As part of the process evaluation (PE) of Alive & Thrive in Ethiopia, a large-scale initiative to improve infant and young child feeding (IYCF), we assessed these four fidelity elements along three components of its community-based intervention: training of frontline workers (FLWs), delivery of program tools and messages, and supportive supervision.Program effectiveness is influenced by the degree and quality of implementation, thus requiring careful examination of delivery processes and how the program is or is not being implemented as intended. Implementation fidelity is defined by Data from a qualitative study among three levels of FLWs (n = 54), i.e. supervisors, health extension workers (HEWs), and community volunteers, and among mothers with children under two years of age (n = 60); and cross-sectional PE surveys with FLWs (n = 504) and mothers (n = 750) in two regions (Tigray and SNNPR) were analyzed to examine program fidelity.There was strong adherence to the intended cascading design (i.e. transfer of knowledge and information from higher to lower FLW levels) and high exposure to training . Training quality, assessed by IYCF knowledge and self-reported capacity, was high and increased since baseline. Job aids were used regularly by most supervisors and HEWs, but only 54% of volunteers in Tigray and 39% in SNNPR received them. Quality of program message delivery was lower among volunteers, and aided recall of key messages among mothers was also low. Although FLW supervision exposure was high, content and frequency were irregular.There is evidence of strong fidelity in training and delivery of program tools and messages at higher FLW levels, but gaps in the reach of these to community volunteers and mothers and variability between regions could limit the potential for impact. Strengthening the linkages between HEWs and volunteers further can help to reach the target households and deliver IYCF results at scale. Child malnutrition persists in Ethiopia, with high rates of childhood stunting (44%) and underweight (29%) , charactTo scale up primary health care services, the Federal Ministry of Health’s flagship Health Extension Program has deployed government-salaried female health extension workers (HEWs) to health posts in rural communities since 2003 . HEWs deProgram effectiveness is influenced by the degree and quality of implementation -15. A maadherence to intervention design; dosage and exposure; quality of delivery; and participant responsiveness [Implementation fidelity, or program integrity, is the degree to which programs are implemented as intended ,15,18,19siveness . Dosage siveness ,13 and ia (WDAs) or Health Development Armies (HDAs). In addition to the community-based intervention, a large scale mass-media campaign in various local languages was launched in the four regions to promote IYCF messages through radio, TV, and mobile vans to show video clips.Alive & Thrive (A&T) Ethiopia is a multi-year initiative that started in 2009 and aimed at reducing undernutrition caused by suboptimal breastfeeding and complementary feeding practices. The program delivers age-appropriate child feeding messages and counseling to mothers and caregivers of children less than two years of age at the community level primarily through the Health Extension Program, utilizing the large network of HEWs and community volunteers. Coverage of A&T community-based interventions is intended to be achieved at scale through different program platforms in the four most populous regions, i.e. Amhara; Oromia; Southern Nations, Nationalities and Peoples Region (SNNPR); and Tigray. These platforms include a direct partnership with the USAID-funded Integrated Family Health Program (IFHP), which covers more than 80% of A&T program areas, as well as partnerships with other local organizations such as faith-based organizations and women’s associations to provide services to the target population and mobilize communities. Also, there are region-specific partners such as the large nongovernmental organization in Tigray called the Relief Society of Tigray (REST). At the community level, we refer generically to the cadre of frontline workers (FLWs) as community volunteers, previously called volunteer community health promoters, which were scaled up and restructured by government policy in 2012 to the Women’s Development ArmiesThe central approach of the community-based intervention is the cascading schema, involving the transfer of information, knowledge and skills, as well as program tools from FLWs at higher to lower levels (i.e. from HEW supervisors and HEWs to volunteers). FLW capacity building is a major focus of the program, and health workers should receive enhanced training (at least once) and refresher training on nutrition with a particular focus on IYCF, as per the manual and tools developed by A&T. Then FLWs disseminate the program tools and provide education and interpersonal counseling to mothers and caregivers in the community, during health post visits, home visits, or community gatherings. HEWs and volunteers receive monthly supportive supervision and feedback in order to identify program gaps and reinforce capacities. Fulfilment of the program delivery as above is intended to lead to optimal IYCF practices and final impact of improved child nutritional status. To highlight the scope of this study, Figure b of the IRT, and training of trainers and all HEWs on this module was completed by September 2012. In parallel to IRT rollout, A&T/partners provided (1) primary healthcare staff training for supervisors and health workers (to provide on-the-job training to HEWs and other FLWs); (2) training and provision of supportive supervision that includes IYCF; and (3) review meetings to provide additional training or refreshers based on knowledge gaps identified during supervision. Also in mid-2011, a policy for restructuring the volunteer community health promoters into the WDA/HDA was put in place, and the new cadre of volunteers was established in 2012.In relation to the timeline of implementation, initial training of HEWs in some program intervention areas started in August 2010. However, the Federal Ministry of Health instituted the policy of government-managed Integrated Refresher Training (IRT) in June 2011, which stipulated that HEWs were only to receive training through IRTs. As a result, A&T incorporated IYCF information and materials into the maternal and child health moduleThis study is part of a larger process evaluation (PE) of A&T’s IYCF interventions conducted in two regions (SNNPR and Tigray) of Ethiopia , within woredas (districts), three per region, were purposively selected for differences in A&T platforms or partners and operational duration, in order to capture variations in program delivery processes. In each woreda, two kebeles (villages) were selected randomly. Primary data collection involved in-depth semi-structured interviews (n = 54) with HEW supervisors (one per woreda), HEWs (one per kebele), and community volunteers (three per kebele), as well as brief interviews with beneficiaries (n = 60) to triangulate responses of FLWs and verify program exposure. Interviews were audio recorded and transcribed by the interviewers, then translated into English for data analysis.For the qualitative study, six PE surveys for FLWs and households were conducted in the 75 enumeration areas (26 in Tigray and 49 in SNNPR) in 55 woredas that are part of the impact evaluation. Household surveys (n = 750) were conducted among mothers, using a two-stage cluster sampling method . In each enumeration area/kebele, there is usually one health post, which consists of two HEWs. Both HEWs, their supervisor, and approximately four volunteers from a list of community health volunteers identified by HEWs in each enumeration area were selected to participate in the FLW survey (n = 504). A summary of the topics covered and the sample type and size for each data collection method is provided in Table Results from the 2013 PE survey were compared with the 2010 baseline survey data, where similar measures are available such as FLW training exposure and IYCF knowledge. Although similar sampling methods and instruments were used, there were differences in sampling frames and sizes between the two cross-sectional surveys .Quantitative data were analyzed using Stata 12 . DescripResults are presented by the three programmatic components of training, dissemination of program tools and messages, and supervision. For each component, we show results of the fidelity elements of adherence, exposure, quality and participant responsiveness. Given that various measures were used to assess each element of implementation fidelity, not all of the data tables and figures are included in this paper, although the main results are discussed.The study protocol was approved by the Institutional Review Boards of the Ministry of Science and Technology in Ethiopia and of the International Food Policy Research Institute. Written informed consent was obtained from all study participants.Table A total of 54 FLWs were interviewed for the qualitative study in Tigray n = 27) and SNNPR (n = 27), with equal sample sizes across the six different woredas (Table 7 and SNNCapacity building of FLWs is the main focus of A&T collaboration with partner organizations (e.g. IFHP and REST). The A&T enhanced training about child nutrition and IYCF is called ENA-BCC-CF , which enhances the prior training on ENA-BCC that includes BF information. ENA-BCC-CF content was incorporated into the maternal and child health module of IRT, which was rolled out to all HEWs. Additional training or refreshers are also provided by A&T/partners to supervisors and HEWs on a needs basis during review meetings for various health programs, in coordination with the Regional Health Bureaus. Then HEWs develop their plans for training and orienting the community volunteers, in order to transfer their knowledge and expand coverage of IYCF counseling and education in the communities.Given potential exposure to similar training content from different sources, unique A&T program “tracers” such as the “7 Excellent Feeding Actions” (A&T’s key IYCF messages) and specific content items  were used to determine adherence to content and verify types of training received. Most FLWs confirmed having received nutrition training, specifically ENA-BCC-CF training  . The importance of reaching the volunteers to train and work with them was reiterated by supervisors and HEWs: “Training quality was measured distally in terms of IYCF knowledge Table  and selfThere were very few negative self-reported perceptions about work or job performance (data not shown). In both regions, 76.5% to 96.0% of all FLWs agreed or strongly agreed on their confidence about job performance, serving as a reference for overall work-related self-efficacy. FLWs in Tigray (72.1% to 88.0%) expressed more confidence about their ability to provide IYCF education, compared to their counterparts in SNNPR (59.2% to 67.8%). Community volunteers were the least confident about their ability to give IYCF education in either region. Most FLWs also reported the need for further training on IYCF counseling, with the highest response rate (92.3%) among volunteers in SNNPR. These results corroborated the trends in IYCF knowledge among different FLW types and between regions.I really liked it because the 7 feeding activities are compiled together.”); (2) practical activities such as the food preparation demonstrations ; and (3) the focus on fathers’ involvement in child feeding. Community volunteers also reinforced these aspects, particularly the usefulness of practical food demonstrations and the focus on locally available foods. While no respondent directly expressed negative opinions about the training, 3 of the 12 HEWs and 7 of the 36 volunteers interviewed reported the need for more frequent or continual training to help them retain the information received.Training participants responded positively about the A&T training content and delivery. Three particular aspects were highlighted by HEWs: (1) the succinct messages of the 7 Excellent Feeding Actions , but only 53.9% of volunteers had received the tool despite 81.7% having seen it . Only 55.4% of mothers in Tigray and 49.5% in SNNPR had ever seen the tool, with far fewer (31.4% in Tigray and 18.5% in SNNPR) having received a copy to keep as a reminder in their homes Figure . Among mMost HEWs and volunteers who had the IPC tool reported using it regularly (once to at least three times a week) to provide education and counseling to beneficiaries (data not shown). The main reasons for not using the IPC tool more often were related to the issue of time; FLWs perceived that either they or the mothers had insufficient time to use the tool to discuss its content.This tool is prepared in an easily understandable