Mw = 7.3) with the depth at 20.3 km. The precursor of the Puerto earthquake is not detectable. TEC anomaly is not to be found related to the Jan Mayen Island earthquake (Mw = 6.8) at 13:43:24 on August 30, 2012 (UT). These earthquake-related TEC anomalies are detectable by using 2DPCA rather than PCA. They are localized nearby the epicenters of the Philippines and Puerto earthquakes.Two-dimensional principal component analysis (2DPCA) and principal component analysis (PCA) are used to examine the ionospheric total electron content (TEC) data during the time period from 00:00 on August 21 to 12: 45 on August 31 (UT), which are 10 days before the M = 7.6 Philippines earthquake at 12:47:34 on August 31, 2012 (UT) with the depth at 34.9 km. From the results by using 2DPCA, a TEC precursor of Philippines earthquake is found during the time period from 4:25 to 4:40 on August 28, 2012 (UT) with the duration time of at least 15 minutes. Another earthquake-related TEC anomaly is detectable for the time period from 04:35 to 04:40 on August 27, 2012 (UT) with the duration time of at least 5 minutes during the Puerto earthquake at 04: 37:20 on August 27, 2012 (UT) ( Principal component analysis (PCA) has been used to detect the ionospheric total electron content (TEC) precursors regardless of nonearthquake TEC disturbances from Lin's statistical work  about PCMw = 7.3) occurred at 04:37:20 on August 27, 2012 (UT) with the epicenter of  and the depth at 20.3 km. The second earthquake is the Jan Mayen Island earthquake (Mw = 6.8) occurred at 13:43:24 on August 30, 2012 (UT) with the epicenter of  and the depth at 9.9 km. The third earthquake is; the Philippines earthquake (Mw = 7.6) occurred at 12:47:34 on August 31, 2012 (UT) with the epicenter of  and the depth at 34.9 km . The examined ionospheric total electron content (TEC) data are during the time period from 00:00 on August 21 to 12:45 on August 31, 2012 (UT), which are 10 days before the Philippines earthquake. The TEC precursors were usually found in 5 days before the large earthquakes [In this paper, both two-dimensional principal component analysis 2DPCA) and principal component analysis (PCA) are performed to detect TEC anomaly related to three large earthquakes. The first earthquake is; the Puerto earthquake y=Wx  is defined,The trace of Wx is called covariance matrix. The alternation criterion is expressed by J(x) = tr(xTWx), where the data inner-scatter matrix Wx is computed in a straightforward manner byThe matrix x maximizing  data. Therefore the SSS problem will be caused by using PCA. The SSS problem causes larger data reconstruction error when data in the PCA domain are transformed back to their original domain, and corresponding principal eigenvalue is not very precise to represent main characteristics of data. The SSS problem will be removed when performing 2DPCA due to a different algorithm from the PCA. More detailed contents about the algorithm of 2DPCA can be read from the studies of Fukunnaga [The vector ximizing  correspoukunnaga , Kong etukunnaga , and Sanukunnaga .The previouly examined TEC data are processed by using PCA and 2DPCA, and no earthquake-related anomaly is found. Only during the time period from 04:20 to 04:45 on August 28, 2012 (UT) related to the Philippines earthquake and the time period from 04:35 to 04:45 on August 27, 2012 (UT) related to the Puerto earthquake, earthquake-related TEC anomalies are detectable by using 2DPCA. Therefore the procedure of TEC data processing during the previous time periods is represented in this study. Kp indices  on August 27 and 28, 2012 (UT) are small indicating that geomagnetic activity can not be responsible for the TEC anomaly.TEC data of the GIMs in For comparison, the TEC data of the GIMs during the time period from 04:20 to 04:45 on September 02, 2012 (UT) after the three earthquakes in 2DPCA is able to detect a TEC precursor nearby the epicenter of Philippines earthquake during the time period from 04:25 to 04:40 on August 28, 2012 (UT) with the duration time of at least 15 minutes. The TEC anomaly related to the Puerto earthquake nearby the epicenter is found during the time period 04:35 to 04:40 on August 27, 2012 (UT) with the duration time of at least 5 minutes. 2DPCA has the ability to detect the clear TEC anomalies related to the large earthquakes in this study rather than PCA. The reason which caused the TEC anomaly related to the Puerto earthquake should be shock acoustic wave. The results of Afraimovich et al.'s work –14.A TEC precursor has been detectable for the Philippines earthquake during the time period from 04:25 to 04:40 on August 28 (UT), and its duration time was at least 15 minutes. An earthquake-related TEC anomaly during the Puerto earthquake was found during time period from 04:35 to 04:40 on August 27, 2012 (UT), and its duration time was at least 5 minutes. TEC anomaly related to Jan Mayen Island earthquake was not detectable.


There is currently no software tool available to render the large number of structures available in molfile or SMILES format to LATE X source code. We here present mol2chemfig, a Python program that provides this capability. Its output is written in the syntax defined by the chemfig TE X package, which allows for the flexible and concise description of chemical structures and reaction mechanisms. The program is freely available both through a web interface and for local installation on the user’s computer. The code and accompanying documentation can be found at  While TE X and LATE X provide excellent built-in support for mathematics and physics, the same cannot be said for chemistry. Several TE X and LATE X packages have been devised to address this lack of built-in support and to facilitate the hand-coding of chemical structures. Older examples of this approach are xymtex  and ppchThe molfile  and the mol2chemfig is written in Python version 2 . It was The program, which is used from the command line, and its required libraries can be installed on the user’s computer. Alternatively, a server installation of the program can be accessed through a web interface. As a third option, a command line-driven thin web client is available, which accepts input in the same way as the locally installed program but then hands it off to the server installation. The web interface is also implemented in Python. The thin client is implemented in Lua. Since TeXLive contains a Lua interpreter, it runs the thin client without installing any other software. MikTex should to the same, but the authors have not confirmed this. The thin client also transparently accesses the most up-to-date version of mol2chemfig.The code in mol2chemfig is divided into several modules, whose functions are briefly outlined in Table 1. Using indigo, the molfile or SMILES input is read into the data structures defined by that library. If coordinates are missing (SMILES input) or the user has explicitly requested calculation of new ones, indigo is used to compute them.2. From the data structures populated by indigo, a tree representation of the molecule is built.3. The tree is traversed and annotated in order to satisfy the user-selected options for molecule rotation, bond scaling and so forth.4. The tree is rendered to chemfig code, which is returned.The chemfig code generated by mol2chemfig uses several custom macros. These macros must be loaded by LATE X documents in order to execute the generated code; they are contained within a separate small LATE X package (mol2chemfig.sty) that also takes care of loading the chemfig package. The chemfig package, in turn, requires and loads the TiKZ package Figure .As of this writing, both TiKZ and chemfig are available in the two major TE X distributions (MikTeX and TeXLive). The custom LATE X code for mol2chemfig is included in this program’s download.The use of the program and its features will here be illustrated with a few short examples; some more examples are contained in the documentation available through the program’s website, as well as in the Additional file The program is invoked from the command line. It takes exactly one argument, which by default is the name of a file containing a single molecule in molfile format. Output is written to stdout; output redirection will typically be used to write to a file instead. A miscellany of options is available to modify input and output. Invoking mol2chemfig -h or simply mol2chemfig will display the full list of options and their descriptions.Figure Outside of the ring, bond angles cannot be inferred and are specified explicitly between angular brackets. A preceding single colon denotes an absolute angle; an angle that is relative to the preceding bond can be specified with two colons, as in [::45]. Branches are again created by parentheses, as in line 5 of Figure While elegant and effective for hand-coded molecules, chemfig’s syntax for rings is somewhat orthogonal to the tree syntax used with other parts of the molecule and thus is not implemented in mol2chemfig; therefore, the generated code in Figure In the generated code, line-end comments and dispensable whitespace can be suppressed by passing the -z or --terse option  are placed so as to minimize interference with bonds attached to the atom in question. Figure In 4In the rendered structure, the bond angles seem just a little off; this is confirmed by looking at the generated code, which shows angles that are close to, but not quite exactly the multiples of 30 degrees. Instead of fixing up all those angles manually, we can ask mol2chemfig to recalculate them for us with the -u or --recalculate-coordinates option; this is shown in Figure Note that, in the recalculated structure, the orientations of some substituents are changed. These decisions are made by indigo, from which mol2chemfig adopts the coordinate calculation wholesale.The chemfig package allows us to define sub-molecules that we can reuse as parts of larger assemblies. Figure Let us assume we want to build the tripeptide shown in The submol mechanism operates essentially through string substitution; therefore, subsequent sub-molecules are simply connected across the last and first atoms of their respective main chains. In order to place those connecting bonds correctly, we thus need to take control of the entry and exit atoms for the sub-molecules. To find the correct ones, we can let mol2chemfig