Drosophila larval wing imaginal discs after damage by ionizing radiation. We detected faithful regeneration that restored a wing disc and abnormal regeneration that produced an extra wing disc. We describe a sequence of changes in cell number, location and fate that occur to produce an ectopic disc. We identified a group of cells that not only participate in ectopic disc formation but also recruit others to do so. STAT92E (Drosophila STAT3/5) and Nurf-38, which encodes a member of the Nucleosome Remodeling Factor complex, oppose each other in these cells to modulate the frequency of ectopic disc growth. The picture that emerges is one in which activities like STAT increase after radiation damage and fulfill essential roles in rebuilding the tissue. But such activities must be kept in check so that one and only one wing disc is regenerated.We report here a study of regeneration in  Drosophila melanogaster larvae that have been damaged by high energy radiation show that regeneration occurs to restore the original structure. We report here that, in the same experimental system, abnormal regeneration can also occur to produce extra wing structures. We describe a series of cell rearrangements and fate changes that underlie abnormal regeneration, and identify genes responsible for these events. Modulation of such genes have the potential to mitigate abnormal regeneration that occurs after radiation damage to produce such side effects as ulcers and fibrosis.Accuracy in regeneration ensures that the original structures are restored, no more and no less. Prior studies in the wing primordia of  Ionizing radiation (IR) is one of three main modalities in the treatment of cancer, the others being surgery and chemotherapy. Therapeutic effect of IR relies on its ability to kill cells. But what remains could regenerate a tumor, leading to treatment failure. In parallel, incorrect healing of normal tissues after collateral damage by radiation therapy contributes to side effects such as fibrosis and ulcers . UndDrosophila melanogaster larvae are precursors of adult organs. Because of their high regenerative ability, imaginal discs have been used in studies of tissue regeneration. In classical and recent studies, imaginal discs were surgically fragmented and cultured in adult or larval hosts . Fai. FaiDrosts  and STAT92E as key players in regeneration in both surgically and genetically ablated discs . . eiger, ablation .We have been studying regeneration of imaginal discs after damage by ionizing radiation (IR). Unlike surgical or genetic ablation, IR induces apoptosis that is scattered throughout the disc. Larvae in which about half of the cells in each imaginal discs have been killed by IR  regenerate to produce a viable fertile adult fly , 13. WhiHere, we report that regeneration after IR damage can occur faithfully to restore the wing disc or produce abnormal structures, just like abnormal regeneration after surgical ablation produces duplications, transdeterminations and multiplications. We studied regeneration of irradiated larval wing discs in a time course using a lineage tracing system, and identified a sequence of cellular events that produced a second, ectopic wing disc. We used tissue-specific expression of RNAi to identify cell-autonomous roles for epigenetic regulators, STAT, and Wg in this process. We found that faithful regeneration (to restore the primary wing disc) and abnormal regeneration (to produce an ectopic wing disc) have common as well as distinct genetic requirements. All genetic components we identified are conserved in mammals, making it possible to test their roles in normal and abnormal regeneration after radiation damage in those systems in future studies.ts, to direct gene expression to the hinge, which is the site of IR-resistant cells that participate in regeneration [ts , almost all in the anterior (A) half of the notum. Class I discs showed more RFP+ cells that have spread into the posterior (P) half of the notum (arrows). Class II discs showed a cluster of RFP+ cells near the dorsal-posterior edge of the notum (arrowhead) in addition to scattered RFP+ cells in the notum (arrow). Class III discs showed RFP+ cells in a ring that is often incomplete (arrowhead), also near the dorsal posterior edge of the notum, that still shares a continuous boundary with the rest of the disc (the disc boundary traced with a yellow line appears continuous). Class IV discs showed similar rings of RFP+ cells (arrowhead) that have grown into a structure no longer confined within the notum (the disc boundary traced with a yellow line is dis-continuous). Quantitative analysis showed that all un-irradiated discs were class 0 or I; classes II-IV are strictly IR-dependent , the discs were predominantly class 0 , IR+ 0h.w1118 discs lacked RFP and could not be classified as in w1118 discs means that ectopic growths are not due to 30A-GAL4>G-trace transgenes.The frequency of class III and IV discs at 72 h after irradiation in 30A-GAL4>G-trace discs was 20.9% . w1118 d+ cell clusters in class II discs  notum cells.IR-induced ectopic growths lacked Ubx and were therefore not haltere discs . In contrast, RFP+ cells in the notum in 30A>Rux discs numbered only 57±16 at IR+24 h . We also saw no signs of hypertrophy in irradiated hinges of class III/IV discs  or both. Consistent, we found that depletion of epigenetic regulators of transcription altered the frequency of ectopic wings (Nucleosome Remodeling Factor (NURF) complex. These regulators were chosen because prior studies showed them to have a role in the apoptosis of larval salivary gland [The generation of ectopic wing discs thus described involves changes in cell fate, gene expression status . This rrd instar wing disc where gray Zfh2 signal encompasses and extends beyond the red 30A>RFP domain . Where on e.g. –36). In . In Dros+ cell clump. This, we believe is the critical step that is governed by STAT, Wg, Set2, Egg and Nurf-38 (model in + cells can lose their hinge fate (become RFP-GFP+) and recruit un-related cells (RFP-GFP-) to form an ectopic wing disc . While we cannot rule out translocation of hinge cells into the notum in the formation of ectopic discs, our findings do not favor this possibility as described above . Insteadmodel in . Once foing disc . Moreoveing disc , cell auAre ectopic discs duplications or transdeterminations? Because we see two wing discs instead of one, we may classify ectopic discs as duplications. On the other hand, if duplication means copying of existing structures, ectopic discs are not exactly duplications; ectopic pouch, for example, is not derived from the primary pouch. Likewise, notum to hinge/pouch fate change we see may be classified as transdetermination. On the other hand, if transdetermination is defined as when one disc takes on the fate of another (e.g. leg->wing), ectopic discs that remain as wing disc do not fit this definition. Therefore, we will refer to what we see simply as ‘ectopic discs’, to avoid confusion.w1118) seems high but is in fact lower than the frequency of abnormal regenerations recorded in classical studies of surgically ablated discs. Schubiger saw, for example, that among lateral (posterior) leg fragments cultured in the adult abdomen, 33/41 (80%) regenerated discs with duplications [The frequency of ectopic wing discs after irradiation  [All ectopic wing discs we saw grew out of the dorsal posterior notum. Their location and appearance resemble ‘supernumerary wings discs’ that result from ectopic expression of Wg , 40 or SFR (DER) . In the FR (DER) . In our NURF is known to oppose JAK/STAT signaling in the innate immune response in Drosophila, specifically in the larval hemocytes and the fat body . In thosDrosophila adult abdomen occurs partly through polyploidization and cell fusion [+) and recruits from outside , Ptub-GAL80ts on Ch III, 10XSTAT-GFP , UAS-Ax92E06346 , 26. Allts/GAL80ts virgin females were crossed to w1118 males (GAL4 only controls) or UAS-dsRNA males. STAT RNAi virgin females were crossed to 30A-GAL4>UAS-RFP, G-trace/CyO-GFP; GAL80ts/GAL80ts males. Progeny bearing G-trace (RFP+GFP+ larvae) were sorted for use.30A-GAL4>UAS-RFP, G-trace/CyO-GFP; GAL80Larvae were raised on Nutri-Fly Bloomington Formula food (Genesee Scientific) at 25°C unless otherwise noted. The cultures were monitored daily for signs of crowding, typically seen as ‘dimples’ in the food surface as larvae try to increase the surface area for access to air. Cultures were split at the first sign of crowding.Larvae in food were irradiated in a Faxitron Cabinet X-ray System Model RX-650  at 115 kv and 5.33 rad/sec.Drosophila Hybridoma Bank Cat#4D4), Ubx , and Zfh2 , Wingless . SecondWith the exceptions noted below, the discs were imaged on a Perkin Elmers spinning disc confocal attached to a Nikon inverted microscope, using a SDC Andor iXon Ultra (DU-897) EM CCD camera. The NIS- Elements acquisition software’s large image stitching tool was used for the image capture. 20–21 z-sections 1 um apart were collected per disc and collapsed using ‘maximum projection’ in Image J. The exceptions are + area, and STAT-GFP were analyzed using a 2-tailed t-test. For sample size justifications, we used a simplified resource equation from [The distribution of disc classes was analyzed using the Chi-square test, using the numbers for GAL4 only control +IR to generate the expected ratios of classes. Cell number in the notum, RFPion from ; E = TotS1 FigRelated to  Larvae were treated as shown in ts/+ (A-C) and 30A-GAL4>UAS-RFP, G-trace/UAS-Rux; GAL80ts/+ (D-F). Disc margins were traced from DNA images. Boxed sections in C and F are magnified 3X, black/white inverted for ease of viewing, and shown in C’ and F’ respectively. All images are Dorsal up and Posterior to the right of the viewer. Scale bar = 120 μm in A-F and 40 μm in C’ and F’.(PDF)Click here for additional data file.S2 FigRelated to  (A-B) Larvae were treated as shown in ts/+ in (A) and UAS-STAT RNAi/+; 30A-GAL4>UAS-RFP, G-trace/+; GAL80ts/+ in (B). (C) Larvae were treated as in ts/ UAS-Axin. Scale bar = 50 μm.(PDF)Click here for additional data file.S3 FigRelated to  (A-B) Wing discs from–IR (A) and +IR (B) larvae are shown to illustrate how translocation of hinge cells into the pouch (arrow) was quantified. The area of GFP+RFP- cells within the circle was quantified in Image J and divided by the area of RFP+GFP+ cells in the hinge. (C) A wing disc showing STAT-GFP reporter expression. Average fluorescence in the circle was quantified in Image J from the notum (1), the hinge (2), and the pouch (3). Background fluorescence was quantified from three locations (4–6), averaged and subtracted from (1–3).(PDF)Click here for additional data file.S1 TableRelated to Figs  The frequency of disc classes observed after genotype/treatment (Column 1) was tested for significant differences from the expected (Column 2) using a Chi-square test. For values in column 3, five disc classes were taken separately. For values in column 4, the discs were binned into either IR-induced (class II-IV) or others (classes 0/I). p values that correspond to each chi-square value are provided as: ns = not significant, *p<0.05, **p<0.01, ***p<0.001. Considering the five classes separately, we believe, can provide false positives because the differences in the frequencies of non-IR-dependent classes, 0 or I, could contribute to the chi square value. Therefore, more conservative values in column 4 (bold) were used in the main text.(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.


