students to …" pe teachers' responded to items such as "… exercise outside school more than today?". answers were given on 11-point scales ranging from not confident at all (0%) to absolutely confident (100%). cronbach's alphas for these scales were 0.90 and 0.94, for t1-t3 respectively. teacher degree of internal satisfaction with pe.t.co.n. training was measured with a 5-item instrument, adapted to the specific context/situation (duda & nicholls, 1992) . group members were asked to mark in a 5-point likert type scale (from 5/strongly agree to 1/strongly disagree) their degree of agreement with statements as: "i like pe.t.co.n."; "i find pe.t.co.n. interesting". cronbach's alphas of this instrument for t2-t3 measurements were 0.91 and 0.92 respectively. (e) teachers' intentions to recommend pe.t.co.n. to their colleagues (t3) following the theory of planned behavior (tpb), and ajzen's (2002) guidelines, two items assessing pe teachers' intentions to recommend pe.t.co.n. to their colleagues were used: "during the next season i plan to recommend to my pe teachers colleagues to become members of pe.t.co.n. training …" and "during the next season i am determined to recommend to my pe teachers colleagues to become members of pe.t.co.n. training …". participants responded in 7-point semantic differential scales (likely/unlikely and yes/no, respectively). the coefficient alpha for this scale was 0.67, but, given the small number of scale's items (only 2) it was considered acceptable. from facebook platform automated functions provided, we made use of specific insights and results/figures which were available to group-members, (i.e., likes, post views, learning posts completions), and engagements details (posts, comments, reactions). all participant responses produced 367 short statements, corresponding to 14 digital pages (times new roman 12, 1.5 spacing). 2.5.3. data analysis 2.5.3.1. quantitative. data analyses were made with spss v.22 and amos v.20. descriptive analysis included the calculation of mean and standard deviation for each variable. construct validity of bnss was evaluated via confirmatory factor analysis (cfa). internal consistency of the scales evaluated through cronbach's alpha index. mean differences across time points were examined via paired samples t-tests (pre/mid vs post), and effect sizes via cohen's d index. 2.5.3.2. qualitative. as soon as data were collected and became available, there was an on-going reflection and analyses of them (rossman & rallis, 1998) . qualitative data from open-ended questions was handled with qsr nvivo 8 software. raw data were analyzed following the first three generic steps suggested by creswell (2003) consisting of a) organizing and preparing the data, b) reading thoroughly to gain a general impression and to reflect, c) comprehensive text analysis to generate codes and categories (coding process) (creswell, 2003, p. 191) . thematic analysis of the data was conducted following a deductive (theory-driven) approach following suggestions by boyatzis (1998) : a) generating a code, b) reviewing and revising the code in the context of the nature of the raw information, and c) determining the reliability of the coders and therefore the code. (boyatzis, 1998, pp. 35e36 ). this approach was used because the purpose of the study was to evaluate online training design features (examine if there is any agreement of the data with sdt) based on the sdt framework. the data that did not fit into any theory-driven categories were further analyzed inductively, generating new themes. in order to establish credibility and to check for the accuracy of the findings a peer debriefer (creswell, 2003, p. 196 ) enhanced the whole procedure by reviewing and asking questions, while a second analyst (coder) assisted the coding process, until consensus was met (analyst triangulation) (patton, 1990) . means and std. deviations of the study variables are depicted at table 4 . it appears that in general, teacher basic needs satisfaction, autonomous motivation and satisfaction with training were high in both time points presenting mean scores above 5.0 ±.82 in 7-point scales, with the only exception of relatedness need satisfaction which presented slightly lower levels with mean scores below 5.0 in both time points, and relatedness frustration which was found to be very low, with mean scores below 2.5 ± 1.1. self-efficacy mean scores were also high with mean scores above 7.0 ± 1.7 in 11-point scales. teacher intention to recommend pe.t.co.n. to colleagues were very high with mean score above 6.1 ± 1.1 in a 7-point scale confirming hypothesis (h1d). internal consistency of all the scales were satisfactory with alpha scores >.73, apart from intention scale which was low (0.67) but it was considered acceptable due to the small number of scale's items (only 2). in order to examine differences in teachers' basic needs satisfaction, three paired samples t-tests were conducted suggesting: (a) a significant increase in teachers' autonomy need satisfaction scores from t1 (m ¼ 5.19, sd ¼ 0.78) to t3 (m ¼ 5.83, sd ¼ 0.90) measurement, t (62) ¼ -5.80, p < .001, d ¼ 0.73; (b) a significant increase in teachers' relatedness need satisfaction scores from t1 (m ¼ 4.40, sd ¼ 0.83) to t3 (m ¼ 4.81, sd ¼ 0.88) measurement, t (62) ¼ -4.32, p < .001, d ¼ 0.54; (c) but also, a significant decrease in teachers' competence need satisfaction scores from t1 (m ¼ 5.25, sd ¼ 0.83) to t3 (m ¼ 4.99, sd ¼ 0.91) measurement, t (62) ¼ 2.35, p ¼ .022, d ¼ 0.30; (d) and, a significant decrease in teachers' relatedness need frustration scores from t1 (m ¼ 2.52, sd ¼ 1.07) to t3 (m ¼ 2.14, sd ¼ 1.04) measurement, t (62) ¼ 2.43, p ¼ .018, d ¼ 0.31. these results, with the only exception of competence need satisfaction, confirmed h1a and h1b hypotheses. furthermore, two paired samples t-tests were conducted in order to examine differences in teachers' satisfaction with training and motivation to participate in p.e.t.co.n. expectedly, teachers' internal satisfaction with training showed a significant increase in scores from t2 (m ¼ 5.0, sd ¼ 0.87) to t3 (m ¼ 5.37, sd ¼ 0.94) measurement, t (46) ¼ -4.16, p < .001, d ¼ 0.61, confirming h1d hypothesis. interestingly, autonomous motivation to participate in training scores from t1 (m ¼ 5.67, sd ¼ 0.89) to t3 (m ¼ 5.81, sd ¼ 0.97) measurement, even though it was increased, this improvement did not reach a statistical significant level, t (62) ¼ à1.23, p ¼ .22, not confirming h1c. in order to examine differences in teachers' self-efficacy to promote students' self-regulation in out of school pa, a paired samples t-test was conducted suggesting a significant improvement in self-efficacy from t1 (m ¼ 7.02, sd ¼ 1.69) to t3 (m ¼ 7.65, sd ¼ 1.78) scores, t (62) ¼ -3.25, p ¼ .002, d ¼ 0.41, confirming hypothesis (h2). group insights (posts, comments, reactions, active engagement, task completions) feature of facebook groups revealed enhanced participatory dynamics in terms of active membership (reading and commenting on other's posts and comments) active actions (such as sharing links, writing posts, sharing resources, etc.) (image 2). the active participants of the group were 116 pe teachers/members, along with the 4 administrators/researchers of the project. in the end, about 80 members (69%) completed the training process by fulfilling a minimum attendance of over 60% of the learning-posts. these data underscore the dynamic and cooperative climate of the training, and the relatively small number of attrition rate. we recorded 4424 completions of learning-posts (image 3), 1348 comments-posts, and about 7310 reactions (e.g., likes), to the 72 learning-posts posted by group administrators during the entire training; each unit included several posts with a large number of completions each (from 46 completions in the "outdoor-alternative recreational activities for pa promotion (educational material)" post, to 92 completions in the "learning topics" post). on average, each learning post had about 114 views, 31 likes and 19 comments, and each learning post was completed by 61 participants (see table 2 for details). qualitative analysis of open-ended questions generated three themes corresponding to sdt basic needs satisfaction, namely autonomy, relatedness and competence, and three respective themes reflecting sdt basic needs frustration. furthermore, after inductive analysis was concluded, the data that did not fit into these themes resulted in the three last categories presented in table 5 . accordingly, some participants commented positively on the overall training procedure, during and in the closing of the training (expressing gratitude and praise for the initiative), confirming the general sense of written answers/statements in the questionnaires. this was also evident during their personal communications via messenger chat and/or emails. the focus of the present study was physical education teacher in-service training, which was delivered in the form of an online cop via social networking, utilizing "facebook groups" function as a tool. although recent research applying sdt in online learning environments seems promising (e.g., chen & jang, 2010; hsu, wang, & levesque-bristol, 2019; martin et al., 2018; wang et al., 2019) , there is a scarcity of research in the context of snss such as facebook, testing sdt applicability not only to samples of students, or undergraduates (e.g., saini & abraham, 2019) but to inservice teachers as well. to address this gap, an online in-service pe teacher training which was founded on sdt, implemented and evaluated in terms of participants' motivation and active engagement with the learning process. overall, our results suggest that teacher training delivered in the form of a cop such as pe.t.co.n., can be beneficial in enhancing teachers' basic needs fulfillment, autonomous motivation, selfefficacy and satisfaction with the training supporting in the most part our theoretical hypotheses. the quantitative and qualitative data collected at three time-points were in agreement, complementing and confirming each other. pe teachers reported that they were highly satisfied with the training and the educational materials, and they would definitely recommend pe.t.co.n. training to their colleagues. pre-post comparisons of quantitative data revealed that teacher participation in pe.t.co.n. training has led to improvements in diverse significant dimensions for training success. in specific, teacher need for autonomy was found to be fulfilled in the context of pe.t.co.n. since a quite high score was found and a significant increase revealed at the closing of the program. this evidence suggests that pe.t.co.n. training was delivered in an autonomous supportive way, providing participants sufficient opportunities to interact, share (experiences, ideas etc.), and learn, out of their free will, following their personal needs and choices. it should be noted that autonomy need satisfaction was already relatively high from the beginning of the training, since it was emphasized that participants would undertake the training volitionally in an unobtrusive manner following their own pace in terms of attendance. however, at the end of the program, autonomy need satisfaction indicated a significant increase in scores presenting a remarkable effect size which was quite high in magnitude, suggesting that participants felt as being the source/origin of their own behavior during pe.t.co.n. training. in similar line, teacher relatedness need satisfaction exhibited significant improvements at the closure of the process, suggesting that their participation in pe.t.co.n. training enhanced their sense of belongingness by making them feel as an integral and equal part of the teacher online community. in accordance to this, initial relatedness need frustration scores were low and mean scores declined even further at the closing of the program. these findings can be easily explained considering some of the training features such as membership in a cop characterized by sincere and open interaction between group-members and administrators (digital friends) with the use of kind non-evaluative and non-judgmental language; mutual respect, acceptance and appreciation of every opinion with the provision of positive feedback and affective reactions to every individual comment (e.g., "likes", heart signs). however, relatedness need satisfaction mean scores in both times were relatively moderate suggesting that the sense of relatedness fulfillment may have further potential for improvement within this particular context. this was apparent also in teachers' responses in open-ended questions. specifically, a number of participants suggested that participants' interaction could be more intense and stable over time and they would prefer more direct interactions and fruitful participation from their colleagues in each topic of the training. this may be related to individual psychological characteristics of the participants, as probably some of them attach greater importance to the fulfillment of relatedness (e.g., schwartz & bardi, 2001) . this has great implications for the success of the training as identifying the unique contribution and the strength of each need in perceived need satisfaction, could lead researchers in creating more positive motivational environments. surprisingly, although teacher competence need satisfaction was relatively high in both time points it was the only motivational variable, that demonstrated a significant difference in the opposite direction than expected (even though small in magnitude) by decreasing from t1 to t3. this evidence may be interpreted in light of the fact that participants were not familiar to this type of on-line training, where learners interact, share, and discuss each topic and actively form/shape and purposefully direct the learning process. indeed, some teachers stated that they would prefer a more "classic" approach to training with more intense and correctional presence of administrators/instructors and the provision of educational materials before the initiation of discussion on each topic. however, some participants admitted that they were unfamiliar with some of the topics (e.g., physical literacy) and that the format of questioning without providing any educational material in advance, challenged them to search for resources and answers. another interpretation could be that some participants were not familiar with the social-learning groups function of facebook and its features. in this direction, a limited number of group-members acknowledged the fact that they could not navigate easily between the training posts, facing difficulties in accessing some learning-posts and comments (e.g., the current learning-post, their last comment, and their completion progress). this may also reflect the fact that many users decided to participate in the group, while accessing the training units via their mobile devices, such as smart phones or tablets. the user interface of the facebook application for mobile devices (e.g., android and ios) is displayed quite differently compared to a pc browser, and subsequent frequent updates of facebook mobile applications altered the way pe.t.co.n. appeared in mobile screens. this evolving characteristic of facebook might have resulted in increased difficulty for some participants, hindering their ability to seamlessly navigate between the learning units thus diminishing teacher perceptions of efficiency on training attendance. the finding that teacher autonomy and relatedness needs satisfaction were enhanced while competence need satisfaction was diminished, could explain why the improvements in teacher autonomous motivation did not reach statistical significance. it seems that the decrease of competence need satisfaction might have counteracted the increases of autonomy and relatedness need fulfillment and their potential positive effect on teachers' autonomous motivation, suggesting that the satisfaction of all three needs should improve in order to enhance autonomous motivation significantly. however, this notion should be further examined and interpreted with caution, because teacher autonomous motivation was quite high from the beginning, leaving very small room for improvement due to scales' limitation. teacher high scores on autonomous motivation can be easily explained by the recruitment process whereby they responded voluntarily to our open call and decided willingly to participate in the training in the absence of external incentives and/or impositions. in general, all the present findings should be interpreted taking into consideration the particular characteristics of the specific teacher group which was highly motivated since the onset of the training. regarding teacher confidence to promote students' pa levels outside school, as expected, self-efficacy increased significantly, suggesting that this form of informal training has the potential to improve teachers' perception that they can succeed in promoting students' self-regulation in out-of-school pa, which was a central aim of the training. this according to past research (gorozidis & papaioannou, 2011) can be considered as a first stage for teachers' adoption/implementation of innovative teaching practices such as the teaching strategies proposed by pe.t.co.n. training. moreover, even though teachers' internal satisfaction with training in the middle/half of training was already high, in the ending of the training after members having experienced the whole process and had a complete image of the pe.t.co.n., they responded even more positively, presenting significantly improved levels of satisfaction with the training. teachers' intention to recommend pe.t.co.n. training to their colleagues were highly positive which seems reasonable/justified since they were very satisfied with the project at both time-points that they provided information. overall, teachers' responses to open questions showed that they were highly satisfied with pe.t.co.n. informal training. it was found that specific features of this form of training supported teachers' basic needs satisfaction. specifically, the absence of strict deadlines and the option to navigate backwards and forwards into training modules as these were unfolding, provided all participants the opportunity to customize their engagement/involvement with the training according to their personal choices/needs and availability. furthermore, the fact that this group comprised of in-service pe teachers who exchanged ideas and shared their experiences from their day-to-day (professional) lives/practice with students, was a pivotal feature that most of the participants considered important. our results are in accordance with past research evidence with samples of pre-service and in-service teachers suggesting that facebook groups is a well promising medium to enhance teacher learning, formally and/or informally (bissessar, 2014; o'bannon et al., 2013; ranieri et al., 2012; rutherford, 2010) . in a similar vein, the fact that 80 out of the 132 registered participants (60.6%), table 5 categorization of pe teacher responses to open-ended questions (t2-t3) (n ¼ 75). teacher representative statements n what i like/liked is/was … autonomy need satisfaction "… the acceptance of all opinions, the democracy and the kindness of the coordinators/managers." (m, 42yο, 15 ye, p, t3) "… the ability/flexibility to choose when to watch each module without time pressure and the fact that i can refer to the previous modules whenever i want" (f, 50yο, 18 ye, s, t2) 20 relatedness need satisfaction "… that there is a very good climate among colleagues …" (m, 53yο, 20 ye, s, t2) "… that i had the opportunity to interact with colleagues and exchange experiences and ideas." (f, 51yο, 18 ye, s, t2) "… is the feeling of belonging to a social group that has the ability to make great suggestions in the field of physical education." (m, 54yο, 20 ye, p, t2) competence need satisfaction "… that i have updated my knowledge on the theory of pe, but also on practical issues that i come across daily." (f, 51yο, 18 ye, s, t3) "… the provision of knowledge, and the respect of each member's personal view." (f, 52yο, 18 ye, p, t3) 12 what i don't/didn't like is/was … autonomy need frustration "what i don't like is the lack of personal time due to professional & family daily obligations, which makes it relatively difficult to consistently participate in several cases asked for more learning quizzes, and more presentations and educational materials in additional topics such as "first aids", "healthy diet", "learning difficulties", "daily practical matters/problems", "work related issues" remained active throughout the training process and completed it is considered satisfactory, thus supporting the premise that well designed online training, drawing from sdt principles, has the potential to motivate and sustain participants' engagement effectively, which is consistent with recent research evidence in mooc literature (martin et al., 2018) . in addition to this, it is pivotal that online training is delivered in an autonomous supportive, collaborative social environment such as snss (i.e., facebook) in the form of a cop as it has the potential to minimize attrition rates (i.e., noncompletion or drop-out) in on-line learning contexts. in the present study, the percentage of active participants that successfully completed the training, (i.e., 69 percent) seems significantly higher than the average (i.e., 12 percent) that has been reported in similar online learning courses (jordan, 2015) . the proposed novel form of in-service training seems promising and should be further developed and refined in prospective studies. however, it should be underlined that we selected as a "vehicle" to deliver the intervention as a cop via a popular social medium with the aim to highlight the fact that similar social media have the potential to provide an excellent means to deliver educational training courses online effectively. and, taking into consideration participants' statements and personal observations, it is suggested that there is also potential for improvement. thus, building upon participants' views in joint consideration with sdt propositions p.e.t.co.n.'s future improvements should include further actions such as: a) become accessible for more participants from diverse contexts and populations, b) evolve and expand its thematic units with more topics of interest, c) create a corresponding web-site which is user-friendly and easily accessible to anyone interested, d) present more knowledge quizzes and practical examples in media format, and e) enhance synchronous communication with live chats and/or the organization of live video-supported events utilizing diverse virtual tools, f) in order to enhance training portability and to avoid confusion of participants with different devices, the provision by the network operators of several short instructional manuals/videos for each major operating system and device type (phone, tablet, pc), would be beneficial. some fundamental design characteristics of the training to those who deliver teacher professional training programs follows below. the social environment of the training should promote teachers' basic needs satisfaction and optimal motivation for teacher participation and active involvement with the learning process, educational materials and tasks. professional training should underline/promote teachers' ownership and should be delivered in an unobtrusive manner without imposing strict deadlines and obligations. participants' views and opinions should be valued and accepted without destructive criticism by providing positive, constructive feedback in a polite manner by trainers and colleagues. teachers should be able to choose the place and pace of attendance and the amount of time they wish to commit/invest. educational material, tasks and the training process should provide optimal challenges by offering opportunities to teachers to apply their expertise, and to develop new skills. teachers should have the option to connect and interact openly and sincerely with significant others in the training. a great combination of all these features can be found in a professional training which is delivered online in the form of cop through a popular social network platform. when interpreting the present results, some limitations of the study should be taken into consideration. firstly, the study recruitment and sample was limited to facebook users only and even though we did not forbid new users to apply, to our knowledge there was a small number of potential participants (nonusers) that disliked facebook and did not wish to create a profile for taking part in the training. further, although the study design included an experimental group, we did not manage to obtain data by a corresponding control group to compare our results. in addition, we did not examine for other confounding factors that might have affected our results, such as teacher participation in diverse educational/learning experiences during the academic year (and simultaneously with pe.t.co.n.), or their familiarity/experience with online learning environments and social networks. in addition, from participants' demographics it was apparent that most of the group-members, (approximately 60 percent), held postgraduate degrees which is a significantly higher rate compared to the percentage of the general population of greek in-service teachers that hold similar qualifications (i.e., in 2013 was from 15% for primary school to 21% for high school teachers; kanep/ gsee, 2015) . this evidence might indicate that most of the members had an inclination towards lifelong learning, and they might have been already more positively predisposed towards in-service training, which may have been reflected in our findings. regular membership of the pe teachers, and enhanced participatory dynamics of the group members might surmise that pe.t.-co.n. is an innovative teacher professional development approach that can increase teacher motivation to participate in educational innovations which in turn, may promote youth pa and well-being. even though this study was conducted prior to the global coronavirus pandemic, current health restrictions make online professional trainings such as pe.t.co.n., more appropriate than ever, due to the lock downs and social distancing measures imposed globally to limit sars-cov-2 spreading. further, it is suggested that virtual teaching environments that require minimal digital skills, can enhance learning in diverse contexts such as pe. it is of great interest to further investigate whether learning which occurs in these virtual environments transfers in professional contexts that involve a physical environment with practical tasks and activities such as pe students learning environments. in addition, it would be very interesting to further explore how pe.t.co.n. members reacted/ adapted to students' on-line classes during school lockdown due to covid-19 pandemic emergency measures, and whether their cop experience have facilitated their efforts to collaborate with colleagues more efficiently during this unprecedented reality. this research is co-financed by greece and the european union (european social fund-esf) through the operational program "human resources development, education and lifelong learning 2014e2020" in the context of the project "pe teachers collaboration network (pe.t.co.n.)" 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an investigation of online social networking impacts investigating the relationships among teachers' motivational beliefs, motivational regulation, and their learning engagement in online professional learning communities supplementary data to this article can be found online at https://doi.org/10.1016/j.tate.2020.103184. key: cord-352040-zmkjine7 authors: dominski, fábio hech; serafim, thiago teixeira; siqueira, thais cristina; andrade, alexandro title: psychological variables of crossfit participants: a systematic review date: 2020-08-29 journal: sport sci health doi: 10.1007/s11332-020-00685-9 sha: doc_id: 352040 cord_uid: zmkjine7 objective: this study aimed to review the existing literature concerning the psychological variables of crossfit participants. methodology: this review followed the prisma guidelines and was documented in the prospero registry (crd42018091177). six electronic databases (scopus, pubmed, sportdiscus, web of science, embase, and cochrane) were searched from their inception through july 2020. the methodological quality of the studies was assessed. results: thirty-four studies met the inclusion criteria. we observed an increase in satisfaction, clinical addiction, and enjoyment among participants related to exercise, social improvement, and high intrinsic motivation to participate for the purpose of enjoyment, challenge, and affiliation. perceptions of effort were high among crossfit participants. some studies found that the reaction time was impaired after the crossfit session, whereas others found no changes in mental health, self-esteem, and well-being after training. conclusion: adherence and maintenance of the practice of crossfit are related to psychological variables such as motivation and satisfaction of basic psychological needs. crossfit participants demonstrated high perception of effort, intrinsic motivation, and reasons for practice such as enjoyment, challenge, and affiliation. the quality assessment demonstrated the need for more detail in the methods section of future investigations. additional high-quality studies are needed to investigate the effects of crossfit training on the mental health of participants. electronic supplementary material: the online version of this article (10.1007/s11332-020-00685-9) contains supplementary material, which is available to authorized users. extreme conditioning programs (ecps) are physical exercise programs characterised by high intensity and high volume, with short or no rest periods [1, 2] . ecps through exercise from gymnastics, weightlifting, calisthenics and others, aim to foster the development of physical fitness in several domains such as cardiorespiratory fitness, strength, flexibility, and power [3] . among ecps, some training methods have emerged as registered trademarks, such as insanity ® , gym jones ® , p90x ® , and crossfit ® , the latter of which has shown greater popularity and growth [2] . crossfit is characterised by a relatively new method of physical training that includes the performance of functional exercises of constant variation, from running and rowing to olympic weightlifting (e.g. snatch and clean and jerk), and gymnastic movements, as well as plyometric and calisthenics, which are performed at a high intensity [4] . crossfit aims to develop components of physical fitness related to health and motor performance: aerobic capacity, muscular strength and endurance, stamina, flexibility, speed, coordination, accuracy, agility, balance, and power [3] . crossfit has been gaining popularity since its inception and implementation about 20 years ago, with significant growth in the number of participants and in the number of gyms offering the practice, called 'boxes' [5] . crossfit boxes are located in 142 countries across all 7 continents, currently totalling more than 14,000 affiliates [6] . evidence shows that high-intensity modalities have shown significant growth amongst different populations including healthy individuals, obese individuals, and athletes [7] [8] [9] . there has been a trend in recent studies to carry out research on psychological factors in sports [10] with respect to the effects of physical exercise on health [11] and the influence of psychological aspects on athletes' performance [12] . however, review studies on crossfit [2, 13] have mainly focused on the effects of crossfit on components of physical fitness focusing on the five domains of physical fitness (cardiovascular/respiratory resistance, endurance, strength, flexibility and power) and on possible injuries in crossfit participants [14, 15] . in addition to improving the physical conditioning of practitioners, the recent expansion of crossfit may be associated with psychological variables of participants, such as motivation, which leads people to adhere to and maintain exercise [16] . in this sense, we highlight the study of motivation in the field of sports and exercise psychology [17] . as reported by dominski et al. [16] , crossfit training is conducted with a great sense of belief and identify, with inherent rewards influencing exercise adherence. however, there is a need to know about other psychological variables that can influence in the participation such as mood states [18] ; anxiety [19] ; body satisfaction [20] ; psychological needs and behavioural regulation [9] . gathering information on the motivation and psychological needs of participants can contribute to the understanding of growth and interest in crossfit, their influence on adherence to and maintenance of physical exercise practice [21] , and