Communities are a pivotal setting in which to promote increases in child and adolescent physical activity behaviours. Interventions implemented in these settings require effective evaluation to facilitate translation of findings to wider settings. The aims of this paper are to i) present findings from a RE-AIM evaluation of a community-based physical activity program, and ii) review the methodological challenges faced when applying RE-AIM in practice.A single mixed-methods case study was conducted based on a concurrent triangulation design. Five sources of data were collected via interviews, questionnaires, archival records, documentation and field notes. Evidence was triangulated within RE-AIM to assess individual and organisational-level program outcomes.Inconsistent availability of data and a lack of robust reporting challenged assessment of all five dimensions. Reach, Implementation and setting-level Adoption were less successful, Effectiveness and Maintenance at an individual and organisational level were moderately successful. Only community-level Adoption was highly successful, reflecting the key program goal to provide community-wide participation in sport and physical activity.This research highlighted important methodological constraints associated with the use of RE-AIM in practice settings. Future evaluators wishing to use RE-AIM may benefit from a mixed-method triangulation approach to offset challenges with data availability and reliability.The online version of this article (doi:10.1186/s12889-015-2466-y) contains supplementary material, which is available to authorized users. Current World Health Organization 2010) and UK (2011) physical activity guidelines recommend school-aged children spend a minimum of 60 min per day engaging in at least moderate intensity physical activity. At least three times a week, vigorous intensity activities should be incorporated that include muscle and bone strengthening exercises 0 and UK . Since aCommunities are a pivotal setting in which to promote increases in child and adolescent physical activity due to the potential high reach within this context. However, a number of factors limit our knowledge of the public health impact of community-based multicomponent physical activity interventions. Firstly, many efficacy evaluations have a weak study design  renderinOne way in which the evaluation and reporting of community-based interventions could be improved is through the use of robust evaluation models such as the RE-AIM framework  . RE-AIM NICE guidelines (2007) stipulate that effective behaviour change interventions require careful planning, design and evaluation, ideally incorporating evidence based on RCTs, high quality meta-analyses, systematic reviews of RCTs or controlled clinical trials , 18. AppThe aims of this paper are to i) present findings from a case study evaluation of a community-based physical activity intervention for children and adolescents within the UK using the RE-AIM framework , and ii) review the methodological challenges of conducting a robust evaluation of an existing community-based program using RE-AIM.The community-based physical activity program was available to children and adolescents aged 7–14 years residing within the local council district area. The program was promoted via on-site flyers and posters, through the program website, leaflets in community organisations  and via word of mouth. The program set four core aims: to create ‘participation pathways’  from ages 4–18 years in all sports included within the program, engage with the community using students as positive role models, encourage participation in sport and physical activity, and provide a fun and safe environment for young people to enjoy sport and maintain an active lifestyle. Attendees could participate in multiple sports and there was no minimum attendance period. During 2009–2010 when this evaluation took place, the program received partial financial support indirectly via National Lottery funding allocated by Sport England to the host site’s sports centre. As this funding stream was finite, a secondary aim was to generate revenue from the sports sessions to maintain its sustainability in the community. The program is unique in that it operates as part of a broader participation pathway which provides routes into performance-specific and participation-only pathways interchangeably. The participation pathway provides individuals with access to sporting facilities throughout their life with the long-term goal of contributing to a healthier lifestyle.At the time of this evaluation, the program offered athletics, badminton, football, hockey, judo, multi-skills, netball, swimming, tennis and trampolining sessions. These activities were offered at a central hub (leisure facility), and as part of an outreach arm that delivers sporting opportunities in local schools, and provides expertise and support to local sports clubs. Hub-based sports are delivered through daily after-school sport sessions on a term-time basis and holiday sports camps during the school half-term breaks, and six week summer holiday. The aim was to mimic the school term times to maximise the program’s reach. The program had existed within the community for 7 years prior to the evaluation taking place.The evaluation was based on a single mixed-method case study using a concurrent triangulation design ; trianguDue to the complexity and multiple components within the program, a mixed method approach was chosen to facilitate greater validity of inferences and more comprehensive and insightful evaluation . Four emEthical approval for this study was granted by the University of Bath Ethics Committee and organisational consent was obtained from the program managers.The three program managers and all 14 program coaches (head and senior coaches) were specifically targeted for recruitment due to their seniority level within the program. This strategy ensured key informants with experience of all 10 sports were included and individuals would have sufficient knowledge of the program to contribute evidence across all five RE-AIM dimensions. Staff were invited via email to participate in a 1-hour semi-structured interview to discuss their experiences and perspectives of the program. Parents of children attending the program were recruited opportunistically via letters of invitation distributed at the main program reception desk and at the end of sports sessions. Based on initial responses, the participants of sports without parent representation were contacted directly via on-site visits, and parents asked verbally to participate. The objective was to maximise parent representation across the program sports and minimise the potential effects of volunteer bias. Signed consent was obtained prior to interview commencement.All children and adolescents attending the program during the data collection phase were eligible to take part. Letters were sent home to parents seeking passive consent for their child’s participation 4 weeks ahead of data collection. Questionnaires were completed at the end of sports sessions over a 2-week period in February 2010. Program attendees could participate in multiple sports and therefore complete multiple questionnaires unique to each activity. Questionnaires were anonymous and participants were able to opt out on the day of data collection.The interview schedule contained 45 questions based on criteria within the five RE-AIM dimensions. The questions were framed in context of the program and the terminology tailored for the context of the managers, coaches or parents involved.A questionnaire lasting approximately 15 min was designed to assess the determinants of children’s and adolescents’ participation in the program, and factors influencing their sustained engagement. Each scale contained 21-items rated on a 5-point Likert scale ranging from 1 “unimportant” to 5 “very important”. Questions were based on environmental/organisational factors (i.e. facilities), social factors , intrapersonal factors  and interpersonal factors (i.e. beliefs) as they map to the specified elements of the socioecological model , 25. TheInternal program documentation describing the history and development of the program was requested monthly from the program managers and coaches. Attendance records were provided for one specific time point during data collection; February 2010. As program participation rates were transient throughout the year, the February attendance records were requested to correspond with the associated questionnaire data collection among the children and adolescents. External program documentation  was searched for weekly via the internet. Field notes were recorded throughout the 12-months data collection, i.e. during the interview and questionnaire data collection phases and impromptu site visits to gain a more reflective account of implementation in the natural context in which it occurred.N = 4), email correspondence with program managers outlining the program’s history and development (N = 1) and participant attendance records for February 2010 (N = 2). Archival records included local council census data containing local population figures and school statistics. Field notes were taken following 20 informal observations during the delivery of program sessions, data collection phases and from personal reflections of the program.Additional evidence included 7 program-related documents: program advertising leaflets, posters and holiday camp brochures . The strength of convergence was determined based on the frequency and extensiveness of overlapping themes. Themes were ranked across the participant group to identify those with the greatest vs the least convergence. It was expected that within-sub-groups, participants would have a similar experience and understanding of the case due to their position and level within it, therefore a similar emergence of themes was expected. Triangulation of interviews was then repeated using these emergent themes between participant sub-groups to identify differences across the case. Convergence between-groups was established when at least 2 of