Nepal has a high prevalence of congenital anomaly contributing to high infant mortality. Ultrasound, an important tool to detect congenital anomalies and manage maternity-related risk factors, is not properly used in Nepal because Nepali doctors have limited opportunities for learning ultrasound techniques. Hence, we developed and implemented an ultrasound education program from 2016 to 2018. The objective of this study is to evaluate the education program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.We conducted a mixed-method study to evaluate each component of RE-AIM. The team collected quantitative data from administrative records, tests, surveys, and an online follow-up survey. Qualitative data were collected from individual in-depth interviews at least a year after the program. The proportions, means, and t-tests were used for quantitative data, and thematic coding for qualitative data.p< 0.001, n=85) and self-confidence . The participants were highly satisfied with the program . Among the respondents of the online follow-up survey (n=28), 60.7% had used ultrasound in their daily practice after the education program, and a medical institution established an ultrasound training center. The absence of clear accreditation and practical guidelines in ultrasound use were presented as barriers for adoption and maintenance.A total of 228 healthcare workers representing 27.3% of the districts of Nepal were reached from 2016 to 2018. The program improved participants’ knowledge (29.3, 8.7, and 23.8 increases out of 100, each year, The program was successful in improving participant’s knowledge and self-confidence in ultrasound techniques and showed great potential for the adoption and maintenance of the techniques in their practice. Continuous implementation of the program and institutional policy changes to facilitate ultrasound use may increase the ultrasound use and improve ultrasound service quality in Nepal. Congenital anomaly contributes to 5–7% of perinatal and neonatal mortality in low- and middle-income countries (LMICs) . The preUltrasound has become more widely available for medical professionals in LMICs  with decThese challenges are also evident in Nepal. In Nepal, radiologists generally perform ultrasound scans, but Nepal has only 150 radiologists , who are largely concentrated around the capital city . This unPrevious studies show that intensive ultrasound training courses in LMICs significantly increase knowledge and self-confidence among the radiologists , 14. HenJW LEE CGM held multiple rounds of needs assessments with key experts from Nepal. Respondents expressed multiple topics of interest such as cutting edge technology in medicine, such as Computed Tomography (CT) and Magnetic Resonance Imaging (MRI); fetal health screening for different systems using ultrasound, CT, and MRI; CT and MRI image and report interpretation; recent developments and issues in ultrasound techniques; detailed demonstration on biometry and other important indicator calculations using different imaging techniques. After exploring the perceived needs, JW LEE CGM invited lecturers/experts, Dhulikhel Hospital-Kathmandu University Hospital (DHKUH), and Nepali partners for educational purposes and created the curriculum based on the needs and availability of lecturers. The course was for two days and titled “The Ultrasound, CT and MRI Education Program for Obstetric, Fetal, Neonatal, and Congenital Anomaly” The course was conducted in collaboration with the Nepali Professional Societies. Table A national open call for recruitment in the education program was made through various media and professional societies. The main target group of the program was OB-GYNs, pediatricians, and radiologists, but medical doctors from different specialties and non-physician healthcare providers  were also recruited. A total of 228 healthcare workers participated in the education program from 2016 to 2018.This study utilized the RE-AIM framework, which is a frequently used tool that evaluates multi-organizational and country projects . The RE-n=11). The interviewees were recruited using convenience sampling.This study used both quantitative and qualitative methods for evaluation. Administrative data, test data and survey data among participants were collected during the education program (2016–2018), and an online follow-up survey was conducted in 2019. Two members of the research team conducted face-to-face, in-depth interviews in English with the participants and leaders of participating institutions  package for analysis . PRS codRegarding the tests and surveys, participants verbally consented and voluntarily participated. Written consent was obtained for the online survey and in-depth interviews. Ethical approval was obtained from Institutional Review Boards at the Seoul National University Hospital in the Republic of Korea (SNUH IRB No. 1906–036-1038).Table p< 0.001) compared to pre-test scores. Similarly, the mean post-self-confidence scores were 3.0 in all three years which were increased significantly by 0.6, 0.3, and 1.3 out of 4 points (p< 0.01) compared to pre-self-confidence scores. The participant’s overall satisfaction score of the education program was high  across all 3 years.Table n=28) of the program participants responded to the online follow-up survey. Approximately 50% (n=14) of the online follow-up survey respondents participated for the first time in 2016, 36% (n=10) in 2017, and the remaining 14% (n=4) in 2018. Among the online follow-up survey respondents, 60.7% (n=17) indicated that they were currently using ultrasound in their daily practice (Table n=3) and other specialties  and half of OB-GYNs  began to use ultrasound in their daily practice after participating in the education program. None of the pediatricians who participated in the survey have reported the use of ultrasound.Approximately 12%  and 29 large hospitals, reported that ultrasound was not available in any of accessed small hospitals . The heaThis study shows that the program was effective in increasing the healthcare workers’ knowledge and self-confidence in using ultrasound. The participants were also satisfied with this program. We observed a slight decrease in the satisfaction score from 2016 to 2018, but the mean scores were above 4 out of 5. The education program on ultrasound with several implementation modalities and durations with the use of pre- and post-test to assess knowledge also resulted in significant improvement in knowledge immediately after the programs , 22, 23.This study found a mid-level (60%) of adoption at the individual level via online follow-up survey. The non-adoptees emphasized that further policy changes to encourage the use of ultrasound by non-radiologists along with infrastructure development are considered the major limitations in the use of ultrasound. Setting up and maintenance of the machines can also be significantly challenging in rural areas of Nepal . AnotherThe institutional-level ‘Maintenance’ dimension of the RE-AIM framework had mixed results. Despite the challenges and limitations regarding the changes in policy and infrastructure development, one of the participating institutions in Nepal had established an ultrasound training school, and they collaborated with different specialties to develop courses for training physician and non-physician healthcare providers. However, some organizations are still having trouble in formulating clear institutional policies on ultrasound use by non-radiology doctors. The establishment of the ultrasound training center can be considered a crucial step in the sustainability of interdisciplinary educational programs.This study has several limitations. First, we used convenience sampling methods for in-depth interviews because of time constraints and insufficient resources to travel beyond Kathmandu and its vicinity. The second limitation was low participation rates in evaluations. Participation in the evaluation was voluntary, and many of the registered participants were allowed to select sessions and skip tests and surveys. We offered flexibility since the second day of the training took place during the workday. Many participants were not able to arrange a leave for the day. In the case of the online survey, a low response rate was expected, thus we tried to mitigate this by sending three reminder emails. Due to low participation rates, the findings may have induced selection bias. Finally, the evaluation of self-confidence and use of ultrasound was based on self-reporting, which may cause social desirability bias. Despite these limitations, this study provides evidence that the education program can be used as a platform for sharing knowledge and experiences across healthcare providers with diverse backgrounds.Our study found that the ultrasound education program effectively improved the knowledge and self-confidence of participants in practicing ultrasound. The program also had a positive impact on ultrasound utilization by encouraging participants to use ultrasound; however, determining the influencing institutional environment that facilitates ultrasound utilization and improves service quality was still considered challenging due to the current regulations. Future studies are required to comprehensively understand the various elements influencing the use of learned knowledge and acquired skills that translates into actual practice that significantly affects the health at the population level.


