A review of commercially available allied health educational management software tools was performed to evaluate their capacity to manage program data associated with a CAMPEP‐accredited Therapy Physics Residency Program. Features of these software tools include: a) didactic course reporting and organization, b) competency reporting by topic, category and didactic course, c) student time management and accounting, and d) student patient case reporting by topic, category and course. The software package includes features for recording school administrative information; setting up lists of courses, faculty, clinical sites, categories, competencies, and time logs; and the inclusion of standardized external documents. There are provisions for developing evaluation and survey instruments. The mentors and program may be evaluated by residents, and residents may be evaluated by faculty members using this feature. Competency documentation includes the time spent on the problem or with the patient, time spent with the mentor, date of the competency, and approval by the mentor and program director. Course documentation includes course and lecture title, lecturer, topic information, date of lecture and approval by the Program Director. These software tools have the facility to include multiple clinical sites, with local subadministrators having the ability to approve competencies and attendance at clinical conferences. In total, these software tools have the capability of managing all components of a CAMPEP‐accredited residency program. The application database lends the software to the support of multiple affiliated clinical sites within a single residency program. Such tools are a critical and necessary component if the medical physics profession is to meet the projected needs for qualified medical physicists in future years.PACS numbers: 87.90.+y, 87.53.‐j There are new requirements for eligibility to take the American Board of Radiology (ABR) initial certification examination in radiological physics. Beginning in 2014, in order to take the ABR Part 1 examination in Radiologic Physics, candidates must be enrolled in or have completed a CAMPEP‐accredited residency program. As of 2014, academic programs without an associated link to an accredited residency program will no longer be able to guarantee entry into the medical physics profession.1 Clearly, there will be a large gap between the current number of accredited residency program graduates and the number of medical physicists required unless there are dramatic changes in the way medical physicists are educated and trained within accredited residency programs. If the profession is unable to train enough therapy medical physicists, it is likely the work week for practicing physicists will increase significantly. This may encourage more medical physicists to retire or leave the profession, having a negative impact on the quality of patient care and exacerbating the shortage of medical physicists.The Commission on Accreditation of Medical Physics Education Programs (CAMPEP) was formed primarily to accredit medical physics graduate education programs and residency education programs. Presently, there are 21 CAMPEP‐accredited therapy programs in the United States, and seven in Canada. The United States programs graduate approximately 25 residents per year. The projected need for radiation therapy physicists between 2015 and 2020 is currently being researched by the Medical Physics Workforce Subcommittee of the American Association of Physicists in Medicine (AAPM) Professional Services Committee. Preliminary estimates are that between 125 and 200 therapy medical physicists will be needed per year after 2015.2 CleaAlternative Clinical Training Pathways for Medical Physicists. Key options available for clinical residency training and recommendations from this report include:A formal two‐year residency program at an academic center offering a complete range of treatment techniques and with many, often specialized, qualified medical physicists (QMPs). Such a program, if CAMPEP‐accredited, may serve as a primary site.A formal two‐year residency offered at a center with more limited resources but affiliated with a CAMPEP‐accredited center.Incorporation of a residency program in a professional degree such as Doctor of Medical Physics where it may replace the research/project component of the more conventional Master's and Doctoral degrees. .In August 2008, the AAPM published the Task Group 133 Report: ysicists.3 Key To provide the level of scheduling, tracking, evaluation and documentation expected of Graduate Medical Education (GME) clinical residency programs is a difficult task without automated and customized management tools. The complexity of management increases if residents spend the majority of their time at remote affiliated centers. How can the CAMPEP‐accredited residency program manage program data for the training at an affiliated center including tracking time in conferences, completion of coursework, fulfillment of competency requirements, and management of the resident's time? Many universities have software provided by the Graduate Medical Office intended for use by physician residency programs. However, these tools are often unavailable or unsuitable for non‐physician programs. For example, the reporting requirements of physician residency programs often add substantial complexity and costly administrative training requirements to utilize such software tools. In addition, they may not be accessible from remote locations. What is required is a Web‐based Application Service Provider (ASP) software package that provides a suitable database and interface, with regular backup to remote secure servers.The solution proposed is to manage the residency program using a commercial ASP software solution. Four potential application solutions were evaluated: MyResidency 2.0 from eResidency ; E*Value Allied Health Solution from Advanced Informatics LLC ; Residency Management Suite from New Innovations, Inc. , and Allied Health Student Tracking System from Typhon Group, LLC . This article describes the criteria, summarizes the features of four software tools, and provides a detailed analysis of the selected tool.Administration – Tracking of annual TB test records and immunizations, CPR training, and other employment requirements is an essential component of program management. The tool should be capable of local and remote site administration with assignment of remotely assigned residents, mentors and site administrators.Clinical Competency Records – Procedure logs are defined as procedures performed on specific types of equipment and may include commissioning, continuing quality assurance, and other testing procedures. Case Logs are linked to specific patients and presentations.Conferences – Routinely scheduled clinical conferences are usually not graded but attendance, lecturer and content should be recorded.Courses – Courses may be short  or long (full semester). The course may include tests and grades and, if this is the case, grades should be recorded in a permanent record module. Courses may be offered by professional societies, vendors or other institutions. Courses may be offered onsite, remotely through on‐line training, or at remote sites. All information regarding courses should be accommodated within the application.Evaluations – The application should be able to email surveys automatically, and follow up if the surveys are not returned. Evaluation types should include resident by mentors, mentor by resident, course by resident, rotation by resident, and other custom forms as required.Student Performance Reports – The application should be able to report an accounting of time spent on the various residency tasks by each resident. In addition, there should be a complete reporting of competency completions, attendance at conferences, participation in each course and lecture, and examination performance.Calendar & Scheduling – The application should allow for daily, monthly or rotation resident and mentor assignments, as well as the assignment of special responsibilities or events.Submitted Projects and Reports – The application should allow for uploading of required projects by the resident, such as shielding evaluations or equipment performance reports. In addition, the tool should allow mentors or program directors to permanently upload narrative evaluations or disciplinary reports, with access limited to those with rights to see these documents.Web Features – Residents may wish to build a portfolio of experience accessible to potential future employers. Having the capability to prepare this portfolio as part of the residency management system is a desirable feature.Ease of Use – The tool should be intuitive and relatively simple to use as there are always new residents and mentors that will need to use the software package. Video training support for the tool is a desirable feature.Cost – These applications are priced by the cost of setup, annual support fees, and the number of active students. It is particularly important that the cost is affordable for small programs (2–4 residents).Some desirable components of an accredited residency software package include tracking modules for:The software package should be offered through an ASP with the application, user interface, and database maintained by the provider.Backup support from the vendor should be daily, with backup to secure servers in a remote location.It should have secure log‐in access for several categories of users: residents, mentors, site managers, and program managers.The software package must be customized, fielded, maintained, updated and archived by the user.It should be highly customizable respecting the components of the program and those components should reflect requirements of AAPM Report 90.4It should provide a complete record of the resident's experience within the program as a benefit to program reviewers.Ideally, a management tool would be able to record and document each of these components and component types within the residency program. A search was therefore conducted to evaluate potential physics residency management tools. The selection criteria for evaluation were:Additionally, there are some complex relationships within the structure of a residency program. A competency may be associated with a course, rotation or conference. A course may be associated with a conference. Any of these may be associated with specific mentors, patients or machines. For each event type, the associations, the mentors, the patients and the equipment must be captured on an ongoing basis to provide proper documentation for the residency program. These can be onerous tasks.All of the packages offered relative ease of setup and customization, and all allowed updating of data, tracking resident progress, and the capability to provide custom time, course, competency and conference reports. After comparing the features offered, we determined that cost was our most important criteria, with a simple and intuitive user interface an additional criteria. We wished to avoid unnecessary complications and unneeded features. Our program is small with only two residents in concurrent training. We experimented with demonstration versions of the software packages, and explored what customization features were available. We interacted with individuals who provide front‐line support for these packages.Each of the packages reviewed allowed for full customization of an individual residency program; we customized the program for six‐month semesters. Ours is a four‐semester program with duration of two years. During each semester, each resident is required to complete one full academic course, with tests and a