Purpose: To increase access of underserved/health disparities communities to National Cancer Institute (NCI) clinical trials, the Radiation Research Program piloted a unique model – the Cancer Disparities Research Partnership (CDRP) program. CDRP targeted community hospitals with a limited past NCI funding history and provided funding to establish the infrastructure for their clinical research program.Methods: Initially, 5-year planning phase funding was awarded to six CDRP institutions through a cooperative agreement (U56). Five were subsequently eligible to compete for 5-year implementation phase (U54) funding and three received a second award. Additionally, the NCI Center to Reduce Cancer Health Disparities supported their U56 patient navigation programs.Results: Community-based hospitals with little or no clinical trials experience required at least a year to develop the infrastructure and establish community outreach/education and patient navigation programs before accrual to clinical trials could begin. Once established, CDRP sites increased their yearly patient accrual mainly to NCI-sponsored cooperative group trials (~60%) and Principal Investigator/mentor-initiated trials (~30%). The total number of patients accrued on all types of trials was 2,371, while 5,147 patients received navigation services.Conclusion: Despite a historical gap in participation in clinical cancer research, underserved communities are willing/eager to participate. Since a limited number of cooperative group trials address locally advanced diseases seen in health disparities populations; this shortcoming needs to be rectified. Sustainability for these programs remains a challenge. Addressing these gaps through research and public health mechanisms may have an important impact on their health, scientific progress, and efforts to increase diversity in NCI clinical trials. The Cancer Disparities Research Partnership (CDRP) pilot program was initiated by the radiation research program (RRP) within the National Cancer Institute (NCI)’s Division of Cancer Treatment and Diagnosis (DCTD) in 2002 as a novel strategy to address the cancer health disparities that exist in racial, ethnic, minority, and underserved populations within the United States . Over haThe primary goal was to increase accrual of minority/underserved populations into NCI-sponsored clinical trials. Other objectives were: (1) increasing the number of staff involved in cancer health disparities research; (2) assessing the value of implementing the TELESYNERGY™ telemedicine system; (3) implementing an appropriate patient navigation program; and (4) determining whether this pilot would work in community-based institutions not historically involved in clinical research.Following an NIH/NCI portfolio analysis, which determined a need for the proposed program, the CDRP concept was approved by the NCI’s Board of Scientific Advisors and the request for application (RFA-CA-02-002), was issued in October 2001. An NCI Special Emphasis Panel reviewed six applications and two awards were made in September 2002. Since initial funding was approved for up to six awards, RFA-CA-03-018 was issued in August 2002 and four additional awards were made out of eight reviewed applications producing a success rate of 43% from both RFAs. Table The formal process for reissuance of any currently funded NCI program changed in 2006 and required an external program evaluation. NOVA Research Company  was awar1)Could a community-based hospital/cancer center establish a clinical research infrastructure within a reasonable period and accrue patients into radiation oncology-based clinical trials?2)Was participation of underserved populations in NCI-sponsored clinical trials increased?3)Were mentors helpful in providing necessary training, support, and advice to the grantees?4)Was the TELESYNERGY™ telemedicine system beneficial to the CDRP programs?5)Was the CDRP grantee successful in increasing the number of physicians/other staff interested in cancer disparities research?6)Was the CDRP site successful in disseminating program results through publications/presentations at national meetings?The metrics of success were:Establishing the clinical research infrastructure was challenging because institutions were unfamiliar with its value for their patients. Despite all PIs having prior clinical trials experience, it took many months to educate the hospital administration about the benefits for their patients by participating in NCI clinical trials. By offering trials near their hometowns, patients can access these clinical advances without traveling great distances.Findings from the U56 pilot program revealed important and unique issues regarding outreach to disparities populations not encountered at academic cancer centers and their community oncology affiliates. Disparities researchers needed sufficient time to succeed in: (1) recruiting personnel due to challenges in finding qualified staff to fill positions ; (2) identifying a back-up PI after the loss of the primary PI at Laredo Medical Center; (3) establishing an outreach program so the community gained familiarity and trust with the PI and the research team , 5; and After the infrastructure was established, there was steady patient accrual onto various NCI clinical trials Table . The typAll grantees selected an NCI-designated Comprehensive Cancer Center as a primary or secondary (Laredo) mentor Table  based onBecause of the limited availability of cooperative group trials as noted above, the grantees used two approaches to expand protocol participation: (1) development of PI-initiated clinical trials targeting stage of disease and/or including shorter radiation therapy schedules to address patients’ transportation or accommodations barriers , 8 and . This exHaving breadth in the portfolio of trials was critical to overall participation as shown in Table In addition to informing patients about the clinical trials, the patient navigators supported by CRCHD had a positive influence on reducing the number of missed appointments and addressing other barriers to patient participation –11. PatiWalking Forward Program were implemented .The American Indian (AI) Community Research Representatives (CRRs) were established with CDRP funding at three remote AI reservations in South Dakota. These trained community health educators and Patient Navigators helped RCRH receive a 2-year CDC grant by partnering with the South Dakota Health Department utilizing their CRRs to implement a colorectal screening program for their AI population. Additionally, RCRH partnered with the American Cancer Society to implement the “All Women Count!” Breast and Cervical Cancer Early Detection Program for their AI women at the Pine Ridge Indian Reservation whereby the goals of both ACS and RCRH’s When the CDRP program was initiated, telemedicine was just being established and this program became a pilot test for TELESYNERGY™, a system developed jointly by the NIH Center for Information Technology and NCI. Table The CDRP institutions were very active in presentations at local meetings and nationally at the Radiation Therapy Oncology Group (now part of NRG Oncology) and the annual ASTRO meetings. Additionally, the CDRP program helped establish an annual ASTRO/NCI Cancer Disparity Symposium to help educate members about cancer disparities issues in the U.S. . All CDRP sites were active to various degrees in publishing results of their cancer disparities program with RCRH being the most productive with publications Table .As pointed out in a BSA discussion, CDRP took on some of the most difficult challenges to develop clinical trials because of both the disparity populations and the limited previous NIH funding history. Although a higher level of trial participation may have been possible with health disparities sites within the catchment of an NCI-designated Cancer Center and the Division of Cancer Prevention’s Minority-Based Community Clinical Oncology Program site, that CDRP successfully reached into the more difficult-to-reach areas dispelled the concept that this was impossible and/or that people would reject participation in trials.To expect health disparities sites to achieve similar rates of clinical trial accrual as major cancer centers and their catchment area is not realistic. Implementation takes time and include: (1) developing/training personnel with the necessary research skills and staff to work with government regulations for clinical trials; (2) advising administrators and hospital leadership about the patience needed to develop infrastructure and the wisdom to see the benefit to patients and institution; and (3) establishing physical space and technological facilities needed to conduct research and manage the data.Having an experienced team from NCI initiate the programs with a visit to the institution was also important. Although there was skepticism based on the experiences that the government would “establish a program, do research, and then leave ,” this sWe suggest that the proposed metrics of success for future disparities efforts include the usual “hard” metrics such as clinical trial participation and publications, but also softer metrics such as: (1) surveys conducted, (2) the number of patients screened, (3) the extent of outreach–recruitment activity, (4) additional research efforts leveraging their infrastructure, (5) staff recruitment, (6) enhanced interest in disparities by cooperative groups  and professional societies (ASTRO), and (7) the ability to secure additional funding. Formal program evaluation as established by NOVA was extraordinarily helpful for the awardees and RRP in assessing progress and determining both gaps and opportunities for progress. The CDRP programs shared data and trials among the awardees, which facilitated the implementation science.Several years are needed to ramp up clinical trial participation, including the need for surveys and focus groups, time to listen to the community, understanding their needs, assessing barriers and building teams and trust , 16. EstTelemedicine has evolved significantly as the TELESYNERGY™ system progressed from expensive ISDN phone line systems to a web-based system using off-the-shelf technology. A simplified version is now available for public purchase by outside institutions, both nationally and internationally, with the possibility for support for technical consultations, installation, and training from NIH/NCI if needed.The establishment of CDRP led to some important changes in the radiation oncology community. The RTOG (now part of NRG Oncology) raised the issue of the need for future “health disparities” clinical trials to fill the gaps noted above. ASTRO developed an annual health disparities scientific program  and additional radiation oncology activities related to cancer disparities on the international level include working with the Program of Action for Cancer Therapy (PACT) of the International Atomic Energy Agency (IAEA) American Indian mHealth Smoking Dependency Study” program for the AIs in South Dakota. Several publications resulted from these collaborations with the WFP that ultimately assisted with program sustainability , the University of Washington-Seattle , Marquette University , and the University of New Mexico  to increase cancer screening and palliative care programs in the remote reservations for AIs. In addition, two resident physicians from Harvard University performed their research year at RCRH: Ashleigh Guadagnolo, MD, MPH (radiation oncology) and Sunshine Dwojak, MD (head and neck surgery). RCRH was awarded a 4-year NCI Provocative Questions R01 grant in 2012 by leveraging their CRRs to implement an “nability , 19–21.Coastal Carolina Radiation Oncology (CCRO) used their CDRP success in patient accrual to become a full member of NRG Oncology. To sustain their disparity program, CCRO again partnered with NHRMC to form the Southeastern North Carolina (SENC) CCOP, a grant that was awarded in 2013. Because the minority population in SENC is <50% of the population, the SENC CCOP could not apply to become a new NCI’s Community Oncology Research Program (NCORP) Minority/Underserved Community Site in 2014. Instead, CCRO will revert to full membership in NRG, while NHRMC will likely be an affiliate member of the Alliance group.Deep South Cancer Navigation Network and will receive $1 million over 3 years to support 3.5 FTEs for their patient navigation Program.Singing River Health System is building on their mentor relationship with University of Alabama Birmingham (UAB) Cancer Center. It will expand their current patient navigation program via participation as the only Mississippi-based site participating in the CMS Health Care Innovation Challenge award – Perhaps, the greatest challenge now is program sustainability. There were positive outcomes that were not predicted and are strong evidence of the value of investing in NIH/NCI clinical research in health disparities regions. Examples are provided from the three 10-year awardees.Philanthropy is another means of potential support, but community resources that major cancer centers or cooperative groups have are not accessible in these health disparities communities. For them to raise sufficient funding to sustain their infrastructure and professional staff and become competitive for the major infrastructure, clinical trials and center grants available are not a reasonable expectation.Through the CDRP program, clinical trials were established in health disparities sites not previously participating in the NCI clinical trials enterprise. The initial success of this pilot program is reassuring and may lead to improved general healthcare awareness for their minority/underserved populations and an increase in the diversity in NCI clinical trials.Health disparity is an economic issue as much as a “minority” issue. Some health disparities regions have unique populations  and when the study of the biological basis of cancer is conducted for their benefit, trust can be established and “precision/personalized” medicine targeting their illnesses can then be investigated.The BSA review of the program renewal raised the issue of moral obligation for sustaining programs. Federal agencies support all of the people and the CRCHD has emphasized the large potential value of applying what we already know to help improve cancer outcomes for health disparities communities. While some of what CDRP accomplished met the standard metrics of clinical research as judged by participation numbers, there are aspects that were indeed unique and fall within implementation science. Lessons learned are applicable to future programs. In regard to the moral issue, research programs must pass peer review but, perhaps, different metrics are justified for the disparities sites that suffer from a lack of infrastructure and experience when competing for grants. For all the sites, especially the three 10-year awardees, the CDRP program succeeded in bringing people to clinical trials who previously were on the periphery and without access to the potential advances from these studies. This pilot program showed that reaching health disparities communities who are new to cancer research can be done and the future challenge is not only to broaden access to appropriate cancer care for health disparities populations, but also to sustain these gains.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.http://www.frontiersin.org/Journal/10.3389/fonc.2014.00303/abstractThe Supplementary Material for this article can be found online at Click here for additional data file.