print the atom numbers, as illustrated in Figure Note that, in the sub-molecule definition generated for Figure The mol2chemfig program introduced here allows the conversion of molecules specified in molfile or SMILES format to the TE X-compatible format defined by the chemfig package. The generated code can be included in documents as is, or can be edited and integrated into larger chemfig graphics. We hope the program will be useful for authors who wish to illustrate the structures of organic molecules and reactions in LATE X documents.Project Name: mol2chemfigProject home page: http://chimpsky.uwaterloo.ca/mol2chemfig/Operating system(s): Linux, Windows, MacProgramming language: Python 2.7Other requirements: For full version: Python 2.7, the indigo toolkit and its prerequisite libraries; for thin client: a Lua interpreter. The LuaTeX binary that is available through TeXLive or MikTeX satisfies this requirement. Any Restrictions to use by non-academics: None. The code is freely available under the LATE X public license.The locally installable full version and the thin web client are packaged and available for download from the project’s website. The server setup that is used by both the web interface and the web client is not routinely available, but the required code and setup instructions will be shared upon request.The authors declare that they have no competing interests.EB-M: code implementation and testing, preparation of manuscript; MP: code implementation, preparation of manuscript. Both authors have read and approved the manuscript.mol2chemfig sample LATE X document.Click here for file


In academic medicine, women physicians lag behind their male counterparts in advancement and promotion to leadership positions. Lack of mentoring, among other factors, has been reported to contribute to this disparity. Peer mentoring has been reported as a successful alternative to the dyadic mentoring model for women interested in improving their academic productivity. We describe a facilitated peer mentoring program in our institution's department of medicine.Nineteen women enrolled in the program were divided into 5 groups. Each group had an assigned facilitator. Members of the respective groups met together with their facilitators at regular intervals during the 12 months of the project. A pre- and post-program evaluation consisting of a 25-item self-assessment of academic skills, self-efficacy, and academic career satisfaction was administered to each participant.P = 0.0001), improvement in skills necessary to effectively search the medical literature , an improvement in their ability to write a comprehensive review article , and an improvement in their ability to critically evaluate the medical literature .At the end of 12 months, a total of 9 manuscripts were submitted to peer-reviewed journals, 6 of which are in press or have been published, and another 2 of which have been invited to be revised and resubmitted. At the end of the program, participants reported an increase in their satisfaction with academic achievement (mean score increase, 2.32 to 3.63; This facilitated peer mentoring program demonstrated a positive impact on the academic skills and manuscript writing for junior women faculty. This 1-year program required minimal institutional resources, and suggests a need for further study of this and other mentoring programs for women faculty. Women physicians continue to lag behind their male counterparts in academic advancement and in promotion to leadership positions . Women hStatistics regarding women faculty in leadership positions are equally disconcerting. In 2010, only 13% of department chairs were female, with numerous medical schools reporting never having had a woman in a department chair or dean position -19. LackMentoring has long been an essential component of career advancement within academic medicine and other disciplines -10. UndeReports of women faculty's greater appreciation of the process of collaboration , and difThe Department of Medicine at Mayo Clinic, Rochester, Minnesota, has 153 women  faculty. Gender disparities in academic rank and leadership opportunities led the department's leadership team to evaluate strategies to close the gap. Focus group discussions and surveys suggested that a lack of mentoring and social isolation were common themes reported by women faculty. Peer mentoring was considered to be a critical ingredient to a multipronged approach to address these issues. By means of this paper, we aim to discuss the process and outcomes of an expanded 12-month facilitated peer mentoring project. Our primary objective was to study the impact of facilitated peer mentoring on scholarly output, specifically manuscripts submitted for publication. Secondary objectives were to study the impact of peer mentoring on self-efficacy of writing skills and networking.This project was declared exempt by the Mayo Clinic Institutional Review Board.n = 106) were invited to participate in the project and asked to submit names of peers of similar academic rank with whom they wished to potentially work in a group setting.All women faculty in the Department of Medicine at Mayo Clinic, Rochester, Minnesota, who hold the rank of instructor or assistant professor , the groups were not required to meet on a specific day. A tentative 12-month timeline of projects, primary authors for the manuscripts, and target journals for manuscript submission was also developed.During the year-long program, facilitators were encouraged to meet regularly with their groups at intervals of every 2 to 4 weeks, participate in brainstorming sessions, review the suitability of topics for development and manuscript submission, edit drafts, and provide additional individual and project mentoring on an ad hoc basis. Additionally, phone conferences were scheduled for each month among the 4 facilitators.t-test was used to compare serial survey results, and a P value of < 0.05 was considered statistically significant. The qualitative comments were reviewed and categorized into either positive/value added or constructive/suggested improvement comments.At the end of the program, the initial self-assessment survey was repeated, with the addition of several questions allowing free-text response options specifically aimed to assess the value and effectiveness of the program to participants. A paired Five peer mentoring groups, comprising a total of 19 as mentees and 4 as facilitators, formed the project group. Of the 19 mentees, 17 were on faculty in the Department of Medicine of Mayo Clinic, Rochester, Minnesota. The mean number of years on faculty was 6.20 . Six of the mentees held an academic rank of assistant professor, 11 had achieved the academic rank of instructor, and the clinical fellow and nurse practitioner had no academic rank. The participants were divided into 5 groups each with 3 to 5 mentees and 1 facilitator.Groups were encouraged to meet once weekly, and to meet at least monthly with their facilitator. The actual meeting frequency varied widely from every week to once every 4 to 6 weeks. In one group, the facilitator joined the mentees for most meetings. Others met with their mentees at least once a month. Regardless of meeting frequency, mentees had regular e-mail and phone connectivity with other mentees and facilitators between meeting times. The facilitators had a monthly in-person or phone meeting during which they updated the others, discussed successes, problems and roadblocks, and shared best practices.At the end of the 12-month project, 9 manuscripts were submitted  by the 5 groups. Of the 9 submitted, 6 papers are in press or have been published and another 2 have been invited to be revised and resubmitted. In addition, 1 peer mentoring subspecialty group designed and completed a clinical research project, and at the time of manuscript writing had presented their findings at a national meeting. They are working on completing the manuscript related to this project. The distribution of papers and academic work completed was not equal between the groups: 1 group completed 3 manuscripts, 3 groups completed2 manuscripts, and 1 group completed1 manuscript. Another group did not focus on manuscript writing, but on clinical protocol design and execution. In addition, 1 of the groups who completed 2 manuscripts also completed and submitted a grant.Although each mentor and participant signed an agreement to consistently participate in the group mentoring sessions, the individual groups were not asked to commit to a specific frequency of meetings and were not required to document number and length of interactions. Thus, data on the distribution of frequency or total number of hours the groups met are not available.Participation in the peer mentoring program was associated with the achievement of several additional academic and career goals. Among these participants were 2 individuals who pursued advanced degrees: a masters of public health and a masters in academic medicine, and the appointment of 1 individual as a divisional practice chair. Four individuals received 5 grants . These achievements were distributed throughout the groups without concentration in the groups with the higher manuscript completion.Self-efficacy and career goal data were obtained from the study participants at baseline and after the study period through the self-assessment survey and is represented in Table P = 0.0001) and improved skills necessary for academic success (P = 0.0083). As shown in Table P = 0.0009); use EndNote to manage references ; write a comprehensive review article ; and critically evaluate the medical literature . Skills related to developing clinical research projects from original clinical questions were not enhanced following participation in the program , whereas understanding the process for submitting research protocols for institutional funding was gained . Study participants also stated that the confidence in their ability to assist residents in designing, completing, and publishing academic projects improved over the course of the program . At the conclusion of the 12-month study period, there was also a significant improvement in perceived ability to effectively network with other physicians in the institution to find opportunities for collaboration  and an improved understanding of how to identify an effective mentor . Qualitative feedback from participants is noted in Table At the conclusion of the mentoring program, participants reported an increase in their satisfaction with academic achievement  and with the overall interaction of their individual peer mentoring groups . The facilitators' satisfaction with the quality of the papers was also high, with a mean satisfaction score of 4.25 . All facilitators and 89% of the peer participants reported that they were willing to both facilitate future peer mentoring groups and recommend the program to other faculty members.A recent call for cultural change acknowledged the disappointing progress in the advancement of women in academic medicine . This prPeer mentoring, as used in this project, has been described as an effective mentoring method for both male and female faculty ,16,19-21In our facilitated peer mentoring program, participants were, by design, required to work in a collaborative manner within their own peer group. Also, when queried, the mentees reported an improvement in their ability to effectively network with other physicians to find opportunities for collaboration. Our questions, as posed, did not delineate participants reporting an improvement in networking skills in isolation; rather, it was asked in the context of networking as a way to find opportunities for collaboration.Our program also explored the efficacy of a peer-to-peer mentoring group guided by a more senior faculty member who was gender-matched and acted as a facilitator. The peer mentoring groups in this study were loosely constructed around 3 models of collaboration described by Schneider ,29. Our There are a number of possible explanations for the variable outcomes among the mentoring groups. Facilitator and participant engagement, discrepancies in baseline academic skills, and frequency of group interactions all could have played a role in the degree of each group's success. As above, the facilitators and participants were not required to log meeting times or report on the degree of individual engagement, but all participants did sign a good-faith agreement to remain active participants. Of note, the group that completed only 1 manuscript was comprised of individuals from different specialty divisions, whereas the other groups included individuals from the same specialty or division. This diversity in background may have led to a slower ramp-up period for this group.In response to the survey item, "I have the skills necessary to take a clinical question and develop a clinical research project," peer participants' responses did not show a statistically significant improvement over time. This result was not unexpected, perhaps because the project was designed to enhance the writing skills of the peer groups by producing clinical review articles or resurrecting and publishing results from a previously acquired data set. The relatively limited 12-month time frame prompted a stronger emphasis on publishing, which constitutes a solid criterion for academic promotion at most academic medical centers, and less emphasis on idea generation and research project initiation.As in traditional mentoring relationships, although the gist of instruction regarding manuscript writing was likely similar across all groups, the timing and method of instruction would have varied based on immediacy of issues being discussed in the group, the content of the manuscript, the baseline knowledge of the group members, and the interaction between the facilitators and mentees. Item 14 on the assessment survey, "I have identified an effective mentor," showed a nonsignificant improvement at the end of the program; we are unsure if this means that the various groups were dissatisfied with the mentor assigned to them or if this reflects the participant's response to finding an effective traditional one-on-one mentor.This program was not designed to serve the facilitators in any way; there were, however, unexpected benefits from their perspective. These included the opportunity to interact with motivated early-career faculty, to participate in a novel and exciting department-wide program, and to serve as coauthor on papers with a variety of fresh topics. Thus, this new program itself was truly bidirectional in its benefits, providing positive effects among both participants and facilitators.This study is not without limitations. First, although this study spanned a full year, we do not have data on long-term outcomes beyond the project year. It remains to be seen whether the favorable effects observed here are in fact sustained and whether they ultimately lead to academic promotion and increased leadership roles among these women faculty. Secondly, in an effort to be evenhanded in allocating opportunities, this facilitated peer mentoring intervention was provided to all interested junior women faculty within the department of medicine. Traditional one-on-one mentoring continues to be the mainstay for mentoring models in the department, and this project was introduced to engage faculty without such mentors, which likely accounted for the lower number of women who signed up for the program. We did not compare the academic achievements of the faculty who did not sign up for the program with those who did, as this was beyond the scope of the study. Third, in the absence of a comparative arm that might have included either another intervention or no intervention, it is impossible to assess accurately the true positive impact of this facilitated peer mentoring approach. It remains possible that the program self-selected for highly motivated individuals who might have been productive independent of their participation in the program. We point out that this third criticism could be raised regardless of details on the participants or specifics related to the program, and that it remains a criticism of any mentoring program that does not include a control group. Nevertheless, we also point out that this program's heavy emphasis on introducing the mentees to the practical aspects of acquiring clinical research skills, writing papers, and getting these papers published likely had a direct effect on the favorable survey and productivity outcomes described here.Future efforts may include extending the duration of the intervention, assess long-term outcomes, and seek comparative data that might result from studying other approaches. Although the peer participants in our women-only program did not strongly advocate same-gender mentorship, future studies might also focus on whether different mentoring approaches might resonate better with some groups versus others based on gender distribution.Mentors are a valuable resource within academic medical centers, and the spirit of altruism that drives such mentoring also drives the academic accomplishment of faculty at most academic medical centers. The current project extended such mentoring opportunities to junior women faculty, demonstrated preliminary positive outcomes in terms of academic accomplishment, and suggests a need for further study of this and other mentoring programs for women faculty.The authors declare that they have no competing interests.All authors read and approved the final manuscript; all authors contributed to study design, results analysis and write up of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/12/14/prepub


There is extensive evidence that regular physical activity confers numerous health benefits. Despite this, high rates of physical inactivity prevail among older adults. This study aimed to ascertain if incentives could be effective in motivating physical activity through improving uptake of walking programs, either with or without an enrolment fee to cover corresponding costs.A discrete-choice conjoint survey was fielded to a national sample of older adults in Singapore. Each respondent was given ten pairs of hypothetical walking programs and asked to choose the option they preferred. Each option varied along several dimensions, including the level and type  of incentive and an enrolment fee. For each option, they were asked how likely they would be to join their preferred program. A random utility model (RUM) was used to analyze the responses.Results suggest that a free 6-month program with a $500 cash incentive would generate enrolment rates of 58.5%; charging $50 to enroll lowers this to 55.7%. In terms of incentive type, cash payments were the most preferred incentive but not significantly different from supermarket vouchers. Both were preferred to health savings credits and sporting goods vouchers. Concerns of adverse selection were minimal because those who were inactive represented at least 72% of new participants for any offered program(s) and were the majority.Study results demonstrate the potential for even modest incentives to increase program uptake among inactive older adults. Moreover, although cash was the most preferred option, supermarket vouchers, which could potentially be purchased at a discount, were a close alternative. Results also suggest that an enrolment fee is a viable option to offset the costs of incentives as it has only minimal impact on participation. There is extensive evidence that physical activity exerts a strong protective effect on the health of older adults. This includes reducing the risk and progression of non-communicable diseases and other disabling conditions -4, improWalking is an accessible form of physical activity with proven health benefits  that canBy increasing the benefits of participation, economic theory suggests that the use of incentives could increase participation rates in structured walking programs. Incentives have been shown to be effective in positively shaping various health behaviors and health outcomes -24 althoIn this stated preference conjoint study we estimate the net effect of several types/magnitudes of incentives and enrolment fees for candidate walking programs among a sample of older, multi-ethnic adults in Singapore. We hypothesize that incentives will increase the stated likelihood of participation in the programs regardless of the presence of an enrolment fee. Conjoint analysis is well suited for this task because it allows for generating predictions of program effects in a low-cost and efficient manner for several candidate programs, the most promising of which can then be tested in a randomized controlled trial