Low‐ and middle‐income countries (LMICs) have a large burden of noncommunicable diseases and confront leadership capacity challenges and gaps in implementation of proven interventions. To address these issues, we designed the Public Health Leadership and Implementation Academy (PH-LEADER) for noncommunicable diseases. The objective of this program evaluation was to assess the quality and effectiveness of PH-LEADER.PH-LEADER was directed at midcareer public health professionals, researchers, and government public health workers from LMICs who were involved in prevention and control of noncommunicable diseases. The 1-year program focused on building implementation research and leadership capacity to address noncommunicable diseases and included 3 complementary components: a 2-month online preparation period, a 2-week summer course in the United States, and a 9-month, in-country, mentored project.Four trainee groups participated from 2013 through 2016. We collected demographic information on all trainees and monitored project and program outputs. Among the 2015 and 2016 trainees, we assessed program satisfaction and pre–post program changes in leadership practices and the perceived competence of trainees for performing implementation research.d = 0.62, P <.001), inspired a shared vision , challenged current processes , enabled others to act , and encouraged others by recognizing or celebrating their contributions and accomplishments . Through short on-site evaluation forms , trainees rated summer course sessions as useful , with very good content  and delivered by very good professors , though they highlighted areas for improvement.Ninety professionals  from 12 countries were trained over 4 years. Of these trainees, 50% were from India and 29% from Mexico. Trainees developed 53 projects and 9 publications. Among 2015 and 2016 trainees who completed evaluation surveys (n = 46 of 55), we saw pre–post training improvements in the frequency with which they acted as role models (Cohen’s The PH-LEADER program is a promising strategy to build implementation research and leadership capacity to address noncommunicable diseases in LMICs. Low- and middle-income countries (LMICs) face limited implementation research and leadership capacity to translate evidence into programs and policies addressing noncommunicable diseases.We developed a 1-year training program to build implementation research and leadership capacity among public health professionals in LMICs. From 2013 through 2016, 90 professionals from 12 countries were trained, and results from an evaluation of the program are promising.This training program can contribute to strengthen the global-health workforce and its ability to lead and implement proven strategies to address noncommunicable diseases in LMICs.Cardiovascular disease, diabetes, cancer, mental illness, and chronic respiratory diseases threaten the health and economic well-being of individuals and populations alike . These nLMICs confront major challenges to address the growing burden of noncommunicable diseases. Aside from limited health financing, scarcity of local health research evidence, and heterogeneity in access to health care and care delivery, LMICs face 2 additional and often underrecognized challenges: limited implementation research and limited leadership capacity among the public health workforce to translate research evidence into policy and practice. For instance, limited capacity hinders implementation of proven strategies to prevent noncommunicable diseases  –6 and maThough training can improve implementation research and leadership skills in the public health workforce, existing training programs have targeted these skill sets separately and mainly among professionals from high-income countries –16. OtheThe objective of this program evaluation was to assess the quality and impact of the PH-LEADER training program. We define training as a set of didactic, theoretical, and instructional methods focused on enhancing implementation research and leadership skills. PH-LEADER was developed collaboratively by public health experts from Emory University, the National Institute of Public Health in Mexico, and the Public Health Foundation of India with the goal of building leadership and implementation research capacity to address noncommunicable diseases in 12 countries . These cPH-LEADER was directed at midcareer, high-potential health researchers, public health professionals, and government public health workers affiliated with the National Institute of Public Health in Mexico, the Public Health Foundation of India, and ministries of health or strategic partner institutions in other LMICs. The training program was advertised internally at the National Institute of Public Health in Mexico and the Public Health Foundation of India and externally via email listservs, websites, and word of mouth. To promote equal opportunity, we focused participant recruitment strategies on women, low socioeconomic populations, geographically underserved areas, and professionals with limited access to similar training opportunities. We also asked in-country partners to find and encourage applications from women and to select equal numbers of women and men where possible. This was done with careful consideration to equity and balance in subject expertise where possible; this also helped select candidates from institutions that may otherwise have been overlooked for this training opportunity.Individuals interested in participating submitted an application in English that included a letter of intent, their curriculum vitae, and 2 letters of support from their home institution. The application was screened independently by 2 members of a review committee and ranked by using a simple scoring system from 1 to 10, with 1 being the lowest score. The scoring system was designed to identify applicants with high potential based on years of experience, likelihood of moving into a position of influence in their organization, and potential to affect public health in their home country. We selected participants with the highest scores while also considering diversity in sex, institution, and area of expertise.PH-LEADER program theory and content are described in detail elsewhere . BrieflyThe 1-year program comprised 3 complementary parts. The first was a 2-month in-country preparation period that consisted of webinars and reading materials aimed at laying the knowledge and work-dynamic foundation needed for the course. This was followed by a 2-week, in-person, executive-style course delivered at Emory University in Atlanta. An immersive summer course format was used because it maximized opportunities for trainees and faculty to interact, provided practical learning opportunities, and promoted short-term improvements in trainee skills ,24. The The summer course was followed by a structured 9-month, in-country mentored phase that involved distance learning through monthly webinars and participant-led implementation projects . InteracPre-course orientation webinarsPreparatory readings and materialsModule 1 — Analytical MethodsBasics of epidemiologyBasic economicsSurveillanceEconomic evaluationData integration and information systemsSystematic reviewsResearch ethicsHealth systems researchModule 2 — Implementation ResearchImplementation science frameworksQuasi-experiments and natural experimentsOrganizational designHealth financingQualitative research methodsStructure of health care systemsHealth policyIntervention design, implementation, and evaluationModule 3 — LeadershipEmotional intelligenceNetworking and team buildingQuality improvementOrganizational culture and managementManaging peopleMentoring and coachingManaging changeVisionMonthly webinars (distance learning)Meet and learn from the mentorDevelop and implement the project (with mentor)Alumni networkThe program was expected to have an effect in the short term by improving trainee implementation research skills to develop, implement, and test strategies addressing noncommunicable diseases and by equipping them with leadership skills to lead and manage teams to implement, disseminate, and scale such strategies. In the long term, the program is expected to have a ripple effect through trainees influencing organizational culture and program effectiveness and through their mentoring of young public health professionals in their countries . This arThe program evaluation protocol was reviewed and deemed exempt by the Emory University Institutional Review Board. Four 1-year cohorts were accepted into the program, and courses were delivered annually from 2013 through 2016. Among all trainees, we collected demographic information at the time of enrollment and monitored project and program outputs, such as project and program development, conference presentations, publications, and additional funding obtained that was associated with program participation.We conducted a pretest–posttest single-group evaluation among 2015 and 2016 trainees to assess program effects on leadership practices and perceived competence to conduct implementation research. Leadership practices were assessed by using the Student Leadership Practices Inventory , which iWe also assessed satisfaction among 2015 and 2016 trainees with the summer course they attended at Emory University. Trainees completed this assessment through short online evaluation forms for each training session they attended. In these forms, trainees rated the usefulness of information presented from 0 (very useless) to 10 (very useful), and the overall caliber of the content and faculty in each session from 0 (bad) to 10 (excellent).t tests were used to assess changes in leadership practices and perceived competence from baseline to training completion. Cohen’s d was used to estimate effect sizes for leadership practices and perceived competence changes (d = mean 1 −mean 2 ÷ pooled standard deviation). Values greater than 0.5 were deemed as meaningful effect sizes, indicating pre–post means in leadership practices, and perceived competence scores differ by half a standard deviation. We used the Bonferoni correction method to adjust for multiple comparisons; hence, the significance level was set at α < .006. Data analyses were conducted by using the Statistical Package for Social Sciences, version 23 (IBM Corp).For analyses, data were summarized as means and standard deviations or frequencies and percentages. Paired sample Over the 4 years of program delivery, 270 health care and public health professionals, researchers, and government public health workers working in noncommunicable disease submitted applications, and 95 were accepted in the program. Of these, 90 