ETV6-ABL1 is a rare gene fusion with oncogenic properties, reported so far in 28 patients presenting a variety of haematological malignancies associated with clinical outcome, including chronic myeloid leukaemia (CML), acute myeloid leukaemia (AML), acute lymphoblastic leukaemia (ALL) and chronic myeloproliferative neoplasm (cMPN). Here we report on a 46-year-old female who presented with Philadelphia negative CML, positive for the ETV6-ABL1 fusion. Whole genome screening carried out with oligonucleotide arrays showed a subtle loss at 12p13 and cryptic imbalances within the 9q34.3 region in a highly unstable genome. FISH mapping with custom BAC probes identified two breakpoints 5 Mb apart within the 9q34 region, together with a break at 12p13. While FISH with commercial BCR-ABL1 probes failed to detect any ABL1 changes, the ETV6 break-apart probe conclusively identified the ETV6-ABL1 fusion thus determining the probe’s role as the primary diagnostic FISH test for this chimeric oncogene. In addition, we confirm the association of the ETV6-ABL1 fusion with imatinib resistance reported so far in three other patients, while recording excellent response to the 2nd generation tyrosine kinase inhibitor (TKI) nilotinib. In summary, we highlight the value of ETV6 FISH as a diagnostic test and the therapy resistance of ETV6-ABL1 positive disorders to imatinib. BCR/ABL1 fusion gene as postulated by WHO classification (2008) [BCR can form a fusion product with ABL1. The chimeric proteins contain the kinase domain of ABL1 and are composed of the N-terminal part of the partner protein that includes a coiled-coil or a helix-loop-helix domain. Fusion genes with a break within intron 1 or 2 of ABL1, such as BCR-ABL1, ZMIZ1-ABL1, EML1-ABL1 and ETV6-ABL1, carry transforming activity, while the NUP214-ABL1 requires amplification to be efficient [CML is one of the most extensively studied human malignancies and was the first example of a disease, where the underlying molecular basis was a consistent chromosomal abnormality, the Philadelphia chromosome (Ph), that is the product of a balanced reciprocal translocation involving chromosomes 9 and 22. Over 95% of CML patients are found to carry the tq34;q11) and the resultant 1 and theETV6-ABL1 fusion was reported for the first time in a 22-month-old girl with ALL by Papadopoulos et al. in 1995 [ETV6-ABL1 translocation appears to be eosinophilia, seen in 16 out of the 21 patients for which data was available, a 2:1 male predominance and seen in patients with ages varying between 8 months and 81 years. The ETV6-ABL1 fusion is seen in a wide range of haematological malignancies: 5 patients had AML, 10 ALL and 3 with an MPN while the remaining 11 were described as having Ph negative CML, of which 3 presented in a blast crisis, summarised in Table The  in 1995  and to d in 1995 -6. CommoThe structure of the ETV6-ABL1 oncoprotein is similar to that of BCR-ABL1, as evidenced by the fact that both fusion products lead to activation of the non-receptor tyrosine kinase ABL1 with initiation of similar downstream pathways effecting cellular survival, growth rate and independence as well as transforming capacity .ETV6, fused to exon 2 of ABL1, while type B includes exons 1 to 5 of ETV6 fused to ABL1 exon 2. The difference between the two transcripts at protein level is the presence or absence of a direct binding site for the SH2 domain of the GRB2. Million et al [ETV6 exon 5 leads to a slightly lower tyrosine kinase activity of the type A ETV6-ABL1 protein, although both kinases are as catalytically active as is the BCR-ABL1 product.The existence of two different transcripts, type A and B, is evidence for alternative splicing. Type A transcript includes the first four exons of on et al  showed tETV6 and ABL1 genes have an opposite orientation to the chromosome centromere, the formation of a fusion requires at least three chromosomal breaks to be generated [ETV6-ABL1 fusion cases. Furthermore little is known regarding the effect of treatment with tyrosine kinase inhibitors on ETV6-ABL1 fusion positive haematological conditions.Since the enerated . This coETV6-ABL1 fusion formation. Located on der(9)t, this fusion oncogene is shown to result from multiple events within a 5.6 Mb region at 9q34.12-q34.3, which escapes detection by commercial BCR-ABL1 FISH probes. Importantly, full cytogenetic and molecular remission was achieved only after second generation TKI treatment thus associating the ETV6-ABL1 fusion with TKI resistance.Here we report a female patient, who presented with Philadelphia negative CML and t as a sole bone marrow karyotype abnormality leading to 9/l. The aspirate morphology reported myeloid hyperplasia with reduced erythropoiesis, and increased eosinophilic and basophilic precursors. Histopathology reported a myeloproliferative neoplasm suggestive for CML chronic phase, with a markedly hypercellular bone marrow and myeloid hyperplasia with a left shift and loss of normal architecture. Erythroid activity was markedly reduced - only scattered CD71 positive cells were present. CD34 and CD117 show less than 5% blasts. G-banding identified a balanced t in 10/10 metaphases and interphase FISH was positive in 92% of cells analysed. RT-PCR revealed the presence of ETV6-ABL1 fusion mRNA, while BCR-ABL1 was not detected. Such cases are not adequately covered by the WHO classification of myeloproliferative disorders and could be categorized as a ? CML variant.In August 2011 a 46-year-old female presented with fatigue, a leucocytosis and thrombocytosis. Blood film examination was suggestive for CML with a neutrophilia, myelocyte peak, basophilia and also of note a eosinophilia of 2.5 × 10ETV6-ABL1 mRNA was no longer detectable with nested RT-PCR. Both CCyR and MMR are sustained to date 22 months from diagnosis.Imatinib therapy achieved a complete haematological response (CHR) after 4 weeks and at 3 months, interphase FISH on the peripheral blood was positive in 37/200 cell (18.5%). At 5 months thrombocytosis had recurred with the reappearance of a mild neutrophilia, basophilia and eosinophilia at 6 months. FISH analysis was positive in both interphase (50/200) and metaphase (6/20) cells and residual disease was confirmed by nested RT-PCR. She was switched to nilotinib, once again achieving a CHR after 4 weeks, and a complete cytogenetic response (CCyR) at 3 months. Major molecular response (MMR) was also achieved and in the subsequent specimens taken at 10, 12 and 18 months, Bone marrow (BM) and peripheral blood (PB) cell samples were cultured in RPMI medium following routine protocols as previously described . High-reBCR-ABL1 probes  and ETV6 . Chromosome mapping of the 9q34 regions was carried out with a range of BAC clones . For disease monitoring a double fusion dual colour FISH probe was made with BAC clones covering the regions of ABL1 (RP11-57C19 and RP11-83 J21), ETV6  and NOTCH1 (RP11-707O3 and RP11-678D10) genes.Fluorescence in situ hybridization (FISH) investigations were performed using commercially available Life Technologies, USA). Purified RNA was reverse transcribed, quality controlled and tested for BCR-ABL1 as described previously [ETV6-ABL1 was amplified in pretreatment samples by single step PCR using primers Tel3F2 (5’-CGCTATCGATCTCCTCATTCA-3’) and CA3-b: (5’-ACACCATTCCCCATTGTGAT-3’). Two products were amplified, corresponding to a fusion ETV6 exon 4 to ABL1 exon 2 and ETV6 exon 5 to ABL1 exon 2. Remission samples were tested by nested PCR using primers TEL3F: (5’-CTGCTGACCAAAGAGGACTT-3’) and CA3-: (5’-TGTTGACTGGCGTGATGTAGTTGCTTGG-3’) in the first step and Tel32F2 + CA3-b in the second step. Dilution of pretreatment cDNA into negative control DNA indicated a sensitivity of detection of 10-4.Total RNA was extracted from the cell culture using Trizol reagent  following the manufacturer’s protocol. In brief, 1500 ng genomic test DNA was hybridised against a reference of a pooled DNA samples collected from PBMC of 6 - 8 disease free individuals . We used Genomic Workbench v.6  for data analysis as previously [Array CGH analysis was performed with a high-density customised 400 K oligonucleotide platform enriched with probes covering the coding regions of oncogenes  confirmed the absence of a fusion gene and hence the Philadelphia chromosome. However, some 21% of the interphase BM cells were found to harbour a third, albeit significantly smaller, ABL1 signal found to be absent from the metaphases. The ABL1 part of the D-FISH probe is 650 Kb long and any break upstream of exon 2 would result in two different in size segments. The proximal fragment covering the ASS – ABL1 exon 2 region is larger (~500 Kb) and will remain on der(9)t. However, the FISH signal from the smaller distal segment (~150 Kb) encompassing ABL1 exon 2 to 11 was not found on the der(12)t chromosome as expected, although detected in some of the interphase cells   yielded a split signal located on der(9)t in all dividing and 92% of the interphase BM cells demonstrating the rearrangement t in metaphase cells prompted us to search the 9q34 region by FISH 'walking’ for multiple events that could facilitate the formation of the ETV6-ABL1 fusion  some 40 Kb distal of the NOTCH1 gene  within the 9q34 region of der(9)t. In contrast, FISH using either custom 9q34 BAC clones or commercial BCR-ABL1 probes on interphase cells where the chromatin is less condensed allowing the discrimination of closely spaced DNA probes, revealed a third ABL1 signal indicating breakage. The application of a cocktail of BAC clones in a three colour FISH experiment covering all relevant breakpoints in 12p13, 9q34.12 and 9q34.3, showed that in interphase cells the ETV6-ABL1 fusion is a considerable distance away from the proximal part of ABL1 (exon 1b-2) and the neighbouring NOTCH1 gene , while in metaphase cells their discrimination is impossible. The ETV6-ABL1 fusion (both type A and type B transcripts) was confirmed by the RT-PCR and shown to occur after the break in the exon 1a-2 region of ABL1 and exon 5 of ETV6 as expected. Whole genome scanning using oligonucleotide arrays revealed a total of 37 cryptic copy number aberrations (CNAs), mostly (24/37) gains . A cluster of CNAs was found within 9q33-qter including extra copy of the DAB2IP (a tumour suppressor gene with a recognised role in breast and prostate cancer) and within the regions flanking NOTCH1. A cryptic 140 bp loss at chr12: 12,045,340 – 12,045,484 was found at the breakpoint in the ETV6 gene t9;2 in all olvement . Howeverdy shown ,10 that ETV6 is one of the six genes known to form fusion chimeric transcripts with ABL1. As a rule, the fusion gene results from joining the 3’sequences of ABL1 with the 5’ end of the partner genes. While most of these fusion genes are associated with a specific type of leukaemia, BCR-ABL1 and ETV6-ABL1 are found in a wide spectrum of clinically and morphologically different malignant blood conditions [nditions . In spitnditions .ETV6-ABL1 fusion gene is a truly rare event. So far there are 29 cases including the present study published after the first report in 1995 by Papadopoulos et al. , the dual colour/dual probe BCR/ABL1 set (D-FISH) should indicate an ABL1 rearrangement by producing a third ABL signal on der(12) while BCR remains intact  probe will produce a split (third) signal at the der(9) chromosome that is easy to detect in interphase cells of fusion carriers  probe of samples suspected for CML but negative for BCR-ABL1 rearrangement by FISH, provides a reliable way to reassess the 'rarity’ of this fusion gene. Indeed two recent studies [ETV6-ABL1 fusion transcript may well be around 1%, thus confirming our concerns