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OBJECTIVE: Pediatric COVID-19 vaccination rates remain low in rural areas. A strong clinician recommendation improves vaccine uptake, but the pediatric COVID-19 vaccine recommendation practices of rural primary care clinicians have not been reported. Our objectives were to describe, among rural Colorado pediatric clinicians: 1) recommendation practices for COVID-19 vaccine compared to influenza and school-entry required vaccines, and 2) personal attitudes. METHODS: From July to October 2023, surveys were distributed to clinicians in rural Colorado identified as pediatric vaccine providers in counties designated as rural through the Colorado Immunization Information System using mail and email. RESULTS: Of 89 survey respondents, 37% of clinicians strongly recommended COVID-19 vaccines for children 6 months - 5 years old, compared to 79% for influenza (p=0.05) and 92% for school-entry required vaccines (p=0.04). For children 6 -11 and 12 - 17 years old, 43% and 44% of clinicians strongly recommended COVID-19 vaccines, respectively, compared to 71% and 70% for influenza (p <0.01), and 91% for school-entry required vaccines (p <0.01). 44% of clinicians agreed that COVID-19 vaccines are important for pediatric patients. The most common clinician-perceived challenges to discussing pediatric COVID-19 vaccines included a lack of parent interest in more information (76% "somewhat" or "strongly" agree), lack of ability to change parents' minds (71%), and concerns that the vaccines are too political (40%). CONCLUSIONS: Most rural Colorado clinicians do not strongly recommend pediatric COVID-19 vaccines compared to influenza and school-entry required vaccines. Efforts to improve pediatric COVID-19 vaccine uptake should aim to strengthen clinicians' recommendations of these vaccines.

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Neurotrauma registries (NTR) collect data on traumatic brain injuries (TBI) to advance knowledge, shape policies, and improve outcomes. This study reviews global NTRs from High-Income (HICs) and Low- and Middle-Income countries (LMICs). A systematic review was conducted using PubMed, Google Scholar, Embase, and Web of Science following PRISMA guidelines to identify relevant NTRs. Twenty-six articles were included, revealing ten different NTRs from Europe, North America, Latin America, the Middle East, and Asia. North America had the most registries at four, followed by Europe and Asia with two each, and Latin America and the Middle East with one each. The median database size was 1,734 patients (Range: 65-25,000), with the largest registry from the United States (FITBIR DB) and the smallest from Iran (NSCIR-IR). The longest data collection period was 32 years, with a mean age of 43.1 years (Range: 9.07-60.0). Males comprised 70 % of patients. Sixty-six percent of articles emphasized outcomes such as functionality, length of stay, and mortality. Key challenges identified included issues with missing data and incomplete records (n = 4), lack of standardization in data collection procedures (n = 3), staffing shortages (n = 5), lack of IT infrastructure (n = 3), and problems with reproducibility, particularly in high-income countries (n = 4). Our review highlights the need for a large-scale global NTR, addressing LMIC barriers through private-public partnerships with organized neurosurgery members.

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BACKGROUND: The common femoral artery and radial artery constitute the most common access sites in contemporaneous endovascular neurosurgery. Oftentimes, it may be impossible to reach the vascular target safely due to different circumstances, necessitating alternative approaches. We aim to review these "last resource" access sites described in the literature, focusing on the technical aspects as a convenient reference. METHODS: We performed a comprehensive literature search of PubMed capturing articles from 1958 to 2022. RESULTS: We identified nine alternative approaches for endovascular access, after excluding direct carotid stick: superficial temporal artery access in 60 patients, calvarial foramina access in five patients, occipital artery access in seven patients, middle meningeal artery access in six patients, vertebral artery access in 23 patients and external carotid artery, internal maxillary artery, facial artery or lingual artery in 40 patients. Indications for the use of alternative access points included tortuous or occluded vessels, small vessel calibers, or anatomic variation. Pathologies treated included dural arteriovenous fistulas, arteriovenous malformations, intracranial aneurysms, acute stroke, and intracranial stenosis. Diagnostic brain angiograms were also performed. CONCLUSIONS: Alternative vascular access routes expand the proceduralists' toolkit, enhancing the capability to manage complex cerebrovascular interventions. This review advocates for a broader understanding and consideration of these techniques, given their potential to significantly increase treatment options in neuroendovascular surgery.