attended and completed the program ; 45 (50%) were from India, 26 (29%) were from Mexico, and the remainder were from other countries . Twenty-The 1-year program cost on average $4,000 USD per participant; this cost was estimated for India and Mexico participants only. Cost included travel from India or Mexico , hotel cost for 2 to 3 weeks , the Birkman Method assessment ($150 per trainee), food and snacks over the course ($150 per trainee), course materials , and heavily discounted honoraria for some faculty members . Accepted participants from India and Mexico were supported by program funds, which were sufficient to fund 71 trainees over the 4 years of program delivery. Participants from other countries (n = 19) either obtained support in their country to cover program cost or paid a tiered fee based on country-income group of the participant.As part of the training program, participants across the 4 cohorts  developed 53 in-country projects; 38 were completed, and 15 are ongoing. These included the development of evidence-based health interventions (n = 8), strategies to improve local health care systems (n = 4), approaches to inform policy or assess its effect (n = 7), strategies to inform or change clinical practice (n = 14), strategies to improve surveillance or measurement of health outcomes (n = 8), and epidemiological studies (n = 12). Of these, 18 trainees obtained funding from in-country or international agencies to complete their projects. In terms of academic products derived from these projects, 21 abstracts were presented at scientific conferences; as of November 2018, 13 articles were in preparation, 9 articles were under review in scientific journals, and 8 were published . Also, 1d = 0.62, P <.001), inspired a shared vision , challenged current processes , enabled others to act , and encouraged the heart . We observed no significant improvements in perceived competence to conduct implementation research in trainees’ home institutions.Of the 55 participants attending the 2015 and 2016 training programs, 46 completed the pre–post program evaluations. Mean participant age was 38.5 years  and 28 (60%) were male. We found significant improvements in the frequency with which trainees reported engaging in leadership practices from baseline to end of the training with moderate effect sizes . TraineeOverall, 33 to 41 training sessions lasting between 90 and 120 minutes each were delivered each year over 2 weeks. Trainees regarded course sessions as useful , with a very good content  and delivered by very good professors . When training modules were assessed separately, the leadership module achieved the highest ratings . AlthougLeadership and implementation science are some of the most overlooked yet most essential paradigms in public health ,32. The Our findings align with those from evaluations of similar programs. For instance, the National Public Health Leadership Institute program was found to improve collaborative leadership and to promote the development of knowledge-sharing and problem-solving networks . SimilarWe found no improvements in perceived competence for conducting implementation research, which may be due to a measurement issue. The “perceived competence” measure we used is more akin to control beliefs  and intentions  than to actual competence . Indeed, a study among medical students found perceived competence in evidence-based medicine did not correlate well with objectively assessed competence . A more The 4-year implementation of PH-LEADER taught us several lessons. Through implementation and participant feedback, we learned that the program needed constant refinement, and it did evolve over time. Part of that evolution are current efforts to design a shorter version of the program to be delivered in trainees’ home countries. As previously noted , anotherWe also learned that empathy, respect, and acceptance were essential for promoting positive communication and interactions. The 3-way collaboration among Emory University, Mexico’s National Institute of Public Health, and the Public Health Foundation of India enabled exchange of ideas, broadening of disciplines, and exposure to different research cultures and systems. The program offered an open forum for expression of ideas and fostered cross-cultural exchange and discussion of public health issues. As in previous implementation research training programs , we leveFinally, we learned that strategies to promote the sustainability of the program are needed. Obtaining funding to sustain training programs is a major challenge identified in dissemination and implementation research training programs . One potThe present program evaluation should be interpreted in light of several limitations. The program design prevented us from comparing the training course with other approaches or with no training at all. Leadership practices and perceived competence for implementation research were measured by using self-reports, which are prone to social desirability bias and may bias estimates of training effects toward larger effects. Finally, the participant sample was self-selected; thus, these findings are only applicable to those who participated in the program and are generalizable only to cohorts of motivated public health professionals and researchers linked to these opportunities.The PH-LEADER program is a promising strategy to build leadership and implementation research capacity among 21st century public health professionals from LMICs. To our knowledge, our program is the first to addresses both skill sets jointly, and results from the initial program evaluation are promising. Findings from this evaluation are being used to inform adaptations of the program and to pilot its delivery in LMIC settings using existing resources. Real-world implementation of effective strategies to address noncommunicable diseases can be pursued through training effective public health leaders. If adapted for wide-scale and low-cost delivery, PH-LEADER can contribute to strengthen the global-health workforce and its ability to lead and implement proven strategies to address noncommunicable diseases in LMICs.


The stress associated with caring for a loved one with Alzheimer’s disease or a related dementia can negatively affect mental and physical health. Mindfulness-based stress reduction (MBSR), teaching caregivers to focus on the present moment with non-judgmental awareness, has been shown to improve overall mental health, reduce perceived stress, and decrease depression. At HealthPartners, we implemented the Mindfulness Based Dementia-Care (MBDC) program, an 8-week program designed for family caregivers for those living with dementia. MBDC combines teaching of MBSR skills along with essential education for this chronic disease. Participants attend a 1-hour orientation session, 2-hour classes each week for 8 weeks, at-home practice between classes, and a 6-hour Saturday retreat. Secure electronic surveys are administered at baseline, program completion and follow-up for evaluation of the program. We will discuss barriers and learnings of implementation as well as preliminary results from the evaluation.


The SWI/SNF complex is an important chromatin remodeler, commonly dysregulated in cancer, with an estimated mutation frequency of 20%. ARID1A is the most frequently mutated subunit gene. Almost nothing is known about the other familiar members of the SWI/SNF complexes, SMARCA2 (BRM), SMARCA4 (BRG1) and SMARCB1 (INI1), in oesophageal adenocarcinoma (EAC).We analysed a large cohort of 685 patients with EAC. We used four different antibodies to detect a loss-of-protein of ARID1A BRM, BRG1 and INI1 by immunohistochemistry and correlated these findings with molecular and clinical data.p = 0.044). Tumours with loss or expression of ARID1A and TP53 loss were not associated with a difference in survival. Only one tumour revealed high microsatellite instability (MSI-H) with concomitant ARID1A loss. All other ARID1A loss-EACs were microsatellite-stable (MSS). No predictive relevance was seen for SWI/SNF-complex alterations and simultaneous amplification of different genes .Loss of ARID1A, BRG1, BRM and INI1 was observed in 10.4, 3.4, 9.9 and 2% of EAC. We found a co-existing protein loss of ARID1A and BRM in 9.9% and of ARID1A and BRG1 in 2.2%. Patients with loss of ARID1A and TP53 wildtype EACs showed a shortened overall survival compared with AIRDA1A-positive tumours [median overall survival was 60.1 months (95%CI 1.2–139.9 months)] in patients with ARIDA-1A expression and 26.2 months (95%CI 3.7–19.1 months) in cases of ARIDA-1A loss (Our work describes, for the first time, loss of one of the SWI/SNF ATPase subunit proteins in a large number of adenocarcinomas of the oesophagus. Several papers discuss possible therapeutic interventions for tumours showing a loss of function of the SWI/SNF complex, such as PARP inhibitors or PI3K and AKT inhibitors. Future studies will be needed to show whether SWI/SNF complex-deficient EACs may benefit from personalized therapy. Most EACs arise within Barrett’s mucosa, which, among other things, is attributed to gastroesophageal reflux disease, obesity and low fruit and vegetable consumption. Despite the known tumour heterogeneity of oesophageal carcinomas, due to less reliable response molecules such as TUBB3, unselective preoperative radiochemotherapy or chemotherapy alone is usually the main therapeutic tool for many oesophageal cancer patients [Oesophageal cancer represents the eighth most common malignant tumour worldwide, with an estimated cancer burden of 455,800 cases and 400,200 deaths . Men areAT-rich interactive domain-containing protein 1A (ARID1A) is the most frequently mutated gene subunit [ARID1A are generally inactivating and result in loss of ARID1A protein, which is detectable by immunohistochemistry. Loss of ARID1A expression has been found in a broad spectrum of human cancers, including gastric carcinoma (8–29%) and oesophageal adenocarcinoma (9–19%) [SWitch/sucrose-nonfermenting (SWI/SNF) complexes, first described as transcriptional regulators of inducible and lineage-specific genes, are important members of the chromatin-remodelling family , 4. Mamm subunit –12. Muta (9–19%) –21.ARID1A is currently possible, loss of the tumour suppressor gene results in specific weak points in cancer cells that are suitable for therapy. Helming et al. identified ARID1B, a related homologue of ARID1A in the SWI/SNF complex, as the number one gene mainly required for the survival of ARID1A-mutant cancer cell lines and as a potential therapeutic target for ARID1A-mutant cancers [Although no direct restoration of  cancers . In addi cancers .So