Despite evidence of the benefits of regular physical activity, many older adults are not physically active. Health professionals are challenged to replicate evidence-based programs to address low levels of physical activity among members of their communities.EnhanceFitness is an evidence-based group exercise program developed in Seattle to increase the strength, flexibility, and balance of older adults. Hawai`i's Healthy Aging Partnership supported the rural island of Kaua`i to select, adapt, implement, and evaluate EnhanceFitness to increase physical activity among older adult residents (75% Asian/Pacific Islander [API]).Evaluation measures of the replication of EnhanceFitness included fidelity of EnhanceFitness delivery and participants' attendance, satisfaction with the program, confidence to exercise regularly, and pre-post fitness check measures of physical performance .t = −11.06, P < .001; arm curls, t = −6.66, P < .001; and up-and-go test, t = 6.56, P < .001). Participants reported high satisfaction with the program and instructors and high confidence to continue to exercise regularly.Between July 2007 and December 2010, 223 Kaua`i residents enrolled in EnhanceFitness; 178 (80%) participated at least 4 months and completed the 4-month fitness checks. EnhanceFitness classes were offered with a high degree of fidelity, and both API and white participants significantly improved their physical performance (chair stands, EnhanceFitness is replicable in Hawai`i and increased physical performance among API and white older adults. This case study outlines a replication process that other communities can follow. Regular physical activity can promote physical and psychological well-being and reduce risk of disability and vulnerability to chronic diseases among older adults . HoweverTo support well-being among older adults, attention has been given to implementing evidence-based health promotion interventions that have proved to be effective in reducing risk of disability and chronic diseases . Such evAlthough there is push for broad replication of evidence-based programs, translating evidence-based interventions from the study site to other communities can be challenging. Barriers include insufficient training for providers in these programs, limited time and resources of providers to offer new programs, and inadequate organizational infrastructure and systems to support translation .The state of Hawai`i has 4 counties . More than 20%  of Hawai`i's residents are older adults (aged ≥60 years), and this percentage is expected to increase to 25% by 2030. More than 75% of the aging population in Hawai`i is Asian, Native Hawaiian, and Pacific Islander . These sKaua`i County has approximately 13,800 (21%) older adults. Of these older adults, 53% are Asian/Pacific Islander (API), 34% report at least 1 disability, and 60% experience loss of physical performance . Kaua`i Hawai`i's Healthy Aging Partnership is a statewide coalition that was formed in 2003 to improve the well-being of older adults by replicating evidence-based health promotion programs. Coalition members included professionals from government offices for aging and public health, eldercare agencies, and the University of Hawai`i at Mānoa. Representatives from the County of Kaua`i Agency on Elderly Affairs were founding members of the partnership. Early in the partnership, all 4 counties were supported to assess health promotion preferences of their older adults, and all counties piloted small exercise programs. Successful completion of these activities helped Hawai`i secure federal grants in 2006 to replicate 2 evidence-based programs in the state, and Kaua`i County chose to replicate EnhanceFitness .EnhanceFitness is a group exercise program developed by Senior Services in Seattle to increase the strength, flexibility, and balance of older adults through structured group exercise sessions of stretching, low-impact aerobics, balance, and strength training . The proResearch that documents cross-community translation of evidence-based programs and explores their effectiveness in new populations and locations can help in the dissemination and use of evidence-based programs. The purpose of this article is to describe how Kaua`i County selected, adapted, implemented, and evaluated EnhanceFitness to increase availability of physical activity programs and physical performance among older adults. Evaluation measures included fidelity of EnhanceFitness delivery and participant attendance, satisfaction, confidence to exercise regularly, and pre-post fitness check measures of physical performance . We assessed the effectiveness of EnhanceFitness among API and white participants.To adapt EnhanceFitness to Kaua`i County, the Hawai`i Healthy Aging Partnership used the Track Change Tool adapted by the National Council on Aging from Peterson  to deconWe then used the "adaptation traffic light" to judge the discrepancies because some elements of an evidence-based program should not be modified . Red-ligTo ensure that key components of EnhanceFitness were delivered exactly as prescribed by the program developers, Kaua`i County recruited qualified trainers and instructors, arranged training in EnhanceFitness, and monitored fidelity. An EnhanceFitness master trainer, who is certified to provide instructor training, monitor fidelity of program delivery, and offer Enhance Fitness classes, regularly monitored EnhanceFitness instructors by using a fidelity monitoring tool developed and validated by Seattle's Senior Services . The masDemographicsAt enrollment, participants completed consent, registration, and health forms and provided physician clearance for participation; Senior Services  providedFitness checksPhysical performance refers to a person’s lower- and upper-body strength, agility, and balance. Fitness checks, tests developed by Senior Services  to assesSatisfactionWe gathered data on participant satisfaction by using a tool adapted from Senior Services , which wFrom the EnhanceFitness training and manual, we identified several red-light changes, such as shortening the duration of the exercise program, eliminating phases of exercise , and adjusting the tempo of the music for each phase of exercise. These types of changes were not attempted . Green-lzori  or sandals during the program, as some did not own closed-toe athletic shoes. However, Senior Services strongly recommended against this change, and the Hawai`i Healthy Aging Partnership agreed to find resources for older adults in need of financial assistance with purchasing appropriate shoes.In trying to replicate the program, we identified 2 potential yellow-light changes that were discussed with Senior Services. In Seattle, EnhanceFitness was offered