Alcohol-exposed pregnancies are a health issue for many American Indian communities. The goal of this manuscript is to outline how an existing alcohol-exposed pregnancy prevention program with non-pregnant women (Project CHOICES) was modified to fit the needs and norms of an American Indian community. The Oglala Sioux Tribe CHOICES Program was developed and implemented using community feedback through initial meetings, reviewing materials, gathering input into recruitment and intervention logistics, and conducting interviews to evaluate the program. The intervention was implemented and has been enrolling non-pregnant American Indian women for the past several years. While data collection is ongoing, it has shown preliminary success in changing behaviors and in impacting how the community views the prevention of alcohol-exposed pregnancies. Overall, this study highlights the potential to expand this prevention program to other sites and with other populations, such as adolescents. By the end of this article, readers will comprehend the steps necessary to replicate such a program at other tribal and rural sites. FAS, thn growth ,3,4. In ctioning ,6,7. FASD is especially concerning for American Indian communities, although it is by no means unique among this population . In a prnot trying to get pregnant) were not using any birth control at conception. Traditionally, interventions to prevent FASD have focused on pregnant women, although recent research concludes that prevention of FASD must begin preconceptionally, or before a woman even becomes pregnant, by either reducing alcohol consumption in women at-risk or planning pregnancy, or preventing pregnancy in women drinking at risky levels . StudiesOl use and Increasing Contraception Effectiveness Study (CHOICES) program. This is based on the original Project CHOICES curriculum focused on reducing risk for AEP through alcohol reduction and pregnancy prevention using an in-person brief intervention and motivational interviewing sessions with non-pregnant women at-risk for AEP [One AEP prevention program currently underway with non-pregnant American Indian women is the Oglala Sioux Tribe (OST) Changing High-risk alcoh for AEP ,20,21,22 for AEP . The ori for AEP . The CHOICES theoretical model was previously implemented with OST and two other tribes through a five-year project that utilized a telephone-based enrollment and participation , personaTherefore, OST took data from this study to develop its current OST CHOICES Program, beginning by modifying CHOICES materials and piloting the CHOICES intervention at tribal clinics. The goal of this manuscript is to outline how an existing AEP prevention program (CHOICES) was modified to fit the needs and norms of an American Indian community. We also present preliminary data on the success of the OST CHOICES Program in lowering risk for AEP with non-pregnant American Indian women. The OST CHOICES Program began in September, 2010 by working with three clinics, two located on the reservation and a third that serves American Indian women in an urban setting. There were two major stages to this program that will be reported here: first, an evaluation of the feasibility and acceptability of the CHOICES intervention with a tribal community, and second, the actual implementation of the program, highlighted through preliminary data analysis. To begin the first stage, initial meetings were held with clinic staff at the sites to introduce the project and to discuss questions and concerns. The initial questions involved clearly defining the benefits of this project for the patients and the tribe. The clinics felt the intervention should be conducted by someone already working within the clinics or a tribal member who the women would be comfortable interacting. These types of meetings were held regularly to get input on the development and implementation of the CHOICES curriculum.i.e., local statistics on how many pregnancies are unplanned). Similarly, information in the materials had to be changed to fit with the most common types of alcohol consumed in the communities, and certain types of birth control information had to be taken out, as the clinics did not offer certain methods of contraception.In addition, project staff met with the clinic directors and staff to review the CHOICES materials in an informal group setting where OST CHOICES staff went through all the materials with the CEOs of the clinics involved, nursing/midwife staff, clinical directors, and an administrative officer at one of the clinics. The focus of these meetings was to suggest alterations to make the CHOICES materials more locally appropriate. For example, the clinics wanted local images added to the intervention materials, an acceptable readability, and to make information local  were dedicated to adapting the CHOICES materials for AI women and evaluating the feasibility of the CHOICES components with this population. Overall, the staff at the three tribal clinics involved in this first stage were extremely enthusiastic about the program and the potential for reducing AEP, and there was a willingness to implement the CHOICES curriculum within the clinic protocol. Input was gathered on modifying the CHOICES curriculum to make it appropriate for the tribal partners, including adding culturally appropriate images, checking the materials for readability, ensuring that data (such as rates of unplanned pregnancy) were local rather than national data, and determining the relevance of the information, such as what birth control options are available locally and the types of drinks that women drink. While the OST CHOICES Program began in September, 2012, it began slowly because of various implementation issues. One of the sites dropped out of participation and declined to enroll women because of a staff shortage, meaning that although they were interested in the OST CHOICES Program, they were unable to dedicate any staff time to enrolling participants into the program. Another site began enrolling women but the interventionist soon left the program and no follow-ups were conducted. Staff turnover was a concern, although that challenge is now overcome because both authors of this manuscript, who are key staff with the OST CHOICES Program, attended a national CHOICES “training of trainers” and are now able to train any new staff.However, the results of the qualitative interviews with two of the OST CHOICES interventionists and other relevant clinic staff point to the positive outcomes of the intervention in this feasibility/acceptability stage. These interviews revealed that the focus on preventing AEP with women that aren’t currently pregnant is an ideal prevention route. Most of the women enrolled appear to like the birth control part of this effort. The interventionists also feel that the approach is non-judgmental, which resonates with the women they see. The largest success stories include young women with multiple children who begin using birth control, in particular long-term birth control methods. When asked about sustaining the CHOICES intervention, one suggestion was to make CHOICES an official Indian Health Service program so that all American Indian women would be screened for alcohol consumption and pregnancy risk and would automatically be referred to the local CHOICES interventionist to enroll. Based on the positive input from the OST CHOICES interventionists, two additional sites were added in 2013 with the advent of further funding for CHOICES for a total of three clinic sites, and their data is included here. While enrollment and follow-up is ongoing, as of June 18 2015, 117 women have been enrolled at these three sites for the individual CHOICES sessions see . All parAs stated earlier, during these CHOICES sessions, MI techniques are used along with various activities, including decisional balance exercises, goal setting, and behavioral change plans. One component of the OST CHOICES intervention includes asking the participant to identify a person that can help in reaching behavioral goals and ways they can help. See To start building confidence in myself”; “I’m still young and I just drink all the time” and “Because I want to be here for my children living an alcohol/dry free life.” To change their drinking, they noted steps they needed to take, including keeping the empty bottles or tabs by them to see how much they’ve been drinking, being around friends and family who don’t drink and avoiding friends that do, and keeping busy with work and school. Participants also discussed cultural elements such as praying, going to sweats, smudging, and engaging in ceremonies to get healthy. Regarding using birth control, they said powerful things about using birth control, such as, “Because I believe I am a risky drinker and I don’t want any more children”; “My life as a young adult can be at stake. My life is at stake. I’m not ready” and “Because I do not want STDs or a baby with FAS”. At the final assessment, when asked to make a final goal statement about alcohol use, participants made goals to not binge drink, to socialize with friends and family that do not drink, attend alcohol treatment, AA, or other support meetings, and to look at their children as motivators in avoiding drinking. One participant said, “I plan to not give up on myself.” See Finally, participants were asked to set goals for their drinking and birth control use and reflect on why they chose their particular goal. Women said powerful things about their alcohol goals, such as, “versus those that were not), and some participants have not yet received their follow-up sessions. Of the 63 women reached for the 3-month follow-up, 42 (66.7%) were at reduced risk for an AEP because of their use of birth control , reduced alcohol consumption (4.4%), or changes in both behaviors (34.7%). At the 6-month follow-up, of the 41 reached, 31 (75.6%) were at reduced risk for AEP either because they began utilizing birth control (67.7%) or both began using birth control and reduced alcohol consumption (32.3%). The team is encouraged by the results, as preliminary data analyses indicate that the intervention successfully reduced risk for AEP in the majority of participants.While enrollment and follow-up is ongoing, as of June 18, 2015, 117 women have been enrolled at these three sites for the individual CHOICES sessions see . Becausei.e., training of trainers), meaning that the expansion of CHOICES to other tribal sites and clinics should be fairly economical and straightforward. In addition, while the process to modify and implement the CHOICES curriculum within this community was fairly methodical and relatively time consuming, the implementation in other communities need not be. The CHOICES curriculum is free and available online, therefore communities need only make community-based modifications as they see fit, if at all. The OST CHOICES Program was modified from the original CHOICES program through extensive community and clinic input, highlighting that CHOICES is feasible within a tribal clinic setting, keeping in mind that formative work is necessary to make the program’s materials culturally and geographically appropriate. The intervention has been enrolling non-pregnant American Indian women for the past several years and has shown preliminary success in changing behaviors and in impacting how women as well as practitioners view prevention of AEP. Our study also showed that the CHOICES intervention was an acceptable and even welcomed intervention by this particular tribal community in order to prevent AEP, and its success shows that it can be implemented with other interested populations. In fact, there is interest from other tribes in seeing the CHOICES curriculum developed and implemented in their communities. Two staff members from the CHOICES team were trained to provide the CHOICES curriculum training  approach, we have balanced research and programmatic action for the mutual benefit of our partners and the women we work with. Similar to a previous study by Masis and May (1991), American Indian women at-risk for an AEP can lower their risk by either reducing alcohol consumption or preventing pregnancy, or as is often the case, by doing both [Overall, the OST CHOICES Program is unique because it is a ing both . The OSTWhat makes the evidence-based CHOICES intervention distinctive in the prevention of AEP is that it targets more than one risky behavior related to AEP, reducing risk for AEP either by increasing a woman’s use of contraception or by decreasing alcohol consumption. The women in our study typically focused their behavioral efforts on obtaining and utilizing an effective form of birth control rather than decreasing alcohol consumption or addressing both contraception and drinking. Although our OST CHOICES data is preliminary, our initial analysis indicates that the AI women in our program are more willing to begin utilizing contraception to prevent pregnancy rather than reducing alcohol consumption. This compares to the original CHOICES study, which included a randomized controlled trial, where participants were more equally distributed in their ways of reducing risk for AEP . SpecifiWhile the OST CHOICES Program was successfully implemented and enrollment and data collection is ongoing, our team saw a critical need to expand the program to include components the community deems important. First, we conducted a validity/reliability study to further our efforts on the expansion of the CHOICES intervention with American Indian women . Second,i.e., women no longer interested in participating or their contact information has changed), and our staff continues to work diligently to contact participants via both telephone and letter. Finally, our project has faced staff turnover and a clinic dropping-out of data collection, which although created difficulty in the short-term, added to understanding the feasibility of CHOICES within a tribal community. We were able to add a new site and train additional interventionists to overcome these set-backs. As stated earlier, two of our staff members attended a CHOICES “training of trainers” so that we are able to train new staff in-house, meaning that staff turnover can be quickly addressed. Our staff learned a great deal in developing and implementing the OST CHOICES Program and those lessons learned should assist in sustaining the program long-term. There are a few limitations to this study. First, the development, implementation, and evaluation of preliminary results are confined to one American Indian tribe and one urban community; therefore, the results cannot be generalized to all American Indians/Alaska Natives. In addition, we have a relatively small sample size, although data is ongoing. Also, as with many intervention projects that include follow-up, we did have participant turnover for a variety of reasons (Overall, the methods and results of this study highlight the potential to expand an AEP prevention program to other sites. Garnering community input and appropriately modifying materials has led to a successful AEP intervention within an American Indian community. Ideally, those involved in future CHOICES implementation efforts can utilize the methods and results discussed above to implement and sustain this important AEP prevention program.


