Tobacco mosaic virus (TMV) RNA has been detected in human samples and TMV RNA translation has been described in animal cells. We sought to determine if TMV is detectable, persists, and remains viable in the lung tissues of mice following intratracheal inoculation, and we attempted to inoculate mouse macrophages with TMV. In the animal model, mice were intratracheally inoculated with 1011 viral particles and were sacrificed at different time points. The virus was detected in the mouse lungs using immunohistochemistry, electron microscopy, real-time RT-PCR and sequencing, and its viability was studied with an infectivity assay on plants. In the cellular model, the culture medium of murine bone marrow derived macrophages (BMDM) was inoculated with different concentrations of TMV, and the virus was detected with real-time RT-PCR and immunofluorescence. In addition, anti-TMV antibodies were detected in mouse sera with ELISA. We showed that infectious TMV could enter and persist in mouse lungs via the intratracheal route. Over 14 days, the TMV RNA level decreased by 5 log10 copies/ml in the mouse lungs and by 3.5 log10 in macrophages recovered from bronchoalveolar lavage. TMV was localized to lung tissue, and its infectivity was observed on plants until 3 days after inoculation. In addition, anti-TMV antibody seroconversions were observed in the sera from mice 7 days after inoculation. In the cellular model, we observed that TMV persisted over 15 days after inoculation and it was visualized in the cytoplasm of the BMDM. This work shows that a plant virus, Tobacco mosaic virus, could persist and enter in cells in mammals, which raises questions about the potential interactions between TMV and human hosts.Plant viruses are generally considered incapable of infecting vertebrates. Accordingly, they are not considered harmful for humans. However, a few studies questioned the certainty of this paradigm.  Plantae and Vertebrata exist as infectious members of two separate worlds. Accordingly, plant viruses are not considered harmful for humans. An example of the confidence in this dogma comes from new prospects in the field of vaccine immunization that use plant virus-based vaccines Plant viruses are abundant inhabitants of the biosphere and are responsible for major diseases in a wide range of crops worldwide Tobacco mosaic virus (TMV) is considered to be extraordinarily stable and is the most heat-resistant plant pathogen known Virgaviridae family Tobamoviruses are known for their extraordinary resistance to heat, desiccation, freezing and thawing Xenopus laevis, in mouse liver mitochondria and possibly in rabbit reticulocytes http://www.who.int/tobacco/en/atlas8.pdf) and TMV is known to be present and stable in the tobacco of cigarettes and cigars 10 copies/cigarette Nicotiana tabacum chloroplast DNA, in the bronchoalveolar lavage fluid of mechanically ventilated pneumonia patients, which suggests that TMV may be conveyed to the lungs in tobacco However, TMV RNA entry and translation have been described in oocytes of At different times after intratracheal inoculation, TMV-inoculated and control mice were sacrificed and their lungs were collected. Inflammatory reactions to TMV were observed in lungs of all three inoculated mice at day 3 after intra-tracheal inoculation, whereas no histological changes were found in the two control mice at different times and in other TMV-inoculated mice at day 1, 7 and 14 after the virus inoculation . In TMV-Anti-TMV total antibodies were concurrently tested in serum samples from TMV-inoculated mice and control mice immediately before the intratracheal inoculation and 7 and 14 days after inoculation . For TMV10 copies/ml one day after TMV inoculation, 7.5±6.9 log10 at day 2, 8.2±7.2 log10 at day 3, 8.0±4.5 log10 at day 7, 4.3±3.4 log10 at day 12 and 4.8±4.8 log10 at day 14 , mouse no. 1 at day 3  and mouse no. 3 at day 3 (one lesion). A mosaic was also obtained on Nicotiana benthamiana for TMV-inoculated mouse no. 1 at day 3 . Washing supernatants, culture medium and macrophages from the BAL samples recovered from 10 TMV-inoculated mice and 5 control mice were tested by real-time RT-PCR. TMV RNA was detected in all of the samples from TMV-inoculated mice. TMV RNA titers in the BAL macrophages from TMV-inoculated mice were 8.7±0.4 lognfection . TMV hel10 for 1011 particles per well, by 6.8 log10 for 109 particles per well, and by 3.2 log10 for 107 particles per well. No TMV RNA was detected in non-inoculated samples. In the washed BMDM cells, TMV RNA was detected in inoculated cells, and the titer also decreased over time. Titers decreased by 3.8 log10 in BMDM cells for 1011 particles per well, by 2.2 log10 for 109 particles per well, and at day 15 post-inoculation, TMV RNA was not detected in BMDM cells for 107 particles per well. The non-inoculated BMDM control cells all tested negative for the presence of TMV RNA.To further study the TMV entry into murine macrophages, we inoculated BMDM with the virus. Four hours, 1, 3, 7 and 14 days after TMV inoculation in culture medium, cells were thoroughly washed and then fixed for immunofluorescence assays. Using mouse monoclonal anti-TMV antibodies, viral antigens were localized in the cytoplasm of TMV-inoculated macrophages and were not found in non-inoculated cells . To asse10 copies/ml on days 2 and 7 post-inoculation, and we showed viral persistence for up to 14 days after inoculation, at which time the last mice were sacrificed. In addition, TMV-like particles were observed with electron microscopy, and immunohistochemical analysis indicated the presence of TMV in the mouse lungs. Notably, viruses could be localized within macrophages of the pulmonary tissue. Moreover, TMV remained infectious for its plant host up to 3 days post-inoculation. Finally, TMV-specific antibodies were detected in the sera of most inoculated mice. In addition, our cellular model using BMDM confirmed that TMV could be found inside animal cells, suggesting that TMV might be internalized by macrophages. We showed that TMV was localized in the cytoplasm of murine macrophages and persisted until 15 days after infection.In this study, we showed that TMV could enter and persist in the lungs of intratracheally inoculated mice. We found TMV RNA at high titers using real-time RT-PCR in lung tissues and bronchoalveolar fluids, with RNA loads greater than 7 logTomato spotted wilt virus (TSWV) could infect two human cell lines, HeLa and diploid fibroblasts, depending on the expression of a viral polymerase-bound host factor Cowpea mosaic virus (CPMV), a plant comovirus in the picornavirus superfamily, was able to bind and enter mammalian cells, including endothelial cells, and the binding protein for the virus was identified as a cell-surface form of the intermediate filament vimentin Frankliniella occidentalisCowpea severe mosaic virus, Alfalfa mosaic virus and chimeric plant virus particles induced a durable and systemic immune response in mice Pepper mild mottle virus (PMMoV), with up to 109 virions per gram of dry weight fecal matter, while other tobamoviruses as Paprika mild mottle virus, Tomato mosaic virus, and Tobacco mild green mosaic virus were also detected. In another study, high-throughput sequencing also identified PMMoV RNA and other plant virus-derived sequences in 3 of the 4 fecal specimens collected from adult patients during norovirus outbreaks Although we did not evidence TMV replication in mouse lungs or murine macrophages in the present work, our findings raise concerns about the potential interactions between TMV and human hosts. There is other published literature that challenges the dogma of the strict boundaries between plants and vertebrates for viruses. In non-vertebrate animals, it was shown that plant pathogenic viruses displayed complex interactions with insects, and the transcription and replication of some plant viruses within insects was described Tomato mosaic virus) altered miRNA accumulation to a greater extent than did viruses that produce mild symptoms (Tobacco etch virus and Potato virus Y) Turnip crinkle virus (TCV), the P19 protein of Tomato bushy stunt virus (TBSV) and the P15 protein of Peanut clump virus (PCV) were functional as silencing suppressors in human Hela cells Until now, a major issue that precluded considering plant viruses as potential pathogens in humans was that they could not enter and replicate in vertebrate cells. A few aforementioned studies questioned the certainty of this paradigm Plantae and Vertebrata viruses may be less strict than currently accepted and they prompt a reevaluation of the potential pathogenicity of plant viruses for animals with modern microbiological tools. The role of these virions may be elucidated by