As healthcare systems progress toward initiatives that increase patient engagement, stakeholder hopes are that shared decision making (SDM) will become routine practice. Yet, there is limited empirical evidence to guide such SDM program implementations, particularly in obstetric practices. The first stage of any project implementation is the “initiation stage”, in which project leaders define a project’s purpose and stakeholders and structures are put in place to support the new initiative. Our study’s objective was to identify factors affecting the initiation stage of an SDM program implementation project for TOLAC, trial of labor after Cesarean. We conducted a multiple-case study of an SDM program implementation in three obstetric settings in Washington State. The research design and analysis were guided by implementation science frameworks and project management literature. Data sources included interviews with key informants from the State, SDM tool vendors, and three project sites, as well as implementation documents. The study results provide insight into how the identified project implementation factors provide an essential foundation for informing project planning, execution, and reflection/evaluation. In this study, the State’s decision aid certification program pressured the project sites to shape the project purpose and engage stakeholders that would meet immediate project requirements . The study reveals that external demands may not be in perfect alignment with the internal necessities required for an SDM program’s long-term viability and sustainability. Findings may be used by implementers and researchers to model and strategize the early stages of SDM program implementation projects, particularly in the obstetric setting. Shared decision making is the process in which a provider and patient make a medical decision together—combining clinical evidence with the patient’s values and preferences . One sucSeveral structural elements facilitate SDM: patient decision aids, provider training, and a means to record the SDM process in patient records. An SDM program typically includes all of these tools . Prior rIn 2010, the promotion of decision aid certification by the Patient Protection and Affordable Care Act spurred efforts to increase SDM across the U.S. . In 2016This study focuses on the first stage of an implementation project, which the implementation literature calls the “initiation” stage. The initiation stage is when the purpose of implementation and the stakeholders involved are defined ,12,13,14The objective of our study was to identify factors affecting the initiation stage of an SDM program implementation. We conducted a multiple-case study of the SDM program implementation for TOLAC decision making in Washington State. Our study is the first to apply implementation science frameworks to the context of SDM project initiation and the obstetric setting. Our research is also enhanced by a complex external environment, in which a decision aid was certified by the State. Implementers and researchers may use findings to plan for the implementation of SDM programs in obstetric settings.We canvassed the implementation science literature for conceptual models that focused on innovation, as the innovation itself (SDM and decision aids) is pertinent to project initiation . We identified three implementation science models ,18,19 thWe used a qualitative, multi-case study research design  consistiThe project was part of a state initiative to increase the use of SDM in clinical practice. Central to the initiative was a decision aid certification program, in which an expert panel formally reviewed decision aids. More information about the certification program is available in a previous publication .The State selected the three healthcare systems based on their high-volume obstetric programs. The primary data source was key informant interviews conducted before SDA program implementation with stakeholders from the State, vendors, and project sites. Key informants were selected via purposive sampling to represent the type of stakeholders involved in the implementation . We sent an email invitation to each organization’s point of contact with the research prospectus and a list of requested roles. All points of contact agreed to participate and connected us to individuals in the roles as relevant. Interviews were conducted until we reached thematic saturation , after 1Secondary data sources were documents related to the SDM tools ; implementation plans provided by the vendor; and project management plans, training modules, and EHR-related content provided by the project sites.Data sources were analyzed and triangulated for key themes regarding organization factors affecting the initiation of an SDM implementation. We used the conceptual model as our coding schema, applying procedures described by  and inveThe initiation stage of a project is when the purpose of the implementation and the stakeholders involved are defined. Overall, participants believed that project initiation was critical to ensuring the higher success of the SDM program implementation, particularly for obtaining the resources needed and getting the right stakeholders at the table. Each of the three project sites was affected by their inner context, innovation components, implementation process, and implementation effectiveness during project initiation, which shaped how the project was uniquely defined in each site and which stakeholders bought into the project. Project initiation was made even more complicated by the decision aid certification program and related external factors. These factors pressured project leaders to define the project purpose and identify stakeholders to meet immediate project requirements  versus focusing on what may be necessary for the SDM program’s long-term viability and sustainability. Below, we describe these factors aligning with the initiation domains. In general, the sites provided assenting views except where otherwise indicated. factors out of our control” (Project Site A). For example, Project Site C was undergoing a system-wide EHR upgrade, which reduced the stakeholders’ capacity to be involved .Absorptive Capacity. During the initiation stage, all project sites were initially enthusiastic about the SDM program implementation and their abilities to “absorb” the program into routine operations. However, their enthusiasm began to drain as they realized the number of competing priorities that would lead to delays in project planning. Project site stakeholders reported feeling frustrated because the delays were due to “Culture/Climate/Context. In defining the implementation’s purpose, TOLAC was chosen as the medical decision of initial focus for the SDM program because it was a medical topic with a receptive culture and showed promise from clinical success stories. Leaders across our interview groups felt that SDM about TOLAC could facilitate the organic adoption of SDM in other areas.Leadership Engagement. Participants agreed that leadership engagement at all healthcare system levels was imperative in defining the purpose of the implementation and identifying the right stakeholders to be involved. In initiating this project, the State shared that they engaged leadership from the certified vendor, including their clinical champions, and asked them to meet with leadership at the healthcare systems to which the three obstetric sites belonged. In other words, the State recognized the importance of involving high-level leadership in early discussions about the implementation, alongside the administration at the local obstetric clinics. The certified vendor held early group meetings with the healthcare system leadership and potential implementation team members from the obstetric project sites for all three project sites. The purpose of these meetings was to build consensus on the project definition and the stakeholders to engage in project activities relative to each site’s goals.Network and Communications. All participants noted that an SDM community would be valuable for defining the purpose of SDM program implementations and defining who should be involved. During project initiation, however, even though all three project sites were obstetric settings, they worked internally and did not communicate directly with one another about the specifics of their implementations. All three, however, involved the implementation vendor during project initiation. The vendor created a roadmap for each to use in their project planning.Perceived Need for Change. Participants from the State and the vendors noted that the implementation’s purpose was shaped by a nationwide need for change towards SDM. Specifically, there was a need to engage patients better and reduce medical variation to reduce costs. They further cited that TOLAC had been identified as a priority area due to high variation across the nation, including in Washington State. Thus, the State was strongly motivated about the SDM program implementation and engaged directly with the project sites and the certified vendor during project initiation.Readiness for Change. Project initiation was shaped by the readiness for change of all organizations involved. The State reported that they were primed for change and well-positioned to launch the program; they also had a local role model clinical champion with 3.5 years of SDM experience serving as their consultant. The State remarked that at the heart of the many obstacles to SDM program adoption is a “chicken and egg” (State) phenomenon. For healthcare systems to adopt SDM widely, SDM proponents need to demonstrate that SDM works; yet, to accrue evidence of SDM’s value, SDM needs to be widely adopted. The hope was that the project program would “plant the seeds” (State) of SDM to grow across the State, starting with the obstetric setting. For many of the project sites, however, readiness for change was mixed. The State contractually bound the projects to participate in the SDM program implementation; therefore, conversations about program implementation began as a means to comply with state requirements. However, all sites emphasized that they believed SDM was the right thing to do for patients and families and appreciated the external motivation to turn their beliefs into action.Adaptability. Participants noted that the SDM program’s adaptability affected the project definition and who would need to be involved in the project. At the forefront, participants debated which modality  of the SDM TOLAC decision aid to implement. Each modality had different implications for the resources and stakeholders needed. Participants noted that the paper and classroom options would require less upfront time and resources for implementation because they did not require EHR system modification. All sites reported that they preferred electronic decision aids and hoped to one day move in that direction to meet the needs of younger patients. Secondarily, participants noted that TOLAC, while a relatively straightforward decision , is complicated because it does not need to be fixed or made at a single timepoint. Participants remarked that stakeholders needed to understand that during project initiation, the program could be adapted to other maternal health decisions beyond TOLAC. A TOLAC focus alone may not be a sufficient purpose for an obstetrics SDM program implementation.Nature of Knowledge Required. Relatedly, participants considered the nature of knowledge required to implement an SDM program successfully. The State and both vendors stressed that, for the SDM program to be successful, everyone at the obstetric clinics needed to understand the SDM as a “bundle” (Certified Vendor), including concepts of SDM and how it differs from patient education. In other words, the State and vendors made sure to define the SDM program implementation by its multiple tools , and not just by the decision aid alone.Knowledge/Beliefs about Innovation. Participants reported that the SDM program initiation needed to account for providers’ knowledge and beliefs about SDM. In our interviews, we found that there were indeed differences in providers’ knowledge and opinions of SDM, mainly how SDM was related to patient education and informed consent. Some believed the terms to be