The objectives of this mixed methods research were 1) to study effects of the health behavior modification program (HBMP) conducted under the principles of the PROMISE Model and the CIPP Model and 2) to compare the 3-self health behaviors and the biomedical indicators before with after the program completion. During the program, three sample groups including 30 program leaders, 30 commanders and 120 clients were assessed, and there were assessments taken on 4,649 volunteers who were at risk of metabolic syndrome before and after the program conducted in 17 hospitals. The collected data were analyzed by the t-test and the path analysis. The research instruments were questionnaires used for program evaluation, structuralized interview forms, and questionnaires used for 3-self health behavior assessment. The findings were as follows: 1) During the program, the assessment result deriving from comparing the overall opinions toward the program among the three sample groups showed no difference (F=2.219), 2) The program management factors based on the PROMISE Model  had an overall influence on the product or success of the HBMP (p< 0.05) with size effects at 0.37, 0.13, 0.31 and 0.88 respectively. All of the factors could predict the product of the program by 69%. 3) After participating in the program, the clients’ 3-self health behaviors  were significantly higher than those appeared before the participation (p< 0.05), and their biomedical indicators  were significantly lower than those measured before the program (p< 0.05). The National Health Security Office (NHSO) has underlined health problems associated with metabolic syndrome (MS) including obesity, high hypertension, diabetes, and stroke as such diseases cause illness to people worldwide: the U.S. ; Saudi Arabia (39.3%); Turkey (33%); Tehran, Iran (30%); and South Korea (14.2%) . Thus, hThe plan to modify the 3-self health behaviors  of Thai people at risk of MS was developed by the NHSO, in collaboration with Srinakharinwirot University, on the basis of the PROMISE Model: P = Positive Reinforcement, R = Result-based Management, O = Optimism, M = Motivation, I = Individual or Client Center, and SE = Self-esteem . This reThe main purpose of this study were 1) evaluating the HBMP carried out by the participating hospitals, based on the CIPP Model and the 360 Degree Feedback, 2) examining effects of the health programs administered according to the PROMISE Model by focusing on the context, the input, and the process toward the product received from the programs, 3) comparing the 3-self health behaviors of the clients before participating the program with the ones occurred at the end of the program, and 4) making a comparison of the biomedical indicators  before and after the program.The evaluation research was conducted in line with the CIPP Model of The setting included 30 projects of 17 hospitals in Bangkok Metropolis which were funded by the NHSO in fiscal year 2010.3.3.1 The data used in experimental research were 4,649 Thai clients aged over 15 years, living in Bangkok Metropolis, and proved to be patients or at risk of MS; obesity, diabetes, high hypertension, and stroke. The clients volunteered to participate in the health behavior modification program for 5 to 7 months.3.3.2 The data used in the evaluation research were collected during the program from 30 program leaders, 30 commanders of the program leaders, and 120 clients.3.4.1 Structured interview forms were used to investigate the context, the input, the process, and the product of the HBMP.3.4.2 Four-point rating scale questionnaires consisting of 40 questions were used to evaluate the program based on the CIPP Model. The item discrimination of the questionnaires was found to range between .478 to .733 with the Cronbach’s alpha coefficients of reliability at .873.3.4.3 Four-point rating scale questionnaires containing 20 questions were used to evaluate the program administered under the PROMISE Model. The questionnaires were completed by the clients and the program leaders. The item discrimination of the questionnaires were between .509 to .754 with the reliability at .938.Self-efficacy involves the confidence in one’s ability to adjust health behaviors by oneself with patience and endeavor until achieving the set goal, the part’s reliability equaled .730, 2) Self-regulation is to observe one’s behaviors with changes in one’s health and to set a goal of having good health and a plan to achieve the goal by recording changes in health behaviors as well as reminding of ongoing action, the part’s reliability was at .800; 4.3) Self-care referred to one’s habit of having regular health check, searching for health knowledge, consuming proper food, exercising, and managing stress with an aim to live in good health. Behaving accordingly relied on a practice and a continuous process. The reliability was at .850.3.4.4 Four-point rating scale Questionnaires with 17 questions were launched before and after the program inquiring about the 3-self health behaviors of the clients: 1) 3.4.5 Biomedical instruments comprising, as examples, measurements of BMI, blood pressure, waistline, blood glucose, lipid profiles, cholesterol, and HbA1c which were taken before and after the program.3.5.1 The result of the CIPP Model-based evaluation of the health program is at the good level and indicates the consistency in opinion among the groups of program leaders, clients, and commanders of the program leaders.3.5.2 The factors of the program administration based on the PROMISE Model, namely context, input, and process has an impact on the product of the HBMP.3.5.3 At the completion of the program, the clients’ self-efficacy, self-regulation, and self-care are higher than the beginning of the program.3.5.4 The clients’ biomedical indicators  are better than before the program.3.6.1 To test Hypothesis 1, one-way ANOVA was used in comparing the consistency of the CIPP Model-based evaluation scores deriving from the three sample groups.3.6.2 To test Hypothesis 2, the path analysis was used to analyze the quantitative data about the program administration and the activity provision based on the PROMISE Model during the program so as to study the effect size representing the influence of the factors including positive reinforcement, result-based management, optimism, motivation, individual or client center, self-esteem, context, input, and process that affected the product or success of the program.3.6.3 To test Hypothesis 3 and 4, there were comparisons of the 3-self health behaviors and the biomedical indicators before and after the program with the use of the dependent t-test.4.1As forgeneral information concerning the clients, most of them were female, totaling 3,241 persons ; 1,197 of them aged between 50 to 59 (25.75%). 3,308 of the clients held an academic degree lower than a bachelor’s degree (71.16%). 1,734 clients were under the medical benefit scheme for civil servants or state enterprise employees, including their family members (37.30%). 1,545 clients faced the risk of obesity (33.23%), and 3,248 clients had the BMI higher than 23 kg/m2 (69.86%). 3,783 clients (81.37%) were very satisfied with the HBMP.4.2Theoutcome of the CIPP Model-based evaluation of the program revealed that, generally, the evaluation scores of the clients, the program leaders, and the commanders of the program leaders were not diverse and found to be in the good level  as show in 4.3The results of the analysis on the impact of the key factors on the product of HBMP carried out by the participating hospitals using the LISREL program showed that the factors concerning positive reinforcement, optimism, motivation, context, and input of program generally affected the product or success of the HBMP with effects at 0.37, 0.13, -0.02, 0.31, and -0.02 respectively, and the process was found to had direct effect on the product of the program with highest effect at 0.88 . The relationship between the casual factors and the product of the program was displayed in 4.4After finishing the HBMP, the client’s self-efficacy, self-regulation, self-care, as well as biomedical indicator scores improved as shown in 4.5Key elements to successful HBMP were that the clients displayed attention and willingness toward the program by attending the health activities every time they were conducted. In addition, the clients were given positive reinforcement, optimism, motivation by the staff, as well as support by the commanders. Besides, the activities were diversified and mainly focused on the service receivers.5.1 Having tested Hypothesis 1, the evaluation scores deriving from the clients, the program leaders, and the commanders of the program leaders were found consistent for many reasons. First, all of them perceived the necessity of the program and wanted to respond to the hospital’s policies. Next, all people that at risk were permitted to be part of the health care program; they were allowed to set their own goals and run activities by themselves in order to solve their health problems. Finally, all of the three groups showed hospitality and friendliness to one another; such phenomenon conformed to the concept of 5.2 According to Hypothesis 2, the factors including positive reinforcement, optimism, context, and process of HBMP were found to have an impact on the product or success of the program at the 0.05 level of significance with effects at 0.37, 0.13, 0.31, and 0.88 respectively, and they were able to predict the product or success of the program by 69%. This explained that the staff administered the program by relying on ‘positive reinforcement’ of the PROMISE Model. In such doing, when the clients’ behaviors continually changed to the target ones, the clients were convinced that they would receive awards and acceptance for their efforts. This finding was in line with 5.3 Regarding the tests of Hypothesis 3 and 4, it was found that the clients’ 3-self behaviors and biomedical indicators improved. This was because the PROMISE Model-based program administration encouraged the clients to play an important role in designing and doing health behavior modification programs by themselves. In addition, they were allowed to be a program initiator and an activity administer till the end of the program; as a result, the clients developed the feeling of being the program owner. Besides, there was use of positive psychological techniques to build the clients’ motivation resulting in the demand for activity attendance. These findings agreed with that of The health behavior modification program for people at risk of metabolic syndrome conducted on the PROMISE Model was able to cause increases in the clients’ 3-self behaviors and improve their biomedical indicators.7.1 Commanders should encourage the staff by giving them rewards and positive reinforcement.7.2 Clients with similar ages or health problems should be grouped together so that it will be more convenient for developing motivation strategies.7.3 Regarding the features of activities, the clients must voluntarily participate in the program provided, and they should be allowed to create and adjust activities that individually suit their behaviors. The activities may be divided into three parts: games of cognitive adjustment and thinking change (30%); knowledge of 3-E  (20%); and skill practices of the 3-self behaviors and 3-E (50%). Group activities should be carried out under the regulations firmly established in order to discipline the clients, and all groups of people should be welcomed to participate in the activities. To be more sustainable, these health programs should be promoted as routine work.