ARID1A), frequently mutates inactively in gastric cancer (GC). However, its prognostic value remains controversial. To address this issue, a comprehensive meta-analysis was performed. Studies published until March 2016 were systematically searched. A total of 15 cohorts from 14 literatures involving 3183 patients were subjected to this meta-analysis. The pooled data showed that ARID1A expression loss predicted poor overall survival (OS) in GC (Hazard Ratio (HR) = 1.60; 95% Confidence Interval (CI) = 1.40–1.81; P < 0.001), with low heterogeneity among these studies . Stratification analyses revealed that ARID1A expression loss was associated with poor OS in Asians , proportion of proximal disease ≤30% subgroup  and Epstein-Barr virus (EBV) (+) > 5% subgroup . The robust results were suggested by sensitivity analyses and no evidence of significant publication bias was detected. This study demonstrated a significant relationship between deletion of ARID1A expression and poor OS in GC. Moreover, ethnicity, tumor location and EBV infection status might be potential key factors influencing this correlation.The chromatin remodeling gene, AT-rich interactive domain 1A gene ( Though the incidence has substantially declined in recent years, gastric cancer (GC) remains the third most common cause of cancer-related death globally456ARID1A), encoding a large nuclear protein BAF250a, is one of vital components of the Switch/Sucrose Non Fermentable (SWI/SNF) chromatin remodeling complex9101213141512AT-rich interactive domain 1A gene  studies have revealed that the incidence of To date, a systematic meta-analysis, exploring the prognostic role of ARID1A expression loss in cancer including gastrointestinal cancer, has been reportedThe characteristics of 14 articles (15 cohorts) are summarized in 21222327282924313234Immunohistochemistry (IHC) was the only method applied to detect the expression of ARID1A. Cutoff levels for ARID1A deficiency was defined as cancer cells weak or without nuclear staining, or nuclear staining <10%. All of the 14 studies with sample size from 66 to 489 reported OS, but only two studies reported the disease free survival (DFS) and one study reported the progression free survival (PFS). Thus, only OS was used as the endpoint of this study.P < 0.001) in patients with GC  among these studies  infection rate, TNM staging, tumor differentiation, status of MSI, ARID1A deficiency rate and sample size.P < 0.001), subgroup of disease in upper third part of stomach ≤30%  and subgroup of EBV (+) > 5% . In contrast, ARID1A expression loss did not significantly related to the poor outcome of GC patients in non-Asians , or high proportion of proximal stomach  subgroup, or EBV (+) ≤ 5% subgroup . It seemed that ethnicity, disease location and EBV infection status might affect the correlation between ARID1A loss and poor OS. However, we found ARID1A expression loss was correlated with poor OS in GC, irrespective of tumor clinical stage, tumor differentiation, MSI status, ARID1A deficiency rate and sample size  nor Egger’s test (P = 0.146) detected any evidence of publication bias.Begg’s funnel plot and Egger’s test were used to assess the publication bias. The shape of the Begg’s funnel plot seemed basically symmetrical by visual inspection . NeitherARID1A expression, sample size, tumor differentiation and MSI status. In addition, when stratification was analyzed by ethnicity, disease location and EBV status, ARID1A expression loss could predict poor OS for GC patients in Asians, proportion of proximal disease ≤30% and EBV (+) > 5% subgroup, but not in non-Asians, or proportion of proximal disease >30% or EBV (+) ≤ 5% subgroup.To the best of our knowledge, this is the most comprehensive meta-analysis exploring the prognostic role of loss of ARID1A in GC patients. Our study revealed that loss of ARID1A expression was an indicator of poor prognosis in GC patients. The pooled hazard of death in ARID1A expression loss group was assessed to be 60% up compared with ARID1A expression group. Results from heterogeneity testing, sensitivity analysis and publication bias confirmed the reliability of our finding. The correlation between ARID1A expression loss and poor OS remained in subgroup analyses, regardless of tumor clinical stage, deficiency rate of et al. investigated the prognostic role of mutation status of ARID1A in a variety of cancers and demonstrated that ARID1A expression loss was not connected with all-cause mortality in gastrointestinal cancer patientset al.). Moreover, the results from heterogeneity test, sensitivity analyses and publication bias test showed that our findings are stable.In 2015, a meta-analysis published by Luchilin et al. gave the evidence that ARID1A emerged as a tumor suppressor in 2007 14in vitro has revealed that silencing of ARID1A expression enhanced the proliferation and colony formation of GC cells, whereas restoring ARID1A expression led to the reverse effectCDKN1A (p21) and SMAD3, to arrest cell cycleARID1A can functions as a “caretakers” by preventing genomic instability. Recent data has shown that ARID1A played a vital role in regulating DNA damage checkpoint and subsequently augmented DNA damage signaling181938Since Huang et al. found that complete loss of ARID1A expression was 57.7% in poorly differentiated gastric adenocarcinomas, much higher than that in moderately differentiated GC (25%) and well differentiated GC (7.7%)ARID1A gene frequently mutated in MSI-high GC18In GC, Tumor stage and tumor differentiation have been manifested to be crucial clinical prognostic markers52222ARID1A expression loss in prognosis.Notably, the subgroup analyses by ethnicity revealed that ARID1A expression loss had a significantly adverse impact on the OS in GC patients in Asians, but not in non-Asians. Similarly, this correlation between ARID1A loss and worse OS could be detected in proportion of proximal disease ≤30% subgroup, but not in high proportion of proximal disease subgroup. It seemed that ethnicity and disease location might be potential critical factors which influence the relationship between ARID1A loss and poor prognosis in GC. Tumor location varies markedly by ethnicity and geographic area. For example, non-proximal GC predominates in Japan and Korea, while proximal GC occurs more often in western countries4345EBV associated gastric carcinoma (EBVaGC), often diagnosed in non-antrum of stomach, happens more frequently in western countries47483150As a literature-based meta-analysis, it is vital to note the limitations of our study. First, all of the included studies were derived from retrospective data, potentially leading to selection bias. Thus, prospective studies are requisite to confirm our finding in future. Second, only two studies, which consisted of 3 cohorts and represented only 10% of the total cases, were from non-Asian population. Thus, the conclusion in non-Asians was less persuasive. More original studies in non-Asian GC patients are necessary in future. Third, several HRs were extracted from survival curves, which might bring in small errors. However, our sensitivity analyses did not materially alter the results, which suggested that the effects due to such errors were limited. Finally, these included studies didn’t provide information about chemotherapy or radiotherapy, hence the issue whether chemotherapy and radiotherapy can influence the correlation between ARID1A expression loss and survival in GC was not investigated in our study.Despite the above limitations, this is the most comprehensive meta-analysis, to date, to quantitatively assess the prognostic value of ARID1A expression loss in GC patients. Our results suggest that ARID1A inactivity is significantly related to poor OS for GC patients, which may be used to identify patients with poor outcome and guide clinical treatment modulation. Notably, our subgroup analyses further indicate that ethnicity and tumor location might be key influence factors for this connection, although the sample sizes of some subgroups are relatively small. In the future, larger scale prospective studies are warranted to confirm ARID1A expression loss as a prognostic role in GC patients. Moreover, since multi-markers may provide more precise prognostic information than single indicator, studies estimating ARID1A expression loss in coordination with other prognosis markers are essential to assess their value in GC survival.Literature search was undertaken, using Pubmed, Embase, Web of Science, Cochrane library, Chinese National Knowledge Infrastructure (CNKI) and Wanfang Database for both English and Chinese language articles. Last search was updated in March 3rd, 2016. The searching strategy contained the following terms with varied combination: GC (“gastric carcinoma” or “gastric neoplasm” or “GC” or “cancer of stomach” or “gastric tumor”), ARID1A (“ARID1A” or “BAF250a”) and prognosis . The reference lists of retrieved publications were further reviewed manually to identify potentially relevant articles.Studies included in this meta-analysis had to meet all of the following criteria: (1) patients recruited with histologically proven GC; (2) investigated the association between ARID1A deficiency and prognosis; (3) ARID1A deficiency was tested in primary gastric tumor tissue by immunohistochemistry (IHC), exome sequencing or reverse transcription-polymerase chain reaction; (4) the hazard ration (HR) and its 95% confidence interval (CI) were reported or could be calculated. In the case of duplicated publications or overlapped data, the most recent or more comprehensive article was included. In accordance with the inclusion criteria, two reviewers (L.Y. and H.H.X) performed the eligibility assessment independently, and the disagreements between the two reviewers were resolved by consensus.The following information was extracted from the included studies: first author, publication year, country of origin, sample size, clinical stage, location differentiation grade, ARID1A expression assay  and survival data. If univariate and multivariate HRs and their 95% CI were both reported, multivariate HRs were used.HRs and their 95% CIs were used to conduct the meta-analysis in this study. When they were given in literatures, we obtained them directly. When they were not described directly, we extracted them from available numerical data or published survival curves using methods reported by ParmarP < 0.05). The heterogeneity among the included studies was evaluated using the Cochran Q-test and I2 test. If a P ≤ 0.10 in Cochran Q test or I2 value ≥ 50% in I2 test, the heterogeneity was regarded as statistically significant. If there is no significant heterogeneity, fixed-effects models were used. Otherwise, random-effects models were performed. Subgroup analyses, according to ethnicity, clinical stage, differentiation grade, MSI and so on, were conducted to explore the factors which may influence the effect of ARID1A deficiency on prognosis. Sensitivity analysis was performed to examine the stability of the pooled results. A funnel plot with Begg’s and Egger’s test was applied to assess the publication bias and P > 0.05 was considered for no publication bias. All statistical analyses were performed using STATA Statistical Software, version 12.0 .An observed meta-HR > 1 implied a worse prognosis for the ARID1A deficiency group if its 95% CI didn’t overlap 1 .


