E. coli.Although tobacco mosaic virus (TMV) coat protein (CP) has been isolated from virus particles and its crystals have grown in ammonium sulfate buffers for many years, to date, no one has reported on the crystallization of recombinant TMV-CP connecting peptides expressed in 32) and TMV-CP incorporated His-tags (WT-His-TMV-CP12) simultaneously in ammonium sulfate buffers and commercial crystallization reagents. It was found that the 20S disk form of WT-TMV-CP32 and WT-His-TMV-CP12 did not form high resolution crystals by using various crystallization buffers and commercial crystallization reagents. Subsequently, a new experimental method was adopted in which a range of truncated TMV-CP was constructed by removing several amino acids from the N- or the C-terminal, and high resolution crystals were grown in ammonium sulfate buffers and commercial crystallization reagents.In the present papers genetically engineered TMV-CP was expressed, into which hexahistidine (His) tags or glutathione-S-transferase (GST) tags were incorporated. Considering that GST-tags are long peptides and His-tags are short peptides, an attempt was made to grow crystals of TMV-CP cleaved GST-tags (WT-TMV-CP19). The Four-layer aggregate disk structure of TR-His-TMV-CP19 was solved. This phenomenon showed that peptides at the C-terminus hindered the growth of high resolution crystals and the peptides interactions at the N-terminus were attributed to the quality of TMV-CP crystals.The new crystallization method was developed and 3.0 Å resolution macromolecular crystal was thereby obtained by removing four amino acids at the C-terminal of His-TMV-CP and connecting six His-tags at the N-terminal of His-TMV-CP (TR-His-TMV-CP19 was obtained and the corresponding structure was solved by removing four amino acids at the C-terminus of TMV-CP and connecting His-tags at the N-terminus of TMV-CP. It indicated that short peptides influenced the resolution of TMV-CP crystals.A 3.0 Å resolution macromolecular crystal of TR-His-TMV-CP Tobacco mosaic virus (TMV) has a rod-like appearance and consists of a single, positive strand RNA of 6395 nucleotides encapsulated in a helical virion by approximately 2130 identical coat protein (CP) subunits . CP consNicotiana tabacum (N. tabacum) infected by TMV, and TMV-CP existed as a number of aggregates, depending on PH, ionic strength, temperature, protein concentration, and other factors [TMV-CP was usually propagated and isolated from  factors ,12,14-21 factors -33. At 0 factors -21,30,31 factors . The cry factors ,31-36. T factors -36, they factors -43.E.coli, and the recombinant protein of TMV-CP were expressed, and 3.0 Å resolution TR-His-TMV-CP19 (incorporated His-tags at the N-terminus of TMV-CP and truncated four amino acids at the C-terminus of TMV-CP) macromolecular crystals were obtained.In the present investigation, the genetically engineered structure of TMV-CP was the concern: a series of the recombinant expression vectors contained TMV-CP genes were constructed and transformed into N. tabacum K326) and reverse transcribed into cDNA by primercDNA and reverse transcriptase (TaKaRa). The genetic fragment of wild type TMV-CP  were amplified by using cDNA as template. The following series of genetic fragments, four amino acids truncated at the C-terminus of WT-His-TMV-CP12, (TR-His-TMV-CP19), three amino acids truncated at the N-terminus of WT-His-TMV-CP12 and four amino acids truncated at the C-terminus of WT-His-TMV-CP12 (TR-His-TMV-CP62), three amino acids truncated at the N-terminus of WT-His-TMV-CP12, and five amino acids truncated at the C-terminus of WT-His-TMV-CP12 (TR-His-TMV-CP68), were also amplified by PCR. Compared with the DNA marker, all the PCR products migrated as expected at approximately 500 bp, and the PCR products were marked as the WT-GST-TMV-CP32 , except for the presence of short peptides incorporated at the N-terminal of TMV-CP in their DNA sequences. These correct proteins were successfully cloned to the expression host, E.coli BL21(DE3)-RIL (TakaRa), for protein expression.The corresponding clones were sequenced by ABI Automatic DNA Sequence Machine, and the correct sequences were obtained and aligned Figure . The DNA32, WT-His-TMV-CP12, TR-His-TMV-CP19, TR-His-TMV-CP62, and TR-His-TMV-CP68 were initially assayed by Coomassie brilliant blue method in a small scale experiment in which the final volume was 10 mL was test by migration at approximately 17.5 kDa  was the oligomeric state (dimmers and monomers), and the retention volume of TR-His-TMV-CP19 was transformed to disks mostly after dialyzing against 0.2–0.3 mol/L ammonium sulfate and 0.1 mol/L Tris ( PH 8.0 ) solution at room temperature for more than 10 hr. The disk state of TR-His-TMV-CP19 was confirmed by the map of SEC  (PDB codes 1EI7 and 1VTM), three kinds of WT-His-TMV-CP12 truncated amino acids at the C-terminal  were constructed, expressed, purified and formed 20S disks. And then the crystals of TR-His-TMV-CP19 appeared when the protein concentration  is 8.0–14 mg/mL and crystallization pool solution (pH 7.7) consisting of 0.1 mol/L ammonium sulfate and 0.1 mol/L Tris at 295 K for 24 hr. The increasing of the ionic strength (1.0) and pH of the crystallization pool buffers resulted in the appearance of TR-His-TMV-CP19 crystals in the circumstance of higher protein concentration. Compared with WT-TMV-CP, the purified protein of TR-His-TMV-CP19 was in the form of protein A . A diagram of the growth curve of TR-His-TMV-CP19 crystallization was drawn , the Propagation, purification and acquisition the macromolecular crystals of TR-His-TMV-CP19, TR-His-TMV-CP62, TR-His-TMV-CP68) were grown in the crystallization buffers as mentioned above. The crystals of TR-His-TMV-CP19 were grown by the technique of Hanging-drop vapor diffusion and seeding methods with crystallization reagents including several kinds of ammonium sulfate and Tris solutions. A map of the growth curve of the crystallization of TR-His-TMV-CP19 was drawn. In this map, the proteins of 20s disk form of TR-His-TMV-CP19 (8.0–14 mg/mL) were firstly prepared in solutions (pH 8.0) containing 20 mmol/L orthophosphate and 100 mmol/L sodium chloride and then dialyzed against 0.2–0.3 mol/L ammonium sulfate and 0.1 mol/L Tris solutions ( PH 8.0 ) at 277 K for 12 hr. The corresponding crystals were grown in crystallization pool solutions containing 0.1–0.3 mol/L ammonium sulfate and 0.1 mol/L Tris at pH 6.5–8.5 by the technique of Hanging-drop vapor at 277 and 295 K. Seeding methods were performed at 295 K after 1–7 d, the good macromolecular crystals appeared under different conditions. 2.9–7.0 Å resolution of TR-His-TMV-CP19 (concentration 14 mg/mL) macromolecular crystals were obtained in crystallization pool solution consisting of 0.25 mol/L ammonium sulfate and 0.1 mol/L Tris at pH 7.7. Then, using the same method, the crystals of WT-His-TMV-CP12 without resolution and some tiny WT-TMV-CP32 crystals, were also obtained by series of seeding experiments. It was showed from the experiment that: the genetically engineered proteins of TR-His-TMV-CP19 could grow high resolution crystals. Hence, the present investigations suggest that the C-terminal of TMV-CP was unstable for crystallization buffer, and the amino acids at the C-terminus were hypothesized to be very flexible. Additionally, the inserted sites of short peptides of TMV-CP could access the grown crystals. Short peptides have a positive influence on the stability of the biophysical properties of TMV-CP. Compared with WT-TMV-CP isolated from TMV particles, this recombinant protein of TR-His-TMV-CP19 is easy to purify and grow crystals. Thus, the latter can be applied to structural biology and structure-based drug design.The crystallization and stability of recombinant WT-TMV-CP were influenced by various factors such as the charge, isoelectric point, hydrophilicity of hybrid CP, and especially the length of the amino sequence. Based on the crystallization methods of WT-TMV-CP (isolated from TMV particles), the crystals of TR-His-TMV-CP  was isolated from  Gooding , and mod Gooding ,45. TMV- Gooding . TMV-RNA Gooding -48. In oNA Table  in 50 mm19, WT-GST-TMV-CP32, WT-His-TMV-CP12, TR-His-TMV-CP62, and TR-His-TMV-CP68 sequences were amplified by PCR technology . Both plasmid PGEX-6P-1 (Novagen) and CP