Changes in food availability in worksites can result in changes in eating behavior and weight status. Nemours Health and Prevention Services, in conjunction with partners in Delaware, conducted a 6-month pilot program to assess the feasibility and impact of requiring that 75% of the items in vending machines in 3 state agency buildings have healthful items.We collected process evaluation data from October 2011 through April 2012 by taking weekly photographs of all machines to record the number of healthful items available. Outcomes were measured through sales reports designed to enumerate changes in number and type of items sold and overall profit from each building.We found challenges in fully implementing the 75% goal. In one of the 3 buildings, all machines were compliant within 7 weeks; in another, full compliance did not occur until week 19. Despite these challenges, the number of items sold in each machine was comparable to numbers from the previous year. Total profits from each building varied across the 3 sites and during the pilot. One building had a 51% increase in profits in January 2012 compared with profits averaged for January 2011 and January 2010. In contrast, monthly profit at another building fluctuated from an increase of 6% to a loss of 30%.Overall, our results suggest that collaborative efforts can result in a feasible intervention with little negative influence on profits. In Delaware and throughout the United States, rates of overweight and obesity are high and are continuing to rise. According to the Centers for Disease Control and Prevention, 63.4% of Delaware’s adult population in 2010 was overweight (body mass index [BMI] ≥25.0) and 28.0% was obese (BMI ≥30.0) , the health promotion and disease prevention arm of Nemours pediatric health system, partnered with the Delaware Division of Public Health and the state licensing agency responsible for the oversight and implementation of the Delaware Division of the Visually Impaired Business Enterprise Program. This partnership developed and implemented a 6-month healthful food and beverage vending program at 3 pilot sites in Delaware. The goal of the pilot program was to increase the availability of healthful vended items, maximize consumer choice for these items, and educate consumers on nutrition. The objective of this evaluation was to answer the following questions: Has the program improved the nutritional quality of the food and beverage items available to employees and visitors at pilot sites?To what extent have employees and visitors purchased more healthful items?Have changes in the nutritional quality of vended foods and beverages affected the revenue from machines at pilot sites?The 3 pilot sites were chosen to represent the diversity of Delaware: one building in a northern urban location, one building in a central location on the legislative mall in the state’s capitol city, and one building in a southern rural location. The northern building housed one food machine and 4 beverage machines, all of which were included in the program; the central building had one food and 2 beverage machines, but one of the beverage machines was not included in the program; and the southern building had 2 food and 2 beverage machines, but only the food machines were included. The Division of Public Health and the Business Enterprise Program are part of Delaware’s Department of Health and Social Services, and the pilot sites are Department of Health and Social Services office buildings.The pilot program began with an assessment of employee interest and preferences for food and beverage items. After surveying employees at the 3 sites and conducting on-site taste tests of potential new items, the selection of foods and beverages was adjusted in favor of more healthful alternatives.The pilot program ran for 28 weeks, from October 26, 2011 through April 24, 2012. The program required that at least 75% of the items in all vending machines at the pilot sites meet NHPS’ “Go” or “Slow” food guidelines and that no more than 25% would be “Whoa” items. The 75% goal was set by the director of the Division of Public Health, and contracts were put into place between parties that reflected this goal and the overall goals of the project. The Go, Slow, and Whoa nutrition guidelines  were devSelection of more healthful items was also based on a subset of the Canteen Vending Services’ Balanced Choice Options that meet NHPS guidelines . New iteBecause of concerns over revenue loss, a monetary safeguard agreement was established between the Business Enterprise Program and the Division of Public Health. The Division of Public Health agreed to reimburse vendors for any monthly losses incurred during the pilot program; a loss was defined as an amount less than the average gross revenue for the same month in the previous 2 years.One key assumption of the evaluation was that 2 markets of employees were potentially affected by this program: those who had been purchasing the less healthful items from the vending machines and those who had not been purchasing any items from the machines. The program was designed to change the buying behavior  of the former market and encourage the latter market to use the machines. The evaluation used existing data  wherever possible to reduce burden on participants. Additional data were collected via photographic documentation of the vending machines. These data were supplemented with online surveys and interviews of stakeholders, including but not limited to drivers, operators, and employees at the pilot sites; this evaluation does not include the findings of the interviews or the surveys.To objectively document the contents of the vending machines during the study period, each machine was photographed weekly by a trained building employee. The photographs were then sent to NHPS and converted into planograms, diagrams that provide details on placement of products in retail environments. The planograms were used to determine whether machines complied with the 75% goal, assess the number and type of sold-out items, and confirm pricing. If an item was out of stock or the machine did not meet the 75% goal, the study team contacted the Business Enterprise Program to remedy the problem. Data were recorded in a spreadsheet and tracked during the 28-week study period.Monthly sales reports included information about each item sold in each machine and the amount of revenue generated. We also had access to data on items sold during the same 28-week period in the previous year and access to data on monthly profits made by each building during the study period and during the previous 2 years.We calculated the proportion of Go and Slow items in each machine to determine compliance on a weekly basis at each site. We also analyzed the number and proportion of Go, Slow, and Whoa items in each machine according to the following 5 periods: period 3, November 23 through December 27; period 4, December 28 through January 24; period 5, January 25 through February 21; period 6, February 22 through March 27; and Period 7, March 28 through April 24. We compared the total number of items sold in each period with the number of items sold during the same period in the previous year. Although the beverage machines in the southern location were exempt from the contract with the Business Enterprise Program, the vendors were permitted to stock the machines with the more healthful options, and we included these machines in our analysis.We calculated the monthly profit at each site for 6 months beginning with November 2011. We compared these monthly profits with the profits made in the same months in the 2 years before the pilot; for example, November 2011 was compared with November 2010 and November 2009. Because of the limited availability of data, we could not compare the profits of the pilot sites with the profits of sites not participating in the pilot program; these data could have explained any changes in sales that were not caused by the pilot . In several buildings, we faced challenges in bringing the machines into compliance with the 75% goal and in continuing to achieve this goal throughout the pilot. At the beginning of the pilot program at the northern site, only 28% of the food items and 49% of the beverage items were Go or Slow items. By the third week, 75% of the items in the food machine were more healthful items, but the beverage machines were not fully compliant until after week 13 .At the central location, at the beginning of the pilot program, only 25% of the food items and 12% of the beverage items were Go or Slow items. By the third week, 75% of the items in the food machine were more healthful items, but the beverage machine was not fully compliant until week 19. At the beginning of the pilot program, only 11% of the food items and 50% of the beverage items were Go or Slow items  at the sIn general, we found increases in the total number of items purchased during the pilot program compared with the previous year. For example, at the northern site, the number of items purchased in periods 5 through 7 (n = 434)  was highAt the northern site, although the number of items purchased varied during the pilot program, the proportion of purchases of Slow foods increased from 56% in period 3 to 72% in period 7 (Table 1). At the central and southern sites, purchases were fairly evenly split between Slow foods and Whoa foods. In one machine in the southern location, the best-seller (according to number of items purchased) for 3 of the 5 periods was a Slow food.At the northern site, the proportion of purchases of Go and Slow beverages increased during the pilot period . At the Among the 3 sites, gains (compared with the guarantees) in monthly profits ranged from 4% ($27.68) at the southern site in March 2012 to 51% ($356.58) at the same site in January 2012. Losses ranged from −4% (−$16.74) at the central site in December 2011 to −36% (−$170.99) at the same site in January 2012 . OverallOur experience of piloting healthful vending in Delaware resulted in numerous successes, lessons learned, and areas of opportunity. The program was conducted as a collaboration of public health interests  and entrepreneurial business interests (the vending machine operators). To effectively execute the pilot program, it was critical to understand that each stakeholder was uniquely motivated. Likewise, each stakeholder group needed to have their concerns heard, validated, and woven into the negotiations on pilot parameters. Addressing these unique motivations and divergent perspectives was challenging but essential throughout the process — even getting the pilot off the ground. The Director of Public Health played a key role and provided guidance, vision, and insight on a weekly basis; was debriefed on process details throughout the pilot; and was able to maintain relationships with all stakeholders. Additionally, the director firmly determined the level of compliance to be 75%. During planning discussions, revenue concerns were addressed and business cases for success were shared. At the conclusion of negotiations, vending operators held firm in their request to receive a subsidy for potential losses. This subsidy requirement illustrates the balance and compromise needed for a collaborative initiative to move forward.The processes of the vending industry, from supply chain to distribution, worked in our favor at the southern site. These machines easily complied with the 75% goal, and few issues arose during the pilot program in sustaining the 75% goal. Often, at the other sites, the food supply company made unapproved product substitutions, incorrectly stocked the machines according to the healthy and pre-approved planogram, or no longer carried a particular item in the warehouse. Not all parties in distribution channels were aware of, or agreed to, pilot goals. The substitution of incorrect products required additional project management oversight and ultimately accounted for a majority of machine noncompliance.We did not find substantial reductions in the number of units sold overall from the previous year; sales reductions were a concern of the vendors during the planning process. At the southern site, vending machine profits were 51% higher in January 2012 than profits averaged at that site for January 2011 and January 2010, and profits there were above average levels for 5 of 6 months of the pilot program. However, under the agreement between the Business Enterprise Program and the Division of Public Health, the vending operators were compensated a total of $1,383 during the pilot for overall revenue loss and product spoilage caused by the shorter shelf life of more healthful items.Additional research is needed to understand customer preferences. Although general customer preference and taste surveys were conducted before the pilot program, additional research could determine whether new customers were enticed to use the vending machines or whether repeat and existing customers were purchasing more healthful items than before. Insight into customer preferences can help in the tailoring of healthful product offerings, thereby theoretically motivating the customer to use the machine, make healthful food purchases, and increase sales revenue for the machine’s owner. Our pilot program engaged customers through new, more healthful product taste testing, online taste preferences surveys, and a series of e-mails featuring a more healthful product and health facts .To support and sustain a component of healthy behavior change, contract terms must be in place to support healthy vending. Although our pilot program successfully operated outside of the regular contract negotiation process, we recommend that healthful vending specifications be included in a formal contract with a food service provider so that projects can be sustained. Many models exist around the nation, and Nemours Healthy Vending and Concessions Guidelines can also serve as a tool in defining healthful specifications for any food service operation ,11. In 2Our evaluation has several limitations. We did not have data on vending machines in buildings that did not participate in the pilot, so it is possible that changes in profits from the machines in the pilot program could have occurred had the pilot program not been implemented. Furthermore, research suggests that comprehensive workplace health promotion efforts hold the most promise for significant change in healthful eating and physical activity ; this pr