ARID1A-mutated cancers are currently under development, including EZH2. A synthetic lethal relationship between ARID1A and EZH2 has been revealed in several tumor entities. Although genomic alterations of ARID1A have been described in various cancers, no study has examined correlations between ARID1A gene mutation and protein expression with clinicopathologic parameters and prognosis, particularly in liver fluke-related cholangiocarcinoma (Ov-CCA). Here, we investigated the clinical significance of ARID1A mutations and protein expression in CCA tissues and determined whether there is a correlation with EZH2 protein expression.ARID1A is a member of the SWI/SNF chromatin remodeling complex. It functions as a tumor suppressor and several therapeutic targets in ARID1A were analyzed using the ICGC sequencing data in 489 of Ov and non Ov-CCA and assessed prognostic values.We evaluated ARID1A and EZH2 immunoreactivity using immunohistochemistry in 98 Ov-CCA with a wide range of clinicopathological features. Somatic mutations of ARID1A mutations . We observed that 12 of 13 tumors (92%) with loss of ARID1A expression had truncating mutations. There were nine of 13 tumors (69%) with loss of ARID1A expression and 25 of 41 tumors (61%) with low ARID1A expression exhibited distant metastasis . ARID1A was predominantly mutated in Ov-CCA compared to non Ov-CCA . There were 36 of 72 (50%) and 52 of 79 (66%) tumors with ARID1A mutation showed tumor stage IV and T3/T4, respectively. The significant mutual exclusivity and co-occurrence between ARID1A and TP53/KRAS mutations were not found in ICGC cohort. In addition, high EZH2 expression, a potential synthetic lethal target in ARID1A-mutated tumors, was detected in 49 of 98 Ov-CCA (50%). Importantly, neither ARID1A expression nor ARID1A mutations correlated with EZH2 expression in this cohort.While detecting a loss or reduction of ARID1A expression in 54 cases (55%) in Ov-CCA, ARID1A expression was associated with ARID1A inactivation, by somatic mutation or by loss of expression, frequently occurs in Ov-CCA. Reduction of ARID1A expression and/or somatic mutation was shown to be associated with CCA progression. These findings suggest that ARID1A may serve as a prognostic biomarker, and thus may be a promising therapeutic target for CCA.We found that  Opisthorchis viverri-associated CCA (Ov-CCA) has been associated with infestation of Ov. The highest incidence rates of Ov-CCA are in South-East Asia, where endemic areas of liver flukes occur (Cholangiocarcinoma (CCA) is the second most common liver cancer that develops along the epithelial bile duct, accounting for 10% to 20% of primary liver cancer . The inces occur , especiaes occur . In contes occur .Clinical trials evaluating targeted therapies in unselected CCA populations have shown minimal benefits . The ASCARID1A were detected in 7% to 36% of ICC  encodes a nuclear protein involved in chromatin remodeling. Inactivating mutations in ARID1A have been identified in a wide variety of malignancies   . EZH2 isortunity . Clinicac cancer . Thus, AARID1A have been described in CCA, no study has determined whether there are correlations between ARID1A gene mutation and protein expression with clinicopathologic parameters and prognosis, particularly in Ov-CCA. In the present study, we analyzed sequencing data from the International Cancer Genome Consortium (ICGC) of 489 tumors and performed immunohistochemical staining for ARID1A in 98 Ov-CCA which were sequenced in ICGC cohort. We evaluated whether ARID1A expression and mutational status could be a prognostic biomarker for Ov-CCA. To study if ARID1A could be a surrogate biomarker for EZH2 inhibitors in CCA, we evaluated EZH2 protein expression in Ov-CCA. The correlation between alterations of ARID1A and EZH2 expression in matched CCA tissues was evaluated for the first time in this study.Although genomic alterations of Ninety-eight paraffin embedded human CCA tissues and clinical data were obtained from Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, Thailand. All patients signed consent forms. The study was approved by the Ethic Committee for Human Research, Khon Kaen University (HE611195). The primary tumor at the time of resection was staged according to the 7th AJCC.For mutational analysis, a total of 489 mutational data of bile duct tumors were obtained from the ICGC data portal .36-6300, Invitrogen, CA, USA). IHC was performed as previously described . The primary antibodies include rabbit polyclonal anti-ARID1A  and rabbit anti-EZH2 antibody  and was scored by multiplying of the intensity and frequency of DAB-staining results . The intp-values were calculated using Benjamini–Hochberg correction. The survival analysis was determined using Kaplan–Meier estimate with log-rank test. Statistical significance was considered at p <  0.05.The statistical analysis was carried out using SPSS software (version 19.0). The association between mutational data, protein expression profile and the clinicopathological features of CCA patients were performed using Chi-squared or Fisher’s exact test. Adjusted p = 0.028, adjusted p-value = 0.168), suggesting that ARID1A may play a role in CCA progression. Of note, ARID1A expression was associated with ARID1A mutations . Most of ARID1A mutations were truncating , including nonsense , frameshift insertion/deletions . Interestingly, ARID1A was predominantly  mutated in Ov-CCA compared to non Ov-CCA . As shown in ARID1A mutations tended to associate with CCA staging , liver fluke related-CCA , and T factor . Of note, there were 36 of 72 (50%) tumors with ARID1A gene mutation showed tumor stage IV  of ARID1A wildtype tumors were non Ov-CCA .Even though the landscape of  489 CCA  and eval 489 CCA , ARID1A stage IV  and 52 oTP53 and KRAS mutations in CCA, we performed mutual exclusivity and co-occurrence analysis of ARID1A and TP53/KRAS mutations. The significant mutual exclusivity and co-occurrence between ARID1A and TP53/KRAS mutations were not found in the ICGC cohort , Ov-CCA  and non Ov-CCA  (Given the high frequency of C cohort . There w–1.727]) –2F.ARID1A mutant tumors were T3 or T4 and predominantly ICC  , but it was not statistically significant (p = 0.843).In non Ov-CCA, we found that 63% (30/48) of 49, 82%) . The assn Ov-CCA . There wARID1A mutated cancers are in development, including EZH2 inhibitors. EZH2 inhibition in ARID1A mutated tumors acts in a synthetically lethal manner to inhibit cancer progression, revealing a therapeutic opportunity. Since the response to EZH2 inhibitors correlates with EZH2 overexpression, we then investigated protein expression of EZH2 by IHC staining in tumor cells of Ov-CCA  with loss of ARID1A expression and 25 of 41 CCA (61%) with low ARID1A expression exhibited distant metastasis. Similar correlation between ARID1A expression with invasion was reported in ICC (Regarding the high frequency of d in ICC , suggestd in ICC . Reducedd in ICC . Similard in ICC .ARID1A mutation or protein loss to survival in several carcinomas (ARID1A mutation and protein expression were not significantly associated with overall survival of both Ov-CCA and non Ov-CCA. To date, overall survival affected by mutation in ARID1A has been shown in ICC (ARID1A mutation and protein expression was not determined in that studies. In contrast to ICC, there was no correlation between loss of ARID1A expression and overall survival in ECC (Previous studies have revealed the relevance of rcinomas , althougn in ICC . Low expn in ICC . These fl in ECC . We specl in ECC . In contl in ECC  and may ARID1A mutations was previously reported in ovarian and uterine endometrioid carcinoma (ARID1A mutation showed a loss of ARID1A expression (ARID1A gene. Of note, we observed half of CCA with ARID1A truncating mutations showed positive protein staining. Our findings are similar to those reported in ovarian clear-cell and endometrioid carcinomas (ARID1A mutation occurred in clones of cells within the tumor, resulting in a heterogeneous staining pattern of ARID1A expression. Moreover, the presence of ARID1A immunoreactivity in tumors positive for ARID1A mutation may indicate that haploinsufficiency is pathogenic, as has been reported in mice (Loss of ARID1A protein correlated with the presence of arcinoma . All mutpression . In thisrcinomas . It is l in mice .ARID1A mutation showed tumor stage IV and T3/T4, respectively. Moreover, ARID1A was predominantly mutated in Ov-CCA. These data suggest that ARID1A mutation may involve in CCA progression and the different etiology may be one of the underlying factors that drives CCA heterogeneity. ARID1A and KRAS mutations. However, mutually exclusivity between mutations of ARID1A, TP53 and KRAS was not found in this study.Interestingly, we found that there was 50% and 66% of CCA with ARID1A mutations have focused largely on using synthetic-lethal approaches. ARID1A-mutated cells. EZH2 was overexpressed in many solid cancers, suggesting the promise of therapeutic potential of EZH2 inhibitors for cancers (in vitro study showed that ARID1A-depletion did neither increase EZH2 protein or trimethylated H3K27 levels (ARID1A-mutated and wildtype CCA cells.Novel ways of treating patients with  cancers . The res cancers . Neither7 levels . These fARID1A mutation may involve in CCA progression and predominantly in CCA tumors with high tumor stage. Importantly, ARID1A protein expression was also correlated with ARID1A mutation, suggesting that loss of ARID1A immunoreactivity might be used as a surrogate marker to detect ARID1A mutations in tissues. To expand the therapeutic portfolio for CCA patients, EZH2 expression was investigated in Ov-CCA. Neither ARID1A mutation nor protein expression correlated with EZH2 expression. Further studies are necessary to determine the role of ARID1A-deficiency in response to EZH2 inhibitor in CCA.In conclusion, this is the first investigation that showed the correlation between mutations and expressions of ARID1A within the same Ov-CCA cohort. Based on ARID1A protein expression and mutational analysis, we found that ARID1A inactivation, by somatic mutation or by loss of expression, frequently occurs in Ov-CCA. CCA with distant metastasis had lower ARID1A expression than those without distant metastasis. 10.7717/peerj.10464/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.10464/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.10464/supp-3Supplemental Information 3Click here for additional data file.10.7717/peerj.10464/supp-4Supplemental Information 4Click here for additional data file.10.7717/peerj.10464/supp-5Supplemental Information 5Wildtype denotes tumors with ARID1A wildtype, Missense denotes tumors with ARID1A missense mutation, Truncation denotes tumors with truncating ARID1A mutation.Click here for additional data file.10.7717/peerj.10464/supp-6Supplemental Information 6ARID1A mutations and protein expression level of ARID1A and EAH2.Raw data of clinicopathological information, Click here for additional data file.