analyzing the reprogramming of human cells inoculated by TMV.In summary, our findings and previous works suggest that the boundaries between Nicotiana tabacum Samsun plants were infected with the tmj strain of TMV by mechanical inoculation. Dried infected leaf tissue kept over CaCl2 were then crushed in phosphate buffer 0.01 M Na2HPO4-KH2PO4 pH 7.2 (buffer no. 1) using 1 g of leaves per 4 ml of buffer, with carborundum (75 mg/ml) and activated charcoal (75 mg/ml). Three leaves per plant were inoculated mechanically with a gloved finger before being rinsed with water. Two weeks later, young leaves with signs were collected and fresh leaves were ground into phosphate buffer no. 2 (0.5 M Na2HPO4-KH2PO4 pH 7.2) using 1 g of fresh leaves per 3 ml of buffer; 1% 2-mercapto-ethanol was added just before grinding. After homogenization, 8% (v/v) n-butanol was added to the extract and was stirred for 15 min before centrifugation at 10,000 g for 30 min at 10°C. The supernatant was filtered on cheese-cloth tissue then stirred for 15 min with polyethylene glycol (PEG) 6000 4% (w/v). After a centrifugation step at 10,000 g for 15 min at 10°C, the pellet was diluted into 10 ml of buffer no. 1. This solution was centrifuged at 10,000 g for 15 min at 10°C, and the supernatant was complemented with PEG 6000 4% (w/v) and NaCl 4% (w/v), before stirring for 15 min and centrifugating at 10,000 g for 15 min at 10°C. The pellet was diluted into 1–2 ml of buffer no. 1 and then centrifuged at 10,000 g for 15 min at 10°C. Thereafter, the supernatant was ultracentrifuged for 16 h at 35,000 rpm (Beckman 70.1TI rotor) in a cesium chloride gradient (0.505 g/ml). The whitish band corresponding to the virus was collected with a needle and a syringe, then diluted into buffer no. 1 and ultracentrifuged at 38,000 rpm (Beckman 50.2Ti rotor) for 2.5 h at 10°C. Finally, the pellet containing the purified virus was resuspended into 500 µl of buffer no. 1. The viral titer was obtained by spectrometry using an extinction coefficient at 260 nm of 3 (Nanodrop 1000 Spectrophotometer).10–1011 purified TMV particles, or water for control mice. TMV-inoculated mice and control (water-inoculated) mice were sacrificed at days 1, 2, 3, 7, 12 and 14 post-inoculation. The experiment of mouse inoculation with TMV was realized twice. In experiment 1, three TMV-inoculated and two water-inoculated mice were sacrificed at day 1, 3, 7 and 14 after inoculation. In experiment 2, three TMV-inoculated mice were sacrificed at day 2 and 7, two TMV-inoculated mice were sacrificed at day 12 and one was sacrificed at day 14. One water-inoculated mouse was sacrificed at day 2, 7 and 14. Bronchoalveolar lavages (BAL) were obtained in experiment 2 by injection of sterile physiological salt solution in the respiratory tract of mice followed by aspiration. To obtain macrophages, BAL were centrifuged at 300 g for 10 min at 4°C, the cellular pellet was washed in 1 ml RPMI plus 10% FBS and was incubated at 37°C for 3 h in 1 ml of RPMI plus 10% FBS. Macrophages were collected from the wells in 200 µl of PBS (1X). In addition, lungs were collected from the sacrificed mice.Mice were anesthetized by intra-peritoneal injection with ketamine/xylazine (10 µl per gram of mouse). Next, they were inoculated intratracheally with 50 µl of 10For each mouse, lungs were removed, fixed with neutral buffered formalin (4%), and embedded in paraffin. Serial sections (3 µm) of these specimens were obtained for hematoxylin-eosin and immunohistochemical investigations. Immunohistochemical analyses were performed with a polyclonal rabbit anti-TMV antibody used at a 1∶500 dilution. The immunohistological procedure, in which an immunoperoxidase LSAB K 680 kit  was used, has been described elsewhere In a first manipulation, anti-TMV IgG/IgM antibodies were tested in serum samples from 10 TMV-inoculated mice and 5 water-inoculated mice immediately before the intratracheal inoculation and 7 and 14 days after inoculation. In a second manipulation, anti-TMV antibodies were tested in the serum of 3 TMV-inoculated and 3 control mice sacrificed 7 and 14 days after inoculation. ELISA Nunc Maxisorp plates were coated with 100 µl of purified TMV (1 µg per well) and incubated at 4°C overnight. Thereafter, they were washed with PBS Tween 0.1% and agitated for 30 min after the addition of 200 µl of PBS with 5% milk in each well, and then the plates were washed with PBS Tween 0.1%. The serum samples were diluted to 1∶100 in PBS with 3% dried milk and 0.1% Tween. Then, 100 µl of diluted samples were added to each well and were incubated for 1 h at room temperature. The plates were washed with PBS Tween 0.1%, and then 100 µl of biotinylated anti-mouse IgG/IgM specific antibody diluted to 1∶5000 in PBS-milk 3%-Tween 0.1% were added in each well. The plates were agitated for 1 h. Thereafter, the wells were washed with PBS Tween 0.1%, and 100 µl of streptavidin HRPO conjugate CALTAG  at 1∶10000 dilution in PBS-milk 3%-Tween 0.1% were deposited in each well. Next, the plates were washed with PBS Tween 0.1% and 200 µl of ortho-phenylenediamine was added per well. Finally, 10 min later, optical density was measured for each well at 492 nm.Pieces of lung were crushed in 800 µl of buffer no. 1 using a small pestle directly in the 1.5 ml microfuge tube. Then, RNA was extracted from 200 µl of the homogenates using the EZ1 virus Mini kit (version 2.0) on the BioRobot EZ1 workstation . RNA samples were eluted in 60 µl final volume and stored at −80°C until processing. The same procedure was used for viral RNA extraction from BAL macrophages.2O and 5 µl of RNA extract sample. From the mouse BAL macrophages, TMV RNA was detected and quantified using the capsid gene system.From mouse lungs, TMV RNA was detected and quantified using two systems of real-time reverse transcription (RT)-PCR, one targeting a region that corresponds to a fragment of the capsid gene and the other targeting the replicase gene , with thTMV RNA sequences corresponding to a fragment of the helicase or the movement protein encoding gene  were obtNicotiana tabacum Xanthi, which is a hypersensitive host for TMV, and on Nicotiana benthamiana, which is a susceptible host for TMV. In the presence of infectious TMV in the tested sample, local necrotic lesions appears on N. tabacum Xanthi one week after the mechanical inoculation and mosaic appears on the susceptible hosts after an additional week.Lung samples were crushed in 1 ml of buffer no. 1. Then, 200 µl of this homogenate was mixed with carborundum and mechanically inoculated on 5 adherent BMDM cells per well on glass slides were inoculated with 1010 TMV particles. Four hours, one day, three days, 7 days and 14 days after inoculation, BMDM cells were fixed in 250 µl of 3% paraformaldehyde solution for 20 min at room temperature and were then washed with PBS 1X. Thereafter, the cells were incubated for 15 min with 250 µl of ammonium chloride NH4Cl (0.5 M) and were washed three times with PBS 1X. Non-inoculated cells were used as controls. A drop of 40 µl of PBS 1X solution containing 10% FBS and 0.1% saponin was applied, and the glass slides, cells side up, were incubated for 20 min in a humid chamber,. Then, a 40 µl drop of mouse monoclonal anti-TMV antibody, produced as previously described A total of 105 bone marrow-derived macrophages (BMDM) per well were incubated overnight at 37°C in Dulbecco’s Modified Eagle’s Medium (DMEM) plus 1% glutamine, 1% penicillin-streptavidin and 10% FBS. Each well was inoculated with 20 µl of solutions containing 107, 109, or 1011 TMV particles. Non-inoculated cells were used as controls. Four hours after the inoculation, culture media were discarded and the cells were washed three times with culture medium, then 1 ml of culture medium was added to cells for incubation. The culture media and BMDM cells were collected at day 0 (4 h), 3, 6, 9, 12 and 15 after TMV inoculation. Before collection, cells were washed twice with culture medium and twice with PBS 1X before being recovered in 200 µl of PBS 1X by mechanical scraping with a tip. The culture media and BMDM cells were used for TMV detection by real-time RT-PCR.A total of 10Statistical analysis was performed with EpiInfo version 3.51, centers for Disease Control and prevention (CDP) Atlanta . Means values were compared by using either ANOVA test or Krustal-Wallis test according to the homogeneity of the variance measured by the Bartlett’s test. Differences were considered statistically significant if p value <0.05.This study has been approved by our institutional ethics committee for animal experiment of Aix-Marseille University , according to the guidelines of the ethics committee for animal treatment. (Agreement reference number 16-21052012).


