There are numerous structural and cultural barriers to the progression of women and marginalized groups to leadership in academia, especially in Science, Technology, Engineering, Mathematics and Medicine (STEMM). A range of interventions have been described to address this inequity, with varying success. Here, we suggest that sponsorship could be one effective intervention and propose an institutional action plan to implement a sponsorship program in academia. We outline why sponsorship could be an effective strategy, especially if implemented through a deliberate program by an institution. We then detail the three components of an action plan to be considered in implementation: the elements of the program, the activities that sponsorship in academia likely encompasses, and the selection of sponsors and protégés. The plan could also be enacted by academic leadership in the absence of an institutional program and could serve as a guide to individuals in academia aspiring to address diversity and inclusion in STEMM. This might be termed an administrator or assessment‐based process, as outlined by Cao and Yang . Individuals and institutions would then benefit from curating a list of sponsorship activities. Finally, an organization should consider the attributes of sponsors and protégés that would help the selection of program participants. In the sections below, we have provided suggestions and recommendations that could assist with each stage of the planning process to ensure the goals of the program are achieved for both the sponsor and the protégé.4A sponsorship program would best work if there are support and benefits to the sponsors and protégés for participating in the program. A successful program would include explicit, organizational incentives, such as raised expectations for faculty and department level engagement, with a requirement for each faculty to have a target number of sponsor–protégé relationships enacted. Such a requirement could be supported by listing gender and marginalized group‐based sponsorship within senior staff's performance indicators. Another approach would be to ensure that sponsors are appropriately recognized and suitably rewarded for effective engagement with the program as a part of performance evaluation. Specific incentives for sponsors might include salary loadings, bonus payments, and workload allocation, or indirect incentives, such as internal strategic funding for a new direction/project or increased staffing support with additional direct reports. Such incentives are likely to be beneficial to and fully engage sponsors, especially if sponsors themselves are women or from marginalized groups.We would recommend that to accompany a sponsorship program, the institution would actively require strong representation of different genders and marginalized peoples to provide diversity within senior management teams, institutional level committees, or governance structures that will enable opportunities for the protégés. A sponsorship program would ideally commence with training in sponsorship for both potential protégés and sponsors. A clear statement from senior leadership to these selected individuals that the institution supports the program and that development of the protégé and sponsors would be valuable. As part of this commitment, we recommend that protégés are provided access to relevant professional development and/or leadership courses during the program to ensure they are able to make the most of the opportunities that are facilitated. Given that ability to receive and apply constructive feedback is key to successful sponsorship programs in industry Hewlett, , trainininternal service or “taking care” tasks  as the beneficial, recognized, and rewarded services. This reference may be a useful resource for program managers to provide, or sponsors to use, when reflecting on or evaluating their own possible biases in recommendations of tasks to protégés. At minimum, such tendencies could be openly discussed between sponsors and protégés to ensure that both parties are aware of the breadth of potential opportunities.We strongly recommend that participants (sponsor and protégé) in the program are offered training in unconscious bias prior to entering the program. This is important because sponsorship is subject to existing biases (conscious and unconscious) that are known to contribute to the under‐representation of women and marginalized groups in STEMM leadership positions. Unconscious bias, or implicit association .Notwithstanding the above, we also suggest targeting a potential protégé who has shown high effectiveness in a particular role to facilitate negotiation or realignment of their duties to roles where their strengths lie and will be showcased within the Faculty/Institution/University.Taking opportunities to name, positively identify and recommend the protégé and their achievements when they are not present; for example, when academic leaders are talking with their peers and put their protégé’s name forward. This is an important activity, given previous reports of a backlash effect or hidden penalties some women experience when they self‐advocate .Specifically facilitating protection of the protégé from higher risk, or less supportive members of the senior executive. Examples might include strategically selecting opportunities that only involve supportive leadership team members or actively defending the protégé in some circumstances.Advocating within the institution for financial support for the protégé’s development, such as professional development programs or leadership training schemes.Leveraging organizational commitment to support all protégés to participate in additional support programs, particularly professional coaching.If organizing or asked to contribute to a conference or seminar program, putting forward the protégé to be an invited speaker or session Chair. Note that opportunities such as conference organization may build the protégé’s skill set, but consideration must be given to the associated workload.Ensuring that the protégé is invited as a member on institutional panels or delegations to other institutions when strategic alignments are being formed.Introducing the protégé to key international and national level leaders showcasing their strengths; this might include a separate meeting  with such people when they visit institutions, or by email.Introducing and ask for invited seminar opportunities for the protégé when they are traveling into an area where the sponsor has networks.Facilitating or providing opportunities for the person to “step up” or temporarily act in senior roles, thus developing their leadership profile.Providing/advocating for external opportunities, even if that results in losing the protégé from the institution. We note that losing talent is always a risk for any organization; however, in industry, where this is a commonly reported outcome of sponsorship, it is viewed as a positive Hewlett, .Advising on access to allowances, salary loadings, and even lobbying on behalf of the protégé to have an additional salary loading or allowance if inequities relevant to peers are apparent. This approach has actually been reported to benefit sponsorship programs in industry Hewlett, .Deliberately setting out to use one's leadership role or profile to create opportunities for the protégé, such asointroducing and recommending the protégé to industry, relevant government, or public agency representativesoimplementing new leadership roles or committees to address needs in the institution and providing a leadership role for the protégé .Ensuring that the protégé is aware of and considered for professional development opportunities, such as leadership workshops, coaching, editorial roles, board membership, membership of external bodies, or leadership roles in professional associations. This action may include the need to encourage and even assist the protégé to apply for such opportunities directly in addition to bringing it to their attention.Where roles tend to be based on networks and recommendations , advocating for the protégé to be invited to the role, even if this requires the sponsor to step down from the same board.Encouraging the inclusion of the protégé as an investigator on large ventures that have room for multiple participants (like large grants/projects).For late career professors, providing opportunities for leading postdoctoral researchers or earlier career academics to take senior authorship on research publications.Actively seeking to create diverse and gender‐balanced teams/research groups/committees that encourage each individual to mentor and support each other .For implementation of this action plan, we have constructed a list of sponsorship activities that we feel are most relevant for leaders in academia. These activities could either guide an individual taking the organic approach, or be beneficial in developing a structured program for an organization. We note that not all actions or ideas will work in all institutions and we have attempted to provide a list of possible sponsorship actions broadly applicable to academia. Sponsorship activities in academia could include the following:6In selecting sponsors and protégés, the institution should conduct a self‐evaluation to identify key areas/faculties/departments where diversity in leadership is needed and where current leaders are likely to be capable and proactive sponsors. Effective sponsorship requires a sponsor to reflect on and consider their own motivations in order to engage with the program and protégé. Therefore, it is important to consider what might be good qualities of a sponsor and of a protégé when implementing this program to ensure it achieves the goals (Table Organic sponsorship activities (listed as 1 above) tend to inherently arise from a past mentoring or leadership relationship with the protégé  to proactively facilitate opportunities for women and people from marginalized groups in leadership in academia. This action plan offers a way for academic institutions to implement a programmatic approach to sponsorship as one of many actions to address structural and cultural barriers to achieving diversity and inclusivity in STEMM. If, in attempting to develop a sponsor program, there is insufficient diversity of protégés considered suitable, then the structural barriers to recruitment and retention that have led to this lack of a diverse pipeline must first be addressed.While many of the supporting studies cited above have focused on women in STEMM, we acknowledge that there are additional and greater barriers to other marginalized groups in the same environments. We recommend implementation of a sponsorship program explicitly targeting inclusion and diversity beyond gender, thereby ensuring the organization has potential to achieve a broad representation in leadership. We think the time is ripe for our sector to change, and have presented here one action plan that could be implemented among many by organizations and individuals who are committed to increasing diversity and inclusion and developing the next generation of leaders.None declared.The authors all contributed equally to constructing, drafting, and revising the manuscript. The authors all contributed to considerations of sponsorship plans in academia.