way. Previous tools used written messages only, while this one has attractive pictures and written messages. Even illiterate mothers can easily understand it very well by looking at the pictures and practice.”), they showed partial knowledge of the tool’s contents. The patterns of message recall among mothers were similar to but more attenuated than those among FLWs.Delivery quality was also assessed through open recall of the 7 Excellent Feeding Actions and knowledge of the messages using recall aids (pictures of the 7 Actions) among those who were exposed to the tool. Figure The feedback loop in service delivery flow is the supportive supervision provided to FLWs. This component is particularly important since HEWs are responsible for delivering 17 different packages of health services (among which nutrition is one), thus requiring guidance and motivation to execute all activities as intended. On average, each HEW supervisor supervises 6–8 HEWs, and each pair of HEWs in turn supervises 50 community volunteers in their kebele. These personnel ratios were pre-established by the government and not defined by the program. HEW supervisors schedule monthly visits to health facilities and visit selected households in order to assess and reinforce service delivery  and provide immediate feedback. Nearly all of the supervisors in Tigray reported providing supervisory visits with observations of BF and CF counseling at health posts and group counseling sessions in the past year, an increase from 80% at baseline (data not shown). In SNNPR, 76.1% of supervisors reported observing BF counseling and 78.3% observed CF counseling at health posts and group sessions, which were similar to baseline.However, only 52.5% of HEWs in Tigray and 33.7% in SNNPR reported having received supervisory visits in the past one month, and some reported never receiving any supervisory visits (5.0% in Tigray and 10.8% in SNNPR). Among community volunteers, 41.8% in Tigray and 21.8% in SNNPR received supervision in the past month. Volunteers who received supervision reported receiving visits primarily from HEWs, but often irregularly at a few times a year or at unspecified frequency.Among HEWs who received supervision, most confirmed that visits included orientation about IYCF information (92.1% in Tigray and 90.5% in SNNPR). However, activities such as checking the availability of IPC tools (31.6% of HEWs in Tigray and 20.3% in SNNPR) or providing tools (23.7% and 6.8% respectively) and providing immediate feedback (7.9% and 6.8% respectively) were reported less often. Similar patterns of activities covered in supervision were reported by community volunteers. Supervision received by volunteers were conducted individually or in groups and often included orientation about IYCF information (95.7% in Tigray and 93.0% in SNNPR), but little else of other activities related to IYCF materials or corrective actions. Qualitative findings reinforced that supportive supervision did not cover all the expected elements. Supervisees were routinely checked for completed activities and given some technical information, but the availability and use of materials were not checked, and they rarely received advice on ways to improve on their mistakes or how to complete their activities under constraints.Our study examines evidence of different degrees of implementation fidelity along the delivery pathways of A&T’s community-based IYCF intervention program. As a major programmatic component, FLW training on IYCF was carried out with concentrated effort and resources, as reflected in its strong adherence to the cascading schema of the program design with high exposure at every FLW level and positive trends in quality and participant responsiveness. However, FLWs also received nutrition training from other sources such as the government-supported CBN program. Thus without specific training observations or evaluations or comparable measurements from a control group, our findings of increased IYCF knowledge and work-related self-efficacy may not be attributed to the A&T program training, despite it likely having made a contribution. The partial adherence in the dissemination of program tools and messages, particularly to the volunteers and mothers, highlights the gap between the formal health system and community levels. Community volunteers appeared to remain underutilized in the program delivery chain. Despite the highly positive responses about the appearance and usefulness of the program tools, these opinions appeared to have little effect on the adherence to their proper use and delivery. FLWs who were exposed to the program tools had correct knowledge of several key program messages, but poor aided recall of certain messages and the lower levels of knowledge among volunteers and mothers further signal weak delivery quality. Supportive supervision was intended in tandem with training and dissemination of program tools and messages to address these gaps in delivery and capacity among FLWs. However, there was low supervision fidelity across the FLW levels. Despite a feasible ratio of supervisor to HEWs in place, monthly supervision among HEWs was low; supervision of volunteers by HEWs faced a greater challenge, given the large numbers of volunteers under the responsibility of few HEWs.In addition, there were regional differences for nearly all measures. Given little difference in the participant characteristics between regions, the main variations are likely in program intensity. In Tigray the primary A&T partners, IFHP and REST, have strong technical capacities in the areas of health and nutrition. On the other hand, in SNNPR, the most rural region of Ethiopia, women’s association and the evangelical church were the primary partners and had more limited levels of technical capacity. These factors likely play an important role in the ability to reach beneficiaries and provide quality service delivery.FLWs’ work context may be a factor influencing the apparent program delivery gap between the health system and communities. Although not presented here, time and workload were identified in our study as work constraints particularly among HEWs. These are not surprising findings, as they align with results from other studies on the challenging work conditions of HEWs and implementation of the Health Extension Program ,25. Undeprogram differentiation, or identifying the unique and essential features of programs. We did not explicitly draw out this element, as we considered the “essential components” to be embedded in our study as the program tracers, i.e. the 7 Excellent Feeding Actions. Given the extensive and complex information base for IYCF, A&T conducted formative work to distill them into these 7 Actions, which were the key messages delivered primarily through the FLWs and discussed in our results of dissemination of program tools and messages. However, there are differential uptake and utilization even among these seven actions, which will be addressed later in relation to the effect on impact outcomes.Carroll et al.’s  frameworThere are some limitations to this study. First, the retrospective measurements of adherence and delivery quality are limited by recall bias. Our primary measure of adherence was exposure to intended source and by proportions at each participant level. Although content was traced to verify specific program components, it was not measured through direct observations or evaluations. Frequency and duration were obtained wherever possible, but they were not systematically measured for the different components due to measurement difficulties, poor recall, and inconsistent reporting. However, we applied multiple methods to study the different elements of fidelity, in order to corroborate results as often as possible. Second, there was no comparison group in our study, against which to compare measures of training quality, knowledge, supportive supervision, etc. This limits attributions to the program, and we acknowledge the effects of this in the interpretation of our results. Third, the duration of full implementation and exposure to different program components was shorter than expected, at approximately one year, and not uniform. As previously discussed, the program realized a shorter implementation period than intended due to national policy changes in the training process and structure of community volunteers. Shorter exposure in some areas may result in underestimation of effects. For this reason, we assess only the delivery side of the program impact pathways in this study, from provision of inputs to knowledge, where most changes should be detected. We do not assess for any changes further down the impact pathways such as practices and nutritional status among beneficiaries, which will be evaluated later in the 2014 endline survey. Lastly, the summary scores for IYCF knowledge used as measures of training quality are not standardized, so it is difficult to interpret the meaning of differences and to know what magnitudes of difference affect outcomes such as skills and practice. However, rather than interpreting their effects, we used their relative results to make comparisons over time (2010 baseline to 2013 PE surveys) and across different FLW levels. Determining the meaningful size of differences in knowledge scores and other process-related quality indicators is an area for further research .Our findings suggest that while fidelity in program training has been high, gaps remain in the delivery of program tools and messages to beneficiaries, directly by HEWs and via community volunteers, as well as in the supervision of HEWs and volunteers. Unless these gaps are addressed, it is unlikely that the expected impact at household level will be observed at scale. Given that the delivery of the BCC intervention for improved IYCF requires a sequence of programmatic components and actions to work together, the use of program impact pathways helped to identify how and where the components are or are not implemented as intended. Our study adds to the growing literature on theory-driven process evaluations that assess factors influencing the effectiveness of different nutrition interventions ,27-29. AOur study findings were reported back to the program to address issues related to the ongoing program. However, as the program was preparing to phase out in its current areas by 2014, these findings were considered in developing the design for a second phase of the program to be initiated in 2015. Furthermore, given the longer duration and extensive fieldwork of the process evaluation, this study was not intended to replace routine monitoring for timely feedback and corrective actions. Still, the process evaluation helps to understand critical elements of the implementation process and the conditions and factors influencing the process, and sheds light on how the program might eventually achieve its intended impact.In Tigray and SNNPR, the volunteer cadre is underutilized and presents the greatest challenge to reaching mothers of infants and young children. To maximize the scale and reach of the health extension platform to improve IYCF, efforts should focus on ensuring that the volunteer corps is trained, adequately supported and supervised by the HEW, and in possession of the required materials for delivering BCC to the households in their catchment area. To do so may require a combination of approaches, for example: 1) more intense supervision of the HEWs and volunteers, particularly with explicit instructions and better guidance on supervision and a more feasible ratio of HEWs to volunteers, potentially through intermediary roles by leaders over teams of volunteers; 2) performance-based incentives to motivate these cadres of health workers; 3) a reassessment of the workloads of these cadres and task shifting to ensure that delivery of the expected IYCF interventions is manageable for both; and 4) simplifying the IYCF interventions, for example, by targeting fewer IYCF behaviors (or at least prioritizing those age-specific practices that require greater improvement). Only by strengthening the linkages between the HEW and the volunteers is it likely that this platform will reach the target households and deliver IYCF results at scale.aWDAs, recently referred to as “1for5s,” are women of reproductive age within a village, with one leader responsible for checking and following up on the status of hygiene, childcare practices, health, nutrition, and other topics among a group of five other women. WDAs exclusively working on health topics are also called HDAs, particularly in Tigray.bThe maternal and child health module was one of five modules to be rolled out under IRT in 2012. Training on different modules are conducted on a rotation basis, and IRT on the maternal and child health module was conducted once per region and not repeated by the time of this study.