relatively interchangeable, and therefore SDM was not a new concept. Others noted a clear difference, emphasizing that SDM is a more prescriptive process than patient education that requires more documentation. Given this variation in providers’ knowledge and opinions, participants recommended that the project initiation be deliberately explicit that one purpose of the project was to educate providers at obstetric clinics on core concepts of SDM—essentially, that the SDM purpose was beyond the context of TOLAC.Targeted Users. The targeted users also defined the project. The direct users of decision aids are providers and patients. However, participants reported that during project initiation, they needed to engage “indirect users.” For example, at Project Site C, the implementation team decided to offer SDM training to all the staff in their clinic, including the non-clinical front desk staff and a system-level maternal health workgroup, which included providers and staff outside of their clinic. Regarding patient users, participants noted that 100% patient adoption was a “dream” (Project Site B), citing language and literacy barriers and that it was more realistic to aim for 75% patient adoption. In other words, the purpose of the SDM program was to optimize the adoption of the program in obstetric settings across direct and indirect users while recognizing that 100% adoption was unrealistic.Team Characteristics. The assembly of the SDM program implementation teams was dependent on how the program was initiated. Participants reported that it was essential to identify a clinical champion during project initiation who would “keep the fire alive” (Project Site A), particularly during initiation delays. The clinical champion could also help obtain senior leadership support to allocate resources to the project, allowing the project to advance into the planning stage. The two project sites that cited having strong clinical champions and leadership support during project initiation ended up having larger implementation teams and more internal financial backing.Cost. As participants noted, the cost is rarely absent from the discussion of any project initiation. Implementing an SDM project is an expensive undertaking. Hence, participants relayed that healthcare system stakeholders need to be convinced that SDM adds value to providers and patients before making such an investment. Participants indicated that demonstrating the return-on-investment of SDM is difficult, especially during the initiation of a novel project like this, which has limited evidence on cost savings. They noted that healthcare systems operating with thin margins are unlikely to have extra money to invest in decision aids independently. In our case study, the State was sponsoring the program implementation, and it was imperative to make this clear at the onset. However, the costs needed to sustain the program beyond this initial implementation were unclear and affected the initial project site buy-in.Decision Aid Certification Program and Other External Factors. Interwoven with the factors of the inner context, innovation components, implementation process, and implementation effectiveness was the decision aid certification program . Participants described the decision aid certification program as both a motivation and concern for project initiation. The certification of TOLAC decision aids was welcomed by the vendors, who appreciated additional validation that their decision aids were balanced and unbiased. The project site participants also responded to the external push to implement something they believed was valuable to patients and families (see Readiness for Change section). Thus, the certification program provided a purpose—an impetus—for the State, vendors, and program sites to implement the SDM program: to assess the role of TOLAC decision aid certification in the adoption of an SDM program. Certification of TOLAC decision aids also has legal implications. The State intended to provide additional legal protections and seek reduced malpractice insurance rates if SDM was documented in a patient’s record. Some provider participants had noted that legal protections were critical to include in the project definition because a failed TOLAC could lead to lawsuits. The providers noted that some obstetric gynecologists lean away from TOLAC to avoid potential poor outcomes for their patients and their patients’ babies, in which they would have to do an emergency Cesarean section. This component affected the types of stakeholders  that needed to be engaged and consequentially sold on the project during project initiation.Our multiple-case study identified factors affecting the initiation of an SDM program implementation in three obstetric settings. Our findings can guide future SDM program implementations and research in this area through the following study implications. First, we found that participants believed that deliberate attention to project initiation resulting in viable, propagated project conceptualization is critical to SDM program implementation success. Successful project initiation results in a shared understanding of the project’s purpose and the identification of stakeholders that need to be involved . ProjectSecond, our findings reveal that, during the project initiation stage, multiple factors of the inner context, innovation components, implementation process, implementation effectiveness, and outer context shaped how project leaders uniquely defined the project at each site and which stakeholders were actively engaged in the project. In this study, project initiation was complicated by the State’s decision aid certification program and related external factors, which pressured the project sites to shape the project purpose and engage stakeholders that would meet immediate project requirements . Our study reveals that external demands may not be in perfect alignment with the internal necessities required for an SDM program’s long-term viability and sustainability. Further, stakeholders’ negative beliefs about the value propositions of SDM and the TOLAC medical decision can de-rail a project during initiation. In this case study, the State’s certification of a TOLAC decision aid may have been critical to moving the SDM initiative forward by signaling to the project sites that SDM is important. As indicated by some participants in our study, the application of SDM tools to support the medical decision of TOLAC alone was not seen as a sufficient purpose for an SDM program implementation. During initiation, it is vital to be clear in the project purpose  that the overarching goal is to integrate SDM into routine practice, with TOLAC as the first of many medical decisions within a comprehensive SDM program. The State’s active engagement and interest may help stakeholders see the big picture context and become actively engaged in the project.Third, during project initiation, it is important for implementers to recognize that SDM programs are more than choosing and obtaining a decisional tool . SDM traWe made many decisions for this project that limited the generalizability. First, this is a study focused on three clinical settings, and other settings may have different issues and considerations. Second, the sample size was small, and not sampled in a rigorous way. Therefore, we may have engaged bias in the sampling process. Third, there are no data presented to indicate that clinical care has changed as a result of implementing this shared decision process. We would need to follow these patients and compare them with patients who do not participate in SDM during their delivery choices. For these reasons, we consider this to be an initial study of SDM and will consider a larger, more fully powered study of multiple health care systems to fully understand this phenomenon.Our findings contribute to the field by providing insights for advancing SDM implementation success by focusing on the initiation stage of an SDM project implementation, which provides an important foundation to informing project planning, executing, and reflecting/evaluating. Many of our key takeaways align with an earlier systematic review on providers’ perspectives of the barriers and facilitators to SDM implementation . This st


COVID-19 resulted in societal disruptions across the lifespan. School (K-12) closures were among the most challenging impacts of the virus, leaving many parents with the burden of schooling their children at home. Another major impact of the virus was the social isolation and loneliness felt by many retired, older adults, who were sheltering at home. The disruptions of COVID-19 led our inter-professional team to develop the Intergenerational Tutoring program. Intergenerational Tutoring addresses a service delivery gap in schools because tutors expand schools' capacity to implement evidence-based instruction with students in need of individual support. At the same time, research shows that meaningful volunteering supports the well-being of older adults across physical, psychosocial and cognitive dimensions of health. The aim of the Intergenerational Tutoring program is to pair older adults with kindergarten children in high needs schools to implement early literacy interventions remotely via Zoom. Our poster will describe the Intergenerational Tutoring program including tutor training and tutoring implementation. We will summarize the initial findings from our pilot study conducted in spring and summer 2021 with tutors and children. Data will include (1) themes from tutor interviews regarding the personal meaningfulness of the program and the program’s associated benefits and challenges; (2) implementation fidelity data; (3) impact of tutoring on children’s early literacy skills; and (4) parent feedback. We will summarize lessons learned and next steps for the program.


Over the course of 2 years, from 2018 until 2020, our laboratory followed a spontaneous point mutation in the TMV coat protein—first observed as a 30 Da difference in electrospray ionization mass spectrometry (ESI–MS). The mutation would have been difficult to notice by electrophoretic mobility in agarose or SDS-PAGE and does not alter viral morphology as assessed by transmission electron microscopy. The mutation responsible for the 30 Da difference between the wild-type (wTMV) and mutant (mTMV) coat proteins was identified by a bottom-up proteomic approach as a change from glycine to serine at position 155 based on collision-induced dissociation data. Since residue 155 is located on the outer surface of the TMV rod, it is feasible that the mutation alters TMV surface chemistry. However, enzyme-linked immunosorbent assays found no difference in binding between mTMV and wTMV. Functionalization of a nearby residue, tyrosine 139, with diazonium salt, also appears unaffected. Overall, this study highlights the necessity of standard workflows to quality-control viral stocks. We suggest that ESI–MS is a straightforward and low-cost way to identify emerging mutants in coat proteins.Virus-like particles are an emerging class of nano-biotechnology with the Tobacco Mosaic Virus (TMV) having found a wide range of applications in imaging, drug delivery, and vaccine development. TMV is typically produced  Nature has provided ample source material—viruses that infect humans, bacteria, and plants all fair game when engineering a new and more efficacious drug delivery, vaccine, and imaging platform. Plant-based viruses have gained attention in the field of biotechnology for several reasons. In addition to being robust, at least insofar as proteinaceous materials go, they have the benefit of being literally farmable—the viruses can be produced in plant tissue in a scalable approach. For instance, Medicago Inc, a biotechnology company presently based in Quebec City, has begun phase II–III trials of a plant-produced vaccine against COVID-194.Biotechnology based on non-infectious viral nanoparticles has been an emerging topic of research for the last two decades, with considerable advancement toward biomedical translation occurring recently8. It is rigid, monodisperse, thermostable, functionalizable8, and biocompatible11, giving it a wide range of applications including as a scaffold for biomolecules and small