Several different applications of telehealth technologies have been used in the care of respiratory patients, including telemonitoring, teleconsultations, tele-education, and telehealth-pulmonary rehabilitation (PR). Telehealth technology provides an opportunity to assist in the management of chronic respiratory diseases and improve access to PR programs. While there is inconclusive evidence as to the effectiveness of telemonitoring to reduce healthcare utilization and detection of exacerbations, teleconsultations have been shown to be an effective means to assess patients’ disease prior to the initiation of PR, and telehealth PR has been shown to be as effective as institution-based PR at improving functional exercise capacity and health-related quality of life. To improve PR access across Canada and ensure a high standard of program quality, a team of clinicians and researchers has developed and begun to implement a national standardized PR program that can be delivered across different settings of practice, including remote satellite sites via telehealth PR. The program has adapted the “Living Well with COPD” self-management program and includes standardized reference guides and resources for patients and practitioners. A progressive and iterative process will evaluate the success of program implementation and outcomes. This initiative will address nationwide accessibility challenges and provide PR content as well as evaluations that are in accordance with clinical standards and established self-management practices. In Canada, it is estimated that the national capacity of PR programs is 10,280 people per year, which translates into only 0.4% of the estimated population of patients with COPD having access to PR.16 A systematic review12 of the national program capacity across four countries—the United Kingdom, Canada, New Zealand, and Sweden—reported that ≤1.2% of the estimated population of COPD has access to PR. Given the clear benefits of PR and the increasing impact of COPD on morbidity and mortality,18 strategies to improve the access and capacity of PR are needed.Current guidelines recommend PR for all patients with COPD who experience ongoing symptoms despite optimal pharmacologic therapy, and PR is increasingly recommended for a wide range of non-COPD chronic respiratory conditions.16 people living in rural and remote centers have limited access to PR. This is a particularly pressing issue in countries such as Canada where there is a large geographical area with low population density and few health centers in rural areas. Several advances in the delivery of PR have been implemented to improve access to such programs, including PR delivered with telehealth technology. Telehealth technologies allow for distribution of healthcare services and exchange of information between a healthcare provider and a patient in different geographical locations and provide an important avenue to reach people who live in rural communities.19 Several different applications of telehealth technology have been used to provide health services to people with chronic respiratory diseases; such applications include telemonitoring, teleconsultation, tele-education, and telehealth PR. Each application has its own unique purpose, procedure, benefits, challenges, and evidence of effectiveness. This article reviews the application of telehealth technology to deliver healthcare services to chronic respiratory patients and describes how a team of clinician-researchers propose to address accessibility challenges through telehealth technology, while ensuring program quality and evaluating the effectiveness of a new PR program.As PR programs tend to be located in urban areas,21 Information is then monitored and evaluated by the HCP and patients are informed if there is evidence to suggest worsening of their condition. It has been proposed that telemonitoring may be particularly useful in the management of COPD as it may allow for early detection of exacerbations and subsequently a decrease in healthcare utilization.22 Both COPD patients and HCP tend to have positive experiences with telemonitoring. Patients report feeling satisfied with the process24 and the ease of equipment use;26 they also report feeling empowered to be intimately involved in the self-management of their disease.27 While some studies have reported that telemonitoring lead to positive outcomes, including reduced exacerbations28 and hospitalizations,2931 the effectiveness of telemonitoring is not universally established.33 Rather than supporting self-management of one’s disease, telemonitoring may foster dependence on HCP to interpret symptoms and manage one’s disease.33 Future studies that are well designed, with long-term follow-up and large sample sizes, are needed to determine the effectiveness of telemonitoring on health outcomes in chronic respiratory patients.33Telemonitoring utilizes equipment, sensors, and surveys within patient’s homes, which are subsequently transmitted in real time or in a retrospective manner to a healthcare professional (HCP) or team at a central location.34 reliable,34 and dramatically reduce the amount of travel by patients.19 Teleconsultations are a promising means to connect rural patients with respiratory specialists and provide an exciting opportunity to improve access to consultation services.Teleconsultation is used to assess patients’ clinical status and requires videoconferencing software to connect physicians with COPD patients at satellite sites in real time. Teleconsultations often precede telehealth PR to assess patients’ suitability and safety for PR. HCPs at satellite sites may assist with the communication and transmission of clinical information, including chest auscultations, vital signs, pulse oximetry, and tests of functional capabilities. Teleconsultations have been found to be feasible,35 in 75 COPD patients indicated that 77% of respondents wanted to received health and disease-management information using either web or phone-based applications, with 51% preferring to access information with a computer. Given the interest among patients to access information about disease management, it is important that qualified clinicians and researchers develop accurate, useful, and user-friendly resources for patients to access. Currently, there are numerous online education platforms for patients with COPD, including those developed by professional associations, as well as those developed public–private partnerships, such as Living Well with COPD .Tele-education utilizes web-based platforms to deliver information and services that pertain to the management of patients’ condition. Such platforms can be designed for HCPs to enhance knowledge of disease management program components as well as facilitate the delivery of an intervention to patients. Tele-education platforms can also be designed for patients to facilitate disease self-management knowledge and support the uptake of self-management interventions. There is a growing interest among COPD patients to use web-based and alternative technologies to receive disease-management information. A survey conducted by Rogers et al.34 compared PR delivered via telehealth to 147 COPD patients with PR delivered in person at a healthcare institution to 262 COPD patients. Teleconsultation was used in the initial patient assessment process, with an HCP at the satellite site performing and communicating chest auscultations, vital signs, pulse oximetry, and tests of functional capabilities to the physician at the host institution via videoconferencing software. The telehealth sites joined the education sessions at the host institution remotely via videoconferencing software and patients received supervised exercising training at a local institution. Both groups demonstrated similar attendance, improvements in exercise capacity, and health-related quality of life (HRQOL). This center-based telehealth PR study provides a useful model to develop future telehealth PR initiatives and may be an important step toward addressing PR accessibility challenges.Telehealth PR is a type of telehealth intervention that involves the delivery of PR content through various communication modalities , which connects patients to HCPs. Telehealth PR sessions may be delivered within a healthcare institution, or to within the patients’ homes. Telemonitoring may be used in conjunction with telehealth PR; however, the impact of monitoring physiological variables on PR outcomes and patient self-management is unclear. Stickland et al.26 examined the effectiveness of a home-based PR program in patients with moderate COPD. Readily available telehealth equipment was installed in patients’ homes to allow for videoconferencing, along with an exercise bicycle and pulse oximeter. During the in-home exercise sessions, patients monitored their symptoms and a HCP monitored the patient, their heart rate and SpO2 via videoconferencing. All participants