In 2009 health insurers AOK and Bosch BKK introduced the “FacharztProgramm Kardiologie” - a program for coordinated ambulatory cardiology care in the German state of Baden-Württemberg. It aims for efficient, medical guideline-oriented cardiology care to reduce avoidable hospitalizations as well as costs of care. A high number of cardiologists participate and the program has served as blueprint for programs in other medical fields. With many prerequisites and conditions involved, its implementation cannot be expected to be self-directed. Still, only little data on the actual implementation exists. We aimed to determine to what extent medical specialists and cooperating general practitioners implemented the program, which components they adapted, and which contextual factors they deemed relevant.We collected data from primary care practices of medical specialists and general practitioners within Baden-Württemberg.Qualitative data was obtained through structured telephone interviews with participating and non-participating medical specialists as well as general practitioners cooperating with the program and general practitioners not cooperating. Interviews were analyzed through content-structuring qualitative content analyses via MAXQDA.Quantitative data was obtained using anonymous written questionnaires completed by participating and non-participating medical specialists as well as general practitioners cooperating with the program. Analyses were performed using SPSS Statistics, mainly with regard to differences within and between groups of physicians.Most components of the program regarding medical care were well implemented. However, access to medical care was not completely as intended due to high numbers of patients participating in the program and prioritization by physicians. Procedures for communication and cooperation between medical specialists and general practitioners were only partially adhered to and standardized communication was not implemented. A range of regional and practice-related contextual factors influenced implementation and outcomes.Implementation of this program was mixed. Contextual factors posed individual challenges to participating physicians which can’t be captured by an encompassing program. Both control mechanisms and tailoring of the program to medical care seem needed.DRKS00013070.Though not a clinical study, we deemed registration appropriate to ensure transparency. The study has been registered as a non-interventional observation study at the German Clinical Trials Register under ID:  While managed care first emerged in the United States of America , severalIn late 2009, German health insurers AOK (Allgemeine Ortskrankenkasse) Baden-Württemberg and Bosch BKK (Betriebskrankenkasse) started a program in coordinated ambulatory cardiology care together with MEDIVERBUND (independent group representing physicians’ interests) as a management organization, the Bundesverband Niedergelassener Kardiologen (nationwide association of practice-based cardiologists) and the Berufsverband niedergelassener fachärztlich tätiger Internisten . Within the state of Baden-Württemberg (roughly 11 million inhabitants ), they iConsidering its economic goals and focus on high quality care, the cardiology program encompasses various elements which allow the program to be categorized under the concept of managed care : SelectiThe cardiology program is a medical specialist’s complement to “The AOK Family Doctor Programme” -centered care) in Baden-Württemberg .Medical specialists within the program are required to strictly adhere to cardiologic guidelines to ensure evidence-based therapy . Participating specialists are bound to standardized communication and cooperation with the respective GPs in GP-centered care. Diagnostic findings have to be reported to the GP within 3 days or, in case of an emergency, immediately . As the cardiology program entails a high number of prerequisites and conditions, its implementation cannot be expected to be self-directed. Still, nearly 10 years after the program’s initiation, with about 70% of cardiologists and 15% of AOK-insured patients in Baden-Württemberg participating , there As part of a larger study conducted by the University Hospitals of Jena and Heidelberg, Goethe-University Frankfurt am Main and aQua-Institute  Göttingen, we performed the mixed-methods process evaluation of the cardiology program based on interviews and surveys with physicians. The Medical Research Council Guidance on process evaluations of complex interventions served as guidance for study design and procedures .For the qualitative data, we included a purposeful sample of a) medical specialists participating in the cardiology program, b) eligible, but non-participating medical specialists, c) GPs participating in GP-centered care and d) non-participating GPs. For the quantitative data, both medical specialists and GPs participating in GP-centered care were included. All practices needed to be in the state of Baden-Württemberg, as the cardiology program exists only there. As the cardiology program is predominantly directed towards adult patients, pediatricians were excluded.Participating medical specialists and GPs in GP-centered care were identified through participant lists provided to us by AOK Baden-Württemberg. Non-participants were manually identified in the online physician’s database of the Association of Statutory Health Insurance Physicians of Baden-Württemberg . EligibiTo explore diverse experiences and opinions, the qualitative study aimed towards a saturation of statements in a high number of different practices instead of physicians. Otherwise there had been the risk of including several physicians from one and the same practice, limiting insight gained from the study. One hundred thirty-nine specialists’ practices participating in the cardiology program and 84 non-participating practices were identified. From 3903 GPs identified as participating in GP-centered care we drew a sample of 316 practices. Finally, we identified a total of 91 GPs’ practices not participating in GP-centered care. We contacted one physician per practice. Contact was initially established via mail, soon replaced by fax to check for general interest as this proved to be more feasible for physicians, giving them the chance to directly decline or indicate their interest in further information. Interested physicians received necessary background information and had to sign a written form of consent before an appointment for the interview was made. Confidentiality was assured through pseudonyms to prevent bias resulting from socially desirable answers.The quantitative study focused on individual physicians regardless of the respective practices. In updated lists and searches 212 specialists participating in the cardiology program, 99 non-participating specialists and 3599 participating GPs were identified. Both groups of specialists were contacted entirely, a total random sample of 400 GPs was drawn. Physicians received a postal quantitative questionnaire with an accompanying letter and a self-addressed stamped envelope. Completing and returning the questionnaire was interpreted as consent, the questionnaire was anonymous to ensure confidentiality and prevent bias resulting from socially desirable answers.From 09/2017 to 07/2018 qualitative data were collected through structured, guideline-based telephone interviews preceded by a short, written questionnaire   where data was not normally distributed) as well as frequencies. To test for significant differences between participants and non-participants, we used Pearson’s Chi or, when the assumed cell count of at least 5 per cell was not reached, Fisher’s exact test. Metric data largely proved to be not normally distributed, hence comparisons were made using a two-tailed non-parametric Mann-Whitney-U-Test. Within groups we performed a two-tailed Wilcoxon-test. Significant differences relevant to the research objectives are marked in each table. For mean and median values, the corresponding n is given in square brackets where data was missing. Frequencies are given in absolute numbers with valid percentages respectively.Qualitative interview study: Of the 139 contacted specialists participating in the cardiology program, 23 (16.5%) agreed to participate in the qualitative interview study. Out of the 23 specialists, 2 repeatedly could not be reached to make an appointment, 21 were interviewed. Of the 84 non-participating specialists, 1 turned out to be deceased while 11 (13.3%) participated in the qualitative interview study. Of the 316 contacted GPs in GP-centered care, 1 turned out to be deceased while 19 (6.0%) participated in the study and were interviewed. Of the 91 non-participating GPs, 7 (7.7%) participated in the study and were interviewed. Table Quantitative study: Of the 212 contacted specialists participating in the cardiology program, one mailing was returned to sender. Of the remaining 211 specialists, 75 (35.5%) returned their questionnaire. Of the 99 non-participating specialists, 21 (21.2%) returned their questionnaire. From the total sample of 400 GPs participating in the GP program, one mailing was returned by the corresponding practice because the physician retired shortly before our mailing arrived. Of the remaining 399 GPs, one returned questionnaire was left completely blank and therefore unusable while 73 (18.3%) were completed. Table When it comes to accessing care within the cardiology program, the GP is planned to be the primary gatekeeper to ambulatory medical specialist care within the program and waiting times for patients are supposed to be limited. The actual implementation proved to be highly diverse as Table The expected appointment within 2 weeks was only partially adhered to, while most physicians stated that waiting time for an appointment can be up to 1 month or longer. Qualitative results indicated this might be based on the high numbers of patients participating in the cardiology program or prioritization issues .Waiting time differences in regular healthcare proved to be insignificant between participating and non-participating physicians. However, within the group of participants, self-reported waiting time for an appointment differed significantly between the cardiology program and regular care .However, there were significant differences compared to non-participants regarding extended consultation hours, as non-participants were less likely to offer them (Fisher’s exact test(2) = 13.331, The uptake of recommended care-related aspects within the cardiology program seemed to be implemented well. As Table p = .030, n = 94; Cramer-V = .295, p = .042). We asked specialists how often they received the accompanying letter GPs are ought to send with every referral of patients within the cardiology program on a scale from 1 (it had never been received) to 6 . Of all specialists, 76.8% indicated a value between 1 and 3 while 15.0% indicated a value between 4 and 6 on the scale. An additional 8.2% claimed they did not know about the existence of the document at all. Vice-versa, we asked GPs how often they sent the accompanying letter on a scale from 1 (it is never sent) to 6 . Of all GPs, 60.0% indicated a value between 1 and 3 while 22.9% indicated a value between 4 and 6 on the scale. Additionally, 17.1% claimed they did not know about the existence of the document at all. This heterogeneous range of structured communication and contact in general was also reported by physicians in the qualitative study  = 11.924, p = .001, n = 95; Phi = .354, p = .001).The majority of designated contents of the specialists’ reports to the GPs were reported in most cases according to medical specialists. However, appropriate ICD-codes and an overview of suitable health products on offer were seldom given. Still, with ICD-codes there was significant difference in reporting between participating and non-participating specialists  do not enlist in such databases. This leaves room for a biased sample. Last, physicians had to report on their own behavior, possibly leading to socially desirable answers regardless of ensured confidentiality.A question that our data is unable to answer: Did specialists in the cardiology program behave differently prior to participation or did they fulfill most criteria anyway? A contract might not be able to change physicians’ behavior in such a strong manner that significant differences to those not entering the contract emerge. Participation in the cardiology program might rather be a sign of quality, signalizing standards already present instead of improving the status quo. Future research should therefore collect ex ante data to allow before-after-comparisons and direct statements on effects of such programs within the group of participating physicians. Furthermore, it would be interesting to conduct another study in 5 to 10 years to see if the future of the cardiology program will eventually be similar to other managed care programs such as those in the USA, as some of our findings already resemble the onset of trends observed overseas.Being the first German medical specialist-related selective contract, the cardiology contract still poses as an example for other selective contracts and resulting programs. Providing a first insight into the implementation of a program based on § 73c SGB V and showing accompanying challenges, our study delivers knowledge for the program’s improvement and the development of future selective contracts.Eight years after the cardiology program came into full effect, several components seemed to be implemented well while others were still lacking complete translation to medical care. Possible reasons we discussed were a lack of controllability of behavior, an increase in participating patients and infeasibility of regulations due to contextual factors. Our findings can pave the way for reforms of the existing program and deliver useful insights for future selective contracts. In our case, policymakers may reevaluate the cardiology program, especially regarding the feasibility of measures on aspects such as cooperation between physicians, as deviant behavior is already present. This might hint at a need for a more specific tailoring to medical care reality and the individual situation of practices. For similar (future) programs, room for these individual needs of participating physicians seems needed, always in light of a thorough consideration of medical care reality before a program starts. Furthermore, more extensive support for the implementation might be adequate to avoid implementation discrepancies due to misconceptions, like we observed them regarding consultation hours. Like our process evaluation, lots of health services research bears a rather practical relevance, as health systems around the world are highly heterogeneous and cannot be compared easily. Still, some of our results could be linked to international concepts of managed care and parallels emerged, showing possible perspectives for managed care programs in general and the cardiology program in particular.Additional file 1. Questionnaires.Additional file 2. Questions from the qualitative interview guides on implementation of the cardiology program.Additional file 3. Themes/categories and representative quotes from the qualitative data analysis relevant to the implementation of the cardiology program.


