Internet-delivered mental health  interventions produce treatment effects similar to those observed in face-to-face treatment. However, there is a large degree of variation in treatment effects observed from program to program, and eMental Health interventions remain somewhat of a black box in terms of the mechanisms by which they exert their therapeutic benefit. Trials of eMental Health interventions typically use large sample sizes and therefore provide an ideal context within which to systematically investigate the therapeutic benefit of specific program features. Furthermore, the growth and impact of mobile phone technology within eMental Health interventions provides an opportunity to examine associations between symptom improvement and the use of program features delivered across computer and mobile phone platforms.The objective of this study was to identify the patterns of program usage associated with treatment outcome in a randomized controlled trial (RCT) of a fully automated, mobile phone- and Web-based self-help program, “myCompass”, for individuals with mild-to-moderate symptoms of depression, anxiety, and/or stress. The core features of the program include interactive psychotherapy modules, a symptom tracking feature, short motivational messages, symptom tracking reminders, and a diary, with many of these features accessible via both computer and mobile phone.Patterns of program usage were recorded for 231 participants with mild-to-moderate depression, anxiety, and/or stress, and who were randomly allocated to receive access to myCompass for seven weeks during the RCT. Depression, anxiety, stress, and functional impairment were examined at baseline and at eight weeks.Log data indicated that the most commonly used components were the short motivational messages  and the symptom tracking feature . Further, after controlling for baseline symptom severity, increased use of these alert features was associated with significant improvements in anxiety and functional impairment. Associations between use of symptom tracking reminders and improved treatment outcome remained significant after controlling for frequency of symptom tracking. Although correlations were not statistically significant, reminders received via SMS  were more strongly associated with symptom reduction than were reminders received via email.These findings indicate that alerts may be an especially potent component of eMental Health interventions, both via their association with enhanced program usage, as well as independently. Although there was evidence of a stronger association between symptom improvement and use of alerts via the mobile phone platform, the degree of overlap between use of email and SMS alerts may have precluded identification of alert delivery modalities that were most strongly associated with symptom reduction. Future research using random assignment to computer and mobile delivery is needed to fully determine the most ideal platform for delivery of this and other features of online interventions.http://www.anzctr.org.au/TrialSearch.aspx? (Archived by WebCite http://www.webcitation.org/6WPqHK0mQ).Australian New Zealand Clinical Trials Registry (ACTRN): 12610000625077;  When used correctly, Internet-delivered mental health  interventions produce treatment effects similar to those observed in face-to-face treatment -4. HowevExisting frameworks posit a range of features that are most likely to influence program usage and treatment outcome , and recWithin trials of eMental Health interventions, examining user log data provide an ideal means of identifying the patterns of program usage that are associated with the greatest therapeutic gain. As such, research has recently turned to focus on how specific patterns of program usage impact on treatment outcome. For example, in a trial of a Web-based intervention for diabetes self-management, use of a self-monitoring feature was associated with improvements in healthy eating, reductions in dietary fat, and increased exercise, but not with medication compliance . SimilarThe growth and impact of mobile phone-based interventions provides an opportunity to examine the therapeutic benefits of adding a mobile phone platform to deliver program functions. A particular advantage of mobile phone technology is its capacity to facilitate ecological momentary assessment (EMA); that is, self-monitoring of symptoms and behaviors in real-time and in real-world contexts ,15. SelfThe current study examined associations between patterns of program usage and improvements in symptoms of depression, anxiety, stress, as well as functional impairment, in a randomized controlled trial (RCT) of a Web and mobile phone intervention for individuals with mild-to-moderate mental health symptoms. The current study also examined associations between symptom reduction and use of features across both computer and mobile phone platforms, thereby providing novel insights into the potential benefits of incorporating mobile technology into Web-based interventions.Known as “myCompass”, the program under current consideration is a stand-alone, fully automated self-help program that contains a variety of therapeutic features including interactive psychotherapy modules, self-monitoring, a diary, automated reminders, and motivational messages. The outcomes from the myCompass RCT are described elsewhere . During The aims of this study were to describe the site usage patterns of participants who received access to the myCompass program for seven weeks during the RCT, and to identify the program features associated with enhanced program engagement and reductions in depression, anxiety, stress, and functional impairment.In the RCT, participants were randomly allocated to the myCompass intervention, to an attention control condition, or to a waitlist control condition, for seven weeks. The RCT took place between October 2011 and June 2012, during which time usage data were recorded. The usage data presented here are derived from all participants who were randomly allocated to the myCompass intervention condition (n=231).The myCompass program is a fully automated, interactive, stand-alone mobile phone and Internet-delivered intervention designed for the treatment of mild-to-moderate symptoms of depression, anxiety, and stress. Users can access the program through any Internet-enabled device, including smart phones, tablets, laptops, and desktop computers. The program comprises four key features that users can access and engage with in a manner they choose.The program contains 12 modules that are based on principles of cognitive behavior therapy, interpersonal psychotherapy, and problem solving approaches. These modules are: (1) Managing Stress and Overload, (2) Communicating Clearly, (3) Problem Solving, (4) Tackling Unhelpful Thinking, (5) Fear and Anxiety, (6) Happiness, (7) Sleep, (8) Relaxation, (9) Taking Charge of Worry, (10) Increasing Pleasurable Activities, (11) Smart Goals, and (12) Managing Loss. Modules are accessed via the Web only on computers , each module is approximately 10 Web pages in length and is divided into three sections that take approximately 5-10 minutes to complete, with a homework exercise at the end. Users are encouraged to complete one module session per week (with most modules containing 2-3 sessions), with the aim of completing 2 full modules over the course of the intervention. Participants are also encouraged to complete the homework tasks in between sessions. Module sessions are delivered in a tunnelled manner, such that it is necessary to complete a section and enter homework data before moving on to the next section.A number of predefined tracking dimensions are available for users to select from: (1) anxiety, (2) depression, (3) irritability, (4) restlessness, (5) stress, (6) worry, (7) alcohol, (8) diet, (9) exercise, (10) medication, (11) sleep, (12) smoking, (13) confidence, (14) concentration, (15) energy, and (16) motivation. In addition, users can define their own dimension to track. A maximum of three dimensions can be tracked at one time. Users can choose to track daily or weekly and to receive tracking reminders via email or SMS. Each time a user enters tracking information, they are also prompted to enter situational information, such as where they are , whom they are with , and what they doing  in order to help users identify potential triggers to their mood symptoms.“Snippets” are brief mental health tips, facts, and motivational messages that a user can elect to receive via SMS or email throughout the intervention. Users can choose the frequency with which they receive snippets, and can turn the feature on or off whenever they choose.myCompass also contains a diary feature in which users can make notes about insights they have gained or information they have learned while engaging with the program. For example, users may use the diary to make notes about situational factors that appear to be linked with their mood symptoms on the basis of their symptom tracking data.Did not apply to me at all) to 3 (Applied to me very much/most of the time). The DASS-21 has adequate internal consistency and test-retest reliability [The Depression, Anxiety, and Stress Scale (DASS-21)  is a 21-iability , and hasiability . Total sNot at all) to 8 (Very severely). The WSAS has been shown to have sound psychometric properties when administered on the Internet [The Work and Social Adjustment Scale (WSAS)  is a 5-iInternet , and higDemographic information was also collected as part of the baseline questionnaire, and included age, gender, highest level of education attained, and employment status. Frequency with which the participant used mobile phones and computers provided a proxy measure of technology acceptance.Treatment outcome measures were administered at baseline, 8 weeks after baseline, and at 5 months after baseline. In this paper, we report the relationship between patterns of usage and treatment outcomes specifically during the intervention period .Data for the following usage variables were obtained: log-ins, modules, symptom tracking, snippets, and diary.Log-ins was the total number of times a user logged in to the myCompass program.Modules were the number of modules a user started, the number they completed, and which modules they completed.Symptom tracking was the number of times a user entered symptom tracking data, the number of tracking reminders a user received (by SMS and email), and the number of times a user tracked a particular symptom. A tracking latency variable was also calculated to determine how long, on average, it took for users to respond to tracking reminders by entering tracking data. This was calculated as the average length of time (in hours) between when a tracking reminder was received and the next instance of entering tracking data.