that the occurrence of this translocation in haematological diseases is underestimated.The tq3;p13, the) that incorporates some of the suggested changes and highlight the fact that the ETV6-ABL1 fusion resides on der(9)t in nearly a third of the cases thus rendering FISH with ABL1 probes unfit for purpose.There are few descriptions in the literature of in-frame fusion products involving genes with different orientations. As a rule, formation of these fusion genes is associated with more than one event and more than the two breaks that are necessary for a classical reciprocal translocation. For example, Van Limbergen and colleagues  suggeste4ETV6-ABL1 and BCR-ABL1 induced leukaemia in mouse models, the only difference being the latency period. They found that the ETV6-ABL1 fusion protein is significantly more active compared to the p210 BCR-ABL1. Importantly, both fusion proteins were shown to have similar helix-loop-helix domains, which is fused to the kinase domain of ABL1 and implicated in protein oligomerisation process [ETV6-ABL1 positive patients respond to treatment with tyrosine kinase inhibitors (TKI) as expected. Kawamata et al., reported a favourable response to imatinib in chronic phase CML with normal karyotype and ETV6-ABL1[ETV6-ABL1 fusion positive patient with a myeloproliferative disorder who developed morphologic and cytogenetic relapse after 17 months on imatinib but achieved complete remission on a second second-generation TKI (nilotinib). After an initial haematological response to imatinib 400 mg daily our patient, who presented with typical chronic phase CML and t as sole karyotype abnormality, progressed at 3 months; whereas nilotinib achieved a prompt CCyR, followed by an MMR 16 months after diagnosis, which is sustained to date. The mechanism of the imatinib resistance reported here and by others is still unexplained. Although the long-term response to second generation TKIs remains to be determined, their implementation as first line therapy in ETV6-ABL1 (+) disorders is well supported.Million et al.  demonstr process . Indeed ETV6-ABL1. HoweverETV6-ABL1,15. SimiETV6-ABL1 positive disorders: firstly, the diagnostic value of FISH with the ETV6 (BA) probe and secondly, while this chimeric oncogene is associated with poor long term response to imatinib, our patient achieved a sustained response to nilotinib.In summary, we highlight two main features of Written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.KG carried out the molecular genetic studies, participated in the design of the study and drafted the manuscript. AV provided the clinical care and treatment and edited the manuscript. NC carried out the diagnostic RT-PCR analysis and edited the manuscript; JHR, DB, PK and FP carried out the diagnostic G-band and FISH analysis together with response to treatment. CG coordinated the array analysis and edited the manuscript. EN conceived, designed and coordinated the study. All authors read and approved the final manuscript.Addresses of the BAC clones.Click here for fileGene addresses.Click here for fileArray CGH results.Click here for file


The research prevention project entitled “HIV/AIDS and Substance Abuse Primary Prevention in Minority Adolescents”, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), targets minority male and female adolescents 12-17 years old in the implementation and evaluation of a program designed to prevent adolescents from engaging in substance abuse and sexual activities which place them as risk for contracting the HIV/AIDS virus. The five-year intervention will serve 750 adolescents and 750 parents.The program combines the effects of a program that consists of two evidence-based primary components: 1) refusal skills training and education for the adolescent focusing on issues relating to sexuality and substance abuse; and 2) a family prevention educational and skills component involving the parent(s) of the participating adolescents. The small group educational techniques employed with the adolescent component are based on the Teams-Games-Tournaments (TGT) Alcohol Prevention curriculum, cited as a Model Program in SAMHSA’s National Registry of Effective Programs and Practices (NREP) and as a Model Program by the Office of Juvenile Justice and Delinquency Prevention, and the Reducing the Risk (RTR) curriculum, both of which have been empirically evaluated as effective methods of teaching adolescent skills development in the areas of substance abuse and high-risk sexuality prevention. The parent prevention component is based on extensive research in which problem-solving skills and communication procedures have been used effectively with parents of adolescents.The evaluation component of the project assesses participants (adolescents and parents) at baseline, post participation, and at 6-month follow-up periods. Dependent variables include the adolescents’ and parents’ knowledge of, attitudes toward, and behavior related to HIV AIDS and substance abuse. Additionally, adolescents’ self-efficacy and quality of peer and parental relationships are assessed. For all participating family members, conflict and communication measures are secured.Significant differences have been shown for adolescents and parents between baseline, post participation, and 6 month follow-up for all dependent variables. Training manuals provide program implementation requisites and materials to facilitate dissemination at local, state, and international levels.


Best practices identified solely on the strength of research evidence may not be entirely relevant or practical for use in community-based public health and the practice of chronic disease prevention. Aiming to bridge the gap between best practices literature and local knowledge and expertise, the Ontario Public Health Association, through the Toward Evidence-Informed Practice initiative, developed a set of resources to strengthen evidence-informed decision making in chronic disease prevention programs. A Program Assessment Tool, described in this article, emphasizes better processes by incorporating review criteria into the program planning and implementation process. In a companion paper, “Strengthening Chronic Disease Prevention Programming: The Toward Evidence-Informed Practice (TEIP) Program Evidence Tool,” we describe another tool, which emphasizes better evidence by providing guidelines and worksheets to identify, synthesize, and incorporate evidence from a range of sources  to strengthen local programs.The Program Assessment Tool uses 19 criteria derived from literature on best and promising practices to assess and strengthen program planning and implementation. We describe the benefits, strengths, and challenges in implementing the tool in 22 community-based chronic disease prevention projects in Ontario, Canada. The Program Assessment Tool helps put best processes into operation to complement adoption and adaptation of evidence-informed practices for chronic disease prevention. Closing the gap between research knowledge and daily operation of community-based programs and policies is a central concern in public health and chronic disease prevention. Key reviews –3 and seBest practices may be derived by synthesizing the results from a pool of rigorous research studies that demonstrate the effectiveness of a program for a given health problem or public health concern. The use of the term “best” is derived from evidence-based medicine and the levels of evidence paradigm articulated by Sackett . AlthougThe concept of “promising practices” in public health emerged to recognize interventions achieving local success in the absence of sufficient research and evaluation resources to be labeled a best practice ,11–13. MAdaptation frameworks ,18 have In 2005, the Ontario Public Health Association (OPHA) received provincial funding to develop better processes to support evidence-informed practice at the local level, extending previous work focused solely on dissemination strategies . This inThe primary purpose of a program assessment is to strengthen existing programs through use of a structured review and rating process. The process was built on review criteria used previously to identify best and promising practices in health promotion and chronic disease prevention . DevelopThe 19 review criteria  compriseProgram assessment consists of 5 steps: 1) selecting a program for assessment and assigning roles, 2) gathering information, 3) assessing the program, 4) achieving consensus, and 5) planning for program enhancement. A description of the guidelines and accompanying worksheets used in each step are outlined in Program assessment is a generic process that can be applied to a range of community-based health promotion initiatives. Programs that most benefit from the full assessment process tend to be established programs that are not achieving expected outcomes or have not been updated.A program assessment requires at least 4 participants: 1 to gather information about the program and 3 to independently review the program information against the review criteria. Three types of reviewers are recommended: a local program stakeholder known as the internal reviewer, an external reviewer, and an expert reviewer who has knowledge of the audience or the initiative under review. If resources permit, 3 additional roles are recommended: an assessment coordinator, a consensus meeting facilitator, and a consensus meeting note taker .Once a program has been selected and roles assigned, a program informant, usually the manager or coordinator of the program under review, completes the program information survey, which consists of 19 questions designed to document how the program addresses each of the 19 review criteria. Gathering program information can take several hours to several days, depending on how well program records have been maintained. Many past participants have reported that simply completing the program information survey leads to useful insights for improving program processes. Once completed, the survey becomes a valuable source of program documentation, especially in situations where record keeping was previously inconsistent .Theory and Evidence:1. Describe any health promotion theories used to inform program design  as well as relevant and credible sources of evidence . How recently was this information gathered? Please describe relevant examples of how the research, including theory or a conceptual framework, informed program development and implementation.Program Objectives and Logic Model:2. List all program level and activity level objectives, whether process or outcome-related. Identify those which are SMART . If a program logic model exists, please provide.Environmental Support:3. To what degree, if any, has your program addressed Environmental Support to create physical and/or social environments that support healthy behaviours ?Policy:4. To what degree, if any, has your program addressed policy ? Some examples are advocacy to support by-law change or worksite policy development.Sequencing:5. Does this program involve a sequence of activities designed to maximize population impact over time ? Please explain.Figure 2. The program information survey directs the process of collecting program information. This excerpt details 5  of 19 review criteria.In the third step, the program information survey and supporting documentation are assessed by 3 reviewers, each of whom may have a different perspective. The internal reviewer is knowledgeable of the program under review. External reviewers, of which there are usually 2, can be a public health colleague, a program stakeholder, or someone with expert