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BACKGROUND AND OBJECTIVES: Studies note a high prevalence of pediatric coronavirus disease 2019 (COVID-19)-specific vaccine hesitancy in the United States. Our objective was to assess whether clinicians perceive a spillover effect of COVID-19 vaccine hesitancy onto other vaccines, and the impact of this spillover on their general recommendation behavior. METHODS: We conducted semistructured interviews with pediatricians in California and Colorado pediatric practices (January-March 2023). We transcribed, coded, and analyzed interviews using content analysis. RESULTS: We interviewed 21 pediatricians (10 in California, 11 in Colorado). Clinicians observed some spillover effect of vaccine-favorable changes among some parents and greater hesitancy among others regarding the risks and benefits of childhood vaccination in general. This spillover was informed by 2 divergent patterns of parental trust in health systems and individual clinicians caused by the COVID-19 pandemic. Factors driving perceived changes included media coverage, greater knowledge about vaccination, and misinformation. Some clinicians felt that their approach to vaccine recommendations became more patient-centered, whereas others reported declining engagement in persuading hesitant parents about vaccination. CONCLUSIONS: Clinicians described a hardening of parental views toward vaccines in both directions, which impacted their recommendation behavior. There is a need for vaccine hesitancy monitoring and better training and support for clinicians facing vaccine hesitant parents.

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OBJECTIVE: Aneurysmal bone cysts (ABCs) are benign but aggressive vascular lesions within bone. Orbital ABCs, though rare, are clinically significant due to the risk of debilitating symptoms such as vision loss. METHODS: Our systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Google Scholar, Embase, and SCOPUS databases to identify and assess primary articles exploring orbital ABC cases. Additionally, we present an illustrative case report. RESULTS: Among the 54 cases from the 51 studies included, the mean age was 16.87 years, with 23 males, 29 females, and 2 unspecified. The most prevalent symptoms were exophthalmos (N = 36) and diplopia (N = 21). Regarding laterality, the right orbit was most commonly affected (N = 27), followed by the left orbit (N = 21), with 4 cases of bilateral involvement. Within the orbit, the medial wall most frequently impacted location (N = 14), followed by the orbital roof (N = 13), posterior wall (N = 7), lateral wall (N = 3), and orbital floor (N = 2), with 15 cases involving multiple locations. Surgical resection was the primary treatment, resulting in complete resolution in 44 cases. In our case, a 30-year-old male with an orbital ABC was managed surgically through bifrontal craniotomy with superior orbitotomy for lesion excision and orbital roof reconstruction. CONCLUSIONS: ABCs in the orbit can be challenging, and complete removal of the lesion is essential for achieving optimal patient outcomes.

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Background Patients utilize online health information to inform their medical decision-making. YouTube is one of the most popular media platforms with abundant health-related resources, yet the quality of the disseminated information remains unclear. This study aims to evaluate the quality and reliability of content pertaining to diverticulosis and diverticulitis on YouTube. Methods One author queried the terms "diverticulosis," "diverticulitis," "acute diverticulitis," and "chronic diverticulitis" on YouTube. The first 50 videos per search were selected for analysis. Duplicates, non-English videos, or procedural content were excluded. Video characteristics including view count, likes, comments, duration, days since upload, view ratio, video power index, and video sources (professional organizations (POs), health information websites (HIWs), and entertainment/independent users (EIUs)) were collected. Videos were scored using the mDISCERN and Global Quality Score (GQS). Results Sixty-four videos were included. DISCERN scores significantly differed between POs (n=20, mean=4.35), HIWs (n=29, mean=2.97), and EIUs (n=15, mean=1.83). GQS also significantly differed between POs (n=20, mean=4.47), HIWs (n=29, mean=3.62), and EIUs (n=15, mean=2.5). Video characteristics significantly differed between groups, with most user engagement seen in EIUs. Conclusion POs and HIWs disseminate higher quality health information about diverticular disease on YouTube. The higher viewer engagement with EIUs is concerning, as these sources were found to have lower quality content. Although YouTube has the capability to provide valuable information on diverticulosis and diverticulitis, enhanced content screening is needed to ensure accuracy and validation.