far, little is known about the importance and possible heterogeneous distribution of ARID1A loss and its correlations to various other molecular changes at a very large collective of EAC. Almost nothing is known about the remaining ATPase subunit members  in EAC.We analysed formalin-fixed, paraffin embedded material from 685 patients with EAC who underwent primary surgical resection or resection after neoadjuvant therapy between 1999 and 2016 at the Department of General, Visceral and Cancer Surgery, University of Cologne, Germany. The standard surgical procedure was laparotomic or laparoscopic gastrolysis and right transthoracic en bloc esophagectomy including two-field lymphadenectomy of mediastinal and abdominal lymph nodes. As described previously, reconstruction was performed by high intrathoracic esophagogastrostomy . PatientWe used a multi-spot tissue microarray (TMA) with up to 12 tumour spots as a test cohort consisting of 165 patients with EAC  of the test cohort did not receive any neoadjuvant treatment. We considered equally the tumour surface/centre and the tumour infiltration margin whenever possible. This multi-spot TMA is also suitable for detecting heterogeneous distribution of proteins within the tumour. In addition, we analysed 15 adenocarcinomas on whole slides with regard to possible heterogeneity. Furthermore, we created a single-spot TMA considering 520 additional patients as a validation cohort .For tissue microarray analysis (TMA), one tissue core from each tumour was punched out and transferred into a TMA recipient block. TMA construction was performed as previously described , 27. In Immunohistochemistry (IHC) was performed on TMA slides. Lymphoid tissue served as an internal control. All markers showed a nuclear staining pattern. All details about the antibodies we used are listed in the supplement.ARID1A, BRG1-, BRM- or INI1 was interpreted as an underlying mutation, deletion or promotor alteration. Strong nuclear stainability of the surrounding non-tumour cells served as an internal control. Score 1 was determined as nuclear staining of tumour cells and interpreted as an intact, unmuted ARID1-, BRG1-, BRM- or INI1 gene with regular protein expression. Discrepant results were resolved by consensus between the reviewers.ARID1A-, BRG1-, BRM- and INI1 were analysed manually by two pathologists (A.Q. and S.S.). ARID1A-, BRG1-, BRM- and INI1 staining was assessed according to a two-tier scoring system (Score 0 and Score 1). A score of 0 associated with the loss of protein and defined as unequivocal clean absent staining in the nuclei of viable tumour cells for For analysis of ERBB2, membranous expression of HER2 in carcinoma cells was evaluated according to the criteria for biopsies as already described , 29.The assessment of TP53 was carried out as already described .We have analyzed all tumors for their DNA mismatch status for a previous publication (please compare ). For thKRAS, PIK3CA, cMET, c-MYC and GATA6, FISH was performed. All details about the FISH probes we used are listed in the supplement.To determine the gene amplifications of KRAS followed the recommendations KRAS/CEN12 ratio ≥ 2.0 or KRAS extrachromosomal cluster signals [The strategy for detecting amplifications of  signals .PIK3CA gene amplification analysis was carried out according to the manufacturer’s protocol . For PIKMET amplification was defined as MET/CEP7 ratio ≥ 2.0 or a MET gene copy number > 4 .Amplification of C-MYC was defined as gene copy cluster in > 50% of carcinoma cells or gene copy number (> 6) .GATA6 amplification was defined as gene copy cluster in > 50% of carcinoma cells or gene copy number (> 6).The current retrospective study was carried out with the approval of the Ethics Committee of the University of Cologne. Clinical data were collected prospectively according to a standardised protocol.Including all types of mortality, prognosis was calculated beginning on the date of surgery. To describe survival distribution, Kaplan–Meier univariate analysis was used, and log-rank tests were used to evaluate survival differences. To analyse the effect of several risk factors on survival, we made use of the Cox proportional hazard regression with sequential backward elimination of the non-significant variables. Survival analysis and the multivariate cox-regression model were carried out on the entire cohort .p < 0.05.Descriptive analysis included the median with lower (LQ) and upper (UQ) quartiles for numeric variables , the frequency of nominal parameters, and the mean for numeric variables with a normal distribution. Univariate analysis was conducted for tables using chi-squared statistics or Fisher’s exact test if necessary. To determine whether there was a linear trend between the column number and the fraction of subjects in the top row, we made use of the Cochran–Armitage test for trend. The Mann–Whitney U test was employed to compare continuous variables. Significant differences between groups were defined as http://www.medcalc.org; 2018) was used for graphic presentation of the results. Details are summarized in [Statistical analyses were performed using the statistic program IBM SPSS v22.0 . MedCalc Statistical Software version 18.2.1  consisted of 149 men (90.4%) and 16 women (9.7%), with a median age at the time of operation of 65.1 years (range 33–85 years). For the validation cohort, 520 additional patients were considered for analysis . The median follow-up for the entire cohort was 57.7 months, with a calculated 5-year survival rate of 26.6%. Patient characteristics are given in Table The test cohort n = 65 consisOn the test cohort TMA between 147 and 149 cases were analysable, respectively depending on the analysed protein. We found losses of ARID1A, BRM, BRG1 and INI1 in 9,5%, 11,5%, 4,7 and 0.6% of cases. In 57 tumours we found a co-existing protein loss of ARID1A and BRM (9.9%) and in 15 samples 2.2%) a protein loss of ARID1A and BRG1 , loss of BRG1 in 3.4% (n = 14), loss of BRM in 9.9% (n = 41) and loss of INI1 in 2% (n = 1) of cases. Correlation with clinical and pathological staging is shown in Table The validation and test cohort showed no significant differences in the clinical and pathological base line characteristics with a similar distribution with respect to sex, patients age, tumor stage (pT), lymph node metastasis (pN) and grading. Loss of ARID1A was observed in 10.4% (n = 57 (10.0%) and INI1 n = 1 (1.9%). Cross-table analysis and Table For the entire patients cohort, loss of ARID1A was observed in 58 patients (10.3%), BRG1 in 19 patients (3.4%), BRM We defined heterogeneity as tumours with preserved protein expression and areas with complete protein loss. Heterogeneity of protein loss was low in the entire cohort. We observed heterogeneous distribution of ARID1A in 4.8% of the tumours, heterogeneous distribution of BRM in 9.6% of cases and heterogeneous distribution of BRG1 in 0.6% of the EACs. The single INI1-deficient carcinoma showed homogeneous negativity within the entire tumour area . TP53 loss and ERBB2 amplification were available in 366 patients, and all other molecular changes were available for 520 patients .Analysis of the correlation with several other molecular changes in our EAC collective was performed considering TP53 loss, A correlation between loss of ARID1A and the histological subtype was also carried out. We were not able to detect a correlation between morphological aspects of the tumour or grading and ARID1A status (data not shown).p = 0.044). Tumours with ARID1A loss or expression and TP53 loss were not associated with a difference in survival. Only one tumour showed high microsatellite instability (MSI-H) with concomitant ARID1A loss  of the SWI/SNF complex were analysed. Recently, ARID1A loss was detected in 10% of the 120 oesophageal adenocarcinomas examined in a work using a similar methodology , 37.Within the gastrointestinal tract, the importance of ARID1a loss in gastric carcinoma and colon carcinoma has been described. In particular, an association with microsatellite instability (MSI-H) was described in both tumour entities  and addienzyme that participates in histone methylation and transcriptional repression, as novel treatment options for cancers involving ARID1A mutations [In MSI-H tumours, alteration of ARID1A and other genes of the SWI/SNF complex could only be an epiphenomenon, since this tumour subtype already has many mutations due to its DNA repair defect, so that ARID1A alterations could only be passenger mutations without biological relevance of their own. According to our results, this does not apply to adenocarcinomas of the oesophagus. We can thus confirm the results of the only other study that has dealt with ARID1A loss in EAC thus far. Apparently, mutually exclusive mutations of ARID1A and TP53 are not present in EAC. Our data suggest that alterations in ARID1A may be a relevant event in EAC. In this context it is interesting to note that alterations of ARID1A are already found in precursor lesions of EAC (Barrett’s dysplasia), and here we show a mostly homogeneous loss of ARID1A in the tumour . In the utations , 47.Nearly nothing is known about the functional relevance of the other investigated proteins of the ATPase subunit  in oesophageal carcinoma. Only one study of gastrointestinal tract tumours has shown a connection to undifferentiated carcinomas thus far . Recentlp < 0.001). On the other hand, loss of BRM and INI1 was not correlated with EAC grading. Furthermore a correlation between a BRM loss and a MET amplification could be detect. Unfortunately, even an extensive literature search did not provide any information on the underlying mechanisms. Loss of BRG1 or INI1 was not associated with other molecular changes. BRM, BRG1 or INI1 silencing did not correlate with shortened overall survival in Kaplan-Meier survival analysis or morphological aspects.Interestingly in our study, there was also a significant correlation between BRG1 silencing with EAC grading .In conclusion, this study describes for the first time the importance of a failure of the SWI/SNF ATPase subunit ARID1A in a large number of adenocarcinomas of the oesophagus. In addition to ARID1A, we observed a significant amount of protein loss of BRM, to a lesser extent, of BRG1 and, very rarely, of INI1. In EAC, we did not observe an important association with microsatellite instability (only one case), in contrast to gastric carcinomas. Within the group of The majority of tumours show a homogeneous loss of these proteins within the tumour. Future studies will be needed to show whether EACs that show a loss of function of the SWI/SNF complex can benefit from personalized therapies.