to quantify the effects on both uptake and outcomes.The conjoint survey was administered in 2011 by a local survey firm to a national sample of 1,000 Singaporeans aged 50 and over. Trained interviewers took written consent and administered the paper and pencil survey in respondents’ homes. The interviews were conducted in four languages: English, Mandarin, Malay and Tamil.Very likely” or “Somewhat likely”, they were assumed to join their preferred program. Prior to fielding the conjoint questions, participants were introduced to the various program features and were told that the programs lasted for 6 months, were to be conducted in a group setting, and that each session comprised of 45 minutes of walking and 15 minutes of stretching, and that a non-refundable enrolment fee was to be paid in advance but that if they met program goals a financial incentive would be provided at the conclusion of the program. Other aspects of the programs varied along six dimensions (six attributes) as shown in Table The survey contained questions concerning socio-demographic characteristics and health status. Data on past and present physical activity levels were also collected as were attitudes towards walking programs. The core of the survey was the discrete choice conjoint experiment. Each respondent was given ten pairs of hypothetical programs and asked to choose the option they preferred. They were then asked whether or not they would join their preferred program if given the option. If they responded “All attributes and their levels were finalized through a series of focus groups and cognitive interviews. Travel time and related costs were included as travel considerations were likely to affect program participation. There were 4 levels for travel time ranging from 15 minutes to 45 minutes and 3 for travel cost: $0, $2 and $5, which approximate the cost of public transportation as well as the effect of a potential travel subsidy that offsets travel costs. A key component of the program was the inclusion of financial incentives. As is common in programs of this sort, various types of financial incentives were offered  credits and sporting goods vouchers) with the amount of incentive ranging from $150 to $450 over the 6-month period. Finally, a one-time enrolment fee which varied from $0 (a free program), $20 and $50 was also included to quantify the effect of these fees on program participation.For each of the ten pairs of hypothetical walking programs, participants were asked to choose their preferred program and then indicate how likely they would be to join the program if it were offered to them. The response options consisted of four choices: “Very likely”, “Somewhat likely”, “Somewhat unlikely” and “Very unlikely”. An example choice task is reproduced in Figure Since our survey contained 6 attributes (each with either 3 or 4 levels), it was not feasible to show respondents every possible combination of attributes and levels. Therefore, following common practice in DCEs , we prodThe study was approved by the National University of Singapore IRB, and was performed in accordance with the Declaration of Helsinki.A random utility model (RUM) was used to analyze responses to the conjoint survey tasks. This model assumes that the utility associated with each program is a function of its attribute levels:i’s utility for scenario j in t tasks. vi represents the observable components of the utility function and is composed of a vector of all program attribute levels excluding the incentive payment (xjt) and the incentive payment (Cjt). A model which specified incentive payment levels as categorical  was found to produce estimates that were not significantly different from those generated from a linear specification. For ease of exposition, the incentive payment was coded as a linear term. All other attributes were effects-coded. Effects coding allows for easy comparisons of the relative importance of the levels as the sum of the preference weights within an attribute will be zero. Linear coding yields a single coefficient for an attribute. In this case, the coefficient on the incentive payment term is assumed to be linear within the range of incentives offered, thus allowing the coefficient to be interpreted as the marginal utility of an additional dollar of incentives. In this specification, rocedure  . If greater, they were assumed to join the program. We present results for a free program and for one with a $50 enrolment fee. In addition to the above, we also present the proportion of those enrolling who were already meeting activity guidelines, as incentives for these individuals merely represents a transfer payment and are not expected to increase activity levels.Table Regression results from the conjoint analysis are presented in Additional file The relative value of various types of incentives can be seen in Table Figure Figure The objective of this study was to identify a promising walking program for older, multi-ethnic adults in Singapore, and then to test the effects on stated enrolment when incentives and/or an enrolment fee are offered. Not surprisingly, results showed that respondents most prefer the least onerous program with the greatest benefits. This is one involving minimal travel time and cost, comprising the least number of weekly activity sessions (1 session per week), offering a 450SGD cash incentive and without any enrolment fee. Although minimal, one brisk walking session per week would account for 30% of recommended weekly activity if participants walk at the recommend pace. Moreover, this level of activity is still associated with some health benefits, especially among sedentary adults -31. TherA key finding of this study is that financial incentives increase predicted uptake for all programs offered and more so among the least active older adults. For the hypothetical six month program offered, providing SGD$150 for meeting participation goals (SGD$25 ≈ USD20 monthly over 6 months assuming 1SGD = 1.25USD) increases predicted program uptake by 8.5% (assuming no enrolment fee). Raising this to SGD$450 (SGD$75 ≈ USD 60 monthly over 6 months) increases uptake by 13%. These results demonstrate the potential for even modest incentives to increase uptake. Moreover, although cash was clearly the most preferred option, supermarket vouchers, which could potentially be purchased in bulk at a discount, were a close alternative. Health savings account credits and sporting goods vouchers/equipment are not recommended as respondents place a lower value on these rewards and thus they are less of a motivator.Although we show that incentives increase program uptake and have been shown to be successful in improving outcomes in prior activity studies ,32, theygreater stated effect on enrolment for inactive participants. This result may not be surprising given that active participants may have their routines well established and may be less interested in these types of programs. A financial incentive may also be less of a motivation to them, as they have already made the decision to be active. Nevertheless, active participants may benefit through accruing more health benefits to the extent that incentives induce additional physical activity [When incentives are provided, there is always the concern of adverse selection. In this case the concern is that the incentives go to those who would have been doing the required amounts of activity even without the incentives. Although it is unclear whether these results would generalize to other older adult populations, we found that incentives have a activity -35. MoneAlthough the first of its kind in a multi-ethnic sample of older adults, this study adds to growing evidence of the potential for financial incentives to motivate health behavior change ,25,36,37The use of incentives has raised concerns about a “crowding out effect”. This would result if the incentives undermine intrinsic motivation. Yet, although theory suggests this could be the case, there is no empirical evidence to support it . SeveralStudy findings add to the growing literature that incentives are a feasible and potentially effective strategy to increase program uptake among older adults. Although cash is the most preferred incentive type, supermarket vouchers are a close alternative. To offset associated costs, enrolment fees are a viable option. Future research should assess the affordability of incentive use and sustainability of model programs in addition to identifying other strategies to encourage sustained activity of older adults.ACSM: America college of sports medicine; AHF: American heart foundation; NCD: Non-communicable diseases; HPB: Health promotion board; RUM: Random utility model.The authors declare that they have no competing interests.EAF, MAF and YTT contributed to the conception and design of the project. MAF performed all analyses and MB assisted with interpretation. MAF and YTT completed the first draft while EAF provided critical revision. All authors edited and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/141/prepubRegression results.Click here for file