The Gerontology Interdisciplinary Program at the University of Utah has a long history of offering certificates (48 years) and a Master of Science degree (25 years). Relatively new to our program is the minor in gerontology, first available in 2013. This paper will describe efforts to grow this program, barriers to enrollment, and plans for expansion. In 2018, the program developed a targeted strategy to increase student awareness of and enrollment in the minor. First, we focused on newly enrolled pre-nursing students through new student orientation presentations and registration support. The introductory course within the minor jumped in enrollment from 6 students in Fall of 2017 to 40 in Fall 2018. Students taking courses in the minor received follow-up support and instructions mid-semester to ease matriculation. Enrollment in the minor increased by 140%. Next, we plan to apply these strategies to a broader number of colleges and departments throughout campus.


A growing body of literature shows that health promotion and disease prevention strategies and messages may not be effective in reaching racially and ethnically diverse communities, unless those strategies are culturally and linguistically adapted for target communities . The Rachttps://millionhearts.hhs.gov/) blood pressure medication adherence resources at faith-based sites, community-based pharmacies, and health care providers’ offices  with the locations of implementation sites and participants. A desire lines (or spider diagram) approach was used to visualize KOT program participation. Mapping provides a visual means of evaluating program reach and is a concise way of communicating the role of implementation sites in delivering culturally, linguistically, and geographically targeted health prevention strategies.z scores, determined by the ArcGIS Hot Spot Analysis (Getis-Ord Gi*) tool (Esri) with the Contiguity Edges Corner and Apply False Discovery Rate correction parameters; the shading indicates intensity of clustering with darker shading indicating more clustering of high values (larger z scores). Overlaps in population clusters were found by using the ArcMap Intersect tool, version 10.3 (Esri).We geocoded the addresses of 12 implementation sites active as of 2016 and residential addresses of KOT program participants reported in baseline surveys from 2015 and 2016 –6. All rAn overarching objective of REACH FAR is delivery of targeted strategies for 4 Asian American communities. The map demonstrates that program implementation sites are located in population clusters of targeted Asian American subgroup populations, as intended at program inception: Asian Indian in Middlesex and Queens counties, Bangladeshi in Kings and Queens counties, Filipino in Queens county, and Korean in Queens and Bergen counties. By mapping KOT program participants, we found that large concentrations of congregants residing in areas neighboring each faith-based site are reached by the KOT program. However, the maps also demonstrate that the programs also reached community members residing outside of immediate or neighboring ethnic enclaves. We suspect that people attending these events prefer or need culturally and linguistically adapted resources that are unavailable in the neighborhoods in which they reside. Culturally and linguistically adapted materials regarding healthy eating and blood pressure control developed for limited English-proficient Asian Americans were disseminated at implementation sites , reachinOur map provides a visual illustration of the network of faith-based organizations and community-based organizations coordinating to promote healthy eating and heart health and the progress of implementation as illustrated with the KOT program. To this end, mapping products are being used in the following ways to enhance future coordination and collaboration between partners:The map is being presented to the NYC DOHMH to demonstrate the need for reaching Asian American populations. Before our coalition efforts, the KOT program had not been implemented in any faith-based organizations serving Asian Americans. Our results demonstrate both success and potential for future NYC DOHMH engagement efforts with Asian American communities.The map is being reviewed at coalition meetings to discuss opportunities for scaling the program to expand program reach. For example, the map suggests that partnering with community-based organizations serving the Asian Indian and Filipino communities in Hudson County or the Bangladeshi community in Bronx County may expand reach.


Earthquake prediction has been a challenging research area, where a future occurrence of the devastating catastrophe is predicted. In this work, sixty seismic features are computed through employing seismological concepts, such as Gutenberg-Richter law, seismic rate changes, foreshock frequency, seismic energy release, total recurrence time. Further, Maximum Relevance and Minimum Redundancy (mRMR) criteria is applied to extract the relevant features. A Support Vector Regressor (SVR) and Hybrid Neural Network (HNN) based classification system is built to obtain the earthquake predictions. HNN is a step wise combination of three different Neural Networks, supported by Enhanced Particle Swarm Optimization (EPSO), to offer weight optimization at each layer. The newly computed seismic features in combination with SVR-HNN prediction system is applied on Hindukush, Chile and Southern California regions. The obtained numerical results show improved prediction performance for all the considered regions, compared to previous prediction studies. Earthquakes are one of the major catastrophe and their unpredictability causes even more destruction in terms of human life and financial losses. There has been a serious debate about the predictability of earthquakes with two concurrent point of views related to their prediction. One school of thought considers it impossible phenomenon to predict while other have spent their resources and efforts to achieve this task. It is an undeniable fact that the seismologist community has been unsuccessful in developing methods to predict earthquakes despite more than a century of efforts. Earthquake prediction remained an unachieved objective due to several reasons. One of the reasons is the lack of technology in accurately monitoring the stress changes, pressure and temperature variations deep beneath the crust through scientific instruments, which eventually results in unavailability of comprehensive data about seismic features. The second probable cause is the gap between seismologists and computer scientist for exploring the various venues of technology to hunt this challenging task. With the advent of modern computer science based intelligent algorithms, significant results have been achieved in different fields of research, such as weather forecasting , churn pContemporary studies show that scientists have conducted earthquake prediction research through diverse techniques. Retrospective studies of various earthquake precursory phenomena show anomalous trends corresponding to earthquakes, such as sub-soil radon gas emission , total eEt). The calculation of seismic parameters corresponding to every Et provides a feature vector related to Et. Thus, earthquake prediction is carried out on the basis of computed features in place of time series of earthquakes, thereby converting a time series prediction problem into a classification problem. The mathematically calculated seismic parameters are basically meant to represent the internal geological state of the ground before earthquake occurrence. This research work employs the known mathematical methods and computes all the seismic features in a bid to retain maximum information, which leads to sixty seismic features corresponding to every earthquake occurrence (Et). After acquiring maximum available seismic features, Maximum Relevancy and Minimum Redundancy (mRMR) based feature selection is applied to select most relevant feature having maximum information. Support Vector Regression (SVR) followed by Hybrid Neural Network (HNN) model and Enhanced Particle Swarm Optimization (EPSO) is applied to model relationship between feature vectors and their corresponding Et, thereby generating robust earthquake prediction model (SVR-HNN). The distinctive contributions of this research methodology is summarized as:Earthquake prediction problem is initially considered as a time series prediction  Later, sSixty seismic features, calculated on the principle of retaining maximum information.A unique application of SVR in combination with HNN, on mRMR selected seismic features.Hindukush, Chile and Southern California are three of the most active seismic regions in the world, thus considered in this study for studying problem of earthquake prediction. Earthquake prediction studies based on Artificial Neural Networks (ANN) have been performed on the considered seismic regions , 11, 15.The rest of the manuscript is structured as the section 2 contains literature survey. Section 3 details about the calculation of dataset, where section 4 explains the SVR-HNN based prediction mode. Results are evaluated and discussed in section 5.Numerous researchers have performed earthquake studies from prediction and forecasting perspectives through different angles. During earthquake preparation process beneath the surface, different geophysical and seismological processes occur. These happenings below the surface are believed to cause changes in sub-soil emission, vertical electric field and ionosphere. These precursory changes are studied and mapped retrospectively with major earthquakes , 5. EartAlgorithm M8 which aims to forecast the earthquake of magnitude 8.0 and above tested successfully at the different regions of the globe along with increased efficiency of intermediate term earthquake forecasting. The study analyzes the earthquake catalog and gives the alarming area in circular region for next five years , 18. TheThe Three Dimensional Pattern Informatics (PI) approach is also applied which aims at the forecast of earthquakes with natural and synthetic data sets . ConsideIn another research work, the earthquake prediction for the regions of Southern California and San Francisco bay area have also been studied. Eight seismic parameters are mathematically calculated through the temporal sequence of past seismicity. The seismic parameters are then used in combination with Recurrent Neural Networks (RNN), Back Propagation Neural Network (BPNN) and Radial Basis Functions (RBF), separately. RNN yielded better results as compare to the other two applied neural networks . Later, Earthquake magnitude prediction for northern Red Sea area is carried out in . The metAlexandridis et al. used RBF to estimate intervent time between large earthquakes of California earthquake catalog . AftershThe authors of , 15 propLast et al.  performeAll the aforementioned methodologies study the earthquake prediction, while focusing only one region. The prediction models are not applied and tested to other earthquake prone regions and no comparisons are also carried out with the results of other research studies. In this research, the prediction model is applied to more than one region and comparisons are also drawn with the results, available in literature.In this