The calibration approach basically uses the difference in the instrumental isotope fractionation of two different types of mass spectrometers, leading to two different fractionation lines in a three-isotope diagram. When measuring the same sample with both mass spectrometers, the different fractionation lines have one point in common: this is the ‘true’ logarithmized isotope ratio pair of the sample. Thus, the intersection of both fractionation lines provides us with the absolute isotope ratios of the sample. This theory has been tested in practice by measuring Cd and of Pb isotope ratios in the certified reference materials BAM-I012 and NIST SRM 981 by thermal ionization mass spectrometry and by inductively coupled plasma mass spectrometry while varying the ionization conditions for both mass spectrometers. With this experiment, the theory could be verified, and absolute isotope ratios were obtained, which were metrologically compatible with the certified isotope ratios. The so-obtained absolute isotope ratios are biased by − 0.5 % in average, which should be improved with further developments of the method. This calibration approach is universal, as it can be applied to all elements with three or more isotopes and it is not limited to the type of mass spectrometers applied; it can be applied as well to secondary ion mass spectrometry or others. Additionally, this approach provides information on the fractionation process itself via the triple-isotope fractionation exponent The online version contains supplementary material available at 10.1007/s00216-020-03050-4. Nearly immediately after the invention of the first mass spectrograph, the isotopic composition of neon was investigated . It tookα (Eq. n(iE) being the amount of substance of isotope i and n(jE)/n(iE) representing the isotope ratio Rj/i.When elements undergo a chemical or a physical process leading from a starting material (A) to a product (B), most likely their isotopes are being treated disproportionally, which results in the so-called isotope fractionation. For any of these processes, the extent of this fractionation can be described by the isotope fractionation factor α Eq. , with n isotopes x, y, z sorted in ascending mass, the mass dependence of the isotope fractionation yields correlated isotope ratios. The isotope fractionation factors of the isotope ratios t’ θ Eq.  8].2\do.2\doRy/xθ describes the nature of the isotope fractionation, i.e. whether it is an equilibrium or a non-equilibrium process. It can be described as the slope in the three-isotope diagram  is not accessible. Then, samples which underwent the same fractionation process, but to a varying extent, can be plotted in the three-isotope diagram Fig. . The staFor all sample solution preparations and subsequent dilutions, only precleaned labware and high-purity water and acids were used. Further details can be obtained from the literature . For allw = 20 g/kg).The MC-ICP-MS measurements were carried out in standard configuration using a Neptune Plus type  instrument. Different degrees of the instrumental isotope fractionation were obtained by changing the plasma power from 1100 to 1300 W in steps of 20 W each and by changing the nebulizer gas flow from 0.01 mL/min below to 0.01 mL/min above the optimum set value by steps of 0.005 mL/min. For each of the steps, one blank measurement and five isotope ratio measurements of the iCRMs were carried out. Amplifier gain and background calibration was carried before each daily sequence. Each measurement was corrected for the blank measured in dilute nitric acid  per block. Background corrections were carried out for each block and gain factors, which were obtained by daily amplifier gain calibration, were applied. Block data, i.e. averages of 25 cycles, were used as individual measurement. The instrument parameters and the measured isotope ratios were provided as MC-TIMS measurements were carried out using a Sector 54  instrument. Cd and Pb solutions were diluted such that 1 μL of each solution could be loaded directly on Re single filaments using the silica gel technique. Different degrees of the instrumental isotope fractionation were achieved by variations in the loaded analyte mass—5 ng, 15 ng, 50 ng, 250 ng and 1000 ng for Cd and 5 ng, 10 ng, 50 ng, 250 ng and 1000 ng for Pb—and in the target intensity, which was varied from 220 mV to 1020 mV for 112Cd/110Cd) vs. ln(114Cd/110Cd)—short notation 112-114-110.The above outlined model assumption was tested by applying MC-TIMS and MC-ICP-MS. The completely different ion sources ensure different fractionation processes. Variations in the analyte mass loaded onto the filaments and the target intensity in MC-TIMS should provide a distinct IIF line in a three-isotope plot. Variations in the plasma power and the nebulizer gas flow in MC-ICP-MS should provide another distinct IIF line in the same three-isotope plot with the intersection of both IIF lines giving the absolute isotope ratio of the sample. This experiment was carried out for Cd and Pb isotope ratio measurements using the iCRMs BAM-I012 (Cd) and NIST SRM 981 (Pb), because they provide certified absolute isotope ratios, which can be used as reference. The raw isotope ratios (only background/blank and gain corrected) were plotted in a three-isotope diagram as described above and visualized in Fig. Both IIF lines show very similar slopes and it is visible that the intersect is close to, but not exactly at, the corresponding ln values of the certified BAM-I012 ratios. The correlation coefficient of the MC-ICP-MS line is closer to 1 than that of the MC-TIMS line, demonstrating a higher precision in the isotope ratio measurement for MC-ICP-MS and the fact that with the chosen parameters the IIF is more under control than for TIMS.uc; the reference values; the bias to the reference values and the En value. The latter is the difference between the measured value and the reference value divided by the expanded uncertainty of this difference (see k = 2) [En values of less than or equal to 1, both values are metrological compatible with each other; in older terms, they agree within their uncertainties.Similar diagrams have been obtained for cadmium 111-113-110 and 112-114-111 and for Pb 207-208-206. It has to be noted that the MC-TIMS data in the cadmium 111-113-110 diagram are distributed in elliptic form with some outliers. For the other three-isotope diagrams, i.e. cadmium 112-114-110, cadmium 112-114-111 and lead 207-208-206, linear distributions were obtained. Each diagram provides an intersect of the two fractionation lines. The isotope ratios of Cd and Pb obtained from the delogarithmized intersects are displayed in Table n(113Cd)/n(110Cd) isotope ratio. This agreement demonstrates the validity of the postulated calibration approach within the stated measurement uncertainties. An investigation of the remaining systematic negative bias’s origin or even an accurate determination of its nature is hardly possible, because the bias is fully covered by the measurement uncertainty. However, two possible scenarios can be assumed: (a) As the intersection of the TIMS and the ICP-MS regression lines is always at or close to the measured TIMS bulk data (at least closer than to the ICPMS bulk data) and as, due to the specific instrumental isotope fractionation, TIMS raw data are always lower than the certified ratios while ICP-MS raw data are always higher (for isotope ratios heavy over light isotope), the less precise TIMS data  may lead to negatively biased results, and (b) Mass-independent fractionation effects (or other artefacts) may be responsible for the bias, although they are rather unlikely to occur at this level and have not yet been observed to this extent. A proof for either of the two assumptions is not possible at this stage and will require further investigations and a further improvement of this method.The bias between the obtained absolute isotope ratios and the certified ones is in the range of − 0.2 % to − 1 %. Although not completely satisfying, concerning todays requirements, the bias is covered by the measurement uncertainty and thus all obtained absolute isotope ratios are metrologically compatible with the certified values of the iCRMs, except for the Certainly, at this stage, the obtained measurement uncertainties and the residual bias do not fulfil todays requirements for absolute isotope ratios, and at the current state, this approach is not comparable to the ‘isotope mixture approach’  and the n(112Cd)/n(110Cd) and the n(114Cd)/n(110Cd) isotope ratios is being reduced to 0.3 % and 0.05 % respectively. This points to a non-linear artefact and requires consideration in the further development. In the other diagrams, there are subtle differences in the bias when swapping the axis, but not at this level.When changing the axis in the cadmium 112-114-110 diagram to obtain the 114-112-110 diagram, the bias in the θ, which describes the isotope fractionation within the mass spectrometer. Considering that fractionation in magnetic sector fields and Faraday cup detectors is comparatively low, it describes in fact the fractionation in the ion source and the interface. When looking at the θ values of these measurements  with the theoretical range of equilibrium and non-equilibrium isotope fractionation, while θ values obtained by MC-TIMS in most cases do not. For TIMS, this might be an indication for mass-independent effects, whereby it is more likely that two or more mass-dependent fractionation effects are coupled, which can lead to θ values outside the theoretical range [Additional information is obtained for both mass spectrometers in the form of the triple-isotope fractionation exponent ts Table , it is oal range . In the θ values, it might be even applicable to two different instruments of the same type of mass spectrometer, e.g. two MC-ICP-MS instruments.The here presented standard-free triple-isotope calibration approach is valid. Admittedly, the obtained measurement uncertainties do not meet the requirements for many isotope ratio applications. Therefore, the procedure needs to be improved, mainly on the TIMS side. Here, the range within which the parameters were varied can be tightened to produce less outlier values, especially the very low analyte masses of 5 ng loaded onto the filaments should be avoided, because in these cases, the analyte reservoir is quickly exhausted leading to extreme fractionation behaviours. Variations in the target intensity, which affect the filament temperature via the filament current, might be reduced as well to keep the experiments under better controlled conditions. In MC-ICP-MS, the range of the tested plasma power might be reduced a bit, as the 1300 W stage produced outliers at least for Pb. The triple-isotope calibration approach is not limited to TIMS and ICP-MS; it might be applied to other mass spectrometers as well such as SIMS together with ICP-MS. As long as different ionization conditions can be realized, i.e. two different θ values in mind, it might be interesting as well to decouple the evaporation and ionization process by applying double-filament techniques. When varying the evaporation and ionization filaments independently, it might be possible to obtain new information on the ionization process in TIMS and to check whether it is a two- or more-stage process.With the obtained TIMS ESM 1(PDF 284 kb)ESM 2(XLSX 251 kb)