Objective. Our purpose was to investigate radiology fellowship directors' and recent fellows' experiences and perceptions with regard to the fellowship application and selection process and to compare these experiences and perceptions. Materials and Methods. Institutional review board approval was obtained. We conducted an online survey of the memberships of three radiology subspecialty societies between October 2009 and December 2009 to learn about radiologists' views regarding various aspects of radiology fellowships. Results. In the process of selecting fellows, program directors and recent fellows consider performance during the radiology residency and the quality or prestige of the residency program as the most important objective factors, and the personal interview, letters of recommendation, and personality as the most important subjective factors. 25% of the program directors were in the match, and 41% of the recent fellows were in the match. Most (48%) of program directors favored a match, but most (56%) of the recent fellows disfavored participating in a match. Both program directors and recent fellows expressed satisfaction with the fellowship application and selection process. Conclusion. There was no majority support for a fellowship match among program directors and recent fellows and less support among recent fellows. Recent fellows appear more satisfied with the current selection and application process than program directors. The radiology fellowship is one- or two- year clinical training in a subspecialty area that is served after completion of the four-year residency and its prerequisite preliminary transitional internship year. Radiology fellowships therefore represent an optional sixth and seventh years of clinical training. The vast majority of US-trained radiologists complete a fellowship before entering practice. In a survey from 1999, 80% of fourth-year and 84.6% of third-year trainee respondents had accepted fellowship offers or were expected to do so . FellowsOur purpose was to investigate radiology fellowship directors' and recent fellowship applicants' experiences and perceptions with regard to the fellowship application and selection process and to compare these experiences and perceptions.Institutional review board approval for this study was obtained from the University of Washington Human Subjects Division.We conducted an online survey of radiologists between October 2009 and December 2009 to learn about radiologists' views regarding various aspects of radiology fellowships. The full survey was comprised of 34 questions, many of which had multiple response items. A subset of questions concerned the fellowship application and selection process and the responses to those questions form the basis for this report. Our survey initially separated the respondents into those who were fellowship program directors (“program directors”), those who had been through the fellowship application process within the past three years (“recent fellows”), and those who were neither. Program directors were asked about their participation in a fellowship match, their most recent complete application cycle, the application requirements for their program, the importance to them of various objective and subjective selection factors, their ability to recruit excellent fellows, their perceptions of the fellowship application and selection process, and whether they favored a fellowship match. There were 55 total items requesting a response from the program directors. Recent fellows were asked about their own application process, their participation in a match, the importance of various objective and subjective selection factors, their perceptions of the process, and whether they favored a fellowship match. There were 43 total items requesting a response from recent fellows. Most items used a 5-point Likert scale for responses; some questions were yes-no, some questions required numeric responses, and most questions offered the opportunity to add unstructured comments.The survey was made available online using a commercially available survey web site . Members of the study population were sent an e-mail describing the survey, its purpose, and the privacy policy applicable to the survey, identifying the investigators, and inviting the recipient to access the survey by following a hyperlink. Survey responses were anonymous.The study population was drawn from the active memberships of the Association of University Radiologists (AUR), the Association of Program Directors in Radiology (APDR), and the Society for Skeletal Radiology (SSR). The active membership of the AUR is drawn from faculty members of academic radiology departments, mostly radiologists at US medical schools. The active membership of the APDR is drawn from program directors and associate program directors of radiology residency and fellowship programs in the USA The active membership of the SSR is drawn from US-based radiologists whose clinical practice was predominantly musculoskeletal radiology at the time of joining. Three rounds of invitations to participate in a survey regarding radiology fellowships were sent by the societies themselves to each e-mail address in their active membership directories. Approximately, three weeks elapsed between mailings. To account for the three rounds of invitations and the possibility of overlapping memberships, the invitations asked the recipients to take the survey just once. At the time of the survey, there were approximately 750 addresses in the AUR directory, 300 in the APDR directory, and 450 in the SSR directory. Membership in these organizations is not mutually exclusive, but the proportion of overlap was unknown. We also did not know how many program directors or recent fellows were among the recipients of the invitations.P values ≤ 0.05 indicate a statistically significant association. Open-ended responses and general comments about the survey were collected, categorized, and counted.Survey data were analyzed using commercially available statistical software . Statistical significance was assessed using Kruskal Walllis tests, which accommodate data tables with cell frequencies of ≤5. Chi-Square probabilities are reported for two-tailed tests; by convention, A total of 427 responses to the email invitations were recorded, for an overall response rate of 28.4% . There were 201 responses to the AUR mailings, 84 responses to the APDR mailings, and 142 responses to the SSR mailings. However, the actual response rate may have been higher because the 1,500 e-mail addresses that were solicited could have included an unknown fraction of duplicates, invalid addresses, and addresses not in use. It is also unknown whether any radiologists responded multiple times to the invitations; such an action would have decreased the response rate. Among the 427 respondents, there were 114 who identified themselves as program directors, and 37 as recent fellows. This study is thus based on a total of 148 respondents, but not all respondents answered all of the items presented to them.The subspecialties represented by the program directors were diverse , consistP = 0.046), received more interview offers (P = 0.033), and completed more interviews (P = 0.005) than those not in the match. Match participants did not differ from nonparticipants in the number of fellowship offers they received. Most (84.6%) recent fellowship applicants felt that they were given adequate time to respond to offers. About 37% (10 of 27) reported that they were internal candidates. Because of the application cycle and completion of the actual fellowship are two to three years apart, the responses of the recent fellows and the program directors did not correspond to the same cycle.We asked the program directors about the most recent complete application cycle, including the number of fellowship applications, interviews, offers, and fellows signed. Program directors reported receiving an average of 19 applications, resulting in an average of about 8 interviews, 3 to 4 offers, and between 2 and 3 fellows signed. There were no significant differences between the program directors of accredited and nonaccredited fellowships in this regard. We asked recent fellows about their own application experience. Recent fellows reported submitting an average of 5 to 6 applications, receiving 4 to 5 interview offers, completing 3 to 4 interviews, and receiving 2 to 3 offers. We note that match participants submitted more applications  and on reference checks (P = 0.136) than those of nonaccredited fellowships.We asked program directors about the importance of twelve objective and ten subjective factors in the process of selecting fellows. Objective factors were those for which there is a reference standard outside of the program director, even though that standard might itself be subjective. For example, performance during the residency may reflect an aggregate of subjective faculty evaluations and performance observations, but these evaluations and observations are not made by the program director receiving the application. Subjective factors were those judgments that were made by the program director or other faculty involved in the selection process. Among twelve objective factors, only one—performance during the radiology residency—was viewed as “very important” by a majority of the program directors  responding to this question . A majorWe asked recent fellows about the importance of the same objective and subjective selection factors that we asked program directors about Figures -3. AmongP = 0.008), and directors place less value on the M.D.-D.O. distinction (P = 0.051). Both groups consider personality and performance during the personal interview as the two most important subjective factors. Interestingly, program directors place less importance than recent fellows on letters of recommendation (P = 0.021) and the results of reference checks (P = 0.035).Recent fellowship applicants tend to place somewhat greater importance on test scores from the radiology residency   of program directors responding to our question reported that their program participated in the match during the last complete application cycle. Of the program directors who responded to questions about accreditation and match participation, 50% (20 of 40) of accredited programs participated in the match, while 50% (20 of 40) did not. Neuroradiology and vascular-interventional radiology programs were in the match; pediatric radiology, musculoskeletal radiology, nuclear medicine, and abdominal imaging programs were not. There were 46 non-accredited programs not in the match, and surprisingly, there were two nonaccredited programs  said to be in the match.Of the recent fellows who responded to our questions about match participation, most  did not go through a match, and of the 11 who did, 7 did so for all of their applications, whereas 4 only went through a match for some of their applications.Fewer than half of the program directors were in favor of a match , while 16% (14 of 90) were neutral, and 37% (33 of 90) disfavored a match . There wRecent fellows were less in favor of a match than the program directors. Whereas 30% (9 of 30) were neutral on this point, 40% (12 of 30) of recent fellow respondents disfavored or strongly disfavored participation, and only 30% (9 of 30) favored or strongly favored it . There wP = 0.005) and recent fellows (P = 0.027). We did not find a significant association between match participation and the importance placed on selection factors on the part of either program directors or recent fellows.There is a significant association between participation in the match and favorable views on match participation for both directors (P = 0.027).We found no differences between internal candidates and other fellows' support for participation in match. Match participants responded more favorably than other recent fellows to the question regarding participation in match (P = 0.006), stressful (P = 0.041), or poorly-timed (P = 0.005). With regard to fairness, 81% (73 of 90) of the program directors thought the applicants found the process moderately fair to very much fair. Directors participating in the match did not differ significantly from other directors regarding the predictions of fellows' assessments of the fellow selection procedure. There were 8 unstructured comments regarding the question about program directors' perceptions about fellowship applicants' views of the application process. 7 out of 8 (87.5%) were negative views of the process, and most of them (6 of 7) were concerns about timing (“it is too early in many cases”).We asked program directors the extent to which they thought fellows viewed the following characterizations of the fellowship application and selection process: chaotic, expensive, fair, time-consuming, stressful and poorly-timed. In all six dimensions, directors' modal response was to attribute the most neutral view to fellows, on a scale ranging from “very much” to “not at all.” There was, however, substantial variation in program directors' responses . Only 30P = 0.005) or time consuming (P = 0.032), and more likely to view it as fair (P = 0.034). Those with recent match experience were more likely to view the process as expensive (P = 0.024), time consuming (P = 0.010), stressful (P = 0.029), and less fair (P = 0.072).We asked recent fellows about the extent to which they did or did not view the selection process as chaotic, expensive, fair, time-consuming, stressful, and poorly timed. As with the program directors, there was a wide range of responses . Only 40Comparing the program directors' perceptions with the recent fellows' responses, the program directors consistently thought that applicants would find the process worse and less fair than they actually did.P = 0.058). We did not find a significant difference between program directors who were participants and nonparticipants in the match.The program directors reported overall levels of satisfaction with the fellowship application and selection process that bordered on the satisfied to neutral . More prA majority of recent fellows reported being satisfied  or very satisfied , whereas fewer reported being either unsatisfied  or very unsatisfied  with the process ; neutralIn an open-ended question, program directors and recent fellows what they would change about the fellowship application and selection process, if they could change just one thing. From the program directors, we received 59 comments: 15 in favor of a match, 12 in favor of a standard timetable, and 11 in favor of moving the process to later in residency (end of PGY-4 or early PGY 5), 7 about more transparency between programs and applicants, 6 about enforcing the commitment of accepted candidates, 3 about attracting better or more candidates, 1 about getting rid of the match, and 4 had no suggestions. From the recent fellows, we received 13 responses: five in favor of a match, two each against a match, against any changes, and about increasing transparency, and single comments about decreasing the cost and delaying the timeline.Limitations to our study are principally related to sampling. We chose to use e-mail as the method of solicitation because of its negligible cost, and a web-based survey for similar reasons. The AUR, APDR, and SSR were chosen because the authors had access to their membership directories, and as a result, the sample was skewed towards program directors of musculoskeletal fellowships. Musculoskeletal radiology fellowships are mostly nonaccredited and none are in the match. The proportion of recent fellows among the memberships of these societies is low and appears to be reflected in the small size of our sample. Also, responses of recent fellows may have been affected by their postfellowship experience such as job market. We have no basis for speculating how these limitations may have affected our results.Our survey demonstrates that program directors and recent fellows clearly consider performance during the radiology residency and the quality or prestige of the residency program as the two most important objective factors in the process of selecting fellows. The personal interview, letters of recommendation, and personality appeared to be the most important subjective factors for both program directors and recent fellows. Overall, program directors are fairly optimistic about their ability to recruit excellent fellows and weed out nonviable candidates, and recent fellows generally have confidence in directors' recruitment capacities, although not as much as the directors have in themselves. Interestingly, with regard to the perceptions about the application process, program directors generally seem to think that fellows had a dimmer view of the process than they actually did. Both program directors and recent fellows expressed satisfaction with the fellowship application and selection process, with recent fellows being more satisfied than program directors.In our survey, program directors and recent fellowship applicants had divided opinions about match participation. Among program directors and recent fellows, there appears to be no majority support for a match, and there was less support among recent fellows than among program directors. The NRMP Radiology Fellowship Match was instituted to address a number of perceived problems with the fellowship application process, and the process was developed through discussion among leaders in radiology, including the National Intersociety Fellowship Application Task Force . HoweverThere was no majority support for a fellowship match among program directors and recent fellows and less support among recent fellows. Recent fellows appear more satisfied with the current selection and application process than program directors.