Recent evidence supports the efficacy of programs that promote improvements in the health practices of workers 50 years and older who are at higher risk for chronic diseases than younger workers are. Internet-based programs that promote healthy practices have also shown promise and, therefore, should be especially appropriate for workers aged 50 years and older.The purpose of the research was to evaluate the effectiveness of HealthyPast50, a fully automated Web-based health promotion program based on social cognitive theory and aimed specifically at workers 50 years and older.The randomized controlled trial was conducted across multiple US offices of a large global information technology company. The sample included 278 employees aged 50 to 68 who were recruited online and randomly assigned to the Web-based HealthyPast50 program or to a wait-list control condition. Self-report measures of diet, physical activity, stress, and tobacco use were collected online before and 3 months after the program group was given access to the program. Use data included number of log-ins and number of pages accessed. The primary analysis was multiple linear regression, following intent-to-treat principles with multiple imputation using the Markov chain Monte Carlo (MCMC) approach for nonmonotone missing data. Potential moderators from demographic characteristics and program dosage effects were assessed using multiple linear regression models. Additional analyses were conducted on complete (nonimputed) cases, excluding program participants who used the program for less than 30 minutes.P=.048), planning healthy eating , and mild exercise . Moderator and dosage analyses of the dataset found no significant program effects. Analyses of the nonimputed dataset comparing program users with controls found additional significant program effects on eating practices , exercise self-efficacy , exercise planning , and aging beliefs . Moderator analysis of this dataset also found significant moderator effects of gender on multiple measures of exercise.Retention rates were good for both groups: 80.4% (111/138) for the program group and 94.3% (132/140) for the control group. Program group participants spent a mean of 102.26 minutes in the program (SD 148.32), logged in a mean of 4.33 times (SD 4.28), and viewed a mean of 11.04 pages (SD 20.08). In the analysis of the imputed dataset, the program group performed significantly better than the control group on diet behavioral change self-efficacy (estimated adjusted difference [Δ]=0.16, A Web-based health promotion program showed promise for making a significant contribution to the short-term dietary and exercise practices of older working adults. Gender effects suggest that the program effects on exercise are due mainly to improvements among women. Decades of studies have confirmed the link between chronic illness and common modifiable risk factors, such as smoking, physical inactivity, poor diet, and high stress ,2. MoreoConsequently, providing older workers (50 and older) with effective tools that can help them improve their health practices could be beneficial to these workers, who are more likely to be affected by major diseases such as cancer, cardiovascular disease, diabetes, and musculoskeletal disease. Moreover, decreasing the health risks of older workers has special relevance for employers and health care companies because annual losses from chronic diseases exceed US $1 trillion (including productivity losses), and older workers account for a disproportionate share of the organization’s health care costs . In addiComputer-based approaches to workplace health promotion and disease prevention strategies have become more numerous, including Web-based modes of delivery -22. WithBecause there are physical and psychological characteristics of older workers that distinguish them from younger workers, any workplace intervention directed at this older group must be tailored to their particular needs and characteristics. Most of the health promotion topics that comprise the typical workplace health promotion program  should also be part of an older workers’ program. However, both the content of the programs and the recruitment and motivational strategies would most appropriately be altered for this age group.The purpose of the research was to evaluate the impact of a multimedia Web-based health promotion program on central health attitudes and practices of older workers. This program, called HealthyPast50, was designed as a stand-alone intervention to address a wide variety of health behavior topics, including physical activity, healthy eating, stress management, and tobacco cessation—the health behaviors that contribute to the prevention of major diseases.The impact of a multimedia Web-based program on the health practices of workers 50 years of age or older was assessed in a randomized controlled trial (RCT) in which participants were randomly assigned to the Web-based program condition or to a wait-list control condition. Participation was voluntary and all protocols and procedures were approved by the ISA Associates, Inc Institutional Review Board, Alexandria, VA. All participants, employees of a large global information technology company, were surveyed on multiple outcome measures before and 3 months after the program group received access to the Web-based program. The specific objectives of the study were to assess the extent to which the Web-based program produced significant positive changes, from baseline to posttest, on measures of stress, diet, physical activity, aging beliefs, and tobacco use. All outcome measures were self-reports, collected through an online survey. The full study protocol is shown in A recruitment flyer briefly describing the purpose of the study was emailed by company officials to all employees 50 years of age and older (approximately 2500 employees) located in multiple US offices of a global information technology company. The flyer stated that the study was being conducted by a research organization through a grant from the National Institutes of Health. The flyer also explained that participants would receive US $25 for completing the first questionnaire and US $25 for completing the second questionnaire, and that their name would be entered into a drawing in which 1 participant would receive US $500 during each questionnaire round. Interested employees who fit the inclusion criteria (age 50 and older) were instructed to contact the project staff directly by email or telephone. When interested employees contacted the study team, they were provided additional information about the study and their eligibility to participate  was confirmed. Employees interested in participating after learning more about the project provided the study team with an email address to be used to send a personalized email and link to the online baseline survey, which also included the consent document. The full consent document is shown in After reading the consent document, participants selected 1 of 2 responses indicating whether they consented or declined to participate. Participants were not able to continue with the survey until they acknowledged and indicated that they consented to participate. No participant declined to participate . An electronic copy of the consent document was then emailed to participants after they completed the baseline survey.A total of 290 employees contacted the study team in response to the initial email and were sent a link to the online survey, 279 of whom completed the baseline survey. One participant subsequently contacted the study team to withdraw from the study leaving a total sample size of 278 participants .Randomization was conducted by the second author using a block-randomized design with blocks of 4 and 6. The 0 and 1 within each block were random and the order of the group of 4 and the group of 6 was random. Randomization occurred after each participant completed the baseline survey. The online survey program was checked every day to determine who completed the survey each day and individuals were assigned to the next condition on the randomization table as they completed the survey. Once randomization was complete, participants were notified of the condition to which they were assigned (no blinding procedures were employed) and were informed of next steps; the program group was given the program link and log-in information and the control group was told that their access to the program would be delayed until the end of the test period. Participants could complete the online questionnaires and (for those in the program condition) access the online program on work time or at home.Participants in the program group could access the Web-based program at any time during the 3-month test period, both at work or outside work . The program operated alone and automatically; no human contact was involved. A “project update” email was sent to participants at 1 month and 2 months after randomization. For the program group, the emails included a reminder to use the program and information about the latest update to the program (a brief message on the home page). With the exception of the project update, the program was unchanged throughout the test period. For the control group, the email included information about when the second survey would be available. In addition, the project staff was always available to answer questions by telephone and email if participants had any difficulty accessing the program. The data collection started on October 10, 2012 (first participant enrolled) and ended on February 23, 2013 (last participant completed posttest). Individual access to program by participants was limited to the 3-month test period. No discernable secular events of note occurred during the test period. At the end of the 3-month test period and prior to administering the follow-up survey, access to the program was blocked. Three months after randomization, participants were sent an email with the link to the follow-up survey. After the posttest survey was complete, all participants received access to the program.Study participants were 278 employees of a large global information technology company whose US offices are located primarily in Massachusetts and California. The study was powered for a sample size of 250 (after attrition) based on previous studies by the authors. The computer literacy of the workforce was estimated to be relatively high. Demographic characteristics of the sample are displayed in HealthyPast50 is a Web-based multimedia program containing information and guidance on the major health promotion topics of healthy aging, diet, physical activity, stress management, and tobacco use. In addition, a central module of the program contained assessments across the major health topics, providing recommendations on particular segments of HealthyPast50 that users should visit based on the results of the assessments. Sample screenshots are shown in Program content was shaped specifically for older adults in many ways. Throughout the program, from the home page through all the modules, there are numerous depictions  of older adults along with dozens of video segments  featuring people older than 50 years of age describing their health practices, struggles, and successes. An entire module is devoted to “Facts About Healthy Aging,” emphasizing the importance of making positive changes in health practices now, and containing a segment on “Aging Myths and Facts.” The assessment module  is geared to older adults, tailored by age  and including questions about current diseases and preventive health screenings. A central segment of the Stress and Mood Management module describes with text, video, graphics, and narration, the relationship between stress and aging, featuring detailed information on how stress accelerates the aging process at the cellular level by shortening the ends of chromosomes (telomeres). Dietary information in the Healthy Eating module emphasizes the role of a nutritious diet and a healthy weight in preventing chronic disease and increasing longevity. Much of the content of the Active Lifestyle module is oriented toward older users, including the use of the Physical Activity Readiness Questionnaire (PAR-Q), assessing one’s readiness for physical activity, the relationship of physical activity to mobility and energy in later years, and the need to moderate