AT-rich interactive domain-containing protein 1A (ARID1A) is a subunit of the mammary SWI/SNF chromatin remodeling complex and a tumor suppressor protein. The loss of ARID1A been observed in several types of human cancers and associated with poor patient prognosis. Previously, we have reported that ARID1A protein was rapidly ubiquitinated and destructed in gastric cancer cells during DNA damage response. However, the ubiquitin e3 ligase that mediated this process remains unclear.The interaction between ARID1A and β-TRCP was verified by co-immunoprecipitation (Co-IP) assay. The degron site of ARID1A protein was analyzed by bioinformatics assay. Short hairpin RNAs (shRNAs) were used to knockdown (KD) gene expression.Here we show that DNA damage promotes ARID1A ubiquitination and subsequent destruction via the ubiquitin E3 ligase complex SCFβ-TRCP. β-TRCP recognizes ARID1A through a canonical degron site (DSGXXS) after its phosphorylation in response to DNA damage. Notably, genetic inactivation of the Ataxia Telangiectasia Mutated (ATM) kinase impaired DNA damage-induced ARID1A destruction.Our studies provide a novel molecular mechanism for the negative regulation of ARID1A by β-TRCP and ATM in DNA damaged gastric cancer cells. Recent genome-wide association studies (GWAS) have demonstrated that the AT-rich interactive domain 1A (ARID1A) gene is frequently mutated in a wide variety of cancer . The majGastric cancer (GC) is the fourth most common cancer and the second leading cause of cancer death worldwide . The raiThere are 69 SCF ligases in human cells, and are distinguished by the exchangeable F box proteins that provide specificity for the SCF E3 ligases . PhosphoThe aim of this study is therefore to determine which F-box protein is involved in the degradation of ARID1A. By using an unbiased F-box proteins binding screen assay, we identified β-TRCP is the E3 ligase for ARID1A degradation and found that β-TRCP interacted and ubiquitinated ARID1A in a phosphorylation-dependent manner during DNA damage response.2/95% air at 37 °C. DMSO, proteasome inhibitor MG132, cycloheximide (CHX), λ-ppase and VP16 (Etoposide) were purchased from sigma.HEK293T cells and gastric cancer cells line NCI-N87 and AGS cells were cultured in Dulbecco’s modified Eagle’s medium (Invitrogen) supplemented with 10% fetal calf serum . All these cells were cultured in a 5% COARID1A plasmid was purchased from Addgene (#39475). Flag-tagged F-box protein plasmids were gifts from Liu . ARID1A Protein extracts were loaded on 10–12% SDS-PAGE, electrophoresed, and transferred to nitrocellulose (NC) membrane. After blocking with 5% nonfat milk in PBS, the membranes were then incubated with the primary antibodies and followed by horseradish peroxidase (HRP)—linked secondary antibodies. The signals were detected by chemiluminescence phototope-HRP kit WBKLS0100  according to manufacturer’s instructions. Antibodies were obtained from the following sources: anti-ARID1A , anti-β-TRCP (D13F10) Rabbit mAb , anti-ATM , anti-Flag M2 , anti-HA , anti-Cullin1 , anti-SKP1  and anti-β-actin .Cells were lysed in 5 ml of lysis buffer  for 20 min at 4 °C and sonicated for 4 min. Lysates were cleared using centrifugation , the supernatant was then subjected to IP with 15 μl anti-mouse IgG or HA antibody with 20 μl protein G beads (Sigma) overnight at 4 °C with gentle rotation. Beads containing immune complexes were washed with lysis buffer 6 times. Precipitates were denatured in 2× SDS buffer at 99 °C for 5 min. For Flag-tagged protein IP, the supernatant was then subjected to IP with 20 μl Flag M2 beads (Sigma) overnight at 4 °C with gentle rotation.To analyze protein half-life, cells were treated with CHX (25 μg/ml) for different durations followed by western blot assay.P < 0.05, **P < 0.01 or ***P < 0.001.Values were shown as mean ± SEM. Statistical differences were determined by a Student t test. Statistical significance is displayed as *The ARID1A protein levels were rapidly decreased during DNA damage response and this decreased was major caused by proteasome. In gastric cancer NCI-N87 cells, we have found that DNA damage treatment caused significant decrease of ARID1A protein levels which were drastically increased by the administration of MLN4924 or overexpression of a dominant negative Cullin1 mutant . MLN4924To investigate whether β-TrCP affects ARID1A protein abundance, we measured the protein levels of ARID1A upon β-TrCP knockdown (KD) using short hairpin RNAs (shRNAs). Compared to control cells, β-TrCP KD increased ARID1A protein levels in both NCI-N87 and AGS cells, suggesting β-TrCP controls the stability of steady state ARID1A Fig. a, b. As β-TrCP recognizes two phosphorylated serine residues in a DSGXXS sequence in its substrates . By searIn consistent with the above-mentioned data, we found that λ-ppase treatment significantly prevented the interaction between β-TrCP and ARID1A Fig. a, furtheBy epigenetically regulating gene expression, the SWI/SNF chromatin remodeling complex mediates diverse biological pathways including DNA damage response . ARID1A,In the present study, our data reveal a novel molecular event taking place in DNA damage response which is mediated by ATM and β-TrCP. Our previous studies suggest that ARID1A was associated with a SCF complex. Thus, we focus on identification the exact F-box protein which is responsible for the recognizing and destruction of ARID1A. By using unbiased F-box protein library screen, we identify that β-TrCP controls the stability of ARID1A. Our biochemical data reveal that ARID1A is a novel substrate of β-TrCP which interacts and targets phosphorylated ARID1A for ubiquitination and degradation. We show that ARID1A is recognized by β-TrCP through a DSGXXS motif after phosphorylation of two serine residues (S1316 and S1320). Although we have not identified the kinase directly responsible for phosphorylation of residues S1316 and S1320, we still able to provide evidence to show that the DNA damage-activated kinase ATM is involved in the degradation of ARID1A. As genetic or pharmacologic inactivation of the Ataxia Telangiectasia Mutated (ATM) kinase impaired DNA damage-induced ARID1A destruction. However, the in vitro kinase assay should be utilized in the future to clarify whether ATM is the direct kinase or the upstream kinase. The phosphorylation of ARID1A would ensure rapid degradation of ARID1A to transcriptional activate or repress the expression of some genes needs for DNA damage checkpoint activation and preventing the cell death, as we previously have found that overexpression of ARID1A protein caused significant cell death after DNA damage insult in gastric cancer cells.By using unbiased F-box protein library screen, our study is the first to show F box protein β-TrCP controls the stability of ARID1A. We further found that ARID1A is recognized and ubiquitinated by β-TrCP through a DSGXXS motif after phosphorylation of two serine residues (S1316 and S1320) during DNA damage response. We provide a novel molecular mechanism for the negative regulation of ARID1A by β-TRCP and ATM in gastric cancer cells in response to DNA damage insult. Our data suggest that ARID1A acts as a participant in the damage response pathway, the fine tune of which might contribute to tumorigenesis prevention and affect the response of patients towards DNA-damaging chemotherapies.


Research suggests that social isolation in Appalachian older adults may be associated with reduced cognitive function. Despite this, few interventions for these individuals incorporate both social and cognitive components in a community-based setting. The “Memory Masterclass” program was developed to address this care challenge, and implemented through an Adult Day Services Center. With 29 community-dwelling older adult participants from western Virginia, the six-week pilot program focused on strategies and practices associated with improving long-term memory or executive function. In addition to the lifestyle-focused curricula, the course included group activities focused on connecting participants to community networks of resources that might enable them to successfully implement lifestyle changes. Findings support the feasibility of implementation with a wider group of rural Appalachian older adults and suggest that individual differences in self-reported memory may be closely tied to improvements following the program.


Purpose: To adapt, implement, and evaluate a public health research methods training program for youth. The Community Research Fellows Training Program is an evidence-based public health research methods training program for adults (18 years and older). The Youth Research Fellows Training (YRFT) is an adaptation of this program for youth.Methods: University faculty facilitate didactic training sessions and experiential small group activities in biweekly sessions conducted as part of an existing 4-week summer camp. Participants were African American girls (n=11) ranging from ages 10 to 14 years (most recent grade completed 4th–8th). To evaluate participant knowledge gain and satisfaction pre-tests were administered before each session, and post-test and evaluations were administered after each session. In addition, faculty completed web-based evaluation surveys on their experience teaching in the program.Results: Mean and median post-test scores were higher than pre-test scores for most (6 of the 7) of the training sessions; one session had no difference in scores. Participants rated the sessions well, on average overall session ratings of 4.3–4.8 on a 5-point Likert scale. Faculty rated their experience teaching in the program as excellent or very good and would be willing to teach in the program again .Conclusion: This pilot implementation of the YRFT program proved highly successful in terms of participant and faculty experience. The program evaluation demonstrates increased knowledge of public health research methods. This program has the potential to prepare youth to engage in public health research as partners not just participants. In a review by the Harvard Family Research Group (2002), five key elements were identified as being essential for successful youth-involved research and evaluation projects: (1) organizational and community readiness, (2) adequate support and training for involved youth, (3) adequate support and training for adult staff, (4) selecting the right team, and (5) sustaining youth involvement. An important component in the success of programs is the attention given to coaching the adults to act as facilitators, not as authoritative figures, to give youth the driving voice of the project.8Although the prevalence of Community-Based Participatory Research (CBPR) involving youth is thought to be increasing, some researchers have noted that it can be hard to determine to what degree youth are truly partnering with researchers as CBPR can be defined and interpreted differently among researchers.9 The significance of representation in terms of both underserved populations as well as researchers reflecting the youth they are partnering with is a repeated theme discussed throughout the literature base.11 Although the importance of engaging marginalized populations in researching solutions to the problems they disproportionately face is widely accepted in the literature, a study by Galletta and Jones discusses how critical it is that there is representation of these communities among the adult researchers as well.12Many studies identified motivating factors that were important in sustaining the active engagement of the youth partners, including the opportunity to change the perspectives of adults and for research to be a vehicle for change.13–18The Youth Research Fellows Training (YRFT) program is a public health research methods training program for youth adapted from the Community Research Fellows Training (CRFT) program. The CRFT program is an evidence-based training program to increase research literacy among adults (≥18 years old) based on a standard Masters in Public Health (MPH) curriculum. The goal of CRFT is to increase the role of minority and medically underserved communities in the research enterprise by developing the foundational infrastructure for community-academic partnerships through community research capacity building. CRFT has been implemented and evaluated in St. Louis, MO (four cohorts), Jackson, MS (two cohorts), and Hattiesburg, MS (one cohort); details about program implementation and evaluation have been discussed elsewhere.The goal of the YRFT program is to provide training on public health research and use of data for youth activist interested in conducting social action projects. Trainees gain an understanding of the research process, research methods, and sources of data that can be used to explain, document, and evaluate progress on social justice issues in their communities. In this study, we discuss the implementation and evaluation of the YRFT pilot.13–18 The 4-week program met twice each week for 90 min on Tuesdays and 75 min on Thursdays. In addition to participating in the on-site training sessions, participants were given four homework assignments . At the first session, participants received supplies needed to participate in the training, including a backpack, binder, notepad, and pens. Handouts with session presentation and activities were provided at each session. Supplies needed for breakout activities  were provided when needed.The principal investigator of the YRFT program collaborated with the president of the GrassROOTS Community Foundation (GCF), to pilot YRFT as a component of the GFC 2018 Super Camp in Essex County, New Jersey. The YRFT piloted in July–August 2018 was adapted for youth from the CRFT, an evidence-based public health research methods training program for adults.Session topics and learning objectives are presented in n=3), Brown School of Social Work at Washington University in St. Louis (n=3) and the College for Public Health and Social Justice at Saint Louis University (n=1). The majority  of the faculty were African American, women, and had previously taught in the CRFT program for adults. The majority of the faculty are in public health  and cover a range of health disciplines, including behavioral science, health education, biostatistics, epidemiology, social science, clinical psychology, and social work.The first seven sessions were led by faculty from New York University College of Global Public Health . The YRFT evaluation was approved by New York University Institutional Review Board (NYU IRB)/University Committee on Activities Involving Human Subjects, Office of Research Compliance. Both parental consent and participant assent were obtained for the program evaluation. Statistical analysis was conducted using SAS 9.4 ; statistical significance is assessed as The research fellows took pre-tests before each training session and post-tests after each of the seven training sessions. The tests were written by the YRFT evaluation team and approved by the faculty member teaching the session. Each of the tests consisted of 10 multiple-choice questions. The pre- and post-tests had the same questions but in differing order and were linked using participant ID numbers. The questions assessed the learning objectives that were intended to be covered by the session's instructor. The tests were graded by YRFT research assistants using an answer key developed for the pre- and post-tests. Given the small sample size and paired pre-/post-test data, the nonparametric Wilcoxon signed-rank test was used to test median differences between the pre- and post-test scores for each session.At the end of each session (1–7), participants completed a session evaluation. At the beginning of the last session, participants completed a program evaluation. Session evaluations were anonymous and consisted of five multiple-choice Likert response questions with a rating scale of 1 “strongly disagree” to 5 “strongly agree,” one multiple-choice Likert response questions with a rating scale of 1 “poor” to 5 “excellent,” and four open-ended questions. Closed-ended questions assessed whether the session learning objectives were met, information from the session was helpful, concepts presented were understood, the teacher was organized, the teacher was knowledgeable, and an overall rating for the session. Open-ended questions assessed the three most important things learned during the session, what was liked most about the session, what was not liked about the session, and any additional comments or suggestions.At the completion of the program, faculty were sent an email to participate in a web-based evaluation survey using Qualtrics survey software. Two weeks after the initial invitation, an automated system reminder was sent to faculty with incomplete surveys. The faculty evaluation survey consisted of 11 closed-ended and 3 open-ended questions. Eight of the closed-ended items were asked on 5-point Likert scale from “strongly disagree” to “strongly agree” and assessed fellows' preparation, engagement, and participation in the training session. Faculty were also asked if they would teach in the YRFT program again (yes/no), the appropriate grade level for the youth program (middle school/high school/undergraduate), and to rate their overall experience teaching in the program (poor/fair/good/very good/excellent). Open-ended questions assessed structural/format changes for the program, memorable moments during teaching, and additional suggestions/comments for the program.n=11) were participants of the GCF 2018 New Jersey Super Camp; African American girls ranging from ages 10 to 14 years (most recent grade completed 4th–8th). The YRFT program was imbedded into the Super Camp schedule as a result the majority  of participants had perfect attendance; one participant missed one session and one participant left one session early. All participants completed three homework assignments ; one participant did not complete the playground audit assignment (All YRFT fellows (signment .p=0.016), session 1B: Social Determinants of Health (p=0.004), session 2A: Research Methods (p=0.047), and session 4A: Using Research and Data for Social Justice (p=0.023).When comparing pre-test and post-test scores, mean and median post-test scores were higher than pre-test scores for six of the seven of the training sessions; one session had no difference in scores , and this session had the highest mean (77%) and median (80%) pre-test score. Based on the Wilcoxon Signed-Ranked test, the increases in scores were statistically significant in four sessions : sessionParticipants rated the sessions positively, with means for each question across sessions ranging from 4.0 to 4.9 on a 5-point Likert scale . For oven=7). Faculty rated their experience teaching in the program as excellent  or very good  and would be willing to teach in the program again . The mean response for the seven Likert response questions related to fellows participation and engagement ranged from 4.4 (fellows took notes during the session) to 5.0 . All faculty stated that the fellows were engaged in the breakout activity during their session and the program would be good for middle school, high school, and undergraduates. Faculty commented on how this program has the potential to enhance the public health pipeline and demonstrates the importance of exposing youth to public health. When asked what they would change about the program, location (temperature and noise level) and session length were two common themes across faculty responses (data not shown).All participating faculty completed the evaluation survey ; the qualitative methods session was adapted to qualitative methods: understanding community health and one new session was added using research and data for social justice. There were 15 training sessions in CRFT and 7 for YRFT. CRFT sessions were once a week for 3 hours and YRFT sessions were twice a week for 90 and 75 minutes for a total of 2 hours and 45 minutes per week. However, many of the YRFT sessions started early allowing for additional time. We believe that 2 hours per session would be adequate for the instructor's presentation and the small breakout group activity. The four YRFT homework assignments were adapted for youth from the six CRFT homework assignments. While CRFT participants had 2 weeks to complete each assignment, YRFT participants were given assignments the week before they are due. Each assignment was modified to be shorter and appropriate for youth .Adapting a graduate-level public health curriculum for youth was a major challenge for YRFT faculty. In addition to the reduced session time allowed to cover to the material. Key to the success of the adaption was limiting the number of PowerPoint slides to 15–20, using YouTube videos to reinforce key concepts, and adapting the breakout activities to feel like games. The training format allowed us to routinize the participants enabling completion of session tasks in the time allotted. Similar to CRFT each session was facilitated by a different faculty member exposing participants to university faculty all of who have the same gender and/or race of the participants. Similar to the CRFT faculty, the YRFT is very diverse in terms of gender and race providing great exposure for youth to see professors who look like them.n=11), which is adequate for pilot implementation and nonparametric statistical tests are used to examine differences in pre-test and post-test scores. The sample is all African American girls as it was implemented as part of the GCF Super Camp for African American girls. This sample is unique as both the girls and parents must complete an application and interview to be accepted into the camp. The camp focuses on social justice issues providing a unique sample of girls that were actively engaged in the training program. Most of the YRFT faculty were from the CRFT faculty having previously taught for multiple CRFT cohorts and were used to the format of the training.This pilot implementation and evaluation study has provided evidence that the CRFT program curriculum can be tailored and adapted to other populations. However, the results should be considered in light of several study limitations that preclude generalizability. The sample size is small (Despite these limitations, this pilot implementation of the YRFT program proved highly successful in terms of participant satisfaction. The fellows were excited to take a college style course taught by college faculty and receive certificates of completion with a college logo. The participants created a video about their participation in the program; two participants developed qualitative interview questions and interviewed other participants about their thoughts and experience in the program. This unanticipated outcome demonstrated key skills learned in the program about collecting data and using data to tell a story.The results of the pilot program has strong implications for future implementation among larger cohorts of youth, the potential for integration into middle and high school curriculum, tailoring for other racial/ethnic minority subgroups, and broader dissemination in other geographic locations. This work makes a significant contribution to enhancing the infrastructure for youth-academic partnerships in public health increasing the potential for studies that address issues of importance to youth and can lead to the reduction of health disparities.