who completed the 8-week program had clinically significant improvements in exercise capacity and the dyspnea subscale of the Chronic Respiratory Questionnaire. Tsai et al.36 conducted a randomized controlled trial of 37 COPD patients that compared an in-home telehealth PR program to a no PR control group. This intervention included telemonitoring, telehealth PR, and telehealth consultations. The telehealth PR program included in-home virtual supervision of walking, cycling on an exercise bike, and strength training. The telehealth PR group had improved exercise capacity, self-efficacy, and mood at the end of the intervention, as compared to the non-PR control group. However, clinically and statistically significant improvements in HRQOL were not observed, which may indicate that some aspect of the intervention environment does not mimic that of traditional institution-based PR. While not PR, Nield and Hoo37 conducted a randomized controlled trial to determine the effectiveness of a pursed-lip breathing intervention delivered via Skype™ software. The 4-week intervention included feedback on the technique as well as instruction on the application of pursed-lip breathing to activities of daily living, such as walking. The intervention group had a decrease in dyspnea intensity and increase in social support; however, no differences in functional exercise capacity, dyspnea severity, or dyspnea distress were observed between the experimental and control groups.There have been several other creative initiatives designed to improve access to PR services, including the delivery of telehealth home-based interventions. Holland et al.These telehealth intervention and PR studies illustrate the potential of institution-based and in-home virtual telehealth programs to effectively delivery PR to the large number of rural and remote patients who are unable to access a specialized PR institution. There is also the potential of delivering institution-based telehealth PR to other urban health centers, such as primary care medical centers. This approach could expand the delivery of PR services within urban communities and reduce the need for specialized institutions. Further, it would ensure that community-based programs are supporting the delivery of evidence-based, disease-specific information and practices. Clearly, telehealth PR has the potential to be an important vehicle to increase the accessibility of PR services to both rural and urban patients. However, well-designed studies with careful consideration of intervention content are needed to progress our understanding of the delivery and effectiveness of such programs.7 This definition places an emphasis on the importance of behavior change in the long-term management of chronic respiratory diseases. However, the improvements charted throughout PR typically diminish as soon as 6 months after completion,39 and PR maintenance programs have been unsuccessful in sustaining improvements.4042 Furthermore, the impact of PR on health behaviors such as physical activity, breathing management, medication adherence, exacerbation self-management as well as on the motivational predispositions that might drive behavior change remains unclear, despite the latter being considered a key deliverable.The quality of PR content and delivery is fundamental to successfully improve health and behavioral outcomes. The most recent definition of PR put forward by the American Thoracic Society/European Respiratory Society (ATS/ERS) specifies that PR comprises patient tailored therapies “…that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors.”44 The purpose of self-management education within PR is to guide patients through the acquisition and implementation of skills that will help them perform the health behaviors required for them to independently manage their disease. These skills often include goal setting, problem-solving, and identifying and acting on collaboratively determined action plans.7 LWWCOPD is an evidenced-based program designed to improve patient disease self-management. The program focuses on improving pre-disposing factors  and enabling factors  of behavior change. The LWWCOPD program has been shown to reduce exacerbations, hospitalizations, and emergency department visits, as well as improve HRQOL in patients with COPD.4547There is evidence to suggest that self-management training in conjunction with PR translates into positive outcomes, including improved quality of life, dyspnea, and healthcare utilization.16 within Canada and to ensure that evidenced-based self-management education is being provided to all patients receiving PR services, a group of clinicians and researchers have come together to develop a standardized PR program that can be used within different settings of practice, including traditional PR centers, primary care medical centers, and satellite sites (i.e. sites that are remote from major institutions) with the use of telehealth and web-based resources. The goal of the initiative is (1) to improve ease of access/clinical implementation of PR, (2) to ensure PR program quality, and (3) to ensure that standard PR program content is in accordance with clinical standards and established self-management practices. The program includes web-based comprehensive resources for patients and HCPs, with reference guides on approaches for (1) pre-program evaluation/physician consultation, (2) exercise training, (3) interactive, patient-centered education to support disease self-management, (4) post-program evaluation, and (5) follow-up and maintenance. Importantly, the program has adapted LWWCOPD for the self-management education component of the PR program, which includes educational handouts based on adult education methods, as well as educational presentations that can be delivered to patient(s) in-person by an HCP or via videoconferencing software. The unique aspect of this program is that the evidenced-based self-management intervention material will be made accessible to support different mediums of delivery, including in-person and web-based platforms.To address PR capacity and accessibility challenges48 is guiding the development of the new standardized Canadian PR program. The purpose of the ORBIT model is to provide a structured framework for developing behavioral interventions that optimizes and integrates fundamental behavioral and social sciences research into practically relevant treatments to prevent/manage chronic diseases.48 The ORBIT model outlines a progressive and iterative process to evaluate the success at each phase based on pre-determined milestones. Achievement of a milestone represents forward movement and sub-optimal results represents a backward movement to further refine the behavioral treatment, which may include changes to the content or delivery of the program.The Obesity-Related Behavioral Intervention Trials (ORBIT) modelIn this initiative, HCPs have participated in all phases of the iterative development process. A variety of HCPs have created, reviewed, and provided feedback on the content and delivery of education material and the disposition of material on the program website. Self-management education, based on LWWCOPD material, is the cornerstone of the new standardized PR program. Often HCPs do not have training in behavior change and self-management techniques. The goal in this new PR initiative is to provide adequate resources for HCP to effectively deliver the PR intervention. Therefore, all HCP will receive training specific to the self-management tools used and have access to a researcher that specializes in health behavior change research. Further, to support the HCP in the content and delivery of the PR program, the following tools have been developed: standardized learning materials for patients, reference guides that describe how the intervention is to be delivered by the HCP, and reference guides that describe the process for evaluating health and clinical outcomes among patients. These materials will see that patients obtain consistent messaging, style, and methods of delivery should they receive the self-management education alone or attend in PR. A process evaluation of the adequacy of training and resources made available to ensure that HCPs are adequately supported in the delivery of the program.15 Formal surveys as well as informal interactions are being used to obtain feedback from HCP at each individual site, which will then be carefully considered before continuing with implementation at the next site. Each satellite site has a unique set of resources and staff, and the aim is to provide a program that is adaptable so that it can be implemented in all types of settings.HCPs will continue to play a vital role in the implementation of this initiative across the country. Consideration of the needs of HCPs and resources available at satellite sites is fundamental to successful implementation of PR programs. HCPs have indicated that resources , time demands, and lack of adequate skills and knowledge are barriers to the implementation and sustainability of telehealth PR programs.Currently, two pilot trials are being conducted to determine the effectiveness of the new standardized Canadian PR program before nation-wide implementation begins. The primary outcome of the pilot trials is objectively assessed physical activity, which will be assessed before, immediately after, and 6 months after PR. Secondary outcomes include behavioral indicators (i.e. medication adherence and adherence to exacerbation action plan), pre-disposing factors of behavior change , and clinical outcomes .7 To effectively tackle this issue, collaboration among researchers and HCPs will be paramount, along with the development and implementation of creative strategies to help connect patients to PR programs. The initiative presented represents a significant step-forward in the care of respiratory patients by attempting to address nationwide accessibility challenges and providing PR content and evaluations that are in accordance with clinical standards and established self-management practices.Given the demonstrated effectiveness of PR programs, improving access to PR is one of the most pressing issues within the respiratory community.