the intensity of exercise as one ages.The program functions were monitored throughout the test period to ensure quality of operation. As with our group’s previous Web-based interventions, HealthyPast50 was shaped by a social-cognitive conceptual model based primarily on the work of Bandura -25, emphThe Web-based HealthyPast50 program was developed by our group over a 2-year period through multiple cycles of development and testing, beginning with focus groups of older workers (age 50 and older) providing feedback on specific features of the planned program, followed by ratings of prototype content, and culminating in the workplace-based RCT. The program was constructed using the ColdFusion-based Mura content management system, with the many interactive elements and assessments developed in Flash. The program also contains ample graphics, audio, and video. Many of these main elements are congruent with health behavior change theory and principles .For access to the full HealthyPast50 program for review or replication purposes, please contact the first author.The 30-45 minute online self-report survey contained the measures described subsequently. In addition, program utilization data, including number of log-ins, minutes in the program, and pages accessed, were recorded for each member of the program group.Seven items assessing respondents’ gender, age, race, ethnicity, marital status, education, and income.A 15-item scale developed by Orioli et al  and usedTwelve items assessing the type of strategies one uses to cope with difficult situations and events . QuestioA 9-item scale developed and validated by Trenkner and associates  assessinAn 8-item scale also developed and validated by Trenkner and associates , assessiA 10-item subscale that is part of the Weight Control Assessment scale developed by O’Neil and Rhodes , the meaA 15-item scale assessing one’s confidence in resisting overeating in different situations, with responses on a 7-point scale ranging from 1 (no difficulty controlling overeating) to 7 (most difficulty controlling overeating). Typical items included “overeating when depressed” and “overeating around holiday time.” Developed by McCann et al , this scA 5-item scale previously used by the study team  that askr=.77).A 2-item scale that asks respondents if they have a good plan for “maintaining a nutritious diet” and for “minimizing the amount of fats and sugars in my diet.” The response scale for both items is a 4-point scale, ranging from 1  to 4 (definitely true); a higher score=better planning  measures.The Godin Leisure-Time Exercise Questionnaire  is a briAn 8-item scale assessing the respondent’s confidence in engaging in regular exercise. All items begin with “I am confident that...” and are answered on a 4-point response scale from 1  to 4 ; a higher score=higher exercise self-efficacy. Typical items included “I can accomplish the physical activity and exercise goals that I set” and “I can overcome barriers to and challenges to physical activity and exercise if I try hard enough.” This scale was developed by Kroll et al  (α=.91).A 13-item scale that asks respondents how confident they are that they can “exercise 3 times a week for the next 3 months” under potentially difficult circumstances, including bad weather, lack of interest, schedule conflicts, etc. The 10-point response scale ranges from 0  to 100 (highly confident) in 10-point intervals; a higher score=higher self-efficacy to overcome barriers to regular exercise. This scale was developed by McAuley  (α=.94).r=.85).A 2-item scale that asks respondents if they have a good plan for “incorporating regular physical activity into my life” and “overcoming barriers to getting regular physical activity.” The response scale for both items is a 4-point scale, ranging from 1  to 4 (definitely true); a higher score=a better plan . The response scale is a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree); a higher score=more healthful attitudes (α=.54).Seven items assessed whether or not participants currently smoke cigarettes or use other tobacco products and, if so, how often they use tobacco products, how many times they use tobacco products per day, and whether and how often they have tried to quit using tobacco products.Multiple linear regression models were used to examine program effects on outcome measures and potential moderators and to assess dosage effects. Analyses followed intent-to-treat principles, including all participants irrespective of protocol violations and events arising postrandomization . MultiplP=.41), gender (P=.99), race (P=.38), income (P=.80), or education (P=.33). Comparing the 2 groups on all outcome measures at baseline revealed significant differences only on symptoms of distress .On most outcome variables, missing data occurred for less than 15% of the participants. Before imputing missing data, attrition analysis was conducted to examine potential baseline differences between those who completed the follow-up survey and those who did not. These data indicated that responders and nonresponders were virtually equivalent. Chi-square tests showed no differences between the groups on age , and planning healthy eating . The estimated adjusted difference [Δ] for eating practices was 0.07 and was not statistically significant (P=.08). In addition, there were no differences between the groups on diet outcome expectancies, healthy diet barriers, or overeating self-efficacy.The program group showed significantly greater improvement than the control group on diet behavioral change self-efficacy . Two other measures of physical activity, including moderate exercise  and overall exercise  were not statistically significant. In addition, there were no differences between the groups on strenuous exercise, sweat, exercise self-efficacy, exercise planning, or self-efficacy for overcoming barriers to exercise. There were no differences between the program and control groups on symptoms of distress or coping with stress. However, the lack of a significant effect may be partly a function of a ceiling effect .Compared to the control group, the program group showed significant improvement on mild exercise .There was also no significant difference between the groups on the measure of aging beliefs, although the trend was in the desired direction  to perform meaningful analysis on the measure of tobacco use.To determine whether program effects on outcomes differed based on participant demographics, potential moderators were tested on all outcome measures. Regression analysis models included main effects as well as interactions between condition and potential moderators. No significant interactions were detected between condition and gender, age, marital status, education, or income on any outcome measures.Data on number of log-ins, minutes in the program, and number of pages accessed were recorded for all members of the program group. An examination of the distribution of number of minutes in the program revealed one major outlier of 2053 minutes (more than 34 hours), more than twice as long as the next longest number of minutes. In calculating average use of the program, this participant’s data were removed. The mean number of log-ins was 4.33 , the mean number of minutes in the program was 102.26 minutes (SD 148.32), and the mean number of pages viewed was 11.04 . An examination of the distribution of number of minutes in the program showed that 39 participants spent less than 30 minutes in the program and 99 participants—71.7% (99/138) of the program group—spent 30 minutes or more in the program.To assess the extent to which the program effects were associated with the extent to which participants in the program group accessed the HealthyPast50 program, multiple regression analysis was conducted to examine the dosage effect of the number of pages viewed on all outcome variables. There were no significant associations between the number of pages viewed and any of the outcome measures after adjusting for the corresponding baseline measures.P=.03), exercise self-efficacy , exercise planning , and aging beliefs .A total of 39 participants in the program group who used the program less than 30 total minutes were defined as “nonusers” and were excluded from the analysis of the nonimputed dataset. The results of these analyses are shown in P=.05), moderate exercise (P=.06), and sweat (P=.07) did not meet the threshold for statistical significance. As shown in Moderator analysis of the dataset excluding the 39 nonusers found that the interactions between gender × condition on overall exercise . These analyses found additional significant program effects on eating practices, exercise self-efficacy, exercise planning, and aging beliefs. Interestingly, the moderator analyses of the program users showed that program effects on exercise were due largely to significant effects on females, not males. An examination of pretest and posttest means on exercise measures indicated that the lack of significant improvement by men was at least partly a function of the fact that men in both groups exhibited much higher mean scores than women at pretest.The effects of the Web-based program on multiple measures of diet and exercise are noteworthy, as numerous studies have shown diet and exercise to be critical behaviors—perhaps the most critical health behaviors after tobacco use—in reducing the risk of major disease. By reducing, at least partially, these key modifiable health risks in midlife, working adults might be laying the foundation for improved health and vitality in their later years.These findings indicate not only that HealthyPast50 was more effective for women than men, but also that the program did not attract as many men with poor health practices as desired. There has not been a focus on these particular types of gender effects in studies of Web-based interventions; however, the role of self-efficacy and planning among women in this trial has a parallel in a study of an in-person exercise intervention tested in Finland . At 3 moThese findings are congruent in many respects to the findings from previous research by our group, as well as research by other investigators who have tested the efficacy of Internet-based interventions on the health practices of working adults. Across several randomized trials testing the effects of multiple Web-based programs on working adults, our group found significant effects on outcome measures of diet, exercise, stress, and substance misuse ,19,22,38To our knowledge, HealthyPast50 is the only Web-based program specifically developed for—and shown to be efficacious with—working adults 50 years and older. A recent trial of a health promotion program targeting older workers compared an in-person program with a publicly available Web-based program and found significant effects on both diet and exercise behaviors for the in-person program, but few effects for the Web-based program .Tests by other investigators of Web-based programs only have found results similar to the findings of our trial. The multiple trials of the Web-based Guide to Health (GTH) program have generated impressive results on both dietary and physical behaviors ,18. Of pAlthough this study exhibited a variety of strengths, including a randomized design, an advanced Web-based intervention, and a sizable workforce sample, the study also has some limitations, including—and perhaps foremost—the single posttest at 3 months and the reliance on self-reports. In addition, because of the particular characteristics of the sample, caution should be exercised in generalizing these findings to workforces that are less educated and affluent. Future research on HealthyPast50 should include longer-term posttests and the inclusion of physical measures . The program also needs to be tested on older workers who are less educated and affluent.The Web-based HealthyPast50 program demonstrated significant effects on the short-term dietary and exercise practices of older working adults. Significant program effects were not shown on measures of stress or aging beliefs, and there were too few smokers in the sample for meaningful analysis. Analysis of the nonimputed data indicated that program effects were stronger for women than men. The findings suggest that a multimedia Web-based program could be a promising vehicle for delivering health promotion material to older working adults.