in indoor, temperature-controlled, exercise rooms with a carpet-free wooden floor and straight-back chairs. However, many of the community-based facilities on Kaua`i were built with concrete floors and trade-wind ventilation and offered only folding chairs. Senior Services agreed that our classes could be held in these facilities but recommended purchasing straight-back chairs when funds allowed. We also asked if our program participants could wear Once the adaptations were set and implementation planned, representatives from Kaua`i County organized and coordinated the classes, finding certified fitness instructors willing to be trained as EnhanceFitness master trainers and instructors, scheduling training, securing sites, and recruiting participants. Hawai`i's Healthy Aging Partnership helped to bring EnhanceFitness trainers from Senior Services, adapt marketing tools, develop consent forms, obtain institutional review board approval, monitor fidelity of delivery, and evaluate participant outcomes.EnhanceFitness instructors must have nationally recognized fitness instructor certification, and our initial group of certified fitness instructors was trained by Senior Services in June 2007. By January 2011, 5 trainings had been provided, yielding 1 master trainer and 21 instructors on Kaua`i. However, by 2011, only 8 trained instructors were offering classes regularly . Our results showed that all instructors had areas in need of improvement during their first week of offering EnhanceFitness. At month 4, however, instructors met or exceeded standards in all 8 areas, suggesting that EnhanceFitness was being offered with a high degree of fidelity.ParticipantsInitially, Kaua`i County implemented EnhanceFitness classes 3 times per week every week of the year at 2 sites. The average class size was 19.3 . EnhanceFitness classes were popular, and new sites were opened in 2008, 2009, and 2010. By 2011, 8 different classes were offered at 7 sites in Kaua`i County.Compared with white participants, API participants were older, more likely to live in larger households and to have lower incomes, and more likely to have hypertension . There wOf the 223 initial enrollees, 178 (80%) completed the 4-month fitness check, and 119 (53%) attended longer than 1 year . ParticiFitness checksAll program participants (N = 223) successfully completed baseline fitness checks during the first week of class, and 178 (80%) participants completed the 4-month fitness checks . Both APProgram satisfactionBecause the anonymous satisfaction survey was administered at the 4-month fitness checks and annually thereafter, 374 forms were completed. More than one-third of EnhanceFitness participants heard about the program through county agency on aging  and partner agencies . Almost all participants (97%) attended EnhanceFitness because they sought to improve their health. Other reasons included desire to learn about exercise  and meet with friends . Program participants were very satisfied with EnhanceFitness and the program's instructors , willing to continue the exercise learned from EnhanceFitness , and confident that they could continue to exercise regularly . We were not able to assess differences between API and white participants because of the anonymity of the survey.Evidence-based physical activity programs are available, but the challenges in translating them to community practice are documented ,17. EnhaIn replicating EnhanceFitness, we found that few adaptations were needed. As others have found, the use of familiar music helps "localize" EnhanceFitness , and theAlthough EnhanceFitness did not require major adaptations to fit our older adults, the replication process was assisted by the Track Changes Tool and the "adaptation traffic light." Using these tools forced us to carefully consider how EnhanceFitness had been implemented by its designers and how closely we could replicate it in Kaua`i County. Other communities would benefit from guidelines on using these tools and from a list of allowable and unallowable modifications to EnhanceFitness.P < .001), and arm curls , and reduced time for the up-and-go test   and the proportion of people attending the class more than twice each week (60%). However, these figures compared favorably to the national average of 60% completing the 4-month fitness check and 39% attending the class more than twice each week, based on 3,803 EnhanceFitness enrollees across 7 states in 2009 . Our pro < .001) ,13. SimiStates planning to implement EnhanceFitness should expect that some certified fitness instructors trained in EnhanceFitness may not be able to follow through with leading classes. We lost 13 instructors from our pool because they lost interest, changed jobs, or moved away from the county. An issue for the Hawai`i EnhanceFitness is that we have only 1 recognized master trainer who believes in and is committed to the program. Because providing transportation for this master trainer to other counties to train instructors and monitor program fidelity, expansion of EnhanceFitness to other communities would require us to develop more master trainers and committed instructors.Efforts to replicate evidence-based programs to serve a state's aging population can be challenging . There iAnother challenge to replicating evidence-based programs is sustaining them. In the case of Hawai`i, funds to support the replication of EnhanceFitness were provided by the US Administration on Aging, National Council on Aging, county government, and US Department of Health and Human Services.Hawai`i's Healthy Aging Partnership analyzed costs associated with starting EnhanceFitness and estimated potential cost savings to Hawai`i that may have resulted from the implementation of EnhanceFitness. Our analysis was based on a comprehensive controlled study of EnhanceFitness conducted in Seattle that showed that participants who attended at least 1 EnhanceFitness class per week cost the health care system 20% less per year than controls . HoweverOur research had limitations. First, participant data were collected by instructors and program staff; although they were trained to conduct each physical performance test, individual deviations may have occurred. Second, falls were self-reported and subject to recall bias. Third, we did not have a control group for this study.Replicating an evidence-based program requires effort; programs must be identified to fit to new communities, provider capacity must be built, and the programs must be implemented and sustained. However, our study findings indicate that EnhanceFitness is capable of being modified for and is effective in an API community. This case study outlines a replication process that other communities can follow.


