N = 9), five were randomized to SSSH and four were randomized to deliver LIFT. Fifty percent of educators randomized to SSSH delivered the program, whereas 80% of the health educators randomized to LIFT delivered the program. The health educators deemed LIFT more suitable for delivery than SSSH, self-reported high rates of fidelity in program delivery, and intended on delivering the program in the following year. In conclusion, this study provides transparent methods for using an IRPP to adapt an intervention as well as preliminary outcomes related to adoption, implementation, and maintenance.Efficacy and effectiveness data for strength-training programs targeting older adults have been well established, but it is evident that they are not translated within practice-based settings to have a public health impact, as most (~90%) older adults are not meeting strength-training recommendations. Strength-training interventions developed, delivered, and evaluated in highly controlled settings  may not reflect real-world needs. One strategy to improve these outcomes is to work through an integrated research–practice partnership (IRPP) to plan and evaluate an intervention to better fit within the intended delivery system. The purpose of this study was to describe the IRPP method by which academic and practice representatives can partner to select and adapt a best-fit strength-training program for older adults. This work was planned and evaluated using the reach, effectiveness, adoption, implementation, and maintenance framework, applying the AIM dimensions to complement the methodology of the partnership. In this pragmatic work, members of the IRPP adapted the evidence-based program, Stay Strong, Stay Healthy (SSSH) into a new program, Lifelong Improvements through Fitness Together (LIFT). Of the health educators who agreed to be randomized to deliver LIFT or SSSH ( A number of strength-training programs for older adults that include home-based resistance training, supervised and unsupervised strength training, and strength training with groups of individuals have been effective –3. UnforMany evidence-based programs restrict their eligibility requirements based on medical status such as having osteoarthritis, living with diabetes, or those who identify with a specific gender –7. SimilLimiting the “fit” of an intervention leads to the absence of full penetration within a delivery setting and potential reach of the priority population, a shortcoming of delivery agents willing to adopt the intervention, and ultimately, inadequate implementation of the intervention , 13. To One way to systematically capture these factors is to plan and evaluate a strength-training intervention using the RE-AIM  framework . AccuratTo improve adoption, implementation, and maintenance outcomes of behavior change interventions, interventions should identify and align with the existing resources, mission, and values of practice-based settings and staff  , 17. HeaOne system with a particular mission to adopt and deliver effective behavior change interventions is the Cooperative Extension (CE) Extension system. Extension health educators represent communities and may serve as appropriate facilitators of behavior change interventions related to strength training because of their preexisting relationships with community members and leaders, access to community resources, and understanding of their communities needs . HoweverThrough an integrated research–practice partnership (IRPP), health educators and researchers equally contribute toward identifying a public health concern, design an intervention that is feasible, acceptable, and appropriate for delivery within the delivery system, and transparently report lessons learned to advance the utility and translation of the intervention within the intended delivery system , 26, 27.The overall purpose of this article is to describe the process by which an evidence-based, strength training program underwent research- and practice-based adaptations through the scope of a partnership to develop a program that would be adopted by community health educators, implemented throughout the community with fidelity, and maintained in a practice-based setting, beyond the life of the intervention , 33. Desvia WebEx for regular check-ins, program updates, and adaptations needed by members to better suit their needs for delivery of physical activity programs. All study procedures were completed in accordance with and with the approval of the Virginia Tech Institutional Review Board, participation was voluntary, and all data were kept confidential. All participants gave written informed consent before participation.In order to introduce quality programs that focus on physical activity within Virginia’s Extension system and improve older adult individual-level strength-training compliance, an IRPP was formed among health educators of Extension and behavioral and implementation scientists in 2015. Specifically, the partnership consisted of nine health educators across each of the four districts of Virginia Extension who had previously delivered physical activity programs to their community and one exercise specialist (statewide exercise leader of Extension). The partnership also included three graduate research assistants and two external health educators with communities in need of older adult physical activity programing. The stakeholders involved in the partnership labeled themselves as the Physical Activity Leadership Team. Members of the Physical Activity Leadership Team agreed to meet biannually in-person at a central location and biannually Based on the research- and practice-based evidence of effective and sustainable strength-training programs for older adults in Extension, Stay Strong Stay Healthy (SSSH)  and BettEach SSSH session is intended to last 1 h and consists of strength-training, balance, and flexibility exercises, and cool-down stretches Figure . The undHowever, the Physical Activity Leadership Team requested evidence- and practice-based adaptations before translating SSSH into the Virginia Extension system. These adaptations Figure  includedTo translate SSSH into Virginia Extension system, the exercise specialist of the Missouri Extension system delivered an in-person training on SSSH to the exercise specialist and one health educator of the Virginia Extension. While at the training, Missouri health educators that have delivered SSSH to aggregates of individuals, anecdotally noted that “camaraderie” was a by-product of participation in SSSH. However, camaraderie is not a “natural” by-product of working out among a group of individuals. For example, anyone can attend a weekly group fitness exercise class without actively engaging or communicating with the people around them. Implementing a group dynamics-based approach in which communication and interaction is facilitated between participants within a setting can foster group cohesion  or, “theA group dynamics-based intervention is one approach that has been successful with older adults . This apAlthough most Extension programs focus on nutrition education and integrate components of physical activity , LIFT isTo influence motivation toward long-term behavior change, participants are encouraged to track their physical activity behaviors and fruit and vegetable consumption outside of the LIFT program. Participants were provided with a self-tracking sheet that they could complete at their own leisure. Self-tracking and self-monitoring of behavior helps individuals regulate their behavior and stay motivated toward long-term behavior change .Reported results of SSSH inform that health educators deliver the intervention twice a week for 10 weeks . SSSH haTo summarize, the core components of LIFT are 16 in person sessions, the same warm-up, strength-training exercises, and cool down stretches from SSSH , and theN = 52) were invited to attend a 2-day physical activity training hosted by the lead and senior authors. Thirty-four Virginia Extension agents signed up to attend. Over the course of 2 days (5 h on day 1 and 6 h on day 2) all agents learned the following: (1) the primary evidence-based principles of reaching physical activity behavior change, (2) strength-training exercises , (3) the importance of evaluation tools , and (4) personal experience and practice in leading groups through strength-training exercises. Specific to LIFT, health educators received a thorough information session, via PowerPoint Presentation, introducing the evidence-based strategies and specifics of the program. The information session was followed by a 2-h demonstration consisting of the eight, full-body exercises, functional fitness assessments, and a testimonial from the perspective of a health educator who has delivered physical activity interventions within communities she serves for over 10 years. Health educators also spent 2 h of experiential learning and performing a sample LIFT session .In 2015, all Masters trained and professional Virginia Extension health educators (n = 13) of LIFT versus SSSH were invited to attend a 3-h, in-person information session where they were (1) refamiliarized with the adapted program, LIFT and (2) given repeat demonstrations of the eight strength-training exercises and functional fitness assessments in January 2016. Eligible attendees included health educators who either (a) attended the training in 2015 or (b) were members of the Physical Activity Leadership Team. The purpose of the feasibility study was to evaluate the potential reach of LIFT and practicality of implementing program adaptations for sustainable delivery within the Virginia Extension system, ensure that the evidence- and practice-base adaptations