“Snippets” were the number of “snippets” a user received via SMS and via email.Diary was the number of diary entries a user made.First, the sample was divided into two groups, those who used and those who did not use a specific feature. Chi-square tests  and separate univariate Analyses of Variance (for continuous demographic variables) were then used to test for differences between the two groups on demographics and baseline scores on the DASS subscales and WSAS. Second, for those who used a specific feature, partial correlations were carried out to determine whether frequency of feature use was correlated with post intervention DASS or WSAS scores, after controlling for baseline scores on these measures.Of the 720 participants who screened eligible to participate in the myCompass RCT, 242 were randomly allocated to receive the myCompass program for seven weeks. There were eleven participants in this group that withdrew from the RCT, leaving a final sample of 231 for the current analysis. The sample was predominantly female , university educated , employed , married or de facto , and the mean age was 38.8 years. The majority reported using a computer  and a mobile phone  daily.Google Analytics was used to extract site usage data for those in the myCompass group over the course of the RCT, spanning from October 4, 2011 to June 25, 2012. Google Analytics defines visits as the number of times visitors have been to the website. If a visitor is inactive for 30 minutes or more, any future activity is attributed to a new session. Visitors who leave the site and return within the same 30-minute period are counted as part of the same session. During the RCT period, there were a total of 4724 visits to the site, 1182/4724 (25.02%) of which were unique  visits. Across the 266 days, the site recorded 58,296 page views, with an average of 12.34 page views per visit and an average visiting time of 10 minutes and 37 seconds. The bounce rate, which reflects the proportion of visitors who enter the site and leave (“bounce”) without viewing other pages within the site, was 19.37%.Participants were given access to the myCompass program for seven weeks. They were encouraged to track three symptom dimensions and complete two modules of their choice during the intervention period. A little under a third n=66/231, 28.6%) of the participants never logged in to the program. Those who did use myCompass logged in a total of 2463 times, with the mean number of log-ins per user being 14.9 (SD 16.5), ranging from 1 to 105. The most commonly used feature of the program was the “snippets” feature, used by 158/231 (68.4%) participants. This was followed by the symptom tracking feature, used by 142/231 (61.5%) participants, and 118/231 (51.1%) also used the optional tracking reminder feature. There were 118/231 (51.1%) participants who also used the modules, 57 of whom completed at least one module. The mean number of modules started was 1.2 (SD 1.6) and the mean number completed was 0.6 (SD 1.3). The least commonly used feature was the diary, used by 61/231 (26.4%) participants. Key usage statistics of those who used the program (n=165) are shown in 1, 28.6% r=.19, P=.02) and total instances of symptom tracking  increased with participant age. Baseline demographic and symptom characteristics were not associated with frequency of starting or completing modules. Females chose to receive more “snippets” than males t155 = 2.15, P=.03, as did those with lower functional impairment , and higher baseline anxiety was associated with a greater number of diary entries .Of the 231 individuals who received access to the myCompass program for 7 weeks during the RCT, 165 individuals logged in at least once. Reasons for nonusage included lack of time, poor motivation, and having intermittent access to the Internet or a computer. There were no significant differences between those who did and did not log in in terms of baseline demographics or clinical symptoms, however, for those who did use the program, log-in frequency , however, there was no association between reminder use and depression, anxiety, or stress. Of those who used tracking reminders, 29 received at least one reminder via email, 97 received at least one reminder via SMS, and 8 subjects received reminders via both modalities. After controlling for baseline severity, frequency of tracking reminders received via email , and via SMS  were both associated with decreased functional impairment at post intervention, although neither correlation was significant when examined individually.After controlling for baseline severity, increased use of the symptom tracking reminders was associated with decreased functional impairment at post intervention , indicating that reminders were associated with improvements in functional impairment independently of any associated increase in symptom tracking.Bivariate correlations were conducted to determine whether reminders were associated with increased program use. The total number of tracking reminders was positively correlated with the number of program log-ins, as well as the frequency of symptom tracking . A greatr=-.20, P=.04). Increased use of snippets was also associated with nonsignificant reductions in post intervention depression , stress , and functional impairment . Of those who used snippets, 153 received at least one via email and 15 received at least one via SMS. Partial correlations between the number of email snippets received and post intervention scores were nonsignificant, as were partial correlations involving the number of SMS snippets. The lack of difference between the email and SMS delivery modes is possibly due to a high degree of overlap between the two, as 10 of the 15 users who received snippets via SMS also received snippets via email.After controlling for baseline symptom severity, a greater number of snippets received were associated with reduced anxiety at post intervention (Use of the diary feature was not correlated with treatment outcomes.The aims of this study were: (1) to use log data to identify patterns of program use in an RCT of myCompass, a tailored, Web and mobile phone-based intervention for depression, anxiety, and stress; and (2) to determine whether use of certain program features was associated with enhanced program engagement and therapeutic gain. Overall, the results showed that the alert features of the myCompass program were the most commonly used, were associated with increased rates of program engagement, and were associated with the greatest therapeutic gains.The average number of log-ins per user over the course of the intervention was 14.9, which is somewhat higher than that reported in other eMental Health interventions  . The bouIn the RCT, participants were encouraged to complete at least one myCompass module session per week . Log data revealed that module completion rates were lower than expected, with a mean module completion rate of 0.6 modules. This may be partly due to the fact that modules could not be accessed via the mobile phone due to screen size, and reformatting the modules for compatibility with a mobile phone platform is one obvious means of addressing this issue. Low module completion rates may also have arisen because the module sessions were delivered in a tunnelled fashion, whereby subjects were required to complete the module sessions in a predetermined sequence. Although research suggests that a tunnelled format may facilitate greater program engagement  , subjectThe most commonly used feature of myCompass was the “snippets” function. “Snippets” were short motivational messages, quotes or facts, which were sent by email or SMS at a time and frequency chosen by the user. The appeal of the “snippets” may lie in the fact that they are supportive, normalizing, and instill hope, yet demand little of the user in terms of behavior change, attention, or time. The second most commonly used feature was the symptom tracking function. Among the most common symptom dimensions tracked were stress, worry, anxiety, motivation, and depression, indicating that users chose to track symptom dimensions most closely tied to the primary goal of the study, which was to reduce symptoms of depression, anxiety, and stress.A substantial proportion of participants who used the symptom tracking feature also chose to receive tracking reminders. As expected, increased frequency of tracking reminders was associated with increased frequency of symptom tracking. This finding aligns with those of previous research showing that use of reminders enhances engagement with eMental Health interventions . In partAfter controlling for baseline symptom severity, participants who chose to use the alert-based features of myCompass, such as the reminders and “snippets”, showed significantly greater reductions in post intervention symptoms and functional impairment compared to those who did not use these functions. In particular, there appeared to be a consistent relationship between alerts received via email and reductions in post intervention anxiety and functional impairment. In one respect, this is unsurprising, as self-monitoring is one of the most important components of psychotherapy for anxiety and other mental illnesses , and is This finding indicates that alerts may serve multiple therapeutic functions and may therefore be an especially potent feature in eMental Health interventions. First, in terms of program usage, alerts act as prompts that enhance program engagement, and so may help to combat the high rates of nonusage attrition common to many Internet interventions ,32. AlerInterestingly, neither initiation nor completion of the psychotherapy modules was associated with treatment outcome. This finding was unexpected; as we had hypothesized that the core skills taught in the modules would be key to producing symptom reduction. The lack of association may be due to limited variability in use of the modules, as the overall rate of module completion was low. However, ours is not the first study to find a lack of association between module completion and treatment outcome. In a study examining the association between usage metrics and treatment outcome in an RCT of an Internet depression treatment program, Donkin et al  found thThe current study examined whether specific patterns of program usage were associated with superior treatment outcomes in an RCT of myCompass, a mobile phone and Web-based self-help intervention for individuals with mild-to-moderate depression, anxiety, and stress. The current findings contribute to our understanding of the mechanisms through which eMental Health interventions exert their therapeutic benefits, by isolating the program features most strongly associated with improvements in symptoms and functional impairment.Although our findings suggest that alerts are associated with both increased program engagement and greater treatment outcome, this is only a first step, and further research is needed to confirm our findings. Specifically, the current analysis used a correlational design in the single group of individuals who were assigned to receive the active myCompass intervention within the broader RCT. Future studies using random assignment to specific program features is needed in order to reach firm conclusions about the causal relationship between patterns of program usage and reductions in symptoms.Along similar lines, better information about potential nonlinear relationships between patterns of program use and treatment outcome could be obtained by assessing symptom improvement at more frequent intervals. Assessing symptomatology at each week of the intervention may provide a greater insight into the usage patterns and points of disengagement of those with low rates of adherence, or alternatively, those who may be classified as “e-attainers”. This information could then be used to further develop and refine the features that show the strongest associations with symptom reduction, as well as to incorporate prompts at key junctures to assist in reducing rates of program attrition.In the current study, the rate of module completion was approximately one quarter to one sixth of that expected, which is a limitation, and this may be partly due to the modules being unavailable via mobile phone. However, a lower-than-expected rate of module completion is not an issue that is unique to our intervention. Indeed, many self-paced eMental Health interventions have low rates of module completion, however, there is evidence to suggest that this may not necessarily equate to receiving a lower “dose” of the program. Studies suggest that individuals may derive substantial benefit from symptom tracking alone , and it Finally, the sample used in the current study was predominantly female , university-educated , and around 40 years of age. Although sex, education, and age were not found to be strong predictors of program use, it is possible that rates of program engagement, or use of certain features, may differ in other populations. It is possible that rates of program usage may be lower in individuals with poorer literacy, or indeed, those who present with more severe forms of psychopathology.The current study examined associations between patterns of program usage and symptom improvement in myCompass, a Web and mobile phone-based intervention for mild-to-moderate depression, anxiety, and stress. The alert features of myCompass were most closely associated with symptom improvement, indicating that brief cues that signal self-monitoring or that provide positive reinforcement may be an especially potent feature of eMental Health interventions. Although data suggested a stronger association between symptom improvement and alerts received via email than via SMS, there was substantial overlap between use of email and SMS reminders. As such, future studies using random assignment to specific program platforms are needed to determine the most therapeutically beneficial platform for delivery of this program component.