molecules, nanocontainers for drug delivery19, and as a platform for vaccine development and testing23.Likely the most studied virus in plant-harvested viral-nanotechnology is the Tobacco Mosaic Virus (TMV), a noninfectious, plant-based virus-like particleTobamovirus genus. Its RNA encodes four proteins: two 126- and 183-kDa replicase proteins, a 30 kDa movement protein, and a 17.5 kDa coat protein24. The intact TMV contains 2130 copies of the coat protein assembled into a helical rod with a length of 300 nm, an outer diameter of 18 nm, and a pore diameter of 4 nm. Both exterior and interior surfaces of this hollow rod can be modified on solvent-exposed amino acids24. We, like most groups that produce plant-based viral nanoparticles, use an extremophile strain of the Australian plant Nicotiana benthamiana for large-scale production of TMV. It is the most widely used host for plant virus replication as it is very susceptible to infection. An RNA silencing gene in N. benthamiana (NbRdRP1m) is mutated and less active, contributing to the species’ susceptibility of RNA-virus infection27.TMV is a positive-sense single-stranded RNA virus under the 28. Though the mechanism is not established yet, Sanjuán et al. (2016) suggested that the genetic material in viruses with single-stranded genomes are more exposed to oxidative deamination and other chemical stress28. In fact, mutant populations are ubiquitous in plant RNA viruses and their presence is rarely considered significant until the mutant phenotype dominates29. RNA viruses, except Coronavirus, contain RNA polymerases that lack 3′ → 5′ exonuclease proofreading mechanisms, which makes them more prone to error than DNA viruses30. One study showed that infecting tomato plants containing the Tm-2 Gene with TMV strain Ltbl, resulted in point mutations in the 30 kDa movement protein31. TMV is well-known to be susceptible to environmental and evolutionary stressors and the emergence of mutants should not be surprising; however, there is little discussion in the literature of how coat protein mutations might alter the viruses’ physical properties vis-à-vis chemical functionalization and antibody binding. Best practices for monitoring TMV mutation and the impacts of TMV mutation on virus usability are not well established. Knowing what to look for, the relative time scale, and how to identify mutation in plant-sourced viruses would be helpful to the broader community.Single-stranded RNA viruses, like TMV, are very susceptible to mutationHere, we report the emergence of a mutant strain of TMV over the course of two years in the absence of any purposeful chemical or environmental stressor. The strain contains a single point mutation in the coat protein and was identified by electrospray ionization mass spectrometry (ESI–MS) of TMV stocks archived from January 2018 to January 2020. Over this period, the mutant strain largely displaced the wild-type strain, suggesting a competitive advantage. While we were following best practices for purifying and testing isolated TMV at the time, we have since identified additional practices that should be followed to identify emerging mutants. In many assays, the mutant was indistinguishable from wild-type. This work highlights the need for standard workflows to quality-control viral stocks in the chemical and bioengineering laboratory, particularly if they are being considered for translational purposes.N. benthamiana eight weeks after germination while the plants are around 11.5 cm tall. N. benthamiana is grown in a purpose-built plant growth room with constant temperature (22 °C) and humidity (67%). TMV (15 mg) from a prior harvest is added to 1 g of silicon carbide as an abrasive and rubbed into the leaves of N. benthamiana. Once the leaves become discolored, two weeks after infection, the leaves are collected and stored at − 80 °C until the virus is extracted as previously described12.Our TMV stock is grown in e.g. SDS-PAGE), transmission electron microscopy (TEM), size exclusion chromatography, and intact protein mass spectrometry24. RNA sequencing has been done in some cases33 but is not routinely reported. If mutant TMV strains have been detected by sequencing, they have not been widely reported in the literature to date.A small amount of TMV is always set aside for the next infection. In the literature, the TMV stock is typically characterized by electrophoretic mobility , had become dominant.We monitor our TMV purifications using liquid chromatography mass spectrometry (LC–MS). We conducted LC–MS using ESI–MS on denatured viral samples. 20 µL of 10 mg/mL TMV was mixed with 40 µL of glacial acetic acid and the RNA removed via centrifugation. Over two years, from January 2018 till January 2020, we observed the appearance of a new mutant TMV strain  responsible for the 30 Da difference between wTMV and mTMV coat protein, we adopted a bottom-up approach. We compared a sample containing 60% wTMV and 40% mTMV, to one almost entirely composed of mTMV Fig. A. TryptiWe next generated a list of all possible single point mutations that would cause a mass increase of 30 ± 1 Da in the last 8 residues of the coat protein. The list contained nine possible sequences and each sequence was used to interrogate the tryptic and peptic digests of the mTMV sample. Only one sequence gave a passing result and identified the C-terminal peptide of the mTMV coat protein. This sequence contained a G155S mutation. In the two C-terminal peptides (142–158 and 151–158), collision-induced dissociation data show a serine at position 155 with consecutive fragmentation products recovered at the precise site of mutation . ELISA run on both mTMV and wTMV bind TMV antibodies at the same concentrations to produce linear curves with a correlation coefficient of 0.998, indicating the binding is almost identical Fig. A. Therefame Fig. D. These m/z, would likely have insufficient resolution to detect the presence of single point mutant strains. Further RNA sequencing methods that can detect mutants when they are not the dominant species are complicated and expensive. Bottom-up analysis and peptide sequencing with collision-induced dissociation identified the residue 155 as the site of a glycine to serine point mutation. Dramatic physical effects of this mutation are not predicted but given its surface localization there was the possibility of altered binding and surface chemistry. However, ELISA shows that both mutant and wild-type TMV have identical binding to TMV antibodies and can be equally functionalized at tyrosine 139. It is unclear precisely why the G155S mutant emerged and overtook the wild-type in our laboratory environment. Our discovery, however, highlights the necessity to monitor every batch of purified TMV as spontaneous point mutation can occur even in the absence of stress and mutagens.In a span of 2 years, the wild-type TMV has spontaneously mutated in the laboratory environment as observed in the ESI–MS data collected in that period. It should be noted that similar data collected on intact proteins using nominal resolution MALDI-TOF, where the detected ion is the + 1 Chemicals were purchased from Sigma-Aldrich , ThermoFisher Scientific , Agdia , ChemImpex , Alfa Aesar , and TCI America  and were used without further purification.LC–MS were obtained using an Agilent 1100 HPLC with a PLRP-S column for separation and an AB Sciex 4000 QTRAP system for detection; also, a Waters SYNAPT G2-Si Q-TOF with an M-class UPLC. TEM was conducted using a JEOL JEM-1400Plus transmission electron microscope. Bio-rad ChemiDoc MP was used for gel imaging. ELISA data were obtained using a BioTek Synergy H4 Hybrid microplate reader.Nicotiana benthamiana) plants were grown for 8 weeks and infected with TMV solution with 2 weeks of incubation. The harvested infected leaves were stored at − 80 °C. About 100 g of leaves were blended with cold (4 °C) potassium phosphate (KP) buffer  and 2-mercaptoethanol (0.2% (v/v)) was added. It was subsequently ground to have an effective extraction. The slurry was filtered and centrifuged at 11,000 × g . The resulting supernatant was filtered again. The volume was measured and an equal amount of chloroform/1-butanol with 1-to-1 ratio was mixed . Another centrifugation was done at 4500 × g for 10 min. The collected aqueous phase was mixed with NaCl , PEG 8000 (8% (w/w)), and Triton X-100 surfactant (1% (w/w)). It was stirred on ice for 30 min followed by storing for 1 h at 4 °C. It was centrifuged again at 22,000 × g . The pellet was collected and resuspended in KP buffer  and was stored at 4 °C overnight. The suspension was added carefully to 40% (w/v) sucrose gradient in KP buffer  and centrifuged using swing bucket rotor at 96,000 × g for 2 h. The blue band was collected with the assistance of LED light shined upward from the bottom of the centrifuge tube. The colloidal suspension from blue band was centrifuged at 360,562 × g for 1.5 h. The pellet was resuspended in KP buffer .The tobacco  filter paper and the grids were left to air dry. Images were taken with an accelerating voltage of 120 kV.g for 10 s to separate the precipitated RNA. The supernatant was collected and run on an Agilent 1100 series HPLC system with a PLRP-S column for separation followed by a 4000 QTRAP mass spectrometer. The flow rate is 0.250 mL/min, and the solvent system comprises of Milli Q water, 0.1% formic acid, and pH 7.0 in a 0.1 M sodium phosphate buffer. This system was used for running both TMV and TMV-Alk samples.TMV samples were prepared by denaturing 20 µL of 10 mg/mL in 40 µL of glacial acetic acid. Sample was then centrifuged at 4300 × 1% (w/v) Agarose gels were used. The sample was prepared by mixing 3 µg TMV with 5 µL Thermo Scientific 6× DNA Loading Dye. From that mixture, 4 µL was added to each well. The gel was run at 100 eV for 45 min, stained with coomassie brilliant blue, and visualized using Bio-rad ChemiDoc MP gel imager.10% SDS-PAGE gel was used. The sample was prepared by mixing 3 µg TMV with 5 µL of SDS loading dye (β-Mercaptoethanol (5%), Bromophenol blue (0.02%), Glycerol (30%), SDS (Sodium dodecyl sulfate 10%), Tris–Cl ) and 5 µL of 0.1 M dithiothreitol. The mixture was boiled for 10 min. 4 µL of sample was added to each well and the gel was run at 100 eV for 45 min, stained with coomassie brilliant blue, and visualized using Bio-rad ChemiDoc MP gel imager.Trypsin digestion was performed according to manufacturer’s protocol . Briefly, TMV samples were dialyzed into a solution of 8 M urea and 50 mM triethylammonium bicarbonate (TEAB) at pH 8.5. 500 mM DTT was added to the sample to a final concentration of 20 mM and incubated for 1 h at 60 °C. 1 M Iodoacetamide was prepared and added to the sample to a final concentration of 40 mM and incubated for 30 min at room temperature in darkness. The alkylation reaction was quenched by adding 500 mM DTT solution to a final concentration of 10 mM. The samples were then diluted to reduce the concentration of urea to 1 M by adding 50 mM TEAB, pH 8.5. Trypsin in 50 mM TEAB pH 8.5 was added to the samples to a final protease-to-protein ratio of 1:20 (w/w) and incubated for 24 h at 37 °C. Samples were then flash-frozen and stored until injection. Samples for pepsin digestion were diluted to 1 µM in TEAB pH 8.5. Samples were then mixed 1:1 (v/v) with a solution of 1.6 M GuHCl, 0.8% formic acid at pH 2.3 to prepare them for on-line pepsin digestion. Samples were then flash-frozen and stored until injection.Sus scrofa pepsin A (Waters Enzymate BEH) at 15 °C. Peptides were desalted on a C18 pre-column (ACQUITY UPLC BEH C18 VanGuard Pre-column) for 3 min at 100 μl min−1 and 1 °C. The liquid-chromatography buffer was 0.1% formic acid. Peptides were separated over a C18 column (Waters Acquity UPLC BEH) and eluted with a linear 3–40% (v/v) acetonitrile gradient for 7 min at 40 μl min−1 and 1 °C.LC–MS  and high-energy (ramping 22–44 V) peptide-fragmentation data for peptide identification. All samples were acquired in resolution mode. Capillary voltage was set to 2.8 kV for the sample sprayer. Desolvation gas was set to 650 l h−1 at 175 °C. The source temperature was set to 80 °C. Cone and nebulizer gas was flowed at 90 l h−1 and 6.5 bar, respectively. The sampling cone and source offset were both set to 30 V. Data were acquired at a scan time of 0.4 s with a m/z range of 100–2000. Mass correction was done using [Glu1]–fibrinopeptide B as a reference mass.Mass-spectrometry data were acquired using positive-ion mode in HDMSSus scrofa pepsin A and native TMV coat protein. In PLGS, the minimum fragment ion matches per peptide was 3, and methionine oxidation and N-terminal acetylation were allowed. Trypsin samples included cysteine carbamidomethylation (CAM) as a fixed modifier. The low and elevated energy thresholds were 250 and 50 counts, respectively, and the overall intensity threshold was 750 counts. Peptides were curated in DynamX 3.0 with thresholds of 0.3 products per amino acid and one consecutive product.Raw data were processed by PLGS  using a database containing 2CO3, 0.034 M NaHCO3, NaN3 in dH2O, pH 9.6) and incubated overnight at 4 °C. The plate was washed 3 × with washing buffer (0.2% (v/v) Tween-20 in PBS, pH 7.4). After washing, wells were blocked with blocking buffer (1% (w/v) BSA in washing buffer, pH 7.4) at RT for 1 h, followed by 4 × washes with washing buffer. 