Primary welfare outcomes evaluated are household food security, as measured by the Household Food Insecurity Access instrument, and OVC educational attainment. We compared outcomes between the CBCO and the subset of Group L not meeting program eligibility criteria (L-N) to investigate disparities within local communities. We compared outcomes between the CBCO group and the subset of Group A meeting eligibility criteria (A-E) to consider program impact. We compared outcomes between households not eligible for the program in the local and adjacent community groups (L-N and A-N) to consider if the adjacent communities are similar to the local communities. In May-June 2011, at the end of the OVC program, the majority of CBCO households continued to be severely food insecure, with rates similar to other households living in nearby communities. Participation rates in primary school are high, reflecting free primary education. Among the 18–22 year olds who were “children” during the program years, relatively few children completed secondary school across all study groups. Although the CBCO program likely provided useful services and benefits to program participants, disparities continued to exist in food security and educational outcomes between program participants and their non-OVC peers in the local community. Outcomes for CBCO households were similar to those observed for OVC households in adjacent communities.The Community-Based Care for Orphans and Vulnerable Children (CBCO) program operated in Kenya during 2006–2010. In Eastern Province, the program provided support to approximately 3000 orphans and vulnerable children (OVC) living in 1500 households. A primary focus of the program was to support savings and loan associations composed of OVC caregivers  to improve household and OVC welfare. Cross-sectional data were collected in 2011 from 1500 randomly selected households from 3 populations: program participants (CBCO group,  The Community-Based Care for Orphans and Vulnerable Children (CBCO) program operated during 2005–2011 in Eastern Province of Kenya. The CBCO program supported the development and operation of saving and loan associations (SLAs) composed of OVC caregivers. In the final program year, the program supported 52 SLAs composed of approximately 1500 OVC caregivers and 3000 OVC  and young adults (18–22), who would have been “children” during the program implementation years.The CBCO program used a general OVC definition consistent with criteria outlined in the Kenya Aids Indicator Survey . For example, one member may have access to a piece of land that could be used for maize production, but she does not have enough labor in her household to work the land . With this land, the SLA as a group could purchase maize seed  and as a group allocate time to this activity. Group IGAs are a fundamental component of the CBCO SLA model. Each individual in the group does not need to be an entrepreneur and face individual financial risks, as is essentially the case with more formal micro-finance institutions.The SLA as an institution also provides a mechanism for social support and risk pooling. If one SLA member or someone in their household becomes sick, the SLA may organize an additional voluntary contribution from SLA members to provide the member with inputs to meet their unexpected needs . In the CBCO program, these one-time activities are separate and do not show up in the SLA's accounts.Beyond supporting the development and operation of SLAs, the CBCO program was designed to provide additional support to OVC caregivers and their children, including assistance with paying for school-related expenses. Rather than traveling to 30 individual households who might be caring for 40–60 OVC, the CBCO program worked through the SLA's regular meeting structure to meet with the 30 caregivers. Two members of each SLA group also volunteered in a social worker capacity to visit caregivers and their children at their homes (at least once per month). These volunteers were called “mentors” by the program, whose role was simply to talk to caregivers and their children (separately from caregivers for older children), listen to their concerns, and informally monitor OVC welfare.The CBCO program included individuals trained on developing and managing SLAs, called a facilitator. The facilitator played various roles in the program. He/she supported the creation of the SLA and provided training and management support for financial matters . The facilitator was also the person the CBCO program used to distribute any materials or services to OVC caregivers and their children, usually at an SLA meeting, such as seeds for home gardens or support with school materials. And third, the facilitator acted like a rural extension agent, who assisted the SLA with learning about and identifying income-generating project ideas.CBCO group (n = 500); (2) households living in the CBCO sub-locations with at least one child < 18 years of age at the time of the survey ; and (3) households living in sub-locations adjacent to the CBCO sub-locations .The study was a retrospective cohort study of CBCO program participants (the intervention group) and other households living in sub-locations where the program was implemented and in nearby communities (adjacent sub-locations) where the CBCO program did not operate. Households were randomly selected from three main study groups: (1) the We obtained ethics approval from the Human Ethics Research Committee of the Kenya Medical Research Institute and the IRB of the Boston University Medical Center before implementing the survey. Written informed consent was obtained from all study participants. After obtaining consent, the study questionnaire was administered verbally by a trained study enumerator. The questionnaire included sections on household demographics including education attainment, housing characteristics, asset ownership, participation in groups, and recent loan history.The “Household Food Insecurity Access Scale (HFIAS) for Measurement of Food Access”, based on 18 questions with a 4-week recall period, was also included in the survey. The HFIAS tool has been used in several countries for measuring food security and assigning households along a continuum from food secure to severely food insecure .A more complete description of the study design, survey instruments, and statistical analyses is provided in the final study report . We incln = 486; Group A, n = 659; and Group L, n=284). Groups L and A were further stratified into two groups: those meeting the eligibility requirements for the CBCO program at the time of the survey (Group A-E and Group L-E), and those households not meeting eligibility requirements (Group A-N and L-N). A significant share of Group A and Group L households met the CBCO program eligibility criteria at the time of the survey (55% in Group A and 43% in Group L), mainly because orphaned children were living with the household.The final sample size used in this analysis is 1429  a simple impact analysis. The disparities analysis focuses on differences between the CBCO Group and Group L-N. Comparing outcomes for the CBCO Group to Group L-N provides perspective on how “deprived” CBCO households are compared to households in their local communities whose children would not be classified as orphans or vulnerable (their non-OVC peers).We discuss two basic analyses here: (1) a Comparing outcomes for the CBCO to Group A-E (adjacent community households meeting program eligibility requirements) is called here a “simple” impact analysis. If the adjacent sub-locations are similar to the CBCO program sub-locations (they are next door to each other with similar ecosystems and ethnicity), then A-E group could be a reasonable comparison group for discussing program impacts. We recognize that social support and public health programs, as well as economic changes, occurred throughout Eastern Province during the CBCO program years. Thus, outcomes in 2011 for all study groups incorporate any impacts of such programs. Assuming that similar programs existed or would have existed in the CBCO program areas, the simple “impact” analysis discussed in this paper is impacts beyond what might have occurred in the absence of the CBCO program .The “HFIAS for Measurement of Food Access” has been used in several countries for measuring food security and assigning households along a continuum from food secure to severely food insecure . The HFIEducational attainment information was obtained for all children in each household interviewed. We assessed the proportion of children completing the most recent school term stratified by two age groups: 7–13 year olds (primary school age) and 14–17 year olds (secondary school age). We also assessed the proportion of children age-for-grade congruent (within 1 year plus or minus) also stratified by primary and secondary school age groups. As a third educational outcome, we assessed the proportion of young adults (18–22 years of age) who completed secondary school. These young adults would have been considered “children” at some point during the CBCO program period.For each outcome, we compared simple proportions across study groups using OLS regression (STATA 11 with robust standard errors).The HFIA scores show poor food security for all groups in both regions . The majRegarding impact, the CBCO and A-E households had similar mean and median HFIA scores and essentially the same percentage of households (60%) were classified as severely food insecure in both groups. Also note in Responses to educational attainment of young adults and school attendance of children are shown in As of June 2011, CBCO households were more likely to be severely food insecure than other “non-OVC” households in their local communities, while OVC educational outcomes were close to those of their non-OVC peers. Outcomes for CBCO households were similar to those observed in households in adjacent communities who would be classified as “OVC households.”The limitations of a cross-sectional study design to evaluate impact from a multi-dimensional, multi-year program that was not assigned randomly to program participates are well known. Given the urgency to provide and scale up services to OVC in 2006, it is not surprising that the CBCO program did not assign households with OVC randomly into treatment and control groups or sequence implementation across multiple years. With or without randomization, at least two rounds of data for at least two groups are very useful for identifying program impacts, but relevant data collected before the CBCO program began (or at least early in the program) do not exist.http://go.worldbank.org/2IL8VR9LX0). As another example, it costs $84 to identify one new HIV infection in a home-based HIV testing program implemented in Kenya  in 2009. The program relied on large quantities of volunteer labor, which, if valued at reasonable local wages, might increase these costs by 100%. While some variation occurred across the program years, these are very modest levels of program services. For perspective, a scaled-up “Cash Transfer Programme for Orphans and Vulnerable Children” in Kenya is reported to cost about $320 per year  are still needed.