final examination. The four courses are Dosimetry, Radiobiology, Physics and Advanced Physics. Course records including attendance, grades and performance on oral examinations are accommodated within each of these packages. Other courses, such as orientation, short courses, laboratory courses, vendor courses, board review courses, self‐study, on‐line, and other course information and records are also provided as a part of our residency program. Conferences, such as chart rounds, morbidity and mortality, journal club, tumor, multi‐modality and core competency conferences are also included as part of our program.During each semester, the resident is expected to complete the individual competencies within three of a total twelve competency sections. Each competency section contains a number of individual competencies that must be completed. The competency sections are to be completed in order. Competency sections include external beam treatment planning and verification, brachytherapy treatment planning and verification, room shielding design, quality assurance , annual calibrations of clinical equipment, TBI photons and TSE electrons, intraoperative electrons, stereotactic cranial and body, IMRT / IGRT, Respiratory gating, HDR / LDR Brachytherapy, and administrative and professional duties. There are a total of approximately 150 individual competencies in our program. The software packages typically allowed for 1000 or more competencies to be entered, many more than required by our program. All packages allowed for individual competencies to be grouped together into sections.The applications listed typically serve dozens or hundreds of residency programs and serve many thousands of students or residents. They provide a full assortment of features, functions and flexibility beyond the needs of most physics residency programs. Any of the applications would likely provide all the functionality required to manage data for a CAMPEP residency program. In the final analysis, one application provided a superior price to performance value for our small program, and consequently was selected for implementation.Each of the four applications selected for evaluation meet the general criteria listed above. The applications were evaluated and the results are reported in The login screen leads the program manager to the main operational screen of the Typhon Group ‐ Allied Health Student Tracking module, reproduced in Student Logins: This category lists login and other demographic information for each resident.Sub‐Administrator Logins: The demographic data for the site coordinator of an affiliated program may be listed here along with data permissions and any administrative responsibilities permitted.Evaluation and Survey Instrument: Resident evaluation, course evaluation, program evaluation and mentor evaluations surveys may be created, managed and conducted using this tool.Scheduling System: This tool allows the program manager to add, edit and delete events from the schedule of a resident or several residents. Residents may enter or request for approval their own events with permission.The “System Options” section allows for detailed customization of the residency program . The folThis section records and displays statistics based on live records such as patient encounters, course and conference attendance, and completed competencies. A security feature allows the program manager the ability to prevent data in the system from being altered. Data may be locked or unlocked by selecting a specific date and range.The application provides a number of alternatives for viewing the progress of the resident through case log reports. One very useful display is the Daily/Weekly Case List (Spreadsheet by Student) . This opAttendance at a course lecture or conference is recorded by the resident. Information includes the lecturer, topic, date and time of lecture, duration, and any associated course. Resident submissions such as shielding reports, special medical physics reports or PowerPoint presentations may be reviewed with faculty/preceptor comments. Students may create an on‐line portfolio of resident accomplishments and experiences along with a detailed Curriculum Vitae and a photograph. This portfolio is assigned a Web address for use by the resident in a job search.An active file within the system is maintained for all current residents and purchased one year at a time. All records associated with a specific resident may be locked and archived upon graduation or a short time thereafter, with no additional cost to the program. However, the records are still accessible and may be viewed at any time by the program manager for up to three years after graduation. Program managers should print out and/or electronically record in a separate permanent local database all resident information needed for future uses, such as program reviews. Otherwise, the ASP database would become larger than needed and much more expensive to maintain. In our view, it is reasonable for program reviewers to view paper or Adobe .pdf electronic archives for previous residents and electronic records for current residents.Complete instructions for managing the application are provided. Several hours of video instruction are included in this section, broken up into segments related to specific topics for specific persons . Common topical questions are addressed in the Administrative Frequently Asked Questions (FAQ) section. A simple one‐page instruction sheet to guide residents in this use of the application is offered.Although the application seems complex at first, the menus are well laid‐out and intuitive to follow. Our program of semesters, courses, conferences, competencies, evaluations and examinations fit readily into the overall structure of the software package. We viewed the tutorials and defined the scope of information required by the system. We listed the courses, named the conferences, defined the competency categories and listed the individual competencies within these categories. Also we listed the demographic information for mentors in the program: roles, contact information and credentials. With telephone help and support from the vendor, the system was ready for initial testing after approximately four hours of setup. The system was completed with approximately another four hours of program entry. This included entry of all demographic information, faculty, residents, conferences, courses, competency categories, individual competencies, course descriptions, and evaluation and survey instruments. We experimented with the system for about a week before releasing it to the residents and mentors. We have made only a very few changes since its release.Residents began using the system with a lot of enthusiasm. It was easy for them to see the benefit of having all their effort in the residency program captured and recorded for archive. We released the software package the end of the first week in July of 2008, coinciding with the midpoint of the program of our senior resident and the beginning of the program respecting our junior resident. The software allows data to be entered for up to a maximum of one year in the past. This allowed our senior resident to record the entire residency experience within the software package. By December 2008, the senior resident, 1.5 years into the program, had accumulated 625 conference and course hours, 177 specific case encounters, and completed 145 competencies. In addition, 33 separate evaluation records  are included in this resident's record. The residents continue to use and value the system; the information contained helps them to build a website and portfolio of personal accomplishments, useful in their search for employment after completion of the residency.There are some distinguishing features of a therapy physics residency program that are unique, making the use of a generic software package somewhat awkward. For example, other medical and allied health residency programs are very much oriented toward patient interaction, patient education, drug administration and patient demographics. Examples of the latter are rural population, indigent populations, and Medicare or Medicaid coverage. There is some ability within the software package to limit or eliminate the queries for this type of information for a patient encounter.There is no category for an “equipment encounter” in the software model. As therapy physics programs need to record encounters such as commissioning, annual calibrations, and chamber and electrometer monthly quality assurance, for example, there is a need to record an encounter that is not specific to an individual patient. Within this system, “equipment encounters” are listed as “group encounters”; this method has proven workable to record equipment specific tasks and competencies.Another unique feature of medical physics residency programs is that not all of them begin on the same day, such as July 1. In addition, it is sometimes desirable to admit a resident into a program earlier or later, by up to several months. A variable start and/or finish date should not be a problem for this software system. Since courses, competencies and conferences are handled both independently and yet with optional association with one another, the system is able to handle any form of data entry at whatever point within the program. A resident may graduate at any point, assuming program requirements for coursework, conferences and competencies are completed and evaluations are satisfactory.While this residency program does not yet have an active affiliation, an affiliation was simulated within the system using the sample student. Recording of competencies, courses, conferences and case logs for the sample resident was seamless and straightforward within the system. For this test, the approval of competencies, review of performances, and grades is handled as for any resident in the program. Completion of competencies may be approved by a local administrator within the system, if these rights are allocated. Recording of course examination results, grades and oral exam evaluations is accomplished using the Evaluation and Management feature. It is straightforward to build a questionnaire for the resident that queries the grade for each test, course and oral examination. This has proven to be a workable method for faculty to record grades of students for archiving and for subsequent program reviews. Also, it is possible to upload documents associated with a specific student but not visible to that student. This is useful if a mentor or program director wishes to deposit a narrative report on resident performance into the permanent record of the resident. This feature may serve to document disciplinary actions or probations respecting the behavior or performance of the resident. Overall, the Typhon system was deemed an appropriate tool for the management of remote or affiliated residency programs.The ABR year 2014 initiative will require affiliated training for medical physics residency programs; at present there is little alternative to this eventuality. It is expected that these programs will need to train a minimum of 125 and ideally 200 radiation oncology physicists in CAMPEP‐accredited residency programs each year after 2014.The Typhon Group software tools and database will allow tracking of resident case reports, coursework, competencies and time within a residency program. As an application service provider tool, the Typhon Group software may be used simultaneously by any number of clinical sites for a given program. Residency software and management tools are an important component if the medical physics profession is to meet the projected needs for qualified medical physicists in future years.