100 μL of native TMV and mutant TMV—concentrations determined by Lowry assay (0.5–0.015 µg/ml)—were serially diluted with sample extraction buffer  Polyvinylpyrrolidone (PVP) 40 k, 0.2% (w/v) Powdered egg (chicken) albumin, 0.003 M NaN3, 0.2% (v/v) Tween-20 in washing buffer) was then added to each well and incubated at RT for 2 h. Wells were then washed 8 × with washing buffer, followed by the addition of 100 μL alkaline phosphatase-conjugated rabbit anti-TMV IgG in conjugate buffer  PVP 40 k, and 0.003 M NaN3 in washing buffer) and incubated at RT for 2 h. Wells were then washed 8 × with washing buffer, then developed by adding 100 μL one-step p-nitrophenylphosphate (PNPP) substrate for 45 min at RT. The plate was read at 405 nm, 420 nm, and 450 nm, and the absorbance values of buffer blank wells averaged and subtracted from the entire plate. Experiments were performed in triplicate.96-well Microtiter Plates High Bind-Solid (ACC 00948/0005 Agdia) were coated with 100 µl of diluted (1:200) capture antibody rabbit anti-TMV IgG (CAB 57400/1000 TMV Capture antibody Agdia) in coating buffer (0.015 M Nag)  was added to a 2 mg/mL wTMV or mTMV solution in 0.1 M borate buffer at pH 8.8. This was incubated on ice for 45 min. The resulting TMV-alkyne was purified and concentrated via centrifuge filtration using an EMD Millipore Amicon Ultra Centrifugal Filter Unit  (4303×g) .The authors comply with the IUCN Policy Statement on Research Involving Species at Risk of Extinction and the Convention on the Trade in Endangered Species of Wild Fauna and Flora. This plant and plant use studies were approved by the University of Texas at Dallas Institutional Biosafety and Chemical Safety Committee. Seeds and plants used are not listed as endangered or threatened and were a gift from Prof. James Culver at the University of Maryland.Supplementary Figure S1.


In response to the lack of evidence for visualizing the monetary value of professional sport teams' CSR-related social impact, this study aimed to calculate the social impact of a Japanese professional soccer team's corporate social responsibility (CSR) activity  by using a social return on investment (SROI) framework. Specifically, Matsumoto Yamaga Football Club was used for the estimation. This professional soccer team was ranked in the top division of the league (J1) during the estimation period and engaged in CSR activities at 129 community soccer schools in a year (2019–2020). The SROI calculation involved five stages: (1) identifying key stakeholders, (2) mapping inputs, outputs, and outcomes, (3) measuring and valuing outcomes, (4) establishing impact, and (5) calculating SROI. For the first step, we specified seven major stakeholders  and conducted interview investigations with each stakeholder. Our result showed that the social value of the teams' targeted community soccer school was USD 54,160, and the total financial and non-financial inputs to the school were USD 10,134, meaning an SROI ratio of 5.3. This means that for every USD invested in a community soccer school, social benefit worth USD 5.3 was generated. This study contributes to advancing social impact research in sport by shedding light on the monetary value of the social impact of professional sport teams' CSR activities. In addition, it also has practical implications for team managers looking to utilize CSR activities as a management strategy, through cost-effective investment and optimization of resources. By virtue of its focus and methodology, the current study, therefore, contributes to progressing social impact research by shedding light on the monetary value of a single CSR activity for professional sport teams. This enables us to understand the monetary value of a social activity in a clear way by targeting a single CSR program. Furthermore, the SROI framework sheds light on the “outcomes” of a social activity, which are more correlated with future productivity than inputs, contributing to the visualization of the social impacts of CSR activity. This could be one of the solutions to the ambiguity (in-tangibility) of social impacts, and we expect to show another method of measuring estimate social activities.Taylor et al.  summarizWhile CSR has increased practical and academic attention toward creating value between business, firms, and society  of social activities for which no market values exist and includes several stakeholders' perspectives  are that it (1) strengthens accountability and communication with several stakeholders  was founded in 1991 and began its first season with 10 clubs in 1993 . In addition to the top division of the league , they established Division 2 , dividing the league into 18 (J1) and 10 (J2) clubs in 1999. Five years later, Division 3 was launched, and as a result, by 2014, the J. League had 51 clubs . At present, the number of clubs is 55, and the J. League aims to create a society in which everyone can enjoy not only soccer, but also any sport. To achieve this goal, the J. League set up the overarching 100-year vision to become an agent of change by fostering a sport culture in Japan rooted in community-based sport clubs. Thus, each club needs to create an environment for a healthy, fully integrated sport culture for children based on their vision.For instance, each club has been providing hometown activities to their host city, and consequently made great progress in fostering the development of Japan's sporting culture to improve the mentally and physically health of the people. Recently, the J. League launched another social corporation program called “SHAREN” to foster partnerships with public/private organizations for community development in each hometown since 2018 , key stakeholders, and analysis period.Next, we identified stakeholders that are engaged in the program based on the definition by Davies et al. , which iIn the first group, MYFC and coaches were extracted as internal stakeholders. They are running the community soccer/physical activity programs, and they could obtain some social benefits from their activities. In the second group, nursery school teachers, children, and the children's parents were extracted as external stakeholders. This program was carried out for nursery school children and they were the main targeted participants of the activities. As a final group, local football associations and local governments  were retrieved as external stakeholders. The local football associations provided MYFC with funds for the program as compensation for the promotional sport and soccer activities in their region. MYFC delivers the program in each region as a return on funding. Local governments also play a role in sport development for the health of residents, including kids; thus, they are also regarded as key stakeholders in the program. As a result, we specified seven key stakeholders  from the three groups to proceed with further analysis.via interview questions: (1) relationship with the MYFC's community soccer/physical activity program and (2) outcome (change) by the program. We also added other questions depending on the stakeholders' answers and collected supplemental materials from websites, archives, and other references.In the second stage, we created the impact map of the activities by performing eight semi-structured interviews (including two focus group interviews) in total with nine stakeholders on October 6, 13, and 27, 2020 see . MappingThe impact map was created based on the interviews. As an input, cost for coaches' working hours , travel expenses (USD 9.71 × 129 times = USD 1252.427), cost of equipment (USD 79.551), and staff working hours for the program operation  were included in total USD 10,133.895.In the third and fourth stages, we confirmed and identified the impact of actual activities and their values. To quantify the eight outcomes, the authors discussed the best financial proxy to describe the outcomes see .Development of children's exercise motivation was calculated by the average price . We found that parents (at least one of each child's parents) looked at their children's pictures in the program on the MYFC official website, which could increase their attention to the club. The one-click banner advertisement on their website was worth USD 0.002; thus, we exchanged the attention (click on the website) increase into the advertisement value.Thus, as a financial proxy, the program could provide a basis for considering the price of private sport programs for children. Improvement of coaching skills was replaced with the tuition fees for coaches to undergo child training lectures  in the local football association . Through the program sessions, coaches have opportunities to develop their coaching skills, and they mentioned that these skills are applicable not only for children, but also for adults. Here, the financial proxy is validated by the price of the Kids Leader Training Course in a local city.Improvement of teaching skills of nursery school teachers was also converted to the tuition fees for teachers to undergo child training lectures  in local football associations . In addition, the reduction of labor load for them was calculated as a proxy by considering public servants' salaries (unit change amount: per hour) in Matsumoto . Through the interview investigation, we found that they could acquire 10 new members of the formal/regular-basis MYFC soccer school because of the program. The following representative response was obtained from one of the parents:My child participated in the program and joined the formal MYFC soccer school afterward. He naturally loves exercising, and compared to other soccer schools, this school provides a unique program for children.Promotion of soccer/physical activity in their region was exchanged for the funds provided to the MYFC  by local football associations. Local football associations have signed a business trust agreement with the MYFC to spend USD 2,427.184 funding them. Their aims are to further develop sport and soccer in these regions. In return for the fund, the MYFC delivers the sport development program on behalf of the local football associations. Finally, local governments' labor reduction to provide sport opportunities  was accounted for by public servants The SROI was calculated in the fifth stage based on the estimation process . As a result, the total social value of the community soccer school was USD 54,160 see , which iA sensitivity analysis was performed based on the previous literature  using an SROI framework. The study contributes to advancing social impact research in sport by shedding light on the monetary value of the social impact of specific CSR activities by professional sport teams. This novel approach could be one of the solutions to the problem of ambiguity of social impact that has plagued past studies in this field , which indicates that these activities could create not only social, but also monetary value in the community. For example, cost savings for nursery teachers and staff of local community/government institutions are important considering the limited resources of nurseries school and communities. In particular, human resources in the local government are limited, and soccer schools are a valuable opportunity for providing