This study evaluated the efficacy of cationic nanoparticle (leciplex) to deliver carvedilol to ocular surface for glaucoma treatment as recent studies pointed out the effect of topical carvedilol on intraocular pressure, therefore carvedilol loaded leciplex formulae were prepared using soy phosphatidyl choline (SPC) and cationic surfactant (CTAB/DDAB) and characterized for morphology, entrapment efficiency, particle size, zeta potential and ex-vivo corneal permeation. Then the selected formula was evaluated via in-vivo studies in comparison with carvedilol solution. Leciplex nanoparticles appeared spherical in shape with entrapment efficiency exceeded 95% in all formulae. Leciplex formula composed of SPC and DDAB in (1:1) molar ratio showed the smallest particle size (16.04 ± 1.2 nm), highest zeta potential value (53.9 ± 0.91 mv) and highest apparent corneal permeability coefficient (0.1157 cm/h). Carvedilol leciplex reduced intraocular pressure (IOP) to normal range in ocular hypertensive rabbits after 30 min and duration of action lasted for 24 h, while carvedilol solution reduced IOP to normal value after 60 min and duration of action lasted for 6 h. Furthermore, histological examination of eyeballs of rabbits treated with carvedilol leciplex showed improvement of retinal atrophy of glaucomatous eyes. This study concluded that leciplex improve transcorneal permeation and bioavailability of carvedilol. Carvedilol is a beta-adrenergic blocking agent, indicated for the treatment of hypertension, angina pectoris, and heart failure . Recent Topical eye drop is usually selected for the treatment of eye diseases as it is the most desirable dosage form. However, traditional eye drop usually suffers from low bioavailability due to the limited eye capacity, blinking reflex, lachrymal fluid erosion and nasolacrimal drainage. Also corneal and conjunctival epithelia of human eye, along with the tear film, construct a compact barrier preventing the drug absorption into the intraocular area which shorten the retention time in the eyes and produce less absorption in the intraocular area , therefoThe use of colloidal drug delivery systems such as liposomes, niosomes, microemulsion, nanoemulsion and nanoparticles in ophthalmic drug delivery have been widely studied. Advantages of colloidal carriers include sustained and controlled release of the drug at the targeted site, reduced frequency of administration, ability to overcome blood–ocular barriers, and efflux-related issues associated with the parent drug and ease of administration as it can be applied in liquid form just like eye-drops solutions. Thus, they avoid the discomfort that results from the application of viscous or sticky preparations . DespiteSeveral attempts have been made to prolong the preocular retention, improve the absorption of the drug and increase patient compliance by reducing the number of required administrations . One of Leciplex is self-assembled phospholipid based cationic nanocarriers for the improved delivery of hydrophobic drugs. The advantage of leciplex over traditional vesicular systems is in simplicity of preparation as it is a one-step fabrication process that yields nanosized vesicular systems by simple mixing . The majLeciplex improve oral delivery of hydrophobic drugs as quercetin where cationic nanocarriers are known to increase the permeability and uptake of the drug associated with them . Also, cThe current study is focused on screening efficacy of leciplex as ocular drug delivery system, therefore carvedilol leciplex were prepared and evaluated. Ex-vivo and in-vivo permeation studies were conducted and reduction of IOP was assessed in comparison with carvedilol solution.@ HP) was obtained from Gattefosse India Ltd., Mumbai, India, potassium dihydrogen phosphate, disodium hydrogen phosphate and sodium chloride were purchased from El-Nasr Pharmaceutical company, Egypt, soy phosphatidylcholine, cetyltrimethylammonium bromide (CTAB) and dimethyldidodecylammonium bromide (DDAB) were purchased from Sigma-Aldrich, St. Louis, MO, USA. All other reagents and solvents were of HPLC analytical grade obtained from Fisher Scientific company, Waltham, MA, USA.Carvedilol was kindly gifted by Global Nabi pharmaceuticals company, Egypt, highly purified diethylene glycol monoethyl ether . All animal studies were approved by the ethical committee of Misr university for science and technology.Soy phosphatidylcholine and the cationic surfactants (CTAB/DDAB) were used in a 1:1 or 5:1 molar ratio as shown in One milliliter of carvedilol leciplex was centrifuged at 20,000 rpm for 1 h at 4 °C using a cooling centrifuge . Following centrifugation, the sediment was lysed using 5 mL of methanol and sonicated for 10 min then analyzed at 242 nm using UV-Vis spectrophotometer . Carvedilol entrapment was determined using the following equation:Particle size (PS), polydispersity index (PDI) and Zeta potential (ZP) for leciplex formulae were measured by the dynamic light scattering (DLS) technique at 25 °C using Zetasizer . The leciplex dispersion was properly 100-fold diluted with purified water. Means and standard deviations were calculated for triplicates measurements.The morphology of leciplex was analyzed using a transmission electron microscope (TEM) . Samples were placed on the surface of carbon coated grid and negatively stained with a 1% aqueous solution of phosphotungstic acid and dried at room temperature prior to visualization [2. Fresh cow cornea was fixed between the donor and receptor compartments. Accurately measured 200 µL of leciplex dispersion, equivalent to 1000 µg of carvedilol, were placed in the donor cells. The receptor compartment filled with 10 mL of phosphate buffer saline solution (pH 7.4) containing 20% propylene glycol to ensure sink condition and maintained at 35 ± 1 °C under magnetic stirring at 100 rpm. At appropriate time 0.5 mL of permeation media was withdrawn and an equal volume of fresh media was added into the receiver cell. The samples were filtered through a 0.45 µm membrane and analyzed by using a validated HPLC method. Carvedilol solution was used as a control and the results were reported as the mean of three runs. The amount of drug permeating through the corneal epithelium was plotted versus time, and the apparent corneal permeability coefficient (cm/h) was determined according to the equation: Papp = Jss/C0 where Jss (steady stat flux) is the slope of the linear portion (µg/hr·cm2) and C0 is the initial drug concentration (µg/cm2).Ex-vivo corneal permeation studies were carried out using modified franz’s diffusion cell with a diffusion area of 0.785 cmThe rabbits were randomly divided into the following two groups: a group treated with the carvedilol solution and a group treated with the selected carvedilol leciplex dispersion. The rabbits were kept under anesthesia throughout the experiment using sodium pentobarbital (30 mg/kg) injected into the marginal ear vein. After administration of 100 μL carvedilol solution or leciplex formulation (both 5.0 mg/mL), 100 μL aqueous humor was extracted with 1 mL insulin needle after 15, 30, 60, 120, 240, and 360 min and placed in a centrifuge tube. Protein was precipitated by vortex mixing with 0.5 mL methanol. Precipitated protein was removed by centrifugation at 10,000 rpm for 10 min, and the concentration of drug in the supernatant was determined by HPLC. The pharmacokinetic parameters were calculated by noncompartmental method using the WinNonlin pharmacokinetic software .The rabbits were topically anesthetized with paclitaxel eye drops. Dexamethasone (0.025%) was dissolved into saline and injected into limbus for each eye. The IOP was measured by an ophthalmotonometer . If the IOP was higher than the upper limit of the normal IOP of 24.4 mmHg and continued for 1 week, the model was considered successful. Rabbits with high IOP were randomly assigned into two groups (six rabbits per group) where the first group (GP1), the left eye only of each rabbit was treated with single dose 100 μL carvedilol solution and the right eye was treated with saline solution and considered as sham control. The second group (GP2) the left eye only of each rabbit was treated single dose 100 μL carvedilol selected leciplex formula and the right eye was treated with saline solution and considered as sham control. The IOP was measured for 2 days and effects of lowering IOP were compared.Following the pharmacokinetic and pharmacodynamic studies, the rabbits were sacrificed by injecting phenobarbital sodium to marginal vein, then eyeballs were removed and placed either in 10% formalin. Tissue specimens were trimmed off, washed and dehydrated in ascending grades of alcohol. The dehydrated specimens were then cleared in xylene, embedded in paraffin blocks and sectioned at 4–6 µm thick. The obtained tissue sections were deparaffinized using xylol and stained using hematoxylin and eosin (H&E) for histopathological examination through the electric light microscope .p < 0.05) was considered to be statistically significant.To investigate the significance difference between the results of studied formulae, the one-way analysis of variance (ANOVA) test was used. The level of significance was set at 0.05, and (p > 0.05), the encapsulation of hydrophobic drug carvedilol (log P 3.22) exceeded 90% in all formulae as shown in There was no significant difference between encapsulation efficiency of different leciplex formulae (p < 0.05), these results might be attributed to stabilizing property of DDAB which was demonstrated by the high surface charge obtained by DDAB leciplex compared to CTAB leciplex. The high surface charge was correlated with decreased aggregation and fusion of nanoparticle and led to subsequent decrease in particle size. These results are in agreement with Varghese et al. who found that particle size of lecithmer formulations was dependent upon stabilizing properties of cationic agent (DDAB/DOTAP). As increasing surface charge led to increase stabilizing properties with subsequent reduction in particle size [The particle size is a crucial factor affecting ophthalmic formulations. Generally, the particle size of nanocarriers that are able to penetrate through the cornea should be smaller than 200 nm . Also, scle size . All DDAB/CTAB leciplex formulae revealed positive surface charge (+31.6 to +53.9 mv) indicating good colloidal stability, the preferential of positive charge for these formulae is to promote the electrostatic interaction between cationic nanovesicles and the negatively charged sialic acid residues of corneal mucins . DDAB foThe TEM micrographs of carvedilol leciplex formula (F2) showed that the leciplex nanovesicles have almost spherical shape as shown in 8) 480.36 ± 0.58 µg/cm2 which was 2.38 times higher than that of drug solution as shown as in Cationic positively charged nanovesicles are not likely penetrate the cornea but rather than bind to the negatively charged mucus . TherefoIn general, DDAB leciplex formulae showed better permeation parameters than CTAB leciplex formulae as shown in app equal to 0.03515 µg/cm, this can be attributed to increased particle size. Leciplex formulae prepared without cationic surfactant (F5 and F6) showed low permeability coefficient 0.0078 and 0.00415 µg/cm, respectively compared to drug solution which showed P1/2) of carvedilol solution was 4.48 ± 0.8 h and the area under the curve (AUC) from 0 to 6 h was 41.79 ± 2.8 μg h/mL. Carvedilol solution had peak concentration (Cmax) of 5.93 ± 0.42 μg/mL. On the other hand, the results obtained from second group (GP2) which was treated with carvedilol leciplex showed the following parameters, AUC of 74.47 ± 1.3 μg h/mL, indicating a higher drug bioavailability. The leciplex had a peak time (tmax) of 30 min, which was shorter than that with carvedilol solution indicating rapid onset of action. Its Cmax was 7.53 μg/mL, which was higher than that for carvedilol solution. Carvedilol incorporated into leciplex had a t1/2 of 7.0 ± 0.67 h, which was 1.56 times longer than that of the carvedilol solution. Its average retention time (MRT) was 10.30 h, which was the 1.5 longer than drug solution. These results were consistent with the higher transcorneal permeability of carvedilol leciplex compared to carvedilol solution. It can be concluded from the pharmacokinetic study that the leciplex was capable of prolonging the retention time of carvedilol and enhance its bioavailability. These results are in agreement with several studies showed the effect of encapsulation the drug into nanoparticles on drug pharmacokinetics in aqueous humor where Ban et al. found that dexamethasone charged lipid nanoparticle revealed higher drug retention time and enhanced drug permeation to the cornea and consequently higher ocular bioavailability in comparison with dexamethasone aqueous solution [The drug concentration–time profiles and pharmacokinetic