Mental Health Promotion among adolescents in schools using life skills education (LSE) and teachers as life skill educators is a novel idea. Implementation and impact of the NIMHANS model of life skills education program studied.The impact of the program is evaluated at the end of 1 year in 605 adolescents from two secondary schools in comparison to 423 age, sex, socioeconomic status-matched adolescents from nearby schools not in the program.P=0.002), perceived adequate coping (P=0.000), better adjustment generally (P=0.000), specifically with teachers (P=0.000), in school (P=0.001), and prosocial behavior (P=0.001). There was no difference between the two groups in psychopathology (P - and adjustment at home and with peers (P=0.088 and 0.921). Randomly selected 100 life skill educator-teachers also perceived positive changes in the students in the program in class room behavior and interaction. LSE integrated into the school mental health program using available resources of schools and teachers is seen as an effective way of empowering adolescents.The adolescents in the program had significantly better self-esteem ( The school mental health program (SMHP) is a very important and integral part of the educational system worldwide. In India, the SMHP is yet to be recognized and initiated as a part of the health component in schools. In practThe educational philosophy in ancient India was one of guru-chela/shisya parampara and stressed on the teacher being responsible both for literacy/knowledge and personality development in the ward. However, education, which is currently prevalent in our country, is achievement oriented than child oriented. It does not address the needs of all the children who in spite of various levels of scholastic competence are capable of learning and need to develop those skills, and become empowered to live effectively in this world. This empowerment is very essential in today’s context in India as there is rapid globalization and urbanization with a breaking up of joint families and the traditional support systems. AcademicMethods to improve the psychosocial competence and resilience of the adolescent as health promotional activities and development oriented approach need to be included in the school syllabus and provided as much relevance as the Three Rs .LSE is one such program. The currTo assess the impact of the life skills education program (LSE program -NIMHANS model) by assessing the difference between adolescents who were in the program and not in the program.More specifically to assess the difference between the adolescents who were in the LSE program (NIMHANS model) for a year and the ones who were not in the program in the following areas.CopingSelf-esteemAdjustment in various areasPsychopathologyThe present model of health promotion using life skills approach for adolescents in secondary schools was initiated by the authors in late 1996 but crystallized in late 2002.–6 It is Life skills (LS) are abilities for adaptive and positive behavior that enable individuals to deal effectively with the demands, challenges, and stress of everyday life. Childhood and adolescence are the developmental periods during which one acquires these skills through various methods and people.The generic LS, which need to be taught at the schools level especially to adolescents, are as follows.Critical thinking and creative thinkingDecision making and problem solvingCommunication skills and interpersonal relationsCoping with emotions and stressSelf-awareness and empathyDepartment of Public Instruction (DPI), Karnataka, in collaboration with NIMHANS planned to implement the NIMHANS model of the health promotion using LSE in four diverse districts  covering selected 261 secondary schools and 55,000 adolescents. Following steps were adopted in three phases for the implementation.Translation of the resource materials into the local language, i.e. Kannada.–11Discussion with the Adolescent Education Division of the Department of State Education, Research and Training (DSERT), Karnataka, identification of master trainers in each of the identified district from District Institute of Education and Training (DIET).Training of the identified 31 master trainers over 5 days in two batches on the concepts of adolescent development, challenges and opportunities in adolescence, life skills, values, LS education, facilitation, using the activities to impart LSE in classes, use of the resource materials, and training of teachers as LS educators.LSE awareness workshops for the block education officers (BEOs) and the head masters of the identified schools.Planning/preparatory workshops with BEOs of the identified four districts.Capacity building by training of the teachers in the identified secondary schools as LS educators by the trained master trainers over 3 days. More than 1000 teachers were thus trained from 261 schools over 3 months. Evaluation of the training.Implementation of the LS program in the identified secondary schools once a week for an hour over 12 to 20 sessions during the academic year.Impact of the program on a sample of adolescents at the end of 1 year.Impact of the program at every level was assessed and evaluated. The resource materials were evaluated and field tested. Feedback for the training sessions by both master trainers and teachers were done. Impact of the training was also assessed both in the master trainers and teachers by a pre- and post-assessment evaluation.The aim of this paper is to discuss only the impact of the program in an objective manner in a sample of adolescents who participated in the program for a year.The sample and control were selected from two schools in the Bangalore rural district (Chennapatna) and two schools from Udupi District. The control adolescents were selected from secondary schools in the same district as the sample group. Selection of the schools was random.Since all the students who were in the program for the previous 1 year in the two selected schools needed to be included, a total of 605 students were taken as the sample group.Adolescents of both sexes 14 to 16 years studying in 8th, 9th or 10th standard in the two schools  implementing the NIMHANS model of the LSE program the previous 1 year were selected. Informed Consent was taken from the parents as the adolescents were minors. These adolescents had undergone on an average 10 sessions of LSE classes during the previous year (minimum 5 and maximum 16 sessions)A total of 423 students were assessed as controls. They were adolescents of both sexes, 14 to 16 years studying in 8th, 9th or 10th standard, in secondary schools not covered by the NIMHANS model of LSE (or other adolescent education program). Informed consent was taken from their parents also.Out of the 1000 odd teachers who were trained as LS educators, 100 were selected randomly and their feedback on the perceived changes in their students who were in the LSE program, NIMHANS model, was compiled. The student indicators were prepared by the authors as a part of the resource material and available in the activity manuals–6 were uRosenberg Scale of Self-Esteem[lf-Esteem . Though called preadolescent scale has been used in Indian studies with adolescents . It assesses adjustment in five areas of home, school, teachers, peers, and general behavior. The total adjustment ranges from −46 to +34.ent Scale . It is a brief behavioral screening questionnaire. Has 25 items divided over five psychological areas. The self report version is used for 11-16 adolescents.t Version  as they were pre-selected from specific classes in government secondary schools. Their age ranged from 155 to 200 months (mean 175±13.8 months). 35 to 40% of the study groups were girls. There were more girls in Udupi school but was not significantly different from the other schools. 52% of the students in the sample group had participated in 10 LSE classes in the previous year; 23% in less than 10 sessions; and the remaining >10 sessions. The trained teachers were the LS educators and followed the NIMHANS model of LS program. The classes were interactive and participative.The study groups both the sample and the control group did not differ in age and sex or socioeconomic status .LSE is a novel promotional program that teaches generic LS through participatory learning methods of games, debates, role-plays, and group discussion. Conceptual understanding and practicing of the skills occur through experiential learning in a non-threatening setting. Such initiatives provide the adolescent with a wide range of alternative and creative ways of solving problems. Repeated practicing of these skills leads to a certain mastery and application of such skills to real life situation and gain control over the situation. It is a promotional program, which improves the positive mental health and self-esteem. Our counIn India, education has become institutionalized. Schools need to be recognized as the single most important and recognized forum to reach out to the young population. Any program to reach the adolescents/youth has to be incorporated into the educational system to be feasible, effective, and cost-effective. In a country like ours, where resources and trained professionals are sparse and few, it is more be practical to involve and work with the teachers. The teachers are the personnel who interact with the adolescents closely. They could be trained to transfer these skills to the adolescents. The methMost of the programs done earlier have evaluation of implementation-money planned spent, measurement of capacity building, extent of training, and conduct of program. Impact of an effective preventive/promotional program is of paramount importance and has been discussed at length. The signOriginal resource materials in English and later even the translated resource materials were evaluated and modified both by expert professionals and the end users (teachers).Trainings both at the level of the master trainers (MTs) and the teachers were evaluated both qualitatively and quantitatively-the effectiveness of training was established.Impact of the LS program on the target population (students) is the most powerful step of the program which was planned as an integral part of the project and presented here. A total of 55,000 students in 261 secondary schools in 21 taluks of 4 districts being the target population, impact evaluation was not possible of every student before and after the LSE program. Hence impact evaluation was carried out in a sample (±500) of the target population in a comparative manner.Since no specific assessment tools have been found to be superior to elicit LS of the adolescents, hence a set of instruments assessing assessment, presence of problems, coping and self-esteem were used. The tools were chosen such that they were self-administered, simple, earlier used in the local vernacular, and chosen diverse areas of competence-coping GSES, self-estP=0. 921 and 0.670) though the LS Educator teachers reported better interaction with peers in students in the program [P=0. 088) in the home adjustment between the two groups.Using the above tools the present comparative study indicated that even at the end of 1 year, there was a significant change in the way the adolescent perceived himself/herself in the school, with the teachers, and the confidence level of his/ability to deal with developmental challenges. One year is a very short period in development; however the model which is experiential and focused on specific issues of development seems to increase the ability of the adolescents to adjust well in the school with teachers and improve coping and self-esteem. This was also perceived by the LS educator teachers who reported better classroom behavior and interaction among the students in the program. The students in the program did not perceive better adjustment with peers than those not in the program ( program . The pro program –19 ParenP=0.000), better self-esteem (P=0.001), and better general adjustment (P=0.000) were important aspects which were significantly different between the two groups, indicating that the program prepares the adolescent to be a ‘competent’ and ‘empowered’ person in a changing, competitive, globalized world.[Perceived self-efficacy  and the educational policy of our country to promote psychosocial competence and reduce problem behaviors in adolescents.