Early-Phase Oncology Research Training (EFFORT) program is a joint effort between Jiangsu Hengrui Medicine Co., Ltd, China and the United States–Chinese Anti-Cancer Association (USCACA) to provide academic and financial support to junior clinical research staff including physicians and nurses of early-phase oncology clinical trial centers in China. The program will select 1–2 qualified candidates per year and place them through rotation programs at 2–3 phase 1 cancer centers in the United States (US).Current US cancer centers engaged in the EFFORT program include Wisconsin University Comprehensive Cancer Center, H. Lee Moffitt Cancer Center & Research Institute, and MD Anderson Cancer Center. The program also includes a rotation at Cancer Therapy Evaluation Program (CTEP) at National Cancer Institute. The duration of rotation is 4–8 weeks at each center. The exchange scholars will go through a structured clinical rotation with curriculum specifically designed for the individual needs and tailored for special features at each cancer center. The rotation at CTEP focuses on the clinical trial design, and the candidate will be part of the multi-disciplinary team to review, discuss, and evaluate study proposals under the guidance of experienced CTEP medical staff. For more information about EFFORT, please see the article by Dr. Jingji Yang detailing the experiences from the pilot EFFORT program .Shu-Kui Qin, Nanjing Bayi Hospital, China; Immediate Past President of Chinese Society Clinical Oncology (CSCO) and the President of CSCO FoundationLin Shen, Beijing Cancer Hospital, ChinaWeijing Sun, University of Pittsburg, USAYi-Long Wu, Gaungazhou General Hospital, China; President of CSCOLi Xu, Vice President and Global Head of Oncology, Jiangsu Hengrui Medicine Co., Ltd; USCACAJie Wang, Beijing Cancer Hospital, ChinaRui-Hua Xu, Sun Yat-sen University Cancer Center, ChinaLi Yan, Beijing Cancer Hospital, China; USCACACai-Cun Zhou, Shanghai Pulmonary Hospital, Tongji University School of Medicine, ChinaThe program is overseen by a Governance Committee that consists of the following members.The responsibilities of the Governance Committee include implementing the EFFORT program in China, e.g., distributing the program information through professional organization , hospitals, and cancer centers; identifying, reviewing, and qualifying candidates.The EFFORT program is open to all junior clinical research staffs in academic research centers that are accredited for phase 1 studies on oncology. In principle, the expenses of rotation program are shared between the candidates’ home institution in China and USCACA. USCACA is also responsible for designing the rotation program in collaboration with the home institution and the candidate.The implementation of the EFFORT program is led by Drs. Roger Luo and Pascal (Jiang) Qian of USCACA. To apply, please contact USCACA at luofr@yahoo.com and pascal.qian@novartis.com. Please send your application with a brief introduction of your background and experience in clinical oncology trials, any particular aspects of the early clinical trials you are looking to strengthen, together with curriculum vitae (CV), the letter of support from the head of department and hospital providing the vision of your institution in early phase clinical oncology trials, and the rationales why your participation in the program will benefit your home institution.USCACA wants to take this opportunity to thank the following individuals in the US for their support to the Hengrui-USCACA Scholarship.Dr. George Wilding and Ms. Dona Alberti, University of Wisconsin Carbone Cancer CenterDrs. Wei Sheng and Dan Sullivan, Moffitt Cancer CenterDrs. Helen Chen and Pamela Harris, CTEP at National Cancer InstituteDrs. David Hong, Funda Meric-Bernstam, Denise De La Cruz, and Sarina Anne Piha-Paul, MD Anderson Cancer CenterThe program would be impossible without the generous grant from Jiangsu Hengrui Medicine Co., Ltd, China. The USCACA want to thank Mr. Piaoyang Sun, Drs. Li Xu, and Lianshan Zhang for their support of the program.


In the early 1990s, the Stanford Patient Education Research Center developed the Chronic Disease Self-Management Program (CDSMP) to test the hypothesis that people with comorbid conditions could benefit when placed in a common intervention. At that time, the existing paradigm consisted of having patients attend only disease-specific education programs. In 2013 alone, 50–100,000 people in 36 countries attended the CDSMP. How did this happen? We do not know the answer, but have some ideas. The following is a brief history and some key insights.In 1990, to determine patient-perceived problems, we held 11 focus groups with people with chronic conditions. Participants talked predominately about symptoms, and thus the program was built around breaking the symptom cycle and tools that participants could use to accomplish this. By basing a program on end-user problems, we assured their interest. Insight: one cannot underestimate the importance of having happy and excited end-users. This can only be accomplished by meeting user needs.We developed the CDSMP for translation into practice. It is taught by peers. Every minute was and continues to be scripted for both content and process. Insight: the design process accounted for many of the things that enabled the CDSMP to be a success. Translation cannot occur without a set protocol that can be followed by others.The CDSMP was based on self-efficacy (SE) theory. While many interventions are informed by theory, the CDSMP systematically incorporated SE theory. SE theory states that one’s confidence in achieving a desired behavior predicts their level of success. SE can be enhanced through skills mastery, modeling, reinterpretation, and social persuasion . All of The original randomized trial had four outcome categories that were of interest to different communities . BehavioAt the end of the original randomized trial, there were improvements in all four categories. Hospitalization was reduced by 8 days. Based on these data, Kaiser Permanente, one of the original study partners, decided to trial the program nationally in 1998. This longitudinal study had similar outcomes to the original trial . InsightAt about this same time, having read our original article, others from around the country began to call inquiring about the program. Insight: publish as soon as practical using language understandable outside the scientific community. Publications should be aimed at scientific, practice, and policy communities.Based on this interest, we started offering one or two yearly trainings in 1999. Our aim was to give each organization the capacity to train its own leaders and to grow its own program. As developers, we saw our role as offering training and technical assistance. What began with 20–40 trainers per year has grown to 400 or more new trainers per year. Each pair of new trainers has the capacity to offer programs and train local leaders. Insight: building organizational capacity is an important translation element. To do this, one must devote resources to training and supporting others.By the early twenty-first century, requests for training were rapid. There was a need to put more structure around the translation process. There has never been a business plan. Rather, the business of translation was and continues to respond to changing needs. Early on, Stanford administration showed little interest in our activities. As we involved more organizations, the University became concerned about liability. To mitigate this issue, we worked with the Stanford Office of Technology Licensing to establish policies. Insights: program developers need to worry about liability and licensure issues.There were five potentially competing interests, the legal interests of the University, the need to keep the workshops affordable for adopting agencies, the need to sustain a training technical-assistance (TA) infrastructure, the financial interests of the program developers, and the need to minimize bureaucracy. At this stage in translation, many program developers form their own companies or collaborate with an existing company. However, the developers were not interested in becoming entrepreneurs. We decided to continue working within the University. License price ($500) was set to allow an agency to offer 30 workshops over 3 years for approximately 300 participants. Insight: in translating products to widespread use, there are many competing interests. It is best to acknowledge these and work at a fair compromise early.http://patienteducation.stanford.edu/licensing for current license policy and http://patienteducation.stanford.edu/training/trnpolicies.html for training policy. Insight: while personal preference and knowledge can run early translation efforts, true widespread translation requires “rules and regulations.”Between 2000 and 2010, both the licensing and training policies adapted to changing times and became more codified. With the help of the Office for Technology Licensing, we created and continue to create different types of licenses. See In 2003, the U.S. Administration on Aging, AoA  in collaboration with CDC and other public and philanthropic organizations, funded 14 sites to embed evidence-based programs into community-based organizational networks. It was only after several of the applicants wanted to use the CDSMP that the head of the National Council on Aging TA Center for these grants called Stanford. Until this time, no one at Stanford knew anything about this initiative. Because of this collaboration, more than 3000 people had participated in evidence-based programs including the CDSMP . InsightAmerican Recovery and Reinvestment Act, ARRA recovery funding, AoA in collaboration with CDC, provided grants to 45 states, Puerto Rico and the District of Columbia for disseminating the CDSMP. The goal of 50,000 completers (those who had attended four or more sessions out of six) was reached and surpassed. Insight: even in bad times good things can happen. Insight: when opportunity knocks it is important to have “shovel ready” projects.In 2006, the U.S. Department of Health and Human Services announced collaboration between AoA, NCOA, and the Atlantic Philanthropies to build CDSMP capacity across the United States. AoA awarded funding to 27 states. This funding mandated adoption of the CDSMP and encouraged the use of other evidence-based programs. These programs served approximately 50,000 people my population.” These requests range from wanting to change content to changing length or format. Insight: there is distrust of anything “Not Invented Here.”There is constant pressure to adapt and modify the CDSMP. These requests usually come from people who have not seen or participated in the program and usually know “what is best for We usually tell the requesters to try the program, and then ask the participants what they want to change. Requests for changes in format and length or large amounts of content cannot be met without rewriting the CDSMP and re-evaluating the new format with a new population. This has been done successfully a few times and has resulted in the pain self-management program and the hepatitis-c self-management program, among others , 9. ReceEvidence-based programs always have the challenge of standardization. Without standardization, the evidence base is lost. As the core of trainers has grown larger (over 1000 master trainers and many thousand leaders), maintaining quality programs is more difficult. The use of webinars, administrative and fidelity manuals, and email discussion groups helps with the centralization of key training and technical assistance . InsightIt is unusual for a program creator to remain involved with widespread translation. There have been several challenges. First of these is moving among academic, training, technical assistance, promoting, and cheerleading roles. Insight: if you do not like juggling, do not join the circus.The second is how to finance core translations activities such as training, technical assistance, and updating materials. Monies from federal agencies and foundations, for the most part, go for program delivery and are seldom earmarked for these core activities. This means that the core functions must become self-sustaining through charging for such activities as training, materials, and TA. Insight: the financing of core translation activities can help or hinder translation and must be planned and flexible.This is a personal 22-year retrospective look at insights gained as the CDSMP has moved from concept to translation. This retrospective look has been both surprising and humbling. I look forward to learning what comes next.The author receives royalties from Stanford University and Bull Publishing.This paper is included in the Research Topic, “Evidence-Based Programming for Older Adults.” This Research Topic received partial funding from multiple government and private organizations/agencies; however, the views, findings, and conclusions in these articles are those of the authors and do not necessarily represent the official position of these organizations/agencies. All papers published in the Research Topic received peer review from members of the Frontiers in Public Health  panel of Review Editors. Because this Research Topic represents work closely associated with a nationwide evidence-based movement in the US, many of the authors and/or Review Editors may have worked together previously in some fashion. Review Editors were purposively selected based on their expertise with evaluation and/or evidence-based programming for older adults. Review Editors were independent of named authors on any given article published in this volume.