knowledge of the type of program or the intended audience.Reviewers use the program assessment worksheet to document levels of achievement and suggestions for improvement for each of the 19 criteria. There are 3 levels of achievement. Level A indicates substantial room for improvement, level B indicates some room for improvement, and level C indicates the criterion has been satisfactorily addressed and there is little room for improvement. The counterintuitive rating scheme  endeavors to decrease the unintentional perception of being judged and to increase the positive intention of developing suggestions to strengthen the program .Environmental Support:6. The program creates physical and social environments that support healthy behaviours . Identified opportunities for creating physical and/or social environments within program but no plan to address them.A plan to address physical and/or social environments is available and appropriate partners engaged by no action yet taken on the plan.Appropriate partners engaged and action taken to address physical and social environments.Level:Rationale:Suggestions for Enhancement:Policy:7. The program develops and, as appropriate, implements policy. Policy refers to changing formal or informal rules of governing bodies to support healthy behaviours, both development and implementation. Policy efforts can be directed at the municipal level  and/or the institutional level .Steps taken to plan for and engage appropriate partners  to develop a policy.Appropriate partners are engaged . A policy change plan is in place.All of 3 above and action taken to operationalize strategy to promote policy change.Level:Rationale:Suggestions for Enhancement:An experienced reviewer can complete a program assessment in 90 minutes. Someone new to the assessment process may need 3 to 4 hours. How well the program information survey is completed also factors into the time required to complete an assessment.Figure 3. The program assessment worksheet helps reviewers rank the program against the 19 review criteria and record the rationale for the ranking and suggestions for improvement. This excerpt is for criteria 3, Theory and Literature Evidence.The consensus meeting provides an opportunity for program reviewers and stakeholders to establish a final rating for each criterion and to generate, through a dialogue of multiple perspectives, final suggestions to improve the program. Before the meeting, input from each program reviewer is collated via the consensus summary worksheet and distributed to all participants. The final consensus ratings and suggestions for program enhancement are also documented on this worksheet .A successful consensus meeting requires that all participants feel they have equal opportunity to contribute to the discussion. We have found that assigning a consensus meeting facilitator is useful in this regard. This role is also charged with keeping discussions to within the established timeline, usually 90 minutes, and ensuring that all 19 criteria are addressed.The consensus meeting is perhaps the most critical aspect of a program assessment. Our experience has shown that participating in these discussions accounts for much of the learning and capacity building that occurs throughout the program assessment process.Program stakeholders decide which, if any, of the suggestions for program enhancement are implemented. Decisions are based on factors such as resource availability, political acceptability, and organizational support, all of which are context dependent. Thus, the final step in a program assessment involves program stakeholders meeting to select priorities and to develop feasible plans for program enhancement. Final decisions are documented on the program enhancement work plan .The suggested timeline to complete all 5 steps in a program assessment is 7 weeks. The actual time required of participants depends on their role or roles, other work responsibilities, and their experience in conducting assessments. The first assessment is the most time consuming, as participants spend time understanding the process and the criteria.Since 2005, the TEIP Program Assessment Tool has been applied to municipal public health programs in Ontario and to health promotion initiatives where public health practitioners partner with a community-based coalition. Examples of initiatives applying the tool include smoking prevention and cessation, elementary school health promotion, active transportation, blood pressure education, pedometer lending libraries, grade 9 healthy heart screening, stroke prevention, and various workplace wellness initiatives. The tool is not as good a fit for the more clinically oriented and hospital-based programs  where health promotion principles are not well embedded into the culture of practice. However, use of the tool in these contexts can lead to increased understanding of health promotion concepts and approaches among clinic staff.We conducted a TEIP Program Assessment of an adult smoking cessation program delivered at a small health unit serving a largely rural population. The smoking cessation program consisted of 4 weekly sessions led by a facilitator and an optional monthly support group. The program was created on the basis of a promising practice developed for low-income women at another health unit 10 years earlier. Program materials had not been revised in many years and looked dated, although the information and the concepts themselves were sound. Enrollment was small, 6 to 8 people per session, despite the region having among the highest rates of smoking in the province. Some sessions were cancelled because of insufficient enrollment. Evaluation of the program consisted mainly of satisfaction-type questions, the results of which were never collated or used to influence program decisions. Program staff avoided asking outcome-related questions out of fear the program would be unfairly deemed unsuccessful since it was generally known that most individuals require multiple quit attempts before achieving success.During the consensus meeting, suggestions for enhancement focused on several areas: 1) update the look of program materials to be more modern and appealing, 2) streamline program registration to collect baseline and follow-up data to measure interim outcome indicators toward quitting , and 3) increase marketing efforts by drawing on partners in the hospitals and stroke clinics to advertise their program.The program team took the suggestions for enhancement seriously. They invested in the services of a marketing consultant. The program was rebranded as the iQuit Program, and an eye-catching logo and new program materials were developed. The health unit’s epidemiologist assisted in developing a preintervention, postintervention, and 6-month follow-up evaluation to assess interim outcome indicators for smoking cessation, drawing on indicators found in peer-reviewed literature. A marketing plan was developed to better promote their program across the region.The program assessment breathed new life into a tired and underappreciated program. The refreshed program was presented at provincial smoking cessation conferences and was nominated for a local health promotion innovation award. Three years later, the program coordinator continued to review the original suggestions from the consensus committee for additional program enhancement ideas.Feedback on use of the Program Assessment Tool was obtained from a formative evaluation conducted during 2005 and 2006, and from approximately 300 participants who attended TEIP Master Trainer workshops from 2008 through 2011.Benefits of using the Program Assessment Tool have been reported at the individual, program, and organizational levels. At the individual level the process is seen as particularly helpful in increasing understanding and skills in the application of best practice concepts. Practitioners appreciate the focus on program enhancement in the assessment process and the supportive context of the review. They also report increased knowledge and interest about program evaluation. At the program level, the structured review process is reported as useful in strengthening planning processes for any chronic disease prevention program. Many participants report that the program information survey provides an opportunity to improve program documentation and that the overall assessment process provides suggestions to strengthen program evaluation activities. At the organizational level, the tool is reported to strengthen collaboration between other groups engaged in chronic disease prevention programming through involving partners and collaborators in the assessment process and in consensus meetings.The most consistent challenge cited by participants is the substantial time and resource constraints under which they work. In response, alternative applications of the Program Assessment Tool have been explored, including assessing 1 aspect of a program such as evaluation needs or program content, using the review criteria as a checklist in planning new programs or in conducting a mini-program review, using the assessment process to initiate relationships with new partners, and using the criteria to set planning goals for future program achievement. Another common challenge is the reported lack of adequate documentation of the local programs needed to complete the review process.Creating relevant opportunities for knowledge exchange and deliberative dialogue is essential given the array of evidence and information available ,24. The Just as important as creating space for knowledge exchange is the content of the dialogue and discussion. The TEIP Program Assessment Tool provides a process that emphasizes continual program improvement and using research as well as experiential knowledge to support decision-making. The tool and related supports meet public health practitioners where they are, helping to build on existing program design and implementation strengths. The process also acknowledges the complexity of community-based programs, organizational and management structures, and available resources. The combined opportunity for meaningful knowledge exchange and the emphasis on program enhancement empowers public health practitioners to be more confident in making program-related decisions and reduces apprehension about review of programs for the purposes of ongoing improvement. As a user observed, “[It is] important to put the criteria out there and people will rise to the bar.”Provision of capacity building and leadership are particularly important in maintaining momentum and enthusiasm for the assessment process in the implementation of effective and robust chronic disease prevention programs ,23. ThusThe TEIP Program Assessment Tool contributes to the use of evidence-informed practice through reinforcing and supporting the use of best practices by focusing on strengthening better processes and ongoing program improvement. The impact of the TEIP Program Assessment Tool will only be realized with adequate organizational support and leadership at multiple levels. Public health leaders at multiple levels need to champion and support the dissemination and use of the tool, including ongoing improvements over time. Future work should assess the extent to which the use of the tool affects longer-term outcomes at the practitioner, program, and organizational levels. Accreditation bodies can acknowledge and give credit to organizations employing continuous improvement processes such as the TEIP Program Assessment Tool. The result will be improved public health and chronic disease prevention activities.