parameters were detected after single instillation as shown in solution . Also, Hsolution . max and longer MRT compared to carvedilol solution. These results are in agreement with Rathod and Deshpande who found that positively charged liposome containing pilocarpine nitrate showed greater duration of action and higher IOP reduction compared to negatively charged liposomes [Intraocular pressure was measured for each albino new zealand rabbit for 2 consecutive days and the normal IOP range was determined 20.6~24.4 mmHg. After 1-week injection of dexamethasone in the anterior chamber, IOP was increased to above 40 mmHg. The IOP of the right eye of each rabbit in both groups maintained above 40 mmHg during measurement period. For the carvedilol solution treated group (GP1), the IOP decreased to normal value (22.5 ± 2.0 mmHg) after 1 h of administration, IOP was kept in the normal range for the first six hours then IOP gradually increased as shown in iposomes . Also, Hiposomes . Leonardiposomes .Histological examination of right eye of each rabbit (sham group) showed that all glaucomatous eyes of induced animals showed similar findings lesions. The hallmark of glaucoma, retinal atrophy with loss of retinal ganglion cells (RGC) and their axons. Atrophy of some layers included internal plexiform layer and internal nuclear layer were seen. Retinal atrophy, which was prominent in the inner nuclear layer and ganglion cells. Microcystoid degeneration of retina of glaucomatous eyes which characterized histologically by multiple clear round spaces found usually in the inner plexiform layer Histological examination of group (GP1) which was treated by drug solution revealed that retina showed moderate retinal atrophy with some loss of internal plexiform layer and ganglion cells. Small vacuoles were seen in choroid which accompanied with slight thickening of retina Histological examination of group (GP2) which was treated by carvedilol leciplex formula showed improvement of retinal atrophy of glaucomatous eyes with some loss of ganglion cells. No vacuolation of choroid was detected in treated animals group The cationic leciplex nanoparticles were able to deliver the carvedilol effectively via electrostatic attraction with anionic mucin present on the cornea. Also, the nanosized of vesicles create large contact surface with ocular surface enabling enhanced corneal absorption. Based on the results of aqueous humor pharmacokinetic parameters, the selected DDAB leciplex colloidal formulation showed a significant improvement in ocular bioavailability and retention time of carvedilol compared with the drug aqueous solution. Consequently, leciplex formulation provided rapid reduction of IOP with increased duration of action compared to drug solution. Furthermore, histological examination of carvedilol leciplex treated group showed improvement of retinal atrophy of glaucomatous eyes compared to carvedilol solution treated group. These results indicated that leciplex nanoparticles are promising vectors to deliver the drug through ocular mucosa.


The diagnostic yields and safety profiles of transbronchial lung biopsy have not been evaluated in inexperienced physicians using the combined modality of radial probe endobronchial ultrasound and a guide sheath (EBUS-GS). This study assessed the utility and safety of EBUS-GS during the learning phase by referring to a database of performed EBUS-GS procedures.From December 2015 to January 2017, all of the consecutive patients who underwent EBUS-GS were registered. During the study period, two physicians with no previous experience performed the procedure. To assess the diagnostic yields, learning curve, and safety profile of EBUS-GS performed by these inexperienced physicians, the first 100 consecutive EBUS-GS procedures were included in the evaluation.The overall diagnostic yield of EBUS-GS performed by two physicans in 200 patients with a peripheral lung lesion was 73.0%. Learning curve analyses showed that the diagnostic yields were stable, even when the procedure was performed by beginners. Complications related to EBUS-GS occurred in three patients (1.5%): pneumothorax developed in two patients (1%) and resolved spontaneously without chest tube drainage; another patient (0.5%) developed a pulmonary infection after EBUS-GS. There were no cases of pneumothorax requiring chest tube drainage, severe hemorrhage, respiratory failure, premature termination of the procedure, or procedure-related mortality.EBUS-GS is a safe and stable procedure with an acceptable diagnostic yield, even when performed by physicians with no previous experience.The online version of this article (10.1186/s12890-018-0704-7) contains supplementary material, which is available to authorized users. Until now, the pathological diagnosis of a peripheral lung lesion was usually made by transthoracic needle biopsy, surgical resection, or bronchoscopy; however, transbronchial lung biopsy using conventional bronchoscopy has a low diagnostic yield . TechnolBased on the results of previous studies, EBUS-GS for peripheral lung lesions is considered a relatively safe procedure with an acceptable diagnostic yield , 7. GiveFrom December 2015 to January 2017, a retrospective study was conducted to investigate the clinical outcomes of patients undergoing EBUS-GS performed by beginners. During the study period, two physicians, neither of whom had previously performed EBUS-GS or radial probe EBUS only, began EBUS-GS at Pusan National University Hospital, a university-affiliated, tertiary referral hospital in Busan, South Korea. Before starting EBUS-GS, the two beginners both had 4 years of experience with conventional bronchoscopy and 3 years of experience with convex probe EBUS . All of the consecutive patients with a peripheral lung lesion, who underwent EBUS-GS performed by one of the physicians, were prospectively registered. For each physician, the first 100 consecutive patients who received EBUS-GS were included in the analyses. Prior to EBUS-GS, written informed consent was obtained from all of the patients. The Institutional Review Board of Pusan National University Hospital approved this study (No. E-2016084) and informed consent was waived due to the retrospective nature of this study and the anonymized personal information prior to analysis.All of the chest computed tomography (CT) scans were performed within 2 weeks prior to EBUS-GS. The imaging parameters were 120 kVp and 100–250 mAs. The stored CT raw data were used to reconstruct images at a slice thickness of 0.625 mm and intervals of 0.625 mm. The size of each peripheral lung lesion was measured from the CT images, based on the mean diameter of the lesion on the axial lung window setting. A peripheral lung lesion was diagnosed when the location of the lesion was beyond the segmental bronchus .All of the EBUS-GS procedures were performed during in-patient hospital stays. Before the procedure, a 20 MHz radial probe EBUS  and GS kit  were prepared according to the standard method of Kurimoto . PatientP-value < 0.05 was considered statistically significant. To assess the learning curve of the procedure, cumulative sum (CUSUM) analyses were used to produce a learning curve for each physician. The definition of CUSUM analysis applied in this study was that of Bolsin and Colson . The results are presented as numbers (percentages) or medians (interquartile ranges [IQRs]), as appropriate. Pearson’s chi-square test or Fisher’s exact test was used for categorical variables and the Mann–Whitney U-test was used for continuous variables. A Two hundred patients with peripheral lung lesions were included in the study (100 patients per physician). Their baseline characteristics are shown in Table P < 0.001) (Table P = 0.553). However, the diagnostic yield of ground-glass opacity nodules was only 25%. Diagnostic yield “within the lesion” on EBUS findings was significantly higher than that of “adjacent and outside the lesion” on EBUS . In addition, the diagnostic yield obtained by the two physicians did not differ significantly .Table 1) Table . No signThe results of the CUSUM analysis are presented as learning curves, in which a positive deflection represents false results and a negative deflection represents true results Fig. . The curAdditional CUSUM analyses were performed for 50 consecutive patients with peripheral lung lesions < 30 mm. The respective curves remained between the predetermined decision interval (H0 = − 5.15 and H1 = 5.15), again indicating that the physicians attained competence immediately, even when performing procedures involving small lung lesions.Overall, complications related to EBUS-GS during the learning curve occurred in three patients (1.5%): pneumothorax developed in two patients (1.0%) but resolved spontaneously without the need for chest tube drainage Fig. , and oneDuring the study period, two radial probes EBUS were used by the two physicians and one probe broke. During EBUS-GS, breakage of the GS, observed fluoroscopically, only occurred in one patient (0.5%) Fig. .Fig. 4BrThis study demonstrated that EBUS-GS is a useful and safe procedure, even when performed by inexperienced physicians. To the best of our knowledge, this is the first report in which the diagnostic yields, learning curve, and safety profile of EBUS-GS during the learning phase were evaluated. We found that EBUS-GS performed by beginners resulted in diagnostic yields comparable to those of experienced physicians , 16, 17.The diagnostic yield of EBUS-GS when performed without any assistance from navigation modalities has been previously reported to be 69.2–77.3% , 18. In Interestingly, the graphs of the two physicians crossed the lower decision boundary, indicating that the diagnostic yield improved over time in the analysis of all study subjects Fig.  and b. HA previous meta-analysis of EBUS-GS reported that pooled rates of any pneumothorax or pneumothorax requiring intercostal catheter drainage are 1% and 0.4%, respectively . These lMoreover, we also found that the durability of the radial probe EBUS and GS were tolerable during the learning phase of EBUS-GS. The vulnerability of the radial probe EBUS is well known, and the probe can be used during 50–100 EBUS-GS procedures . In thisThere were several limitations to our study. First, it was retrospective and conducted at a single center. Although the data were prospectively collected, potential selection bias might have influenced our results. In particular, the proportion of “within the lesion” on the endobronchial ultrasound image and malignant disease in the clinical diagnosis was relatively high in the present study. Previous studies have reported that factors contributing to successful EBUS-GS are “within the lesion” on sonography, a higher proportion of malignant disease in all subjects, and lesion size , 21, 23.Recent guidelines recommend the use of radial probe EBUS in patients with peripheral lung nodules . Our resAdditional file 1:Figure S1. Three sets of endobronchial ultrasound images. (DOCX 71 kb)Additional file 2:Figure S2. A representative case. (DOCX 66 kb)Additional file 3:The definition of cumulative sum analysis. (DOCX 15 kb)Additional file 4:A detailed description of the cumulative sum analysis. (DOCX 14 kb)Additional file 5:Table S1. Comparison of baseline characteristics between the two study groups. (DOCX 14 kb)


