To build the spindle at mitosis, motors exert spatially regulated forces on microtubules. We know that dynein pulls on mammalian spindle microtubule minus-ends, and this localized activity at ends is predicted to allow dynein to cluster microtubules into poles. How dynein becomes enriched at minus-ends is not known. Here, we use quantitative imaging and laser ablation to show that NuMA targets dynactin to minus-ends, localizing dynein activity there. NuMA is recruited to new minus-ends independently of dynein and more quickly than dynactin; both NuMA and dynactin display specific, steady-state binding at minus-ends. NuMA localization to minus-ends involves a C-terminal region outside NuMA’s canonical microtubule-binding domain and is independent of minus-end binders γ-TuRC, CAMSAP1, and KANSL1/3. Both NuMA’s minus-end-binding and dynein-dynactin-binding modules are required to rescue focused, bipolar spindle organization. Thus, NuMA may serve as a mitosis-specific minus-end cargo adaptor, targeting dynein activity to minus-ends to cluster spindle microtubules into poles. Every time a cell divides, it needs to duplicate its DNA and evenly distribute it between the two new ‘daughter’ cells. To move and distribute DNA, the cell builds a large machine called a spindle, which is made of stiff cables called microtubules.Many proteins, including a motor called dynein, help to organize the spindle’s microtubules. One of dynein’s jobs is to cluster all microtubules at the two tips of the spindle, pulling them into shape. Without this clustering, spindles have the wrong shape and structure and can make mistakes when moving DNA.Microtubules have a ‘plus’ end and a ‘minus’ end, and motor proteins usually only travel in one specified direction. Dynein, for example, moves towards the minus end of microtubules, which is where most of the clustering happens. It can form a complex with other proteins that help clustering, one of which is called NuMA. Until now, it was thought that dynein transports NuMA to the minus ends.To test this model, Hueschen et al. studied dividing human cells under a microscope and isolated minus ends with the help of a laser. The experiments showed that, in fact, NuMA gets to minus ends independently of dynein. Once it is on the minus ends, NuMA grabs hold of another protein complex called dynactin, which then gathers dynein. Dynein then pulls the spindles into shape from the minus ends. When NuMA was experimentally removed from the cells, dynein-dynactin complexes were scattered along the entire length of the microtubule instead of pulling specifically on minus-ends, which resulted in disorganized spindles. Thus, where dynein complexes pull determines what spindle shape they build.Hueschen et al. also showed that dynein complexes only pull on minus-ends while the cell divides, which makes sense, because NuMA remains hidden in the cell nucleus for the rest of the time. Together, these results suggest that NuMA makes sure dynein pulls specifically on the minus-ends of the microtubules to tighten the spindle at the right time.A next step will be to test how the mechanical properties of the spindle are changed without dynein pulling on minus-ends. A better knowledge of how different proteins work together to build the spindle and help cells divide can help us understand what goes wrong when cells divide abnormally, as in the case of cancer cells. Each time a cell divides, molecular motors help remodel the microtubule cytoskeleton into a bipolar assembly of microtubules called the spindle. The spindle’s bipolar architecture is essential to its function – accurate chromosome segregation. In mammalian spindles, microtubule plus-ends mechanically couple to chromosomes, while microtubule minus-ends are focused into two poles that dictate where chromosomes are transported at anaphase. To build the spindle’s architecture, motors must exert spatially regulated forces on microtubules. Microtubule ends offer platforms for such localized regulation, since they are structurally distinct. Indeed, motor recruitment and activity at plus-ends is well-documented , but motDynein is a minus-end-directed motor which slides parallel spindle microtubules to focus their minus-ends into spindle poles , workingHow dynein becomes localized at minus-ends remains an open question. Dynein may be enriched near minus-ends because it walks toward them on microtubules and piles up when it runs out of track; indeed, pile-up of dynein has been observed at minus-ends in vitro  and can Here, we use laser ablation in cells to create new, isolated minus-ends in the mammalian spindle, and quantitative imaging to map protein recruitment to these ends and its mechanistic basis. We demonstrate that NuMA binds at minus-ends independently of dynein, and that NuMA targets dynactin – and thereby dynein activity – to spindle minus-ends. This challenges the prevailing model that dynein delivers NuMA to spindle minus-ends and poles . NuMA loGlued  and NuMA strongly co-localized at one end of these individual microtubules . In addition, the rate of NuMA or dynactin accumulation at new minus-ends did not correlate with the length of k-fiber stubs created by ablation  . After dIf NuMA does target dynein-dynactin to minus-ends, localizing force there, we would expect NuMA to be required for dynein to transport minus-ends created by k-fiber ablation . To testDynein activity at minus-ends could require NuMA because NuMA modulates dynein-dynactin’s ability to pull on microtubules, or because NuMA localizes dynein to minus-ends. Given the findings in In addition, nocodazole washout experiments revealed that dynactin (p150) localization to individual microtubule minus-ends was lost upon NuMA deletion . InsteadDrosophila homolog, Patronin  of NuMATo define the NuMA domain required for spindle minus-end localization, we performed rescue experiments with different NuMA truncations in the NuMA-knockout background . This avWe sought to more closely define which sections within NuMA’s C-terminus (a.a. 1701–2115) are involved in microtubule minus-end localization. The second half of the C-terminus , which contains residues previously implicated in NuMA-microtubule interactions , localizImportantly, NuMA’s C-terminus (‘C’) localized to minus-ends but could not rescue proper pole focusing or spindle architecture, unlike full-length protein or N-C . This suTo test whether recruiting dynein-dynactin to the sides of microtubules was sufficient for proper microtubule clustering into poles, we fused NuMA’s N-terminus to the Tau microtubule-binding domain (‘N-Tau’). N-Tau localized along the length of spindle microtubules and recruited dynactin there . DespiteLike a traditional cargo adaptor, NuMA may target force to spindle minus-ends using a cargo (minus-end) binding module (‘C’) and a dynactin-recruitment module (‘N’). Furthermore, the inability of N-Tau to rescue spindle architecture in the absence of endogenous NuMA suggests that specifically targeting dynein-dynactin to minus-ends, not just all along spindle microtubules as N-Tau does, is critical for organizing a focused, bipolar spindle.Our data indicate that NuMA localizes to spindle microtubule minus-ends independently of dynein and minus-end binding proteins γ-TuRC, CAMSAP1, and KANSL1/3. NuMA then targets dynactin to minus-ends, localizing dynein motor activity there. In addition, targeting dynein to the end of its track could permit amplification by motor pile-up, as NuMA at minus-ends captures processive dynein complexes. Altogether, our findings are consistent with a model in which NuMA confers minus-end targeting of the dynein-dynactin complex upon nuclear envelope breakdown (NEB), when NuMA is released from the nucleus. Indeed, active microtubule clustering by dynein is first observed coincident with NEB . Thus, NThe data also indicate that NuMA’s minus-end localization at mitosis is mediated by the tail1+2A region of its C-terminus, while previously identified microtubule-binding domains tail2A or tail2B  are not Models of spindle assembly in silico predict that enriching a minus-end-directed motor at microtubule ends can break gridlock between parallel microtubules and allow robust minus-end clustering into poles . HoweverThe data suggest that NuMA in the mammalian spindle body may function as a traditional cargo adaptor, with a cargo (minus-end)-binding module and a motor-binding module. In the spindle body context, microtubule minus-ends are the cargo, just as the cortex can be framed as cargo for cortical dynein – analogous to more canonical interphase cargo like membranous vesicles or organelles. This framework raises the question of whether NuMA additionally serves as a dynein activator, inducing highly processive motility like interphase dynein adaptors can .Dynein’s localization in mammalian mitosis is more ubiquitous than that of dynactin ; high cyUnlike known dynein activators, NuMA is thought to not only homodimerize but also oligomerize into higher order assemblies . NuMA’s 2 and were transfected with DNA using ViaFect  48 hr (RPE1/HeLa) or 72 hr (PtK2) before imaging.PtK2 cells were cultured in MEM  supplemented with sodium pyruvate , nonessential amino acids , penicillin/streptomycin, and 10% heat-inactivated fetal bovine serum (FBS) . RPE1 and HeLa cells were cultured in DMEM/F12 with GlutaMAX  supplemented with penicillin/streptomycin and 10% FBS. For Tet-on inducible CRISPR-Cas9 cell lines, tetracycline-screened FBS  was used. Cell lines were not STR-profiled for authentication. All cell lines tested negative for mycoplasma. Cells were maintained at 37°C and 5% COhttp://crispr.mit.edu. sgRNAs are listed in Key Resource Table. The plasmid used to express sgRNAs under control of the hU6 promoter (pLenti-sgRNA) was a gift from T. Wang, D. Sabatini, and E. Lander (Whitehead/Broad/MIT). An RPE1 cell line containing doxycycline-inducible human codon-optimized spCas9 was a gift from I. Cheeseman (Whitehead/MIT) and was generated as described in  and imaged in a stage-top humidified incubation chamber  maintained at 30°C and 5% CO2. To visualize tubulin, 100 nM siR-Tubulin dye  was added 2 hr prior to imaging, along with 10 µM verapamil . Under these conditions, there was no detected defect in spindle appearance or microtubule dynamics. As described elsewhere , cells wFor immunofluorescence, cells were plated on #1.5 25 mm coverslips coated with 1 mg/mL poly-L-lysine. Cells were fixed with 95% methanol + 5 mM EGTA at −20°C for 3 min, washed with TBS-T (0.1% Triton-X-100 in TBS), and blocked with 2% BSA in TBS-T for 1 hr. Primary and secondary antibodies were diluted in TBS-T+2% BSA and incubated with cells overnight at 4°C (primary) or for 20 min at room temperature (secondary). DNA was labeled with Hoescht 33342  before cells were mounted in ProLongGold Antifade . Cells were imaged using the spinning disk confocal microscope described above. Antibodies: mouse anti-α-tubulin DM1α , rabbit anti-α-tubulin , rabbit anti-NuMA , mouse anti-p150-Glued , mouse anti-α-tubulin DM1α conjugated to Alexa488 , mouse anti-dynein intermediate chain , rabbit anti-EB1 , rabbit anti-KANSL1 , rabbit anti-CAMSAP1 , mouse anti-actin , rabbit anti-γ-tubulin , and camel nanobody against GFP coupled to Atto488 .