did not compromise the effectiveness of the intervention, and determine health educator level-adoption, and maintenance, or intentions of continued delivery in a community-based setting.Before a full launch of LIFT across the state of Virginia, it was essential to test the feasibility of the adaptations and build the evidence-base of the program. Health educators interested in participating in a feasibility trial  to capture the implementation and feasibility of current adaptations and further report real-world adaptations made during class sessions. Although health educators were free to change the suggested activities of the program, adaptations were still recorded to ensure they did not deviate from the underlying core components of LIFT and to gather a repository of adaptations that captures for whom, what, how, and when  the program in the future.and when  adaptatiOf the 13 eligible and interested health educators who expressed the need for translating LIFT into their community, 9 (70%) agreed to deliver LIFT or SSSH as part of a feasibility trial. Five of the nine health educators were randomized to LIFT and four delivered the program to older adults in the community. Four of the nine health educators who agreed to participate in the feasibility trial were randomized to SSSH and two delivered the program to older adults in the community.interested in delivering the program, the proportion delivering LIFT was 4/13 (31%) whereas the proportion delivering SSSH was 2/13 (15%).Using the denominator of 9 (those eligible and agreed to deliver), 4/9 (44%) delivered the LIFT program in practice, whereas 2/9 (22% of those eligible and agreed to deliver) delivered the SSSH program in practice. However, using the denominator of 13 health educators, i.e., total number eligible and Health educators reported on delivering the program with high fidelity 58% of the time for warm-up exercises. When a health educator reported an adaptation during the warm-up activity, the adaptation included, “completed high knees and grapevine exercises instead of marching in place while pumping arms.”Health educators reported high fidelity to the group dynamics-based activities 64% of the time. However, when an adaptation was reported, they stated within the adaptation that the activity did not fit their priority audience or there was not sufficient time within the session to complete the activity. An example adaptation reported was, “Instead of encouraging everyone in the group to perform the specific activity, I would ask for volunteers to complete the activity to save on time.”Health educators reported doing more repetitions of exercises than was prescribed in the program manual 38% of the time. Only one health educator reported doing less than the number of repetitions prescribed . Health educators reported changes in the equipment used to complete exercises 10% of the time. With regard to equipment changes, an example adaptation included, “used resistance bands in place of dumbbell weights.”Health educators reported delivering the cool down stretches as intended 89% of the time. When a change in exercise was made, health educators reported the adaptation as, “participants wanted to walk around the gym instead of stretch” or “completed different stretches.”Health educators reported delivering the program as intended 99% of the time, overall.One hundred percent of the health educators who delivered LIFT reported “yes” that they had intentions to deliver LIFT in the future. Of those who delivered SSSH, 100% confirmed their intentions (yes) to deliver LIFT in the future instead of SSSH. The health educators who delivered SSSH expressed their desire to incorporate the nutrition component and active facilitation of the social environment for their older adult participants. To date, five of the six health educators have continued delivery of LIFT within their community to different cohorts of older adults. The health educator not delivering LIFT has since left Virginia Extension.The overall purpose of this article was to describe the process by which an evidence-based intervention underwent research- and practice-based adaptations through an IRPP approach. Results of preliminary fit of the adapted intervention were based on the Adoption, Implementation, and Maintenance dimensions of the RE-AIM framework. Together, the IRPP identified an evidence-based program, adapted it to meet the mission and values of the Extension setting and staff, delivered the intervention, and transparently reported any further, real-world adaptations made during delivery.Lifelong Improvements through Fitness Together, the adapted intervention of SSSH, was delivered in practice at a higher rate than the original program, although the sample size was too low to determine significance (Adoption). Although SSSH continues to show positive effects in strength-training behavior and has been delivered and sustained within the Missouri Extension system for over 10 years, the adapted intervention, LIFT, was deemed more appropriate than SSSH within the intended setting for the priority population. This is unsurprising as LIFT was adapted to fit the needs, values, and resources of the existing delivery system (Implementation) , 34. WorEvidence-and practice-based adaptations are planned and executed to improve the feasibility, acceptability, appropriateness, and overall fit and delivery of an intervention in a given system. Adaptations are not to be mistaken for program deviations or unplanned changes made throughout an intervention that have a negative impact on system-level or participant-level outcomes , 44. TheIt can be concluded that although health educators were reporting adaptations being made or changing the “form” of the warm-ups, group dynamics-based activities, exercises, or cool downs, those adaptations were not changing the “function” of the activity. Meaning, the adaptations being made were still targeting the underlying program principles and core components of LIFT . It is iProviding health educators who will deliver LIFT in the future with a repository of changeable strategies to target the underlying core components of LIFT, will allow them to better meet the individual needs of their participants  and may Inevitably, real-world adaptations often occur in all practice settings and implementation with satisfactory fidelity to the intervention design is rarely achievable , 44. ThrThere were few limitations to be addressed. First, research members of the partnership stressed the importance of transparent communication between all members of the partnership and felt it would be unfair to blindly randomize members to deliver LIFT or SSSH. Instead, there was open communication about the importance of testing the feasibility of the two interventions within the Virginia Extension system and further build the evidence-base for LIFT within Virginia. However, once each program was assigned to the respective communities, health educators expressed disappointment in being assigned to the SSSH protocol, as they wanted to incorporate behavior change strategies and actively interact with their study participants. The research team further elucidated the importance of the feasibility trial, however, there may be program drift that went undetected due to the small sample size . Second,The research–practice partnership implementation strategy allowed the research team to work with the intended delivery system and the health educators within the system to improve the quality of the intervention integrated within the setting. Although this work was conducted in Extension, the method can be applied in other pragmatic settings. Through results of this study, it is evident that working through a research–practice partnership and involving stakeholders in the design and delivery of an intervention is key in the successful implementation of an intervention. This approach allowed for real-time, transparent tracking of further adaptations needed by the health educators and intervention participants, did not compromise the effectiveness of the program for the priority population, and resulted in relatively successful program fidelity.Together, researchers and invested stakeholders can identify a need that targets a specific community, design or tailor an existing intervention to improve the overall fit within the community, test the implementation outcomes , and determine if the intervention is ready for full-scale translation into a specific setting. The process of implementing an intervention into a specific setting should be nonlinear and simultaneous, meaning that the IRPP should design, test, and deliver the intervention while planning for long-term sustainability from the beginning.All study procedures were completed in accordance with and with the approval of the Virginia Tech Institutional Review Board, participation was voluntary, and all data were kept confidential. All participants gave written informed consent before participation.MW: significant contribution toward writing and editing the manuscript. Also collected, analyzed, and reported results of data. TS: significant contribution toward editing the manuscript and overseeing data collection, analyzes, and reports. RD: significant contribution toward editing the manuscript. Was also our program champion within our research–practice partnership. Helped to spear head meetings, trainings, program delivery, data collection, etc. SH: Significant contribution toward writing and editing the manuscript. Oversaw all research activities.The authors do not have any conflicts of interest to declare and results of this study do not constitute endorsement by the American College of Sports Medicine.