study, three different regions, namely Hindukush, Chile, Southern California have been selected for prediction of earthquakes of magnitude 5.0 and above. The same regions selected in the precedent studies are also considered for this research , 11, 15.Earthquake catalogs of these regions have been obtained from United States Geological Survey (USGS)  for the Et). In this study, earthquake prediction problem is designed/modeled as a binary classification problem. Every earthquake magnitude is converted to Yes, No  through applying threshold on magnitude 5.0. It is too early in this field of research to predict actual magnitudes of future earthquakes; however, endeavors are on the way to predict the categories of future events.After parameter calculation a feature vector is obtained corresponding to every target earthquake , which is to be predicted using the feature vector. The numbers of features reach to 60 in every instance according to suggested methodology. Later, in order to handle the issues related to curse of dimensionality, the feature selection technique based on Maximum Relevance and Minimum Redundancy (mRMR) is employed to choose the features having maximum relevant and discriminating information.All the seismic features are calculated using the 50 seismic events before the event of interest , while Eqs mlk) method for calculation of a and b values. In earthquake prediction study for Southern California, linear least square regression analysis based method is proposed RF = mRMR (T)         = SVR[RF]for j = 1 to 3     if (j = = 1)(First NN takes SVR_Predictions as auxiliary input)        j_Model, NNj_Predictions] = NNj              = EPSOj           = NNj            = EPSOj          In this work, the output of SVR is treated as its own opinion about the earthquake occurrence. Thus, in a bid to improve the performance of earthquake prediction a combination of three ANNs and EPSO, called as Hybrid Neural Network (HNN) is formulated. Seismic Features are passed to HNN for yielding the predictions. At this point of stage, the results obtained through SVR are considered as auxiliary predictions and passed on to HNN, along with other features. The opinion of SVR would also hold importance in terms of discriminating power between earthquake and non-earthquake occurrences. Therefore, when coupled with dataset of other seismic features, it highly improves the discriminating power of earthquake prediction, resulting in improved prediction performance of HNN. In HNN, the weights and outputs of each ANN is passed to the next layer of ANN, to make the consequent layer start learning ahead of a certain point. Thus, the feedback of SVR or ANN at a specific layer enhance the learning of HNN, leading to the improved earthquake prediction. The role of EPSO is to rescue ANN, when it is trapped in local minima through optimizing the weights. However, in case when ANN is performing well, the EPSO refrains from updating the weight. The model is trained using 70% of feature instances and later independent testing is performed on unseen 30% of data. In the training data two-third part is used for training the algorithm while one-third is used for validation of model. The evaluation of model is performed on unseen feature instances through considering well-known evaluation measures.There are total 7656 feature instances for Chile out of which 2067 correspond to “Yes” earthquake while 5589 correspond to “No” earthquake. The total instances for Southern California are 33543 out of which 7671 belong to “Yes” earthquake while 25872 belong to “No” earthquake. Similarly, for Hindukush dataset, out of 4350 instances 1379 correspond to “Yes” while 2971 correspond to “No”. Therefore, the data distributions of the considered regions are highly imbalanced as shown in 1), negative predictive value (P2), Matthews correlation coefficient (MCC) and R score. Whenever, predictions are made through an algorithm, it yields four categories of outputs, namely true positive (TP), false positive (FP), true negative (TP) and false negative (FN). TP and TN are the correct predictions made by the prediction model while FP and FN are the wrong predictions of the algorithm.There are well-known performance metrics available for evaluation of binary classification results, such as sensitivity, specificity, positive predictive value or precision (Pn) is the rate of true positive predictions out of all positive instances while specificity (Sp) is the rate of true negative predictions out among all negative instances. P1 is the ratio of correct positive predictions out of all the positive predictions made by prediction model, whereas P0 refers to the correct negative predictions made by algorithm out of all negative predictions. P1 inversely relates to false alarms, which refers higher P1 means lesser false alarms and vice versa. Similarly, R score and MCC are also proposed as a balanced measure for binary classification evaluation. These are calculated using all four basic measures  and vary between -1 and +1. The values approaching +1 correspond to perfect classification, while 0 refers to total random behavior of prediction algorithm and -1 relates to opposite behavior of classification model. These two performance measures can be considered as a benchmark measure for drawing comparison, because the four types of basic measures are also incorporated in them as shown in Eqs Sensitivity . A notable difference between the performances of individual techniques and their combination can be observed. MCC of 0.43 and 0.41 is obtained for Hindukush region using SVR and HNN, respectively. The combination of two techniques by including SVR as auxiliary predictor for HNN improves MCC to 0.58. A similar trend in improvement is also observed for other performance measures, as shown in The role of EPSO is to optimize the weights of neural networks. Artificial neural networks have tendency of getting trapped in local minima. If such a situation happens during the training of a neural network, EPSO helps ANN in escaping local minima and guides in towards optimum solution. But this is not the case every time that ANN is trapped in local minima. It may happen occasionally. If ANN is already performing well and learning in the right direction, the inclusion of EPSO does not affect the weights of ANN in such a situation. The term HNN stands for combination of three different neural networks coupled with EPSO. Sometimes HNN without EPSO would show the similar results as compare to HNN with EPSO, however, on some other training occasions, it may show lesser performance.The performance of SVR, HNN and EPSO are dependent on respective parameter selection. Thus, the collective performance obtained in SVR-HNN model is governed through selection of appropriate parameter values. The extensive experimentation is performed to empirically select the values for parameters, which obtain good results for each of the used algorithms . The proposed model has shown consistent performance for the three regions, which approves the appropriate selection of values for parameters. The ten simulation runs of SVR-HNN model show little variation, which strengthens the claim of appropriate selection of parametric values, leading to a stable earthquake prediction performance in three regions. The graphs given in In this study, interdisciplinary research has been carried out for earthquake prediction through interaction of seismology-based earthquake precursors and computer science based computational intelligent techniques. A robust multilayer prediction model is generated in combination with the computation of maximum obtainable seismic features. Sixty seismic features are computed for Hindukush, Chile and Southern California regions. Separate feature selection is performed for every region through maximum relevance and minimum redundancy (mRMR) approach. The selected features are employed for training of an earthquake prediction model. The prediction model consists of Support Vector Regressor (SVR) followed Hybrid Neural Networks (HNN) and Enhanced Particle Swarm Optimization (EPSO). SVR provides an initial estimation for earthquake prediction which is passed to HNN as an auxiliary predictor in combination with features. Three different neural networks are further employed along with EPSO weight optimization. Thus SVR-HNN based prediction model is trained and tested successfully with encouraging and improved results for all three regions.


Currently, sCJD subtyping is only fully achievable post mortem. However, a rapid and non-invasive method for discriminating sCJD subtypes in vita would be invaluable for the clinical management of affected individuals, and for the selection of participants for clinical trials. The CSF analysis by Real Time Quaking Induced Conversion (RT-QuIC) reaction is the most sensitive and specific ante mortem sCJD diagnostic test available to date, and it is used by a number of laboratories internationally. RT-QuIC takes advantage of the natural replication mechanisms of prions by template-induced misfolding, employing recombinant prion protein as reaction substrate. We asked whether epitope mapping, of the RT-QuIC reaction products obtained from seeding RT-QuIC with brain and CSF samples from each of the six molecular subtypes of sCJD could be employed to distinguish them and therefore achieve in vita sCJD molecular subtyping. We found that it is possible to distinguish the RT-QuIC products generated by sCJD biological samples from the ones generated by spontaneous conversion in the negative controls, but that different sCJD subtypes generate very similar, if not identical RT-QuIC reaction products. We concluded that whilst RT-QuIC has demonstrable diagnostic value it has limited prognostic value at this point in time.Sporadic Creutzfeldt-Jakob disease (sCJD) is a transmissible, rapidly progressive and fatal neurodegenerative disease. The transmissible agent linked to sCJD is composed of the misfolded form of the host-encoded prion protein. The combination of histopathological and biochemical analyses has allowed the identification and sub-classification of six sCJD subtypes. This classification depends on the polymorphic variability of codon 129 of the prion protein gene and the PrP C), a copper binding glycoprotein bound by a glycophosphastidyl-inositol (GPI) anchor to the outer leaflet of cell membranes, which is constitutively expressed in the central nervous system (CNS).Prions are the infectious agents associated with Transmissible Spongiform Encephalopathies (TSEs) or prion diseases. Prion diseases are transmissible, rapidly progressive and invariably fatal neurodegenerative diseases affecting humans and other mammals. According to the protein only hypothesis ,2, prionSc) isoforms, replicates inside a host by imposing their conformation on PrPC. The conformational change of PrPC to PrPSc makes the latter insoluble in non-denaturing detergents and partially resistant to proteases such as protease K (PK), a broad-spectrum serine and threonine protease. PK is routinely used in prion research because the product of the digestion of PrPSc with PK, referred to as resistant PrP (PrPres), is used for the molecular characterisation of prion diseases [The misfolded PrP scrapie  in combination with the molecular weight of the unglycosylated PrPres found