Variability characterization of tsunami generation is quintessential for proper hazard estimation. For this purpose we isolate the variability which stems solely from earthquake spatial source complexity, by simulating tsunami inundation in the near-field with a simplified digital elevation model, using nonlinear shallow water equations. For earthquake rupture, we prescribe slip to have a log-normal probability distribution function and von Kármán correlation between each subfault pair, which we assume decreases with increasing euclidean distance between them. From the generated near-field inundation time-series, emanating from several thousand synthetic slip realizations across a magnitude 9 earthquake, we extract several tsunami intensity measures at the coast. Results show that all considered tsunami intensity measures and potential energy variability increase with increasing spatial slip correlations. Finally, we show that larger spatial slip correlations produce higher tsunami intensity measure exceedance probabilities within the near-field, which highlights the need to quantify the uncertainty of earthquake spatial slip correlation. Hence, in order to better understand tsunami potential impacts, it is necessary to simulate many scenarios, with physics-based methods, to quantify the inherent TIM aleatory uncertainty, that is, uncertainty attributed only to the earthquake source variability, characterized by the different earthquake rupture processes which take place on faults4.There are few well instrument recordings of destructive tsunami intensities produced by large subduction zone earthquakes, which makes the task to characterize tsunami hazard a very difficult one. With the developments of tsunami numerical modeling, there have been great advances in determining the actual hazard through the quantification of tsunami intensity measures (TIMs) using numerical modeling. Even with all the data available after an event, due to the epistemic uncertainty of the seismic source rupture parameters, there is a great variability of tsunami initial conditions (TIC), as well as tsunami inundation forecasting, as shown by many authorsw9, which are very likely to produce large tsunami waves.Two of the most important questions related to near-field tsunami intensity, for hazard assessments, are: How do TIM average and variability change with the variation of key earthquake source parameter statistics? How do the TIM variability control the annual rate of exceedance of TIMs, given a seismicity rate? To answer these questions, it is crucial to identify some of the key earthquake source parameters that can affect both the average and variability of the TIMs. The most important source parameter that can control TIMs is magnitude, since large earthquakes usually produce large tsunami waves and inundations. Therefore, in this study we simulate subduction earthquakes with a target moment magnitude M7, wave focusing on bays and submarine canyons10, resonance on the continental shelf13, among other effects. Other parameters such as geometry and size relative to the earthquake magnitude of the faulting area are of great importance14, which show an increase of peak near shore tsunami amplitude, which is primarily due to the peak slip areas within the fault. Increased ratios of seismic moment to area are shown to yield higher TIM amplitudes results with respect to homogeneous slip fault models as shown by An et al.15, provided the total rupture area is small. It is for this reason that the determination of earthquake scaling relationships between area and seismic moment are related to the TIM values.Another factor that largely controls TIMs is the coastal topo-bathymetry. However, in this study, we focus solely on the source contribution. Then, to isolate the impact of the spatial rupture process, we have designed a simplified topo-bathymetric digital elevation model (DEM), which includes only the first order features. In this way, we avoid unwanted coastal wave processes (which cannot be attributed to the earthquake source process) such as edge wavesw 4.7 and 8.216. More recent scaling relationships have been derived for crustal and subduction zone earthquakes22.To carry out the tsunami simulations, the fault extensions  need to be prescribed with proper earthquake scaling relationships. For these parameters, many relationships have been constrained from finite fault slip inversions of seismic data, which relate the earthquake size, width and length with respect to magnitude. The earliest work of this nature was accomplished for earthquakes with magnitudes ranging between M23, it has been found that slip distribution on faults can be characterized as a truncated exponential distribution24, which has a heavy-tail, allowing many more incursions into great slip extreme’s. Much earlier, other works have shown26 that for several crustal earthquakes, the slip distribution resembles more a truncated Cauchy distribution, which without any truncation is a self-similar distribution. Several authors use log-normal probability distributions to characterize slip on faults30. They simulate an underlying Gaussian random field by expanding a finite amount of Karhunen Loève (KL) terms31, which later, they take into the logarithmic domain with a resulting log-normal random field for slip. Log-normal slip distribution has also recently been employed as a prior probability distribution for seismic waveform slip inversion, within a Bayesian framework32. The log-normal distribution naturally accounts for slip positivity, not requiring truncation. In this study, we assume slip to be a log-normal distribution.Knowledge of the statistics of fault slip is vital for producing stochastic slip realizations that mimic expected behaviour of earthquakes. Using the SRCMOD database33, who initially measured slip correlation by fitting several analytical solutions of power spectrum density (PSD) models to the power spectra of finite fault inversions. Most of the events in this catalog correspond to crustal earthquakes. For the case of subduction zone earthquakes, there are several studies which indicate that the slip PSD have a flat portion up to a corner wavenumber, after which the amplitude decays. Skarlatoudis et al.20 fit a PSD to a two dimensional Butterworth filter, Goda et al. and Raghukanth and Sangeetha35 fit a von Kármán (VK) PSD to large subduction zone earthquakes. All three studies show that the slip correlation lengths of these earthquakes scale with magnitude. In particular, the latter used the SRCMOD finite fault source database23 to constrain the correlation length parameter for each earthquake. These results show a radial correlation length of Lc ≈ 70 km for a magnitude Mw9 earthquake. Melgar and Hayes36 have computed directly spatial correlations by fitting a VK auto-correlation in the spatial domain, estimating correlations between magnitude, along strike and down dip correlation lengths, effective lengths, etc. Results show a mean Hurst exponent of 0.36 and correlation lengths along strike and down dip of approximately Lx ≈ 150 and Lz ≈ 80 km for a magnitude Mw9 earthquake.Owing to the vast amounts of evidence which shows that the earthquake rupture process is spatially complex, it is important to probe the effects fault spatial slip distribution have on tsunami wave generation. Much work has been done to measure the spatial correlation of slip, that is, the size of the slip asperities of an earthquake, with the available finite fault source inversions of seismic, geodetic and tsunami data. The spatial correlation has been quantified by several authors, including the seminal findings of Mai and Beroza14, who introduced a seminal effort to determine the statistics of TIMs using a k2-model slip correlation consistent model37. He concludes that peak near-shore wave height can vary by a factor of three, with the inclusion of slip heterogeneity. Other studies38 use linear runup models and assumed a plane wave propagation to determine inundation. These assumptions produce large variability of runup intensities along the coast. Using low resolution DEMs, such as GEBCO39, Goda et al.40 have further shown that along shore runup variability increases dramatically with the inclusion of stochastic realizations of slip across faults. Furthermore, it has been shown, for the near field case of the Hikurangi subduction zone42, that peak runup amplitudes are much greater that the runups produced by equivalent magnitude homogeneous slip earthquake model. Fukutani et al.43, use a stochastic model to simulate kinematic earthquake rupture on Mw9 faults on the same place where the 2011 Mw9.1 Tohoku earthquake ruptured. They concentrate greater amount of seismic moment in the shallower portions of the subduction zone, concluding that the inclusion of slip heterogeneity on the fault increases the annual probability of exceedance of tsunami wave height, based on several stochastic realizations.The use of complex earthquake rupture distributions for tsunami simulation have been recently adopted in several studies. Among the first tsunami wave propagation simulations using complex rupture sources, we point out the work of Geist46 type analyses, several studies have concentrated on wave height calculations using heterogeneous earthquake slip models, without any inundation calculations. LeVeque et al.28 incorporate earthquake source complexity in their tsunami wave propagation models, by incorporating several KL expansion terms, based on the assumption of a Gaussian random field. They later impose slip positivity by taking the logarithmic value of slip at each point of the fault domain. Sepúlveda et al.29 simulate the tsunami wave propagation of the 2014 Mw 8.2 Iquique earthquake by utilizing the KL expansion to characterize the earthquake source through stochastic slip simulations. Murphy et al.47 use dynamic rupture simulations to constrain physics-based compliant kinematic rupture of large subduction zone earthquakes. With their results they simulate tsunami wave propagation at near-field distances, for the particular case of the 2011 Tohoku earthquake. Li et al.48 use a k2 source model in the South China Sea, simplifying the tsunami propagation to the linear regime, so that, tsunami waveforms can be efficiently modeled as a superposition of Green’s functions. Sepúlveda et al.30 shows that with the inclusion of correlation length uncertainty, the hazard integral is unmodified, in comparison to the great sensitivity if has to the seismicity-rate quantified through the Gutenberg-Richter law. Their results are for the intermediate to far field shore locations and specifically for the South China Sea. It is worth noting that for far-field tsunamis, magnitude and directivity are critical source parameters50.In the spirit of performing Probabilistic Tsunami Hazard Assessment (PTHA)et al.41, with several stochastic realizations of earthquake slip on the Hikurangi subduction zone interface. They estimated TIMs such as inundation and flow depth. Since then, there have been many other similar contributions52.Tsunami wave generation calculated from heterogeneous earthquake slip models with high resolution DEMs to capture the runup and inundations processes have been performed initially by Mueller 55.In the last years, there have been several contributions regarding the estimation of structural fragility functions for tsunami damage assessment purposes with alternative TIMs, such as momentum flux, flow velocity and other related TIMsw9 earthquake scenario, i.e. we vary the VK radial correlation length of slip, in order to quantify TIM variability. To this end, we have implemented a stochastic earthquake rupture model which allows for changes in the degree of spatial correlations of slip on the fault with ease. With this method, we have computed sixty thousand earthquake rupture scenarios, ten thousand for each radial slip correlation lengths  ranging between 10 and 60 km. We must point out that the radial correlation lengths are lower than the 70 km correlation length proposed by Mai and Beroza33. The reason behind these values correspond to no TIM significant statistical changes beyond 50 km radial correlation length . For each rupture scenario, we model the vertical deformations of the seafloor with an analytic solution56, summing all the contributions of free surface deformations due to each rectangular homogeneous slipping subfault on an elastic homogeneous half space. With the deformation, we have quantified the sea-surface initial conditions of each of the many rupture models, which are then used to simulate the tsunami wave generation process with a finite volume numerical method that solves a nonlinear version of the