A number of facilitators directly affecting program implementation were identified; these pertained to embedding continuity into the program’s implementation and delivery, a robust governance structure, and executive sponsorship. Barriers to implementation were also identified. These barriers pertained to organizational or workforce challenges; staff turnover and movement , insufficient staff to allow people to attend training, and a lack of organizational commitment to the program, especially at an executive level. As a result of successful implementation, it was observed that over three years, the BPSO program positively influenced the uptake and implementation of EBP by clinicians and the organizations into which they were introduced. Conclusions: The BPSO model can be translocated to new healthcare systems and has the potential to act as a mechanism for establishing and sustaining EBP change. This study was the first to apply an implementation evaluation framework to the BPSO program, which allowed for structured analysis of facilitating or impeding factors that affected implementation success. The findings have important implications for other health systems looking to translocate the same or similar EBP programs, as well as contributing to the growing body of implementation evaluation literature. Background: Nurses and midwives are central to the implementation and delivery of quality care through evidence-based practice (EBP). However, implementation of EBP in nursing and midwifery is under-researched with few examples of systematic and sustained change. The Registered Nurses Association of Ontario’s Best-Practice Spotlight Organization (BPSO) Program was adopted in South Australia as a framework to systematically implement EBP in two diverse and complex healthcare settings. Methods: The study was a post-implementation, mixed-method evaluation conducted at two healthcare settings in Adelaide, South Australia utilizing qualitative and quantitative data. Proctor’s implementation evaluation framework guided the evaluation design. Information sources included; interviews, focus groups, questionnaires, and document review. Results: Clinical and executive staff ( Nurses and midwives are at the forefront of providing high quality, patient-centered care and ensuring patient safety. In Australia, they are the largest group of healthcare practitioners representing 57% of the total healthcare workforce ,2. The mAustralia’s hospitals are a mixed system of approximately 65% public beds and 35 % private. It is a complicated system with different levels of government responsible for funding, service provision, education, and training. Operating within this system are different levels of organizational culture, leadership, and existing models of care . This coThe Australian Commission on Safety and Quality in Health Care is the Australian organization responsible for the establishment of and updates to National Safety and Quality in Health Service (NSQHS) Standards. The Commission aims to support quality improvement initiatives by providing a safety and quality framework for all hospitals and healthcare facilities. This framework is mandated by Health Ministers and linked to hospital accreditation. The NSQHS were updated in 2017 to eight Standards , many ofEvidence-based practice (EBP) is the interrelationship between the best available evidence, clinical expertise, the health service context, and the patient’s needs, values, and preferences for their treatment and care ,7,8. EBPNurses and midwives play a critical role in bringing about EBP change, and although they understand the value of EBP, many perceive their own knowledge and skill in the area as insufficient . Indeed,Implementing and sustaining EBP in healthcare settings whether at the hospital, network or system-wide level requires a foundation on which to do this. Professional nursing organizations throughout the world, but in particular in North America, the UK, Europe, and Australia have served as peer leaders in the promotion of EBP among nurses, and the development of EBP programs and best practice guidelines (BPGs) . BPGs arThe Best Practice Spotlight Organization (BPSO) Program was first launched in Ontario in 2003 and was developed by the Registered Nurses Association of Ontario (RNAO) as part of its nursing BPG program ,16. The Implementation of EBP through the RNAO framework is based on the knowledge-to-action framework; a process model that follows specific stages in the process of translating research into practice, including the implementation, diffusion, and dissemination of research into various implementation aspects . CriticaEstablishing dynamic, long-term partnerships  that focus on patient care via knowledge-based nursing/midwifery practice;Identification of effective strategies for system-wide disseminating of best practice guidelines (BPG) implementation;Demonstrate creative strategies for successfully implementing nursing and midwifery best practice guidelines (BPGs) at both individual and organizational levels;Inaugurate effective evaluation protocols using structural, process and outcome indicators;Ensure sustainability and long-term integration of the program by creating attitudinal change among staff and therefore positively changing the culture of the organization.In South Australia, where this study is based, EBP initiatives have been attempted over many years. The Australian Nursing and Midwifery Federation  is an organization committed to supporting nurse- and midwife-led EBP. Through the organization’s efforts to improve sustained EBP change in SA, the ANMF (SA Branch) engaged with the Registered Nurses’ Association of Ontario regarding the BPSO Program. In 2012, SA became the first host internationally of the BPSO Program through a contractual agreement between the RNAO, the ANMF (SA Branch) and the South Australian Government Department of Health. The program was adopted to the SA public healthcare sector with the goals of:The selection of the BPSO program framework to the Australian context was influenced by several factors including; the adaptability of the program to the local context, alignment with state and national initiatives , recognizing the role of positive practice environments, and the support of professional organizations and leaders in bringing about change. Despite growing recognition of the value of EBP to support the advancement of nursing- and midwifery-led care, there has been little research evaluating the barriers and facilitators to implementing programs designed to support the adoption and sustainment of EBP into healthcare settings ,21,22. FThe study was conducted in accordance with the National Health and Medical Research Council guidelines for the conduct of evaluation studies in healthcare settings. Ethical approval for the BPSO program was obtained through the SA Health Human Research Ethics Committee (HREC-14-SAH-21). South Australia (SA) is one of eight Australian states and territories with approximately 80% of the population living in the catchment area of its capital city, Adelaide. At the time of the evaluation, there were five local health networks (LHNs); four based in the Adelaide metropolitan region, and one across regional South Australia. These LHNs manage the delivery of public hospital and community services in SA. The study was conducted at two sites within two of these LHNs. Each site was required to submit a proposal to participate in the BPSO program. In 2015, two sites were selected through a competitive application process to participate in the BPSO program as pre-designate sites from 2016–2018: Site 1 was focused specifically on the care of women and pediatrics and Site 2 was a directorate focused on caring for people living with mental health issues . The study was defined and undertaken as a post-implementation, mixed-method evaluation from the perspective of the health care provider. The evaluation design was structured to align to the evaluation framework for implementation outcomes developed by Proctor and colleagues ,24. ProcParticipants were recruited using three methods: interviews, focus groups, or via an online questionnaire. Participants selected for interview or focus group attendance were determined based on stakeholder positions from the BPSO program governance structure including senior nursing staff at each LHN , BPSO steering committee representatives, BPSO site leads, BPSO site champions, safety and quality coordinators, other LHN nursing and midwifery and multidisciplinary staff, and consumer and community engagement representative/s, the ANMF (SA Branch), and office of the Chief Nurse/Midwife. Staff within each site were invited to participate in an online questionnaire, which allowed the researchers to evaluate the perceptions of staff from outside of the key stakeholder group with respect to the BPSO program at their site. This allowed for corroboration of interview findings or identified areas of discrepancy.The study included an analysis of routinely collected program data collected by each site over the three-year pre-designate period, review of BPSO key resources , and questionnaires and interviews with key stakeholders.The routinely collected BPSO data used to monitor and evaluate the success of the pre-designate sites against the BPSO program objectives was provided by the sites included in the study. These data incorporated qualitative and quantitative indicator data and measurements aligned to the LHN’s policy, safety and quality, and reform agendas.Additional documents provided by sites  were reviewed according to the objectives. Key documents included BPSO program resources pertinent to each LHN along with those resources developed by each LHN, ANMF (SA Branch), and RNAO to support program implementation.Interviews and focus groups were used to collect data relevant to stakeholders’ experiences of the BPSO program and the dissemination and adoption of BPGs within the LHN. These were coordinated in collaboration with the ANMF (SA Branch) and the LHNs to ensure key stakeholders within LHNs are present. The interviews and focus groups followed a semi-structured format with prompt questions provided to participants captured under the four main questions of the evaluation. Introductory questions were used to capture basic demographics and experience with the BPSO program.A questionnaire was developed to gather self-reported feedback from staff at the two sites regarding implementation of the BPSO program including staff perceptions of barriers and facilitators. The questionnaire included a mixture of dichotomous (yes/no), Likert-type responses , and short open-ended questions. The questionnaire was modified slightly for each site to suit the local context  and administered electronically via SurveyMonkey to staff members within LHNs with varying levels of exposure and engagement with the BPSO program. The questionnaire was opened from 23 November to 12 December 2018.The questionnaire included questions related to people’s level of awareness of the BPSO program overall and that their site was a pre-designate site. The questionnaire also included a 14-item assessment of how conducive the workplace environment was to support the implementation of an EBP program (like the BPSO program) using a four-point, Likert-type scale . Examples of questions included “Senior staff actively encourage staff to participate in BPG training”, “We are encouraged to pursue continual quality improvement”, and “We have good teamwork between all clinical disciplines”.The study was conducted between 8 November 2018 and 14 December 2018. Interview participants were invited via email or telephone. Some interviews were conducted together at the request of the interviewee. Two researchers were present for each interview, except for one interview. Focus groups were coordinated with the support of each site. BPSO site leads were responsible for identifying and supporting communication to attendees. It was understood by the researchers that those invited were people familiar with and engaged with the BPSO program at each site . Notes and audio recordings were taken at each interview and focus group for subsequent analysis.Data synthesis and analysis relied on triangulation of the data collated from the multiple data collection tools described above. Qualitative data was the primary type of data relied upon for this evaluation study with quantitative data used to describe participants and to verify qualitative information reported . Qualitative data  were analyzed using a deductive thematic analysis approach  aligned Quantitative data  were analyzed using descriptive analysis techniques including counts and frequency statistics. Crosstabs with Chi-square statistics were used to compare the two site questionnaires’ workplace environment responses (strongly agree/agree vs. strongly disagree/disagree).In total, 16 people were invited for interviews regarding the BPSO pre-designate site experience and 11 people accepted . While eFour focus groups were originally planned (two per site) in order to cover a representation of staff engaged in the BPSO program outside of the key stakeholder groups, to seek their perspectives on its implementation and effectiveness within each site. However, after discussion with the BPSO pre-designate site leads, due to the difficulty of finding a time when a sufficient number of staff could attend, only one focus group was conducted per site with as many people encouraged to attend as possible. In total, 12 people attended across the two sites .In total, 53 people from Site 1 and 37 from Site 2 commenced the online questionnaires. Four people (two from each site) were removed from analyses because they did not complete beyond the first page of questions (demographics); resulting in 51 from Site 1 and 35 from Site 2, respectively. In addition, not all people completed all questions, so the number of respondents varied per question.With respect to questionnaire respondents, a higher proportion of females completed the survey (98% from Site 1 and 69% from Site 2). While there was some deviation in age range distribution of respondents from each site, the majority of people (70%) from both sites were aged over 45 years. There was some observable difference in the length of service of respondents at each of the BPSO pre-designate sites, with people from Site 1 reporting a longer length of service (73% vs. 