The effects of CD concentration, pH value and composition of the background electrolyte, capillary temperature, running voltage and injection parameters have been investigated. The method was validated for precision of peak-area response, linearity range and limits of detection and quantification. An efficient stereoselective capillary zone electrophoretic method was developed for the determination of carvedilol enantiomers using a simple 25 mM phosphate buffer at a pH = 2.5 and 10 mM β-CD as chiral selector, resulting in baseline separation of the two enantiomers with sharp peaks and relatively short analysis time. Highly satisfactory results were obtained from the analysis of carvedilol from tablets, indicating that the method is suitable for routine analysis of carvedilol in pharmaceutical products.Carvedilol is administered as a racemic mixture of the R(+)- and S(-)-enantiomers, although it was demonstrated that the two enantiomers exhibit different pharmacological effects and stereoselective pharmacokinetics. The aim of this study was the evaluation of several native and derivatized cyclodextrines as chiral selectors for the separation of carvedilol enantiomers. Stereoselective interactions were observed with four cyclodextrines ( It has vasodilating properties, attributed mainly to its blocking activity on α receptors; but at higher doses calcium-channel blocking activity may contribute also. Carvedilol is reported to have no intrinsic sympathomimetic activity and only have weak membrane-stabilizing activity  and lack of reflex tachycardia ( -adrenergic antagonism)  .β-blockers that are currently used in clinical practice, carvedilol contains an asymmetric carbon atom in the amino-alkanol side chain resulting in the existence of two enantiomers. The chemical structure of carvedilol (1-(4-carbazolyloxy)-3-(2-(2-methoxy) ethyl-amino)-2-propanol) is presented in Like all other The d-enantiomer of carvedilol shows the (R)-configuration while the l-enantiomer shows the (S)-configuration .β-blockers, the S(–) enantiomer of carvedilol is more potent (200-fold higher) as an antagonist of β-receptors than the R(+) enantiomer. When β-blocking effects of the R(+) and S(-) enantiomers have been compared, the results were similar both in-vitro and in human studies, revealing that the S(-) enantiomers are markedly more effective. Both the R(+) and S(-) enantiomers, however, are equally effective in blocking α-adrenergic activity  enantiomer are higher than those of the S(–) enantiomer. Also the degree of stereoselectivity in the pharmacokinetics of carvedilol is susceptible to change according to the patient and/or disease characteristics .Metabolism of carvedilol is also stereoselective giving rise to different bioavailabilities of the enantiomers of about 15% for S(–)-carvedilol and about 31% for R(+)-carvedilol; while, terminal elimination half-life for R(+)-carvedilol ranges from 5 to 9 hours, compared with 7 to 11 hours for S(–)-carvedilol ,5.Taking in consideration all these aspects mentioned above elaboration of new methods for the chiral separation of carvedilol enantiomers becomes a necessity but also a challenge.High performance liquid chromatography (HPLC) methods using chiral derivatization with an optically pure derivatization reagent followed by separation of the two diasteromers using an achiral method, have been developed, however these methods can be rather expensive and sometimes an incomplete reaction and multiple derivatization could occur .Meanwhile capillary electrophoresis (CE) has obtained increasing importance in analytics, especially in the separation of chiral compounds, including here the enantioseparation of carvedilol . SeveralThe advantages of CE compared to conventional HPLC methods in the enantioseparation of chiral substances are being related to the: rapid and simple method development, small amounts of solvent, sample and chiral selector required for the separation and especially with the high selectivity in choosing and changing the chiral selector .However, the optimal separation conditions for the CE chiral separation of carvedilol enantiomers are significantly different in several cases, and the basis of the differences has not been clearly identified ,10.The most widely used chiral selectors in CE are the cyclodextrins (CDs), cyclic oligosaccharides having an external hydrophilic surface and a hydrophobic cavity, in which they can include other compounds by hydrophobic interaction. The inclusion mechanism is sterically selective because analytes must ﬁt the size of the cavity, the diameter of which depends on the number of glucose units in the CD structure. Interaction with an analyte will occur by inclusion of its hydrophobic portion in the cavity and from hydrogen bonding to the chiral hydroxyl groups of the rim. In CE chiral separation can be achieved by adding CDs directly to the buffer electrolyte .The large majority of the published studies in this field, are dealing with the separation of beta-blockers in general or with the separation of carvedilol using only a particular CD derivative, and not with the screening of several CD derivative and the optimization and understanding of the separation process, in order to evaluate the optimum chiral selector for the enantioseparation ,5,9,10.Our aim was to develop an alternative rapid, simple and efficient method for the chiral separation of carvedilol enantiomers using a systematic screening approach of different native and derivatized CDs as chiral selectors and the optimization of electrophoretic conditions in order to obtain a good chiral resolution in a short analysis time.ChemicalsR,S–carvedilol, R-carvedilol and S-carvedilol of pharmaceutical grade were purchased from Moehs Productos Quimicos . The internal standard S-propranolol was also acquired from the same producer. For the determination of carvedilol from commercial pharmaceuticals we used Carvedilol  tablets containing 25 mg carvedilol. The following reagents of analytical grade were used: phosphoric acid , methanol, sodium hydroxide , sodium tetraborate, disodium hydrogenphosphate, sodium didydrogenphosphate . Purified water was provided by a Milli-Q Plus water purification system .α-CD, β-CD, γ-CD), derivatized neutral CDs , anionic substituted charged CD . All CDs were obtained from Cyclolab  with the exception of SBE-β-CD - Capsitol .As chiral selectors we used the following CD derivatives of research grade: native neutral CDs . The electropherograms were recorded and processed by Chemstation 7.01  software. The pH of the buffer solutions was determined with the Terminal 740 pH–meter .Sample preparation-1 and later diluted with the same solvent to the appropriate concentration. The samples were introduced in the system at the anodic end of the capillary by hydrodynamic injection. Buffer solutions were prepared in water; the pH was adjusted with sodium hydroxide. All samples and buffers were ﬁltered with a 0.45 μm ﬁlter and degassed in an ultrasonic bath for 5 minutes before use.μFor the determination of carvedilol from tablets, twenty Carvedilol tablets were weighed, and the medium net weight of each tablet was calculated. The tablets were powdered in a mortar and an amount of powder equivalent to the average weight of a tablet was weighed and dissolved in methanol, and the solution was diluted to 100 mL in a volumetric flask and sonicated for 10 minutes. The samples of the tablet solution were centrifuged at 3500 rpm for 10 minutes. The supernatant was diluted, following the same procedure as for the preparation of standard solutions, before CE separation.Separation conditions and methodologyThe capillaries were conditioned before use with 0.1 M sodium hydroxide for 30 minutes and with the background electrolyte used in the analysis for 30 minutes. The capillary was rinsed for 1 minute with 0.1M sodium hydroxide and buffer solutions before each electrophoretic separation.-1.We recorded previously the UV spectra of carvedilol and found absorption maximum in methanol at 242 nm, which was elected as detection wavelength in the CE separations. We applied some “standard” electrophoretic conditions for a CE analysis: temperature 20 ˚C, applied voltage + 20 kV, injection pressure/time 50 mbar/3 sec., sample concetration 10 μg mLIn the initial experiments the studied compounds were injected in the absence of CDs and their effective mobility was calculated. Then we performed the measurements using the same BGE, containing a relatively low amount of chiral selector in order to verify the decrease in the effective mobility of the analytes. We applied a direct chiral separation method by simply dissolving the optically pure additive in the selected buffer solution.2 - t1)/(w1 + w2) equation, where the migration times (t1 and t2) and the peak-widths at the baseline (w1 and w2) were marked for the slow and fast migrating enantiomers, respectively.αm) defined as the ratio of the migration time of the analyte  in the buffer containing the chiral selector and the migration time of the analyte in the plain buffer; which represents an approximate parameter for measuring the strength of the host–guest interaction.We also evaluated the migration retardation factor , 25 mM disodium hydrogenphosphate – 25 mM sodium didydrogenphosphate (pH = 7) and 25 mM sodium tetraborate (pH = 9.3) background electrolytes (BGEs) respectively and modified the buffer pH by adding a 0.1M sodium hydroxide solution.