psychological aspects related to recreational performance, athlete performance [22] , and injury [15] . the crossfit training shows peculiar characteristics including the sense of community promoted by the training group mode with a supportive and tight-knit community [23] , the functionality and scalability of movements and exercises [24] , the motivational and the competition environment including self-challenge not only through breaking of personal fitness records, but also among the pairs [25, 26] . furthermore, it is recognized that the crossfit environment emphasizes the body's function over its appearance [27] , differing from traditional resistance training modalities. crossfit encourages individuals to change their behavior, influencing the adoption of a healthy lifestyle, involving general practitioners of varying levels of fitness and athletes as a sport modality [28] . a comprehensive review of the available literature, considering multiple psychological variables related to health and performance can foster the understanding of this type of training, collaborating for evidence-based practice, and to highlight gaps in the literature and offering directions for future research. in view of the current levels of physical activity around the world, knowledge about the influence of psychological variables on individuals' participation in crossfit may be useful to promote exercise interventions that boost long-term adherence. in sum, the aim of the present study is to review the existing literature concerning the psychological variables of crossfit participants, with a view of distinguishing between short-term (acute) and long-term (chronic) effects. this systematic review was conducted according to the recommendations from the preferred reporting items for systematic reviews and meta-analyses (prisma) [29] . the review was recorded in the international prospective register of systematic review (prospero) registry (registration number crd42018091177), prior to completion of formal screening of search results based on eligibility criteria. the prisma checklist is provided in the supplementary material. studies were searched using the following electronic databases: scopus (elsevier), pubmed (national library of medicine and national institutes of health), sportdiscus via ebsco, web of science (main collection-thomson reuters scientific), embase, and cochrane library. the search strategies for each database are provided in the supplementary material. the search terms used in the databases were "extreme conditioning program*" or "crossfit" or "high-intensity functional training" or "crosstraining" and "psychology" or "sport psychology" or "exercise psychology" in the search fields of the databases. this strategy was permuted in all databases, with integrated searches in the title, abstract, and subject fields. we searched these databases from their inception through july 2020. the web of science database was prioritised in decisions regarding duplicate articles, and such searches were carried out in the core collection in the basic research field with the terms for the topic item and the time stipulated as all years. the supplementary material contains the search strategies used in each database. references lists of all identified studies were searched for further relevant articles [30] . eight additional studies were identified from the manual search. besides that, the search strategy was complemented with a comprehensive search of the 'grey' literature, including publications not published in indexed peer-reviewed journals. we included only original articles that investigated psychological variables of crossfit participants. a crossfit participant was defined as a person who practices cross-fit as an athlete or common participant at least three times a week. we included studies that investigated the following topics related to the psychology of crossfit participants for the analysis: attention, activation, cohesion, cooperation, cognition, concentration, coping, feedback, flow-feeling, leadership, motivation, satisfaction, self-determination, sense of community, decision making, mental health, perfectionism, personality, mental training, and visualisation (related to participation), abandonment, addiction, aggression, anxiety, burnout, dependence, dropout, mood, body image, perception of competence, self-confidence, self-efficacy, self-esteem, depression, emotions, stress, reaction time (related to psychological effects of participating). only quantitative and qualitative studies (or mixed method) with an abstract and full text available online until july 2020 and in the english, spanish or portuguese languages were included. we did not restrict the search by starting date. we excluded review articles, case studies, conference papers, editorials, and letters. eligibility criteria for this systematic review were based on the population, intervention, comparator, outcome, study design (picos) statement [31] (table 1) . two reviewers (fhd and tts) independently performed the search and assessed the eligibility of each article. discrepancies were solved by a third researcher (tcs). we screened all included titles and abstracts and reviewed the full text of articles that met our predetermined inclusion and exclusion criteria. the authors (fhd and tts) independently extracted the data from all included studies. our search identified 646 articles; the full text of 34 was reviewed, and 26 were selected, besides 8 further studies identified by reference checking, totalling 34 studies included in the narrative review. a prisma flowchart of the search is presented in fig. 1 . full references of included studies are provided in the supplementary material. after study selection and data extraction, analyses were carried out regarding the study design: cross-sectional, experimental, and qualitative. we extracted the following data: title, authors, journal, year of publication, objective of the studies, sample (number of subjects, gender, age, and level), study design, type of intervention, and main study results. because our objective focused on a broad range of psychological factors, we have divided the discussion section according the prevalence of psychological variables studied. if findings related to a variable appeared in at least two studies, then this was considered to be a specific topic in the discussion, and the variables in a topic were grouped. quality assessment of the 34 studies that met the inclusion criteria was performed using three established scales (strobe, srqr, and testex) according to the study design (cross-sectional, qualitative, and experimental, respectively). two independent reviewers (fhd and tts) evaluated each of the 34 studies using the three established scales, and the assessment of each study is described in supplementary material (tables s6, s7 , and s8). to assess the methodological quality of the studies, the recommendations of strobe (strengthening the [32] . this checklist includes 22 items that received a score from 0 (does not meet) to 1 (meets), where total adherence is expressed as a percentage of the items present. the standards for reporting qualitative research (srqr) recommendations [33] were used to evaluate the qualitative studies. this scale has 21 items, and each study was given a score from 0 to 21 and was coded as being of low (score of 0-7), medium (score of [8] [9] [10] [11] [12] [13] [14] , or high quality (score of [14] [15] [16] [17] [18] [19] [20] [21] . the testex (tool for the assessment of study quality and reporting in exercise) [34] scale was used to evaluate the quality of experimental studies. this scale was designed specifically for use in exercise training studies, and it uses a 15-point scale (5 points for study quality and 10 points for reporting). exercise psychology themes such as motivation, adherence, self-esteem, attention, well-being, body awareness, exercise addiction, effort, mood, anxiety, social identity, athletic identity, sense of community, enjoyment, personality, perception of body competence, satisfaction with body image, and mental health were identified. in total, the 34 studies included 7101 participants, comprising 6122 (86.21%) crossfit participants and 979 (13.79%) participants of other types of exercise, who composed the control group. the sample comprised 3749 (52.79%) men and 3352 (47.21%) women. two studies analysed athletes (n = 94) of crossfit [19, 35] . four studies (11.77%) used a qualitative (semi-structured interview and focus group) design, and the remaining 30 studies (88.23%) used a quantitative design (cross-sectional n = 20, experimental n = 10). one study used a mixed method (quantitative and qualitative design), but the study was classified as quantitative due to the predominance of this design. regarding cross-sectional studies, the adherence to the strobe criteria varied between 36.3 and 83.3%. the median testex score for experimental studies was assessed as 6 (min. 1; max. 14). tables 2 and 3 present the sample characterisation and results found in the studies with a cross-sectional design (20 studies), experimental (10 studies), and qualitative design (4 studies), respectively.s the results of cross-sectional studies revealed an increase in satisfaction [9, 36] , addiction [3] from exercise, social enhancement [9] and sense of community [26] , and high intrinsic motives for practice to gain enjoyment, challenge, and affiliation [7, 37, 38] . the studies showed that the perception of effort was high among crossfit participants [36, 39, 40] and that competence-related goals were higher among more experienced individuals [41] . weekly training frequency was also related to greater social capital and a greater feeling of community [23] , as well as with body image [42] . the length of participation was positively related to relatedness and enjoyment [43] , and negatively associated with disordered eating [38] . there is no link between cross-fit participation and self-esteem [38, 49] . studies have noted that men have more performance-related goals [41] and that they are more motivated by factors associated with challenge, social recognition, competition, strength, endurance, the participants expressed that crossfit is a demanding and rigorous workout regimen and felt as though they needed to embrace the challenge. participants viewed their commitment as the integral aspect of their success. all the participants expressed crossfit improving their mood. all participants expressed a strong commitment to crossfit, as a primary motivation to continuing crossfit in some cases [37] than women. such goals relate to avoiding incompetence in tasks [41] , and they are motivated by factors related to stress, weight control, and appearance [37] . experimental studies have found no changes in mental health [44] and well-being after crossfit training. concerning the consequences of crossfit training, in an acute effect, some studies have found that reaction time was impaired, and that there are mood changes after a crossfit session [18, 35] . regarding chronic effects, a study showed that mood may be impaired [45] . the objective, sample characteristics, intervention, results, and score in quality assessment of the experimental studies are presented in table 3 . qualitative studies were conducted through semi-structured interviews and focus groups to investigate the factors that encourage individuals to adopt crossfit as an exercise program [46] , the motives that lead individuals to continue or discontinue a physical exercise program such as crossfit [47] , and the organisational culture of crossfit [48] . in addition, the development of women's body image and appearance management practices was investigated [27] . qualitative studies have demonstrated high methodological quality, as assessed by the srqr. the theme, sample, and results of the studies are presented in table 3 . implications from the results of the investigated studies can be generated to collaborate the utility of crossfit practice, mainly with respect to factors related to motivation, adherence, and maintenance regarding training (table 4 ). this is the first systematic review that has synthesised comprehensively and deepening the current state of scientific production on the psychological variables of crossfit participants. we analysed the motivation for participation and determined the effects of crossfit on the psychological variables of participants. knowledge production on the psychological variables of crossfit participants is recent. due to the greater number of studies investigating the themes motivation and mood, we analysed and discussed these variables separately, while psychological factors assessed relating to psychological health and performance were incorporated into the remaining sections of the discussion. furthermore, the practical implications of the studies were described based on the results. the 34 selected studies were not suitable for quantitative synthesis through meta-analysis, owing to the lack of homogeneity regarding study design and data analysis. consequently, we performed a qualitative synthesis to summarise and explain the characteristics and findings of the selected studies. based on the results of their study, fisher et al. [7] suggested that the reasons (intrinsic reasons and reasons related to enjoyment, challenge, and affiliation) for participants to join crossfit resemble those related to sports. such factors may influence participants to keep the practice in the long-term in comparison with other modalities of resistance exercise [59] . however, attention should be paid to the inverse relationship observed in environments characterised by high-intensity activities in which engagement in this type of activity is likely to reduce pleasure [60] . due to the lack of studies on dropouts of crossfit [17] , we point out the urgency of studies specifically on the motivational characteristics that lead the participants to dropout versus continue; this may improve the understanding of physical exercise behaviours related to high-intensity functional training modalities. according to meta-analysis of reljic et al. [61] in high-intensity interval training (hiit), the exercise intensity was not related to dropout, with lower dropout rates than commonly reported for traditional exercise programsmoderate-intensity continuous training. self-determination theory (sdt) has been proposed to account for motivation in physical activity and sports [59, 62] and it was the dominant theory in the studies we reviewed. basic psychological needs theory (bpnt), a subtheory of sdt, suggests that we have three psychological needs: autonomy, competence, and relatedness. the satisfaction of these needs is related to the motivation of the individual to practice physical exercises [63] . two studies have shown that crossfit frequency is related to significantly higher levels of basic needs satisfaction with respect to all three needs [9, 36] . on the other hand, köteles et al. [49] found that a high frequency of crossfit training was not related to well-being, affection, body awareness, self-esteem, and body satisfaction. in the case of crossfit, relatedness is clearly fostered by the sense of community promoted by crossfit, as this sense of belonging to group favours participation [23, 36, 45, 55] . in this regard, one of the characteristics of the modality is group training, so everyone can perform the exercises independently of their physical fitness level-scalability. for this, there are categories, called scale (exercises performed with the least intensity of adapted form, usually destined to beginners) [55] and rx (exercises with a higher level of difficulty, usually destined to experienced participants). the social characteristics of crossfit, which refer to affiliation and relatedness which arguably have contributed to its growth in popularity [7] . crossfit skill positively predicted women's body image self-perceived physical skill and/or fitness should be promoted. crossfit's use of strength training may be particularly effective in increasing body image crossfit may be a viable intervention method for promoting positive body image swami [42] participating in crossfit is associated with improvements in body image freire et al. [20] a positive association of body dissatisfaction with risk behavior for eating disorders and addiction to exercise was observed well-being, body awareness, satisfaction with body image, and perceived body competence köteles, kollsete, kollsete [49] there was no relationship between the variables and the crossfit training future investigations must be carried out regarding these variables köteles, kollsete, kollsete [49] eather, morgan, lubans [44] coyne, sarah, woodruff [38] anxiey and coping wilke, pfarr, moller [19] competition fears are highly prevalent in athletes of crossfit eather, morgan, lubans [44] there were no significant crossfit effects on mental health personality box et al. [53] the personality dimensions were not different among crossfit and other groups of exercise mood drake et al. [45] the effects on mood states of crossfit practice were ranged from unclear to possibly harmful box et al. [56] there were no significant changes in mood states across five weeks of crossfit competition sławińska, stolarski, jankowski [57] physical exercise strongly improves mood and that this effect depends on time of day and morningness-eveningness levels pereira et al. [18] changes in mood states could be promoted by an extreme conditioning training session social variables and community belongingness whiteman-sandland, hawkins, clayton [23] greater social capital in crossfit participants strong sense of community indicates a motivational factor to adherence of crossfit regionally crossfit's organizational culture and sense of community can be explored as motivational factors and for greater adherence of participants to training pickett et al. [26] crossfit group showed a higher sense of community woolf and lawrence [55] strong identification of participants as part of crossfit bailey, benson and bruner [48] strong sense of community by the participants exercise initiation, enjoyment, adherence heinrich et al. [8] less time spent in the group that performed crossfit with maintenance of enjoyment and more likely to continue less time spent in physical exercise favors adherence explore motivational factors such as recording individual performance nielsen et al. [47] reports of improvement in well-being and mood during intervention with crossfit competence was the strongest predictor of high levels of identified and intrinsic regulations in the study of sibley and bergman [9] . a common practice in crossfit is to record performance in training and competitions (personal record), which is related to the load performed, as well as the number of repetitions and time. this characteristic fosters competitiveness and progress for each individual, increasing the participant's sense of competence [3, 47] . the goals promoted by the crossfit boxes environment, related to accomplishing tasks and learning new skills [38, 45] shows that the extrinsic motivation appears in a more autonomous way in the context of crossfit training. davies, coleman, and stellino [36] noted that for professionals working in the field, it is clear that boosting autonomous aspects and increasing the motivation to practice will foster satisfaction among participants seeking basic psychological needs. in this sense, autonomy is related to the performance of the professional responsible for practice. according to sibley and bergman [9] , when participants are offered the possibility of choosing exercises and the level of intensity, there is an increased sense of autonomy. also, the monitoring of each individual's progress and continuous pursuit of performance optimisation may be aspects that promote autonomy [37] . similar to sports environments, crossfit training has assumed a social nature, with the creation of communities [26] in which the sense of affiliation is an important characteristic and an elementary condition for the support of the basic psychological needs [7] . we observed that more autonomous forms of motivation appeared in cross-fit training participants, so the motivational characteristics indicated an autonomous form of extrinsic motivation (identified as integrated regulations, and by intrinsic regulation). therefore, people engaged in crossfit training may achieve such goals as enhancing their own identities through exercise [7, 50] . although crossfit participants demonstrated intrinsic motivation, and reasons for practice such as enjoyment, challenge, and affiliation, this is preliminary evidence. box et al. [43] found similar results in individuals who actively engage in hift, the participants with greater length of participation reported more motives associated with relatedness, as affiliation, compared those with less hift participation. thus, future investigations should examine the potential role of motivation on psychological health. considering individuals that are more extrinsically motivated to perform crossfit, for example, aiming for better physical appearance or improving physical abilities/skills [38] , these participants may be more likely to suffer adverse effects on psychological health (e.g., developing body image disorders), when compared to individuals that are intrinsically motivated, according to previous research autonomous motivation has been shown to reinforce positive mental health outcomes [64] . the effect of physical activity and sport participation on mood state has been extensively researched. numerous studies have investigated both change in mood states arising from exercise and the relationship between mood and performance [12] . however, there has yet to be a great interest among researchers in crossfit-five studies addressed the theme, possibly because it is a fairly recent ecp. experimental studies showed that the results regarding effects of crossfit on mood ranged from unclear to possibly harmful, with some of the mood factors showing likely detrimental effects and without differences between baseline and pre-workout, across weeks in the crossfit open competition [45, 56] . the negative mood changes after crossfit arose from the stimulus generated by both the high volume and intensity of the modality [45, 56] . similar findings were found in studies with basketball and soccer athletes [65, 66] . on the other hand, two qualitative studies have shown improved mood among participants after crossfit training [46] . sławińska, stolarski, and jankowski [57] found that crossfit training performed in the morning boosted mood and that participation in intense physical exercise may compensate for the negative effects on moods of non-optimal time-of-day exercise. considering the inconsistencies, and the initial stage of research that the theme is in, this variable lacks new investigations on crossfit, as variations in mood are associated with sports performance. some studies have shown that there may be negative changes to mood as a consequence of the intensity of training, participation in competition, or periodization of training [67] . regarding acute effects, pereira et al. [18] found that after one session of training, there were significant changes, albeit small and moderate, in mood states in trained and untrained individuals. it was observed a significant increase in vigour immediately after and reduction in fatigue 30 min after the end of the session. in this sense, research should be conducted on the effects of crossfit practice on mood-both acutely and chronically. it is clear from the review findings that more studies are needed on the relationship between crossfit and psychological health. considering the impact of the covid-19 pandemic on people's lives, exercise should be promoted as a form of psychological self-care [68, 69] , including cross-fit. few studies were found that investigated mental health and well-being and the differences after crossfit training [27, 44] . in addition, neither study found effects of crossfit training on self-esteem [38, 44, 49] . the body image was improved with the crossfit training, mainly related to the development of skills, since this modality focuses on body's function over its appearance [38, 42] . the significant growth of ecps such as crossfit has been driven by the interest of the population as healthy individuals, obese individuals, and athletes. then, due to more people involved and exposed, there is more chance to some participants have problems arising from excessive practice. in this context, we highlight the study of lichtenstein and jensen [3] that reported a prevalence of exercise addiction of 5% related to crossfit, measured by the exercise addiction inventory. behavioural indicators were found between addiction and the tendency to exercise despite injuries and feelings of guilt when one is not able to exercise. attention should be paid to the satisfaction with body image in crossfit participants, because this variable is recognized as a mediator factor for the development of addiction to exercise [20] . crossfit is a high-intensity functional training (hift) [70] with short or no time for rest. such practice implies large variations in effort levels and significantly interferes with the subjective perception of effort [36, 39, 40] . the perception of effort in relation to crossfit sessions was considered high by participants in some studies [36, 39, 40] . this is closely linked to exercise intensity [71] , considered a defining characteristic of ecps. compared with moderate-intensity training, crossfit participants spend less time exercising each week and are more likely to continue exercising. considering that lack of time is one of the most common reasons given for the physical inactivity [72] , the high intensity and consequent reduced time spent in the activity are advantages presented by ecps such as cross-fit, being well placed to address physical inactivity in the general population, considering this perceived barrier. as practical implications, the researchers of sport and exercise science could use an instrument to evaluate the subjective perception of effort in the practice of crossfit, as the monitoring of the perception of effort can allow better control of training load, in order to minimize the risk of injuries [73] and excessive training (overtraining and burnout). we can obtain the internal training load of each individual using the rating of perceived exertion (intensity) multiplying by the total duration of the training session [74] . such assessment becomes essential in the case of ecps such as crossfit, where training intensity is often high. regarding performance, the intensity and selectivity of athlete's attention decreased after crossfit sessions [35] . concomitant to the increase in blood lactate was an increase in reaction time, number of errors in task execution, and number of omissions. with the exception of one study, all cross-sectional studies selected for review met 50% or more of the criteria defined by strobe. most of the items that did not meet the criteria were related to the methods section-mainly bias and sample size, reporting any efforts to address potential sources of bias and explain how the study size was arrived at, respectively. of these, only five studies presented high quality, with compliance of items above 80%. these results suggest the need for future investigations to provide additional details in the methods section. on the other hand, such details in methods were observed in the qualitative studies, mainly in relation to the methods for processing and analysing the data, with high methodological quality. in the review by claudino et al. [13] , of the 32 articles selected, only two studies presented a high level of evidence with a low risk of bias. there is thus a need for better quality in some aspects of the experimental studies involving the practice of cross-fit, especially with respect to the specification of randomisation and allocation concealment-characteristics that were absent in most of the studies reviewed. several practical implications can be generated from the results of the studies. to increase the adherence and maintenance of the crossfit practice, we pointed out that emphasis should be placed on some characteristics present in the practice of the modality, such as the challenge that the exercises themselves impose on the participant, the high intensity and thus reduced time spent in physical exercise, the affiliation with crossfit boxes, and the promotion of a sense of community, as well as the recording of personal records in the exercises and training that stimulate competitiveness. these factors were related to motivation and adherence in the selected studies, and applications from the results must be performed inside the boxes. however, we acknowledge that the listed factors are based on associations through observational studies, thus intervention studies are needed. we summarized the findings of all the empirical studies on the psychological variables of crossfit participants to provide an overall examination of the body of knowledge related to the topic, including quality assessment and practical implications. this allows instructors, gym managers, participants, and researchers to consider practical applications and future research directions. although there are few studies published to date, growing interest in the psychological consequences of crossfit participation reflects that in the broader hift literature [70] . the number of studies in the present review reveals that the psychological variables have been more investigated more than other topics on crossfit. in a review analysing the literature on crossfit, claudino et al. [13] found 11 studies on psychosocial behaviour, 7 on the risk of musculoskeletal injury, 4 on body composition, and 4 on aspects of life and health. the comprehensive characteristic of this work allowed the inclusion of 34 studies, while feito, brown and olmos [70] and gianzina and kassotaki [25] found only 13 and 3 studies on psychological parameters, respectively. as limitation of this work, we did not perform a metaanalysis as part of our systematic review, because we felt such an analysis was not warranted given our motivations of the review, and given that our review is not focused on a specific outcome, as well as the heterogeneity (mainly methodological) of the data. this review aimed to synthesise the literature on the psychological variables of crossfit participants. the review of the studies showed that the adherence and maintenance of the practice of crossfit are related to psychological aspects such as motivation and satisfaction of basic psychological needs; however, this is preliminary evidence. in the studies, crossfit participants demonstrated high perception of effort, intrinsic motivation, and reasons for practice such as enjoyment, challenge, and affiliation. crossfit has characteristics related to training and competition that seem to satisfy the basic psychological needs of the participantsrelatedness, autonomy, and competence, which compose the weekly practice frequency associated with basic psychological needs. the low number of selected studies that were published before 2014 reveals that research on the psychological variables of crossfit participants remains at an initial stage. therefore, although we found relationships mainly between the crossfit practice and the motivation and basic psychological needs of participants, the findings should be generalised with caution. it is essential for more studies to be published with high methodological quality to allow better analysis of the results and greater power of evidence for future conclusions. the results have practical implications mainly regarding motivation and adherence of participants. through the review, we identified the need for more and better quality studies, as well as intervention studies to investigate the effects of crossfit practice on mental health, mood, stress, self-esteem, and anxiety among participants. author contributions all authors contributed to the study conception and design. material preparation, data collection and analysis were performed by fhd, tts, tcs and aa. the first draft of the manuscript was written by fhd and all authors commented on previous versions of the manuscript. all authors read and approved the final manuscript. conflict of interest the authors reported no potential conflict of interest. ethical approval not applicable. informed consent not applicable. register of systematic review (prospero registry) was performed prior study initiation (registration number crd42018091177). extreme conditioning programs extreme 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inactive australian adults consortium for health and military performance and american college of sports medicine consensus paper on extreme conditioning programs in military personnel validity of session rating perceived exertion method for