Nurses are in key positions to plan and implement alcohol screening and brief intervention (aSBI). To simultaneously advance aSBI of nurses in various roles, we developed a self-paced program for Clinical Nurse Leaders, Nurse Informaticists, Nurse Administrators, and Registered Nurses including Advanced Practice Nurses. The content for the program is based on the Centers for Disease Control & Prevention (CDC) 2014 Planning and Implementation Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices. The objective is to present the results of a cooperative agreement between the Centers for Disease Control & Prevention, Johns Hopkins School of Nursing, and the University of Pittsburgh School of Nursing. The framework used to design the aSBI Program and key aspects of the program will be demonstrated and discussed.The aSBI Program flow, depicted in the CDC guide defined the modules for learning: patient population, assess alcohol consumption, negative screen (and subsequent conversation), positive screen (and assessment of harm and dependence), brief intervention and referral to treatment. The modules were developed using Articulate Storyline, the premier rapid e-learning development platform, and hosted on a learning management system. Special focus was given to the assessment portion of the e-learning modules to ensure learners are provided with authentic assessments that accurately measure their mastery of real-world skills needed to be successful when applying the module educational materials.When finalized, the self-paced aSBI Program, funded by the American Association of Colleges of Nursing through the CDC, will be widely disseminated to the nursing community across the U.S.This easily accessible on-line educational program will bring evidence-based alcohol screening and intervention to current and future nurses.


Differential effects on the mineralization of the TMV surface were demonstrated, where a (KD)x charge-relay peptide (designed in this study) led to the most reproducible and selective silica deposition. A homogenous coating of the biotemplate and tight control of shell thickness were achieved.The coating of regular-shaped, readily available nanorod biotemplates with inorganic compounds has attracted increasing interest during recent years. The goal is an effective, bioinspired fabrication of fiber-reinforced composites and robust, miniaturized technical devices. Major challenges in the synthesis of applicable mineralized nanorods lie in selectivity and adjustability of the inorganic material deposited on the biological, rod-shaped backbones, with respect to thickness and surface profile of the resulting coating, as well as the avoidance of aggregation into extended superstructures. Nanotubular tobacco mosaic virus (TMV) templates have proved particularly suitable towards this goal: Their multivalent protein coating can be modified by high-surface-density conjugation of peptides, inducing and governing silica deposition from precursor solutions in vitro. In this study, TMV has been equipped with mineralization-directing peptides designed to yield silica coatings in a reliable and predictable manner via precipitation from tetraethoxysilane (TEOS) precursors. Three peptide groups were compared regarding their influence on silica polymerization: (i) two peptide variants with alternating basic and acidic residues, i.e. lysine–aspartic acid (KD) Amon2 [2 . TMV par2 [2 –46. The 2 [2 ,47–48.The CP subunits of TMV can be genetically or chemically modified for the presentation of effector molecules ,49–52. MTo vary and control the deposition of inorganic minerals on TMV templates, extensive modifications of the surface amino acids are desirable. They enable defined alterations of the outer TMV–CP surface charge and the introduction of specific amino acid motifs, guiding the nucleation and growth of mineral coatings around the TMV core. This is in analogy to natural biomineralization-directing protein domains identified for various organisms –59. DireTherefore, we have followed a third strategy and made use of plant-enriched, moderately engineered TMV templates, exposing selectively addressable reactive surface groups. These were subjected to chemical conjugation of synthetic peptides meant to regulate subsequent coating with silica  in alcohol-containing media , polyaniline interlayers were employed to shield both charges and hydrophobic patches of the viral protein coating before subjecting it to TEOS-mediated mineralization . A more 56Since a growing body of experience with relatively diverse silicification-guiding peptides is available, we decided to install a number of distinct amino acid sequence types on structure-directing TMV nanorods. This allows for the systematic investigation of their influence on silica coating reactions via ethanol-containing TEOS on this viral backbone for the first time.Lys) with an accessible amino group on every CP subunit [5C and (KD)10C with alternating amino and carboxyl functionalities  on the basis of Kuno et al. [4H4 (sequence CAAAAHHHH) according to Yuwono and Hartgerink [Lys templates were incubated in TEOS precursor solution in parallel with linker-coated and plain TMVLys controls (and in some tests wildtype TMVwt) under equal conditions. The products were analyzed and compared to determine favorable TMV template–peptide combinations for specific silica mineralization.Genetically modified TMV particles  CArtgerink , with twrtgerink . The disLys particles from plants. Every CPLys subunit provided a primary amine group of a lysine residue at the protein's C terminus. This resulted in ≈2130 sites selectively accessible to NHS ester-mediated coupling reactions per rod [N-maleimidopropionamido)-tetraethylene glycol ester, SM(PEG)4) serving as spacers and adapters for mineralization-affecting peptides. These were installed via maleimide-mediated conjugation of the cysteine sulfhydryl groups of the peptides. The resulting five distinct types of TMVLys–PEG–peptide particles with their different CP derivatives are listed in Lys templates used as references. The abbreviation scheme used was the following: abbreviations underscore the relevant functionalities or amino acids exposed; therefore, TMVLys is named TMV–Lys from now on. Covalent conjugation of peptides was confirmed for both single CPs and intact TMV particles by denaturing and native gel electrophoresis, respectively. Peptide modification of CPs resulted in a band shift with respect to increasing molecular weight, as compared to nonmodified CP in denaturing sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE)  . The effDS-PAGE) .Lys–PEG (TMV–PEG) exhibited an increase in negative net charge in comparison to TMV–Lys, resulting in a higher electrophoretic mobility. This effect was reduced by the conjugation of mineralization-affecting peptides: TMVLys–PEG–CA4H4 (TMV–AH), TMVLys–PEG–44C (TMV–44C) and TMVLys–PEG–31C (TMV–31C) exhibited retarded bands, which indicated the linkage of the peptides to the TMV–PEG template. TMV derivatives TMVLys–PEG–(KD)5C (TMV–KD5) and TMVLys–PEG–(KD)10C (TMV–KD10) could not be separated under the conditions applied: both samples did not migrate into the gel phase to a sufficient extent.The intact TMV particles were analyzed by native gel electrophoresis  and in 30 mM Tris-HCl buffer, pH 8.0, respectively  compared to those determined in buffer (−10 mV to −25 mV), owing to the lower pH of ≈5.5 of ultrapure water with CO2 dissolved in equilibrium with that in the air [2O are closer to the electric surface (Stern) potential of the particles [The zeta potentials (ZPs) of TMVectively . The ZPs the air . In addiarticles .4 linker molecules devoid of peptides (TMV–PEG) introduced the most negative net charge .For inorganic particles, the physical stability of dispersions increases with the magnitude of the ZP. That is, highly negative or highly positive ZPs typically both result in stable suspensions –82 due tThe different TMV templates were subjected to silica deposition by dispersion in a buffer-free deposition solution of ≈11% (v/v) TEOS precursor solution in ≈45% (v/v) ethanol in ultrapure water (resulting in a pH of ≈5.5) under agitation (500 rpm) at 25 °C for up to twelve days in parallel experiments . These conditions were adapted with respect to the ethanol concentration from an earlier comparative study on the mineralization capacities of distinct kinds of peptides . The met65All TMV templates with absolute ZP magnitudes above 50 mV showed a good dispersion in the mineralization solution, while TMV–AH, –44C and –31C did not form stable suspensions. At different reaction times, products were collected by centrifugation. After seven days of incubation, inorganic material sedimented from all reaction mixes, regardless of the presence or absence of TMV templates . The prewt) did not show any substantial inorganic coating at all, instead, some unspecific silica precipitation was observed , and high resolution scanning electron microscopy HRSEM; . A clearobserved . It is kThe other peptides explored in this study, AH, 31C and 44C, all contain histidine residues as potential mineralization effectors. Their imidazole rings can catalyze hydrolysis of the TEOS precursor, resulting in deprotonated, negatively charged silicic acid, which then accumulates in the vicinity of the positively charged amino acids to facilitate silica mineralization . The gooMost of the silicification-active peptides that convey the dehydration of precursor molecules such as TEOS 73,86–87 wt was also not mineralized in this experimental setup to an electron-optically detectable extent. This is in contrast to the strong and much faster mineralization of TMVwt particles from TEOS solution in alkaline or more acidic pH regimes, as performed in other labs and described above.TMV2 deposits began to differentiate on the nanotube surfaces, rendering them less smooth than during earlier stages. The overall diameter, that is, the height of TMV–KD10-templated hybrid rods, after ten days of mineralization was additionally measured by AFM (data not shown). For this purpose, mineralized viruses were deposited on a silicon substrate. The average of the resulting mean values of the virus height was in good agreement with the TEM data and revealed a typical particle diameter of 30 nm, corresponding to a ≈6 nm linker–peptide–silica coating of the 18 nm TMV core. Different from non-modified viral rods immobilized on a silicon substrate, where reduction of the virus height due to attraction to the substrate surface is observed [TEM analyses of the mineralized products confirmed the