Identify the perception operating agents have on the Brazilian National School Feeding Program. This is an observational, cross-sectional and quali-quantitative study developed in non-probability and convenience sampling selected in an event promoted by the National Fund for Educational Development in 2015 in Rio de Janeiro. Data were collected through questions related to pre-defined categories concerning the National School Feeding Program. The questionnaire was answered by 43 nutritionists, 41 members of the School Feeding Board, and 16 school feeding administrators from 38 cities of Rio de Janeiro. The narrative analysis was based on benchmarks of cognitive analysis of public policies. The association among variables was investigated with chi-square test, being calculated the power for association testing. The perception of the implementation of the National School Feeding Program has been characterized by some challenges: 1) low number of nutritionists to meet the demand from schools; 2) low adhesion to the public call for the purchase of family farming products due to bureaucratic difficulties and insufficient local food production; 3) reduced coverage of food and nutritional measures due to the restriction of human, material and financial resources; and 4) limitation of the participation of the School Feeding Board due to insufficient training and transport for regular visits. The adequacy of the number of nutritionists showed statistically significant association with the purchase of family farming products  and with the food and nutritional education activities . The results indicate the need for employment of nutritionist in sufficient numbers to meet the demands of the National School Feeding Program, investment in educational activities of healthy eating in schools, training of the School Feeding Board, greater availability of vehicles for school visits and assistance to family farmers in order to facilitate their participation in programs of institutional purchases and encourage the diversification of production. These changes involve the inclusion of a nutritionist as a responsible technician (RT), the social control of the implementation of the program by the School Feeding Board (CAE) and the purchase of family farming products, with an investment of at least 30% of the financial allocation made by the National Fund for Educational Development (FNDE) ,The National School Feeding Program (PNAE) is one of the largest and oldest programs in the world and, in Brazil, is part of the Food and Nutrition Security Policy ,Considering PNAE is one of the most important health promotion programs in the country, a fact evidenced by its contribution to the formation of healthy eating habits of students from primary public education Such limitations should be better understood to facilitate the proposition of strategies that contribute to overcoming the challenges. However, few studies explore the context in which the measures envisaged by the program are developed, expressing the origin of these obstacles superficially. Thus, this study aimed to identify the perception operating agents of PNAE have about the fulfilment of its primary legal parameters.The study is in line with the Resolution 466 of December 12, 2012. This study was approved by the Research Ethics Committee of the Universidade Federal Fluminense (CAAE 3620.0.000.258-10).All the participants signed an informed consent form after being informed of the procedures in this study. The questions were answered in writing without personal identification or the city. Only the participant’s position was identified for data analysis.This is a descriptive and observational cross-sectional study with a quali-quantitative approach developed in a non-probability and convenience sampling. The operating agents of PNAE present at the event “Technical Meeting of the National School Feeding Program” The sample size calculation was carried out with the pwr Pack of the R program version 3.4.3 . Considering the factors and respective levels of the semi-structured questionnaire, the power of test of 80%, and the significance level of 5%, 85 participants are needed (4x3: 6 degrees of freedom) to observe a medium to large effect size (w = 0.4).A total of 189 operating agents of PNAE from 58 cities participated in the event, being excluded those living outside the state of Rio de Janeiro (n = 5). One hundred individuals agreed to participate in the research, including nutritionists (n = 43), members of CAE (n = 41) and school feeding administrators of (n = 16) from 38 (41.3%) of the 92 cities of the state of Rio de Janeiro. Among the cities represented in this study, 33 (86.8%) are predominantly urban, while 5 cities (13.2%) are rural The information was collected through a semi-structured questionnaire created by the researchers based on the categories of analysis predefined in this study. The questions addressed the following items related to the implementation of PNAE in the cities of Rio de Janeiro: adequacy of the number of nutritionists in the program; percentage of purchase and foodstuffs from family farming; main difficulties found in the implementation of PNAE; development of educational activities to promote a healthy eating habit at schools; and the activity of CAE in the city.We used a contents and narrative analysis Pre-exploration of the material: skimming of all the answers contained in the questionnaire to seize and organize in a non-systematized way the main ideas and perceptions that provided initial evidence for a more systematized presentation of the data in the following steps;Ex ante categorization: use of predefined categories based on the implementation of PNAE: role of nutritionists; purchase of family farming products; activity of CAE in the city; food and nutritional education measures; several difficulties in implementing the PNAE.Selection of subcategories of analysis: guided by the questions, corresponding to items related to the implementation of PNAE. The subcategories of analysis were identified from text clippings by an inductive process, considering the explicit message and the non-apparent meanings of the context. The grouping of units of analysis is based on the repetition of contents common to most respondents and on the implicit relevance, when the topic was considered important for the study, but it was not repeated by the respondents.This whole process was conducted along with the researchers to avoid perceived bias and to provide a different view of the categories proposed.The narrative analysis was based on the perception of the subjects participating in the operationalization of PNAE in cities of the state of Rio de Janeiro. Thus, the program was considered a social practice 2). For 2 x 2 tables, the Fisher’s exact test was used. The power of test (1-β) was calculated with the R program version 3.4.3  and the pwr pack. A significance level (α) of 5% was adopted.Data were tabulated in contingency tables and analyzed in the statistical program SPSS version 21 . The variables were described by absolute and relative frequency . The association between the categorical variables was investigated through the chi-square test , purchase of family farming products , activity of CAE in the city , food and nutritional education measures , and difficulties in implementing the PNAE .The Box presents qualitative synthesis of the perception operating agents of PNAE have about the key challenges faced in the implementation of the program in their cities. in natura form, such as lettuce, tomatoes, cassava, yams, parsley and chives, cabbage, pumpkin, wild cabbage, banana, orange, pineapple, sweet potato, carrot, beet, persimmon, okra, eggs, honey, and milk. Analyzing the answers per city, 55.3% (n = 21) were buying over 30%, while 10.5% (n = 4) had not acquired foodstuffs yet for being in a public call process. The main justification presented for the purchase of family farming products was the enforcement of legislation. Although they met the requirement, 21.0% (n = 8) of cities reported difficulties due to the lack of the aptitude certificate for the National Program for Strengthening Family Farming (PRONAF) by farmers ( The purchase of family farming products over 30% of the resources provided by FNDE was reported by 70.1% (n = 47) of respondents, while the purchase of organics had a frequency of 12.5% (n = 11). However, these variables did not show statistically significant association with the operating agents of PNAE (p > 0.05). Foods commonly purchased from family farming come farmers    and forThe existence of educational activities to promote healthy eating habits in schools was reported by 83.7% (n = 82) of the respondents. Training through workshops with the lunch ladies were the main activities carried out   . In a lMost respondents  classified the activity of CAE in the cities as good and significant ; the members of the board  classified their own work as good. One of the measures developed includes technical visits and supervision of schools, participation in meetings, conversations with students about the acceptance of menus and monitoring of the implementation of PNAE resources. Regular and bad qualifications were mostly attributed to the lack of training for board members and transport for regular visits   .Isolating the quantitative answers of the operating agents of PNAE from the same city (25 cities with more than one agent), few showed differences among themselves. Regarding the adequacy of the number of nutritionists and purchase of organic foods, only 8% (n = 2) of the cities presented divergent answers. As to the purchase from family farming, 16% (n = 4) of cities showed disagreement. The questions with more differences were those related to the implementation of activities of EAN  and CAE . This observation is important to identify whether the answers reflect the reality of each city.The integrated narrative analysis, based on different segments of subjects who participate directly in the operationalization of PNAE in the cities, indicates as the main strategic questions for the quality of the program aspects related to the institutional structure, the articulation with family farmers, the financial contribution, and social participation.About the role of nutritionists, almost all of them reported an insufficient number of professionals, which is a possible limitation for the fulfilment of the tasks established in the program, generating workload. The optimal number of nutritionists to participate in the program is referenced in the Resolution 26/2013 of FNDE5 ,Two other important matters mentioned by nutritionists are the weekly workload of 20 hours and the difference of employment relationship among professionals, which contributes to the reduction of autonomy and turnover of those working under CLT regime. Given this scenario, the monitoring and implementation of the PNAE guidelines are compromised, hindering the control of the nutritional status of students, food and nutrition education activities and the supervision of the entire production process of meals, since the acquisition of food until the distribution in order to meet the principles of food and nutrition security and ensure hygienic sanitary conditions As to the participation of family farming in school meals, the minimum percentage of acquisition became mandatory as of January 2010 Another difficulty reported about the purchase of family farming products is linked to the lack of compliance with the demand for school meals to local production. Some cities, especially those with more urban-rural characteristics, present insufficient production in quantity and variety of foodstuffs. Although the legislation allows the purchase from farmers in neighboring cities, some reports showed that they are not interested in selling due to the logistics of foodstuff transportation to schools. Saraiva et al. In a study carried out in cities of the southern region and published in 2015 Saraiva et al. As provided for in article 19 of the Resolution June 26, 2013 The Organic School Feeding Program, from Santa Catarina, receives financial resources from the state Regarding the social control of the program, the study showed that some cities lack visits from the CAE to the schools, claiming lack of transport. Other difficulties reported refer to the lack of training for its members and adhesion to the activities assigned by the legal devices. According to legislation ,In this study, the participants classify the activity of CAE in the cities between good and regular, a perception that is not significantly associated with purchases of family farming products and organic food, nor with carrying out activities of EAN. It is important to consider that this is the perception of the participants and not an assessment or analysis of the role of the entity. Some studies have found that, in cities where CAE held about 20 meetings a year, there was the hindrance of school feeding outsourcing and closer monitoring of the development and acceptance of the menus by students Among the PNAE guidelines, the need for inserting food and nutritional education in the teaching-learning process has gained prominence. For the development of healthy eating habits, it is not enough to offer a menu; educational measures are also needed for a better understanding of the students, who are going through the cognitive development process According to FNDE, EAN is regarded as “the set of formative measures, of continuous, permanent, transdisciplinary, multidisciplinary, intersectoral, and multi-professional practice, aiming to encourage the voluntary adoption of healthy practices and better food choices that collaborate to a learning experience, to the student’s health state and to the individual’s quality of life” Considering the large number of schools for each nutritionist in EAN, we suggest investing in the training of agents of the school community who are involved with the program, such as teachers, food handlers, principals and parents, in order to share experiences in food and nutrition and contribute to building a healthy eating environment. Gabriel et al. ,,Despite the activity of EAN being mandatory and the role of the nutritionist in PNAE The results of this study should be interpreted considering its advantages and limitations. First, the participation of different operating agents of PNAE  of approximately 40% of the cities in the state suggests a moderate representation of Rio de Janeiro. The inclusion of other cities can contribute to socially different perceptions and should be considered in future studies. Second, the perception operating agents have about the implementation of PNAE was investigated so reality could be portrayed and interpreted in accordance with the position the professional occupies in the organizational structure of the program. Although perception and implementation may differ, the perception that the program is not contemplated in any way justifies a reflection upon its execution. The identification of perceptions in this study reveals the challenges faced in the implementation of PNAE, resulting in the construction of new perspectives to be directed to the solution of problems.The perceptions of operating agents were based on the role of the nutritionist in the program, on the purchase of family farming products and organics, on the activities of EAN and CAE as a mechanism of social control. The insufficient number of nutritionists and the inadequate employment relationship were considered limiting factors for the accomplishment of all the tasks assigned to the professional. The insufficient number of nutritionists who work in the program showed significant association with the reduced percentage of purchase of family farming products and EAN activity in the school environment. The activities, in turn, were scarce when directed to the promotion of healthy eating habits with the school community. Although most respondents classified the activity of CAE as good, the lack of training courses for advisers, the lack of transport for school visits and the lack of engagement of all members in the execution of their duties in the board are some of the current difficulties.Thus, based on the main difficulties experienced by operating agents of the program, we suggest as strategic measures for the strengthening of PNAE: (1) employment of nutritionists in sufficient numbers to meet the demands of PNAE, (2) investment in educational activities to promote healthy eating habits in the school environment, (3) training of members of CAE and availability of vehicles for school visits and (4) technical support, within the municipal management framework, for organic and family farmers, in order to facilitate the organization and participation in programs of institutional purchases and encourage the diversification of production.