shallow water waves equations. With these simulations we have calculated, on a very simple bathymetry, TIMs such as runup, wave height, wave momentum, and velocity flows. Details pertaining the model setup and the simulations are explained in the Methods section.In this work, we quantify TIM statistics due to distributions of different slip asperity sizes due to a MEp) transferred by the earthquake rupture to the sea surface, is computed from the initial free surface deformation, ηo57,ρ is the seawater density and g is the gravity constant. The potential energy results obtained for each rupture scenario are shown in Fig. et al.42), which is always outside of the probability density distributions obtained from the stochastic finite fault slips. The average and variability of TIC potential energy increases with correlation length, and tend to saturate at the largest values. Because of the quadratic nature of potential energy shown in Eq.  is the rate of occurrence of earthquakes greater than mmin, rupturing at any portion of the pre-defined seismogenic zone, fM(m) is the probability density function of the magnitude distribution, and P(TIM > χcrit|m) is the conditional probability of TIM exceedance, given a specific magnitude. Since the mean TIM values are constant for any correlation length, the probability exceedance for χcrit values greater than the mean TIM should increase with greater correlation lengths, as shown in 3. Since uniform slip models have no variability, the probability exceedance of this specific model will be smaller for extreme values, therefore the annual rate of TIM exceedance will also increase for extreme values of χcrit, when considering greater VK slip correlation lengths. Although these results have been calculated assuming Mw9 earthquakes, they should hold for other magnitudes based on the assumptions of earthquake source self-similarity we have made59. To illustrate the consequences of slip correlation length has on the tsunami risk of coastal infrastructure, we use the tsunami fragility curve . From the curve, we determine the inundation depths corresponding to 90 and 99% probability of total damage, which are 3.2 and 3.7 m respectively. With these inundation depths, we estimate the probability to exceed these critical values, for each slip correlation length. These results are shown in Fig. 55.We have implemented a slip model, based on observed earthquake characteristics, that preserves the imposed VK spatial correlations of slip on faults. When the VK correlation length increases, we observe an increase of the TIM variability. Uniform slip earthquake scenarios are widely used for PTHA calculations, however they are not able to capture the TIM variability which arise from the complexity of the rupture process. This has great implications on the PTHA integral proposed by Cornellrve Fig.  developeBeyond 50 km of VK slip correlation length, all TIM variability values tend to saturate, due to the finite amount of available TIC potential energy, which are later radiated into tsunami waves. Since correlation length determined the average size of the slip asperities, and therefor of the larger seafloor deformation areas, there is a point at which the fixed dimension of the fault geometry cannot contain larger slip asperities. Another constraint in our model that hinders on the average asperity growth is the potency scaling relation imposed on each slip model. We expect no TIM saturation when the fault geometry increases for different earthquake magnitude scenarios.36 are constrained with global finite fault models from different subduction regions. With the future increase of finite fault models, in the future it may be possible to determine characteristic spatial slip correlations for each subduction region, which will improve TIM variability estimations.Our simulations are meant to explore TIM variability with respect to to correlation length, however there are several key earthquake source parameters which have great uncertainties and will have an impact on TIM variability as well. Among some of these parameters we can mention the Hurst parameter, magnitude scaling relationships for rupture area, length and width, fault geometry, etc. Also, it is important to mention that the current spatial slip correlation models42, but still higher than ruptures with slip concentrated in the deeper portions of the subduction interface. Although the simplified bathymetry that we present is capable to generate complex hydrodynamic processes such as edge waves, in conjunction with spatially complex earthquake rupture patterns6, it obscures other hydrodynamic processes that are known to have important controls on tsunami propagation and inundation (and hence on TIMs). Among them shelf and local resonance, which are important to describe spatial and temporal variations of tsunami hydrodynamics when acting over complex realistic bathymetries61. At this stage, it is not possible to predict the effects of spatial rupture complexities have on TIM variability when considering real bathymetries, due to the non-linearity of these complex hydrodynamic processes and local reflections that may induce wave amplification. To answer this question it is necessary to perform different numerical experiments of non-linear inundations on realistic topo-bathymetries.As a final observation, inundation will depend on the source location, local DEM and near field effects, like subsidence. However, the inundation of a uniform slip scenario will be in average, lower than the heterogeneous distributionsw9 target earthquake, which is later used to propagate tsunami waves on a simplified topo-bathymetry, as shown in Fig. A stochastic slip distribution is generated to obtain finite fault scenarios of slip across a Mw7.5. Given a Moment Magnitude as a target, we use the subduction interface scaling relationship of effective fault area, length L and width W of Allen and Hayes21, which are shown below,The model we have constructed is only valid for subduction mega-earthquakes, for magnitudes greater than MThe uncertainty of these scaling relationships is quite large (with standard deviation between 0.3–0.4), a property that most definitely should increase the variability of TIMs, and can be explored more thoroughly in the future.29, we have assumed log-normal probability distributions for the slip on target faults. For the spatial correlations of slip, we use an autocorrelation function consistent with the VK PSD, used in the work of Mai and Beroza33. The seismic rupture scenarios we generate have correlations lengths of 10 to 60 km. Since we fix the moment magnitude to a target value, we obtain the seismic moment (M0) through the following relation62:Following recent worksN subfaults, we have:Gi, and Ai are the shear modulus, and area of the i th subfault, respectively. The area Ai is equal to 10 × 10 km2. We assume that the logarithm of slip vector x follows a multivariate normal distribution, with mean μ and covariance matrix ∑:Given a target moment magnitude si follow a log-normal distribution. We let the mean of such distribution be C into variances ρ2 and correlations R, such that:Therefore, slip samples i-th subfault. The slip correlation matrix R is constructed so that correlations for each subfault pair decays with distance according to a VK distribution64. VK type spatial correlations, for the slip field, have shown to describe reasonably the statistics of seismic rupture models obtained by finite fault inversions33 and are employed for stochastic slip simulation29. Then, we write the slip correlation matrix as:Lc is the correlation length, rij is the euclidean distance between subfaults i and j, H is the Hurst parameter, KH is the modified Bessel function of the second kind for real order H, and Γ is the Gamma function. Following Žerovnik65, the covariance matrices for slip C and logarithmic slip ∑ are related as follows:Note that We can now relate our target mean slip s, we simply exponentiate samples drawn from μ are computed from Eqs. Thus, to obtain samples of the slip vector 32. This approach allows for a more flexible specification of the covariance matrix, as opposed to the KL expansion method employed in previous works29, which require explicit calculation of the expansion terms for the desired covariance. Also, it is important to mention that this method allows the possibility to change the subfaults marginal variances, by specifying ρ2. This can be useful to resolve non-stationary spatial correlation structures of the rupture process, e.g., variation with depth or segmentation along strike of slip. Additionally, slip distribution samples are selected so that they satisfy the relation between the maximum Pmax and average potency Pavg shown by Hayes59, within a margin of 0.15, which roughly corresponds to 1.5σ of his regression. Thus, we only retain samples that verify:i-th subfault is To sample the correlated normal distribution 66.To perform the tsunami simulations, we use the computational package, GeoClaw, which solves the nonlinear shallow water equations with a shock-capturing finite volume method56 produced by each realization of the earthquake slip model. The free surface field is assumed to be equal to the seabed deformation, and the rupture process to be instantaneous. Then, the tsunami is propagated over a simplified bathymetry with a trench far enough from the coast to avoid unwanted inland coseismic deformation. The inundation is modeled by allowing cells to dynamically change from dry to wet conditions, incorporating a bottom friction term67, therefore, we obtain runup, i.e. elevation above sea level at the point of maximum inundation. Finally, as shown in Fig. 1/3. In Fig. The TIC is obtained by first finding the deformed field of the seabed using the Okada solution33, based on the finite fault database they collected, and a constant marginal slip standard deviation ρi, equal to 5 m, however this value is selected to produce more realizations than the ones we use to simulate tsunami wave propagation, with the intention to select rupture scenarios that do satisfy the scaling relationship between maximum and average potency59. As mentioned before, we have simulated 10000 earthquake rupture scenarios for 6 different correlation lengths ranging between 10 and 60 km. The range we have selected for correlation lengths is in response to several preliminary simulations for correlation lengths of 90 and 120 km, which produce almost identical TIM variability results as the 60 km correlation length. This correlation length range is below the average value of a Mai and Beroza33 Mw9 earthquake radial correlation length, which is ~70 km. As reference, inundations produced by a uniform slip scenario with the same magnitude Mw9 are also considered. As shown in Fig. 51; therefore the earthquake rupture simulations produce the required TIMs from the source area up to the inundated area.For the earthquake source, we use a Hurst parameter value of 0.75 as proposed by Mai and Berozaw9, so we restrict our stochastic sampling to earthquake sources of magnitudes ranging between Mw9 ± 0.01. The subfault spacing is 10 × 10 km2 and the shear modulus is 30 GPa. From the simulations, we obtain the TIMs of wave momentum (Mx) and (Ex) wave energy68. These quantities are computed at the center of the domain, at a location where the still water depth is 1 m. The mathematical expressions read respectively,u and v are the velocity components in two Cartesian directions, h is the total water depth and η is the water level elevation above a datum. The wave amplitudes are measured at the same location. The maximum runup above the still water level is also extracted for each simulation.The tsunami wave propagation and inundation is conducted over a simplified DEM to avoid alongshore effects on the hydrodynamics, with resolutions varying between 1000 to 5 m grid spacing, in 4 consecutive nested grids; the analysis is thus solely focused on the seismic source control. The target magnitude for these simulations is MSupplementary Information.