Depression is common in adolescence and leads to distress and impairment in individuals, families and carers. Treatment and prevention guidelines highlight the key role of information and evidence-based psychosocial interventions not only for individuals but also for their families and carers. Engaging young people in prevention and early intervention programs is a challenge, and early treatment and prevention of adolescent depression is a major public health concern. There has been growing interest in psychoeducational interventions to provide accurate information about health issues and to enhance and develop self-management skills. However, for adolescents with, or at high risk of depression, there is a lack of engaging Web-based psychoeducation programs that have been developed with user input and in line with research guidelines and targeted at both the individual and their family or carer. There are also few studies published on the process of development of Web-based psychoeducational interventions.MoodHwb (HwbHwyliau in Welsh): a Web-based psychoeducation multimedia program for young people with, or at high risk of, depression and their families, carers, friends, and professionals.The aim of this study was to describe the process underlying the design and development of The initial prototype was informed by (1) a systematic review of psychoeducational interventions for adolescent depression; (2) findings from semistructured interviews and focus groups conducted with adolescents (with depressive symptoms or at high risk), parents or carers, and professionals working with young people; and (3) workshops and discussions with a multimedia company and experts . Twelve interviews were completed  and six focus groups .Key themes from the interviews and focus groups were: aims of the program, design and content issues, and integration and context of the program. The prototype was designed to be person-centered, multiplatform, engaging, interactive, and bilingual. It included mood-monitoring and goal-setting components and was available as a Web-based program and an app for mobile technologies.MoodHwb is a Web-based psychoeducational intervention developed for young people with, or at high risk of, depression and their families and carers. It was developed with user input using qualitative methods as well as user-centered design and educational and psychological theory. Further research is needed to evaluate the effectiveness of the program in a randomized controlled trial. If found to be effective, it could be implemented in health, education, youth and social services, and charities, to not only help young people but also families, carers, friends, and professionals involved in their care. Depression is common in adolescence and is associated with distress, social and educational impairments, and poor physical health. It also predicts suicide and deliberate self-harm and can mark the beginning of long-term mental health difficulties . Early tGuidelines for the prevention and management of depression in young people , which deliver accurate information to individuals, families, and carers about mental health or a specific diagnosis, management and prognosis, and relapse prevention strategies ,8-10 Te. AlthougMuch of the existing literature on PIs has been in relation to individuals (mainly adults) with schizophrenia or bipolar disorder and their families ,8,11, alElectronic health  and electronic multimedia have been identified as a key area of future clinical practice and research in depression in adolescents ,14. TherMoodHwb: a Web-based psychoeducation multimedia program for young people with, or at high risk of, depression and their families and carers. The program was designed so that it could be used regularly within everyday health, social, education, youth services, and charities. This method of development provides an example and framework that could help inform the development of future Web-based programs, to ensure that they are codesigned with potential users to maximize the chances of user engagement and therefore impact.However, to our knowledge, there is no Web-based PI that has been specifically developed for adolescent depression (or those at high risk) and developed and evaluated in line with key guidance on the development and evaluation of complex interventions . This isThe American Academy of Child and Adolescent Psychiatry (2007): “Practice parameter for the assessment and treatment of children and adolescents with depressive disorders” describe psychoeducation as “education of family members and the patient about the causes, symptoms, course, and different treatments of depression and the risks associated with these treatments as well as no treatment at all. Education should make the treatment and decision-making process transparent and should enlist parent and patient as collaborators in their own care.” .preclinical or theory and phase I or modeling phases of the Medical Research Council (MRC) framework for complex interventions and the development phase of the new guidance on developing and evaluating complex interventions  are, how they work—make it more likely that they’re used.Young person focus group 3They felt that there should also be information for parents or carers and others, and professionals suggested there was a need for reframing:There’s a risk—a child wants to concentrate on positives, parent wants to say why it’s not perfect yet—child is then more depressed.Professional 1: male: psychiatristFocus group participants agreed there should be levels of information, with a hierarchy of sections and subsections. The overall structure and content evolved with each group and the program prototype included sections on mood and depression, possible reasons, self-help, and where to get help. Although there were differing views, overall, it was felt there should be a separate section on “other health issues” such as anxiety, bipolar disorder, and physical illness, although there was caution:It’s easy for the programme to become an ‘all mental health problems’ programme’.Research professional focus groupTo help with adherence and encourage support, participants in the interviews and groups suggested it would be helpful for the young person to be able to use the program with others, including family, carers, friends, or professionals, as well as independently. The creation of a separate user pathway and section for parents, carers, friends, and professionals was supported by all focus groups—with information on signs, symptoms, and triggers; supporting the young person; and dealing with difficulties.With regard to implementation, schools were considered an important setting for the intervention, particularly personal, social, and health education sessions. It was also felt that the program could be integrated into health and other services:This is essential...teachers see you every day for five years!Young person 2: female: under CAMHSThe name and promotion of the program was discussed, and the use of the term “mood” was considered more acceptable than “well-being” to young people.Across the interviews and groups, young people were as interested, if not more so, in the design as they were in the content. Although parents, carers and professionals also stressed the importance of design, they were especially interested in the content. Health and research professionals stressed the underlying evidence base and guidelines for assessment and management and suggested that young people should decide on the design.Some differences emerged in how “adults” perceived adolescent depression compared with the actual adolescent experience. Possible reasons included the adults “normalizing” of depressive symptoms and episodes, how some might not consider this to be a “real illness,” and the changing experience of young people with each generation, for example, in relation to stressors such as exam pressure, expectations, social media, cyberbullying, and parental separation.It felt like it could actually do something. Parents and carers tended to be more cautious, for example, some noted that mood monitoring might encourage a preoccupation and rumination . To address these concerns, they suggested including alerts when the mood was low and links to sources of help. With regard to the mood boards presented in the focus groups, young people preferred the graphic and