INSL3/RXFP2 genes and the spatiotemporal expression of INSL3 in the nonhuman primate may shed light on the functional aspects of the system in humans.Although insulin-like 3 (INSL3) has been identified in the gonad of both sexes in many species, there are only limited reports on the distribution of INSL3 and its receptor, relaxin/insulin-like family peptide receptor 2 (RXFP2), in the primate ovary. Since the hormone-receptor pair is believed to play a role in female reproduction, investigating the transcription of Database mining, molecular and immunological methods were applied.INSL3 transcript and three novel splice variant transcripts of RXFP2 were identified in the ovary of rhesus macaques. While the full-length RXFP2 transcript is barely detectable in granulosa cells during the periovulatory period, INSL3 transcript and protein are highly abundant in theca cells surrounding antral follicles. Moreover, the INSL3 level in follicular fluid is 3-4 times higher than that in female serum which remains low throughout the menstrual cycle.One single The presence of INSL3 and its receptor in the ovary implies a potential role of the ligand-receptor pair in female reproduction in nonhuman primates. However, the existence of multiple splice variants of RXFP2 indicates a very complex nature of the hormone-receptor system. Insl3 knockout mice [Insl3/RXFP2 genes have been linked to a small number of human cryptorchidism cases [Insulin-like 3 (INSL3), also known as Leydig cell insulin-like peptide (Ley-IL) and relaxin-like factor (RLF), was originally discovered in the porcine during a search for testis-specific genes . Closelyout mice ,5. Althosm cases -10, funcExpression of the INSL3-RXFP2 system has been detected in many mammalian species including rodents, domestic and wild animals as well as primates -17. The INSL3 and RXFP2 transcripts and splice variants in the ovary of rhesus monkeys, and investigated the tissue and cellular localization of INSL3 at both mRNA and protein levels. Due to the close resemblance of reproductive physiology between macaque species and humans, these findings may provide insights into the functional significance of the INSL3-RXFP2 signalling pathway in human female fertility.In the present study we report the identification and expression of the INSL3-RXFP2 system in a nonhuman primate species, the rhesus macaque. Taking molecular and immunological approaches, we identified the macaque Macaque tissues were collected from adult rhesus monkeys between 5 and 15 years of age through a tissue distribution program provided by the Division of Animal Resources (DAR) at the Oregon National Primate Research Center (ONPRC). All animal protocols and procedures were approved by the Institutional Animal Care and Use Committee (IACUC) of Oregon Health & Science University (OHSU) and were conducted in accordance with the National Institute of Health's Guide for the Care and Use of Laboratory Animals.INSL3 mRNA sequence (NM_005543) was used to search a rhesus macaque genome database [INSL3 homologue, and gene-specific primers (Table INSL3 mRNA sequence from a monkey testis cDNA pool. Using a predicted macaque RXFP2 mRNA sequence (XM_001118169.1) as template, we designed a specific primer . The exon-intron boundaries in macaque RXFP2 mRNA were determined by alignment with the human RXFP2 mRNA sequence using Vector NTI software .Human database  and a nodatabase  for the rs Table  were desnce XM_00118169.1 RXFP2-specific primers  in a DNA Engine thermal cycler . The PCR amplicons were cloned into the PCR cloning vector pGEMT  and subjected to DNA sequencing.Macaque rs Table  spanningFor oocyte and granulosa cell collection, the controlled ovarian stimulation (COS) protocol, follicular aspiration, and oocyte collection procedures were performed as previously reported ,22. Huma12-18 primers and Superscript III Reverse Transcriptase (Invitrogen). RT-PCR primer pairs and corresponding annealing temperatures are listed in Table PPIA  served as an internal control.Total RNA was extracted from monkey tissues and granulosa cells using Trizol reagent (Invitrogen), and from monkey oocytes and laser captured theca cells using Absolutely RNA Nanoprep Kit  following the recommended manufacturers' protocols. The integrity of total RNA was assessed using an Agilent 2100 Bioanalyzer . Total RNA was then treated with RNase-free DNase  and reverse-transcribed into cDNA with Oligo (dT)INSL3 and RXFP2 amplicons obtained by RT-PCR were cloned into the pGEMT vector (Promega). Monkey ovaries and testes were fixed in 4% paraformaldehyde, embedded in paraffin, and sectioned at 5-μm intervals. α-35S-UTP-labeled antisense and sense probes were generated by the Riboprobe T7/SP6 combination systems (Promega). Hybridization was carried out as previously described [35S-UTP-labeled sense probe were used as a negative control.Selected macaque escribed ,24. The Macaque tissue total protein was extracted using 1× RIPA buffer  containing 1× Complete Protease Inhibitor Cocktail . Eighty μg of total protein in 1× Laemmli sample buffer (Bio-Rad Laboratories) was heated at 85°C for 5 minutes and then cooled to room temperature before being separated on a precast 4-20% polyacrylamide Tris-HCl gel (Bio-Rad Laboratories). The protein was transferred onto a PVDF membrane . The membrane with immobilized protein was blocked with StartingBlock T20 (TBS) Blocking Buffer  first, and then blotted with a rabbit anti-INSL3 antibody  at a 1:1,000 dilution. HRP-conjugated anti-rabbit IgG (Santa Cruz Biotechnology) was used as secondary antibody at a 1:10,000 dilution. Following a 5-minute incubation with ECL Western blotting substrate (Millipore), the signal was visualized on a Kodak Biomax light film . The size of the detected protein band was determined by the PageRuler™ Plus Prestained Protein Ladder  separated on the same gel. The same membrane was stripped and re-blotted with HRP-conjugated mouse monoclonal beta-ACTIN  antibody , which served as an internal loading control.Macaque ovary paraffin sections at 5-μm thickness were used for IHC. Before incubating with a rabbit anti-INSL3 antibody  which recognizes INSL3 precursor, the ovarian sections were deparaffinised, hydrated, and blocked with a universal blocking reagent named CAS BLOCK™(Invitrogen). IHC was performed with EnVision™dual link HRP (DAB+) kit  according to the manufacturer's manual. The INSL3 antibody was diluted at 1:2,000, and the sections were counterstained with hematoxylin. Normal rabbit serum-stained sections were used as a negative control.Individual macaque blood and follicular fluid samples were collected from 3-4 different monkeys and measured separately for INSL3 level with an INSL3 (human)-RIA kit  following the manufacturer's protocol. The kit has a standard range of 10-1280 pg/ml with a minimum detectable range of 20.17 pg/ml. The intra- and inter-assay coefficient of variation is 5-7% and 12-15%, respectively. Female serum at follicular phase was collected from day 1 to day 14 of the menstrual cycle, while luteal phase serum was collected from day 15 to day 28 of the cycle. Follicular fluid was collected from preovulatory follicles during COS protocols . FollicuAll experiments described above were replicated at least three times with biological samples derived from different animals. Tissues and cells collected from each animal were assayed individually.INSL3 mRNA sequence without the poly(A) tail was amplified from the monkey testis cDNA pool and deposited in the GenBank database [INSL3 homologue comprises 2 exons and shares ~93% identity with its human counterpart at the nucleotide level. The deduced macaque INSL3 precursor protein is composed of 131 amino acids which are ~90% identical with that in human INSL3 (NP_005534.2).A full-length macaque database  with accRXFP2 mRNA was amplified by 5'-RACE with cDNA derived from the macaque uterus (GU326354), and the protein deduced from RXFP2 coding region shares 96% identity with human RXFP2 protein (NP_570718.1). Macaque RXFP2 mRNA consists of 18 exons. To demonstrate whether RXFP2 splice variants exist in female reproductive system of rhesus macaques, we amplified exons 6 to 17 in the ovary and uterus by RT-PCR , has deleted exons 8, 11 and 15  and luteinized granulosa cells (LGC). The experiment was repeated with oocytes of various stages  and ovarian somatic cells derived from multiple animals, and the full-length RXFP2 transcript was never amplified from either oocytes or thecal cells.The transcription of R Figure . Whereasin situ hybridization detected abundant expression of INSL3 mRNA in the theca layers surrounding antral follicles, but not those surrounding secondary follicles  endocrine system unique to higher primates and absent in lower primates and nonprimates . Thus, nINSL3-RXFP2 have been studied in primates in a limited manner. Previously an alternative splicing of INSL3, which possesses an extra exon (exon 1A) between exons 1 and 2, has been reported in marmoset monkeys [INSL3 does not exist in rhesus macaques for the primers spanning both exons consistently amplified one single transcript from different tissues derived from several monkeys. INSL3 mRNA has been detected in various mammalian tissues, mostly only by highly sensitive RT-PCR. In the marmoset monkey, INSL3 transcript was only identified in the testis by Northern blot and the ovarian corpora lutea by RT-PCR [INSL3 mRNA in the hypothalamus and pituitary in the macaque. The hypothalamic expression of INSL3 transcript is consistent with a previous report in the cow, but has not been observed in rodents [The structure and expression of  monkeys  and humay RT-PCR . Besides rodents . However rodents . It remaRXFP2 is transcribed in several tissues including the hypothalamus, ovary and uterus. A previous study showed that RXFP2 was expressed in the testis but not in the ovary in humans [RXFP2 transcript was amplified by primers spanning between exons 11 and 15 in our experiment, the amplification of 3'-UTR region of human RXFP2 would include various spliced transcripts. Indeed, the identification of three RXFP2 splice variants was previously reported in the human uterus and adrenal glands [LGR8.1 which lacks exon 11 of RXFP2, can be found in the GenBank (AY899851.1). None of the three splice variants identified from the macaque corresponds exactly to LGR8.1, although two of them  are missing exon 11. We noticed that the primers used to amplify LGR8.1 span exons 7-13 of human RXFP2, which could explain why the primer pair failed to identify the missing exon 15 that was found in all three splice variants reported in the current study. Unlike LGR8.1 that can be translated into a truncated RXFP2 protein with partial leucine-rich repeat (LRR) region, translation of all three RXFP2 splice variants identified in the current study can cause early termination of the full-length open reading frame (ORF) prior to the seven-transmembrane (7TM) domain-coding region  protein-coupled receptor (GPCR). Although some recent evidence shows that the oocyte maturation in response to LH may be independent of Gi proteins [RXFP2 transcript or protein in the germinal vesicle intact oocyte, so any effect of INSL3 on maturation must be mediated through the cumulus granulosa cells. More functional studies in higher species will be required to solve this puzzle. The failure of RXFP2 detection in the ovary could be due to very low-level expression of GPCRs in individual cells, the specificity of antibodies applied, and/or an unknown nature of RXFP2 gene transcription and translation. The presence of three differentially spliced transcripts of RXFP2 in the