were digested with BamH I /Xho I  and cloned into the same sites in PGEX-6P-1 (PGEX-6P-1-WT-GST-TMV-CP32). Transcription reactions were performed by using the corresponding transcription system. E. coli BL21(DE3)-RIL (TaKaRa) cultures were transformed into vectors involving aforementioned recombinant plasmid. Expression plasmids were grown in Luria-Bertani (LB) medium containing 30 μg/mL kanamycin at 310 K until the OD600 reached 0.65–1.0. After cooling the cultures to 289 K, the expression product was induced by the addition of 1.0 mmol/L IPTG, and the culture was incubated for 16 hr. The cells were harvested by centrifugation and resuspended in 35 mL lysis buffer . Then, the cells were thawed, lysed by supersonic device, and then centrifuged at 15000 rpm for 30 min at 277 K. The supernate was then passed through 0.22 mm syringe filters (Millipore) and loaded onto a Ni Sepharose High performance column , washed with five column volumes of 40 mmol/L imidazole, and eluted with 400 mmol/L imidazole. The N-terminal His-tags failed to cleaved with thrombin (1.0 unit/mg) and N-terminal GST-tags was cleaved successfully with PreScission Protease (1.0 unit/mg) by incubating overnight at 277 K. The cleaved GST-tags and uncleaved His-tags were removed by the same chelating column, and the flow-through was concentrated in an Amicon Ultra centrifugal filter device (Millipore) with a 10 kDa filter and then loaded onto a HiLoad 16/60 Superdex 200 pg column equilibrated in the dialysis solution . The protein was concentrated to 5.0–25 mg/mLfor the crystallization trials by using Amicon Ultra centrifugal filter units (Millipore) with a 10 kDa molecular weight cutoff. The target proteins were briefly stored at 277 K.The dsDNA of correct length was purified and identified by 1% agarose gel electrophoresis. Both plasmid pET28a (Novagen) and CP were digested with Nde I /Xho I  and cloned into the same sites in pET28a (pET28a-WT-His-TMV-CPβ-lactoglobulin (35 kDa), Ribonuclease A (13.7 kDa), Cytochrome (13.6 kDa), Aprotinin (6.51 kDa) and Vitamin B12 (1.36 kDa). Protein was monitored by absorbance at the wavelength of 280 nm. The crystals of purified proteins were obtained by the technique of Hanging-drop vapor diffusion. The protein concentration was 5.0–25 mg/mL, and the crystallization solutions contained 0.1–0.3 mol/L ammonium sulfate and 0.1 mol/L Tris at PH 6.5–8.5  ,36,49-52ß-D-thiogalactopyranose; SDS: Dodecylsulfate; PAGE: Polyacrylamide gel electrophoresis; Native-PAGE: Native-polyacrylamide gel Electrophoresis; SEC: Size Exclusion Chromatography; WT: Wild type; TR: Truncation; Tris: Tris(hydroxymethyl)aminomethane; DTT: DL-dithiothreitol; LB: Luria-Bertani; E.coli: Escherichia coli; N. tabacum: Nicotiana tabacum.TMV: Tobacco mosaic virus; CP: Coat protein; His: Hexahistidine; GST: Glutathione-S-transferase; Ni-NTA: Nickel-nitrilotriacetic acid; dsDNA: Double-stranded DNA; cDNA: Complementary DNA; IPTG: Isopropyl The authors declare that they have no competing interests.BAS and SY designed this study. XYL carried out the clone and protein expression studies, participated in the sequence alignment and drafted the manuscript. ZC,ZCW,MJZ and DDY performed Crystallization tests. LHJ collected and analyzed the data of genetically engineered TMV-CP crystals. BAS, SY, DYH, and ZC critically revised the manuscript. All of the authors read and approved the final version of the manuscript.


Public health programs can deliver benefits only if they are able to sustain programs, policies, and activities over time. Although numerous sustainability frameworks and models have been developed, there are almost no assessment tools that have demonstrated reliability or validity or have been widely disseminated. We present the Program Sustainability Assessment Tool (PSAT), a new and reliable instrument for assessing the capacity for program sustainability of various public health and other programs.A measurement development study was conducted to assess the reliability of the PSAT. Program managers and staff (n = 592) representing 252 public health programs used the PSAT to rate the sustainability of their program. State and community-level programs participated, representing 4 types of chronic disease programs: tobacco control, diabetes, obesity prevention, and oral health.The final version of the PSAT contains 40 items, spread across 8 sustainability domains, with 5 items per domain. Confirmatory factor analysis shows good fit of the data with the 8 sustainability domains. The subscales have excellent internal consistency; the average Cronbach’s α is 0.88, ranging from 0.79 to 0.92. Preliminary validation analyses suggest that PSAT scores are related to important program and organizational characteristics.The PSAT is a new and reliable assessment instrument that can be used to measure a public health program’s capacity for sustainability. The tool is designed to be used by researchers, evaluators, program managers, and staff for large and small public health programs. The new discipline of dissemination and implementation science has driven an increase in studies of how new scientific discoveries are translated and developed into programs, policies, and practices . The eviThe concept of program sustainability is not new, and theoretical work has been done in many fields, including business, health care administration, social services, and public health . CurrentAlthough much conceptual work has been done on defining sustainability, a dearth of tools is available to scientists, evaluators, and public health program managers to assess sustainability. Of all the frameworks for sustainability, few have been translated into valid and reliable tools for measuring sustainability. In an extensive literature search, Hutchinson found references to 33 tools measuring some aspect of sustainability . HoweverWe present a new assessment tool based on our program sustainability framework  that allThis measurement development study was designed to produce a reliable assessment instrument that could be easily used to measure capacity for program sustainability. The structure of the PSAT was based on our previous sustainability conceptual framework . The desOn the basis of our prior literature review and concept mapping study , we deveThe pilot instrument development study was not designed as an in-depth validation study. However, we collected a small number of items from a sample of the participants that could be used for simple validation analyses. The focus of the PSAT is to accurately characterize the sustainability capacity of a public health program. As such, if the instrument is valid, the sustainability scores should reflect characteristics of the program, agency, or organization. Conversely, sustainability scores should not be strongly related to characteristics of the individual program directors or staff members who are filling out the PSAT.We employed 2 primary tools to collect data: paper surveys administered in person at trainings and online surveys administered using Qualtrics . The paper and electronic versions of the surveys were identical. Each was composed of 63 elements organized into the 9 original domains.The sustainability project advisory group identified initiatives (comprising multiple grantees with separate programs) and individual programs for a pilot test of the instrument . To ensuSeveral variables that described the respondents’ programs were used as covariates in the validation measure. These variables were program level, program type, role in program, years in program, and perceived sustainability. Program level had 2 options, state or community. Program type described the public health issue that the program focused on: obesity prevention, diabetes, oral health, tobacco, or multiple health topics. Role in program indicated the respondent’s role in their organization: manager/director, evaluator, financial/operations/business manager, program staff, board member, community partner, or other. “Years in program” was a continuous variable that indicated how long the respondent had been with the organization. Perceived sustainability was measured on a 7-point Likert scale with anchors of 1  and 7 (very sustainable) in response to the question “How would you rate the overall sustainability of your program?” The perceived