Keeping older adults healthy and active is an emerging challenge of an aging society. Despite the importance of personal relationships to their health and well-being, changes in family structure have resulted in a lower frequency of intergenerational interactions. Limited studies have been conducted to compare different interaction style of intergenerational interaction. The present study aimed to compare the changes in visual attention, facial expression, engagement/behaviour, and intergenerational conversation in older adults brought about by a performance-based intergenerational (IG) program and a social-oriented IG program to determine a desirable interaction style for older adults.The subjects of this study were 25 older adults who participated in intergenerational programs with preschool children aged 5 to 6 years at an adult day care centre in Tokyo. We used time sampling to perform a structured observation study. The 25 older participants of intergenerational programs were divided into two groups based on their interaction style: performance-based IG program (children sing songs and dance) and social-oriented IG program (older adults and children play games together). Based on the 5-minute video observation, we compared changes in visual attention, facial expression, engagement/behaviour, and intergenerational conversation between the performance-based and social-oriented IG programs.Constructive behaviour and intergenerational conversation were significantly higher in the social-oriented IG programming group than the performance-based IG programming group (p<0.001). No significant differences were observed in frequency of smiles, however, when weighted smiling rate was used, smiles were significantly more frequently observed in the social-oriented IG programming group than the performance-based IG programming (p<0.05). The visual attention occurred between the generations was significantly higher in the performance-based IG programming group than the social-oriented IG programming group (p<0.05).Intergenerational programs with preschool children brought smiles and conversation to older adults. The social-oriented IG program allowed older adults to play more roles than the performance-based IG program. The intergenerational programs provide opportunities to fulfil basic human needs and reintegrate older adults into society. Further development of such beneficial programs is warranted.UMIN000010439UMIN-CTR clinical Trial: Older adults are at risk of being socially isolated due to poor health, low morale, and communication difficulties. KeepingIntergenerational (IG) programs were proposed as a way to develop bonds between two generations in the United States and have expanded to other regions of the world. As defiThe Intergenerational School (TIS) in Ohio in the United States represents a model of intergenerational programs in which older adults in the community teach reading and mathematics to children as mentors. In JapaThe IG programs in current elder day services in Japan include a “performance-based IG program” (children sing songs and dance) and a “social-oriented IG program” (older adults and children play games together). Depending on the available exchange time, either program or a combination of both programs is implemented. The performance-based and social-oriented IG programs each have advantages and disadvantages. In the performance-based IG program, even physically vulnerable older adults  can participate in the program. However, this program does not promote the older adults’ autonomy because the older adults are passive. The socThe present study aimed to compare the changes in visual attention, facial expression, engagement/behaviour, and intergenerational conversation in older participants in performance-based and social-oriented IG programs to determine a desirable interaction style for older adults.Using time sampling, we conducted a structured observation study, which was used to document specific behaviours, actions, and events. Time saThe participants of this study were 25 older adults aged 71 to 101 years who participated in intergenerational programs with preschool children aged 5 to 6 years (one group consisted of about 20 children) at a day care centre in Tokyo and for whom video observation was available. Regarding the Activities of Daily Living (ADLs), the participants were independent or could walk with walking assistance devices. Regarding cognitive function, we used the day-service user information under long-term insurance. The level of independent living in the elderly is considered from the aspect of cognitive function in addition to physical function to determine eligibility for long-term care insurance using the national criteria. The levThe participating day care centre was founded in 1987, and has provided programs to promote communication with community residents. Children from a nursery school or kindergarten in the neighbourhood visit older adults at the day care centre once or twice a month and spend 20 – 30 minutes with them at each visit.The study took place from December 2011 to February 2012. Three intergenerational programs during the study period were recorded with two digital high-vision cameras . The first program (December 2011) was follows: The “performance-based IG program” included 11 older adults for observation. Each child answered questions about their activities on Christmas Day at home, while older adults sat in chairs and listened to the children talk. The second program (January 2012): The “social-oriented IG program” included 8 older adults for observation. Children and older adults were divided into three groups, and they played “Karuta ,” “Cat’s cradle,” and “Fuku-warai (a game similar to ‘pin the tail on the donkey’)” together. The third program (February 2012): The “social-oriented IG program” included 6 older adults for observation. One elder and 3 to 4 children played “Action Songs” (hand play) as one group.We assessed the changes in visual attention, facial expression, engagement/behaviour, and intergenerational conversation among the participants during the intergenerational programs. According to the Japanese version of the Intergenerational Exchanges Attitude Scale (IEAS), we deveSmile 1= smiling/interest with change in mouth angle and eyes only. Smile 2=smiling with mouth open indicating joy or surprise. Smile 3 = laughter, change in eyes with vocalization to accompany smile.We assessed ‘engagement/behaviour’ in accordance with the Myers Research Institute Engagement Scale (MRI-ES) as developed by Judge et al.. EngagemThe observation time was determined to be 5 minutes , with one unit consisting of a 15-second interval as proposed by Nakazawa et al. and Mats2test and the Mann–Whitney U test. A P-value of <0.05 was considered to be statistically significant.The 25 older participants in intergenerational programs were divided into two groups by interaction style. Eleven older adults who participated in the first program were in the performance-based IG programming group, while 14 older adults who participated in the second and third programs were in the social-oriented IG programming group. We used Pearson’s χAll the participants were given full oral and written information about the study, and they all provided written informed consent before the study. For preschool children, the principal of the nursery school or kindergarten was fully informed of the study, and written information about the study was given to their parents by the principal. We obtained informed consent for the study and also signed written consent from their parents for video recording. The confidentiality of personal data was preserved. This study was approved by the Ethical Review Board of the Faculty of Medicine at Tokyo Medical and Dental University (No. 1079). This trial has been registered with UMIN-CTR clinical trial (UMIN000010439).Table Kappa coefficients among the 2 reviewers were assessed for 6 participants . Lombard et al. recommenConstructive behaviour and intergenarational conversation were significantly higher in the social-oriented IG programming group than the performance-based IG programming group (p<0.001). No significant differences were observed in smiles, however, when weighted smiling rate was used, smiles were significantly more frequently observed in the social-oriented IG programming group than the performance-based IG programming group (p<0.05). The visual attention occured between the generations was significantly higher in the performance-based IG programming group than the social-oriented IG programming group (p<0.05) Table .In the present study, there were differences in the changes in visual attention, facial expression, engagement/behaviour and intergenerational conversation in association with the interaction style of intergenerational program. Smiles, constructive behaviour and intergenarational conversation were significantly higher in the social-oriented IG programming group than the performance-based IG programming group, while the visual attention occured between the generations was significantly higher in the performance-based IG programming group than the social-oriented IG programming group.Smiles were observed in both the performance-based and social-oriented IG programming groups in this study. The older adults smiled just as a result of looking at the children’s faces in the performance-based IG program, while laughter was also heard in the social-oriented IG program, when the older adult picked up a good card, achieved a successful string figure, created a funny face in Fuku-warai, or played paper, rock and scissors. In general, social smiles sometimes occur, but laughter often breaks out when an individual is really enjoying something.Laughter and smiles are means of non-verbal communication that express interpersonal attitudes. Laughter and smiling are usually produced as messages of good will to others, signalling acceptance. Laughter is believed to have evolved in humans to express a secure and safe message to others. A chainEffective intergenerational programs provide opportunities to plan and reflect on experiences. AlthougWhen older adults are given meaningful roles such as the opportunity to nurture and mentor children, their self-esteem increases in assocVisual attention is also a form of non-verbal communication,40. In tClose interaction and repeated contact make self-disclosure and other friendship-developing mechanisms possible. It is vIntergenerational programs have the great potential to promote health and well-being of older adults. Given the limited number of such programs at present, we need to develop new programs which attract the participation of both older adults and children, with natural smiling and laughter. There are a variety of potential interactions including the pairing of older adults with children. Since the interest taken by older adults in activities is affected by their experience and character, programIt is important for facilitators to assess whether older adults communicate well with children in the program and to provide support. It is the role of facilitators to offer a program which draws out the strengths of both generations and to promote sustained attention and self-motivated involvement, while eSince the present study was a cross-sectional research design to compare a single set of observations of different adults in intergenerational programs, the effect of continuity of the IG programs was not determined. In addition, the participants in the performance-based IG program and the social-oriented IG program were different, and thus the effect of subject characteristics  cannot be ruled out. To eliminate the effect of subject characteristics, the same persons should participate in both the performance-based and social-oriented IG programs in a cross-over research approach. Also, we need to determine whether the same effects can be expected for older adults with severe dementia and whether the contents of intergenerational programs involving elementary school or junior high school children should be the same as those involving preschool children aged 5 to 6. The present study was conducted in one facility with small number of subjects. Therefore we need to increase number of facilities and subjects and examine whether the same results are obtained. Also, randomization of subjects to different interaction-style programs is necessary.Although data collection is often difficult using questionnaire surveys when the subjects are older adults or preschool children due to problems with the reliability and validity of the survey results, we overcame such difficulties with objective video observation in the present study. Facial expression changed for only a few seconds at a time, therefore it was difficult to observe all of the changes in a single interaction, however, repeated play enabled us to improve the accuracy of the data.Intergenerational programs with preschool children bring smiles and conversation to older adults. Smiles and conversation correspond to interpersonal acceptance, which is a basic human need. The social-oriented IG program allows older adults to engage in more roles than the performance-based IG program. When older adults are given meaningful roles as mentors or role models, they are reminded of their ability to contribute to society. Intergenerational programs provide the opportunity to fulfil basic human needs and reintegrate older adults into society. Further development of beneficial programs is warranted.The authors declare that they have no competing interests.KM was responsible for the study conception and design, data analysis, and manuscript drafting. MK participated in the study conception and design, and advised of the analysis. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2318/13/111/prepub