Earthquake load and heavy truck load are considered as random processes with respective characteristics, and the maximum combined load is not the simple superimposition of their maximum loads. Traditional Ferry Borges-Castaneda model that considers load lasting duration and occurrence probability well describes random process converting to random variables and load combinations, but this model has strict constraint in time interval selection to obtain precise results. Turkstra's rule considers one load reaching its maximum value in bridge's service life combined with another load with its instantaneous value , which looks more rational, but the results are generally unconservative. Therefore, a modified model is presented here considering both advantages of Ferry Borges-Castaneda's model and Turkstra's rule. The modified model is based on conditional probability, which can convert random process to random variables relatively easily and consider the nonmaximum factor in load combinations. Earthquake load and heavy truck load combinations are employed to illustrate the model. Finally, the results of a numerical simulation are used to verify the feasibility and rationality of the model.Issues of load combinations of earthquakes and heavy trucks are important contents in multihazards bridge design. Current  LRFD bridge design specifications [The current American bridge design specifications are mainly based on AASHTO load and resistance factor design methodology, which are fully calibrated against gravity load and live load. In AASHTOications , a typicications . AgainstIn recent years, bridges are subject to more and more diversified natural hazards, and the frequencies of various extreme hazards also seem to be increasing, which bring great threats to safety of the bridges so as to bring potential danger to personal life and property safety. The concept of multihazards design is quoted in many papers and reports at present –7. An orWhen there is only one extreme load , the load combination includes an extreme load and dead load and in such case no matter whether the extreme load is a random variable or random process, its combination only relates to the maximum value. It is quite a different situation when two or more extreme loads are considered in the combinations. Because the intensity of extreme load is a function related to time and even two extreme loads occur simultaneously in a short time, the probability for them to reach their highest intensities at the same time is very low, which means that when multiple extreme loads are combined, the maximum combined load is not simply the superimposition of their maximum value. Among many load combination models, Ferry Borges-Castaneda model , TurkstrIn this paper, a model based on conditional probability is proposed to combine advantages of the Ferry Borges-Castaneda model and Turkstra's rule to achieve a more reasonable result of load combination. Then earthquake load and heavy truck load combinations are employed to illustrate the model.Earthquake load usually lasts for a short time and has enormous destructive power, while the frequency of heavy trucks is relatively high and some overloaded trucks or multiple trucks “running side by side” bring damage to the bridge greatly. It should be noticed that the maximum 75-year truck load was usually great and can be considered as extreme load. Generally, extreme load is of low occurrence probability and great intensity and even lower chance of simultaneous occurrences. Even the extreme loads do occur simultaneously; the chances that they achieve their respective maximum value are very low. Therefore, the common occurrence frequencies of different extreme loads are generally not considered . AccordifX(x) is the probability density of load in τ interval, which is the function of time and load intensity. The occurrence of load is determined through Poisson distribution. When only two random processes are considered, assume that the time interval of load 1 is t1, that of load 2 is t2, and t1 ≥ t2. Under only one kind of loads, the maximum value of load 2 in t1 interval can be described with   is the cumulative distribution function (CDF) of the maximum value of combined load in T period; FX(x) is the cumulative distribution function of load combination in t1 interval; n is integer, which can be obtained from T and t; namely, n = T/t.One of the main tasks of load combination is to find the maximum value of combined load under multiple kinds of loads in the service life of bridge. Therefore, based on the assumptions of load definition of Ferry Borges-Castaneda model, the maximum value of load combination in x1) see ; then tht; if it is small enough, the results are nearly precise. However, the interval of time depends on many factors; it is not small enough and the duration of the maximum load effect of each load within a time interval, such as heavy truck passing a common bridge, is relatively certain, while this “duration” is usually shorter than time interval t. Therefore, the probability of simultaneous occurrences is not equal to the product of respective occurrence probabilities of the loads. If they are made to be equal, the probability of maximum load effect is exaggerated so as to lead to conservative results. It is assumed that the probability of occurrence probability of load 1 within interval t is p1, that of load 2 is p2, and the probability of simultaneous occurrences is p. The probability of load 1 event in its duration is pr1 and the probability of load 2 event in its duration is pr2; then we can findAccording to the Ferry Borges-Castaneda model, the service life of the bridge can be divided into equal time interval T0 to that in an interval t, when T0 ≫ t, the probability curves may have error after root of large number and the error is cumulative, especially for curves with values on negative part of X axis . For earthquake, annual probability curve is obtained from the USGS Mapping [Besides, power conversion of probability curves is required when using Ferry Borges-Castaneda model. For example, converting probability curve in a long time  Mapping  and the τe and the time for the heavy truck passing through the bridge is τt; the probability of the heavy truck on the bridge during the earthquake is P; then,λ is the frequency of heavy trucks.Based on these problems, Ghosn et al.  improvedThe probability is less than 30% when  holds thSince the number of earthquakes in a 75-year return period is usually few, it is mentioned in the report of Ghosn et al.  that, acThe earthquake and heavy truck load combinations are different from other extreme load combinations (except for scour), and the probability of simultaneous occurrences cannot be ignored just as described above. In case of earthquake load and heavy truck load combination, the combination situations include heavy truck load only, heavy truck load and earthquake load, and earthquake load only , incorporating the conception of Turkstra's rule, the difference is that the heavy truck load here is not instantaneous value or mean value. Since heavy truck is “observed” when earthquake has happened, earthquake should be analyzed by number and then earthquake and heavy truck combination could be considered. The expected numbers of earthquakes are provided by USGS Mapping Project.Analysis of the truck issues based on earthquake condition will make the most concerned extreme load such as earthquake load outstanding and clear, make load effect combination clarified, and prevent the “confusion” when sample spaces are mixed, so as to simplify the concept of load effect combination. During each time Fe(x), of load for one earthquake's occurrence is defined byney is the annual average number of earthquake;  Py(x) is the annual cumulative probability function curve of earthquake load.The cumulative distribution, ney may not always appear as an integer for calculation accuracy and convenience according to different areas and is related to total occurrence number of earthquake.Note that Ftr(x) is calculated using the following equation:ntr is the quantity of heavy trucks in effective combined action time of earthquake and heavy trucks; F(x) is the load cumulative distribution function of a single heavy truck; ne is the number of earthquake meeting with heavy trucks.On the basis of reliability theory, combining heavy truck with earthquake, the cumulative distribution function of possible maximum truck load P(eonly). P is the probability of combined action of earthquake and heavy truck; then there is P + P(eonly) = 1. Based on earthquake condition, the modified model can be expressed asFe,tr(x) is the cumulative distribution function of load combining earthquake with heavy trucks; Fe,only(x) is the cumulative distribution function of load of the rest earthquakes “alone.”The maximum value of combination of earthquake load and heavy truck load is obtained through . The profe,tr(x) is the probability density function of load combining earthquakes with heavy trucks; fe,only(x) is the probability density function of load of earthquakes “alone.”Therefore, considering both combination of earthquakes and heavy trucks and earthquakes “alone,” the probability density function of total load is calculated asFTmax,(x) is the joint cumulative probability function of earthquake load and heavy truck load in time T period; Fcom(x) is the cumulative probability function in earthquake condition; Ftr,only(x) is the cumulative probability function of maximum value of heavy trucks in time T period.Since the methodology in this paper is based on the condition of earthquake, the whole load combination is divided into those with earthquake condition and without earthquake condition, which are “alternative.” The “circumstance” without earthquake is the situation of remaining heavy trucks, which refer to those not coming across earthquake . Therefore, the joint cumulative probability distribution function of earthquake and heavy truck load combination is given asDetermine the time intervals of earthquake load and heavy truck load.