β-blockers  carvedilol has a pKa value of 7.97; the explanation of this discrepancy being attributed especially to the inductive effect of the β-O-atom, which lowers the basicity of the amino group  is sensitive to pH in the range between 3.0 and 7.0; as it decreases considerably with decreasing pH. The migration time of carvedilol increased when the pH of the buffer increased from 2 to 5, and decreased as the pH was increased from 5 to 7.For a basic drug like carvedilol with a pKThe most suitable BGE proved to be a 25 mM phosphoric acid solution at a pH of 2.5; using this buffer we obtained well-shaped peak for carvedilol with a migration time of 6.8 minutes. At this low pH the effect of the EOF is minimal, and the analyte will migrate mostly through its own electrophoretic mobility.Method optimizationBuffer ionic strength, pH, CD type and concentration, as well as applied voltage, temperature and injection parameters were optimized.The first requirement for inclusion complexation is fitting the analyte into the CD cavity, thus selecting the appropriate CD is related to the shape and dimension of the analyte.Several CDs (native and derivatized) were tested in order to obtain chiral resolution of carvedilol enantiomers. Initial concentration of 10 mM neutral CDs were added to the buffer solution, while for charged CDs we added a concentration of 5 mM in order to limit the increase of ionic strength which generated high currents and instability of the electrophoretic system.α-CD and γ-CD. Clearly α-CD was not able to separate the carvedilol racemic mixture because its cavity is too small, β-CD allowed chiral resolution while γ-CD was not able to guest the studied analyte probaby because carvedilol molecule is too small. Stereoselective interactions of the two enatiomers were observed also in the case of β-CD derivatives, HP-β-CD and RAMEB; as substitution at the secondary hydroxyl rim on the surface of the CD can affect selectivity of the separation, as it will provide additional interaction points with the analyte.No chiral separation only an increase of the migration time was observed when using β-CD as chiral selector the maximum concentration was 20 mM, due to its poor solubility in aqueous solutions. Resolution of the enantiomers was calculated and the optimal concentration for the separation was determined. If complexation was observed but insuficient resolution was achieved, we increased the concentration of the chiral selector (5-40 mM) until satisfactory separation was obtained. When using The CD concentration plays a very important role in the chiral resolution, and should be carefully controlled in order to find the optimal experimental conditions. The optimal concentration depends on the binding affinity of the two enantiomers with the chiral selector. The migration times increased with an increase in CDs concentration. This is due to longer residence time of the analyte in the complex form as well as to an increase in the viscosity of the buffer with a reduction of the mobility of the analytes.An increase in the pH value of the BGE increased migration times but no direct correlation due to increase or decrease of the pH on the chiral resolution was obtained. At low pH values there is more time for the analyte to interact with the CD to result in increased time spent in the capillary; while at pH values above 5 where the effect of the EOF becomes more significant, the migration times of the analytes increased. Low operational pH was found to be essential for the resolution of carvedilol enantiomers. A buffer pH of 2.5 was elected for the separation.β-CD) resulted in long migration times (above 20 minutes) but only a small peak splitting and also a severe peak tailing was observed at a pH of 2.5. At this pH, SBE-β-CD is negatively charged while carvedilol is positively charged, consequently SBE-β-CD moves towards the anode while carvedilol towards the cathode  led to an increase of migration times but only a small peak splitting has been observed.The use of a dual CD system, which include a combination of a neutral and a charged CD , the two enantiomers migrating faster than the EOF. An increase in the SBE-β-CD concentration didn’t increase resolution of the separation.But, using a phosphate buffer solution with a pH of 7 and 5 mM SBE-The chemical composition and the concentration of the buffer can affect the baseline stability, peak shape and separation selectivity. The enantiomer separation using phosphoric acid as BGE was better than those compared with disodium hydrogenphosphate – sodium didydrogenphosphate and sodium tetraborate buffers. A slight increase in the migration time of the analyte was observed with increasing buffer concentration, but only little inﬂuence on the separation could be observed. Hence a 25 mM phosphoric acid buffer was elected for the enantioseparation.Addition of an organic modiﬁer such as methanol or acetonitrile to the phosphate buffer resulted in longer migration times but there was no significant improvement in the chiral separation.0C was elected, in order to obtain an adequate resolution of the separation and a satisfactory analysis time.Running voltage did not have a strong effect on the resolution; while a decrease in temperature led to extension in analysis time and to a slight increase of the chiral resolution. An optimal voltage of + 20 kV and a temperature of 15 A high injection pressure of 50 mbar and a fast injection time of 1 second provided a reasonable sample load and maintained resolution. The amount injected was enough to achieve a sufficient signal/noise ratio but not large enough to cause band broadening.The electrophoretic mobility of carvedilol stereoisomers decreased with increasing capillary length because of the longer migration time to the detection window.The migration order of the two enantiomers was determined by injecting a solution of the racemate enriched with the pure enantiomer separately. The ﬁrst peak to pass the detector window was determined to be R(+) carvedilol followed by S(-) carvedilol.β-CD, buffer pH = 2.5, applied voltage: + 20 kV, temperature: 15 0C, injection pressure/time: 50 mbar/1 s, UV detection at 242 nm. Also HP-β-CD (20 mM) or RAMEB (30 mM) can be used successfully as chiral selectors in the enantioseparation of carvedilol, with good chiral resolutions but longer migration times.Taking in consideration the aspects presented above we can conclude that the optimal electrophoretic conditions for the carvedilol enantioseparation are: BGE: 25 mM phosphoric acid chiral selector: 10 mM β-CD and HP-β-CD as chiral selectors are presented in The electropherograms of the enantiosepartion using Analytical parametersβ-blocker, S-propranolol was used as an internal standard (IS); its migration time being faster than the one of R(+)-carvedilol. Quantiﬁcation was accomplished on the basis of carvedilol enantiomer to IS peak-area ratios (peak area of carvedilol enantiomer/peak area of IS).The pure enantiomer of another -1), and showed good linearity  at six concentrations in a specific concentration range (concentration range: 2.5 - 50 µgmLinearity . High coThe limits of detection (LOD) and quantiﬁcation (LOQ) were estimated as: standard deviation of regression equation/slope of the regression equation multiplied by 3.3 and 10, respectively .The precision of the method was determined by measurement of repeatability (intra-day) and intermediate precision (inter-day), expressed as RSD (relative standard deviation) % for a series of measurements.Standard solutions of carvedilol and internal standard were prepared in methanol and injected on three consecutive days, six times a day .-1 was used to evaluate precision as degree of repeatability by performing six replicate analyses and calculating the coefficient of variation, the RSD values were 1.35% for R(+) carvedilol and 1.36% for S(-) carvedilol, respectively; these results showing that the method is sufficiently precise.A concentration of 10 µgmL±±β-adrenergic antagonists share similarities with respect to pharmacologic effects, with the S(–)-enantiomer usually possessing a substantially higher ability to bind to β-adrenergic receptors. In the case of carvedilol the enantiomers may posses also other useful pharmacological qualities that add to the β-blocking properties of the drug. Therefore, maybe the time has arrived that the optically pure enantiomers should be recognized as distinct drugs; hence the racemates can no longer be regarded as optimal for patients on β-blocker therapy, as R(+)-enantiomers that make up 50% of every racemic β-blocker may contribute to an increase of side effects as well as to drug interactions.In general, the enantiomers of the CD type and concentration, pH value of the BGE had a strong influence on the efficiency of the chiral separation. The changes in the concentration of the CDs and in the pH of the BGE showed uneven effect on the resolution of the optical isomers.β-blockers reported the faster migration of the S enantiomers, but in the case of carvedilol the changing in the migration order of the enantiomers only reflects the particularities in its chemical structure (The faster migration of the R(+) carvedilol indicates that this enantiomer have weaker interaction with the CDs, while the interaction of S(-) carvedilol has a stronger one. Previous studies involving other tructure .β-CD, HP-β-CD and RAMEB showed baseline separation of the two enantiomers, while the use of SBE-β-CD led only to partial separation. The best results were obtained using a 25 mM phosphate buffer at a pH = 2.5 and 10 mM β-CD as chiral selector.Among the analyzed CDs, In conclusion, an efficient stereoselective CE method was developed for the determination of carvedilol enantiomers using a simple phosphate buffer and CDs as chiral selectors, resulting in baseline separation of the two enantiomers with sharp peaks and relatively short analysis time.