This paper describes the research and development of the SwapMyMood smartphone application designed to support use of evidence-based executive function strategies by people with traumatic brain injury. Executive dysfunction is a common sequela of traumatic brain injury (TBI) resulting in diminished cognitive-behavioral functioning. Problem-solving and emotion regulation are cognitive-behavioral functions that are often disrupted by changes in the executive control system. SwapMyMood is an electronic version of the Executive Plus/STEP program, a set of clinical techniques taught to people living with brain injury to help them 1) identify and implement solutions to problems encountered in daily life and 2) to utilize the emotion cycle to understand and regulate emotional responses to these problems. The Executive Plus/STEP program has until now relied on paper-based instruction and use. Input from target users – people with brain injury and clinical professionals who teach this program to their patients – has contributed to key refinements of features and functioning of the mobile app. Data gathered from target user participation in the user-centered design process are presented. Future directions for ongoing development of technologies to support executive function strategies are also discussed. The paper describes the research and development of the SwapMyMood smartphone application designed to support use of evidence-based executive function strategies by people with traumatic brain injury (TBI). SwapMyMood is an electronic version of the Executive Plus/STEP program, a set of clinical techniques taught to people living with brain injury to help them 1) identify and implement solutions to problems encountered in daily life and 2) utilize the emotion cycle to understand and regulate their emotional responses to these problems. Data gathered from target users who participated in the design process are presented. Future directions for ongoing development of technologies to support executive function strategies are also discussed.Executive dysfunction is a common sequela of traumatic brain injury (TBI) resulting in diminished cognitive-behavioral functioning. Problem-solving and emotion regulation are cognitive-behavioral functions that are often disrupted by changes in the executive control system. Such changes can impact a person’s independence community integration. Cognitive rehabilitation literature supports systematically training metacognitive strategies—particularly problem-solving strategies—to support executive functioning in people with TBI –4. The lThe Executive Plus/STEP program is an evidence-based model incorporating instruction in metacognitive strategy and training in formal problem-solving to support problem-solving (using SWAPS strategy) and emotion regulation (using Emotion Cycle strategy). An RCT of the Executive Plus/STEP program concluded it is efficacious in improving self-reported post-TBI executive function and problem solving .The Executive Plus/STEP program was adapted for use in Shepherd Center’s SHARE Military Initiative, a comprehensive rehabilitation program focused on assessment and treatment of service members with TBI and Post-Traumatic Stress Disorder (PTSD). Data gathered using the National Outcome Measurement System (NOMS) created by the American Speech-Language-Hearing Association (ASHA) were used to evaluate program outcomes following implementation of this adapted approach within the SHARE program. Program outcomes data were analyzed for 95 clients with chronic symptoms of TBI who received this problem-solving intervention, revealing 86% improved by at least one level on the Adult NOMS Problem Solving Functional Communication Measure and 54% improved by two or more levels.Despite successful adaptation and implementation of the Executive Plus/STEP program, many SHARE clients report difficulty recalling the multiple steps in the interventions, recalling which strategies they have used successfully and initiating strategy use under stress. When learning the strategies, clients routinely refer to a written workbook that describes the Executive Plus/STEP program interventions. But they often do not have the workbook with them for support when problems arise.We developed the SwapMyMood mobile app for iOS to make the Executive Plus/STEP program more accessible and useful wherever the user may be. SwapMyMood is designed to assist people with TBI in using evidence-based methods to maximize problem-solving and emotion regulation. The goal was to make it portable while including functionality enabled by the electronic interface and cloud-based storage/interaction. Development of a smartphone app makes information contained in the workbook more accessible and portable by providing an easily navigable electronic version of these tools which can be carried in the user’s pocket. The electronic version also has the potential to provide users with added support for completing each step in the intervention and recalling previous strategies used, which can be saved and retrieved quickly.Development of SwapMyMood employed user-centered design principles by including target users throughout the design process , 9. The Seven SMEs  and 6 target users with TBI contributed to the development via interviews, sit-by demonstrations and take-home testing. Interviews and sit-by demonstrations lasted approximately 60 min. Take-home testing lasted 2 weeks.Traumatic brain injury – Greater than 2 weeks post-onset.Identified by their speech-language pathologist and behavioral health provider as an appropriate candidate to use the SWAPS and Emotion Cycle interventions.18 years of age, or older.Functional hearing & vision.Ability to follow 2 step directions (English speaking).Functional reading.Participants with TBI were recruited from the SHARE Military Initiative at Shepherd Center. Subject matter experts were recruited from the researchers’ professional networks. The inclusion criteria of participants with TBI are listed below:Inclusion criteria for the Subject Matter Experts (SME) were: 1) licensed clinician in the United States, and 2) experience using the SWAPS and Emotion Cycle interventions with people with TBI.The Executive Plus/STEP program is complex with a numerous actions that require users to input information related to problems they are facing and aspects of the emotion cycle the observe in their current state. Translating the substantial training manual into an app requires considerable effort to ensure intelligibility of the overall flow and perceivability of the information presented.Guidance through the multiple steps of problem-solving and emotion regulation.Inclusion of video tutorials.User selected customization options.Links to strategy banks and useful tips based on the Executive Plus/STEP manual.Functionality to record, edit and save information input for future reference.Functionality to send strategy plans to a caregiver via email.Feedback from interviews and sit-by demonstrations informed solution features, including:“It looks great.”“Really well-designed.”“That’s really cool.”“I like it. It’s not as clunky as I thought it was going to be.”Seven SMEs and 4 target users with TBI participated in sit-by demonstrations. Most gave positive feedback:Design changed to permit optimal viewing when screen is in vertical position.Reduction of dropdown boxes.Ability to edit and email strategy plans.Target users with TBI identified specific features or qualities of SwapMyMood that were strongly appreciated and those that were cause for concern Table . They liAs part of our user-centered design process, we invited two target users with TBI to use the app in their daily lives for two weeks to allow the user to explore the solution more fully and under more varied conditions. Results show greater knowledge and use of the problem solving and emotion regulation techniques in the Executive Plus/STEP program by Target User 1 Table .Table 2.Target User 2 reported no change in the levels of knowledge and use over the testing period: high levels of knowledge of problem solving and emotion regulation techniques and moderate levels of use of these techniques Table .Table 3.User-centered design resulted in several iterations of the SwapMyMood app and continues to inform work on major version updates currently underway. Initial interviews, sit-by testing sessions and take-home testing supported the general concept of developing an app-based version of the Executive Plus/STEP intervention. Notably, the take home testing participant who expressed little confidence in his ability to use the strategies reported a marked increase in confidence after using the app for 2 weeks. He also reported using the app for support more frequently than he used the paper workbook prior to using the app.Informed by a user-centered design approach, the SwapMyMood mobile app extends findings from other research on problem solving and executive functioning by people with brain injury. Rath, Hennessy and Diller (2003) found that social problem solving (SPS) is an important component of community integration following traumatic brain injury (TBI). These researchers stressed the importance of assessing a persons’ confidence in their ability to cope with problems after brain injury; a focus on objective test scores alone may lead to under-detection of disabling problem-solving deficits. SwapMyMood provides a portable set of potentially useful tools and allows the user and clinician to track historical problem-solving performance in daily life.Other researchers have developed and tested of an electronic version of an intervention to support emotion regulation or problem solving, but not both. Ehlhardt, et al. report on development and evaluation of a web-based program to support problem-solving skills after brain injury . Other eAdditional development of the app is currently underway. Version 2.0 will be released on Android and iOS in June 2020. It will include enhanced navigation, including the ability to pause/resume the problem-solving process in order to complete the emotion cycle to regulate emotions which may be interfering with effective problem solving. The new version also will improve display of summaries of each problem-solving instance and retrieval of previous problem-solving instances. The visual design of the interface – logo, colors, general layout of each screen – will be enhanced, as well.Launch of SwapMyMood 2.0 will allow testing for clinical efficacy. The team will conduct a pragmatic clinical trial to compare outcomes in people with TBI who use SwapMyMood versus the paper workbook. Improvement in executive functioning, frequency of app use, types of problems encountered, strategies selected and satisfaction with outcomes of strategy use will be assessed. Study design will be a between-subjects test with random assignment to two groups of clients in Shepherd Center’s SHARE military and veterans rehabilitation: 1) those receiving conventional training in the Executive Plus/STEP program and use of the workbook only; and 2) those receiving conventional training with the workbook and the SwapMyMood mobile app, with subsequent use of the SwapMyMood app only. Participants in both groups will utilize the Executive Plus/STEP program in their respective formats for 1 month. Participant use of each format will be recorded in weekly conversations with their speech therapist during treatment sessions. Additionally, use of the mobile app will be recorded in the app’s Amazon Web Services (AWS) cloud-based reporting system.The R&D team is already planning version 3.0 which will incorporate machine learning (ML) and artificial intelligence (AI) to support context awareness and predictive modeling to anticipate the user’s need to perform either or both problem-solving and the emotion cycle. The team expects that these features and functions will enhance support for the user by delivering timely prompts, reminders and engagement, while minimizing risk of over-communicating with the user.