λ of heavy truck load during the time interval according to the stable Poisson process assumption and calculate the occurrence probability and probability distribution function of heavy truck load within the interval.Calculate the occurrence frequency T period with reference to USGS Mapping and calculate the distribution of maximum earthquake load within t1 using  number of earthquakes within 1 using .Determine the probability of earthquake and heavy trucks coming across each other.Determine the number of heavy trucks of occurrence within the time interval of earthquake and calculate the possible maximum value distribution function with  when theDetermine the number of earthquakes combined with the trucks and calculate the cumulative distribution function of the combined portion of earthquake and heavy trucks.Using  and 9),,9), calcCalculate the final maximum value distribution using .T (such as 75 years) period.If constant load effect such as dead load participates in the combination with other load effects, it should be combined with the dead load effect within To sum up, the procedures of load (effects) combination based on earthquake condition are generally summarized as follows.M = W · A · H, where M is the column bent moment, W is superstructure weight, A is peak ground acceleration (PGA), and H is column calculation height. The truck load is given by M = F · e, where F is the truck weight and e is the eccentricity between the vertical center axis of the truck and the vertical axis of the column. The effects of soil and secondary effect of gravity are ignored. The computing model of the bridge is shown in W = 500 ton, H = 6.0 m, and e = 4 m, and the bridge locates in Seattle, USA. Further it is assumed that the maximum number of trucks on one lane is two in one direction and in a special site heavy truck may have an average number of 1000. Moses [In order to illustrate the feasibility and clarity of the methodology of load combination described in the preceding section, a simple example of load combination simulation is presented here. In order to illustrate the method clearly, some simplifications are made, which include the assumption that the earthquake load is given by 0. Moses suggested0. Moses , 14. AccAccording to Figures According to the disadvantages of Ferry Borges-Castaneda model, the unreasonable assumption of Ghosn's improved model, and the merit of Turkstra's rule, a modified model of multihazard load combination is proposed in this paper. The model considers load effect combinations based on earthquake conditions.Compared with the traditional Ferry Borges-Castaneda method, the main advantages of this methodology include the following: it can prevent the complexity of sampling in multiple load sample spaces and it pays more attention to extreme load such as earthquake load. Based on load occurrence frequency, this methodology does not focus on one extreme load effect but on their joint effects. This methodology combines advantages of Ferry Borges-Castaneda model and idea of Turkstra's rule. It is like the Ferry Borges-Castaneda model in general and the Turkstra's in partial, whose implications are more definite and the thought is clear.τ , cumulative distribution of earthquake curve generally requires the root of 1051200 , while the new method generally needs only root of a small number. Besides, the product of multiple cumulative distributions is used to calculate the maximum value of load combination in this model, which will simplify multiple load combination greatly. If the probability of multiple extreme loads simultaneous occurrences is very low, their combination is the product of their respective cumulative distribution, which simplifies the calculation a lot.Another advantage is to prevent the cumulative error due to the root of large numbers of earthquake curve. Since the Ferry Borges-Castaneda model requires earthquake curve to be reduced within time interval T period is the most conservative. Furthermore, the results of different regions may be different because the earthquakes of the chosen regions are greatly different. For example, earthquakes in California are frequent, and thus the load combination is greatly affected by earthquake. Earthquakes in St. Paul are less frequent, and thus the impact is mainly from the trucks. For New York, the impacts from neither earthquake nor trucks can be ignored and the participation of earthquake and heavy trucks in the results is approximate.With respect to the simulation value, the means of the new method is the minimum and the maximum with reliability index, while the value of combination in


In this paper we present a 39-year old former athlete complaining with pain in his legs during long walk resembling to intermittent claudication. Color duplex scan described a popliteal artery with 10 mm in diameter with mural thrombus that caused stenosis 75% of lumen. Digital subtraction angiography demonstrated a stenosis of right popliteal artery. The suspicion for Cystic adventitial disease was set. The patient was operated on by posterior direct approach. After incision, a yellowish viscous material was observed in adventitia. Partial resection of the affected popliteal artery and replacement by an autogenous great saphenous vein graft was performed. Patient was dismissed on the seventh postoperative day, in good condition and without any complication.Cystic adventitial disease of the popliteal artery should be considered in the differential diagnosis of intermittent claudication, especially in former sportsmen patients. Partial resection of the affected popliteal artery and replacement by an autogenous great saphenous vain graft produces excellent results. Atkins A 39-year-old man former athlete was investigated for pain in the right popliteal fossa and lower leg caused by walking. The claudication distance was about fifty meters. The symptoms have started suddenly, approximately one month prior to hospitalization. The recovery time after running was sometimes about 10 min. Vascular risk factors were not reported. There was not history of trauma. The lower extremities didn’t reveal signs of ischemia and all the palpable pulses were present, but pulses were weaker as compared to the contralateral limb. Color duplex scan (CDS) described a popliteal artery with 10 mm in diameter with mural thrombus that caused stenosis 75% of lumen. Digital subtraction angiography (DSA) demonstrated a stenosis of right popliteal artery  and 2.The suspicion for CAD was set. The patient was operated on by posterior direct approach. After incision, a yellowish viscous material was observed in adventitia . PartialIn the postoperative period the patient received acetylsalicylic acid as antiplatelet agent. Patient was dismissed on the seventh postoperative day, in good condition and without any complication. Control CDS at discharge, after first and third month confirmed patent findings.Cystic adventitial disease (CAD) is rare vascular disease characterized by mucin containing cyst in the adventitial layer of the artery . CAD mosCAD is predominantly situated in the popliteal artery  but other authors have reported affection of the other localizations  . There aThe similar symptoms as a peripheral arterial disease and popliteal entrapment syndrome make differential diagnosis of the CAD of the popliteal artery very difficult. The cysts may compress the artery during muscle activity and flexion of the knee. That can be explanation of the pain reported by our patient. In the neutral position arterial pulses can be normal but they are less intense or disappear with knee flexion. In the present case, the popliteal and pedal pulses in the affected leg were weaker as compared to the contralateral limb, due to a stenotic arterial lesion visualized in the CDS and DSA.Ultrasonography and CDS may demonstrate lesions within the affected arterial wall. DSA may show curvilinear/spiral narrowing of vessels with a paucity of collaterals and an absence of post-stenotic dilatation . Other iThe irregularities and stenosis of the vessel lumen lead to unsure diagnosis. In our patient, age, symptoms, CDA and DSA was enough to set suspicion of CAD.Spontaneous resolution of CAD has been described . Timely In conclusion, CAD of the popliteal artery should be considered in the differential diagnosis of intermittent claudication, especially in former sportsmen patents. Ultrasound and DSA can be useful tools for setting diagnosis of CAD. Partial resection of the affected popliteal artery and replacement by an autogenous great saphenous vain graft produces excellent results.