children in the community with enjoyable sport activities. Thus, it might be useful to promote the program not only for children but also for teachers/schools and local sport organization/government by visualizing the cost saving benefits of the program. Second, SROI could help explain teams' accountability to their stakeholders , which contributes to enhancing the teams' community awareness King, . For insThe current study is an advanced research paper that has applied the SROI framework to the sport industry. Even though the framework is one of the most established social impact assessment methods Mulgan, , the litThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Tokai University. The patients/participants provided their written informed consent to participate in this study.DO, SY, TF, and YT contributed to conception/design of the study and organized the database. TF performed the statistical analysis. DO wrote the first draft of the manuscript. SY wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Unmarried mothers living in residential facilities (UMLFs) in Korea face complex and challenging physical, psychological, and socioeconomic issues. This study developed a physical and mental health promotion program using urban forests for UMLFs based on the transtheoretical model and evidence. We utilized an intervention mapping approach (IMA) and assessed the needs of UMLFs by analyzing previous quantitative studies. Moreover, we conducted a qualitative hermeneutic phenomenological study involving nine participants. Based on the needs assessment, important and changeable determinants were identified; further, the program performance and change objectives were classified to achieve the program goals and establish the intervention strategy. We found that physical activity using forests, self-reflection using metaphors, five-sense activities, achievement activities using natural objects, building interpersonal relationships in the forest, and designing future plans, are desirable methods for improving the health of UMLFs. The IMA was deemed appropriate for the systematic development of health promotion programs for UMLFs through clear links among change objectives, theoretical methods, and practice strategies. These results should be applied to future intervention studies. The extramarital birth rate in most Organization for Economic Cooperation and Development (OECD) countries increased from less than 10% in 1970 to 24% and 41% in 1995 and 2018, respectively . Thus, tCompared with other OECD countries, the rate of UMs in South Korea  in 2018 was 2.3% , whereasThese recent changes are related to the government’s support policy ,12, whicAlthough material support has increased, UMs living in residential facilities (UMLFs) face various challenges, similar to UMs worldwide ,8. UMLFsNevertheless, prior studies highlighted that the support provided in residential facilities generally focuses on material assistance and does not comprehensively reflect the substantial needs of the UMLFs . MoreoveForests therapy is one of the most accessible methods, especially for people with low socioeconomic status, because the program utilizes currently existing and available urban forests . ForestsEvidence for the healing effect of forests has been investigated by previous studies ,27,28,29Since a majority of the UMLFs issues are related to psychological difficulties ,17, selfThis study aimed to elucidate the process of the systematic development of a health promotion program for UMLFs, which not only integrates urban forests but is also based on the six-step protocol of IMA. In particular, this study focused on steps 1–5 of the IMA  and TTM This program development follows the six steps of the IMA proposed by Bartholomew et al. . The sixIn this study, to understand the stressors experienced by UMLFs and their responses comprehensively, complete studies conducted over the last 10 years were gathered to perform a systematic review  and the The needs of UMLFs were analyzed using interpretive phenomenological analysis (IPA), based on the philosophy of hermeneutic phenomenology . In-deptIn Step 2, the change objectives (COs) to be achieved through the program were determined based on the needs identified in Step 1. The COs of the program were structured into a matrix, which included determinants, performance objectives (POs), and their correlation with the COs. In the process of selecting determinants, we aimed to increase the scientific evidence and effectiveness of the program through a review of the factors affecting the health of UMLFs. Determinants were finally selected through iterative comparison and discussion of the health determinants and needs of UMLFs. Further, POs affecting the determinants were identified based on theoretical grounds.In Step 3, TTM was selected to identify changes in the participant. Based on the theory, COs were achieved through behavioral changes in UMLFs. Further, specific and practical intervention strategies were organized.In Step 4, the content and order of the overall program were organized based on the specific COs and practical intervention strategies determined in the previous steps. The theme of each session was determined by considering the POs and the TTM that would reflect the participant’s changes. For the program implementation, urban forests, natural objects, and materials used in the activities were selected after considering the accessibility of the UMLFs. In Step 5, the program’s implementation was determined by assessing the feasibility of the implementation. In this study, the specific implementation method of the program was systematically reviewed by experts in related fields. To increase the level of content validity evidence, this study recruited three experts with high levels of scientific and applied knowledge and experience on the construct of interest. Furthermore, two experts with experience in test construction and psychometrics evaluated the items using a different perspective than that of the recruited content experts . Thus, iIn the final step, an evaluation plan for behavioral changes that may occur in UMLFs was developed. In this step, the process of whether the program was adequately applied and implemented among UMLFs is evaluated, and a study design and measurement parameters are planned to evaluate the effectiveness of the program.Most UMLFs experience threats to their physical health owing to chronic fatigue from raising their children alone, without the support of their spouses or family . In partThe average age of UMLFs was 28.7 (20–37) years, and the average age of their children was 19.3 (3–36) months. The UMLFs reported feeling depressed, sad, and guilty due to their experiences of raising children in a facility, without spousal or family support. Even if they were dissatisfied with facility workers or other UMLFs, they were more concerned about the disadvantages of living outside the facility and being psychologically withdrawn because they were unable to endure their living conditions. In addition, UMLFs reported feeling anxious, as they were not able to trust others due to their painful life experiences; they were afraid and angry about their uncertain future and criticism from others. The UMLFs reported that they felt guilty about not being able to provide enough for their children due to their current situation. However, they reported feeling anger when their children asked them for something. Through in-depth individual interviews, it was confirmed that the UMLFs were living with chronic mental health issues such as depression, anxiety, and low self-esteem, which contributed to their parenting stress. Through a needs assessment, we found that UMLFs required pain relief as well as an object of psychological consolation.Specific outcome variables to evaluate changes in UMLFs were selected based on the priorities identified in the review of previous studies and the qualitative data analysis. Consequently, physical health, depression, anxiety, self-esteem, and parenting stress variables were selected.The ultimate goal of this program is an improvement in the quality of life of the UMLFs. The specific objective of the program is a statistically significant reduction in the physical and mental health problems of UMLFs at the end of the program, compared with their state prior to program participation. This program aims to objectively assess the health status of UMLFs and confirm the effectiveness of the intervention program by scientifically measuring their improvement in health status after the intervention.Based on the analysis of previous studies and in-depth individual interviews on personal determinants affecting the health status of UMLFs, knowledge and skills affecting the relief of distress in their lives, and improvement of health status, helplessness, and the attitude of resignation to the reality that they have no one to rely on were selected. For environmental determinants, accessibility to available resources according to socioeconomic status was selected . The specific POs for improving the mental and physical health status of UMLFs were developed after considering the characteristics of the determinants and outcome variables. The details of the six POs are as follows: PO1: determination of improvement in mental and physical health using forests; PO2: using forests for self-reflection of one’s inner being; PO3: attempts at self-care using forests; PO4; experiencing emotional comfort in forests; PO5: practicing positive child rearing based on cooperation and communication learned in the forests; and PO6: designing and planning a positive future with a child using forests.In particular, PO1 and PO2 focus on reducing anxiety (present), PO3 on the enhancement of self-esteem, PO4 on depression, PO5 on parenting stress, and PO6 on anxiety (future) reduction. The order of these POs was based on a report that revealed that individual changes through the use of forests occur in the order of body, emotion, cognition, and behavior , and a sKnowledge, skills, attitudes, and accessibility are important determinants in the metrics of this study. The TTM proposed by Prochaska and DiClemente et al.  was emplSince the intervention strategy provides information to improve the knowledge of UMLFs, it is suitable for enhancing their level of understanding. Further, small group lectures with audio-visual materials were utilized ; moreoveTo achieve COs for the health promotion of UMLFs, a program with eight sessions was designed, and themes that fit the COs for each session were selected. Moreover, strategies and tools that can effectively deliver the program were selected and organized for each session .The eight-session health promotion program using urban forests was implemented for eight weeks, with one 90 min-session per week. The sequence of sessions followed the five-change steps of the TTM . In the The specific contents of individual sessions were designed by considering the POs and COs based on a thorough literature review.This program aimed to promote the physical health of UMLFs by including physical activities in the sessions. In particular, session 1 was designed to develop an interest in the UMLFs to select forests as a tool for restoration, provide instructions on specific methods of using the forests for therapeutic purposes, and improve their knowledge level and motivation for participation based on the proposition of TTM . SpecifiSessions 1 and 2 were designed using forests and natural objects to allow UMLFs to experience emotional relaxation and anxiety reduction through self-reflection and expression of emotions . SpecifiIn sessions 3 and 4, UMLFs focused on self-care while experiencing the forest through meditation in the forest and walking using the five senses ,26. PartIn sessions 5 and 6, UMLFs are encouraged to modify their negative emotions through five-sense activities in the forest  and experiencing psychological comfort by walk in an urban forest path and share the experience of taking pictures in the forest ,26,37. IIn sessions 7 and 8, the experiences of parenting stress are shared; the UMLFs practice effective communication and exchange parenting methods to reduce parenting stress . AdditioThe urban forest, which is the physical space for the implementation