At present only few studies directly compare the diagnostic yield of endobronchial ultrasound guided fine needle aspiration (EBUS-FNA) and transcervical video-assisted mediastinoscopy (TM) for mediastinal lymph node staging in patients with NSCLC. If and when EBUS-FNA may replace TM as Gold Standard remains controversial.From April 2008 to December 2009, 36 patients with mediastinal lymphadenopathy underwent simultaneous EBUS-FNA/ TM at our institution. Among them were 26 patients with confirmed or suspected NSCLC.p < 0.001; 14.9% vs. 1.4%, p = 0.007). Less paratracheal nodes were sampled by EBUS-FNA , while sampling rates in the subcarinal localisation were comparable . Among patients with confirmed NSCLC and conclusive EBUS-FNA/ TM findings (n = 18), the prevalence of N2/N3 disease was 66.7% (n = 12) according to TM findings. Diverging nodal stages were found in five patients (27.8%). Three patients who were N2 negative in EBUS-FNA were upstaged to N2 or N3 by TM, two patients with N2 status in EBUS-FNA were upstaged to N3 by TM.A total of 133 samples were obtained by EBUS-FNA and 157 samples by TM. EBUS-FNA achieved significantly less conclusive, but more indeterminate pathological results in comparison to TM (78.7% vs. 98.6%, Compared to TM, EBUS-FNA had a lower diagnostic yield and resulted in systematic mediastinal nodal understaging. At this point we suggest corroborating negative EBUS-FNA results by transcervical mediastinoscopy. Accurate mediastinal nodal assessment is crucial to stratify patients with NSCLC for adequate therapy, including (neo)adjuvant and definitive treatment protocols or primary curative resection. Though transcervical mediastinoscopy (TM) remains the gold standard for mediastinal nodal staging, endobronchial ultrasound guided fine needle aspiration (EBUS-FNA) has gained widespread acceptance as alternative diagnostic modality in recent years -4. LiterHitherto, it is still controversial if and when EBUS-FNA may replace TM as gold standard in mediastinal nodal assessment prior to curative lung resection. Very few published studies directly compare the diagnostic value of EBUS-FNA and TM in this regard. While certain groups report lower sensitivity and similar specificity of EBUS-FNA , other pWe launched a prospective trial set to compare the diagnostic value of EBUS-FNA and TM for mediastinal nodal staging in patients with confirmed or suspected NSCLC by performing both procedures concomitantly.From April 2008 to December 2009, 117 patients were screened for enrolement in the present study. Our inclusion criteria consisted of histologically proven or suspected NSCLC, eligibility for lung resection and adult age (> 18 years). The exclusion criteria included distant metastasis, neoadjuvant therapy, N2-bulky disease, previous mediastnoscopy, pregnancy, coagulation or platelet function disorder, ongoing anticoagulation therapy. A total of 26 consecutive patients were subsequentially enlisted and underwent concomitant EBUS-FNA/ TM for mediastinal nodal assessement in accordance with current ESTS guidelines after multidisciplinary tumour board approval. Sixty-nine patients were excluded due to refusal of simultaneous EBUS-FNA and TM. Enrolement modalities and final diagnoses are presented as chartflow  connected to an ultrasound processor (Olympus EU − C60). Cytological specimens were obtained by means of 22-guage needles for transbronchial aspiration . The technique was similar to that previously described by Yasufuku et al. . Mediastt-test. Statistical significance was assumed if p < 0.05. All statistical evaluation was performed using SPSS .Descriptive statistics are presented as mean ± standard deviation. Categorical variables are expressed as percentages and evaluated with Fischer’s exact test. Continuous data were compared using the student A total of 26 patients  were enrolled in this study. All showed cT1 and cT2 tumour lesions except for one patient with a cT3 tumour. Results of preoperative clinical mediastinal nodal staging are listed in Table Analyses of all sampled LN stations are presented in Table A detailed analysis of sampled mediastinal LN is presented in Table Neither EBUS-FNA nor TM lead to postoperative complications. Over our observation period, nine patients underwent curative lung resection with systematic radical lymphadenectomy. The postsurgical LN staging was in accordance to TM results in all patients. Three patients received adjuvant chemotherapy due to single station N2 disease determinated by both TM and postsurgical pathological examination. A high prevalence of N2/N3 disease allowed for postsurgical LN staging only in nine out of 26 patients. This prevented us from extrapolating sensitivity, specificity, diagnostic accuracy and false-negative rate for each procedure.In the present study, EBUS-FNA and TM were directly compared for mediastinal nodal assessment in patients with proven or suspected NSCLC. In this series, EBUS-FNA had a lower diagnostic yield and resulted in systematic understaging of mediastinal LN metastases, mainly due to false negative findings. These results are generally in line with recent meta-analyses evaluating the diagnostic value of EBUS-FNA for preoperative mediastinal LN staging in lung cancer patients. Among them is a meta-analysis on which the current ACCP guidelines are based, where EBUS-FNA had a false negative rate as high as 24% . A furthIn recent years EBUS-FNA has gained widespread acceptance as an alternative diagnostic modality for mediastinal staging in NSCLC. Despite technical improvements  and adequate techniques, the inherent limit of small tissue volumes obtainable through FNA-procedures persists. Small metastatic tumour deposits are more likely to be missed by needle aspiration than by extensive biopsy. As pointed out by Dr. Shrager in his comment, a needle-based technique can hardly achieve the same reliability than a surgical procedure that allows