Lack of positive attitudes towards aging has shown to cause challenges within intergenerational networks in employment situations. These can include job satisfaction, intrinsic motivation to work, and ageism subjectivity as underlying determinants and consequences. The collaborative intervention pilot training program goals were two-fold: 1) To expose and understand ageism as a discriminatory action. 2) To create a more positive social dynamic network in a diverse workplace in regard to general expectations of ageism. Two team-based learning intervention programs were created in order to increase collaborative awareness of ageism and were presented to a medium size intergenerational department staff (N=64) as part of a professional development series on equity, diversity and inclusion. Through three multidimensional self-help training activities, learning was done individually, within similar age employee groups, and within intergenerational employee groups. Participants were able to discuss and express general understandings and expectations of aging and learning tools such as intergenerational reactivity and emotion regulation strategies were presented. Within survey responses at the completion of the trainings, key findings showed that respondents had a better understanding of ageism (76%) and felt better equipped to work within an employment team of diverse ages (71%). Additionally, the subject matter of this pilot training program resulted in re-conceptualized positive aging (61%). Future implications and goals for the program include interventions to further increase positive intergenerational understanding and workplace generational inclusiveness.


There has not been much research on the impact of the museum environment on the formation of visitor loyalty. The purpose of this study is to discover the convoluted relationships among internal and external physical environments, involvement, knowledge value, satisfaction, and desire in forming visitor loyalty. A field survey was carried out at museums. A confirmatory factor analysis with the collected data showed that the measures used included an adequate level of measurement quality. The proposed model was revised by adding four meaningful approaches to improve the anticipatory ability and model fit. Results from the structural analysis demonstrated the criticality of both internal and external dimensions of physical environments in loyalty formation and identified the significant mediating impact of cognitive, evaluative, and motivational factors in our theoretical framework. Moreover, the relative importance of desire in increasing loyalty was found. Research contributions to the museum literature are discussed. The function of museums in a classical fashion is providing cultural heritage to visitors . Yet, itThere has been a significant change in the paradigm of museums ,4. In reIn the existing literature, a few gaps exist, which elicits the need of this research. First, although visitor loyalty at museums is a timely topic under the competitive market environment of the museum industry, little research has examined museum visitors’ post-purchase behaviors. Second, while a museum’s physical environment or atmospherics is emerging as a vital topic , its rolOverall, an understanding of museum visitors’ loyalty generation processes is somewhat narrow. The present study intends to fill these existing research gaps in a museum context. Particularly, in an empirical manner, we attempted (1) to develop a robust loyalty model of comprising physical environments, involvement, knowledge value, visitor satisfaction, and desire in museums, (2) to identify the role of internal and external physical environments in building up loyalty, (3) to explore the potential mediating effect of cognitive, evaluative, and motivational factors in the proposed theoretical framework, and (4) to compare the relative effectiveness of study variables in determining visitor loyalty.Physical environments are important in museums as they are unique places where customers interact/communicate with diverse exhibits  in a limited architectural space . Under tThe external environment that refers to outdoor atmospherics is also crucial as it influences visitor experiences ,16. In mInvolvement refers to one’s perceived level of application, absorption, and attention stimulated by a particular behavior/experience . An indiWhile the definition of customer loyalty varies, researchers have evolved two main approaches, namely behavioral and attitudinal approaches ,28,29,30To date, the need to understand how the physical environment affects visitors’ and workers’ behaviors has been increasingly stressed in the museum industry ,13. WithHypothesis 1 (H1).Internal museum environment positively and significantly affects involvement.Hypothesis 2 (H2).Internal museum environment positively and significantly affects knowledge value.Hypothesis 3 (H3).External museum environment positively and significantly affects knowledge value.Hypothesis 4 (H4).Internal museum environment positively and significantly affects visitor satisfaction.Hypothesis 5 (H5).External museum environment positively and significantly affects visitor satisfaction.In their consideration of museum visitor experiences and post-purchase behavior, Dirsehan  found thHypothesis 6 (H6).Involvement positively and significantly affects visitor satisfaction.Hypothesis 7 (H7).Knowledge value positively and significantly affects visitor satisfaction.Within the museum and cultural tourism contexts, individuals’ perceived level of value  and invoHypothesis 8 (H8).Visitor satisfaction positively and significantly affects desire.Hypothesis 9 (H9).Visitor satisfaction positively and significantly affects visitor loyalty.Numerous studies in various sectors have shown that satisfaction and desire are of importance in generating one’s loyalty. In his research about exploring the role of satisfaction, Oliver  demonstrIn this research, we employed the measures previously validated in the extant literature ,47,48,49D2 (30) > 59.703, p < 0.001). After the removal of such extreme cases, our final data set included 305 respondents.We conducted a visitor survey at seven major museums located in the Seoul metropolitan area. Students who received survey training distributed the questionnaires to visitors in the rest areas of these museums. A detailed explanation about the study objectives was given to those who wished to participate in the survey. The sample population includes general museum visitors in Korea. Only those visitors who visit major museums in Korea at least once a year on average were eligible to participate in this survey. All participants were advised that their responses were kept both confidential and anonymous. We requested the respondents to fill out the survey questionnaire and return it onsite for a better response rate. In addition, well trained students checked the completeness of the questionnaire for the enhancement of high usable rate. A total of 310 complete questionnaires were obtained. Among them, we excluded five problematic multivariate outliers , followed by 24,999,999 won or less (30.0%), and 70,000,000 won or more (23.2%). When their education level was queried, about 70.6% of the respondents have a bachelor’s degree, followed by graduate-degree holders (14.2%), 2-year college or some college graduates (8.1%), and high-school graduates or less (6.1%). The survey asked participants to report the frequency of museum visit. The largest group visits a museum about 2–5 times a year (51.0%), about 32.3% reported that their visit frequency is once a year or less, approximately 11.0% indicated 6–10 times a year, and about 5.7% reported that they visit a museum 11 times a year or more. Lastly, survey participants’ mean age was 31.6 years. The age of the respondents was between 19 and 72 years old.In the present research, we utilized IBM SPSS Statistics 20 and AMOS 20  for Windows for all statistical analyses. Descriptive statistics were utilized to identify the sample characteristics. To achieve research objectives, we followed Anderson and Gerbing’s  two-step2 = 1092.539, df = 380, p < 0.001, χ2/df = 2.875, RMSEA = 0.079, CFI = 0.915, IFI = 0.915, TLI = 0.902). Each latent variable’s loadings were significant at a 0.01 level. Internal consistency for each research construct was assessed. As shown in We generated the measurement model using the CFA. Our result from the CFA indicated that the measurement model included an adequate fit to the data  [Inv.–KV = 0.274, p < 0.01; β Inv.–Des. = 0.350, p < 0.01; β KV– VL = 0.152, p < 0.05; β VS–VL = 0.253, p < 0.01).The structural model was determined. Our results from the SEM demonstrated that the goodness-of-fit statistics for the proposed model comprised an insufficient fit to the data (χ= 0.891) . Accordi2 (4) = 100.964, p < 0.01). The revised model included a satisfactory fit to the data . Moreover, these added links are theoretically and empirically supported by previous studies [2 = 0.665) than the original model (R2 = 0.600). Accordingly, this revised final model was maintained for hypotheses testing and further analysis. This final model is exhibited in The chi-square difference test results disclosed that the addition of these paths also significantly improved the model fit  and knowledge value  were a significant and positive function of internal museum environment, which supports Hypotheses 1 and 2. Hypothesis 3 was tested. The relationship between external museum environment and knowledge value was found to be significant  and such outcome supported Hypothesis 3. The proposed impact of internal and external museum environments on visitor satisfaction was evaluated (H4 and H5). Our findings revealed that while the internal museum environment exerted a significant influence on satisfaction , external environment  was not significantly associated with satisfaction. Hence, the results supported Hypothesis 4 but not Hypothesis 5. Hypotheses 6 and 7 were tested. As expected, both involvement  and knowledge value  significantly and positively affected visitor satisfaction. Thus, Hypotheses 6 and 7 were supported. The hypothesized links between satisfaction and desire and between desire and visitor loyalty were evaluated. The results indicated that visitor satisfaction exerted a substantial impact on desire , and visitor loyalty was a noteworthy function of desire . This finding supported Hypotheses 8 and 9. The variables within the proposed theoretical framework explained 24.2%, 45.8%, 66.7%, and 55.4% of the total variance in involvement, knowledge value, visitor satisfaction, and desire, respectively.The proposed impact of the internal museum environment on involvement and knowledge value was tested (Hypothesis (H) 1 and H2). Results showed that both involvement  and external museum environments  meaningfully influenced visitor satisfaction indirectly via involvement and knowledge value. That is, involvement and knowledge value served as a key mediating role in the physical environments–satisfaction relationship. Our results also showed that involvement  and knowledge value  had a significant indirect influence on desire through visitor satisfaction, and this satisfaction had a significant indirect effect on visitor loyalty through desire . In other words, both satisfaction and desire acted as significant mediators in the proposed theoretical framework.The mediating role of research variables was examined. An investigation of the mediating framework within a theoretical model contributes to a better understanding of the complex associations among research constructs . The outp < 0.01) had the utmost impact on visitor loyalty, followed by satisfaction , internal environment , involvement , knowledge value , and external environment . Moreover, the findings indicated that the relative importance of involvement , satisfaction , and internal environment  in generating desire was greater than other