The aim of this paper is to provide an overview of the phases of the action research process involved in developing, implementing, and evaluating the Heart Beads program. The aim of the project is to enrich the hospital experience of children with cardiac conditions. Heart Beads involves children receiving unique beads specific to each cardiac treatment, procedure or event in recognition of their experiences, and endurance. An action research approach, involving a partnership between clinicians and researchers and emphasising the involvement of patients and their families, was used to guide the Heart Beads program. The project followed the five phases of action research: identification, investigation, program development, implementation, and evaluation. Heart Beads began as a small project which continues to grow in popularity and significance with children at a tertiary paediatric hospital in Sydney, Australia. The program is now being implemented nationwide with the vision that all Australian children hospitalised with cardiac conditions can benefit from Heart Beads. In July 2008, The Children's Hospital at Westmead, Sydney launched the Heart Beads program for children with cardiac conditions. The program involves children receiving unique beads specific to each cardiac treatment, procedure, or event in recognition of their experiences and endurance. The program aim was to document the children's experiences in a unique and child-friendly form, adding a positive dimension to their treatment process and ultimately reducing the strain involved in their hospital admission. The project team  hoped that children would feel a sense of achievement for their courage and be able to trace their continuing journey as their collection became increasingly unique and also that the beads could act as a medium for the children and families to develop more positive relationships with staff and other children and families in the hospital.Heart Beads was developed using an action research approach to help address the needs of children, families, and staff identified both within the hospital and the existing literature. The stresses parents experience when a child is diagnosed with a serious illness is well documented –5. The lAction research has been widely used in nursing and other disciplines to help guide the development of new programs, the introduction of these programs into clinical settings, and the subsequent evaluation of the program –20. TherThe aim of this paper is to provide an overview of the phases of the action research process involved in developing, implementing, and evaluating the Heart Beads program created with the aim of enriching the hospital experience of children with cardiac conditions.An action research approach was used to guide the development, implementation, and evaluation of the Heart Beads program. This approach was deemed the most appropriate due to the facilitative nature of action research and the fact that staff were familiar with action research processes. Such an approach is important as the program was aimed not only at improving the experience for children, young people, and their families but also included supporting clinical staff to undertake and learn about research, to make changes to practice, to evaluate the outcomes of such changes, and to report the findings to a range of audiences . Meeting This project followed the five phases of action research , as outlPhase 1 involved identification of the potential value of documenting children's and parent's experiences of hospitalisation for a cardiac condition.Phase 2 was the investigation of bead programs as a way of documenting the child's experiences as well as enabling staff to review and change their current practice.Phase 3 encompassed the program development which involved establishing a project team and planning the project including identification of elements and stages of the program.Phase 4 involved the clinical implementation of the program with the incorporation of various required changes in the process.Phase 5 was the overall evaluation of the program primarily through interviews with both staff and families.The project phases discussed in this paper were conducted between 2007 and 2009. The Heart Beads program continues to be run at the hospital.Ethics approval for the study was gained from the hospital Human Research Ethics Committee. Participation in the Heart Beads program is optional with the only inclusion criteria being that the child's primary reason for hospital admission is a cardiac condition. Written consent (for the child and their parents) is obtained from families who wish to participate in the program. Additional consent was sought for interviews and included consent from children and young people where they were able to be involved.Practice Development projects conducted in the cardiac ward enabled staff to increase their awareness of the experiences of children, parents, and other staff and thus initiate improvement projects with the capacity for change at the ward level. During this phase ward staff saw a potential for recognition and documentation of children's and parents' experiences of hospitalisation. A bead program was identified as a project that could improve the experiences of cardiac patients and their families. Awareness of the potential value of bead programs in a health care setting was raised at a conference attended by the cardiac ward nursing unit manager (NUM) and cardiology clinical nurse consultant (CNC) at which “Bravery Beads,” a reward program for oncology children, was presented. The concept originated from the British Columbia's Children's Hospital, Vancouver where “Bravery Beads” was first developed as a tool to honour and document the journey of children with cancer . Since tThe cardiac ward NUM and cardiology CNC presented the bead concept to staff in the ward and staff in the nursing research and practice development unit. The program was subsequently discussed and investigated via literature search and communication with the developers of the Bravery Bead program. Whilst there are many anecdotal accounts of the Bravery Bead program and its benefits, it was found that there are to date no reported research studies on the implementation of such programs. There has, however, been research indicating the importance of finding ways to encourage children and prepare them for procedures they are about to undergo where possible . A bead The development stage consisted of planning and designing the Heart Beads program. In this third phase a project team was established consisting of the project officer (the nurse educator on the cardiac ward), the cardiac ward NUM, cardiology CNC, other nurses on the cardiac ward, and researchers from the Nursing Research and Practice Development Unit at the hospital. This team met on a monthly basis to discuss project progress and issues arising and to evaluate the process and its evolution with staff. Program development, from initial funding approval to clinical implementation of the Heart Beads program, took approximately eight months. Program creation was multifaceted including developing staff education seminars, bead selection, brochure and logo development, structure and process development, formation of a risk management plan, development of patient and family consent forms and bead prescriptions, and stakeholder engagement and consultation. Not all aspects of program development were predictable, and some were only revealed as the program evolved. Further information on these aspects and overall program development are detailed in Dengler et al. . EvaluatConsultation took place with nursing and research staff, families, and representatives of the four hospital units where children with cardiac conditions reside: the cardiac ward, the preadmissions clinic and the Paediatric and Neonatal Intensive Care Units (PICU and NICU). The purpose of these consultations was to ensure that stakeholders including clinical staff and families were involved in the project from the beginning, and that the program was responsive to the needs of both staff and families. The procedures chosen to be represented through the beads to signify the most significant, traumatic, or memorable moments of a hospital stay were agreed upon. A pilot trial with one family was conducted with a sample set of beads. The five-year old patient was a long-term cardiac patient, thus relevant beads were backdated for previous events and procedures. The family's responses were sought by researchers during an interview. The family responded enthusiastically to the concept, the beads chosen and the processes and events they represented. The patient also featured in photos for Heart Beads brochures and other program material.A process for dispensing the beads to children was developed to ensure safe distribution. The program was designed so that the workload of ward staff was kept to a minimum. After a process of trial and consultation with all stakeholders, a prescription idea was adapted from the “Bravery Bead” program. The onus was placed upon parents to carry a script and prompt staff when confirmation of an event was needed. Ultimately this meant that all that was required of the clinical staff was to initial and date a box on the child's distribution form once a procedure or event had occurred for which a bead could be dispensed. Due to procedure evaluation the script format changed to ensure that it was more effective and encompassed all relevant events and procedures.This phase was important for establishing the project team  and their roles in the Heart Beads program which was based in the cardiac ward. Ongoing consultation between the project team and other units that were involved in the care of cardiac children and their families was also an important aspect. Processes and materials were continually refined as a result of constant evaluation throughout the program development, and this evidence informed ongoing change. Stakeholder input was high with keen interest in the development of the program from the various units and families on the ward.Phase four of the action research cycle involved clinical implementation of the program with the incorporation of various required changes in the process. Stakeholder consultation and collaboration had a large impact in this stage. Education sessions were provided in the clinical units to facilitate understanding by the staff of the processes involved and also to offer an opportunity for staff to express concerns or other feedback including suggestions for improvement. Three sessions were run in each unit. A Heart Beads resource folder was created containing the printed materials from education sessions, distribution forms, consents, and a journal for frontline ward staff to record candid comments and feedback from children, families, and other staff members relating to the program. Regular emails were sent to staff to ensure that they were informed about new developments and program feedback. Staff were also encouraged to use this mechanism to provide feedback and reflections to the project team.The Heart Beads program was launched in July 2008. Participation in the program commences at the cardiac preadmission clinic and continues as the child is admitted to the ward. Families are offered the opportunity to be involved in Heart Beads and those wanting to participate complete a written consent. The child (or parent if the child is too young) is given a set of beads with the child's name spelt out and some of the beads for initial procedures planned. The beads are small porcelain shapes of varying colours and patterns that can be threaded onto a string. Families are also given an information flyer which outlines the purpose of the program and specifies what each of the distinct beads is for and how their child will access the beads during their stay in hospital. A distribution form or script is provided to the family so that they can continue collecting beads for the duration of the child's hospitalisation. The