The May-June 2016 issue of the International Braz J Urol presents original contributions with a lot of interesting papers in different fields: Urinary Incontinence, Urethral Stricture, Bladder Cancer, Pelvic-Ureteric Junction Stenosis, BPH, Prostate Cancer, Renal stones, Uroginecology, Pediatric Urology and basic research. The papers come from many different countries such as Brazil, USA, Turkey, Italy, Austria, Australia, Israel, Netherlands, India, Mexico, China, Saudi Arabia, United Kingdon, Korea and France, and as usual the editor ´s comment highlights some papers. We decided to comment 2 papers about a very usual topic in urologic practice: The Urethral Stricture.Doctor Prabha and collegues from India performed on page 564 an interesting study about the single stage dorsolateral onlay buccal mucosal urethroplasty for long anterior urethral strictures. The authors studied 20 patients with urethral strictures: Lichen sclerosis in 12 cases (60%), Instrumentation in 5 cases (25%), and unknown in 3 cases (15%). Strictures were approached through a perineal skin incision and penis was invaginated into it to access the entire urethra. All the grafts were placed dorsolaterally, preserving the bulbospongiosus muscle, central tendon of perineum and one-sided attachement of corpus spongiosum. The mean stricture length was 8.5cm (range 4 to 12cm) and the overall success rate was 85%. There were 3 failures . Other complications included wound infection, urethrocutaneous fistula, brownish discharge per urethra and scrotal edema. The authors concluded that dorsolateral buccal mucosal urethroplasty for long anterior urethral strictures using a single perineal incision is simple, safe and easily reproducible by urologists with a good outcome.The success of urethroplasty using bucal mucosa graft (BMG) is significantly better compared to others grafts . The BMGWe can conlude that the two techniques  had similar sucess results in long anterior urethral strictures and the surgeon experience and preference with the technique is the most important factor for the sucess of the surgery.Professor Associado da Unidade de Pesquisa Urogenital da Universidade do Estado de Rio de JaneiroUrologista do Hospital da Lagoa Federal, Rio de JaneiroEditor Associado da International Braz J UrolLuciano A. Favorito, MD, PhD


Sc) in human cerebrospinal fluid (CSF). We performed a CSF study to determine the effects of prion disease type, codon 129 genotype, PrPSc type, and other disease-related factors on the real-time quaking-induced conversion (RT-QuIC) response. We analyzed times to 10,000 relative fluorescence units, areas under the curve and the signal maximum of RT-QuIC response as seeding parameters of interest. Interestingly, type of prion disease (sporadic vs. genetic) and the PRNP mutation (E200K vs. V210I and FFI), codon 129 genotype, and PrPSc type affected RT-QuIC response. In genetic forms, type of mutation showed the strongest effect on the observed outcome variables. In sporadic CJD, MM1 patients displayed a higher RT-QuIC signal maximum compared to MV1 and VV1. Age and gender were not associated with RT-QuIC signal, but patients with a short disease course showed a higher seeding efficiency of the RT-QuIC response. This study demonstrated that PrPSc characteristics in the CSF of human prion disease patients are associated with disease subtypes and rate of decline as defined by disease duration.The development of in vitro amplification systems allows detecting femtomolar amounts of prion protein scrapie (PrPThe online version of this article (doi:10.1007/s12035-014-8709-6) contains supplementary material, which is available to authorized users. Sc) in the brain. Spontaneous (sporadic), genetic, and transmitted forms of prion diseases are known. In sporadic Creutzfeldt-Jakob disease (sCJD), molecular characteristics of PrPSc, and codon 129 genotype of the prion protein gene (PRNP) determine molecular sCJD subtypes [Prion diseases are characterized by the accumulation of abnormally misfolded prion protein , these are the three most common PRNP mutations in Europe [The two genetic CJDs (gCJD), examined in this study, are defined by pathogenic n Europe -7.C), which in its pathological conformation (PrPSc) is prone to aggregation and seeding. Various in vitro conversion assays, such as protein misfolding cyclic amplification (PMCA), enhanced quaking-induced conversion (eQuIC), or real-time QuIC (RT-QuIC) use this high aggregation and seeding activity to amplify miniscule amounts of PrPSc to a detectable level.Human prion diseases are unique with respect to their self-propagating replication of the abnormally folded host-derived prion protein  [Sc detected by thioflavin-T (Th-T) can be monitored in real-time, which is a key advantage of RT-QuIC. The kinetic of the signal detection is used to evaluate the efficiency of the reaction. RT-QuIC can detect aggregated PrPSc also in various artificial prion disease models such as in the blood and the CSF of scrapie-infected hamsters [While this worked well with brain material in various settings, recent studies demonstrated the potential of RT-QuIC to replicate PrPid (CSF) , 9. Aggrhamsters , 11 and hamsters .Sc seeding response in human CSF samples and not to apply the RT-QuIC as a diagnostic tool to diagnose gCJD or different sCJD subtypes. We propose that the application of the RT-QuIC method as a reliable diagnostic test for prion diseases can be extended to show that PrPSc seeds from different prion diseases convert recombinant PrP (recPrP) with a different efficiency.In the present study, we applied RT-QuIC assay to human CSF and analyzed the prion seeding efficiency in humans with different forms of genetic and sporadic prion diseases. Our aim was to study the characteristics of the PrPSc was determined by autopsy.The study included 110 prion disease patients consisting of 64 sporadic CJD, 39 genetic CJD , and 7 FFI (D178N mutation) as well as 189 control subjects. All sCJD , E200K , V210I , and FFI patients  were diagnosed as definite cases by neuropathological examinations . GeneticControl group  composed patients with either clinically or pathologically defined alternative diagnosis. Our cohort consisted of Alzheimer’s disease patients , alpha synucleinopathies , psychiatric disorders , epilepsy (11), inflammatory and autoimmune diseases , and other non-prion diseases (61).The study was conducted according to the revised Declaration of Helsinki and Good Clinical Practice guidelines. Informed consent was given by all study participants or their legal next of kin.PRNP was performed after isolation of genomic DNA from blood samples according to standard methods [All CSF samples were stored at −80 °C prior to analysis. The analysis of the codon 129 genotype of  methods .RT-QuIC analysis uses recPrP as a substrate to amplify small amounts of a PrP seed in human CSF to a detectable limit (comparable to a PCR for proteins). Converted and aggregated PrP can be monitored in real time by a fluorescence dye (thioflavin-T) analysis by a fluorescent reader.Reaction buffer consisted of 162 mM phosphate buffer (pH 6.9), 170 mM sodium chloride, 1 mM ethylenediaminetetraacetic acid , 10 μM thioflavin-T , and 0.1 mg/ml recPrP. Eighty-five-microliter reaction buffer was seeded with 15 μl freshly thawed, neat CSF to a final volume of 100 μl. Reactions were prepared in a black 96-well, optical-bottomed plate . Prepared plates were sealed  and incubated in a plate reader  at 42 °C for 80 h with intermittent shaking cycles, consisting of 1 min double orbital shaking at the highest speed (600 rpm) followed by a 1-min break. Fibril formation kinetics were determined by measuring thioflavin-T fluorescent signal (450 nm excitation and 480 nm emission) every 30 min.154 Q171 polymorph [All RT-QuIC experiments were performed using the chimera recPrP composed of the Syrian hamster residues 14 to 128 followed by sheep residues 141 to 234 of the Rolymorph . The recEscherichia coli Rosetta cells (EMD Biosciences). RecPrP was expressed using the Overnight Express Autoinduction system (EMD Biosciences). Isolated inclusion bodies were denatured  and bound to Ni-NTA Superflow resin . Using an AKTA Explorer system , the denatured recPrP was refolded using a linear gradient to refolding buffer . After elution of recPrP applying a linear gradient , the recPrP was dialyzed against 10 mM phosphate buffer pH 5.8 overnight and filtered with a 0.2-µm syringe filter. The concentration of recPrP was determined by measuring absorbance at 280 nm. The recPrP was diluted to 0.5 mg/ml with 10 mM phosphate buffer pH 5.8 aliquoted and stored at −80 °C until analysis was performed.Briefly, DNA sequences coding for hamster  and sheep  recPrP residues were amplified and ligated into the pET41 vector (EMD Biosciences). Transformation of the plasmids occurs into As a precaution to possible batch-to-batch variability of recombinant PrP, batches were generally mixed in equal parts. Functionality of the recPrP was verified by analyzing serial dilutions of sCJD-infected brain homogenates in RT-QuIC experiments according to the method described by Wilham et al. .To determine the PrP concentration, we used a commercial BetaPrion BSE-ELISA Test Kit  and followed the manufacturer’s instruction.Levels of 14-3-3 in CSF were determined by using the CircuLex 14-3-3 Gamma ELISA Kit . We followed the manufacturer’s instructions. Briefly, CSF samples were used in a dilution of 1:5 in dilution buffer. Level of 14-3-3 was detected in arbitrary units (AU) per ml . For capturing, samples were incubated for 1 h at room temperature (25 °C). After washing, 14-3-3 gamma detection antibody and later HRP conjugated anti-IgG antibody were added and incubated for 1 h at room temperature each. The colorimetric reaction was measured at 450 nm with a 1420 multilabel Counter Victor2  .CSF levels of total tau protein was measured using a commercially available ELISA kit . For the determination of tau level, we followed the manufacturer’s instructions.Briefly, before antibody incubations, each sample (75 μl) was diluted 1:1 in sample diluent. The colorimetric reaction was measured at 450 nm with a 1420 multilabel Counter Victor2  . Each sample was measured in duplicates. For analysis, we calculated the median.t-tests and ANOVAs (+Tukey’s post-hoc tests) as appropriate. In the second step, the maximum seeding activity was calculated for each individual sample. Again, maximum values were checked for being normally distributed and then compared between group using means, t-test and ANOVAs (+Tukey’s post-hoc tests). In the third step, the time to 10,000 rfu was calculated for each individual sample. Times to 10,000 rfu were compared using logrank tests and Bonferroni-adjusted logrank tests (for pairwise post-hoc testing). All analyses were conducted on an exploratory basis only and were performed using SPSS 20.0 and R 2.15.For investigating differences between predefined groups, three variables were defined as seeding parameters of interest. First, areas under the curve  were calculated for each individual sample and were transformed for convenience reasons by dividing rel. AUC by the number of total measurements. Rel. AUCs were checked for being normally distributed; means (and standard deviations (SD)) of rel. AUCs were then calculated for the respective groups of interest and were compared between groups using For graphical illustration, time series plots are presented at each step of the analysis displaying means (+standard errors of the mean) of seeding activity for each point in time (each measurement) in the respective groups. Thus, these illustrations show aggregated data for each time point; information about means of AUCs, individual maximums, or times to 10,000 rfu cannot be read out of these plots. Graphical “AUCs” (representing the AUC of means at each time point) do not correspond to calculated rel. AUCs .To investigate the effect of type of prion disease on RT-QuIC response, we used CSF from sCJD, gCJD (E200K and