−2. A translation stage was used to shift the laser beams towards the edge of the objective so that light reached the sample at incident angles slightly smaller than the critical angle of the glass-water interface. A 405 nm laser was used concurrently with either the 647- or 560 nm lasers to reactivate fluorophores into the emitting state. The power of the 405 nm laser  was adjusted during image acquisition so that at any given instant, only a small, optically resolvable fraction of the fluorophores in the sample were in the emitting state. Emission was recorded with an Andor iXon Ultra 897 EM-CCD camera at a framerate of 220 Hz, for a total of ~120,000 frames per image. For 3D STORM imaging, a cylindrical lens of focal length 1 m was inserted into the imaging path so that images of single molecules were elongated in opposite directions for molecules on the proximal and distal sides of the focal plane  were plated on photo-etched, gridded coverslips  coated with 1 mg/mL poly-L-lysine  and imaged at 29–30°C in a homemade heated aluminum coverslip holder using the confocal microscope and ablation system described above. 20–30 s after k-fiber ablation, imaging media was replaced with fixative (as above) chilled to −80°C, and the coverslip holder was placed on ice for 1 min. Cells were incubated with 3% BSA in PBS for 1 hr at room temperature, and then with primary antibodies overnight at 4°C. Secondary antibodies ; anti-rabbit AF647 ) were incubated for 30 min at room temperature. Antibody incubations were followed by four washes with 0.2% BSA in PBS. Samples were stored in PBS during confocal imaging, and coverslip grid was used to re-find the individual ablated cell. For 3D STORM imaging, samples were mounted on glass slides with a standard STORM imaging buffer consisting of 5% (w/v) glucose, 100 mM cysteamine, 0.8 mg/mL glucose oxidase, and 40 µg/mL catalase in 1M Tris-HCI (pH 7.5) . Coverslal plane . Two-colal plane .To inhibit γ-tubulin, 30 μM gatastatin   was adde217-548   by Gibson assembly between GFP and Arp1A of GFP-Arp1A  . 2x-GFP-versity) ; mCherryversity) ; GFP-NuMversity) ; GFP-CAMversity) .To determine the percentage of p150 at plus-ends vs. minus-ends , we usedhttps://github.com/chueschen/IntensityAtMinusEnd (https://github.com/elifesciences-publications/IntensityAtMinusEnd). After background subtraction, the intensity measured at the cut site during the three frames before ablation (k-fiber intensity) was averaged and set to zero. For NuMA and Arp1A, we then fit a sigmoid function (y = intensity and x = time) to each trace, normalized to plateau height (a = 1), and solved for the time b at which y = 0.5*a to determine time to half-maximum intensity  and then averaged.Minus-end position data  were genr) and p values were performed in Matlab. One-way ANOVA and Tukey post-hoc tests .All data are expressed as average ±standard error of the mean (SEM). Calculations of correlation coefficients  and three reviewers, one of whom is a member of our Board of Reviewing Editors. The following individual involved in review of your submission has agreed to reveal their identity: Reto Gassmann (Reviewer #2).Thank you for submitting your article "NuMA Targets Dynein to Microtubule Minus-Ends at Mitosis" for consideration by The reviewers have discussed the reviews with one another and the Reviewing Editor has drafted this decision to help you prepare a revised submission.Summary:In this manuscript, Hueschen and co-workers use microscopy, laser ablation and molecular genetic techniques to investigate NuMA's role in regulating dynein and dynactin within the mitotic spindle. Their findings include the observation that NuMA localizes rapidly to newly created microtubule minus ends, and that this behaviour does not appear to depend on dynein, dynactin, or known minus-end binders γ-TuRC, CAMSAP1, and KANSL1/3. Conversely, the localization of dynactin  does depend on NuMA. The experiments suggest a specific region of NuMA autonomously recognizes minus ends, thereby recruiting dynein activity there. This work provides interesting evidence regarding the hierarchy of minus end association between NuMA, dynein, and dynactin, while raising a number of mechanistic puzzles and experimental queries.This manuscript exhibits rigor in quantifying the localization kinetics of microtubule minus-end-binding proteins and in using knockout cell lines to perform clean molecular replacement experiments. The results are well presented with sound statistical analysis and fully support the authors' conclusions. The central idea of the study – NuMA targets dynein motor activity specifically to microtubule minus ends, and not vice versa as previously thought – is an important novel insight that will be of great interest to motor biochemists, developmental biologists and cell biologists.Essential revisions:1) Minus-end recognitionIn several places in the manuscript, it is stated that NuMA "recognizes" minus ends. To many, this will imply a direct interaction, which is not explicitly tested in this work. The authors state that previous in vitro experiments with related NuMA fragments have not shown specific minus-end localization. An in vitro microtubule-binding experiment with the exact 'C-tail1+2A' construct used in this work would greatly strengthen the authors conclusions. Alternatively, instances of "recognizes" should be softened to "localizes to" or another expression that does not imply direct binding.Further, discussion of the Sedlin et al. (2016) study could be expanded on. For example, if the 1811-1985 region of NuMA localizes to plus and minus ends as that paper suggests, is it conceivable that cellular factors are required to prevent plus-end binding? The notion of microtubule curvature recognition by NuMA is also raised in that paper. The authors should comment on these points.2) NuMA localization under conditions of dynein inhibition or knockoutTo investigate whether NuMA is localized to minus ends by direct recruitment or dynein transport, dynein activity is perturbed by p50 overexpression, p150 overexpression, and knockout of the dynein heavy chain. However, the kinetics of NuMA recruitment are only probed in detail in the p50 overexpression case. This provides the interesting observation that NuMA can still localize to minus ends when dynein activity is perturbed, but apparently with slower kinetics, suggesting that both direct recruitment and transport may contribute to NuMA localization. However, as the kinetic traces are noisy, it would be important to show the same trend in at least one of the other dynein inhibition conditions .The key point here is to strengthen the conclusion that dynein transport alone does not target NuMA to minus ends.3) 4) 5) 6) Gatasin treatmentDo the authors have data to establish how effectively γ-TuRC was removed from minus ends by this treatment? Spindle length measurements do not probe this directly.7) Super-resolution microscopyA control with another minus-end binder (e.g. CAMSAP) needs to be included to provide convincing evidence for "organized clusters of NuMA puncta", rather than a lawn of molecules along the lattice near the minus-end.8) Title: NuMA Targets Dynein to Microtubule Minus-Ends at MitosisThere is a disconnect between title and the experiments in the study, as the localization data pertain mainly to dynactin rather than dynein. "Dynein" should be replaced with "Dynein and Dynactin" or "dynein activity".There may also be some confusion with the use of "Targets" as some will feel dynein naturally targets minus end via its motor activity. Replacing with "Recruits" or "Localizes" may avoid this confusion.9) The Materials and methods suggest that T-tests were used for statistical comparisons. However, because multiple comparisons are made, ANOVA and a suitable post-hoc test seems more appropriate and avoids the risk of Type I errors with multiple T-tests.10) A 2xGFP-Arp1A construct is generated. Please state how the functionality of this construct in the dynactin complex was verified.11) Also, please comment on the fidelity of EB1 labelling plus ends of acentrosomal microtubules i.e. do these microtubules ever have EB1 signal at both ends?12) N-Tau experimentsThe conclusion that dynein needs to be localized at the minus end, rather along the length of the microtubule, is based on use of an N-Tau construct. Please comment on caveats associated with this construct. For example, is the affinity between Tau and the microtubule load bearing? What is the expression level of the N-Tau construct compared to endogenous NuMA and other constructs?" Essential revisions:1) Minus-end recognitionIn several places in the manuscript, it is stated that NuMA "recognizes" minus ends. To many, this will imply a direct interaction, which is not explicitly tested in this work. The authors state that previous in vitro experiments with related NuMA fragments have not shown specific minus-end localization. An in vitro microtubule-binding experiment with the exact 'C-tail1+2A' construct used in this work would greatly strengthen the authors conclusions. Alternatively, instances of "recognizes" should be softened to "localizes to" or another expression that does not imply direct binding.Further, discussion of the Sedlin et al. (2016) study could be expanded on. For example, if the 1811-1985 region of NuMA localizes to plus and minus ends as that paper suggests, is it conceivable that cellular factors are required to prevent plus-end binding? The notion of microtubule curvature recognition by NuMA is also raised in that paper. The authors should comment on these points.We appreciate the feedback that our language in certain places implied knowledge of a direct interaction between NuMA and minus-ends. We have carefully reviewed the text with this concern in mind and have softened our language to better convey our intended message: that our data do not distinguish between direct or indirect recruitment of NuMA to minus-ends  NuMA localization under conditions of dynein inhibition or knockoutTo investigate whether NuMA is localized to minus ends by direct