findings for the distinct TMV templates (not shown), with TMV–KD10–silica composites showing the strongest and most homogeneous contrast of otherwise non-stained samples. This template was therefore selected for a twelve day time course experiment to investigate the growth kinetics of its mineral shells, and if the thickness of the silica coating might be controlled via the TEOS incubation time. Total widths of randomly selected, low-contrast TMV–KD10 cores surrounded by electron-dense sheaths were measured in digital TEM images by help of image processing software from the fifth day onwards. This revealed an increase of layer thickness with progressing time . After tobserved , the adhwt or TMV–KD10 particles (both with and without 10 days of exposure to TEOS). Positive and negative secondary ion spectra were recorded from random positions of the TMV deposits. The peak assignment is based on high mass resolution data and isotope patterns for Si. As shown in + signal decreases substantially from TMV–KD10 particles incubated with TEOS (blue) to the TMVwt control with TEOS (red) to both negative controls not incubated in TEOS solutions (green and purple). Analyzing SiOH+ and several fragments characteristic of silica in negative polarity spectra  indicated the same trend. Since the sample preparation method did not yield fully TMV-covered samples, the recorded mass spectra averaged over a field of view of 500 × 500 µm2 show individual levels of Au− stemming from the underlying substrate. In order to correct for this dispersion or area effect, the raw intensities of Si+ and SiOH+ were normalized according to the gold signals of each analyzed spot. Semi-quantitative silicification levels obtained thereof are presented in An analysis of the deposited materials with time-of-flight secondary ion mass spectrometry (ToF-SIMS)  was perf+ and SiOH+, both TMV–KD10 and TMVwt exposed to TEOS did form insoluble silica to considerably different extents. This resulted in about five times higher amounts of mineral on the peptide-modified virus. This finding is in agreement with our microscopic observations, which were not sufficient to resolve the deposition of silica on the wild type viral template. The ToF-SIMS analysis therefore revealed either a spontaneous hydrolysis of TEOS  or a low but specific mineralization-promoting activity of the bare viral CP surface . The low SIMS Si+ and SiOH+ signal intensities, and the necessary high mass resolution for unambiguous fragment assignments, precluded SIMS imaging with high lateral resolution. Hence, the obtained SIMS data cannot visualize mineralized individual TMV particles or distinguish between silica bound to virus particles and silica deposited by self-hydrolysis.As shown in A systematic comparison of TMV-based nanobiotemplates chemically functionalized with different types of mineralization-affecting peptides revealed superior capacities of repetitive, alternating KD sequences in guiding the deposition of silica sheaths from TEOS precursor solutions around the viral soft-matter cores. The peptide KD10 designed in this study on the basis of earlier tests  allowed The KD10-fashioned plant viruses thus enable the one-pot manufacture of freely suspended silica nanorods with a soft-matter core, devoid of significant amounts of byproducts. It would be interesting to characterize the mechanical properties of these composites in comparison to synthetically synthesized silica nanorods. This could potentially lead to fundamentally novel types of fiber-reinforced biohybrid materials. Furthermore, the method may also give rise to an efficient fabrication of rigid, ultrasmall components of unusual shapes, on the basis of different nonlinear kinked and branched TMV-based architectures generated recently in our lab .Finally, peptides spatially immobilized in a selective manner on certain target sites of biotemplates might also be a clue to the use of silica deposition as a “bionic glue”. On appropriate TMV variants, specific coupling groups of amino acids are confined to outer, inner or end surfaces of the nucleoprotein tubes, respectively. Serial in vitro assembly of different genetically engineered CP types on RNA scaffolds can even generate nanorod subdomains, offering unique coupling functionality . AddressTaken together, extended composite bio-hybrid materials and complex miniaturized systems both might profit from the precise shapes, high availabilities and immense in vitro tuning potential of plant viral templates, and their peptide-controlled transformation into mineralized nanostructured composites adapted to specific future applications.5C, (KD)10C, and CA4H4, of 90% purity were provided by GeneCust . Peptides 31C and 44C were purchased from EMC Microcollections .The peptides, (KD)wt and genetically modified TMVLys [N-maleimidopropionamido)-tetraethylene glycol ester (SM(PEG)4, Thermo Scientific, Karlsruhe, Germany) dissolved in dimethyl sulfoxide and incubated at 37 °C for 2 h under agitation . The TMV particles were sedimented for 1.5 h at 90,500 g and 4 °C in an Optima L-90K ultracentrifuge . The resulting pellet of linker-equipped TMV (named TMV–PEG) was resuspended in 600 µL of 10 mM SPP pH 7.2. A volume of 100 µL of TMV–PEG solution was mixed with 800 µL of 10 mM SPP pH 7.2 and 40 µL of peptides (3.3 mg/mL) dissolved in dimethylformamide and incubated at 30 °C for 2 h and subsequently at 4 °C overnight under agitation as above. The TMV particles with conjugated peptides were sedimented by ultracentrifugation as above. The pellets were washed with 1 mL of ultrapure water  and resuspended in 100 µL of ddH2O. The TMVwt and TMV–Lys concentrations were determined by UV spectroscopy with a NanoDrop ND-1000 spectrophotometer  at a wavelength of 260 nm, using the extinction coefficient of TMV particles (3 mL mg−1 cm−1 [Lys after SDS-PAGE separation and Comassie Blue staining were compared (see below).Wild type TMVd TMVLys   . For eThe modified CPs were analyzed by denaturing SDS-PAGE . SamplesModified and unmodified TMV–Lys templates were separated as intact particles in native 0.9% agarose gels in 98 mM Tris pH 8.0, 89 mM boric acid, 2 mM EDTA. 12 µg of total protein in sample buffer  bromophenol blue, 10% glycerol) were applied per lane. TMV bands were stained with Coomassie Brilliant Blue R250.2O (pH 5.5) as well as in 30 mM Tris-HCl at pH 8.0.The zeta potential was measured with a Malvern Zetasizer Nano ZS  using disposable folded cuvettes. The Smoluchowski approximation was used according to instrument settings to convert the electrophoretic mobility to a zeta potential. The experiments consisted of 30 runs per measurement. All experiments were conducted in triplicate. The zeta potential was measured for each sample with a concentration of 0.5 mg/mL TMV particles solution in ddHg and 18 °C. The supernatant was discarded and the pellet washed twice with 200 µL of 50% (v/v) ethanol to remove residual unconverted TEOS. The pellet was resuspended in 50 µL of ddH2O and centrifuged for 30 min at 10,000g. The resulting pellet was dissolved in 50 µL of ultrapure water.Peptide-functionalized TMV templates resuspended in water (see above) were kept for one to two days at 4 °C to allow their complete dispersion after ultracentrifugation. For the mineralization of particles with and without linkers and conjugated peptides, a 40 µL TMV template solution (10 mg/mL) was mixed with 50 µL 20% (v/v) TEOS  in ethanol (99.8% p.a.), resulting in final concentrations in the mineralization reaction mixture of 4.4 mg/mL TMV, 11.1% (v/v) TEOS, and 44.4% (v/v) ethanol in an aqueous solution of pH 5.5–5.6. It was crucial to mix TEOS and ethanol before combining it with TMV particles in order to preserve their structural integrity. Mineralization reactions were incubated for 1, 2, 5, 7, 10 or 12 days under agitation  at 25 °C. The reaction mixture was precipitated in a table centrifuge for 15 min at 20,000The surface of mineralized TMV particles was characterized by SEM analysis. 20 µL of 1:250 diluted, mineralized TMV solutions in ultrapure water  were pipetted on n-Si wafer substrates and air dried. The samples were analyzed in an ultrahigh resolution field emission SEM  at 30 kV.The TEM analysis was carried out to determine the silica shell thickness of TMV–KD10 particles after different reaction times. 3 µL of mineralized TMV particles in solution were incubated on a 400-mesh formvar, carbon-covered copper grid for 5 min. The droplet was removed with five droplets of ultrapure water and air dried. The samples were analyzed under a Zeiss EM-10A TEM  at 60 kV.For ToF-SIMS analysis, Si chips (5 × 10 mm) were cut from n-Si wafers  and used as supporting substrates. These were coated with a 4 nm thick chromium layer for adhesion and a 30 nm thick gold layer by physical vapor deposition . All samples used for mineralization analysis were found to be free of Si and silicon oil contamination, which could potentially interfere with the analysis.−9 mbar. For high mass resolution, the Bi source was operated in the “high current bunched” mode, providing short Bi1+ primary ion pulses at 25 keV energy and a lateral resolution of approximately 4 μm. The short pulse length of 0.6 to 1.0 ns allowed for high mass resolution. The primary ion beam was rastered across a 500 × 500 µm2 field of view on the sample, and 128 × 128 data points were recorded. Primary ion doses were kept below 1011 ions/cm2 (static SIMS limit). The spectra were calibrated against C−, CH−, CH2−, and Au-, or on the C+, CH+, CH2+, and CH3+ peaks, respectively. Based on these datasets, the chemical assignments for characteristic fragments were determined.10 µL of a 1:250 diluted solution of mineralized TMV or control preparations in ultrapure water  were pipetted on a gold-covered n-Si wafer and air dried. ToF-SIMS was performed on a TOF.SIMS5 instrument . The spectrometer was equipped with a Bi cluster primary ion source and a reflection-type time-of-flight analyzer. The UHV base pressure was <5 × 10


There is an error in the grant number in the Financial Disclosure (FD) statement for this article. Please refer to the correct FD statement below:This study was supported by grants 81071095, 81120108011, and 81361128010 (to XX) from the National Natural Science Foundation of China, Suzhou science and technology development program (SYS201232), the Priority Academic Program Development of Jiangsu Higher Education Institutions of China, Jiangsu Province’s Key Provincial Talents Program (to XX), and the National Basic Research Program of China . The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.