in brain tissue samples and scored by western blot (WB) with an anti-PrP monoclonal antibody [In humans, the most common form of prion disease is sporadic Creutzfeldt-Jakob disease (sCJD) accounting for 85%-90% of all human prion disease cases. The remaining 10–15% of human prion disease cases are mainly due to genetic forms, linked to point or insertional mutations in the prion protein gene e rarest ,5.The clantibody ,7  systems are methodologies that emulate prion replication pothesis  and invepothesis ,13 and hante mortem sCJD diagnostic RT-QuIC protocol, based on cerebrospinal fluid (CSF) analysis [Since its first introduction, RT-QuIC has been applied to human prion disease diagnosis –16. To manalysis ,18.A widely used and characterised substrate for the sCJD RT-QuIC diagnostic protocol is the full-length hamster prion protein (a.a. 23–231) . Howeverante mortem diagnostic test for sCJD available at this point in time, prompting researcher to ask whether it might be employed to discriminate sCJD subtypes. The discrimination of the sCJD subtypes by RT-QuIC would provide an outlook on the disease progressionas well as diagnostic information, which would inform the clinical management of affected individuals. Moreover, sCJD molecular subtypes ascertained in vita could be used as inclusion criteria for the recruitment of patients into future clinical trials.RT-QuIC has shown to be the most sensitive and specific in vitro identification [res subtyping from brain tissue. Or to put the same point in more theoretical terms: whether conformational and perhaps even strain characteristics are conserved during quaking induced conversion.Testing a limited number of sCJD brain samples, Peden and colleagues , firstlyfication –29. ThesBy seeding the diagnostic RT-QuIC reaction with brain and CSF samples accounting for the most common sCJD subtypes , we have analysed the RT-QuIC reaction products for their resistance to limited proteolysis and investigated the length of the resistant fragments via epitope mapping using a set of six commercially available antibodies, including those usually employed for sCJD molecular typing.All the human biological samples were provided by the National CJD Research and Surveillance Unit (NCJDRSU) Brain and Tissue Bank in Edinburgh, UK (part of the MRC Edinburgh Brain Bank) ethical approval . The inclusion criteria for the sCJD and non-CJD samples used in this study were based on of the appropriate consent for research for each individual case and the availability of frozen tissue. The cases selected comprised three frozen brains each of sCJD subtypes MM1, MM2, MV1, MV2, VV2 and two of subtype VV1 . In addition, one case reported to the NCJDRSU with neurological symptoms but no signs of prion disease (non-CJD) following pathological investigation, was selected as negative control. Small pieces of frontal cerebral cortex were sampled from all the above-mentioned cases.The collected tissue samples were homogenised to 10% weight/volume in Phosphate Buffered Saline (PBS) supplemented with 150 mM NaCl, 1 mM ethylene-diamine-tetra-acetic acid (EDTA), 0.5% Triton X-100 and Complete Protease Inhibitor (Roche) using a FastPrep-24 automated homogeniser (MPbio) and lysing matrix D.res in each 10% brain homogenate (10% BH) was evaluated by densitometric analysis following Western blot (WB) analysis using purified recombinant PrP as a standard. The amounts of brain used to seed individual RT-QuIC reactions were normalised to 100 fg of PrPres. All the 10%BH were diluted in PBS, the range of 10%BH dilution factors used after normalisation was from 10−3.8 to 10-5.7 and the mean of this dilution factor range was adopted as the dilution factor for the non-CJD 10%BH used as negative control. PBS was used in the unseeded samples as a control for the spontaneous aggregation of the substrate.The levels of PrPCSF samples were selected on the basis of volume availability, testing positive in a previous RT-QuIC analysis and being from patients with neuropathologically-confirmed sCJD with a known sCJD subtype. The selected CSF sample set included three examples of sCJD MM1, MV2 and VV2 and two examples of MV1 and MM2 . Two additional CSF samples were selected as negative controls based on being assigned with diagnosis of a non-prion related neurological disease, sample volume availability and testing negative in a previous RT-QuIC analysis. A volume of 15 μL of neat CSF were used to seed individual reaction wells .PRNP (accession K02234) expression and translation from transformed Escherichia coli Rosetta cells (Invitrogen), was obtained with Overnight Express Instant TB medium (Merck Novagen). Bacteria were collected and inclusion bodies (IB) isolated in pellets by means of Bug Buster Master Mix (Merck Novagen). IB pellets were resuspended and bound to Ni-NTA Superflow resin beads (Qiagen) in denaturing conditions. Protein was refolded on the column and subsequently eluted. Concentration was adjusted by means of Amicon Ultra-15 centrifugal Filter Units (Merck Millipore) and one millilitre aliquots were prepared, flash frozen and stored at -80°C until use.An individual batch of full-length Syrian Golden Hamster recombinant prion protein  was purified and used in this study. Purification protocol was as previously described , in brieThe RT-QuIC reaction was performed in a sealed 96 well plate with clear bottom (Thermo-Fisher) incubated at 42°C for 90 h in a FLUOstar Optima (BMG Labtech) plate reader. During the incubation, the plate reader performed cycles of intermittent shaking  and took fluorescence readings from the bottom of each well every 15 min  .All the RT-QuIC reaction buffer components were purchased as concentrated stock solutions from Sigma-Aldrich and diluted in cell culture grade water. RT-QuIC reaction buffer composition was as follows: PBS , 170 mM NaCl, 1 mM EDTA and 10 μM ThT. Because PBS contains NaCl, the final RT-QuIC reactions contained 324mM NaCl. Thioflavin T (ThT) solution was prepared monthly as a 10 mM solution which was syringe filtered through a 0.22 μm filter (Merck Millipore) and kept at +4°C in the dark. Prior to use, ThT was diluted to 1 mM and used at a final concentration of 10 μM in the RT-QuIC reactions. Recombinant FLHa-rPrP substrate was thawed (1 hour on ice followed by 30 minutes at room temperature) and filtered through a 100 kDa centrifuge filter . Following filtering, the concentration of the substrate was calculated from measures of absorbance at 280 nm taken on a dilution 1:2 in 0.1% sodium dodecyl sulphate in PBS (0.1%SDS/PBS) using a NanoDrop OneC (Thermo-Fisher), blanking with 0.05%SDS/PBS.res. After preparing the RT-QuIC reaction plate, a volume of PBS accounting for the absence of seed (15 μL of CSF or 2 μL of 10% BH dilution) was added to the excess of reaction mixture. These mock reaction mixtures were then stored in 1.5 mL polypropylene tubes (APEX NoStick Alpha Laboratories) at -20°C. These samples, termed “Mix”, were used as RT-QuIC untreated controls in subsequent immunochemical analyses of the RT-QuIC reaction products.The FLHa-rPrP was then incorporated to the reaction buffer at 0.1 μg/μL, generating a bulk reaction mixture that was subdivided between reaction wells. The final reaction volume was 100 μL per well including seed. The RT-QuIC reactions were seeded with 15 μL of CSF or 2 μL of 10% BH serially diluted in PBS containing 100 fg of PrPAt the end of each RT-QuIC, the sealed plate was extracted from the plate reader and left to equilibrate at room temperature. Condensation was spun down by centrifugation at 2505 x g for 1 min. The content of the wells was collected by carefully scraping the well surfaces with a disposable pipette tip, prior to transferring the liquid suspension to a storage tube. A minimum of six technical replicates per seed were prepared on an individual plate. Collected samples were stored in 1.5 mL polypropylene tubes (APEX NoStick Alpha Laboratories) at -20°C until use.All SDS-PAGE analyses were performed using pre-cast 10% bis-tris gels (NuPAGE). Following preparation, samples were incubated at 100°C for 10 minutes in sample loading buffer  or in LDS4X supplemented with 2% volume/volume (v/v) 2-mercaptoethanol (LDS4XβMA) and loaded onto the gel. Electrophoretic separation was performed in MES-SDS buffer (NuPAGE) at 200V for between 35 and 45 minutes.Gels were blotted on polyvinylidene fluoride membrane (BioRad Immun-Blot PVDF) by means of wet transfer  using Towbin buffer . This syres Type 1 specific mAb 12B2 (epitope 89–93) and C-terminus specific 94B4 (epitope 186–192) were purchased from the Central Veterinary Institute at Wageningen University Netherlands, EU, as 1 mg/mL solutions and used at dilutions of 1:10000 and 1:1000, respectively. Monoclonal PrP specific mAb 8H4  was used at a dilution of 1:2000, while mAb 6H4  and mAb SAF70  were diluted 1:1000 .Anti-PrP monoclonal antibody (mAb) 3F4  was purchased from Millipore as a 1 mg/mL solution and was used at a dilution of 1:10000. PrPFor each digestion experiment, PK (Merck Millipore) was diluted fresh on the day from a glycerol stock to working stock in cell culture grade water. PK working stock concentrations were calculated to digest RT-QuIC reaction products with different amounts of PK. The final digestion volume included 76 μL of sample and 4 μL of a PK working stock solution. Digestions were carried out at 37°C for 1 hour and stopped by placing the tubes on ice. PK activity was irreversibly inhibited by adding Pefabloc SC (Sigma-Aldrich) to 1.25 mM.Products of PK digestion were methanol precipitated with 10 volumes of -20°C 99.9% pure methanol . Samples, with added methanol, were thoroughly vortexed and incubated overnight at -20°C. The following day samples were centrifuged for 35 minutes at 18200 x g , the supernatant was discarded, and residual methanol evaporated by incubating the open tubes at 100°C in a Class II microbiological safety cabinet. Pellets were resuspended in 42 μL of 0.1%SDS/PBS, half of the volume was moved to a fresh tube and added to an equivalent volume of either LDS4X/2%βMA (reduced samples) or LDS4X with no βMA (not reduced samples).In experiments using 10%BH seeded RT-QuIC, in order to discriminate between fluorescence signal due to aggregation  and the stochastic fluctuation of baseline fluorescence intrinsic to the RT-QuIC detection system (noise), a fluorescence threshold was calculated as equal to the average of the first fluorescence reading from each used well on a 96-well plate plus three standard deviations. Those reaction wells that produce three consecutive fluorescence readings equal or greater than threshold were deemed true positive signals and the time of the third fluorescence reading equal or above threshold was termed Time to Threshold (TtoT). The CSF seeded RT-QuIC reaction results were analysed with reference to the diagnostic criteria as described in .PRNP polymorphic codon-129 and the evaluation of the electrophoretic mobility and glycoform ratio of PrPres as is assessed by WB using mAb [Sc PK digestion products (i.e. PrPres Type 1 21 kDa and Type 2 19 kDa) suggests that PK exerts its activity on, at the very least, two different PrPSc conformations that are generated and conserved during the prion replication process in vivo.Currently, the molecular typing of the different sCJD subtypes is based