program evolved after consultation with the units involved and led to the development of individualised PICU and NICU distribution forms. As it is common for the child to progress through different units before arriving on the ward, a uniform process was developed. The distribution form was developed to allow the nurses to tick off procedures for which the child could collect a bead. The forms are given to families at the clinic so that once they return to hospital for admission, they can continue collecting beads when they are transferred to the PICU postsurgery or in the NICU if they are admitted there. Rather than beads being dispensed in every unit, it was decided to confine this part of the process to the ward. The form is carried through PICU with the child, and the parents are encouraged to prompt staff to sign off and date it once procedures/events have taken place. When the child is transferred to the cardiac ward, a new form is given to the parents listing more tests for which the child can receive beads. Parents go to the ward to receive the beads on the form even while the child is still in the PICU.Initially, some resistance about the program was received from a small number of staff in the clinical areas concerned about whether it would add to their workload and what benefit it would be to the child and family. However, through education and witnessing the passionate reactions of children and families, they were ultimately able to see that the program added value rather than being an onerous task.There was some dissatisfaction expressed by ward staff relating to the restriction on the number of people able to distribute the beads. The ward staff were reassured that this was not a trust issue, that it was related to the Risk Management Plan and that to ensure the continuation of organisational support the restriction needed to be adhered to. Staff were encouraged to be involved in the process of bead distribution by accompanying the child, young person, or parent when the script was redeemed through a designated person. Nurses were then able to maintain involvement in the program and had additional opportunities to communicate with children, young people, and parents in relation to their procedures and their experiences of them. The issues that arose during implementation were able to be taken into account and the program modified accordingly by utilising the knowledge gained through practice. Processing of bead distribution forms was further refined, new beads were added to recognise procedures as requested by other units and families.The methods for program evaluation were determined after consultation between members of the project team . Program evaluation, for the purpose of this report, involved staff and family interviews, process notes from the project officer, and anecdotal accounts from ward staff.The Heart Beads program had been running for one year when formal evaluation, in the form of interviews, commenced in 2009. Purposive sampling was used for the interviews, and every attempt was made to include fathers, children, and young people where possible. Seven staff  and eleven families consented to being interviewed after the commencement of the program. These interviews were conducted in a private room on the ward with a researcher and ranged from ten- to thirty-minute duration. Interviews were conversational in nature and were audiorecorded and transcribed. Interviewees were informed that the researchers (whom they had not previously met) were there to ask them about their experiences of the Heart Beads program and were provided with an information sheet explaining the evaluation. Interviewees were asked for their impressions of the Heart Beads program, what the program meant to them and their perceptions of the program overall. Interviews were coded and themed independently by two researchers, themes were discussed, and final themes agreed upon. Themes from family interviews have been discussed extensively in Redshaw et al. . The project officer documented staff feedback, details of correspondence, project meeting notes, and other relevant information as process notes. These process notes, particularly relating to staff feedback, were used to continually refine the Heart Beads program. Continual review of the action research process, identifying issues and barriers and taking action to address these  enabled the project team and staff on the ward to maintain momentum. Frontline nursing staff wrote up anecdotal accounts of the experiences of patients and their families involved in the project into a ward Heart Beads journal. The information from the process notes and anecdotal accounts, which was reviewed by researchers, has been brought together with the outcomes for staff and families. Qualitative data from the project thus includes interviews with staff, children, and families, analysed and themed following a grounded theory approach, and process notes and accounts from ward staff. It is not the purpose of this paper to discuss the findings of these interviews as these outcomes have been reported elsewhere. Briefly, outcomes included enthusiasm and excitement about the program, beads assisted with documentation of procedures and provided a record of experiences that impressed on staff and families the extent of what the child endured and the distress this involved. Evaluation of the Heart Beads program is ongoing and will continue for the duration of the program to ensure that the program meets its objectives and continues to enrich the hospital experience of children with cardiac conditions.The Heart Beads action research project involved a series of reflective cycles and continual evaluation , allowinThe action research approach as outlined by McNiff et al.  resultedThe action research approach was effective in bringing about the involvement of staff in the program and its continual enhancement and the development of their insights in relation to the care they provide. Increasing staff awareness of the experiences of the children in their care is imperative in paediatric nursing . Providi Details of the Heart Beads program, particularly relevant outcomes, have been communicated throughout the hospital and at local, national, and International conferences. Scott  emphasisThe Heart Beads program began as a small project in the cardiac ward and continues to grow in popularity and significance. Throughout the development, implementation, and evaluation process, the Heart Beads program encountered numerous setbacks and challenges, many of which were overcome using the action research approach, as well as witnessing inspiring results and enthusiasm. Due to the overwhelmingly positive reactions from staff, children, and families alike, program continuation appears likely. The value of bead programs as a tangible tool to facilitate reflection and dialogue surrounding children's and families' hospital experiences is clearly acknowledged. The program has highlighted the importance of recognising the experiences of patients and families. Heart beads have allowed patients, families, and staff to appreciate the journey of children hospitalised with cardiac conditions.Undertaking the project of developing, implementing, and evaluating the Heart Beads program through an action research approach has meant greater involvement of staff in the shaping and running of the program. Issues that have been raised in the process have been addressed and workable solutions found to ensure that the program remains effective and sustainable. Collaboration with researchers and with families provided opportunities for reflection and feedback from outside the ward environment, thereby enhancing program success.


Christchurch, New Zealand, was struck by 2 major earthquakes at 4:36am on 4 September 2010, magnitude 7.1 and at 12:51pm on 22 February 2011, magnitude 6.3. Both events caused widespread destruction. Christchurch Hospital was the region's only acute care hospital. It remained functional following both earthquakes. We were able to examine the effects of the 2 earthquakes on acute cardiac presentations.Patients admitted under Cardiology in Christchurch Hospital 3 week prior to and 5 weeks following both earthquakes were analysed, with corresponding control periods in September 2009 and February 2010. Patients were categorised based on diagnosis: ST elevation myocardial infarction, Non ST elevation myocardial infarction, stress cardiomyopathy, unstable angina, stable angina, non cardiac chest pain, arrhythmia and others.There was a significant increase in overall admissions (p<0.003), ST elevation myocardial infarction (p<0.016), and non cardiac chest pain (p<0.022) in the first 2 weeks following the early morning September earthquake. This pattern was not seen after the early afternoon February earthquake. Instead, there was a very large number of stress cardiomyopathy admissions with 21 cases (95% CI 2.6–6.4) in 4 days. There had been 6 stress cardiomyopathy cases after the first earthquake (95% CI 0.44–2.62). Statistical analysis showed this to be a significant difference between the earthquakes (p<0.05).The early morning September earthquake triggered a large increase in ST elevation myocardial infarction and a few stress cardiomyopathy cases. The early afternoon February earthquake caused significantly more stress cardiomyopathy. Two major earthquakes occurring at different times of day differed in their effect on acute cardiac events. On 4 September, 2010, Christchurch, the second largest city in New Zealand with an urban population of 400,000, was struck by a 7.1 magnitude earthquake at 4:46 am. The city suffered significant damage to its infrastructure and buildings. A state of emergency was declared and financial loss was estimated to be as high as $5 billion. Fortunately, there were no direct fatalities. Six months and thousands of mild to moderate aftershocks later, Christchurch was again struck by a powerful earthquake on 22 February 2011 at 12:51 pm. Although smaller on the Richter scale than the first one, the epicentre of this magnitude 6.3 earthquake was 5 kilometres deep and 10 kilometres southeast of the city centre. It generated a vertical 2.2G force, the highest peak ground acceleration ever recorded in the world Major stressful events are well documented to increase the incidence of acute cardiac events The Southern Health and Disability Ethics Committee was consulted for consideration of expedited ethical approval. They advised ethical approval was not required because this study did not require direct patient contact and would not identify individuals.Within hours of the September 2010 event, acute Cardiology admitting staff noted an increased number of chest pain presentations precipitated by the earthquake and its immediate aftershocks. Faced with this, they maintained a log of all patients who reported that their chest pain was triggered by the earthquake or one of the immediate aftershocks. An audit was then commenced 4 weeks after the earthquake to fully document the pattern of cardiac admissions. Clinical notes and electronic discharge summaries were systematically reviewed and relevant data collected. Following the second earthquake in February 2011 a second review was performed using the same methodology as the first. This has allowed for stringent comparison of the effects of the 2 events.The electronic patient management system at Christchurch Hospital was used to identify all acute admissions to the Cardiology Department in the period of 3 weeks prior to and 5 weeks following each earthquake . The control groups were all acute Cardiology admissions in the corresponding time period from the previous year . Patients who were not residents of the earthquake zone  were excluded from the study as were peripheral hospital transfers and elective admissions.Systematic review of the clinical files, electronic discharge summaries, coronary angiograms and echocardiograms were undertaken for each patient by a senior investigator. Data collected included