recruitment or dynein transport, dynein activity is perturbed by p50 overexpression, p150 overexpression, and knockout of the dynein heavy chain. However, the kinetics of NuMA recruitment are only probed in detail in the p50 overexpression case. This provides the interesting observation that NuMA can still localize to minus ends when dynein activity is perturbed, but apparently with slower kinetics, suggesting that both direct recruitment and transport may contribute to NuMA localization. However, as the kinetic traces are noisy, it would be important to show the same trend in at least one of the other dynein inhibition conditions .The key point here is to strengthen the conclusion that dynein transport alone does not target NuMA to minus ends.As suggested, we have performed laser ablation experiments in the inducible dynein heavy chain (DHC) knockout HeLa cell line. We measured GFP-NuMA recruitment to new minus-ends with and without deletion of DHC, and the data show the same trends as with and without p50 overexpression in PtK2 cells . NuMA is3) We have added an explanation as suggested . Thank you for this feedback. In brief, high cytoplasmic levels of dynein result in variable and low signal-to-background imaging of the motor on microtubules. This precluded accurate measurements of dynein’s dynamics.4) We agree with the reviewers and have added a western blot demonstrating dynein depletion after inducible DHC KO to 5) We thank the reviewers for this feedback and have moved the dynein localization into the main 6) Gatasin treatmentDo the authors have data to establish how effectively γ-TuRC was removed from minus ends by this treatment? Spindle length measurements do not probe this directly.To more directly test how effectively gatastatin blocks γ-TuRC’s interaction with minus-ends, we performed a microtubule regrowth assay in the presence of 30 μM gatastatin or equivalent DMSO . After cold treatment, 30 μM gatastatin dramatically blocked γ-TuRC’s ability to bind α-tubulin to nucleate new microtubules . Gatastatin did not depolymerize existing microtubule networks (top panels), demonstrating its specificity in binding γ-tubulin, not α- or β-tubulin. We thank the reviewers for suggesting this important control and have included these data in 7) Super-resolution microscopyA control with another minus-end binder (e.g. CAMSAP) needs to be included to provide convincing evidence for "organized clusters of NuMA puncta", rather than a lawn of molecules along the lattice near the minus-end.n = 32 nodes, 4 ablations for NuMA; n = 28 nodes, 3 ablations for CAMSAP). This spacing is consistent with measured spacing between individual microtubules within PtK2 k-fibers . These data support the idea of “organized clusters of NuMA puncta, rather than a lawn of molecules along the lattice near the minus-end”.We thank the reviewers for this suggestion. We have performed 3D STORM of CAMSAP at PtK2 k-fiber minus-ends created by ablation, as done for NuMA in Unfortunately, limited signal from these minus-ends structures meant that we could only detect NuMA or CAMSAP clearly when labeled with the high-photon-yield and low-duty-cycle dye Alexa 647; this precluded two-color imaging of NuMA and CAMSAP co-localization in the same cell. In addition, while the large size and flat shape of mitotic PtK2 (rat kangaroo) cells made STORM experiments possible, commercially available CAMSAP1 antibodies raised against human antigen did not label any PtK2 proteins. The images in 8) Title: NuMA Targets Dynein to Microtubule Minus-Ends at MitosisThere is a disconnect between title and the experiments in the study, as the localization data pertain mainly to dynactin rather than dynein. "Dynein" should be replaced with "Dynein and Dynactin" or "dynein activity".There may also be some confusion with the use of "Targets" as some will feel dynein naturally targets minus end via its motor activity. Replacing with "Recruits" or "Localizes" may avoid this confusion.We appreciate this feedback and have changed the title accordingly: NuMA Recruits Dynein Activity to Minus-Ends at Mitosis.9) The Materials and methods suggest that T-tests were used for statistical comparisons. However, because multiple comparisons are made, ANOVA and a suitable post-hoc test seems more appropriate and avoids the risk of Type I errors with multiple T-tests.We thank the reviewer for this suggestion. We conducted ANOVA analyses on all data in which multiple comparisons are made: F = 9.26, p = 0.0005). A Tukey post hoc test showed a significant difference between recruitment timescales for Arp1A vs. NuMA (p = 0.03) and Arp1A vs. CAMSAP1 (p = 0.001). NuMA vs. CAMSAP1 differed at p = 0.10.F = 0.45, p = 0.72.F = 267, p <0.00001). A Tukey post hoc test showed a significant difference between recruitment timescales for FL or N-C vs. C (p = 0.001) and FL or N-C vs. N-Tau (p = 0.001).10) A 2xGFP-Arp1A construct is generated. Please state how the functionality of this construct in the dynactin complex was verified.The 2xGFP-Arp1A construct localized correctly within the spindle , just like 1xGFP-Arp1A, and it did not perturb spindle organization. We have added a sentence stating this in the Materials and methods (subsection “Plasmids”).11) Also, please comment on the fidelity of EB1 labelling plus ends of acentrosomal microtubules i.e. do these microtubules ever have EB1 signal at both ends?We thank the reviewers for this feedback. We have changed the corresponding text to make it clear that 12) N-Tau experimentsThe conclusion that dynein needs to be localized at the minus end, rather along the length of the microtubule, is based on use of an N-Tau construct. Please comment on caveats associated with this construct. For example, is the affinity between Tau and the microtubule load bearing? What is the expression level of the N-Tau construct compared to endogenous NuMA and other constructs?"We have added a discussion of this caveat: “we cannot formally exclude […] that while N-Tau recruits dynactin , it cannn = 19 for FL NuMA and n = 16 for N-Tau. Thus, N-Tau’s inability to rescue spindle organization is not due to low protein expression. Comparison to endogenous levels was not possible, as the polyclonal NuMA antibody binds with unknown stoichiometry to N-Tau vs. NuMA. Due to these limitations, we do not report this data in the manuscript.To quantify the expression level of the GFP-N-Tau construct compared to full-length (FL) GFP-NuMA, we measured the average GFP intensity within the spindle region  for a confocal slice through the spindle center, for all cells used in our analysis of spindle organization . Unfortu


This review aims to introduce the concept of normothermic machine perfusion (NMP) and its role in liver transplantation. By discussing results from recent clinical studies and highlighting the potential opportunities provided by this technology, we aim to provide a greater insight into NMP and the role it can play to enhance liver transplantation.NMP has recently been shown to be both safe and feasible in liver transplantation and has also demonstrated its superiority to traditional cold storage in terms of early biochemical liver function. Through the ability to perform a viability assessment during preservation and extend preservation times, it is likely that an increase in organ utilisation will follow. NMP may facilitate the enhanced preservation with improved outcomes from donors after cardiac death and steatotic livers. Furthermore, it provides the exciting potential for liver-directed therapeutic interventions.Evidence to date suggests that NMP facilitates the enhanced preservation of liver grafts with improved early post-transplant outcomes. The key role for this technology is to increase the number and quality of liver grafts available for transplantation and to reduce waiting list deaths. A number of studies have demonstrated a relationship between peak serum AST in the early post-transplant period and patient survival, graft survival, early graft dysfunction and primary non-function following liver transplantation [In recent years, clinical outcomes from livers preserved via NMP have been reported. The first was a phase I study by Ravikumar et al. which demonstrated the safety and feasibility of NMP •• using antation , 28. Thiantation , 30. Botwww.cope-eu.org). Two hundred and twenty-two livers were transplanted as part of the study , and data from a published abstract [p < 0.001). There was also a significant reduction in early allograft dysfunction (EAD), another surrogate marker of graft outcome, in livers preserved via NMP . Another important finding was that of a significantly reduced rate of liver discard in organs randomised to NMP . Although, to date, no trial has shown an improvement in patient or graft survival or reduction in biliary complications, it is notable that trials with much larger numbers and longer term follow-up would be required to test these outcomes.The first randomised controlled trial comparing the efficacy of NMP compared to SCS in adult liver transplantation has recently been completed by the Consortium for Organ Preservation in Europe  [NMP’s benefits have been demonstrated in porcine DCD transplantation models , 14. Sch = 0.02) . These dAs previously mentioned, a major cause of morbidity and graft loss after DCD liver transplantation is ischaemic cholangiopathy which affects around 16% of transplanted livers . In a poThe utilisation of steatotic livers is limited by a greatly increased susceptibility to IRI ; ~ 1000 Current cold storage with a preservation solution facilitates the storage and transportation of a liver for up to 16 h before transplantation . HoweverThe ability to predict post-transplant outcome is an attractive prospect and could improve organ utilisation. Over the course of the last 10 years in the UK, the number of livers retrieved but not transplanted has doubled from 8.2 to 16.6% . The sitNMP provides a potential platform to treat the liver ex vivo during the preservation period. This is unique to NMP, as opposed to other machine perfusion techniques, as active metabolism permits graft intervention and modification during preservation. This could be applied in the context of de-fatting steatotic livers, as previously mentioned , 45. AnoNormothermic machine perfusion has heralded a new era in liver transplantation and organ preservation. It is hoped that with this new technology, more livers can be transplanted with improved outcomes and that fewer lives will be lost on the waiting list. More clinical studies are required to assess its true clinical impact as well as exploit its true potential in organ regeneration and enhancement.