Uptake of prevention of mother-to-child HIV transmission (PMTCT) programs remains challenging in sub-Saharan Africa because of multiple barriers operating at the individual or health facility levels. Less is known regarding the influence of program-level and contextual determinants. In this study, we explored the multilevel factors associated with coverage in single-dose nevirapine PMTCT programs.® Donation Programme (VDP) from 269 sites in 20 PMTCT programs and 15 sub-Saharan countries from 2002 to 2005. Site performance was measured using a nevirapine coverage ratio (NCR), defined as the reported number of women receiving nevirapine divided by the number of women who should have received nevirapine . Data on program-level determinants were drawn from the initial application forms, and country-level determinants from the Demographic and Health Surveys (DHS) and the World Bank (World Development Indicators). Multilevel linear mixed models were used to identify independent factors associated with NCR at the site-, program- and country-level.We analyzed aggregate routine data collected within the framework of the ViramuneOf 283,410 pregnant women attending ANC in the included sites, 174,312 women (61.5%) underwent HIV testing after receiving pre-test counselling, of whom 26,700 tested HIV positive (15.3%), and 22,591 were dispensed NVP (84.6%). Site performance was highly heterogeneous between and within programs. Mean NCR by site was 43.8% (interquartile range: 19.1-63.9). Multilevel analysis identified higher HIV prevalence , higher proportion of persons with knowledge of PMTCT , higher health expenditure as a proportion of Gross Domestic Product  and lower percentage of rural population  as significant country-level predictors of higher NCR at the p<0.05 level. A medium ANC monthly activity (30-100/month) was the only site-level predictor found .Heterogeneity of nevirapine coverage between sites and programs was high. Multilevel analysis identified several significant contextual determinants, which may warrant additional research to further define important multi-level and potentially modifiable determinants of performance of PMTCT programs. Since the HIV epidemic began, children have borne a significant part of the burden of morbidity and mortality. Mother-to-child transmission (MTCT) of HIV, occurring principally during labour, was responsible for approximately 390,000 new infections in 2010 . In thisDespite considerable progress made thus far, improving prevention program effectiveness in the field still remains a complex challenge, as suggested by discrepancies often observed between anticipated and actual uptake of services ,11. In lA better knowledge of these multidimensional constraints could help improve final coverage and guarantee program success. In addition, there is still great interest in documenting lessons learned from the implementation of single-dose NVP programs, given probable similarities between such challenges and those that programs based on more complex ARV interventions might encounter. Consequently, the objective of this study was to assess the site-, program- and country-level characteristics associated with NVP coverage levels achieved by PMTCT programs conducted in sub-Saharan African countries.® Donation Programme (VDP). Viramune® (nevirapine) has been offered to developing countries since 2000 by Boehringer Ingelheim. Axios International has been responsible for the management of NVP distribution and monitoring of participating PMTCT programs. All sub-Saharan African countries were eligible for participation in VDP. The nevirapine donation was available to governments directly, as well as Non Governmental Organisations (NGOs), international organisations and public and private health care providers with government approval.We used aggregate monitoring and evaluation data collected within the framework of the ViramuneAmong VDP participating programs , we selected those with data available by site or single-site programs. During the study period (January 2002 to December 2005), a total of 269 sites were included, participating in 20 PMTCT programs in 15 sub-Saharan countries . No statistically significant differences between selected and not-selected VDP programs were identified with respect to their main characteristics, including institution status, mean number of sites, mean ANC per program per month and mean HIV prevalence .To assess the overall performance of PMTCT sites, a coverage indicator was calculated. The NVP coverage ratio (NCR) was defined as the [observed number of women receiving NVP] divided by [the expected number of women who should have received NVP]. This denominator was calculated as the number of women attending antenatal care (ANC) visits multiplied by the observed HIV seroprevalence at each site (number of HIV-positive women/ number of HIV-tested women).Following acceptance to VDP, participating institutions were required to submit a progress report every six to 12 months with the following data for each site: number of women registered in antenatal care, number of HIV-tested and HIV-positive women and number of women receiving NVP tablets. These data did not permit assessment of the number of newborn NVP doses provided. The mean NCR over the period of follow-up was calculated for each site from all available progress reports. Predictors assessed at the site level included the site-observed HIV prevalence, the site activity (number of women receiving ANC), and the type of health facility .Inclusion in VDP required programs to submit a descriptive application form and receive approval by a body of independent experts. We collected the following data in application forms: type of responsible institution or organisation (public/private) and number of sites included.Variables collected at the national level were drawn from the Demographic and Health Surveys (DHS)  and the s) were used to assess univariate correlation of NCR with intermediate process indicators .Descriptive statistics were computed for the characteristics of the PMTCT programs and are provided as medians (Interquartile Range [IQR]) for quantitative variables and as percentages for qualitative variables. NCR dispersion across sites was assessed by using univariate boxplots. Non-parametric Spearman correlation rank tests (rnull) model without any predictor. The proportional change in the variance (PCV) was then computed in the final model for each level: PCV was defined as the proportion of variance “explained” from the variance initially estimated in the null-model. A two-tailed P-value of less than 0.05 was considered to be significant. All statistical analyses were performed using Stata, version 11.0 .Multilevel linear mixed models were used in univariate and multivariate analyses to identify factors associated with NCR, accounting for the hierarchical clustering of sites (level 1) nested in programs (level 2) within countries (level 3). The following multivariate modeling strategy was applied: predictors associated with NCR at the p<0.2 level in univariate analysis were entered sequentially, starting from level 1 to level 2 and 3, using a backward stepwise method at each level. Beta coefficients are given for each predictor variable, indicating the adjusted difference in NCR (0–100) between categories for qualitative variables or per 1-point difference in predictor value for continuous variables. Rural population proportion and total healthcare expenditure group-level predictors were modeled continuously after checking for linearity of the regression coefficients. The initial variance partition between levels was explored in an empty  and women treated rate .Of the 283,410 pregnant women attending antenatal care, 174,312 women (61.5%) were offered, accepted and underwent HIV testing after receiving pre-test counselling, of whom 26,700 (15.3%) tested HIV positive. After post-counselling, 22,591 women (84.6%) were eventually dispensed NVP. Using these figures, the global NCR was 52.0%. Considering the performance rates per site, the mean testing coverage was 61.5% (IQR 42.2 - 83.8), the mean treatment rate was 70.2% (IQR 50.0 - 98.6) while the mean NCR per site was 43.8% (IQR 19.1 – 63.9). NCR differed greatly across sites ranging from 0.0 to 1.0, and across programs (0.07 to 0.94) as shown in Figure Results from univariate multilevel analysis of PMTCT performance by site-, program- and country-level predictors are shown in Table Multivariate analysis using linear mixed models Table  identifinull-model including no site- or program/country-level predictors, 58.5% was found at the site-level and 41.5% at the program/country level (2.7% [program-level] + 38.8% [country-level]). To determine the proportion of variance explained by the predictors retained in the final model, we computed the PCV for each level: PCV was 99.9% for the program/country level whereas only 0.22% of the site-level variance was explained by the final model.Of the initial total variance of NCR measured in the In this study, we analysed aggregate data from 283,410 pregnant women attending 269 PMTCT sites. We identified several factors operating at the country-level that significantly influenced nevirapine coverage in women, including PMTCT knowledge, HIV prevalence, rural population proportion and proportion of GDP dedicated to healthcare expenditure. These factors were independent of site-level factors, such as the site activity or the type of health facility, and program-level factors, such as the status of the institution or the program burden measured as the number of sites included. To our knowledge, this study is the first to explore the contextual determinants of PMTCT program performance within the formalized framework of multilevel modeling. The contextual predictors identified explained almost 100% of the initial variance at the program/country level. Our data also showed a huge heterogeneity of performance between sites within the same programs.Among 269 PMTCT sites, we found a nevirapine coverage ratio of only 44%. Our result is only somewhat more optimistic than a study by Temmerman et al. reporting a NVP administration rate of 20%, using a similar whole-ANC-population-based calculation process . The takSpecific PMTCT and general comprehensive knowledge about AIDS were significantly associated with higher nevirapine coverage, whereas general awareness about AIDS – as measured by the proportion of persons who had heard of AIDS – and accepting attitudes or stigma were not significantly linked to NCR. This is consistent with previous reports showing knowledge as an important factor of success in antiretroviral adherence  or breasThe national prevalence of HIV remained significant after accounting for knowledge about AIDS and healthcare expenditure. In this context, the interpretation of this indicator might be of interest because it likely encapsulates several other contextual features  or other factors not assessed in our analysis. Thus, we may interpret national HIV prevalence as an awareness and readiness marker indicative of both population and health services.Rural population as a percent of total population was negatively associated with NCR. This result is consistent with the loss to follow-up of pregnant women , as mateNational health expenditure as a proportion of GDP was an independent and positive predictor of nevirapine coverage, probably suggesting an overall positive impact of increased investment in the organization and infrastructure of health services. This finding may confirm the importance of overall health system strength to ensure effective PMTCT services in the field, where performance is notably linked to sites’ infrastructure and testing capacities ,14 as ilAt the site-level, the highest and lowest nevirapine coverage results could be observed within the same program, emphasizing