basic patient characteristics, date of admission and discharge, and investigations performed. Cardiac diagnosis was defined according to set criteria.Cardiac arrhythmia presentations were classified into heart block (second degree or complete), ventricular arrhythmia, atrial fibrillation, atrial flutter or supraventricular tachycardia. Cardiac arrest was defined as arrhythmia (ventricular or asystole) that required electrical cardioversion or CPR to support circulation. All diagnoses of arrhythmia had to be confirmed by review of the ECGs.ST elevation myocardial infarction (STEMI) was defined as chest pain associated with at least 2 millimetres of ST segment elevation in 2 precordial leads or 1 millimetre in 2 other contiguous leads on ECG. Non ST elevation myocardial infarction (NSTEMI) was defined as chest pain without associated ST segment elevation. Other focal ECG changes such as ST segment depression may or may not be present. For both STEMI and NSTEMI diagnoses a serial troponin I rise to over 0.03 µg/l and a culprit lesion identifiable on coronary angiography were required.Unstable angina was defined as ischaemic symptoms which can be frequent and onset with little or no physical exertion, with or without dynamic ECG changes, and serial troponin I of<0.03 µg/l. Stable angina was defined as ischaemic symptoms onset only with physical activities, without dynamic ECG changes and serial troponine I of<0.03 µg/l. For newly presented patients, the diagnosis is made following either positive stress tests or coronary angiography to confirm coronary artery disease. For both conditions, in those who have known coronary artery disease on previous coronary angiography, further stress test or repeat imaging was not necessary to make the diagnosis.Non-cardiac chest pain (NCCP) was defined as chest pain presentation without associated ECG changes and with serial troponin I<0.03 µg/l at least 12 hours after the onset of symptoms. Other significant causes of chest pain had to be excluded to the satisfaction of the attending Cardiologist. Where exercise ECG, exercise Echo or Dobutamine stress Echocardiograms were undertaken, the results were negative. In cases where coronary angiography was performed, significant coronary artery disease was excluded for the patient to be classified as having NCCP.Stress cardiomyopathy (SCM) was defined similar to the modified Mayo criteria Patients presented with heart failure had symptoms and signs in keeping with the diagnosis, plus one of the following – radiographic changes of fluid overload, elevated BNP, or ventricular dysfunction on Echocardiogram. A diagnosis of pericarditis was made if patient had typical symptoms and saddle shaped ST elevation on ECG, with normal serial troponin I (<0.03 µg/l), with or without pericardial effusion on echocardiogram and prodromal illness. Significant valvular heart disease was diagnosed when patients have severe valvular lesion on echocardiography and associated symptoms. The diagnosis of pulmonary embolus was made radiologically either by CT pulmonary angiography or ventilation perfusion scanning.For each earthquake statistical analysis was performed for total cardiac admissions and for each specific cardiac diagnosis. The change in admission rate from the 3 weeks prior to each earthquake to the 2 weeks after was compared with the relevant control period. A poisson regression model which included terms for the pre and post-earthquake periods, the earthquake and control periods, and the interaction of these 2 factors was used to compare these changes. The interaction term which directly compares the changes between the control and earthquake periods was the focus of the analyses. A two-tailed p-value<0.05 was taken to indicate statistical significance.The pattern of acute cardiology admissions in the weeks before and after the 2 earthquakes is shown in In the first 2 weeks after the September 2010 earthquake, there was a significant increase in the mean admission rate for STEMI (p = 0.016) compared to that of the control period (3 weeks before and 2 weeks after 4 September 2009), and to 3 weeks prior to the earthquake .Similarly, there were significantly more NCCP admissions in the first 2 weeks following the September 2010 earthquake, p = 0.022 . AmongstThere were no statistically significant changes in acute cardiac arrhythmia presentations in the first 2 weeks following both earthquakes , includiThere were no reported cases of SCM in the 2009 and 2010 control periods. After the September earthquake there were 6 cases . There was a dramatic increase with 21 SCM presentations within 4 days of the February 2011 earthquake . The 95% confidence intervals on the rate over 5 weeks are 0 to 1.27 for the control period and 0.44 to 2.62 and 2.6 to 6.4 respectively for each earthquake. Statistical analysis showed this to be a significant difference between the earthquakes (p<0.05). The February 2011 earthquake resulted in significantly more SCM cases than the September 2010 earthquake. Neither earthquake affected presentation rates for congestive heart failure, pericarditis, pulmonary embolus, or significant valvular heart disease .The most striking finding of this study is that the 2 earthquakes differed in their effects on acute cardiac admission pattern. This was most apparent in the first 2 weeks. After that, the changes in acute cardiac admission dissipated. The 2 major earthquakes struck Christchurch within 6 months of each other and each was associated with a different pattern of cardiac admissions. In the week of the September 2010 earthquake and the week following, there was an increase in acute STEMI presentations and a lesser increase of SCM. In the week of the second earthquake, there were 3 times as many SCM cases within 4 days, without a spike in acute myocardial infarction. The pattern following the first earthquake is similar to that reported after the 1994 Northridge earthquake Our data also raises the possibility of circadian variation in propensity to SCM. The earthquake at 12:51pm in February 2011 was smaller than that at 4:36am in September 2010 but resulted in 3 times more cases. The only study specifically examining such condition after an earthquake was from Watanabe et al after the Niigata earthquake in 2004 Earthquakes are unheralded events. As with previous studies our study has the weakness that by necessity it is retrospective. It's strength however is that it is a single centre experience. Christchurch Hospital is the only acute hospital for the region, and that we have the same population exposed to 2 different earthquakes in a 6 month time period. There was no significant migration in or out of Christchurch between the earthquakes. Furthermore, Christchurch Hospital and our patient management systems remained fully functional in spite of the disruption to the rest of the city, ensuring good data capture.The major implication of this study for clinicians and policymakers is that each earthquake, and by extrapolation each natural disaster, is different. Christchurch Hospital was fortunate to have effective natural disaster procedures in place prior to these earthquakes. These permitted the Cardiology service to remain functioning throughout and allowed for provision of continued normal care. In our study, the majority of earthquake induced acute cardiac presentations occurred within the first 2 weeks following the events. Such knowledge allows better future disaster planning, focusing on efficient resource and personnel allocation in the initial period following a catastrophe.It is unclear from this study why SCM might have a diurnal variation. Variations in autonomic tone and haemostatic factors have been proposed as possibly important in the mechanism in myocardial infarction. Following the Hanshin-Awaji earthquake increases in D-dimer, von Willebrand factor, tissue-type plasminogen activator and blood pressure were reported


BMS309403 is a biphenyl azole inhibitor against fatty acid binding protein 4 (FABP4) and regarded as a lead compound for effective treatment of obesity related cardio-metabolic diseases. Here we discovered an off-target activity of BMS309403 in that it stimulates glucose uptake in C2C12 myotubes in a temporal and dose dependent manner via activation of AMP-activated protein kinase (AMPK) signaling pathway but independent of FABPs. Further analysis indicated that BMS309403 activates AMPK through increasing the ratio of intracellular AMP:ATP while decreasing mitochondrial membrane potential. These findings provide mechanistic insights on the action of BMS309403. BMS309403 is a biphenyl azole inhibitor specifically designed to target FABP4 with a Ki value less than 2 nM In the present study, we found that BMS309403 enhances glucose uptake in myotubes through activation of the AMPK signaling pathway, which was accompanied by altered mitochondrial membrane potential and AMP/ATP ratio. These actions are at least partially independent of FABPs. Our findings provide new mechanistic insights into the actions of BMS309403 and this class of pharmacological reagents in combating obesity and related metabolic diseases.BMS309403 was previously reported to increase glucose uptake in adipocytes BMS309403 increased glucose uptake in a dose dependent manner up to 20 µM with a maximal stimulatory effect at 20 µM . LikewisMaterials and Methods, before treated with BMS309403. As shown in To determine whether BMS309403 has the same effect on muscle cells other than the C2C12, rat L6 cells were tested. L6 cells were cultured and differentiated into myotubes, as described in The above results indicate that BMS309403 induced enhancement of glucose uptake was accompanied by activation of AMPK. To further evaluate whether AMPK is directly responsible for the BMS309403-induced glucose uptake in myotubes, C2C12 myotubes were pre-incubated with or without an AMPK inhibitor, compound C, before the addition of BMS309403. Insulin was also added alone or in combination with BMS309403 as a control. As shown in BMS309403 was designed as a competitive inhibitor not only for FABP4 but also for FABP3 and FABP5, exhibiting Ki values<2 nM for FABP4, compared with these of 250 nM for FABP3 and 350 nM for FABP5 Furthermore stable C2C12 transfectants expressing shRNAs against mouse FABP3 were established following lentiviral transfection and selection with puromycin . Resultii.e. AMPKα2β1γ1 33P] into the SAMS peptide 50 of about 5 µM  is a well-developed indicator of mitochondrial membrane potential. C2C12 myotubes were treated with DMSO or different concentrations of BMS309403. The mitochondrial membrane potential was measured using the dye JC-1. As shown in Whether BMS309403 increased ratio of AMP to ATP was investigated as well. To do this, adenine nucleotide in C2C12 myotubes was measured by HPLC following treatment with DMSO or 20 µM BMS309403. Consistent with the uncoupling effect observed for BMS309403, the AMP: ATP ratio was increased up to two folds by this compound .In the current study, we provide several lines of evidence to support our hypothesis that BMS309403 stimulates glucose uptake through selective activation of AMPK signaling pathway. First of all, we demonstrated that BMS309403 significantly increased glucose uptake in myotubes in a time and dose dependent manner, which was paralleled by phosphorylation of AMPKα, p38 and ACC, without involvement of Akt. More direct evidence comes from the fact that inhibition of AMPK by compound C strongly alleviated BMS309403 evoked glucose uptake in C2C12 myotubes. It should also be noted that an additive effect on glucose uptake by BMS309403 and insulin was observed, further supporting our hypothesis that BMS309403 stimulated glucose uptake exclusively through AMPK but not insulin/Akt signaling cascade.BMS309403 is originally designed as a highly selective inhibitor against FABP4 by occupying the internal lipid binding pocket and competing for the lipid binding in the target proteins in vivo warrants further investigation, which will provide new insights to establish this class of compound as pharmacological reagents to combat obesity and related diseases.Although BMS309403 is not a direct activator of AMPK, our results indicate that this compound acted as an uncoupler of mitochondrial proton gradient. Interestingly, several anti-diabetic agents, such as troglitazone, rosiglitazone, metformin and berberine, have been shown to activate AMPK via modulation of mitochondrial membrane potential, and thereby exert their pharmacological effects 3H] glucose (37 MBq (1 mCi)) was purchased from GE Healthcare . Compound C was purchased from Calbiochem . The HIV-based lentiviral vectors and cDNA encoding full-length human FABP3 were purchased from Genecopoeia . pCMV-3tag vector was purchased from Agilent technologies .Dulbecco’s modified Eagle’s medium (DMEM) and fetal bovine serum were purchased from Hyclone . Donor equine serum was purchased from Thermo Scientific (U.S. Origin). Specific antibodies against Acetyl-CoA Carboxylase, Phospho-Acetyl-CoA Carboxylase (Ser79), AMPKα, Phospho-AMPKα (Thr172), Phospho-p38 MAP Kinase (Thr180/Tyr182), Akt, Phospho-Akt (Ser473) were purchased from Cell Signaling Technology . Horseradish peroxidase-conjugated secondary antibodies were purchased from Sigma-Aldrich . PVDF membrane was purchased from Millipore . BMS309403 was synthesized in our lab  and dissolved in DMSO in several dilutions. 