The Institute of Medicine recommended the advance of innovation and entrepreneurship training programs within the Clinical & Translational Science Award (CTSA) program; however, there remains a gap in adoption by CTSA institutes. The University of Michigan’s Michigan Institute for Clinical & Health Research and Fast Forward Medical Innovation (FFMI) partnered to develop a pilot program designed to teach CTSA hubs how to implement innovation and entrepreneurship programs at their home institutions.fastPACE).The program provided a 2-day onsite training experience combined with observation of an ongoing course focused on providing biomedical innovation, commercialization and entrepreneurial training to a medical academician audience (FFMI fastPACE course or modified existing programs. Two reported greater collaboration with their technology transfer offices.All 9 participating CTSA institutes reported a greater connection to biomedical research commercialization resources. Six launched their own version of the FFMI fastPACE course and training program may be suitable for CTSA hubs looking to enhance innovation and entrepreneurship within their institutions and across their innovation ecosystems.The FFMI  The Clinical & Translational Science Award (CTSA) program was established by the National Institutes of Health (NIH) in 2006 to realize a new vision for translational and clinical science . The UniAcademic researchers engaged with the CTSAs have ideas at all stages of development, many of which hold the key to critical breakthroughs in the prevention, diagnosis, and treatment of disease in the form of novel therapeutics, devices, diagnostics, and software/mobile app solutions. However, there is a long, resource intensive route to a viable commercial pathway that leads to a product. Compounding that challenge, the commercialization of research discoveries is often a secondary pursuit for academicians who are time-constrained with clinical care, education, and research responsibilities. In addition, they have competing priorities such as a tenure and promotion goals that often emphasize traditional academic behaviors over other activities.The NIH has since partnered with The National Science Foundation (NSF) to develop an I-Corps™ program specifically focused on biomedical innovation, leveraging the model of the long-standing and successful program originally designed to improve the impact of recipients of NSF Small Business Innovation Research or Small Business Technology Transfer grants . HoweverInnovation Navigator to provide translational funding and mentorship tailored to academic researchers and clinician-scientists, (2) Business Development to connect academic researchers with industry partners, and (3) Innovation, Commercialization, and Entrepreneurship Education with programs tailored to the busy medical academician , house officer, graduate student, postdoctoral student, and medical student [fastPACE  course, a 4-week experiential learning course customized for the busy medical academician and focused specifically on teaching the foundational concepts for biomedical technology commercialization  [fastPACE course was co-developed with the U-M College of Engineering’s Center for Entrepreneurship, a long-standing NSF I-Corp™ node, to incorporate the core principles and successfully complement the NSF I-Corps™ program [In 2012, the U-M Medical School launched a research strategic plan and included development of an innovation and entrepreneurship program: Fast Forward Medical Innovation (FFMI) . FFMI’s  student . In resp Course) . The fas program .fastPACE course specifically targets early stage projects and academicians exploring an exit agnostic route to commercialization in an accelerated timeframe (4 wk). The course does not have eligibility mandates nor team formation requirements and supports enrolled academicians without a strong network of entrepreneurial contacts by connecting them with trained postdocs, medical students, and graduate students interested in a career in biomedical commercialization; as a result, potential barriers keeping the single academician from participating are eliminated. fastPACE to serve as a precursor program to NSF/NIH I-Corps™. Indeed, this potential has been demonstrated by the successful matriculation of three project teams from fastPACE cohorts 1–3 into the NSF I-Corps™ program.The fastPACE course extends to the cultivation of an innovation ecosystem that can support the successful execution of such a customized biomedical innovation education program. Key partners for fastPACE implementation include the U-M Office of Technology Transfer, core units supporting the research enterprise , diverse schools and colleges , and regional economic development agencies. Members from each group promote and advocate for the course, assist in the recruitment of project teams, and serve as course instructors. The course also serves as a means for recognizing potential gaps in the innovation ecosystem and as a foundation on which to build impactful, collaborative programming to enhance the mission of a CTSA.Since fall of 2014, the course has successfully completed 6 cohorts, graduated over 250 clinicians, researchers, and students from across the country, and helped 125 project teams navigate the early stages of commercialization by receiving more than $8 million in downstream funding and development partnerships. Outcome metrics from cohorts 1–3 have demonstrated initial success, as 3 project teams have formed startups since completing the course and one has licensed the technology to an existing company. As project teams from cohorts 4–6 (completed as recently as 2017) continue to mature, it is likely that a comparable or greater number of projects will achieve similar outcomes. Importantly, in addition to outcome metrics, the value of the fastPACE course has had on the acceleration of biomedical research commercialization, as well as its complementarity to NSF/NIH I-Corps™, FFMI and MICHR partnered to execute on the National Center for Advancing Translational Science and CTSA vision to disseminate resources and methodologies that foster innovation in translational science across the CTSA network. In March 2017, FFMI and MICHR launched a pilot fastPACE Train-the-Trainer (TtT) program designed to teach CTSA leads and other institutional collaborators how to implement the fastPACE course at their home institutions. The program attracted participation from nine CTSA institutions and 16 representatives, providing each with the training, materials, and support to launch their own fastPACE program within 6–12 months. Critical success factors, such as key partners and collaboration strategies, were introduced and workshopped to ensure broad campus-wide support and the culture change required for the success of fastPACE. To highlight the approach for disseminating biomedical commercialization education throughout the CTSA network, we fully describe the design, implementation, and outcomes from the pilot fastPACE TtT program.In recognition of the impact that the fastPACE course is tailored to the specific needs and constraints of busy academic researchers and clinicians exploring the commercial potential of biomedical and life science research projects. The course helps learners of all levels develop a basic vocabulary for commercialization and entrepreneurship, and enhances their understanding of key concepts most critical for the commercialization of life science technologies. The desired outcome is to de-risk current and future technologies by preparing academicians for successful commercialization through university exits of all types including entrepreneurship in the form of starting a new company, a license to an existing company or a research agreement with an industry partner.The fastPACE course.Over 4 weeks, the course covers innovation and entrepreneurship concepts while addressing unique biomedical commercialization risks, such as Food and Drug Administration (FDA) regulations, reimbursement strategies, and intellectual property considerations. By using a track-specific structure, where project teams are streamed into 1 of 3 product verticals , each track receives customized education for its unique vertical. For example, the FDA regulatory considerations for a healthcare software/mobile app solution versus a new drug therapy have very different levels of risk, timelines for approvals, and required resources. fastPACE TtT program provided a 2-day onsite training experience (at U-M) combined with observation of a fastPACE cohort that was launching simultaneously. The 2-day training was divided into 3 parts: (1) a fastPACE course training workshop, (2) a MICHR overview and discussion for future CTSA collaboration, and (3) observation of the fastPACE course Kickoff Event. Following the 2-day training, program participants observed the remaining weekly progression (4 wk) of the fastPACE course via weekly webinars. At the conclusion of the entire program (2-d training and observation), participants were expected to have a broader knowledge of biomedical commercialization education and resources, as well as the materials and strategies to implement the