challenges to the on-the-ground feasibility of PMTCT programs. Beyond infrastructure and testing capacities, lack of sufficient and well trained staff have been suggested to explain some of the discrepancies observed between sites. Integration of voluntary counselling and testing (VCT) services in pre-existing ANC settings represents an undeniable additional workload for in-place health workers. At the same time and for economic reasons, human resources have not always risen adequately ,20,25. EWe consider the generalizability of our findings in the context of global PMTCT programs. We included VDP programs with data available by site or one-site programs, which raises the question of the representativeness of the sites included, both in regard to the whole VDP program and to other existing PMTCT programs. We did not identify any significant difference between included and not-included VDP programs regarding their main characteristics, which suggests limited selection bias within the VDP program itself. As for the other PMTCT programs, our program panel cannot be considered as fully representative of all programs, implemented either within the same countries or elsewhere in sub-Saharan Africa and/or based on different antiretroviral drugs and regimen designs. However, our analysis was conducted on a range of sites and programs, including primary or secondary/tertiary health facilities with various ANC activities within programs from several different sub-Saharan African regions, thereby supporting the external validity of our results. Secondly, a possible selection bias cannot be excluded in regards to the pregnant women included in this study, since only women actually attending ANC services were considered. Finally, our findings stem from an early era in large scale implementation of PMTCT services, when antiretroviral interventions were based on much simpler regimens than the multi-drug regimens currently recommended ,10. HoweOur study has several limitations that should be noted. In particular, we were not able to control whether a pregnant woman actually took the NVP dose she was dispensed in PMTCT services. Specifically, we lacked the ability to directly measure the drug compounds contained in cord blood samples, which is an accurate and useful means to counter the limited quality of reported medical data when assessing program coverage . NCR tenIn conclusion, we observed a wide range of coverage outcomes among PMTCT sites and programs. To explain these discrepancies, we identified several country-level factors, including knowledge about PMTCT and AIDS or the proportion of GDP allocated to healthcare, adjusting for a variety of site- and program-level characteristics. Our findings illustrate the potential role of surrounding contextual and global health system features, in addition to local characteristics of sites. While qualitative and quantitative research is still needed at the site level, the overall understanding of factors associated with program performance would benefit from further research that attempts to identify more distant but important and potentially modifiable determinants of success.ANC: Antenatal care; DHS: Demographic and Health Surveys; GDP: Gross Domestic Product; HIV: Human Immunodeficiency Virus; IQR: Interquartile Range; NCR: Nevirapine Coverage Ratio; NGO: Non Governmental Organization; NVP: Nevirapine; PCV: Proportional Change in Variance; PMTCT: Prevention of Mother-To-Child Transmission of HIV; VDP: Viramune Donation Programme.The authors declare that they have no competing interests.All authors participated in the study conception and design. MHB, JS and JL participated in the data acquisition and extraction. EA and JL performed the statistical analysis and interpretation of data. EA made the drafting. All authors participated in the critical revision of the manuscript and have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/286/prepub


During SARS, high compliance in healthcare workers to hand hygiene was primarily driven by fear.However, the post-SARS period confirmed that this practice was not sustainable.At the Singapore General Hospital, a 1600-bedded acute tertiary care hospital, the hand hygiene program was revised in late 2006 following Singapore's signing of the pledge to the WHO "Clean Care is Safer Care" program.The WHO audit tool was used in the measurement of hand hygiene compliance from 2007. Innovative education and prominent cues to action were initial building blocks used in transforming behaviour. Creative use of posters, stickers, advertisements on shuttle buses help to create awareness in staffs, patients and the public. A giant poster placed on one of the hospital walls is a strong public statement expressing the hospital's commitment to patient safety through good hand hygiene practices. Incentives in the form of handphone straps, magnets, bookmarks and vouchers given to staffs are other innovative means of staff engagement. The program was enhanced further with system changes, evaluation and feedback; and the fostering of institutional safety climate. Annually, the WHO Hand Hygiene day on 5 May was observed with creative fun activities involving both staffs and public.Hand hygiene compliance rate improved from 20% (2007) to 61% (2010). Improvement was also seen annually in the compliance to each of the 5 moments as well as in all staff categories. Healthcare-associated MRSA infections was reduced from 0.6 (2007) to 0.3 (2010) per 1000 patients days.Leadership’s support of the program through its visible presence, messaging and release of resources is the key factor in helping to make the program a true success. The hospital was recognised as a Global Hand Hygiene Expert Centre in January 2011.None declared.


Single-port laparoscopic surgery is a new technique that leaves no visible scar. This new technique has generated strong interest among surgeons worldwide. However, single-port laparoscopic colon surgery has not yet been standardized. Our aim in this study was to evaluate the feasibility of single-port laparoscopic colectomy compared with conventional laparoscopic colectomy for colon cancer.We conducted a case-matched, controlled study comparing single-port laparoscopic colectomy to conventional laparoscopic colectomy for right-sided colon cancer.A total of ten patients were included for the single-port laparoscopic colectomy (S-LAC) group and ten patients for the conventional laparoscopic colectomy (C-LAC) group. The length of the skin incision in the S-LAC group was significantly shorter than that of the C-LAC group.Our early experiences indicated that S-LAC for right-sided colon cancer is a feasible and safe procedure and that S-LAC results in a better cosmetic outcome. The first report about laparoscopic colectomy was published by Jacobs et al.  two decaet al. ,3. Recenne model . Marescacal case . HoweverThis study was performed with permission of the Ethics Committee of the Hiroshima University.n = 10). Patients who underwent conventional laparoscopic surgery for right-sided colon cancer between April 2006 and March 2010 were selected as the control group for this study (n = 10). These patients were matched with regard to the patient's age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, history of abdominal surgery, disease type and tumor location. No consideration or analysis of surgical parameters and outcomes was made until these groups were definitively selected as the best comparison cohort based only on preoperative variables.We conducted a case-matched, controlled study comparing single-port laparoscopic colectomy to conventional laparoscopic colectomy for right-sided colon cancer. The inclusion criteria were right-sided colon cancer which required colon resection with D2 lymph node dissection. The single-port laparoscopic colectomy group included selected patients who completed their treatment between February 2010 and March 2011  and conventional laparoscopic colectomy (C-LAC) were performed using a mediolateral approach, and the hand-sewn anastomoses were performed extracorporeally. In the S-LAC group, a 3-cm skin incision was made in the umbilicus and laparotomy was performed. The Gelport  was inserted through this incision and used as the access port. We usually used three trocars of different sizes  to prevent clashes between these trocars. The camera was a flexible videolaparoscope , and the energy source was the Harmonic Ace . The other laparoscopic instruments were the same as those used in conventional laparoscopic colonic surgery Figure . For theThe perioperative outcomes, including the surgical method, length of skin incision, length of operation, estimated blood loss and conversion rate to conventional laparoscopic surgery or open surgery, as well as the complications, were analyzed Table . The patU test. The χ2 test and Fisher's exact test were used to compare discrete variables. Statistical calculations were performed with the help of the SPSS version 18.0 software program , and a P value < 0.05 was considered to indicate statistical significance.All continuous variables are expressed as the median (range) and were compared using the Mann-Whitney P < 0.001). In terms of the hospital stay, the median stay of 8.0 days in the S-LAC group (range 6 to 13 days) was significantly shorter than the median of 10.5 days in the C-LAC group , as shown in Table Twenty patients  were enrolled in this study, and they were distributed into two groups: S-LAC and C-LAC. All patients were matched as closely as possible in terms of their selection criteria. The data for both groups are shown in Table The use of single-port laparoscopic cholecystectomy has spread rapidly, and many procedures have already been performed throughout the world. On the other hand, single-port laparoscopic colon surgery for colon cancer has not yet been standardized. There are only a few reports of small sample size studies in the literature -14. It hP < 0.001). To evaluate the invasiveness of the procedure, we compared the length of the operation, estimated blood loss and hospital stay. In our series, there were no significant differences between the S-LAC and C-LAC groups regarding the length of the operation or estimated blood loss. In terms of the hospital stay, the median of 8.0 days in the S-LAC group (range 6 to 13 days) was significantly shorter than the median of 10.5 days in the C-LAC group (range 7 to 21 days) (P = 0.023). Generally, the duration of the hospital stay has been used as one of the most important parameters of invasiveness. However, the hospital stay is defined not only by the patient's situation but also based on the characteristics of many Japanese patients who hope to stay for a long period in the hospital. Hence, the hospital stay is not necessarily a reliable parameter on which to objectively assess the invasiveness of such patients. However, these findings demonstrate that S-LAC is not more invasive than C-LAC or open colectomy.The apparent advantage of single-port laparoscopic colectomy is a better cosmetic outcome. Our data also reveal that the median length of the skin incision in the S-LAC group of 3.0 cm (range 2.0 to 3.0 cm) was significantly shorter than that of 5.0 cm in the C-LAC group (range 3.0 to 6.0 cm)  had no conversions (Table Our series of single-port laparoscopic colectomies for colon cancers n = 0 had no P = 0.912), as shown in Table In terms of the median number of extracted lymph nodes, there were no significant differences between the S-LAC group  and the C-LAC group  (This study is limited by its small sample size. However, it provides an initial comparison between S-LAC and C-LAC and can provide the foundation for large, randomized controlled studies.Our early experiences indicates that S-LAC for right-sided colon cancer is a feasible and safe procedure. Although there were no significant benefits regarding the perioperative and oncological results, S-LAC does provide a better cosmetic outcome. Before extending the indications of this procedure to advanced cases and those with rectal cancer, however, it will be necessary to evaluate this technique's perioperative and long-term oncological safety in a large, randomized controlled trial.ASA: American Society of Anesthesiologists; BMI: Body mass index; C-LAC: Conventional laparoscopic colectomy; NOTES: Natural orifice transluminal endoscopic surgery; S-LAC: Single-port laparoscopic colectomy.The authors declare that they have no competing interests.HE participated in the treatment of these patients and the literature search and drafted the manuscript. MH helped to draft the manuscript. TH, YT, YK, MS, MT, TA, TU and TI participated in the treatment of these patients. HO participated in treatment planning for these patients and helped to draft the manuscript. All authors read and approved the final manuscript.