A total of 196 schools participated in the Tier 1 Program (Secondary 2 curriculum) of the Project P.A.T.H.S.  in Hong Kong. After the completion of the program, 1,178 instructors completed a subjective outcome evaluation form in order to assess their views of the program, instructors, and perceived effectiveness of the program. Results showed that high proportions of the instructors had positive perceptions of the program (range: 76.79–93.69%) and their own performance (range: 83.20–98.60%), and most of the respondents (range: 78.45–92.43%) regarded the program as helpful to the program participants. While the ratings in some items in the present findings were relatively better than those in the Experimental Implementation Phase, they were similar to those based on the Secondary 1 curriculum. Consistent with previous studies, the ratings on the program, instructors, and perceived effectiveness were significantly correlated.


Central venous catheters (CVCs) are commonly used in the management of critically ill patients. This study aimed to determine whether an educational program could reduce the rate of catheter-related bloodstream infections (CRBSIs) in intensive care units (ICUs).All patients admitted to a medical ICU at a college affiliated with the Japan Society of Intensive Care Medicine between January 2008 and December 2014 were surveyed prospectively for the development of CRBSIs. A mandatory educational program (the intervention) targeting an infection control committee consisting of physicians was developed by a multidisciplinary task force to highlight correct practices for preventing CRBSIs. The program included a 30-min video-based introduction, 120-min lectures with a number of hands-on training sessions, a post-test, posters, safety check sheets, and feedback from the infection control committee. Lectures based on the education program were held every 3 months, and participants were free to choose when they attended the lectures. Each participant was required to view the 30-min introduction before attending the 120-min lectures and complete the post-test after each lecture. Safety check sheets were made to ascertain adherence to contents of the educational program. Posters describing the educational program were posted throughout the ICU. A pre- and post-intervention observational study design was employed, with the main outcome measure being yearly CRBSIs. We also calculated cost savings that resulted from improved CRBSI rates.P ≤ 0.05). The estimated cost savings secondary to this decreased rate for the 1 year following introduction of the program was between 1850,000 and 27,000,000 yen .During the 12-month pre-intervention period, four episodes of CRBSIs occurred in 1171 patient ICU-days . In the first year after the intervention, the rate of CRBSIs decreased to 0 in 1157 patient ICU-days (A program aimed at educating healthcare providers on the prevention of CRBSIs led to a dramatic decrease in the rate of primary bloodstream infections. This suggests that educational programs may substantially decrease medical care costs and patient morbidity attributed to central venous catheterization when implemented as part of mandatory training. Central venous catheters (CVCs) are commonly used in the management of critically ill patients. In the USA, 15 million CVC days  occur in intensive care units (ICUs) each year –4. CatheTo improve patient outcomes and reduce healthcare costs, there is considerable interest in reducing the incidence of these infections. Although there is no consensus on the optimal approach to achieve this, several recent studies indicate that educating healthcare providers on evidence-based approaches to prevent these infections can decrease infection rates –11. The Against this backdrop, we carried out a clinical investigation to determine whether an educational program could reduce the rate of CRBSIs in the ICU of a teaching hospital. This study aimed to evaluate the effects of the program for up to 48 months after its implementation.This study was judged to not require registration by the institutional review board of Osaka Medical College (Osaka Japan) due to the use of unlinked anonymous data. This study was conducted in a medical ICU at a college affiliated with the Japan Society of Intensive Care Medicine. The medical ICU (8 beds) is an open unit with a multidisciplinary team providing patient care under the direction of attending physicians who are board certified in critical care medicine. Nurse staffing is maintained at a ratio of two patients per nurse. From January 2008, all patients admitted to the medical ICU were surveyed for the occurrence of CRBSIs. Intravascular catheters  used in the hospital were standard catheters without antimicrobial or antiseptic coatings. Arterial catheters were not surveyed in this study. The use of ultrasound/Doppler is recommended during insertions, except in emergent cases. Mostly residents (3–6 years of experience) and fellows (7–12 years of experience) insert CVCs at our hospital, and are required to use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, when inserting CVCs. The primary study hypothesis was that the rate of CRBSIs would be reduced during the first year after implementation of the educational program (intervention) as compared with baseline. The secondary hypothesis was that the observed decrease in infection rate between 0 and 12 months after implementation of the program would be sustained over the subsequent observation period.A pre- and post-intervention observational study design was employed with the main outcome measure being yearly CRBSIs. The educational program was developed in 2010 by an infection control committee comprising a physician, surgeon, anesthesiologist, intensivist, and nurses. The 2009 calendar year served as the baseline period for the incidence of CRBSIs. Throughout the study, data on the number of CRBSIs, as well as the following parameters, were recorded prospectively and on a daily basis: occurrence of primary bacteremia, number of patient ICU-days prior to the onset of bacteremia, and the species of microorganism associated with bloodstream infection. To coincide with the implementation period of the study intervention, daily data were aggregated into 1-year periods. The yearly rate of infection was calculated as the number of infections per 1000 patient-ICU days for each 1-year period. Yearly rates were assigned to one of six categories based on when the study intervention was implemented: at baseline, during the implementation period, or during one of four 1-year intervals up to four years after implementation. Data on who inserted the central catheters, average duration of catheter use, and number of lines in individual patients were not collected.Staphylococcus aureus, Enterococcus species, Candida species) unrelated to infection at another site, and (2) fever of ≥38.0 °C, chills, or hypotension, and either of the following: common skin contaminant  isolated from two blood cultures drawn on separate occasions within 24 h that are unrelated to infection at another site, or a common skin contaminant isolated from a blood culture of a patient with an intravascular device and the physician institutes appropriate antimicrobial therapy. CRBSI was defined as primary bacteremia in the presence of a CVC. Secondary bacteremia was defined as a bloodstream infection that develops as a result of a documented infection with the same microorganism at another body site.A central catheter is defined herein as a catheter that ends at or near the heart or in a great vessel near the heart, and includes peripherally-inserted central catheters. CRBSIs were classified as primary or secondary based on CDC NNIS definitions . PrimaryNewly hired physicians  were required to complete the educational program, which covered indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections. The program was implemented from April 2010 and consisted of a 30-min video introduction, 120-min lectures with a number of hands-on training sessions (not required for fellows and attending physicians given their experience), a post-test (not required for attending physicians given their experience), posters, safety check sheets, and feedback from the infection control committee. Lectures based on the education program were held every 3 months, and participants were free to choose when they attended the lectures. Contents of the safety check sheets were entered through each patient’s computer terminal located directly outside the patient’s room after inserting the CVC to improve clinician-to-medical safety committee communication within the hospital. This process allowed for monitoring adherence to the program’s contents. The 120-min lectures and post-test were held every three months and based on CDC guidelines. The post-test was held after the 120-min lectures to reinforce the topic and group discussion of hands-on training. A score of 85% correct was required for the post-test. If this score was not achieved, the post-test was repeated until a passing score was achieved. Topics covered in the 120-min lectures and post-test included the epidemiology of CRBSIs, aseptic technique, use of maximal barrier precautions during central vein catheter insertion, preference for the jugular vein as a central vein insertion site, routine central vein catheter site care, proper technique for obtaining blood cultures, and guidelines for changing IV tubing and administration sets. The program was revised and recently updated in 2013 . Fisher’s exact test was used to compare categorical variables. The incidence rate of CRBSIs per 1000 patient ICU-days was calculated, and the risk difference of CRBSIs in the post- vs pre-intervention period was determined. All reported P ≤ 0.05). The difference in CRBSI rates between the pre- and post-intervention periods was 3.4 per 1000 catheter ICU-days. However, the markedly reduced rates of CRBSI were not sustained for up to 36 months of follow-up , a total of four episodes of CRBSI occurred during a total of 1171 patient ICU-days. This amounts to an infection rate of 3.4 per 1000 patient ICU-days. During the post-intervention period , no episodes of CRBSI were recorded for a total of 1157 patient ICU-days. The rate of CRBSIs decreased from 3.4 infections per 1000 patient ICU-days at baseline to 0 at 0–12 months after implementation of the program (Assuming a continued infection rate of 3.4 per 1000 patient ICU-days (pre-intervention rate), four infections would have been expected to occur for the 1157 patient ICU-days in the 12 months after the intervention. When the reduced number of CRBSI occurrences  resulting from the educational program was calculated, the savings associated with improvements ranged from ¥1,850,000 to ¥27,000,000  annually using the yen-dollar exchange rate in 2015.This study demonstrated that an educational program for physicians working at Osaka Medical College was able to significantly reduce the incidence of CRBSIs. These results suggest that behavioral changes may have played a crucial role in the success of the program. Simulation-based learning was recently found to be more effective than video training alone in improving resident skills . In the enterococci [Our results are consistent with those of published studies reporting significant reductions in the occurrence of hospital-associated infections with the implementation of education-based interventions. For instance, previous studies have reported 66, 58.5, and 27% reductions in the incidence of CRBSIs as a result of implementing education-based programs , 21. Eduerococci . These rerococci ).Within a year after implementation, the rate of CRBSIs was reduced to 0. However, this significant reduction was not sustained over a longer period  who inserted the central catheters, or the varying experiences of attending physicians versus interns, for example, regarding CVC insertion. This raises the possibility that differences in behavior/experience other than the implementation of the educational program may have accounted for these results. Third, we did not record the duration of central venous catheterization or the number of lines in individual patients. An unrecognized reduction in the duration of catheterization or the number of lines could have influenced our results. Fourth, our study design does not allow us to determine which aspects of the intervention accounted for the reduction in the rate of CRBSIs. Another potential limitation is that we did not evaluate outcomes other than bloodstream infection. As a result, we cannot determine whether the intervention influenced antibiotic utilization, length of hospital stay, mortality, or antibiotic resistance patterns.Despite these limitations, our results indicate that implementation of the educational program directly or indirectly reduced the rate of CRBSIs. Thus, we were able to achieve the original aim of the study, despite the limitations discussed above and inability to identify the specific aspects of the intervention accounting for the reduction.Here, we demonstrated that a relatively simple educational program can reduce CRBSIs in a hospital setting. The observed reduction in rate from 3.4 per 1000 patient-ICU days to 0 per 1,000 patient-ICU days was associated with an estimated cost savings of between ¥1,850,000 and ¥27,000,000 annually within the first year after implementing the program. However, rates did not remain significantly reduced throughout the remaining three years of follow-up. Although the program needs further refinement, our findings suggest that the implementation of education-based infection control programs is important for the optimal functioning of medical ICUs.