fastPACE course at their home institution. fastPACE TtT program.The fastPACE course training (day 1) workshop was intended to provide specific details on the design and implementation of the course at U-M. The 4-hour training session addressed key strategies for designing a biomedical commercialization education program at any institution, including collaboration between key campus partners , the value of expanded promotion and tenure guidelines to include innovation and entrepreneurship metrics, and the value in leveraging student groups across the university to support faculty researchers and clinicians.The Following an introduction by FFMI and MICHR leadership, participants discussed the unmet need for commercialization education at each institution. In a roundtable format, participants shared examples of existing innovation and entrepreneurship programs, as well as any gaps in programming on their campus. Remarkably, none of the existing programs described by the participating institutions specifically targeted biomedical researchers or clinicians, nor did they facilitate collaboration between faculty and students. Participants also shared challenges such as the difficulty of modifying existing programs to meet the specific needs of their CTSA, and navigating the institutional support required to start a new program. Presentations and facilitated discussion by FFMI staff addressed each of these concerns, as well as program planning strategies. For instance, strategies and processes were presented for selecting and targeting an audience of biomedical researchers, clinicians, graduate students, and medical students during a match-making and team formation process. Potential key partners and materials used for support were presented, including innovation and entrepreneurship centers from across the university, and community resource centers with access to local biomedical industry and venture experts. Specific preprogram and postprogram planning activities were also presented in the form of a timeline of key events and dates. Critical activities identified include the assembly of an expert teaching team, the request for applications and project team onboarding, and the program budget. Metrics for tracking success and opportunities for improvement were also discussed with the group. The session concluded with a panel discussion including FFMI, MICHR, and cross-campus collaborating units at U-M, including the Tech Transfer Office (both licensing and venture creation) and the Center for Entrepreneurship at the College of Engineering (NSF I-Corps™ node), to highlight strategies for successful teamwork and to summarize positive outcomes achieved.The 2-hour MICHR/CTSA collaboration session (morning of day 2) was designed to highlight the successful integration and collaboration between MICHR and FFMI, including a portfolio of programs as part of the optional CTSA renewal module for innovation (online Supplementary Appendix) submitted by MICHR in 2016. These included examples of projects utilizing FFMI innovation and entrepreneurship resources and/or MICHR programs as they leveraged various follow-on funding and additional programs to further expedite the translation of the project. Two specific FFMI initiatives presented were Business Development, a dedicated team that focuses on industry research engagement, and the Michigan Translational Research and Commercialization for Life Sciences program, a funding and mentorship program in partnership with the state’s Michigan Economic Development Corporation. Complementary MICHR programs presented included the Michigan Investigator Assistance Program, established to provide IND/IDE consultation and support, the Research Development Core, offering pre-award support and advice for research proposals, and the Pilot Grant program that supports innovative clinical and translational research. The session concluded with a roundtable discussion on best practices for sharing and disseminating materials, training, and additional resources throughout the CTSA network, as well as the discussion of formation of a special interest group focused on commercialization of life science technologies.fastPACE cohort starting at U-M. By planning the TtT concurrently with a fastPACE cohort, participants of the TtT program were able to see the composition of each participating team, the interaction with the assembled teaching team members, and the innovation, entrepreneurship, and biomedical commercialization topics taught throughout the course.The 2-day onsite training concluded (afternoon of day 2) with the opportunity to observe the course Kickoff Event for a As observing members of the course, TtT participants were provided with the same instructional materials, syllabus, presentation slide decks, notes, and handouts as participating project teams. Specific instruction observed during the course Kickoff Event provided exercises to teach the development and articulation of a value proposition, the mapping of an innovation’s ecosystem of critical stakeholders (to identify gaps in understanding), and the skills in behavior-based interviewing techniques (for eliminating any gaps identified), also known as customer development (discovery), a popular and successfully proven process used during the NSF/NIH I-Corps™ program for launching new ventures .fastPACE course weekly progression via webinar  were invited to attend an informational webinar detailing the program agenda 1 month prior to the start. Communications were also sent to individual CTSA working groups, including the Clinical Research Training for Investigators Workgroup that hosted a 15-minute informational presentation during a scheduled conference call. Additional recruitment efforts in the form of follow-up email communication and phone conversations were critical in assembling the final roster CTSA institutions and participants.fastPACE program at their home institution. In total, 9 CTSA institutions and 16 representatives participated in the program. Each individual institution determined what units, functions, and representative(s) should participate in the training program, considering who would be best equipped to implement the fastPACE course. There was no registration fee for the participating institutions; however, each institutional representative provided their own travel and accommodations estimated at $500 each.Total direct expenses for FFMI and MICHR to provide the TtT program were approximately $4800 (indirect or administrative/overhead expenses not included). Hosting for 16 institutional guests to attend the 2-day onsite training totaled $3400. Remaining expenses were $1400 for the design, printing, and distribution of all training materials including training binders, presentations, handouts, and other materials to allow institutional representatives to implement the FFMI fastPACE course, and interest in continued collaboration. The evaluation received a 31% response rate of the 16 participants (n=5). Following the onsite training, all 5 respondents strongly agreed or agreed that the program met their expectations, it was delivered appropriately across 2 days, and it successfully broadened their knowledge of biomedical commercialization resources and education. In addition, all 5 respondents strongly agreed or agreed that the program will directly impact their institution because they plan to implement all or part of the FFMI fastPACE course.An evaluation was administered via online survey tool  immediately following the initial 2-day onsite training to evaluate the program’s effectiveness across a variety of criteria, including broadening the participants’ knowledge base of biomedical commercialization resources and education, assessing potential impact on participating institutions by implementing all or part of the FFMI fastPACE course or to modify and bolster existing innovation and entrepreneurship programs at their institution. Two of the 9 institutions have recommended that project teams from their institution enroll in a fastPACE course cohort at U-M prior to receiving funding from their own translational science programs. As a near-term and temporary approach, this will allow teams to access fastPACE training while their home institution works toward potential implementation of its own program. Two participating representatives reported resulting collaboration between the technology transfer office and CTSA at their home institution. Perhaps most importantly, representatives from all attending institutions reported a greater connection to biomedical research commercialization resources and the desire to stay connected through a potential new CTSA-based consortium focused on biomedical research, innovation, and commercialization.Phone interviews were conducted with all TtT participants 3 months postprogram to capture preliminary outcomes, in the form of implementation activities and impact from attending and observing the entire 4-week program. Six of the 9 attending institutions, including University of Arkansas Medical Sciences, Ohio State University, Northwestern University, University of Kentucky, University of Washington, and Indiana University were using shared materials and