St. Joseph's Health System has implemented an integrated comprehensive care bundle care (ICC) program with the hopes that it would improve patients' care while reducing overall costs. The aim of this analysis was to evaluate the performance of the ICC program within patients admitted with chronic pulmonary obstructive disease (COPD). We conducted a retrospective observational cohort study comparing ICC patients to non-ICC patients admitted to St. Joseph's Healthcare Hamilton for COPD being discharged with support services between June 2012 and March 2015, using administrative data. Confounding adjustment was achieved through the use of propensity score matching. Medical resource utilizations during the initial hospitalization and within the 60 days following discharge were compared using regression models. All 76 patients who entered the ICC program (100.0%) were matched 1 : 1 to 76 eligible non-ICC patients (28.4%). Length of stay (6.47 [7.29] versus 9.55 [10.21] days) and resource intensity weights (1.16 [0.80] versus 1.64 [1.69]) were lower in the ICC group within the initial hospitalization but, while favoring the ICC program, healthcare resource use tended not to differ statistically following discharge. The ICC program was able to reduce initial medical resource utilization without increasing subsequent medical resource use. Healthcare demand and costs are rising in Canada and abroad with the fear that this continuous rise could affect the sustainability of the healthcare systems. Many attempts have been made to curb this increase through the use of multiple hospital/physician/healthcare provider organizations funding models with various degrees of success –7. Most The current ICC model in place at the SJHH is composed of three registered health care professionals who act as the ICC coordinators for all of the clinical streams and are supported by an administrative/research support position. Patients followed within the ICC program have access to the ICC team 24 hours a day, seven days a week through a toll free telephone number. In addition to the ICC personnel, the ICC program leverages an independent version of the SJHC Information System  to provide real-time remote access to client files. Remote access to these files is accomplished by using tablets, laptops, or desktop computers to securely access the information and clinical documentation remotely and provide the option to take digital pictures when required .The ICC program is currently offered to patients in four clinical streams . It was hypothesized that the ICC program could potentially (1) reduce inpatient length of stay (LOS) of the index admission by favoring earlier evaluation for homecare intervention, (2) provide added benefits following discharge, and (3) improve patient and provider experience.A previous evaluation of the ICC program within the thoracic surgery clinical stream at SJHH showed that, despite having minimal impact within the initial hospitalization, the ICC program was associated with lower proportions of emergency department visits and hospitalization in the postdischarge phase and with a tendency to reduce overall costs . HoweverThe current manuscript provides the results of our initial evaluation of the performance of the pilot ICC program within the COPD clinical stream for patients admitted to SJHH.We conducted a comparative retrospective cohort study using data from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD) linked to the SJHC dataset maintained in Procura ContinuLink.We used CIHI Case Mix Group (CMG) classifications to identify all patients admitted at SJHH for COPD between June 1, 2012, and March 31, 2015. All eligible patients  were approached by the ICC coordinator on the first day of their admission (or on the day of COPD diagnosis for incident COPD cases) for enrollment into the ICC program. Patients in this group who accepted enrollment and were subsequently discharged home formed the ICC group.Concurrent comparator patients who were admitted to SJHH for COPD and discharged with standard support services during the study follow-up period were eligible to act as comparator patients (hereby defined as the non-ICC group) . In the The primary outcome of this study was the in-hospital LOS for the index admission. Secondary outcomes included other in-hospital medical resource utilization rates and included the resource intensity weights (RIW)   of the iDiscrete data are presented in absolute (number) and relative (percentage) values and continuous data are presented as mean (standard deviation [SD]) or as average rate of event  per 100 persons; rates were defined per 100 persons per month or per two months in function of the examined follow-up period . Baseline sociodemographics of all patients included within the ICC and non-ICC group were assessed on the index admission's admission date as well as the numbers of time they were admitted in the 60 days prior to their index admission.We used propensity score (PS) matching to control for measured baseline confounding between the two groups . PatientP values < 0.05 as significant.Between group balance in terms of the baseline characteristics within the unmatched and matched populations was assessed using absolute standardized differences (ASDD); ASDD > 0.10 were assumed to indicate lack of balance between groups , 15. ProA patient flow-chart is shown in Baseline comparison of the ICC and non-ICC group is shown in Matched non-ICC comparators were found for all 76 patients in the ICC group. PS matching attained balance on all examined baseline characteristics . OutcomeEvaluation of the ICC program is fundamental to adequately assess its value to patients and the healthcare system . Our stuThis is the second pilot evaluation of the performance of the ICC program within SJHH. Though none of the results regarding the ICC program in either stream would indicate worse outcomes with the ICC program, added benefits provided by the ICC program seem to differ between streams. For example, within the COPD stream, benefits with the ICC program were generally observed within the index hospitalization , whereasDespite these positive results, concerns regarding the fact that both currently available evaluations of the ICC program have been conducted within a research university hospital center and that the results we show may not be reproducible within community hospitals could be raised. It is important to note that the ICC program was later expanded in September 2013 to another SJHS hospital, St. Mary's General Hospital, a community hospital center in Kitchener-Waterloo, Ontario . AlthougOur study has several limitations. First, we had access to limited patients' baseline characteristics as well as a limited sample size. Although we used PS matching to further select balanced comparator groups, we may not exclude the risk that we did not fully adjust for measured confounding  nor can we fully exclude the risk of confounding due to unmeasured confounders  , 24. SecFrom a broader perspective, this evaluation also depicts issues associated with evaluating an intervention which is offered in a nonrandomized manner. Unlike results observed within a randomized controlled study, any differences, or lack of differences, observed within a nonrandomized study may be due to confounding. To address this potential issue, we had determined a priori that confounding adjustment would be conducted in a stepwise approach. First, the ICC program's performance would be evaluated only in patients who could be eligible for inclusion within the ICC program  and second, subsequent differences in measured baseline characteristics would be further adjusted thanks to a PS matching approach . Had we We recommend that any research team planning to conduct a similar analysis reflect on the following points. Firstly, identification and selection of an optimal comparator group are pivotal for the appropriate evaluation of the program. Secondly, all nonrandomized studies are subject to confounding bias; following the selection of the comparator group, researchers must thoroughly examine all available characteristics to identify the level of balance between both groups. Thirdly, following identification of unbalanced characteristics, comparisons must be conducted using optimal adjustment methods . Finally, as shown within our example, full access to all relevant databases and the ability to link data between these databases must be obtained in order to extensively evaluate all short- and long-term implications of such programs across both inpatient and outpatient healthcare services. In addition, the evaluation of these complex healthcare interventions must move beyond the traditional first-level indicators  to better appreciate their impact across the whole spectrum of care.In conclusion, based on our preliminary results, implementation of the ICC program to the COPD clinical stream within the SJHH statistically reduced patients' index LOS which should reduce in-hospital costs and showed a potential for a reduction in the number of days patients were hospitalized in the 30 and 60 days after discharge. Additional analyses focusing on patients' outcome following discharge, their perception regarding outpatient care, and a full economic evaluation of the ICC program must be conducted prior to concluding on its full value.