Taken together, our results not only revealed the novel mechanism by which HNF-4α promoted ChREBP transcription in response to glucose, but also demonstrated that ChREBP-α and HNF-4α synergistically increased ChREBP-β transcription.Transcription factor carbohydrate responsive element binding protein (ChREBP) promotes glycolysis and lipogenesis in metabolic tissues and cancer cells. ChREBP-α and ChREBP-β, two isoforms of ChREBP transcribed from different promoters, are both transcriptionally induced by glucose. However, the mechanism by which glucose increases ChREBP mRNA levels remains unclear. Here we report that hepatocyte nuclear factor 4 alpha (HNF-4α) is a key transcription factor for glucose-induced ChREBP-α and ChREBP-β expression. Ectopic HNF-4α expression increased ChREBP transcription while knockdown of HNF-4α greatly reduced ChREBP mRNA levels in liver cancer cells and mouse primary hepatocytes. HNF-4α not only directly bound to an E-box-containing region in intron 12 of the ChREBP gene, but also promoted ChREBP-β transcription by directly binding to two DR1 sites and one E-box-containing site of the ChREBP-β promoter. Moreover, HNF-4α interacted with ChREBP-α and synergistically promoted ChREBP-β transcription. Functionally, HNF-4α suppression reduced glucose-dependent ChREBP induction. Increased nuclear abundance of HNF-4α and its binding to  Moreover, knockdown of HNF-4α greatly reduced glucose-dependent ChREBP-α and ChREBP-β induction.Here we discovered that HNF-4α overexpression increased transcription of both human ChREBP-α and ChREBP-β whereas siRNA-mediated HNF-4α knockdown reduced ChREBP-α and ChREBP-β mRNA levels in human 293T, HepG2 cells and mouse primary hepatocytes. Further analysis revealed that HNF-4α promoted ChREBP-α and ChREBP-β transcription by directly binding to an E-box-containing sequence in intron 12 and DR1 sites in the ChREBP-β promoter, respectively. ChREBP-α cooperated with HNF-4α in promoting ChREBP-β transcription. Glucose increased HNF-4α mRNA and protein levels, nuclear abundance and its binding to http://genome.lbl.gov/vista/rvista/submit.shtml)  and 2.9 kb (nucleotides −2612~+271) DNA sequences of human ChREBP-α and ChREBP-β genes using the rvista software (t.shtml) . Positiot.shtml) . HNF-4α shtml) 20. Using pshtml) 20. Althougshtml) 20. Moreoveshtml) 20.In order to further investigate the effect of suppressing HNF-4α expression on ChREBP transcription, we transfected HepG2 cells with two independent siRNAs for HNF-4α and successfully suppressed HNF-4α expression . In compWe treated mouse primary hepatocytes and human liver cancer HepG2 cells with 0 mM, 5.6 mM and 25 mM glucose for 18 hours, respectively. Real time PCR analysis showed that 25 mM glucose was more potent than 5.6 mM glucose to increase mRNA and protein levels of ChREBP-α, ChREBP-β and total ChREBP in comparison to the 0 mM glucose treatment in mouse primary hepatocytes and HepG2 cells . Our res2in vivo, wild type C57Bl/6 mice were fasted or given access to food for 18 hours before mRNA levels of ChREBP in the liver were assayed. Transcription of ChREBP-α, ChREBP-β and total ChREBP was up-regulated in the fed state compared with the fasted control  and 2.9kb (−2612 bp~+271 bp) human ChREBP-β promoter from human genomic DNA and subcloned them into pGL3-Basic and pGL4-Basic vector , respectively. Position +1 is the transcription start site. We cloned the 164 bp, 174 bp, 378 bp and 140 bp DNA fragments containing the non-perfect DR1 sites located in intron 2, intron 6, intron 7 and intron 12 from human genomic DNA and subcloned them into the pGL3-Promoter vector . The C/EBPα and c-Jun plasmids were provided by Dr. Zhaoyuan Hou and Dr. Man Mohan of Shanghai Jiao Tong University School of Medicine. The FoxA2 plasmid was provided by Dr. Jianguo Song of Chinese Academy of Sciences. The HA-HNF-4α and LXR plasmids were provided by Dr. Xiaoling Li of National Institute of Environmental Health Sciences in USA. The USF1 and USF2 plasmids were provided by Dr. Jingwen Liu of VA Palo Alto Health Care System in USA.The following reagents were used: Dulbecco’s Modified Eagle’s Medium (DMEM) , Opti-MEM and no glucose DMEM , Fetal bovine serum (FBS) , Triton X-100 and Nonidet P40 (NP-40) , anti-ChREBP , anti-HNF-4α , anti-actin , anti-FLAG , anti-HA and anti-Myc  antibody. All other chemicals were analytical grade.Six 6–8 week-old C57BL/6 wild type mice were divided into two groups. One group of three mice were fasted for 18 hours while the other group of three mice were fed with a normal diet for 18 hours before being sacrificed. Liver tissues were removed for further study. All protocols were approved by the Shanghai Jiao Tong University School of Medicine Animal Care and Use Committee. All experiments were carried out in accordance with the approved guidelines.6 cells /ml in hepatocyte medium  supplemented with 5% FBS, 1% hepatocyte growth supplement and 1% penicillin/streptomycin antibiotic mix. After primary hepatocytes attached, the medium was replaced by DMEM supplemented with 10% FBS, 1% L-glutamine and 1% penicillin/streptomycin antibiotic mix. Primary hepatocytes were cultured in DMEM containing 5.6 mM glucose for 24 hours before 0 mM, 5.6 mM or 25 mM glucose treatment.Primary hepatocytes were prepared from male C57/BL6 mice using the collagenase  perfusion method293T human embryonic kidney cells and HepG2 human hepatocellular carcinoma cells were cultured in DMEM supplemented with 10% FBS, 1% L-glutamine and 1% penicillin/streptomycin antibiotic mix. Cells at 80% confluency were transfected with plasmids or siRNAs. 48 hours after transfection, cells were harvested for subsequent experiments. For the glucose treatment experiments, cells were cultured in DMEM containing 5.6 mM glucose for 4–12 hours before being treated with 0 mM, 2.5 mM, 5.6 mM or 25 mM glucose medium for 18 hours.Cells were washed twice with PBS and lysed in 1% Triton-X-100 lysis buffer  with protease inhibitors  at 4 °C for 30 minutes. Western blot analysis was performed as described previouslyTotal RNA was isolated with Trizol and reverse-transcribed into cDNA using the PrimeScript RT Master Mix kit . The expression of specific genes was quantitated by real time PCR using SYBR Premix Ex Taq kit  on an ABI 7500HT machine  with β-actin (human) or 18sRNA (mouse) as internal controls.TM RNAiMAX  according to the manufacturer’s protocol.The siRNA oligonucleotides were purchased from Jima pharmaceutical company . The control siRNA sequences were 5′-UUCUCCGAACGUGUCACGUTT-3′. The HNF-4α siRNA sequences were 5′-UCUUGUCUUUGUCCACCACTT-3′and 5′-AAUGUAGUCAUUGCCUAGGTT-3’. The siRNA oligonucleotides were transfected using Lipofectamine293T cells were transfected with 0.5 μg of the reporter plasmid, 0.1 μg of the β-gal plasmid and 1 μg of either pcDNA3-HNF-4α or empty vector. 24 hours later, cells were harvested and assayed using the luciferase reporter assay system  and Beta-Gal Assay Kit  according to the manufacturers’ instructions.cis-element in intron 12 of the human ChREBP-α gene are 5′-GGGCTGCAACATGAGTCATTGGGGT-3′ (forward) and 5′-CTGGGCCCAGGTCAAGGAGCTGC-3′ (reverse). Sequences of primers used in PCR for the region containing DR1 sites in the human ChREBP-β promoter are 5′-CCCACGTGCTAAGGAGAGAA-3′ (forward) and 5′-GTGTCCTTTGCCCCTTGATC-3′ (reverse). Sequences of primers used in PCR for the region containing the ChoRE site in the human ChREBP-β promoter 5′-GCGTCTTTCTCTGCCCAC-3′ (forward) and 5′-TGCCTCCTTCTCTCCTTAGC-3′ (reverse).ChIP was performed using an EZ-ChIP kit  according to the manufacturer’s protocol. Sequences of primers used in PCR for the E-box-containing Cells were freshly lysed in the lysis buffer , and incubated with primary antibodies at 4 °C overnight, followed by an additional 2-hour incubation with protein A/G-agarose beads  at 4 °C. The beads were washed with the lysis buffer and boiled in 2× SDS protein loading buffer. Western blot analysis was performed after immunoprecipitation. For quantification, NIH image software was used.All the following steps were performed, and all buffers contained the EDTA-free protease inhibitor cocktail . After PBS rinses, cells were centrifuged at 2000 × g for 5 min at 4 degree. Cell pellets were fractionated as described previouslyLivers were fixed in 4% paraformaldehyde overnight and embedded in paraffin. Immunohistochemistry was performed according to standard procedures. The following primary and secondary antibodies were used: anti-ChREBP  and anti-HNF-4α  antibodies; biotinylated anti-rabbit secondary antibodies ; streptavidin-HRP .The shRNA for mouse HNF-4α (5′-AGGCTGTTGGATGAATTGAGG-3′) was obtained from Open Biosystems  and then subcloned into the lentiviral vector PLKO. The shRNA were transfected into 293T cells with the packaging plasmids PMD2G and psPAX2 using Lipofectamine 2000  according to the manufacturer′s instructions. Viral supernatant was collected after 48 hours. 1 ml viral supernatant and 1 ml fresh medium were added to primary hepatocytes per well in six-well plates, and the medium was replaced by fresh medium after 24 hours.Experiments were performed at least three times independently and one representative experiment was shown.How to cite this article: Meng, J. et al. Identification of HNF-4α as a key transcription factor to promote ChREBP expression in response to glucose. Sci. Rep.6, 23944; doi: 10.1038/srep23944 (2016).