V210I), FFI, and non-prion disease control cases. The optimal running time for RT-QuIC reaction was 80 h because no additional sCJD case became positive after this time period. Therefore, a longer incubation period was not required. From each individual sample, we calculated the average from rel. AUC, times to 10,000 rfu (lag phase) and the maximal intensity of Th-T fluorescence signal over a time period of 80 h, using these parameters as indicators for the seeding efficiency of the RT-QuIC reactions Fig. . The relSc type or PRNP codon 129 polymorphism on the RT-QuIC response, we compared the seeding efficiency from CSF samples derived from different sCJD patients exhibiting PrPSc type 1 or 2 (independently from codon 129 genotype) as well as different PRNP genotypes . Neither the PrPSc type nor the PRNP codon 129 genotype alone had a significant impact on RT-QuIC response   Fig. , no signV2) Fig. .p < 0.001), whereas there was some evidence for a difference of rel. AUC  when compared to sCJD , different genders or different PrPp et al.  showed nAccording to Fig. Sc seed in sCJD and gCJD (E200K) CSF-seeded RT-QuIC reactions and performed an end-point analysis each with three randomly chosen samples. We used six serial dilutions from 1:4 to 1:24 and calculated the percentage of the number of positive replicates within the first 80 h for each dilution. In both groups, we observed a clear correlation between the amount of CSF seed and the number of positive replicates in the RT-QuIC assay  was determined by ELISA in the CSF of 26 randomly selected sCJD patients and tested for an association with seeding efficiency in the RT-QuIC assay. No association between whole PrP concentration and lag phase was observed, which indicates that the amount of whole PrP had no influence on the RT-QuIC response  parallel by 14-3-3-, tau ELISA, and RT-QuIC. Afterwards, we correlated the RT-QuIC seeding signal response with the level of total tau and 14-3-3 protein, which are known markers of neuronal damage. However, the correlation of 14-3-3 level with RT-QuIC  results was not significant . The same could be observed, when we compared the tau level and the RT-QuIC seeding response , tau and maximum: Spearman’s rho = −0.0848 (p = 0.624).To investigate whether the PrP seeding efficiency depends on neuronal damage, we analyzed sCJD samples . So far, our knowledge of PrPSc characteristics in gCJD originates from studies using brain material. Accordingly, in E200K or V210I mutation carriers, the disease is caused by an altered structure of PrPC [Sc by affecting the interactions with other cellular partners or the fibrillation process of PrP [Sc in the brain [There are several ways to explain the more rapid kinetics of the aggregation process in genetic, sporadic CJD and between different mutations in  of PrPC  and the he brain .C (23–90) plays an important role for the conversion of protein [Sc in the brain of affected individuals, a clear effect of the codon 129 genotype on disease onset and disease phenotype, and low transmission rates in animal experiments with very long incubation times [Sc characteristics and PRNP codon 129 genotype [Sc types on the prion seeding efficiency in the RT-QuIC assay. Patients with sCJD can be categorized according the PRNP codon 129 genotype and the biochemical characteristics of PrPSc into six molecular subtypes [PRNP  [For FFI, where the N-terminal part of PrPC –90 playson times , 25, wheon times , 26, 27.genotype . TherefoC 2–90 plays and VV) , the exiRecent work using RT-QuIC assay on brain tissue demonstrated distinct RT-QuIC responses in single sCJD subtypes. In particular, atypical CJD (MM2 or VV1) or variant CJD samples showed a lower seeding efficiency compared to sCJD MM1 and MV1, indicating a delayed and slower conversion process in these samples .Sc type in CSF separately, we performed a comparative analysis of three sCJD codon 129 genotypes  and two PrPSc types (1 and 2). In doing so, we tested both factors separately and examined the impact of codon 129 genotype in patient groups of the same PrPSc type. In addition, we compared sCJD patient groups with the same codon 129 genotype, but different PrPSc types, and found an effect of the PRNP codon 129 genotype on RT-QuIC response. Methionine homozygosity at codon 129 was associated with a higher signal maximum of RT-QuIC response, which could be shown in sCJD MM1 patients as opposed to sCJD MV1 or VV1 patients. However, we could not observe any difference when comparing the RT-QuIC responses by grouping our study participants according to the suggested four PrPSc strains [To study the effect of the codon 129 genotype or PrP strains  as definIn E200K cases, the RT-QuIC assay showed a shorter lag phase and higher rel. AUC in MM than in MV genotypes, suggesting a higher seeding efficiency in homozygous patients. There is a remarkable parallel to the observation that in E200K patients, codon 129 genotype has a major influence on the risk and disease characteristics, such as earlier age at onset and shorter disease duration (3.7 +/−2.0 months compared to 7.84 +/−7.3 months) .Sc type, type of PRNP mutation, and codon 129 genotype.The question remains as to which factors may influence the kinetics of RT-QuIC response in addition to PrPInterestingly, in sCJD patients, we found that the disease duration had an impact on the seeding efficiency of PrP, e.g., patients with short disease courses showed a higher seeding efficiency in the RT-QuIC response.Sc seed in the CSF. However, performing a serial dilution of gCJD and sCJD CSF samples, we could not find any differences between both groups. We suggest that conformational or structural differences in the PrPSc seed, caused by the mutation in gCJD, may be the decisive factor responsible for the increased RT-QuIC response in gCJD, rather than the amount of PrPSc seeds.Since the whole PrP concentration has no influence on the seeding efficiency, other factors might also be important, such as the amount of PrPSc seeding efficiency in human CSF. It clearly shows that PrPSc characteristics in the CSF of humans with a prion disease are distinct and modulated by the type of prion disease, codon 129 genotype and rate of decline as defined by disease duration. For the first time, a method can be applied to study these effects in humans affected by the disease during the symptomatic phase.These findings together raise questions about the structure and characteristics of PrP in human CSF, which might be different from those in the brain of affected individuals. In conclusion, the data obtained confirms that the RT-QuIC assay allows us to study the characteristics of PrPSupplement Fig. 1Sc strain, PrPSc type and PRNP codon 129 genotypes on the RT-QuIC response. (A) CSF samples derived from sCJD patients of different ages , (B) different genders and (C) different PrPSc strains , (E) different PrPSc types and (F) different PRNP codon 129 genotypes were analyzed by RT-QuIC over a period of 80 h. Comparison of the seeding activity revealed no significant influence of age, gender, PrPSc strain, PrPSc type or codon 129 genotype on the RT-QuIC response (mean + SEM).  The absolute values for rel. AUC, maximal Th-T signal (mean + SD) and time to 10,000 rfu (median + IQR) were shown for each group and the p-values were calculated for each comparative analysis. For comparison between groups, we used ANOVAs or t-tests (rel. AUC) and logrank test  with Tukey Post-hoc tests and Bonferroni-adjusted logrank test as appropriate. All p-values < 0.05 are significant. (DOC 397 kb)Impact of age, gender, PrPBelow is the link to the electronic supplementary material.


BCR-ABL1 fusion proteins contain constitutively active tyrosine kinases that are potential candidates for targeted therapy with tyrosine kinase inhibitors such as imatinib in chronic myeloid leukemia (CML). However, uncharacterized BCR-ABL1 fusion genes can be missed by quantitative RT-PCR (qRT-PCR)-based routine screening methods, causing adverse effect on drug selection and treatment outcome.BCR-ABL1 fusion gene with breakpoints in the BCR intron 14 and the ABL1 intron 2, respectively, in a rare case of CML. Its mRNA with an e14a3 junction was then detected using customized RT-PCR followed by Sanger sequencing. Subsequently, the patient received targeted medicine imatinib initially at 400 mg/day, and later 300 mg/day due to intolerance reactions. With this personalized treatment, the patient’s condition was significantly improved. Interestingly, this novel fusion gene encodes a fusion protein containing a compromised SH3 domain, which is usually intact in the majority of CML cases, suggesting that dysfunctional SH3 domain may be associated with altered drug response and unique clinicopathological manifestations observed in this patient.In this study, we demonstrated that the next-generation sequencing (NGS) can be employed to overcome this obstacle. Through NGS, we identified a novel BCR-ABL1 fusion gene using NGS in a rare case of CML while routine laboratory procedures were challenged, demonstrating the power of NGS as a diagnostic tool for detecting novel genetic mutations. Moreover, our new finding regarding the novel fusion variant will provide useful insights to improve the spectrum of the genomic abnormalities recognizable by routine molecular screening.We identified a novel  BCR and ABL1 in the intron regions, resulting in the formation of BCR-ABL1 fusion genes and accordingly in the expression of chimeric gene transcripts with a juxtaposition of e13-a2, e14-a2, e19-a2, or e1-a2  . The patient was then released with continued imatinib usage at 300 mg/day and with periodic follow-up examinations.Diagnosed with CML, the patient was initially treated with hydroxyurea to improve blood count. Additional medicines, including antibiotics and anti-infection drugs, were also prescribed to relief fever, gum swelling and redness, and other complications. After detecting the novel BCR-ABL1 fusion gene was identified by NGS technology, but not by a routinely-used, RT-qPCR-based method in a rare case of CML. Its mRNA transcript was subsequently detected using RT-qPCR with customized primers. Our result suggested that the NGS-based application can be employed as a diagnostic tool in those difficult cases with novel or complex genomic abnormalities.In this study, we reported that a novel BCR gene fragment at the 5′ end and the ABL1 gene fragment at the 3′end [BCR-ABL1 fusion gene is likely oncogenic, which can be transcribed into BCR-ABL1 fusion mRNA and translated into BCR-ABL1 fusion protein. As discovered by genomic and cDNA sequencing in CML patients, the breakpoint in the ABL1 gene is usually detected in a region between exon 1a and exon 2 [BCR gene, the breakpoints are most frequently detected in introns between exons 13 and 14 or exons 14 and 15 within a region recognized as the major breakpoint cluster region (M-bcr) covering exons 12–16  [BCR-ABL1 fusion proteins with junctions described as e13a2 or e14a2. In rare cases, the breakpoints were found in the minor bcr (m-bcr) between the two alternative exons e2′ and e2 [BCR-ABL1 and p230BCR-ABL1.CML, a malignant myeloproliferative disorder, originates from a hematopoietic stem cell that carries a Philadelphia chromosome, characterized by a reciprocal translocation between chromosomes 9 and 22, or t . This translocation generates a fusion gene with the juxtaposition of the he 3′end . An in-fd exon 2 . In rare′ and e2  or μ-bcr′ and e2 –26. TheiBCR-ABL1 fusion mRNAs that were previously characterized and detected in the majority of CML cases. To resolve the discrepancy, we performed WGS on an Illumina HiSeq X and identified a novel BCR-ABL1 fusion gene. Although the breakpoint in the BCR gene is located in intron between exons 13 and 14 within the M-bcr region, the breakpoint in the ABL1 is novel, located in intron 2, a region downstream to the exon 2. The resulting fusion gene is presumably transcribed into a smaller fusion mRNA with an e14a3 junction, skipping the entire