The Tier 2 Program of the Project P.A.T.H.S.  targets adolescents with greater psychosocial needs, and the related programs were designed and implemented by school social workers. After completion of the Tier 2 Program, 2,173 students in 52 schools responded to the Subjective Outcome Evaluation Form (Form C), assessing their views of the program, instructors, and perceived effectiveness of the program. Based on the consolidated reports submitted by the agencies to the funding body, the research team aggregated the consolidated data to form a “reconstructed” overall profile of the perceptions of the program participants. Four major types of program were identified, including programs based on the adventure-based counseling approach (N = 8), programs concentrated on volunteer training and services (N = 7), programs incorporating both adventure-based counseling and volunteer training elements (N = 30), and other programs with different foci (N = 7). Results showed that high proportions of the respondents had positive perceptions of the programs and the instructors, and roughly four-fifths of the respondents regarded the program as helpful to them. The present study provides support for the effectiveness of the Tier 2 Program of P.A.T.H.S. in Hong Kong for the experimental implementation phase.


RW uses expert clinical coaches via phone contact to deliver an educational intervention promoting lifestyle change to families with at least one overweight or obese child in an eligible Medicaid health plan. This gives RW significant potential for reach and population impact. This project aimed to understand how to maximize this impact by exploring perspectives of RW, using a conceptual framework informed by the Conceptual Model of Implementation Research, including assessment of the feasibility, acceptability, and appropriateness of RW; determining satisfaction among those experiencing coaching; identifying reasons individuals do not participate; and developing recommendations to enhance interest and participation.Raising WellSemi-structured interviews were conducted with 70 RW-eligible families across four states, who were described as: active participants, respondents who dropped or stopped RW, and RW non-participants. Following the interviews, the transcripts were coded inductively and deductively using a grounded theory approach, considering themes from the conceptual framework; themes also emerged from the data.From this sample, 19 families reported to be active coaching participants, 24 had dropped coaching, and 27 were RW non-participants. A number of themes were identified. Feasibility themes included coaches’ flexibility and willingness to work with the family’s schedule. Acceptability themes suggest providing actionable strategies tailored to the family’s context and needs, beyond just nutrition information and tips, early in the coaching relationship so the family perceives a benefit for continued participation. With regard to appropriateness, families were also interested in other methods of communication including email, texting, and in person visits. Access to resources for activity and healthy eating in their local community was also recommended.RW has the potential to improve health and promote wellness. To enhance the impact of this program, RW could incorporate these findings to promote feasibility, acceptability, and appropriateness and improve program implementation. Strategies may include modifying the information provided or the mode of delivering the information. Obesity is prevalent among children and adolescents in the United States –5. Exces® (RW) program in 2015 at the request of health plans seeking a solution to work with families on Medicaid that have a child with overweight or obesity. Envolve PeopleCare is a subsidiary of Centene Corporation, one of the largest Medicaid Managed Care providers, via state health plans, in the US. RW is currently offered in seven states and provides telephonic health coaching with a dietitian or exercise specialist to help caregivers improve the nutrition and activity behaviors of the child with overweight or obesity. RW works with parents to create a supportive home environment where healthy lifestyle changes can occur, and is based on motivational interviewing, and therefore is driven by participant goal selection. Many states mandate that the health plans address pediatric obesity. This gives RW significant potential for reach and population impact as the program is gradually being expanded to more states.The industry partner, Envolve PeopleCare™, launched the Raising WellImplementation science explores not only the intervention , but also the implementation strategies used to put the intervention in place within a practice setting  . FurtherThe goal of this formative study was to evaluate the intervention (RW) and the aspects of the multicomponent implementation strategy in terms of three implementation outcomes: acceptability, feasibility, and appropriateness .The study population included the caregivers of children eligible for the RW pediatric obesity program in four states . To be eligible for RW, a child must be enrolled in an included health plan, be between 2 and 18 years old, and be overweight or obese (body mass index (BMI) ≥85th percentile). Purposive sampling was used so that participants represented different levels of engagement with RW based on administrative data: 1) current coaching families, 2) families who dropped coaching, 3) families who declined coaching, and 4) those who were not able to be contacted by a health coach. In Florida, families that could not be reached by the RW coaches (group 4) were not recruited for the current study, as data saturation with group 4 respondents had already been reached. In addition, Missouri had only recently started offering RW at the time of this study, and therefore only a small number of MO members were eligible for this study; only members listed as current participants in RW in Missouri were recruited. Upon speaking with respondents during their interviews, it became apparent that the administrative data categorization for the respondent’s engagement level in RW differed from the interview participant’s own perspective of their level of engagement, so respondents were organized into three groups based on their reported engagement . However, families found it difficult to engage in RW if they felt their coach did not call at the scheduled time, missed scheduled calls, or called at inconvenient times ; this was more common among respondents who dropped or stopped RW. With regard to call frequency, bi-weekly calls were preferred.The majority of the themes were related to the outcome acceptability. These included: content/tailoring/goals, making changes, providing cues to action, coaching relationship, and resources/referral(s). RW participants found coaching content such as actionable strategies, tailored to their family and its context, to be most useful, as opposed to standard nutrition information, which was regarded as redundant. An important issue related to the content of RW was the tailoring of the recommendations provided by the health coach to the family and the family’s context . RW participants who described a positive experience with RW felt the program was tailored to their family and were able to provide specific information they had learned, articulate goals they had set, and describe examples of changes they made from being in the program. Those who had dropped RW reported they had not set goals or could not remember the goals they had set. Behavioral changes reported included drinking more water and paying attention to portion size. Even when they did not feel the information provided by the coach was particularly useful or relevant, some RW participants felt that the coaching calls and the regular engagement of talking with a health coach served as a cue to action, supporting their behavior change efforts. Reporting that information was not tailored or was redundant was more common among respondents who dropped or stopped RW.RW participants did appreciate when coaches were able to provide referrals. A benefit of the RW program nested within the Envolve PeopleCare organization is access to other professionals, such as an exercise specialist, as member needs become apparent. In addition to referrals, there was a positive response by some respondents to educational materials the coaches were able to send by mail. Respondents thought it would be helpful to receive materials, particularly child-friendly recipes. It is important to note that while respondents mention alternate communication channels , they only expressed interest in the channel the family already used, and were not interested in using a new channel. This suggests channels offered to families be flexible and tailored to the family’s communication preferences.Overall, RW participants valued supportive, caring relationships with their coach. Some of the coaching interaction required significant assessment from the participants, and if this was perceived as excessive, it could interfere with the coaching relationship , whereas efforts on the part of the coach to get to know the family were greatly appreciated. Another aspect of the coaching relationship participants appreciated was when the coach engaged directly with the child, so the respondent did not feel like a mediator.Within appropriates, constraints/reach was an important theme. The families participating in RW had many stressors in their lives , which took precedence over healthy eating and activity. Part of tailoring RW to families requires awareness of these important issues so they can be taken into account and working with the family where they are.This evaluation of a childhood obesity program with families enrolled in Medicaid, which focused on feasibility, acceptability, and appropriateness provided important insights. Respondents stated they wanted information tailored to their family and their family’s context, which goes beyond generic nutrition information . As the Scheduling issues and the ability to incorporate multiple family members also arose as important feasibility and appropriateness findings. The families served by RW face a number of challenges in terms of access to communication, which can include changing residence (and phone numbers), issues with paying cell phone bills (which can lead to the phone service being cut off until the bill is paid), and reaching the maximum number of minutes allowed for use in a month before the month has ended; these challenges can make it hard to stay in touch with and serve this population. Attention to such implementation factors can improve future intervention efforts and the overall program expertise for future participants , 42–44.Positive aspects of the current RW program can be emphasized while aspects perceived less positively by those who dropped or stopped RW  can be refined to improve the overall program experience. Further, understanding respondent perspectives of the implementation outcomes can be informative for those seeking to implement obesity prevention and treatment interventions or to work with families like those eligible for RW.This study has limitations worth noting. While the respondents were dispersed across the country, only four states were represented. This study also included only members eligible for the RW program, but did not include the perspectives of the health coaches delivering RW. Further, though some respondents were included in the current study that RW coaches had not been able to contact, this was a small number of participants, suggesting the perspectives of this population may be underrepresented. However, data saturation was reached, in this group , when outreach to this group was stopped. This study is also limited in that it only solicits the perspectives of respondents, to identify potential changes to the program, but does not test alternate interventions, to determine whether these changes might enhance program uptake, adherence, and/or effectiveness; future research should evaluate these factors.This study provides valuable perspectives from families eligible for an obesity prevention/treatment program for children enrolled in Medicaid. These perspectives address the feasibility, acceptability, and appropriates of the program. Future research could incorporate these perspectives to interventions in this population to determine if program perceptions and program efficacy are improved.