sustainability question was added partway through the pilot study, and 205 participants were able to respond to this question. Although we were limited in the types of covariate questions we could include in this pilot study, these 4 were included to capture potential differences in program sustainability capacity. For example, whether a program is organized at the state or community level may influence its access to resources or partnerships that support sustainability capacity.Using the lavaan structural equation modeling package version 0.4-11 in the R statistical software  ,13. Initoutcome rather than a program’s capacity for sustainability. The final PSAT comprised 40 items organized within 8 subscale domains. Each domain had 5 items. This simple and balanced structure facilitates training and scoring with programs and groups.The item and confirmatory factor analyses resulted in the final structure of the PSAT. 2 = 78.0, degrees of freedom [df] = 32, P < .001), but no difference was detected between tobacco and other types of public health programs, including diabetes, obesity prevention, and oral health . For each of these tests, only 2 groups could be compared because of the small sample size in some of the subgroups. Although the results suggested that the item-factor structure is not identical between community and state programs, examination of the individual item loadings for the multiple group tests showed that the factor loadings are quite similar  for the PSAT were excellent, especially given the small size of each subscale (5 items)  Table 4Table 4. Using the data obtained from the 592 participants of the PSAT pilot development, we created the final PSAT scale to be used for a small number of exploratory descriptive and validation analyses. The average total sustainability score across the 252 programs was 4.84, with a range of 1.32 to 7.00 and an interquartile range of 4.17 to 5.58. Scores had good coverage across the range of possible scores, although program participants were not likely to report extremely low sustainability scores .4,587 = 3.33, P = .01), and level of program . At the same time, PSAT scores are unrelated to 2 individual-level predictors: years in program , and role in program . This provides some discriminant validation evidence that the PSAT instrument is working as intended. The subscale scores vary by level and type of program (Analyses looking at the relationship between the overall sustainability scores and a small set of organizational and individual-level covariates showed that the sustainability scores obtained from the PSAT are significantly related to 2 important organizational predictors: type of program (F program . These pFinally, we conducted a simple construct validity analysis. A sample of 205 of the pilot participants were asked, after filling out the PSAT and before receiving their results, to indicate their perception of their program’s general sustainability. If the PSAT were a valid measure of program sustainability, we would expect PSAT sustainability scores to be positively related to what program managers and staff perceive is the sustainability of the program. The correlations between the perceived sustainability scores and the PSAT overall sustainability scores as well as the 8 domain scores were as follows: overall = 0.68, Political Support = 0.48, Funding Stability = 0.67, Partnerships = 0.44, Organizational Capacity = 0.58, Program Evaluation = 0.45, Program Adaptation = 0.32, Communications = 0.55, Strategic Planning = 0.63. The formal PSAT sustainability scores had a moderate positive correlation with perceived program sustainability. The Funding Stability and Strategic Planning domains were most closely associated with general perceived program sustainability.The results of our psychometric study of the PSAT indicated that the tool is reliable and ready to use for assessing a program’s capacity for sustainability by researchers, evaluators, and program managers and staff. The confirmatory factor analyses show that even with only 40 items, the PSAT is able to capture the distinct elements of program sustainability suggested by previous conceptual work (Preventing Chronic Disease provides more in-depth description of how the PSAT can be used for community and public health programs (The PSAT was designed to be easy to use by a wide variety of public health and other social service programs. It is short, has a consistent structure that facilitates training, and can be used for numerous purposes including program monitoring, program evaluation, and strategic planning. A companion article in programs .There are numerous research and evaluation next steps for the PSAT. A strength of this study is the diversity of public health program types used to test its psychometrics. However, despite this diversity, the tool has been used only with chronic disease programs. On the basis of confirmatory factor analysis, the poorly performing domain of Public Health Impacts was dropped. By removing this public health–specific domain, the tool can now be used by social service and clinical care programs as well. In particular, the promise of sustainability assessment for large-scale health systems is intriguing . MeanwhiA second area of future work is to further validate the PSAT. Although the simple validation data presented here suggest that the sustainability scores obtained with the PSAT are associated with important organizational and program characteristics, this finding needs to be explored in more detail. For example, our data showed that across more than 250 programs, state programs have lower sustainability scores than community programs. Future work can tell us if this is a typical result and help to uncover the underlying causes. It is not surprising that state and local programs may differ in their sustainability. State programs are typically larger, exist in more diverse political environments, have broader partnership structures, and have typically been in existence longer than local programs, which tend to have shorter life cycles. More research is needed to identify the sustainability differences across program types.The ultimate validation challenge for the PSAT is to use it to predict and understand long-term sustainability outcomes for public health and other types of programs . Program


Background. With the increase in bariatric surgery in the UK, there has been a substantial increase in patients undergoing massive weight loss (MWL) seeking postbariatric body-contouring (bariplastic) surgery. However, there is a wide variation of availability on the National Health Service (NHS). Aims. To (1) review the funding policies of Primary Care Trusts (PCTs) in England for bariplastic surgery and (2) analyse the number of procedures funded in two consecutive financial years. Methods. We sent out questionnaires to all PCTs in England regarding their funding policies for bariplastic surgery and requested the number of procedures funded in 2008-09 and 2009-10. Findings. 121/147 (82%) PCTs replied to our questionnaires. 73 (60%) excluded all bariplastic procedures. 106/121 (87.6%) PCTs had referral guidelines for plastic surgery. 