of the program, is selected in a place accessible to the UMLFs. If program activities cannot be conducted in urban forests , the online medium will be adopted. In the case of the online program, the items required for each session are delivered to the facility where the UMLFs reside, and guidance is provided for the preparation of these items prior to the session. While conducting the program online, a video conferencing application that can be accessed through web browser as well as mobile is used; further, the UMLFs are notified on this application prior to the commencement of the program to facilitate their access and use.The beneficiaries of this program are UMLFs who are raising children. This program is intended for adult female UMLFs who can cope with common risks and workers in collective housing facilities. UMLFs’ families of origin or fathers of children are not eligible for the program. Among UMLFs, those experiencing severe depression or anxiety, who are judged to require acute hospitalization and drug treatment are not prioritized for participation in this program.The staff were trained in accordance with the National Institutes of Health Behavior Change Consortium recommendations . DeliverIn this study, the evaluation of the program’s content validity index (CVI) was assessed by five experts comprising two professors in psychological nursing, one professor in pediatric nursing, one professor in forestry, and one professor in community health nursing, who had research experience in forest healing. The CVI consists of eight questions and is measured using a 4-point Likert scale from 1 = not valid at all, to 4 = very valid. The contents of the CVI were constructed based on items such as participant characteristics, the feasibility of implementation, possibility of online/offline application, number of sessions and sequence of composition, theoretical framework, forest healing factors, and the possibility of change in participants. Item-level content validity index (I-CVI) is the evaluation of each item by experts; points 1 and 2 are scored as 0 and points 3 and 4 are scored as 1; further, the expert’s I-CVI for this program ranged from 0.8 to 1.0. The scale’s content validity averaging method (S-CVI/Ave), which is the average value of I-CVI, was also applied. It is considered valid if the value is 0.9, or higher ; as the The final step was to develop an evaluation plan. The evaluation plan was prepared for the future study, and it is conducted by separating the process evaluation and the effect evaluation.The key factors of the process evaluation are context, reach, dose, fidelity, implementation, and recruitment . In contTo evaluate the quantitative effectiveness of the program, the study will be conducted with a non-equivalent control group pretest-posttest design after considering the feasibility of the study, as residential facilities are scattered across Korea and the number of residents per facility (approximately 10) is small ,13. Quanp = 0.05. The qualitative data were analyzed using qualitative content analysis [The G*power 3.1 program was used to determine the number of participants required for the study. As the t-test and repeated measures analysis of variance (RM ANOVA) are essentially the same , the minanalysis . DescripThe questionnaire is administered before and after the intervention. It comprises 84 questions pertaining to physical health, depression, anxiety, self-esteem, parenting stress, and general characteristics. Participants are required 20–30 min to complete the questionnaire. Specifically, subjective health status is measured using one item, physical health is measured using a 14-item physical health scale (PHS) (Cronbach’s α = 0.74~0.87) , and depSince UMLFs are a vulnerable group, the content and method of this study must be approved by the Ethics Review Committee. Participants are provided detailed explanations of the purpose of the research, the process of programs, the anonymous handling of the written consent, confidentiality, voluntary participation, and possibility to withdraw from the study at any time without any disadvantage. They are reassured that in the process of completing the questionnaire, unnecessary personal information such as name and address will not be investigated, and the collected data will be statistically analyzed with a unique serial number. To prevent leakage of personal information, the collected data is stored in the form of a file with an access password, and is not viewed by anyone other than the research director.In this study, an eight-session health promotion program using urban forests was developed for UMLFs. Hermeneutic phenomenology was used to assess the needs of UMLFs, who experience complex and diverse psychological problems. In particular, IPA was selected as an analysis method to reflect the philosophy of hermeneutic phenomenology. IPA is an interpretive and exploratory analysis method that enables sophisticated and nuanced analysis with its core concern being psychological . TherefoThe distinctive strength of the program developed in this study was that it was based on the TTM, a theory suitable for establishing and evaluating changes in UMLFs. The strength of the TTM is that it provides knowledge on behavioral changes by promoting gradual changes and underlying motivating factors ; hence, Another strength of this study is that as an intervention development method for behavioral changes, the IMA was applied, which identifies the needs of the participants. Moreover, COs and intervention strategies were selected based on the identified needs . Thus, tFurthermore, this study is meaningful as it has a high possibility of implementation; moreover, it was developed by evaluating the content validity of the program, with the assistance of experts, to adopt activities that are practically applicable to UMLFs. In particular, to assess the needs of UMLFs , the firThis program is highly applicable as it enables both online and offline applications in cases where face-to-face intervention are not quite possible, such as the COVID-19 pandemic. In particular, for UMLFs living in groups, face-to-face intervention has a potential risk of exposure to infection; thus, an online program version eliminates this risk. Based on studies that reveal the association between an increase in depression and the restrictions on external activities to suppress the spread of infectious diseases ,35, the The limitation of this study is that the effectiveness of the proposed intervention program was not evaluated after program development. Moreover, for the feasibility of the study, a small number of nonequivalence pre- post-experimental designs were proposed to evaluate the effect. This is a limitation as the design of an experimental study must be scientific, while considering the possibility of approach and implementation. In addition, the challenge of selecting and training a mediator may also be a limitation of this study.However, this study is significant as the program was developed through the application of a comprehensive needs-assessment of UMLFs; moreover, it was based on the theory of behavioral change and adhered to a systematic intervention development method. Additionally, since the program developed in this study can be applied using both offline and online mediums, the program considers the needs and demands of today’s circumstances, in which external activities are restricted ,41. ThisIn this study, the steps and principles suggested by IMA and TTM were systematically structured with forest healing factors to develop a health promotion program using urban forests for UMLFs. This scientifically designed program was developed based on the various needs of UMLFs with a comprehensive assessment of their mental and physical health status; it is therefore expected to contribute to the health promotion of UMLFs from a holistic perspective. Based on the results of this study, for the health promotion of UMLFs, strategies such as physical exercise in the forest, self-reflection using metaphors, five-sense activities, achievement activities using natural objects, building interpersonal relationships in the forest, and designing future plans are desirable. Regarding further research, we propose an intervention study based on the results derived from this study.


BackgroundToday’s residency applicants submit more applications than those in the past. To facilitate holistic review, many program directors have encouraged applicants to submit fewer applications. However, whether programs provide sufficient information to help applicants determine where to apply is unclear.ObjectiveTo evaluate the frequency of missing information on residency program websites and in the Fellowship and Residency Electronic Interactive Database (FREIDA).MethodsWe used FREIDA to identify all categorical pediatric residency programs in the United States. We noted the presence of information programs reported in each FREIDA data field. We compared information available on the program website for consistency with the information in FREIDA and additionally searched for current resident information and any description of the qualities of applicants/residents desired on the program website.ResultsTwo hundred and eleven pediatric residency programs were included in FREIDA. Approximately 25% of programs did not include basic information such as number of first year residents, salary, work hours, or consideration of applicants requiring work visas. Over half of programs did not report minimum licensing examination scores required for interview consideration. Discrepancies between information on program websites and FREIDA related to work visas occurred in 6-8% of programs. While 88% of program websites included information on current residents, only 17% included any description of the applicant attributes sought by the program.ConclusionsMany pediatric residency programs do not provide much of the information that applicants need to help determine if a program is a good fit or whether their application is competitive. Residency applicants today submit many more applications than those in the past -3. This To help applicants identify residency programs for which they may be a good fit, the American Medical Association (AMA) publishes the Fellowship and Residency Electronic Interactive Database Access (FREIDA). FREIDA allows applicants to search programs by specialty and geographic region and reports a variety of program-specific information. Anecdotally, most residency applicants seek information on programs both from FREIDA and individual program websites when determining where to apply. However, to our knowledge, the completeness of these sources of information has never been evaluated. Without an understanding of whether their application will be competitive - or rejected out of hand - applicants cannot sensibly limit the applications they submit. Therefore, we sought to evaluate the quality of information available to applicants on FREIDA and on pediatric residency program websites.We reviewed information available in FREIDA and on individual residency program websites for all categorical pediatric residency programs in the United States. We chose to evaluate pediatric programs because this specialty attracts a large and diverse group of applicants, including many from osteopathic (DO) and international (IMG) medical schools. Data were collected in a cross-sectional fashion in May 2020.We identified pediatric residency programs using FREIDA. FREIDA is a publicly available online residency database sponsored by the AMA. Each year, FREIDA surveys all Accreditation Council for Graduate Medical Education (ACGME)-accredited residency programs in the United States regarding their application requirements, demographics, and program amenities. Information obtained from this survey is uploaded to the database in February, August, and October. In addition to the annual survey, programs can update their individual profiles throughout the year upon request. Newly accredited programs are added throughout the year as they receive accreditation .From FREIDA, we collected the information available to residency applicants featured in Table We then reviewed each program’s webpage to collect additional data to