quantifying internal training load during high-intensity functional training key: cord-013023-uanozm00 authors: crouse, richard b; kim, kristen; batchelor, hannah m; girardi, eric m; kamaletdinova, rufina; chan, justin; rajebhosale, prithviraj; pittenger, steven t; role, lorna w; talmage, david a; jing, miao; li, yulong; gao, xiao-bing; mineur, yann s; picciotto, marina r title: acetylcholine is released in the basolateral amygdala in response to predictors of reward and enhances the learning of cue-reward contingency date: 2020-09-18 journal: nan doi: 10.7554/elife.57335 sha: doc_id: 13023 cord_uid: uanozm00 the basolateral amygdala (bla) is critical for associating initially neutral cues with appetitive and aversive stimuli and receives dense neuromodulatory acetylcholine (ach) projections. we measured bla ach signaling and activity of neurons expressing camkiiα (a marker for glutamatergic principal cells) in mice during cue-reward learning using a fluorescent ach sensor and calcium indicators. we found that ach levels and nucleus basalis of meynert (nbm) cholinergic terminal activity in the bla (nbm-bla) increased sharply in response to reward-related events and shifted as mice learned the cue-reward contingency. bla camkiiα neuron activity followed reward retrieval and moved to the reward-predictive cue after task acquisition. optical stimulation of cholinergic nbm-bla terminal fibers led to a quicker acquisition of the cue-reward contingency. these results indicate bla ach signaling carries important information about salient events in cue-reward learning and provides a framework for understanding how ach signaling contributes to shaping bla responses to emotional stimuli. learning how environmental stimuli predict the availability of food and other natural rewards is critical for survival. the basolateral amygdala (bla) is a brain area necessary for associating cues with both positive and negative valence outcomes (baxter and murray, 2002; janak and tye, 2015; ledoux et al., 1990) . a recent study has shown that genetically distinct subsets of bla principal neurons encode the appetitive and aversive value of stimuli (kim et al., 2016b) . this encoding involves the interplay between principal neurons, interneurons, and incoming terminal fibers, all of which need to be tightly regulated to function efficiently. the neuromodulator acetylcholine (ach) is released throughout the brain and can control neuronal activity via a wide range of mechanisms. ach signals through two families of receptors (nicotinic, nachrs and muscarinic, machrs) that are differentially expressed on bla neurons as well as their afferents (picciotto et al., 2012) . ach signals through these receptors to increase signal-to-noise ratios and modify synaptic transmission and plasticity in circuits involved in learning new contingencies (picciotto et al., 2012) , especially in areas that receive dense cholinergic input, like the bla (woolf, 1991; zaborszky et al., 2012) . the effect of ach signaling can differ depending on the receptor, as metabotropic machrs work on a slower timescale than the rapid, ionotropic nachrs (gu and yakel, 2011; picciotto et al., 2012) . the overall impact of ach signaling on the bla is likely quite heterogeneous as machrs are coupled to both inhibitory and excitatory signaling cascades and nachrs are found on both glutamatergic and gabaergic bla neurons (picciotto et al., 2012) . the basal forebrain complex is a primary source of ach input to the bla. in particular, the nucleus basalis of meynert (nbm) sends dense cholinergic projections to the bla (woolf, 1991; zaborszky et al., 2012) . optical stimulation of bla-projecting cholinergic terminal fibers (nbm-bla) during fear conditioning is sufficient to strengthen fear memories (jiang et al., 2016) and may support appetitive behavior (aitta-aho et al., 2018) . cholinergic nbm neurons increase their firing in response to both rewarding and aversive unconditioned stimuli (hangya et al., 2015) . cholinergic signaling in the medial prefrontal cortex and visual cortex has been linked to cue detection (parikh et al., 2007) and reward timing (chubykin et al., 2013; liu et al., 2015) , respectively. a recent study has also demonstrated that nbm cells fire in response to a conditioned stimulus during trace fear conditioning, indicating that ach signaling may be involved in learning about cues that predict salient outcomes (guo et al., 2019) . we hypothesized that ach signaling in the bla is a critical neuromodulatory signal that responds to both unconditioned stimuli and cues that gain salience, thereby coordinating activity in circuits necessary for learning cue-reward contingencies. to test this hypothesis, we measured relative levels of bla ach (ach signaling), cholinergic nbm-bla terminal fiber activity (bla ach signal origin), and the activity of bla principal neurons (bla output) across all phases of learning in an appetitive operant learning task to evaluate how bla output and ach signaling are related to behavioral performance in this paradigm. we then optically stimulated cholinergic nbm fibers locally in the bla, while mice learned to nose poke in response to an auditory cue to receive a food reward to determine if accelerating the increase in ach signaling that occurs as mice learn the task would enhance performance. we also pharmacologically blocked different ach receptors during the learning task to determine the subtypes involved, and varied the timing of optical stimulation of cholinergic nbm-bla terminal fibers to determine whether ach release time-locked with the reward-predictive cue is necessary for the improvement of the task performance. these studies provide a novel framework for understanding how nbm ach signaling in the bla is recruited during the perception of novel stimuli and how it contributes to linking previously neutral cues to predictions about future salient outcomes. acetylcholine release in the bla occurs at salient points in the cuereward learning task and shifts as mice learn the cue-reward contingency the bla is critical for learning that previously neutral cues can predict future punishments or rewards and for assigning valence to those cues (baxter and murray, 2002; janak and tye, 2015) . the bla receives dense cholinergic input (woolf, 1991; zaborszky et al., 2012) and we speculated that, since ach signaling is involved in both attention and several types of learning (picciotto et al., 2012) , it could be essential for learning about cues that predict salient events, such as reward delivery. based on data showing that ach neurons fire in response to unexpected or salient events (hangya et al., 2015) , we also hypothesized that ach release might vary as mice learn a cue-reward contingency. therefore, we designed a cue-reward learning task in which food-restricted mice were trained to perform a nose poke when signaled by a cue (tone) to receive a palatable reward (ensure) on a 30 s variable intertrial interval (iti; figure 1a -d). we injected adeno-associated virus (aav) carrying an improved version of the fluorescent ach sensor grab ach3.0 (ach3.0; jing et al., 2018; jing et al., 2019) construct into the bla of mice and implanted an optical fiber above the bla to record ach signaling during the cue-reward learning task ( during the pre-training phase of the task, mice received reward and receptacle light presentation for performing a nose poke in the active port during tone presentation ( figure 1c , purple active nose poke coincident with tone) but there was no consequence for an incorrect nose poke ( figure 1c , red active nose poke not coincident with tone). animals quickly learned to make a high number of responses over the course of each pre-training session. in this paradigm, mice obtained most available rewards by day 5 of pre-training ( figure 2b , blue shaded region). however, this phase of training did not promote learning of the cue-reward contingency, (i.e. that they should only nose poke during tone presentation) seen by the high number of incorrect nose pokes (figure 2figure supplement 2a, blue shaded region). mice performed roughly eightfold more incorrect nose pokes than correct nose pokes, suggesting that mice were not attending to the task contingency. the training phase of the task was identical to pre-training except incorrect nose pokes resulted in a 5 s timeout, during which the house light was illuminated, that concluded with a restarting of the iti timer ( figure 1d , red active nose poke not coincident with tone). on day 1 of the training phase, all animals earned fewer rewards ( figure 2b , pink shading) and, while still high, incorrect nose pokes dropped (figure 2-figure supplement 2a, pink shading). animals that did not meet acquisition criterion by day 9 (defined as consistently earning 20 or more rewards per session, figure 2b , white horizontal line) were moved to a 20 s variable iti to promote responding ( figure 2b , pink shading day 10). following the change in iti, mice acquired the cue-reward behavior at different rates. after figure 1 . experimental timeline and cue-reward learning paradigm. (a) experimental timeline. mice began food restriction 7 d after surgery and were maintained at 85% free-feeding body weight for the duration of the experiment. after 7 d of handling, 5-6 d of operant familiarization prepared the mice for the cue-reward learning task (pre-training through extinction). (b) behavioral chamber setup. mice were placed in modular test chambers that included two nose poke ports on the left wall (active and inactive) and the reward receptacle on the right wall. a tone generator and timeout light were placed outside the modular test chamber. for fiber photometry (fp) and optical stimulation (laser) experiments, mice were tethered to a patch cord(s). (c-d) details of the cue-reward learning paradigm. (c) in pre-training, an auditory tone was presented on a variable interval 30 schedule (vi30), during which an active nose poke yielded ensure reward delivery but there was no consequence for incorrect nose pokes (active nose pokes not during tone). (d) training was identical to pre-training, except incorrect nose pokes resulted in a 5 s timeout, signaled by timeout light illumination, followed by a restarting of the intertrial interval (iti). during pre-training, when there were high numbers of both correct and incorrect nose pokes, there was a large increase in ach release following correct nose pokes, which were followed by reward delivery and receptacle light, but not incorrect nose pokes ( figure 2c + figure 2 -figure supplement 1b-c). we used bootstrapped confidence intervals (bcis) to determine when transients were statistically significant (bci did not contain the null of 0 [jeanrichard-dit-bressel et al., 2020] ). correct, but not incorrect, nose poke trials consistently showed a sustained, significant responses of mice expressing ach3.0 in bla. individual mice acquired the task at different rates as measured by rewards earned. horizontal white line: acquisition threshold, when a mouse began to earn 20 rewards consistently in training. incorrect nose pokes shown in figure 2 -figure supplement 2a. pre-training (pt): blue shaded area, training: pink shaded area, extinction (ext): orange shaded area. (c) fluorescence traces from bla of ach3.0expressing mouse. a significant increase in fluorescence representing bla ach release consistently coincided with correct (green line) but not incorrect (gray line) nose pokes on the last day of pt (data are shown from mouse 1). the mean z-scored precent df/f0 (z%df/f0) overlaid on bootstrapped 99% confidence intervals (99% bcis). shaded significance bars under traces represent time points where 99% bcis do not contain 0 for at least 0.5 s. correct: n = 24; downsampled incorrect: n = 24 of 58. traces of signal and reference channels (%df/f0) during nose pokes are shown in figure 2 figure supplement 1b-c. incorrect nose pokes on the last day of pt versus training day 1 shown in figure 2 -figure supplement 2b. (d) heatmap of bla ach signaling in mouse 1 across all training phases, aligned to tone onset (tone), correct nose poke (np), and receptacle entry (rec). each row is the average of rewarded trials across a training session. white dashed horizontal line: first training day earning 10 rewards. horizontal white line: acquisition threshold, when a mouse began to earn 20 rewards consistently in training. black horizontal lines: divisions between training phases. black vertical lines: divisions between breaks in time to allow for variable latencies in tone onset, correct nose poke, and receptacle entry (reward retrieval). the bci plot for mouse 1 is in figure 2 increase in fluorescence close to the time of nose poke onset ( figure 2c) . we also observed a significant decrease in fluorescence for most mice around 2-4 s after correct nose poke, which corresponds to the time of reward retrieval. ach release occurred in response to different events as mice learned the task (data for individual mice are shown in figure 2d + figure 2 -figure supplement 1d-g and averaged data across all mice at key time points in the task is shown in figure 2e + figure 2 -figure supplement 1h). during pre-training rewarded trials, the highest levels of ach release occurred close to the time of correct nose pokes (np), with a smaller peak at the time of reward retrieval (entry into the reward receptacle, rec). as training began, the ach release during reward trials shifted dramatically toward the time of reward retrieval, likely because the animals were learning that many nose pokes did not result in reward delivery. incorrect nose pokes that triggered a timeout were also followed by a modest but non-significant increase in bla ach levels ( ), ach level significantly increased at the time of the tone, suggesting that as animals learned the cue-reward contingency, the tone became a more salient event. at this time point, there was still a peak at the time of reward, but its magnitude was diminished. after task acquisition, the increase in ach following correct nose pokes remained but was diminished, and incorrect nose pokes did not elicit apparent ach release ( ) but met the acquisition criteria faster than initial mice because aspects of the behavioral setup were optimized (3d printed wall extensions) to allow the imaging apparatus to be used inside sound attenuating chambers (see materials and methods section). one difference observed in this group that learned the task more rapidly, was small magnitude, but significant, increases in bla ach release following tone onset late in pre-training (figure 2-figure supplement 3c-i). as behavioral performance during the training phase increased, ach release to tone onset became more pronounced, as in the initial cohort. in order to determine the source of the ach released in the bla during cue-reward learning, we recorded calcium dynamics as a measure of cell activity of chat + nbm terminal fibers in the bla (nbm-bla), since the nbm is a major source of cholinergic input to the bla (jiang et al., 2016; woolf, 1991; zaborszky et al., 2012) . we injected aav carrying a cre-recombinase-dependent, genetically-encoded calcium indicator (dio-gcamp7s) into the nbm of chat-ires-cre mice and implanted an optical fiber above the ipsilateral bla ( figure 2f . strikingly, nbm-bla cholinergic terminal activity most closely followed correct nose pokes in pre-training and shifted primarily to tone onset as mice learned the contingency during training. as in the replication cohort for the ach sensor, small magnitude, but significant, increases in terminal activity were observed following tone onset late in pre-training ( figure 2j in order to record nbm-bla cholinergic terminal activity and bla ach levels simultaneously in the same mouse, we injected aav carrying a construct for cre-recombinase dependent red-shifted genetically-encoded calcium indicator (dio-jrcamp1b) into the nbm of chat-ires-cre mice, ach3.0 sensor into the ipsilateral bla, and implanted a fiber above the bla (figure 2 -figure supplement 9a-e, mouse 1). dio-jrcamp1b was also injected into the nbm of a wild-type littermate so cre-mediated recombination would not occur to control for any crosstalk between the ach3.0 and jrcamp1b channels. while this was only a single animal and proof of principle for future studies, we found that nbm-bla cholinergic terminal activity coincided with ach levels (figure 2 -figure supplement 9f-g). importantly, this relationship between ach release and nbm-bla terminal fiber activity was not explained by signal crosstalk (figure 2 -figure supplement 9h-i), further indicating that the bla ach measured comes at least in part from the nbm. bla principal neurons respond to reward availability and follows cuereward learning glutamatergic principal cells are the primary output neurons of the bla (janak and tye, 2015) , and their firing is modulated by nbm-bla cholinergic signaling (jiang et al., 2016; unal et al., 2015) . bla principal neurons can increase their firing in response to cues as animals learn cue-reward contingencies (sanghera et al., 1979; schoenbaum et al., 1998; tye and janak, 2007) . calcium/calmodulin-dependent protein kinase (camkii) has been shown to be a marker for glutamatergic bla principal cells (butler et al., 2011; felix-ortiz and tye, 2014; mcdonald, 1992; tye et al., 2011) . to determine whether ach modulates principal neuron activity during cue-reward learning, we injected aav carrying a cre-recombinase dependent genetically encoded calcium indicator (dio-gcamp6s) into the bla of camkiia-cre mice to record bla principal cell activity during the learning task ( figure 3a + figure 3 -figure supplement 1a). as was seen for bla ach levels, there was a significant increase in bla camkiia cell activity following correct and a modest decrease in activity following incorrect nose pokes on the last day of pre-training ( figure 3b ). however, the activity peaked later after the correct nose poke response (~2.5 s) compared to the ach3.0 signal (~0.5 s) and appeared to align more tightly with reward retrieval ( during pre-training, the highest levels of bla camkiia cell activity followed reward retrieval. in addition, during the first few days of training, bla camkiia cell activity after reward retrieval was higher than it was during pre-training, and the magnitude of response decreased as mice learned the contingency and earned more rewards, ultimately reaching similar intensity to that observed during pre-training. concurrently, as mice approached acquisition of the task ( figure 3c , white horizontal line), bla camkiia cell activity significantly increased in response to tone onset ( figure 3d -e + figure 3 -figure supplement 1e-h, acq.), suggesting that the recruitment of bla camkiia cell activity likely reflects the association of the cue with a salient outcome (lutas et al., 2019; sengupta et al., 2018) . incorrect nose pokes that triggered a timeout did not elicit a different response in camkiia cell activity compared to before timeouts were incorporated (figure 3-figure supplement 2b-g). in an independent cohort of mice, those with more posterior fiber tip placements (mice 4 + 7) replicated the primary findings (figure 3-figure supplements 3-4). since ach released by nbm-bla terminals during training shifted to tone onset during acquisition of cue-reward learning ( figure 2e ,j), we hypothesized that ach may potentiate learning the cuereward contingency. we, therefore, tested whether increasing ach release in bla during learning could alter cue-reward learning by injecting aav carrying a cre-recombinase-dependent channelrhodopsin-eyfp (aav-dio-chr2-eyfp) construct bilaterally into the nbm of chat-ires-cre transgenic mice and placing fibers over the blas to optically stimulate cholinergic terminals originating from the nbm selectively ( figure 4a figure 4c ) and training ( figure 4d ). stimulation usually occurred during at least a portion of all three components of a during pre-training, auditory tones were presented on a variable interval 30 schedule (vi30), during which an active nose poke (correct) yielded ensure reward delivery and 2 s of optical stimulation but there was no consequence for incorrect nose pokes (active nose pokes not during tone). (d) training was identical to pre-training, except incorrect nose pokes resulted in a 5 s timeout, signaled by house light illumination, followed by a restarting of the iti. (e) behavioral performance in a cue-reward learning task improves with optical stimulation of chat + fibers in bla. eyfp-and chr2-expressing mice earn similar numbers of rewards during pt (blue shaded region). chr2-expressing mice more rapidly earn significantly more rewards than eyfpexpressing mice during training (pink shaded region). no significant differences were observed during extinction training (orange shaded region). horizontal white line: acquisition threshold, when a mouse began to earn~20 rewards consistently in training. mean ± sem, eyfp: n = 5, chr2: n = 6. figure 4 continued on next page rewarded trial: tone, correct nose poke, and reward retrieval, since these events were often separated by short latencies. as seen in previous experiments, during the pre-training phase animals made a high number of nose poke responses over the course of each session, obtained most available rewards by the last day ( figure 4e as the animals learned that a nose poke occurring outside of the cued period resulted in a timeout, both control eyfp and chr2 groups learned the contingency and improved their performance, resulting in acquisition of the cue-reward task (20 rewards earned). however, significant group differences emerged, such that chr2 mice earned significantly more rewards than eyfp controls ( figure 4e two-way repeated-measures anova, f (1, 9)=12.67, p=0.0061), suggesting that the chr2 group learned the tone-reward contingency more quickly than the eyfp group. eyfp mice were able to reach the same peak cue-reward performance as the chr2 group only after 4-6 additional days of training. once peak performance was achieved, there was no difference in extinction learning between the groups (main effect of group (eyfp versus chr2) in a two-way repeated-measures anova, f (1, 9)=2.293, p=0.1643). while sex differences in the behavior were not formally tested side by side, an independent cohort of male mice (eyfp n = 7, chr2 n = 7, figure 4 -figure supplement 4) was tested to determine whether both male and female mice would respond to ach stimulation, revealing similar trends during training for rewards earned ( in order to determine if optical stimulation of nbm-bla cholinergic terminals improved performance in the task by increasing the rewarding value of the outcome, rather than enhancing cuereward learning by some other means, we allowed mice to nose poke for optical stimulation rather than for ensure (figure 4-figure supplement 5a ). there were no differences between the eyfp control and chr2 groups (two-way repeated-measures anova, f (1, 9)=0.6653, p=0.4357). we also tested whether nbm-bla cholinergic terminal activation was reinforcing on its own by stimulating these terminals in a real-time place preference test. mice were allowed to explore two similar compartments to determine baseline preference, and nbm-bla cholinergic terminals were then stimulated in one of the two chambers to determine whether it increased time spent in the simulationpaired chamber. there was no difference between groups (figure 4-figure supplement 5b, main effect of group (eyfp versus chr2) in a two-way repeated-measures anova, f (1, 9)=0.1311, p=0.7257) in place preference, confirming that optical activation of nbm-bla cholinergic terminals is not innately rewarding. stimulation of nbm-bla cholinergic terminals also did not lead to changes in nose poke behavior in an uncued progressive ratio task ( muscarinic, but not nicotinic, receptors are required for acquisition of the cue-reward contingency ach signals through multiple receptor subtypes, with rapid, ionotropic signaling mediated through stimulation of nachrs, and metabotropic signaling mediated through stimulation of machrs (picciotto et al., 2012) . to determine which ach receptors were involved in this cue-reward learning task, mice were injected intraperitoneally with saline (n = 8), mecamylamine (non-competitive nicotinic antagonist, mec, n = 9), scopolamine (competitive muscarinic antagonist, scop, n = 8), or a combination of both antagonists (mec+scop, n = 9) 30 min prior to pre-training and training, during the same epochs of the task in which optical stimulation was administered ( figure 5a ). like optical stimulation, blockade of ach receptors during the pre-training phase of the task had no effect on rewards earned ( figure 5b we have shown that this dose of mecamylamine delivered i.p. has significant effects in tests of anxiety-like behavior and responses to inescapable stress. in addition, chronic treatment with mecamylamine at this dose is sufficient to decrease bla c-fos immunoreactivity (mineur et al., 2007) . consistent with the inability to acquire the cue-reward contingency, mice treated with scop or mec+scop also obtained very few rewards during extinction ( figure 5b ach-mediated accelerated cue-reward learning does not require contingent stimulation of chat + nbm terminals in the bla acetylcholine is often thought of as a neuromodulator (picciotto et al., 2012) , and the window for cholinergic effects on synaptic plasticity varies across ach receptor subtypes (gu and yakel, 2011) . it is therefore possible that ach signaling may result in intracellular signaling changes that outlast the cue presentation window. in order to determine if the effect of nbm-bla stimulation is there was no significant difference between saline controls and those receiving the nicotinic achr antagonist (mec) during training and mice extinguished responding at similar rates. figure 5 continued on next page dependent upon the timing of correct nose poke and laser stimulation contingency, we repeated the experiment in an independent cohort of mice with an additional non-contingent chr2 group that received the same number of stimulation trains as the contingent chr2 group, but in which light stimulation was explicitly unpaired with task events ( figure 6a + figure 6-figure supplement 1) . as in the previous experiment, there were no differences between the eyfp control (n = 6) and stimulation groups (contingent-chr2 n = 5 and non-contingent chr2 n = 5) during pre-training ( figure these results demonstrate that chr2-mediated ach release does not have to be time-locked to the cue, nose poke, or reward retrieval to improve performance of the task, suggesting that ach may alter the threshold for neuronal plasticity for cue-reward pairing over a much longer timescale than might be expected based on results from the ach3.0 recording and nbm-bla recordings, which could be consistent with the involvement of machr signaling in this effect. as in the previous experiment, once all groups reached criterion for acquisition of the cue-reward contingency, there were no differences between any of the groups during extinction ( figure it is increasingly recognized that the bla is involved in learning to predict both positive and negative outcomes from previously neutral cues (cador et al., 1989; janak and tye, 2015; ledoux et al., 1990) . cholinergic cells in the basal forebrain complex fire in response to both positive and negative reinforcement (hangya et al., 2015) . the results shown here indicate that ach signaling in the bla is intimately involved in cue-reward learning. endogenous ach is released in the bla in response to salient events in the task, and ach dynamics evolved as the subject formed associations between stimuli and reward. while the pattern of ach signaling in the bla may seem reminiscent of how dopamine neurons encode reward prediction errors as measured in other brain areas (schultz et al., 1997) , the current results suggest that ach release in the bla may instead be involved in signaling a combination of salience and novelty. ach release and nbm-bla activity increased following correct nose poke and, around the time that animals acquired the cue-reward task, following tone onset. however, earlier in training, incorrect nose pokes that resulted in a timeout were also followed by ach release, although this was smaller in magnitude. further, stimulating nbm-bla cholinergic terminals during learning enhanced behavioral performance, but was not intrinsically rewarding on its own and did not support responding for the tone alone. although ach was released in the bla at discrete points during the task, the effects of heightened bla ach signaling were relatively long lasting, since it was not necessary for stimulation to be time-locked to cue presentation or reward retrieval to enhance behavioral performance. thus, cholinergic inputs from the basal forebrain complex to the bla are a key component of the circuitry that links salient events to previously neutral stimuli in the environment and uses those neutral cues to predict future rewarded outcomes. we have shown that ach release in the bla is coincident with the stimulus that was most salient to the animal at each phase of the task. use of the fluorescent ach sensor was essential in determining these dynamics (jing et al., 2018; jing et al., 2019) . previous microdialysis studies have shown that ach is released in response to positive, negative, or surprising stimuli, but this technique is limited by relatively long timescales (min) and cannot be used to determine when cholinergic transients align to given events in an appetitive learning task and how they evolve over time (sarter and lustig, 2020) . in this cue-reward learning paradigm, when there was no consequence for incorrect nosepoking (pre-training phase), animals learned to perform a very high number of nose pokes and received a large number of rewards, and bla ach signaling peaked following correct nose pokes. both the behavioral response (nose poking that was not contingent with the tone) and the ach response (linked to the correct nose poke) suggest that the animals were not attending to the tone during most of the pre-training phase of the task, but rather were attending to the cues associated with reward delivery, such as the reward light or the sound of the pump that delivered the reward. consistent with this possibility, in the next phase of the task when mice received a timeout for responding if the tone was not presented, performance of all groups dropped dramatically. interestingly, in animals that had difficulty learning the cue-reward contingency, during early training sessions ach release shifted to reward retrieval, likely because this was the most salient aspect of the task when the majority of nose pokes performed did not result in reward. finally, as mice acquired the contingency between tone and reward availability, the tone also began to elicit ach release in the bla, suggesting that mice learned that the tone is a salient event predicting reward availability. since there are multiple sources of ach input to the bla, it was important to determine whether nbm cholinergic neurons were active during the periods when ach levels were high (woolf, 1991) . recordings from cholinergic nbm-bla terminal fibers showed similar dynamics to ach measurements, suggesting that the nbm is a primary source of ach across the phases of cue-reward learning. perhaps the most well-known example of dynamic responding related to learning cue-reward contingencies and encoding of reward prediction errors is the firing of dopaminergic neurons of the ventral tegmental area (vta; schultz, 1998) . after sufficient pairings, dopaminergic neurons will fire figure 6 . non-contingent stimulation of cholinergic nbm-bla terminals is sufficient to enhance cue-reward learning. (a) experimental details of laser stimulation in non-contingent-chr2 mice. non-contingent-chr2expressing mice received the same number of light stimulations as contingent-chr2-expressing mice, but stimulation was only given during the iti, when non-contingent mice had not made a response within 2 s. injection sites and fiber placements are shown in figure 6-figure supplement 1a-b. (b) non-contingent nbm-bla optical stimulation also improves behavioral performance in cue-reward learning task. there was no significant difference in the number of rewards earned between eyfp (n = 6), contingent-chr2 (n = 5), or non-contingent-chr2 (n = 5) mice during pre-training. contingent-and non-contingent-chr2-expressing mice more rapidly earned significantly more rewards during training than eyfp-expressing mice. no differences were observed between groups during extinction training. mean ± sem eyfp: n = 6, contingent-chr2: n = 5, non-contingent-chr2: n = 5. horizontal white line: acquisition threshold, when a mouse began to earn 20 rewards consistently in training. individual data are shown in figure 6 -figure supplement 2a. (c) incorrect nose pokes. there was no significant difference in the number of incorrect