A significant number of chronic pain patients experience a decline in therapeutic effects after rehabilitation. As face-to-face contacts with health care professionals are not always feasible after treatment, new, innovative, fully automated relapse-prevention programs are highly needed.In this study an online, automated relapse-prevention program based on acceptance and commitment therapy (ACT)—both as a website and as a mobile app—was developed and evaluated. At each step of the development, end users  were consulted in order to fully address their needs.In a step-by-step process, a contextual inquiry, requirement specification, and design were executed with chronic pain patients by conducting, respectively, a focus group (n=10), interviews with rapid prototyping (n=28), and a user- and expert-based usability evaluation (n=14). Furthermore, a pilot evaluation was conducted with 14 chronic pain or fatigue patients who had received the online relapse-prevention program following a multidisciplinary ACT treatment. They were interviewed about their usage and the usefulness of the program in supporting them to maintain changed behaviors and prevent relapses in avoidance and pain control behaviors.The three stages provided information about the expected needs of end users, comments about the usefulness of the proposed features, and feedback about the design and usability of the program. This resulted in a fully operational, online relapse-prevention program. Results from the pilot evaluation showed that 9 patients used the online program after treatment, 5 of whom indicated that the program supported them after treatment. Of all the patients, 4 of them indicated that the program did not support them because they wanted more social interaction with other users.This study showed that an innovative, automated, online program that is user friendly can be developed by involving the end users in each step. The program was evaluated positively by some participants. The evaluation showed that the online relapse-prevention program has the potential to support chronic pain patients in maintaining their changed behaviors and preventing relapses in avoidance and pain control behaviors.Nederlands Trial Register (NTR) Number: NTR4177; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4177 (Archived by WebCite at http://www.webcitation.org/6Ur6EFD1D). Multidisciplinary rehabilitation programs based on cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT) for chronic pain patients have shown positive effects on the interference of pain in daily life and on physical and mental functioning -3. HowevIn this study we describe the development of a new, online relapse-prevention program—in the form of a website and/or mobile app—based on ACT. The main focus of ACT is enhancing psychological flexibility which includes the processes of acceptance and value-based behavior . For chrHowever, despite the promising results of eHealth interventions for chronic pain, the effect sizes are often less than expected. One reason for this might lie in the low adherence rates of eHealth interventions, for instance, participants are not following the intervention as intended. For example, in the study of Moessner et al it was shown that a Web-based aftercare intervention following multidisciplinary therapy for chronic back pain had positive effects on pain intensity, but 70% of the patients did not adhere to the intervention . KristjáThe first aim of this study is to develop an innovative, fully automated, online relapse-prevention program that enables rehabilitation centers to implement this program. For the development process, a user-centered design was used that might overcome the problems described above. A user-centered design has been shown to have positive effects, especially on user-satisfaction levels and on addressing user needs . A user-In the contextual inquiry, intended users are asked for information about their needs for a technology. Contextual inquiry also examines how the technology may fit into the day-to-day life of the intended users . In the Respondents were asked to discuss what they believed would help them to prevent relapses and whether they would use a website and/or a mobile app as a relapse-prevention program. They were also asked whether they wanted to have guidance by email or SMS text message. This focus group session was audiotaped with the permission of the respondents. The audiotapes were transcribed and were analyzed qualitatively by the researcher by summarizing common themes.In the requirement specification activity the expected needs are translated into requirements of the technology . Therefo1. Values and actions: Users could add or change various life values and corresponding actions.2. Diary: The diary is for monitoring value-based living and included one question that asked whether the user had lived according to his/her values on a rating scale from 1 to 10. The answers to this question were presented in a chart including positive smileys if a score of 6 or more was achieved.3. Exercises: Users could add various ACT exercises or search in a database that contains all the exercises included in the treatment.4. Tips: Users could add their own tips, share these tips with other users, or see shared tips from other users.5. Coach: Various options of guidance with SMS text message or email were shown to the participants and they could all choose which text message they would like to receive: (1) a reminder SMS text message to use the diary or to use the program itself, (2) a motivational SMS text message written by a health care professional, (3) a self-composed motivational SMS text message which could be sent at a later date, or (4) a motivational SMS text message tailored to particular scores that are obtained from the diary—this tailors the content more to the individual situation.To obtain the requirements, semistructured interviews combined with the prototypes of the eHealth technology were conducted with chronic pain patients . TherefoA fully operational program, both as a website and as a mobile app, was developed. For examples of these, see In this phase, the quality of the design was examined by evaluating its usability. Consequently, a user-based and expert-based evaluation method using a scenario-based think-aloud protocol was performed . UsabiliBased on the results of the usability evaluation, the system quality was improved and a manual was developed to give the users more information, for example, whom the tips were shared with. A pilot user evaluation was conducted with patients who received the online program after a multidisciplinary pain treatment for 2 months. This study was approved by an independent Dutch medical ethics committee  and recorded in the Dutch primary trial registry for clinical trials .Inclusion criteria were chronic pain or fatigue patients who were following an inpatient 8- to 12-week, group pain treatment which started in March or April 2013 at the Pain Department of the Roessingh Rehabilitation Centre. Chronic pain and chronic fatigue patients receive the same multidisciplinary treatment in the rehabilitation center. Patients needed to have access to the Internet through a computer and/or a mobile phone at home. The information letter described that it was recommended to use the online program for 5 to 10 minutes daily. The researcher had access to the actual accessed data use of the program, including how many times the participants were logged in and which features they had used, so self-report data use could be compared to the actual usage. In the fourth week of their treatment, the researcher explained the study and the patients received a letter with information about the study and a letter requesting their informed consent. In the sixth week of the treatment, patients who agreed to participate handed over the signed informed consent, were given access to the online ACT relapse-prevention program, and received a short introduction to the program. Following a period of 2 months after the group treatment, all of the participants were invited for a telephonic, structured interview conducted by the researcher (MF). The interviews were audiotaped with the permission of the participants and took, on average, 20 minutes to complete. The interview scheme started with a general question on the helpfulness of the online ACT relapse-prevention program in supporting them with the actions they intended to carry out after treatment. Participants were asked how many times they had used the program and whether they intended to continue using the program. The interview continued with an open discussion to identify which parts of the intervention they found to be most useful. Furthermore, they were also asked whether they would recommend this program to other patients. The interview ended with the question “Do you have any recommendations for improving the program?”In total, there were 5 groups that started with the pain treatment with a total of 27 patients. All of them were given a letter with information about the program and a form requesting their informed consent. The informed consent form was signed by 17 patients and they subsequently received the online program. The mean age of the participants was 38 years and most of them were female . All 17 patients were invited for the interview and 14 of them were interviewed by the researcher. The reasons for not taking part in the interview were medical , feeling very good , and unknown .All participants indicated that there is a need for an aftercare program and they would all like to have contact with their health professionals after treatment, for instance, through a telephone call or individual face-to-face contact. Most respondents would use an eHealth program, such as a website or mobile app. In this online program 8 participants out of 10 (80%) found it useful to register their values and actions and to read ACT-based exercises. Of the 10 participants, 4 of them (40%) thought it would be useful to make a start with completing these exercises and registering their values and actions during treatment. All participants would like to have contact with other patients to share tips and to give each other pep talks. Of the 10 participants, 2 of them (20%) proposed a forum for facilitating this contact with other patients. All participants would like to receive reminders by SMS text messaging or email from a health care professional to help them adhere to value-based behavior after treatment. Of the 10 participants, 8 of them (80%) indicated that reminders could be preformulated and sent automatically, preferably at a higher frequency rate and directly after the end of the treatment. Of the 10 participants, 3 of them (30%) also thought that it would be helpful to add their own motivational texts during treatment in the online program that can be sent after treatment. Additionally, 2 participants out of 10 (20%) indicated that the text messages should be tailored to the individual patient’s personal situation.Almost all of the participants indicated that they would use the online aftercare program . Some stated that they would like to use a website , a combination of a website and a mobile app , or only a mobile app . In general, participants found the design of the five features to be clear and convenient. All comments are represented in Reasons for nonuse were feeling well at that particular moment , a medical reason , and having other priorities . Of the 5 nonusers, 2 of them (40%) received motivational messages and found them very pleasant and supporting. Of the 5 nonusers, 3 of them (60%) thought they would use the program in the near future, especially in the case of a relapse . No suggestions for improvements were given.Out of the 14 participants, 5 of them (36%) indicated that the online program supported them in their efforts to perform their intended actions. Out of these 5 participants, 2 of them (40%) used the online program regularly  and the other 3 participants (60%) used it 3 to 5 times in total. The online program functioned as a summary of the treatment and