supplement and compare against the data found in FREIDA. Using information provided from the program’s website, we noted the names of program leadership; resident salary information; the percentage of residency graduates who pursue subspecialty fellowship training after graduation; minimum United States Medical Licensing Examination (USMLE) and Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) scores required for interview consideration; and the number of letters of recommendation required. We also noted whether the program provided any information about their current residents, including resident names, photographs, and/or biographical information . In addition, we searched for any description provided by the program illustrating the qualities of applicants/residents desired.Regarding osteopathic residency applicants, we evaluated program websites to determine whether applications from DO students or graduates were accepted, and whether USMLE scores were required for DO applicants to be considered. Similarly, we searched program websites to determine if applications were accepted from IMGs and whether J-1 and/or H-1B work visas were accepted. We also noted any statements regarding specific USMLE score minimums for IMG applicants or the need for U.S. clinical experience for interview consideration. To determine whether a program had filled in the National Residency Matching Program (NRMP) Match, we used data from the 2020 NRMP Main Residency Match report .We calculated descriptive statistics and determined the association between variables and outcomes of interest using chi-square tests or logistic regression, as appropriate. All statistical analyses were performed using IBM SPSS version 25 , with p < 0.05 considered significant.Two hundred and eleven categorical pediatric residency programs were included in FREIDA. Of these, 109 (51.7%) were academic, 82 (38.9%) community/academic, 14 (6.6%) community, and six (2.8%) military programs. Seventy programs (32.7%) were located in the Northeast, with 70 (33.2%) in the South, 45 (21.3%) in the Midwest, and 27 (12.8%) in the West. Among the programs that participated in the NRMP Match in 2020, 175/197 (88.8%) filled all available resident positions. Program websites were identified and reviewed for 204 (96.6%) programs, while seven programs (3.3%) either did not have a program website available online via publicly available search engines and/or had a non-functional website link listed on FREIDA.The number of programs with missing information on FREIDA and program websites varied, as shown in Table Some programs had discrepancies between the information listed on FREIDA and the information found on their website. For instance, 6/204 (2.9%) programs had different program directors listed between the websites. Only 108 programs (51.2%) listed their willingness to interview applicants who required a J-1 or H-1B visa on both FREIDA and their program website. However, among these programs, nine (8.3%) provided discrepant information regarding applicants with a J-1 visa, while six (5.6%) provided discrepant information regarding applicants with H-1B visa.Only 109 programs (53.4%) noted on their program website whether USMLE scores were required for DO applicants. Of these, 14 required DO applicants to submit USMLE scores, while 95 specifically noted that they did not. Similarly, although 137 programs (64.9%) reported considering applicants with J-1 visas on FREIDA, only 86 (62.8%) of these programs included information on whether U.S. clinical experience was required of applicants on their program website. Among these, 40 required U.S. clinical experience and 29 reported that U.S. clinical experience was preferred, while 20 noted no U.S. clinical experience requirement. Only 31 program websites (15.2%) included any statement regarding USMLE minimum scores or requirements  for IMGs.Most program websites  contained information on current residents. Resident photographs were provided by 159 (77.9%) of programs, and biographical information was provided by 164 (80.4%) programs. However, only a minority of program websites  included a written description of applicant qualities or attributes sought by the program.Here, we present data on the amount of information available to pediatric residency applicants on FREIDA and program websites. Although most programs provided high-quality information to applicants, approximately 25% of programs failed to include important factors that may influence an applicant’s decision whether to apply to that program, such as screening thresholds for USMLE scores or willingness to evaluate applicants who require work visas.In 2020, the average fourth year medical student from an MD school in the United States who applied to pediatric residency programs submitted 34 applications, while the average IMG submitted 44 . While tThe data presented here highlight one significant challenge that must be overcome for applicants to be convinced to apply to a lesser number of residency programs: inadequate information. “Overapplication” is expensive for applicants, but the cost of going unmatched is immeasurably greater. When applicants do not know where their application might be favorably received, applying broadly is a rational strategy. To make an informed decision requires universally available, high-quality data.What is most striking about our findings is how frequently basic information is missing from FREIDA and program websites. Many programs do not report simple application requirements that may be used as exclusionary criteria. For instance, while many programs listed minimum USMLE scores for consideration, over half did not. It is possible that some of these programs do not use USMLE scores for screening and left this field blank intentionally to communicate this policy. However, any program that uses strict score filters but does not report them to applicants likely encourages students to apply whose applications will never be seriously reviewed. Similarly, while most programs communicated their willingness (or unwillingness) to consider IMGs who require work visas, one-quarter were silent on this issue. Many programs that invited J-1 visa applicants to apply still failed to mention other factors often used in application screening such as the need for U.S. clinical experience or IMG-specific USMLE scores.We also identified important discrepancies between FREIDA data and residency program website data. Though these discrepancies occurred relatively infrequently, their importance should not be discounted. Similar to the adage about the man with two clocks who is never sure of the time, the presence of differing information on FREIDA and program websites generates uncertainty for applicants. It is also noteworthy that we struggled to locate some program websites; despite significant effort, we were ultimately unsuccessful in identifying a program website in 3.3% of cases. From the standpoint of an applicant, if the marginal cost of obtaining more information is less than the cost of one additional ERAS application, it is reasonable for applicants to apply to programs where their application may not even be considered, “just in case.”The 2020-2021 interview season was conducted virtually due to the novel coronavirus pandemic. Initial signs suggest that virtual interviews may persist even after the pandemic is over, making it even more important for programs to have a high-quality website so applicants can learn about the program and its unique goals and mission. Currently, only a minority of programs provide a verbal description of the type of applicant they seek. This represents a clear opportunity for improvement. However, in this study, there was no relationship between the amount of information a program provided and the likelihood of that program filling in the Match, suggesting that there may be little penalty to programs with missing information in FREIDA or on their website. In the absence of a natural incentive to provide information to applicants, assistance from a third-party like the Accreditation Council for Graduate Medical Education may be needed. Conditioning the residency program's accreditation upon reporting a certain amount of standardized information to applicants would add an administrative burden to programs, but this cost may be outweighed by the benefits to applicants and programs alike by reducing excess applications.At a minimum, we believe all programs should be required to transparently report exclusionary criteria. When applicants who do not meet the program’s minimum requirements nonetheless apply, it adds congestion to the system and is wasteful for the applicant and the program alike.The strength of this work is its novelty. We are unaware of any previous systematic evaluation of FREIDA and pediatric program websites. This work therefore both adds a unique perspective and builds upon other surveys documenting applicant dissatisfaction with program websites. For instance, a 2008 survey of anesthesiology applicants found that only 2% of applicants felt that the majority of program websites contained all important content; the average program website contained only 46% of the content identified as important by applicants . SimilarNonetheless, this study has several notable limitations. First, we evaluated only categorical pediatric programs. These findings may not be generalizable to other specialties. Second, we evaluated only two data sources - FREIDA and program websites - through which applicants obtain information. Applicants may obtain missing information using other resources which were not evaluated in this study. Third, our findings provide only a “snapshot” of the information available to residency applicants. It is likely that some of the data has changed since our review, and some programs may have corrected the discrepancies and deficiencies we identified. Finally, it is possible that some of the information for which we searched was in fact available in areas of the program's website that were not easily located. However, we thoroughly evaluated each website, and if we were unable to locate the information, we believe that many (if not most) applicants would have been similarly unsuccessful.In a cross-sectional review of pediatric residency program websites and profiles on FREIDA, important deficiencies were found in at least 25% of programs. To assist applicants in selecting residency programs at which their application will be seriously considered, efforts should be made to report consistent, standardized information to potential applicants.


The AHRQ Safety Program for Improving Antibiotic Use aimed to improve antibiotic use by engaging clinicians and staff to incorporate antibiotic stewardship (AS) into practice culture, communication, and decision making. We report on changes in visits and antibiotic prescribing in AHRQ Safety Program ambulatory practices during the COVID-19 pandemic.The Safety Program used webinars, audio presentations, educational tools, and office hours to engage clinician champions and staff leaders to: (a) address attitudes and culture that pose challenges to judicious antibiotic prescribing and (b) incorporate best practices for the management of common infections into their workflow using the Four Moments of Antibiotic Decision Making framework. Total visits , acute respiratory infection (ARI) visits, and antibiotic prescribing data were collected. Using linear mixed models to account for random effects of participating practices and repeated measurements of outcomes within practices over time, data from the pre-intervention period (September-November 2019) and the Ambulatory Care Safety Program (December 2019-November 2020) were compared.Of 467 practices enrolled, 389 (83%) completed the program, including 162 primary care practices , 160 urgent care practices , and 49 federally-supported practices (13%). 292 practices submitted complete data for analysis, including 6,590,485 visits. Visits/practice-month declined March-May 2020 but gradually returned to baseline by program end . Total antibiotic prescribing declined by 9 prescriptions/100 visits (95% CI: -10 to -8). ARI visits/practice-month declined significantly in March-May 2020, then increased but remained below baseline by program end . ARI-related antibiotic prescriptions decreased by 15/100 ARI visits by program end (95% CI: -17 to -12). The greatest reduction was in penicillin class prescriptions with a reduction of 7/100 ARI visits by program end (95% CI: -9 to -6).During the COVID-19 pandemic, a national ambulatory AS program was associated with declines in overall and ARI-related antibiotic prescribing.Pranita Tamma, MD, MHS, Nothing to disclose Sara E. Cosgrove, MD, MS, Basilea  Involved: Self): Consultant Jeffrey A. Linder, MD, MPH, FACP, Amgen (Shareholder)Biogen (Shareholder)Eli Lilly (Shareholder)