for extensive tissue sampling . These fRecent reports on comparable or even higher sensitivity of EBUS-FNA are mostly based on analyses of enlarged mediastinal LN in cohorts with high prevalence of malignancy. In a study of Ernst et al. comparing EBUS/FNA and TM in n = 66 patients, only radiologically enlarged mediastinal LN (mean short axis 15 mm) were sampled and analyzed . CertainMediastinal nodal staging in NSCLC is initially based on the results of conventional imaging. To confirm nodal involvement in radiologically enlarged mediastinal LN, either EBUS-FNA or TM are reasonable ,7. Even The authors do recognize various limitations of the present study. They primarily include an inherent single investigator bias and a modest sample size. On the other hand, an interpersonal bias, which was common to various previous comparative studies, was avoided.Our current results suggest that EBUS-FNA still has a lower diagnostic yield than TM and may lead to systematic nodal understaging in patients with suspected or confirmed NSCLC. At present EBUS-FNA appears as not reliable enough to safely rule out mediastinal nodal metastases and we therefore encourage to still corroborate a negative EBUS-FNA by transcervical mediastinoscopy.EBUS-FNA, Endobronchial ultrasound guided fine needle aspiration; NSCLC, Non small cell lung cancer; TM, Transcervical video-assisted mediastinoscopy; ACCP, American College of Chest Physicians; ESTS, European Society of Thoracic Surgeons; cMRI, Cerebral magnetic resonance imaging; PET/CT, Prositron-emission tomography/computer tomography.All authors have no financial or other interests regarding the submitted manuscript.RZ and CM carried out the conception and design of the study, acquisition of data, analysis and interpretation of the data, statistical analysis as well as drafting of the manuscript. MK participated in the analysis and interpretation of the data, drafting of the manuscript and critical revision of the manuscript. BW and SD participated in the acquisition of data. HG and AH participated in the analysis and interpretation of the data, critical revision of the manuscript and supervision of the study. PZ performed surgeries, participated in the conception and design of the study, acquisition and interpretation of the data, drafting and critical revision of the manuscript. All authors read and approved the final manuscript.


ARID1A (BAF250) are the most common molecular genetic changes in ovarian clear cell carcinoma (OCCC). ARID1A mutations, which occur in approximately half of OCCC cases, lead to deletion of the encoded protein and inactivation of the putative tumor suppressor. In this study, we determined the significance of loss of ARID1A immunoreactivity with respect to several clinicopathological features in a total of 149 OCCCs. First, we demonstrated that ARID1A immunohistochemistry showed concordance with the mutational status in 91% of cases with 100% sensitivity and 66% specificity. Specifically, among 12 OCCC cases for which ARIDA mutational status was known, ARIDIA immunoreactivity was undetectable in all 9 cases harboring ARID1A mutations and was undetectable in one of 3 cases with wild-type ARID1A. With respect to the entire cohort, ARID1A immunoreactivity was undetectable in 88 (59%) of 149 OCCCs. There was no significant difference between ARID1A negative and positive cases in terms of histopathologic features, age, clinical stage, or overall survival. In conclusion, this study provides further evidence that mutations in ARID1A resulted in loss of ARID1A protein expression in OCCC, although no significant differences between ARID1A positive and negative cases were observed with respect to any clinicopathological features examined.Recent genome-wide analysis has demonstrated that somatic mutations in  The majority of ARID1A mutations in OCCC belong to either insertion or deletion of base pairs, leading to frame shifts and ending in stop codons. As a result, ARID1A mutations typically generate truncated proteins that are highly prone to degradation , a characteristic feature of classical tumor suppressors.Recent genome-wide sequencing analyses of all exons and transcriptome in ovarian clear cell carcinomas (OCCC) have identified somatic mutations of  complex ,5. While complex ,8. IndeeARID1A mutation status and loss of ARID1A expression in selected cases to demonstrate the sensitivity and specificity of applying ARID1A immunoreactivity as a surrogate marker for ARID1A mutations. We then performed immunohistochemistry to assess ARID1A expression patterns on paraffin sections from a total of 149 cases of ovarian clear cell carcinoma with well annotated clinical follow up information. The findings from this report provide further evidence to characterize the biological and clinical significance of loss of ARID1A expression in OCCC.Inactivating mutations in tumor suppressors could participate, not only in tumor initiation, but also in tumor progression and response to therapy. In the current study, we asked whether loss of ARID1A protein expression had clinical significance in patients with OCCCs and whether loss of ARID1A correlated with any histopathological features in those cases. We first correlated the 2.2.1.We employed immunohistochemistry to evaluate the expression of ARID1A in OCCC tissues. Results of ARID1A immunohistochemistry in OCCCs are summarized in In order to determine the biological significance of ARID1A expression in OCCC, we also analyzed ARID1A immunoreactivity in normal endometrium and adnexal endometriosis because OCCC most likely arises from endometrial glandular epithelium . The resARID1A, we correlated mutational status and immunoreactivity in 12 representative OCCCs. All OCCCs that harbored ARID1A mutations exhibited negative immunoreactivity, suggesting that ARID1A mutation resulted in loss of protein expression (ARID1A mutations), 2 of 3 cases exhibited diffuse ARID1A