on the genotyping of sing mAb ,7. BroadOur hypothesis was that if seeds from sCJD subtypes specifically induced different misfolded conformations of the recombinant substrate in the RT-QuIC reaction products, then we could detect these alternate conformations by means of proteolytic treatment (PK digestion) and WB.res by diluting the 10% BHs in PBS and an individual batch of recombinant substrate was used. At least six replicate reactions were performed for each seed in the same experiment.To study this, we initially generated RT-QuIC reaction products using sCJD 10% brain homogenates (10%BH) as RT-QuIC seeds, and then analysed them for their resistance to PK digestion. In addition, the protease resistant regions of PrP in the RT-QuIC reaction products were assessed by means of epitope mapping. The selected sCJD and non-CJD controls (i.e. 10%BHs) seeds were assayed in two RT-QuIC experiments. The amount of material used to seed individual RT-QuIC reactions with different 10%BHs was normalised to 100 fg of PrPFig 2A).While the spontaneous aggregation of the substrate was never observed in the negative controls or in the unseeded reactions, all sCJD seeded reactions showed aggregation-associated fluorescence for at least two replicates, and 89.2% of all the sCJD seeded wells showed fluorescence above threshold. No significant subtype specific trend, however, was observed (To investigate our hypothesis that the conformation(s) of the RT-QuIC reaction products are dependent on seed subtype, we sought to preserve the integrity of the misfolded conformation assumed by the recombinant substrate during RT-QuIC. With this aim, we collected the contents of individual reaction wells without using any detergent or denaturant. Densitometric analysis following WB with anti-PrP monoclonal antibody (mAb) 3F4 showed that it was not possible to recover the totality of the input substrate from individual reaction wells (i.e. 10 μg of FLHa-rPrP per well) and that the efficiency of collection was highly variable. By washing the wells with 0.1%SDS/PBS, and performing densitometric analysis on the collected washes, it was possible to show part of the input substrate was adherent to the well surface. Pooling replicated wells together reduced collection variability and, on average, 60 to 70% of the input recombinant substrate per group of replicates per seed was recovered.C folded domains, Fig 1A), to detect of FLHa-rPrP was negatively affected by the presence of the reducing agent β-mercaptoethanol . Therefore, this component was excluded from the preparation of samples to be probed with these mAbs.We then selected a panel of commercially available monoclonal antibodies to construct an epitope map of the RT-QuIC reaction products after proteolytic treatment with PK. The anti-PrP monoclonal antibodies (mAbs) sensitivity for detecting the RT-QuIC substrate (FLHa-rPrP) by WB was assessed. We found that the ability of mAbs 6H4, 8H4 and 94B4, . However, treating the RT-QuIC reaction products with PK at 10 μg/mL abolished or dramatically reduced the detection signal from all of the mAbs except SAF70 , which also showed readily detectable resistant prion protein fragments after treatment with higher concentrations of PK .All the antibodies in our panel were able to detect the RT-QuIC reaction products prior to proteolytic treatment .RT-QuIC reaction products treated with PK 10 μg/mL and probed with mAb SAF70, showed a reduction in the signal intensity of the band corresponding to the full-length RT-QuIC product as well as the appearance of additional bands. In particular, a new band was detected at ~ 22 kDa as well as a prominent band at ~10 kDa . SAF70, however, detected a similar if not identical banding pattern, characterised by a signal at 10 kDa, irrespective of the sCJD subtype used to seed the reaction .In addition, the 10 kDa band was detectable by SAF70 even following treatment with 30 and 50 μg/mL PK, whereas the 22 kDa band was eliminated with these treatments. When treating samples with 30 or 50 μg/mL PK, occasionally, very faint bands were detected by mAbs other than SAF70 at a molecular weight corresponding to the intact FLHa-rPrP and more rarely at 22 kDa and 17 kDa , consistent with the previous observation using sCJD brain homogenates.Having established the WB methodology for the detection of RT-QuIC reaction products resulting from reactions seeded with 10%BH, we moved our study to the RT-QuIC reaction products resulting from seeding the reaction with CSF samples. Following a similar experimental design as with 10%BH, we assayed in three independent experiment the seeding activity of CSF samples from all the different sCJD subtypes except sCJD VV1. Upon testing by RT-QuIC, all the selected sCJD CSF samples satisfied the diagnostic criteria for positivity (17). Even though spontaneous aggregation of the substrate was observed in two out of 20 unseeded reaction wells, none of the negative controls showed aggregation-associated fluorescence. Treating CSF-RT-QuIC reaction products with 50 μg/mL PK and probing the digested material with mAb SAF70 in WB, resulted in a banding pattern characterised by two prominent signals at around 10 and 22 kDa irrespective of the sCJD subtype of the CSF sample used to seed the reaction. . The reducing agent was added to reduce and thereby break the one disulphide bond in PrP , favouring the linearisation of the protein structure by LDS and preventing the rPrP intermolecular dimerisation while in the denatured state. The fact that reducing conditions suppressed the binding of mAbs 6H4, 8H4 and 94B4 suggests that the correct presentation or availability of the epitopes recognised by these mAbs may depend on the local secondary structure of the protein, i.e. specific amino acid residues at the epitopes must be spatially arranged in a specific conformation. The disruption of the 6H4 epitope by reduction and alkylation has been reported previously [The initial assessment of the sensitivity of the selected mAbs toward the RT-QuIC substrate FLHa-rPrP in WB, showed that the binding of mAbs 6H4, 8H4 and 94B4 to their respective epitopes was negatively affected when the reducing agent β-mercaptoethanol was added to the sample loading buffer  states in the product information sheet that 94B4 epitope is “assumed to be conformation dependent” hence its binding may be susceptible to the conformational modifications determined by the reducing agent.Fig 1A). Hence, the 8H4 and 94B4 epitopes are contiguous and map on one arm of the hairpin loop that may remain intact when the protein is denatured and the disulphide bond is oxidised. It is therefore conceivable that the disruption of the hairpin loop by reduction of the disulphide bridge may lead to a conformational rearrangement that in turn negatively affects the 8H4 and 94B4 epitopes.The cysteine at position 179 that forms one half of the disulphide bridge, is part of 8H4 epitope ,35 and tS1A Fig). The treatment of the RT-QuIC reaction products with 10 μg/mL PK, was sufficient to delete the signal detected by all the selected antibodies apart from SAF70 . The fragment detected by SAF70 was specific to sCJD seeded RT-QuIC reactions and has an apparent molecular weight of around 10 kDa. The latter estimate was made on the basis of the migration distance on western blot, and is only therefore approximate. Nevertheless, the SAF70-detected band was observed irrespective of the sCJD subtype or whether brain or CSF was used to seed the reaction. Moreover, the fragment detected with SAF70 was unaffected by the harsher PK treatment used . Taken together these observations indicate the fragment detected by SAF70 represents the PK resistant conformational core generated during sCJD seeded RT-QuIC reactions.In the absence of reducing conditions and when no PK treatment was used, all the antibodies in our panel detected both the FLHa-rPrP substrate prior to RT-QuIC and the FLHa-rPrP recovered from the plate following RT-QuIC . Taking into consideration the susceptibility of 6H4 epitope to distal conformational changes that we have observed , possibly the structural integrity of this epitope was affected by the proteolytic digestion of either or both the N-terminal and C-terminal domains, rather than a by direct effect of the PK.The apparent molecular weight of the fragment detected by SAF70 cannot be reconciled easily with the lack of detection by 6H4 and 8H4 because the region of hamster PrP between 6H4 and 8H4 epitopes has a much smaller molecular mass (~2.7 kDa) than the apparent molecular mass of 10 kDa . The digestion of the hinge may lead to a topological change in the local sequence that negatively affects 8H4 and 94B4 binding without destroying the peptide sequence encompassing their epitopes.It is also possible that the observed loss of 8H4 and 94B4 signals might also arise from a secondary conformational effect resulting from PK exerting its activity on distal domains so that the sequence encompassing these epitopes may contribute to the observed molecular weight of ~10 kDa. In particular, PK activity may determine an outcome similar to the one determined by the reducing agent (i.e. the disruption of the hairpin loop between α2 and α3), by exerting its activity on the hinge between the arms of the hairpin loop : products of RT-QuIC reactions seeded with sCJD 10%BH subtypes MM1, MM2c, MV1, MV2, VV1, VV2, respectively. Lane (7): products of reaction seeded with non-CJD 10%BH. Lane 8: unseeded reaction products. Lane (9): RT-QuIC untreated reaction mixture. Row (A) RT-QuiC reaction products before proteolytic treatment, row (B) RT-QuIC reaction products treated with PK 10 μg/mL, row (C) PK 30 μg/mL, row (D) PK 50 μg/mL. Each row displays blots that were transferred on an individual PVDF membrane.(TIF)Click here for additional data file.


Parkinson’s disease (PD) is a progressive disease that targets many aspects of the nervous system, both motor and non-motor functions. Dance as an intervention provides a creative outlet that can be more motivating than other interventions by allowing people an opportunity for not only increased movement and activity, but also socialization. Creative expression through dance also has the potential to improve not only motor capabilities like balance, but also non-motor aspects like self-efficacy, cognition, and quality of life. For the community program described in this presentation, dance faculty led the dance and choreography components of the program while an occupational therapist (OT) served to maximize options for adaptations, safety, and accessibility. OT faculty also led efforts in gathering and analyzing data regarding community participation and program design utilizing a qualitative approach by conducting semi-structured interviews with five participants  in the program. Content analysis of the data suggests some emerging themes which include: 1) forming common bonds and making friendships within the class due to PD diagnosis and similar enjoyment of the class, 2) increased appreciation and enjoyment of music, 3) appreciation of dance instruction, and 4) how transportation options, or lack thereof, impact participation in the class. These themes will assist in informing future program delivery with the hopes of reaching a larger contingent of the community who may also be interested in dance.