ovary, and the localization of full-length RXFP2 mRNA in granulosa cells has not been previously reported. The majority of primate genes produce splice variant transcripts [RXFP2 encode truncated protein isoforms without the seven-transmembrane domain, these protein products are unlikely to function as GPCRs even if they do exist [RXFP2 transcript in the ovary is specific to rhesus monkeys.Within the ovary, INSL3 transcript and peptide are predominantly expressed in the theca cells surrounding antral follicles and weakly detectable in the corpus luteum. This finding is similar to previous observations in the cow  as well proteins , the hignscripts ; it is ido exist ,40. It aINSL3-RXFP2 transcripts and determined the tissue and cellular distribution of INSL3 in the ovary of rhesus macaque monkeys. Despite the rapid increasing number of studies on this newly identified ligand-receptor pair, the expression and function of the system appear much more complex than originally thought, especially in more advanced species. Further biochemical and pharmacological studies in nonhuman primates may eventually reveal the roles of INSL3 and the significance of multiple splice variants of RXFP2 in the ovary.Taken together, we identified the The authors declare that they have no competing interests.INSL3 and RXFP2 transcripts and splice variants, as well as PCR amplification of INSL3 from multiple macaque tissues. SY performed Western blot and IHC for INSL3. MCP participated in sample preparation and collection. JTJ conducted the measurement and analysis of INSL3 in the follicular fluid and blood. XW carried out INSL3 and RXFP2 sequence alignment, analysis, and manuscript preparation. All authors read and approved the final manuscript.CBH carried out the identification of


To investigate the effectiveness of IgM-enriched immunoglobulins (IgM-eIVIG) in reducing short-term mortality of neonates with proven late-onset sepsis.All VLBW infants from January 2008 to December 2012 with positive blood culture beyond 72 hours of life were enrolled in a retrospective cohort study. Newborns born after June 2010 were treated with IgM-eIVIG, 250 mg/kg/day iv for three days in addition to standard antibiotic regimen and compared to an historical cohort born before June 2010, receiving antimicrobial regimen alone. Short-term mortality (i.e. death within 7 and 21 days from treatment) was the primary outcome. Secondary outcomes were: total mortality, intraventricular hemorrhage, necrotizing enterocolitis, periventricular leukomalacia, bronchopulmonary dysplasia at discharge.79 neonates (40 cases) were enrolled. No difference in birth weight, gestational age or SNAP II score (disease severity score) were found. Significantly reduced short-term mortality was found in treated infants  considering all microbial aetiologies and the subgroup affected by Candida spp. Secondary outcomes were not different between groups.This hypothesis-generator study shows that IgM-eIVIG is an effective adjuvant therapy in VLBW infants with proven sepsis. Randomized controlled trials are warranted to confirm this pilot observation. An immature innate immune response is a major factor in the high rate of systemic infections among very low birth weight newborns. Preterm babies have less endogenous immunoglobulins whose transplacental transfer mainly occurs after 32 weeks of gestation -4. IntraA recent international, randomised trial, INIS study, on standard immunoglobulins (S-IVIG) added to antibiotic therapy in neonates with suspected infection concluded that S-IVIG had no effect on death or major disability at the age of 2 years . The resThe charts of consecutive VLBW infants included in the local section of the Vermont Oxford Network (VON) database from January 2008 to December 2012 for a total of 491 neonates were reviewed . Neonates were born at the Università “Federico II” di Napoli, the largest delivery place in the Naples regional area assisted by a level III NICU. Inclusion criterium was the diagnosis of blood culture-proven late onset sepsis (i.e. sepsis occurring after 72 hours of life) in VLBW infants.For defining blood culture as positive, we adopted the Vermont Oxford Network criteria, i.e.:– sepsis by coagulase negative staphylococcus: pathogen recovered from either a central line, or peripheral blood sample in association to one or more signs of generalized infection and treatment with 5 or more days of intravenous antibiotics after the above cultures were obtained;– sepsis by other bacteria: bacterial pathogen recovered from blood culture;– sepsis by fungi: fungus recovered from a blood culture obtained from either a central line or peripheral blood sample .2/FiO2 ratio, multiple seizures, urinary output) initially designed for NICU admission [Clinical signs for the diagnosis of generalized infection were: apnoea, mottled skin, temperature instability, feeding intolerance, significant abdominal distension, respiratory distress or hemodynamic instability. Laboratory criteria used were elevated CRP (cut off =1 mg/dL), abnormal leukocyte count (cut off less than 5.000/μl or more than 20.000/μl) and I/T ratio (cut off >0.2). To assess the clinical severity of cases and controls at enrollment, we used the SNAP II score, a composite index of six physical parameters  and meropenem (20 mg/Kg q 8 hours).In the event of a positive blood culture for Candida spp., antibiotic therapy was withdrawn and a standard antifungal regimen  was used for 3 weeks.Starting from June 1st 2010, IgM-eIVIG (Pentaglobin® Biotest Germany) 250 mg/kg/day i.v. for three days was added to the NICU protocol for sepsis treatment in the first 24 hours sepsis was suspected when antibiotic therapy was started. In order to compare neonates before and after the introduction of IgM-eIVIG in our clinical practice, meticulous care was exerted to ascertain that no other major change had been made that could have been relevant to the study outcome .VLBW preterms with late onset sepsis may have a prolonged hospital stay after a septic episode and their demise might be related to many factors other than infection; therefore, short-term mortality (i.e. death within 7 and 21 days from treatment) was an appropriate primary outcome for this study. Secondary outcome measures were: in-hospital total mortality, rates of intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, bronchopulmonary dysplasia at discharge.ANOVA was used to compare the main characteristics of study population between treated and untreated neonates with IgM-eIVIG; to evaluate the strength of association or non –indipendence between two binary data values, odds ratios with confidence interval were calculated with SPSS 19.0 software ; p ≤ 0.05 was considered statistically significant.Of the 82 VLBW infants enrolled, 2 neonates were excluded for congenital anomalies and one for TORCH infection; of the remaining 79 . Secondary outcomes were not significantly different between cases and controls  neonates died in treated group versus 8/15 (53%) deaths in untreated group .An accurate review of patients’ charts did not show acute reactions compatible with IgM-eIVIG infusion.This pilot retrospective study shows that IgM-eIVIG are effective in reducing short-term mortality in VLBW infants with proven sepsis. When compared with S-IVIG, IgM-eIVIG show more efficient complement activation, better opsonisation, greater neutralization of the streptococcal superantigen SpeA and better binding both to bacterial antigens and toxins all possibly due to their pentameric structure . This biIn a randomized trial of 60 Saudi septic neonates of various gestational ages, Haque showed that IgM-eIVIG significantly decreased total mortality . In a seWith a larger population we detect a clinically relevant difference focusing only on the most susceptible babies. Under the standard conditions of VON, we show an effect of IgM-eIVIG on short term mortality on those babies who had culture proven sepsis.Unlike the Haque series, our most prevalent pathogens were fungi against which IgM-eIVIG proved to be very effective. Over the study period, our incidence of Candida spp. positive blood cultures was above the Italian average but mostly below the third quartile when compared to the local section of the VON database. We later found out that the IgM-eIVIG used had an average anti C. albicans specific titer of 1.618 U/ml of IgG, 171 U/ml of IgA, 194 U/ml of IgM (courtesy of the manifacturer). The explanation for this novel observation may be related to the dominant protective role of antibodies against disseminated candidiasis. In fact, antibody opsonization is crucial to optimal Candida phagocyting and killing by neutrophils and monocytes. Moreover, antibodies against Candida mannan antigens activate complement .Our retrospective study was focused strictly on short-term mortality on the assumption that a therapeutic advantage of immunotherapy would be easier to demonstrate. Total mortality is influenced by many variables other than sepsis acting long after the resolution of an infection in a ELBW or VLBW infant. It is not surprising, therefore, that short term and total mortality may differ and that secondary outcomes were not significantly different between cases and controls.Despite the encouraging results, our study finds the main limitation in its observational nature; however, searching for confounders, we were not able to detect significant change of NICU practices or outcome variations in the study period. Also, mortality is an immediate clear-cut endpoint.This hypothesis-generator study shows that IgM-eIVIG is an effective adjuvant therapy in VLBW infants with proven sepsis reducing short term mortality.We believe that this analysis fulfilled its original purpose to set the ground for larger, randomized prospective trials. Given the considerable burden of morbidity and mortality imposed by neonatal sepsis, new research should urgently be addressed not only to validate our results but also to tailor the optimal scheme of treatment.The authors declared that they have no competing interests.LC and FR conceived the study and wrote the protocol. LC supervised data collection. FR and ACB performed statistical analysis. ACB, CP, SL, CC collected data. MRC and VDI performed microbiological analysis. LC, FR and ACB wrote the manuscript. All authors read and approved the final manuscript.