exon 2 (174 nucleotides). This novel transcript was initially undetectable by routine RT-qPCR-based diagnostic screening as this type of fusion transcripts have only been reported in rare cases and have not been the subjects for detection using RT-PCR-based routine BCR-ABL1 screening [BCR exon 14 (e14) and ABL1 exon 3 (a3), respectively, and followed by Sanger sequencing of PCR amplicons. Similar to our study, a recent publication has shown that an e14a3 transcript was detected by a customized PCR using primers targeting the BCR exon e13 and the ABL1 exon a3, but not by the PCR using conventional primer sets [BCR-ABL1 negative result was obtained by conventional screening, care should be taken to avoid misdiagnosis, which may cause an adverse impact on therapeutic outcome. The correct diagnosis will allow physicians to make right decisions whether a targeted therapy (imatinib in this case) or other treatment plans should be used for better outcome achievement.In this study, we reported a CML patient with constant low fever, swollen gums, bilaterally cervical lymphadenopathy, and splenomegaly. Interestingly, this patient showed otherwise normal physical and mental conditions. Upon blood and bone marrow tests, this patient was diagnosed as CML. Further cytogenetic analysis confirmed the existence of Philadelphia chromosome. However, routine fluorescent RT-qPCR screening cannot detect any form of creening . This racreening  and threcreening –30, Unlimer sets . Thus, iBCR gene creates a fusion protein with an constitutively active ABL1 tyrosine kinases, which are believe to be causative in CML [BCR-ABL1 fusion gene. Thus, this fusion gene is predicted to encode a fusion protein with a compromised SH3 domain. It is not clear whether this SH3 domain truncation is associated with some of the less common clinical presentations and drug response including intolerance to the normal dose of imatinib. Further studies are warranted to clarify these questions.ABL1 protein is a nonreceptor tyrosine kinase containing a tyrosine kinase domain. The fusion with the e in CML . The maje in CML . It has e in CML . In conte in CML , is a nee in CML . Moreovee in CML , 37. SH3TP53, FLT3, KIT, and PAX5, which were co-existed with BCR-ABL1 fusion. This result suggested that this CML is highly heterogeneous. TP53, the most frequently mutated gene in cancer, has often been detected with mutation in acute myeloid leukemia (AML), ALL, and chronic lymphocytic leukemia (CLL), predicting poor prognosis [FLT3 and KIT mutations have been shown to be associated with poor prognosis in AML [PAX5 are considered as signature mutations in precursor B-ALL [FLT3 and PAX5 mutations identified in this CML patient have never been reported before in any type of cancer, while the TP53 and KIT mutations were only described in prostate cancer and melanoma [Through NGS, we also detected nonsynonymous mutations in leukemic genes rognosis –40. Boths in AML , 42, whior B-ALL , 44. Altmelanoma , 46. It BCR-ABL1 fusion (with an e14a3 junction) that is undetectable by routine qRT-PCR-based laboratory procedures in a rare case of CML. Due to the correct diagnosis, the physicians prescribed targeted therapy using imatinib to this patient, leading to a better treatment outcome. Our NGS result also suggested that this fusion gene encodes a protein containing a truncated SH3 domain, which may contribute to the unique clinical presentation and altered drug response in this patient. Moreover, novel nonsynonymous mutations in the TP53, FLT3, KIT, and PAX5 genes, are co-existed with BCR-ABL1 fusion, indicating the high heterogeneity in this disease. Therefore, this study has demonstrated the value of NGS as a powerful diagnostic tool for identifying novel and complex genetic mutations.Through NGS application, we have identified a novel CML, Chronic myeloid leukemia; FISH, Fluorescent In-Situ Hybridization; NGS, Next-generation sequencing; TKI, Tyrosine kinase inhibitor; WES, Whole exome sequencing; WGS, Whole genome sequencing


In the search for the efficacious elements within eHealth programs, it is important to understand how a program using lapse management may simultaneously support working alliance, internalization of motivation, and behavior maintenance. These processes have been applied to fully automated eHealth programs individually. However, given their significance in face-to-face counseling, it may be important to simulate the processes simultaneously in interactive, tailored programs.We propose a theoretical model for how fully automated behavior change eHealth programs may be more effective by simulating a therapist’s support of a working alliance, internalization of motivation, and managing lapses.Endre, a fully automated smoking cessation program that engages the user in several “counseling sessions” about quitting. A descriptive case study based on tools from the intervention mapping protocol shows how each therapeutic process is simulated.We show how the model is derived from theory and its application to Endre and computerized motivational interviewing. Computerized motivational interviewing also supports internalized motivation to quit, whereas a lapse management component responds to lapses. The description operationalizes working alliance, internalization of motivation, and managing lapses, in terms of eHealth support of smoking cessation.The program supports the user’s working alliance through alliance factors, the nonembodied relational agent A program may simulate working alliance, internalization of motivation, and lapse management through interactivity and individual tailoring, potentially making fully automated eHealth behavior change programs more effective. We use a focused, descriptive analysis to conceptualize the translation from theory to intervention. The analysis is based on a modified intervention mapping protocol [Endre. This paper therefore also exemplifies the use of intervention mapping as an approach ideally suited to investigate potentially important elements in the “black box” of eHealth programs.No published description exists, as far as we know, of a program supporting all 3 processes simultaneously, as proposed in the theoretical model in protocol , which iEndre is a fully automated eHealth program for smoking cessation that has evolved from the third author’s experience with the smoking cessation program Happy Ending [Endre has some of the same basic structures as Happy Ending. It uses tunneling [Endre and Happy Ending. However, as opposed to Happy Ending, which in addition to lapse management consisted of a large number of theoretical and methodological underpinnings [Endre is centered on 2 other theoretical concepts: internalized motivation  and  factors  as the mEndre consists of 26 tunneled [tunneled ,39 Web sEndre provides no additional human support. Most sessions involve user interactivity, requesting input from the user (see screenshots below for examples). We anticipate that an adult, typical user with average reading abilities may spend 4-6 minutes on each session. The user receives synchronous and immediate feedback on input. The lapse management component of Endre is based on the lapse management component in Happy Ending [y Ending  and consEndre by using selected steps from the intervention mapping protocol  [Endre was developed using intervention mapping. Intervention mapping is conventionally used to describe everything in a program [We describe how a counselor’s support of a working alliance, internal motivation, and lapse preparation and management are simulated in , and 4) . Interve program ,30,40-50Endre ’s theoretical change model  and its context (a fully automated program). An analytic text accompanies the change model to describe how the 3 processes are represented in the change model. The change model that was used for the development of Endre . In theof Endre  is simplAfter showing how supporting a working alliance, internalized motivation, and lapse preparation and lapse management are operationalized through change objectives, we describe how the 3 therapeutic processes are simulated through specific program elements (steps 3 and 4 in intervention mapping ). The pr, believed to be causing or influencing the behavior. Each therapeutic process is represented within the model either as a personal determinant or a performance objective. The personal determinants and performance objectives intersect in cells containing change objectives , which specify how each personal determinant must change for the individual to be equipped to do each performance objective.The operationalization of the therapeutic processes can be viewed in the change model matrix . In the Endre, if one assumes that a successful simulation of supporting a working alliance can have the same benefits for therapy outcome in a fully automated program as it has in face-to-face counseling [Endre, internalized motivation is an important psychological process for succeeding in quitting smoking at all. In the model, internalized motivation is separated into the underlying personal determinants relatedness, competence, and autonomy; the 3 “needs” that influence the internalization of motivation [Working alliance and internalized motivation are operationalized as personal determinants, whereas behavior maintenance through lapse preparation and lapse management is operationalized as a performance objective. Having a working alliance to the program is not a necessary psychological process for quitting smoking in general. It might, however, be an important process for quitting smoking with the help of unseling ,8. Thougtivation . Competetivation . In contEndre. For each therapeutic process, we present program elements that are involved in the simulation and describe the methods that are used. To support working alliance we adapted MI [Endre, which has a double meaning in Norwegian, being a man’s name, as well as literally meaning “to change.” Internalized motivation is primarily supported through cMI, whereas behavior maintenance is strengthened with a psycho-educative session before the quitting day, as well as a special Web-based session that is made accessible if the user reports a lapse. If the user experiences several lapses, this is recognized by Endre, and the content of the session is adjusted accordingly.In this section, we describe how the therapeutic processes are simulated in apted MI  to a comEndre is used throughout the program. Endre is a nonembodied, text-based relational agent that simulates a “counselor” the user “communicates” with. Some key attributes of Endre can be found in Working alliance is supported in program elements using a nonembodied relational agent , cMI Mu, and dynUses first person tense.Introduces a new topic for each session.Asks questions and reflects answers empathically .Uses appropriate greetings and farewells according to time of day .Uses humor .