immunoreactivity; however, one case of OCCC with no ARID1A mutations demonstrated loss of ARID1A protein expression (score = 0).To determine if loss of ARID1A expression was associated with inactivating mutations of pression . Among wP = 0.97)  .2.2.ARID1A as the most commonly mutated gene in OCCC. Inactivation mutations of ARID1A resulted in loss of expression in tumors and loss of tumor suppressor function of ARID1A. In this report, we asked if loss of ARID1A expression correlated with morphological features or had an influence on disease aggressiveness and treatment response in OCCC. Although a recent study of 132 OCCCs demonstrated a lack of significant correlation between absence of ARID1A expression and overall survival in OCCC patients [ARID1A mutations in the pathogenesis of OCCC.Genome wide mutational analysis has identified The observation that 59% of OCCCs exhibited an ARID1A intensity score of 0 is similar to the frequency (57%) of ARID1A mutation among OCCCs in a previous report that used purified OCCC samples for mutational analysis . NeverthARID1A mutational status in 38 previously analyzed OCCCs [ARID1A mutations and either cystic or adenofibromatous features . Further studies should focus on determining the molecular difference between OCCCs with and without ARID1A expression using genome-wide approaches. Finally, those OCCCs with ARID1A expression may utilize other mechanisms such as genetic deletion or loss of expression of the ARID1A binding partner, BRG1, to inactivate the ARID1A-BRG1 chromatin remodeling complex.One may ask whether pathogenesis differs between OCCCs with and without ARID1A expression. It has been proposed, based on a recent comprehensive clinicopathological study, that OCCC develops from two distinct morphological pathways . One pat3.3.1.Formalin-fixed and paraffin-embedded OCCC tissues were obtained from the Department of Pathology at the University of Tokyo Hospital (89 cases) and the Department of Pathology at the National Taiwan University Hospital (60 cases). All tumors were primary and were retrieved from the archives of each institution. Hematoxylin and eosin stained slides were reviewed to confirm the diagnosis using the most recent criteria of the World Health Organization. The tumor samples were arranged in tissue microarrays to facilitate immunohistochemistry. At least 2 cores (3 mm) were punched out for each case, and immunoreactivity of ARID1A was evaluated on those available cores. Tissue collection was in accordance with institutional guidelines.vs. stage III/IV), and retroperitoneal lymph node metastasis. Specifically, clinical stage was assessable in 121 cases for which the staging procedures were complete; the remaining 28 cases were not included in analysis due to either incomplete surgical procedures or missing data. Results of retroperitoneal lymph node dissection were obtainable in 70 cases. Follow-up information included overall survival and cancer-related death. The follow-up period was calculated from the date of surgery to the date of death or last clinical evaluation. The mean follow-up interval was 59.9 months (range 1–196 months). In this study, the cases with adenofibromatous features were defined as those non-cystic lesions containing any percentage of adenofibromatous component; cystic cases were defined as those with a grossly identifiable cyst. The distinction among different structural patterns  was based on the predominant component in a given specimen. Nuclear grades were made according to their relative nuclear atypia and were classified as mild, moderate, or severe atypia.Clinical information including demographics, age at diagnosis, clinical stage based on International Federation of Gynecology and Obstetrics (FIGO), and survival time after treatment were obtained for patients from whom records were available for review. Correlations of ARID1A expression with the following clinical variables were evaluated: age, stage of carcinoma  for 5 minutes. Slides were placed onto a Ventana Benchmark® XT autostainer  and immunohistochemical reactions were performed according to standard techniques of the autostainer. A commercially available monoclonal anti-ARID1A antibody, clone 3H2 (Sigma-Aldrich), was used at an optimal dilution of 1:25.Tissue sections (4 μm) were prepared from the tissue microarray blocks. In addition, whole sections were used for analysis of tumors in the correlation study of ARID1A mutational status and immunoreactivity, we selected 12 clear cell carcinomas for which the ARID1A mutational status was known from our previous study [Because the distribution of ARID1A immunoreactivity was almost always homogenous within a given tumor, we used intensity scores of 0 (undetectable), 1+ (weakly positive), or 2+ (strong positive) to evaluate ARID1A immunoreactivity. A positive reaction was defined as discrete localization of the chromogen in the nuclei. The tissues were scored in a blinded fashion without knowledge of clinical information. Because we were focused on the loss of expression, we divided the cases into two groups: those scored as 1+ or 2+, and those scored as 0. To correlate the 3.3.P < 0.05 was considered statistically significant.Statistical analysis was performed using the Fisher’s exact test. Overall survival of OCCC cases was calculated using the Kaplan-Meier method, and statistical analyses were performed using the log-rank test. Statistical analyses were performed with StatView 5.0 software  and 4.In conclusion, results from this study provided cogent evidence that ARID1A immunoreactivity did not correlate with any clinicopathological features examined in OCCC. It is likely that loss of ARID1A protein expression is not as important for tumor progression or response to treatment as it is for tumor initiation. Future studies will be required to define the molecular mechanisms by which loss of ARID1A expression contributes to tumor development in OCCC.