This paper integrates the evaluation findings based on program implementers in nine datasets collected from 2005 to 2009 . Using consolidated data with schools as the unit of analysis, results showed that program implementers generally had positive perceptions of the program, themselves, and benefits of the program, with more than four-fifths of the implementers regarding the program as beneficial to the program participants. The subjective outcome evaluation instrument was found to be internally consistent. Multiple regression analyses revealed that perceived qualities of the program and program implementers predicted perceived effectiveness of the program. In conjunction with evaluation findings based on other sources, the present study provides support for the effectiveness of the Tier 1 Program of the Project P.A.T.H.S.  in Hong Kong. In the context of evaluation, subjective outcome evaluation or the client satisfaction approach is a widely used strategy to evaluate programs in human services. There are several strengths of subjective outcome evaluation –3. FirstTraditionally, subjective outcome evaluation has been predominately used to understand the perceptions of program participants . However, it is equally important to examine the view of the program implementers, especially those who are not directly involved in the development process of the program. It is quite common that youth programs, such as substance abuse and violence prevention programs, are often designed and developed by academics and experienced field workers but implemented by front-line workers in the field, such as teachers in school settings and social workers in social welfare settings. Facing programs with these characteristics, front-line workers might have strong resistance towards the program because they have had little involvement during the development process. Things get worse when they do not agree with the program philosophy and mission. Furthermore, rumors about additional workload and organizational constraints may adversely affect staff morale, which in turn lowers the workers' motivation to implement the program in an authentic and enthusiastic manner.There are several reasons why subjective outcome evaluation should include the perceptions of the program implementers. First, because program implementers are also stakeholders of the developed programs, their views should be understood. According to the Joint Committee on Standards for Educational Evaluation , stakehoSecond, as program implementers are usually more experienced than the clients, it can be argued that their views may be more “accurate” than those of the clients. For example, in adolescent prevention programs, it is common to ask the program participants and workers regarding their perceptions of the program design, objectives, and rationales. It seems that the program implementers in this context possess better skills and experience in judging the quality of the program designed. Similarly, with their professional training and experience, workers will be in a better position to assess the effectiveness of the program and they can view the program from a deeper perspective.Third, it can be argued that subjective outcome evaluation based on the perspective of the worker would facilitate reflective practice. Osterman and Kottkamp  noted thFourth, the inclusion of subjective outcome evaluation based on the worker's perspective can give them a sense of fairness, which is an important determinant of the morale of the workers. Obviously, if only the program participants are asked to assess the program implementers, the workers may think the evaluation is rather unfair because only the voices of the program participants are heard. Furthermore, when the workers are invited to express their views and thoughts freely, they will feel more respected and less likely to view themselves as the victims of consumerism.Fifth, in situations where a developed program is used in different sites , implementation experiences may vary across schools. For some sites where the implementation experiences are negative, such news may spread quickly and the related rumors may adversely affect the program. Nevertheless, if the researchers can build a systematic profile of the experiences of the workers for documenting and disseminating the related findings, this can dispel the rumors and provide an accurate picture that truly reflects the implementation quality. In short, evaluation based on the program implementers can provide a better view about the implementation process.Finally, according to the principle of triangulation, collection of subjective outcome evaluation data from different data sources can definitely help to answer the question of whether data collected from different sources generate the same picture. For example, while the workers may perceive themselves as performing well during the implementation process, the students may not necessarily have the same perceptions. Similarly, students and instructors may have different views on the students' learning motivation. In short, inclusion of subjective outcome evaluation data from different perspectives can enable researchers to grasp a more complete and balanced picture regarding perceived program attributes and effects.Reppucci  also indNevertheless, there are several arguments against the use of evaluation data collected from the program implementers. The first argument is that program implementers may not have the required expertise in conducting the evaluation. Second, there may be role strain and role confusion involved if program implementers have to perform the roles of both program implementer and evaluator. Third, there are several sources of bias that are involved in the evaluation conducted by program implementers. In the first place, because program implementers have to be accountable for their delivered service, they may boost the effectiveness rating for the sake of job security . In addition, because program implementers have invested time and effort in the program implementation process, it is difficult for them to evaluate a program in a negative manner . On the other hand, because the program implementers may not be totally willing to implement a program, they may consciously or unconsciously minimize the program effectiveness and evaluate the program in an unfair manner .However, there are several counterarguments responding to the above criticisms of involving program implementers in the evaluation process. First, some professionals  are trained to conduct evaluation research. Second, because evaluation is part of the practice in many professions, professionals are actually expected to implement the program as well as to evaluate the program. In the case of teachers and social workers, role conflict is basically not a problem. In fact, they are expected to carry out both program implementation and evaluation tasks in their practice. In addition, the emphasis on reflective practice in these professions actually encourages professionals to evaluate the delivered programs in an honest and sincere manner. Third, based on different evaluation perspectives , it is legitimate and indispensable to collect the views of the program implementers (conservative view) or to engage the program implementers as evaluators .The Project P.A.T.H.S.  –16 is a From 2005 to 2009, the total number of schools that participated in the Project P.A.T.H.S. was 244, with 669 schools in the Secondary 1 level, 443 in the Secondary 2 level, and 215 in the Secondary 3 level. Altogether, there were 9,915 instructors who participated in the Tier 1 Program in these 5 years. The mean numbers of teachers and social workers implementing the program per school per form were 4.79 (range: 0–28) and 2.60 (range: 0–12), respectively. In these three grades, the mean number of students per school was 167.28, with an average of 4.61 classes per school. Among them, 46.27% of the respondent schools adopted the full program , whereas 53.73% of the respondent schools adopted the core program . The mean number of sessions used to implement the program was 22.77 (range: 3–66). While 51.54% of the respondent schools incorporated the program into the formal curriculum , 48.46% used other modes  to implement the program. Data characteristics can be seen in After completing the Tier 1 Program, the implementers were invited to respond to the Subjective Outcome Evaluation Form (Form B) developed by the first author . From 20The respondents replied to Form B in a self-report format. They were asked to indicate if they did not want to respond to the evaluation questionnaire . Adequate time was provided for the respondents to complete the questionnaire.The Subjective Outcome Evaluation Form (Form B) was used to measure the program implementers' perceptions of the Tier 1 Program. Broadly speaking, there are several parts in this evaluation form as follows.Program implementers' perceptions of the program, such as program objectives, design, classroom atmosphere, interaction among the students, and the students' participation during class (10 items).Program implementers' perceptions of their own practice, including their understanding of the course, teaching skills, professional attitude, involvement, and interaction with the students (10 items).Workers' perceptions of the effectiveness of the program on students, such as promotion of different psychosocial competencies, resilience, and overall personal development (16 items).The extent to which the workers would recommend the program to other students with similar needs (1 item).The extent to which the workers would teach similar programs in the future (1 item).The extent to which the program implementation has helped the workers' professional growth (1 item).Things that the workers obtained from the program (open-ended question).Things that the workers appreciated most (open-ended question).Difficulties encountered (open-ended question).Areas that require improvement (open-ended question).For the quantitative data, the implementers were requested to input the collected data into an Excel file developed by the research team that would automatically compute the frequencies and percentages associated with the different ratings for an item. When the schools submitted the reports, they were also requested to submit the soft copy of the consolidated datasheets. After receiving the consolidated data by the funding body, the data were aggregated in order to “reconstruct” the overall profile based on the subjective outcome evaluation data as collected by the research team.Percentage findings were examined using descriptive statistics. A composite measure of each domain  was created based on the total scores of each domain divided by the number of items. Pearson correlation analysis was used to examine if the program content and program implementers were related to the program effectiveness. Multiple regression analysis was performed to compare which domain would predict the program effectiveness. All analyses were performed by using the Statistical Package for Social Sciences Version 17.0.Quantitative findings based on the closed-ended questions are presented in this paper. Several observations can be highlighted from the findings. First, the program implementers generally had positive perceptions of the program , includiα = 0.94), 10 items related to the implementer (α = 0.92), 16 items related to the benefits (α = 0.97), and 36 items measured program effectiveness overall (α = 0.98). Results of correlation analyses showed that both program content  and program implementers  were strongly associated with program effectiveness . Further analyses showed that perceived program content (β = 0.66) was a significantly stronger predictor than program implementers (β = 0.37). This model explained 91% of the variance toward the prediction of program effectiveness. Interestingly, the above relationships and the amount of variance were consistent across grade levels.The purpose of this study was to integrate the evaluation findings of the Tier 1 Program of the Project P.A.T.H.S. based on the perspective of the program implementers. There are several unique features of this study. First, in contrast to the common focus on the program participants alone, the present study examines subjective outcome evaluation findings based on several cohorts of students. Second, a large sample involving 244 schools and 7,926 participants was utilized in the present analysis. Third, responses from students in different grades in the junior secondary school years were collected. Fourth, this is the first known scientific subjective outcome evaluation study in different Chinese communities. Finally, it is also a rare attempt in the international literature on positive youth development that examines subjective outcome evaluation as derived from the program implementers' perspective.Generally speaking, the quantitative findings showed that a high proportion of the workers had positive perceptions of the program and themselves; roughly four-fifths of the respondents regarded the program as helpful to the program participants. The findings are basically consistent with those findings reported previously based on the perspective of the program implementers in the Experimental and Full Implementation Phases using separate cohorts as the bases of analysis. In fact, an examination of the percentages of responses to different items revealed that the figures were very similar across different studies. Furthermore, the findings are generally consistent with those findings based on subjective outcome evaluation data collected from the program participants.One of the unique things about the present study is the involvement of the program implementers as evaluation partners throughout the evaluation process. Researchers noted the importance of active participation of the program stakeholders for enhancing the use of evaluation findings , 19. TheAnother advantage of the involvement of program stakeholders is the promotion of their evaluation capacity and engagement in the program. During the evaluation process, stakeholders are more motivated to design an appropriate program, respond to the changes quickly, and play a greater role in modifying the program towards meeting the needs of the program participants. In particular, they would utilize their evaluative skills and knowledge effectively, integrate and apply what they learned from evaluation data, and become more responsive to the participants' concerns. Through this ongoing reflection process, their sense of ownership and dedication towards the program would be fostered , 24. Thin = 7, 926 workers involving 244 schools). Such a big sample size substantially enhances the generalizability of the research findings to other student populations. Second, different aspects of subjective outcome, including views of the program, worker, perceived effectiveness, and overall satisfaction, were covered in the study. Third, the present study demonstrates the strategy of “reconstructing” the overall profile of the subjective outcomes based on the reports submitted by the participating schools. In fact, this study is the first published scientific study utilizing this “reconstruction” approach based on such a large number of workers in a series of databases in the Chinese culture.There are three strengths of this study. First, the subjective outcome evaluation findings are based on a large sample size  and the workers responded in an anonymous manner. Despite these limitations, the present findings suggest that the Tier 1 Program and its implementation were perceived in a positive manner by the program implementers and the workers perceived the program to be beneficial to the development of the students and the program implementers. In view of the limited international and local research studies documenting the perceptions of workers in youth development or prevention programs, the present study can be regarded as a useful contribution.