46/121 (38%) PCTs provided the total number of funded abdominoplasty-apronectomy (A-A) in the two financial years: total number of A-A applicants rose from 393 to 531, but approval for funding fell from 24.2% to 19.6%. Only 3 (2%) PCTs indicated increase in their future spending on bariplastic procedures in the next 5 years, with 67% planning to decrease or unsure about future funding. Conclusion. There exists a postcode lottery for bariplastic surgery in England and we feel the need for guidelines on provision of bariplastic procedures following MWL. Paralleling the increasing prevalence of obesity, there has been an exponential rise in bariatric surgery worldwide. A recent report showed a 70% rise in bariatric procedures in England in 2009-10 compared to 2008-09  and may In England, the National Health Service (NHS) is a publicly funded healthcare system and treatment on the NHS is free of cost at the point of delivery, but spending is presently controlled by the Primary Care Trusts (PCTs). Each PCT serves patients within a defined geographical area and decides independently how to allocate its budget. Bariplastic surgery is often regarded by the PCT as cosmetic and therefore of low priority, which means funding is either unavailable or subject to various criteria as determined by the PCT. In this age of economic constraints and rationing within the modern NHS, it is widely acknowledged that such treatments would be less available to patients on the NHS. As the PCTs make these difficult decisions independently of each other, treatments that are available in one trust may not be available in another.The “Action on Plastic Surgery” (AoPS) document was produced by the NHS Modernisation Agency in 2005  . This doIndex 1. (AoPS guidance on who should be offered abdominoplasty-apronectomy (A-A)).AoPS recommends that A-A may be offered to the following groups of people:those who are undergoing treatment for morbid obesity and have excessive skin folds,previously obese patients who have achieved significant weight loss and have maintained their weight loss for at least two years,2,stable BMI between 18 and 27 Kg/m(iv)suffering from severe functional problems with the following:recurrent intertrigo between the skin folds,activities of daily living, for example, ambulatory problems,surgical scarring leading to poor appearance and resulting in disabling psychological distress,poorly fitting stoma bags.andThe aims of this study were (1) to review the funding policies of PCTs in England for bariplastic surgery; (2) to evaluate the degree to which the AoPS guidelines are followed; and (3) to look at the total number of bariplastic procedures funded in England in the two consecutive financial years, 2008-09 and 2009-10. We also asked PCTs about their plans for expenditure on bariplastic surgery in the next 5 years. This study is the first comprehensive review of funding policies for bariplastic surgery in England.http://dx.doi.org/10.1155/2014/153194).We sent out a detailed questionnaire electronically to all 147 PCTs in England asking about their funding criteria for bariplastic surgery and whether they used the AoPS guidelines while drafting their policies. We also asked for the number of bariplastic procedures being funded in the two consecutive financial years, 2008-09 and 2009-10. We requested information on abdominoplasty, breast reduction and augmentation, facelift, and buttock, arm, and thigh lift postbariatric surgery  (FOI) was used where the information was withheld. The data was collected over ten months, from February to November 2011. Data was collated and analysed on Microsoft Excel spreadsheet.Out of 147 PCTs, responses were received from 121 (82.3%) PCTs. 4 PCTs acknowledged our request but refused to use the FOI to provide us with the data.Of the 121 PCTs, 48 (40%) PCTs fund bariplastic surgery on the NHS. The remaining 73 (60%) PCTs excluded all bariplastic surgery . Of thes106 out of 121 (87.6%) PCTs had a guideline for plastic surgery procedures. Of these, 5 PCTs (4.7%) followed the AoPS guidelines exactly and 46 PCTs (43.4%) had guidelines similar to it. Of the rest, 25 PCTs (23.6%) had their own guidelines that did not match the AoPS and 30 PCTs (28.3%) were unsure or did not specify in the reply whether they followed the AoPS .2 as the upper limit of BMI for abdominoplasty-apronectomy (A-A). Of the 106 PCTs which had guidelines for A-A, 79/106 (74.5%) had specific body mass index (BMI) targets, ranging from 25 Kg/m2 to 30 Kg/m2, which the patient needed to achieve to be eligible for the procedure (The AoPS guidelines mention 27 Kg/mrocedure . Only 8/75/106 (70.7%) PCTs specifically required the patients to have functional problems in the form of ambulatory difficulties, and 51/106 (48.1%) PCTs required the patients to have troublesome intertrigo, refractory to medical treatment from a period ranging from 6 weeks to 1 year. 8/106 (7.5%) PCTs required the abdominal apron to hang below the symphysis pubis and 9 (8.5%) required the patients to stop smoking to be allowed the A-A. Specific conditions imposed by the PCTs are shown in The most common bariplastic procedure performed was A-A. The PCTs did not provide analyzable data on the other bariplastic procedures like mastopexy, brachioplasty, and buttock and thigh lift. 46/121 (38%) PCTs provided the total number of funded A-A in the two financial years (2008-09 and 2009-10). The total number of A-A applicants rose from 393 to 531, but the approval rate for funding fell from 24.2% to 19.6% consecutively in the two financial years .On future service provision and expenditure, only 3/121 (2%) PCTs indicated that they would increase their spending on bariplastic procedures in the next 5 years, with 37/121 (31%) maintaining the current level of spending and the rest (67%) either planning to decrease or unsure about the future level of funding .There is very little in the literature on the prevalence of bariplastic surgery after bariatric surgery. According to a study by Mitchell et al. 33, out of 70 (47%) patients underwent bariplastic procedures after gastric bypass surgery . GusenofDespite successful weight loss following bariatric surgery, the patients' body image and psychological state may actually deteriorate following the soft tissue deflation noted with MWL , 14. BarThe PCTs act independently of each other while drawing up their guidelines for the purposes of rationing. This leads to variability in funding for procedures in different regions within the NHS. Wraight et al., in 2007, showed a variation in guidelines across Trusts in the UK, amounting to a “postcode lottery” for patients seeking breast reduction . More re2 for these reasons [2 for A-A, but stricter criteria are being set by many PCTs as a means of rationing. Of the 79 PCTs who had specific BMI targets, 26 (32.9%) PCTs had criteria stricter than AoPS, but 15 (18.9%) PCTs have set a higher BMI cut-off at 30 Kg/m2 and acknowledge the fact that it might be difficult for these patients to lose further weight because of the intrinsic weight of the abdominal apron itself. In fact, Dafydd et al. have shown that the weight of the abdominal pannus in patients undergoing MWL may affect their BMI and exclude them from bariplastic procedures. They have therefore recommended that these patients should be considered for surgery even if their BMI is within 1-2 BMI points from the cut-off [At the present time there is no clear BMI cut-off above which bariplastic surgery should not be performed, but higher BMIs have been associated with increased complications . A-A is  reasons , 22. The cut-off .The ideal timing for the bariplastic procedure is when the weight loss has plateaued, the catabolism has ceased, and there has been an improvement in the comorbidities . HoweverBariplastic surgery should be regarded as an integral component of the total care of the obese patient . The NatIn our study 46 PCTs provided us with the actual number of A-A funded in consecutive years. The number of A-A funded was 95 and 104 in the two consecutive years which means at most on average each PCT was funding about 2 A-A in a year. This means a huge proportion of MWL patients are being denied A-A even at this present moment.A recent survey from the UK, commissioned by the BAPRAS, shows that, of 1000 GPs questioned, 45% support NHS funding for bariplastic surgery . We propOur study had a response rate of 82% which is a very good response for this type of questionnaire study and provides a good estimation of the current postcode lottery for these procedures in England. Our questionnaire looked into the funding criteria for bariplastic procedures in England and further studies should be undertaken to compare the availability of these procedures in Wales, Scotland, and Northern Ireland where the healthcare is devolved.This study shows that there exists a postcode lottery for bariplastic surgery in England. There is a strong need for national guidelines on the provision of body contouring procedures following MWL for the comprehensive treatment of these patients.Detailed questionnaire that was sent out to PCTs in England asking about funding criteria for bariplastic surgery, conformation to the AoPS guidelines and the number of procedures being funded. Information was requested on abdominoplasty, breast reduction and augmentation, facelift, and buttock, arm, and thigh lift post bariatric surgery.Click here for additional data file.