illustrative imagery, whereas parents and carers felt that the photographs would be more appealing:Young people were generally positive about early versions of the program presented in the groups, and one young person stated, They should be real, not posed or pretending to be sad, cheesy...type of thing you’d see in a school slideshow.Young person focus group 3Young people want real people...they can relate, connect with them...everyone wants faces.Parent and carer focus groupSimilar issues were raised in other consultations, for example, with the Funky Dragon youth group. Everyone highlighted the advantages of multimedia, given its role in the lives of young people and that the program should also target those concerned about a young person.hwb is the Welsh translation for hub and also means a lift or boost) was designed so that it could be delivered across platforms using a range of multimedia and an app. As recommended by participants, the information was developed to be clear, factual, comprehensive, age-appropriate, avoiding jargon, but not patronizing. The bilingual approach meant that the program was more inclusive and that it was designed so that it could be translated into other languages in future. Security and confidentiality were also key considerations, and this was reflected, for example, in the password-protected log-in and encryption of data. In conjunction with the multimedia company, information architecture documents were created  were all structured in a similar manner, so that the user could scroll through the subsections and use menus and progress bars to navigate  represented the help sections. The typography chosen was clear and had a distinctive character. Metaphors for depression were used to help engage the user and communicate ideas. These included “being weighed down,” “a black dog,” nature, and weather . This program could help young people with (or at risk of) depression, as well as their families, carers, friends, and professionals. It has the potential to be integrated into a range of services including health, education, social, and youth services and charities.MoodHwb meets the need outlined in the guidelines for depression in young people ,6 for goThe program also fits with the UK government’s push to provide access to Web-based therapies to young people through information and communication technology -42. OverThe findings from the development work suggested the program might be particularly helpful in the early stages of depression when a young person starts to experience difficulties. This could be when they first present to professionals in education, health, or other sectors. MoodHwb could be integrated into each of these services at the lower levels of the stepped care approach for depression in young people . It coulMoodHwb fits with the guided self-help approach as it has been designed so that it can be used either independently or with another person. PIs could be delivered by a range of professionals, and Colom , a pioneHistorically, pressure to identify effective interventions in public health has led to many interventions being tested for effectiveness in randomized controlled trials (RCTs), with little rigorous development work being completed . This haIn the world of digital health, this development phase is also crucial, and user-centered design is a common approach used -22. As mThere is a lack of literature not only on the overall development process of Web-based (PI) programs but also specific elements such as the approach to graphic design or illustration in the context of youth mental health. This paper gives a detailed account of the process of development and a practical example of how to follow existing guidelines and could help inform other studies and programs in this field. The paper stresses the importance of involving all potential users  in the development of all aspects of the program—not only the content but also the design and technical elements and why this is crucial especially when attempting to engage young people with mental health issues. The underlying theories associated with all these aspects were considered , and this influenced the development of the logic model. The researchers were also involved in all stages and in regular discussion with the multimedia company and other agencies.There are few studies that describe the process of development of Web-based PIs to give context to this study. However, there was some overlap in the content of MoodHwb and existing Web-based or computerized PI programs. For example, the program The Journey by Stasiak et al  also covThe graphic illustrative and animated approach favored by the participants in this study is different to the approach taken by many youth mental health sites , Headspace , and The Lowdown  -54) thatWeb-based CBT and other therapeutic programs for adolescent depression incorporate a range of elements, from mainly text-based to image-based designs ,17. SomeOne of the main strengths of the project relates to the rigorous methodology, which followed the MRC guidance for complex interventions and the consultative and person-based approach . InterviAnother strength was the diverse range of participants, including young people from mental health services (primary and secondary care) and volunteers, many of their parents and carers, and a mix of professionals. Young people at high risk were also recruited from a previous study sample. There were a range of recruitment centers in urban and rural areas, including in areas with several ethnicities and areas of deprivation. Participants were also recruited from communities where Welsh was spoken widely.The results from the review, interviews, and focus groups were complemented by other investigations, including advice from experts, visits to centers of excellence in youth mental health and eHealth in the United Kingdom and overseas, and workshops with multimedia professionals. The development was further strengthened by using user-centered design, educational and psychological approaches, and a logic model, as well as basing the content and design on current research evidence and guidelines. All these approaches helped to create a potentially accessible, engaging, and informative program that the user could personalize, which fits with the increasing interest in precision  medicine . The detThe research or multimedia teams were involved throughout the project, and it is possible that their personal views could have influenced the process of development. However, a range of different groups was consulted, which would help minimize bias. Certain decisions regarding development were made before the interviews and groups , and the key themes that emerged may have been influenced by the topic or discussion guide. However, it was necessary to have some focus to the discussions, and this was not intended as an open scoping exercise. All prior decisions were based on a literature review and expert clinical opinion.As with all methods of data collection, there are limitations to the interview and focus group approach. Although efforts were made to recruit a diverse sample with different backgrounds and experiences of depression, the overall number of participants was small and may not be representative of the population of adolescents who are experiencing depression or who are at risk. In addition, it is possible there was self-selection, in that participants who volunteered were more likely to have an interest in the project. Although the number of initial interviewees (n=12) was small, many ideas and themes were repeated as the interviews progressed, indicating that saturation might have been reached. The participants were purposively chosen at this early stage of the project to offer a range of viewpoints or ideas to guide later focus groups.Focus groups were balanced as far as possible with regard to age, gender, and experience of mental health difficulties. However, the number of those who attended the focus groups varied across the study. Recruitment for young person groups 2 and 3, where the majority had experience of mental health difficulties, was difficult. Some participants cancelled at short notice or did not attend, although this is not unusual for focus groups ,58. In aA Web-based psychoeducation program was coproduced to help adolescents with or at high risk of depression and their families, carers, friends, and professionals. The program MoodHwb was developed following rigorous methods. This included a review of the literature, interviews and groups with potential users at all stages, and consultations with experts and with a multimedia company.An early evaluation is planned to assess whether the program (and its assessment) is potentially acceptable, feasible, clear, and easy to use. Young people (and their parents or carers) will be recruited from CAMHS, the EPAD sample, primary mental health services, and school counselors and nurses. Participants will complete questionnaires before and after using MoodHwb, a subsample will be interviewed to collect feedback on the package and the study process, and there will be a focus group for professionals. Web usage will also be analyzed.The results will inform the future development of the program. A feasibility trial would then be completed in line with the MRC guidance . A key f