35% >10 years’ service). The majority of staff from Site 1 were registered nurses , registered midwives , or RN/RM (24%). Site 2 respondents were more varied with 58% RN, 3% RM, and 39% other from allied health, medical, and administration roles.Site 1 respondents reported high levels of awareness of the BPSO program overall (94%) and awareness that Site 1 was a pre-designate site (92%). Site 2 respondents reported moderate levels of awareness of the BPSO program overall (54%) and that Site 2 was a pre-designate site (42%).With respect to implementation outcomes, it was observed that a number of facilitators directly affected program implementation; these mainly pertained to embedding continuity into the program’s implementation and delivery . It was reported that having an executive responsible for the program implementation and delivery was a critical success factor. In addition, the champions network was noted by interviewees and questionnaire respondents as an important mechanism for engaging all levels of employees and tangibly linking them using the champion title.Barriers to implementation were also identified. These barriers predominantly related to organizational or workforce challenges; staff turnover and movement , not enough staff to allow people to attend training, and lack of organizational commitment to the program, especially at an executive level. The origins (nursing) and language of the BPSO program, which affected other disciplines initial engagement with the program .2 = 13.76, p < 0.001), “Opportunities are provided to attend non-mandatory training” , “Staff are supported when wanting to trial or implement practice changes” , “A philosophy of patient care that pervades work” , “Senior staff actively encourage staff to participate in BPG training” , and “We are encouraged to pursue continual quality improvement” . There were only two questions where Site 1’s responses showed a less positive trend, but these differences were not significant.Staff perceptions of how conducive the workplace environment was to support the implementation of an EBP program showed that Site 1 had consistently more positive responses than Site 2 . Site 1 Where challenges to implementation were observed, the program still demonstrated some early indication of service changes with respect to initiatives led or supported under the auspices of the BPSO program. However, due to the implementation challenges, downstream impact on service outcomes was not as evident and not observable at a site-wide level. There were some specific examples described where there had been a concerted effort and investment towards implementation of an innovation, but these were isolated and it was not evident that the program was an instrumental factor in their adoption within the healthcare setting. For example, Site 2 was rolling out a program as part of its “Alternative use of restraints” BPG that replaced use of security guards with health worker assistants (HWAs) who were provided with an activity box. This approach was designed to engage the patient more humanely. While commendable for its objectives and potential to impact service delivery with respect to ‘patient-centered’ and ‘efficient’ (HWAs are cheaper than security guards), it was the implementation difficulties related to changing senior management and releasing staff for training to this BPG that affected its implementation penetration over three years.The aim of this study was to report on the implementation outcomes of the BPSO program at two BPSO pre-designate sites within a complex health service context and to illustrate how implementation affected service outcomes using examples from these sites. The first three years of a BPSO program at a site presented a unique opportunity to observe factors that affected the implementation of the program and allowed for identification of those factors critical to its success. This is important when considering translocation of programs to new settings . This stProctor’s framework allowed for structured evaluation of the BPSO program implementation performance with respect to identifying facilitators and barriers to implementation. Both sites considered broader strategic initiatives being progressed within their site, which was a strategically wise decision when selecting the three BPGs as part of their pre-designate period. For example, the SA Health suicide prevention plan, published by the Office of the Chief Psychiatrist, was closely aligned to activities undertaken within Site 2 . This facilitated many of the implementation outcome domains including acceptability, adoption, feasibility, and sustainability. However, this also made it difficult to directly ascribe all activities to initiatives being progressed under the banner of the BPSO program. This was noted for other BPGs, and potentially, exemplifies that alignment to broader initiatives is required, especially when attempting systemic change and/or a difficult BPG .Partnerships between units were also critical to success. For example, at Site 1 the partnership of the site BPSO program lead unit  with the consumer and community engagement unit was critical. The BPSO program’s service delivery was greatly augmented through this partnership with many people commenting on the value of having consumer presence and voice at training. In addition, many of their BPSO activities were directly aligned with existing works of the Consumer and Community Engagement Unit, which reduced duplication of effort. Extensive documentation of organizational level activities related to the BPSO program and changes helped to support the demonstration of the program’s impact, as well as efficiently building in program accountability and recognition. These included activity reporting, evaluation of Champion’s training, consumer and community engagement strategies, practice level activities, and changes and awards that have occurred against each BPG. The organizational commitment at the site, and the commitment of the external parties—in this instance ANMF (SA Branch), SA Health, and the RNAO—who each had roles to play to support the site, was critical to implementation success. Senior stakeholders interviewed commented that, given the numerous pressures a large healthcare providers faces in Australia and therefore the potential risk the organization is taking when committing to an organization-wide clinical quality improvement program like the BPSO program, understanding and communicating the benefits such a program would bring to the organization, and reinforcing this with evidence as the program rolled-out was necessary to maintain this commitment. Financing the BPSO program also supported this commitment. The financing arrangement in this instance was a three-way commitment between the three South Australian parties, and so there was internal and external interest in its success. In this sense, the funds acted more than just as money to pay for people and activities. It gave the program a budget line in the organization, it represented a financial risk to multiple parties, and combined gave the program greater substance. Champions training and the Best Practice Champions Network were vital elements in the uptake and embedding of EBP across organizations. While nurses may have positive attitudes and beliefs toward EBP, their beliefs are associated with the extent to which EBP is implemented . The BPSImplementation barriers were not always the antithesis of facilitators. While it was observed that factors critical to implementation success were also barriers when not in place , there were also other barriers identified that presented separate challenges. As noted, there was resistance amongst clinicians to the introduction of the Woman’s Abuse BPG at Site 1. This was in part due to uncertainties regarding screening and responsibilities of clinicians around this sensitive area. Consequently, it took this BPG considerably longer to bring to a mature training and practice improvement program compared with the two other BPGs adopted by Site 1.The results of this study provide program and service-level considerations related to BPG and EBP program implementation, as well as sustained practice change. First, this study reinforces previous research that there is no single solution to the application of EBP in healthcare , but thaSecond, the study identified that the BPSO program was more than just a ‘vehicle’ to implement BPGs; its structure was acting as an ‘anchor’ for establishing and sustaining EBP change in the healthcare setting. In a stable, more positive workplace environment , this assisted with supporting continual quality improvement and provided a vehicle for sites to improve organization-wide policy and evidence-based practice. In an organizational environment undergoing continual, widespread, and/or significant reform , the program acted as a stabilizing function to maintain course direction towards continual quality improvement of safe and quality care. This is not to be underestimated when there may be changes in one or more levels of leadership, budget cuts, or changes in the political landscape that may result in decisions that impact on practice improvement programs.Third, this study demonstrated that non-discipline specific change to improve the safety and quality of healthcare could be implemented irrespective of which discipline is nominally ‘leading’ it. As the single largest providers of health care in Australia, nurses have the potential to significantly influence and address gaps in EBP. While some have questioned the need for discipline-specific guidelines for EBP, it is the responsibility of members across all disciplines to be informed by best available research and some of this is discipline-specific . HoweverFourth, the study highlighted the need for measurement and reporting as part of program success. Implementation of BPGs is a legal directive as well as a professional requirement in Canada  and measThis study also served to demonstrate the practical application of an implementation framework to guide the structuring of the data analysis and reporting. Use of Proctor’s framework was important for aligning service outcomes to indices meaningful to healthcare services, especially as it relates to hospital accreditation safety and quality standards. This top-down approach focused the data analysis process on extracting only those bits of information relevant to the pre-defined domains. In an environment that is awash with data , this expedited the data extraction and reporting process, which may serve others interested in reviewing programs in their healthcare settings.The IOM standards are quite broad terms, and are agnostic to the health system, so are useful outcomes to report against. However, it may be more suitable to use system context-specific measure of quality and safety to demonstrate benefit locally .The main limitation to the study was the limited amount of raw, quantitative data available to complement other data sources, as part of assessing the implementation outcomes and service outcomes. For example, it was not possible to extract firm evidence regarding impact on health service efficiency. While this is not a priority of the BPSO program , the cost of healthcare delivery is an important component to capture, especially if planning to affect large-scale change. Similar rationale could be argued for the other service outcome domains.Greater emphasis was placed on qualitative data sourced from staff perceptions, perspectives, and experiences with respect to the implementation of the BPSO program, and how it affected the healthcare delivery. This was in part due to the nature of the methodological design and analysis, and the inherent limitations of having a small number of questionnaire respondents meaning less exploratory analysis were possible .Response bias was a risk given the stake or interest many of the participants had, especially those who were interviewed or part of the focus group. The questionnaire assisted here by gathering feedback from people with very little awareness of or interest in the program. However, the questionnaire results should not be viewed as a generalizable representation of each site, and likely has other biases.This research has added to the body of scholarship on enhancing and sustaining EBP programs in nursing and midwifery, and in health services more broadly. The research identified and described key implementation factors that facilitate successful implementation of a program, or are indeed, barriers to its implementation, designed to support the translation and embedding of EBP into healthcare. Furthermore, the research demonstrated that such programs can be translocated to a different health system context with moderate adaptations, but where careful planning and adherence to the program’s underlying theory is critical to sustained success.