In this study, we performed a network meta-analysis to compare the outcomes of seven most common surgical procedures to fix DRF, including bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating. Published studies were retrieved through PubMed, Embase and Cochrane Library databases. The database search terms used were the following keywords and MeSH terms: DRF, bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating. The network meta-analysis was performed to rank the probabilities of postoperative complication risks for the seven surgical modalities in DRF patients. This network meta-analysis included data obtained from a total of 19 RCTs. Our results revealed that compared to DRF patients treated with bridging external fixation, marked differences in pin-track infection (PTI) rate were found in patients treated with plaster fixation, volar plating, and dorsal and volar plating. Cluster analysis showed that plaster fixation is associated with the lowest probability of postoperative complication in DRF patients. Plaster fixation is associated with the lowest risk for postoperative complications in DRF patients, when compared to six other common DRF surgical methods examined. Search terms used for retrieving relevant literature from these databases included combinations of the following keywords and MeSH terms: DRF, bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating.Studies were selected for incorporation into this network meta-analysis if they conformed to the following inclusion criteria: (1) study type: RCTs; (2) interventions: bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating; (3) study subjects: patients clinically or radiologically confirmed as DRF; (4) study outcomes: incidence of CTS, CRPS and PTI rate in DRF patients. Studies were excluded if they (1) lacked data integrity; (2) were not RCTs; (3) were duplicate studies; or (4) involved complex intervention strategies.Two investigators independently extracted the required data using a standard data collection form. The following information was collected from the selected studies: first author, publication year, country, ethnicity, language, disease, interventions, age, gender, adverse outcomes and number of research subjects. Any disagreements between the two investigators during study selection or data collection were resolved by discussion, re-examination of the data or consulting other investigators.R 3.2.0 software, an open source statistical program, was used to generate the graphical output of the network diagram. Each node represents an intervention, while the node size represents sample size and the width of the connecting line between each node represents the number of studies reporting the comparison. The gemtc installation package of the R software provided a comprehensive set of predictive tools to conduct network meta-analysis in a Bayesian setting.There were four common outcomes for input of Arm- or contrast-level network data: binary, continuous, count or survival. As first described by Lu and Ades, it models relative effects  by setting a generalized linear model (GLM) under Bayesian framework by connecting to JAGS, WinBUGS or OpenBUGS2122Electronic database search and manual searches retrieved a total of 1249 articles. After excluding 227 duplicate studies, 36 letters and reviews, 12 non-human studies and 209 studies irrelevant to DRF, 765 studies remained for full-text evaluation. Of the 765 studies, 289 articles were excluded since they were not RCTs or were irrelevant to PTI, CRPS and CTS, and 11 studies were eliminated for lack of sufficient data or for having incomplete or weakly correlative data. Finally, 19 RCTs met our stringent inclusion/exclusion criteria and these 19 studies were selected for inclusion in our network meta-analysis91014262728293031323334353637383940This study included 7 most common surgical treatments for DRF: bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating. The highest incidence of CTS was observed in patients treated with bridge external fixation. In this network meta-analysis, majority of the studies showed direct comparisons for bridge external fixation vs. volar plating, bridge external fixation vs. K-wire fixation and bridging external fixation vs. non-bridging external fixation . With reP values for all the direct and indirect comparisons were more than 0.05, indicating the results were consistent between direct and indirect comparisons  . Dorsal The results of network meta-analysis showed statistically significant differences in PTI rate when DRF patients treated with plaster fixation, volar plating, and dorsal and volar plating were compared with patients treated with bridging external fixation . However, such differences were not found in DRF patients treated with non-bridging external fixation, K-wire fixation and dorsal plating  . PlasterThe results of network meta-analysis revealed no statistically significant differences in the incidence of CRPS in DRF patients treated with non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating when compared to patients treated with bridging external fixation  . PlasterThe results of cluster analysis for CTS and PTI rate showed significantly better outcomes for plaster fixation, dorsal plating, volar plating, and dorsal and volar plating in DRF patients . The resThe best treatment choice for DRFs remains a topic of intense debate. In this study, we compared the risk of postoperative complications in patients who underwent seven different surgical approaches to treat DRF. Our network meta-analysis consisted of 1805 DRF patients pooled from 19 RCTs that reported the risk of CTS, PTI rate and CRPS in DRF patients following various surgical interventions. Our results showed that plaster fixation offered the highest probability for avoiding postoperative complications, compared to six other treatment modalities.Although, DRF patients treated with dorsal plating carried the lowest risk of CTS, the risk for CRPS and PTI was the lowest in DRF patients treated with plaster fixation. Dorsal plating is a well-established treatment for DRF with several advantages, including ease of exposure, visualization of the articular surface and the biomechanical advantage of placing the plate as a dorsal buttressInterestingly, bridging and non-bridging external fixation, K-wire fixation, dorsal plating, volar plating, and dorsal and volar plating, are described as unsuitable for unstable DRFs and these methods are often associated with poor outcomes. Open reduction and internal fixation was widelyused to fix unstable DRFs in the past, but significant complications have been reported recently, such as rupture of tendons, CTS and CRPS30The major merits of this network meta-analysis are: first, due to the absence of head-to-head trials for all the surgical interventions, indirect comparisons were obtained through network analysis. Second, we used consistent measurements across different studies and synthesized the data from selected studies within a single network meta-analysis, avoiding potential selection bias. Third, this updated network meta-analysis provides new insights to address the debate on the best approach by synthesizing the existing evidence and revealing important results related to the clinical care of DRF patients. Our study also has limitations. First, only 19 RCTs were enrolled in our study, the relatively small number of included studies increase the uncertainty of our conclusions. Second, incomplete data existed in some studies, which might bias our results.In conclusion, our network meta-analysis provides strong evidence that plaster fixation is associated with the lowest risk for postoperative complications in DRF treatment, compared to the six other treatment approaches. However, future RCTs that are better designed and containing larger sample size will be needed to confirm our findings and begin testing clinical applications.How to cite this article: Qiu, W.-J. et al. The comparative risk of developing postoperative complications in patients with distal radius fractures following different treatment modalities. Sci. Rep.5, 15318; doi: 10.1038/srep15318 (2015).


Shield tunneling construction of metro infrastructure will continuously disturb the soils. The ground surface will be subjected to uplift or subsidence due to the deep excavation and the extrusion and consolidation of the soils. Implementation of the simultaneous monitoring with the shield tunnel construction will provide an effective reference in controlling the shield driving, while how to design and implement a safe, economic, and effective structural monitoring system for metro infrastructure is of great importance and necessity. This paper presents the general architecture of the shield construction of metro tunnels as well as the procedure of the artificial ground freezing construction of the metro-tunnel cross-passages. The design principles for metro infrastructure monitoring of the shield tunnel intervals in the Hangzhou Metro Line 1 are introduced. The detailed monitoring items and the specified alarming indices for construction monitoring of the shield tunneling are addressed, and the measured settlement variations at different monitoring locations are also presented. Establishment of the urban metro system will not only efficiently alleviate the problem of urban traffic congestion but also vigorously promote the integrated development among different urban regions –3. Deep In recent years, a significant amount of research has been devoted to the technological progress of the shield tunneling construction and the relevant uncertainty analysis. Goel  presenteRegarding the safety monitoring and condition assessment of the underground structures, Bhalla et al.  addresseAs illustrated in ④4, ⑥1, ⑥2, ⑦1, ⑧2, and ⑨1, while the shield tunnels of the Wenhua Square Station-Wulin Square Station interval go through the soil layers ④2, ④3, ⑥1, ⑦1, and ⑦2.The geological structure of the shield tunnel section consists of a considerable amount of silty soils and sandy soils. Due to the differences of accumulation periods and consolidation conditions, the compaction extent varies from loose condition to medium density in the vertical direction. The properties of the soil layers are different, and the general thickness of the soil layers is about 20 m. The silt soft soils and clayey soils are buried beneath with a dense condition and the thickness of the soil layers is about 40~45 m. The depth of the bottom bedrock is about 55~63 m from the ground surface. According to the geological properties and forming conditions, the foundation soils are divided into different soil layers, as listed in After a comprehensive investigation on the type and characteristics of the metro-tunnel shield sections, various construction teams are established, namely, shield construction team, tunnel segment construction team, and integration construction team. During the whole construction process, the shield construction should be prepared in advance and the accessory structures will be constructed during the construction intermittence of the main structures. The construction time nodes are settled in accordance with the completion of the construction of the milestone part of the project. The timely completion of the construction of the shield tunnel intervals is ensured through harmonious construction planning. By doing so, the general organization of the shield tunnel construction will be legitimately controlled.As illustrated in Following the Chinese code of metro design, a cross-passage between two tunnels should be set up if the continuous length of one of the tunnels is larger than 600 m. On the basis of the geological conditions of the shield tunnel sections, the soils around the tunnels are reinforced through the horizontal freezing and then the tunnel linings are constructed after excavation. By doing so, a high-strength sealing frozen curtain will be formed to guarantee the safety of excavation construction. For the managers of metro infrastructure, the implementation of efficient surveillance and measurement of engineering projects with large risks is crucial such as the deep excavations with a depth over 5 m and the shield tunnel intervals. The execution of the informationalised construction through in-construction monitoring can make the engineering measurement normal and standard. The design principles for monitoring the metro infrastructure include the following: (i) all the monitoring items are effectively synthesized and the measurement data can be interactively verified; (ii) a comprehensive monitoring scope should be established to ensure that the measurement data are promptly acquired with a continuous and accurate manner; (iii) the mature and advanced measurement equipment is adopted and should be protected during installation; (iv) the critical parameters in the structural design are monitored for optimization; (v) special attention should be paid to the key construction sections for dense monitoring; (vi) the monitoring types, locations, and protection measures are determined based on the realistic construction; and (vii) the monitoring method is selected in accordance with the rules of concision and cost-effectiveness. In this project, the monitoring items include the settlement, inclination and cracking of the surrounding buildings, the vertical displacement of the adjacent underground colligation pipelines, the settlement of the ground surface, the underground water level, the sink deformation of the tunnel vault, the tunnel bottom heave, and the tunnel clearance convergence. The alarming indices are generally stipulated based on the total variations and the variation velocities of the monitoring parameters, and the warning value of the total variation should not be larger than the design value. Development and utilization of the urban underground space have gained increasing concerns from the urban administrative agency and the civil engineering community, which has been a significant flag for urban modernization. In the past years, the design and construction of the urban underground structures are considered in terms of the strength and stability of the structural components. However, the deformation control design is deemed to be dominant for the deep excavation of the metro infrastructure due to the increasing number of the surrounding buildings as well as the scope and depth of the metro-tunnel shield construction. In this connection, monitoring of the metro infrastructure during the shield tunnel construction becomes important which will facilitate the condition tracking and safety evaluation of the metro infrastructure with the help of the long-term measurement data.