To increase access to safe and appropriate exercise for people with balance and mobility limitations, community organizations have partnered with healthcare providers to deliver an evidence-based, task-oriented group exercise program in community centers in Canada. We aimed to understand challenges and solutions to implementing this program model to inform plans for expansion.At a 1-day meeting, 53 stakeholders  identified challenges to program implementation that were captured by seven themes: Resources to deliver the exercise class ; Program marketing ; Transportation ; Program access ; Maintaining program integrity; Sustaining partnerships ; and Funding . Stakeholders prioritized solutions to form an action plan. A survey of individuals supervising 28 programs revealed that people with stroke, acquired brain injury, multiple sclerosis, and Parkinson’s disease register at 95–100% of centers. The most prevalent issues with program fidelity across centers were not requiring a minimum level of walking ability (32%), class sizes exceeding 12 (21%), and instructor-to-participant ratios exceeding 1:4 (19%). Findings provide considerations for program expansion.The online version of this article (10.1186/s13104-018-3313-x) contains supplementary material, which is available to authorized users. Many chronic health conditions, such as stroke and multiple sclerosis, result in persistent balance and mobility limitations –3. BalanIn Canada, a group, task-oriented, CBEP incorporating a healthcare-recreation partnership (CBEP-HRP) called “Together in Movement and Exercise” (TIME™) has been developed , 19. ThiTIME™ involves a 1-h exercise class provided twice a week for 12 weeks. Classes involve seated warm-up and cool-down exercises, and practice of functional exercises , with standardized progressions, designed to improve balance and mobility. A minimum instructor-plus-volunteer-to-participant ratio of 1:4 is required to maintain adequate supervision and exercise progression . Family After a pilot study demonstrated the safety, feasibility, and potential benefit of the TIME™ model , a toolkA 1-day stakeholder meeting and two follow-up surveys were undertaken. Seventy-seven individuals from academic, healthcare, and recreation sectors from across Canada who had experience with the TIME™ program or a similar program were invited to participate in the stakeholder meeting in May 2014. Recreation coordinators obtained permission from TIME™ exercise participants and caregivers to contact them with an invitation to participate.Prior to the meeting, individuals were asked to document challenges, facilitators and strategies to implementing or participating in CBEPs using a standardized form  attended the meeting. Of the 53 attendees  Program marketing: Healthcare and recreation personnel recognised the challenge of promoting and raising awareness of the program among healthcare and rehabilitation professionals who could endorse the program and support referral to ensure adequate registration. (3) Transportation: Exercise participants and healthcare/recreation personnel agreed that transportation to the program could be costly and inconvenient. Adapted transport services did not consistently arrive on schedule, were cancelled during inclement weather, or were unavailable in rural areas. (4) Program access: Registration was not always possible. The program was either full or the exercises were inappropriate for some clients with multi-morbidities and low mobility levels and some clients with high functional levels who had already taken the program. These challenges were perceived as preventing long-term exercise participation. (5) Maintaining program integrity: This challenge related to ensuring consistent delivery of the program as intended over time across centers. (6) Sustaining partnerships: Maintaining roles, communication and collaboration between healthcare and recreation partners was considered challenging. (7) Funding: All stakeholders identified the need for additional funding to sustain the TIME™ program model. Recreation partners needed funding for staff wages, equipment, and program expansion; healthcare providers required funding to offer training and support; and clients needed funding to pay for program registration and transportation. Table Challenges identified during meeting discussions and voting results are described in Additional file Seventeen supervisors of TIME™ programs run by 25 organizations in 28 community centers completed the online questionnaire (100% response rate). Across 28 centers, TIME™ programs had been running for ≤ 1 year (14%), 1–2 years (46%), 2–4 years (32%), and 6–8 years (7%). Exercises were performed in a circuit  or three superstations , in 57 and 29% of centers, respectively. Most frequently, classes were 60 min in length (89%), provided twice a week (57%) for 12 weeks (36%), and 3 times per year (39%). Volunteers and caregivers were permitted to assist in 75 and 89% of centers, respectively. Table This mixed methods study revealed a range of program challenges related to recreation center resources, program marketing, transportation, access, integrity, funding, and sustaining partnerships, relevant to six stakeholder groups. Stakeholders identified high priority strategies targeting each of these challenges, with the exception of transportation. These strategies can be used to inform the development of action plans to help implement and sustain the TIME™ program. Following spread of the TIME™ program to 28 community centers, certain recommended program elements, including class format and duration, participation of caregivers, involvement of and referral of participants by healthcare professionals, were maintained, while others, such as admission criteria, weekly class frequency, program duration, maximum class size, instructor-to-participant ratio, and use of volunteers, were adapted.Some challenges to delivering the TIME™ program, such as program cost and transportation, have been noted previously by people with stroke –24, HIV The importance of maintaining partnerships to sustain program referral, delivery, and integrity was underscored in our study. People with physical disability prefer a trusted healthcare practitioner to refer them to CBEPs, as this reassures them that the program is safe and appropriate . KnowledStakeholders involved in the unplanned spread of the CBEP-HRP TIME™ model in a publicly-funded healthcare system encounter challenges related to inadequate funding and infrastructure that may threaten the sustainability of these programs. Local application of the solutions proposed in this research is likely to result in slow and haphazard improvements as it will depend on the resources of individual organizations. Public health agencies, supported by a mandate and dedicated funding, will find our study findings relevant to planning for systematic development and scale-up of CBEP-HRPs to enable widespread and equitable access to exercise participation for people with a wide range of balance and mobility limitations.Challenges and strategies identified in this study may primarily reflect the priorities of healthcare and recreation professionals as they had a high degree of representation. Their opinions, however, were informed by presentations made by exercise participants and caregivers early in the meeting. Seating participants by stakeholder group and inclusion of anonymous voting were strengths of the meeting process that helped to ensure representation of multiple stakeholder perspectives.Additional file 1. Pre-meeting Activity.Additional file 2. Meeting Agenda.Additional file 3. TIMETM Survey Questionnaire.Additional file 4. Meeting participant positions and organizations.Additional file 5. Identification and endorsement of challenges.


The purpose of this study was to explore stakeholders' perception of an on-going evidence-based task-shifting strategy for hypertension (TASSH) in 32 community health centers and district hospitals in Ghana.Using focus group discussions and in-depth interviews, qualitative data were obtained from 81 key stakeholders including patients, nurses, and site directors of participating community health centers involved in the TASSH trial. Qualitative data were analyzed using open and axial coding techniques.Analysis of the qualitative data revealed three themes that illustrate stakeholders' perceptions of the ongoing task-shifting strategy for blood pressure control in Ghana and they include: 1) awareness and understanding of the TASSH program; 2) reasons for participation and non-participation in TASSH; and 3) the benefit and drawbacks to the TASSH program.The findings support evidence that successful implementation of any task-shifting strategy must focus not only on individual patient characteristics, but also consider the role contextual factors such as organizational and leadership factors play. The findings also demonstrate the importance of understanding stakeholder's perceptions of evidence-based task-shifting interventions for hypertension control as it may ultimately influence the sustainable uptake of these interventions into "real world" settings. Stakeholders’ perceptions of the implementation of evidence-based task-shifting strategies in low- and middle - income countries (LMICs) including Ghana are important for several reasons. First, decisions regarding transferring research to practice are often complex, involving a number of policymakers and other key stakeholders –3. ThereTask-shifting strategy is defined as the rational movement of primary care duties from physicians to non-physician health care workers, such as nurses, pharmacists, or community health workers , 10. In In 2012, a cluster randomized task-shifting strategy for hypertension (TASSH) control trial was implemented in 32 community health centers (CHCs) and district hospitals in Ghana . This stThe purpose of this study is to explore stakeholders’  perceptions of the on-going task-shifting cluster-randomized control trial for hypertension in Ghana. The valuable and often understudied perspectives of stakeholders in LMICs may provide necessary insight to inform rapid scale-up of known evidence-based interventions implemented in settings like Ghana.n = 16) or the control group (n = 16). Both patients in the intervention and control group received health insurance and follow-up care every three months. However, patients in the intervention condition received care from community-health nurses who had been trained in blood pressure measurement, hypertension diagnosis, treatment and management, in addition to the WHO Package of Essential Noncommunicable diseases (WHO-PEN) Patients in the intervention group received “usual care,” which varied based on the clinic they attended. Blood pressure outcomes are evaluated at baseline, 12 months, and 24 months. To date, the trial has enrolled 757 patients, of which 86% of all the patients have completed the primary outcome of the study at 12 months. A total of 64 nurses (2 from each of the 32 study sites) were trained in the delivery of the TASSH protocol. Nurses were recruited from each of the 32 clinics involved in the study, and trained in theWHO-PEN CVD Package. The WHO-PEN involved fours steps: 1) inquiry about the patient’s history ; 2) physical and laboratory experiments ; 3) estimation of cardiovascular disease risk based on risk charts provided by WHO ; 4) initiation of drug therapy, lifestyle counseling, and follow-up visits  this program.”Patients’ participation in TASSH was influenced by previous difficulty obtaining care for hypertension. For some, the previous care received for their condition was sporadic and unsatisfactory. One patient stated, “checking my blood pressure every month, counseling about eating at night and eating fruits are some of the reasons why I like participating in the [TASSH] program.” For the patients, access to consistent care, medications and education and counseling on lifestyle changes influenced their continued participation in the program.Participation was also influenced by the program structure, including education and regular check-ups. One patient stated: “I like the program because the prescribed medication regime I am receiving from [the] TASSH [has less side effects than what was previously provided by my previous doctors at the local clinics.”e] TASSH  has lessThe patients interviewed shared both benefits and drawbacks of participating in the TASSH program. With regards to the benefits, one participant shared the following:“one thing I like about the program is that checking my weight has helped them [the nurses] to become aware of what I am eating.” Another patient shared the following: “the educational component, especially the group format is helpful with gaining knowledge about how to manage my blood pressure.” While some patients felt that the TASSH program provided more individualized treatment and that the nurses were able to offer them support and feedback that they previously had not received, many of them encountered financial challenges with implementing the necessary lifestyle changes. Some patients noted that: “the lack of money for purchasing healthy food is a problem.” One patient shared the following statement:The challenge for me with this program is finances, because not all healthy foods you recommended are available in my immediate surroundings, so I need finances to travel a few miles to buy them and they are also expensive.”