Variceal bleeding is a major event in the natural history of end-stage liver disease with a subsequent high mortality rate. Non-selective β-blockers are currently the drugs of choice for preventing first variceal bleeding. Endoscopic rubber band ligation of high risk varices features as a first line option if cirrhotic patients cannot tolerate β-blockers. Despite adequate β-blockade, some patients may still present with variceal bleeding. The effect of carvedilol, a non-selective β and α-1 receptor-blocker, on lowering portal pressure has been investigated in several clinical trials and found to be superior to propranolol in both acute and chronic hemodynamic studies. Recently, carvedilol has also been compared with band ligation for primary prophylaxis against variceal bleeding with equivalent results to band ligation. Patient tolerance to carvedilol in advanced liver disease remains a source of concern. This review examines the place of carvedilol as an alternative to the currently recommended pharmacological therapy in prophylaxis against variceal bleeding. Hepatic hemodynamic studies enable us to indirectly estimate the degree of portal hypertension in cirrhotic patients. Clinically significant portal hypertension is defined as hepatic venous pressure gradient (HVPG) greater than 10 mmHg.The clinical course of cirrhosis, commonly identified as compensated and decompensated forms, has recently been characterized into four prognostic stages. Stage 1 Given the significant mortality associated with variceal bleeding, and that varices may be present in a majority of cirrhotics, clinical trials dealing with portal pressure reduction have channeled their efforts into three main strategies. The first strategy (pre-primary prophylaxis) dealt with prevention of gastroesophageal varices development by using non-selective β-blockers. This strategy was eventually found to be ineffective in preventing development of varices. The seco11Salvage invasive techniques such as transjugular intrahepatic portosystemic shunt (TIPS) and surgical devascularization/shunting are typically reserved for refractory variceal bleeding when appropriately indicated.Non-selective β-blockers exert their effects via blockade of both β1 and β2 receptors. The β1 receptors are located in the myocardium and their blockade results in a decrease in cardiac contractility and output. In the other hand, blockade of β2 receptors located in the splanchnic (mesenteric) vascular bed results in vasoconstriction due to unopposed activity of α1 adrenergic receptors with a net effect of reduction in portal blood inflow.The intrahepatic vascular resistance represents another essential component in development and progress of portal hypertension in cirrhotic. It is caused by morphological changes in the hepatic microcirculation architecture due to pathological changes associated with cirrhosis. It is estimated that up to 40% of this intrahepatic vascular resistance is functionally reversible. This revThe α1 adrenergic receptors are distributed in both the systemic and splanchnic vascular smooth muscles and other sites such as smooth muscles of the genitourinary tract. Pharmacological antagonism of α1 adrenergic receptors would lead to a reduction in the intrahepatic vascular tone. Therefore, the addition of α1 blockers to non-selective β-blockers may attenuate portal pressure. In one trial, propranolol was combined with prazosin (n = 28), a selective α1 blocker, and compared to propranolol plus isosorbide-5-mononitrate (n = 28) for short-term use over 3 months. The formR (+) and S (–). The S (–) enantiomer is mainly responsible for the β-blocking effect of carvedilol, whereas both R (+) and S (–) contribute to the a1-blockade. It is rapidly absorbed following oral administration with a low absolute bioavailability, approximating to 25%. It has a rapid onset of action of 1-2 h. It undergoes extensive hepatic first-pass metabolism with plasma levels of R (+)-carvedilol two to fourfold higher than S (–)-carvedilol in healthy persons. The major P450 enzymes responsible for the metabolism of both R (+) and S (–) carvedilol in human liver microsomes are CYP2D6 and CYP2C9, and to a lesser extent CYP3A4, CYP2C19, and CYP2E1. The elimination half-life of carvedilol is 6-10 h. Drugs that inhibit CYP450 2D6 activity such as sertraline may increase plasma concentrations of R-carvedilol, in turn augmenting the systemic hypotensive effect of carvedilol. Drug excretion is mainly biliary and into feces, and renal elimination is minor requiring no dose adjustment in kidney impairment.Carvedilol16 is a rCarvedilol is available in various immediate release (used as once or twice daily) and extended release formulations (used as once daily). The drug is FDA approved for management of essential hypertension, congestive heart failure, and left ventricular dysfunction following myocardial infarction.Due to its unique mechanism of action, carvedilol was compared to propranolol in several clinical trials.–1922 In 19et al,[Clinical trials evaluating the acute hemodynamic effects of carvedilol at a dose of 25 mg on portal pressure showed a reduction in HVPG by 17–27% from baseline measurements Table 1Table 1. et al, reportedChronic carvedilol administration at lower doses of 12.5 mg was studied in two clinical trials.21 Both tIn the first and only randomized controlled trial comparing carvedilol with variceal band ligation for primary prophylaxis against variceal bleeding, 152 cirrIt should be noted that in these clinical trials, the predominant liver dysfunction was Child-Pugh class A. Cirrhotic class B or C patients were more likely to suffer adverse effects, particularly when doses higher than 12.5 mg were used. It is also worth addressing that lower doses of carvedilol at 12.5 mg showed a comparable portal hemodynamic effect when administrated chronically as reported from at least two studies.21 TitratGiven the powerful effect of carvedilol on portal hemodynamics, the question remains whether carvedilol should be the drug of choice in patients with varices who have non-cirrhotic portal hypertension? As of yet, this issue has not been addressed yet in this cohort of patients who may tolerate higher doses of carvedilol. Secondly, another question that remains unanswered is whether carvedilol should replace non-selective β-blockers in Child-Pugh class A cirrhotic patients presenting with variceal bleeding despite adequate β-blockade? Finally, despite of the promising results reported in these trials, larger randomized, controlled clinical trials comparing carvedilol with other non-selective β-blockers, or further head-to-head trials comparing carvedilol to band ligation must be conducted. Adequately powered trials with better patient selection, well-defined clinical end points, careful assessment of adverse events, and sufficient follow-up are required before we can advance carvedilol into an evidence-based treatment algorithm of portal hypertension.


The antigen recognition pattern of immunoglobulin M (IgM) could, when directed against protein antigens, provide an indication of the antigenic moieties triggering new B cells. The half-life of IgM is short and memory B cells against T-cell-dependent protein antigens typically produce IgG and not IgM antibodies. In this study, we analyzed whether a difference exists between the fine specificity of IgM versus IgG anti-citrullinated protein antibodies (ACPAs).We determined the fine specificity of IgM and IgG ACPAs in 113 ACPA-positive rheumatoid arthritis patients with IgM cyclic citrullinated peptide 2 (CCP2) levels above 100 AU/ml. Fine specificity was assessed by performing ELISA using citrullinated peptides derived from vimentin, fibrinogen-β, fibrinogen-α and α-enolase, as well as citrullinated proteins fibrinogen and myelin basic protein. The arginine counterparts were used as controls.P < 0.0001).Recognition of defined citrullinated antigens by IgM ACPA was confined to samples that also displayed recognition by IgG ACPA. However, the IgM ACPA response displayed a more restricted antigen recognition profile than IgG ACPA (OR = 0.26, Our data show that several defined citrullinated antigens are recognized only by IgG ACPA, whereas others are also recognized by IgM ACPA. These observations suggest that not all citrullinated antigens are able to activate new B cells despite concurrent recognition by IgG ACPA. Anti-citrullinated protein antibodies (ACPA) may be involved in the disease pathogenesis of rheumatoid arthritis (RA). ACPA can be found early in the disease course , even be+ T cells. These T cells provide the helper activity required for affinity maturation, isotype switching and memory cell formation. When such T-cell help cannot be provided, as in the case of hyper-IgM syndrome, IgG, IgA and IgE antibody levels are absent or severely reduced [The ACPA response likely represents a T-cell-dependent B-cell response, given the protein nature of the antigen recognized and the strong association with the human leukocyte antigen shared epitope alleles. The evolution of such a response is typically characterized by a first wave of IgM antibodies after the first antigen contact, quickly followed by the presence of IgG. After repeated antigen exposure, the IgG responses are further boosted while the IgM peak declines. The latter observation is explained by the presence of Ig-switched, affinity matured, memory B cell