Nurses increasingly form global health partnerships through academic and voluntary organizations that are designed to improve health outcomes. Many such partnerships are funded for specific time periods and have short- or long-term goals to achieve during the partnership. Other partnerships are sustained for longer periods of time through the efforts of partners committed to their joint work. The case example of the Health Volunteers Overseas Nursing Education partnership in Kampala, Uganda, demonstrates key components of partnerships that promote sustainability of programs. This case example is analyzed using literature that reports partnership models to identify those factors that have led to sustainability. Additionally, both objective and subjective program outcomes are reported. Recommendations for further evaluation are included. Partnerships are essential to the work of global health professionals to improve health outcomes . The orgThe HVO nursing education program began in Uganda in 2000. At that time, Ms. Speciosa Mbabali, the Acting Head of the Department of Nursing at Makerere University, approached the HVO orthopedics team liaison at Mulago National Referral Hospital to inquire about HVO support for the newly formed undergraduate nursing baccalaureate degree program. Ms. Mbabali recognized that without opportunities in Uganda for higher education in nursing, that a partnership with out of country nurses with advanced degrees was essential in order to build capacity for a strong faculty. HVO sent two experienced nurses, Marie O’Toole, EdD, RN, FAAN, and Julia Plotnick, RN, MPH, FAAN, RADM, USPHS (RET), to collaborate with Ms. Mbabali and the department of nursing at Makerere . The conMakerere University is one of the oldest and most prestigious universities in East Africa founded in 1922 in Kampala. Currently, the Department of Nursing is part of the College of Health Sciences with schools of Medicine, Public Health, Biomedical Sciences, and Health Sciences. Dean Rose Chalo Nabirye currently leads the School of Health Sciences, composed of the Departments of Nursing, Dentistry, Pharmacy, and Allied Health Sciences. The Department of Nursing has approximately 12 full-time faculty of whom 3 have now completed a PhD and all others have an MS degree with 4 enrolled in PhD programs.The current literature about partnerships for global health designates key factors that increase the likelihood of successful and sustainable partnerships. Relationship building strategies such as knowledge of the host country social, cultural, economic, and political factors for mutual planning, clear expectations, intentional listening, honesty and openness, mutual trust, cultural respect, and willingness for commitment are integral to partnership formation , 5, 6. CSince the establishment of the HVO nursing education partnership with the nurse leadership at Mulago National Referral Hospital and Makerere University in 2000, there have been significant projects completed and some that currently continue. The primary goal of the Ugandan partners at the outset was to build capacity for nursing faculty and for clinical nurses at Mulago National Referral Hospital with a focus upon pediatrics due to the high infant and child mortality rates. Data reported in the 2000/2001 UDHS report showed infant mortality rate of 89 deaths per 1,000 live births and under-five mortality rate to be 152 deaths per 1,000 live births. Results reported in the 2011 UDHS report showed a decline in infant mortality of 39% to 54 deaths per 1,000 live births, while the under-five child mortality declined from 152 to a rate of 90 deaths per 1,000 live births. This indicates that about 1 in 18 Ugandan children dies before their first birthday and 1 in 11 Ugandan children dies before their fifth birthday  improvements to the pediatric nursing curriculum, (2) improvements to the fundamentals of nursing course, (3) introduction of a critical care curriculum, and (4) the establishment of Masters Degree Program. At Mulago National Referral Hospital, the nursing clinical partnerships have been in the following areas: (1) partnerships for the Special Care Babies Unit to build capacity for care of newborns, (2) clinical care for pediatrics, (3) clinical care for critical care, and (4) the diabetes partnership. Using exemplars from four of these collaborative projects, we show how the key factors for successful partnerships have positively impacted the HVO nursing education partnership in Kampala, Uganda. First, we will provide brief descriptions of each project and then highlight the key partnership factors. Finally, we will describe outcomes from the HVO nursing education collaboration  program at Makerere University.The Department of Nursing administration engaged with its former students, nurses, and stakeholders in the country for a needs assessment. Former and current students and stakeholders raised concerns and urged the department to provide them with an opportunity for a clinically focused Masters Degree in Nursing. In recent interviews with more than one half of the BSN graduates of the Makerere Program, 90% of those who had not acquired a Masters degree stated they were motivated to return to school for a Masters in Nursing. The faculty at MU identified the lack of available clinical specialist at the masters’ level in nursing to serve as educators, clinical practitioners, and nurse researchers as a high priority.In 2008, an HVO volunteer with experience as a graduate program director and nursing curriculum chair came to work with the department at Makerere. Among her other collaborative assignments, she was asked to write a proposal for an MSN program. Partnership factors that positively affected the collaboration were the response to an expressed need, mutual trust, shared decision-making, and commitment to the project. While this was not the final proposal that led to the MSN program that began in 2011, it helped to provide a template for the faculty to move forward with a partnership to develop an East African joint program where the specialties would be shared across countries to minimize duplication and share resources. Since the Makerere University Department of Nursing had strong capacity for midwifery, that program was launched first.The Aga Khan University Advanced Nursing Studies Department in East Africa and the University of Nottingham School of Health Science worked on a prestigious European Union funded program called Improving Nursing Education and Practice in East Africa (INEPEA). This ambitious program was supported by the WHO and involved three universities in East Africa, Makerere University, Muhimbili University of Allied Health Sciences, and Zanzibar College of Health Sciences. It resulted in the development of a shared competency framework and MSN curriculum for advanced nursing practice (ANP) in East Africa. The program developed ANP in the East African context. The Master of Nursing-Midwifery and Women’s Health (MN-MWH) was developed to help to address the urgent needs and demands in the country and the region for primary care practitioners who are competent and skilled in midwifery and women’s health. The program also produced nurse educators and scholars, and nurse researchers in Ugandan and regional universities, hospitals, and other settings. The MN-MWH program also provided candidates for doctoral studies in nursing and subsequently researchers to develop locally