the 3 participant sub-groups referred to a theme. As the program managers, coaches and parents represented different levels within the case, they were not expected to have a similar experience of the program. Instances of evidence divergence were therefore expected and reported.The interview data provided the greatest coverage of all five RE-AIM dimensions therefore initial synthesis was undertaken using this source. Firstly, the interview data was triangulated Evidence from the remaining four data sources was then additionally integrated into each dimension where applicable and triangulated with the existing interview themes. Questionnaire data contributed to assessing Reach, Effectiveness and Implementation. Documentation assisted with the assessment of Reach, Effectiveness, Adoption and organisational-level Maintenance. Population census data was used to assess Reach and Adoption, and field notes provided evidence for all five RE-AIM dimensions. , and (ii) Dimension outcome (i.e. the positive/negative outcome based on assessment of the dimension criteria using the available data).Following triangulation of all five data sources within each RE-AIM dimension, an individual ‘success score’ was allocated to each dimension . The success score was based on (i) What is the absolute number, proportion and representativeness of individuals willing to participate?): the assessment was based on whether the data available (i.e. program attendance records and interview data on uptake) could assist in quantifying the number of individuals willing to participate (success criterion i) and secondly whether the program had attained a positive outcome in terms of its Reach, defined in this case as whether the individuals included within the evaluation were representative or not of the target population based on the triangulation of participant accounts (success criterion ii). A single score was given to each dimension combining these considerations, as the interaction of data applicability and outcome meant that a high score in one would be meaningless  without a high score in the other.For example Reach , 3 head coaches , 4 senior coaches  and 10 parents  participated in an interview. The coaches represented 7 of the 10 sports  and the parents had a combined experience of 8 of the 10 sports . Parents represented 15 program attendees aged between 7 and 14 years old  who had participated in the program for between 2 months to 6 years. Additional file  female, Approximately 409 children and adolescents participated in the program during February 2010. In total, 334 questionnaires were completed (boys completed 181 and girls completed 153) and the mean (SD) age of participants was 9.69 (+1.88) years. Questionnaire reliability was established from Alpha coefficients which exceeded 0.70, the mean inter-item correlations exceeded 0.30 and the participant to item ratio ranged from 5:1 (for 11–14 year olds) to 11:1 (for 7–10 year olds); supporting the reliable use of the scales within this study. Results following synthesis of the data against the RE-AIM criteria is presented in Additional file N = 409) of the total eligible population of 6–15 year olds living within the local council district .The program reached approximately 2.5 %  of the schools within the local education authority. Program adoption at the setting-level varied. Consistent with field notes, during interviews the coaches and parents identified weaknesses with adherence to the program principles, such as the creation of participation pathways in all program sports; which were described as inconsistently available. Data on organisations approached by the program, including those who declined uptake, was not systematically recorded. This lack of internal program documentation meant interview data was the dominant source of evidence for setting-level adoption.Adoption was estimated based on (i) the extent that the individual program sports adhered to the program principles and (ii) the proportion of schools and organisations within the local council district that had established links with the program. Adoption at the community-level was extremely high as links and/or partnerships were established with 95 % . Attendees typically joined at a young age and sustained participation within multiple sports for several years. However, formal rates of attrition were not available nor program documentation to assist this assessment. Attendees who were more likely to drop out were consistently described by program managers and coaches as ‘less sporty’, less competitive within sport, and from families with less support for the program. Documentation confirmed that pathways into community sport that young people could follow after the program existed, but this did vary across sports. Nonetheless, the inconsistent availability of community sports pathways after the program was identified by parents in interviews and in field notes as a barrier to children’s ongoing activity participation. Interview data and field notes highlighted parents’ lack of awareness of program pathways, despite that documentation supported their existence and availability.This paper presents findings from a RE-AIM evaluation of a community-based physical activity program aimed at children and adolescents. The study had two aims, firstly to evaluate the program according the RE-AIM criteria through the triangulation of data of different formats, and secondly, to provide a critique of the challenges and facilitators of this evaluation approach in practice. Implementation of the RE-AIM framework to evaluate the program indicated that the program had only limited success in terms of Reach, Implementation and setting-level Adoption. It was highly successful in terms of community-level Adoption whereas only moderately successful in terms of Effectiveness and Maintenance; at both an individual and organisational level.The feasible adoption of the program within the local community and its demonstrated sustainability at an organisational-level, is comparable with previous community-based interventions aimed at reducing obesity (C.H.A.M.P)  and incrDespite challenges identifying the individual-level impact of the program, evidence for successful integration and institutionalisation of the program in the community remains an important indicator for future expansion or replication. Our findings revealed that community partnerships and adoption were integral to perceived program success, prioritised above evidence of positive participant outcomes. While this propensity emphasizes how intervention efficacy is insufficient in isolation to predict any long-term public health impact , it alsoWhile data quality and availability limited the rigour with which some elements of the framework could be assessed through a single indicator, greater confidence in these conclusions was achieved through triangulating different data sources. Assessment of all the available data ultimately led to a consistent outcome for each RE-AIM dimension, however, triangulating multiple sources provided greater clarity to instances of evidence divergence. For example, assessment of organisational-level maintenance revealed parents perceived community pathways as unavailable, yet documentation supported the expansion and availability of such community links. Rather than revealing contradictorily data, this finding highlighted an underlying lack of communication within the program regarding such pathways which emerged as a divergence of evidence.Our second aim was to explore the methodological challenges to using the RE-AIM framework to evaluate an existing community-based physical activity initiative. To achieve the maximum informative potential of RE-AIM, assessment of all five dimensions is advocated , 36. HowThe absence of reliable data in the program reflects a common constraint within community-based intervention evaluation. Previous evaluations of community-based interventions have reported assessment limitations to include a lack of baseline data and challenges with the organisational context , a lack The lack of objectively measured outcome data may also be a consequence of conflicts between the public health-related objectives and the underpinning financial drivers of delivering a sustainable physical activity program. It has previously been suggested that appraisal of evidence should consider whether the outcome variables address the interests of the important stakeholders, and not just those who appraise the evidence . AccordiTo ensure the framework criteria are addressed in sufficient depth to ascertain impact, significant consideration needs to be given to the context within which the program occurs and the underlying drivers that mediate its existence. The inclusion of setting-specific criteria within the RE-AIM framework, for example the requirement for sustainable income generation in the present case, is pivotal to its utility in practice-based and community contexts. The inclusion of only individual-level impact criteria to define effectiveness may be sufficient for estimating health impact, but it is likely that organisational-level success factors take precedence in practice. Guidance on the ways community-driven outcomes can be used as additional indicators of program effectiveness at both individual- and organisation-levels may facilitate more meaningful application of RE-AIM in practice.Despite difficulties implementing RE-AIM due to variations in the quality and availability of setting-level data, using mixed-methods to populate the framework enhanced the richness and contextual relevance of the overall evaluation . For exaCollecting multiple sources of data across multiple levels strengthened the conclusions drawn from this case study when faced with the challenges of data limitations. Triangulation of the evidence enabled conflicts and consistencies to emerge and be addressed in a transparent and systematic fashion. This enabled a more in-depth understanding of factors which mediate program impact. These aspects are fundamental to the transferability of research to other settings . The greThe main limitation during