The onset of type 2 diabetes mellitus can be prevented or delayed by lifestyle changes. Communication technologies such as a mobile phone can be used as a means of delivering these lifestyle changes.The purposes of this analysis were to explore applicability of potential components of a mobile phone-based healthy lifestyle program and to understand motivators and barriers to continued engagement in a mobile phone healthy lifestyle program.2 (Asian >23 kg/m2) based on self-reported weight and height or 5) having a self-reported prediabetic condition.We conducted 6 focus groups  in May and June 2010 with 35 focus group participants. The qualitative data were analyzed by 3 researchers using a qualitative description method in an ATLAS.ti software program. Inclusion criteria for enrollment in a focus group were as follows: (1) being aged from 30 to 69 years, (2) speaking and reading English, (3) having a sedentary lifestyle at work or during leisure time , and (4) having a body mass index (BMI) >25 kg/m2. In the qualitative analyses, the following 4 major themes and their subthemes emerged: (1) real-time social support , (2) tailoring of mobile phone programs (3) self-monitoring and motivation, and (4) potential barriers and sustainability of the program .The mean age was 51 (SD 10.6) years; 54% (n = 19) were white; 71% (n = 25) used a mobile phone at least once a week during the last month prior to the study enrollment; and mean BMI was 32.5 (SD 6.5) kg/mParticipants from a wide range of age and racial groups expressed interest in a mobile phone-based lifestyle program. Such a program that incorporates the themes that we identified may be able to help motivate participants to increase their physical activity and to improve their diet. The rapidly growing incidence of diabetes is a serious worldwide public health concern. Approximately 7.8% of the population has diabetes and 18% is prediabetic in the United States ,3; howevThe mobile phone has become one of the most personalized technologies in everyday life and is omnipresent across the world today. In the United States, 87% of adults own a mobile phone, and adoption rates are even higher in other global locations . Mobile Qualitative methodologies, including focus groups, have been used to evaluate feasibility and acceptability of existing mobile phone-based disease management or healthy lifestyle programs -8. HowevSix focus groups  were conducted in May and June 2010. Potential participants were recruited from urban communities through newspapers and flyers in hospitals. We screened 63 potential participants over the telephone, of whom 44 met all inclusion criteria. Of those who met all inclusion criteria, 35 participated in the focus group and 9 either did not show up for their scheduled focus group or had scheduling conflicts with potential focus group dates. The study was approved by the University of California San Francisco Institutional Review Board. All participants signed a written informed consent prior to the focus group study.2 (Asian >23 kg/m2) based on self-reported weight and height or (5) having a self-reported prediabetic condition. Exclusion criteria were (1) known medical conditions or other physical problems requiring special attention in an exercise program, (2) severe hearing or speech problems, (3) current participation in a lifestyle modification program or research study, and (4) known eating disorder. We did not exclude people who had never used mobile phones or were not current mobile phone users, since a previous study indicated that both nonusers and users of mobile phones were able to effectively use mobile phone applications  would make a huge difference. I mean if it is very positive and if it’s reinforcement, positive reinforcement, yes. But if you say,“Did you meet your goal this week?”then I’m going to be full of guilt, you know what I mean.60-year-old womanFor me it would be like—I would need more aspects of my life incorporated. Say, for instance, I talk to you this week that next week I want to do such-and-such and such-and-such. And then you call me up and you say,“How about doing such-and-such and while you’re at it—you know, While you’re doing it you’re getting this much exercise or you could do this instead of taking the bus.” Incorporate it in my life so if I fail in one area I haven’t necessarily failed in another area and I am kind of in a way feeling like a failure.I think that’s why I could never do a diet. To minimize participant’s fear of failing and to motivate participants to change their lifestyle, the program should be positive, and feedback and messages should be encouraging and nonjudgmental. As one participant suggested:62-year-old womanIt has to be a really warm human person that’s not going to sit there and judge you.Some participants reported that they were not comfortable using mobile technologies. Most of these participants were older and had limited experience in using mobile technologies. They indicated that, due to this lack of experience, older participants might view the program as non-user-friendly or too complicated to use. Two women in their 60s stated:62-year-old womanThere might be an issue here too with the age.I mean you people really—they have these machines down, you know. They do it in their sleep, you know, text. But there might be a hurdle for people who are older and there might be some fear around—I mean I still can’t text. I mean I’m lucky when I can text correctly. And I work for software companies.69-year-old womanI’m not tech savvy, so, I’m from the “old school” and I hate the cell phones my children give me.In addition, some participants did not own a mobile phone or preferred not to use one because of financial reasons or because of its intrusiveness in their lives. Several participants commented on the cost of the cell phone within their limited budget, one stating: “I’m not paying $40 a month for telephone service.” However, others indicated that they felt that cell phones disrupted their lives, as the 2 quotes below exemplify:65-year-old womanI don’t own a cell phone. I have an aversion to being on call.65-year-old womanCould it be the same thing? See, you’re on call, you’ve got to answer to this damn phone. I don’t know, I’m probably in the minority.Another identified potential barrier was that participants who were initially motivated to be involved in the program could lose interest over