Given the magnitude of increasing heart failure mortality, multidisciplinary approaches, in the form of disease management programs and other integrative models of care, are recommended to optimize treatment outcomes. Remote monitoring, either as structured telephone support or telemonitoring or a combination of both, is fast becoming an integral part of many disease management programs. However, studies reporting on the evaluation of real-world heart failure remote monitoring programs are scarce.This study aims to evaluate the effect of a heart failure telemonitoring program, Connected Cardiac Care Program (CCCP), on hospitalization and mortality in a retrospective database review of medical records of patients with heart failure receiving care at the Massachusetts General Hospital.Patients enrolled in the CCCP heart failure monitoring program at the Massachusetts General Hospital were matched 1:1 with usual care patients. Control patients received care from similar clinical settings as CCCP patients and were identified from a large clinical data registry. The primary endpoint was all-cause mortality and hospitalizations assessed during the 4-month program duration. Secondary outcomes included hospitalization and mortality rates , risk for multiple hospitalizations and length of stay. The Cox proportional hazard model, stratified on the matched pairs, was used to assess primary outcomes.P=.01). The differential effect on hospitalization rates remained consistent until the end of the 4-month program . The program was also associated with lower mortality rates at the end of the 4-month program: relative risk (RR)=0.33, 95% 0.11-0.97, P=.04). Additional 8-months follow-up following program completion did not show residual beneficial effects of the CCCP program on mortality  or hospitalizations .A total of 348 patients were included in the time-to-event analyses. The baseline rates of hospitalizations prior to program enrollment did not differ significantly by group. Compared with controls, hospitalization rates decreased within the first 30 days of program enrollment: hazard ratio (HR)=0.52, 95% CI 0.31-0.86, CCCP was associated with significantly lower hospitalization rates up to 90 days and significantly lower mortality rates over 120 days of the program. However, these effects did not persist beyond the 120-day program duration. Despite the advances made in the management of heart failure, the burden of disease due to heart failure still remains unacceptably high. Prevalence is projected to increase by 46% from 2012-2030 [Given the magnitude of this problem, multidisciplinary approaches in the form of disease management programs and other integrative models of care are recommended to optimize treatment outcomes . Remote An ideal heart failure remote monitoring approach would be one that empower patients for self-care—knowing and able to perform day-to-day care processes, able to early identify symptoms of worsening of disease, and initiating appropriate action. This can be achieved by a care model that incorporates regular out-patient clinic follow-up with ongoing education (provided at clinic visits or via telemonitoring), objective monitoring of clinical condition, and provision of timely feedback. The telemonitoring program at the Partners HealthCare, Center for Connected Health, Connected Cardiac Care Program (CCCP), is one of such programs that model this approach.CCCP is a 4-month home telemonitoring and education program designed to improve self-management in heart failure patients at risk for hospitalization within the Partners HealthCare network of hospitals. Participants monitor relevant physiologic parameters  and answer questions on heart failure–related symptoms on a touch-screen computer on a daily basis . The remThis study aims to evaluate the effect of a heart failure telemonitoring program, Connected Cardiac Care Program (CCCP), on hospitalization and mortality in a retrospective database review of medical records of patients with heart failure receiving care at the Massachusetts General Hospital (MGH). While the heart failure remote monitoring literature is replete with studies in controlled settings, there is a dearth of literature reporting on the evaluation of real-world heart failure remote monitoring programs. In addition, by following up with patients after disenrollment from the CCCP program, this study sheds some light on the downstream impact of completely taking patients (who have built disease self-efficacy skills) off remote monitoring programs.This study is a retrospective analysis to evaluate the effect of CCCP on clinical outcomes in patients enrolled in the program in a 1:1 match cohort study. Matching on potential confounders is a methodology that is commonly adopted to increase efficiency ,9. It isCCCP participants were compared with control patients, within the same health care system, not enrolled in the CCCP. The control patients received the usual standard of care at MGH. A 1:1 individual matching was done to identify controls for each CCCP participant by selecting a control patient that had a hospitalization within 30 days of the corresponding CCCP’s patient index hospital admission. Every patient enrolled in the CCCP program must have an index hospitalization. The index admission is the last heart failure–related hospitalization a patient must have prior to enrollment in the CCCP. Other matching parameters are age ±2 years, race, and gender. We used the matching without replacement method. In this method, once a matched patient from the control population is selected, they are no longer eligible for subsequent selection. The best matched control was selected to maximize the precision of the analysis. Gender and race were the first considerations in selecting the best match, followed by the nearest age and index admission date in that order.All subjects included in this study are patients with a diagnosis of heart failure receiving care at MGH. Eligible participants were English-speaking heart failure patients, who had a Partners HealthCare primary care provider or cardiologist that utilized the electronic medical record. They were also required to have a hospital admission to a Partners HealthCare hospital to be eligible to participate in the CCCP. Eligibility requirement for enrollment in the program included that patients must have a diagnosis of heart failure, must have an MGH care provider, and must have been flagged as having a high risk for readmission and referred into the program by their care provider. Patients with end-stage renal disease, on any chemotherapeutic medication, or having had any organ transplant were excluded from participation.We conducted a retrospective review of the remote monitoring database (RMDR) to identify participants enrolled in the CCCP between Jan. 1, 2008, and Aug. 31, 2012. The RMDR is a secured database housed within the Partners HealthCare firewall where connected health data are processed and stored. From the RMDR, we also collected program information of participants. This information included program start of care and end of care dates. The list of identified program participants was sent to the Partners HealthCare’s Research Patient Data Repository (RPDR) to access participants’ full clinical data and also to identify eligible match controls. The RPDR is a large clinical data registry that gathers medical records from various hospital systems and stores them in a central location . We idenThe primary source of data for this study is the RPDR. The detailed dataset from the RPDR contained demographic and clinical information of patients including age, gender, race, diagnoses, hospital visits, clinical notes, and vital status. All diagnoses were carefully verified in the electronic medical records to limit misclassification of disease status due to data coding errors. We collected and reviewed all-cause hospitalization and mortality data of CCCP patients and their corresponding controls starting from 120 days before enrollment in the CCCP program and up until 1 year after the CCCP enrollment date. The study was approved by the Partners HealthCare Human Research Committee.Outcomes were classified based on follow-up times. The primary outcomes were the effects of the intervention assessed during the program duration of 4 months. The primary effects at 30 days, 60 days, 90 days, and at 4 months were on mortality and hospitalizations.Secondary outcomes were the cumulative effects of the intervention assessed over a 1-year follow-up period from the date of program enrollment, that is, following up participants for an additional follow-up time of 8-months following program completion. The secondary effects evaluated were on mortality, hospitalizations, risk for multiple hospitalizations, and length of hospital stay.t test or the Wilcoxon-Mann-Whitney test for continuous data and chi-square tests for categorical data. We also assessed baseline hospitalization rates 120 days prior to CCCP enrollment to see if differences existed in hospitalization rates across both groups prior to follow-up. Cumulative survival curves for time-to-event analyses were constructed by the Kaplan-Meier method. The Cox proportional hazard model using time to death and hospitalization as endpoints was used to estimate hazard ratios (HR). Multiple hospitalizations were accounted for in the model. All analyses were stratified on the matched pairs [P<.05 was considered as significant. All analyses were performed using data analysis and statistical software, STATA 12 version.Baseline data were summarized using descriptive statistics: means and standard deviation for continuous data with normal distribution, medians for skewed data, and percentages for categorical data. We examined group differences using the ed pairs , and we P=.87). All patients were followed up for a maximum duration of 1 year from the period of program enrollment for CCCP patients and their corresponding controls. All baseline characteristics are summarized in The majority of the sample population were Caucasian males with an average age of 77 years in both groups, but they differed by marital status. The median duration of follow-up, 365 days, was similar in both groups. The baseline rates of hospitalization, 120 days prior to CCCP enrollment, did not differ significantly in the 2 groups . However, after 30 days of enrollment in the program, this rate decreased significantly in the CCCP group compared to the control group . This differential effect remained consistent throughout the duration of the program: at 60 days , at 90 days , and at the end of the 4-month program . Similar beneficial effect was observed on the mortality rate, which was significantly lower in CCCP patients compared with the control group  at the end of the program. The number of hospitalization and death events and corresponding rates measured at various points during the follow-up period are reported in In the model accounting for multiple events, the hospitalization rate in both groups was similar at baseline  (P=.20). Additionally, the mean length of hospital stay was