online resources made available during the TtT program to launch their own version of the FFMI fastPACE TtT program successfully disseminated a valuable biomedical commercialization education program to the group of participating CTSA institutions. This result represents a proof of principle that CTSA institutes and institutional commercialization and entrepreneurship programs can partner, both internally and externally, to address the NAM’s recommendation to the CTSA program regarding enhancing its focus on innovation and entrepreneurship in education and training programs.Based on analysis of the evaluation data and preliminary outcomes, the fastPACE TtT program successfully addressed strategies for each participating institution to identify existing biomedical commercialization resources within its own ecosystem to enhance their impact through partnerships via collaborative programs such as fastPACE. As previously mentioned, none of the participating institutions knew of existing programs that addressed the unique and specific needs of biomedical faculty and academic researchers who are time-constrained and also require tailored education on specific concepts that are most relevant to the successful commercialization of their technologies. Interestingly, some of the participating institutions were in relatively close proximity to existing I-Corps™ programs, further underscoring the opportunity for fastPACE to complement I-Corps™ in preparing teams at an earlier stage than those that would typically enroll.In addition, the fastPACE at U-M has led to benefits that further address the NAM’s critique and uncovered new opportunities for partnering with our CTSA organization (MICHR), as well as many others. For example, FFMI and MICHR have partnered to create the nation’s first Continuing Medical Education accredited series of seminars for providers in an academic medical center that focuses on core topics related to commercialization, industry partnership, and entrepreneurship. Furthermore, FFMI and MICHR are working together to enhance workforce readiness with an internship program that places postdoctoral fellows and graduate students in industry settings. Students seeking a career in industry will participate in commercialization courses, including fastPACE, as a prerequisite to obtain foundational training and placement preparedness. In addition to fastPACE, FFMI has launched other commercialization education programs within the PACE portfolio with tailored formats for multiple audiences. The fullPACE program, a 12-week multidisciplinary team-based program for medical residents, fellows, graduate students, and postdocs has graduated 2 cohorts of ~35 participants since 2015. Beginning in the fall of 2017, the fullPACE program will be offered through the U-M Rackham Graduate School as a 3-credit hour course. The firstPACE series, a 3-part series on medical needs finding, design thinking for healthcare innovations, and value proposition analysis is delivered to medical students in a novel co-curricular program, known as the Path of Excellence in innovation, entrepreneurship, and commercialization, offered in collaboration with the U-M Medical School. Finally, fittedPACE offerings are customized learning opportunities for sponsoring departments within the U-M Medical School to help achieve specific strategic objectives related to innovation. As a customized program, fittedPACE has offered everything from a 9-month experiential program for an entire department of 90 faculty to short ideation sessions for an individual product vertical  that enhance learning and generate new ideas. It is clear that the potential value of a program such as fastPACE extends well beyond the parameters of a single course or framework and can have a far greater impact across the entire innovation ecosystem in which it is implemented.The success of fastPACE course and its TtT program may be suitable for a broad range of academic medical centers, including those with CTSA programs looking to enhance opportunities for innovation and entrepreneurship within their ecosystems.In conclusion, the partnership between FFMI and MICHR presents a novel model and opportunity to deliver on the overall CTSA mission to disseminate best practices and successful methodologies that accelerate the process of translating laboratory discoveries into clinical practice. Preliminary experience with the program suggests that the


While mobile health  programs are increasingly used to provide health information and deliver interventions, little is known regarding the relative reach and effectiveness of these programs across sociodemographic characteristics. We use data from a recent trial of a text-messaging intervention on adolescent sexual and reproductive health (SRH) to assess the degree to which mHealth programs reach target adolescent subpopulations who may be at higher risk of poor SRH outcomes.The study was conducted among girls aged 14–24 in 22 secondary schools in Accra, Ghana. The mHealth intervention was an interactive mobile phone quiz in which participants could win phone credit for texting correct answers to SRH questions. We use detailed data on individuals’ level of engagement with the program, SRH knowledge scores, and self-reported pregnancy collected as part of the original trial to assess the extent to which engagement and program impact vary across parental education, sexual experience, SRH knowledge deficit, and parental support.Eighty-one percent of participants engaged with the mHealth program, with no evidence that the program disproportionally reached better-off groups. The program was effective at increasing knowledge of SRH across all strata. Higher levels of engagement were associated with higher knowledge scores up to year later. There was no significant impact of the program on self-reported pregnancy within subgroups.mHealth programs for adolescents have the potential to engage and increase SRH knowledge of adolescent girls across sociodemographic strata, including those who may be at higher risk of poor SRH outcomes.NCT02031575. Registered 07 Jan 2014.ClinicalTrials.gov  With the rapid expansion of mobile phone ownership in low- and middle-income countries (LMICs) over the past decade, the field of mobile health  has emerged as a novel and potentially cost-effective way to increase access to health information and improve health knowledge as well as health outcomes –4.mHealth programs have been particularly popular in the area of adolescent sexual and reproductive health (SRH), where knowledge gaps remain large –11. A reA growing body of evidence highlights early sexual debut and one-parent households as key risk factors for adolescent pregnancy and childbearing, and knowledge about contraception as a key protective factor against these outcomes . StructuRecent evidence suggests that mHealth programs can increase average health knowledge and that these programs are generally well-received by youth –7. HowevIn this study, we analyse detailed data collected as part of a randomized trial of a text-messaging intervention conducted among secondary school students in Accra, Ghana. As part of the trial, adolescents were invited to participate in an interactive mobile phone program aimed to increase knowledge of SRH. We seek to answer the following research questions: (1) how effective was the program in engaging adolescents from key target populations including adolescents with low parental education, early sexual debut, low parental support, and low knowledge of SRH; (2) how did the impact of the program on SRH knowledge vary with level of engagement; and (3) how successful was the program at improving SRH knowledge and reducing incidence of pregnancy in key target populations?The study was conducted in the urban area of Accra, Ghana . In a suDespite enacting a National Adolescent Reproductive Health Policy in 1996, the SRH of Ghanaian adolescents remains a significant challenge. According to the 2014 Demographic and Health Survey, by age 19, 36% of women have given birth or are pregnant . Among aThough adolescents are generally aware of HIV and pregnancy risks, SRH knowledge tends to be limited and mostly superficial. Results of a 2004 national survey of Ghanaian adolescents found that while more than 95% of girls aged 15–19 knew of at least one method of modern contraception, only 67% were aware that a woman is more likely to get pregnant on certain days than others. Only 28% knew both previous items and were able to reject two common misconceptions (that a woman cannot get pregnant the first time she has sex or if she has sex standing up) . MoreoveWe used secondary data from a recent randomized trial that provided SRH information by text message  to adolescent girls in Ghana. The original trial, which is described in further detail in Rokicki et al. (2016), found relatively large and persistent increases in SRH knowledge among adolescents participating in the interactive mHealth program .n = 12), a simplified unidirectional messaging intervention (n = 12), and the control group (n = 14). After randomization, we found 3 schools to be ineligible and 1 refused to participate due to time constraints  as