that are formed in the presence of CD4 reduced . The pre reduced ,8, thereTo the best of our knowledge, IgM-producing memory B cells against T-cell-dependent antigens have not been described, in contrast to T-cell-independent B-cell responses against, for example, repetitive sugar residues on bacteria ,10. For We determined the fine specificity of ACPA IgM and IgG in 113 serum samples of anti-cyclic citrullinated peptide (CCP2) IgG and IgM double-positive RA patients collected from the Leiden Early Arthritis Clinic (EAC), an inception cohort of recent-onset arthritis that was initiated at the Department of Rheumatology at Leiden University Medical Center in 1993 [Demographic data  of ACPA IgG-positive RA patients who had ACPA IgM ≥ 100 AU/ml were not different from patients displaying ACPA IgM levels < 100 AU/ml. The peptides used in this study are linear citrulline (Cit)-containing peptides, which are known ACPA IgG epitopes in RA, as well as their arginine counterparts . SpecifiFine specificity assays of ACPA IgG were performed essentially as described before , with miSamples from 18 patients were used to analyze the specific reactivity of IgM against CCP2, Fib-α and Fib-β over time. We used serum samples obtained at baseline and at 1, 2 and 5 years of follow-up. Samples were tested by ELISA as described above. Samples were considered positive when they displayed an absorbance value higher than the cut-off and a difference of at least 0.1 absorbance units when comparing the reactivity against the Cit-containing peptide and its arginine-containing control peptide.U test or analysis of variance. The associations between ACPA IgM and ACPA IgG positivity were evaluated by using 2 × 2 tables for the estimation of ORs and 95% CIs. The correlation between ACPA IgM and ACPA IgG responses were determined using Spearman's rank-correlation coefficients. The χ2 test was used to evaluate differences in the frequency distribution of ACPA IgG and IgM. All data were analyzed with GraphPad Prism version 4.0 software  or SPSS for Windows release 16.0 software . In all tests, P < 0.05 was considered significant.Differences between groups were analyzed using the Mann-Whitney It has been shown that IgM ACPA can be detected in the sera of RA patients with established disease, suggesting an ongoing recruitment of new B cells into the ACPA response . If IgM Our data show that some but not all citrullinated epitopes are recognized by IgM ACPA Table . These dP < 0.0001). For those reactivities where, next to IgG ACPA, IgM ACPA responses also were apparent, a correlation between the titers of IgG and IgM ACPAs was observed between the positive samples (data not shown).We next determined the recognition profile of IgG ACPA. Although not all patient sera recognized all citrullinated epitopes, the IgG ACPA epitope recognition pattern was clearly much broader than the epitope recognition profile of IgM ACPA Figures  and 2. IWhen reactivity patterns were directly compared at an individual level, we observed that IgM ACPAs against some citrullinated epitopes, but not others, were present. However, in all cases, IgM positivity was paralleled by the presence of IgG recognizing the same epitopes. In contrast, patients can display certain IgG ACPA reactivities in the absence of IgM reactivities against the same antigen Figure . TogetheTo address the question whether the observed differences between IgG and IgM reactivity are limited to baseline samples only or whether they are also present at later follow-up, we analyzed ACPA IgM reactivity against three peptides over time. The reactivity of ACPA IgM against CCP2, Fib-α and Fib-β at baseline and at 1, 2 and 5 years of follow-up was analyzed in sera of 18 patients. We observed that the ACPA IgM levels against these peptides appeared rather stable Figures  to 3C. SIn this study, we observed that ACPA IgM responses are different from ACPA IgG responses, as they display a more restricted antigen recognition pattern. These data are intriguing, as they indicate that the regulation of the IgM ACPA response differs from the regulation of B cells producing IgG-directed against citrullinated antigens. Although the reason for this difference is not known, we think it is most conceivable that these findings are explained by a limited recruitment of new B cells into the ACPA response that is driven by some, but not other, citrullinated antigens. Given the short half-life of circulating IgM and the lack of memory B cells producing IgM against protein antigens, we think that the IgM ACPAs detected in this study are produced by new B cells that are recruited into the ACPA response against certain citrullinated antigens. Even in the case where ACPA IgM-producing memory B cells exist, it is still interesting that such cells are present only against certain citrullinated antigens.For this study, we selected patients who are double-positive for IgG and IgM CCP2 reactivity. To exclude the possibility that differences between IgG and IgM may be explained by differences in the sensitivity associated with the detection of IgG or IgM antibodies by ELISA, we selected only patients with an IgM level of at least 100 AU/ml. Indeed, in the setup we used, we observed that, although the IgG responses against the different citrullinated antigens were rather similar in absorbance units, IgM reactivity was detected only against some antigens but not others. This observation was made at baseline but appears also to be present at follow-up. To ensure that we did not introduce additional bias into our data, we compared the demographic data  of ACPA IgG-positive RA patients who had ACPA IgM ≥ 100 AU/ml with those who had ACPA IgM < 100 AU/ml and observed no differences.-activated-Sepharose beads , there was no reduction of ACPA IgM levels. Moreover, after mixing sera which were highly positive for RF IgM but negative for ACPA IgG and ACPA IgM with sera which were RF IgM- and ACPA IgM-negative but ACPA IgG-positive, ACPA IgM could not be detected [Since IgM rheumatoid factor (RF) could also be a confounding factor, we compared RF levels between the patients who displayed ACPA IgM ≥ 100 AU/ml with those who had ACPA IgM < 100 AU/ml and observed that in RA patients with ACPA IgM ≥ 100 AU/ml, the levels of RF IgM were higher than in RA patients who had ACPA IgM < 100 AU/ml (RF IgM 50 AU/ml 25 to 118) and 28 AU/ml (12 to 60), respectively). To exclude the possibility that our findings were influenced by IgM RF, we analyzed ACPA IgM specificities in relation to IgM RF. We observed that IgM RF-positive samples can be negative for IgM ACPA reactivities and that, in the absence of IgM RF, IgM ACPA reactivities can be detected readily (data not shown). RF-positive samples that have IgG reactivity against all fine specificity epitopes may have IgM ACPA against only some antigens and not others, confirming that our assay did not merely detect IgM RF. Previously, we addressed this issue experimentally [ and 28 AAlthough it is tempting to speculate, these studies should not be taken as an argument for the involvement of the antigens analyzed here in the recruitment of new B cells into the ACPA response. Peptides are unlikely to reflect correctly the three-dimensional structure of citrullinated proteins that form the epitope for antibodies. Moreover, ACPA IgG is cross-reactive to multiple citrullinated antigens ,16, and How IgM can be formed in the presence of an active IgG response against the same antigen is not clear. In other situations, as exemplified by the prophylactic administration of anti-Rhesus D antigen antibodies to pregnant women carrying a Rhesus D-positive child, the presence of IgG against a certain antigen will prevent the induction of a novel IgM response. The mechanism behind this protective measure is thought to be mediated by either the capture and clearance of circulating Rhesus D antigen and/or by IgG-Rhesus D immune complexes that inactivate new Rhesus D-reactive B cells through FcγRIIB, the inhibitory Fcγ IIB receptor . ClearlyCollectively, our data show that the immune response against one citrullinated antigen is different from the immune response against another citrullinated protein. Some responses are dominated by IgG, whereas both IgM and IgG responses were found for other ACPA antigens. Elucidation of the mechanism behind this observation could be of relevance to the identification of those citrullinated antigens that drive ACPA responses and could provide clues to how the continuous recruitment of new B cells can be halted.ACPA: anticitrullinated protein antibody; Arg: arginine; AU: arbitrary unit; BL: baseline; Cit: citrulline; CCP2: cyclic citrullinated peptide 2; EAC: Early Arthritis Clinic; ELISA: enzyme-linked immunosorbent assay; Fib: fibrinogen; FU: follow-up; Ig: immunoglobulin; IgM: immunoglobin M LUMC: Leiden University Medical Center; MBP: myelin basic protein; RA: rheumatoid arthritis; RF: rheumatoid factor.The authors declare that they have no competing interests.PS, TWJH, REMT and LAT conceived the study and participated in its design and edited the manuscript. PS and LAT drafted and prepared the manuscript and performed the statistical analyses. AW assisted with manuscript preparation. PS, LVT, GSR and NL performed blood analyses. JWD provided peptides essential for the assays. All authors contributed to the interpretation of the study findings and approved the final manuscript.