This cohort study estimates the association of a park-based violence prevention and mental health promotion after-school program with youth arrest rates in Miami-Dade County, Florida. Written informed assent or consent was obtained from study participants and guardians.Fit2Lead is a park-based violence prevention and mental health promotion after-school program in Miami-Dade County, Florida, developed through extensive cross-agency collaboration for youth ages 12 to 17 years residing in high-crime, low-resource neighborhoods.4 Potential confounding variables included area-level sex, age, race/ethnicity, single-parent households, low-income households, and youth perceptions of park safety (binary variable) representing at and above vs below grand mean–centered zip code–level scores using the Teen Environment Neighborhood measure,5 Barriers to Activity in Your Neighborhood subscale.This prospective cohort study used difference-in-differences models to estimate the association between program implementation and youth arrest rates. The primary factor evaluated was presence or absence of this program (vs other after-school programs) in areas matched by (1) park serving the zip code and (2) baseline youth arrest rates and sociodemographic characteristics (aggregated) drawn from the American Community Survey. The main outcome was change in arrest rates  per year among youth ages 12 to 17 years across matched zip codes for 3 years before and after program implementation (2013-2018). Arrest rates were used as a proxy for youth engagement in violent behaviors, consistent with prior literature.P < .05, and SAS software version 9.4 (SAS Institute Inc) was used for all analyses.Descriptive statistics were computed for all park area–level sociodemographic characteristics and youth baseline arrest rates across matched zip codes. Preimplementation parallel trends were examined graphically, and potential for reverse causality was tested using crude and adjusted repeated-measures generalized linear models with random intercepts to ensure program site selection was not driven by preimplementation arrests. Differences in youth arrests by zip code before and after implementation were assessed using crude and adjusted repeated-measures Poisson regression models with random intercepts. Statistical significance was set at 2-tailed b = 0.02; 95% CI, −0.05 to 0.10; P = .23 [crude]; and b = 0.24; 95% CI, −0.08 to 0.56; P = .14 [adjusted]). Sociodemographic variables were included in adjusted models to account for residual differences across matched zip codes. Adjusted difference-in-differences coefficient estimates  compared with those where it was not. Findings indicated 252 fewer arrests per 10 000 population aged 12 to 17 years over the 3-year intervention period in zip codes where the program was vs was not offered.The program was offered in areas with a population that was 48% male, 60% Hispanic, and 29% non-Hispanic black. In all, 33% of households were single parent and 33% were low income. The program served a mean (SD) of 501 (37) youths per year. stimates , represe6 and support growing evidence that leveraging community-based settings through cross-agency collaboration promotes population-level health and resilience.6 Study limitations include residual differences across matched zip codes, although changes in arrest rates (vs counts) were tested, and models were adjusted for multiple area-level factors to control for group differences. In addition, we did not account for spillover effects and concurrent violence-prevention programs. Parks are abundant in many high-crime settings in the United States. Future analyses could allow continued monitoring of outcomes associated with the program to inform potential for scalability in other high-need settings.This prospective cohort study found that adjusted youth arrest rate estimates were lower in areas where a park-based violence prevention and mental health promotion after-school program was offered compared with areas hosting other after-school programs. Results suggest that park-based settings can foster positive mental health among youth confronting adversities common to living in high-crime, low-resource neighborhoods


N = 43) beliefs about addiction. Both adolescents’ and parents’ (N = 21) psychosocial competencies were enhanced post-intervention. Subjective outcome evaluation from both adolescent (N = 47) and parent (N = 22) groups showed positive perceptions of the program content, implementers, and achievement of program objectives. Findings provided preliminary evidence to support and yielded practical implications for the adoption of the multi-addiction syndrome model, positive youth development, and expressive arts approaches in the development of interventions for high-risk adolescents and addictive parents.This study evaluated an expressive arts intervention program (“Colorful Life”) for adolescents with addicted parents and parents with addiction in Hong Kong. Different evaluation strategies were employed. Objective outcome evaluation adopting a one group pretest-posttest design showed positive changes in adolescents’ ( In the new edition of Diagnostic and Statistical Manual, 5th edition , approximately 8.3 million children under 18 years of age lived with at least one parent who abused illicit drugs or alcohol during the past 1 year   and addiction. Via the use of art therapy, the addicted parents are encouraged to freely express their emotions and share their experiences with their counterparts and helping professionals so as to gain and provide support to one another. To evaluate the effectiveness of the program, both qualitative and quantitative studies have been conducted  and 21 parents  participated in objective outcome evaluation, all participants responded to subjective outcome evaluation. The background information of the intervention programs is summarized in Table Participants of the programs were recruited from January to July 2016. The social workers from the Integrated Centre on Addiction Prevention and Treatment sent out invitation letters to school social workers to invite students with addicted parents to participate. Parent participants  were recruited via various organizations such as Cross Centre and Even Centre. A total of 47 adolescents and 22 parents participated in the program. While 43 adolescents  were developed based on the existing objective outcome assessments The adolescent version of the objective outcome evaluation was composed of 53 items tapping on five domains related to addiction as follows:never, 1 = once, 2 = twice, 3 = three times, 4 = once per week, 5 = several times per week, 6 = daily).Domain B: Addictive Behavioral Intention The respondents indicated on a seven-point Likert scale the frequency that they engaged in the stated addictive behavior  in the past month. Options included 0 = unlikely to 4 = definitely. Items included “spending a considerable amount of time on the Internet or playing video games” and “participating in gambling activities”.α = 0.90 and posttest: α = 0.95)Domain C: Psychosocial Competencies Domain D: Knowledge on Addiction . Sample items included “Addictive behaviors may impact every family member” and “I am aware of different avenues to seek help”.α = 0.57 and posttest: α = 0.91)Domain E: Beliefs about Addiction ’ addiction” and “Even though my parent is an addict, I can still have a positive identity”.The participants indicated their agreement on a scale ranging from 1 = strongly disagree to 6 = strongly agree. The Cronbach’s alpha for the pretest and posttest were 0.92 and 0.94, respectively.The parent version of the objective outcome evaluation was made up of 18 items tapping the parenting skills and practices , as well as intrapersonal competencies . The participants indicated their agreement to the statements such as “I understand the importance of maintaining a positive relationship with my children” and “I do not respect myself” (reversed scoring), ranging from 1 = α = 0.98 and parent α = 0.95); (2) implementer attributes ; and (3) program effectiveness . The first two sections of the adolescent and parent subjective outcome evaluations were identical. Participants rated on a six-point Likert scale the extent they agreed on the items anchored at 1 = strongly disagree to 6 = strongly agree. The program effectiveness section was designed based on the intended program outcomes which are differed between the adolescent and parent versions. Participants were invited to rate on a five-point Likert scale the extent to which they perceived the program to have helped them achieve the stated outcomes. Options were anchored at 1 = of no help to 5 = of great help.The subjective outcome evaluation forms were revised based on a widely used program evaluation tool in Hong Kong and mainland China with high reliabilities  = − 2.40, p < 0.05) while there were no significant differences in other indicators between pretest and posttest. However, a positive trend in the acquisition of psychosocial competencies was also observed.To gauge adolescent participants’ changes in terms of (1) addictive behaviors, 2) behavioral intentions, (3) psychosocial competencies, (4) knowledge about addiction, and (5) beliefs about addiction, paired sample  behaviort tests on the parents participating in the program are shown in Table t (20) = − 2.03, p < 0.05). Results also showed that the parents at posttest reported a significantly higher level of positive identity and problem-solving capability (t (20) = − 2.29, p < 0.05). The findings provided evidence on the effectiveness of the training program for the parents.The results of paired sample Subjective outcome evaluation findings are presented in Tables Parent participants were highly satisfied with the program content and implementers as evidenced by the positive responses across all items (100%) . Although there were no significant change in other domains , a positive trend in the acquisition of psychosocial competencies was observed.Several observations deserve our attention. First, the present program is one of the pioneer multi-addiction intervention programs for the adolescents with addicted parents and parent addicts. The unique feature of the adolescent program is that it was developed based on the syndrome model of addiction. Moreover, it adopts the positive youth development approach by aiming to strengthen adolescents’ intra- and interpersonal competencies among these high-risk youths. The aforementioned approach may possibly explain the positive trends observed in the acquisition of psychosocial competencies  among the adolescent participants. Our findings are in line with the previous studies that have shown the effectiveness of adopting the positive youth development approach in the prevention of problem behaviors, such as drug abuse among Hong Kong youths Shek . A largeSecond, the non-significant findings regarding addictive behaviors may be attributed to the floor effects  which made the changes difficult to detect. Regarding knowledge about addiction, the majority of the traditional addiction prevention and intervention programs in Hong Kong have focused much on imparting knowledge about addiction. As students may easily access the Internet where they may acquire knowledge about addiction themselves, it is not surprising that the program did not help them acquire incremental knowledge on the matter, especially when our program adopted an expressive arts approach as opposed to the traditional uni-directional type of “lecturing” in most prevention and intervention programs.For the parents, the findings from the objective outcome evaluation were generally positive. Participating in the program significantly helped parents to build a positive identity and improved their problem-solving skills. A non-significant positive trend was also found in the acquisition of parenting skills and psychosocial competencies after their participation in the program.To complement the objective outcome evaluation findings, subjective outcome evaluation was also conducted. The findings from both adolescent and parent groups were generally positive. Particularly, the students liked the program and enjoyed the interactive activities. More importantly, the majority of the adolescents reported that the program helped them better understand the influence of addictive behavior on the family. They also reported enhancement in their ability to express and control their emotions. Also, the program helped them realize that even though their parents were addicts, they may still have positive self-perception. As for the parents, in terms of the program content and implementer attributes, almost all participants’ subjective evaluations were positive across all items. The results also revealed that the program was useful in introducing various ways to discipline their children and allowed them to understand the importance of maintaining a good relationship with their offspring. The program encouraged them to be a better parent and view themselves in a more positive light. Taken as a whole, the findings from the subjective outcome evaluation from both adolescent and parent participants are highly positive, and both parents and students perceived that the programs were beneficial to them.According to the syndrome model of addiction (Shaffer et al. The present intervention is unique because few interventions in Hong Kong have articularly targeted at parent addicts. Specifically, our sessions aimed to highlight the relationship between parenting and addiction, to help parents better understand the needs of their offspring at different developmental stages, to equip them with parenting skills to strengthen parent-child relationship, and to strengthen parents’ own positive identity. Both quantitative and qualitative findings converged to demonstrate the effectiveness of the “Colorful Life” Intervention Program, particularly for the parent addicts in achieving the aforementioned objectives.A review of literature also showed that many interventions for addicted parents are targeted at mothers, likely due to the assumption that the mothers are often the primary caregiver in the family (Silva et al. Our findings also provide evidence for the effective use of expressive arts in helping addicted parents and their children. The strengths of the use of expressive arts in creative counseling interventions have been well documented, such as fostering group cohesion, active participation, encouraging self-exploration and self-expression, and itself being a form of mind-body intervention. While the use of expressive arts in the treatment of substance abusers and relapse prevention in Hong Kong has gained popularity in recent years (Tam et al. To sum up, the evaluation findings from the present study provided evidence to support the effectiveness of the intervention and yielded practical implications. Nevertheless, readers should be cautious about the interpretation of the findings. First, the evaluation tools administered in this study were self-report in nature which may have impacted on the veracity of the findings. However, considering both practical and ethical concerns, this is the most feasible methodology. Future evaluation studies may consider adopting a more holistic evaluation approach by gathering perceptions from the family members of the participants as well. Second, the parents in the participant group were self-selected in terms of a strong motivation to improve their parent-child relations which brought them to the intervention. Thus, the present sample may represent a limited group of addicts who are willing to seek professional help and to invest in their family.Our present work concludes with a call to develop, implement, and evaluate more multi-addiction interventions targeted at the offspring of addicts and parent addicts. Future research should be directed to the reduction of the effects of the risk factors, the promotion of the effects of protective factors at the individual, familial, and societal levels for the at-risk children and adolescents, and the strengthening of the role of both mothers and fathers in this care giving triad.