PES) are expected to promote ecological restoration while simultaneously improving human livelihoods. As an adaptive management tool, PES programs should be dynamic and adjusted according to changing natural and socio‐economic contexts. Taking the implementation of China's famous ecological restoration policy known as the Grain for Green Program (GGP) in the Wolong National Nature Reserve as an example, we analyzed changes in the livelihood capitals and strategies of local households that had participated in the GGP over a 10‐year period and discussed the implications of these changes for the next stage of the program's implementation. Data were collected from a locally implemented questionnaire in both 2004 and 2015. We found that local livelihood capitals and strategies had experienced dramatic change over the 10‐year period. Natural capital decreased and was unequally distributed among local respondents. In terms of financial capital, despite that agricultural and nonagricultural income increased, compensation from the GGP decreased and did not keep pace with increasing cost of cropland, household income and more broadly national economic development and inflation. Regarding human capital, the local labor force is facing huge transformational pressures. In particular, there is a increase in the supply of local labor force aged between 21 and 40 and the implications of this for the future of the GGP should be given more attention. The findings have demonstrated that: Some changes in participants’ livelihood were expected by the GGP but were not evenly distributed among the participants; and PES programs are embedded in changing and multi‐dimensional socio‐economic contexts, and so their design and implementation must be coordinated with other related policies if they are to achieve long‐term success.Payments for ecosystem services ( By converting steep  cropland or wasteland to grassland or forest, the GGP aimed to mitigate ecological degradation, improve the provision of ecosystem services, and simultaneously change the economic structure in mountainous areas by increasing local household income and making local households’ land use and agricultural production patterns more sustainable  and 24 species of rare plants including the dove‐tree (Davidia involucra).The research was conducted in the Wolong National Nature Reserve which is located in Wenchuan County, Sichuan Province, southwest China . The reserve has an area of 2,000 kmThe reserve is managed by the Administrative Bureau of the Wolong National Nature Reserve, under which there are two township governments—Wolong Township and Gengda Township. The reserve contains a total of 1,164 households and in 2013 had a population of approximately 5,954. Although Han constitute the major ethnic group in China, approximately 70% of the people living within the reserve belong to three ethnic minority groups, namely Tibetan, Chang, and Hui. Chengdu‐Xiaojin Road is the only main road connecting the local people to areas outside of the reserve. There are six administrative villages within the reserve, each with a committee responsible for management.The GGP has been implemented in the reserve since 2000. By the end of 2003, approximately 370 ha of cropland had been converted to forest. Since then, the program has been implemented in the reserve in two stages. In the first stage, for each hectare of cropland converted to forest, the local people were compensated with 2,250 kg of grain and 300 Yuan in cash once a year for 8 years’. In the second stage, only cash compensation was provided in the amount of 3,600 Yuan per hectare of cropland converted to forest once a year for 8 years’. A third stage of the program commenced in the reserve in 2015. While researchers have devoted significant attention to the levels of enrollment and farmers’ re‐converting their previously forested land back to cropland associated with the GGP . PRA is a conventional method for learning from farmers and is widely used to gather research information from rural people. Local livelihood capitals in 2004 and 2015 were chosen to discern changes over this 10‐year period. The 2004 livelihood capitals values were derived from a questionnaire used to evaluate the sustainability of the GGP  was converted to a cash value according to the grain price in 2003 /kg). Hence, the 2004 “cash + grain” values in Table There were varying changes in the distribution of income among households. Average agricultural income per household became more unevenly spread, with the p90/p10 increasing from 6.4 to 20.0 (an increase of 212.5%). Average nonagricultural income per household became more evenly spread, with the p90/p10 decreasing by approximately 38%. Average total income per household also became more unevenly spread.3.4Changes in household human and material capitals are outlined in Table 3.5Changes in household material capitals are outlined in Table 3.6The GGP aimed to reduce farmers’ dependence on agriculture and encourage redundant rural labors to find other nonagricultural employment. We defined the labor force as those household members aged 18 or older. Every family member of the surveyed households was asked about his/her occupation and so we were able to determine the number of labor force that was employed in nonagricultural industries. The results showed that nonagricultural employment increased substantially since 2004 Table . The pro4There have been dramatic changes in livelihood capitals and distribution among households in our study area over the past 10 years. In general, it is optimistic to have found a dramatic decrease in local cropland holdings and a dramatic increase in the households’ nonagricultural income, as these outcomes indicate that the locals’ dependence on agriculture has decreased and that redundant rural workers have shifted away from growing crops. These changes align with the initial objective of the GGP. Although the GGP is not the only driver of these changes, it is now confronted with new socio‐economic conditions in our study site and will have to be adjusted if its planned next stage is to be an effective and smooth implementation. We highlight the following three challenges for the sustainability of the GGP's planned next stage in our study site.4.1There were distinct uneven distributions of cropland holdings and agricultural income among the respondents. At least two typical groups were evident among the respondents—landless respondents and land‐secure respondents. In the study area, it has been established that households with more cropland are less willing to re‐enroll in the GGP due to their dependence on farming  and the obvious increase in local incomes. In the first stage of the program, the absolute value of compensation was lower than cropland income, because most local croplands were under cabbage cultivation , compensation paid to households for their cropland conversion decreased substantially (−46.9%). The proportion of this ecological compensation to household total income and agricultural income decreased even more so . This is a result of the continued decline in compensation from the first stage to the third stage of the GGP .The GGP itself actually has a small positive effect on nonfarm employment (Kelly & Huo, 5It is well‐known that PES or restoration programs should be adaptable to changing socio‐economic and environmental conditions at their target locations. In this context, our research contributes a case study of the household livelihood changes associated with implementation of the GGP in the Wolong National Nature Reserve in southwestern China and the implications of these changes for the sustainability of the program. A number of conclusions are made:The livelihood changes expected by the program were not evenly distributed among the participants. This has varying effects for households and PES program designers should therefore regularly review such contextual changes and adjust the program accordingly. A bottom‐up approach and the precise targeting of disadvantaged households are recommended when reviewing the contextual changes;As an economic and market‐oriented method, the costs and benefits of a PES program change with the general socio‐economic context. Competitive economic incentives are needed to sustain the program and ensure ongoing provision of ecosystem services; andPES programs cannot be divorced from other policies. Changes in participant characteristics and the effects of these changes are out of the control of the program itself. Hence, coordinating with other related land‐use policies is advised to advance a PES program.As both society and the environment are not static, a constant PES will lag behind the socio‐economic and environmental context at its targeted locations. Ensuring a PES is dynamic according to it targeted context will contribute to its long‐term success. Taking both household average and unevenly distributed changes associated with participation in a PES program into consideration in a holistic way provides new insights for PES implementation. Contextual changes happen for individual households, the broader community, and at the district/national level. Household‐level analysis is an important means of understanding the fine‐scale contextual changes and their implications for the design and implementation of targeted PES programs. In the long term, PES program should establish a regular monitor system for typical households in the community and inform the significant feedback of changes to program managers.The authors declare no conflict of interest.Jianying XU designed the research, conducted field work in 2004 and 2015, and wrote the manuscript. Qing WANG and Ming KONG conducted field work in 2015.