assessment of all dimensions was the absence of formal monitoring data that mapped against RE-AIM recommendations. Data on the target population, eligible population, uptake and attrition were not systematically prioritised and recorded. In other cases, outcomes did not map to RE-AIM guidelines due to practical issues. For example, Implementation could not be assessed based on costing information as recommended within RE-AIM, due to the complex financial and organisational structure of the program; total program delivery cost was unavailable as some of the sports were managed and partly funded as independent entities.The program was delivered in the community as a single organisation, yet the sports implemented within it had varying implementation procedures and their own additional program objectives. The lack of internal program standardisation challenged assessment of all five RE-AIM dimensions, in particular at the organisational level. Assessment of setting level Adoption was challenged by the differing autonomy of head coaches over others, making adherence to the program principles and standardisation of reporting procedures more diverse.and the extent that the data available could contribute to assessing that dimension. Objectivity of ‘success’ was achieved by continually mapping the data against the RE-AIM specifications, and whilst this meant the program was evaluated in the context within which it occurred; the additional non-standardised assessment criteria may only apply to this current situation. Nonetheless, assessing RE-AIM using only the dimension criteria as the benchmark without consideration of data availability could have led to distorted conclusions of potential program impact.The scoring method used in this research was developed based on recommendations for using mixed methodology when applying RE-AIM in practice , and in The lack of availability of data experienced in this research is a true reflection of many community-based programs implemented in similar settings. The use of robust evaluation frameworks such as RE-AIM in these contexts is warranted, and recommended, however acknowledgement and inclusion of context-specific information such as data availability may be necessary to achieve more reflective interpretations.Case study research has previously been criticised for the potential limitations associated with the generalisability of results , howeverThis study adds knowledge to existing methodologies used to implement RE-AIM in the community and facilitates discussion of possible solutions to the methodological challenges experienced in practice settings. Funding organisations are increasingly acknowledging the importance of health as an outcome in addition to sports participation , and thus the ability to provide robust evidence that meets the needs of different audiences is increasing , 46. Thi


Background: In Chile, there are inconsistencies in the management of depression in primary care settings, and the National Depression Program, currently in effect, was implemented without a standardized training program. The objective of this study is to evaluate the acceptability of a training program on the management of depression for primary care health teams.Methods: The study was a randomized controlled trial, and two primary centers from the Metropolitan Region of Santiago were randomly selected to carry out the intervention training program. Pre-post surveys were applied, to evaluate expectations and satisfaction with the intervention, respectively. Descriptive and content analysis was carried out.Result: The sample consisted of 41 health professionals, 56.1% of who reported that their expectations for the intervention were met. All of the training activities were evaluated with scores higher than 6.4 . The trainers, the methodology, and the learning environment were considered strengths and facilitators of the program, while the limited duration of the training, the logistical problems faced during part of the program, and the lack of educational material were viewed as weaknesses.Conclusion: The intervention was well accepted by primary health care teams. However, the clinical impact in patients still has to be evaluated. In Chile, depression is one of the most common psychiatric disorders in adult population, with a six-month prevalence of 4.7%  and a onThe results of the 2009–2010 Chilean National Health Survey indicated that 17.2% of the general population suffered from depressive symptoms in the last year, and that 21.2% reported having been diagnosed with depression at some point in their lives . Among iIn response to the high prevalence of depression in primary care settings, international evidence has suggested the use of stepwise treatment with multiple components for management of the illness, offering different levels of complexity, and different combinations of psychosocial, pharmacological, and/or psychotherapy interventions, according to the severity of the case .In line with these recommendations, a randomized controlled trial was carried out, taking into account the idiosyncrasies of the Chilean primary care system, in which professionals who are not physicians provide a large portion of the interventions in these centers. The results of this study were promising, with the active group having a recovery rate of 70% compared to a 30% rate in the control group, after 3 months; the differences between the groups were still significant at the six-month follow-up .This evidence, demonstrating primary-care-based intervention to be effective, as well as cost-effective , was insCurrently, more than 80% of depressed patients in the Chilean public health care system are treated by primary care teams . HoweverThis situation is not limited to Chile. International evidence has also found that the management of depression is not always consistent with clinical guidelines; sub-detection of the illness, insufficient treatment, excessive use of psycho-medication, and scarce use of cognitive-behavioral interventions are fairly common occurrences .Because the multidisciplinary health teams in Chilean primary care settings are the gateway into the health system for a significant portion of patients, and considering that implementation of the National Depression Program does not include a training component for these health teams, the authors saw the need to train members of primary care teams to improve the detection, diagnosis, and treatment options provided to individuals with depression .The objective of this article is to assess the acceptability of a training program in depression management for primary health care teams in Chile.This manuscript presents an evaluation of the acceptability of the first component of the randomized controlled trial “Comprehensive Technology-Assisted Training and Supervision Program to Enhance Depression Management in Primary Care,” corresponding to the training portion of the program. The results from the health teams of two CESFAM in the Metropolitan Region of Santiago, Chile, randomized to the study’s intervention arm, are presented.The selection of the CESFAM for the study was carried out in two steps. First, two urban municipalities from the Metropolitan Region, with clinical campuses of the Universidad de Chile, were randomly selected. Municipalities were excluded if they had a high Human Development Index, a high percentage of immigrants, a large proportion of older adults, and/or psychiatry residents working in primary care centers. Secondly, in the two selected municipalities, two CESFAM were randomly chosen, with one assigned to the intervention arm and the other to the control arm of the study.The training program was designed by a group of psychiatrists, psychologists, social workers, and educators from the Universidad de Chile Faculty of Medicine and Clinical Hospital.The content of the intervention was based on recommendations from the Clinical Guidelines for Depression in Individuals older than 15 years of age  and inclThe training was carried out in the CCA of the Medical School of Universidad de Chile, with two, 12-h sessions held for each group. Overall, five groups were trained in April, September, and October 2014, for a total of 60 h of training in 10 sessions.The following educational activates were included in the training: oral expositions, analysis of clinical cases, role playing to practice clinical interviewing and problem solving, and a OSCE, along with clinical simulations with standardized patients.An open-ended survey was given to all participants before and after the training program, to explore their expectations prior to starting the program, the degree to which their expectations were met, and their perceptions of the program’s strengths and weaknesses.In addition, immediately after the training program, a closed seven-item survey, with response options on a Likert scale  was completed by the participants, to evaluate the various activities included in the program. The data from this survey were input into a 2007 Excel for Windows spreadsheet, for descriptive statistical analysis . The resThe Ethics Committee of the Faculty of Medicine, Universidad de Chile, granted approval for the study (project number 103-2012). Informed and written consents were obtained for all participants. The study was performed in accordance with the ethical standards laid down in the Declaration of Helsinki.Table 1). All of the participants responded to the survey questions.The sample consisted of 41 participants, who were health professionals from the selected CESFAMs , with a multidisciplinary approach; to learn or improve clinical interviewing skills; and to increase patients’ treatment adherence. To a lesser extent, professionals mentioned wanting to develop techniques to care for patients in crisis, and those who face multiple, contextual problems.In terms of the degree to which these expectations were met, the post-training survey indicated that 56.1% of the professionals’ reported that their expectations were at least completely satisfied . On the other hand, 14.6% of the sample reported that their expectations were only