Electrophysiological picture rhyming (sound) effects were evident in terms of both N400/N450 and late effect amplitude: Non-rhyming images elicited more negative waves than rhyming images. Remarkably, the magnitude of the late ERP rhyming effect was modulated by spelling – even though words were neither explicitly seen nor heard during the task. Moreover, both the N400/N450 and late rhyming effects in the spelled-the-same  condition were larger in the group with higher scores (by median split) on a standardized measure of sound awareness. Overall, the findings show concomitant meaning (semantic), sound , and spelling (orthographic) activation for picture processing in a rhyming paradigm, especially in young adults with better reading skills. Not outwardly lexical but nonetheless modulated by reading skill, electrophysiological picture rhyming effects may be useful for exploring co-activation in children with dyslexia.In an event-related potential (ERP) study using picture stimuli, we explored whether spelling information is co-activated with sound information even when neither type of information is explicitly provided. Pairs of picture stimuli presented in a rhyming paradigm were varied by both phonology (the two images in a pair had either rhyming, e.g.,  The Lexical Quality Hypothesis e.g.,  posits tBut what if no lexical information is provided? The third component in the Lexical Quality Hypothesis is semantics e.g., . What ifchairmoose-) elicit a more negative N400/N450 than rhyming targets , for both visual  or mismatch  between the spellings of the rime units of the prime and target words in a pair. Thus, the N400/N450 rhyming effect can provide a simultaneous index of orthographic and phonological processing of lexical items.Event-related potential studies using prime-target pairs of stimuli and a rhyme judgment task have consistently reported a rhyming effect: Non-rhyming targets  and, in languages with a deep orthography such as English, orthography .Critically, all of these studies have directly presented either orthographic or phonological lexical information to participants. Arguably, providing neither type of cue offers a more rigorous test of co-activation of spelling and sound with meaning. A handful of studies have shown that picture stimuli can elicit ERP rhyming effects e.g., : both thWithin the literature involving spoken word stimuli, there is debate about whether the effect of co-activation of spelling with sound is automatic or strategic and task-based e.g., . For exaIn summary, in this study, we investigated whether orthographic processing is co-activated with phonological processing in fluent, young adult readers – even when neither phonological nor orthographic lexical information is explicitly provided. Rather, the entry point was the third leg of the stool of the Lexical Quality Hypothesis: semantics . This afSD 1;5). All participants were right-handed  participants aged 18;0 to 24;4 years  and orthographically mismatched  single-syllable rhyming word pairs that could be represented by images were generated through brainstorming and web and print searches. Words composing the pairs were not in the same semantic category so as to reduce the possibility of semantic priming. Real, full-color pictures representing each word were identified using Google Images. These pictures were cropped to 1 × 1 in. with 240 pixels/in. resolution in Adobe Photoshop CS. In an iterative process, these images were subjected to cloze testing: Ten participants  were asked to “label the following pictures. What is the first word that comes to mind when you see the picture? What is the best name for the picture?” Only pictures with 80% or greater cloze scores were maintained in the final stimulus set. Responses that included the critical rhyme portion of the word were considered correct . Based on this cloze procedure, average name agreement across all pictures included in the final stimulus set used in the experiment was 93.8% (SD = 7.5). Average name agreement was not significantly different for items in the orthographically matched  and orthographically mismatched  conditions, t(154) = 0.32, p = 0.75.Initial lists of orthographically matched . t-Tests confirmed that the names of the pictures in the orthographically matched and mismatched conditions did not differ in terms of number of letters, p = 1.0; number of phonemes, p = 0.16; orthographic neighborhood size, p = 0.12; word frequency based on the Kučera and Francis, p = 0.43, CELEX, p = 0.48, or Brown, p = 0.33, corpora; constrained bigram, p = 0.12, or trigram, p = 0.10, frequency; or unconstrained bigram, p = 0.36, or trigram, p = 0.13, frequency. In addition, the words in the two conditions did not differ on measures of imageability, p = 0.56, concreteness, p = 0.35, or familiarity, p = 0.94.In addition to the pictures in the orthographically matched and mismatched conditions being labeled equally accurately in cloze pretesting, the words that the pictures represented were balanced across a number of linguistic variables based on metrics from the MCWord  and MRC t-tests indicated no differences between the words representing pictures designated as primes and those designated as targets on any of the linguistic variables listed above . Within each orthographic condition, non-rhyming pairs were created by pseudorandomly re-pairing a previously rhyming target picture with a prime picture with which its name did not rhyme; constraints included not matching final coda consonants  or vowel pairs , and avoiding onset alliteration and semantic relatedness. For example, goat from the rhyming pair boat-goat was re-paired with the prime crown to create the non-rhyming pair crown-goat. Thus, each prime picture was seen twice (once preceding a rhyming target and once preceding a non-rhyming target) and each target picture was seen twice (once as a rhyme and once as a non-rhyme); this afforded comparison of the ERPs to the exact same image as a rhyming and a non-rhyming target in the rhyming manipulation. Picture pairs were separated randomly into a List 1  and List 2  such that each picture occurred only once in each list. The picture pairs comprising each list were presented in pseudorandom order such that no more than 3 rhyming or non-rhyming pairs occurred in a row, no more than 3 orthographically matched or mismatched pairs occurred in a row, and no target of one pair was semantically or phonologically related to the prime of the subsequent pair. All participants viewed both lists, with order of list presentation counterbalanced across participants. Please see Supplementary Materials for the full stimulus lists.The final stimulus set consisted of 39 pairs of orthographically matched rhyming pictures and 39 pairs of orthographically mismatched rhyming pictures. Within each rhyming pair, which picture would be the prime (presented first in the pair) and which picture would be the target (presented second in the pair) was determined randomly; This study was approved by the Institutional Review Board at Dartmouth College, the Committee for Protection of Human Subjects. Participants were given an overview of the procedures and any questions were addressed before they signed a consent form. Standardized behavioral testing (see above), which took about 30 min, was conducted in a quiet room prior to participation in the ERP task. For electroencephalogram (EEG) recording, participants were fitted with an elastic cap  with active electrodes including Fz, Cz, Pz, FP1/2, F7/8, FT7/8, F3/4, FC5/6, C3/4, C5/6, T3/4, CT5/6, P3/4, T5/6, TO1/2, and O1/2. Midline  and frontopolar (FP1/2) sites were not included in statistical analyses, but are shown in the voltage map plots. Mastoid electrodes were used for reference; on-line recordings were referenced to the right mastoid and recordings were re-referenced to averaged mastoids in the final data averaging. Electrodes located below the right eye and at the outer canthi of the left and right eyes were used to identify blinks (in conjunction with recordings from FP1/2) and horizontal eye movements, respectively. Mastoid and scalp electrode impedances were maintained below 5 KΩ, and impedances for the electrodes near the eyes below 10 KΩ. Once electrode preparation was complete, participants were seated in a comfortable chair in a sound-attenuating and electrically shielded booth for the ERP task. EEG was amplified with SA Instrumentation bioamplifiers (bandpass 0.01 to 100 Hz) and digitized on-line (sampling rate 4 ms). ERPs were time-locked to the onset of each target picture.SD = 3.3) than the second list , t(79) = 2.66, p = 0.01; however, since presentation order of Lists 1 and 2 was counterbalanced, time to complete each list was not significantly different, p = 0.98. A brief practice session  preceded the experimental session.The picture stimuli in the ERP task were presented using Presentation software  at the center of a 19-in. LCD monitor approximately 66 in. in front of each participant, on a black background. The images subtended about 1.9° of horizontal visual angle, minimizing the need for scanning eye movements. The sequence of events began with a red asterisk at the center of the screen, to which participants needed to press either one of two buttons on a hand-held response device to advance to the presentation of the prime stimulus. Upon pressing a button, the prime picture was presented for 500 ms, followed by a gray fixation cross for 900 ms, the target picture for 500 ms, a blank screen for 500 ms, and a blue question mark that appeared for a maximum of 3 s. Participants were asked to press one button to indicate a rhyme decision and another to indicate a non-rhyme decision as quickly as possible after the onset of the question mark; rhyme/non-rhyme response hand was counterbalanced across participants. The question mark disappeared with the press of a response button (or when 3 s had elapsed), to be replaced by the red asterisk to begin the next trial. The session was self-paced in that only a button press by the participant would advance from the asterisk to a stimulus pair. On average, participants were slower to complete the first list presented  by typing in a name for each picture in an Excel file. A criterion for inclusion in further analyses was at least 85% correct on this post-test.a priori established threshold. Data were subsequently analyzed on an individual basis for artifact rejection as needed, by modifying the threshold if blinks or eye movements were still visible in the individual average data after the standard, automatized procedure. The average number of trials included were: rhyming targets, mean 59.8 (SD = 8.0), and non-rhyming targets, mean 67.5 (SD = 9.1). More non-rhyming than rhyming target trials were included in analyses, t(79) = 10.12, p = 0.001. Within rhyming targets, the average number of trials included was greater for orthographically matching  than orthographically mismatching  targets, t(79) = 7.12, p = 0.001. Within non-rhyming targets, the average number of trials included was also slightly greater for pictures in the orthographically matching set  than in the orthographically mismatching set , t(79) = 2.11, p = 0.038.Off-line, ERPs to target pictures were averaged for each subject at each electrode site over a 1000 ms epoch, using a 200 ms pre-stimulus-onset baseline. Only trials to which participants responded correctly and within the allotted time were included in the ERP averages. Trials contaminated by eye movements, blinks, or electrical noise were not included in analyses. Standard artifact rejection parameters were initially employed: Blinks and eye movements were detected through a “peak-to-peak amplitude” function, and trials were rejected if the amplitude value between the maximum and minimum data points in the specified time window was larger or smaller