Arachis hypogaea transposable element (AhTE) markers. Using single marker analysis and QTL analysis, the markers with high phenotypic variance explained (PVE) were identified for branching pattern (32.3%), number of primary and secondary branches , protein content (26.4%), days to 50% flowering (22.0%), content of oleic acid (15.1%), test weight (13.6%) and pod width (12.0%). Three genic markers  with Arachis hypogaea miniature inverted-repeat transposable element (AhMITE1) activity in the genes Araip.TG1BL (B02 chromosome), Aradu.7N61X (A09 chromosome) and Aradu.7065G (A07 chromosome), respectively showed strong linkage with these taxonomic, productivity and quality traits. Since TMV 2 and TMV 2-NLM differed subtly at DNA level, the background noise in detecting the marker-trait associations was minimum; therefore, the markers identified in this study for the taxonomic and productivity traits may be significant and useful in peanut molecular breeding.A mapping population of recombinant inbred lines (RILs) derived from TMV 2 and its mutant, TMV 2-NLM was employed for mapping important taxonomic and productivity traits using genic and non-genic transposable element markers in peanut. Single nucleotide polymorphism and copy number variation using RAD-Sequencing data indicated very limited polymorphism between TMV 2 and TMV 2-NLM. But phenotypically they differed significantly for many taxonomic and productivity traits. Also, the RIL population showed significant variation for a few additional agronomic traits. A genetic linkage map of 1,205.66 cM was constructed using 91 genic and non-genic  Arachis hypogaea L.) is an important oilseed and legume crop apart from being a fodder crop. Peanut improvement through molecular breeding demands the development of genomic resources like quantitative trait loci (QTL) regions and their linked markers for various traits. Such a gene discovery approach can be best-employed with genotypes that differ for many traits but are genetically related , B [homozygote as the second parent (TMV 2-NLM)], H (heterozygote), C [not genotype a ] and D [not genotype b ] as per JoinMap 4 format [Total genomic DNA from the RILs was extracted from young leaves using modified cetyl trimethyl ammonium bromide (CTAB) method . The RILh marker  and the 4 format ,F statistic and simple linear regression coefficient [2 were analyzed for their position in the genome and functional annotation using the gene prediction data from the diploid genomes (available at https://peanutbase.org).Single marker analysis was performed to find out the association between the AhTE markers and the traits observed in this study by calculating fficient  using Wifficient . Those sLinkage analysis was performed with JoinMap 4.0 . The “LoThe QTL mapping was performed for the phenotypic data collected during the two seasons; the rainy seasons of 2014 and 2015 and the linkage map using Windows QTL Cartographer version 2.5  to detecField evaluation of TMV 2 and its mutant, TMV 2-NLM during the rainy seasons of 2014 and 2015 showed main stem flowering, sequential branching pattern and erect growth habit and for TMV 2, and absence of main stem flowering, alternate branching pattern and semi-spreading growth habit for TMV 2-NLM . TMV 2 hAraip.NZ9YG gene on chromosome B04 coding for a protein with “F-box protein interaction domain” carried 14 SNPs, while Araip.X5KQ1 gene on chromosome B01 coding for probable sugar phosphate-protein carried four SNPs. In total, nine genes showed sequence alterations due to SNPs with or without possible functional alterations. An effort was made to check the copy number variations (CNVs) between TMV 2 and TMV 2-NLM. A total of 1,200 genomic regions showed significant CNVs  sites between TMV 2 and TMV 2-NLM. Of them, 57 sites represented genic regions, while 48 belonged to non-genic regions. Sequence analysis indicated that out of the 57 genic sites, the transpositional activity of the AhMITE1 was found in the exons at six sites. In 16 genic sites, the transposon activity was restricted to intronic regions. Six genes had transposition site at untranslated regions (UTRs). Fifteen genes had transposition site at upstream regions (23–949 bp) and 14 genes had transposon activity at downstream regions (8–934 bp). Overall, the phenotypic and genotypic data revealed very limited genotypic polymorphism between TMV 2 and TMV 2-NLM, despite significant phenotypic differences.TMV 2 and TMV 2-NLM were also checked for the differential activity of In order to map the genomic regions governing taxonomic and productivity traits, the mapping population of TMV 2 × TMV 2-NLM was employed. One hundred and five AhTE markers showing polymorphism between TMV 2 and TMV 2-NLM were used for genotyping the 432 RILs. A linkage map of 1,205.66 cM was constructed with 91 markers on 20 linkage groups (LGs)  Tables. RILs were field-evaluated during the rainy seasons of 2014 and 2015. They differed significantly for most of the taxonomic, agronomic, productivity and nutritional traits . High PCMajority of the traits showed normal distribution as tested by skewness and kurtosis . Correla2 with one or more traits during 2014 and/or 2015 (2 (32.8%) for the branching pattern . AhTE0357 also showed strong association with days to 50% flowering and number of primary and secondary branches. AhTE0391 showed strong association with the contents of protein, oil, oleic acid, linoleic acid and palmitic acid. Apart from these three markers, AhTE0025 showed high R2 with test weight and pod width.Single marker analysis (SMA) was performed to find any association between the AhTE markers and the traits. A total of 41 and 43 traits in 2014 and 2015, respectively were subjected for SMA  Tables. /or 2015 . AhTE035AhMITE1 at AhTE0357 locus was located at 79 bp downstream of the gene Araip.TG1BL. The marker locus corresponding to AhTE0391 coincided with the gene Aradu.7N61X. The AhMITE1 transposition site was present at 2,129 bp of the second intronic region of Aradu.7N61X , respectively.Analysis of the genomic position of these four markers showed that AhTE0357, AhTE0391 and AhTE0025 were genic. The transposition site of du.7N61X . At AhTEQTL analysis was attempted using the linkage map and the phenotypic data for 31 traits in 2014, and 33 traits in 2015  Tables. QTL flanked by AhTE0357-AhTE0050 showed high PVE for days to 50% flowering, number of primary and