partially met, 12.2% said that they did not have initial expectations, and 17.1% did not respond to that survey item.Table 2).All of the activities included in the training program were evaluated with scores higher than 6.40 . The average score was 6.63, with a standard deviation of 0.15. The professionals who most highly ranked the activities were occupational therapists, who gave an average score of 6.86, while midwives gave the lowest average score , and “Treatment of simulated patients” received the lowest average score (6.46).Table 4), while the short duration of the program, logistical problems with the organization of OSCE, and the lack of educational materials were seen as weaknesses (Table 5).The analysis of the health teams’ preferences reveal that the principal strengths of the program were the training staff, the methodologies used, and the educational environment, which all served to facilitate learning new skills  the short duration of the program, and (ii) the lack of educational material made available to them. In this vein, the caseload burden of primary care health teams significantly limits professionals’ time availability, open for training, though the duration of training program could be extended in the form of continuing booster sessions, to consolidate skill development, address problems in clinical practice, and cover any issues that the participants feel are pending. Regarding the second aspect, the training program should provide participants additional support, by expanding the availability and increasing the relevance of educational material.Finally, future studies should determine not only if this depression management training program is effective in the local Chilean population, and for national public mental health policies, but also if the intervention model could be applied in primary care settings of other countries, where depression remains an unsolved public health problem.In summary, it can be concluded that the training program was accepted by primary care health teams, and although some participants thought that certain aspects of the program could be improved, there was a high level of satisfaction with the intervention, and it coincided with the professionals’ preferences, which could indicate that its future application with other health teams could be well received. Nevertheless, investigators still have to evaluate if this training program translates into better clinical results for depressed patients, who attend Chilean primary care centers.RM contributed to the planning of the training evaluations, the data analysis, the preparation of the manuscript and its final approval. PM collaborated with the implementation of the research project, the data analysis, the preparation of the manuscript and its final approval. JC and JP planned activities for the training program and revised the manuscript. BD participated in the execution of the training program and contributed to drafting the work. AT assisted with the manuscript, revising it critically and giving final approval for submission. GR designed and implemented the research project, carried out the training program, and reviewed critically the manuscript, giving final approval for submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Cybister japonicus Sharp (order: Coleoptera) was investigated. The motion characteristics of the blood in the veins of the structure system show that the veins have microfluidic control over the hydraulic mechanism of the unfolding process. A model is established, and the hind wing extending process is simulated. The blood flow and pressure changes are discussed. The driving mechanism for hydraulic control of the folding and unfolding actions of beetle hind wings is put forward. This can assist the design of new deployable micro air vehicles and bioinspired deployable systems.The diving beetles  are families of water beetles. When they see light, they fly to the light source directly from the water. Their hind wings are thin and fragile under the protection of their elytra (forewings). When the beetle is at rest the hind wings are folded over the abdomen of the beetle and when in flight they unfold to provide the necessary aerodynamic forces. In this paper, the unfolding process of the hind wing of  The concept of a micro air vehicle (MAV) was first introduced in the early 1990s. It was extensively researched because of its advantages over traditional aircraft, such as its small size, light weight, good concealment, flexibility, low cost, and portability. There are three main flight modes: fixed wing, rotor, and flapping. Insects possess a remarkable ability to fly, far superior to what humans achieved in the production of MAVs with a low Reynolds number.In general, the hind wings of a beetle are larger than its forewings (elytra) to maintain the ability of the beetle to fly. One exception are the hind wings in perfectly flying jewel beetles, which are not folded at all and are smaller than its elytra. The hind wings of a beetle are membranous and folded under the elytra while at rest . In ordePachnoda marginata). When beetles are at rest, their wings will be folded and tucked under the elytra, and the folding process includes the lateral and longitudinal folding of the membranous hind wings. Folding is carried out along a folding line [The folding/unfolding behavior of beetle hind wings has been extensively researched. Its mechanism has been under continuous investigation . Forbes ing line . It may ing line ,8–9. Theing line –12. The ing line . Moreoveing line ,13. The Another possibility is that the folding and unfolding actions are controlled by two different mechanisms . FoldingAn insect wing consists of a thin membrane and a system of veins. There are cavities within major veins that contain nerves and trachea, and because they are connected with the hemocoel, hemolymph can flow into the wings (http://medlibrary.org/medwiki/Insect_wing). Hemolymph can transfer mechanical pressure caused by muscle contraction, and facilitate fluid-feeding, prey capture, pupation, and the ecdysis and eclosion processes . HoweverDorcus titanus platymelus , which is a xylosaprophagous beetle, and its hind wings are folded down to 55% of their full length. In this paper, the hydraulic mechanism in the veins of hind wings of diving beetles (C. japonicus) was investigated, and the unfolding process, including blood flow and pressure changes, was simulated. The study of the hydraulic mechanism in the folding and unfolding process will be provide insights for the design of micro air vehicles with morphing wings, and give inspiration for the development of bioinspired deployable systems.In a previous work , we inveC. japonicus) is an aggressive predator: larvae and imagines devour small fish and invertebrates  for 10 min; 100% concentration acetone twice for 20 min; and 100% concentration propylene oxide once for 20 min). After that, ultrathin sections of 50–100 nm thickness were cut out by an ultrathin slicing machine. In order to easily view the sample structure, dye (hematoxylin eosin) was used to stain the specimens.All beetles were anesthetized with ether. Their hind wings were cut out with a scalpel, and a 1 mmTo confirm which veins of the hind wings were involved in the hydraulic mechanism during unfolding, a retinal camera  was used. Retinal camera testing was performed with a fluorescent agent to color the walls of the veins. One milliliter of green fluorescent indicator (FITC) was injected into the beetle abdomen at time zero. The measurement was taken with an excitation wavelength of 488 nm in the retinal camera.i-SPEED 3, camera speed of 400 frames/s). The beetle was suspended in front of the camera.The unfolding hind wings process of the hind wings of a flying beetle was photographed with a high-speed camera  were designed as a control system to investigate the variation of fluid pressure in the veins of the hind wings .The speed and pressure changes during the unfolding process were numerically simulated via computational fluid dynamics (CFD) solver. To simulate the insect wing veins within the fluid flow during the unfolding process, the CFD solver, FLUENT 6.3.26, was used to solve the momentum conservation equations  based on the pressure method. The motion of an unfolding wing was modeled by using the dynamic mesh technique.Assuming that the flow is laminar, the fluid medium is blood, and the inlet effect is not considered, the control equation of fluid flow in the beetle hind wing is the 3-D incompressible NS equation:u, v, w are the velocity components (m/s) for the x, y, z-directions, respectively, and ρ is the density of the fluid. Momentum equations are given as,where fx, fy and fz are the generalized source terms for the momentum equation, only for inertia force, the external forces on the volume element in the x, y and z-directions Fx = Fy = Fz = 0.where The purpose of simulation in this is the analysis of the motion of veins, mainly focusing on the vein expansion process, and the variation of the flow field and coordination. Thus, when defining the parameters for the simulation study, the model was set to a rigid body. If we are only concerned about the whole movement of the object and the internal deformation does not affect the whole movement, then the object can be simplified as a rigid body with no penetration of the wall .C. japonicus was recorded using a high-speed camera, as shown in 16The deployment process of the hind wings of C. japonicus, with cutting positons as shown in Figure 1D. The exocuticle, endocuticle, and epidermis layers appear brown and light pink (the thin basement membrane), respectively, in a manner similar to that found in [found in . It was found in . The are4 were observed to be nearly full of fluorescence , the posterior face is a thin membrane, and the top and bottom faces are sclerotized plates. Pass [Pieris rapae demonstrated that the movement of hemolymph into the wings along the veins was a unidirectional flow. In adult Lepidoptera, Coleoptera and Diptera, and perhaps in some other insects, the blood is shunted backwards and forwards