than an p-values are reported. Partial eta squared , and were compared in terms of the sizes of the ERP rhyming effects  at the sites where each effect was maximal .Table 2.For the most part, participant scores were average or above, although there was variability. Results, in terms of raw, percentile, and standard scores, are summarized in SD = 4.7%). t-Tests indicated that participants were more accurate at identifying non-rhyming  than rhyming  targets, t(79) = 14.4, p < 0.001, and more accurate with orthographically matching  than mismatching  rhyming targets, t(79) = 10.8, p < 0.001.Overall accuracy was 89.4% (SD = 3.5%) of the pictures at post-test, similar to the results of our cloze procedure for choosing the picture stimuli .On average, participants correctly identified 92.5% (SE = 0.29) elicited a more negative N400/N450 than rhyming targets , particularly over right hemisphere, frontocentral, medial sites . For example, the size of the rhyming effect was smaller at the temporal, lateral, left hemisphere site T5  than it was at the frontal, medial, right hemisphere site F4 , t(79) = 6.74, p < 0.001, d = 0.75, and smaller at the frontal, lateral, left hemisphere site F7  than it was at the frontocentral, medial, right hemisphere site FC6 , t(79) = 6.51, p < 0.001, d = 0.73.We found a typical ERP rhyming effect on N400/N450 amplitude such that non-rhyming targets  eliciting a more negative late effect than rhyming targets , particularly over right hemisphere, posterior, medial sites. For example, the size of the late rhyming effect was smaller at the frontal, lateral, left hemisphere site F7  than at the parietal, medial, right hemisphere site P4 , t(79) = 16.81, p < 0.001, d = 1.88, and at the temporal, lateral, left hemisphere site T5  than at the central, medial, right hemisphere site C4 , t(79) = 8.63, p < 0.001, d = 0.96.This pattern extended into the 500–700 ms time window, with non-rhyming targets . In the later epoch, the rhyming effect for orthographically matched targets was larger than the rhyming effect for orthographically mismatched targets, particularly at posterior sites. Follow-up analyses indicated no significant effect of orthography across the electrode sites composing the two most anterior rows , p = 0.33, but a larger effect for orthographically matched than mismatched targets across the sites composing the two most posterior rows , t(79) = -2.94, p < 0.01, d = 0.33.In difference wave analyses investigating whether the orthographic congruence  between primes and targets modulated these effects, there were no conventionally significant effects in either the N280 or N400/N450 time windows (see n = 40) by median split of standard scores on the Sound Awareness subtest . The median split (cut-off: 95) created significantly different lower-scoring  and higher-scoring  groups, t(78) = -12.43, p < 0.001, d = 2.8. . The size of the N280 rhyming effect for orthographically matched pictures was greater for the higher-scoring group , t(78) = 2.78, p < 0.01, d = 0.62. For the N400/N450, both the size of the rhyming effect overall , t(78) = 2.02, p < 0.05, d = 0.45, and the size of the rhyming effect for orthographically matched pictures , t(78) = 2.63, p = 0.01, d = 0.59, were larger for the higher-scoring group. The magnitude of the late rhyming effect for orthographically matched pictures was also larger for the higher-scoring  than the lower-scoring  group, t(78) = 2.28, p < 0.05, d = 0.51. Thus, across all three time windows in this exploratory analysis, the pattern is consistent with greater combined phonological and orthographic priming for participants with better phonological skills.In planned analyses exploring possible categorical effects related to individual differences, participants were divided into lower-scoring and higher-scoring groups  time window, it would seem that co-activation of spelling and sound in this paradigm was strategic and/or task-related e.g., . Some prAnd yet there was other evidence suggesting that orthographic congruence may indeed contribute to lexical access – and, thus, that orthography may have both automatic and strategic influence – in this picture rhyming paradigm. In planned, exploratory analyses, the group with higher scores on the Sound Awareness subtest by median split showed a larger overall N400/N450 rhyming effect, as might be expected: Better phonological skills were associated with greater differentiation of rhyming and non-rhyming targets. But the group with higher scores on the Sound Awareness subtest also showed larger N280, N400/N450, and late rhyming effects for orthographically matched (but not mismatched) targets, as compared to the lower-scoring group. Thus, participants with better speech sound processing skills  appeared to benefit more from phonological-orthographic congruence  than those with poorer speech sound processing skills, across all three time windows of measurement. Moreover, the higher-scoring Sound Awareness group also had higher standard scores on the WJ-III Letter-Word Identification, Spelling, Word Attack, Picture Vocabulary, and Spelling of Sounds subtests, as well as on the Basic Reading and Phoneme/Grapheme Knowledge Clusters, in comparison to the lower-scoring Sound Awareness group, suggesting that greater dual phonological-orthographic priming may not be specific to sound-based skills, but rather to better reading skill overall. Intriguing, this greater facilitative effect of spelling and sound congruence in the orthographic match condition for better, as compared to poorer, readers awaits replication. Although metaphonological, the picture rhyming task also focuses on meaning, as each image must be semantically identified for retrieval of its label. Typical rhyme judgment tasks tend to be “shallow” lexical processing tasks , p. 120;An influence of orthographic congruence that varied by group was observed across all three time windows. The N280 elicited here is similar to a right-lateralized, anterior N2 that was associated with maintenance of context information, and was largest to repeated images, in a previous study with picture stimuli . The repTaken together, these findings suggest that co-activation of spelling and sound in a rhyme task – both automatic, as indexed in early time windows, and strategic, as indexed in later time windows – may not only be task-dependent e.g., , but alsOur findings of orthographic modulation of phonological effects in a picture rhyming task are consistent with the automatic co-activation of meaning, sound, and spelling proposed in the Lexical Quality Hypothesis e.g., , as wellDC conceptualized and designed the study, collected, analyzed, and interpreted the data, wrote the manuscript, and supervised undergraduate research assistants.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer SD and handling Editor declared their shared affiliation.


Popliteal artery entrapment syndrome (PAES) is an uncommon cause of lower extremity claudication that is often overlooked. It most commonly occurs in young athletes without risk factors for peripheral vascular disease. We present a case of a 47-year-old man who went undiagnosed for over 10 years despite multiple orthopedic, chiropractic, and neurosurgery consults. A definitive diagnosis of PAES was confirmed in the catheterization lab by angiography. The patient underwent popliteal artery bypass surgery and his symptoms completely resolved. PAES must be considered in the differential diagnosis of lower extremity pain, especially in younger patients. The popliteal fossa is the region of the lower extremity posterior to the knee. It is surrounded by the medial head of the gastrocnemius , the lateral head of the gastrocnemius and plantaris , semitendinosus and semimembranosus , and biceps femoris  muscles. This fossa contains the popliteal artery, popliteal vein, and tibial nerve. Of the three, the artery is most medial while the tibial nerve is most lateral. The popliteal artery is an extension of the femoral artery. While in the fossa, the popliteal artery is most medial; prior to entering the fossa, the femoral artery is lateral to the femoral vein .Anatomic popliteal artery entrapment syndrome (PAES) is a rare congenital abnormality. Atypical embryological development of the popliteal fossa can result in compression of the popliteal artery in any one of four ways: the artery courses medially around the gastrocnemius (type I), lateral attachment of the medial head of the gastrocnemius (type II), an accessory slip of gastrocnemius muscle (type III), or the artery running below the popliteus muscle or a fibrous band of the popliteus muscle (type IV). Functional PAES (type VI) similarly leads to the occlusion of the artery due to a suspected etiology of hypertrophy of the gastrocnemius muscle, without an obvious anatomic abnormality in the popliteal fossa -4.Most studies report a higher occurrence in male athletes with a mean age between 30 and 35 and find that it is often bilateral . PAES maA 47-year-old Caucasian male with a past medical history of hypertension, hyperlipidemia, and everyday tobacco use presented with left lower extremity pain for over 10 years. The pain, described as a throbbing and cramping sensation without immediate relief after rest, had worsened significantly over the past two years, leading him to seek further medical attention. Prior to the onset of lower extremity pain, the patient was healthy and led an active lifestyle. On exam, his feet were warm and pink with normal sensation and 2+ distal pulses.Arterial Doppler of the left lower extremity noted severe stenosis of the left superficial femoral artery and popliteal artery. He was started on cilostazol 100 milligrams two times per day, but his symptoms did not improve. Arteriography revealed normal iliac, common femoral, and superficial femoral arteries without atherosclerosis. There was occlusion of the left popliteal artery and extensive collateral flow to the leg. This raised suspicion for PAES and provocative maneuvers were performed during the study. Dorsiflexion and plantar extension of the ankle caused the cessation of the collateral and distal popliteal artery flow. When the ankle was returned to neutral position, the occlusion ceased and flow was restored. These findings confirmed the diagnosis of PAES with resulting popliteal artery occlusion  is a potential cause of overlooked intermittent lower extremity pain in patients without atherosclerotic risk factors, especially in young, active males. Despite multiple consultations, the patient was not diagnosed with this syndrome for over 10 years, leading to occlusion of his left popliteal artery. Notably, the patient was an athlete and began to experience symptoms at age 32, consistent with the typical demographic of a 30 to 35-year-old athletic male. We believe the delay in diagnosis to be due to the patient's history of hypertension, hyperlipidemia, and tobacco use, which suggested peripheral vascular disease as a more likely diagnosis.PAES typically presents in younger men as bilateral lower extremity pain that is not alleviated immediately with rest -6. The pWithout treatment and quick diagnosis, consistent compression of the popliteal artery can lead to arterial intimal damage and worsening occlusion ,11. The Popliteal artery entrapment syndrome (PAES) should be considered primarily in patients without atherosclerotic risk factors, especially young athletes who present with lower extremity exertional pain that lingers after rest. However, a medical history that places a patient at risk for peripheral vascular disease should not solely exclude PAES from the differential diagnosis. The diagnosis can be definitively confirmed with arteriography while the patient is performing provocative maneuvers. Surgical decompression of the artery is the preferred treatment of choice for this syndrome.