Professional development is a key component of effective public health infrastructures. To be successful, professional development programs in public health and health promotion must adapt to practitioners’ complex real-world practice settings while preserving the core components of those programs’ models and theoretical bases. An appropriate balance must be struck between implementation fidelity, defined as respecting the core nature of the program that underlies its effects, and adaptability to context to maximize benefit in specific situations. This article presents a professional development pilot program, the Health Promotion Laboratory (HPL), and analyzes how it was adapted to three different settings while preserving its core components. An exploratory analysis was also conducted to identify team and contextual factors that might have been at play in the emergence of implementation profiles in each site.. Information about teams and their contexts/settings was obtained through documentary analysis and semi-structured interviews with HPL participants, colleagues and managers from each organization.This paper describes the program, its core components and adaptive features, along with three implementation experiences in local public health teams in Quebec, Canada. For each setting, documentary sources were analyzed to trace the implementation of activities, including temporal patterns throughout the project for each program componentWhile each team developed a unique pattern of implementing the activities, all the program’s core components were implemented. Differences of implementation were observed in terms of numbers and percentages of activities related to different components of the program as well as in the patterns of activities across time. It is plausible that organizational characteristics influencing, for example, work schedule flexibility or learning culture might have played a role in the HPL implementation process.This paper shows how a professional development program model can be adapted to different contexts while preserving its core components. Capturing the heterogeneity of the intervention’s exposure, as was done here, will make possible in-depth impact analyses involving, for example, the testing of program–context interactions to identify program outcomes predictors. Such work is essential to advance knowledge on the action mechanisms of professional development programs.The online version of this article (doi:10.1186/s12913-015-0903-3) contains supplementary material, which is available to authorized users. Public health practice is constantly evolving, shifting frequently as new discourses emerge across the field and the practice context is transformed by health system reforms , 2. ProfBased on recent developments in complexity theories and planned adaptation models , this arfidelity, defined as respecting the core nature of the program that underlies its effects, and adaptability to a specific context, to maximize the benefit of the intervention in a specific situation [Empirical research has demonstrated that, to be effective, professional development must be contextualized, related to practice, and situated within a community that supports learning, rather than delivered in a discrete package using a didactic and disembodied approach –13. Thisituation , 16, 17.ituation , 16, 18.Over the past decade, implementation science has proposed some guidelines to deal with the ‘adaptability–fidelity’ tension when implementing an evidence-based program in different settings. Indeed, given the impossibility of standardizing programs across different social and complex settings, some authors have proposed to focus on the integrity (fidelity) of the program and its core components , 16, 18.In recent years, many authors have called for the development of a ‘science of replication’ , 17. In provincial, governed by the Ministry of Health and Social Services; regional, administered by regional health and social services agencies; and local, delivered by health and social services centers, or CSSS (centres de santé et de services sociaux). The CSSS structure was created as part of the province’s 2004 health reform [In Quebec, healthcare and public health are managed at three levels: h reform , when 95h reform . Incorpoh reform , 25. Forh reform . In 2009The HPL offers an approach to professional development based on competencies development, reflective practice, and problem-based learning. Broadly speaking, the program supports a team of multidisciplinary practitioners in using a population-based approach to design and implement a specific health promotion intervention , 28. MorConcretely, each HPL’s issue or theme is chosen by the participating CSSS based on its priorities. Once the broad theme is chosen by the organization, a team of voluntary participants is created to work on it in the HPL. Teams are composed of seven to ten professionals from various disciplines and managers. The HPL formula involves an ongoing and lengthy process in which participants meet for three hours every two or three weeks for 18 to 36 months, depending on the organization’s needs and preferences. Meetings are held during the participants’ normal working hours, and they are freed up by the organization to attend. Sessions are led by one of the participating managers or professionals, supported by a mentor from the program promoter agency (PHDM). Each team is guided by a different mentor but all follow the approach described below. External participants may be invited once in a while, for example, to provide key expertise or to liaise with partners from the organization. Mentors encourage reflection and discussion, offer feedback to participants, and guide the HPL teams by providing recommendations on processes and resources for learning, but the teams assume leadership. A detailed description of the HPL program is available elsewhere .While the program does not build on one specific theory, it has been inspired by literature on competencies development, adult learning, reflective practice and organizational change –32. It aoperational approach to guide the HPL activities. This approach, which stems from the program’s intervention theory, comprises seven steps that can be conceived as interrelated steps of a change process, each functionally defined by an objective (which corresponds to an objective of production). While each objective specifies a direction to take, the composition  of each step is highly flexible, to be adapted to each team’s situation and needs. Also, the whole approach is iterative, and the form the overall process adopts may vary. The steps of the operational approach thus represent the program’s core components. Logic analysis confirmed the different steps of the operational approach as crucial components of the program [per se, with initial tailoring to the needs of the participating CSSS ; and (2) during the implementation, with ongoing adjustment to the different needs of the teams, which assume the leadership role in implementing the different steps of the HPL .The PHDM promoters developed an  program . In sum,Table Analyse des laboratories de promotion de la santé – Analysis of the Health Promotion Laboratory) is a multiple case study evaluating the processes and outcomes of the HPL, a professional development pilot program in public health in Quebec, Canada [The work presented here is part of a larger project. The ALPS Project .Two sources of data were used. Implementation data were primarily collected using documentary analysis. Sources included agendas and minutes of HPL meetings (212 items), logbooks of the PHDM mentors (274 entries), internal reports (14 items), as well as educational tools (106 items) for the three sites. Because some minutes and logbook entries were missing, informal interviews with mentors were conducted to complete the information.N = 28). Interviews were conducted at the end of the implementation phase. An interview grid exploring different dimensions of the laboratory experience and context  was used to ensure consistent data collection across sites. Data pertaining to teams’ characteristics and organizational contexts were used in the present study.Data related to the characteristics of teams and their contexts were collected through the analysis of the documents mentioned above as well as through semi-structured interviews with key informants, including HPL participants, PHDM mentors, and managers and colleagues not involved in the HPL  and University of Montreal (#12-094-CERES-D) ethics committees.Data pertaining to HPL activities were retrieved from the PHDM’s electronic database and paper records. Based on the HPL presentation documents and internal reports, we created a code book to define each step of the operational approach and identified activities to exemplify each step .The three teams consisted on average of nine professionals and managers. They differed in terms of members’ activity sectors and targeted issues. Team A  had a higher proportion of members with longer work experience, and its participants had a long history of working together. Because of their particular position in the CSSS , members had a more flexible time frame that facilitated their involvement in the HPL.Team B  consisted of participants coming mainly from the family/child/youth sector. The professionals in this sector were primarily mandated to respond to the needs of the schools of the territory and, as such, distributed their time among the different schools and the CSSS. The team members were engaged for the most part in individual practice with clients and did not have a long history of working together before the HPL.Team C  consisted of participants coming mainly from the CSSS’s child and family services division. The professionals were primarily mandated to offer counseling on various issues and providing ante- and postnatal support to mothers. Most members already knew each other very well before the HPL and had a long history of working together. A particularity of this site is that members ended up creating not just one, but four intervention projects acting on different factors related to protecting vulnerable children in their territory. Also of interest is the higher number of participants who withdrew (temporarily or definitively) from the HPL for various reasons—illness and maternity, among others.Each team was guided by a different PHDM mentor, but all mentors followed the operational approach described above. All teams reported having access to informational resources and continuing education. However, many participants from sites A and B pointed out that training was limited due to budget cutbacks. While subject to the same budget restrictions, team C participants appeared to enjoy more educational opportunities because of their CSSS’s university affiliation . CSSS C also received a recognition award for its continuing education program. Table Given their particular contexts and composition, each team came up with its own adapted process for working through the operational approach.Each team invested a substantial number of hours, over different time spans, in both the planning meetings and the HPL meetings themselves: Team A – 140 hours over 17 months (29 meetings); Team B – 195 hours over 26 months (40 meetings); Team C – 280 hours over 35 months (56 meetings). The core members’ participation rates were similar across the teams, ranging from 74 to 85 %.Table The HPL’s operational approach suggests an iterative process. It is possible for teams to progress through the steps either sequentially or simultaneously. As such, a team could choose to perform most of the activities in one step before initiating those in another or could make progress on several fronts simultaneously. We constructed line charts showing the cumulative numbers of activities for each step from one meeting to another. For the sake of parsimony, steps 1 and 3a, whose implementation patterns were almost identical in all teams, have been excluded from the charts. In each case, these steps were initiated early (in the first six meetings) and then remained unchanged over the course of the process. The findings showed that each team developed a unique pattern of working its way through the operational approach.Team A’s work is notable in that it completed the program in much less time than did the others. Figure Figure Figure The results showed that the first three steps required small and relatively similar percentages of activities for all three teams. Thus, the implementation of activities related to identifying the issue, specifying the operational approach, and acquiring basic concepts of public health did not seem much affected by the particular contexts of teams and participants. However, the picture that emerged for the other steps was quite different. For example, Team C took much longer to complete the operational approach, in particular with regard to identifying options, developing partnerships, and implementing