nose pokes between groups during pre-training. contingent-and non-contingent-chr2-expressing mice made significantly fewer incorrect nose pokes during training than eyfpexpressing mice. no differences between groups were observed during extinction training. mean ± sem eyfp: n = 6, contingent-chr2: n = 5, non-contingent: n = 5. individual data are shown in figure 6 in response to the cue that predicts the reward, and no longer to the rewarding outcome, which corresponds with behavioral changes that indicate an association has been formed between conditioned stimuli (cs) and unconditioned stimuli (us). it should be noted that dopamine signaling is not unique in this learning-related dynamic response profile. serotonergic neuronal responses also evolve during reward learning in a manner distinct from dopaminergic neurons (zhong et al., 2017) . plasticity related to learning has also been observed in cholinergic neurons in the basal forebrain complex during aversive trace conditioning, such that after several training days, neuronal activity spans the delay between cs and us (guo et al., 2019) . additionally, a recent study suggested that ach may signal a valence-free reinforcement prediction error (sturgill et al., 2020) . future studies on the selective inputs to nbm to bla cholinergic neurons would be of interest to identify the links between brain areas involved in prediction error coding. we found that bla camkiia cells were most reliably activated following reward retrieval before contingency acquisition (both when they were receiving several rewards but no timeouts in pre-training and few rewards early in training). similar to the recording of ach levels, after acquisition, the tone began to elicit an increase in bla camkiia cell population activity. however, activity of camkiia neurons differed from ach signaling in the bla in important ways. ach was released in response to the salient events in the task that were best able to predict reward delivery or availability. by contrast, the activity of bla camkiia neurons was not tightly time-locked to correct nose poking, and instead followed reward retrieval until acquisition, when activity increased in response to tone onset. the divergent dynamics of ach release and camkiia neuron activity underscores that ach's role in the bla is to modulate, rather than drive, the activity of camkiia neurons, and therefore may alter dynamics of the network through selective engagement of different populations of gaba interneurons (unal et al., 2015) . neuronal activity and plasticity in the bla is required for both acquisition of appetitive learning (conditioned reinforcement) and fear conditioning, however the inputs that increase activity in the structure during salient events likely come from many brain areas (mckernan and shinnick-gallagher, 1997; rogan et al., 1997; tye et al., 2008) . in particular, dopaminergic inputs to the bla are important for acquisition of conditioned reinforcement and for linking the rewarding properties of addictive drugs to cues that predict their availability (cador et al., 1989) . our results indicate that ach is a critical neuromodulator upstream of the bla that is responsive to salient events, such as reward availability, motor actions that elicit reward, and cues that predict reward. we show here that increasing endogenous ach signaling in the bla caused mice to perform significantly better than controls in an appetitive cued-learning task. heightened ach release during learning of a cueaction-reward contingency led to fewer incorrect responses and increased acquisition rate in both female and male mice. the optical stimulation was triggered by correct nose poke, thus the cholinergic nbm-bla terminal fiber stimulation overlapped with all three salient events: tone, nose poke, and reward retrieval, since the tone terminated 2 s after correct nose poke. we chose this stimulation pattern, as opposed to linking optical stimulation to tone onset, to ensure stimulation was dependent on behavioral responses. therefore, stimulation did not precisely recapitulate the ach release profile observed in mice that had already acquired the task (when ach increases following tone onset). this suggests that behaviorally-contingent increases in bla ach are sufficient to enhance task acquisition (but see below). it is also possible that optogenetic-mediated ach release may last longer than endogenous, tone-evoked release. a simultaneous stimulation and recording approach would be required to compare ach release under both conditions (pisansky et al., 2019) . it is important to note that basal forebrain neurons have been demonstrated to co-release ach and gaba (ma et al., 2018; saunders et al., 2015) , and cholinergic basal forebrain neurons that project to the bla have been shown to co-express a glutamate transporter (ma et al., 2018; nickerson poulin et al., 2006) . thus, it is possible that both fiber photometry and optogenetic results could be influenced, in part, by co-release of other neurotransmitters from chat-positive neurons. future studies employing additional fluorescent neurotransmitter sensors (marvin et al., 2013; marvin et al., 2018; marvin et al., 2019) could help understand the interaction between the different signals employed by basal forebrain neurons. it is possible that ach improved learning by increasing the intensity of the reward, potentiating the learned association, improving discrimination, or a combination of these phenomena. however, increasing ach release in the bla was not inherently rewarding, because it did not support self-stimulation or real-time place preference. this is at odds with a recent study that found stimulation of nbm-bla cholinergic terminals could induce a type of place-preference and modest self-stimulation (aitta-aho et al., 2018) . perhaps slight differences in targeting of chr2 infusion or differences in the behavioral paradigm could be responsible for the lack of direct rewarding effects of optical chat terminal stimulation in the current study. other recent work (jiang et al., 2016) has demonstrated that stimulating this nbm-bla cholinergic pathway is sufficient to strengthen cued aversive memory, suggesting that the effect of ach in the bla may not be inherently rewarding or punishing but instead potentiates plasticity in the bla, allowing learning of cue-outcome contingencies. similarly, it is possible that ach alters motor activity. however, there were no effects of optical stimulation on locomotion or responding in the inactive nose poke port. in addition, during the pre-training phase when there was no consequence for incorrect nose pokes, all groups earned the same number of rewards, regardless of optical stimulation or pharmacological blockade of ach receptors, suggesting that ach is not involved in the motor aspects of the task or the value of the reward. indeed, differences emerged only during the training phase, when attention to the tone was critical to earn rewards. further, incorrect nose poking remained high for mice administered scopolamine. this suggests that scopolamine-treated animals were seeking the reward, as in the operant familiarization and pre-training phases of training, but were unable to learn that they should only nose poke in response to the tone. cell-type-specific expression of achrs and activity-dependent effects place cholinergic signaling at a prime position to shape bla activity during learning. for instance, late-firing interneurons in the bla exhibit nachr-dependent epsp's when no effect is seen on fast-spiking interneurons, while principal neurons can be either excited or inhibited through machrs, depending on activity level of the neuron at the time of cholinergic stimulation (unal et al., 2015) . bla machrs can support persistent firing in principal neurons and can be important for the expression of conditioned place preference behavior, as well as trace fear conditioning (baysinger et al., 2012; egorov et al., 2006; mcintyre et al., 1998) . similar to studies of trace fear conditioning, in which activity of the network over a delay period must be maintained, we found that metabotropic (machrs) but not ionotropic (nachrs) ach receptors were required for learning the contingency of this cue-reward task. the timing of cholinergic signaling can be a critical factor in the induction of synaptic plasticity in other brain regions, so we hypothesized that the enhancement of cue-reward learning observed might be dependent upon when nbm-bla terminal fibers were stimulated with respect to tone presentation and/or behavioral responses (gu and yakel, 2011) . however, we found that heightened ach signaling in the bla improved behavioral performance even when stimulations were explicitly unpaired with the cue or correct nose poking. this suggests that the effect of increased cholinergic signaling in the bla is long lasting, and that stimulation during a learning session is sufficient to potentiate synaptic events linking the cue to a salient outcome-even if cs and/or reward delivery are presented tens of seconds later. given the findings from fiber photometry recordings, which showed endogenous ach release was time-locked to salient stimuli during the task and evolved with learning, it is surprising that time-locking of exogenous ach release was not necessary for enhancement of cue-reward learning. coupled with pharmacological evidence demonstrating that muscarinic signaling is necessary for reward learning in this task, these results suggest the involvement of metabotropic signaling downstream of muscarinic receptors that outlasts the initial cholinergic stimulation. to conclude, the abundant ach input to the bla results in ach release in response to stimuli that predict reward in a learned cue-reward task. increasing cholinergic signaling results in accelerated learning of the cue-reward contingency. these findings are consistent with the hypothesis that ach is a neuromodulator that is released in response to salient stimuli and suggests that ach signaling may enhance neuronal plasticity in the bla network, leading to accelerated cue-reward learning. key resources all procedures were approved by the yale university institutional animal care and use committee (protocol: 2019-07895) in compliance with the national institute of health's guide for the care and use of laboratory animals. experiments were performed in mice of both sexes, in keeping with the nih policy of including sex as a biological variable. sex of mice in behavioral graphs is indicated by circles for females and squares for males. female and male heterozygous mice with cre recombinase knocked into the choline acetyltransferase (chat) gene (chat-ires-cre, b6;129s6-chat tm2(cre)lowl/j , jackson laboratory, bar harbor, me) were bred in house by mating chat-ires-cre with c57bl6/j mice. camkiia-cre (tg(camk2acre)2gsc) mice obtained from ronald duman (casanova et al., 2001; wohleb et al., 2016) were bred in house as above. c57bl6/j mice were obtained from the jackson laboratory at 6-10 weeks of age, and tested at 5-7 months of age, following at least 1 week of acclimation. all mice were maintained in a temperature-controlled animal facility on a 12 hr light/dark cycle (lights on at 7:00 am). mice were group housed 3-5 per cage and provided with ad libitum food and water until undergoing behavioral testing. mice were single housed 1-3 weeks before surgery to facilitate food restriction and body weight maintenance. surgical procedures for behavior were performed in fully adult mice at 4-6 months of age, agematched across conditions. for viral infusion and fiber implantation, mice were anesthetized using isoflurane (induced at 4%, maintained at 1.5-2%) and secured in a stereotactic apparatus (david kopf instruments, tujunga, ca). the skull was exposed using a scalpel and bregma was determined using the syringe needle tip (2 ml hamilton neuros syringe, 30 gauge needle, flat tip; reno, nv). for fiber photometry surgeries, 0.4 ml of aav9 hsyn-ach3.0 (vigene biosciences inc) to measure bla ach levels ( figure 2a -e + figure 2 -figure supplements 1-2) was delivered unilaterally to the bla (a/p; à1.34 mm, m/l + or -2.65 mm, d/v à4.6 mm, relative to bregma) of chat-ires-cre or wild-type c57bl6/j mice at a rate of 0.1 ml/min. the needle was allowed to remain at the infusion site for 5 min before and 5 min after injection. a mono fiber-optic cannula (1.25 mm outer diameter metal ferrule; 6 mm long, 400 mm core diameter/430 mm outer diameter, 0.48 numerical aperture (na), hard polymer cladding outer layer cannula; doric lenses, quebec city, quebec, canada) was implanted above the bla (a/p; à1.34 mm, m/l + 2.65 mm, d/v à4.25 mm) and affixed to the skull using opaque dental cement (parkell inc, edgewood, ny). for bla camkiia cell calcium dynamic recordings (figure 3 + figure 3-figure supplements 1-2) , 0.5 ml of aav1 syn-flex-gcamp6s-wpre-sv40 (addgene, watertown, ma) was injected into the left bla using the same procedure and coordinates but was injected into camkiia-cre mice. cholinergic nbm-bla terminal fiber calcium dynamic recording ( figure dana et al., 2016; dana et al., 2019) . mice were allowed to recover in a cage without bedding with a microwavable heating pad underneath it until recovery before being returned to home cage. for 2 d following surgery, mice received 5 mg/kg rimadyl i.p (zoetis inc, kalamazoo, mi) as postoperative care. figure 6-figure supplements 1-2) , surgeries were performed as above except as follows: 0.5 ml of control vector (aav2 ef1a-dio-eyfp) or channelrhodopsin (aav2 ef1a-dio-hchr2(h134r)-eyfp; university of north carolina gene therapy center vector core, chapel hill, nc) was delivered bilaterally into the nbm (a/p: -0.7 mm, m/l ± 1.75 mm, d/v -4.5 mm) of chat-ires-cre mice. mono fiber-optic cannulas (1.25 mm outer diameter zirconia ferrule; 5 mm long, 200 mm core diameter/245 mm outer diameter, 0.37 na, polyimide buffer outer layer cannula; doric lenses) were inserted bilaterally above the basolateral amygdala (bla, a/p; à1.22 mm, m/l ± 2.75 mm, d/v à4.25 mm). mice were randomly assigned to eyfp or chr2 groups, controlling for average group age. for ex vivo local field potential electrophysiology experiments ( figure 4b) , the nbm was injected with dio-chr2-eyfp as described above, except mice were 8 weeks of age (see supplemental methods for current clamp recording methods). the coronal brain slices containing the nbm were prepared after 2-4 weeks of expression. briefly, mice were anesthetized with 1â fatal-plus (vortech pharmaceuticals, dearborn, mi) and were perfused through their circulatory systems to cool down the brain with an ice-cold (4˚c) and oxygenated cutting solution containing (mm): sucrose 220, kcl 2.5, nah 2 po 4 1.23, nahco 3 26, cacl 2 1, mgcl 2 6 and glucose 10 (ph 7.3 with naoh). mice were then decapitated with a guillotine immediately; the brain was removed and immersed in the ice-cold (4˚c) and oxygenated cutting solution to trim to a small tissue block containing the nbm. coronal slices (300 mm thick) were prepared with a leica vibratome (leica biosystems inc, buffalo grove, il) after the tissue block was glued on the vibratome stage with loctite 404 instant adhesive (henkel adhesive technologies, dü sseldorf, germany). after preparation, slices were maintained at room temperature (23-25˚c) in the storage chamber in the artificial cerebrospinal fluid (acsf; bubbled with 5% co 2 % and 95% o 2 ) containing (in mm): nacl 124, kcl 3, cacl 2 2, mgcl 2 2, nah 2 po 4 1.23, nahco 3 26, glucose 10 (ph 7.4 with naoh) for recovery and storage. slices were transferred to the recording chamber and constantly perfused with acsf with a perfusion rate of 2 ml/min at a temperature of 33˚c for electrophysiological experiments. cell-attached extracellular recording of action potentials was performed by attaching a glass micropipette filled with acsf on eyfp-expressing cholinergic neurons with an input resistance of 10-20 mw under current clamp. blue light (488 nm) pulse (60 ms) was applied to the recorded cells through an olympus bx51wi microscope (olympus, waltham, ma) under the control of the sutter filter wheel shutter controller (lambda 10-2, sutter instrument, novato, ca). all data were sampled at 3-10 khz, filtered at 3 khz and analyzed with an apple macintosh computer using axograph x (axograph). events of field action potentials were detected and analyzed with an algorithm in axograph x as reported previously (rao et al., 2008) . one week after surgery, mice were weighed daily and given sufficient food (2018s standard chow, envigo, madison, wi) to maintain 85% free-feeding body weight. all behavioral tests were performed during the light cycle. mice were allowed to acclimate to the behavioral room for 30 min before testing and were returned to the animal colony after behavioral sessions ended. two weeks after surgery, mice were handled 3 min per day for 7 d in the behavioral room. mice were given free access to the reward (ensureplus vanilla nutrition shake solution mixed with equal parts water (ensure); abbott laboratories, abbott park, il) in a 50 ml conical tube cap in their home cages on the last 3 d of handling to familiarize them to the novel solution. mice were also habituated to patch cord attachment during the last 3 d of handling for optical stimulation and fiber photometry experiments. immediately before training each day, a patch cord was connected to their optical fiber(s) via zirconia sleeve(s) (1.25 mm, doric lenses) before being placed in the behavioral chamber. all operant training was carried out using med associates modular test chambers and accessories (env-307a; med associates inc, georgia, vt). for optical stimulation experiments, test chambers were housed in sound attenuating chambers (env-022m). two nose poke ports (env-313-m) were placed on the left wall of the chamber and the reward receptacle (env-303lphd-rl3) was placed on the right wall. the receptacle cup spout was connected to a 5 ml syringe filled with ensure loaded in a single speed syringe pump (phm-100). nose pokes and receptacle entries were detected by infrared beam breaks. the tone generator (env-230) and speaker (env-224bm) were placed outside the test chamber, but within the sound attenuating chamber, to the left. the house light (used for timeout, env-315m) was placed on top of the tone generator to avoid snagging patch cords. each chamber had a fan (env-025f28) running throughout the session for ventilation and white noise. behavior chambers were connected to a computer running medpc iv to collect event frequency and timestamps. for optical stimulation experiments, a hole drilled in the top of the sound attenuating chambers allowed the patch cord to pass through. initial bla ach3.0 (figure 2a-e) and bla camkiia gcamp6s (figure 3 ) fiber photometry recordings occurred in a darkened behavioral room outside of sound attenuating chambers due to steric constraints with rigid fiber photometry patch cords. later behavioral chamber optimization (wall height was extended with 3d printed and laser cut acrylic panels to allow removing the test chamber lid while preventing escape) allowed all other fiber photometry cohorts to be tested inside sound attenuating chambers. for fiber photometry experiments, a custom receptacle was 3d printed that extended the cup beyond the chamber wall to allow mice to retrieve the reward with more rigid patch cords. each mouse was pseudo-randomly assigned to behavioral chamber when multiple chambers were used, counterbalancing for groups across boxes. three weeks after surgery, initial operant familiarization consisted of one 35 min session of free reward to demonstrate the location of reward delivery; all other sessions were 30 min. during free reward, only the reward receptacle was accessible. after 5 min of habituation, ensure (24 ml over 2 s) was delivered in the receptacle cup and a light was turned on above the receptacle. the receptacle light was turned off upon receptacle entry. the next phase of operant familiarization, mice learned to nose poke to receive reward on a fixed-ratio one (fr1) schedule of reinforcement. mice in experiments involving manipulations (optical stimulation and antagonist studies) were pseudo-randomly assigned to left or right active (reinforced) nose poke port. mice in fiber photometry experiments were all assigned to right active port to minimize potential across subject variability. the inactive (unreinforced) port served as a locomotor control. during fr1 operant familiarization, each nose poke response into the active port resulted in receptacle light and reward delivery. after the mice reached criterion on fr1 operant familiarization (group average of 30 rewards for 2 consecutive days, usually 4-5 d), mice were advanced to the pre-training phase. this phase incorporated an auditory tone (2.5-5 khz,~60 db) that lasted for at most 10 s and signaled when active nose pokes would be rewarded. only active nose pokes made during the 10 s auditory tone (correct nose pokes) resulted in reward and receptacle light delivery. the tone co-terminated with ensure delivery. during pre-training, there was no consequence for improper nose pokes, neither in the active port outside the tone (incorrect nose pokes) nor in the inactive port (inactive nose pokes). the number of inactive nose pokes were typically very low after operant familiarization and were not included in analysis. after reward retrieval (receptacle entry following reward delivery) the receptacle light was turned off and the tone was presented again on a variable intertrial interval schedule with an average interval of 30 s (vi 30), ranging from 10 to 50 s (ambroggi et al., 2008) . after 4-5 d of pre-training, mice progressed to the training phase, which had the same contingency as pre-training except incorrect nose pokes resulted in a 5 s timeout signaled by house light illumination, followed by a restarting of the previous intertrial interval. mice were considered to have acquired the task after earning 20 rewards during the training phase of the task. in order to promote task acquisition, mice that were not increasing number of rewards earned reliably were moved to a vi 20 schedule after 9 d of vi 30 training for bla ach3.0 or 6-7 d for bla camkiia cell mice. the vi 20 schedule was only needed for the two groups that were trained outside of the sound attenuating chambers. mice progressed to extinction after 12 d of training or, in the case of fiber photometry cohorts, once all mice met the acquisition criteria. extinction was identical to training except no ensure was delivered in response to correct nose pokes. the replicate cohorts of the bla camkiia gcamp6s and nbm-bla terminal fiber recording experiments were advanced to 1 d of extinction after only 7 d of training due to the covid-19 shutdown. between mice, excrement was removed from the chambers with a paper towel. at the end of the day chambers were cleaned with rescue disinfectant (virox animal health, oakville, ontario, canada) and ensure syringe lines were flushed with water then air. mice were excluded from analyses if a behavioral chamber malfunctioned (e.g. syringe pump failed) or they received the improper compound. fiber photometry mice were excluded from analyses if they did not meet the acquisition criterion by the last day of training. see supplementary file 1 for number of mice that acquired, were excluded, and further explanations for behavioral paradigm deviations. optical stimulation was generated by a 473 nm diode-pumped solid-state continuous wave laser (opto engine llc, midvale, ut) controlled by a ttl adapter (sg-231, med associates inc). the laser was connected to a fiber optic rotary joint (doric lenses) via a mono fiber optic patch cord (200 mm core, 220 mm cladding, 0.53 na, fc connectors; doric lenses). the rotary joint was suspended above the sound attenuating chamber with a connected branching fiber optic patch cord (200 mm core, 220 mm cladding, 0.53 na, fc connector with metal ferrule; doric lenses) fed into the behavioral box. laser power was adjusted to yield 10-12 mw of power at each fiber tip. the stimulation pattern was 25 ms pulses at 20 hz for 2 s modified from parameters in jiang et al., 2016. jiang et al. used a 20 hz pulse frequency, 5 ms pulses, and 10-12 mw power at the fiber tips. in this study, we used a 2 s stimulation duration because it matched the time of syringe pump activation for reward delivery and co-terminated with the pump and auditory tone. a 25 ms pulse width was used because our lasers were not able to generate sufficient power with 5 ms pulses. optical stimulation was only delivered during the pre-training and training phases of the operant task. both control (eyfp) and experimental (chr2) groups received identical light delivery, and stimulation was triggered by a correct nose poke and co-terminated with the auditory tone and ensure delivery. for the non-contingent experiment, the number of light stimulations was yoked to the concurrently running chr2 mouse. the timing of the non-contingent stimulation was explicitly unpaired with correct nose pokes or tones and was held in queue until the mouse had not made a response in the last 2 s, a tone was not going to be delivered within the next 2 s, or at least 5 s had passed since the mouse entered the receptacle after earning reward. fluorescent measurements of ach and calcium levels were recorded using two doric lenses 1-site fiber photometry systems: a standard 405/465 nm system and a 405/470/560 nm system. the standard 405/465 system was configured as follows: the fiber photometry console controlled the two connectorized leds (cleds, 405 nm modulated at 208.616 hz and 465 nm modulated at 572.205 hz) through the led module driver (cassidy et al., 2019) . each cled was connected via attenuating patch cord to the five-port fluorescence minicube (fmc5_ae(405)_af(420-450)_e1(460-490)_f1 (500-550)_s). a pigtailed fiber optic rotary joint was connected to the minicube and suspended above the behavioral chamber with a rotary joint holder in order to deliver and receive light through the implanted optical fiber. the other end of the rotary joint was connected to the mono fiber optic patch cord via m3 connector and attached with a zirconia sleeve to the implanted fiber optic as above. the f1 (500-550 nm) port of the minicube was connected to the photoreceiver (ac low mode, new focus 2151 visible femtowatt photoreceiver, new focus, san jose, ca) via a fiber optic adapter (doric lenses) that was finally connected back to the fiber photometry console through an analog port. the 405/470/560 nm system was set up similarly, except a 560 nm led was incorporated (modulated at 333.786 hz), a six-port minicube with two integrated photodetector heads was used (ifmc6_ie(400-410)_e1(460-490)_f1(500-540)_e2(555-570)_f2(580-680)_s), and doric fluorescence detector amplifiers were used (ac 1â or 10â mode, dfd_foa_fc). a ttl adapter (sg-231, med associates inc) was connected to the digital input/output port to allow for timestamping when events occurred in the behavioral chamber. signal was recorded using doric neuroscience studio (v 5.3.3.14) via the lock-in demodulation mode with a sampling rate of 12.0 ks/s. data were decimated by a factor of 100 and saved as a comma-separated file. pre-processing of raw data was performed using a modified version of a matlab (mathworks, natick, ma) script provided by doric. the baseline fluorescence (f0) was calculated using a firstorder least mean squares regression over the~30 min recording session. second-order least mean squares regressions were used when photobleaching of the sensor was more pronounced, as in the case of nbm-bla terminal fiber recordings. the change in fluorescence for a given time point (df) was calculated as the difference between it and f0, divided by f0, which was multiplied by 100 to yield %df/f0. the %df/f0 was calculated independently for both the signal (465 nm) and reference (405 nm) channels to assess the degree of movement artifact. since little movement artifact was observed in the recordings (figure 2-figure supplement 1b-c, figure 2 -figure supplement 5d-e, figure 3 -figure supplement 1c-d, tan lines), the signal %df/f0 was analyzed alone (the code provided allows for running the entire analysis pipeline with the reference channel %df/f0 if desired). the %df/f0 was z-scored to give the final z%df/f0 reported here. for the bla camkiia cell recordings (figure 3-figure supplement 1c-d) , the reference channel displayed some mirroring (moving in the opposite direction) compared to the signal. this is likely because 405 nm is not the 'true' isosbestic point for gcamp and we were instead measuring some changes in calciumunbound gcamp rather than calcium-insensitive gcamp signal alone (barnett et al., 2017; kim et al., 2016a; sych et al., 2019) . graphs and heatmaps for averaged traces aligned to actions were based on licking bout epoch filtering code from tdt (alachua, fl; link in code comments). combined action heatmaps were generated in matlab (2020a) by analyzing data 5 s preceding tone onset (rewarded trials only) to 5 s after receptacle entry. actions were aligned despite variable latencies by evenly splitting a maximum of 4 s post-tone onset/pre-correct nose poke and 1 s postcorrect nose poke/pre-receptacle entry for each trial within a day. the resulting aligned trials were averaged to generate daily averages that made up the rows of the individual animal heatmaps. blanks in the rows of heatmaps (black time bins) indicate time bins added for alignment, meaning that no trials for that day had a latency that stretched the entire window. only rewarded trials where the mouse entered the receptacle within 5 s after nose poke were analyzed. full or partial training days were excluded from analysis if there were acquisition issues such as the patch cord losing contact with the fiber or behavioral apparatus malfunction. lack of trials (fewer than three) for analysis or recording issues led to missing rows of fiber photometry data in the heatmap despite having behavioral data, in which case these rows were skipped rather than adding entire blank rows. due to individual differences in behavior, across-mouse average data was calculated by using a selection of days in which behavior was roughly similar or milestones such as the first and last day of pre-training, first day earning 10 rewards in training, first day crossing acquisition threshold (and maintaining afterward), last day of training, last day of extinction (with three or more rewarded trials that met analysis criteria). additional days were included in across-mouse average heatmaps when possible. incorrect nose poke heatmaps were generated by averaging signals for 5 s before and 5 s after incorrect nose pokes that were not preceded by an incorrect nose poke in the last 5 s. the incorrect nose poke heatmaps averaged across mice were generated using the same selection of days as the combined action heatmaps for a given experiment. bootstrapped confidence intervals (bcis) of the z-scored % df/f0 fiber photometry data within and across mice were generated using the methods described in jeanrichard-dit-bressel et al., 2020 for the following events: tone onset, correct nose poke, receptacle entry, and incorrect nose poke. for the within-mouse analysis by day, trials were aligned to event onset, and bcis were generated for events that had at least 3 trials from 5 s before to 10 s after each event. each series of data were bootstrapped 10,000 times and a two-sided 99% confidence interval was constructed. data were considered significantly different from baseline (z% df/f0 = 0) when their 99% bcis did not contain zero for an interval of time designated by a consecutive threshold of 0.5 s. to avoid comparing vastly different numbers of trials, in graphs where correct and incorrect nose pokes were plotted together, incorrect nose pokes were downsampled to match the number of correct nose poke trials. for incorrect nose pokes graphs where last pre-training day and training day 1 were plotted together, both days were downsampled to the number of correct nose pokes on the last pre-training day. for the combined action bci plots (tone onset, correct nose poke, and receptacle entry), the selection of days for each mouse matched that of the cohort-averaged combined action heatmaps. the three-event plots were combined by cropping to match the maximum latencies used in the combined action heatmaps. for the across-mouse averaged bci plots, analyses were carried out as above except the bootstrapping used mouse trial averages. the mean lines for across-mouse averaged bci plots were calculated by taking the mean of all individual trials together. the nbm-bla cholinergic terminal fiber experiment required combining the two independent cohorts to obtain n ! 