reminded them of what they had learned during treatment. The (mindfulness) exercises, the motivational messages, and the tips were evaluated as being “useful” and “very pleasant” as they functioned as reminders about the treatment. One participant recommended changing the question “How are you?” to more personal actions.Of the 14 participants, 4 of them (29%) indicated that the program did not support them after treatment. Of these 4 participants, 3 of them (75%) used the program 1 to 3 times, and 1 of them (25%) used the program at least once a week. All 4 participants out of 14 (29%) indicated that they missed the interaction with other patients in the program, for example, using a forum to share experiences with other users. Participants were satisfied with the motivational messages and the exercises because they served as a reminder for the treatment. They will continue to use the program, particularly the motivational messages , as well as the tips and the values and actions .In this study, a new, innovative, online relapse-prevention program for chronic pain patients based on acceptance and commitment therapy was developed and evaluated. The first aim of the study was to develop an automated, user-friendly, online relapse-prevention program that fulfills the needs of chronic pain patients. A contextual inquiry by focus group discussion, requirement specification by interviews with rapid prototyping, and a user- and expert-based usability evaluation of the fully operational program successively provided the input for the next step in the development process. The chronic pain patients reviewed the program from their points of view and context, both on design and content for ensuring that the eHealth program was usable and acceptable. Accordingly, our user-centered developmental process resulted in a program with a simple design, large icons, and few layers of information and text. A pilot evaluation with chronic pain or fatigued patients who had received the online relapse-prevention program following a multidisciplinary ACT treatment (n=14) showed that this development process was satisfactory. Two-thirds of the participants  used the program in the 2 months after treatment. They did not have new suggestions on the usability of the program and nonusers  stated that their nonuse was not caused by complexity or inadequate usability of the program. This probably improves the uptake of the online relapse-prevention program, as many problems with adherence to eHealth programs are due to complexity and inadequate usability .Furthermore, the user-centered development process resulted in information on the needs concerning the content of the program. The resulting program consists of the essential building blocks of a relapse-prevention program . FirstlyThe second aim of the study was to evaluate whether the online program supported patients after treatment in maintaining their changed behaviors and preventing relapses in avoidance and pain-control behaviors. The results of the pilot evaluation showed that, most of all, the motivational messages and the exercises were evaluated as very useful and pleasant. Results from the pilot evaluation showed that 9 patients out of 14 64%) used the online program after treatment, 5  of whom indicated that the program supported them after treatment. In general, the adherence rates and the evaluation of the program were disappointing. Although it was recommended to use the program daily, the 9 participants out of 14 (64%) that actually used the program only used it once a week or 1 to 5 times in total. Furthermore, 5 out of 14 (36%) participants never used the program. Of these 5 nonusers, 3 (60%) of them indicated that they will use the program in the near future, but we do not know whether these participants really intended to use the program or whether they were providing socially desirable answers. Our results corroborate with earlier results on low adherence rates in online programs for chronic pain patients 4% used t. Daily uA possible explanation for the low adherence in this study is that most patients had an initial preference with using the program during treatment, particularly with regard to registration of values and values-based actions. For further use, we recommend integrating the program into the multidisciplinary pain treatment program and to train health care professionals to inform and motivate patients to use the program during treatment. Furthermore, the program is not yet successful in providing sufficient social support. The 4 participants out of 14 (29%) who stated that the program was not helpful in the period after treatment indicated that they missed interacting with other participants. Therefore, it is advisable to implement a function where users can react to the shared tips.Limitations of this study included the small samples of users involved in each step and the recruitment of all participants from the same rehabilitation center. Although generalization has to be made with care, the number of participants concurs with the recommended numbers by other studies ,30. AnotRelapse prevention is still a topic that is hardly examined in the area of chronic pain . This st


Residency interview apparel has traditionally been the dark business suit. We changed the interview dress code from a traditionally established unwritten ‘formal’ attire to an explicitly described ‘informal’ attire. We sought to assess if the change in dress code attire changed applicants’ perceptions of the residency program or decreased costs.The authors conducted an anonymous survey of applicants applying to one emergency medicine residency program during two application cycles ending in 2012 and 2013. Applicants were asked if the change in dress code affected their perception of the program, comfort level, overall costs and how it affected their rank lists.We sent the survey to 308 interviewed applicants over two years. Of those, 236 applicants completed the survey for a combined response rate of 76.6% (236/308). Among respondents, 85.1% (200 of 235) stated they appreciated the change; 66.7% (154 of 231) stated the change caused them to worry more about what to wear. Males were more uncomfortable than females due to the lack of uniformity on the interview day . A total of 27.7% (64/231) agreed that the costs were less overall. The change caused 50 of 230 (21.7%) applicants to rank the program higher on their rank list and only one applicant to rank the program lower.A change to a more informal dress code resulted in more comfort and fewer costs for applicants to a single residency program. The change also resulted in some applicants placing the program higher on their rank order list. The interview for residency remains a rite of passage for physicians seeking specialty training throughout the country. Usually during their last year of medical school, students apply to residency programs in the specialty of their choice. During the months of November through January they interview at multiple residency training programs, and then list the programs they prefer in the rank order list (ROL). One tradition of the interview, which has remained across specialties, is the formal business attire. However in recent years, the dress code of medical schools has become more relaxed to even allow fleece jackets or ‘sneakers’.3Few articles about dress codes for physicians exist and what does exist does not describe residency interviews. Furthermore, few articles actually study any dress attire phenomena beyond patient perceptions. No study to date has addressed cost or physician perceptions with dress code. What does exist concerns the dress code for medical student or physicians while seeing patients.8We challenged the dominant paradigm of “a residency interview requires business attire” by explicitly changing the dress code expectations for applicants on their interview day at our emergency medicine (EM) residency training program. We then explored whether changing the dress code for residency interviews also changed applicants’ perceptions of the program, comfort level, or decreased the cost of the interview season. Furthermore, we surveyed applicants about their opinions as to whether EM residency programs should adopt this practice.During the initial interview offers to applicants of our residency program in the 2011–12 and 2012–13 seasons, we stated in the letter that formal business attire was not required. The letter stated, “We don’t want you to wear suits to the interview day, unless you absolutely love wearing suits. We will all be dressed in some version of jeans, scrubs, and at the most, business casual.” We reiterated this new policy in our follow-up communication and provided examples of appropriate but more casual attire. Once the interviewees had submitted their match list and the program had also submitted the match list, we surveyed applicants who had interviewed at our program using a commercially available survey website (SurveyMonkey.com). The survey was submitted to the institutional review board at our home institution, Alameda Health System, and was approved.We developed and then piloted our survey with departmental education faculty with a combined total of 40 years of residency leadership experience. In addition, the survey was piloted with residents within our own program  The pilot and revisions were in accordance with survey design methodology to maximize validity and reliability.The survey was emailed to residency applicants twice after the deadline to submit rank order lists for both programs and applicants had passed. The option to respond was closed prior to the release of match results to either applicant or program. Respondents were allowed to not answer all of the questions. We surveyed applicants about demographic information including age, gender, and geographic location. In addition, applicants were queried about their impressions of the change in dress code expectations. For an example of the instrument, see attached survey.We collapsed the five-point Likert scale anchored by “1-disagree” and “5-agree” into 1 to 2 (disagree), 3 , and 4 to 5 (agree). A general comments section was included at the end of the survey. We performed statistical analysis using SAS . Each survey question was analyzed by gender, age, and medical school region. We calculated differences using chi square analysis for categorical variables  and t-test for age.We sent the survey to all 150 interviewed applicants the first year and all 158 the second. It was completed by 120 applicants the first year and 116 applicants the second year for a combined response rate of 76.6% (236/308) . There wOverall, a minority of applicants stated that a change in dress code cost them less money overall in the interview process. Only 27.7% (64/231) agreed that the costs were overall less compared to costs incurred interviewing at other residency training programs.Regarding perceptions of the residency program itself, 212 of 234 (90.6%) ‘disagreed’ or ‘somewhat disagreed’ with the statement “The change in dress expectation lowered [program] in my esteem.” A confirmatory question later in the survey asked whether the dress code change improved their feelings of the program. Of respondents, 150 of 229 (65.5%) stated the change in dress code improved their feelings about the program and an additional 66 (28.8%) stated it had no change on their feelings about the program. Only six applicants of the 234 (2.6%) ‘somewhat agreed’ that the change in dress code lowered their esteem of the program and two applicants took the stronger position of ‘agreed’ (0.9%). When asked if the change in dress code reflected the attitudes and demeanor of the programs’ attendings and residents, 203 of 234 (86.8%) responded in the affirmative.Per survey responses, the dress code change during the interview season increased discussion with other applicants also in the residency interview process. When asked if other applicants discussed the dress code change while interviewing at other programs, 195 of 234 (83.3%) stated that other applicants brought up the topic. The question