time. The participants reported that they might delete a message without reading it, or ignore a message if they were no longer excited about the program or no longer valued the messages that they received.I get something called N___. At first when I got it—it’s a download every day—I’d look at it and be interested.Now I mean I’ve got to delete, I have about five hundred that I haven’t read.59-year-old womanI know that I get like breaking news. When I first got it I read every one of them and now it’s—I mean now it has to be“President dies”or something before I’m interested.59-year-old man...they immediately text message you and I got so many text messages I just stopped reading, I just start deleting.To avoid this barrier, messages and feedback should not be dull or predictable in pattern. Also, tailored timing, components, and frequency of messages may help to maintain participants’ interest in the program.Only a few focus group studies have been performed to understand participants’ needs and expectations for a mobile phone program as a process of program development for the prevention of chronic illnesses ,11,12. PThe themes we identified were (1) having real-time peer social and professional support, (2) tailoring timing, frequency, and content of messages in mobile phone programs, (3) combining motivations, self-monitoring, and goal setting, and (4) identifying potential barriers and sustainability of mobile phone programs. These findings suggest that creating a mobile virtual community could be effective in engaging and sustaining participants in lifestyle change programs. This virtual community acts as a closed social network that can provide both peer and professional support to participants. It is flexible enough to provide messages and self-monitoring that are tailored to individual participants and address barriers to participation (see Participants indicated that the primary component of a successful mobile phone-based healthy lifestyle program was real-time peer social and professional support that would create a mobile virtual community. Through this mobile virtual community, participants could create a peer social network that would support their efforts to change their diet and physical activity and receive immediate feedback from health care providers, a designated sponsor, or a peer ,14. PartTailoring of the program is another key component of a successful mobile phone program -21. FreqThis study reinforces the need for self-monitoring; however, participants also connected this idea with broader motivations for enacting behavioral changes. Participants identified the value of competition to keep one engaged and the importance of some form of reward mechanism. The challenge for a mobile phone program is to incorporate different ways to motivate participants. The program would have to be able to engender a sense of competition, at least within participants that are so motivated, but it would also need to determine effective rewards that can be potentially tailored, both individually and over time.Participants also identified potential barriers to initiating and sustaining engagement with the program. Fear of failing was one of the major potential barriers addressed by participants. A previous study found that women who used a mobile phone physical activity program perceived the program as a virtual coach to increase their motivation for a healthier lifestyle. Coaching is an effective approach to behavior change, but pressure from a coach or another’s expectation can create fear of failure in the participant ,26. To mAge and the potential intrusiveness of mobile phones in people’s lives could also be a barrier to engagement with the program. Older participants expressed concerns about their ability to use the mobile phone technologies, especially texting, and that their lack of technical ability might limit their willingness to participate in the program. Over 25% of the participants had not used a mobile phone in the last month. For some, this was due more to lack of funds than to a dislike of mobile phones. However, a few expressed a rather strong antagonism toward the impact of mobile phones on their way of life. Given this expressed antipathy to mobile phones and the number of nonusers in the focus groups, conducting further research with only nonusers could be warranted to more fully understand this barrier.In terms of sustaining participation in this type of program, there is limited research that has explored issues around long-term engagement in these types of programs. Participants in this study indicated that they needed to continue to value the program. Suggestions for how to maintain interest over time included keeping the program simple and user friendly. This component may be particularly important to accommodate older adults, people with less education, and people who are unfamiliar with mobile phones.Additionally, the messages need to be short and varied over time. In addition, a system of rewards needs to immediately reflect their positive behavior change but may also need to change over time. A randomized variety of messages may help to avoid the boredom, and a program tailored to the individual’s needs could help to keep participants motivated. However, more research is needed to understand how these rewards can be incorporated into mobile phone technologies and how to modify them over time. Finally, resistance to using mobile technologies among older individuals is also a potential barrier  that neeThe study results should be interpreted within the following limitations. All participants in this focus group were recruited from only 1 geographic location, San Francisco, approximately 74% of the participants were unemployed, and 49% had incomes less than $20,000. Thus, the findings in the study may not be representative of more affluent or more fully-employed populations in the United States.Participants from a wide range of age and racial groups expressed interest in a mobile phone-based lifestyle program. A mobile phone-based lifestyle program that incorporates these identified themes may be able to help motivate participants to increase their physical activity and to improve their diet. This study can help researchers to further understand individual needs and expectations of a mobile phone program to motivate and promote healthy lifestyle modifications in sedentary and overweight or obese adults.