3. for the incorrect nose poke bci plots, the number of trials used for each day was downsampled to 20 if a mouse performed more than 20. male wild-type c57bl/6j mice were injected i.p. 30 min before each pre-training and training session with a volume of 10 ml/kg with the following compounds: 1â dpbs (thermo fisher scientific, waltham, ma), 1 mg/kg mecamylamine hydrochloride (millipore sigma, st. louis, mo), 0.5 mg/kg (-) scopolamine hydrochloride (millipore sigma), or 1 mg/kg mecamylamine + 0.5 mg/kg scopolamine ( figure 5 + figure 5-figure supplement 1) . after completion of behavioral experiments, animals were anesthetized with 1â fatal-plus (vortech pharmaceuticals). once there was no response to toe-pinch, mice were transcardially perfused with 20 ml ice-cold 1â dpbs followed by 20 ml 4% paraformaldehyde (pfa, electron microscopy sciences, hatfield, pa). brains were extracted and post-fixed for at least 1 d in 4% pfa at 4˚c and transferred to 30% sucrose (millipore sigma) for at least 1 dy at 4˚c. brains were sliced 40 mm thick on a self-cooling microtome and stored in a 0.02% sodium azide (millipore sigma) pbs solution. brain slices were washed in pbs, blocked for 2-3 hr (0.3% triton x-100, american bioanalytical, canton, ma; 3% normal donkey serum, jackson immunoresearch, west grove, pa), then incubated overnight with primary antibodies (1:1000 + 1% normal donkey serum). slices were then washed in pbs and incubated with secondary antibodies (1:1000) for 2 hr, washed, stained with dapi for 5 min, washed, mounted, and coverslipped with fluoromount-g (electron microscopy sciences). all incubations were at room temperature. microscope slides were imaged using a fluoview fv10i confocal microscope (olympus). injection sites and fiber placements were designated on modified allen mouse brain atlas figures (lein et al., 2007) . mice were excluded from analyses if fluorescence was not observed at injection sites or if fiber tips were not identified at the intended site. operant behavioral data saved by medpc iv was transferred to excel using mpc2xl. data were organized in matlab and analyzed in prism (v8.3.0, graphpad software, san diego, ca). differences between groups and interactions across days for training were evaluated using two-way repeated measures anovas. we computed the required sample size for a 90% power level with an alpha of 0.05 by estimating the control (eyfp) group mean would be 10 rewards and the mean experimental (chr2) group would be 20 rewards with a standard deviation of 5. we utilized a power calculator for continuous outcomes of two independent samples, assuming a normal distribution. the result was six samples per group. each manipulation experiment started with at least six mice included in each group (sealed envelope, 2020) . in each experiment, each animal within a group served as a biological replicate. these studies did not include technical replicates. masking was not applied during data acquisition but data analyses were semi-automated in matlab and performed blind to condition. editing; miao jing, yulong li, resources, writing -review and editing; xiao-bing gao, data curation, formal analysis, investigation, writing -review and editing; yann s mineur, conceptualization, investigation, methodology, writing -review and editing; marina r picciotto, conceptualization, resources, supervision, funding acquisition, project administration, writing -review and editing supplementary files . supplementary file 1. number of mice that acquired the reward learning behavior, number that were excluded, and any training deviations. (a) mice in the initial bla ach3.0 group were trained outside of the sound attenuating chambers. these mice had 5 dof pre-training because they were trained concurrently with another cohort of mice (not shown) that required an extra day to reach two consecutive days of 20 rewards earned and were advanced to a vi 20 schedule of reinforcement during training after 9 d to promote responding. training was extended to allow all mice to acquire. due to time constraints during acquisition, mouse 3 in this cohort was moved to extinction after 20 d of training because it had acquired earlier, was earning the most rewards, and we wanted to record more extinction days. (b) mice in the bla ach3.0 and nbm-bla terminal fiber replicate experiments were advanced to 1 d of extinction after only 7 d of training due to the covid-19 shutdown. (c) bla ach3.0 and nbm-bla terminal fiber jrcamp1b mice were analyzed as dual channel mice just through pre-training and were instead used as replicates of the bla ach3.0 experiment. one of the mice had apparatus errors during training and had to be excluded. (d) mice in the initial bla camkiia gcamp6 were trained outside of the sound attenuating chambers. mouse 1 progressed from pre-training to training a day earlier than the rest of the group and was able to have an extra day of training before the 2 d of extinction. mice in this group were advanced to a vi 20 schedule of reinforcement during training after 6-7 d to promote responding. training was extended to allow more mice to acquire. . transparent reporting form data availability all data generated or analysed during this study are included in the manuscript and supporting files. source data files have been provided for all experiments on dryad digital repository: https://doi. org/10.5061/dryad.3xsj3txcf. the following dataset was generated: conceptualization, resources, data curation, software, formal analysis, validation, investigation, visualization, methodology, writing -original draft data curation, formal analysis, investigation, methodology, writing -review and editing conceptualization, data curation, investigation, methodology, writing -review and editing data curation, software, formal analysis, investigation, visualization, writing -review investigation, methodology, writing -review and editing basal forebrain and brainstem cholinergic neurons differentially impact amygdala circuits and learning-related behavior basolateral amygdala neurons facilitate reward-seeking behavior by exciting nucleus accumbens neurons deciphering the molecular mechanism responsible for gcamp6m's ca2+-dependent change in fluorescence the amygdala and reward muscarinic receptors in amygdala control trace fear conditioning activation of phenotypically-distinct neuronal subpopulations of the rat amygdala following exposure to predator odor involvement of the amygdala in stimulus-reward associations: interaction with the ventral striatum a camkiialpha icre bac allows brain-specific gene inactivation a lateral hypothalamus to basal forebrain neurocircuit promotes feeding by suppressing responses to anxiogenic environmental cues ultrasensitive fluorescent proteins for imaging neuronal activity a cholinergic mechanism for reward timing within primary visual cortex sensitive red protein calcium indicators for imaging neural activity. elife 5:e12727 high-performance calcium sensors for imaging activity in neuronal populations and microcompartments muscarinic control of graded persistent activity in lateral amygdala neurons amygdala inputs to the ventral hippocampus bidirectionally modulate social behavior timing-dependent septal cholinergic induction of dynamic hippocampal synaptic plasticity the cholinergic basal forebrain links auditory stimuli with delayed reinforcement to support learning central cholinergic neurons are rapidly recruited by reinforcement feedback from circuits to behaviour in the amygdala analyzing event-related transients: confidence intervals, permutation tests, and consecutive thresholds cholinergic signaling controls conditioned fear behaviors and enhances plasticity of cortical-amygdala circuits a genetically encoded fluorescent acetylcholine indicator for in vitro and in vivo studies an optimized acetylcholine sensor for monitoring in vivo cholinergic activity simultaneous fast measurement of circuit dynamics at multiple sites across the mammalian brain antagonistic negative and positive neurons of the basolateral amygdala the lateral amygdaloid nucleus: sensory interface of the amygdala in fear conditioning genome-wide atlas of gene expression in the adult mouse brain selective activation of a putative reinforcement signal conditions cued interval timing in primary visual cortex state-specific gating of salient cues by midbrain dopaminergic input to basal amygdala dual-transmitter systems regulating arousal, attention, learning and memory an optimized fluorescent probe for visualizing glutamate neurotransmission stability, affinity, and chromatic variants of the glutamate sensor iglusnfr a genetically encoded fluorescent sensor for in vivo imaging of gaba projection neurons of the basolateral amygdala: a correlative golgi and retrograde tract tracing study intra-amygdala infusions of scopolamine impair performance on a conditioned place preference task but not a spatial radial maze task fear conditioning induces a lasting potentiation of synaptic currents in vitro cytisine, a partial agonist of high-affinity nicotinic acetylcholine receptors, has antidepressant-like properties in male c57bl/6j mice vesicular glutamate transporter 3 immunoreactivity is present in cholinergic basal forebrain neurons projecting to the basolateral amygdala in rat prefrontal acetylcholine release controls cue detection on multiple timescales acetylcholine as a neuromodulator: cholinergic signaling shapes nervous system function and behavior nucleus accumbens fast-spiking interneurons constrain impulsive action regulation of synaptic efficacy in hypocretin/orexin-containing neurons by melanin concentrating hormone in the lateral hypothalamus fear conditioning induces associative long-term potentiation in the amygdala visual responses of neurons in the dorsolateral amygdala of the alert monkey forebrain cholinergic signaling: wired and phasic, not tonic, and causing behavior corelease of acetylcholine and gaba from cholinergic forebrain neurons orbitofrontal cortex and basolateral amygdala encode expected outcomes during learning a neural substrate of prediction and reward predictive reward signal of dopamine neurons power calculator for continuous outcome superiority trial basolateral amygdala neurons maintain aversive emotional salience basal forebrainderived acetylcholine encodes valence-free reinforcement prediction error high-density multi-fiber photometry for studying large-scale brain circuit dynamics rapid strengthening of thalamo-amygdala synapses mediates cue-reward learning amygdala circuitry mediating reversible and bidirectional control of anxiety amygdala neurons differentially encode motivation and reinforcement impact of basal forebrain cholinergic inputs on basolateral amygdala neurons gaba interneurons mediate the rapid antidepressant-like effects of scopolamine cholinergic systems in mammalian brain and spinal cord the basal forebrain cholinergic projection system in mice. the mouse nervous system was connected to a computer running ethovision xt (version 10.1.856, noldus, wageningen, netherlands) to track the position of the mouse and deliver optical stimulation when the mouse was on the laserpaired side (via ttl pulse to otpg_4 laser controller (doric lenses) connected to the laser; 20 hz, 25 ms pulses). optical stimulation on a progressive ratio schedule (escalations given below) these studies were supported by grants da14241, da037566, mh077681. lw, dt, and pr were supported by ns022061, mh109104 from the national institutes of health, and by the intramural programs of ninds and nimh. x-bg was supported by da046160. rbc was supported by t32-ns007224. this work was funded in part by the state of connecticut, department of mental health and addiction services but this publication does not express the views of the department of mental health and addiction services or the state of connecticut. the views and opinions expressed are those of the authors. we thank samantha sheppard for the use of her mouse illustration and animal care assistance and nadia jordan-spasov for genotyping and laboratory help. li jiang performed the ex vivo current-clamp recordings. angela lee and wenliang zhou provided helpful input into experimental planning. colin bond, marcelo dietrich, usman farooq, onur iyilikci, sharif kronemer, matthew pettus, and zach saltzman provided insightful discussion and assistance with analysis and figure design. ralph dileone, stephanie groman, hyojung seo, and jane taylor offered helpful discussion about experimental design and analysis. the support teams at doric lenses (alex cô té and the funders had no role in study design, data collection and interpretation, or the decision to submit the work for publication. olivier dupont-therrien) and tucker-davis technologies provided discussion, analysis support, and matlab code assistance. supplemental methods ex vivo electrophysiology slice preparation coronal brain slices were prepared from virus injected mice after 3 weeks from surgery. animals were anesthetized with a mixture of ketamine and xylazine (100 mg ketamine and 6 mg xylazine/kg body weight injected ip). then the mice were transcardially perfused with a sucrose-based solution (see below). after decapitation, the brain was rapidly transferred into a sucrose-based cutting solution bubbled with 95% o 2 and 5% co 2 and maintained at~3˚c. this solution contained (in mm): sucrose 230; kcl 2.5; mgso 4 10; cacl 2 0.5; nah 2 po 4 1.25; nahco 3 26; glucose 10 and pyruvate 1.5. coronal brain slices (300 mm) were prepared using a leica vt1000s vibratome (leica biosystems inc). slices were equilibrated with a mixture of oxygenated artificial cerebrospinal fluid (acsf) and sucrose-based cutting solution at room temperature (24-26˚c) for at least 1 hr before transfer to the recording chamber. pyruvate (0.15-0.75 mm) was added to reduce oxidative damage and enhance survival. with this protocol, slices are initially incubated in a mixture of 50% cutting solution with pyruvate and 50% acsf (in mm): sucrose 115; nacl 63; kcl 2.5; nah 2 po 4 1.25; mgso 4 5; cacl 2 1.25; mgcl 2 1; nahco 3 26; glucose 10; and sodium pyruvate 0.75 at 35˚c for 30 min and then transferred to a mixture of 10% cutting solution and 90% acsf (in mm): sucrose 23; nacl 113.4; kcl 2.5; nah 2 po 4 1.25; mgso 4 1; cacl 2 1.85; mgcl 2 1.8; nahco 3 26; glucose 10; and sodium pyruvate 0.15 at 35˚c for 1-4 hr before recording. the slices were continuously superfused with acsf at a rate of 2 ml/min containing (in mm); nacl 126, kcl 2.5, nah 2 po 4 1.25, nahco 3 26, cacl 2 2, mgcl 2 2 and glucose 10 bubbled with 95% o 2 and 5% co 2 at room temperature. brain slices were placed on the stage of an upright, infrared-differential interference contrast microscope (olympus bx51wi, olympus). nbm neurons were visualized with a 40 â water-immersion objective by infrared microscopy (cohu 4915 camera, cohu, inc, poway, ca). patch electrodes with a resistance of 4-6 mw were pulled with a laser-based micropipette puller (p-2000, sutter instrument company). signals were recorded with a multi clamp 700a amplifier and pclamp10 software (molecular devices, inc, san jose, ca). the pipette solution contained (in mm) 130 k-gluconate, 2 kcl, 2 mgcl 2 , 10 hepes, 0.5 egta, 1 atp and 0.2 gtp (ph = 7.3).to examine action potential firing frequency, nbm neurons were recorded in a current clamp configuration after forming a giga-ohm seal. membrane potentials were clamped at à60 mv by injecting 0-~50 pa current through the recording electrode as needed. cells that maintained steady membrane potentials for at least five mins were included in the analysis. channelrhodopsin was activated with a train of light flashes delivered through the 40â microscope objective. the light source was an olympus x-cite 120q lamp (olympus) gated with a ttl controlled shutter (lambda sc, sutter instrument). the filter cube contained an hq480/40x excitation filter, a q505lp bypass filter and an hq535/50 m emission filter (chroma technology corp., bellows falls, vt). the fluorescence illumination intensity delivered at the brain slices was adjusted to 1-3 mw/ mm 2 , measured with a pm100d optical power and energy meter (thorlabs inc, newton, nj). in the nbm, cholinergic neurons were identified by egfp fluorescence and light flashes were delivered at 1 hz, 5 hz, 10 hz, 15 hz, 20 hz, 25 hz, and 30 hz. after xtinction, responding was reinstated in training for 2 d. then mice underwent a modified training paradigm where correct nose pokes yielded only laser stimulation, without ensure delivery. locomotor data was collected using an accuscan instruments (columbus, ohio) behavior monitoring system and software. mice were individually tested in empty cages, with bedding and nesting material removed to prevent obstruction of infrared beams. mice were injected (i.p.) with saline, mecamylamine (1 mg/kg, sigma), scopolamine (0.5 mg/kg, sigma), or mecamylamine+scopolamine (1 mg/kg and 0.5 mg/kg, respectively) 30 min before locomotor testing. locomotion was monitored for 20 min using 13 photocells placed 4 cm apart to obtain an ambulatory activity count, consisting of the number of beam breaks recorded during a period of ambulatory activity (linear motion rather than quick, repetitive beam breaks associated with behaviors such as scratching and grooming). a rectangular box was divided evenly into a light (clear top, illuminated by an 8w tube light) and dark (black walls, black top) side with a black walled divider in the middle with a small door. the lid and divider were modified to allow the optical fiber and patch cord to pass through freely. mice were placed facing the corner on the light side furthest from the divider and the latency to crossing to the dark side was measured. the number of crosses and time spent on each side were measured for 6 min following the initial cross. key: cord-340882-why0t9ld authors: carneiro, lara; afonso, josé; ramirez-campillo, rodrigo; murawska-ciałowciz, eugenia; marques, adilson; clemente, filipe manuel title: the effects of exclusively resistance training-based supervised programs in people with depression: a systematic review and meta-analysis of randomized controlled trials date: 2020-09-15 journal: int j environ res public health doi: 10.3390/ijerph17186715 sha: doc_id: 340882 cord_uid: why0t9ld the purpose of this study was to systematically review the effects of supervised resistance training (rt) programs in people diagnosed with depression or depressive symptoms. the following databases were used to search and retrieve the articles: cochrane library, ebsco, pedro, pubmed, scopus and web of science. the search was conducted in late june 2020. search protocol required the title to contain the words depression or depressive or dysthymia. furthermore, the title, abstract or keywords had to contain the words or expressions: “randomized controlled trial”; and “strength training” or “resistance training” or “resisted training” or “weight training”. the screening provided 136 results. after the removal of duplicates, 70 records remained. further screening of titles and abstracts resulted in the elimination of 57 papers. therefore, 13 records were eligible for further scrutiny. of the 13 records, nine were excluded, and the final sample consisted of four articles. results were highly heterogeneous, with half of the studies showing positive effects of resistance training and half showing no effects. in two of the four combinations, the meta-analysis revealed significant benefits of rt in improving depressive symptoms (p ≤ 0.05). however, considering significant differences with moderate (effect size = 0.62) and small (es = 0.53) effects, the heterogeneity was above 50%, thus suggesting a substantial level. to draw meaningful conclusions, future well-designed randomized controlled trials (rcts) are needed that focus on understudied rt as a treatment for depression. data from 2016 has revealed that depression is the leading cause of mental health-related disease burden globally, affecting an estimated 300 million people worldwide [1] . the who declared the sars-cov-2 (covid-19) outbreak a global pandemic in march 2020, which has affected the lives of 71,429 people globally [2] , and may potentially generate an increase in depressive states as a result of psychosocial stressors like life disruption, fear of illness, or fear of negative economic effects [3, 4] . therefore, it is important to understand how to approach depression and depressive symptoms in order to better prepare for an expected increase of people affected by it. the conventional treatment to treat depression is antidepressant medication. besides pharmacotherapy, clinicians recommend cognitive behavior therapy and mindfulness-based therapy [5] , as well as physical exercise [6] . thus, treatment guidelines for mental illnesses from leading international organizations now recommend the integration of physical activity-based interventions as part of routine psychiatric care [7] . exercise promises to be an efficacious treatment for people with depression. indeed, several systematic reviews and meta-analyses have positively assessed the effects of exercise on depression [8] [9] [10] [11] [12] [13] [14] . furthermore, persons with depression are at an increased risk of sedentary behavior [15] , and exercise contributes to physical health in addition to mental health [6] . specifically, evidence-based recommendations for the prescription of exercise for patients with major depressive disorders (mdds) propose interventions of 2-3 sessions of supervised aerobic and/or aerobic and resistance training exercise of 45-60 min duration with moderate intensity per week [7] , although it has been suggested that the volume of training may be more relevant than frequency [16] . to achieve optimal outcomes and decrease dropouts, the evidence also indicates that physiotherapists and qualified exercise professionals should lead and supervise physical exercise programs [17] . even home-based programs, which may occur due to a plethora of reasons (e.g., distance, difficulties with transportation, costs), could benefit from being supervised through the utilization of new technological tools [18] . this could become more relevant if future scenarios similar to the covid-19 situation are to be repeated and, therefore, force people to stay at home for prolonged periods of time. the benefits of aerobic exercise (ae) for depression have been well documented; namely, it has been recognized that it promotes neurophysiological effects of which results may be similar to those observed after antidepressant drug treatments [19] . a meta-analysis of seven randomized controlled trials [20] showed that there was also good evidence that aerobic exercise over roughly 12 weeks improved cardiorespiratory fitness in people with depression. however, the effects of resistance training (rt) are less investigated, and the literature regarding rt as a stand-alone therapeutic intervention for mdd is limited [7] . earlier studies that focused on rt for people with depression reported positive effects. however, these must be interpreted with caution due to the heterogeneity of the interventions and poor methodology by reporting several confounding variables that could interfere and introduce the potential for bias. as an example, kim et al. [21] aimed to investigate the effects of 24 weeks of the rt program on depression in older women and their neurotransmitters. however, the rt intervention was composed of a 10 min warm-up consisting of walking and dynamic stretching, and then a 10 min cool-down with static stretching. therefore, 20 min of the program, 40% of the session in part i, 33 .3% in part ii and 28.5% to 25% in part iii, were devoted to activities that were not resistance training, and this may have contaminated the data. to date, only one meta-analysis examined the efficacy of rt on depressive symptoms. gordon and colleagues [22] analyzed 33 papers meeting their inclusion criteria. their review concluded that rt significantly reduced depressive symptoms in adults regardless of health status, the total prescribed volume of rt, or significant improvements in strength. however, in the present systematic review and meta-analysis, which differs from the previous, more strict inclusion and exclusion criteria were defined. namely, we excluded other comorbidities (e.g., parkinson's, alzheimer's, cancer and dementia) and only supervised exclusively resistance training-based interventions, with minimal warm-up activities outside the scope of the main exercise mode. therefore, this systematic review and meta-analysis allows for a more comprehensive assessment of the potential benefits of rt for depression pathology. hence, this systematic review with meta-analysis (srma) addresses one question: how effective is a stand-alone supervised intervention with rt at improving depression? this systematic review and meta-analysis followed the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines and the cochrane collaboration guidelines for the evaluation of risk of bias in randomized studies. the protocol was published in the international platform of registered systematic review and meta-analysis protocols with the number inplasy202070004 and doi 10.37766/inplasy2020.7.0004. articles were eligible if they were published or in press in a peer-reviewed journal, with full text in the english language. no limitations were placed regarding publication date, and articles in press were considered. the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines were adopted [23] . p.i.c.o.s. was established as follows: (i) participants were humans explicitly diagnosed with any form of depression according to established criteria (e.g., the american psychiatric association's [24] diagnostic and statistical manual of mental disorders-dsm-5 ® or previous versions, or the world health organization's [25] international classification of diseases-icd-11 or previous versions) or those with depressive symptoms above clinical threshold (cutoff values) determined by a validated screening measure (e.g., beck depression inventory-bdi or bdi-ii-by beck et al. [26] , the hamilton rating scale for depression-ham-d-by hamilton [27] , the geriatric depression scale-gds-of yesavage [28] ), but without other major disease (e.g., parkinson's, alzheimer's, cancer, dementia); (ii) only supervised exclusively resistance training-based interventions were considered, with minimal warm-up activities outside the scope of the main exercise mode; comparators were control groups not performing any training protocol and/or supervised contrast groups also performing an alternative exercise program (i.e., yoga, stretching, aerobic exercise); outcomes were any effects on performance, health and quality of life; study design was limited to randomized controlled trials (rcts). the following databases were used to search and retrieve the articles: cochrane library, ebsco, pedro, pubmed, scopus and web of science. the search was conducted in late june 2020. search protocol required the title to contain the words depression or depressive or dysthymia. furthermore, the title, abstract or keywords had to contain the words or expressions: (i) "randomized controlled trial"; and (ii) "strength training" or "resistance training" or "resisted training" or "weight training". no limitations were established for publication date, and in press articles were considered. for cochrane library, only trials were considered. for ebsco, the title and abstract had to be searched separately, and, therefore, we chose to search (i) "randomized controlled trial"; and (ii) "strength training" or "resistance training" or "resisted training" or "weight training" without any limitations in the field. for pubmed, combined search only afforded the selection of title/abstract, not keywords. the same was valid for pedro, besides only affording one field at a time. therefore, multiple searches were needed in pedro. in addition, the criterion of "clinical trial" was selected, therefore automatically excluding practice guidelines and systematic reviews. in web of science, the combination of title, abstract and keywords was termed "topic". the initial screening provided 136 results. after the removal of duplicates, 70 records remained. screening of titles and abstracts resulted in the elimination of 57 papers. this was due to the following reasons: (i) non-scientific production (e.g., protocol registrations without actual research; book chapters, letters, replies); (ii) reviews (e.g., narrative or systematic reviews, meta-analyses); (iii) abstract-only records; (iv) original research where the exercise intervention did not apply resistance training; (v) original research where there was no group exclusively using resistance training; (vi) participants with other major health problems (e.g., cancer, parkinson's disease, dementia, end-stage renal disease); (vii) single group experiments; and (viii) papers unrelated to our topic. therefore, 13 records were considered eligible for further scrutiny, and all were written in the english language. of the 13 records eligible for full-text analysis, nine were excluded. the paper by kim, o'sullivan and shin [21] was excluded because the warm-up consisted of 10 min of walking and dynamic stretching, and the training session was followed by a 10 min warm-down consisting of static stretching. therefore, 20 min of the program (representing 40% of the training in part i of the program, 33.3% in part ii and 28.5% to 25% in part iii) was devoted to activities that were not resistance training, and this may have contaminated the results. similarly, the paper by pereira et al. [29] included a 20 min warm-up consisting of walking and stretching, thereby meaning that 40% of the training session duration was not composed of resistance training. in a similar vein, sims et al. [30] stated that there were warm-up and warm-downs besides resistance training, but there was no reporting of the duration and type of activities performed in these two stages. the paper of teychenne et al. [31] was excluded because the strength and conditioning group had a mixture of resistance training and aerobic training. the papers of ansai and rebelatto [32] , chin et al. [33] , kekäläinen et al. [34] , lecheminant et al. [35] , and levinger et al. [36] were excluded because there was no diagnostic of depression and the average values of the utilized scales for evaluation of depression or depressive symptoms did not reach the cut-off value indicative of depressive symptoms. the final sample consisted of four articles: krogh et al. [37] , moraes et al. [38] , sims et al. [39] and singh et al. [40] . the process is synthesized in figure 1 . two of the four articles included had more than one main outcome, resulting in the need to perform more than one meta-analysis ( figure 1 ). ja and fmc conducted the initial search and the screening and exclusion process independently. lc later reviewed the entire process. after this stage, the entire process was compared step by step, and disagreements were discussed with all the authors of this manuscript until consensus was achieved. study characteristics: (i) sample size and general characteristics (e.g., age, sex/gender, physical activity habits); (ii) duration and characteristics of the intervention; (iii) adherence rates to the training protocol. primary outcomes: mean change in depressive symptoms in the exercise group assessed by any validated scale, from baseline to post-intervention, in comparison with the mean change of the control and/or comparison groups. if an author reported the results of two outcome measures meeting our criteria (i.e., mean change/pre and post-test change in depressive symptoms according to two different measures), we used the primary outcome chosen by the author. if this was not clear, we used the ham-d or the bdi to increase homogeneity in our results. these outcome measures were also prioritized since they were commonly used in the exercise and depression literature [9] . secondary outcomes: (i) physical (e.g., performance tests, body composition, perceived exertion); (ii) psychosocial (e.g., body image and appearance, reporting of positive or negative feelings, self-esteem, cognitive evaluations, memory and concentration tasks). the revised cochrane risk-of-bias tool for randomized trials (rob 2) was applied to evaluate the individual studies, considering its five dimensions: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in the measurement of the outcome and bias in the selection of the reported results. ja and fmc completed the risk-of-bias evaluation independently. after completion of the first coding, the figures were compared, and all disagreements were discussed with all authors of the manuscript and reanalyzed until consensus was achieved. the analysis and interpretation of results in this srma were only conducted if at least three study groups provided baseline and follow-up data for the same measure [41] . means and standard deviations for a measure of pre-post rt interventions were converted to hedges' g effect size (es). the inverse-variance random-effects model for meta-analyses was used because it allocated a proportionate weight to trials based on the size of their standard errors [42] and enabled analysis while accounting for heterogeneity across studies [43] . the ess were presented alongside 