between the thorax and abdomen, rather than circulated [A retinal camera was used to confirm which veins were involved in the hydraulic mechanism of the unfolding of the hind wings. A fluorescent agent was injected into the abdomen of a live beetle. At 0.05 s, fluorescence was found in CuA, and at 0.09 s it nearly flowed through AAP; 1.21 s later, C, CuA, AAP, and APrescence . After tg region . This phes. Pass  put fortes. Pass  showed tDuring the deployment of the hind wings, the blood pressure in the veins of the wings changes continuously : the preThis expansion time is a little quicker than that measured in The hexahedral mesh is orthogonal and gridded . Thus, iThe blood circulation of insects is pumped by the heart in the abdomen, with arteries flowing to the head . BecauseThere are two stages: in the first stage, S1 is fixed and S2 rotates around the point q1; in the second stage, S1 and S2 are fixed, and S3 rotates around the point q2. As shown in The flow changes in the vasculature were also simulated . Figure Via FLUENT post-processing, we set up monitoring points at q1 and q2. In C. japonicus and its hydraulic mechanism were investigated. To confirm which veins were involved in the hydraulic mechanism of the unfolding of the hind wings, the cross sections of the veins were captured using an inverted fluorescence microscope and flow of blood was examined by means of a retinal camera. After 3.31 s, C, CuA, AAP, and AP4 were observed to be nearly full of fluorescence, and the fluorescence stopped at over RA 2 mm. To determine the unfolding action of the hind wings and corresponding time required for each action during the unfolding process, high speed camera sequences were used (400 frames/s). It was found that the beetle can start to flap its hind wings while they are still folded (0.651 s), and until 0.741 s, the hind wings were completely extended. Then, the pressure of the vein of the hind wings of four beetles during the unfolding process was tested. The results showed that with the unfolding action of the hind wings, the pressure kept changing. The wing veins unfolded within the flow field successive dynamic simulation deployment process of the hind wing during the entire time of travel in FLUENT. This is mainly from the two aspects of pressure and the velocity vector of the corresponding numerical study on the movement characteristics, which provide a bionic foundation to design and develop flying micro-robots.The unfolding of the hind wings of


Procedural skills training forms an essential, yet difficult to assess, component of an Internal Medicine Residency Program. We report the development of process of documentation and assessment of procedural skills training.An explanatory sequential mixed methods design was adopted where both quantitative and qualitative information was collected sequentially. A survey was conducted within the Department of Internal Medicine at The Aga Khan University Hospital, Karachi, Pakistan to determine the optimum number of procedures needed to be performed by residents at each year of residency. Respondents included both faculty and the residents in the Department. Thereafter, all responses were compiled and later scrutinized by a focus group comprising of a mix of faculty from various subspecialties and resident representatives.A total of 64 responses were obtained. A significant difference was found in eight procedural skills’ status between residents and faculty, though none of these were significant after accounting for multiple consecutive testing. However, the results were reviewed and a consensus for the procedures needed was developed through a focus group. A finalized procedural list was generated to determine: (a) the minimum number of times each procedure needed to be performed by the resident before deemed competent; (b) the level of competency for each procedure for respective year of residency.We conclude that the opinion of both the residents and the faculty as key stakeholders is vital to determine the number of procedures to be performed during an Internal Medicine Residency. Documentation of procedural competency development during the training would make the system more objective and hence reproducible. A log book was designed consisting of minimum number of procedures to be performed before attaining competency.The online version of this article (doi:10.1186/s12909-015-0457-4) contains supplementary material, which is available to authorized users. Internal Medicine Residency Programs are responsible for identifying and implementing the requirements to ensure comprehensive training of the residents enrolled in the program. This includes procedural skills training, and the mandate for a competency-based postgraduate medical training requires all residency programs to teach clinical skills formally , 2. StudThe residency program needs to identify specific procedures in which competency is to be expected of the graduating residents as a response to its specific context, and furthermore determine after performing what number of procedures under supervision are the residents deemed to be competent enough to perform them independently. However, determination of such numbers remains a challenge despite work being done in the past to unveil this dilemma , 11, 12.We, at the Aga Khan University have taken the systematic instructional design process which has the core elements of analysis, design, development, implementation and evaluation (ADDIE). Instructional design is a set of procedures for developing education and training programs in a systematic, reliable and consistent manner.The Aga Khan University Hospital (AKUH), Karachi, Pakistan is a major tertiary care hospital catering to more than 18 million people of Karachi and the surrounding region. With an operational strength of 545 beds, the facility serves over 42,000 inpatients and over 500,000 outpatients annually. Established since 1985, it is one of the few teaching hospitals in South Asia accredited by the Joint Commission for International Accreditation .The Internal Medicine residency program at AKUH, comprising a total of 50 residents, is a 4 year program during which residents rotate through General Internal Medicine as well as all other medicine sub-specialties. The faculty members for the department have received training from programs in the United States of America, the United Kingdom as well as Pakistan.This study was conducted to identify the number of times a procedure needs to be performed by residents at different procedure status levels, during a residency program in the developing world, in order for them to achieve sufficient competency in their technical performance. We aim to formulate a set of guidelines to be implemented in our institute, as well as having applicability internationally, in our region and beyond.This was an explanatory sequential mixed methods design –16, wherA written informed consent for participation in the study was obtained from the participants after explaining the research study and design to them.In order to identify the optimum number of procedures required to achieve procedural skills competency a comprehensive list of procedures was identified according to the program’s contextual and certification requirements, which included peritoneal paracentesis, pleural paracentesis, urethral catheterization, lumbar puncture, CVP/JO Cath insertion into femoral vein, CVP/JO CATH insertion into Internal Jugular vein, CVP insertion into subclavian vein, Internal Jugular Vein, Temporary Pace Maker placement, Arterial Line placements, drawing of Arterial Blood gases (ABGs), Cardiopulmonary resuscitation (CPR), Bone Marrow aspiration, Joint aspiration, Chest Tube insertion, Endotracheal intubation, Swan Ganz catheterization, Pericardial paracentesis and Pleural biopsy. This list was then sent to all faculty members of the department as well as all residents enrolled in the program. The list was designed in the form of a questionnaire in order to yield two different pieces of information from faculty and residents separately: (1) what the residents and faculty felt was the adequate number of times each procedure listed is to be performed in order to achieve competency and (2) the status of the individual resident while performing the procedure in their opinion in the residency program. Four different statuses were determined as follows:Observer status: Procedure observed without any active involvement in the intervention.Assistant status: Assisted the procedure which was performed by a trained Post Graduate/FacultyPerformed under supervision: Performed procedure under direct supervision of a trained Post Graduate/FacultyIndependently performed: Perform a particular procedure independently, in consultation with the Faculty/ConsultantAll results from the above mentioned questionnaire were compiled and analyzed using SPSS Ver. 17.0 . Basic descriptive statistics (medians and interquartile ranges) were generated. The Kolmogorov-Smirnov test identified that the data was non-parametric; hence, the Mann-Whitney test was used to compare differences in the responses of the faculty and the residents at significance level of .05. Due to multiple Mann-Whitney tests applied, a Bonferroni correction was applied to the significance level to deal with the potential problems with an inflated Type I error. Results were tabulated for presentation.The preliminary responses were gathered and discussed within a focus group comprising of 12 faculty members, including the program director and coordinator of Internal Medicine residency program, ex-Program Director of internal medicine, faculty representatives of all the medical sub-specialties, and two Chief Residents of Internal Medicine. The chief residents represent the opinion of residents while the sub specialty faculty provided the faculty’s perspective ensuring equal and unbiased viewpoint from all the stakeholders. Furthermore, a list of certain basic procedures , which were not included in the questionnaire, and certain advance procedures (e.g. Upper and Lower GI Endoscopy etc.) which were supposed to be only observed or