Background: Increasing accreditation requirements as well as transformations in medical school curricula necessitate administrative staff who are not only invested in the clerkship coordinator role but also view what they do as a career. To date, there has been a lack of professional development opportunities for clerkship administrators. Methods: In 2003, the Central Group on Educational Affairs of the Association of American Medical Colleges recognized a need for professional development for clerkship administrators. The Clerkship Administrator Certificate Program emerged from that decision and presented for the first time in 2004 in Omaha, Nebraska. This article provides an overview of the program, how it has been evaluated, and how it continues to evolve. Results: The program had two guiding principles: to offer professional development opportunities for clerkship administrators through interactive workshops and to ensure the program was feasible both in terms of completion and in cost. Over the past 16 years, the Clerkship Administrator Certificate Program workshops have been delivered to over 300 clerkship administrators. Of those, 206 have completed a project in order to receive their certificate. Projects have related to innovations in medical education (n = 41), grading (n = 26), professional development (n = 26), and patient care (n = 20) to name a few. Discussion: In order to meet the demands for presenting the workshops, a train-the-trainer model has been employed to expand the number of individuals presenting the workshops. Additional research needs to be done to determine influence of the program on future professional development endeavors. Over the past 15 years, the role of the administrative staff supporting required clinical medical student experiences has evolved. No longer can a clerkship director rely on a part-time staff person to aid with the daily challenges presented during a clerkship. In 2003, the Alliance for Clinical Education published a position statement asserting a full-time clerkship coordinator is necessary to effectively run a clinical clerkship [As with residency program coordinators , increasContinuous professional development is essential for clerkship administrators to appropriately manage the medical student education mission as well as collect data for accreditation of the medical school. Residency program coordinators also have opportunities for professional development  through In 2003, the executive committee of the Central Group on Educational Affairs (CGEA) of the Association of American Medical Colleges recognized a need for professional development for clerkship administrators. The leaders noted that this population was absent from meetings and wanted to offer a program specifically for them. The CGEA Clerkship Administrator Certificate Program emerged from that decision and presented for the first time in 2004 in Omaha, Nebraska. This article provides an overview of the program, how it has been evaluated, and how it continues to evolve.The development of this program had two guiding principles. The first was to elevate clerkship administrators as medical education professionals through workshops and individual projects. The second was to offer something feasible, both in terms of completion and in cost. At the time this program was conceived in 2003, many medical schools did not have professional development funds allocated for clerkship administrators to attend meetings. We therefore encapsulated the required workshops into a 4-h pre-conference block. This would allow participants to complete the core material during one meeting.The content for the program was adapted from a faculty development leadership program offered at one of the author’s (GBD) home institution. The philosophy behind the sessions chosen was to encourage clerkship administrators to embrace their role as an educational leader. Although they may not be content experts in clinical medicine, their skills in other domains are equally valuable to medical student education. The first workshop walked participants through the importance of having a personal vision and mission. As part of that discussion, participants identified personal and professional responsibilities, identifying which are personal priorities and perceived priorities of the institution. The objectives of this session included: 1) Articulate your personal mission; 2) Correlate your passions with your mission; and 3) Compare and contrast your personal mission, vision and values with that of your organization.The second workshop focused on leadership skills. Using the Good to Great framework , levels These two workshops have been core to the Clerkship Administrator Certificate Program since its inception. During the third year the program was offered at the CGEA meeting, a session was added to train participants about the importance of emotional intelligence and how to approach difficult conversations. One of the first graduates of the certificate program proposed this session and joined the team of facilitators. Research related to the importance of emotional intelligence was presented, asking participants to reflect on the material in small groups. Using the framework for crucial conversations , multiplIn order to obtain the certificate of completion, participants must complete a project over the course of a year, or longer. Offering workshops contribute to continuing education, but often this information is not applied after a meeting. Since our first goal was to elevate the role of clerkship administrators as medical education professionals, we included the project requirement to apply leadership through pursuit of educational research or quality improvement. Examples of projects were discussed so participants understood what could be done. The expectation was that participants would return the following year to present their work for new attendees. Flexibility was also built into this requirement, taking into consideration institutional budgets, by allowing a written report summarizing the project and results be submitted in lieu of a presentation.This program has been evaluated in two ways. The first has been through completion of an evaluation form at the end of each program. The second was from completion of a project.Program evaluations have been revised and modified over the past 15 years. Initially, standard program evaluations from the CGEA meeting were used. As workshops were presented at other national meetings, such as the Council on Medical Student Education in Pediatrics (COMSEP) and the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), their standard evaluations were collected to assess the workshops.As presented in To receive a certificate, participants had to complete a project once they completed the workshops. Projects took the form of quality improvement or educational research. After the first year of the program, clerkship director names and emails were obtained so the certificate program leaders could contact them. We explained to the clerkship director the project completion requirement and encouraged the clerkship director to work with the clerkship administrator to undertake a project mutually beneficial for their clerkship.To date, 206 projects have been completed. Several of these projects have been submitted through the CGEA, COMSEP or ADMSEP peer-review process as poster presentations at the annual meetings. A number of programs have invited the authors to deliver the certificate program at their own institutions, providing further evidence that the program is feasible, affordable, and valued. The University of Iowa was the first medical school to invite us to present to all of their educational administrators. The certificate program leaders worked with faculty at the institutions to ensure projects were completed and either presented locally or a written summary was submitted. Over the years, the certificate program has been presented in Arizona, California, Florida, Illinois, Iowa, Kansas, Maryland, Missouri, Nebraska, Texas, Virginia, and Vermont.Over the past 16 years, we have had the opportunity to offer the CGEA Clerkship Administrator Certificate Program workshops to over 300 clerkship administrators. Of those, 206 have completed a project in order to receive their certificate. The continued invitations to offer the program at institutions as well as the expansion to specialty-specific organizations demonstrate the need for professional development programs for clerkship administrators.Our guiding principles for the program continue to be relevant. Medical schools are facing fiscal challenges with the changing health-care landscape. TherefoThe authors learned a number of lessons early, including first and foremost the need for flexibility with project completion requirements. Initially, our hope in requiring a presentation was that it would encourage schools to invest in clerkship administrators’ careers and allocate funds to attend at least one meeting per year. However, this was proven to be unrealistic and led to alternative methods of presentations such as permitting local oral presentations or submitting a structured written report.Additionally, the architects of this program later recognized the need for succession planning. As they moved out of their roles as clerkship administrators , it was evident that a train-the-trainers model needed to be adopted. When the current program leaders took over, they expanded the team of individuals who are trained to deliver the core content to ensure that if a presenter was unable to attend, others could step in to deliver the content.A limitation of this report is the lack of follow-up data regarding the long-term impact of this program on job satisfaction or continuing professional development of the participants. Although the impact has been noticeable through increased presence and formal programming for clerkship administrators at ADMSEP, CGEA and COMSEP meetings, the true magnitude has not been investigated. A future endeavor is to conduct follow-up studies with participants to inquire what sort of catalyst effect the certificate program has had for them.As accreditation requirements in medical student education expand and health-care delivery becomes more complex, clerkship directors need clerkship administrators capable of managing the educational program. Clerkship administrators need to understand their role in the continuum of medical student education. The Clerkship Administrator Certificate Program has proven to be a robust, affordable professional development program for clerkship administrators. After 16 years and over 200 completed projects, the need for dedicated professional development for clerkship administrators continues.