similar in both groups . Of the 174 CCCP patients, 47% had at least one all-cause hospitalization over the 1-year follow-up period compared with 46% in controls  . The rish groups .P=.31). Compared with controls, mortality rates over 1-year follow-up were lower in the CCCP group, but this was also not statistically significant   .This study was designed to evaluate the effect of CCCP, a heart failure remote monitoring program with objective feedback and coaching, compared with matched control patients that received usual care in the similar clinical settings, on clinical outcomes. Our findings from these retrospective analyses of medical record data suggest that compared to the control group, CCCP was associated with lower hospitalization and mortality rates over the 4-month program duration. Although not statistically significant, the mortality benefit appeared to continue even after following up for an additional 8 months after program completion  but hospitalizations increased over this period. We also observed that participants in the program were more likely to have multiple hospitalizations, but there was no difference in length of hospital stay.Altogether, these findings suggest that the program was associated with reduction in hospitalization and mortality rates during the 4-month program duration and kept patients alive who probably would have died had they not been enrolled in the remote monitoring program. However, the program was associated with increased rates of hospitalizations and mortality after program completion. We speculate that the finding of increased hospitalization and mortality after the 4-month program period could be explained by the progressive nature of the disease, early disproportionate deaths of sicker controls, and also by the fact that participants had become dependent on being monitored remotely with regular access to monitoring devices and the telemonitoring nurses. Tapering of the beneficial effect of monitoring after disenrollment from the program at the end of the 4-month period could also suggest that patients had not developed sufficient self-competency to manage the disease after leaving the program. An alternative explanation for higher hospitalization rates could also be that patients had become sensitized to the early symptoms of disease decompensation due to telemonitoring education and would present earlier than patients who did not have this education.Although mortality rates increased in the CCCP group after program completion, the overall effect was still beneficial compared to controls over the 1-year follow-up. This finding is similar to results from eight meta-analyses published between 2007 and 2013 evaluating the effect of remote monitoring on mortality -17. ThesTraditionally, remote monitoring is seen as a short-to-medium term adjunct to regular care to empower patients for self-management following hospitalization. Long-term use is not usually feasible due to cost. However, based on our findings, we speculate that increasing the duration of the program to enable patients to develop self-competency may improve outcomes. Although this may not be cost-effective for all participants, risk stratification to identify patients who will benefit from prolonged monitoring may be needed. Alternatively, because patients have built disease self-competency on the program and accompanying monitoring devices, a graduated removal of program components  may be helpful. Less intensive monitoring following a remote monitoring program like CCCP is appealing and feasible because of the increasing availability and reducing costs of consumer-oriented monitoring devices that can be easily used by patients ,23. FutuApart from the retrospective nature of this study, it has a number of other limitations. The individual matching done in this study did not include any measure of disease severity. To ensure that patients and their matched controls were comparable at baseline, in terms of severity of disease, we evaluated and found that the rates of hospitalization were similar in both groups 120 days prior to (the CCCP patient and corresponding matched control) enrollment in the CCCP program. We also controlled for measures of disease severity (ejection fraction and NYHA classification) in our analysis. Another limitation is that any hospital admission occurring outside of the Partners’ electronic medical records were not captured in these analyses. However, this effect is minimized in the CCCP group because they were monitored daily and had more regular contact with their health care providers. On the other hand, we were more likely to have missed hospitalizations in the control group who may have out-of-system hospitalizations. We also cannot rule out unmeasured confounding from comorbidities and the fact that control patients might have received other treatments including a remote monitoring program other than CCCP. Additionally, given that the program was implemented in the setting of an academic medical center, findings from this evaluation may be generalizable only to such settings.Results from these analyses suggest that compared with usual care controls, this remote monitoring program is associated with significantly lower hospitalization rates up to 90 days and significantly lower mortality rates over 120 days of the program. However, these effects did not persist over an additional 8 months of follow-up after program completion. There is a need to evaluate the potential impact of risk stratification to determine optimal duration for remote monitoring and also the effect of less intensive, long-term remote monitoring.


Although our country faces a looming shortage of doctors, constraints of space, funding, and patient volume in many existing residency programs limit training opportunities for medical graduates. New residency programs need to be created for the expansion of graduate medical education training positions. Partnerships between existing academic institutions and community hospitals with a need for physicians can be a very successful means toward this end. Baylor College of Medicine and The Children's Hospital of San Antonio were affiliated in 2012, and subsequently, we developed and received accreditation for a new categorical pediatric residency program at that site in 2014. We share below a step-by-step guide through the process that includes building of the infrastructure, educational development, accreditation, marketing, and recruitment. It is our hope that the description of this process will help others to spur growth in graduate medical training positions. In March 2014, the Association of American Medical Colleges (AAMC) Center for Workforce Studies published its report on the 2013 Medical Student Enrollment Survey  at a community hospital for an established US academic institutional sponsor. What follows is a ‘nuts and bolts’ guide to navigating this process which we hope will help others in some way. In reality, many of these steps occur concurrently in a joint effort by stakeholders both at the training sites and the institution .Every residency must first have an accredited institution as its sponsor. The startup process can be made much more expeditious when a relationship is secured with an established academic institutional sponsor. There can be benefits to both parties. More and more institutions are successfully using this as an expansion tactic, developing programs in other cities and even outside of their own states or countries. Collaboration with community hospital partners in remote sites can not only build tertiary referral bases but also help meet medical needs in underserved areas. Existing institutional sponsors have expertise which places them in the best position to develop new residency programs for community hospitals, and the reputation of the institution can lend credence to the venture. The collaboration also strengthens the credibility of a fledgling program among applicants, and an academic partner with a medical school may be a helpful recruitment stream for potential candidates. The addition of educational programs often increases the stature of the hospital within the community and ultimately can provide a long-term solution for physician shortages in the area as residents begin to graduate the program.Next, the primary training site must be selected, taking into consideration the adequacy of facilities, patient volume, and teaching faculty. If ancillary sites are needed to supplement the educational experience, Program Letters of Agreement (PLA) will need to be arranged prior to the first accreditation site visit for each required rotation that takes place there. At the minimum, a program director and coordinator located at the primary site will need to be selected early on in the process of accreditation, with additional supporting staff a strong consideration. The Designated Institutional Official (DIO) will need to be identified within the sponsoring institution and will be the initiator of the application process with the ACGME.Funding for resident salaries and benefits, administrative faculty time, recruitment, and other operating costs will need to be arranged. In the United States, some federal funding will go to the primary training site; however, prior to the establishment of a revenue stream, part of the startup burden may need to be shared by the sponsoring institution. Some administrative costs will occur 2 or more years prior to the induction of the first trainees. Given that nearly 53% of residents stay in the states where they are trained, some state legislatures have now begun offering startup and expansion grant funding for new GME positions, particularly in primary care . PrivateThis step hinges on ACGME Residency Review Committee (RRC) meeting dates for your specialty. Approximately 1 year is normally needed for preparation of the application and completion of the site visit process. In addition, a minimum of 1 year will be needed after the accreditation for the recruitment and match process, starting in the summer when students begin applying to programs. If the accreditation decision is made after July, strong consideration should be made to putting off the start of the program for another academic year due to difficulty in marketing the program to potential applicants in time for the residency interviews. Because of these intricacies, mapping out a timeline early is crucial.A primary role of the program director is to ensure that the program meets all the ACGME requirements. Reviewing the institutional, common, and specialty-specific program requirements in detail is an important and ongoing task. Typically, the language of the requirements includes ‘must have’ and ‘should have’ recommendations, as well as some requirements which leave a great deal of flexibility in their application. Ensure that all sections of the ACGME website are explored, especially the ‘frequently asked questions’, power point presentations, and notable practices sections, as they often provide clues as to the preferred interpretations of some of these guidelines. In general, the ACGME staff are amenable to answering questions that remain when the website cannot provide the exact answers that are needed. The program directors association for your specialty can be another valuable resource and can provide remarkable insight into the ways that other programs have implemented the guidelines and requirements put forth by the ACGME.For true educators at heart, the next two steps are the most invigorating and should be approached as a golden opportunity. Take stock of your resources – unique clinical programs, stellar faculty, facilities, patient population, hospital organizational structure, positioning within the community, etc. What will be your program's unique niche? What educational approaches will best suit your situation? How will you advance education in your field? Few get the chance to consider these questions and develop a program from scratch that perfectly fits every aspect of the existing infrastructure, and without the constraints of having to worry about complete coverage of the hospital or even a particular service by their residents. Carefully consider the ideal balance of service and education in order to structure this from the start. Working in conjunction with institutional, departmental, and hospital administration ensures that the vision becomes unified early and helps to eliminate differences of opinion that will bog down your application process.