Collaborations between cancer prevention and tobacco control programs can leverage scarce resources to address noncommunicable diseases globally, but barriers to cooperation and actual collaboration are substantial. To foster collaboration between cancer prevention and tobacco control programs, the Global Health Partnership conducted research to identify similarities and differences in how the 2 programs viewed program success. t tests to compare the mean importance of ratings assigned to each cluster.Using concept mapping, cancer prevention and tobacco control experts generated statements describing the components of a successful cancer prevention or tobacco control program and 33 participants sorted and rated the final 99 statements. Multidimensional scaling analysis with a 2-dimensional solution was used to identify an 8-cluster conceptual map of program success. We calculated Pearson correlation coefficients for all 99 statements to compare the item-level ratings of both groups and usedEight major clusters of success were identified: 1) advocacy and persuasion, 2) building sustainability, 3) partnerships, 4) readiness and support, 5) program management fundamentals, 6) monitoring and evaluation, 7) utilization of evidence, and 8) implementation. We found no significant difference between the maps created by the 2 groups and only 1 mean difference for the importance ratings for 1 of the clusters: cancer prevention experts rated partnerships as more important to program success than did tobacco control experts.Our findings are consistent with those of research documenting the necessary components of successful programs and the similarities between cancer prevention and tobacco control. Both programs value the same strategies to address a common risk factor: tobacco use. Identifying common ground between these 2 research and practice communities can benefit future collaborations at the local, state, tribal, national, and international levels, and inform the broader discussion on resource sharing among other organizations whose mission focuses on noncommunicable diseases. Noncommunicable diseases (NCDs) are the leading cause of illness and death in high-income countries and are emerging as a leading cause of death in low- to middle-income countries . HoweverThere have been notable examples of collaboration between cancer prevention and tobacco control organizations in the United States and Canada . TobaccoDespite their common focus on reducing tobacco use, substantial misunderstandings and myths have created barriers to working relationships between the tobacco control and the cancer prevention communities . AmeliorOur objective was to define a successful program in terms of how experts in cancer prevention and tobacco control described, categorized, and rated its components. We used concept mapping to examine the extent to which these 2 fields shared a common conceptual framework for program success.We used concept mapping to identify and organize best practices common to both the tobacco control and cancer prevention communities. Concept mapping is a type of Delphi method, a participatory process in which findings represent the ideas of those who contribute. As a mixed-methods planning and evaluation approach, it integrates familiar qualitative group processes  with multivariate statistical analyses to help a group describe its ideas on any topic of interest and represent these ideas visually through a series of maps ,13.During May to June 2008, a convenience sample of 70 cancer prevention and tobacco control program grantees and stakeholders associated with the Pfizer Global Health Partnerships (GHP) initiative, which provided 3 years of funding to 31 diverse tobacco control and cancer prevention interventions in 46 countries, were contacted by e-mail and asked to participate in a study about their perceptions of a successful tobacco or cancer prevention program. The e-mail included the address of a project-specific website where participants were asked to complete the following prompt: "Given your expertise and/or knowledge of the Global Health Partnerships program, a specific characteristic of a successful tobacco and/or cancer prevention program would be . . .". This process yielded 161 statements, which were reduced to 99 statements once duplicates were eliminated.The original 70 participants were subsequently contacted by e-mail and asked to rate each statement on a scale from 1 (relatively unimportant) to 5 (very important) and to sort the entire list of ideas into groups or themes based on similarity of ideas. The rating and sorting tasks required more time and effort to complete than the brainstorming task, and we anticipated attrition among the original participants. As a result, Pfizer GHP program stakeholders nominated an additional 10 leaders in tobacco and cancer control, who were also invited to participate. Participants identified their field of expertise, the geographic area in which they worked, and whether they were GHP grantees.We used the Concept System  to facilitate the concept-mapping process. This software uses multidimensional scaling and hierarchical cluster analysis to integrate the sorting information from each participant and develop a series of easily readable concept maps and reports. The maps provide a visual representation of how participants sorted and rated the statements generated during the brainstorming phase. For these analyses we generated 3 maps: 1 using all respondent data, 1 using data from 19 tobacco control participants, and 1 using data from 12 cancer prevention participants.The analysis aggregated the sort information from each participant to construct a 99 x 99 matrix of similarities; values in the cells represented the extent to which individuals within the group sorted the 2 ideas together. The total similarity matrix was analyzed by using nonmetric multidimensional scaling (MDS) analysis with a 2-dimensional solution. The 2-dimensional solution yields a configuration in which statements grouped together most often are located more closely in 2-dimensional space than those grouped together less frequently. The 2-dimensional  configuration resulting from the MDS analysis was the input for the hierarchical cluster analysis. To determine the best-fitting cluster solution, we examined a range of possible cluster solutions suggested by the analysis. We took into account the fit of the contents within clusters and an overall understanding of public health program design and evaluation. Detailed descriptions of the procedures and analyses used in concept mapping are described elsewhere ,13. Altht tests to compare the mean importance ratings for each cluster to determine any differences between cluster ratings of tobacco control and cancer prevention experts.To further examine the similarity or agreement in the sorted arrangements produced by tobacco control and cancer prevention participants, we compared the aggregated sort matrices of the 2 groups. Each group's symmetric matrix was arranged in a vector and a Pearson product moment correlation between the pairs of values in the 2 columns was computed as a measure of congruence of the interrelationships among statements. We also calculated a Pearson correlation for all 99 statements to assess the overall correspondence of the item-level ratings between both groups. Finally, we computed independent sample GHP stakeholders and evaluators reviewed the maps and developed a preliminary interpretation. The final map labels and interpretations were completed after the maps were presented and additional comments solicited from GHP stakeholders and grantees at an August 2008 evaluation workshop.Thirty-seven of the 70 original invited participants (53%) completed the brainstorming task. Of the 80 participants  invited to complete the sorting and rating task, 33 (41%) completed it, a response rate comparable to published web-based survey response rates of 31% . ApproxiThe final map that resulted from the sorting and rating task  shows thMoving from the lower left side of the map through each sector, the following summarizes the 8 clusters:Advocacy and persuasionThe statements in this cluster focused on understanding context  and using information about context to increase program effectiveness and sustainability. Themes raised included using program outcomes to advocate for interventions, policy change, and increased funding. Having organizational management with strategic and visionary leadership capabilities was found to be an important component of this cluster.Building sustainabilityThe statements in this cluster described what participants viewed as the most important factors to program sustainability. Many of these statements incorporated concepts from the other 7 clusters. Developing future leadership was a key theme and included recognition that sustainability requires leadership among multiple organizations and within affected populations. Institutional capacity and skills, including the development of systems to ensure that staff skills are sustained and emerging knowledge is incorporated into program practice, were also considered important components of sustainability building.PartnershipsThe statements in this cluster focused on building networks for program development, implementation, and dissemination of findings. The partnerships identified include the target population, allied organizations, government and civil society, and technology networks. Several statements cited the benefits of partnerships including knowledge flow, coordination, and the potential to reduce duplication of efforts.Readiness and supportThe statements in this cluster focused primarily on the need to assess the resources that a program has available and can potentially access, including staff skills, knowledge and training, and technical assistance.Program management fundamentalsThe statements in this cluster were few and relatively diverse. However, the major themes focused on the importance of not only having sufficient resources but also being able to access and manage those resources, including money, staff, and equipment.Monitoring and evaluationThe statements within this cluster focused on evaluation components , practices , and specific indicators (policy change).Use of evidenceThis cluster was located close to the monitoring and evaluation cluster, meaning that participants saw them as similar. The statements focused on the importance of using evidence from research, practice, and evaluation to guide program design and implementation.ImplementationThe statements in this cluster described what participants considered key guiding principles for program implementation. These principles emphasized the use of a policy-based approach; identifying and tailoring the program to the population served; and specific operational guidelines, such as identification and education of staff with appropriate skills and the inclusion of conflict-of-interest policies.4948 = .73, P < .001) and how important they rated them  on the 1 to 5 scale. At the cluster level, where item ratings were aggregated within the cluster to which they were assigned, 1 significant difference was observed: cancer prevention experts rated the importance of partnerships significantly higher  than tobacco control experts did . Although the difference in absolute values appears small, the cluster means are derived from the average across both the participants and items within a cluster. This produces a very narrow range of means across the clusters, so even slight differences in averages between clusters can be meaningful  and thus could prove useful as the dialogue concerning NCDs continues to develop.Our results represent the views and opinions of a small sample of experts in tobacco control and cancer prevention. However, concept mapping is a technique that has been used to develop frameworks that can be adapted to similar contexts and thus does provide a basis for generalization. In this case, we are comparing tobacco and cancer organizations. The results can be generalized to other groups or organizations that are working on prevention and control issues, especially those related to NCDs (Most low- and middle-income countries lack the basic knowledge and capacity to plan and implement separate cancer prevention and tobacco control programs  and thusTackling modifiable risk factors through prevention is essential to successfully ameliorating the coming epidemic of NCDs in low- and middle-income nations . However