95% confidence intervals (cis) and interpreted using the following thresholds [44] : <0.2, trivial; 0.2-0.6, small; >0.6-1.2, moderate; >1.2-2.0, large; >2.0-4.0, very large; >4.0, extremely large. the analyses were carried out using the comprehensive meta-analysis program (version 2; biostat, englewood, nj, usa). to estimate the degree of heterogeneity between the included studies, the percentage of total variation across the studies due to heterogeneity was used to calculate the i 2 statistic [45] . low, moderate and high levels of heterogeneity corresponded to i 2 values of <25%, 25-75% and >75%, respectively [45] . finally, the extended egger's test [46] was used to assess the risk of bias across the studies. in case of bias, a sensitivity analysis was conducted. as described in the methods, the initial search provided 136 articles, of which 70 remained after the removal of duplicates. screening delivered 13 articles eligible for full-text analysis, after which nine papers were excluded with reasons that were previously explained. four articles were included in the qualitative synthesis and meta-analysis. table 1 presents the general data items for the individual studies. the article by krogh, saltin, gluud and nordentoft [37] was an rct with patients diagnosed with unipolar depression according to the icd 10th revision. the sample of 165 patients (73.9% of which were women) was by far the largest among the included articles, potentially affording greater confidence in terms of the generalizability of the results. furthermore, it was the longest trial, with 16 weeks of intervention. three randomized groups of 55 patients each were formed: (i) rt; (ii) aerobic training; and (iii) relaxation, which had characteristics that approximated it to a true control group. primary outcomes were assessed with the hamilton scale, and there were no changes after the 16-week intervention. there were also no changes in secondary outcomes, such as quality of life and cognitive abilities. however, the resistance training group improved in 1 repetition maximum (1rm) testing, while the aerobic group improved in maximal oxygen uptake. most importantly, there were reduced percentages of days absent from work in the rt group. the lack of broader and better results may, however, be due to very poor adherence rates to the training programs, with the top value of 56.2% being attributed to the rt group. table 2 synthesizes the details concerning the rt protocols, table 3 synthesizes the parallel group protocols, while table 4 synthesizes the results for primary outcomes. exercise did not change primary outcomes, but rt reduced absences to work. rt group improved in 1rm chest press, while at group improved in maximal oxygen uptake. no effect on cognitive abilities. moraes et al. [38] randomized trial with three exercise groups as adjunct treatments to pharmacotherapy (antidepressants and anxiolytics) for 25 persons diagnosed with major depressive disorder (mdd) according to dsm-iv, not engaged in physical exercise outside of the treatment setting. patients were over 60 years old and sedentary for more than 3 months. exclusion criteria: psychiatric comorbidities, score >18 points in ham-d, score <24 on the mini-mental state examination, cerebrovascular infarction, neurodegenerative disease, severe cardiovascular disease, illiteracy, poor mobility, balance disorders, and severe deficits in visual and/or auditory function. a 12-week intervention. resistance training (n = 9). aerobic training (n = 9). low intensity exercise control (n = 7). all patients had a minimum of 75% attendance rate. none. rt and at groups showed significant reductions in depressive symptoms in both scales compared to controls, therefore improving upon the efficacy of pharmacological treatment only. authors report the rt group had lower depression scores after the intervention, but not at the 6-month follow-up. however, the rt group already had much lower depression scores at baseline. rt group improved significantly in strength, but ultimately there were no significant changes in ces-d from pre-to post or at follow-up. singh et al. [40] randomized controlled trial with 60 adults (33 women and 27 men, >60 years old) with major or minor depression or dysthymia, determined through dsm-iv, and who also had gds score ≥14. exclusion criteria: dementia, folstein mini-mental state examination score ≤23, medical contraindications for exercise, bipolar disorder, active psychosis, perceived suicidal tendencies, currently seeing a psychiatrist, prescribed antidepressant drugs in the previous 3 months, or participating in any exercise training more than twice a week.an 8-week intervention. high intensity rt (n = 20). eighteen completed the study. low intensity rt (n = 20). seventeen completed the study. controls (n = 20). nineteen completed the study. there were six drop-outs. of those who completed the study, adherence rates were >95%. ham-d 17 . gds. physical outcomes: 1rm chest press, upright row, shoulder press, leg press, knee extension and knee flexion. moraes, silveira, oliveira, matta mello portugal, araújo, vasques, bergland, santos, engedal, coutinho, schuch, laks and deslandes [38] performed a 12-week, three-armed randomized intervention with 25 patients diagnosed with mdd according to dsm-4, and all taking medication, with the three groups (i) rt; (ii) aerobic training; and (iii) low-intensity exercise control. the small sample, especially the small number of patients per group, advises caution when generalizing the results. the adherence to the intervention was solid, with all patients engaging in ≥75% of the training sessions. after the intervention, both exercise groups outperformed the controls, showing significant reductions in both the hamilton scale and the beck depression inventory, suggesting that exercise improves the efficacy of exclusively pharmacological interventions. no secondary outcomes were assessed. in their investigation, sims, galea, taylor, dodd, jespersen, joubert and joubert [39] investigated 45 stroke survivor patients (stroke > 6 months before the investigation) diagnosed with depressive symptoms, but that were otherwise healthy at the beginning of the intervention, including in cardiovascular terms (see exclusion criteria in table 1 ). the 10-week program compared an rt group with a non-exercise control group. adherence was solid, with an average of 75% attendance rate to training sessions. the authors reported lower depression scores in the rt group after the 10-week intervention, but not after the 6-month follow-up. this should be interpreted as a normal detraining effect; after all, the patients exercised for 10 weeks, but later went through a detraining process lasting 14 weeks. however, even the short-term comparisons after the 10-week intervention should be taken with a grain of salt, as the differences in the centre for epidemiologic studies for depression scale (ces-d) were already significant in baseline testing, with the exercise group presenting lower scores even before the intervention had started. there were no changes in secondary outcomes, such as quality of life, social support, self-esteem and other psychosocial assessments. unsurprisingly, the rt group improved in 1rm strength testing. finally, singh, stavrinos, scarbek, galambos, liber and singh [40] selected 60 adults with some form of depression or depressive symptoms and randomized them into a high-intensity rt group, a low-intensity rt group and a control group. adherence rates to the 8-week program were excellent, with over 95% average attendance rate to the training sessions. primary outcomes were assessed using the hamilton scale and gds, and showed improvements in depressive symptoms for both experimental groups. interestingly, this was the only study analyzing a dose-response relationship, and the improvements observed in the high-intensity group were much superior to those registered in the low-intensity group. however, the differences between the two experimental groups may have been exaggerated due to an excessive dissimilarity in exercise intensities. firstly, one group worked with 80% 1rm, while the other was limited to 20% 1rm, which was already a very significant difference. most importantly, though, while the 80% 1rm group was regularly re-tested to keep the loads adjusted at 80%, the 20% 1rm group kept the initial loads. therefore, with adaptation to training, it is possible that by the later weeks, the low-intensity group was actually working with 10-15% 1rm. additionally, this study showed that strength gains were associated with a decrease in depressive symptoms. the high-intensity group also experienced greater increases in quality of life. risk of bias was assessed using cochrane's rob 2 (see table 5 ). risk of bias arising from the randomization process was low for the articles by krogh, saltin, gluud and nordentoft [37] and singh, stavrinos, scarbek, galambos, liber and singh [40] , but there were concerns with the other two papers [38, 39] . risk of bias due to deviations from intended interventions (effect of assignment to intervention) was low for all articles. risk of bias in the effect of adhering to intervention was high in the paper of krogh, saltin, gluud and nordentoft [37] , but low for the remaining articles. all articles had a low risk of bias due to missing outcome data. risk of bias in measurement of the outcome was low for the paper of krogh, saltin, gluud and nordentoft [37] , but there were some concerns with the other three papers. finally, risk of bias was uniformly low for the selection of the reported results. out of six dimensions, the article by krogh, saltin, gluud and nordentoft [37] had a high risk of bias in one dimension and low risk of bias in the remaining dimensions. the article by singh, stavrinos, scarbek, galambos, liber and singh [40] presented some concerns in one dimension, but low risk for the others. finally, the articles by moraes, silveira, oliveira, matta mello portugal, araújo, vasques, bergland, santos, engedal, coutinho, schuch, laks and deslandes [38] and sims, galea, taylor, dodd, jespersen, joubert and joubert [39] raised some concerns in two dimensions, but had a low risk of bias in the others. two of the articles [38, 40] had two primary outcomes, which required different combinations resulting in four separate meta-analyses (figures 2-5) . the relaxation group in the article by krogh, saltin, gluud and nordentoft [37] was considered a control group for practical purposes. first, the exercises were relaxation-based and with extremely low intensity, and therefore did not fit into recognizable categories of training programs. furthermore, adherence rates to the sessions was <35%, meaning that this experimental group behaved very similarly to a true control group. the following results represent the possible combinations for detecting the effects of rt in primary outcomes related to depressive symptoms. in the first combination, four randomized-controlled studies provided data for depressive symptoms, involving five experimental and four control groups (pooled n = 198). there was no significant effect of resistance training on depressive symptoms (es = 0.39; 95% ci = −0.05 to 0.84; p = 0.082; i 2 = 53.2%; egger's test p = 0.310; figure 2 ). the relative weight of each study in the analysis ranged from 12.2% to 28.6%. in the second combination, four randomized-controlled studies provided data for depressive symptoms involving five experimental and four control groups (pooled n = 198). there was a significant effect of resistance training on depressive symptoms (es = 0.62; 95% ci = 0.03 to 1.20; p = 0.040; i 2 = 71.9%; egger's test p = 0.155; figure 3 ). the relative weight of each study in the analysis ranged from 13.7% to 25.3%. in the third combination, four randomized-controlled studies provided data for depressive symptoms, involving five experimental and four control groups (pooled n = 198). there was no significant effect of resistance training on depressive symptoms (es = 0.48; 95% ci = −0.06 to 1.02; p = 0.081; i 2 = 67.2%; egger's test p = 0.235; figure 4 ). the relative weight of each study in the analysis ranged from 12.9% to 26.1%. in the fourth combination, four randomized-controlled studies provided data for depressive symptoms, involving five experimental and four control groups (pooled n = 198). there was a significant effect of resistance training on depressive symptoms (es = 0.53; 95% ci = 0.02 to 1.03; p = 0.040; i 2 = 62.7%; egger's test p = 0.206; figure 5 ). the relative weight of each study in the analysis ranged from 13.6% to 26.9%. this meta-analysis is, to the best of our knowledge, the first to examine rcts aimed at measuring the efficacy of exclusively rt supervised programs in people having depression. although multimodal interventions are usually advised, understanding the role of each exercise modality is paramount to understanding the effects and necessity of such a training component. this is highly relevant health-wise, but also to assess whether time should be invested in a given training modality, or if better investments would be applied elsewhere. therefore, the purpose of this study was to systematically review the effects of supervised resistance training programs in people diagnosed with depression or depressive symptoms. upon retrieval of 136 papers (70 after the removal of duplicates), only four papers fulfilled the inclusion criteria, meaning the effects of resistance training on depressive symptoms is still not widely studied, against our expectations. the risk of bias was assessed with cochrane's rob 2, with only a few selected concerns having arisen, but overall the four analyzed studies had a low risk of bias, and so we believe the reported results are trustworthy. primary outcomes focused on depressive symptoms. here, results were highly heterogeneous, with half of the studies showing positive effects of resistance training and half showing no effects. in two of the four combinations (figures 3-5) , the meta-analysis revealed significant benefits of rt in improving depressive symptoms (p < 0.05). although considering significant differences with moderate (es = 0.62) and small (es = 0.53) effects, shown respectively in figures 3 and 5 , the heterogeneity was above 50%, thus suggesting a substantial level [42] . in fact, in combinations 2 and 4 ( figures 3 and 5) , the experiment of sims, galea, taylor, dodd, jespersen, joubert and joubert [39] was favorable to the control group, and the experiment of moraes, silveira, oliveira, matta mello portugal, araújo, vasques, bergland, santos, engedal, coutinho, schuch, laks and deslandes [38] largely benefited the rt group. however, no experimental group experienced a worsening of symptoms as a result of resistance training. the reason different combinations lead to different results appears to be a factor of analysis. it is important to note that several rating scales were used to assess the severity of depression in research and clinical settings. these measures were categorized as clinician-rated, such as the ham-d, montgomery åsberg depression rating scale (madrs) [47] or quick inventory of depression symptomatology clinician rating [48] , and self-reported scales, such as bdi and its revised version bdi-ii, and patient health questionnaire-9 [49] . in this study, as a primary outcome, ham-d (17-item version), bdi, ces-d and gds were used. nevertheless, other studies utilized different assessment measures for their different interests. choosing appropriate outcome measures is a fundamental component of any assessment. therefore, selecting outcome measures could be considered as a compromise between factors. for example, depression measures should be selected based on the patient population. indeed, depression occurs in children, adolescents, adults and the elderly. as a matter of example, gds was specifically designed to screen and measure depression in geriatric patients. it contains 30 forced-choice "yes" or "no" questions, a format that is helpful for individuals with cognitive dysfunction [28] . although various scales for rating depression severity have been developed to date, the ham-d (17-item version) is the most regularly used clinician-rated scale in research and clinical settings. originally published by max hamilton in 1960, the first version of the ham-d, the ham-d21, comprised 21 items [27] . hamilton recommended, nonetheless, to use only the first 17 items of the ham-d21 since the last four symptoms (i.e., diurnal variation, depersonalization, derealization, paranoid and obsessional/compulsive symptoms) were either not considered part of the illness, or they were relatively infrequent or not considered features related to depression severity [50] . on the other hand, the bdi is one of the most widely used self-rating scales. thus, both the ham-d and the bdi/bdi-ii are frequently adopted as the primary outcome to assess depression severity in this scope [9] . in this line, it should be important to know what a given total score or a change score from baseline on one scale means in relation to the other scale. this notion is supported by a review carried out by furukawa et al. [51] , these results can help clinicians interpret the ham-d or bdi scores of their patients in a more versatile way and also help clinicians and researchers assess such scores reported in the literature when scores on only one of these scales are provided. these dates were obtained from the rcts of psychological and pharmacological treatments for major depressive disorders. however, despite being extensively used, the clinician-administered ham-d [50] has been identified to present various psychometric problems, including lack of unidimensionality and poor ability to detect changes among persons with mild to moderate depressive symptoms [52] . these problems may be particularly relevant to studies investigating the antidepressant effects of exercise because exercise is a treatment that is particularly recommended for individuals with mild to moderate symptom severity. consequently, the use of the ham-d scale may not accurately reflect the magnitude of the antidepressant effect of exercise [53] . another key point to address is related to a clear definition in the rcts, which is the scale, aimed at measuring the main outcome. therefore, it is crucial to provide clear information about it. frequent omissions of key details, namely on the primary outcome and the scale used to measure the main outcome, may impair interpretability, replicability and synthesis of rcts that could interfere with decision-making. in the first meta-analysis [22] , which examined the efficacy of rt on depressive symptoms, there was wide variability in the scales used to measure depression, including beck depression inventory another important topic is how to better frame the primary outcomes. it is very important to analyze adherence rates (i.e., compliance with training sessions). these were excellent in three of the four papers, but were very low in the study of krogh, saltin, gluud and nordentoft [37] . therefore, despite being the longest study and having the greatest sample size, the very low adherence rates may have compromised the results of the interventions. dropouts from exercise treatment represent a huge barrier that impedes individual benefit from an intervention, and appear to be a particular problem in persons with depression [54] . in this line, stubbs, vancampfort, rosenbaum, ward, richards, soundy, veronese, solmi and schuch [17] conducted the first systematic review and meta-analysis which explored the incidence and predictors of dropout rates among adults with depression participating in exercise rcts. these authors found that in mdd patients, higher baseline depressive symptoms predicted an increased dropout. some strategies may serve as facilitators to reduce the impact of dropouts in those with mdd, namely sessions supervised by physiotherapists and exercise physiologists. moreover, schuch, vancampfort, richards, rosenbaum, ward and stubbs [14] identified that, in people with depression who have higher social support, the likelihood of having symptom improvements in response to exercising increases. additionally, incorporating a motivational component into exercise interventions for depression may be needed to decrease dropouts. vancampfort et al. [55] found that autonomous motivation (i.e., acting out of choice and pleasure) was the key to adopting and maintaining physical activity behavior in patients with severe mental disorders defined as schizophrenia, bipolar disorder or mdd. additionally, understanding that exercise is not a "one size fits all" intervention leading to immediate results is a key step to achieving progress [56] . at a certain point, [37] state that the american college of sports medicine's guidelines suggest three weekly sessions, and lament the fact that their study could only provide two weekly sessions. however, as became apparent, even those two sessions had very low compliance rates. the classic study of dunn, trivedi, kampert, clark and chambliss [16] assessed the dose-response relationship between frequency of activity (three or five times per week) and the amount of exercise based on energy expenditure (7 or 17.5 kcal/kg/week). the results demonstrated that the most important factor for decreasing depressive symptoms in people with mild to moderate depression seems to be the amount/dose of activity instead of frequency. with these populations, a home-based supervised protocol could help. indeed, home-based exercise programs may be an effective method to overcome barriers to exercise and increase exercise adherence. as a matter of example, blumenthal, babyak, doraiswamy, watkins, hoffman, barbour, herman, craighead, brosse, waugh, hinderliter and sherwood [19] randomized 202 individuals into four groups for 16 weeks of either home-based aerobic exercise, supervised group exercise, taking a placebo pill or taking sertraline. the authors concluded that individuals receiving active treatments tended to achieve higher remission rates than the placebo group: supervised exercise = 45%; home-based exercise = 40%; medication = 47%; placebo = 31% (p = 0.057). however, further research with larger sample sizes is needed to confirm adherence and efficacy for improving depressive symptoms. in any case, home-based exercise may be a good alternative to practicing physical activity, in particular for vulnerable people. even in the other three studies, which had very good adherence to the programs, no study had more than two weekly training sessions. this may be a manifestly low frequency, perhaps insufficient to promote more expressive gains. it should also be highlighted that the study of singh, stavrinos, scarbek, galambos, liber and singh [40] presented the greater improvements in primary outcomes, despite being the shortest trial of only 8 weeks. the adherence rate of >95% presence in each training session can potentially explain this success. therefore, training programs should be designed in a motivating manner to ensure high adherence rates, especially if only two weekly training sessions are performed. motivation is a crucial predictor of success and a critical factor in supporting sustained exercise. concerning secondary outcomes, only one study failed to assess physical outcomes [38] . this is unfortunate because the other three studies showed that even when depressive symptoms do not ameliorate, there are still benefits in terms of strength and cardiovascular response, which is positive in itself. several reviews and studies have shown that people with severe mental illness, including people with mdd, have an excess mortality, being two or three times as high as those within the general population, and this excess mortality is mainly due to physical disease [57] . in this sense, and as an example, the rate of type ii diabetes mellitus in individuals with mdd is around 8%, representing an increase of around 50% in comparison to the rate achieved for people without mdd [58, 59] . a meta-analysis [20] revealed that individuals with depression could achieve clinically relevant improvements in cardiorespiratory fitness levels in response to exercise interventions. furthermore, previous studies have found that exercise can improve physical and psychological domains of quality of life in individuals with severe mental illness [60] , and specifically in people with depression [61] . thus, exercise may act in these two directions, not only by improving symptoms of depression but also by improving the cardiovascular health and wellbeing of this vulnerable population. additionally, none of the four articles reported the rest times between exercises, although this a highly important and well-recognized variable to consider when prescribing rt. indeed, when prescribed appropriately with other key prescriptive variables (i.e., volume and intensity), the amount of rest between sets could influence the efficiency, safety and effectiveness of an rt intervention [62] . even if rest times were self-regulated in the studies, that should have been reported. relatively to psychosocial variables, effects on cognitive abilities and quality of life were scarce and heterogeneous. moreover, only one study tested for a dose-response effect [40] , with the high-intensity group having experienced not only the greatest improvements in depressive symptoms, but also in the quality of life. this raises the necessity of designing training programs that avoid excessively low intensities. however, despite the evidence which supports a dose-response relationship, people with depression typically have low cardiorespiratory fitness, so it seems to be idealistic to start with high volumes or intensities of exercise. literature within this scope has shown that intensity is not critically significant for symptom management, and that exercise of even a light intensity can lead to short-term improvements in mood in this specific population [63] . for example, people with severe mental illness may face additional challenges towards exercise such as inexperience with intense physical efforts, associated fatigue and discomfort, increased risk of physical injuries, limited availability of physical activity facilities and specialized equipment, and costs associated with access to facilities or training [56] . moreover, other barriers may include psychiatric medication side effects (e.g., sedation, fatigue, weight gain), lack of motivation and low self-confidence [64] . lastly, recommendations for the prescription of exercise for patients with mdd should not be discarded. small, incremental improvements can be obtained through real-life interventions aimed at improving the health of people with severe mental illness [7, 65] . the existence of only four articles fulfilling inclusion criteria is daunting and reveals that this field has potentially not been adequately investigated. moreover, the considerable heterogeneity of the studies (i.e., sample size and characteristics, experimental protocols, evaluated parameters, and so on) makes comparisons difficult and conclusions tentative. also, only one study evaluated a dose-response effect [40] . furthermore, it should be underlined that the four studies referred to samples from brazil, denmark and australia. therefore, out of the entire american continent, only south america is represented (and only by one country), while europe also has a single representative. no data on the topic is available from asia and africa. this is troublesome, as the prevalence of depression may vary depending on a country's human development index [66] . patel et al. [67] carried out a systematic review and meta-analysis, which included 26 studies on developed countries. approximately two-thirds of all studies and five out of six longitudinal studies showed a statistically significant positive relationship between income inequality and the risk of depression. moreover, because societal context is paramount for understanding access, motivation and engagement with structured physical activity [68, 69] , cultural specificities may be important in understanding why, how and how often people have access to and engage with supervised exercise programs [70, 71] . in the case of depression, country of origin, ethnicity and cultural differences are suspected of playing a major role in the patients' symptoms and on the behaviors of their family aggregates [72] . in summary, the majority of interventions in this specific scope have been focused on aerobic exercise, and it is perhaps time to change the paradigm and invest in more research to assess the effects of rt in treating depression. notwithstanding, to achieve this aim, it is essential to be rigorous and first assess the efficacy of exclusively rt supervised programs; otherwise, it may lead to misinterpretations. additionally, it is crucial for those involved with the prescription of rt, namely exercise physiologists, to acquire an understanding of the program variables (e.g., loading and volume, exercise selection and order, rest periods, frequency) and the importance of their application [73] . overall, to draw meaningful conclusions, future well-designed rcts are needed that focus on understudied rt as a treatment for depression. addressing the burden of mental, neurological, and substance use disorders: key messages from disease control priorities the outbreak of coronavirus disease 2019 (covid-19)-an emerging global health threat anxiety and depression among general population in china at the peak of the covid-19 epidemic the psychological impact of the covid-19 epidemic on 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illness: a systematic review and meta-analysis exercise improves physical and psychological quality of life in people with depression: a meta-analysis including the evaluation of control group response rest interval between sets in strength training chapter 1-exercise for the prevention and treatment of depression. in exercise-based interventions for mental illness exercise for adults with depressive symptoms: beyond the weight loss paradigm why moving more should be promoted for severe mental illness prevalence of depression in the community from 30 countries between 1994 and income inequality and depression: a systematic review and meta-analysis of the association and a scoping review of mechanisms. world psychiatry off neighborhood social cohesion as a mediator of neighborhood conditions on mothers' engagement in physical activity: results from the geographic research on wellbeing study longitudinal examination of social and environmental influences on motivation for physical activity structural and cultural factors influencing physical activity in switzerland socio-cultural determinants of physical activity across the life course: a 'determinants of diet and physical activity' (dedipac) umbrella systematic literature review cultural differences in the development and characteristics of depression designing resistance training programmes to enhance muscular fitness: a review of the acute programme variables this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord-315991-uecdbanf authors: hughes, david; saw, richard; perera, nirmala kanthi panagodage; mooney, mathew; wallett, alice; cooke, jennifer; coatsworth, nick; broderick, carolyn title: the australian institute of sport framework for rebooting sport in a covid-19 environment date: 2020-05-06 journal: j sci med sport doi: 10.1016/j.jsams.2020.05.004 sha: doc_id: 315991 cord_uid: uecdbanf abstract sport makes an important contribution to the physical, psychological and emotional well-being of australians. the economic contribution of sport is equivalent to 2–3% of gross domestic product (gdp). the covid-19 pandemic has had devastating effects on communities globally, leading to significant restrictions on all sectors of society, including sport. resumption of sport can significantly contribute to the re-establishment of normality in australian society. the australian institute of sport (ais), in consultation with sport partners (national institute network (nin) directors, nin chief medical officers (cmos), national sporting organisation (nso) presidents, nso performance directors and nso cmos), has developed a framework to inform the resumption of sport. national principles for resumption of sport were used as a guide in the development of ‘the ais framework for rebooting sport in a covid-19 environment’ (the ais framework); and based on current best evidence, and guidelines from the australian federal government, extrapolated into the sporting context by specialists in sport and exercise medicine, infectious diseases and public health. the principles outlined in this document apply to high performance/professional, community and individual passive (non-contact) sport. the ais framework is a timely tool of minimum baseline of standards, for ‘how’ reintroduction of sport activity will occur in a cautious and methodical manner, based on the best available evidence to optimise athlete and community safety. decisions regarding the timing of resumption (the ‘when’ ) of sporting activity must be made in close consultation with federal, state/territory and local public health authorities. the priority at all times must be to preserve public health, minimising the risk of community transmission. on 12 january 2020, the world health organisation (who) reported a cluster of 41 confirmed cases 83 of viral severe acute respiratory syndrome in wuhan, hubei province, people's republic of china, 84 following a novel coronavirus outbreak in december 2019. [1] coronaviruses, enveloped ribonucleic 85 acid (rna) viruses with surface spikes, are a group of viruses that affect both animals and humans, 86 (loss of smell) and ageusia (loss of taste). [52, 53] less commonly reported symptoms include headache, 138 abdominal pain, nausea, vomiting and diarrhoea. [45, 50, 54] 139 in a review of clinical presentations from china, 81% of infected people have mild symptoms (no 140 respiratory distress), 14% have severe illness (dyspnoea, tachypnoea and hypoxia) and 5% have 141 critical illness (respiratory and other organ failure, septic shock). [55] the observed timeline of 142 symptoms and pathological changes in symptomatic individuals is an influenza like illness (fever, 143 cough and myalgia) in the first few days followed by respiratory symptoms (dyspnoea +/-hypoxia) in 144 the second week of the illness. the characteristic features on chest ct are bilateral, peripheral, 145 multifocal ground glass opacities. [56] these imaging findings can also be seen in asymptomatic and 146 pre-symptomatic individuals. the median time from onset of symptoms to intensive care unit (icu) 147 admission in the critically ill is 10 days. [57] in most instances the cause of death is respiratory failure, 148 septic shock or myocardial injury and cardiac failure. [50] hospitalisation and mortality rates increase 149 with age. 150 case fatality rates (cfr) vary from country to country and are likely to reflect the extent of testing (if 151 only severe cases who present to hospital are tested cfr will appear higher), demographics (regions 152 with a higher proportion of elderly will have higher cfrs) and stress on the health systems (the size 153 of the outbreak versus the capacity to provide ventilatory support). 