®  and building on the strong work of other educators who have been willing to share their curricula.Once you have decided on your educational approach, you must begin planning your curriculum, ensuring that you meet every aspect of the program requirements in your specialty. Not only must you develop the overall plan for clinical rotations but also for didactic teaching, board review, and any other longitudinal curricula you wish to implement. Rotation directors with a strong interest in medical education should be selected and recruited to help plan the program and write competency-based goals and objectives for each clinical rotation. It is important to create an overall educational map, determining how you are teaching and assessing each competency in multiple educational arenas and over time. Much assistance in these tasks can be gained from researching MedEdPORTALIt is important to consider at this step how you will meet requirements for program evaluation, assessing clinical competency, and ensuring the quality and safety of the clinical learning environment. If your institution does not already have them in place, formal policies for duty hours, supervision, moonlighting, etc., will need to be drafted. Planning for research involvement for your residents, counseling support and wellness programs, and integration of resident documentation in the electronic medical record may require additional infrastructure to be developed within your institution, and space for didactic conferences, call rooms, and GME administration will need to be identified. Strong consideration should be given to the use of electronic residency management evaluation systems and a web-based educational platform for more expeditious and documented dissemination of information between program leaders and residents.At this point, you would be wise to begin selecting and engaging your faculty and bringing them into the vision. We set up regular bimonthly faculty development sessions which started more than 18 months prior to the start of our program to begin informing, motivating, and developing educational skills in our faculty, and to align those who had come from many different institutions. It can be a huge cultural shift to introduce GHE into a primarily non-academic environment, but if you are already at an academic institution, enlisting existing faculty development resources can streamline the process. Business literature, such as Transformational Leadership by Bass and Riggio  or LeadiThe tedious process of completing the application(s) for accreditation requires an incredible amount of data and careful attention. The DIO must grant initial access to the electronic application system. Wording and framing are very important to ensure that you are addressing the aspect(s) of the ACGME requirements that a particular question is actually aiming to assess. Seek experienced outside reviewers to take a look at your responses with a critical eye and make sure you are explaining your program in a way that can be easily interpreted by the review committee. As you compile the application, maintain supporting documentation for each answer in preparation for the site visit. This is traditionally done by preparing sets of binders by category: faculty information, curricula, policies, patient data, etc. Once completed, the application will be submitted first to the DIO, and then to the ACGME for review.After review of your application by the ACGME, you will be notified of a date for your site visit. They will be interviewing program leadership, administration, and a selected group of faculty and will assess concordance on all aspects of the application. Each group will need to be prepared to verify the information contained in your application, so appropriate information distribution and education on program requirements is key. We developed binders for our faculty team which detailed the most important details of the overall program design and served as an important reference for the aspects of the program application which pertained to their own clinical areas. A ‘mock site visit’ to let faculty know what they will experience that day can help to ease nerves and ensure that you are adequately prepared. This may be conducted either by someone who has extensive ACGME experience or by someone who has just gone through the accreditation process.®, Electronic Residency Application Service® (ERAS), and the National Residency Matching Program® (NRMP), if those are appropriate for your situation. Utilize faculty contacts at home schools, and consider contacting local and regional student groups in your specialty and offering to speak or send information. Many schools offer residency fairs where your program can be advertised. Clerkship directors in your region who mentor medical students should also be informed of your accreditation and opening as soon as the decision is official. Consider offering an open house of some sort where students can come and learn about your vision. Think strategically about your market niche and what will be the likely biggest selling points for your program, and be prepared to answer every email with an overabundance of information. Remember that each student you come in contact with has many friends not only in their class but in the years below them as well.As you wait for the accreditation decision, develop your marketing plan. How will you get the word out to students about your program? Establishing a web presence early is extremely important, and this includes not only the development of a vibrant website but also registering early with FRIEDA OnlineRecruitment into a new program can be very challenging. In the 2013 National Residency Matching Program applicant survey, more than 60% of applicants cited reputation of the program, quality of residents in the program, work life balance, and house staff morale as important in their ranking decisions, all factors which cannot readily be assessed in a new program. In addition, concrete data such as board passage rates, specialty choices, and fellowships obtained by previous graduates are simply not available. Other concerns, such as lack of upper-level resident mentorship, perceived readiness of hospital and personnel to transition to an academic environment, and a simple fear of a program just not having ‘all the kinks worked out’ may also have a negative impact on a candidate's interest in a new program. There are, however, factors which may be attractive to a candidate in a new program, which could be highlighted during the recruitment process. The ability to work one on one with faculty, especially during the first year, and the ability to help shape and develop a training program could be very appealing to some candidates. Personal attention, a high level of involvement with the program director on the day of the interview, and many opportunities to interact with faculty during their visit can help to reassure applicants about their concerns. Seek to identify candidates with the right type of independent and pioneering spirit which will be required of your first class. Always remember that part of the recruitment process is marketing, as students will take their impressions of your program back to their home institutions even if they do not end up matching with your program. Consider interviewing 15–20 candidates per spot and be open to interviewing not just your top candidates but also others who will ensure your program is marketed within a large geographical spread. Your faculty will need to take the place of residents in the recruitment process and exposure to as many faculty as possible during the interview experience is key, as the residents will be working closely with them and will be reassured by the opportunity to interact. When developing your rank list for the match, it is important to list as many applicants as possible to ensure that your program fills, and equally important to never list anyone that you absolutely would not want in your program.Match day will come and the residents will soon follow. Take time to celebrate your successes and hard work! Reward the faculty for their participation with recognition of their efforts. After your residents are selected, the lengthy onboarding process will begin. It is important to engage hospital staff in this process so that they become comfortable and understand the residents’ new roles. Orientation is an important time – a careful balance between giving the new interns the amount of information they need without overwhelming them with things they will likely forget is crucial, as is having a written or electronic resource for all information given that theywill be able to refer back to in the future. It will be an exciting time for everyone to see all your hard work come to fruition, and taking a few moments to enjoy the momentous beginning of your program will give you the fuel to dive into the process of training your residents with renewed vigor.Existing academic institutions have a critical role to play in integrating with and investing in their surrounding communities to address US medical workforce needs. As the GME community enters into a rapid growth phase, it will be in need of data and resources to help in the building of new residency programs. It is important to share lessons learned by our experiences and success at The Children's Hospital of San Antonio in order to enable others to build on what we have already learned. While our experience may not be translatable to the structure of every program, these overarching principles will help guide others through the basic steps of creating a brand new residency program and will hopefully encourage them in the process.