action. In comparison, Team A took half the time to complete the HPL, for example, devoting only five activities to identifying an option for action (the preferred intervention).Many factors may have contributed to this differential implementation profile ; and (2) ongoing adaptation of implementation to take into account the needs and contexts of the participants (as shown in the results). The HPL program’s original parameters were tailored to the implementation sites by allowing each CSSS to choose a target issue based on its needs and the availability of its staff. Then the program’s operational approach was implemented in ways that allowed for ongoing adaptation to the teams’ particular contexts and needs, leaving room for flexibility and creativity in carrying out the different steps. Even though each team developed a unique pattern of implementing the activities, the results of the analysis show that every step of the program was implemented. These steps, which are crucial to the entire change process intended by the program, represent the ‘active ingredients’ of the HPL, its core components.The findings presented here show that a health promotion professional development program aimed at local public health organizations can be successfully tailored to different settings without compromising its core components. In this paper, we present a program that allows for two types of adaptation: (1) initial The implementation of core components is meant to ensure a program’s fidelity to its logic model and theory, thereby promoting achievement of the intended outcomes , 36. Howadjusting the local context to optimize the implementation [Another issue concerns adapting the context to the intervention. In fact, most often success depends not only on tailoring the intervention to the implementation context, but also on entation , 37. Theentation . In the To be successful, professional development programs in public health and health promotion must be adaptable to practitioners’ complex real-world practice settings while preserving core program components. This implementation analysis has shown that the HPL clearly satisfies this criterion. Capturing the heterogeneity of forms the intervention may take, as was done here, will make possible in-depth impact analyses, including the testing of program–context interactions to identify program outcomes predictors. Such work is essential to advance knowledge on the action mechanisms of professional development programs.This study may suffer from certain limitations, and the results should be interpreted accordingly. A first limitation was that the implementation steps were assessed and compared across teams using numbers of activities rather than the amount of time devoted to each, which could be misleading, as the time required for different activities can vary. We believe activity numbers provide a generally accurate picture of the amount of effort dedicated to achieving one particular step, and this assumption was also deemed valid by the HPL participants. Nevertheless, we suggest that a qualitative analysis of activities, taking into account the time devoted to each, would be a useful complement to consider in future research. Second, some documentary sources, such as mentors’ logbooks and minutes of meetings, were not homogeneous and varied from one team to another. To overcome this limitation, several data sources were used to provide a comprehensive picture of each team’s activities. Third, at some meetings, teams took few or no minutes and some mentors did not keep detailed notes of the activities discussed. To address this challenge, missing data were completed through informal interviews with key informants. Lastly, our analysis of the contextual factors affecting the implementation process was exploratory and limited to a few organizational dimensions, setting aside other key dimensions related to, for example, the external context, the PHDM mentors, and other organizational-level factors –40. FutuNotwithstanding these limitations, we employed several means to ensure the validity of this study’s conclusions. Most of the researchers were involved with the PHDM program team for several years to develop a deep, comprehensive understanding of the HPL model and its operational approach. The findings were also validated with PHDM mentors and participants to ensure accuracy of data and interpretation of results. We believe these results provide a useful picture of the HPL implementation process in the three sites and, more specifically, of the HPL’s capacity to be adapted to different contexts while preserving its core components. In the next phase of our research, we will investigate the relationships between these different implementation profiles and program outcomes.In this article we have explored the question of implementation fidelity and adaptation of a professional development program in health promotion. Based on our findings, we have proposed some points to consider when developing and implementing such a program. First, this study has highlighted the need to make explicit the core elements of program theory that are critical to achieving the program’s intended outcomes. This component analysis can be done in reference to a theory, a proven logic model, or evidence-based science, but should make it possible to identify the features of the program that account for its outcomes. Second, our results emphasize the importance of providing flexibility in a program’s design, such that it can be adapted beforehand to different contexts and then on the ground as the implementation unfolds. Third, we have explored the potential role of organizational dimensions in the implementation process. Given the great variety of public health and health promotion practice settings, the heterogeneity of professional backgrounds, and the complexity of determinants that need to be addressed to promote the health of populations, program adaptability is a prerequisite for health promotion professional development. The present study has confirmed the great potential of the HPL in this respect.


Increasingly, medical students and practicing clinicians are showing interest in traveling to low-income settings to conduct research and engage in clinical rotations. While global health activities have the potential to benefit both the individual and the host, there can be challenges. We describe one way to harmonize the desire of volunteers to have a meaningful impact on the health care delivery system in a developing country with the needs of that country.The Project Health Opportunities for People Everywhere (HOPE)-Ghana Emergency Medicine Collaborative (GEMC) Partnership has successfully integrated short-term volunteer physicians and nurses to facilitate the training of emergency medicine (EM) residents and specialist nurses in Kumasi, Ghana.Since the launching of this partnership in 2011, eight physicians and 10 nurses have rotated at Komfo Anokye Teaching Hospital (KATH). The impact of these volunteers goes beyond the clinical service and supervision they provide while on the ground. They act as mentors to the trainees and assist the program leadership with teaching and assessments.Although generally smooth, there have been challenges, all of which have been met and are being resolved. This partnership is an example of how collaborations can harness the expertise and energy of short-term volunteers to achieve the goals of capacity building and self-sustainability. Interest in global health experiences has been growing in recent decades. Medical students are increasingly requesting global health rotations as part of their training , and recFurther, the relationships between and among institutions and trainees can be unbalanced as the visitor often comes with supplies and other resources that may or may not be ideal to the local context. While supply donation seems to be positive, if those supplies are not locally available or used, these initiatives fall short. Perhaps most importantly, sustainability is not ensured with these sorts of trips . Many ofThere are vast needs in developing countries in terms of health capacity building and vast resources in more developed countries. In this paper, we describe one example of a way to harmonize the desire of practicing clinicians to have a meaningful impact on the health care delivery system in a developing country with the structural needs of a country. We describe the Project HOPE-Ghana Emergency Medicine Collaborative Partnership which utilizes short-term volunteer physicians and nurses to facilitate the implementation of a residency and specialty nurse training program in Kumasi, Ghana. This approach attempts to merge the strengths of developed countries with the strengths of developing countries to address their self-identified needs. We believe this model can be useful for others interested in global health partnerships, as a way to harness the human capacity of short-term medical volunteers to build local capacity and be a part of a sustainable global health program.The Ghana Emergency Medicine Collaborative (GEMC) arose from the recognition that there was a significant need to increase human resources for health (HRH) in Ghana. Specifically, there is a need for health care workers with specialized knowledge and training in managing acutely ill and injured patients. Worldwide data indicates that injury results in 5.8 million deaths every year—32 % more than HIV, malaria, and tuberculosis combined . AlthougTo provide a trainee with the appropriate tools, training, and supervision to carry out the task of an emergency physician (EP) takes an extensive amount of clinical supervision. There is an evolved training process for EPs in the United States. This process is recognized for producing high quality clinicians, researchers, and educators. From the very beginning, GEMC was intent on creating a program that would produce not only sound clinicians but also future educators. To accomplish these goals, there was a recognized need for clinical educators.Ideally, a program to train residents begins with a bank of fully qualified physicians locally to serve as faculty for the program. However, as this was the first program in Ghana, this was not available. GEMC approached this difficulty by securing international EM faculty (from the US and UK) to provide the educational and administrative requirements of the program, requiring a constant on-the-ground presence by US-trained and board certified EPs. The residents are recruited, supervised, and examined by the GCPS, the national body responsible for postgraduate medical training in Ghana. The graduates of the program are therefore fully certified specialist clinicians and educators. Therefore, those who are being trained by the program will take over the training of future classes of emergency medicine residents, and thus, the program will, in the future, be self-sustaining.GEMC also recognized the need for specialty trained EM nurses to practice with the trained physicians. Working with the leadership at KATH and KNUST, a 1-year diploma program in emergency nursing (EN) for practicing nurses was developed. The program was developed in a “sandwich” format, where students are in-house at KATH for 2 weeks out of each month and at their home institutions the rest of the time. The EN diploma program encompasses the full scope of learning activities including didactic lectures, precepted clinical experience, and simulation laboratory time. The diploma, due to its unique structure, addresses a specific Ghanaian need by allowing nurses to work and train concurrently. However, a consistent challenge to making the program a success includes recruiting, funding, and supporting external faculty willing to spend 3 weeks at a time in-country. As EM is a new specialty in Ghana, there are very few in-country experts with formal EN training or experience.As with the physician training, GEMC has committed to sending emergency nursing clinical and content experts to Ghana each month for the first 3 years of the training program. The rate of knowledge transfer, safety of patients receiving care, and overall quality of care is dependent upon quality, supervised training. Upon completion of the diploma program, nurses are qualified to take the professional examinations conducted by the Nurses and Midwives Council (NMC) of Ghana for certification.Moving forward, the GEMC continues to collaborate with all relevant stakeholders to strengthen the partnership while promoting career advancement for graduates of the program. Additionally, the program seeks to establish new partnerships, such as the collaboration with Project HOPE, to continue providing training to residents and nurses to continue establishing the numbers of emergency medical care providers in Ghana.Project Health Opportunities for People Everywhere (HOPE), the People-to-People Health Foundation, was founded in 1958 with the mission to achieve sustainable advances in health care around the