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BACKGROUND: Children with influenza-like-illness (ILI) often require clinician clearance or antibiotics to return to child care or school. Study objectives were to examine the association between antibiotic receipt during an Emergency Department (ED) visit for ILI and the outcomes of class absenteeism and illness duration. METHODS: A secondary analysis of 251 children aged 2 months to 12 years with uncomplicated ILI discharged from the ED from December 1, 2018 to November 30, 2019 was conducted. The primary exposure was receipt of antibiotics over the course of illness (assessed by chart review and family follow-up survey). RESULTS: Patients prescribed antibiotics (n = 65) experienced a median of 3 (interquartile range [IQR]: 1,5) days of class missed and 5 (IQR: 3,7) days of illness compared to 2 (IQR: 1,4) days of class missed and 4 (IQR: 3,7) days of illness for those not prescribed antibiotics (n = 186, p = 0.08 and p = 0.13, respectively). There was no statistically significant association with missed class days (incidence rate ratio [IRR]: 1.14 [0.86-1.50], p = 0.37) or days of illness (IRR: 1.06 [0.88-1.27], p = 0.55) for patients prescribed antibiotics compared to patients not prescribed antibiotics for ILI. CONCLUSIONS: Antibiotic use for ILI was not associated with reduced class absenteeism or illness duration. IMPACT STATEMENT: Child care centers and schools sometimes exclude children with influenza-like-illness (ILI) from class until cleared to return by a clinician and/or prescribed antibiotics. This study addresses these social drivers of overprescribing. Antibiotics were prescribed in 26% of children with ILI discharged from a large Emergency Department in the US. Antibiotic use was not significantly associated with class absenteeism or illness duration. This study can serve as a discussion point for clinicians when navigating parental or social pressures to prescribe antibiotics for uncomplicated acute respiratory tract infections, particularly when these pressures are influenced by concerns about returning to class.

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The Advisory Committee on Immunization Practices (ACIP), a group of medical and public health experts that provides advice to the Centers for Disease Control and Prevention, normally meets 3 times per year to develop US vaccine recommendations. The ACIP met June 26-28, 2024. This update summarizes the proceedings of this meeting, with an emphasis on topics that are most relevant to the pediatric population. Major updates for pediatric clinicians include COVID-19 and influenza vaccine recommendations for the 2024-2025 season, meningococcal vaccination considerations, information regarding preferred Haemophilus influenzae type B containing vaccines for American Indian and Alaskan Native infants, and updates regarding implementation and effectiveness of RSV immunization in pregnant people and infants.

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Background: Anterior cruciate ligament injury of the knee is common and leads to decreased activity and risk of secondary osteoarthritis of the knee. Management of patients with a non-acute anterior cruciate ligament injury can be non-surgical (rehabilitation) or surgical (reconstruction). However, insufficient evidence exists to guide treatment. Objective(s): To determine in patients with non-acute anterior cruciate ligament injury and symptoms of instability whether a strategy of surgical management (reconstruction) without prior rehabilitation was more clinically and cost-effective than non-surgical management (rehabilitation). Design: A pragmatic, multicentre, superiority, randomised controlled trial with two-arm parallel groups and 1:1 allocation. Due to the nature of the interventions, no blinding could be carried out. Setting: Twenty-nine NHS orthopaedic units in the United Kingdom. Participants: Participants with a symptomatic (instability) non-acute anterior cruciate ligament-injured knee. Interventions: Patients in the surgical management arm underwent surgical anterior cruciate ligament reconstruction as soon as possible and without any further rehabilitation. Patients in the rehabilitation arm attended physiotherapy sessions and only were listed for reconstructive surgery on continued instability following rehabilitation. Surgery following initial rehabilitation was an expected outcome for many patients and within protocol. Main outcome measures: The primary outcome was the Knee Injury and Osteoarthritis Outcome Score 4 at 18 months post randomisation. Secondary outcomes included return to sport/activity, intervention-related complications, patient satisfaction, expectations of activity, generic health quality of life, knee-specific quality of life and resource usage. Results: Three hundred and sixteen participants were recruited between February 2017 and April 2020 with 156 randomised to surgical management and 160 to rehabilitation. Forty-one per cent (n = 65) of those allocated to rehabilitation underwent subsequent reconstruction within 18 months with 38% (n = 61) completing rehabilitation and not undergoing surgery. Seventy-two per cent (n = 113) of those allocated to surgery underwent reconstruction within 18 months. Follow-up at the primary outcome time point was 78% (n = 248; surgical, n = 128; rehabilitation, n = 120). Both groups improved over time. Adjusted mean Knee Injury and Osteoarthritis Outcome Score 4 scores at 18 months had increased to 73.0 in the surgical arm and to 64.6 in the rehabilitation arm. The adjusted mean difference was 7.9 (95% confidence interval 2.5 to 13.2; p = 0.005) in favour of surgical management. The per-protocol analyses supported the intention-to-treat results, with all treatment effects favouring surgical management at a level reaching statistical significance. There was a significant difference in Tegner Activity Score at 18 months. Sixty-eight per cent (n = 65) of surgery patients did not reach their expected activity level compared to 73% (n = 63) in the rehabilitation arm. There were no differences between groups in surgical complications (n = 1 surgery, n = 2 rehab) or clinical events (n = 11 surgery, n = 12 rehab). Of surgery patients, 82.9% were satisfied compared to 68.1% of rehabilitation patients. Health economic analysis found that surgical management led to improved health-related quality of life compared to non-surgical management (0.052 quality-adjusted life-years, p = 0.177), but with higher NHS healthcare costs (£1107, p < 0.001). The incremental cost-effectiveness ratio for the surgical management programme versus rehabilitation was £19,346 per quality-adjusted life-year gained. Using £20,000-30,000 per quality-adjusted life-year thresholds, surgical management is cost-effective in the UK setting with a probability of being the most cost-effective option at 51% and 72%, respectively. Limitations: Not all surgical patients underwent reconstruction, but this did not affect trial interpretation. The adherence to physiotherapy was patchy, but the trial was designed as pragmatic. Conclusions: Surgical management (reconstruction) for non-acute anterior cruciate ligament-injured patients was superior to non-surgical management (rehabilitation). Although physiotherapy can still provide benefit, later-presenting non-acute anterior cruciate ligament-injured patients benefit more from surgical reconstruction without delaying for a prior period of rehabilitation. Future work: Confirmatory studies and those to explore the influence of fidelity and compliance will be useful. Trial registration: This trial is registered as Current Controlled Trials ISRCTN10110685; ClinicalTrials.gov Identifier: NCT02980367. Funding: This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/140/63) and is published in full in Health Technology Assessment; Vol. 28, No. 27. See the NIHR Funding and Awards website for further award information.