relevant research in Uganda. The MN-MWH program has prepared students at the postgraduate level and equipped them with clinical, leadership, teaching, and research skills to practice in the primary care settings, in hospitals, schools of nursing, universities, research organizations, and other settings. In addition, the HVO nurse who in 2008 helped develop the first draft of the MN-MWH program proposal returned in 2012 to teach a course for the first cohort of that program.As an organization of volunteer health professionals primarily from the US and Canada, HVO partnerships during much of this 16-year partnership lacked formal evaluation measurements for each project required of most program partnerships that are funded through public or private sources. Instead, volunteers completed Trip Reports until recently and now complete Volunteer Surveys or for returning volunteers Impact Assessment Surveys in an effort to develop stronger evaluation measurements . In addiFor most of the duration of the long-term collaboration between HVO nurse volunteers and the Ugandan nurse partners, there has not been a formal evaluation method in place to guide planning and ensure sustainability until recent years. Instead, there have been several structural components that have contributed to continuity. First, HVO nurse volunteers have submitted trip reports that highlight program activities and achievements for each volunteer experience and these are posted on the HVO KnowNet website to allow for future volunteers to build upon the work of prior participants. Second, each HVO program has a US-based Project Director whose job is to coordinate not only the screening of applicants for the program but to work with the host partners to ensure continuance of key collaborative projects or to prepare for new collaborative innovations based upon the skill set of the HVO volunteer. During the 16-year history, two prior Project directors each served for 7 years contributing to the continuity to of the program. The ongoing engagement of the stakeholders in the Department of Nursing with the HVO project directors helps to identify areas of need for support. This continues to involve both groups of partners in planning for future volunteers and projects. Third, HVO sponsors an HVO staff person in Uganda to assist all HVO volunteers coming to Uganda with their professional and logistical accommodations including obtaining a professional license in Uganda, housing, and setting up meetings with professional partners. Each of these processes serves to advance the partnership and collaboration.Some outcomes of the long-term partnership between HVO nurse education volunteers and the Ugandan nurse partners are objective and could be measured by formal evaluation tools. These include outcome measures such as the number of nurses educated at training sessions, number of courses taught and students in attendance, actual teaching materials and presentations developed for the partnership, number of joint publications, number of joint research projects, and formal feedback from the Ugandan nurses. While some of these objective data are reported in HVO volunteer trip evaluation reports, there has not been a uniform evaluation tool in use across HVO nursing education programs. However, there are sustained outcomes as educational programs continue for each of the projects discussed in this paper  curriculum (2008-2011). This program was the first clinical Masters in Nursing at Makerere University, Uganda in 2011. The HVOs were also involved in the operationalization of the curriculum for the first cohort and continue to participate in the teaching of this program.The Dean of the School of Health Sciences, Dr. Rose Chalo Nabirye wrote:One important feature of the partnership has been the ongoing relationship between several nurse volunteers and Ugandan nurse faculty members. This has been aided not only by the return visits to Uganda by many of the volunteers over 3- to 15-year time periods but also with the aid of technology such as email, Skype, and cell phones to sustain the partnership over time .Further, the partnerships impact the HVO nurse volunteers in a variety of ways that are difficult to measure. First, in their trip report evaluations, they noted that the opportunity to live and work in a culture very different from their own culture and work environments expanded their understanding of cultural practices and health-care systems. Second, they learned to become more adaptable in planning nursing care due to the lack of material resources and technology they had been accustomed to at home. Finally, for some, the partnership fostered opportunities for research and scholarship.Outcome measurement of the HVO/Uganda partnership in Kampala is complicated by the fact that the contributions have not been made in isolation. During the same time period that HVO nurse volunteers offered support to the Makerere University nursing faculty and Mulago National Referral Hospital clinical nurses, many other partnerships were operating as direct collaborations between academic or clinical partners throughout Africa as well. The capacity built by intra-continental collaboration as well as global partnerships all were influential in strengthening capacity. The long-term partnership with the Karolinska Institute of Sweden included bilateral exchange for both nursing faculty and students alike as well as opportunities for support for higher education, research, and scholarship. The Bill and Melinda Gates Foundation “Partnership for Building the Capacity of Makerere University to Improve Health Outcomes in Uganda,” a grant funded Collaborative Learning Initiative with Johns Hopkins University  providedThe examination of this case example of the partnership between HVO nurse volunteers and the academic and clinical nurses at Makerere University and Mulago National Referral Hospital in Uganda offers global health professionals lessons for future partnerships and program sustainability. Capacity building remains a high priority to build stronger academic programs . Spies eA second recommendation is that formal evaluation tools be developed by HVO for use with specific projects. These would support the evaluation measures currently in place , 14. ThiFinally, a pre-trip preparation tool to supplement the resources available on the HVO KnowNet link on the HVO website would be helpful for new volunteers in order to learn about ongoing projects and allow them to increase their effective contributions both while in country and as ongoing partners. The tool could include content areas for the new volunteer to complete related to history and culture of the host setting, health-care system information, and summary of host country ongoing projects with a focus upon components for successful partnerships in order for the volunteer to prepare fully for the assignment. Both the pre-trip and post-trip evaluation tools could be useful for all HVO projects across countries and professional disciplines.The case example of the nursing partnership between HVO volunteers and Ugandan nurses in Kampala, Uganda, advances knowledge of partnership factors that promote successful partnership and sustainability. Although outcome measurement is more difficult than for shorter term funded projects with defined goals and outcomes, the ability to sustain the partnership over almost two decades fosters greater potential for new innovations over time. Long-standing relationships between health professionals from visiting and host settings promotes the honesty and openness, clear communication, mutual trust, cultural respect, and strong involvement of host partners necessary for relationship building to create successful partnerships.SM: author, manuscript writing, revision of the manuscript, and final approval of the submission. RN: co-author, manuscript writing, revision of the manuscript, and final approval of the submission. EO: co-author, manuscript writing, and revision of the manuscript. SB: co-author, manuscript writing, revision of the manuscript, and final approval of the submission. JL: senior author, manuscript writing, critical revision of the manuscript, and final approval of the submission.The authors declare no commercial or financial relationships related to the program reported in this manuscript that could be construed as a potential conflict of interest.