2-deoxy-D-, incubated with 0.5 ml of BMS309403 of various concentrations in KRPH buffer for 15 min. The medium was switched to KRPH buffer containing BMS30943, 5 mM D-glucose and 0.5 µCi/well of 2-deoxy-D [3H]-glucose for the last 15 min or 5 min. Myotubes were then washed three times with ice-cold PBS and lysed with 0.5 M NaOH and 0.1% SDS. Cell lysates were neutralized with HCl. Radioactivity was measured by liquid scintillation counting .Differentiated C2C12 cells were starved in serum free-medium for 2 h before incubation with BMS30943. Myotubes were washed twice with glucose free KRPH buffer  into the SAMS peptide. Radioactivity that had been incorporated in the proteins was determined by liquid scintillation counting in a Wallac MicroBeta TriLus .The method to measure AMPK enzymatic activity C2C12 myoblasts were seeded into black 96-well optical-bottom plates at 7,000 cells per well . On day 5 of differentiation, compounds were added and plates were incubated at 37°C for 1 h. The samples for mitochondrial membrane potential assay were prepared and analyzed as previously described C2C12 myotubes cultured in 60 mm dishes were treated with 20 µM BMS309403, washed with PBS and trypsinized. The samples for cellular adenine nucleotides measurements were prepared and analyzed as previously described t-test. Differences were considered significant at a p value of <0.05.Data were presented as means ± SE. Comparison analysis between groups was performed by using the two-tailed Student’s


It is increasingly recognized that the bacteria that live in and on the human body (the microbiome) can play an important role in health and disease. The composition of the microbiome is potentially influenced by both internal factors (such as phylogeny and host physiology) and external factors , and interspecific comparisons can aid in understanding the importance of these factors.Pan troglodytes) and bonobos (Pan paniscus) from two sanctuaries in Africa, and from human workers at each sanctuary. The saliva microbiomes of the two Pan species are more similar to one another, and the saliva microbiomes of the two human groups are more similar to one another, than are the saliva microbiomes of human workers and apes from the same sanctuary. We also looked for the existence of a core microbiome and find no evidence for a taxon-based core saliva microbiome for Homo or Pan. In addition, we studied the saliva microbiome from apes from the Leipzig Zoo, and found an extraordinary diversity in the zoo ape saliva microbiomes that is not found in the saliva microbiomes of the sanctuary animals.To gain insights into the relative importance of these factors on saliva microbiome diversity, we here analyze the saliva microbiomes of chimpanzees (Pan species to one another, and of the two human groups to one another, are in accordance with both the phylogenetic relationships of the hosts as well as with host physiology. Moreover, the results from the zoo animals suggest that novel environments can have a large impact on the microbiome, and that microbiome analyses based on captive animals should be viewed with caution as they may not reflect the microbiome of animals in the wild.The greater similarity of the saliva microbiomes of the two  A major effort is underway to categorize the human microbiome and understand the factors that can influence the distribution of microbial taxa within and among individuals -4, as weInterspecies comparisons can help address some of these issues ,8,9. IndPan troglodytes) and bonobos (Pan paniscus) from two sanctuaries in Africa, and from human workers at each sanctuary. We reasoned that if internal factors such as phylogeny or host physiology are the primary influence on the saliva microbiome, then the saliva microbiomes of the two Pan species should be more similar to one another than either is to the two human groups, and the saliva microbiomes of the two human groups should be more similar to one another. Conversely, if the saliva microbiome is mostly influenced by external factors such as geography or environment, then the saliva microbiome from each Pan species should be more similar to that of human workers from the same sanctuary. We also investigate the existence of a core microbiome in humans vs. Pan. Finally, we also studied the saliva microbiome from apes from the Leipzig Zoo, and found an extraordinary diversity in the zoo ape saliva microbiomes that is not found in the saliva microbiomes of the sanctuary animals.Like the gut microbiome, the oral microbiome influences human health and disease and is an important target of investigation , and theWe analyzed saliva microbial diversity in 22 chimpanzees from the Tacugama Chimpanzee Sanctuary in Sierra Leone (SL), 23 bonobos from the Lola ya Bonobo Sanctuary in the Democratic Republic of the Congo (DRC), and 13 and 15 human staff members from each sanctuary, respectively . Moreover, the number of genera detected per species/group is not related to the sample size . Thus, after correcting for differences in the number of reads, there are more genera detected in the saliva microbiome of the two Pan species than in the two human groups. However, despite the smaller number of genera detected in the two human groups, a larger fraction of the variance in their saliva microbiome is due to differences among individuals (28.9-36.3%) than is the case for the two Pan species (11.3-19.1%), as shown in Table Pan saliva microbiome.To determine if the differences in number of genera observed among groups simply reflect differences in the number of sequences obtained, we carried out a rarefaction analysis, which involves subsampling different numbers of reads from each group. The results  are indicated in the pie charts in Figure Pan and Homo . The most striking differences were seen in the Gamma-Proteobacteria in which various genera within the family Enterobacteriaceae (particularly the genus Enterobacter) consistently dominated in humans. Conversely, a number of genera within Pasteurellaceae consistently dominated in the apes, along with Neisseria (from the Beta-Proteobacteria). With one exception (Granulicatella) genera within the phyla Firmicutes and Actinobacteria had higher abundances in humans than in apes. In contrast, genera within Fusobacteria and Bacteroidetes exhibited higher abundances in apes compared to humans (with the exception of Prevotella).A heat plot . Within Proteobacteria, most genera correlated with others even from the same family (i.e. genera within Enterobactericeae correlate with each other and so did the genera within the Pasteurellaceae).Partial correlation analysis was performed in order to compare possible interactions among bacterial genera in humans with those in apes  was significantly higher  than that between bonobos and staff members at the DRC sanctuary (mean = 0.30) or that between chimpanzees and staff members at the SL sanctuary (mean = 0.38). Similarly, the distribution of correlation coefficients was significantly higher (p < 0.001) between SL humans and DRC humans (mean = 0.46) than between either group of humans and apes at the same sanctuary.Pan species from that of the two human populations, albeit not completely.We also carried out UniFrac analysis  to estimThe average UniFrac distance between the two human groups is significantly larger than that between the two ape species, while the average UniFrac distance between the humans and the wild apes is significantly larger than that within either species  that they were found in. The resulting diagram Figure A completFirmicutes is most abundant in fecal samples while the phylum Proteobacteria is most abundant in saliva samples). The average correlation coefficient for the distribution of bacterial phyla (regardless of the host species) was higher among fecal samples (average r = 0.86) and among saliva samples (average r = 0.86) than between fecal and saliva samples (average r = 0.56). Lower correlation coefficients were obtained for the comparison between fecal and saliva samples from the same species . Thus, this analysis indicates that the microbiome tends to be more similar in the same sample type  across different species than in different sample types from the same species. However, it should be noted that different individuals from different locations were analyzed for the fecal vs. saliva microbiome, and moreover different regions of the 16S rRNA molecule were analyzed. It would be desirable to further investigate this issue by analyzing the same region of the 16S rRNA molecule in fecal and saliva samples from the same individuals.We also compared the saliva microbiome from the humans and sanctuary apes to the fecal microbiome from humans and wild apes from a previous study . For thiHomo saliva core microbiome by considering the OTUs shared by both human groups and absent in the apes, and similarly the existence of a Pan saliva core microbiome by considering the OTUs shared by both chimpanzees and bonobos and absent in the two human groups. We adopt a conservative approach and consider an OTU as belonging to the Homo core microbiome if it is present in at least one member of each human group (and absent from bonobos and chimpanzees), and as belonging to the Pan core microbiome if it is present in at least one chimpanzee and one bonobo . This allows for the possibility that OTUs were present in additional individuals in each species, but were not sampled .The evaluation and characterization of the core microbiome associated with a particular habitat  is a fundamental concern in studies of microbiome diversity ,21,22. THomo core microbiome, while 6.9% of the OTUs are shared by the two Pan species exclusively and hence constitute the putative Pan core microbiome. The OTUs constituting the putative Homo core occurred in an average of 12.1% of the humans (range: 7.1 – 35.7%), and the average number of reads per core OTU was 7.8 (range: 2 – 116). For the putative Pan core, the OTUs occurred on average in 10.3% of the apes (range: 4.4 – 55.6%), and the average number of reads per core OTU was 16.0 (range: 2 – 330). Altogether, the OTUs in the putative Homo core microbiome comprise 11.5% of the total OTUs  for the two human groups, while the putative Pan core microbiome OTUs comprise 9.7% of the total OTUs  for the bonobos and chimpanzees.A Venn (sharing) diagram based on OTUs Figure  shows thHomo-Pan core saliva microbiome, based on OTUs that are present in at least one individual from each of the two human groups and from each of the two ape species. As shown in Figure We also considered the existence of a potential joint To determine if the above results based on sanctuary animals also