assisted by the residents, was finalized.This group evaluated the responses of the faculty and residents, and was given the responsibility to approve the optimal number of procedures, the year in residency when the procedure must be performed and procedure status of the residents for different procedural skills in light of the earlier conducted survey. Furthermore, wherever there was a significant difference in the opinion of the faculty and residents regarding specific procedures, the focus group gave its expert opinion regarding the final number of procedures to be recommended in the program guidelines. These consensus guidelines for the program were then approved by the Chair of the Department of Medicine and the Quality Improvement Committee of the hospital chaired by the Medical Director of the hospital. The compiled results after thorough debate and consensus were given the form of a log book to facilitate documentation and evaluation of procedures performed by a resident , blood drawing for arterial blood gases (independent), cardiopulmonary resuscitation (observed and independent), joint aspiration (assisted and supervised), and pleural biopsy (assisted and supervised). None of these results were however significant with a Bonferroni correction applied which reduced the p-value to 0.0007. Table All the results depicted in Table While identification of specific procedures and number of times they need to be repeated to achieve a level of competency is a matter of debate , 17, metTherefore, while developing these guidelines, equal weightage was given to the residents’ and the faculty’s opinion to arrive at the optimal number, while the focus group served to streamline their opinions in cases where the opinions diverged significantly. Taking residents’ opinion to form these tools has been suggested by earlier literature –30. LackResidents in our country have to undergo a mandatory internship year before joining a residency program and have already given the first part of their accreditation exam (Fellowship of College of Physicians and Surgeons—FCPS); they are adequately exposed to the ground realities of training in order to give them an informed opinion. Taking responses from faculty is more intuitive as these are the ones who perform these procedures themselves or supervise and train others.The focus group was necessary to factor in the expectations from individuals who have actually designed or are responsible for academic and administrative affairs of the program. The individuals comprised, thus remained aware of the realities of the society in which graduates of the program are expected to serve. Hence, their expert consensus was important in bringing the expectations of the patients and society into account while designing these guidelines. This system evokes experience published for other systems and programs such as that of the Accreditation Council for Graduate Medical Education (ACGME) of the United States  translatWe also believe that supervision and assessment at different competence levels or procedure status levels for necessary skill acquirement could have better objectivity, than only direct observation to acquire competency , 33. FurWe, at the Aga Khan University have a trainee centered program and strongly believe in the transition of trainer based to trainee based curriculum Table . We traiAs a result of this exercise, a log book has been designed, wherein the residents are required to log all procedures performed during each residency year. Figure The development of this log book has been placed at the “implementation” element of the ADDIE model as explained earlier. We have analyzed the need and importance of the issue, designed and developed a log book which is currently being filled by the residents at their respective levels of training. We believe that this tool will help bring a uniform consistency and competency to the training of the resident, which unfortunately has not been achieved earlier . The folFirstly, the initial survey was performed on the faculty and residents of only one institution, further multi-centered studies must be performed in order to generalize its applicability. Secondly, time for competency level accomplishment may vary according to residents’ rotation, personal motivation, availability of cases and their learning abilities.We feel that one potential bias could be information bias as data obtained was subjective and dependent upon the individual faculty/residents’ understanding of obtaining expertise in a certain procedure.Future studies done on the same topic may rectify the number of procedures to be performed by residents to become competent in a particular procedure. Log book is designed in such a way that a resident is being observed through various stages and finally performs supervision.It will be valuable to also see which procedures are performed and also the attainment of competence in performing these procedures in programs globally and compare the training methodologies between the programs in this part of the world to those in the West.The ultimate value of these set of numbers compiled in a log book lies in the cumulative effort and input of the residents and faculty of a teaching hospital to define competence of a trainee in procedural skills in the Internal Medicine Residency Program. These numbers can never be of any value unless practically implemented, monitored and regularly updated.It has remained a challenge to identify the precise number and procedures to achieve procedural skill competence in an Internal Medicine Residency Program. It is vital to consider the opinions of all stakeholders including both the post graduate trainees and faculty before any guidelines are formulated. Documentation of each skill developed and accountability for each mistake made during the training would make the system more objective and hence reproducible globally. A general consensus should be sought to eliminate the difference of region or country where the training is provided regarding Procedural Skills Competency.This study suggests that residency programs in different parts of the world have different requirements regarding procedural skills. It also adds to the literature in terms of an illustrative exercise for development of guidelines in a developing world setting, which is responsive to its national healthcare context. Further assessment of the logbook developed will benefit in streamlining these proposed guidelines and may serve as a model for other programs in similar settings. These can thus form the basis and provide the tools for conducting, potentially large scale, multicenter studies to promulgate a set of such precise guidelines, having a much wider applicability.Through this study, we have identified different ‘numbers’ of procedures and their respective status quantitatively, and compiled them in a log book form. Further work is required to fine tune this effort and to add a qualitative aspect to determine the efficiency and effectiveness of a resident while performing, assisting or even observing these procedures. Ultimately, the next step for the University is to evaluate how this documentation of acquisition of procedural skills can change the quality of care in terms of fewer complications due to appropriate supervision and better skills thus enriching the quality of residents we produce and eventually impact patient care.


BCR–ABL1 mRNA is an important therapeutic indicator in chronic myeloid leukaemia, but there is a substantial variation in results reported by different laboratories. To improve comparability, an internationally accepted plasmid certified reference material (CRM) was developed according to ISO Guide 34:2009. Fragments of BCR–ABL1 (e14a2 mRNA fusion), BCR and GUSB transcripts were amplified and cloned into pUC18 to yield plasmid pIRMM0099. Six different linearised plasmid solutions were produced with the following copy number concentrations, assigned by digital PCR, and expanded uncertainties: 1.08±0.13 × 106, 1.08±0.11 × 105, 1.03±0.10 × 104, 1.02±0.09 × 103, 1.04±0.10 × 102 and 10.0±1.5 copies/μl. The certification of the material for the number of specific DNA fragments per plasmid, copy number concentration of the plasmid solutions and the assessment of inter-unit heterogeneity and stability were performed according to ISO Guide 35:2006. Two suitability studies performed by 63 BCR–ABL1 testing laboratories demonstrated that this set of 6 plasmid CRMs can help to standardise a number of measured transcripts of e14a2 BCR–ABL1 and three control genes . The set of six plasmid CRMs is distributed worldwide by the Institute for Reference Materials and Measurements (Belgium) and its authorised distributors .Serial quantification of  BCR–ABL1 fusion gene is the primary pathogenic driver of chronic myeloid leukaemia (CML) and also characterizes a subset of patients with acute lymphoblastic leukaemia. As well as being of diagnostic importance, BCR–ABL1 also serves as a specific marker of the malignant clone, and many laboratories worldwide routinely use serial reverse-transcription quantitative PCR (RT-qPCR) analysis to monitor the response of, individual CML or acute lymphoblastic leukaemia, patients to treatment.3 Indeed, international recommendations for the management of CML include key time-dependent therapeutic milestones based in part on such molecular monitoring.4The BCR–ABL1 transcripts as a measure of the burden of leukaemia and also the number of transcripts of an internal reference or control gene (CG) as a measure of overall quantity and quality of cDNA. Results for specimens that test positive for BCR–ABL1 are expressed as the ratio of BCR–ABL1/CG transcript numbers in the same volume of cDNA, subject to previously described performance criteria.6 For samples that test negative for BCR–ABL1, the number of CG transcripts gives an indication of the sensitivity with which residual disease can be excluded for that particular specimen.1 However, despite the established clinical utility of RT-qPCR for monitoring of CML patients, the comparability of results between testing laboratories may vary