154 while people of all ages can be affected by covid-19, children tend to have a milder illness, lower 155 rates of hospitalisation and asymptomatic carriage is not uncommon. [58] the proportion of infected 156 individuals who remain asymptomatic is not known as widespread population screening has not been 157 undertaken but reports vary from 18% to 79%. [59, 60] the proportion of asymptomatic carriage is likely 158 to be higher in a younger population. unlike sars-cov which was most infectious approximately 159 one week after symptom onset, [61] the most infectious period for sars-cov-2 is the 48 hours prior to 160 onset of symptoms and the day of symptom onset. [62] it is estimated that 44% of infections are 161 transmitted prior to the onset of symptoms in the index case. [62] this has significant implications for 162 community transmission. several risk factors, other than advanced age, have been found to be associated with severe disease 164 and death. these include; male sex and co-morbidities including diabetes, cardiovascular disease, 165 hypertension, respiratory disease and immunosuppression. [50, 61, 62] the laboratory findings associated 166 with an increased risk of severe disease and death were; leucocytosis, lymphopenia, elevated liver 167 enzymes, elevated inflammatory markers, elevated d-dimer, elevated troponin, eosinophilia and 168 abnormal renal function. [50] it has been postulated that more severe cases of covid -19 may be 169 associated with hyperinflammatory syndrome characterised by a fulminant and fatal 170 hypercytokinaemia (cytokine storm) causing multi-organ pathology. [50, 63] 171 reports of non-respiratory manifestations of covid-19 are increasingly being described. while 172 pneumonia is still the most frequent serious manifestation, cardiomyopathy has been reported in one 173 third of critically ill patients in the united states of america. [47] approximately one third of 174 hospitalised patients display neurological symptoms including headache, dizziness, agitation, 175 delirium, ataxia and corticospinal tract signs. [66] neurological symptoms are more common in those 176 with severe respiratory disease. [48] coagulopathies with thrombotic events and elevated phospholipid 177 antibodies have also been described. [49] 178 to date, there are no clinical data on possible long-term complications of covid-19. whether 179 individuals who have been infected and "recovered" have residual organ damage, in particular 180 respiratory or cardiac complications, is unknown at this time. the other current unknown is whether 181 infection confers immunity to future infection and if so, how long that immunity lasts. 182 183 prevention 184 pre-emptive low-cost interventions such as enhanced hygiene and social distancing measures reduce 185 numbers of cases through several mechanisms. social distancing decreases the risk of transmission by 186 reducing incidence of contact while enhanced hygiene reduces disease transmission, if a contact occurs. [39] education of the public and enhanced medical resources have also been shown to reduce 188 transmission. [39, 65, 66] 189 the australian governor-general declared a 'human biosecurity emergency period' on 18 march 2020 190 in response to the risks posed by this empowered the australian government to make 191 a series of decisions including prohibition of cruise ships, travel bans (domestic and international), 192 limiting gatherings to two persons (with exceptions for people of the same household and other select 193 groups), and closing a range of indoor and outdoor public facilities. [70] after peaking in australia in 194 mid to late march 2020, the number of daily new cases of covid-19 began to drop in response to in australia, indications for conducting testing for covid-19 have changed over the course of the 202 pandemic, as case definitions have evolved, and testing kits have become more available. [71, 72] testing 203 availability was initially limited to patients with relevant symptoms who were returned overseas 204 travellers or known contacts of a covid-19 case. testing criteria have now broadened gradually, and 205 doctors should refer to current local health guidelines. [71] 206 there are currently two main types of tests available for sars-cov-2: 207  nucleic acid detection tests: commonly referred to as polymerase chain reaction (pcr) tests 208 detects sars-cov-2 genetic material. the preferred test to confirm the diagnosis of covid-19 is pcr testing of nasopharyngeal and/or 211 throat swabs, combined with relevant clinical findings. despite the potential for faecal-oral 212 transmission [45, 46] , the role of faecal pcr testing remains unclear. 213 the absence of sars-cov-2 on a pcr test on a single occasion is insufficient to definitively rule out 214 covid-19 infection. public health authorities in australia have recommended using multiple 215 samples over multiple days in those whose symptoms are strongly suggestive of 71] in 216 general, pcr tests for other respiratory viral infections tend to have a high sensitivity and specificity, 217 although there is limited data specific to covid-19. see appendix a for more detailed information 218 regarding testing for sars-cov-2. 219 serology tests are available, including point of care (poc) serology tests that can provide results from 220 venous or finger prick samples in 15-30 minutes. [71, 74] it is likely that antibodies take 5-10 days to 221 become detectable after infection, and around 30% of patients may not produce detectable levels at 222 all. [75] at present the sensitivity and specificity for serology testing is not well known. in addition to 223 false negatives, false positives may arise from exposure to other coronavirus strains. as serology is 224 testing for antibodies and not the presence of the virus, it does not provide clinically useful 225 information as to whether a patient could be infectious. [ champions (individuals and teams). [84] the sport sector employs >220,000 individuals and engages 264 >1.8 million volunteers. the economic contribution is equivalent to 2-3% of gross domestic product 265 (gdp). [85] regular community-based sport participation in australia generates an estimated $18.7b 266 value per annum in social capital including direct economic benefits. [86] australia has enjoyed many 267 benefits as a result of a rich sporting culture. 268 preventative measures taken in australia and other countries, while required to limit the spread of 269 covid-19, have impacted upon a range of work and social pursuits including sport activities. the olympic games and the international community". [87, 88] there is contested uncertainty about the likely course of the pandemic and the resulting timelines for 291 safe return to training and competition. in professional sport, loss of revenue from sponsorship, gate-292 takings and broadcast deals has resulted in job losses and reappraisal of operational imperatives. [116] it 293 is unclear what long-term effects there will be on other factors such as fan engagement, sport 294 participation, employment in the sport industry and athlete/staff welfare. global and national 295 economic conditions will also have repercussions for sport. 296 the covid-19 pandemic has impacted people in varying ways with many experiencing 300 deteriorations in mental health. [117, 118] resumption of sport can significantly contribute to the re-301 establishment of normality in society, in a covid-19 environment. some established norms 302 associated with sport from sharing drink bottles, hugging and shaking hands to arenas packed with 303 spectators are the antithesis of social distancing. sport organisations and participants will be faced 304 with complex decisions regarding resumption of training and competition in the current 305 circumstances. the ais, in consultation with sport partners (nin directors, nin chief medical 306 officers (cmos), national sporting organisation (nso) presidents, nso performance directors and 307 nso cmos), has developed a framework to inform the resumption of sport. national principles for 308 resumption of sport formed the foundation of 'the ais framework for rebooting sport in a covid-309 19 environment' (the ais framework). given the recency of covid-19 there is a paucity of 310 research, particularly in athletic populations. the ais framework is based on current best evidence, and guidelines from the australian federal government extrapolated into the sporting context by 312 specialists in sport and exercise medicine, infectious diseases and public health. the ais framework 313 will be regularly updated to reflect the evolving scientific evidence about covid-19. the ais 314 framework is a timely tool of minimum baseline of standards, for 'how' reintroduction of sport 315 activity will occur in a cautious and methodical manner, based on the best available evidence to 316 optimise athlete and community safety. the principles outlined in the ais framework apply to high 317 performance/professional, community and individual passive (non-contact) sport. decisions regarding 318 the timing of resumption (the 'when') of sporting activity must be made in close consultation with 319 federal, state/territory and local public health authorities. the priority at all times must be to 320 preserve public health, minimising the risk of community transmission. resumption of sport and recreation activities can contribute many health, economic, social and cultural benefits to australian society emerging from the covid-19 environment. 2. resumption of sport and recreation activities should not compromise the health of individuals or the community. 3. resumption of sport and recreation activities will be based on objective health information to ensure they are conducted safely and do not risk increased covid-19 local transmission rates. 4. all decisions about resumption of sport and recreation activities must take place with careful reference to these national principles following close consultation with federal, state/territory and/or local public health authorities, as relevant. 5. the ais 'framework for rebooting sport in a covid-19 environment' provides a guide for the reintroduction of sport and recreation in australia, including high performance sport. the ais framework incorporates consideration of the differences between contact and non-contact sport and indoor and outdoor activity. whilst the three phases a, b and c of the ais framework provide a general guide, individual jurisdictions may provide guidance on the timing of introduction of various levels of sport participation with regard to local epidemiology, risk mitigation strategies and public health capacity. 6. international evidence to date is suggestive that outdoor activities are a lower risk setting for covid-19 transmission. there are no good data on risks of indoor sporting activity but, at this time, the risk is assumed to be greater than for outdoor sporting activity, even with similar mitigation steps taken. 7. all individuals who participate in, and contribute to, sport and recreation will be considered in resumption plans, including those at the high performance/professional level, those at the community competitive level, and those who wish to enjoy passive (non-contact) individual sports and recreation. 8. resumption of community sport and recreation activity should take place in a staged fashion with an initial phase of small group (<10) activities in a non-contact fashion, prior to moving on to a subsequent phase of large group (>10) activities including full contact training/competition in sport. individual jurisdictions will determine progression through these phases, taking account of local epidemiology, risk mitigation strategies and public health capability. a. this includes the resumption of children's outdoor sport with strict physical distancing measures for non-sporting attendees such as parents. b. this includes the resumption of outdoor recreational activities including (but not limited to) outdoor-based personal training and boot camps, golf, fishing, bush-walking, swimming, etc. 9. significantly enhanced risk mitigation (including avoidance and physical distancing) must be applied to all indoor activities associated with outdoor sporting codes (e.g. club rooms, training facilities, gymnasia and the like). 10. for high performance and professional sporting organisations, the regime underpinned in the ais framework is considered a minimum baseline standard required to be met before the resumption of training and match play, noting most sports and participants are currently operating at level a of the ais framework. 11. if sporting organisations are seeking specific exemptions in order to recommence activity, particularly with regard to competitions, they are required to engage with, and where necessary seek approvals from, the respective state/territory and/or local public health authorities regarding additional measures to reduce the risk of covid-19 spread. 12. at all times sport and recreation organisations must respond to the directives of public health authorities. localised outbreaks may require sporting organisations to again restrict activity and those organisations must be ready to respond accordingly. the detection of a positive covid-19 case in a sporting or recreation club or organisation will result in a standard public health response, which could include quarantine of a whole team or large group, and close contacts, for the required period. 13. the risks associated with large gatherings are such that, for the foreseeable future, elite sports, if recommenced, should do so in a spectator-free environment with the minimum support staff available to support the competition. community sport and recreation activities should limit those present to the minimum required to support the participants (e.g. one parent or carer per child if necessary). 14. the sporting environment (training and competition venues) should be assessed to ensure precautions are taken to minimise risk to those participating in sport and those attending sporting events as spectators (where and when permissible). 15. the safety and well-being of the australian community will be the priority in any further and specific decisions about the resumption of sport, which will be considered by the covid-19 sports and health committee. all community and individual sport participants, parents/guardians of participants, coaches, 353 spectators, officials and volunteers (collectively termed community sport members) and sport 354 organisations must play a role help slow the spread of covid-19. the safe reintroduction of 355 community and individual sport requires thorough planning and safe implementation. 356 prior to the resumption of community sport, it is important for sports clubs/groups to safely prepare 358 the sporting environment. a thorough risk assessment must be carried out and preparation will be 359 specific to the sporting environment. a resumption of sport activity should not occur until appropriate 360 measures are implemented to ensure safety of community sport members. 361 education of community sport members about covid-19 risk mitigation strategies is crucial. 363 education will help to promote and set expectations for the required behaviours prior to 364 recommencing activities. improved health literacy including awareness of self-monitoring of 365 respiratory symptoms (even if mild). community sports may benefit from consulting with local 366 government and public health authorities on education materials and options available. 367 possible education measures include: 368  provide education material for community sport members to promote required behaviours (e.g. -what is the strategy to ensure that social distancing of at least 1.5m is maintained by 428 community sport members attending training or competition? 429 -what strategies can be used to communicate/inform community sport members of preventive 430 -what is the strategy to reduce in-person contact between athletes and other personnel? 432 -what is the strategy to manage increased levels of staff/volunteer absences? 433 -what is the strategy to reduce risk to vulnerable groups? 434 proposed criteria for resumption of sporting activity 435 initial resumption of community and individual sport will be governed by public health policy and 436 relaxing/increasing restrictions may be required in response to fluctuating numbers of covid-19 443 an initial resumption of sporting activity is dependent on several factors: 445  a sustained decrease in covid-19 transmission 446  healthcare system capacity 447  community sport clubs/groups and individuals making their own risk assessment guided by 448 their local public health authorities (i.e. community sports clubs and individuals cannot 449 restart sport before permitted by local public health authorities but may decide to delay a 450 restart due to their own circumstances / risk assessment). 451 three levels (levels a, b, c) of sporting activities are recommended in the context of a covid-19 452 environment (table 1) . for each level, permitted activities, general hygiene measures, and spectators, 453 additional personnel considerations are provided as recommendations before the resumption of 454 community or individual sport. a more detailed description of the sport-specific activities has been 455 developed in conjunction with medical staff working within sport (table 1) . 456 457 <insert there should be no unnecessary body contact (e.g. hand shaking, high fives). 473 community sport organisations should minimise unnecessary huddles of spectators. spectators 474 should be encouraged or directed to spread out and maintain social distance. 475 consideration should be given as to whether it is appropriate to serve food and drink at community 476 events, as this will likely encourage spectators to come into close proximity with each other. 477 hand hygiene stations should be placed in high traffic areas and entry/exit points. 478 479 progression from level a to level b sporting activities will be considered when the local effective 480 reproduction number (r t ) has remained <1 for two incubation periods (i.e. four weeks) as determined 481 by public health authorities. [36, 119] 482 when sport activity has been at level b for a further two incubation cycles without an increase in r t , 483 progression to level c sporting activities can be considered, as determined by with public health 484 authorities. the timing of the progression from level b to level c may be influenced by any 485 evidence of transmission issues within the sporting cohort. 486 community sport members and individuals should not return to sport if in the last 14 days they have 489 been unwell or had close contact with a known or suspected case of covid-19. in an environment of 490 community transmission of covid-19, any individual with respiratory symptoms (cough, sore throat, 491 fever or shortness of breath), even if mild, should be considered a possible case of covid-19. all 492 community sport members must be made aware not to attend sport environments if they are unwell 493 and should use a cautious approach. anyone who is unwell should be referred to a doctor in 494 accordance with local public health authority guidelines. an athlete with a possible case of covid-495 19 should refrain from training (even at home) until they have been cleared to do so by a doctor, given 496 the potential for worsening illness. 497 it should also be considered that anyone returning to sport and exercise after a period of social 498 isolation and not exercising regularly may be at an increased risk of injury. clubs and individuals 499 should apply a graded return to mitigate injury risk, understanding that a sudden increase in training 500 load will predispose to injury. [120] 501 vulnerable groups 502 vulnerable groups such as para-athletes and others with medical conditions may be at increased risk. 503 those with concomitant medical conditions need individualised management in consultation with 504 their regular treating doctor(s) prior to return to training environments. considerations include 505 increased susceptibility to respiratory infections, unique equipment (e.g. wheelchairs) that requires 506 cleaning, accessibility of medical resources, risk of medical sequalae from covid-19, and access to 507 alternate training options. 508 athletes/other personnel with concurrent medical conditions including; respiratory or cardiac disease, 509 hypertension, diabetes [121, 122] , obesity [54] and immunosuppression due to disease or medication may be 510 at increased risk. other groups that require special consideration include; individuals over 70 years of 511 age, carers for or a household contact of a vulnerable person, athletes with suboptimal access to 512 medical care (e.g. remote) and aboriginal and torres strait islander communities. there are two separate points to consider for athletes and other personnel who have been infected 522 with covid-19, prior to returning to sport: 523  ensure they no longer pose any infection risk to their community and 524  ensure they have sufficiently recovered to safely participate in exercise (specifically for 525 athletes and other personnel undertaking physical roles). 526 in both instances, clearance from their doctor is required. 527 athletes and other personnel who have recovered from covid-19 must satisfy the communicable 528 disease network of australia (cdna) criteria to ensure they are no longer infectious. [72] 529 while there is increasing research on the multi-organ nature of covid-19 in the acute phase, there is 530 currently limited research on medium to long-term complications. long-term decreased exercise 531 capacity has been noted following previous coronavirus infections (sars and mers). [123] athletes 532 and volunteers/officials with physical roles may be at increased risk of health complications after 533 covid-19 and warrant multidisciplinary specialist medical assessment before resuming high exertion 534 activities. [124, 125] they should be instructed to see their local doctor for a full medical review. an 535 outline of the recommended assessment process following a covid-19 case is illustrated in table 2. <insert high performance/professional athletes are 'returning to work' and safe resumption of sport in a 544 covid-19 environment will be a complex process. for high performance/professional sporting 545 organisations, the 'ais framework' is considered a minimum baseline of standards required to be met 546 before the resumption of training and match play. 547 the ais framework provide minimum baseline of standards for 'how' high performance/professional 548 sport activities can be reintroduced based on the best available evidence to ensure the safety of 549 athletes/other personnel and the wider community ( figure 5 ). if sporting organisations are seeking 550 special exemption to recommence activity, they are required to demonstrate to the respective 551 state/territory and/or local public health authorities that they meet the 'ais framework' 552 requirements and are also taking additional measures to prevent the spread of covid-19. federal, 553 state/territory and local public health authorities must be closely consulted in decisions regarding 554 the resumption of ('when') high performance/professional sport activities. all individuals and sport 555 organisations must follow directions of the local public health authorities. 556 (table 3) . for each level, permitted activities, general hygiene measures, and medical 673 servicing considerations are provided as minimum baseline of standards required to be met by high 674 performance/professional sport before the resumption of training and competition. a more detailed 675 description of the sport-specific activities has been developed in conjunction with medical staff 676 working within sport (table 3) . 677 progression from level a to level b sporting activities will be permitted when the local effective 679 reproduction number (rt) has remained <1 for two incubation periods (i.e. four weeks) as determined 680 by public health authorities. [36, 119] 681 when sport activity has been at level b for a further two incubation cycles without an increase in r t , 682 progression to level c sporting activities can be considered, in consultation with public health 683 authorities. the timing of the progression from level b to level c may be influenced by any 684 evidence of transmission issues within the sporting cohort. the assessment process will depend on multiple factors including medical resources, athlete risk 698 factors and sport-specific risk factors. it may be appropriate for an initial screening to be conducted vulnerable groups such as para-athletes and others with medical conditions may be at increased risk. 720 those with concomitant medical conditions need individualised management in consultation with 721 their regular treating doctor(s) prior to return to training environments. considerations include 722 increased susceptibility to respiratory infections, unique equipment (e.g. wheelchairs) that requires 723 cleaning, accessibility of medical resources, risk of medical sequalae from covid-19, and access to 724 alternate training options. athletes/other personnel with concurrent medical conditions including; respiratory or cardiac disease, 726 hypertension, diabetes [121, 122] , obesity [54] and immunosuppression due to disease or medication may be 727 there will be athletes/other personnel who have been infected with covid-19 wanting to return to 739 the sport environment. some individuals may have been infected and not be aware (asymptomatic or 740 minimally symptomatic cases that did not meet testing criteria at the time of illness). athletes/other 741 personnel who have recovered from covid-19 must satisfy the communicable disease network of 742 while there is growing research on the organ systems affected by covid-19 in the acute phase, there 744 is currently limited research on medium to long-term complications. long-term decreased exercise 745 capacity has been noted following previous coronavirus infections (sars and mers). [123] athletes 746 and other personnel with physical roles may be at increased risk of health complications after 747 covid-19 and warrant multidisciplinary specialist medical assessment before resuming high exertion 748 activities. [124, 125] medical clearance of staff may be conducted by the sport, or by external doctors, depending on the individual sport organisation resources and policies. an outline of the recommended 750 assessment process following a covid-19 case is illustrated in table 2 in australia, currently most respiratory tract infections will be tested for covid-19. if an individual 764 is being tested for covid-19: 765  they must immediately self-isolate and discontinue training until covid-19 has been excluded 766 and they have been medically cleared by a doctor to return to the training environment 767  isolation of close contacts will be a decision for medical staff, based on case specific details 768 definition of close contacts: 769  "face-to-face contact in any setting with a confirmed or probable case, for greater than 15 770 minutes cumulative over the course of a week, in the period extending from 48 hours before onset 771 of symptoms in the confirmed or probable case, or  sharing of a closed space with a confirmed or probable case for a prolonged period (e.g. more 773 than 2 hours) in the period extending from 48 hours before onset of symptoms in the confirmed or 774 probable case 775  contact is considered to have occurred within the period extending 48 hours before onset of 776 symptoms in the patient, until the patient is classified as no longer infectious by the treating team 777 (usually 24 hours after the resolution of symptoms)". [72] and key surfaces before/after every patient. 794  for manual therapy treatment or massage, it is recommended that the athlete and therapist wear a 795 face mask. the therapist must wash their hands before and after treatment, and the athlete should 796 shower before and after treatment. symptoms/illness must be tested for covid-19 and cleared by a doctor. 799  unwell athletes should be instructed to see a doctor and must not receive any other type of 800 medical servicing such as assessment for injury (unless urgent) or manual therapy until cleared to 801 do so. 802 detailed description of medical service considerations pertaining to level a, b, c sporting activity is 803 illustrated in table 3 all sectors of society, including sport. in a covid-19 environment, sport has an important role to play in restoring normality. sport organisations and athletes will be faced with complex decisions 821 regarding resumption of training activities in the current circumstances. 'the ais framework for 822 rebooting sport in a covid-19 environment' is based on current available evidence, extrapolated 823 into the sporting context by specialists in sport and exercise medicine, infectious diseases and public 824 health. the ais framework provides a timely tool for sport organisations to guide the cautious and 825 methodical resumption of sport activity (the 'how') . decisions regarding resumption of sporting 826 activity must be based on objective medical information regarding the transmission of federal, state/territory and local public health authorities must be closely consulted in decisions 828 regarding the timing of resumption of sport (the 'when'). the ais framework will be updated to 829 reflect the evolving evidence regarding covid-19. while navigating the return to sport, 830 organisations must ensure that the health and wellbeing of athletes and other personnel informs 831 decision making. the overriding priority for sport, however, must ensure that any return to activity 832 does not endanger public health.  the overriding priority for sport, however, is to ensure that any return to activity does not 881 endanger public health. 882 activity that can be conducted by a solo athlete or by pairs where at least 1.5m can always be maintained between participants. no contact between athletes and/or other personnel. examples for all sports -general fitness aerobic and anaerobic (e.g. running, cycling sprints, hills) . strength and sport-specific training permitted if no equipment required, or have access to own equipment (e.g. ergometer, weights) . online coaching and resources (e.g. videos, play books). as per level a plus: indoor/outdoor activity that can be conducted in small groups (not more than 10 athletes and/or other personnel in total) and with adequate spacing (not more than 1 person per 4m 2 ). spitting and clearing of nasal/respiratory secretions on ovals or other sport settings must be strongly discouraged. communal facilities can be used after a sport-specific structured risk assessment and mitigation process is undertaken. 