secondary branches . QTL betTMV 2 contributed the favourable allele at AhTE0003-AhTE0332 for protein content. The allele contributed by TMV 2 at AhTE0357-AhTE0050 resulted in reduced days to 50% flowering and number of primary branches. TMV 2-NLM contributed favourable allele at AhTE0391-AhTE0572 for oleic acid content. For test weight, TMV 2-NLM contributed the favourable allele at AhTE0025-AhTE0296.Aradu.A01_2581365, Aradu.A06_112199516, Araip.B02_34272578 and Araip.B10_2552983 SNP sites, the four-foliar disease resistant lines shared the same nucleotide in contrast to TMV 2, indicating a possible co-segregation between SNP and resistance to LLS and rust.An attempt was made to select the superior RILs for variety development and commercial release. High heritability and genetic advance over mean (GAM) were observed for LLS score at 90 DAS, days to 50% flowering, test weight, pod width, oil and protein content, oleic acid, linoleic acid and SCMR. Fifteen RILs were marginally superior for pod yield/plant over the best parent, TMV 2 . HoweverAhMITE1 at 105 loci out of 369 loci tested in this study. Further, it was found that AhMITE1 activity was restricted to exons of only six genes. Thus, TMV 2 and TMV 2-NLM could constitute ideal parents of a RIL population which can be employed for mapping the traits by reducing the background noise.TMV 2, a popular and elite variety of peanut, and its EMS-derived mutant TMV 2-NLM were used to identify the genomic regions contributing to the important taxonomic and productivity traits in peanut by QTL mapping using a large number (432) of their recombinant inbred lines (RILs). TMV 2 and TMV 2-NLM differed significantly for the growth habit, number of branches (primary and secondary), productivity traits and quantity and quality of the oil. The RIL population showed considerably high variability not only for those traits for which the parents differed, but also for a few other traits , thus allowing QTL detection for several traits. RAD-Sequencing, which is a reduced representation of genome sequencing method evaluating ~1% of the genome, revealed genetic differences in terms of SNPs and copy number variations. The density of SNP was about 1 per Mb, which was comparable to the density found in tomato mutants . Of the AhFAD2A on chromosome A09. AhFAD2A and AhFAD2B (on B09) are the main genes [Using 91 AhTE markers, a partial linkage map of 1,205.66 cM was constructed in a new RIL mapping population (TMV 2 × TMV 2-NLM) in peanut. The marker order was grossly comparable to the maps for SKF2 (Satonoka × Kintoki) and NYF2 (YI-0311 × Nakateyutaka), which were also constructed with TE markers . The marin genes , though AhMITE1 insertion polymorphism at 79 bp downstream of the gene Araip.TG1BL on chromosome B02, could differentiate the genotypes with sequential and alternate branching pattern to an extent of 32.8%. AhTE0357 was also associated with days to 50% flowering and number of primary and secondary branches. But selection for early maturing genotypes using AhTE0357 was not expected to bring any yield advantage since days to 50% flowering recorded negative and significant correlation with productivity and oil quality traits. AhTE0391, apart from being associated with the contents of oil, oleic acid, linoleic acid and palmitic acid, also showed association with protein content. The marker locus corresponding to AhTE0391 coincided with the gene Aradu.7N61X, which codes for alpha-glucosidase. In germinating grains of barley, HvAGL97 codes for α-glucosidase, which is a major endosperm enzyme. It catalyzes conversion of maltose to glucose, but is not required for starch degradation [The markers flanking the QTL were also found to be strongly associated with the same traits when checked with single marker analysis. The marker AhTE0357 with radation .Aradu.7065G on A07 chromosome coding for aldo/keto reductase family oxidoreductase. In Digitalis purpurea, aldo/keto reductase is known take part in the biosynthesis of cardiac glycosides [Aradu.7065G on A07 chromosome. Thus, Aradu.7065G on A07 chromosome could be a candidate gene for test weight.Test weight and pod width were positively and significantly correlated, and both showed strong association with AhTE0025, which corresponded to the gene ycosides . In the ycosides  and Huanycosides , respectThe genomic resources (QTL regions/genes/markers) developed in this study help in generating the genetic resources to breed for improved peanut varieties. But the RILs used in this study directly provide an opportunity to select the superior lines for productivity traits. RILs 2-14(a)(ii), 2-29(g), 2-33(a) and 2-23(c) were superior since they recorded 7–15%, 35–50% and 1–4% increase over TMV 2 for pod yield, test weight and oil content, respectively. They also had 12–21% O/L higher oleate than TMV 2. They matured one to two days earlier than TMV 2. These RILs are being multiplied and evaluated in detail for variety development and commercial release.The linkage map of TMV 2 × TMV 2-NLM, QTL regions and markers identified in this study for taxonomic, agronomic and productivity traits will be of immense use for fine-mapping and identifying the candidate genes. The loci of TE markers both at genic and non-genic regions are known to influence the gene expression , therebyAhMITE1 insertion polymorphism, three genes Araip.TG1BL (B02 chromosome), Aradu.7N61X (A09 chromosome) and Aradu.7065G (A07 chromosome), respectively were identified for their association with taxonomic, productivity and quality traits.QTL mapping using 432 recombinant inbred lines derived from TMV 2 and its mutant, TMV 2-NLM could identify the major QTL for days to 50% flowering, number of primary and secondary branches, test weight, pod width, protein and oil content, oleic acid, linoleic acid, palmitic acid, stearic acid, and behenic acid. Based on the three markers  detecting S1 Table(XLSX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.S3 Table(XLSX)Click here for additional data file.S4 Table(XLSX)Click here for additional data file.S5 Table(XLSX)Click here for additional data file.S6 Table(XLSX)Click here for additional data file.S7 Table(XLSX)Click here for additional data file.S8 Table(XLSX)Click here for additional data file.S9 Table(XLSX)Click here for additional data file.S10 Table(XLSX)Click here for additional data file.S11 Table(XLSX)Click here for additional data file.