widely.7 A major contributor to this variability is the use of different CGs to normalise results.For routine testing, two measurements are typically made for each sample under investigation: an estimate of the number of BCR–ABL1 was proposed,8 which is gradually being implemented by testing laboratories worldwide, most commonly by the derivation of laboratory-specific conversion factors (CFs) or the use of IS-calibrated kits or reagents.11 The IS expresses results as a percentage relative to the standardised baseline established in the International Randomized Study of Interferon and STI571 study; for example, major molecular response (MR), which corresponds to a 3-log reduction from the standardised baseline, is defined as 0.1% BCR–ABLIS.12 However, the IS was conceived at a time when most patients had RT-qPCR detectable disease and a major clinical consideration was whether a patient had or had not achieved major MR.13 Second-generation tyrosine kinase inhibitors result in faster and deeper responses compared with imatinib,15 and have prompted the need to define levels of deeper MR within the context of the IS. For example MR4, which corresponds to a 4-log reduction from the International Randomized Study of Interferon standardized baseline, has been defined as either (i) detectable disease ⩽0.01% BCR–ABLIS or (ii) undetectable disease in cDNA with ⩾10 000 ABL1 CG transcripts.16 Importantly, many patients treated with second-generation tyrosine kinase inhibitors (as well as an increasing proportion of patients treated long-term with imatinib)17 have undetectable BCR–ABL1 mRNA by RT-qPCR and thus, it has become increasingly important for testing laboratories to estimate comparable and reliable numbers of CG transcripts. Indeed, recent data from the German CML-Study IV have shown that achievement of confirmed MR4,5 at 4 years predicted significantly higher survival probabilities compared with cases who only achieved 0.1–1% BCR–ABLIS.17To help improve the comparability of results, an International Scale (IS) for BCR–ABL1 and CG transcripts are typically performed by using a plasmid calibrator, however different calibrators  are in use worldwide and until now no common reference material exists to which they could be aligned. The aim of this study was to develop an internationally accepted plasmid certified reference material (CRM) that includes BCR–ABL1 and the three most commonly used CGs  to help calibrate all measurements of residual disease in CML, and in particular, levels of deep MR.Determination of the number of 1E0.01 buffer containing 50 ng/μl Escherichia coli tRNA  to yield a range spanning 106–10 copies/μl. The plasmid solutions were sterilised by filtration with a 0.22-μm pore size hydrophilic polyethersulphone membrane  and dispensed into high recovery polypropylene vials. A total of 5000 vials containing approximately 600 μl of plasmid solution were produced for each dilution.Six plasmid solutions (ERM-AD623a-f), each with a different concentration level, were prepared starting from individual aliquots of the linearised stock pIRMM0099 plasmid . DilutioABL1 and one for BCR–ABL1 e14a2) were amplified in duplex reaction using the Europe Against Cancer primer/probe sets.18 Each sample was analysed on five panels of one digital array and the mean of these five results was considered as one measurement.Digital PCR was performed by three experienced laboratories: Institute for Reference Materials and Measurements, Geel, Belgium; LGC Limited, Molecular and Cell Biology Team, Teddington, UK and National Measurement Institute, Department of Innovation, Industry, Science and Research, Bioanalysis Group, West Lindfield, NSW, Australia. All three laboratories used the BioMark System  and the 12 756 digital array Integrated Fluidic Circuit, which comprises 765 individual partitions of approximately 6 nl volume each with total volume per panel of approximately 4.6 μl. Two PCR targets  measurements to assess the homogeneity and stability were performed by the Institute for Reference Materials and Measurements, Geel, Belgium, using the ABI 7900 HT instrument . The PCR conditions were the same as those used for the digital PCR measurements. For each concentration level, several vials were selected for the homogeneity and stability studies using a random stratified-sampling approach scheme for the whole batch. Each vial was measured three times in separate qPCR runs, and every measurement result was the mean result from three PCR wells (triplicate). A calibration curve with common plasmid solutions of pIRMM0099, produced independently from the stock solutions of ERM-AD623, was included in every qPCR run. This study design avoided 'between-run' effects by using a common calibrant for the calibration curves on each plate. The qPCR results of the uchar), potential between-unit heterogeneity (ubb) and potential degradation during long-term storage(ults). These different contributions were combined to estimate the expanded, relative uncertainty of the certified values  with coverage factor k:The certified copy number concentration of the six ERM-AD623 plasmid solutions was defined as the mean value of the accepted results from the digital PCR measurements. The combined expanded uncertainties associated with these copy number concentrations consist of uncertainties related to characterisation  are described in the certification report.19Based on the degrees of freedom of the different uncertainty contributions, a coverage factor uchar, was also calculated; no statistical difference between the results reported by the three laboratories was found  were determined by digital PCR measurements, carried out in three experienced laboratories. Eighteen vials of each concentration level were selected using a random stratified-sampling scheme. Each laboratory received six vials of each concentration level and was requested to provide six independent results, one per vial. The content of each vial was diluted gravimetrically and measured on different days and different arrays. For each concentration level, 18 independent results were obtained . Owing tas found .ubb,rel was calculated for each concentration level . In total, 171/174 (98.3%) calibration curves had a slope within the range of −3.1 to −3.6; BCR–ABL1 (n= 84), ABL1 (n=36), BCR (n=23) and GUSB (n=28). Three (1.7%) calibration curves had a gradient less than −3.60 (−3.61 (n=2), −3.62 (n=1)). All calibration curves had an r2 above 0.993.Two suitability studies were performed to test the performance of the plasmid solutions  were sent to 57 European laboratories. These laboratories used a variety of different assays , the median number of ABL1 copies per μl aRNA was 49 347 using the laboratory standard curve and 56 992 using ERM-AD623 as a standard curve.Estimates of ilutions  and 5. HBCR–ABL1 and CG measurement by RT-qPCR have been developed. Typically, these calibrators have independently assigned copy number concentrations based on their molecular weight and DNA concentration, but in the absence of an internationally accepted CRM it is inevitable that variation between calibrators has become established. Although the magnitude of this variation is not known, it is likely to adversely affect patient results since our study, as well as a previous study, both found that the use of a common plasmid calibrator substantially improves the comparability of test sample results between centres.22 Although it is likely that this variation may have been at least partly captured by laboratory-specific CFs, for samples with detectable disease, there is an increasing clinical need for laboratories to make comparable estimates of test sensitivity when BCR–ABL1 is undetectable. Thus, there is an increasing need for laboratories to be able to make comparable and reliable estimates of CG transcript numbers.Over the years, several different in-house and commercial plasmid calibrators for BCR–ABL1 e14a2 transcript, one DNA fragment specific for the GUSB transcript and one DNA fragment specific for the BCR transcript  of the plasmid solutions in different qPCR assays is within previously defined recommendations.23 In the small-scale suitability study, ERM-AD623 was used to calibrate qPCR measurements of two common cDNA samples. The BCR–ABL1/CG copy number ratios thus obtained were equivalent between the different qPCR assays used. However, when comparing the copy number concentration of BCR–ABL1, these results seem to confirm the previously reported variability between methods using TaqMan platforms versus methods using LightCycler platforms.22 This variation may be partly due to the lower input of cDNA in many LightCycler protocols and is likely captured by CFs for detectable disease for which a BCR–ABL1/CG ratio can be calculated. This difference might, however, may need to be taken into consideration in attempts to standardise measurement of undetectable disease. In the large-scale suitability study, we found that the use of ERM-AD623 improved the degree of agreement of results when BCR–ABL1 is detectable for both cell lines and aRNAs. However, there were still large differences in estimates of CG copy numbers for the aRNA samples, for which the initial number of RNA molecules was known. Overall, the median estimates of ABL1 and BCR–ABL1 aRNA numbers were five- to sixfold lower than expected . A similar proportion expresses the smaller e13a2  variant. About 10% of cases express both e14a2 and e13a2. The remaining 2% of cases are accounted for by multiple-atypical variants, the most common of which are e14a3, e13a3, e6a2, e19a2 and e1a2. Most (70%) cases of BCR–ABL1-positive acute lymphoblastic leukaemia cases express e1a2, with the remaining 30% split, expressing e14a2 and/or e13a2. As e14a2 and e13a2 only differ by 75bp, many laboratories use a common probe/primer set to amplify cDNA derived from both transcripts. However, it should be noted that ERM-AD623 is only certified for the measurement of e14a2 BCR–ABL1; for e13a2 the suitability of ERM-AD623 has to be verified at each laboratory by determining that e14a2 and e13a2 are amplified with equal efficiencies, which can be determined