Pseudomonas syringae pv. tomato DC3000 harboring the effector AvrRpm1, AvrRpt2 or AvrRps4. Specifically, the influence of bacterial titer on AvrRpm1-induced HR was investigated. Not only the amplitude, but also the timing of the maximum rate of the HR reaction was found to be dose-dependent. Finally, using vacuum infiltration, we were able quantify induction of phospholipase D activity after AvrRpm1 recognition in leaves labeled with 33PO4.One of the most studied defense reactions of plants against microbial pathogens is the hypersensitive response (HR). The HR is a complex multicellular process that involves programmed cell death at the site of infection. A standard method to quantify plant defense and the HR is to measure the release of cellular electrolytes into water after infiltration with pathogenic bacteria. In this type of experiment, the bacteria are typically delivered into the plant tissue through syringe infiltration. Here we report the development of a vacuum infiltration protocol that allows multiple plant lines to be infiltrated simultaneously and assayed for defense responses. Vacuum infiltration did not induce more wounding response in Arabidopsis leaf tissue than syringe inoculation, whereas throughput and reproducibility were improved. The method was used to study HR-induced electrolyte loss after treatment with the bacterium  Arabidopsis thaliana (hereafter Arabidopsis) mutants showing reduced pathogen triggered PCD but unaffected in their ability to restrict growth of avirulent bacteria , leading to activation of defense mechanisms and MAMP-triggered immunity (MTI) . Consequbacteria . HR indubacteria .In the post-genomic era, enormous progress has been made in the understanding of the underlying genetics of plant immunity. Large scale transcriptomic and proteomic studies have identified thousands of genes and gene products as directly or indirectly responding to effector elicitation . Candida+/H+ fluxes  and rpm1.3 (d rpm1.3  were sowLeaf discs were prepared using a cork borer (7 mm diameter) by punching them out from detached leaves against a piece of Styrofoam. Approximately 35 discs from 3 individual plants were made for each plant line/treatment and placed in 50 ml plastic centrifuge tubes. Thereafter discs were covered in 20 ml of the bacterial suspension and immediately placed in a SpeedVac vacuum concentrator  with the rotor removed. It is important that the lids of the centrifuge tubes are loosely tightened to allow free exchange of air between the tube and the surrounding, while keeping the solution and the discs in the tube. To avoid aerosolized vapor containing bacteria in the laboratory environment, the vacuum concentrator was connected to a vapor trapping system. Pressure was decreased until the bacterial suspension started boiling at room temperature and kept as such for 10 s. Pressure was then quickly increased and samples brought back to atmospheric conditions. Note that the majority of the discs are infiltrated when the negative pressure is removed. We usually observe between 75 and 100% efficiency in infiltration, i.e., discs that lose their buoyancy. If the infiltration efficiency is low, the vacuum treatment may be repeated. There is no need for the addition of a surfactant to aid the infiltration, in fact, this will cause the bacterial suspension to foam and limit contact with the leaf discs. After infiltration, discs were poured into a tea strainer, rinsed in deionized water and transferred to Petri dishes containing water. Finally, fully infiltrated discs (sunken discs) without any visible damage from the coring were transferred using plastic bacterial inoculation loops to 6 well cell cultivation plates filled with 10 ml deionized water (four discs in each well in 6 replicates per treatment). Conductivity was measured by moving 5 ml of the bathing solution to a 15 ml centrifuge tube in which a conductivity meter  was placed. The solution was thereafter returned to the plate well.Pseudomonas syringae pv. tomato DC3000 expressing the effector protein AvrRpm1, AvrRpt2 or AvrRps4, or a strain carrying an empty vector (DC3000)  containing kanamycin (50 mg l−1) and rifampicin (50 mg l−1) in a drawer in darkness at room temperature unless stated otherwise. P. syringae hrcC mutant  in the cuvette mode. OD600 = 1.0 correspond to 3.55∗108 CFU ml−1 as determined by serial dilution and plating. Trypan blue staining of discs was adapted from ((DC3000)  were proC mutant  were groted from . Four di2O and kept on light agitation on an orbital shaker. Discs were removed at indicated times and samples were acidified with 50 µl 1.6 M HCl follow by phase separation through the addition of 2 ml ethyl acetate. The organic phase was collected and the original sample was re-extracted with 2 ml of ethyl acetate before drying under a stream of nitrogen gas. Samples were dissolved in 50 µl methanol, run on an Agilent 1290 Infinity LC coupled to an Agilent 6410 triple quadrupole mass selective detector and the amounts of JA and free OPDA were quantified as described (In tissue quantification of glycerolipid-bound 12-Oxo-phytodienoic acid (OPDA) was performed as previously described . For theescribed , except 33PO4  over night as described (P. syringae expressing AvrRpm1 at OD600 = 0.1 as described above. Mock treatment was performed by inoculating plants with 10 mM MgCl2. Lipids were extracted as previously described (http://rsb.info.nih.gov/ij/). Unlabeled PA was measured in a total lipid extract obtained from two leaf discs by LC-MS/MS. A total lipid extract was obtained as described  using the five parameter Weibull regression model with a Box–Cox transformation of the concentration . Variances are expressed as standard deviation and significance was determined by Student’s ntration  (Scholzentration . (1)\docThe aim of this study was to develop a simple and quick protocol for scoring plants for effector-triggered defense responses. Vacuum infiltration has previously been used as a means to deliver bacteria into the leaf tissue of whole plants for the quantification of resistance and ETI . Vacuum 2 were compared to discs that had been submerged in MgCl2 and subjected to vacuum infiltration. As a positive control, leaf discs were frozen in liquid nitrogen and left to thaw at room temperature since this treatment activates a strong wounding response in terms of accumulation of lipid-bound OPDA  and both free and lipid-bound forms of its precursor 12-oxo-phytodienoic acid (OPDA), as these jasmonates are highly induced by mechanical wounding in Arabidopsis . Discs mund OPDA . The amound OPDA –2C. Neitund OPDA . Discs wund OPDA . No cellPseudomonas syringae expressing the effector AvrRpm1 cause a strong HR in Arabidopsis mediated through the R-protein RPM1  and infiltrated into leaf discs of wild-type Col-0 plants. Discs were washed in deionized water for 10 min, placed in 6 well culture plates filled with water and the conductivity of the bathing solution measured hourly for a total of eight hours  elicited the strongest plant defense response in terms of electrolyte leakage and was selected for use in further experiments. Notably, bacteria cultivated on Pseudomonas agar base  elicited only approximately half the ion leakage and initiation of the response reaction appeared to be delayed.We wanted to test how the cultivation conditions of the bacteria used for the vacuum infiltration affect the defense reaction of the plant; this in order to standardize the procedure. lleagues . The exaid media  were susht hours . BacteriP. syringae pv. glycinea synthesizes substantially higher levels of the phytotoxin coronatine when grown at 18 °C as compared to growth at 28 °C  using syringe or vacuum were compared. The deviation from the average in each experiment was determined 6 h after inoculation and represented in a box plot  , no significant difference in conductivity was observed between untreated samples and samples mock inoculated with MgCl2. Again demonstrating that the vacuum procedure does not cause more cell death and loss of electrolytes than the tissue preparation in itself. A clear induction of the HR was noted in samples infiltrated with bacteria expressing AvrRpt2 after eight hours. The same reaction was observed slightly later in AvrRps4-treated samples. At 24 h after infiltration, there was no significant difference in samples inoculated with virulent DC3000 and those inoculated with AvrRpt2 or AvrRps4. P. syringae pv. tomato DC3000 carries approximately 300 confirmed and putative virulence genes (P. syringae lacking the type III secretion system (hrcC mutant) did only provoke a very small release of electrolytes from leaf discs over 24 h (The AvrRpm1 effector induces a relatively fast HR in wild-type Col-0 plants . To exteFU ml−1) . Discs ice genes . P. syriver 24 h . The relver 24 h . The resP. syringae expressing AvrRpm1, from the same overnight culture, were simultaneously vacuum infiltrated into leaf discs of wild-type Col-0 and rpm1.3 plants . The rapid conductivity change was accompanied by a massive cell death where almost all of the mesophyll cells stained dark with trypan blue three hours after inoculation. A more moderate increase in electrolyte leakage was observed in Col-0 plants treated with lower bacterial titers . No statistical difference in the maximum electrolyte leakage and the appearance of cell death from trypan blue staining were observed when wild-type was inoculated with bacterial titers as high or higher than OD600 = 0.05. In this context, it is tempting to speculate that mutants hyperactive in HR or mutants that display kinetic differences in HR-PCD associated release of electrolytes may have been missed or overlooked in studies where high bacterial inoculum has been used. This since the number of bacteria necessary for activating HR-PCD is significantly lower than what is commonly used. Electrolyte release, as measured by conductivity, remained low at all concentrations throughout the experiment in rpm1.3 samples, although a small dose-dependent increase in electrolyte leakage was noticed. This increase in electrolytes is likely the result of activation of the plant RPS2 protein and other R proteins by the AvrRpm1 effector  and conductivity measured every 30 min for a total of eight hours  or mock treated with 10 mM MgCl2 and placed in deionized water. Lipids were extracted 0.5 and 4 h after infiltration and subsequently subjected to thin layer chromatography and autoradiography. Films were scanned and the intensity of the radiolabeled PA was determined , increase in PA radiolabel could be observed after 4 h in discs treated with the bacterium. PA levels in mock samples remained low over the four hours of the experiment. To support this, leaf material from Col-0 and rpm1.3 plants was vacuum infiltrated with P. syringae DC3000 avrRpm1 and analyzed for PA content with LC-MS/MS (Phosphatidic acid (PA) is a key signaling lipid involved in plant responses to both abiotic and biotic stresses . We havepromoter . Prior ttermined . A five-LC-MS/MS . A similP. syringae and we propose that this may be an important factor to consider when screening for mutants with perhaps weak or conditional phenotypes. The results also show that the status of the pathogen is important, as demonstrated by the effect of different media compositions and temperatures during pre-culture. However, we acknowledge the existence of additional factors, beyond our control, that affect both the kinetics and final amplitude of the conductivity curve.The term hypersensitiveness was introduced by We further demonstrate that the method is applicable to experiments when manual handling of the leaf material is preferentially avoided. The vacuum infiltration protocol presented here can be combined with several types of analytical methods and we have successfully used it in our lab to monitor early changes in metabolite content, gene expression and protein abundance after pathogen and chemical elicitation. The method is particularly useful when large quantities of inoculated leaf material are needed, for example when quantifying low abundant metabolites. Finally, we believe the described method will be an excellent tool to screen large populations of Arabidopsis mutants for aberrant defense response phenotypes.10.7717/peerj.1469/supp-1Figure S1P. syringae DC3000 or the hrcC mutant lacking type III secretion system at OD600 = 0.1. Mean and standard deviation where n = 6 are shown. The experiment was replicated with similar results.Wild-type Col-0 Arabidopsis leaf discs were vacuum infiltrated with virulent Click here for additional data file.10.7717/peerj.1469/supp-2Figure S2P. syringae expressing the effector AvrRpm1 at three different concentrations.A regression analysis was performed on electrolyte leakage data from two independent experiments  where leaf discs from Col-0 plants had been infiltrated with Click here for additional data file.10.7717/peerj.1469/supp-3Data S1Click here for additional data file.10.7717/peerj.1469/supp-4Supplemental Information 1The document describes a step by step protocol for the method described in the article.Click here for additional data file.10.7717/peerj.1469/supp-5Table S1Pseudomonas sp. Numbers inducate g/L media as reported by the manufacturers.Nutritional composition of three different media for cultivation of Click here for additional data file.10.7717/peerj.1469/supp-6Table S2P. syringae expressing the AvrRpm1 effector.Given in the table are the estimated parameters used for modeling electrolyte leakage from Col-0 plants inoculated with Click here for additional data file.