expressly stated that they, the applicant, did not bring up the topic in conversation.When asked if other residency programs should change their dress code, 148 of 232 (63.8%) stated they agreed or somewhat agreed. Additionally, another 51 (22%) stated they neither agreed nor disagreed. There were no statistical differences by school region or age for those in favor of dress code change. Only 4.2% of applicants from the Southern region (1/25) and one of 13 applicants (7.7%) from the Rocky Mountain region were not in favor of a dress code change. (Perhaps we should explicitly say there were no differences by school region or age.)The change in dress code caused 50 of 230 (21.7%) applicants to rank the program higher on their rank list. Only one applicant indicated the dress code change caused him or her to rank the program lower. We found no significant difference in response to any dress code question by age or medical school region.Anecdotally, there were a few applicants (less than 10) who still wore formal business attire to the interview. Applicants who interviewed earlier in the season seemed to have more apprehension with the new dress code than later applicants. It may be that later applicants heard about the dress code from fellow interviewees at other programs or their own medical school and had more time to confirm the information being sent from the program itself.The authors do not believe there were negative affects on the program itself. The program’s rank list was filled within three spots of prior years’ matches, so it appears that at least for those years’ rank lists, there was no negative impact to the program.Our experience demonstrated that changing dress code expectations from formal to more casual did not negatively impact the interview process for either applicant or program at our single institution. The results of our survey demonstrate the majority of applicants to our EM residency preferred to have a more casual interview dress code.This result must be taken in the context of the study. This was a change in dress code in one EM program over two years. While the results suggest relatively little impact upon the program reputation or the ranking of the program by applicant, one must consider the setting.EM is a relatively newer specialty that does not have a ‘clinic’ type setting, and thus the practitioners tend to wear surgical scrubs in the emergency department. A change in interview attire may not be seen as acceptable to more traditional specialties who retain a clinic or office based setting. These specialists often have more formal attire during these clinical settings.In terms of cost savings, a change in dress code may not provide dramatic cost savings. Anecdotally, many applicants have commented over the years on the cost of flying all over the country doing interviews. Some have applied for additional credit cards or applied for loans from their medical schools to help defray the costs of interviewing. We had hoped the change in dress code might limit some of the costs of cleaning or maintaining their formal business attire but that may not be the case. Applicants still have to have their formal business attire for interviewing. More money is likely saved by staying overnight with current residents/friends and taking public transit/carpooling , rather than hotels and rental cars.The study suffers from a number of limitations common to surveys. Recall bias is a clear limitation as surveys were completed perhaps more than a month after the actual interview. In addition, despite the anonymous survey being sent in the ‘quiet period’ when the National Resident Matching Program has each program’s and applicant’s list, it is possible that applicants felt their response was perhaps traceable back to them or might negatively influence their application or their ranking.While the response rate was 76.6%, it is also possible the applicants who did not answer the query had more negative feelings about the dress code change and might have lowered the favorable percentages or have resulted in applicants stating they lowered the program on their rank lists.Additionally, the residency program where this change in dress code was implemented trains EM residents. This is a specialty that does not have ‘clinic days’ or any standard outpatient office setting. Applicants who prefer this specialty may also tend to prefer acute care settings in which scrubs are more favored. Finally, the program is also located in a county hospital in California and where the ‘formality’ of the hospital and the faculty might be more informal than other institutions located in other parts of the country. As an example, most faculty do not wear white coats and some have tattoos visible.Another potential limitation is that we did not explicitly notate which applicants did not follow the new dress code and were dressed in a more traditional fashion. We, therefore, could not exclude them from the study as the survey was sent anonymously to all applicants who interviewed.Changing the dress code for the residency interview does not appear to negatively affect the program’s reputation or rank order list results. Most applicants prefer a less formal dress code. It appears to make them more comfortable and, for a minority, incurs less cost. The change in dress code at the single study site was associated with some applicants raising the program on their rank lists and very few lowering it. Further investigations should study how individual applicants are perceived by their interpretation of the dress code and if some are ranked higher or lower based on their actual apparel or their ‘following’ the suggested dress code.


Because of the shortage of health professionals, particularly in specialty areas, Rwanda initiated the Human Resources for Health (HRH) Program. In this program, faculty from United States teaching institutions (USF) "twin" with Rwandan Faculty (RF) to transfer skills. This paper assesses the twinning model, exploring USF and RF goal setting, satisfaction and perceptions of the effectiveness of skill transfer within the twinning model.All USF and RF in the HRH Program from August 2012-May 2014 were invited to participate. An 85-item questionnaire for USF and 71-item questionnaire for RF were administered via Survey Monkey in April and May 2014. Associations among primary outcomes were assessed and factors related with outcomes were modeled using logistic regression.Most RF and USF reported setting goals with their twin . Half of RF (52 %) reported effective skill transfer compared to 10 % of USF. Only 38 % of RF and 28 % of USF reported being very satisfied with the twinning model. There was significant overlap in the three operational outcomes. For RF, the following factors were associated with outcomes: for effective skill transfer, being able to communicate in a common language and working at a nursing site outside of Kigali; and for satisfaction, 7+ years of professional experience and being part of a male RF-female USF twin pair. For USF, the following factors were associated with outcomes: for setting goals, prior teaching experience; and for satisfaction, experience in low resource settings for one month or less and feeling that HRH promotes a culture of respect.Twinning is the cornerstone of the HRH Program in Rwanda. These findings helped the HRH team identify key areas to improve the twinning experience including better recruitment and orientation of USF and RF, consideration of additional factors during the twinning process, provide language training support, facilitate joint twin activities and cross-cultural training and improve the site leadership buy-in and support of the program. These results can inform other programs using twinning to develop skills in the health workforce.The online version of this article (doi:10.1186/s12992-016-0141-4) contains supplementary material, which is available to authorized users. With the established link between positive health outcomes and a sufficient number of well-qualified heath workers –3, develAfrica, particularly sub-Saharan Africa, is highly affected by its limited health workforce. While Africa bears 24 % of the global disease burden, it employs only 3 % of healthcare workers worldwide , questioSub-Saharan Africa faces two critical issues: 1) the quantity/distribution of healthcare providers and 2) the skills of those providers, particularly in specialty areas. Many countries have deployed government and donor funds for long-term programs to address these challenges. In 2005, Malawi secured USD$272 million for a five-year program to train and retain health professionals . In TanzSimilar to other African countries, Rwanda has a persistent shortage of qualified health professionals but the issue was heightened by the 1994 Genocide against the Tutsi where a large number of health workers were killed and others fled the country . In the Even with these changes, Rwanda still struggles to increase the number of healthcare professionals  to the minimum recommended by the WHO and to train health care specialists. In 2012, the Rwandan Ministry of Health, with support of the Centers for Diseases Control and Prevention and The Global Fund to Fight AIDS, Tuberculosis and Malaria, initiated the innovative 7-year Human Resources for Health (HRH) Program , 22. TheEvidence of impact of international partnerships is limited but critical for maximizing partnership effectiveness . While rSince its inception in 2012, over 313 USF and 210 RF have been engaged in the HRH Program. The HRH Program targets four disciplines for RF development: medicine, nursing/midwifery, oral health and healthcare management. Each year, the University of Rwanda College of Medicine and Health Sciences (UR-CMHS) selects priorities in each discipline for specialized skills development. RF are selected at the department level at each teaching site with consideration of department goals, personal goals and skill of potential Rwandan twins.Partner institutions in the United States screen potential USF candidates and submit these candidates for University of Rwanda consideration through the HRH team. RF and USF already based in Rwanda then advise on these applications and recommend candidates, based on their suitability for a RF twin, to subcommittees for approval. Approved USF are contracted by the respective USI for periods of time that are typically one year, except for physician sub-specialists who rotate for a minimum of 8 weeks.Orientation is provided to USF by their home institutions prior to their departure for Rwanda. The HRH Program also organizes a pre-departure orientation phone call that focuses on programmatic and logistic matters. Once in Rwanda, HRH staff in the MOH welcome USF and introduce them to the country, and their placements, head of department and twin. Further, the HRH staff in the MOH organize a pre-orientation meeting for RF and site leadership to help them prepare to receive the USF. In August, usually within one month of the USF arrival, an annual orientation event is organized by the MOH for both USF and RF. The orientation is expected to continue at the site level by site leadership as needed. At the beginning of each year, the twin-pair is expected to set goals to be achieved during their time together; however, they are given autonomy in how they achieve these goals. HRH staff in MOH and sites leadership provide the needed support for twins to implement their goals and ensure the follow-up on progress made throughout the twinning process.All USF and RF engaged in the HRH Program from August 2012 to May 2014 were invited by email to respond to an online questionnaire about their perspectives and attitudes of the twinning process, program management and possible cultural and interaction challenges. The 85-item questionnaire for USF and the 71-item questionnaire for RF, administered via Survey Monkey, were identical except the USF questionnaire included additional questions about preparation and adjustment to Rwanda. The RF could opt to take the survey in either French or English, with the French version translated