“Remembers” earlier conversations by explicitly referring to them or implicitly adjusting program content.Endre has presented the program plan, the user is asked to choose a topic he or she considers important when quitting. On the subsequent page, Endre assures the user that “he” will make time for this topic during the course of the program. The user’s topic is visited 2 times during the program.To further support a working alliance, users are allowed to influence the program content  change . After EEndre provides guidance to the user, for example by explaining how new sessions are made available and how the user can log onto them. In addition, new program exercises are demonstrated by four fictional “quitters” , based on:the program plan,which sessions the user has already logged on to,rules that categorize the sessions as either high priority  or low priority (the user only receives these if he or she has done the high-priority sessions thus far).A user who has missed several sessions first receives those that are categorized as high priority.If the user has logged on to all high-priority sessions, he or she receives low-priority sessions that address (in the following order): skills, self-efficacy, relatedness, and autonomy.A final program aspect supporting working alliance is a “mini motivation intervention” , consistBefore quitting day:If the user misses one session, nothing happens.Endre, reminding him or her to log on.If the user misses 2 sessions, he or she gets an SMS message from Endre normalizes having second thoughts and recommends logging on to the program.If the user misses 3 sessions, he or she gets an SMS message where If the user misses a fourth session, nothing happens.Endre appeals to the “healthy part” of the user to log on.If the user misses a fifth session, he or she gets a final SMS message where After quitting day:After quitting day, there is no intervention if the user does not log on to the Web page.A part of the lapse management system is that the user every evening receives an SMS message, asking if he or she has been smoke free. If the user does not answer the SMS message, he or she will receive up to 3 extra SMS messages encouraging him or her to answer.Endre strengthening the user’s autonomy, competence, and relatedness [Endre advices the user to choose a “support person,” showing what happens when the user does not want to follow Endre ’s advice. Another way in which Endre supports the user’s relatedness to his or her social network is effectuated if the user reports a lapse after he or she has quit. Endre then asks if this lapse may affect the user’s relationship to his or her social network. If the user answers yes, Endre offers help to ensure the social network’s continued support for the quit attempt (change objective 30). All advice is given using cMI  to reveal the information. An example can be viewed in Endre asks for permission to give information or advice; if the user answers yes, the information is revealed on the next page. For example, one session starts by Endre introducing today’s topic, and then asking the user whether he or she thinks this sounds okay. If the user answers yes, the session continues. If the user answers no, the session is ended.Question + multiple choice yes/no: The user must answer yes or no when sustain talk (reasons for smoking) and discord (dissatisfaction with therapy) [Endre repeats the user’s feelings empathically, and then, depending on the situation, asks more questions, normalizes, offers help, or changes the topic [Endre asks the user how he or she feels about staying smoke free for the rest of the day. The example shows the user choosing the statement representing the lowest degree of self-efficacy; so low that it qualifies as sustain talk. On page 2, Endre offers help. The user chooses that he or she does not want any help; this can be seen as dissatisfaction with the program, or discord. On page 3, Endre reflects empathically and normalizes the user’s feelings.A second way in which autonomy is supported is through handling therapy)  respectfhe topic . HandlinEndre supports the user’s autonomy is through eliciting and reflecting change talk, that is, talk arguing toward change [Endre repeats the user’s change talk and sometimes elaborates on it. For example, in one session, Endre asks the user for his or her most important reason for wanting to become smoke free . Endre repeats the user’s most important reason on the next page . Asking for permission, handling sustain talk and discord, and eliciting change talk is achieved through cMI and dynamic tailoring [A third way d change  . In this session, a car puncturing a tire is used as a visual analogy  for lapsIn the preparatory session, the user is also presented with an advance organizer  of the pEndre then asks if the user has already decided what to do: keep quitting or keep smoking . Asking the user what topic to start with is a way of asking for permission [Following up on the preparatory session on lapses and relapses is a lapse management component which is effectuated after the user has confirmed a quit attempt. Every day, the user receives an SMS message asking if she is still smoke free. If the user answers yes, another SMS message compliments the user’s accomplishment. If however the user answers no, he or she receives an SMS message with a link to a Web-based lapse management session. The user may access the session through the SMS message; if he or she does not log on via the SMS message, he or she receives the lapse management session when logging on to the program next time. The lapse management session helps the user make a choice, become smoke free again and learn from the lapse. When logging on to the Web-page, the user is first reintroduced to the car  and the  smoking . If the rmission , strengtrmission . This scrmission , ambivalrmission , the absrmission , and makrmission , reattrirmission , and cogrmission .Endre, is a fully automated smoking cessation program where each session takes the form of a written “counseling session” between the user and the program. The program content and structure were analyzed using intervention mapping [This case study illustrates our proposed theoretical model for eHealth behavior change interventions: simulating a counselor’s support of working alliance, internalization of motivation, lapse preparation, and lapse management simultaneously. The case,  mapping , illustr mapping ,8 is sup mapping , a nonem mapping ,cMI  and as models in how to exercise autonomy in the quitting process . The fact that many program elements support several therapeutic processes at once implies that the effort needed to incorporate more than one therapeutic process in a program may diminish for each process included.Interaction can be assumed from the operationalization level, but the step to simulation also shows the many methods and program elements that support several therapeutic processes at once. For example, all program material is delivered by the relational agent alliance , and cMIalliance  and intealliance , but in Endre builds on this work, although applying a nonembodied, rather than embodied relational agent, allowing the user freedom to “create” aspects of the relational agent. To further support a working alliance, Endre also incorporates alliance factors [Endre, however, is simulating all 3 processes simultaneously, something that to the best of our knowledge has not been done before systematically in a fully automated eHealth program.All 3 therapeutic processes have been applied to fully automated programs previously. Studies on working alliance have mostly been on relational agents ,12. Endr factors . “Endre” factors ,33 and u factors ,34-37. Tshould be present in the “black box” of eHealth programs.Finally, this paper extends earlier work using intervention mapping eHealth tools to present a focused descriptive analysis of chosen program elements. Papers that use intervention mapping usually follow the structure of the intervention mapping steps and reports on most of these ,30,40-50Endre. Especially the social behavior of the relational agent, cMI, and dynamic tailoring are elements that are used in the entire program, and a full account was therefore not possible. Another limitation is that to highlight the 3 therapeutic processes, descriptive depth was chosen over descriptive breadth. In addition, Endre does not simulate the 3 therapeutic processes perfectly. A fully automated program neither has the flexibility nor the presence of an actual human being. Just as Endre is not a human counselor, cMI is not MI. But the program may nevertheless simulate these 3 therapeutic processes convincingly enough to derive some of the benefits they have in face-to-face counseling. It should also be noted that Endre only represents one way in which these therapeutic processes may be simulated. Thus, if Endre fails to be an efficient program, it may be because the therapeutic processes in a fully automated program are not successful in inducing change or because the simulation of the therapeutic processes in Endre was inadequate.Although comprehensive, the analysis presented here is a simplification of how the 3 therapeutic processes are simulated in Endre represents. First, not everyone who wishes to quit smoking may benefit from such a detailed program. In the first author’s clinical experience, some simply quit and do not wish to spend more time elaborating on the process. A participant in an earlier study conducted by the third author [Endre does make it possible for “unproblematic” quitters to move through many of the sessions rapidly, and the flexible session manager makes it possible to complete fewer sessions than what is in the full program. Nevertheless, it is a quite extensive intervention, communicating an expectation that quitting smoking is a process instead of a one-time action and requiring answers to daily SMS messages. Second, not everyone may wish to convey their thoughts with a program. Efforts to simulate a therapeutic setting aside, the therapy may still seem too artificial and ultimately unconvincing to the user. Alternately, the simulation may be too convincing, and sharing one’s personal thoughts on quitting smoking with a machine that responds empathically to one’s input may create an “uncanny” feeling [Endre so far indicate to the contrary that they respond positively to the “mixture” of Man and machine, this is an area that will require further research.There are, of course, limitations to the type of program that d author  actually feeling  because Endre and the theoretical model presented here will be evaluated in forthcoming studies. Because the application of the model to the program is made explicit, it is possible to test. Empirical investigations may in turn influence or alter the theoretical model or its recommended application to a program.In one current Randomized Controlled Trial (RCT), the lapse management component will be evaluated by randomly allocating participants to one version of the program with the lapse management component and one version without it. The results of this RCT will tell us whether providing immediate help to users who have had a lapse can significantly improve their success rate. We also plan to collect indicators on working alliance and on internal motivation.Endre. The goal of this study is to explore the nature of the working alliance because it is not given that working alliance to a fully automated program is identical to the working alliance to a human therapist. It is only when we can be convinced of the nature of working alliance to a fully automated program that it will be truly meaningful to test its importance for eHealth-assisted behavior change.Another ongoing project is a qualitative study on the users’ working alliance to Endre simulates support of a working alliance, internalized motivation, and lapse preparation and lapse management, we do not know to what extent this simulation is successful for the user. One might establish simulation success through RCTs as the one described previously and compare the results with comparable findings from the counseling literature.Finally, although we have argued that Endre, a fully automated eHealth program, through interactivity and individual tailoring emulate 3 effective mechanisms of face-to-face counseling. By having used intervention mapping to systematically break down Endre into smaller components and showed how the program simulates a counselor’s support of a working alliance, internalized motivation, and lapse preparation and lapse management, our analysis is an example of how knowledge of what works in eHealth programs may be deepened by interpreting them in light of therapeutic processes. We suggest that the combination of these 3 therapeutic processes may result in a synergistic effect. Based on the analysis, we believe the combined support of a working alliance, internalization of motivation, and lapse preparation and management should be an element in the “black box” of automated eHealth behavior change programs that will make them more effective.We have demonstrated how