Myloplus rubripinnis and Metynnis hypsauchen are two compressed-bodied ornamental fishes of Serrasalmidae family. In this study, complete mitochondrial genome sequences of the two species were determined. The mitogenomes were 16662 bp and 16737 bp nucleotides in length, and both contained 13 protein-coding genes (PCGs), 22 transfer RNAs (tRNA), 2 ribosomal RNAs (rRNA) and a control region. The phylogenetic tree revealed that Myloplus rubripinnis was closely related to Myleus sp. and Myleus cf. schomburgkii, while Metynnis hypsauchen was related to Pygocentrus nattereri, and then the two clades clustered into one group. Present mitogenome sequences of M. rubripinnis and M. hypsauchen will provide molecular information to the evolution and ecology studies of the two species. Myloplus rubripinnis, belonging to Serrasalmidae in Characiformes, was native to the Amazon and the Orinoco river basins in South America, While Metynnis hypsauchen originated in Amazon and Paraguay river basins, as well as rivers of the Guiana Shield. They were introduced to China and had been popular aquarium fishes recently due to the silver compressed-body and sharp hook at the abdominal fin. Previous studies mainly focused on the biology  and deposited in Aquaculture Technology Research Laboratory of Tianjin Fisheries Research Institute, China . The mitochondrial DNA was obtained by Sanger sequencing and assembled by software Sequencher5.1.M. rubripinnis and M. hypsauchen were 16662 bp and 16737 bp, with the GenBank accession No. MH358336 and MH358334. They were both consisted of 13 PCGs, 22 tRNAs, 2 rRNAs and a control region. The overall base composition were 29.01% A, 23.70% T, 31.01% C and 16.28% G, with AT content of 52.71% in M. rubripinnis and 29.11% A, 23.83% T, 30.84% C and 16.22% G in M. hypsauchen, being analogous to other fish species  as stop codons, which were completed via post-transcriptional polyadenylation that is common to vertebrate mitochondrial PCGs  was sister to the clade “true piranhas” comprising of Pygocentrus nattereri and M. hypsauchen with strong support.The phylogenetic position of the two species among Serrasalmidae was investigated using 18 mitogenomes by Bayesian and maximum likelihood. In our phylogenetic tree , Myleus


The Carrot Rewards app was developed as part of a public-private partnership to reward Canadians with loyalty points for downloading the app, referring friends, completing educational health quizzes, and health-related behaviors with long-term objectives of increasing health knowledge and encouraging healthy behaviors. During the first 3 months after program rollout in British Columbia, a number of program design elements were adjusted, creating observed differences between groups of users with respect to the potential impact of program features on user engagement levels.This study examines the impact of reducing reward size over time and explored the influence of other program features such as quiz timing, health intervention content, and type of reward program on user engagement with a mobile health  app.Participants in this longitudinal, nonexperimental observational study included British Columbia citizens who downloaded the app between March and July 2016. A regression methodology was used to examine the impact of changes to several program design features on quiz offer acceptance and engagement with this mHealth app.P<.001], air travel , and grocery  relative to gas), (2) time delay between early offers , (3) the content of the health intervention , and (4) changes in the number of points offered. Our results demonstrate that reducing the number of points associated with a particular quiz by 10% only led to a 1% decrease in the likelihood of offer response (P<.001) and that each of the other design features had larger impacts on participant retention than did changes in the number of points.Our results, based on the longitudinal app use of 54,917 users , indicated that the key drivers of the likelihood of continued user engagement, in order of greatest to least impact, were (1) type of rewards earned by users (eg, movies [+355%; The results of this study demonstrate that this program, built around the principles of behavioral economics in the form of the ongoing awarding of a small number of reward points instantly following the completion of health interventions, was able to drive significantly higher engagement levels than those demonstrated in previous literature exploring the intersection of mHealth apps and financial incentives. Previous studies have demonstrated the presence of incentive matters to user engagement; however, our results indicate that the number of points offered for these reward point–based health interventions is less important than other program design features such as the type of reward points being offered, the timing of intervention and reward offers, and the content of the health interventions in driving continued engagement by users. If modifiable chronic disease risk factors  were eliminated, 80% of both ischemic heart disease and type 2 diabetes and 40% of cancers could be prevented ; consequThe smartphone-based mobile health  app market has grown steadily in recent years. In 2017, for example, there were 325,000 mHealth apps available on all major app stores, up by 32% from the previous year ,9) has rrationality by cueing individuals’ financial goals, can have powerful effects on behavioral change at both individual and societal levels [The Carrot Rewards app (Carrot), created by a private company with support from the Public Health Agency of Canada , presentl levels . In exchl levels , only a l levels . Researcl levels  and thatl levels ,22. Thisl levels  and the l levels . In publl levels , opportul levels  are inflIn the first few weeks after its launch in 2016, Carrot underwent several important program changes, resulting in a nonexperimental observational study  that canCarrot Insights Inc was a private company that developed the Carrot Rewards app, in conjunction with a number of federal and provincial government partners  ,31. BritCarrot Rewards was made available on the Apple App Store and Google Play app stores on March 3, 2016, in both English and French . On downloading the app, users entered their age, gender, postal code, and loyalty program card number of 1 of 4 programs of their choice . To successfully register, users had to have entered a valid BC postal code and be aged 13 years or older . British Columbians could download the app in 1 of 3 ways: organically , via an email invitation from a partner, or by using the promotional code friend referral mechanism .StudyDesign section. Quizzes were developed to inform and familiarize users about self-regulatory health skills [Once the app was downloaded and registration was completed, users were offered 1 to 2 educational health quizzes per week over the first 5 weeks after registration, each containing 5 to 7 questions related to public health priorities identified by the BC Ministry of Health—healthy eating and physical activity/sedentary behavior (3 quizzes each)—and 2 separate health risk assessments that included items from national health surveys . The timing, content, and order of quizzes were the same for all individuals, other than the initial quiz timing, which will be discussed in greater detail in the h skills  or stepph skills . After cDuring the roll-out of Carrot in BC, there were 3 notable changes in the program introduced by its administrators, which provided the basis for the program variance that we explored in this study. These changes were driven largely by economic necessity rather than by theory or hypothesis testing but also presented the opportunity for a longitudinal nonexperimental observational study .The first 2 changes were related to the number of points that participants could earn for completing quizzes. Specifically, during the study period following the launch of the app, there were (1) differences in the number of points offered across quizzes to compensate for differing quiz duration and timing  on the day of registration, whereas participants who registered after March 17 were also awarded points for registering but offered only one quiz on the day of registration  under the launch campaign and who registered for the Carrot app between the launch  and July 21, 2016 , with within-subjects repeated measures for each quiz, yielding 383,719 participant-level observations.For the purpose of this research, we explored the extent to which the 2 sources of program-level variance influenced the likelihood that a participant chose to engage with a given quiz. Thus, our outcome measure was a binary measure of whether a participant chose to complete each of the 8 quizzes during the initial 5 weeks postregistration.could have earned to complete a quiz on a given date; and (4) the date of quiz completion for all participants who completed a particular quiz. On the basis of the assumption that participants were choosing to either complete or not complete a particular quiz and to ensure the robustness of our results, we imputed the missing observations for reward points that would have been offered to noncompleting participants in 2 ways, which are detailed in Although we observed the number of points earned for those who completed each quiz offer, including the change in the level of reward points offered (see Reward Points Schedule (first table) in Finally, as discussed previously, another important independent variable of interest was the combination of the differences in the timing of the quizzes and the number of reward points offered. To examine the impact of the timing structure on participants’ probability of quiz acceptance, we created a dummy variable to act as the independent variable that indicates whether or not a participant was facing their first delay between quizzes.We also examined the influence of 4 observed variables that differed across participants or quizzes but were independent of the program-level changes described previously, which are the primary focus of this study. These were (1) self-reported demographic variables of age and gender that participants logged at the time of registration, (2) dummy variables indicating the content of each quiz , and (3) a set of indicator variables for each reward program under which participants could earn points via the Carrot app. Additionally, we controlled for whether a participant completed the quiz preceding the focal quiz. This accounts for the nature of the quizzes and the likely path dependence present in intervention programs of this type .The reward program indicator variables were potentially important observed variables