and back translated to English to ensure consistency in meaning between languages. Both English versions of the questionnaire were piloted among health professionals not engaged with twinning program faculty to test the flow of the question and time for completion. Data were collected in April and May 2014. Participation in the survey was optional. To increase participation, reminders were sent by the HRH staff in the MOH to all eligible participants.In the study, three operational outcomes were evaluated based on HRH Program priorities: whether goals had been set, perceived effectiveness of skill transfer from USF-to-RF and satisfaction with the twinning process. A fourth outcome, time spent with twin, was originally considered as a predictor but was reconsidered as an outcome because it likely happens in tandem with goal setting skills transfer and satisfaction. It was not modeled explicitly in this paper, but was considered with other outcomes in the final models.USF recruitment or RF appointments: for example, time since training, previous teaching experience, experience working overseas or with Westerners before entering in the HRH Program;The twinning of USF and RF: for example, gender differences, age differences, number of twins, shared languages;Factors addressable during orientation or service: for example, understanding of HRH Program goals, understand twinning model, cultural differences; andFactors related to program management: for example, perception of support from the site leadership, feel HRH Program promotes culture of respect.Twenty-five potential predictors were identified in a conceptual framework, grouped in the following factors Fig. :Fig. 1Cop < 0.1). Potential significant factors were considered for multivariate logistic regression models that were built using backward stepwise regression, stopping when remaining variables were associated with the outcome at the alpha = 0.1 significance level. The three primary outcomes were modeled independently and separate models were built for USF and RF, since some variables differed between the two types of faculty. Data were cleaned and analyzed in Stata version 13 . We only present direction of association for statistically significant covariates; however, detailed odds ratios and p-values are available in Additional file We used univariate logistic regression to test independent associations between each predictor and outcome p < 0.. PotentiBoth the RF and USF surveys were reviewed and approved by HRH Program funders as part of the monitoring and evaluation plan. Since the data was collected for program purposes, the study received a waiver from the Rwandan National Ethical Committee. Participation in the survey was optional and no personal identifying information was collected.n = 71/145) and from USF 93 % (n = 107/112). Among USF, 55 (49.1 %) were physicians, 36 (32.1 %) were nurses/midwives and 7 (6.3 %) were health managers (Table n = 57) of RF had a moderate amount of experience working with people from Western cultures before engagement in the HRH Program. Nearly half of the USF  had never worked longer than a month at a time in low-resource countries. For the three primary outcomes, there was significant overlap in prevalence of goal setting, skill transfer and feeling satisfied with the twinning experience overall for both Rwandan and USF  (Table p < 0.1)  Table . In mult1) Table .Table 2Fp < 0.1): participating in a nursing program outside of Kigali compared to the main university campus or working at multiple hospitals, being seven or more years post training and having excellent communication with twin in one or more languages (Table p < 0.1) (Table p < 0.1), though neither factor remained significant in multivariate analysis when satisfaction was in the model (p < 0.1)  of RF reported “very effective” skill transfer from their USF twin, whereas less than 10 % of USF felt they transferred skills very effectively to their RF twin (Table  % of RF p < 0.1) (Table p < 0.1). Among USF in bivariate analysis, satisfaction was predicted by a number of hiring or appointment factors , twinning factors  and orientation or management factors  (p < 0.1) (Table p < 0.1).Among those who answered questions about satisfaction, 38 % of RF and 28 % of USF reported they were “very satisfied” with the twinning experience overall Table . In bivaIn this survey, the link between satisfaction, spending time with HRH twin, goal setting and perceived skill transfer was very strong. The highest performing outcome was goal setting, with 89 % of RF and 71 % of USF reporting that they had set joint goals with their twin. While the proportion of faculty who were “very satisfied” was only 29 % among USF and 38 % among RF, most faculty  expressed satisfaction to some extent. Central to the overall mission of the HRH Program, the lowest performing outcome was effective skill transfer; interestingly, this result was disparate between the RF and USF with 50 % and 10 % reporting effective skill transfer, respectively. It should be noted that all items were self-reported perceptions and all, particularly the effective skill transfer, could be based on cultural or historical expectations such that what RF or USF faculty believe to be effective skills transfer may vary. The findings of important factors that may improve RF and USF twinning experiences are described in more detail below.We were surprised to find that USF with the most overseas experience were the least satisfied with the HRH Program. We assumed extensive prior work overseas would help the faculty set expectations and prepare for their engagement in HRH Program experience. However, the HRH Program uses a unique model with the USF working on a country-developed agenda under the leadership of Rwandans. We suspect this is different from other programs where the USF may have mostly held leadership positions and developed their own workplan. Indeed, previous studies have shown that satisfaction among working professionals in Western settings is closely linked with decision-making ability on the job . As suchWe are certainly not suggesting that in future years the HRH Program should not recruit USF with previous international experience. However, we do think sufficient pre-Rwanda training, focusing on linking faculty’s experiences to what can be expected from their time in Rwanda will be key for managing expectations and increasing overall satisfaction . FurtherCompared to most professional development programs that focus on new faculty , the HRHWe hypothesize the finding that less experienced Rwandan colleagues were less satisfied and perceived less effective skill transfer may also reflect two challenges that were observed in studies from the United States: 1) low motivation because they are unclear how the gain of skills through the HRH Program will tangibly lead to personal and professional promotion  and 2) lThe twinning model creates a framework in which skills are transferred primarily to the RF, and thus how twins are paired is important to the success of the program. The best way to match twins is not yet established. Some programs assign pairs  and otheIn addition to professional relationships with the twin, it turns out that social relationships are also important. Social connections would allow USF to feel more integrated, to gain a deeper understanding of their twin and to understand some of the cultural content surrounding medical practice –33. We aNursing sites outside of Kigali were linked to more effective skill transfer, and the reasons are not entirely clear. One possible explanation is that the nursing programs outside Kigali are located in semi-urban areas where interactions among nursing faculty more easily blend social and professional life compared to faculty located in Kigali or assigned to multiple teaching sites. Further, RF at these nursing sites are often enrolled in formal training and degree upgrading programs, so they may benefit from their twin both directly through HRH Program activities and through informal support for their work in these training programs. We recommend further investigation to understand why skill transfer at nursing sites outside of Kigali was perceived to be so effective, which might improve skill transfer at teaching hospitals and the university located in Kigali.To make twinning more successful and gratifying for USF and RF, HRH Program leadership both at central and teaching sites should be actively involved with creating collaborative work environments. USF who felt supported by site leadership were more satisfied with the twinning process, and we believe that this is linked to receiving support needed to achieve twinning goals. The fact that some site leaders were not heavily engaged in the initial HRH years is a function of the limited human resources at the health institution leadership level, such that they were unable to provide necessary support or resources due to competing institutional demands. To address this, the HRH Program has started a series of meetings with UR-CMHS and department leadership to discuss challenges and provide solutions to overcome potential barriers for effective twinning and skills transfer at site.Several limitations should be considered in the interpretation of these results. The present study targeted all faculty who participated in the program in the period between August 2012 and May 2013; however, it is possible that we were unable to invite some faculty as a result of our inability to make contact with them such as having an incorrect email address. Further, RF participation in the survey was lower compared with USF participation. This may have been due the fact that both clinical and classroom teaching work kept them busy such that finding time to participate in the study was difficult. In addition the use of an online survey may have reduced the number of RF responding due to limited previous exposure to online surveys and poor internet access. The questionnaire was long, which may have increased missing rates for later questions. The survey may have had recall biases, particularly for faculty who had not been in the HRH Program for over a year. Finally, although respondents were assured that no directly identifiable information would be collected, respondents who had unique demographic or job profiles in the program may have been less forthcoming with criticism if they felt responses could not be anonymized. However, despite these limitations, we believe these results are informative, both because of the uniqueness of the twinning model in the HRH Program and because this is the first formal assessment of the satisfaction and perceived effectiveness of this program. We intend to follow-up this assessment with RF and USF interviews to corroborate these findings and to better understand some of the associations observed.Overall, the HRH Program has been useful for improving the skills of the health workforce in Rwanda. However, central to the HRH Program is the twinning model, specifically goal setting and skills transfer between twins, and satisfaction with the twinning model is important for the HRH Program success. The findings of this study helped the HRH team identify key areas to improve the twinning experience. For example, following information gained from this survey, the program has improved pre-orientation of USF and RF, it is increasing its staff support to assist cross-cultural training and social activities, and studying best practices of the nursing sites. Other factors such as age and gender in the matching process need more investigation, but the HRH team is willing to advise on considering these factors in the matching of RF-USF twins if supported by the evidence.To ensure continuous improvement of twinning model, mechanisms to collect feedback on the twinning process will be reinforced to expand best practice and manage reported challenges. This will both optimize the HRH Program in Rwanda and provide information that can contribute to the development of health workforces in other low-income countries through implementation of effective models.