“Another participant stated, “I cannot get the same drugs given to me at TASSH [in the hospitals. The drugs given to us are very expensive and not covered on NHIS [national health insurance scheme drug formulary]. Drugs will have to be purchased on our own.”at TASSH  in the hAdditionally, participants expressed their concerns with the affordability of the prescribed medications. One participant shared the following:In summary, patients described that the TASSH program increased their awareness of lifestyle and behavioral changes they could implement to manage their hypertension, and provided education for them to do this. Some patients also described that even though they were aware of their hypertension status prior to TASSH, they were unable to receive necessary care. Thus, prior inability to access proper care was a strong motivator for patients participation in the program. However, lack of finances, limiting patients ability to purchase antihypertensive medication after the TASSH program ended as well as affordability of healthy foods were noted as barriers to hypertension management.“TASSH has helped many clients with high BP to reduce it from abnormal to normal. It has also helped some patients know more about their condition.”Similar to the patients, almost all the nurses viewed the TASSH program as potentially helping their clients to improve their blood pressure. One nurse shared the following:I have helped them [patients] come to the hospital regularly because they previously just took medication without coming to care for their blood pressure.”“Nurses’ participated in TASSH because they enjoyed seeing the positive effects of the program and improvements in patient health. Nurses noted that the program was effective in improving lifestyle and healthful behaviors in ways that previous care was not. One nurse shared the following:“I provide on-on-one interaction with my patient and I have helped them know their blood pressure level and I motivate and encourage them to take their medications. My patients say that it has helped them a lot and they take their medications seriously.”One nurse described home visits as a critical component of TASSH, particularly for helping patients adherence to their medication:The nurses’ involvement in TASSH contrasted to their typical role at their clinics with hypertensive patients, in which previously hypertension diagnosis and management was solely the responsibility of physicians. Nurses were not allowed to treat hypertension.“their clinical priorities were in line with TASSH,” others mentioned that they: “divide their attention and often do not have enough time to carry out their TASSH duties.” One nurse however described the support provided by her site director as helpful with the following statement:“Even though I have to perform my other duties before TASSH, my site director lets me attend to TASSH patients when they come around, gives me enough time to attend TASSH training, and forwards new patients to me.”For the nurses, leadership support was described as an important factor with carrying out TASSH duties particularly in cases where the primary duties of the nurses at the clinic were not in alignment with their role as TASSH nurses. Although some nurses expressed that: “it [BP equipment] enabled patients to become more knowledgeable about their hypertension,” and, “it allowed me to carry out my duties efficiently.” However, there were drawbacks to having the equipment:“The breakdown of the blood pressure machines [is a challenge] because it [BP equipment] is constantly being borrowed and used at the community health centers or district hospitals for non-TASSH programs.”In addition to leadership support, some of the nurses mentioned that the availability of blood pressure monitors was a potential benefit because “lack of proper [dedicated] space” at the community health centers for the TASSH program was an important issue that limited their ability to see patients and properly store patient information. In addition to the logistics, some nurses stated that “the non-availability of drugs, during follow up care” was a major barrier to implementing TASSH program effectively, particularly as many of the patients cannot afford to buy their medications at the end of the program.Additionally, the logistics involved with implementing the TASSH program was viewed by some nurses with ambivalence. For example, some nurses reported that Overall, nurses felt that the TASSH program was helpful in providing awareness of hypertension status and knowledge of hypertension management to patients. Many nurses cited enjoyment of their work in the TASSH program, including providing necessary education and seeing patient improvement, as reasons for participating as providers in the TASSH program. Finally, nurses described that consistent and strong leadership support was one of the most important facilitators to successful implementation of TASSH. Having clinic directors who were knowledgeable about nurses’ duties with TASSH and accommodated their clinic duties and TASSH duties was critical for success of the program. However, several logistical concerns were noted as primary barriers to program success, including lack of space for seeing patients and equipment breakdown.important with helping to address hypertension management in Ghana in general.” One director described TASSH in the following way: “TASSH is providing an enabling environment with the skilled personnel to provide better care for hypertension patients.” Majority of site directors also suggested that training nurses in the management and control of hypertension was appropriate, given the rather high cost associated with management of a condition like hypertension. One director shared the following:The most important thing is training staff as managing NCDs like hypertension is very expensive. Taking blood pressure is a simple activity that our nurses can do and so it is important that we have programs like TASSH to train them.”“Majority of site directors viewed TASSH as ““first interactions with the program.” One site director shared the following:“It is serious when a medical coordinator in a facility is not aware that the program is actually in the facility. So, going forward, I think that you need to include the head , while others are on temporary suspension of their [blood pressure] medication.” In terms of the potential drawback, staff turnover was a recurring theme shared by most of the site directors (58%). As one director stated the following:“Having to train new nurses in the event of transfer of trained nurses to other health centers not involved with the TASSH [or in the event of maternity leave, may make it difficult to continue the program at participating sites.”he TASSH  or in thThe potential benefit of the TASSH program for patients was described by a site director who noted that since implementation of the program, In summary, the site directors agreed that TASSH plays an important role in promoting awareness of hypertension and chronic disease in general, and in training health care workers to manage such conditions. There were several challenges with regard to site directors’ motivation for participating in TASSH. The primary concern was that several site directors were unaware of the program goals, or in some instances the program itself. This occurred in several instances where there was turnover in clinic administration and replacement staff were not informed of TASSH. Despite this challenge, the site directors noted that a positive benefit of TASSH was that it lightened physician work-loads, allowing them to spend more time with patients with more severe conditions. However, they described that training more nurses may be necessary, as TASSH nurses may transfer to another facility leaving their clinic of origin without a TASSH provider.“produce evidence-based interventions that are more relevant and actionable to policy and practice stakeholders” [In this study, we explored key stakeholders’ perceptions of the implementation of the TASSH program. The findings offer valuable information, as we are only just beginning to understand the role contextual factors play in intervention implementation , 29. Futholders” .Our findings revealed important insights into the on-going implementation of TASSH, particularly the importance of understanding participant awareness and understanding of a program, reasons for participating or not participating, and the benefits and drawbacks of the program. For example, while it was evident that the TASSH strategy increased patients awareness of their hypertension, with the nurses going above and beyond their call of duty to implement the program, and the site directors expressing satisfaction with the reduction of their patient workload, there were challenges identified by the patients, including the perceived lack of self-efficacy to adopt the recommended lifestyle changes long-term. Similarly, for the nurses, the frequent breakdown of the blood pressure measuring devices as a result of being used by other non-TASSH trained clinic staff was a drawback to the effective implementation of their duties as TASSH nurses alongside lack of leadership support. For the site directors, some did not participate in the TASSH program either due to miscommunication, lack of information on the study protocol or persistent staff turnover. However, directors who were aware of the program, helped nurses fulfill their TASSH duties for example, by relieving them from work to attend TASSH training or referring new TASSH patients to the nurses.These findings are similar to those reported by Sanjana and colleagues who evaluated task-shifting strategies in the context of HIV counseling and testing services in Zambia . The autOur finding that implementation and dissemination of the TASSH program will require continuous engagement of key stakeholders at all levels, including patients, nurses, and administrators, is supported by studies by other investigators. For example, Copper and colleagues  as well A key strength of this study is that it drew upon the perspectives of stakeholders  involved in an on-going task-shifting strategy for blood pressure control in Ghana. In doing so, it has been possible to identify similar and sometimes contradictory perceptions of the TASSH trial. On the other hand, there are limitations in the current study worth mentioning. First, we only interviewed a small sample of stakeholders who may not be representative of all the stakeholders involved with the TASSH trial. It is also likely that our sampling strategy introduced a positive bias in that most of the participants in the study were more likely to be positively predisposed to the TASSH program. As a result, it is possible that participants not interviewed may have views that were not reflected in these findings. To counteract this bias, we did interview site directors and staff with less or no direct involvement in the TASSH trial to explore their unique perspectives on the program. Additionally, the focus discussions and interviews likely introduced a social desirability bias as participants may have responded in a way they perceived as being socially acceptable. That said, the nature of qualitative inquiry is to understand the depth of otherwise unknown information / knowledge such as stakeholders’ perceptions of implementation of interventions in LMICs, and to a certain extent, the aforementioned limitation cannot be avoided given this type of inquiry. Despite these limitations, the knowledge derived from our study has the potential to inform the transfer of research to practice by providing key stakeholders with the best evidence available on the benefits as well as drawbacks associated with implementing interventions in LMICs.The findings from the current study have several implications not only for researchers and practitioners that implement interventions in LMICs, but also for the funders and technical assistance providers that support them. First, our findings highlight the need for on-going evaluations of task-shifting strategies to explore key stakeholders’ perceptions, which can provide insight for understanding stakeholders’ awareness of the program, reasons for participation or nonparticipation, as well as perceived benefits and drawbacks. Second, the results of this study show that different stakeholders have different viewpoints, for example, of what are the benefits or drawbacks of evidence-based implementations. Hence, what may be considered important for some stakeholders , may be different for others . Given the importance and cost of implementing programs like TASSH, further research to understand how individual interests or needs of stakeholders translate into decision-making at the policy level are needed , 4. FinaOverall this study provides important contributions to the literature about stakeholders’ perceptions of the implementation of task-shifting strategies for hypertension control. By providing insights into perspectives of key stakeholders, this study offers evidence on potential factors likely to influence rapid scale-up and dissemination of evidence-based CVD prevention services in SSA. These findings have implications for the successful implementation of task-shifting strategies as they demonstrate the importance of understanding participant awareness and understanding of a program, reasons for participating or not participating, and the benefits and drawbacks of the program. The findings may also be used as the basis for the development of more theoretically-informed research that seeks to ensure that interventions for hypertension control are taken up in practice, ultimately achieving results at full scale for CVD improvement efforts in Ghana and other LMICs.