world by implementing health education programs and providing humanitarian assistance in areas of need. Since 1958, Project HOPE has been dedicated to developing and permanently instituting long-term solutions to pressing health problems in some of the world’s poorest countries. Today, Project HOPE’s 30+ programs are launched anywhere from the community level up to the national level and focus on five key areas: infectious disease, non-communicable disease, the health of women and children, health systems strengthening, and humanitarian assistance/disaster relief.Project HOPE began as a volunteer-driven organization, recruiting and deploying medical volunteers to serve aboard the SS HOPE hospital ship in the 1960s and early 1970s. When the ship was retired in 1974 and HOPE’s work transitioned to land-based, volunteers played a smaller role. Since the 2004 tsunami in Southeast Asia, however, HOPE has once again used large numbers of medical volunteers in connection with their partnership with the US Navy’s Humanitarian Civic Assistance programs. Today, Project HOPE’s volunteers not only deploy with the Department of Defense humanitarian assistance/disaster relief missions but also integrate volunteers throughout the organization, cross-cutting all five key practice areas within the global health department. For Project HOPE, the GEMC project is a “volunteer-augmentation program,” where the volunteers deploy to KATH with an established, preexisting program already in place and operational. The volunteers’ roles are then focused on enhancing current activities, extending current services, and building pre-determined organizational capacity using the volunteers’ skillsets and experience.Personnel from Project HOPE and UM met by chance while both were attending a conference on international ethics in Gaborone, Botswana in December 2009. From preliminary conversations held at the conference, areas of intersecting interest were explored. At that time, Project HOPE was evolving their volunteer platform within the organization to begin integrating HOPE volunteers into existing programs. Emergency physicians had rotated at another Ghanaian hospital and, in a trip report, had expressed their observed need for systems changes that were not possible with short-term rotations as they did not allow adequate time for the volunteers to understand Ghanaian culture, the way the department was run, or to develop a level of trust with emergency department (ED) staff and management. Most importantly, these other hospitals were functioning not as true emergency departments with emergency physicians and nurses but rather as acute medical and surgical wards. This setup did not allow for the introduction of emergency medicine processes. Out of leadership interest at Project HOPE and a desire to integrate into ongoing, sustainable programs, through which the needed systems changes were more likely, a partnership with GEMC became attractive.There were internal discussions at both Project HOPE and GEMC to explore the interest of both parties in joining efforts. Once it was agreed internally that a partnership appeared as though it could be mutually beneficial, there were many discussions between Project HOPE and GEMC aimed at making sure goals were agreeable to both parties.There was a consensus within GEMC about the need for a robust selection process for interested volunteers. This process would be aimed at matching the interest of the potential volunteers with the needs of the program. It was critical to GEMC that only volunteers interested in teaching and providing supervision were accepted into the program; therefore, volunteers needed evidence of demonstrated teaching experience per their CV/employment history. Those volunteers looking for an opportunity to solely provide clinical care were not eligible to be a part of the program, and some interested volunteers were not accepted into the program because of this requirement. Matching the goals of the program with the goals of the individual volunteers—expectation management—was of paramount importance to ensure all members had a positive experience that was mutually beneficial.Project HOPE posted a recruiting announcement for the opportunity on their website, and the EM-trained physicians or nurses who applied to the organization were directed to GEMC. Following this application, a phone call between the potential volunteer and the lead of GEMC, during which the programs aims and functions were discussed, was conducted. If the experience the volunteer was seeking matched with the GEMC program goals, they would be accepted for a rotation. GEMC maintained ultimate discretion as to who was accepted into the program. All Project HOPE volunteers are vetted and approved by both GEMC and Project HOPE. Accepted volunteers go through a rigorous screening process, to include completing a hospital credentialing packet, which requires letters of recommendation, license verification, transcripts, and letter of employment, performing a detailed background check for both legal and medical malpractice, obtaining a temporary Ghanaian nursing or medical license and registering with the Nurses and Midwifery Council of Ghana or the Medical and Dental Council of Ghana, all of which takes a minimum of 4 months from the time volunteers are accepted to the program. Recruitment criteria for nurses included a minimum of a BSN, who would only precept nursing students. A masters degree was preferred, and in this role, volunteers spent most of their time delivering didactic lectures.In the summer of 2010, a Project HOPE program officer conducted a site visit at KATH to ensure it was a viable location for HOPE volunteers and an official memorandum of understanding (MOU) was drafted between all parties. The MOU was finalized in November 2010 and physician and nurse rotations began in April 2011.To date, there have been 8 physicians and 10 nurses who have rotated at KATH. In total, this is almost a full year’s worth of on-the-ground faculty time by highly trained personnel. The residents at KATH have benefited greatly from the HOPE volunteers’ supervision of their clinical work. As one third year resident said, “(I) was trying to figure out what to do with a patient with pulmonary TB… The interaction taught me what to do and saved the patient’s life.” Another second year resident said, “I (believe) the Project HOPE volunteers have been very useful to us. They have been good at teaching and supportive with clinical work.” A first year resident said, “Their presence is really helpful to our residency program because we get to learn a lot any time any of them is around.”In addition to their clinical teaching time, these volunteers have each delivered at least two lectures that have been converted to Open Education Resource (OER) format. This OER conversion means the volunteers are contributing to the growing library of materials left on the ground, and their impact is felt even after they leave Kumasi. These lectures are part of the preapproved curriculum being implemented at KATH. The impact of the Project HOPE volunteers goes beyond the clinical service and supervision they provide while on the ground. As one second year resident said, “(The Project HOPE volunteer) prompted us to always try and put ourselves in the shoes of the patients and their relatives and always treat them as we would like to be treated if we were sick.” This sentiment is one that has been repeated by several of the residents who have benefited from the work of the HOPE volunteers.Project HOPE nursing volunteers have provided much needed support to the emergency nursing diploma program that GEMC facilitates. This collaboration has resulted in several key impacts: provision of clinical expertise, alleviating financial burdens, and contributing to faculty staffing. There are few specialty nursing training programs in Ghana, and the general nursing programs provide little education about emergency care. Many nursing students graduate with no formal education about the evaluation and management of injury or acute illness.Project HOPE nursing volunteers fill the “expert” clinical and content gap by spending 3 weeks (the minimum time commitment) working at the bedside and precepting emergency nursing students. The sustainable training program that has been developed will be run locally within 5 years. As with the physician volunteers, the purpose of the Project HOPE nurses is not to provide clinical care but rather to teach nurse trainees clinical care.Feedback from Project HOPE volunteers has been overwhelmingly positive. Participants were interviewed after their experience at KATH, and of those interviewed, all had a positive experience. As this was not a formal process evaluation, there was not an objective measure of satisfaction conducted, although the program reached out to all volunteers and elicited feedback. As one HOPE volunteer stated, “Overall I was very impressed with the ER Nurses at KATH. They are expected to do so much. They set up vents/bipap, care for Peds trauma patients, burns, on top of all the normal ED patients. In Red [the area of the department where the most critically injured and ill patients are cared for] everyone works great as a team in caring for the patients. It was great to be a part of their team for a few weeks. Thanks again for allowing me the opportunity to come.” The collaboration with Project HOPE has been crucial to the successful education of the first cohort of emergency nurses.Although generally smooth, this collaboration has not been without challenges, particularly volunteer recruitment. The specific requirements for the GEMC program mean that GEMC and Project HOPE are very selective during the volunteer recruitment process. Suitable volunteers are not only required to have EM training but need to meet the necessary qualifications and experience as established by KNUST and KATH in order to teach and train EM residents and nurses.The financial requirements for these placements are another challenge. Though some costs such as in-country flights and housing are taken up by GEMC and KATH respectively, volunteers are responsible for all other costs including international flights, visas, and credentialing fees required by Ghana’s medical and nursing regulatory bodies, which are $600 for physicians and $65 for nurses in 2015.Providing a comprehensive orientation for volunteers has also been quite challenging. Volunteers receive an orientation document and communicate with GEMC partners via phone and e-mail prior to their departure. However, orienting the volunteers to the hospital and the program when they arrive on site has not been as efficient as it could be, as there is not a formal orientation program in place on the ground. It has also been evident that each volunteer’s needs in orientation are different, and thus, it is difficult to develop a “one size fits all” structured orientation. In addition, volunteers are expected to teach sections of the existing Ghana College of Physicians and Surgeons—accredited curriculum to physician trainees and the Ghana Nurses and Midwives Council curriculum for nurses in an unfamiliar cultural and clinical context. It can be difficult for volunteers to fully grasp the background information the trainees have received, and it can take time for each volunteer to be oriented into the clinical practice environment and what resources are available to the trainees in their practice. Further, due to the length of time volunteers are on the ground, there is a lack of continuity for the instructors. This lack of continuity is inherent in the form of the partnership as volunteers continue teaching where a previous volunteer left off. This is improving, as there are now program graduates with administrative responsibilities in the department to provide orientation and assistance to volunteers as needed.Project HOPE is a well-established organization that has a long history of international opportunities. HOPE was looking to partner with programs that had sustainable plans and models that promoted global health and was seeking to place volunteers in areas that are underserved or have a high need for skilled health workers. GEMC had a program that was built with significant Ghanaian influence and guidance for sustainability and was seeking skilled health workers and educators to advance their mission. With these goals, the two organizations filled a need for each other for a strong partnership.Despite the few challenges in establishing and conducting this collaboration, it has been highly successful and is still ongoing. Qualitative feedback from hospital staff, leadership, and trainees has been overwhelmingly positive, indicating strong support of the partnership. There is no shortage of global health volunteer opportunities; however, we believe the partnership described above is an example of how programs can utilize the expertise and energy of short-term volunteers to impact long-term change and sustainability.