Objective. To assess the impact of a single versus dual console robotic system on the perceptions of program directors (PD) and residents (RES) towards robotic surgical training among graduating obstetrics and gynecology residents. Design. An anonymous survey was developed using Qualtrics, a web-based survey development and administration system, and sent to obstetrics and gynecology program directors and graduating residents. Participants. 39 program directors and 32 graduating residents (PGY4). Results. According to residents perception, dual console is utilized in about 70% of the respondents' programs. Dual console system programs were more likely to provide a robotics training certificate compared to single console programs . A greater proportion of residents graduating from a dual console program perform more than 20 robotic-assisted total laparoscopic hysterectomies, 30% versus 0% (p = 0.15). Conclusions. Utilization of dual console system increased the likelihood of obtaining robotic training certification without significantly increasing the case volume of robotic-assisted total laparoscopic hysterectomy. Despite recent increases in the use of robotic surgical systems in gynecologic procedures, a trend that is expected to continue , incorpoAlthough the learning curve for robotic surgery may be less steep than for conventional laparoscopic surgery , the dep Qualtrics, a web-based survey development and administration system. After obtaining exempt status from University of South Florida Institutional Review Board, the survey was pilot tested to ensure that it was easy to understand and that questions were relevant and to gauge the time required to complete the survey. The survey was sent by email to all obstetrics and gynecology residency program directors (n = 243). The list of emails was obtained from Association of Professors of Gynecology and Obstetrics (APGO) website. The email survey was also sent to the listserv of the obstetrics and gynecology residency program coordinators, and a request was made to forward the survey to all graduating (PGY4) obstetrics and gynecology residents in their program (n = 1255). After sending the initial email, two additional reminders were sent to improve the likelihood of response. The first section of the survey focused on demographics, the location and type of residency, and the number of residents in the program per year. The second section focused on aspects of individual training and surgical volume and personal perspective on robotic utilization in gynecologic surgery.A survey was developed usingp value of <0.05 is considered statistically significant.Survey responses were analyzed using SAS, version 9.4 . Frequencies and percentages of responses were generated overall, by type of respondent  and by type of robotic system . Since the main study question sought to determine whether responses varied according to the presence of a single or dual robotic system in the program, Fisher's exact tests (characteristics with 2 groups) or Freeman-Halton tests (characteristics with >2 groups) were used to assess crude associations between each individual/program characteristic and type of robotic system. A A total of 84 participants accessed the survey; 13 were missing responses for more than 50% of questions, including the type of robotic system, and were excluded from the analysis. There were 39 PD and 32 RES completed surveys. The response rates were 16% and 2.5% for the PD and RES, respectively. Nearly 94% of RES respondents were female, compared to only 66.7% of PD. The majority of RES were in a university program (71.9%) compared to 53.8% of PD. Nearly half of PD felt comfortable that residents from their program could perform robotic-assisted total laparoscopic hysterectomy (RA-TLH) upon graduation without the need for proctoring, despite their reporting that only 28.2% of their residents performed more than 20 RA-TLH before graduating. Similarly, 53.1% of RES respondents felt comfortable that residents from their program could perform RA-TLH upon graduation without proctoring even though only about 1 in 5 performed more than 20 RA-TLH before graduating. RES and PD shared the same belief that utilization of robotic surgery will increase in gynecologic oncology but probably will either decrease or stay the same in other gynecologic surgery subspecialties, p = 0.66). Regardless of the subspecialty, programs with dual console tended to offer more subspecialty fellowships. The programs with dual console system tended to provide a robotic training certificate more frequently, 50% versus 22% (p = 0.15), and a bigger proportion of their graduating residents performed more than 20 RA-TLH, 33% versus 11% (p = 0.39). The presence of dual console did not significantly change PD perspectives on future utilization of robotics in different subspecialty of gynecologic surgery, Thirty PD (76.9%) and 23 RES (71.9%) report having a dual console in their hospital. Among PD respondents—although not statistically significant—university programs are more likely to utilize a dual console system than community or university-affiliated community programs (p = 0.20). The presence of dual console did not increase the proportion of the programs that offer subspecialty fellowship training. Surprisingly, 44% of single console programs offer minimally invasive gynecologic surgery fellowship compared to only 34.8 of dual console programs (p = 0.70). Dual console system programs were more likely to provide a robotics training certificate compared to single console programs . A greater proportion of residents graduating from a dual console program perform more than 20 RA-TLH, 30% versus 0% (p = 0.15). The presence of a dual console did not significantly change the RES perceptions of the future utilization of robotics in various gynecologic surgery subspecialties, According to RES responses, more university programs tend to utilize a dual console system  was first approved by the Food and Drug Administration for gynecologic surgeries in April 2005, and Intuitive Surgical introduced the da Vinci Si dual console interface in April 2009, allowing 2 surgeons to sit at 2 different surgical consoles and control the same robot simultaneously .This study is the first to compare residents' and program directors' perception of robotic surgical training with and without the dual console system. It is known that a major hurdle to success in robotic surgery is the associated learning curve, which applies to both the surgeon and the surgical team. Utilization of the dual console system might give a second surgeon the opportunity to gain robotic experience, which in turn may result in earlier proficiency . A studyAn advantage of dual console is that the trainee's perception of being removed from the procedure almost disappears . The useIn this study, the dual console system is available in about 70% of the OBGYN residency programs that participated in the survey. A study published by Gobern et al. showed that robotic platforms were available at 82% of institutions associated with a residency program. Robotic-assisted gynecologic procedures were performed at 78% of these institutions. Resident training in robotic surgery, however, was part of the training curriculum at only 58% of those residency programs . Despitep = 0.15)].The effect of surgical volume on perioperative outcomes and resource utilization is evident. In a study by Wallenstein et al., women treated by high-volume surgeons and at high-volume hospitals have lower morbidity; also surgical volume has a direct effect on lowering resource utilization . In a stIt seems from this study that the availability of a dual console system does not add a significant benefit in the robotic training of the residents except that programs with a dual console tend to award more robotic training certificates to their graduating residents. However, there are some limitations such as recall, response, and research biases, which are inherent to the design of survey studies. Our response rates were 16% and 2.5% for the PD and RES, respectively, despite sending two reminder emails to encourage better response. We acknowledge that this is a major limitation of our study. Additionally, we acknowledge that this study might be underpowered to find statistically significant differences between the single and the dual console groups. Therefore, future studies with more participants and analysis of perioperative outcomes as primary endpoint between the two groups will be needed to definitely determine the utility of dual console robotic system in residency training.


Global Health Training for Fellows and Scholars (GHTFS), the new program shifted emphasis from student to post-doctoral trainees.The initial Fogarty International Clinical Research Scholars (FICRS) program, established in 2004, was focused on training in tropical medicine and was very successful in establishing researchers with expertise in communicable and non-communicable disease worldwide. This was a one-of-a-kind program: it allowed medical, veterinary, dental, and pre-doctoral epidemiology students from the United States to train in clinical research at sites in developing countries. The program later expanded, adding training of post-doctoral fellows (FICRS&F). It was originally administered by Vanderbilt University under a grant from the National Institutes of Health (NIH), but 2 years ago it was restructured to be administered by five University centers. As illustrated by its title, AJTMH, describes the earlier FICRS program but focuses only on a subset of the overall program: the fellows, who were either post-doctoral or post-residency. However, we believe that the most valuable part of the FICRS&F program was the training of students, which now is relegated to a minor position in the new GHTFS program.The article by Heimburger and others,In addition to providing funding and mentoring for 1 year of research abroad, the FICRS&F program paired each student with a young doctor or researcher who was also pursuing a career in clinical research in his/her home country.The selection process included an application and in-person interviews at the NIHIn 2012, the trainee selection and orientation process decentralized to multiple sites, called the “global health consortium,” and the FICRS&F program was eliminated. The orientation and mentor meetings were discontinued, eliminating the significant advantages previously mentioned. Our recommendation is that these meetings be reinvigorated, even if they need to be of shorter duration to address funding constraints. This would allow for the networking of trainees, the networking of mentors, and interactions between the two.Most FICRS&F trainees did not write up their research findings until they returned to the United States. This unfortunately meant that publication was delayed or never occurred. Earlier in the program, Fogarty sites were able to provide funding for trainees to return to the international site for additional time, often more than 2 months, allowing them to focus on manuscript writing and even development of future collaborations. In addition, funds were available to present at an international meeting. We also recommend that this financial support be reinstated.The fellows program was added to the original FICRS in 2008 to help achieve the ultimate goal: to develop independent researchers capable of obtaining independent research support. Although students were less expensive to fund than fellows, this shift was in part financially driven: the Fogarty International Center had difficulty attracting funders from NIH institutes because of the long latency period from student to NIH grantee. However, we believe this change has detracted from the main goal of the program.In the previous FICRS&F program, in contrast to the scholars, the fellows were older (average age 33 years), more often married (64%), and currently in residency or fellowship programs (65%).believe), that more of the scholars wind up in overseas research partnerships than do the fellows. Because of their early exposure to global health research and the early stage of their careers, the scholars have more opportunity to consider their goals over the long term. We recommend that this tabulation be performed so that objective evidence is available to evaluate program success.To date, we have not seen any data, tabulated by year of training to correct for a latency period, of long-term success in retaining United States and international scholars or fellows in tropical medicine, either based on publications or grants in this area. The Fogarty website provides minimal information and does not provide this level of detail.One other concern about both the FICRS&F and GHTFS programs is the challenge of tracking trainees from each site using the current format. The tracking system is an online database that requires trainees to tediously and annually enter all their past training, publication, and presentation information; it is not very user friendly. One recommendation is to use social media, such as Facebook, for tracking. This could be a more valuable tool to contact past trainees, update the Institute on the scholar or fellow's current activities, and facilitate tracking in the future.Finally, what is the ultimate goal of the FICRS&F and the current GHTFS programs? The programs are currently tracking publications and grants of past trainees. However, if the goal is to develop leaders, mentors, sustainability at foreign sites, and collaborations between the United States and international researchers, an investment in both scholars and fellows, at a minimum with equal investment in both groups, is critical to the success of this program.