for 3 reasons, and all speak to our attempts to address alternative possible explanations for observed variations in quiz participation. First, each reward program has a different level of engagement with its participants and engaged in different levels of marketing efforts promoting their partnership with Carrot. As such, the inclusion of this variable may theoretically capture the potentially different levels of promotion of the Carrot app undertaken by each reward program. Second, the enrolled participant base of each reward program has varying demographic characteristics that may not be captured in the self-reported age and gender variables described earlier. Data manipulation was conducted using SPSS version 24 (IBM Corporation), and statistical analysis was performed using the xtlogit procedure in STATA version 12.1 (Stata Corp). These random effects panel logit regression method was used to explore the impact of each of our program change variables, observed variables, and control variables on participants’ probability of quiz acceptance across the 8 quiz offers received in the 5 weeks postregistration (the outcome measure). We ran our model using the average days to quiz completion imputation procedures for the data missing from individuals who did not complete a given quiz, as described in waves, which represent the point schedule in place at the time of their registration with the app. These groupings allow us to explore the effects of exogenous point changes on participant program engagement. Although participants self-registered continuously throughout the study period, the date on which they registered placed them in different point schedules (see P<.001); however, the magnitude of the coefficient suggests that the elasticity of this response is limited. Specifically, in our data, a 10% decrease in points offered from the previous quiz resulted in a 1% decrease in the likelihood of response to a given quiz. Second, we found that the impact of the first delay that participants face was negative and statistically significant (P<.001). This result demonstrates that the longer delay between quizzes 2 and 3 faced by those who registered after March 17 decreased their likelihood of response by 64%.Overall, from the regression results summarized in P=.52) on the likelihood of response; however, gender did have a significant impact (P<.001), whereby male participants were 15% to 16% less likely to respond to a given quiz than female participants. The next feature we explored in the model was the impact of quiz content on response rates. We observed that relative to the health risk assessments, participants were 21% more likely to respond to physical activity–related quiz offers (P<.001) and 10% less likely to respond to healthy eating–related quiz offers (P<.001). Finally, the results indicate that the reward program under which a participant registers had a significant impact on the likelihood of a quiz response. Specifically, relative to the gas rewards program, we observed that the movie rewards program participants were 355% more likely to respond to a given quiz (P<.001), the airline rewards program participants were 210% more likely to respond to a given quiz (P<.001), and grocery rewards program participants were 140% more likely to respond to a given quiz (P<.001).With respect to the observed variables, we first examined the impact of demographic characteristics on the likelihood of quiz acceptance. We observed no significant effect of age  decrease in the likelihood of offer response. This relative inelasticity is consistent with the findings of Carrera et al [presence of financial incentives matters for responsiveness [Our study demonstrates that the ongoing provision of a stream of small incentives (as low as US $0.05 per offer) can largely sustain the initial high levels of responsiveness generated by these programs. Interestingly, however, our results also demonstrate that the responsiveness to reward point decreases is relatively inelastic when compared with the other features of the interventions being offered via the Carrot app. Specifically, our results indicate that reducing the number of points associated with a particular quiz by 10% only leads to a 1%  in their response to the quizzes and the size of the financial incentives offered. On the basis of previous research in mHealth and on the findings presented here, quiz response and thus app engagement appear to rely more on the simple presence of points , as opposed to the absolute quantity, as well as on the continued opportunity to earn more points without a delay. This may be for a variety of reasons. First, loyalty points already require users to accumulate over time, so there may be a built-in progress element and a recognition that the ultimate reward will be sometime in the future ,23. This. One important finding from this study is that consistent with research on habit formation [Perhaps most importantly, our results suggest that other elements of the design of these interventions need to be considered when attempting to increase response rates. Existing research has demonstrated the critical importance of including direct end user feedback in the development of such apps early in the design to ensure both short- and long-term engagement ,40,51,52ormation , an incrAdditional findings of our study support the importance of nonincentive elements of this program, although by and large these results are much stronger in suggesting directions for further study than they are for creating concrete recommendations for program optimization. One important factor identified in our findings with respect to participant response rates is the content of the quiz being offered. Our results suggest that when the content of the quiz is focused on healthy eating, individuals are significantly less likely to respond , and when the content of the quiz focused on exercise or physical activity, individuals are more likely to respond . These results suggest that more than just the simple time cost of each intervention should be considered when designing incentive programs, perhaps incorporating individual and/or psychological factors that may influence the attractiveness of a quiz, which may increase or decrease the perceived costs of quiz acceptance and ultimately affect the propensity for uptake of an intervention.Similarly, among the observed variables that measured age and gender, quiz content, participation in previous quiz, and reward program, we find that the strongest predictor of the likelihood of quiz acceptance among all variables studied is the point program under which a participant is earning points for completing quiz offers via Carrot. Specifically, we find that individuals who choose to earn points in the movie (355%), airline (210%), and grocery (140%) programs all have a greater likelihood of response relative to the gasoline rewards program. We previously acknowledged that the differences between these reward programs may vary along multiple dimensions, including differential promotional efforts in support of Carrot, differences in the demographic composition of the participant base for each program, differences in individual responsiveness due to a numeracy effect , and differences in the earning and redemption mechanisms of each point program that may each influence the responsiveness of individuals. This facet of program design requires more exploration, but our results suggest that it is yet another factor that should be considered when designing optimal incentive-based intervention programs.One concern of the modeling approach used in this study is the possibility that the differential observed responsiveness to quizzes between what we have categorized as waves is due to underlying or inherent differences (whether demographic or psychographic) between participants who registered earlier versus later in the observed window of this study, rather than due to the previously described variations of the program. However, given (1) the very short time windows between the changes in the point scheme , but in this study, we do not have the data to be able to empirically substantiate those hypotheses. In addition, we are unable to retroactively document the promotion or advertising of Carrot by each of the 4 participating loyalty programs or to identify underlying psychographic differences between enrollees in one program versus another. The inclusion of these factors in the model would potentially allow us to further control the reward program–specific characteristics to be able to make more informed recommendations for practitioners, program administrators, or government stakeholders in terms of the need for or effectiveness of promotion efforts to drive enrollment in and engagement with the app. In general, there is a lack of data within the literature to date to support the economic basis for the use of mHealth behavioral interventions ,53. AlthAdditional factors that could be integrated into the model include devising quasiexperimental studies to examine other contextual factors that may impact program engagement and effectiveness. These could include individual difference variables such as the impact of socioeconomic or health status on both app engagement and quiz effectiveness at driving attitudinal or behavioral change or program-centered factors, such as the comparative effectiveness of individual rewards versus team-based rewards, norm-based messaging, or differential offer timing. Future programming should use a modular approach such that content can be contained in a specific topic of interest to measure engagement in the quizzes in a more systematic manner and explore how the impacts of different program features may vary over time. Examining these modular programs using microrandomized controlled trial designs, similar to ongoing work by Kramer et al , would aThe results of this study demonstrate that the Carrot program, built around an ongoing stream of a small number of reward points awarded instantly on completion of health interventions, was able to drive significantly higher engagement levels than demonstrated in previous literature exploring the intersection of mHealth apps and financial incentives. Furthermore, although previous studies have demonstrated that the presence of an incentive matters to user engagement, our study suggests that the number of points offered for these reward point–based health interventions is less important than other program design features such as the type of reward points being offered, the timing of intervention and reward offers, and the content of the health interventions for driving continued engagement by users.