Uncommon diseases of the popliteal artery include cystic adventitial disease, popliteal artery entrapment syndrome (PAES) and popliteal artery aneurysm (PAA). Because all of these conditions may present with pain or intermittent claudication, imaging is crucial for differentiating them and directing management. Delayed diagnosis can lead to major complications, including acute limb ischemia. Our aim is to provide an illustrative overview of these conditions in order to make radiologists aware of them and avoid misdiagnosis for timely appropriate management.Teaching PointsCystic adventitial disease diagnosis is based on evidence of cysts within artery walls.• A variety of anatomic variations may result in PAES.• PAES may be bilateral.• PAA is most commonly encountered in men.• Acute complications of PAA include acute thrombosis and distal embolization.• The online version of this article (doi:10.1007/s13244-016-0513-6) contains supplementary material, which is available to authorized users. The popliteal artery is a direct continuation of the superficial femoral artery after it passes through the adductor hiatus. The normal popliteal artery and vein are located between the medial and lateral heads of the gastrocnemius muscle, posterior to the popliteus muscle Fig. . AbnormaMicroscopically, the popliteal artery is composed of three layers: intima, media and adventitia. While atherosclerotic disease involves the innermost layers of the artery , adventiAlthough clinical symptoms resulting from these different conditions are often similar, affected patient populations are usually distinct. Radiologists should be aware of these conditions to facilitate prompt diagnosis and to appropriately direct the patient’s care. The aim of this review is to provide an illustrative overview of cystic adventitial disease, PAES and PAA.Micro-traumatic: supported by the predominance of disease among middle-aged men with heavy occupational activity involving the legs, and some reports of definite trauma prior to discovering the cyst . Repeat Developmental: from embryological migration of mucin-secreting cells from the knee joint to the artery’s adventitia. In this case, mucin-secreting cells from the endothelium of the knee joint appear in the adventitia of the artery, leading to the development of tense cysts over several years . HoweverSynovial: from ectopic synovial ganglions migrating along the vascular branches from the adjacent knee joint capsule . This isCystic adventitial disease is an uncommon condition in which mucinous material containing varying combinations of mucopolysaccharides and mucoproteins form within the adventitia of arteries and veins . While aThe most common clinical presentation is intermittent claudication (89% of cases), although critical acute and chronic limb ischemia have been described in up to 7% of cases , 2322, 2Although not included in this classification, the lateral head of the gastrocnemius muscle may also have an aberrant origin, resulting in compromise of the popliteal artery Figs.  and 7 2, 25.Fig.While PAES is defined by an abnormal relationship between the popliteal vessel and neighboring musculotendinous structures, a more frequent entity, functional PAES. results from muscle solicitation rather than structural abnormality. It occurs in young athletic individuals, particularly in performance athletes. Compression of the popliteal artery may be caused by the gastrocnemius muscle (above the knee) or plantaris muscle (below the knee). Dynamic testing is necessary for diagnosis. Depending on the imaging modality, this testing may include repeat dorsiflexion and plantar flexion, without and with resistance, and may even involve assessment of the patient in the erect position with plantar flexion by standing on the toes, with repeated plantar flexion until the patient is symptomatic. Evidence of both leg pain and reduction in the diameter of the popliteal artery are required for positive diagnosis of functional PAES , 26. UltImaging plays a central role in diagnosing PAES. In addition to arterial displacement, ultrasound may show the presence of a fibrous band between the popliteal artery and vein. Popliteal stenosis, post-stenotic dilation, and thrombus may be seen in the case of long-standing disease. Diagnosis of functional PAES relies upon evidence of arterial diameter reduction and increased maximum systolic velocity at the site of compression upon dynamic testing.Conventional angiography is the classical modality for screening and diagnosis of PAES, showing medial displacement and compression of the artery as well as irregularities of the vessel wall in an otherwise normal arterial tree. Other findings are related to complications of long-standing disease, such as pre- and post-stenotic dilation, aneurysm, and thrombosis , 29. HowMR and CT angiography offer precise analysis of the muscle course and potential conflict with the popliteal vessels. Findings include medial deviation of the vessel by an abnormal slip of the medial or lateral head of the gastrocnemius muscle Figs. , and 7  and 3 orTreatment consists of releasing the trapped vessel by myomectomy. While lateral transposition of the popliteal artery is always needed, the presence of vascular complications such as stenosis, aneurysm, or occlusion warrants additional vascular reconstruction by endarterectomy or bypass grafting . EndovasThere is no agreed-upon definition for PAA. Some authors define it as having a diameter exceeding 0.7cm , while oPAA have an insidious presentation, often with ischemia as a first manifestation. The most feared complication is an acute aneurysm thrombosis, which may lead to irreversible leg ischemia or viable ischemia, both requiring immediate management. Distal embolization often goes unnoticed, causing a loss of distal run-off prior to diagnosis Fig. . RuptureUltrasound can establish the diagnosis and patency of PAA. Conventional angiography may show arterial dilation or occlusion. Cross-sectional imaging, on the other hand, can delineate the aneurysmal sac and detect mural thrombus  Fig. 9)9).The main points of controversy in the management of PAA are (1) when to carry out repair of asymptomatic PAA, and (2) what procedure to perform in the case of acute aneurysm thrombosis. Because of its insidious evolution, repair of PAA is recommended if there are no surgical contraindications . PAA repWe have reviewed uncommon conditions affecting the popliteal artery. An algorithm for suggested imaging workup is presented in Fig. Movie 1Cine sequence of digital subtraction angiography of the same patient as Fig. Movie 2yellow arrow). Normal course of the popliteal artery is along its vein (V). (MOV 3423 kb)Popliteal artery entrapment syndrome. Cine sequence of coronal proton density-weighted MR images in a 39-year-old man with history of left calf intermittent claudication. Medial displacement of the popliteal artery (A) caused by an anomalous origin of the medial gastrocnemius muscle (Movie 3red transparent overlap) causing medial displacement and occlusion of the popliteal artery. The medial head of the right gastrocnemius muscle (green transparent overlap) has normal insertion and relationship with popliteal artery. (MP4 460 kb)Same patient as movie 2. Cine sequence of axial CT images shows abnormally high origin of the medial head of left gastrocnemius muscle (Below is the link to the electronic supplementary material.


Synchrotron radiation facilities are pillars of modern structural biology. Small-Angle X-ray scattering performed at synchrotron sources is often used to characterize the shape of biological macromolecules. A major challenge with high-energy X-ray beam on such macromolecules is the perturbation of sample due to radiation damage.