We examined the benefits and challenges of implementing a program aiming to reduce older Veterans’ loneliness. The program helped connect older Veterans with others through telephone-based group activities. Thirty-four Veterans were enrolled in the program, of which 14 attendees called in to one or more activities. Data were collected at baseline, 3-months, and 6-months. Differences in baseline characteristics between attendees and non-attendees were calculated. Changes in Veterans’ perceived loneliness, depression, anxiety, and quality of life were evaluated. Client satisfaction were analyzed. Qualitative data analyses were conducted to identify perceived benefits and challenges of participating in this program. Attendees were more likely to be depressed and have limited environmental resources to promote quality of life than non-attendees. A significant decrease in loneliness was found among attendees from baseline to 3-months. Overall, Veterans were satisfied with this program and the services provided. Perceived benefits included a structured program with interesting topics to spend time on as well as the opportunity to socialize, exchange ideas, and connect with other Veterans. Perceived individual challenges  and program-level challenges  were observed. Results demonstrated that this telephone-based program is feasible and beneficial for older Veterans to reduce loneliness. Several barriers and challenges were noted, providing insight into ways to improve the implementation of this program.


More than 15 years ago, imatinib entered into the clinical practice as a “magic bullet”; from that point on, the prognosis of patients affected by chronic myeloid leukemia (CML) became comparable to that of aged-matched healthy subjects. The aims of treatment with tyrosine kinase inhibitors (TKIs) are for complete hematological response after 3 months of treatment, complete cytogenetic response after 6 months, and a reduction of the molecular disease of at least 3 logs after 12 months. Patients who do not reach their goal can switch to another TKI. Thus, the molecular monitoring of response is the main consideration of management of CML patients. Moreover, cases in deep and persistent molecular response can tempt the physician to interrupt treatment, and this “dream” is possible due to the quantitative PCR. After great international effort, today the BCR-ABL1 expression obtained in each laboratory is standardized and expressed as “international scale.” This aim has been reached after the establishment of the EUTOS program (in Europe) and the LabNet network , the platforms where biologists meet clinicians. In the field of quantitative PCR, the digital PCR is now a new and promising, sensitive and accurate tool. Some authors reported that digital PCR is able to better classify patients in precise “molecular classes,” which could lead to a better identification of those cases that will benefit from the interruption of therapy. In addition, digital PCR can be used to identify a point mutation in the ABL1 domain, mutations that are often responsible for the TKI resistance. In the field of resistance, a prominent role is played by the NGS that enables identification of any mutation in ABL1 domain, even at sub-clonal levels. This manuscript reviews how the molecular tools can lead the management of CML patients, focusing on the more recent technical advances. ABL1), located on chromosome 9, and the Breakpoint Cluster Region (BCR), on chromosome 22, generate a fusion gene called BCR-ABL1, that, along with the Philadelphia chromosome, is the main diagnostic marker of CML (It is well-known that more than 95% of cases of chronic myeloid leukemia (CML) are characterized by the presence of the Philadelphia chromosome (Ph'), the deleted chromosome 22 produced by the reciprocal  translocation between the long arms of chromosome 9 and 22. During this event, two genes, Abelson 1 , and more rarely (2–3%) on exons 6, 8, or 19  or downstream (subtype a3), with two different fusion constructs; both of these genes encode a protein of 210 kDa (p210). Alternatively, breakpoints might occur between exon 1 of BCR and exon 2 of ABL1 (e1a2), thus encoding a protein of 190 kDa (p190), which is more frequently found in acute lymphoblastic leukemia (>75%), and more rarely in acute myeloid leukemia (2%) and in CML (<1%)  , 5. Finaeukemia”  , able, therefore, to transform the hematopoietic stem cell in a neoplastic clone , followed by b3a2 (38%) and by “rare” rearrangements (occurring in only 2% of CML cases) .The prognostic role of the different transcripts is still a matter of debate: in the scientific community, some authors support the hypothesis that b2a2 is associated with a lower rate of optimal responses –16, wherBCR-ABL1 and identifying the type of rearrangement  in the treatment of CML, RQ-PCR became the gold standard to follow the disease burden reduction kinetics and to allow an accurate prognostic stratification.BCR-ABL1/ABL1 ratio of at least 3 logarithms by 18 months represented an added value to the complete cytogenetic response (CCyR) in terms of long-term survival prediction , RQ-PCR showed that the reduction of the ediction . Interestio >10% , 24. Mortio >10% , thus hiBCR-ABL1/ABL1 ratio of more than 4 logs (The continuous therapeutic improvement of the last 10 years has led to increasingly ambitious treatment endpoints (now culminating in the possibility of achieving TFR), which, in turn, need more and more refined definitions of DMR levels, corresponding to a reduction of the n 4 logs , 27.BCR-ABL1/ABL1 ratio of 3 logs = 0.1%; MR4: reduction of BCR-ABL1/ABL1 ratio of 4 logs = 0.01%, MR4.5: reduction of BCR-ABL1/ABL1 ratio of 4.5 logs = 0.0032%; MR5: reduction of BCR-ABL1/ABL1 ratio of 5 logs = 0.001%) ; the reduction of the transcript was then measured from this value in logarithms (MR3 or MMR: reduction of  0.001%) .Moreover, until 2005 the quantification was still relative in the majority of labs: in fact, the transcript measured after 3 months of treatment was compared to the measurement initially obtained at diagnosis; the transcript was then measured after 6 months and compared to that of the third month and so on. It was a very difficult and time-consuming approach, especially for physicians. After that, the quantification became obsolete due to the introduction of a reference curve or of specific standards in the PCR reaction, which was definitely a success, but the standardization of the molecular tests was necessary to allow us to compare results deriving from different laboratories, thus introducing molecular response as the primary objective of the clinical trials.BCR-ABL1 measure and performed periodic quality controls (https://www.eutos.org/content/home/index_eng.html). Among these laboratories, 3 Italian centers were also present , which started to spread the European project across Italy: in 2008, the Italian network, initially called “X-file,” and then “LabNet,” began its activity, with the aim of creating a network of molecular laboratories distributed throughout the national territory, which could manage the molecular response in CML, for the benefit of all Italian clinical centers. The project included a series of educational meetings, where the methodological aspects and the clinical significance of the evaluation of the residual disease were discussed and presented, with the purpose of rapidly expanding the importance of the molecular monitoring of CML in the TKIs era. We have to consider that at that time, although the prognostic role of the molecular response was evident, the technologies in use were still under discussion. The molecular investigations were carried out only in a few centers all over the world, and that monitoring was recommended to always be carried out by the same laboratory. In the same years, the methodological characteristics had been the subject of a “consensus conference” held in Washington in October 2005, where the technical characteristics were established for an optimal monitoring of the residual disease. A series of recommendations were discussed to harmonize the methodologies used in various laboratories by introducing a conversion factor , which then became the standard to express results  consortium, with the purpose to create an international CML registry, standardize the molecular monitoring, design a path to cure, and become a network of excellence, able to optimize treatment of CML patients and to promote the cooperation among hematologists and scientists across all of Europe. Thirty-eight laboratories from 15 different countries began a process of methodological standardization of the  results .BCR-ABL1 have been performed, all laboratories were able to reach and maintain the MR4, and 69% of them attained the MR4.5, the backbone for a safe TFR (http://www.gimema.it/labnet-cml/)  and constitute a valid and recognized diagnostic support for the whole country. Today, LabNet, thanks to constant development of its web platform, is the interface where clinicians and biologists collaborate in the management of the CML patients; moreover, LabNet allows clinicians to evaluate RQ-PCR as an accurate surrogate marker of response and is also a valid tool for assessing the patients' adherence to treatment. In 2017, as a result of the great effort of the Italian community, more than 33,000 RQ-PCR tests for et-cml/) .BCR-ABL1/ABL1 ratio ≤ 10% at 3 months); ;  whether BCR-ABL1/ABL1 ratio at 3 months <9.84% was associated with a longer overall survival (OS)  (BCR-ABL1/ABL1 ratio lower or higher than 10% at 3 months (94 vs. 87%) (BCR-ABL1/ABL1 ratio at 3 months >10%) and of 3-year OS (96 vs. 86%)  . The Gervs. 87%) . Interesvs. 87%) . The samvs. 86%) .Overall, the data reported above, even if retrospective, concur in sustaining the fundamental role of EMR; but what would happen to patients not in EMR if clinicians would wait for the molecular result at the 6 month instead of changing TKI just at the third month? The Canadian group measured the 3-year freedom from treatment failure rate for patients that at 3 months were not in EMR and who recovered or for patients who did not show the optimal response at the sixth month. The worst outcome was observed for cases with a transcript persistently >10% at the sixth month; nevertheless, no differences were observed between cases already “optimal” at 3 months and those who became “optimal” only after 6 months. This suggests that PCR values at 6 months might be more relevant than those from the third month, at least in the imatinib setting .At the ASH meeting held in 2018, the matter of the “early switch” was discussed again: 108 patients in sub-optimal response or failing imatinib were early switched to nilotinib; the authors sustained that the early switch (change at the third month) offered a significant advantage in terms of MR3 at 2 years  . At the BCR-ABL1 transcript reduction: indeed, in the group of cases with a BCR-ABL1/ABL1 ratio >10% at 3 months, the outcome was better for those who showed a halving time <79 days, that could represent a favorable reduction kinetics that could prelude to the achievement of the optimal response at the second time-point (6 months)  curve showed that patients with a BCR-ABL1/ABL1 ratio <41% after 1 month of therapy had higher probabilities of achieving the optimal response at 3 months, DMR (56 vs. 29%) and presented longer EFS (93 vs. 85%) (Some authors suggested as a possible solution to this debate the measure of the slope of the  months) , 37. Simvs. 