The interaction energy values and reported experimental evidence indicate that the site denominated as “Pore-blocking”, which is formed mainly by hydrophobic residues and the T586 residue, is a probable binding site for the NMP compounds.The cannabinoid receptors (CB1/CB2) and the T-type calcium channels are involved in disorders associated with both physiological pain and depressive behaviors. Valuable pharmacological species carbazole derivatives such as the NMP-4, NMP-7, and NMP-181 (Neuro Molecular Production) regulate both biological entities. In this work, DFT calculations were performed to characterize theoretically their structural and chemical reactivity properties using the BP86/cc-pVTZ level of theory. The molecular orbital contributions and the chemical reactivity analysis reveal that a major participation of the carbazole group is in the donor-acceptor interactions of the NMP compounds. The DFT analysis on the NMP compounds provides insights into the relevant functional groups involved during the ligand-receptor interactions. Molecular docking analysis is used to reveal possible sites of interaction of the NMP compounds with the Ca Furthermore, the Cav3.2 isoform contributes to dorsal root neurotransmission, which is involved in disorders associated to pain and depression  acetamide (Compound 10 in reference [2 = 0.90. The ΔEgap energy with respect to logIC50 follows the trend: NMP-144 (2.971) < NMP-181 (3.002) < Compound 10 (3.031) < NMP-7 (3.142) < NMP-4 (3.169), which correspond to the IC50 values: 5.59 µM > 4.60 µM > 3.68 µM > 1.84 µM y 2.47µM, respectively.The contribution of the LUMO orbital is located at >75% on the NMP carbazole group, it can be speculated that this molecular region possesses the major participation during the ligand-receptor interaction for both CB1/CB2 receptors and T-type calcium channel. The energies of the FMO can be related to the experimental measurements of compounds determining their biological activity. For example, for ethosuximide, another T-type calcium channel blocker, its gap energies obtained at the HF/6-311+G level of theory were correlated with the anticonvulsive activity determined by the logED50 parameter (effective dose 50%) obtaining R2 = 0.97 . Here, i NMP-181 ,11,12, Neference ) blocker−2 and 3.0 × 10−2 e a.u.−3 for the NMP compounds obtained at BP86/cc-pVTZ level of theory using an isovalue of 0.004 a.u. The major electronic density charge (red region) is located around the O1 in the carbonyl group spread toward the carbazole group in the three NMP compounds; additionally N6 of amine in NMP-181 concentrates major electronic density charge; see The Molecular Electrostatic Potential (MEP) is useful for determining different nucleophilic and electrophilic regions in molecular systems. −1. The bond (donor) and anti-bond (acceptor) orbitals, π (C9–C13) → π* (O1–C2), have larger stabilization energy on the ester group of NMP-181 than on the amide group of NMP-4 and NMP-7. The electronegative atoms O and N interact, through their lone pair electrons, with the antibonding π orbitals of carbon neighbor, LP→ π*, with stabilization energy at ~16–40 kcal mol−1, and with the antibonding σ orbital of NMP-181, LP(N6) → σ* (C8–H53), with the energy of 7 kcal mol−1. Finally, the anti-bond/anti-bond interaction, π* → π*, corresponds to ~23–84 kcal mol−1. The electronic delocalization is observed on the conjugated bonds of the carbazole ring, and it is extended to the region of the lone pairs (LP) of the p orbitals of the electronegative neighbor atoms to carbazole moiety. Specifically, in NMP-4 and NMP-7, the electronic delocalization spreads out the amide group (O1 and N3 atoms) and the carbazole group (N17); additionally, on methoxy group (O27 atom) in NMP-4. In NMP-181, the electronic delocalization is observed on the ester group (O1 and O3) and the carbazole group (N17). In this case, in NMP-181, the tertiary amine (N6) contributes to a lesser extent to the delocalization, then it is observed a hyperconjugation interaction. The results state that the stability of the minima energy structures of the NMP compounds is mainly due to the electronic delocalization effect, where the major E (2) values are localized on electronegative atoms and carbazole moiety.The NBO calculations for the NMP compounds were carried out to define a stability measure through the stabilization energy, E (2) parameter. The interaction between donor and acceptor of electrons is larger when the E (2) value increases. The delocalization of electronic density between Lewis-type NBO orbitals (donor) and non-Lewis NBO orbitals (acceptor) corresponds to one stabilizing donor-acceptor interaction . The NMPGlobal reactivity descriptors for the NMP compounds were evaluated: chemical potential (μ), electronegativity (χ), hardness (η), softness (s), and electrophilicity index (ω), according to the conceptual DFT approach . Table 2+ = 0.025−0.072 and f– = 0.011−0.070 for NMP-4, f+= 0.031−0.072 and f− = 0.012−0.074 for NMP-7, and f+ = 0.014−0.086 and f− = 0.002−0.10 for NMP-181. Values of the Fukui functions for relevant functional groups in NMP compounds are f+ = 0.048 in the methoxy group O27 (NMP-4) and f+ = 0.086 in the amine group N6 (NMP-181). The maxima values indicate the most probable zone for local electrophilic and nucleophilic attacks. The C21, N17, and N6 are the more prone to nucleophilic attack for NMP-4, NMP-7, and NMP-181, respectively, while the C20 is more prone to electrophilic attack for NMP-7, and C13 for NMP-4, and NMP-181. For Parr functions, it is found that the same sites for nucleophilic and electrophilic attack for all compounds; however, the results indicate that C13 is the most probable site for electrophilic attack.+ and f− for NMP compounds, using an isovalue of 0.002 a.u. In this figure, it is observed that f+ is located mainly in the carbazol nitrogen N17, in the carbonyl oxygen O1 for NMP-4 and NMP-7, in the methoxy oxygen O27 in NMP-4, and the amide nitrogen N6 in NMP-181. For f− the distribution is located on the carbazol carbons in the NMP compounds and the carbonyl oxygen O1 in NMP-181. In summary, the carbazole group is an important region of electronic density accumulation for the NMP compounds. The calculated distance along this region is 6.6 Å in C9–C20 for NMP-7. It can be proposed functional similarity of the electrostatic recognizing and binding pocket coupling for the NMP compounds with the CB1/CB2 receptors and T-type calcium channel [ channel .v3.2 channel suggested distinct possible molecular poses. From these poses, those located at the transmembrane region were further considered, particularly those involving interaction with residues located at the S5 and S6 helical segments (DI-DIV) of the Cav3.2 channel. Five different poses were considered, namely, S6DI, S6DII, S6DIII, S5DIV, and pore-blocking site, v3.2 channel. It was observed that many hydrophobic and aromatic residues were found in all the binding pockets.The results from the molecular docking calculation of the NMP compounds with the Cav3.1 channel, exhibited phospholipids and cholesterol molecules in this location [v1.1 channel played an important role in the interaction with dihydropyridines [In the S6DII pose a, the calocation . Additioyridines .v3.2 channel [v3.2 by the anandamide and NMP compounds modify the inactivation phase of the channel [v3 [v3.2, residue F949 (the middle residue in the triad) participated in the hydrophobic binding pocket in the pore-blocking site. Further, in the recently solved structure of the cryo-EM Cav3.1 channel with the Z944 ligand, not only a similar binding site was identified for the blocker, but also the ligand displayed interactions with equivalent hydrophobic residues and the T921 polar residue (T586 in Cav3.2 described above) [v3.3 calcium channel was identified [v3.2 channel.In the S5DIV pose d, the me channel . Finally channel ,11,12. Innel [v3 . In Cav3d above) . Lastly,entified . Figure The lowest energy poses are summarized in the 1H NMR and 13C NMR calculations were carried out by using the GIAO method [The optimized molecular structures were obtained from BP86 functional  and cc-pO method . In the O method  was usedO method . The eleO method . The resO method . FrontieO method  was usedGlobal reactivity descriptors, such as chemical potential (μ), electronegativity (χ), hardness (η), softness (s), and electrophilicity index (ω), were evaluated based on conceptual DFT approach . Local r program . In addiv3.2 channel was obtained by homology modeling using the reported methodology [v3.2 was obtained from the UNIPROT database with accession code O95180|CAC1H_Human. The model obtained from the Modeller 9v10 program [The structure of the Cahodology . The ami program  was vali program ,44,45. T program . ADV use program , generat program ,28,29,30 program .1H and 13C NMR chemical shifts, the BP86/cc-pVTZ is established as the best-suited level of theory standardizing all our calculations. The minimum energy conformation is similar in the NMP compounds, and they maintain a semi-rigid structure. Calculations were carried out in the chloroform solvent, using the implicit solvation model PCM, to simulate a non-polar environment in the interaction with the Cav3.2 channel. The FMO analysis establishes a ΔEgap~3.0 eV for the NMP compounds, with the NMP-4 compound being the most kinetically stable and least reactive according to this parameter. The NMP carbazole group contributed mostly (>75%) to the LUMO orbital. For the HOMO orbital, of NMP-4 and NMP-7, the carbazole group contributed notably in 80% and 86%, respectively, while for NMP-181 the amino group represents 97%. Furthermore, in this analysis, a correlation of gap energy was obtained with respect to logIC50  with an R2 of 0.90. The MEP obtained is similar among the NMP compounds with a region of major electronic density charge in the carbonyl group extending to the carbazole group and additionally over the methoxy group of NMP-4 and the amide group in NMP-181. A deficient electronic density charge was observed in the pentyl group. The structural stability, measured by the E (2) parameter, was settled due to the appearance of an electronic delocalization effect located mainly in the electronegative N and O atoms and the carbazole group for the NMP compounds. The global reactivity analysis showed no significant changes in electronegativity, hardness, and electrophilicity index between the NMP compounds. The local reactivity descriptors, Fukui functions, and Parr functions, indicated that the most probable sites to suffer a nucleophilic attack were the C21, N17, and N6 atoms for NMP-4, NMP-7, and NMP-181, respectively. According to the Fukui function, the most probable zone to electrophilic attack was C20 for NMP-7 and C13 for NMP-4 and NMP-181. In this respect, the Parr function indicated C13 as the most likely for the electrophilic attack in the NMP compounds. In summary, the main functional group in the NMP compounds was the carbazole group, according to the HOMO-LUMO orbital distributions, molecular electrostatic potential distribution, and local reactivity Fukui indices. The last conclusion indicated that this molecular region was the most probable for undergoing nucleophilic and electrophilic attacks and could be an important region during the ligand-receptor interaction process with the T-type calcium channels and the CB1/CB2 receptors. A molecular docking helped to determine important amino acids of interaction, being the site of the pore-blocking, a probable binding pocket for the compounds NMP in interaction with Cav3.2 channel.The NMP compounds structures were obtained as unique structures of minimum energy on the PES. By reproducing accurately