β-Amylase) and a rod-shape plant virus (tobacco mosaic virus). Radiation damage on the globular enzyme leads to an apparent increase in molecular sizes whereas the effect on the long virus is a breakage into smaller pieces resulting in a decrease of the average long-axis radius.By employing atomic force microscopy, another common technique to determine the shape of biological macromolecules when deposited on flat substrates, we present a protocol to evaluate and characterize consequences of radiation damage. It requires the acquisition of images of irradiated samples at the single molecule level in a timely manner while using minimal amounts of protein. The protocol has been tested on two different molecular systems: a large globular tetremeric enzyme (These results show that radiation damage can appear in different forms and strongly support the need to check the effect of radiation damage at synchrotron sources using the presented protocol. The most recent step forward in structural biology for characterizing large molecular assemblies is the integration of several complementary techniques to reach the goal of determining structures at atomic level. In this frame, it is essential to combine information from a variety of physical and chemical origins thus providing a solid basis to understanding molecular function. This recent development is known as integrative structural biology .Dmax . . q-regio(2.9 nm) , 51. The% using a mask selecting all points higher than 5 nm. When deposited on HOPG (hydrophobic surface), TMV particles of similar height (17 – 18 nm) were observed with a surface coverage of 11.2 %  but about 2/3 of this value. It is likely that the 2D image fitting algorithm performs poorly when TMV particle appears in bunch rather than well isolated .q-range of 0.025 to 5 nm −1 can be observed which corresponds to a longest particle dimension of approximately 250 nm. As the long axis of tobacco mosaic virus (TMV) is in the order of 300 nm, this dimension could not be measured directly in the standard configuration of BM29. Fortunately, the observed scattering of the TMV is dominated by the circular cross-section of the cylinder, featuring the coat protein and RNA strand allowing direct comparison between SAXS and AFM. The AFM experiments confirmed the rod-like structure of the TMV sample with a cross-section of 17–18 nm. The cross-sectional radius of gyration was calculated as 6.3 nm assuming a rod-like structure. For a homogeneous disc of radius Dmax. In this work, this value was obtained from real space measurements with the AFM allowing a direct access to this parameter, thereby greatly reducing the ambiguity of the analysis. In the case of TMV, using the 18 nm diameter determined by AFM indeed allowed us to calculate the cross-sectional pair distance distribution function without bias.SAXS scattering provides reliable characterization of the average structural properties of biological macromolecules by measuring the scattering curve and interpreting it to determine model-independent structural parameters of molecules. Although 3D reconstructions of shape of macromolecules from scattering curves are possible, they are often not unique. Moreover, SAXS as a technique is able to visualize a wide range of dimensions depending on the X-ray energy and the angular range observed, but the maximum size observable for any given experiment is limited. For the standard setup at BM29 a terature . It shouRadiation damage  have beeRg), still occurs as early as 250 ms exposure time [Rg has been observed in relation to radiation damage [Rg from 3.3 to 5 nm [AFM imaging of single molecules has already been used to observe protective effect of ascorbic acid against double-strand breaks in DNA generated by reactive oxygen species . In addiure time . At incrn damage . Combini to 5 nm . However to 5 nm . Reducti to 5 nm  or using to 5 nm . Besides to 5 nm .β-Amylase revealed a tripling in size upon over-exposure to X-ray beam. From this result, two hypotheses are possible: agglomeration of several β-Amylase monomers or a tightening of β-Amylase tetramer upon X-ray exposure so that when imaged on mica the tetrameric form of β-Amylase is now stable and better preserved than β-Amylase without X-ray exposure. The second hypothesis appears more likely due to SAXS observation that no significant change in Rg was observed upon over X-ray exposition of β-Amylase . The only possible explanation is that only smaller structures are observed, mostly monomers whose presence is also detected by SAXS, for non irradiated β-Amylase while, upon X-ray exposure, AFM images show an expected size of tetrameric β-Amylase. At the moment, it is not possible to speculate about the presence of crosslink in β-Amylase upon X-ray exposure, as the resolution of AFM imaging does not allow such level of details.In our study, AFM imaging of isolated molecules of ase Fig. , and tha-Amylase . The curβ-Amylase: native and X-ray over-exposed while SAXS data does not make a significant distinction.Finally, it is striking that AFM imaging can indirectly distinguish between two conformations of tetrameric β-Amylase essentially due to the high aspect/ratio of TMV which is a rod-like of 300 nm long. TMV, as most plant viruses, are very stable molecular constructs that can resist harsh storage condition (dessicated) for several years. TMV is consequently a perfect sample for studying radiation damage as no degradation is expected to occur when deposited on mica [Radiation damage in TMV particle is different from  on mica . Upon inIt is noteworthy that the imaging substrate surface has a significant importance in AFM. This is for instance brought forward by the comparison between bare mica and nickel pre-treated mica in this study (AFM data not shown). Indeed, TMV adsorption is more efficient on nickel pre-treated mica than on simple mica. However, no substrate is ideal due to the apparent contradictory requirement of strong fixation of biomolecules on a surface with low deformation of adsorbed molecules.Surface charges of mica may affect the shape of deposited single molecules. For instance, a height reduction of 2 nm is observed when TMV is deposited on mica and imaged in air, while the height difference of TMV when imaged in liquid is close to 0.7 nm (manuscript submitted). However, such reduction in height has never been observed to be concomitant with a reduction of TMV length as observed in this study when TMV is exposed to X-ray beam.β-Amylase, is that with TMV radiation damage are detected with short exposure time whereas in β-Amylase radiation damage are mostly visible upon over-exposure time. However, a common behavior between β-Amylase and TMV upon X-ray beam exposure is their apparent change in molecular surface properties. Although it is only suggested for β-Amylase, it is clearly observed for TMV. Indeed, when native TMV is deposited on hydrophobic surface (HOPG) there is non uniform binding of TMV on HOPG whereas, upon X-ray beam exposure, TMV displays an increased uniformity in adsorption with HOPG. Because breakage of long TMV particles into smaller pieces, damaged TMV now exposes hidden buried surfaces. From the TMV X-ray structure, such hidden surfaces are known to be rather hydrohobic explaining the sudden increased affinity of irradiated TMV on HOPG. A clear benefit of AFM imaging is observed, first by looking at individual molecules, and second at global properties when changing imaging substrates. Consequently, if reasonable protein binding is observed on HOPG, it could be recommended to use hydrophobic surfaces for imaging X-ray exposed molecules, and thus detect easily the presence of radiation damage by looking at variation of protein binding on HOPG. Such apparent change in molecular surface properties has been already observed in case of lipid model membranes deposited onto silicon substrates in an in-situ X-ray - AFM combined experiment [Another difference between TMV and periment . Both X-β-Amylase and TMV, respectively.The combination of SAXS and AFM can be applied to a variety of different macromolecules and sample surfaces depending on characterization needs and sample properties. Taking advantage of the flexible user access to both the dedicated bioSAXS beamline (BM29) and ESRF surface science laboratory, these experiments can be undertaken on the same visit to the ESRF. AFM imaging requires around two hours and owing to the high dilution factor from SAXS to AFM no additional sample is needed for AFM in addition to SAXS. While SAXS provides rapid characterization of the average properties of a sample, AFM can be used to verify the homogeneity of the sample and provide measurements at the single particle level. As AFM gives direct measurement of single particles it is possible to use the AFM results as additional constraints for modeling purpose thereby extending the possibilities to interpret the SAXS data and reduce ambiguity in the results. The use of combined SAXS-AFM in one experimental visit is facilitated by the presented protocol which enables cross validation, and increased confidence in the conclusions which can be drawn from the experiments. Furthermore, combination of SAXS-AFM is well adapted to study effect of radiation damage on various type of biological samples. Radiation damage is a very complex process and can produce either a change of the protein surface or a breakage of long biological particles, as it has been shown in this work for


A total of 207 schools  participated in the Secondary 1 Program of Project P.A.T.H.S. in the full implementation phase (2006/07 school year). After completion of the Tier 1 Program, 1,250 instructors completed a subjective outcome evaluation form (Form B) to assess their views of the program, instructors, and perceived effectiveness of the program. Utilizing the consolidated reports submitted to the funding body, the research team aggregated the consolidated data to form an overall profile of the perceptions of the program participants. Results showed that high proportions of the respondents had positive perceptions of the program and the instructors, and roughly four-fifths of the respondents regarded the program as helpful to the program participants and the workers. These findings complement the subjective outcome evaluation findings based on the perspective of the program participants.