from the standard curve equations by looking specifically at the gradient and intercept components. Importantly, the certified copy number concentrations of ERM-AD623 refer to numbers of double-stranded plasmid molecules and thus should be doubled for use as a qPCR calibrator for single-stranded cDNA.Roughly 98% of CML patients express a p210 BCRBCR–ABL1 is not detected. Conversion to the IS requires established CFs processes9 or the use of secondary reference materials that are traceable to the World Health Organisation International Genetic Reference Panel for the Quantification of BCR–ABL translocation.10 The combination of CFs and a common plasmid calibrator should help testing laboratories to generate standardized results. However, some lack of agreement between results from different laboratories using diverse methodologies and CGs will remain. Whether this remaining disagreement is acceptable, depends on the effect it has on clinical interpretation. When evaluating the performance characteristics of a method, two factors should be considered: trueness  and the precision (that is the degree to which repeated measurements under unchanged conditions show the same results). The trueness of a method can be estimated by comparing the average value obtained from several replicate measurements on a reference material with an established IS value. The precision of a method can be estimated from the 95% limit of agreement of all the individual measurement results obtained for the reference material.24 Existing experience with the set-up and validation of laboratory-specific CFs has shown that an average difference within ±1.2-fold of the established value and 95% limits of agreement within ±5-fold of the established value were achieved by the best performing methods.9 This led to an major MR concordance rate of 91%, a level of agreement which probably represents the maximum that can be achieved using the current RT-qPCR technology.It is important to note that the use of ERM-AD623 does not by itself produce results on the IS; instead it helps to improve the accuracy of results prior to conversion as well as the accuracy of CG copy-number estimates for samples where BCR–ABL1 e14a2, and each CG should be identical for each dilution as they are present in a 1/1 ratio. It should be noted that the certified values refer to the use of 5 μl of each dilution; users may wish to use smaller volumes but the uncertainty of the certified value in that case would need to be determined and would be expected to be greater than that stated. In particular, for the lowest level dilution (CRM code ERM-AD623f) Poisson distribution effects would have to be taken into consideration. The plasmid dilutions can be obtained from the Institute for Reference Materials and Measurements or its authorised distributors Although ERM-AD623 can be used by testing laboratories on a day-to-day basis, it may be used to align local plasmid calibrators, if that is preferred. It can also be used for assay optimisation, for example the cycle threshold or crossing point values for


She was looking for a way to serve older adults with depression, including those served by the agency’s home and community-based services (HCBS) program. Depression in this population is high, when we analyzed data from 16,032 elders receiving HCBS in Washington State in 2005, two-thirds met criteria for clinical depression  reduced depression and improved quality of life in two randomized controlled trials , 3. SincRecruitment is an ongoing implementation challenge for PEARLS. Previous data suggest that 10% of eligible participants are referred to PEARLS and 50% of those are enrolled in the program , 9. BarrIn addition to provider engagement, it is essential to use culturally appropriate materials and media for the target community. Strategies include putting photos of PEARLS counselors on recruitment flyers and publishing participant stories in newsletters, community papers, or in digital form , 13. ForSince the original PEARLS study, PEARLS continues to show positive results in older adults with major depression, with all-age adults, with veterans and vet’s spouses or widows, and with elders with low literacy and with limited English proficiency. PEARLS has been implemented with bicultural, bilingual counselors in Hispanic, Chinese, Vietnamese, Korean, and Filipino communities, and using trained medical interpreters with Somali and Russian-speaking elders. More recent studies demonstrate that the improvement in depressive symptoms extended for 18 months following baseline . We ofteDuring the initial PEARLS research study, master’s level social workers and nurses were trained to deliver the intervention. A geriatric psychiatrist provided clinical supervision. In practice, bachelor’s level case managers and social work interns have successfully implemented PEARLS. They may not only require more supervision up front (such as with administering the PHQ-9) but also come to PEARLS with less ingrained therapeutic modalities that may need to be put aside when delivering a structured, participant-driven protocol like PEARLS. A clinical psychologist or other clinician with experience in late-life depression and problem-solving treatment can provide clinical supervision, along with a medical provider who brings expertise on co-occurring chronic conditions and medication use. Community mental health agencies can offer PEARLS as part of their menu of options for persons with mental illness. PEARLS may also be a first step in a person’s depression treatment, using the PEARLS sessions to identify appropriate and accessible longer-term treatment options after the brief intervention ends.One of the reasons that evidence-based programs are adopted is because research shows them to be effective. Thus, there is a concern that fidelity to the research model be maintained when implementing the program. We developed a PEARLS fidelity instrument to assist in measuring fidelity and found that differences exist for clinical supervision, counselor assessment, client eligibility, and some content and format of PEARLS sessions . We do nWhether a person is appropriate for PEARLS is one of the most common questions we get on our technical assistance calls. In practice, organizations see complex clients who often do not have any other acceptable options for depression treatment. Expanding eligibility criteria may require adaptations; for example, focusing on increasing physical and social activities rather than problem-solving for participants with mild cognitive impairment or for those for whom a problem-solving approach is not a cultural norm. Some adaptations occur naturally as PEARLS spreads across the country in diverse settings and communities. Strategies for working with low-literacy participants include reading worksheets aloud and having the counselor or caregiver help fill out the worksheet, being mindful of what is written when others will read the worksheets.The Program to Encourage Active, Rewarding Lives is now active in 50 agencies across 18 states. Some agencies have only begun implementing the program in the past 6 months while others are over 10 years old. Sustainable funding for PEARLS remains a challenge yet successes such as the California “Millionaire’s Tax” supporting the Mental Health Services Act, prevention and early intervention (PEI) funding in Los Angeles, and a property tax levy and a Medicaid waiver in Washington State hold promise. The PEARLS training program continues to support new and existing program needs including an online component and site-based trainings. Former PEARLS program participants are being engaged to spread the word about PEARLS in their communities.There are many opportunities for continuing to improve how PEARLS is delivered and spread across the country and beyond. While PEARLS programs continue to spread across the country, this dissemination pattern is more the result of passive diffusion and a by-product of the ongoing training program and PEARLS inclusion in several evidence-based practice registries. We need future research of more active dissemination approaches (such as policy-level interventions) coupled with ongoing dissemination and implementation research for overcoming challenges. An economic evaluation of the program through formal cost effectiveness or return on investment (ROI) analyses might facilitate broader dissemination activities. Future directions for PEARLS also include building capacity through expanding online and regional training options. With continued interest in fidelity assessment, a larger validation study of the PEARLS fidelity instrument is needed to establish the validity of the items as well as the innovative methodological approach of having a self-reported fidelity assessment. Exploring the relationship of fidelity to client outcomes could then follow and allow for refinement of the instrument and better elucidation of the key components of PEARLS to guide program adaptation to best fit local implementation needs. Addressing these needs will help PEARLS achieve its full potential in improving the lives of older adults.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.This paper is included in the Research Topic, “Evidence-Based Programming for Older Adults.” This Research Topic received partial funding from multiple government and private organizations/agencies; however, the views, findings, and conclusions in these articles are those of the authors and do not necessarily represent the official position of these organizations/agencies. All papers published in the Research Topic received peer review from members of the Frontiers in Public Health  panel of Review Editors. Because this Research Topic represents work closely associated with a nationwide evidence-based movement in the US, many of the authors and/or Review Editors may have worked together previously in some fashion. Review Editors were purposively selected based on their expertise with evaluation and/or evidence-based programming for older adults. Review Editors were independent of named authors on any given article published in this volume.