hold for zoo animals, and to extend them to additional ape species, we also analyzed the saliva microbiomes from three bonobos, five chimpanzees, four lowland gorillas, and five orangutans from the Leipzig Zoo , genera within the phyla Firmicutes and Actinobacteria had consistently higher abundances in zoo than in sanctuary apes. No consistent trend could be observed for the genera within Fusobacteria and Bacteroidetes, however overall those two phyla were more abundant in sanctuary apes  within each species of zoo ape and 0.51 (range 0.49 – 0.54) between each pair of species of zoo ape. For the zoo apes, the within-species correlations are thus closer to (and in some cases even overlap) the between-species correlations, compared to the correlations for the humans vs. the sanctuary apes. Nevertheless, the ANOSIM analysis indicates that the between-species differences are significantly greater than the within-species differences for the zoo apes .To compare the saliva microbiome of the zoo apes to the humans and sanctuary apes, we calculated UniFrac distances. The tree based on UniFrac distances Figure B places Pan core saliva microbiome, 29.6% were also found in the zoo apes (20.5% in just the zoo bonobos and zoo chimpanzees). Thus, the zoo apes do share more OTUs with the putative Pan core microbiome than with the putative human core microbiome. In addition, 42.5% of the putative Homo – Pan core saliva microbiome OTUs  were also found in the zoo apes. Given the more limited sampling of zoo apes than of the sanctuary ape and human groups, these data do provide some support for the idea that these putative core OTUs are indeed widespread in humans and apes.The data from zoo apes also provide further insights into the question of the existence of a core microbiome. Of the OTUs that comprise the putative human core saliva microbiome , 13.6% were also found in the zoo apes. Of the OTUs that comprise the putative Pan species, and between the two groups of human workers, than between the saliva microbiome of workers and apes at the same sanctuary. Here we investigate patterns of OTU-sharing in more detail, to see if there is any sharing of OTUs between apes and human workers at the same sanctuary. Such sharing could be due to either contact between the apes and humans, or independent transfer of the same OTUs from the sanctuary environment to the apes and humans at that sanctuary. Additional file In the above sections we demonstrated overall greater similarity between the saliva microbiome of the two We also investigated this issue with respect to the zoo apes, as here we have different species living in close proximity. As shown in Additional file We provide here the first comparative analysis of the saliva microbiome of bonobos, chimpanzees and humans. We find greater similarity in the composition of the saliva microbiome between bonobos and chimpanzees, and between human workers at the same sanctuaries. These results suggest that internal factors, related to phylogeny or host physiology, have a more important influence on the saliva microbiome than does geography or local environment. Phylogeny  has been previously implicated in an analysis of the fecal microbiome from wild apes  and is iProteobacteria, followed by Firmicutes in humans and Bacteroidetes in apes. Actinobacteria were much more dominant in apes than in humans. Those differences in phyla distribution between humans and apes are within the range that has previously been reported among humans [Proteobacteria, both humans and apes are characterized by high proportions of Enterobacteriaceae, which is in agreement with our previous analysis of African populations [Enterobacteriaceae are known to emerge in the oral cavity with increasing age and they can act as opportunist pathogens, especially in patients with debilitating diseases who are submitted to prolonged treatments with antibiotics or cytotoxic medications [Enterobacteriaceae in the oral cavity of healthy individuals, they have been reported in nasopharyngeal swabs from northern Africans [Enterobactericeae may be a consistent marker bacterial family that distinguishes African populations from other world-wide geographical regions. The reason for the higher abundance of Enterobacteriaceae in African populations remains unknown; knowledge of precise species would help elucidate the source of enterobacterial colonization .Both the human and ape salivary microbiome was dominated by g humans . Hence, ulations ,15 but wulations -28. Enteications . AlthougAfricans  and in tAfricans . We concProteobacteria, most genera within the Firmicutes, Actinobacteria, Fusobacteria and Bacteroidetes were either consistently higher or lower in one group compared to the other. Such consistencies may support the concept of an ecological coherence of high bacterial taxonomic ranks, as discussed previously [Fusobacteria and Bacteroidetes) occurred at much higher levels in sanctuary apes than in humans, differential oxygen levels might be one driving physical factor shaping the oral habitats represented by the salivary microbiome in humans and apes.In addition to the eviously . This meActinomyces, Fusobacterium, Porphyromonas, Prevotella, Streptococcus, and Veillonella) that agrees with recognized dental plaque interactions, and also with a recent study that demonstrated how key oral species interact in order to grow in concert on saliva [Pan and Homo microbiomes. Conversely, there were also a number of positive correlations present in both humans and apes. Although the underlying reasons for those correlations remain unknown for now, they might indicate basic bacterial interactions that are robust across a variety of primate hosts.Since saliva is not considered to have its own microbiota but rather reflects the microbiome colonizing the tongue, tonsils, throat, hard and soft palate, buccal surfaces and gingivae , correlan saliva . Hence, Our results provide only limited support for the concept of a taxon-based core microbiome, i.e. a set of microbial OTUs which are characteristic of the saliva microbiome across a set of individuals/species, and hence may be important for the functional requirements of the saliva microbiome. A previous study that found support for a core oral microbiome (~75% of the OTUs in the study) in healthy individuals  was baseTo extend these results to more groups and additional ape species, we also analyzed the saliva microbiomes of apes from the Leipzig Zoo. The zoo apes exhibit extraordinary diversity in their saliva microbiome that is not evident in the sanctuary apes, with over 180 bacterial genera identified in just 17 zoo apes, compared to 101 bacterial genera identified in 73 apes and human workers at the sanctuaries. Moreover, there is no consistent distinction among the saliva microbiomes of zoo bonobos, chimpanzees, gorillas, or orangutans. The results are in stark contrast to the results obtained from the sanctuary apes. Furthermore, we detect a significantly higher amount of shared OTUs among zoo apes than among the apes and human workers from the same sanctuary. It therefore appears as if the zoo environment is indeed having a significant impact on the saliva microbiome of zoo apes, which seems to contradict the conclusions based on the comparison of sancturary apes and human workers. The artificial nature of the zoo environment  may be responsible for this difference, but further investigation and comparisons of zoo animals with their wild counterparts are needed.Enterobacteriaceae in zoo apes, with a correspondingly higher representation of Neisseria and Kingella instead. Apparently the zoo environment prevents Enterobacteraceae from steadily colonizing the oral cavity. This in turn suggests that Enterobacteriaceae - when not constantly introduced from the environment - are replaced by the related but truly endogenous (or highly host-associated) genera from the Pasteurellaceae and Neisseriaceae families. Hence, environment may play an important role in terms of the opportunities for particular bacteria to colonize the oral cavity.One of the most striking differences between the wild and zoo ape microbiomes was the entire absence of Another striking difference between the zoo and wild ape microbiomes is the very high number of low-abundance bacterial taxa in zoo apes. It is plausible to assume that those organisms are introduced by the food provided in the zoo. As such they might represent only transient species, given that the indigenous microflora is usually able to defend its ecological niches successful against foreign bacteria . This baPan paniscus) and staff members at the Lola ya Bonobo Sanctuary, Kinshasa, Democratic Republic of Congo (DRC), and from chimpanzees (Pan troglodytes) and staff members at the Tacugama Chimpanzee Sanctuary, Freetown, Sierra Leone (SL). The chimpanzee and bonobo samples were collected while the animals were anesthetized (via injection) for annual medical examinations; swabs were used to absorb saliva. Bonobo samples were imported under CITES permit E-02526/09, while chimpanzee samples were imported under CITES permit E-01349/09. Samples from apes at the Leipzig Zoo were collected noninvasively, by using swabs to absorb saliva from the mouth. Swabs from both sanctuary and zoo apes were immediately added to lysis buffer [Saliva samples were collected from bonobos (s buffer  and kepts buffer . While tE. coli K12 reference sequence), using the forward primer for V1 and the reverse primer for V2 and the PCR conditions published elsewhere [DNA was extracted as described previously . Two varlsewhere .The PCR products were processed for parallel-tagged sequencing on the Genome Sequencer FLX platform, as described elsewhere . Brieflyhttp://rdp.cme.msu.edu/seqmatch/seqmatch_intro.jsp) and a threshold setting of 90%. Diversity statistics and the apportionment of variation based on the frequency distribution of genera within and between individuals were calculated with the Arlequin 3.1 software [http://strata.uga.edu/software/). Partial correlation analysis was carried out with the GeneNet package [The initial sequence reads were filtered to remove low-quality sequences and artifactual sequence reads . After removing sequences less than 200 bp in length (as these may not give reliable results), there were 48,168 sequence reads used in the analysis. These sequence reads have been deposited in GenbankSequence Read Archive (SRA) SRP015938. A genus was assigned to each sequence by comparing the filtered sequences against the Ribosomal Database Project [software . Spearmasoftware  were cal package . For the package  and a ph package . Fast Un package  was then package . The OTU package  to generThe authors declare that they have no competing interests.MS designed the study. CA, RMG, MH, and AF collected the samples. DQ carried out the laboratory work. JL, IN, ML, and HPH analyzed the data. MS, JL, and HPH wrote the manuscript. All authors read and approved the final manuscript .Number of reads assigned to each genus in sanctuary apes and human workers.Click here for fileFigure S2. Heat plot of the frequency of each microbial genus in the saliva microbiome of each individual. Figure S3. Partial correlation analysis of associations among bacterial genera from humans and from apes. Figure S4. Heat plot of correlation coefficients, based on the frequency of bacterial genera in the saliva samples from sanctuary apes and human workers. Figure S5. Average UniFrac distances between different groups. Figure S6. Faith’s PD, which is a measure of the within-group diversity based on bacterial OTUs.Rarefaction analysis. Click here for fileBacterial phyla detected in fecal samples from humans, chimpanzees and bonobos from a previous study  and in sClick here for fileNumber of reads assigned to each genus for zoo apes.Click here for fileNumber  and percentage  of OTUs shared between different groups of apes and humans.Click here for fileBacterial genus assigned to each OTU, and number of sequences from each group assigned to each OTU.Click here for file