The study aimed to find out whether it is better to offer surgical reconstruction or rehabilitation first to patients with a more long-standing injury of their anterior cruciate ligament in their knee. This injury causes physical giving way of the knee and/or sensations of it being wobbly (instability). The instability can affect daily activities, work, sport and can lead to arthritis. There are two main treatment options for this problem: non-surgical rehabilitation (prescribed exercises and advice from physiotherapists) or an operation by a surgeon to replace the damaged ligament (anterior cruciate ligament reconstruction). Although studies have highlighted the best option for a recently injured knee, the best management was not known for patients with a long-standing injury, perhaps occurring several months previously. Because the surgery is expensive to the NHS (around £100 million per year), it was also important to look at the costs involved. We carried out a study recruiting 316 non-acute anterior cruciate ligament-injured patients from 29 different hospitals and allocated each patient to either surgery or rehabilitation as their treatment option. We measured how well they did with special function and activity scores, patient satisfaction and costs of treatment. Patients in both groups improved substantially. It was expected that some patients in the rehabilitation group would want surgery if non-surgical management was unsuccessful. Forty-one per cent of patients who initially underwent rehabilitation subsequently elected to have reconstructive surgery. Overall, the patients allocated to the surgical reconstruction group had better results in terms of knee function and stability, activity level and satisfaction with treatment than patients allocated to the non-operative rehabilitation group. There were few problems or complications with either treatment option. Although the surgery was a more expensive treatment option, it was found to be cost-effective in the UK setting. The evidence can be discussed in shared decision-making with anterior cruciate ligament-injured patients. Both strategies of management led to improvement. Although a rehabilitation strategy can be beneficial, especially for recently injured patients, it is advised that later-presenting non-acute and more long-standing anterior cruciate ligament-injured patients undergo surgical reconstruction without necessarily delaying for a period of rehabilitation.