This study reports the results of a pilot volunteer project for older Chinese immigrants and documents benefits for both volunteers and caregiver recipients. Using a social marketing approach, the volunteer project was designed as a social model to promote better health among older Chinese immigrants in New York City. The packaging of this health promotion project as a volunteer program was based on a strengths perspective. In the program, 18 older Chinese immigrants were trained to provide support and referral to family caregivers of ill relatives in the Chinese community. At 6 months, outcomes were evaluated for both volunteers and caregivers. The older volunteers perceived benefits associated with volunteering, specifically, a greater sense of well-being and satisfaction with life. In addition, the majority of volunteers felt empowered by training and volunteering (100 %), felt the skills they learned improved communication with their own families (90 %), and reported physical and emotional health benefits (61 %). At the same time, caregivers reported stress reduction following volunteer support. Findings suggest that a volunteer program model may be an effective health promotion intervention for older Chinese immigrants. Globally, the proportion of people aged 60 and over is growing faster than any other age group as a result of longer life expectancy and a decline in fertility rates , which supports and trains older volunteers to serve their communities. National Senior Corps programs in the US have played an important role in promoting volunteering among old people—approximately half a million older adults have volunteered in their programs—as have a number of other organizations such as Executive Service Corps and the National Retiree Volunteer Coalition.Research on and evaluation of older volunteers programs suggest that they could meet critical needs for their communities. For example, “Experience Corps” provides evidence that older volunteers have the capacity to tutor children with learning difficulties and improve their academic performance . Social marketing is about packaging the program so that the desired target population will buy-in and adopt the program (product) for themselves  to increase volunteers’ trust, confidence, social engagement, and social support; (2) to increase volunteers’ knowledge and skills in active listening, problem-solving, family communication, and stress management; (3) to improve volunteers’ self-efficacy and sense of fulfillment in life; (4) to lower caregivers’ sense of loneliness and suffering from caregiving burden. The goals of the program at the organizational level were: (1) to evaluate the effectiveness of recruitment methods; (2) to evaluate the usefulness and appropriateness of the training curriculum; (3) to evaluate the effectiveness of the infrastructure of the social work team; (4) to evaluate the outcomes of the Phone Angel Program for both older volunteers and caregiver recipients.The Phone Angel Program involved recruitment, knowledge and skills training, consistent supervision, documentation of contact with caregiver and difficulties encountered, a support group to share volunteer experiences, sharing of personal issues among volunteers, and a program evaluation including an assessment of volunteer efficacy and caregiver stress before and after training and services.The program was conceptualized during the summer of 2010 by a university social work researcher and a hospital-based social work researcher, then further developed with input from social workers in a senior center. The University partnership was critical because the social work researcher brought expertise in developing a knowledge-based training curriculum and scientific evaluation of the program. This expertise was complemented by the hospital-based researcher’s in-depth knowledge about caregiver burden and cultural burden among older Chinese Americans. The hospital-based researcher obtained financial support for the pilot, and the social work team agreed on the roles of each partner organization before implementation of the program in November 2010.Volunteers were recruited in various ways. First, a bilingual flyer with an overview of the Phone Angel program was distributed at the senior center. The flyer included information about the Phone Angel Program, the stipend, the 6-month commitment, and the telephone support component. Seniors were invited to a general meeting to learn more about the program. The meeting, held at the beginning of November, was attended by 250 seniors, and 19 signed up to become volunteers. Immediately after the meeting, potential volunteers communicated with the social worker in the center to enquire about the program in greater detail. After people signed up, the social worker followed up with a call to each potential volunteer to confirm their participation and to perform a brief screening. The same 19 volunteers confirmed their interest, and all were deemed appropriate by the social worker. Chinese caregivers of ill relatives with unmet needs were identified by the hospital-based social worker and referred to the senior center social worker for matching with volunteers based on Chinese dialect and gender.Training was comprised of 72-h, intensive training sessions between November 2010 and February 2011, followed by ongoing training sessions every 3 to 4 weeks. As most of the volunteers had no prior family caregiving experience, early training sessions provided context and knowledge about the plight of family caregivers, expectations for their role as volunteers, caregiver burden and life event stressors, active listening and communication skills, coping and problem-solving skills, and family dynamics. Volunteers were trained to provide telephone support to caregivers using Mandarin or Cantonese, whichever language the caregiver had the most linguistic comfort with, at least once a week. Volunteers were educated in basic empathy, learning to assess the needs of caregivers, not adding to the burden of caregivers by calling too frequently, and evaluating when would be the best time to call.Introduction to population aging issues.The family caregivers’ needs and complex emotions.Tasks and Role of Phone Angel volunteers.Basic Communication Skills and Effective Listening.Tips for suggested coping skills/problem solving skillsHow do I talk to the caregiver when I call?Special Tips for Me as a Volunteer Phone Angel: Do’s and Don’ts for volunteers.The following topics were covered:Initially, training was conducted every 2 weeks, but as volunteers gained confidence and a sense of competence in their role as volunteers for caregivers, training was spaced to 3 or 4 weeks apart. Later training sessions were focused on sharing, supervision, and processing and problem-solving difficult caregiver situations. Between meetings, additional monitoring and support were available to the Phone Angels and caregivers from their respective social workers. Role plays were conducted during the training sessions to develop the volunteers’ communication skills. As volunteers showed readiness for their Phone Angel duties, they were assigned a caregiver.Ongoing training and support of the Phone Angel volunteers was fundamental to the success of the program. To establish this, it was necessary to develop a core infrastructure through which the social workers at the hospital and the senior center met regularly to coordinate the matching of the Phone Angels with identified caregivers and to discuss and resolve issues as they arose.Phone Angels were each assigned to one, two, or three caregivers and instructed to call each caregiver at least once a week but up to three times a week as needed. Assignments were based on the Phone Angel’s primary language and gender. Caregivers received an average of three to eleven calls each before the completion of the program, depending on their level of need. Most Phone Angels provided emotional support, practical advice about community resources, guidance about family conflict, and advice about future care planning for the ill relative. In terms of boundaries, Phone Angels were advised to keep calls to 30–60 min in duration, to focus on the needs of the caregiver, and to maintain the relationship over the phone rather than suggesting face-to-face contact. Phone Angels were conscientious in keeping records and producing a weekly report to document the frequency of their calls, the content of each call, and the actions taken. Every call was carefully assessed in terms of the volunteers’ sensitivity and active listening skills. If volunteers encountered a complicated situation that required professional intervention, caregivers would be referred back to the hospital social worker for follow-up. Such cases included the need for ongoing or new medical care, questions about housing, and requests for more paid assistance in the home. Other issues included finding the optimal time for making calls and trying to engage a caregiver who was talking in front of the ill relative using speaker phone.Phone Angel volunteers received a $50 stipend after the intensive training program and another $50 after 6 months of service. The stipend offset volunteers’ travel expenses. It was also a meaningful incentive for volunteers, not only because the majority of the Phone Angel Program volunteers were low-income, but also because payment gave them a sense of dignity and tangible societal worth to their families. The financial cost of maintaining the volunteer service was low because volunteers could call Chinese family caregivers from both the senior center and their own homes. Calling cards were provided to the Phone Angels so that they did not have to use their own phones, which protected their privacy.Nineteen older Chinese seniors signed up as volunteers, one dropped out, and 18 completed the program. The mean age of volunteers was 72.1 (range: 64–86). Phone Angels were disproportionately women (72 %), married (89 %), and born in mainland China (94 %). In