well as locally by the Ghana Health Service (GHS-ERC:05/09/13). The study design was registered on We visited schools at baseline, immediately after the intervention was completed (3-month follow-up), and 1 year later (15-month follow-up). At each visit, participants completed a self-administered questionnaire. Participants’ demographic information was completed at baseline. Reproductive health knowledge was assessed at each time-point. Information on sexual behavior and pregnancies was collected only at the 15-month follow-up.The mHealth platform was designed as an interactive mobile phone quiz game in which participants could win airtime  for texting correct answers to SRH questions. To design the message content, we first conducted focus groups with adolescents to understand their most prevalent SRH concerns, followed by a round table discussion with the Health Promotion Unit at Ghana Health Service who approved appropriateness of topics and finalized wording.For a period of 12 weeks, participants were sent one multiple-choice quiz question about SRH each week via text message to which they were invited to respond free of charge. These messages focused on pregnancy prevention and contained information on topics of reproductive anatomy, pregnancy, sexually transmitted infections (STIs), and contraception including male and female condoms, birth control pills, and emergency contraception. Upon responding, participants immediately received a confirmatory text message informing them whether they answered correctly, the correct answer, and additional information. Participants were sent up to 2 reminder messages if they did not respond; those who had not responded by the end of the week were sent a text message with the correct answer and the additional information at the end of the week. Participants in the same school were encouraged to discuss messages with each other. Participants were told that correct answers were rewarded: for every 2 correct responses, participants were sent 1 GHS (US$0.38) of airtime credit at the end of the week.Over the same 12-week intervention period, the control group participants were sent one message each week with information about malaria. The content of all messages is shown in Table 4 in To measure program engagement, we used two separate variables. First, we measured the total number of times the respondent replied to the weekly text-message quiz questions (maximum of 12), from data extracted from the mobile phone records. Second, we measured self-reported message exposure. At the 3-month follow up, respondents were asked “How often did you receive messages from [the program]” [More than once a week/ About once a week/ About once a month/ Less than once a month]. We created an indicator for having received messages at least once a week.To evaluate reproductive health knowledge, participants completed a true-or-false test consisting of 24 items  of the intervention group. We used quantile-quantile plots to assess normality of the residuals.Finally, we assessed variation in program impact across target subgroups. We used linear regression models stratified by subgroup to estimate the impact of the intervention on knowledge z-score. We then used models with an interaction term for intervention group and subgroup indicator to test equality of the coefficients. For these interaction tests, marginal effects were derived from the interaction model, and then compared using linear hypothesis tests.Due to the small cell sizes in subgroups, we used exact logistic regression models, again stratified by subgroup, to estimate the impact of the intervention on self-reported pregnancy in the past year.Missing values and item response refusals were included in the analyses as separate categories; results for these categories are shown in Tables 6 and 7 in Table Table Figure Figure Finally, Table The results presented in this paper suggest that mHealth programs are not only an effective tool to increase SRH knowledge overall in the studied setting, but that these programs can also engage and increase SRH knowledge of adolescents from key target populations who are at higher risk of poor SRH outcomes, including adolescents with low parental education, adolescents with low SRH knowledge, adolescents with early sexual debut, and adolescents with low parental support.We found that overall engagement in the program was high, and that participants in target groups were just as likely to interact with the program as their counterparts. In fact, participants whose parents had low levels of education had a higher rate of responding to messages than those whose parents had high levels of education.Program engagement also appears to be important for knowledge absorption. We found that those who interacted more with the program had significantly greater knowledge of reproductive health in both the short-term (immediately after the program ended) and in the longer-term (a year later), compared to those who did not interact. Those who did not reply to messages still received the reproductive health information at the end of each week; however, knowledge improvements were minimal at 3 months and not significantly different from the control at 15 months. We cannot interpret the differences causally, as there may be confounding factors such as motivation that affect both desire to interact with the program and knowledge. However, the findings point to the potential importance of including features such as interaction and feedback in the design of mHealth programs for adolescents .We also found that the mHealth program was effective at increasing SRH knowledge across levels of parental education, SRH knowledge, sexual experience, and parental support, in both the short-term and long-term, a surprising finding considering the number of potential cultural and technological barriers that participants in target groups may encounter.Finally, we found no significant impact of the mHealth program on self-reported pregnancy within subgroups. Although girls in the intervention group who were sexually active at baseline had fewer self-reported pregnancies than their counterparts in the control group, the difference was not significant and sample sizes were too small to draw strong conclusions. Providing information via mobile phone to the population that needs the information most – in this case, girls who are sexually active and who immediately benefit from information about contraception and pregnancy prevention – may be an effective way of reducing unintended pregnancy rates; however, the study analyzed here was not powered to directly address this question, and more research is needed to understand the effect of mHealth programs on unintended pregnancy in sexually active adolescent populations.This analysis has a number of limitations. First, there may be measurement error in some of the outcomes studied. Sexual activity and pregnancy were self-reported and thus may be subject to recall bias and social desirability bias. The bias may be differential by intervention group if, for example, provision of sexual health information by mobile phone made participants more likely than those in the control group to respond accurately and honestly to SRH questions. It may also be differential by target subgroup; for example, those with stronger parental connectedness or more baseline SRH knowledge may also respond more honestly. However, neither the size nor the direction of such biases is obvious. In other studies, adolescents’ self-reported sexual behavior data has been reported to suffer from inconsistencies, recall error, and misunderstanding or confusion surrounding the survey question . In futuOur analysis also has a number of strengths. The original trial was a randomized design, and thus reduces the risk of confounding biases relative to observational data. In addition, follow-up rates at both 3 and 15 months were over 95% [Previous research has found that boys are more likely than girls to use mobile phones, and youth from higher socioeconomic backgrounds are also more likely to own and access mobile phones –20. An eAdolescent girls in LMICs face substantial sexual and reproductive health risks, including unintended pregnancy, unsafe abortion, and HIV infection . Accessi