'get in, train and get out' -be prepared for training prior to arrival at venue (minimise need to use/gather in change rooms, bathrooms). minimise use of communal facilities (e.g. gym, court) with limited numbers (not more than 10 athletes/staff in total). have cleaning protocols in place for equipment and facilities. hand hygiene (hand sanitisers) on entry and exit to venues, as well as pre, post and during training. thorough full body shower with soap before and after training (preferably at home). where possible maintain distance of at least 1.5m while training. no socialising or group meals. no spectators unless required (e.g. parent or carer). separate spectators from athletes. spectators should maintain social distancing of at least 1.5m. running, resistance training (solo), skills training (solo). passing, kicking, catching drills. no tackling or grappling. small groups (not more than 10 athletes/staff in total). outdoor range and solo only. full training indoor or outdoor range, with limited numbers / appropriate distancing between athletes. solo training drills only-land based, in own pool or openwater. general fitness, strength work. swimming (own lane). in pool solo technical drills or group technical drills without physical contact. no lifting, holding. outdoor training sessions on own, with coach, or with 1 training partner (no sharing of equipment e.g. javelin, discus, high-jump mats, pole vault, shot put, hammer, starting blocks). full training. avoid running in slipstream of others. running/aerobic/agility training (solo), resistance training (solo), skills training (solo) including kicking, handballing, ball handling skills (e.g. handball against wall, bouncing, ball recovery work). controlled kicking, marking and handball drills. no tackling/wresting, contact, body on body drills. small groups (not more than 10 athletes/staff in total) for both education and training. running/aerobic/agility training (solo), resistance training (solo), skills training (solo) at home or outdoor (no indoor sporting facility access allowed). full training on court, singles or doubles. running/aerobic training (solo), resistance training (solo), skills training (solo). full training with small numbers (not more than 10 athletes/staff in total). laser run practice in small groups, respecting distance on shooting bench. running/aerobic training (solo), resistance training (solo), simulation work at home if available. full training. running/aerobic/agility training (solo), resistance training (solo), skills training (solo), including shooting (outdoor or own ring only) or ball skills e.g. against a wall to self. skills using netball passing, shooting, defending. small group training (not more than 10 athletes/staff in total) based on skills with set drill, but no close contact/defending/attacking/match play drills. para-athletes require individualised consideration and assessment through all levels (a, b, c) of a return to sport. some para detailed planning and consultation with their regular treating medical team prior to a return to formal training, or progression throu (e.g. wheelchairs, prostheses) will require regular cleaning (for all levels). for more information, refer to the 'ais framework for rebooting sport in a covid-19 environment' document. for more sport specific guidelines for levels a, b, c, refer to the relevant sport heading in this document. ergometer if access to own at home. cycling (solo), running (solo), resistance training (solo). on-water single. skill drills using a ball, kicking and passing. no rucks, mauls, lineouts or scrums, no tackling/wresting. small group (not more than 10 athletes/staff in total) sessions. solo or double handlers (if allowed by state regulations) only. full training. aerobic/resistance training (solo), technical skills (solo)e.g. standing/holding and dry firing. mental skills traininge.g. concentration/reaction time, visualisation, arousal control). live fire on home ranges only (no club range access). continuation of athlete-led preparation at home. coach-led training including live fire in small groups at authorised venues (i.e. clubs/ranges). outdoor and solo only, or indoor only if have own facilities. full training with appropriate distancing between athletes. running/aerobic training (solo), resistance training (solo), skills training (solo). small group (not more than 10 athletes/staff in total) skills training. aerobic and resistance training (solo), climbing solo/pairs on own wall or outdoors (if allowed by local government). solo hang board training. full training. cleaning of indoor walls required between athletes/groups. solo or with 1 training partner only. full training. in-water training (solo) in own pool or open-water. use of communal pool with limited numbers, 1 athlete per lane. table tennis running/aerobic/agility training (solo), resistance training (solo), skills training (solo) at home or outdoor (no indoor sporting facility access allowed). full training on court, singles or doubles. running/aerobic/agility training (solo), resistance training (solo), skills training (solo) at home or outdoor (no indoor sporting facility access allowed). small group (not more than 10 athletes/staff in total) skill sessions only. no matches. in-water training (solo) if access to own pool only, or openwater. use of communal pool with limited numbers and distance maintained. swimming, throwing (passing/shooting) drills. no full contact/defending drills, wrestling. resistance training, technical work at home (no indoor sporting facility / gym access allowed). full training with limited numbers to avoid congestion. aerobic training (solo), resistance training (solo), skills training (solo) at home or outdoor (no indoor sporting facility access allowed). non-contact shooting, dribbling drills. other non-contact technical /skill drills. small groups (not more than 10 athletes/staff in total). aerobic training (solo), resistance training (solo), skills training (solo) at home or outdoor (no indoor sporting facility access allowed). non-contact passing drills on court. other non-contact technical /skill drills. small groups (not more than 10 athletes/staff in total). reduced aerobic capacity and increased respiratory distress. potential persisting restrictive lung patterns and reduced diffusion capacity. these respiratory long-term complications been reported follow previous coronavirus epidemics (sars, mers) in non-athlete populations. [126] clinical assessment graded exercise testing, vo2 max testing fbe, crp, spirometry, lung ultrasound, chest x-ray, ct chest respiratory review cardiovascular cardiomyopathy [47] myocarditis [127] pericardial effusion [130] arrythmias [45, 127] autoimmune mimicry of vasculitis and thrombosis [49, 129] a return to exercise with underlying cardiac complications could be contraindicated for some. [123] return to contact sports / trauma could be contraindicated for some. persisting inflammatory states. clinical assessment 12-lead ecg, troponins, coagulation profile, crp, echocardiogram, cardiac mri d-dimer, ferritin, c-reactive protein, erythrocyte sedimentary rate cardiology review neurological multiple symptoms and signs have been described. [66] guillain-barré syndrome [132] elevated d-dimer [131, 132] stroke [135] encephalopathy [136] currently unclear as the neurological sequalae from mild to moderate cases is yet to be elucidated. post-viral fatigue is known to occur following other viral infections [139] and may occur with covid-19. monitoring of self-report measures, fatigue symptoms and training loads. mental health symptoms of depression [140] potential increased risk of post-traumatic clinical assessment and anxiety [140] both were more common in patients with less social support [139] stress disorder (ptsd), depression, anxiety. [123] persistent depression and anxiety have been reported following previous coronavirus epidemics in non-athletic populations. screening questionnaires psychology review and psychiatrist review 1331 1332 1333 activity that can be conducted by a solo athlete or by pairs where at least 1.5m can always be maintained between participants. no contact between athletes and/or other personnel. examples for all sports -general fitness aerobic and anaerobic (e.g. running, cycling sprints, hills). strength and sport-specific training permitted if no equipment required, or have access to own equipment (e.g. ergometer, weights). online coaching and resources (e.g. videos, play books). as per level a plus: indoor/outdoor activity that can be conducted in small groups (not more than 10 athletes and/or other personnel in total) and with adequate spacing (not more than 1 person per 4m 2 ). some sharing of sporting equipment permitted such as kicking a football, hitting a tennis ball, use of a skipping rope, weights, mats. non-contact skills training. accidental contact may occur but no deliberate body-contact drills. no wrestling, holding, tackling or binding. as per lev full sporti size matches). rugby scru for larger separation for some operation no sharing of exercise equipment or communal facilities. apply personal hygiene measures even when training away from group facilities -hand hygiene regularly during training (hand sanitisers) plus strictly pre and post training. do not share drink bottles or towels. do not attend training if unwell (contact doctor). spitting and clearing of nasal/respiratory secretions on ovals or other sport settings must be strongly discouraged. communal facilities can be used after a sport-specific structured risk assessment and mitigation process is undertaken. 'get in, train and get out' -be prepared for training prior to arrival at venue (minimise need to use/gather in change rooms, bathrooms). minimise use of communal facilities (e.g. gym, court) with limited numbers (not more than 10 athletes and other personnel in total). have cleaning protocols in place for equipment and facilities. hand hygiene (hand sanitisers) on entry and exit to venues, as well as pre, post and during training. thorough full body shower with soap before and after training (preferably at home). where possible maintain distance of at least 1.5m while training. no socialising or group meals. return to cleaning m limit unne all consultations undertaken via telehealth unless face to face is considered urgent avoid all routine and non-essential manual therapy. five moments for hand hygiene must be used to minimise the risk of transmission between health professionals and patients. hygiene practises to include no bed linen except single use towels, cleaning treatment beds and key surfaces after each athlete. minimum contact of non-essential surfaces to occur and hands on treatment should be kept to essential only. history taking, or full consultations should be conducted via telehealth if practical. face to face consults should be conducted from at least 1.5m apart when possible, and hands on treatment should be for essential conditions only. a single source therapist is recommended. during any essential manual therapy, it is recommended that the athlete and practitioner wear a face mask. all nonessential athletes and other personnel should avoid the treatment area, and the number of people in treatment areas should be kept to a minimum, following social distancing guidelines. world health organisation. novel coronavirus -china travellers give wings to novel coronavirus (2019-ncov). j 892 travel med international travel health: sars (severe acute respiratory 894 syndrome) european centre for disease prevention and control. mers-cov worldwide overview an outbreak of covid 19 caused by a new 898 coronavirus: what we know so far world health organisation herd immunity -estimating the level required to halt the covid-19 1010 epidemics in affected countries clinical characteristics of 138 hospitalized patients with 2019 novel 1016 coronavirus-infected pneumonia in wuhan, china detection of sars-cov-2 in different types of clinical specimens characteristics and outcomes of 21 critically ill patients with covid-19 1019 in washington state neurologic manifestations of hospitalized patients with coronavirus 1021 disease coagulopathy and antiphospholipid antibodies in patients with covid-19 clinical, laboratory and imaging features of covid-1027 19: a systematic review and meta-analysis. travel medicine and infectious disease self-reported olfactory and taste disorders in sars-cov-2 1030 patients: a cross-sectional study olfactory and gustatory dysfunctions as a clinical presentation of 1032 mild-to-moderate forms of the coronavirus disease (covid-19): a multicenter european 1033 study characteristics of and important lessons from the 1037 coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 1038 cases from the chinese center for disease control and prevention radiological findings from 81 patients with covid-19 pneumonia in 1040 china: a descriptive study. the lancet infectious diseases clinical course and outcomes of critically ill patients with sars-cov-2 1042 pneumonia in wuhan, china: a single-centered, retrospective, observational study. the 1043 lancet respiratory medicine sars-cov-2 infection in children estimating the asymptomatic proportion of coronavirus disease 2019 1047 (covid-19) cases on board the diamond princess cruise ship universal screening for sars-cov-2 in women admitted for delivery clinical progression and viral load in a community outbreak of 1052 coronavirus-associated sars pneumonia: a prospective study baseline characteristics and outcomes of 1591 patients infected 1057 with sars-cov-2 admitted to icus of the lombardy region clinical characteristics of patients who died of coronavirus disease 1059 2019 in china covid-19: consider cytokine storm syndromes and immunosuppression neurologic features in severe sars-cov-2 infection association of public health interventions with the epidemiology of the 1068 covid-19 outbreak in wuhan, china. jama, 2020. 1069 69. parliment of australia. covid-19 human biosecurity emergency declaration explainer world health organisation, laboratory testing for coronavirus disease 2019 (covid-19) in 1085 suspected human cases neutralizing antibody responses to sars-cov-2 in a covid-19 recovered 1087 patient cohort and their implications. medrxiv, 2020. 1088 76. world health organisation presumed asymptomatic carrier transmission of covid-19 national covid-19 clinical evidence taskforce. caring for people with world health organisation, clinical management of severe acute respiratory infection (sari) 1100 when covid-19 disease is suspected. 2020. 1101 82 international olympic committee. joint statement from the international olympic committee 1118 and the tokyo 2020 organising committee game zero?' soccer game attended by 40,000 fans likely made this italian 1126 city a coronavirus epicenter canberra capitals move one step closer toward wnbl title with thrilling game 1129 1 win over southside flyers official release: nba to suspend season following wednesday's games premier league and british football shuts down 1146 until april due to coronavirus -as it happened abc news. new zealand cricket team to return home, postponing odi series with australia super rugby suspended due to coronavirus, jaguares-highlanders cancelled update on covid-19: hyundai a-league to play matches behind closed doors a-league to end quickly behind closed doors football: euros and copa america moved to 2021 due to coronavirus chao fff media. ffa to postpone remaining matches in the hyundai a-league season due to 1180 covid-19 -organising-committee-and-tokyo-metropolitan-government-announce-new-dates-for-1192 the-olympic-and-paralympic-games-tokyo-2020. 1193 112. battett, d. update: pay cut deal ensures 'certainty' in afl industry: aflpa abc news. nrl players lose five months' pay as part of new deal during coronavirus 1200 pandemic ca announces staff cutbacks due to coronavirus article: a wake up call: the effects of coronavirus on the sports industry the differential psychological distress of populations affected by the covid-1209 19 pandemic prevalence and factors associated with depression and anxiety of 1211 hospitalized patients with covid-19. medrxiv the reproductive number of covid-19 is higher compared to sars 1213 coronavirus are patients with hypertension and 1218 diabetes mellitus at increased risk for covid-19 infection? the lancet respiratory 1219 medicine long-term clinical outcomes in survivors of coronavirus outbreaks 1223 after hospitalisation or icu admission: a systematic review and meta-analysis of follow-up 1224 studies respiratory health in athletes: facing the 1226 covid-19 challenge. the lancet infectious diseases the resurgence of sport in the wake of covid-19: cardiac considerations 1228 in competitive athletes clinical characteristics of 24 asymptomatic infections with covid-19 screened 1232 among close contacts in nanjing findings of lung ultrasonography of novel corona virus pneumonia 1236 during the 2019-2020 epidemic long-term clinical outcomes in survivors of 1238 coronavirus outbreaks after hospitalisation or icu admission: a 1239 systematic review and meta-analysis of follow-up studies. medrxiv cardiovascular considerations for patients, health care workers, and 1242 health systems during the coronavirus disease 2019 (covid-19) pandemic covid-19) ct findings: a systematic review 1245 and meta-analysis the use of anti-inflammatory drugs in the treatment of people with severe 1247 coronavirus disease 2019 (covid-19): the perspectives of clinical immunologists from 1248 china guillain-barré syndrome associated with sars-cov-2 unique epidemiological and clinical features of the emerging 2019 novel 1252 coronavirus pneumonia (covid-19) implicate special control measures large-vessel stroke as a presenting feature of covid-19 in the 1256 young impact of covid 19: perspectives from gastroenterology kidney disease is associated with in-hospital death of patients with 1262 covid-19 management of chronic (post-viral) fatigue syndrome. the journal of the 1264 royal college of general practitioners 5 moments for hand hygiene figure 1: history of coronavirus epidemics over the past two decades a series of pneumonia cases of unknown cause with clinical presentations resembling viral pneumonia emerged in wuhan, hubeiin province, people's republic of china cluster of respiratory infections in wuhan reported to world health organisation (who) china country office first death of covid-19 in people's republic of china who first reported a cluster of cases in wuhan, hubeiin province, people's republic of china[9] people's republic of china shared the genetic sequence of first case of covid-19 outside of china australian federal government list 'human coronavirus with pandemic potential' in the listed human disease under the biosecurity act 2015, enabling the use of enhanced border measures lock down in hubei province, people's republic of china[18] 628 confirmed covid-19 cases people's republic of china and 17 deaths australian federal government increased level of travel advice for wuhan and hubei province in people's republic of china to 'level 4 -do not travel first case of covid-19 in australia australian federal government advice return travellers who have been in the hubei province, people's republic of china must self-isolated at home for 14 days who declared covid-19 as a global health emergency australian federal government closed borders for non-citizens and non-residents arrivals from people's republic of china global covid-19 cases >11,900 and >250 deaths (in people's republic of china first death of covid-19 outside people's republic of china covid-19 cases in the diamond princess cruise ship docked yokohama first cases of community transmission of covid-19 in australia global covid-19 cases >145,400 and >5 french government bans gatherings of >100 people new zealand government impose mandatory 14-day self-isolation for all returning travellers australian federal government impose mandatory 14-day self-isolation for all returning travellers australian government banned international cruise ship arrivals for 30 days who launches solidarity trial (international clinical trial to help find an effective treatment for covid-19 australian federal government impose a limit of <100 people for non-essential indoor gatherings and <500 people for outdoor gatherings, and call to limit non-essential domestic travel australian federal government border closure to all non-citizens and non-residents[31] 22 march 2020 most australian state and territory governments advised against non-essential interstate travel australian federal government impose a ban on all overseas travel 'level 4 -do not travel global covid-19 cases >423,100 and >19,000 deaths australian federal government impose mandatory 14 day supervised self-isolation at designated facilities (e.g. a hotel) for all returning international travellers the united states is the new epicentre of the covid-19 global covid-19 cases >3,230,400 and >228 figure 3: new and cumulative confirmed covid-19 cases by notification date in australia groups of single sculls. rugby league running/aerobic/agility training (solo), resistance training (solo), skills training (solo) including kicking, passing, ball skills (e.g. against wall) to self. skill drills using a ball, kicking and passing. no tackling/wresting. small group (not more than 10 athletes/staff in total) sessions. rugby sevens running/aerobic/agility training (solo), resistance training (solo), skills training (solo) including kicking, passing non-contact skill drills using a ball, kicking and passing, small groups (not more than 10 athletes/staff in total) only. no rucks, mauls, lineouts or scrums, no tackling/wresting. rugby union running/aerobic/agility training (solo), resistance training (solo), skills training (solo) including kicking, passing wheelchairs, prostheses) will require regular cleaning (for all levels) on-water single. group resistance training sessions and outdoor group ergometer training placed at least 1.5m apart (not more than 10 athletes/staff in total). groups of single sculls. full trainin rugby sevens running/aerobic/agility training (solo), resistance training (solo), skills training (solo) including kicking, passing non-contact skill drills using a ball, kicking and passing, small groups (not more than 10 athletes/staff in total) only. no rucks, mauls, lineouts or scrums, no tackling/wresting. full trainin sailing solo or double handlers (if allowed by state regulations) only. full training. full trainin shooting aerobic/resistance training (solo), technical skills (solo)-e.g. standing/holding and dry firing continuation of athlete-led preparation at home. coach-led training including live fire in small groups at authorised venues (i.e. clubs/ranges) full trainin skateboarding outdoor and solo only, or indoor only if have own facilities. full training with appropriate distancing between athletes. ful softball running/aerobic training (solo), resistance training (solo), skills training (solo) running/aerobic/agility training (solo), resistance training (solo), skills training and shooting drills (solo) at home or outdoor (no indoor sporting facility access allowed). no ball handling drills with others.non-contact skills using basketball -passing, shooting, defending, screens and team structure (offence and defence). small groups (not more than 10 athletes/staff in total). running/aerobic/agility training (solo), resistance training (solo), technical training (solo). bag work if access to own equipment, without anyone else present.shadow sparring allowed. non-contact technical work with coach, including using bag, speedball, pads, paddles, shields. no contact or sparring. running/aerobic training (solo), resistance training (solo), on-water training (solo).full training. running/aerobic training (solo), resistance training (solo), skills training (solo).nets -batters facing bowlers. limit bowlers per net. fielding sessions-unrestricted.no warm up drills involving unnecessary person-person contact.no shining cricket ball with sweat/saliva during training. solo outdoor cycling or trainer, resistance training (solo). avoid cycling in slipstream of others-maintain 10m from cyclist in front. avoid packs of greater than two (including motorcycle derny). on-land training only (solo non-contact skills training drills in small groups (not more than 10 athletes/staff in total). running/aerobic/agility training (solo), resistance training (solo), skills training (solo).non-contact skill training drills -passing, shooting, headers. small groups (not more than 10 athletes/staff in total). solo or pairs only (if permitted by local government). full training. resistance training, skills training solo and outside of gym only.rhythmic -skills at home. trampoline -off apparatus skills, drills at home only.small groups only -1 gymnast per apparatus (including rhythmic and trampoline). disinfecting high touch surfaces as per the manufacturer's guidelines. running/aerobic/agility training (solo), resistance training (solo), skills training (solo) at home or outdoor (no indoor sporting facility access allowed).skill drills -passing, shooting, defending. no contact drills. small groups (not more than 10 athletes/staff in total). running/aerobic/agility training (solo), resistance training (solo), technical training (solo)-e.g. mirror work.no contact / bouts. non-contact shadow training. non-contact technical work with coach. running/aerobic/agility training (solo), resistance training (solo), technical training (solo)-e.g. mirror work.no contact / bouts. shadow sparring. non-contact technical work with coach, including using pads, paddles. a maximum of 2 people are allowed per green at any one time.all players are to use separate mats and jacks (or ensure that the same player on each rink places mats or places/rolls jacks).other bowls equipment cannot be shared between players (e.g. bowls, cloths, measures) . coaching should be limited to no more than a coach and one other person at the time and all practicing physical distancing of 1.5m during the coaching session.no barefoot bowls activity.a maximum of 10 persons is allowed per green at any one time. bowling clubs may need to have a booking system in place to facilitate (levels a and b). bowling clubs with more than one green need to ensure that compliance is achieved in respect to social gathering restrictions. running/aerobic training (solo), resistance training (solo), skills training (solo).swimming -use of communal pool with limited numbers, 1 athlete per lane. running/aerobic/agility training (solo), resistance training (solo), skills training and shooting drills (solo) at home or outdoor (no indoor sporting facility access allowed). no ball handling drills with others.non-contact skills using basketball -passing, shooting, defending, screens and team structure (offence and defence). small groups (not more than 10 athletes/staff in total). non-contact skills training drills in small groups (not more than 10 athletes/staff in total). running/aerobic/agility training (solo), resistance training (solo), skills training (solo).non-contact skill training drills -passing, shooting, headers. small groups (not more than 10 athletes/staff in total). solo or pairs only (if permitted by local government). full training. full trainin resistance training, skills training solo and outside of gym only.rhythmic -skills at home. trampoline -off apparatus skills, drills at home only.small groups only -1 gymnast per apparatus (including rhythmic and trampoline). disinfecting high touch surfaces as per the manufacturer's guidelines. running/aerobic/agility training (solo), resistance training (solo), skills training (solo) at home or outdoor (no indoor sporting facility access allowed).skill drills -passing, shooting, defending. no contact drills. small groups (not more than 10 athletes/staff in total). running/aerobic/agility training (solo), resistance training (solo), technical training (solo)-e.g. mirror work.no contact / bouts. non-contact shadow training. non-contact technical work with coach. running/aerobic/agility training (solo), resistance training (solo), technical training (solo)-e.g. mirror work.no contact / bouts. shadow sparring. non-contact technical work with coach, including using pads, paddles. a maximum of 2 people are allowed per green at any one time.all players are to use separate mats and jacks (or ensure that the same player on each rink places mats or places/rolls jacks). other bowls equipment cannot be shared between players (e.g. bowls, cloths, measures). coaching should be limited to no more than a coach and one other person at the time and all practicing physical distancing of 1.5m during the coaching session. no barefoot bowls activity.a maximum of 10 persons is allowed per green at any one time.bowling clubs may need to have a booking system in place to facilitate (levels a and b). bowling clubs with more than one green need to ensure that compliance is achieved in respect to social gathering restrictions. para-athletes require individualised consideration and assessment through all levels (a, b, c) of a return to sport. some para-athletes wil detailed planning and consultation with their regular treating medical team prior to a return to formal training, or progression through le small group (not more than 10 athletes/staff in total) skills training. aerobic and resistance training (solo), climbing solo/pairs on own wall or outdoors (if allowed by local government). solo hang board training.full training.cleaning of indoor walls required between athletes/groups. in pool water training if access to own pool (consider using swim tether) or open-water only. consider use of wind trainer and treadmill for those in quarantine (who are medically well). avoid cycling in slipstream of others-maintain 10m from cyclist in front avoid packs of greater than two. avoid packs of greater than 2 running. maintain social distancing while running. use of communal pool with limited numbers, 1 athlete per lane, consider one lane between athletes. running/aerobic/agility training (solo), resistance training (solo), skills training (solo) at home or outdoor (no indoor sporting facility access allowed).small group (not more than 10 athletes/staff in total) skill sessions only. no matches. in-water training (solo) if access to own pool only, or openwater.use of communal pool with limited numbers and distance maintained. swimming, throwing (passing/shooting) drills. no full contact/defending drills, wrestling. resistance training, technical work at home (no indoor sporting facility / gym access allowed).full training with limited numbers to avoid congestion. full trainin aerobic training (solo), resistance training (solo), skills training (solo) at home or outdoor (no indoor sporting facility access allowed).non-contact shooting, dribbling drills. other non-contact technical /skill drills. small groups (not more than 10 athletes/staff in total). aerobic training (solo), resistance training (solo), skills training (solo) at home or outdoor (no indoor sporting facility access allowed).non-contact passing drills on court. other non-contact technical /skill drills. small groups (not more than 10 athletes/staff in total). running/aerobic/agility training (solo), resistance training (solo), balance training (solo).use of institute gym facilities and indoor ice surfaces in small groups (<10 total athletes/support staff). use of acrobatic facilities such as trampoline, bungee and water ramp in small groups with 1 athlete at a time and at least 1.5m distancing to support staff. limited on snow training dependent on travel restrictions. small groups widely spaced, no communal living. full training with small numbers (not more than 10 athletes/staff in total). running/aerobic training (solo), resistance training (solo), skills training (solo).nets -batters facing bowlers. limit bowlers per net. fielding sessions-unrestricted.no warm up drills involving unnecessary person-person contact.no shining cricket ball with sweat/saliva during training. running/aerobic training (solo), resistance training (solo), simulation work at home if available.full training. full trainin running/aerobic/agility training (solo), resistance training (solo), skills training (solo), including shooting (outdoor or own ring only) or ball skills e.g. against a wall to self.skills using netball passing, shooting, defending. small group training (not more than 10 athletes/staff in total) based on skills with set drill, but no close contact/defending/attacking/match play drills. running/aerobic/agility training (solo), resistance training (solo), skills training (solo) including kicking, passing, ball skills (e.g. against wall) to self.skill drills using a ball, kicking and passing. no tackling/wresting. small group (not more than 10 athletes/staff in total) sessions.full trainin 1336 1337 