study variables. Lastly, internal museum environment was identified to be the greatest contributor in increasing visitor satisfaction .Subsequently, we assessed the total impact of the research variables. As presented in Clear comprehension of visitors’ loyalty formation for museums is one of the crucial elements in developing effective marketing/service strategies for visitor retention and revenue increases. The present study successfully integrated such imperative concepts as physical environment, involvement, knowledge value, satisfaction, and desire into one theoretical and conceptual framework of visitor loyalty in the museum industry and explored the complicated interrelationships among these pivotal factors. Our empirical findings enhanced our understanding of personal decision-making and loyalty generation processes through the use of a rigorous and integrative conceptual framework in the domain of museum visitor behavior.p < 0.01; visitor satisfaction: β = 0.591, p < 0.01; desire: β = 0.450, p < 0.01; visitor loyalty: β = 0.448, p < 0.01) was pivotal. Our results imply that designating and managing diverse attributes of internal physical environment nurture visitors’ involvement, learning in museums, satisfaction, desire, and loyalty. Given this, a marketing/operational strategy should involve ensuring a quality internal physical environment in museums. As indicated in this study, to fortify museum visitors’ loyalty by taking advantage of visitor involvement, knowledge value, satisfaction, and desire, industry practitioners in museums should put considerable effort and resource investments into enhancing physical-environment conditions. For instance, providing comfortable temperatures, improving the indoor air quality, offering comfortable natural and artificial lighting, improving the layout, making adequate spatial arrangement of the exhibits, improving the décor, signs and descriptions, and providing adequate spaces for programs, gathering areas, catering, and gift shops would not only make a visitor regard a museum as a user-friendly place but also ultimately lead to an increase in visitor loyalty in the museum industry.The total impact of internal museum environment on its outcome variables  was attributable to the full mediating role of knowledge value. That is, visitors’ perceived knowledge value perfectly mediated the impact of external museum atmospherics on their satisfaction . This result is consistent with the work of Siu et al. [The insignificant relationship for the link from external museum environment to visitor satisfaction . Prior studies on marketing and consumer behavior have repeatedly stressed the importance of desire [The comparison of relative effectiveness among study variables revealed that desire played a prominent and efficient role in determining visitor loyalty (β = 0.511, f desire ,26,48,55The present research findings provided strong support for our theoretical framework and predicted associations among study variables. Nevertheless, as in other studies, this research included a few limitations. Firstly, we tested the conceptual framework using convenience data of the museum customers in seven museums located in one metropolitan city. Therefore, the generalizability of the study findings may be limited. The generalizability should be warranted by adopting a broader sampling range in future research. Second, Siu et al.  indicateOur study tries to develop a visitors’ loyalty model for museums by considering the role of internal and external physical surroundings, cognitive processes, evaluative procedures, and motivational processes. A structural analysis was applied to assess the proposed model and examine the hypothesized associations among constructs. The original model was amended by integrating four paths linking key variables within the proposed theoretical framework. The revised final model generated through this modification process included a better fit and explanatory power for visitor loyalty. Internal and external museum atmospherics were identified to be important in the model, and other research variables were found to be direct and indirect driving forces of loyalty. Overall, our conceptual framework involving seven essential constructs in museums and 13 paths relating such variables was sufficiently capable of explaining visitor loyalty formation. In addition, our specific goals, attempted to fill five major gaps, were achieved in the museum context.


Dementia is the second leading cause of death in Australia. Over half of patients with dementia are undiagnosed in primary care. This paper describes the development, implementation and initial evaluation of the first national continuing medical education program on the timely diagnosis and management of dementia in general practice in Australia.Continuing medical education workshops were developed and run in 16 urban and rural locations across Australia , and via online modules. Two train-the-trainer workshops were held. The target audience was general practitioners, however, international medical graduates, GP registrars, other doctors, primary care nurses and other health professionals were also welcome. Self-complete questionnaires were used for the evaluation.Of 1236 people  who participated in the program, 609 completed the full program , large group workshops (75), online modules (252)); and 627 elected to undertake one or more individual submodules (large group workshops (444), online program (183)). Of those who completed the full program as a small group workshop, 14 undertook the additional Train-the-trainer program. 76% of participants felt that their learning needs were entirely met and 78% felt the program was entirely relevant to their practice.Continuing medical education programs are an effective method to deliver education to GPs. A combination of face-to-face and online delivery modes increases reach to primary care providers. Train-the-trainer sessions and online continuing medical education programs promote long-term delivery sustainability. Further research is required to determine the long-term knowledge translation effects of the program. Dementia or Major Neurocognitive Disorder is a global public health priority  and is aThe timely diagnosis of dementia forms the basis for effective management, offering consumers and their families the opportunity of treatment, support, and to plan for the future , 5, whicAlthough the need for GP education  and the Continuing medical education (CME) programs, are an effective means to deliver dementia educational  and in iThe target audience for the educational material was general practitioners, however, international medical graduates, GP registrars, other doctors, primary care nurses and other health professionals were also welcome.Dementia: 14 essentials of assessment and care planning  some sections were too detailed for me (such as the medications) but still interesting - no comments to improve” Online““Extremely well presented. Appropriate for my PN [Practice Nurse] /Community Care role” NurseAlthough the activity was directed to GPs, non-GP participants also found the material useful:“Less lecture style, more discussion and group work” Rural GP“More small group discussion - might have learned more from colleagues - practical advice” Urban GPA variety of responses of how the activity could be improved were received ; what services and agencies are available and access to them” Rural GP“More reference to/exploration of local services as they relate to the topic” Rural GPSome suggested that more information on local referral services could have been supplied:“Just in regards to the legal aspect of management, good to have guidelines from VIC [Victoria] state as well” OnlineHaving local information was also highlighted in terms of the legal aspects of dementia management:“Not including suggested answers on same page as the question...” OnlineA criticism of the online delivery method was providing suggested answers in made the activity a soft learning exercise:This paper describes the development, implementation and initial evaluation of Australia’s first national, freely available and accredited, CME program on the Timely Diagnosis and Management of Dementia in General Practice. Dementia education training has been shown to have a positive effect on health professionals’ knowledge, attitudes and the provision of patient care  and can Multiple factors influence choice of CME programs, including relevance to area of practice, wanting to remain up to date, the educational value of the program, convenience in terms of time and location, and delivery method . Online There is a need to increase opportunities to expand the reach of dementia education programs to reach larger primary care audiences . This opA key consideration in developing any program is long-term sustainability. Sustainability to deliver future workshops was achieved by upskilling a pool of interested participants as future facilitators through the Train-the-trainer program. Alzheimer’s Australia provided funding for a further series of workshops; however, whether facilitators will be interested in delivering workshops in the future without grant funding is unknown. Once developed, online CME programs offer a sustainable method for delivering CME education programs to large numbers at a comparatively small cost compared to face-to-face workshops, and their feasibility should be explored further.Face-to-face workshops on dementia are opportune times to run Alzheimer’s Australia provider-focused community-based awareness programs and Primary Health Networks  play an important role in advocating training opportunities to GPs in their area.As such, negotiations for collaborative events between different organisations need to commence as early as possible to navigate competing demands and timetabling issues between organisations and to maximise involvement.This study has several strengths. To ensure the integrity of the program, the materials were reviewed by an expert steering committee, including GPs and dementia consumers. The materials comprised a mix of lectures by expert speakers, videos, case scenarios, toolkits and guidelines. Multimodal dementia education programs are reported to be most effective when multiple sources of information are combined with active participation and/or reflection  as was pLimitations include that participants self-elected to participate in the program and may represent a group of motivated and interested individuals. The program was run in the last year of a triennium for CME points which may have influenced participation rates as many GPs may already have accumulated sufficient points. Information would need to be gathered from those who participated to understand why they elected to take part in the program, and from those who did not to understand barriers to participation.The current evaluation is descriptive, describing participants’ ratings of whether the CME program addressed their learning needs and was relevant to their practice and well as suggestions for improvements. It is currently unknown if meeting the perceived educational needs of health care professionals translated to improved practice. The CME program will be further evaluated to determine if long-term sustainable knowledge translation with regards to diagnosing and managing patients with dementia has occurred as a result of the educational program.This was the first nationwide CME program in Australia on the timely diagnosis and management of dementia in primary care. CME programs are an effective method to deliver education to GPs and can provide channels for dementia care knowledge translation.A combination of face-to-face and online delivery modes increases reach to primary care providers. Train-the-trainer sessions and development of online CME programs promote long-term sustainability. Further research is required to determine the long-term knowledge translation effects of CME programs.