BCR-ABL1 fusion variants and, of these, the e6a2 BCR-ABL1 fusion is generally associated with an aggressive disease course. Progression of CML to blast crisis is associated with acquisition of additional somatic mutations yet these events have not been elucidated in patients with the e6a2 BCR-ABL1 genotype. Moreover, molecular monitoring is only sporadically performed in CML patients with atypical BCR-ABL1 fusion transcripts due to lack of consensus approaches or standardization. A case of CML is described in which comprehensive molecular analysis, including targeted next-generation sequencing, revealed a single ASXL1 mutation cooperating with an e6a2 BCR-ABL1 fusion transcript at blast crisis. A quantitative molecular monitoring approach was devised and adopted that reflected the disease response from initial treatment through allogeneic stem cell transplantation which resulted in undetectable e6a2 BCR-ABL1 transcripts. This case emphasizes the requirement for molecular monitoring in CML patients with atypical BCR-ABL1 fusion transcripts and emphasizes that comprehensive sequencing has the potential to identify targets for novel therapies in CML patients with advanced disease. A minority of chronic myeloid leukemia patients (CML) express a variety of atypical BCR-ABL1 oncogene resulting from the t translocation which fuses ABL1 on chromosome 9q34 to BCR on chromosome 22q11. The vast majority of CML patients possess either e13a2 or e14a2 BCR-ABL1 fusion transcripts; however, several alternative transcripts have been reported that are largely the result of either BCR or ABL1 alternative exon splicing. These uncommon, variant transcripts can result in phenotypic variability and affect response to tyrosine kinase inhibitor (TKI) therapy [ BCR-ABL1 transcript that fuses BCR exon 6 to ABL1 exon a2 [ ABL1 kinase domain mutation-associated imatinib resistant, e6a2 BCR-ABL1 CML have been documented [ BCR-ABL1 CML is associated with aggressive disease, allogeneic stem cell transplantation (ASCT) remains the only curative option and in such circumstances conventional AML therapy has been combined with a second-generation TKI as a bridge to ASCT [The molecular genetic hallmark of chronic myeloid leukemia (CML) is them the t9;2 translo exon a2 –9. Altho exon a2 , 11, sevcumented , 13 with to ASCT .Acquisition of further cytogenetic abnormalities and AML-associated, disease driving mutations are common findings in blast crisis of CML  but whet BCR-ABL1 transcripts by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) is an integral part of the modern management of CML patients with achievement of molecular milestones according to internationally standardized practice incorporated into current management guidelines [ BCR-ABL1 breakpoints with quantitative BCR-ABL1 levels reported on an ad hoc basis in those patients with the rare, variant BCR-ABL1 fusions.Molecular monitoring ofidelines , 21. How BCR-ABL1 CML presenting in blast crisis is reported in which a targeted next-generation sequencing (NGS) approach was utilised to ascertain additional cooperating mutations. Furthermore, an RT-qPCR approach was developed to prospectively monitor the atypical BCR-ABL1 transcripts patient throughout the disease course.A case of e6a29/L), normal white cell count, and no splenomegaly. An initial bone marrow (BM) aspirate was hypocellular with increased fibrosis suspected as the underlying cause. The JAK2 V617F and CALR exon nine insertion or deletion mutations were not detected but cytogenetic analysis revealed a karyotype of 46,XX,t in 16 metaphases, trisomy 8 in a further two Ph+ metaphases, and tetrasomy 8 in one further Ph+ metaphase. RT-qPCR analysis with standardized primers and probes [ BCR-ABL1 transcripts but further analysis with a qualitative PCR approach [ BCR exon 6 to ABL1 exon a2  demonstrated 12% myeloblasts that were positive for CD7, CD13, CD33, CD34, CD117, and HLADR and negative for CD3, CD4, CD8, CD11c, CD14, CD15, CD19, and CD64. A repeat BM aspirate was hypercellular with 18% myeloblasts morphologically. The corresponding trephine biopsy was hypercellular and had prominent grade three fibrosis with CD34+ blasts accounting for approximately 40% of the total cellularity, consistent with a diagnosis of blast crisis CML with marrow fibrosis.A 48-year-old female presented with a leucoerythroblastic blood film, anemia (hemoglobin 10.9 g/dL), thrombocytopenia approach  detected exon a2 . No muta BCR-ABL1 transcripts, a BCR exon 6 forward primer [r2 0.996). Control ABL1 transcripts were detected as previously described [ BCR-ABL1/ABL1 transcript level was 78.6%.In order to quantitate e6a2d primer  was usedd primer . A standescribed . At diag BCR-ABL1 fusion in driving blast crisis in this patient. Amplicon libraries covering 30 commonly mutated genes implicated in myeloid malignancies either covering the entire coding region  or mutational hotspots  were generated using 20 ng BM genomic DNA and sequencing performed using Ion AmpliSeq™ methodology . Calling of somatic mutations was achieved using an algorithm that excluded synonymous mutations, variants located within intronic or untranslated regions, and those present at a variant allele frequency (VAF) of <5%. A minimum target depth of coverage for variant calls was set at 500x as previously described [ ASXL1  p.E1102D mutation  was detected with a variant allele frequency of 45.5%.An NGS approach was employed to detect additional mutations cooperating with the e6a2escribed . A singl BCR-ABL1/ABL1 transcript level of 0.06%. She was subsequently treated with a second cycle of chemotherapy (DA 3 + 8) which was complicated by septicemia. Prior to ASCT the PB BCR-ABL1/ABL transcript level was 0.03% ( BCR-ABL1 transcripts were not detected by RT-qPCR at day 38 after ASCT with full donor chimerism achieved (100% at day 43 post-ASCT). The patient remains off TKI and generally well at last follow-up. The CMV reactivation has resolved and she continues on steroid taper for GVHD. Continued close RT-qPCR monitoring is planned.The patient received one cycle of daunorubicin and cytarabine (DA 3 + 10) with imatinib 400mg daily which was escalated to 600 mg daily achieving hematological and morphological remission and resulting in a PBas 0.03% . Her ima BCR-ABL1 variant is rare with less than twenty CML patients of this genotype reported. Clinically, CML cases that express the variant e6a2 BCR-ABL1 fusion transcript often present in advanced stages and display an aggressive disease course, confirmed by this case report: it must be noted that occasional good responses to TKI have also been documented. In the case described herein, imatinib combined with AML induction therapy resulted in a considerable reduction in the BCR-ABL1 transcript level with the patient able to proceed with ASCT.The e6a2 BCR-ABL1 fusion genes. NGS targeted for prognostically and clinically relevant mutations recurrently observed in myeloid malignancies revealed a mutation of ASXL1 in this patient. ASXL1 encodes an epigenetic regulator involved in posttranslational chromatin modification with aberrant histone modification being one of the important mechanisms underlying altered epigenetic regulation in other myeloid malignancies such as the myelodysplastic syndromes (MDS) [ ASXL1 and other genes involved in histone modification and DNA methylation have been characterized in chronic phase CML patients but appear to be more frequent in accelerated or blast crisis phases [ ASXL1-mutated malignancies such as blast crisis CML, suggesting that individual molecular characterization of advanced phase CML patients may be increasingly necessary. It must be acknowledged that mutations of ASXL1 and other myeloid malignancy-associated genes have been detected at low levels by deep sequencing in both Ph-negative and Ph-positive clones of CML patients. These findings suggest that expression of BCR-ABL1 may be insufficient for the development of CML which has implications for treatment with both TKIs and other novel agents [ ASXL1 mutation detected in this case was present in a BCR-ABL1-independent clone cannot be excluded or confirmed as NGS was not performed when the patient had achieved remission after chemotherapy; however, the high ASXL1 mutation VAF at presentation points to the ASXL1 mutation and BCR-ABL1 fusion coexisting in the same clone.Little is known of the biological characteristics of this genetic subtype of CML and in those with other variantes (MDS) . Mutatios phases –28. Noves phases , are potl agents , 30. Whe ASXL1 mutations with BM fibrosis: ASXL1 mutations are associated with a higher degree of BM fibrosis in primary myelofibrosis [ ASXL1 mutations are associated with an increased risk of myelofibrotic transformation in patients with essential thrombocythemia and polycythemia vera [ ASXL1 mutations are more frequently detected in overt as opposed to prefibrotic primary myelofibrosis [ ASXL1 mutations and BM fibrosis that requires further investigation in CML patients.BM fibrosis, as evident in this case, is an infrequent but recurrent feature of CML. In the classical Philadelphia chromosome-negative myeloproliferative neoplasms, several lines of evidence linkfibrosis ; ASXL1 mmia vera ; and ASXfibrosis . An asso BCR-ABL1 transcript types, RT-qPCR has been adopted in some e6a2 BCR-ABL1 cases of CML correlating well with clinical course as in the case described herein. An emerging, alternative methodology to RT-qPCR is digital droplet PCR that allows for more accurate quantitation of target molecules without the use of standard curves. This approach has recently been applied to molecular monitoring of a CML patient with an e6a2 BCR-ABL1 fusion, demonstrating an initial three-log reduction in transcripts with dasatinib monotherapy [Despite the fact that there is no standardized approach to monitoring atypicalotherapy . BCR-ABL1 fusion and accompanying mutations facilitates prospective molecular monitoring and may also provide targets for potential therapeutic intervention in CML patients with this hostile genotype.In conclusion, comprehensive molecular genetic characterization of the rare e6a2