terms of perceived health, 72 % reported that their health condition was “fair,” 22 % reported “good” health, and only 6 % reported “excellent” health. Ninety-four percent of the Phone Angels felt that their English proficiency was fair to poor, and listed Chinese as their preferred language in daily interaction with family and friends. They were considered well educated in their home country (44 % with at least some high school education).After 6 months of service, the social work researcher assessed perceived benefits of the Phone Angel Program for volunteers, using a focus group and a short questionnaire with closed and open-ended questions. Results show that the majority of the older volunteers perceived great benefits from their participation in the Phone Angel Program. These included a better sense of self, self-efficacy, and time management; better relationships and communication skills; higher levels of awareness about social issues; and a sense of improved mental health and emotional well-beingUsing a survey instrument with closed-ended questions worded to attribute any perceived change due to the Phone Angel Program, volunteers were asked to rate or endorse the descriptive items listed below. Some statements used rating options of “Agree” or “Disagree,” while others used response options of “worse,” “same,” and “better.”I feel empowered and happier because I have the opportunity to serve others (100 %)I feel I have made a contribution to the community through this Program (78 %)I have developed a stronger sense of purpose in my life (100 %)I have developed an ability to improve personal time management skills (78 %)I have developed a better understanding of my own emotions (83 %)I have enlarged my social circle of friends (83 %)I feel better about myself (67 %)I have developed better communication skills (100 %)I have developed a bigger vision about life (89 %)I am better able to share the knowledge and skills I learned with my family and friends (89 %)I feel that my family is supportive of me in doing volunteer work (72 %)I know my family is very proud of me being a Phone Angel to help others (56 %)My family is more aware of community issues (72 %)My relationship with my family has improved (72 %)I am considered a role model by my family (72 %)My spouse and I have become more active in social activities (61 %)The following are the descriptive data on perceived benefits reported by the Phone Angel older volunteers. All items started with “After joining the Phone Angel Program”,At the end of the questionnaire, open-ended questions were used to elicit the perceived effects of Phone Angel Program participation on personal growth and family relationships, while also providing the opportunity to make “additional comments” to share perceptions about the impact of the volunteer experience on their lives. Volunteers were asked to rate whether the intensive training and on-going support were useful for them in fulfilling their volunteer responsibilities. Volunteers also reported their perception of the impact of their services to the caregivers. Eighty-nine percent of Phone Angels felt that their work improved caregivers’ lives and caregivers were very responsive and appreciative of their support. Two Phone Angels felt that caregivers did not respond to them initially and felt that their work was not appreciated as expected. However, they learned that these caregivers were too stressed to receive help and needed more time to establish rapport with the Phone Angels.In terms of the usefulness of the training curriculum, 89 % of the Phone Angel volunteers felt that the curriculum, supervision, and on-going support were “extremely useful” for them and only 11 % felt they were just “useful.” Regarding perceived health, 61 % of the Phone Angels felt that their health was “better” as a result of participation in the program, and 39 % stated “same.” These findings suggest that these older Chinese volunteers in the Phone Angel program perceived benefits to themselves, to caregiver recipients, and to family. When asked about other effects associated with the Program participation, all volunteers reported that they learned to improve their time management skills by scheduling training sessions, meetings, and friendly calls to caregivers.Twenty-eight caregivers who received support from Phone Angels were assessed using the Brief Assessment Scale for Caregivers (BASC) in Chinese as well as other measures specifically designed for the program. As a group, these caregivers felt that Phone Angel volunteers reduced their stress and burden, listened well, and made good suggestions when problems were presented. The impact of the program for caregivers is described in another manuscript  to replicate the Phone Angel Program in more senior centers as a health promotion option, and (2) to expand the recipient groups to other needy Chinese sub-groups including people living alone, isolated older adults, mental health patients, caregivers of special needs children and adult individuals, and new immigrants. This program appears to have the potential to provide a large segment of the older Chinese population with opportunities for meaningful productive engagement, and with improved health and mental health benefits. Future research will be needed to answer questions about the long-term impact of the Phone Angel Program on individuals and communities, strategies for older Chinese volunteer programs to be developed in different Chinese communities in other regions, and program sustainability and cost-benefit to society.The Phone Angel Program brought cultural change to the Chinese older adult population, to the senior center and to the hospital, to their families, and to the community at large. Through the program, volunteers brought a personal investment in the welfare of fellow Chinese immigrant families and their community. Social network connections among Phone Angel Program volunteers created new avenues for information exchange and resource mobilization. The Phone Angel Program volunteers created synergies of influence across collaborating organizations and among volunteer individuals so that the organizations, and ultimately the larger community, benefited. These findings suggest that the impact of volunteers is amplified when caregiver recipients are less likely to feel isolated and unsupported.The development and implementation of the Phone Angel Program demonstrated how a social marketing conceptual framework can serve as a social model of mental health intervention for the older Chinese population in New York City. The collaborators demonstrate how social marketing can be used to guide the development of volunteer programs for health promotion. Health prevention and promotion programs embedded in a volunteer program have the potential to engage older Chinese who might not respond to a direct appeal to improve their health and mental health, as it is appealing to their strengths, not their weaknesses.The strength of this pilot program lay in the dual benefits for both volunteers and caregiver recipients. Using an evidence-based approach with a training curriculum, research instruments, and outcome measures ensured program replication. The program was costly in terms of social work time and expertise, but the cost was well worth the benefits: health and mental health benefits for older volunteers; provision of social support and social connection to the caregivers; and an overall benefit to society. Limitations included the small sample size, which affects generalizability of findings. However, the implementation process confirmed the feasibility of the project, the usefulness of the training curriculum, the effectiveness of partnership among social workers and organizations, and the willingness of older Chinese Americans to be volunteers.


It was reported that mid-wall striate late gadolinium enhancement at interventricular septum (MWS-LGE) definite by CMR was strong predictor of prognosis including sudden death with dilated cardiomyopathy (DCM). On the other hand, randomized trial have shown that beta-brokers lead symptomatic improvement, reduced hospitalization and enhanced survival in many patients with heart failure.The object of this study was to evaluate the impact of mid-wall striate of LGE(MWS-LGE) at interventricular septum to beta-broker (Carvedilol) titrating to the target dose and improvement of cardiac function with DCM.Fifty-five patients with DCM examined by LGE-CMR were enrolled. They were treated with Carvedilol at higher dose as possible.They were divided into two groups according to MWS-LGE positive or not.The maximum dose of Carvedilol with each group at chronic stable condition(after 21.6 +/- 21.4 months later from initiation of Carvedilol) were compared. The improvement of UCG parameter of each group by Carvedilol therapy was examined.1) The UCG parameters of all 55 DCM patients recorded just before initiation of Carvedilol were LVDd; 65.2±7.5mm,LVDs; 56.3±8.5mm,EF;28.2.±8.1% and mean final dose of Carvedilol with all 55 DCM patients was 11.5±5.5mg.2) MWS-LGE was found in twenty patients of DCM (38.1%) with LGE-CMR.3) There were no significant difference between two groups in LVDd, LVDs and EFat first echocardiograph.4) The final dose of carvedilol with MWS-LGE -positive group was lower than with MWS-LGE -negative group .5) The UCG parameter showed improvement at chronic stable phase compared to those had recorded at just before initiation of Carvedilol in the both groups, but especially in the MWS-LGE negative group showed a greater improvement than those of MWS-LGE positive group Table .The relationship between the beneficial effect of Carvedilol with DCM and MWS-LGE defined by LGE-MRI was examined. The DCM patients with MWS-LGE negative showed higher maximum dose of Carvedilol and greater improvement of UCG parameters compared to those of patients with MWS-LGE positive. The MWS-LGE has a potential to have a strong worse impact to titrating and beneficial effect of Carvedilol with DCM.