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INTRODUCTION: In children and adolescents, brain and central nervous system (CNS) tumors are the leading types of cancers. Past studies have found differing rates of intracranial cancers among races and identified additional cancer risk factors. This study aimed to see if these differences can be substantiated with further investigation of the latest version (2019) of the Kids' Inpatient Database (KID). METHODS: A total of 7,818 pediatric patients <21 years old in KID with ICD-10 codes consisting of malignant neoplasms of the brain, brainstem, and cerebral meninges (C700, C709-C719) were queried. Modifiable risk factors evaluated include: hospital region, insurance type, hospital city size, the average income of patient zip code, and location/teaching status of a hospital. Non-modifiable risk factors were race and sex at birth. Dependent variables were tested in Excel and GraphPad Prism 9 using a χ2 test with Yates' continuity correction and Tukey's one-way and two-way ANOVAs. RESULTS: Mortality rates of females (2.88%) compared to males (1.99%) were significant (p < 0.05). Mortality was (4.17%) in black patients compared to (1.68%) for white (p < 0.0001), Hispanic mortality (2.95%) compared to white (p < 0.01), and mortality of Asian/Pacific Islander (3.86%) compared to white (p < 0.01). Black patients had significantly higher mortality than white, Hispanic, Asian/Pacific Islander, Native American, and other races overall (p < 0.01). There was no significant difference in the mortality rates between children's hospitals and large hospitals for any race. After accounting for patient race, mortality was still not significantly different for patients with Medicaid insurance compared to non-Medicaid insurance types. Of the children treated at children's hospitals, the most transferred in from outside hospitals were Native American (20.00%) followed by Asian/Pacific Islander (15.09%) then Hispanic patients (13.67%). A significant difference between races was also seen regarding length of stay (p < 0.001) and number of charges (p < 0.001). CONCLUSION: These findings confirm prior studies suggesting gender and race are significant factors in mortality rates for children with intracranial neoplasms. However, the findings do not identify the root causes of these discrepancies but may serve as an impetus for clinicians, healthcare administrators, and governmental leaders to improve national resource allocation to better care for pediatric patients with intracranial neoplasms.

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The worldwide elimination of measles and rubella is feasible, but not without overcoming the substantial challenge of vaccine hesitancy. This challenge is complicated by the spread of misinformation and disinformation fueled by rapidly progressing technologies and evolving forms of online communication. The recent COVID-19 pandemic has only added further complexity to this challenge. However, considerable progress has been made in understanding the scope of the problem and the complex factors that influence vaccine hesitancy. Our understanding of evidence-based strategies for addressing vaccine hesitancy has grown significantly, including evidence for effective communication and behavioral interventions. In this article, we review measles and rubella vaccines and vaccine hesitancy. We then provide an overview of evidence-based strategies for addressing vaccine hesitancy, including communication strategies and behavioral interventions. This article is relevant to healthcare professionals, health system leaders, public health professionals, policymakers, community leaders, and any individuals who have a role in addressing vaccine hesitancy in their communities. Finally, we review future directions and major areas of research need.

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Vaccine confidence is a belief that vaccines work, are safe, and are part of a trustworthy medical system. The COVID-19 pandemic exposed the fragility of the public's confidence in vaccines and the vaccine enterprise, limiting the public health impact of vaccination. In this review, we examine the critical nature of vaccine confidence to pandemic preparedness and response.

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OBJECTIVE: Basilar impression (BI) is a rare yet debilitating abnormality of the craniovertebral junction, known to cause life-threatening medullary brainstem compression. Our study analyzes surgical approaches for BI and related outcomes. METHODS: A systematic review was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to critically assess primary articles examining BI. RESULTS: We analyzed 87 patients from 65 articles, mostly female (55.17%) with a mean age of 46.31 ± 17.94 years, commonly presenting with motor (59.77%) and sensory deficits (55.17%). Commonly employed procedures included posterior occipitocervical fusion (24.14%), anterior decompression (20.69%), and combined anterior decompression with posterior fusion (21.84%). Patients who underwent anterior approaches were found to be older (55.38 ± 17.67 vs. 45.49 ± 18.78 years, P < 0.05) and had a longer duration from symptom onset to surgery (57.39 ± 64.33 vs. 26.02 ± 29.60 months, P < 0.05) compared to posterior approaches. Our analysis revealed a significant association between a longer duration from symptom onset to surgery and an increased likelihood of undergoing odontoidectomy and decompression (odds ratio: 1.02, 95% confidence interval: 1.00-1.03, P < 0.05). Furthermore, after adjusting for all other covariates, a history of rheumatoid arthritis and the use of a posterior approach were significantly associated with an elevated risk of postoperative complications (P < 0.05). CONCLUSIONS: The treatment approach to complex craniovertebral junction disease should be tailored to the surgeon's experience and the nature of the compressive pathology.

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The parasite Toxoplasma gondii persists in its hosts by converting from replicating tachyzoites to latent bradyzoites housed in tissue cysts. The molecular mechanisms that mediate T. gondii differentiation remain poorly understood. Through a mutagenesis screen, we identified translation initiation factor eIF1.2 as a critical factor for T. gondii differentiation. A F97L mutation in eIF1.2 or the genetic ablation of eIF1.2 (∆eif1.2) markedly impeded bradyzoite cyst formation in vitro and in vivo. We demonstrated, at single-molecule level, that the eIF1.2 F97L mutation impacts the scanning process of the ribosome preinitiation complex on a model mRNA. RNA sequencing and ribosome profiling experiments unveiled that ∆eif1.2 parasites are defective in upregulating bradyzoite induction factors BFD1 and BFD2 during stress-induced differentiation. Forced expression of BFD1 or BFD2 significantly restored differentiation in ∆eif1.2 parasites. Together, our findings suggest that eIF1.2 functions by regulating the translation of key differentiation factors necessary to establish chronic toxoplasmosis.