In 2009, the Nepal Ministry of Health and Population launched a national program for prevention of postpartum hemorrhage (PPH) during home births that features advance distribution of misoprostol to pregnant women. In the years since, the government has scaled-up the program throughout much of the country. This paper presents findings from the first large-scale assessment of the effectiveness of the advance distribution program.Data collection was carried out in nine districts and all three ecological zones. To assess knowledge, receipt and use of misoprostol, household interviews were conducted with 2070 women who had given birth within the past 12 months. To assess supply and provision of misoprostol, interviews were conducted with 270 Female Community Health Volunteers (FCHVs) and staff at 99 health facilities.Among recently delivered women, only 15% received information about misoprostol and 13% received misoprostol tablets in advance of delivery. Yet 87% who received advance misoprostol and delivered at home used it for PPH prevention. Among FCHVs, 96% were providing advance misoprostol for PPH prevention; however 81% had experienced at least one misoprostol stock out within the past year. About one-half of FCHVs were providing incomplete information about the use of misoprostol; in addition, many did not discuss side effects, how to recognize PPH or where to go if PPH occurs. Among health facilities, just one-half had sufficient misoprostol stock, while 95% had sufficient oxytocin stock, at the time of this assessment.In Nepal, women who receive advance misoprostol are both willing and able to use the medication for PPH prevention during home births. However the supply and personnel challenges identified raise questions about scalability and impact of the program over the long-term. Further assessment is needed. The government of Nepal has made considerable progress in its efforts to promote safe motherhood. For instance, between 2006 and 2011 there was a 36% increase in the provision of antenatal care ; and a 94% increase in the rate of facility-based births  [In recent years, the government of Nepal has invested in implementing and scaling-up its PPH prevention program throughout much of the country. The main goal is to ensure uterotonic coverage immediately following birth of the baby at all deliveries, regardless of delivery location. The program is run by the government’s Family Health Division (FHD) within the Department of Health Services, in partnership with multiple organizations. It is governed by a set of guidelines that includes a detailed plan for program implementation . The PPHThe second component of the PPH prevention program involves advance distribution of misoprostol to pregnant women for use during home births. Following the success of a 2005 pilot project involving advance distribution of misoprostol to pregnant women in the rural areas of Banke district, the Nepal government began planning for a country-wide program for all home births , 8 The ‘For the advance distribution component, the FHD provides initial training to all new FCHVs and includes material devoted to PPH and the provision of misoprostol. The FHD also provides supervision and refresher training to the FCHVs, although the advance distribution program is not always covered in these trainings.In order to examine the effectiveness of the national PPH prevention program, a study was carried out in 2013 by the Family Health Division, Gynuity Health Projects and New ERA. Although the primary focus was the advance distribution of misoprostol, some aspects of the facility-based provision of oxytocin were also examined. The primary study objectives were to assess the availability, provision and use of misoprostol for home births. This article summarizes the key findings, including the frequency of misoprostol receipt and use among home births; stock of misoprostol and prevalence of program-related knowledge and practices among FCHVs; and supply of uterotonics at government health facilities.To assess knowledge, receipt and use of advance misoprostol, household interviews were conducted with 2070 women who had given birth within the past 12 months (recently delivered women) . Trained interviewers approached a total of 21,767 households to screen for eligibility. If the woman was deemed eligible and gave verbal consent to participate, the interviewer asked a series of questions about demographic characteristics; use of antenatal and delivery services; and knowledge, receipt and use of misoprostol for PPH prevention. Each interview took approximately 20 min to complete.To assess the supply and provision of misoprostol, interviews were conducted with 270 FCHVs  and staff at 99 government health facilities . Trained interviewers asked FCHVs about their knowledge of misoprostol for PPH prevention, current and recent misoprostol stock, program training and supervision, and how to improve the PPH prevention program. Trained interviewers also administered surveys to the focal person of the PPH prevention program within each health facility. Survey items included questions about PPH prevention practices and drugs; availability, storage and supply of uterotonics; and suggestions for improving the PPH prevention program.Data were collected between May 2013 and August 2013 by 30 female interviewers and 10 field supervisors. For the household interviews, the field staff was divided into ten teams, each comprised of three female interviewers and one supervisor. The interviews with FCHVs and the health facility staff were conducted by the field supervisors. All field staff received a one-week training prior to the start of field mobilization. Review of completed data collection forms and data entry were carried out by New ERA in Nepal.The primary variable of interest was advance receipt of misoprostol for PPH prevention among recently delivered women. Receipt was defined as having received advance misoprostol from an FCHV or other health provider for the purpose of PPH prevention during a home birth. Using evidence from previous district-level studies, we hypothesized that receipt of advance misoprostol would differ by ecological region, with prevalence of 37% in the mountain region, 47% in the hill region, and 57% in the terai region –11. We cSelection of the household interview sample was carried out using a three-stage cluster design. In the first stage, nine districts were selected purposively from the 27 districts in which the advance distribution program had been fully implemented at the time of the evaluation, in order to ensure fair representation of all ecological and development regions. Three districts were chosen from each of the country’s three ecological regions . Next, 30 rural clusters were selected from among the three sample districts in each ecological region using probability proportional to size (PPS) methodology. Only rural clusters were considered since rural areas are the key focus of the advance distribution program, given that home births are highest in rural areas. Finally, within each rural cluster, households were screened until a total of 23 interviews had been completed.Within each rural cluster, the health facility located in the rural municipality  was included in the facility sample. In addition, the district hospital from each sample district was included. This provided a total of 99 facilities . A total of three FCHVs per rural cluster were also recruited for interviews . This provided a total of 270 FCHVs .P-values <0.05 were considered significant.We used frequencies to examine program-related variables and background characteristics among recently delivered women, FCHVs, and health facilities. We used Pearson’s Chi-Square and Fisher’s Exact tests for categorical variables to assess regional differences in receipt and use of advance misoprostol among recently delivered women. The analysis was conducted using Stata/SE 12.1 and Table The receipt and use of advance misoprostol for PPH prevention are summarized in Table Table The characteristics and PPH-related services of the 99 health facilities included in the study are presented in Table This assessment identified widespread gaps in the supply of misoprostol among FCHVs and within health facilities in all three ecological regions. Given the central importance of misoprostol to the advance distribution program, irregular and/or insufficient supply is a key barrier to program success. Efforts to identify and address logistical and other supply chain constraints are therefore needed as is more consistent and up-to-date monitoring of misoprostol stock throughout the health system. Since birthing centres are primarily responsible for deliveries in rural areas, priority should be given to ensuring sufficient misoprostol supply at these and other sub-district level facilities. In response to preliminary study findings, the government has initiated efforts to identify and address the sources of the misoprostol supply shortages. As an example, the government’s Logistics Management Division is currently piloting a new electronic system that will enable facility-based tracking of health supplies, including misoprostol, at the district level and above. The government has also continued to expand the advance distribution program, which has now been implemented in 42 out of 75 districts country-wide.Lessons could be learned from the success of the oxytocin component of the PPH Prevention Program in Nepal. In this study, there was a sufficient supply of oxytocin at nearly all health facilities that provide obstetric care. Implementation of the oxytocin program has been underway for many years and has been a collaborative effort of the FHD and various multi-lateral and non-governmental organizations. These are the same entities involved in the advance distribution program and, as a result, comparison of key similarities and differences in program implementation strategies and supply management procedures may be helpful. The program may also benefit from a change made in 2014, in which the distribution of misoprostol was combined with distribution of chlorhexidine for cord care and birth preparedness packages (BPP). All three technologies are now provided by FCHVs in the eighth month of pregnancy, thus potentially boosting commitment to the advance distribution program among FCHVs.Study findings also suggest a need for improving knowledge of and commitment to the advance distribution program among FCHVs. Discussion with FCHVs after completion of this evaluation revealed confusion about the importance of the advance distribution program given the government’s emphasis on facility births. As part of the push to promote facility births, FCHVs formerly received financial incentives for ensuring that women in their communities delivered in facilities, Hence, at the time of this evaluation, many were likely unaware of the continuing need to provide advance misoprostol. In light of this situation, the importance of the advance distribution program should be stressed to all FCHVs, even when women indicate a preference for facility deliveries. The study findings also revealed some confusion about when to provide advance misoprostol (16% were providing it in the seventh or ninth month instead of the eighth month). In addition, many FCHVs were not providing full information about when and how to use misoprostol, or how to recognize PPH. Refresher trainings or review meetings that emphasize proper counseling and misoprostol provision would likely help. In response to initial information about these findings, the government has also increased its emphasis on refresher trainings for FCHVs.Another option being considered by the Ministry of Health and Population (MoHP) is the replacement of FCHVs with a new cadre of community providers with more training—auxiliary nurse midwives (ANMs) who could provide antenatal care as well as assist deliveries both in the home and in health facilities. This would likely be more costly and time consuming, however, and following an initial pilot project involving community ANMs in one district, there has been no subsequent effort to expand this idea.The high rate of institutional delivery, which was 54% overall and 65% in the terai region, is encouraging. This reflects considerable change in a very short period of time, from an estimated 35% of deliveries in the 2011 DHS survey .The high use of misoprostol (87%) among those who received it and delivered at home is also encouraging and mirrors findings from other similar studies conducted in Ethiopia, Ghana, Liberia and South Sudan –15. FurtNepal was one of the first countries to implement a community-based advance distribution program and at the time of this assessment, had been involved in scaling the program up for about 5 years. While it is encouraging that the government remains committed to the PPH prevention program and is working to address the gaps identified in this study, future research should examine more closely whether these gaps have been sufficiently addressed as well as the costs and benefits of long-term investment in a program that may only reach a small share of the target population. Information about the long-term status of similar programs in other countries would also be of interest. While the clinical benefits of advance distribution of misoprostol for home births have been established  and womeThe mixed methods approach used in this evaluation enabled assessment of multiple aspects of the PPH prevention program. In addition, the large number of women included in the household surveys and the large number of facilities and FCHVs surveyed enabled us to assess and compare the program status in all three of the country’s ecological regions. However, the responses obtained in the household interviews may have been subject to some recall bias, particularly among those who delivered closer to 1 year prior to the date of interview.The findings from this study confirm prior research indicating that women who receive advance misoprostol in the third trimester of pregnancy are largely willing and able to use it correctly for PPH prevention during home-births. At the same time, the supply and personnel challenges identified are key barriers to program success and raise questions about the scalability and magnitude of impact of the advance distribution program over the long-term.