Objective. Identify aspects of psychiatry work that are rewarding, as well as those that are challenging, from the perspective of psychiatrists and residents participating in televideo consultation services. Method. A web-based survey was distributed to psychiatrists within the Division of Child Psychiatry at the University of Toronto. Also, semistructured interviews were conducted with six child psychiatrists providing services to a telepsychiatry program. Finally, a focus group interview was held with four psychiatry residents. Results. Child psychiatrists are very comfortable conducting assessments via televideo. Factors identified as being important in the decision to participate in telepsychiatry include assisting underserved communities, supportive administrative staff, enhanced rural provider capacity, financial incentives, and convenience. The study's qualitative phase identified four themes in the decision to participate in telepsychiatry: (1) organizational, (2) shared values, (3) innovation, and (4) the consultation model. Conclusion. The success of televideo consultation programs in attracting child psychiatrists to provide consultation services to underresourced communities makes an important contribution to psychiatric workforce shortages. Understanding what aspects of telepsychiatry are most appreciated by consulting psychiatrists and residents offers useful strategies to telepsychiatry administrators and medical school educators seeking to attract, train, and retain psychiatry practitioners. There is an emerging concern about the shortage of child psychiatrists in Canada and elsewhere , 2, a prLive interactive videoconferencing technology offers an innovative opportunity to address the shortage of child psychiatrists in Canada . The useIn 1997, The Hospital for Sick Children (SickKids), in Toronto, Ontario, undertook a pilot project to provide mental health support to primary care settings through videoconferencing. Fully operational in 2000, the program evolved to become the TeleLink Mental Health Program. The program aims to enhance the knowledge, skill set, and confidence of children's mental health practitioners using videoconferencing and other technologies by providing timely, equitable access to bilingual (English and French) specialist services. Videoconferencing between recipient “far” sites and TeleLink “hub” site occurs by way of Internet Protocol (IP), (maximum bandwidth 384 Kbits/second). Two or more sites can be connected simultaneously, and videos, powerpoint, and scanned documents may be transmitted. The hub site is equipped with five stationary studios, each utilizing a 50 inch plasma or LCD monitor, and one mobile unit containing a 17 inch LCD monitor. Both hub and far sites can be viewed simultaneously, and all cameras have local and remote pan-tilt-zoom control. Polycom or Tandberg videoconferencing units enable the data transmission. Infrastructure support is provided by core staff at the hub and a designated telepsychiatry coordinator at far sites.Referral routes are multiple: 15 primary children's mental health agencies in rural Ontario (including satellite locations); three community hospitals; one youth detention centre; one community youth justice diversion program; and community physicians. Models of service delivery include clinical consultation and/or short-term follow-up, professional to professional consultation, shared care, program consultation, and education and training. As a consultative program, responsibility for the case remains primarily with the referring agency or physician, with the consulting psychiatrist neither accepting ongoing responsibility for primary care, nor prescribing medication. Referring clinicians complete a mental health assessment before the consultation. Supporting documentation such as past psychological/psychoeducational evaluations, school reports, and screening tools, is also requested. It is highly encouraged that the client's primary clinician/case manager be present during the session; other participants may include parents/caregivers and others involved in the child's care.Since its inception, the TeleLink Mental Health Program has successfully recruited a stable core of consulting child psychiatrists. Twenty-three child psychiatrists within the Division of Child and Adolescent Psychiatry at the University of Toronto provide the bulk of services through a regular weekly or monthly roster, as determined by the consultant's interest, availability, and commitment. An additional 16 faculty members are called on regularly for specific consultations and educational sessions, depending on their expertise and availability. Every faculty member must have active privileges at The Hospital for Sick Children.The recruitment of child psychiatrists into the TeleLink Mental Health Program has grown since its inception. However, little is known about the factors that may influence the decision of residents and child psychiatrists to work with rural and remote communities via televideo. In a child and youth mental health system that is fragmented, underfunded, and with a critical shortage of specialists in rural areas, it is important to identify the factors that could enhance recruitment into telepsychiatry and contribute to the expansion of telepsychiatry services to rural and remote communities. This study identifies aspects of psychiatry work that are most rewarding, as well as those that are challenging, from the perspective of psychiatrists and residents participating in televideo consultation services. To enhance our understanding of psychiatrists' decisions to participate in the provision of services via televideo, this study used a mixed method design, combining quantitative and qualitative methods. For the quantitative component, a web-based survey was developed using SurveyGizmo online software. For the qualitative phase, in-depth interviews and a focus group were conducted following Denzin's  interpren = 80) within the Division of Child and Adolescent Psychiatry at the University of Toronto. The distribution sample was based on the fact that the TeleLink Program is well promoted within the division and all faculty members are eligible to participate in the Program. The survey included questions related to their experiences with the TeleLink Program  and all psychiatry residents (n = 26) located at The Hospital for Sick Children at the time of data collection. Despite multiple attempts to engage focus group participants, our efforts to recruit psychiatrists were unsuccessful. As such, one focus group was held with four psychiatry residents. For the individual interviews, eight individuals involved or familiar with pediatric telepsychiatry services were approached, both in Ontario and internationally. Six individuals agreed to participate; four providing services to the TeleLink Program in Ontario and two providing services to programs outside the country, one in the United States and one in Australia. This sampling strategy, focused on “information-rich cases”  what to do.” There was also a lack of knowledge regarding liability and safety issues, clinical follow-up procedures, and funding mechanisms, with one consultant stating “What is the renumeration? I do not know how I get paid; I do not know what it is. It is not all that transparent for some people.” Many of these themes echo concerns expressed by survey respondents, as reported earlier. Despite these concerns, study participants acknowledge that, by providing timely, equitable access to specialist services, the TeleLink Program fills an important gap in the children's mental health system, “distributing (psychiatric expertise) to a wide area.”Other concerns emerging from the qualitative data include the lack of information regarding resources in rural communities, rural clinicians who may be inexperienced due to high turnover rates, and having to “The delivery of psychiatric services using videoconferencing technology is an efficient, cost-effective –16, and For both survey and interview participants, organizational factors were identified as crucial to their participation in the TeleLink Program. Features such as efficient administrative staff, convenient setup, flexible work hours, and financial compensation allowed consulting psychiatrists to deliver services with minimal workload. In the literature, time, money , and tecA second set of factors linked to telepsychiatry participation is related to the technology itself. The majority of survey and interview participants reported being comfortable with the equipment and technology, as well as conducting assessments via televideo. However, results suggest that more could be done to improve technical aspects and provider comfort. As reported in a recent literature review , problemA third factor in attracting consulting psychiatrists is active participation in postgraduate training; since 2005, all psychiatry residents at the University of Toronto are required to participate in at least two telepsychiatry consultations with the TeleLink Program. Additionally, three- and six-month electives are offered to interested residents . This stThis study aimed to gather objective data regarding how a telepsychiatry program in Toronto, Canada, is able to attract and keep child psychiatric consultants to the program, in the context of declining psychiatric recruitment and the difficulty in attracting psychiatrists to do this work, as indicated informally by similar programs in Canada and elsewhere. These results help us understand what aspects of telepsychiatry are most likely to attract and retain psychiatry practitioners, as well as aspects most appreciated by consulting psychiatrists and residents. Also, this study helps inform the effective recruitment of new graduates to the field, a current challenge for the TeleLink Program. In response to this challenge, the University of Toronto's Department of Psychiatry has made adult telepsychiatry a key goal and has asked the TeleLink Program to assist in setting up the program and attracting consulting psychiatrists. The results of this study will assist with this endeavour. More research is needed to better understand residents' experiences of participating in the TeleLink Program, and more specifically what might attract them to continue to work in telepsychiatry after graduation. Future research would include a multicentered study involving other telepsychiatry programs in Ontario and across Canada. This study offers important insights into addressing possible barriers in attracting psychiatrists and residents to a telepsychiatry program. It also provides an opportunity to think about wider recruitment and retention issues in the field of psychiatry. Understanding what aspects of the TeleLink Mental Health Program are most appreciated by consulting psychiatrists and what attracts residents to the Program offers useful strategies to telepsychiatry administrators and medical school educators seeking to attract, train, and retain psychiatry practitioners.