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PURPOSE: The aim of this study was to describe the 10-year findings from the UK National Ligament Registry (NLR). METHODS: A retrospective review was performed for prospectively collected data on the NLR between January 2013 and December 2022. All patients who underwent primary ACL reconstruction (ACLR) on the registry were included. Surgical characteristics were analysed, including surgeon grade and case volume, concomitant knee procedures, venous thromboembolic prophylaxis, graft characteristics, femoral and tibial tunnel drilling, and fixation methods. Clinical outcomes were collected preoperatively and at 6 months, 1 year, 2 years and 5 years following the index procedure. RESULTS: During the study period, 17,492 unilateral ACLR procedures were recorded. Autograft was used in 98%, most commonly a combined semitendinosus and gracilis graft (77%) or patella tendon graft (31%). Allograft was used in only 1% of the patients. In 52% of cases, ACLR was associated with an additional procedure, with isolated medial meniscal surgery being the most common (21%). Femoral tunnel drilling was mostly performed through an anteromedial portal (73%) and tibial tunnel drilling using an outside-in technique (92%). The most common method of femoral graft fixation was with an Endobutton fixed loop suspensory device (77%), while interference screws predominated for tibial tunnel fixation (86%). Patients who underwent ACLR surgery showed significant improvement in their functional outcome scores at six months, 1 year, 2 years and 5 years postoperatively. CONCLUSION: Data from the NLR shows a detailed description of the current trends and evolution of ACLR in the United Kingdom over the last 10 years. Satisfactory functional outcomes were observed 5 years postoperatively. This study provides useful information on the prevalence of ACL-associated injuries and current surgical techniques with the aim of improving the quality of clinical care and patients' outcomes. Moreover, it provides surgeons with a benchmark against which to compare current practices and functional outcomes following ACLR across the United Kingdom. LEVEL OF EVIDENCE: Level III.

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Improving clinician-patient communication can increase uptake of recommended vaccinations during pregnancy. To evaluate adaptations to and pragmatism of the brief Motivational Interviewing for Maternal Immunizations (MI4MI) intervention and to use the Practical Robust Implementation and Sustainability Model (PRISM) to describe context and implementation outcomes among clinician and staff participants. We incorporated data from study team members, clinicians and staff participants, pregnant patients at participating clinics, and patient medical records. Quantitative and qualitative data were collected using surveys, chart reviews, study team notes, interviews, and focus groups. Adaptations were evaluated using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) and pragmatism was measured with PRagmatic Explanatory Continuum Indicator Summary (PRECIS-2). MI4MI was effective at improving participants' vaccine communication experiences. Adoption was limited by our recruitment approach. MI4MI implementation was shaped by contextual factors and associated adaptations related to the COVID pandemic and clinic and participant characteristics. Virtual asynchronous intervention delivery had mixed effects on adoption and implementation that varied across clinics and participants. Participants expressed interest in maintaining the MI4MI intervention moving forward; however, identification of sustainability infrastructure was limited. MI4MI was evaluated to be relatively pragmatic. Contextual factors strongly shaped implementation of MI4MI. Future iterations of MI4MI should include training delivery modes and incentives that accommodate a range of participants across job roles and organizational settings. Future studies including control clinics are needed to measure effectiveness for increasing vaccination and comparing virtual versus hybrid implementation strategies.

We studied a training program called Brief Motivational Interviewing for Maternal Immunizations (MI4MI). This program tried to teach doctors and other healthcare workers how to talk with pregnant people about vaccines. We looked at how this training program worked in different clinics. We talked with and gave surveys to the healthcare workers and patients at clinics who participated in this program. Healthcare workers who completed the MI4MI program had better experiences talking about vaccines after the training. This study happened during the early COVID pandemic, so training was done online. Healthcare workers and clinics had mixed responses to the online training approach. COVID made it hard for some people to participate. Many people who did the training said they would like to keep using the MI4MI training and skills in the future. More studies are needed to learn if the MI4MI training increases vaccination rates and to look at ways to improve online training.

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