Juvenile idiopathic arthritis (JIA) is a chronic rheumatic disease. Patients suffer daily discomforts such as pain, fatigue, stiffness, and mood disturbances. Their exercise capacity is decreased to a variable degree and physical activity levels may be impaired. To prevent long-term cardiovascular risks associated with JIA and medication, it is important to encourage physical activity. To achieve this we developed Rheumates@Work (R@W), a combined internet-based and in person instruction model, an interactive, educational, and cognitive behavioral program. The aim of this study is twofold: to describe the theoretical background and design of R@W based on Pender’s Health Promotion Model, and to assess its acceptance.We enrolled 8 to 13-year-old JIA patients, from 3 outpatients clinics in The Netherlands, in R@W. Inclusion criteria were a low disease activity (VAS physician <20 mm), comprehension of the Dutch language and absence of relevant co-morbidity. We assessed acceptance by measuring the participants’ commitment to the program, the level of interaction on patient’s initiative (f.e. mails send by the patient), technical aspects and satisfaction. Commitment was defined as the percentage of participants that completed the assignments and how much encouragement the participants needed for this. Satisfaction was measured with an anonymous questionnaire concerning f.e. time investment and perceived benefits. Costs were monitored.Of the 64 patients we enrolled, 23 boys and 41 girls, 93.8 % completed the program. Participant-initiated interaction was seen in 10.7 %, 24.7 % send a mail because of technical problems. Eighty-two percent of the participants and 99 % of the parents liked the program, and 85 % of the participants indicated that they had learnt something, or quite a lot. Development costs of the program were low.The HPM is suitable for a behavioral intervention program such as R@W. Acceptance and satisfaction of R@W were high and the costs of the program were low.ISRCTN92733069Trial Number: The online version of this article (doi:10.1186/s12969-015-0029-5) contains supplementary material, which is available to authorized users. Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease of childhood, with a various disease course –4. Due tDaily physical activity plays an important role in preventing chronic conditions, including diabetes, cardiovascular diseases, and obesity –21. EvidIn order to achieve this aim, we developed Rheumates@Work (R@W) , a combined internet-based and in person instruction model, an interactive, educational, and cognitive behavioral program to increase physical activity in 8 to 13-year-olds with JIA. R@W emphasized the importance of coping strategies, self-efficacy, and self-management. Results of a single center pilot of R@W published in 2010 showed that the intervention resulted in an improvement of PA in those patients with low PA levels. It was also able to improve endurance and it was safe, feasible, and had good adherence . The pilThe first aim of this paper is to assess the acceptance of R@W in terms of commitment, level of interaction, technical aspects, costs, effort, satisfaction, educational content, and the perceived benefits of the program. The second aim is to describe the theoretical background and the design of R@W. Results of the intervention on PA will be described separately.All JIA patients aged 8 to 13, from the following departments or hospitals, were invited to participate: the Departments of Pediatric Rheumatology at Beatrix Children’s Hospital (BCH) and Wilhelmina Children’s Hospital (WCH) of University Medical Center Groningen and University Medical Center Utrecht, respectively, and the Reade Center for Rehabilitation and Rheumatology in Amsterdam. Approval was obtained from each center’s medical ethics committee. Inclusion criteria were: diagnosed with JIA, good comprehension of the Dutch language, and access to a computer and to the internet. Patients with high disease activity, defined as > 20 mm on a 0–100 mm physician visual analog scale, were excluded. They could, however, still be included after six month if inactive disease was achieved. Patients with a physical disability caused by another chronic disease were excluded. Each January and September, from 2011 until 2013 a new group with a maximum of 15 patients started. To measure the effect of R@W on physical activity, the patients were randomly assigned to an intervention group and a waiting list group with an electronic function of SPSS version 22. The waiting list patients could participate in the R@W program after a six-month waiting period. R@W ran from September to January or from January to June. The outcome of R@W on physical activity is beyond the scope of this paper. In this paper we measured acceptance based on the participation of all the children in the program without taking into account the results of the randomization.Acceptance was described as commitment to the program, technical aspects, level of interaction and satisfaction.Commitment to the program was measured by the number of participants who had completed the weekly assignments on Monday. We counted the number of participants who had only completed the assignments and the number of participants who had completed both the assignments and the theory. We monitored whether the participants had done the assignments, be it completely or incompletely (fantasy answers were regarded as incomplete). The results were expressed in the average of the percentage calculated for each week of patients who had completed the assignment by Monday. We also monitored how long it took for patients with a backlog to catch up again. We noted the individual reasons for incurring a backlog. We counted the number of participants who needed an e-mail on Friday to encourage them to complete that week’s assignments. We also registered attendance at the group sessions and the reasons for absenteeism.technical aspects of the program we monitored by collecting the e-mails dealing with technical problems, such as log-in problems, crash of the site, etc.The level of interaction we monitored by counting all the e-mails that were sent by the patients to initiate contact with the supervisor, and by registering participation in the chat sessions.The costs by adding the cost of developing the program, the staff costs when conducting the program, and by monitoring the financial consequences for the participants for example traveling expenses, money needed for a babysitter for the sibs.We calculated the satisfaction with the program by asking the participants and their parents to separately fill out an anonymous questionnaire  Fig.  26, 27], 2726, 2For a cognitive behavioral program to be successful it has to be adapted to patients’ experiences. In order to adapt the HPM to the specific requirements of JIA patients, we reviewed the burden of living with JIA from the patients’ point of view and integrated this with the contents of R@W. Two qualitative studies reported on the impact of living with JIA and what patients required to manage their disease , 31. AltWe designed R@W with a view to encourage physical activity, to stimulate self-management strategies, to improve self-efficacy, and to educate patients about JIA. For this purpose we applied the three groups of determinants of health-related behavior of the HPM, i.e. individual characteristics and experiences, behavior-specific cognitions and affect, and situational and interpersonal influences to the circumstances of children living with JIA. These patients need to overcome all barriers hindering health-promoting behavior and need to become aware of the benefits of such changes in behavior , 27.. In R@W we described health-promoting behavior in terms of primary and secondary outcome measures. We defined the primary outcome measure as improvement in the level of physical activity. We used the secondary outcome measure to improve the patients’ knowledge about JIA and to stimulate self-efficacy in dealing with different aspects of JIA, such as pain, setbacks, energy management, and taking medication. The starting point of the program was based on each patient’s prior related behavior, defined as the patient’s activity level as measured by a seven-day activity diary, and on personal factors defined in terms of gender, age, disease activity, joint damage, and functional disability. We assisted the participants in setting attainable goals to improve their health-promoting behavior. These goals were based on the individual patient’s activity level and personal situation.The aim of the HPM is to improve health by achieving health-promoting behaviorbehavioral cognitions and affect, and situational and interpersonal relations. These we supplemented with topics such as pain, energy management, medication, and peer support, since we knew that these are important issues for patients in managing their disease [In order to achieve health-promoting behavior, R@W addressed  disease , 31. Thecommitment to a plan of action by inviting the patients to sign a ‘declaration of commitment’ at the end of the first group session. During the last session we rewarded the participants by giving them each a Certificate of Participation.We realized R@W lasted 14 weeks. Each week we introduced a new topic through film, animation, puzzles, a spoken text, brain twisters, and/or assignments , which measures maximum endurance time [our physical fitness is excellent”, or “Your physical fitness is moderate and requires improvement”, or “Your physical fitness requires considerable improvement”. Based on the results of the patient’s level of activity and his or her physical fitness, and taking into account disease activity, we set a goal, together with the participant, for the next 14 weeks. Examples of goals were: “I want to be just as fit as Buddy. To reach this goal I will ride my bike to school at least three days a week”. Or “To reach this goal l will take the dog on a brisk walk of at least 30 min every day. After the goal was set, the patient signed the ‘declaration of commitment’ to the program.Also prior to starting the program, the patient’s actual physical activity level (prior behavior) was measured with a seven-day activity diary and with an accelerometer. The results were correlated with the Dutch standard for physical activity . This stnce time , 33. Resnce time . These rHello Rheumates! A new week is now open and we will talk about …. Good luck!”). On Wednesday, a standard reminder was sent to the participants by e-mail (“Attention please! It’s Wednesday. Did you remember to do your assignments?”). On Friday, only the patients who had not yet completed that week’s assignment received a reminder by e-mail .The program started with the first group session. On the following Monday, the first internet week was released, and the web administrator released a new week on every Monday thereafter. A single click revealed the theory, the assignments, and each participant’s the tip of the week, and an e-mail was sent to draw attention to the fact that a new week was available on line  were willing to participate . We were not allowed by the Ethics Committee to ask