Parenting programs integrating general parenting and health behaviour messaging may be an effective childhood obesity prevention strategy. The current study explored workplaces as an alternate setting to deliver parenting programs.This study involved two phases. The objective of the first phase was to explore interest in and preferred delivery mode of a workplace program that addresses general parenting and health behaviours. The objective of the second phase was to adapt and test the feasibility and acceptability of a pre-existing program that has been successfully run in community settings for parents in their workplace. To achieve the first objective, we conducted 9 individual or small group qualitative interviews with 11 workplace representatives involved in employee wellness/wellness programming from 8 different organizations across Southwestern Ontario. To achieve the second objective, we adapted a pre-existing program incorporating workplace representatives’ suggestions to create Parents Working Together (PWT). We then tested the program using a pre/post uncontrolled feasibility trial with 9 employees of a large manufacturing company located in Guelph, Ontario.Results from the qualitative phase showed that a workplace parenting program that addresses general parenting and health behaviour messages is of interest to workplaces. Results from the feasibility trial suggest that PWT is feasible and well received by participants; attendance rates were high with 89 % of the participants attending 5 or more sessions and 44 % attending all 7 sessions offered. All participants stated they would recommend the program to co-workers. Just over half of our parent participants were male (55.6 %), which is a unique finding as the majority of existing parenting programs engage primarily mothers. Impact evaluation results suggest that changes in children’s and parents’ weight-related behaviours, as well as parents’ reports of family interfering with work were in the desired direction post-intervention; however, confidence intervals substantially overlapped zero. Contrary to expectations, parents also reported an increase in restrictive feeding practices.Our results indicate that a workplace-based program that addresses general parenting skills and weight-related behaviours may be a feasible way to engage and educate parents, including fathers. A full-scale trial is needed to examine the effectiveness of this approach.The online version of this article (doi:10.1186/s12889-016-3817-z) contains supplementary material, which is available to authorized users. In Canada, an estimated 19.8 % of children ages 5–17 years are overweight and an additional 11.7 % are obese . Obesityp = 0.01). Parents in the intervention also reported less parental stress  and greater confidence in managing children’s behaviour  compared to those in the control arm [The preschool years are a critical time for obesity prevention interventions, as habits developed in childhood tend to persist into later life –9. At thtrol arm . Other itrol arm , as welltrol arm , 23. Partrol arm , 23, 24,As demographic trends change and an increasing proportion of families are dual earners  , workplaIn order to maximize the feasibility and acceptability of the intervention, we utilized a mixed methods approach with a sequential exploratory design . The firIn the second section of this article we describe results from a pre/post uncontrolled feasibility trial of the PWT intervention – the quantitative piece to our mixed methods design. The primary objective was to determine the achievability and acceptability of PWT to employees and the secondary objective was to explore the extent to which the intervention was associated with changes in: a) child and parent weight-related behaviours ; b) general parenting, feeding behaviours, parenting efficacy, and general stress; and c) measures of work-life balance.n = 2) with workplace representatives involved in employee wellness/wellness programming, , from 8 workplaces. Criteria used to select these workplaces included: 1) located in Southwestern Ontario; 2) had a workplace representative able to speak English. The workplace representatives did not need to currently be offering a parenting or other workplace wellness program to be eligible to participate. A member from our research team who is a human resource consultant (AS) identified 11 potential representatives from workplaces that met the inclusion criteria. All identified workplace representatives were sent a scripted email to determine their interest in participation along with a one-page document outlining the rationale for the study. All 11 workplace representatives who were contacted agreed to participate in the study. Of the 11 workplace representatives interviewed, all were female, 8 were human resources (HR) personnel and 3 were occupational health nurses.From April-July 2014 we conducted a series of individual or small group interviews (The semi-structured interview guide was developed by the research team to include questions relating to a) the perceived need for a program such as PWT in the workplace, b) logistical aspects of how a parenting program could be successfully delivered in the workplace, and c) workplace metrics to be added to the evaluation protocol that would be of interest to employers.The interviews were held at the workplaces of the representatives being interviewed during daytime working hours. A member of the research team (LW), who has prior experience with conducting qualitative interviews and focus groups, moderated the interviews. An additional member of the research team (AS) was present to take notes. All the interviews were audio recorded and transcribed. Theoretical saturation was reached by consensus  after which data collection ended.Transcripts were organized for analysis through Microsoft Excel tables and thematic analysis was used to analyze the transcripts . A deducSix main categories of data were identified; five of the categories were predetermined by the interview guide  while one additional category emerged throughout the discussions with participants (suggestions for marketing the program). See Additional file Universally, participants identified that issues with work-life balance are a significant problem for their employees. Many workplace representatives felt that employees’ struggles with work-life balance have been increasing in recent years and this was seen as leading to significant stress and mental health issues for employees, and employers are seeing this impacting workplace performance . In addition to affecting workplace performance, participants identified that the stress resulting from struggles with work-life balance also impacts the personal lives of employees.Overall, when asked about their interest in a workplace parenting program as a tool to ease the stress of work-life balance, most participants were very supportive of such an initiative. One participant even suggested that this is a program worth piloting.When asked about existing or previous programs available to support employee wellness, the majority of participants stated their organizations currently have initiatives to try to support employee wellness; however, none currently offer on-site parenting support programs. Participants reported that their organizations were currently using a number of strategies to address employees’ work-life balance issues . The most common being referral to Employee Assistance Programs’ services, which provide counselling to employees on a broad range of mental health topics, as well as referrals to community and other resources as required.When asked about the potential barriers to implementing a parenting program in the workplace, participants identified four principal barriers that may arise: poorly attended sessions, stigma associated with attending a parenting program, lack of time, and other competing priorities. Participants felt that in their experience, lunch-and-learns tend to be poorly attended and that a way to maximize attendance was to offer incentives to attend . In order to reduce the stigma that may be associated with attending a parenting program held in the workplace, participants suggested marketing the program in a positive way  versus as a program for families who are struggling. Finally, to address the issues of lack of time and other competing priorities, participants suggested a couple of strategies: showing the relevance to employees and employers so that a parenting program becomes a priority and having structured and focused sessions that are clearly communicated to employees.Common suggestions to ensure the program is feasible for delivery in the workplace setting included: keeping the number of program sessions offered to the minimum required, holding sessions in the workplace during workday hours, using a traditional lunch and learn format, and shortening program sessions to fit into the employees’ allotted lunch break.When asked about program evaluation, all participants felt that conducting an evaluation was critical and almost all of the participants mentioned employee engagement as being an important metric to measure. Other measures of interest that were mentioned included financial return on investment and employee satisfaction with the program.Most suggestions for marketing the program to employees centred on using positive messaging . Another suggestion was to focus on parenting struggles as a normal part of raising children. Participants also suggested focusing on the potential benefits associated with the participating in the program, specifically the reduced stress associated with improved parenting. In order to get employer buy-in for such a program, participants discussed stressing that a workplace parenting program could be a solution to work-life balance struggles faced by employees.There were a number of key learnings from our formative assessment with workplace representatives that informed the adaptation of PWT – our workplace parenting program Table .Table 1OTaking these learnings, PWT sessions were condensed from 1.5 h to 30 min in length to fit into the employees’ lunch time and the program was shortened from 9 to 7 weeks in length. Additionally, the eligibility criteria were expanded so that the program could be offered to parents of children age 2–7 years . Given that the content of PWT is specific to the early years, the eligibility criteria could not be expanded further, but an effort was made to maximize the portion of employees that would be eligible to participate.Second, employers suggested that there are a number of potential barriers to attending a parenting program held in the workplace  and they had suggestions for increasing employee buy-in and maximizing attendance, including: positive marketing of the program and structured focused sessions that are clearly communicated to employees so that employees are aware of what is involved in the program prior to signing up.Finally, our results suggest that an evaluation of the program is an important component in order to get organizational support for PWT. If employers are to support a workplace program they are interested in seeing workplace-related outcomes