85%) .Regarding the other two main issues—the ability of RQ-PCR to prove the stability of DMR, and the reliability of the correct definition of the “molecular classes,” we have to consider that, although RQ-PCR is always used to monitor the response to TKIs, it may not be the best approach when the issue is TFR followed by molecular relapse in half of patients who had profound and long-lasting molecular responses at the time of TKI discontinuation –41. In fBCR-ABL1 in the CML leukemic stem cell (LSC) that, when hidden in the hypoxic niche, does not synthetize the tyrosine kinase protein while it retains the fusion gene at DNA and RNA levels  with that measured by RQ-PCR. On a series of 400 patients, the absolute value of LSCs, either measured on peripheral blood or on bone marrow samples, did not correlate with the BCR-ABL1/ABL1 ratio measured by RQ-PCR in peripheral blood, with about 30% of patients with undetectable BCR-ABL1 transcript levels still showing circulating CD26+ LSCs. Perhaps, molecular response could be considered as a picture of the transcriptionally active progenitor cells only .BCR-ABL1 transcript levels   .BCR-ABL1 is used to extrapolate the quantity of unknown samples by comparison between the amplification cycles of the standard references and of the samples , with higher efficiency  Figure .BCR-ABL1 transcript with greater sensitivity and precision than RQ-PCR . Consequently, the absolute quantity of molecules can be determined without the need for a standard curve. One of the main advantages of dPCR is the precise quantification of the nucleic acids, which facilitates the measurement of small percentage differences; overall, dPCR has the potential to detect the presence of the n RQ-PCR .BCR-ABL1/ABL1 ratio (or ratio between BCR-ABL1 and another reference gene) expressed internationally compared to the baseline. When “clinical” sensitivity is considered, three factors must be taken into account: (1) dPCR remains susceptible to pre-analytical errors upstream of the process, such as sampling, RNA extraction and cDNA synthesis, as already occurs for RQ-PCR; (2) the quantification of the reference gene is still necessary to evaluate the processing qualities of the sample and the pre-PCR phases; (3) the use of a conversion factor remains a fundamental requirement for the expression of results according to the international scale, which is, in turn, the basis for the classification of molecular responses.Several factors must be considered in the application of dPCR in CML: first, the “clinical” vs. the “analytical” sensitivity, which is expressed as the limit of detection (LoD) of an analyte, that indicates the lowest concentration detected with certainty at 95% of confidence interval . HoweverAs reported in other hematological malignancies, such as non-Hodgkin's lymphomas  and acutBCR-ABL1 levels from 0.0032% (MR4.5) to 10% across three different dPCR platforms: Bio-Rad QX200, RainDance RainDrop System, and Applied Biosystems QuantStudio3D. This study successfully detected BCR-ABL1 down to MR5, thus demonstrating that dPCR approach was able to increase sensitivity detection levels  and by a cut off of 0.023% (measured by dPCR)  . Anothere <0.468 . FinallyIn conclusion, d-PCR seems to be a good, novel, sensitive and accurate tool for the molecular monitoring in CML; nevertheless, an international standardization is necessary before this technique enters routine molecular methods.ABL1 kinase domain (KD) mutations, that are one relevant mechanism of CML resistance to TKIs and that account for ~50% of acquired resistance in failing CML cases (The scenario of the new molecular technologies employed in CML has been recently enriched by the Next Generation Sequencing (NGS); this method is now frequently used for detecting ML cases . Indeed,ML cases –77.Even if these TKI-specific mutations are present in <10% of cases who do not reach the optimal response, it is relevant to identify and characterize them, in order to evaluate what kind of TKI has to be employed at the moment of the switch for resistance.ABL1 KD mutations are commonly detected by sequencing BCR-ABL1 cDNA according to the Sanger's method. This technique, however, can only detect mutations present in a percentage higher than 10–20%  split reads, that are single reads composed of material from two non-contiguous genomic regions directly mapping a fusion junction to a base pair resolution; and (2) discordant pairs of reads, in which there are individual reads in a pair map to different chromosome locations, indicating the presence of a structural rearrangement within the insert between them. When a sample has an expression level of BCR-ABL1 >10%, a mean read-depth of 50x is sufficient to map the fusion junction. The mapped genomic fusion junctions of each patient are unique and can be used as patient–specific markers for MRD monitoring if DNA or RNA at diagnosis are available. Amplicon deep-sequencing method utilizes a highly multiplexed amplicon generation strategy where multiple regions of interest are amplified and then sequenced at a depth of 100–10,000-fold greater than that offered by Sanger sequencing. Dedicated softwares assemble, align and map the sequenced reads to the reference sequence and perform variant detection. The quantitative feature is gained by sequencing targeted regions at depths of hundreds or thousands of reads, allowing the sensitive detection and quantification of rare events. ADS has been used for sensitive quantification of ABL1 mutations  per base to identify mutations at very high sensitivity (<1%).The application of amplicon deep sequencing for monitoring the genomic fusion junctions as a molecular marker is also a plausible quantification approach that is usually used to detect and track clonally-expanded lymphocytic populations in acute lymphoblastic leukemia (NGS includes two different strategies: (1) the “target capture” via probe hybridization or ligation, and (2) the “amplicon based enrichment” (ultra-deep sequencing [UDS] or the “amplicon” deep sequencing [ADS]). Hybridization-based NGS uses synthetic oligonucleotides specifically designed to target utations –86; overleukemia , 88 and leukemia –93. WhetABL1 mutations could also be responsible for resistance when present at a low level, and that detection of multiple KD mutations is associated with an inferior response rate compared to patients with none or with single mutations  have also emerged as a potential driver of acquired resistance to first- and second-generation TKIs, and show different resistance profiles compared with individual mutations, some of them also being resistant to ponatinib, the third-generation TKI able to overcome the negative prognostic impact of the majority of the he T315I . Compounhe T315I , 97, whehe T315I  showed the T315I .ABL1 mutations, were mixed. Only compound mutations with an observed frequency greater than the false-compound mutation rate were considered “true” compound mutations.On the other hand, novel advances and refinements of the NGS-based sequencing approaches can be interesting: for example, the incorporation of unique molecular identifier tags into the NGS protocol demonstrated that sequencing errors can be identified and removed from analysis , resultiABL1 mutation screening: a concordance between Sanger and NGS was found in 394/398 of the tested samples  is still matter of debate, because it has been demonstrated that LSCs also persist in patients achieving DMR and during TFR. The availability of new molecular methods will probably provide the answer to this question.The technique that is commonly adopted for measuring the ABL1 kinase domain, these being the mutations responsible for resistance to TKIs either in the chronic or in more advanced disease phases. Until now, the Sanger sequencing has been the more commonly adopted method, but NGS, with its higher sensitivity, is able to detect mutations at a sub-clonal level as well as compound mutations that are responsible for the resistance to ponatinib.Another hot field in the CML scenario is represented by the adoption of the NGS tools for evaluating the mutations of the The use of NGS will likely be more frequently adopted for patients who fail the first line of therapy and for those who are in suboptimal response during further treatment lines. In the allogeneic transplantation setting, data produced with NGS are not yet available and Sanger is still the recommended technique.ab initio, a successful and patient-tailored treatment. Obviously, further harmonization of these molecular techniques by international projects is still necessary to speak a universal language.Overall, in this review we have demonstrated the potential to manage many and new promising molecular tools that can help physicians to design, It is clear that, the basis of successful management of CML patients will always be the strict collaboration between biologists, technicians, and physicians. The existing and future networks will help all of us to reach this goal.BI, EG, and SG wrote the manuscript. SE and FD revised the part of methodologies. CB revised the clinical parts.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.


The eligibility for the minimum livelihood guarantee program in China is generally based on means testing, including a complicated income test and a household registration test. Even though the fiscal budget for this program steadily increased in the last two decades, the number of beneficiaries has decreased in both rural and urban areas since 2011. The recipients were stigmatized because their names are reported in the public domain and are known to their neighbors. Some beneficiaries tended to reduce social participation for fear of losing the eligibilities due to the stricter criteria or the stigma associated with receiving benefits. This paper examined the adverse impact of this welfare program on social isolation among Chinese middle-aged and older adults  using the panel data from the China Health and Retirement Longitudinal Study and the propensity score weighted difference-in-differences method (PSM-DID). The results present disparities between urban and rural older adults—The older program recipients in urban areas significantly reduced social participation by 20.53%, while the adverse impact was not statistically significant among rural recipients. Compared to older adults (aged 60 and above), middle-aged adults (aged between 45 and 60) were not socially isolated due to program enrollment in both rural and urban areas at the 95% confidence level. This paper for the first time addresses the causal relationship between program enrollment and the adverse impact of social isolation. It also alerts policymakers and local program administrators to protect older program recipients from stigma, sense of shame, and reduced social connection.