patients and the parents the reason for not willing to participate in this study. Some patients and parents spontaneously indicated why they were not interested to participate. Reasons included: “By Monday, a mean of 53 participants (82.1 %) had fulfilled that week’s assignment completely and 8.6 (12.7 %) had caught up after two weeks Table . A mean On Friday, we send a reminder by e-mail to a mean of 17.9 participants (26.7 %). Group Sessions 1 to 3 were well-attended, i.e. by 54 to 58 (84.4 % to 90.6 %) of the participants. Group Session 4 was less well-attended by 47 patients (73.4 %). The reasons given were: on holiday, a sports tournament, a birthday party, influenza, no babysitter available to take care of the participant’s siblings, hospitalized, or weather conditions. In some cases no specific reason was given. There was no difference in the commitment between centers.A mean of 1.7 (2.7 %) participants per week sent an e-mail concerning technical aspects. These included log-in details that had been forgotten, joints on the skeleton that had been colored incorrectly, or participants were unable to print a form which was needed for an assignment.My goal is to run three times a week, but I find it so boring. But now I take my dog, and every time he has to pee I take a rest”, “I got a surfboard for my birthday, now my muscles are aching terribly, but I’m glad this pain isn’t due to the arthritis” One boy kept on e-mailing long after he had completed the program “Hi Buddy, I started a new school with many stairs, but I divided my energy so I got on very well”.Every week a mean of 6.9 (10.7 %) participants took the initiative to send us an e-mail Table . Of thesSome participants sent e-mails because they were unclear about the assignments or about the dates of the group sessions. A couple of children reacted to the reminder e-mail by explaining why they had failed to complete that week’s assignment or they made a commitment about when they would complete the assignment.Only 26.6 % of the participants took part in the chat sessions.Coping with arthritis on a more conscious level, learning about energy management, limits, and physical activity”.Overall, 81 % of the participants and 99 % of the parents liked R@W. Time investment was just fine or too short for 83 % of the participants. Seventy-one percent of the parents rarely, or never, needed to encourage their children. Ninety-five percent of the participants understood the theoretical topics well or very well. The level of the program and the assignments were perceived as adequate or too easy by 97 % to 89 % of the participants. Seventy-six percent of the parents reported that they had rarely or never needed to help their children. Eighty-five percent of the participants and 75 % of the parents indicated that they had learnt something, or quite a lot. The patients felt that they had learnt something about pain in 84 %, energy management in 84 %, arthritis in 87 %, and about setting goals in 85 % of the cases. Ninety-five percent of the parents felt that their child learnt something or quite a lot. For example: “Eighty-two percent of the participants liked R@W as did 99 % of the parents. Parents and participants wrote about positive aspects of R@W and gave suggestions to improve the program Table . Group sA physiotherapist, a pediatric rheumatologist, and a psychologist developed the contents of the program with financial support amounting to € 10,000. Computer science students developed the technical part of the program as part of their Master’s degree by, for example, working on the application, the sound effects, cartoons, and the chat box. Students of the School for Web Design designed the lay-out of the program. A student teacher adapted the language used in R@W to suit children aged 8 to 13. The total direct costs amounted to less than € 1 500.Staff deployment for the group sessions is described in Table The program consumed a maximum of one hour per week of the participants’ time. If possible, the group sessions were combined with a regular check-up visit to the physician.A reason for the high rate of commitment could be that the participants in our study were well-motivated and actively sought help in dealing with their disease. Only 30 % of the patients we approached were willing to participate. This could indicate that the participants represented the most motivated children. We did not find a difference in commitment between the three centers, even though the number of patients from each differed greatly. We were not allowed by the Ethics committee to ask why patients were not motivated to participate, so we do not know the reasons for the differences in participation between the hospitals. A possible explanation could be that the children in BCH knew the project leaders and thus were inclined to feel more committed. Another reason could be that in WCH many of the patients were already participating in one or more studies. Finally, a factor that could have influenced the participation rate at Reade was that many of the patients had just completed a rehabilitation program, which had been offered to many children diagnosed with JIA. In the BCH, where we had a participation of 88 %, almost all children completed the program. Potentially less motivated children also completed the program.We based the topics on what we knew from the literature as being the burden of living with JIA. R@W reflects the needs of the patients . This prThe high commitment could also be explained by the declaration of commitment we asked the participant to sign. Possibly this made them adhere to the program more than they might have done otherwise. According to the HPM it is important to literally commit oneself to the program .R@W lasted 14 weeks with a time investment of at most one hour a week, which seemed reasonable to the participants. Although the role of duration and time investment in participants’ adherence is not explicitly described in the literature, it could be one of the factors influencing commitment .Another reason might be the interactive character of the program, which could have had an engaging effect on the participants. The value of interaction for the strength of patient commitment has not been investigated in the literature. Our analysis showed that more than a third of the participants had some kind of contact with the supervisors. In most cases this contact centered on reminder e-mails. We did not investigate whether this led to increased commitment or not.We point out that our program was based on an existing theory developed for the express purpose of changing health-promoting behavior.Finally, R@W was combined with group sessions, which involved a limited number of participants at a time. This could have increased participants’ commitment and adherence to the program as well as that of their parents. In a study with adolescent patients, parents were less compliant than their adolescent children. In our study, however, we found that parents of our patients aged 8–13 years, were well-motivated to complete the program . The parJIA has a major impact on patients’ everyday life. Patients suffer from daily symptoms, which influence physical and psychosocial aspects of their lives. R@W is the first interactive cognitive behavioral program for children with JIA aimed at improving physical activity. Commitment to R@W was high and similar to the results of an internet-based self-management program for adolescents with JIA which supported participants by telephone  and highAttendance of the group sessions was also good, but less compared to the internet program itself. An explanation could be the time investment to come to the hospital - some patients had to travel as much as one and a half hours to reach the hospital. Group sessions were organized on the participants’ school-free afternoons, which obliged them to choose between sports, birthday parties, or some such activity, and the group sessions. Participants could complete the internet assignments in their own time. Moreover, not all parents were able to take time off work or to combine the group sessions with the obligations for siblings.As a result of the high satisfaction rate of the participants and their parents, we conclude that the contents of R@W met their needs for education and skills to deal with the program. Most of the suggestions given to improve the program related to the age categories. The age range of 8 to 13 seemed to be too wide and dividing the group in 8 to 11 and 11 to 13 could be a better option for the program. The theory and assignments appeared to be a bit difficult for the youngest and too childish for the oldest participants. If implementing R@W as a standard educational tool for all patients with JIA, we would suggest either selecting patients aged 9 to 11 years, or developing two different programs – one for 8 to 11-year-olds and another for 11 to 13-year-olds. Although patients and parent were positive on the effect of the program the effect on PA, effects on health related quality of life and fatigue need to be evaluated.The costs of the program were relatively low. The time investment for both staff and participants seemed reasonable. Both the patients and their parents were satisfied.In our opinion, the HPM is a suitable model to design a behavioral intervention program such as R@W. Acceptance of the program was high and the costs and effort of the staff to manage it, once the program had been developed, were low.This study does, however, have its limitations. We did not study the reasons why patients were unwilling to participate and, therefore, we cannot assess whether or not our results were influenced by certain biases. Another limitation is that we did not measure knowledge before and after the program was completed, so that we were unable to check the increase in knowledge reported by the participants and their parents. Social desirability could be a limitation of the results of the measurement of satisfaction. Although the participants were asked to be critical on the program, for reason that the feedback should be used for further improvement of the program, we cannot exclude that the participants gave social desirable answers. A final limitation could be that only patients with low disease activity were included. This was done because we aimed with R@W to improve physical activity. Children with high disease activity at the start of the program will improve during 14 weeks on their PA levels simply by reduction of disease activity. Selection of children with low disease activity could have been a bias for the result of acceptance.We conclude that R@W, an interactive combined internet-based and in person instruction model, cognitive behavioral program, stemming from a social cognitive theory such as Pender’s HPM, is a way to educate children, to stimulate them to be more active, teach them self-management skills, and to provide them with peer support. Commitment and satisfaction on the part of the participants were high and the costs were low.Written informed consent was obtained from the patient’s guardian/ parent/next of kin for the publication of this report and any accompanying images.