achieved by their employees. To capitalize on employer enthusiasm, the evaluation protocol for PWT was expanded to include measures of work-life balance and employee engagement.n = 40) were sent an invitation letter from HR inviting them to attend an on-site information session about PWT held at the same time and location as when the program was to be held. We recruited 10 participants for the program; however, after the second week. One participant had to withdraw from the study as his work schedule wouldn’t allow him to attend the weekly sessions . From January to March 2015, we conducted a feasibility trial of PWT. Employees were eligible to participate if they were 1) over the age of 18 years, 2) had a child(ren) between the ages of 2–7 years, 3) were working the day shift, and 4) were literate in English. To recruit participants, the divisional HR department did an initial screen to determine those employees that met the eligibility criteria. All eligible employees  and 4 were mothers; just over half of participants self-identified as Caucasian (55.6 %) with the remaining participants coming from a variety of ethnic backgrounds. Most participants were working as labourers at the plant (66.7 %); the remaining participants had a supervisory role.We present an overview of the program content in Table A member of the research team (LW) led the program sessions and a second research staff member attended all sessions to assess fidelity. As described above, PWT was adapted from PTT. PTT was adapted from a general parenting program, the Chicago Parent Program  to incluGiven that this was a feasibility trial, program evaluation focused on process measures. To assess feasibility of the program, research staff monitored participant attendance. Research staff also assessed fidelity to the program facilitator’s manual by following along with sessions and noting any content that did not get covered/handouts that were not distributed during program sessions. To assess acceptability, attrition over the study period was measured. To assess participants’ satisfaction, we asked program participants via our final process survey to rate how satisfied they were with the overall program using a 4-point Likert scale  as well as how satisfied they were with individual program components . They were also asked whether they would recommend the program to a co-worker, which was assessed using a 3-point Likert scale . Parents were also asked to self-report their perceived change in confidence in handling their children’s health behaviours . Responses were provided on a 4-point Likert scale As a secondary objective, we also assessed the impact of the program on parent and child weight-related behaviours as well as measures of general parenting strategies, parenting self-efficacy, feeding behaviours, and work-family conflict. Parent and child sugary beverage intake was assessed using questions from food frequency questionnaires previously validated in a pediatric populating (Native American and Caucasian children ages 1–5 years) , 39. AveBaseline surveys were provided to employees at the initial recruitment session and employees were asked to return the surveys the following week at week 1 of the program. Final surveys were provided at the end of week 7 and employees returned the surveys to the program facilitator (LW) 1 week later. It was expected that surveys would take approximately 20 min to complete.All data were analyzed using SPSS Version 22. For the process evaluation, frequencies were calculated from the participant process surveys. Additionally LW reviewed answers to open ended questions to categorize specific feedback from parents. For impact evaluation, paired samples t-tests were used to examine the change in outcome variables from pre- and post-intervention.Of the 9 parents who participated in the program, 89 % of participants attended 5 or more sessions with 44 % attending all 7 sessions. From the process survey results, 100 % of participants were either “satisfied” or “very satisfied” with the program and 100 % would recommend the program to a co-worker. 67 % of participants felt that the concerns that made them want to attend the program in the first place were satisfied and 78 % reported feeling either “a little more confident” or “much more confident” in handling their child’s behaviour at home , and watched fewer hours of TV . Parents also reported an increase in child sleep duration from baseline to post-intervention  as well as an increase in child physical activity in terms of both active play and outdoor play .Although changes in children’s weight-related behaviors, , appeared to be in the desired direction at follow-up, the changes were not statistically significant Table . Parentsp = 0.41). Sleep duration and TV watching remaining relatively unchanged from baseline to post-intervention (Table 5). Parents’ use of restrictive feeding practices increased from baseline to post-intervention .In terms of parent weight-related behaviours, parents reported a slight decrease in sugar sweetened beverage consumption; however, this decrease was not statistically significant . As well, there was a decrease in self-reported general stress . Parents reported a decrease in both work interfering with family and family interfering with work from baseline to post-intervention. Although confidence intervals substantially overlapped zero for both measures, it is worth noting that the change in family interfering with work was of a greater magnitude than work interfering with family .Parenting self-efficacy increased from baseline to post-intervention , a general parenting program with embedded weight-related messaging, to be delivered in the workplace as the Parents Working Together (PWT) program. The main finding from the feasibility trial of PWT was that the program was both feasible to implement and acceptable to employees of a large manufacturing company in Southwestern Ontario. Attendance rates were high with 89 % attending most of the sessions offered. PWT was also well received by parents and 100 % of participants stated they would recommend the program to co-workers. Despite good attendance and a high level of participant satisfaction there were suggestions for improvement of the program including allowing more time for discussion and lengthening sessions.PWT fits into the body of literature on workplace parenting programs, which suggests that, when parenting programs are delivered in parents’ workplaces, attendance is high and attrition is low –32. A nop < 0.001) and use of effective parenting practices , as well as significant decreases in child problem behaviours , suggesting that an increased dose of general parenting content may lead to improved outcomes in this area.Results from the impact evaluation of our feasibility trial suggest that PWT may be effective in changing weight-related behaviours for both parents and children in the desired direction as well as improving parenting self-efficacy, decreasing parent-reported general stress, and improving measures of work-life balance. Although we saw non-significant changes in the desired direction for both the weight-related behaviours and parenting outcomes, the magnitude of change in the parenting outcomes was quite small. To shorten the program, we decided to minimize the parenting content and focus on the weight-related content. It may be that the parenting-related messaging was cut back too much and the dose was insufficient to see substantial change in the desired direction. In their 14-session parenting intervention, ParentCorps,  demonstrContrary to expectations, parents also reported a significant increase in restrictive feeding practices . Although PWT does not promote restriction, it is possible that once made aware of the importance of healthful eating and reducing the intake of sugar sweetened beverages, parents may feel that restriction is needed; in particular in an obesogenic environment that promotes unhealthful dietary intake. The research to date on restriction has been mixed, with some studies showing that the use of restrictive feeding practices is harmful and increases a child’s obesity risk , 53, 54 Future trials of PWT should focus on ways to include more time for discussion since we heard from our participants that this was missing from program sessions. One option may be to include an online component – either an online discussion board or a reverse classroom scenario where participants review the content and watch the video vignettes at home online and then program sessions could focus on discussion. The current study only included parents with children aged 2–7 years; future trials should explore whether PWT can be adapted to include content that is relevant to parents with children of a wider age range, which would allow more employees to participate.A primary strength of this study is that it utilized a mixed methods sequential design whereby a thorough formative assessment was used to inform the quantitative piece. Not only do formative assessments increase the likelihood for success of an intervention , they caThis study had several limitations. First, the sample for our feasibility trial was small, which limits our power to detect statistical significant changes in our secondary outcomes . However, the effect sizes that we did find for most measures were quite small indicating that more intensive intervention is needed for meaningful behaviour change. Second, our samples for both the formative assessment and pilot study came from one geographical area , which may limit the generalizability of our findings. Third, we did not have a control group for our feasibility trial; therefore, it is unknown whether our results are due to participation in our program or something external to the program. Fourth, our measures were all self-reported by the parents for both themselves and for their children. This increases the likelihood of self-report bias and errors due to poor recall. Additionally, not all measures used have been validated for use in our specific population. A future randomized control trial should include tools validated for use with parents of children ages 2–7 and objective measures of activity and sleep behaviours. Finally, we did not include any long-term follow up with participants, therefore we are unsure whether the results we saw immediately post-intervention were sustained. Such information could be useful for determining whether we need to add any maintenance elements to our program.Results from the current study showed that a workplace program that addresses general parenting and health behaviour messaging resonates with employers and resulted in a number of suggestions from employer representatives on ways to structure the program to fit into the logistical constraints of a workplace setting. The main finding from the feasibility trial was that PWT is feasible and acceptable to employees. Our results suggest that workplaces should be considered as potential settings to hold interventions as they are convenient to parents and there is the potential to maximize attendance and minimize the rate of attrition, which are common problems with community-based parenting programs , 57. A s