Chronic Myeloid Leukaemia (CML) is caused by the BCR/ABL1 fusion gene. Both the presence and the levels of BCR/ABL1 expression seem to be critical for CML progression from chronic phase (CP) to blast crisis (BC). After the oncogenic translocation, the BCR/ABL1 gene is under the transcriptional control of BCR promoter but the molecular mechanisms involved in the regulation of oncogene expression are mostly unknown.A region of 1443bp of the functional BCR promoter was studied for transcription factor binding sites through in-silico analysis and Chromatin Immunoprecipitation experiments. BCR and BCR/ABL1 expression levels were analysed in CML cell lines after over-expression or silencing of MYC transcription factor. A luciferase reporter assay was used to confirm its activity on BCR promoter.In the present study we demonstrate that MYC and its partner MAX bind to the BCR promoter, leading to up-regulation of BCR and BCR/ABL1 at both transcriptional and protein levels. Accordingly, silencing of MYC expression in various BCR/ABL1 positive cell lines causes significant downregulation of BCR and BCR/ABL1, which consequently leads to decreased proliferation and induction of cell death.Here we describe a regulatory pathway modulating BCR and BCR/ABL1 expression, showing that the BCR promoter is under the transcriptional control of the MYC/MAX heterodimer. Since MYC is frequently over-expressed in BC, this phenomenon could play a critical role in BCR/ABL1 up-regulation and blast aggressiveness acquired during CML evolution. Chronic Myeloid Leukaemia (CML) is a clonal myeloproliferative disorder caused by the constitutive tyrosine kinase activity of the BCR/ABL1 fusion protein, the product of the Philadelphia (Ph) chromosome, generated from the t translocation  (sc-197X)(Santa Cruz Biotechnology), mouse anti c-MYC[9E10] (sc-40)(Santa Cruz Biotechnology), rabbit anti-c-ABL[K-12] (sc-131)(Santa Cruz Biotechnology), rabbit anti PARP-1[E102] (ab32138) and anti-ACTIN (A2066).Western Blot was performed as previously described  using th5′GAGGTAGGTGGTGGGGCTTGGCTGTTCCAGGACTGCAGGACTG3′; MycMax-34-Rw 5′CAGTCCTGCAGTCCTGGAACAGCCAAGCCCCACCACCTACCTC3′.pGL3_BCR promoter constructs were obtained as in . Briefly, FUGW-H1-scrambled control shRNA (shNC) was a gift from Sally Temple [MYC silencing was generated infecting K562, LAMA-84 and KCL-22 cells with lentiviral particles obtained from modified FUGW lentiviral vectors: FUGW-MYC-shRNA(shMYC) kindly provided from Dr. RN Eisenman , FUGW-H1y Temple   and introducing artificial HindIII and EcoRI sites at the 5′ and 3′ ends of the coding region were used for amplification and the PCR product was cloned into the pCDNA3 vector. Sequences of the primers were: MAX_Fw iam Hahn   or the scrambled-shRNA(shNC). RT-qPCR and Western Blot were used to confirm MYC down-regulation. Infected 293 cells were then co-transfected with pRL and pGL3/BCR promoter constructs prepared as described in Marega et al.  and luciCell viability was monitored by CellTiter 96 AQ One Solution Cell Proliferation Assay (Promega). The MTS tetrazolium reagent was added to the cells after 24h, 48h, 72h and 96h from seeding. Absorbance was assayed with a Wallac 1450 MicroBeta Trilux (PerkinElmer).Cells were fixed in ethanol and stained with propidium-iodide (Sigma-Aldrich). Flow cytometry was performed on a Becton Dickinson FACSCalibur  and data were analysed by FCS Express 4 Flow Research Edition software.T-test) were performed by the GraphPad Prism  statistical package.All the statistical analyses (unpaired two-tailed


Compared to naïve B cells, IgM memory B cells had lower integrated mean fluorescence intensity (iMFI) of BAFF-R, CD38, CD73, and IL-21R, but higher iMFI of CD95, CD11c, TLR9, PD-1, and CD122. Compared to switched memory B cells, IgM memory B cells had higher iMFI of BAFF-R, PD-1, IL-21R, TLR9, and CD122, but lower iMFI of CD38, CD95, and CD73. Four days after receiving the CpG/cytokine cocktail, higher frequencies of IgM than switched memory B cells—and these in turn greater than naïve cells—proliferated and differentiated to antibody secreting cells. At this time point, a small percentage (median of 7.6%) of stimulated IgM memory B cells changed isotype to IgG. Thus, among the heterogeneous population of human circulating IgM memory B cells a subset is capable of a rapid functional response to a CpG/cytokine stimulus in vitro.Circulating human IgM expressing memory B cells have been incompletely characterized. Here, we compared the phenotype and  SampleThe Hemocentro Distrital, Bogotá, Colombia, provided buffy coats from de-identified healthy donors that signed informed consent forms. From these buffy coats, an enriched suspension of circulating B cells was obtained by negative selection by rosette formation , as previously described . The enr6 cells/ml) with CFDA-SE  for 5 min at room temp protected from light. After being washed three times with 10ml of PBS 5%, FBS 5%, naïve Bc and IgM mBc and switched mBc were stimulated, as previously described [2 in flat bottom 48 well plates for different periods of time. At the end of the cultures, cells were washed twice with sterile PBS and stained on ice with AQUA (Invitrogen Molecular probes) and subsequently with antibodies  against (labeled): CD19 (APC-H7), CD38 (PerCp-Cy5.5), CD27 (PE-CF594). After washing, cells were resuspended in 100 μl PBS, 0.5% BSA (Sigma-Aldrich) plus 250 μl of cytofix/cytoperm (BD Pharmingen) and incubated for 20 min at 4°C. After washing twice with perm/wash (BD Pharmingen) cells were stained with antibodies against IgM APC (Jackson ImmunoResearch) or IgG APC (BD Bioscience) for 30 min on ice. Samples were acquired on a LSR Fortessa (BD Bioscience) and analyzed using FlowJo v.9.3.2 .B cells subpopulations were labeled with carboxyfluorescein succinimidyl ester (CFSE), as previously described , with miescribed , adaptinSince data was not normally distributed, non parametric tests were used for comparisons. Differences among groups were determined using Kruskal-Wallis tests followed by a Wilcoxon signed-rank test using GraphPad Prism software v.5.0a for Mac OS X, GraphPad Software . Significance was established if p<0.05. Data are shown as median and interquartile range.- IgD+: the transitional Bc subset was not excluded from the analysis), IgM mBc (CD27+ IgD+ IgM+: which included the IgM only but not the IgD only subpopulations) and switched mBc (CD27+ IgD- IgM-), as described in Bc (CD19+) were separated into naïve  of naïve Bc and IgM and switched mBc, Bc were enriched from buffy coats of blood bank volunteers by rosette formation and subsequently each subset was purified by the sorting strategy described in hi CD38hi) was between days three and four, for both types of mBc  compared to switched mBc and naïve Bc, and a subset of IgM mBc are already capable of switching to IgG  , a higheg to IgG . We haveg to IgG .Antigen independent functional response to T cell dependent CD40L) or independent (CpG) stimuli (in the absence or presence of multiple cytokines) of human spleen naïve Bc and IgM and switched mBc have been extensively compared 0L or ind, 39. In Staphylococcus aureus Cowan, IL–2, IL–10, and anti-CD40 for eight days, a similar differentiation of CD27+ IgD+ mBc (most probably IgM mBc), and CD27+ IgD- mBc (most probably switched mBc) to CD38+ ASC was observed [+ mBc CpG induced increased IgM secretion, compared to CD40L [Studies that have compared blood naïve Bc and IgM and switched mBc are scarce: while  [Our results showing that IgM mBc, but not naïve Bc, can change isotype to IgG by day four  are coheIgM mBc) . NonetheIgM mBc) . Altogetin vitro survival advantage that could be reflected on their increased proliferation frequencies   in vitro+ CD27+ Bc is a subject of controversy [+ IgM+ IgD+ Bc are clonally related to switched mBc, suggesting that at least a fraction of these Bc may be true IgM mBc. In support for this hypothesis, CD27+ IgM+ IgD+ cells transferred to immunodeficient mice immunized with Streptococcus pneumoniae [+ IgD+ mBc specific for rotavirus [+ IgM+ IgD+ Bc are true mBc. Finally, as previously mentioned, IgM mBc (excluding IgM only mBc) share a similar gene expression pattern with switched mBc [+ IgM+ IgD+ Bc seem to be heterogenous, a part being innate  while other being antigen dependent mBc (probably GC-) [The nature of human blood IgMtroversy , 30. At troversy , 50, whitroversy . Besidestroversy , but nottroversy , have sheumoniae  can deveotavirus , 18, tetotavirus , 54, andched mBc . Thus, tbly GC-) .In conclusion, we have shown that a subset of IgM mBc rapidly proliferate and differentiate to ASC early after stimulation with CpG/cytokines. The functional assay we have described Figs  and 5, aS1 FigAs indicated in the figure, sorting experiments include a negative microbead enrichment step that incorporated microbeads with antibodies against CD3, CD14, CD16, and CD56. Moreover, staining for both phenotype and sorting experiments included a dump channel with antibodies against CD3, CD14, and AQUA.(TIF)Click here for additional data file.S2 FigRepresentative histograms of the markers studied in naïve Bc (blue), IgM mBC (red) and Sw mBc (green) subsets. Solid gray histogram represents fluorescence minus one (FMO).(TIF)Click here for additional data file.S3 FigSummary of intracellular TLR9 iMFI of naïve Bc and IgM mBC and Sw mBc (n = 6).(TIF)Click here for additional data file.S4 Fighi CD27hi) of IgM (brown) and switched mBc (blue) four days after stimulation with CpG, a cocktail of cytokines , and murine fibroblasts (as feeder cells) for two, three, four, and five days. Kinetic experiments for early  and late responses  were also performed using ELISPOT as readout (data not shown). Since the early time point experiments showed comparable results to the flow cytometry presented in this figure and cell mortality was above 80% in the late time point experiments (data not shown), we chose day four for the experiments reported elsewhere in this paper.Kinetic experiment of proliferation and differentiation to ASC (CD38(TIF)Click here for additional data file.S5 FigCells from a buffy coat were sorted like for the functional experiments of Figs (TIF)Click here for additional data file.