Haloarchaea are the predominant microflora of hypersaline econiches such as solar salterns, soda lakes, and estuaries where the salinity ranges from 35 to 400 ppt. Econiches like estuaries and solar crystallizer ponds may contain high concentrations of metals since they serve as ecological sinks for metal pollution and also as effective traps for river borne metals. The availability of metals in these econiches is determined by the type of metal complexes formed and the solubility of the metal species at such high salinity. Haloarchaea have developed specialized mechanisms for the uptake of metals required for various key physiological processes and are not readily available at high salinity, beside evolving resistance mechanisms for metals with high solubility. The present paper seeks to give an overview of the main molecular mechanisms involved in metal tolerance in haloarchaea and focuses on factors such as salinity and metal speciation that affect the bioavailability of metals to haloarchaea. Global transcriptomic analysis during metal stress in these organisms will help in determining the various factors differentially regulated and essential for metal physiology. Metals such as calcium, cobalt, chromium, copper, iron, potassium, magnesium, manganese, sodium, nickel, and zinc are essential and serve as micronutrients. These metals act as the redox centers for metalloproteins such as cytochromes, blue copper proteins, and iron-sulfur proteins which play a vital role in electron transport . As the o metals –9. Amongeostasis , 11. HowHaloarchaea are members of the third domain of life, the Archaea, within which a total of 36 genera and 129 species have been identified to date . However1B-type ATPases in maintaining metal homeostasis in bacteria and archaea, Coombs and Barkay (2005) [1B-type ATPases containing N-terminal metal-binding motifs are distributed across bacteria and archaea, including haloarchaea. These ATPases along with the ABC transporters, transcriptional regulators, and certain metallochaperones were found to be involved in metal resistance and homeostasis in the haloarchaeon Halobacterium sp. strain NRC-1  [Most of the reports until now are limited to MIC (minimum inhibitory concentration) studies –26. Howey (2005)  have shon NRC-1  . Haloarcn NRC-1  , 24–26. n NRC-1  , 24. An −) content in these environments results in the formation of metal chlorocomplexes. For a metal to act either as a micronutrient or as a toxicant, it has to be available for uptake by the organism . The met−, CO23−, HCO3−, and SO42− to form inorganic complexes [The type of complex formed depends upon the chelating ligand, that is, organic or inorganic ligands, and the kind of heavy metal present in the system . Metals omplexes . Soft acomplexes . The comomplexes , 36. Inoomplexes –40.  Tab3− complex or free cation, and in oceanic waters it exists as highly soluble CdCl2, whereas in estuarine waters, it forms a strong CdCl+ complex which is biologically unavailable [0 is formed in estuarine and oceanic waters, while under hypersaline conditions, soluble AgCl2-, AgCl32−, and AgCl43− complexes are formed [− and sparingly soluble HgCl2 are the predominant complexes of Hg at high salinities [2 and the soluble silver-chloro complexes are lipophilic and can easily diffuse through cellular membranes [+ and CuCl+ which coprecipitate at higher salinities, due to decrease in the net negative charge on macromolecular suspended particles and therefore are not available for uptake. Unlike Zn(II) and Cu(II), Fe(II), Co(II), Ni(II), and Mn(II) form weak complexes with Cl−, that easily dissociate and can be taken up by organisms [While metal bio-availability, uptake, and toxicity decrease in presence of natural dissolved organic ligands, metals differ in their behavior at high salinities. For example, in case of cadmium, speciation is highly dependent on the complexing ligands. In river water it exists either as COvailable –43. In ce formed . Solublelinities . HgCl2 aembranes . Zn and rganisms .  Table The bioavailability of chlorocomplexes also depends upon the type of biotic ligands present. Biotic ligands are the receptors on an organism where metal binding takes place which results in the manifestation of its toxic effects . Metal rThe toxicity of a metal to microorganisms does not have a linear relationship with its concentration, and it depends strongly upon chemical speciation , 50. ForOrganisms inhabiting the metal polluted environments develop resistance mechanisms that enable efficient detoxification and transformation of toxic forms to nontoxic forms. The majority of bacteria and eukarya tolerate metals by a reduced influx/enhanced efflux , 52 or eβ-domain that usually binds 3 metal ions and a C-terminal α-domain that binds 4 metal ions [γ-GluCys)n-Gly where n is usually in the range of 2 to 5. They are enzymatically synthesized by PC synthase using GSH as the substrate [Intracellular chelation  by a vartal ions , 57. PCsubstrate , 59. Theubstrate . They arubstrate . Once chubstrate . TonB prubstrate .Siderophubstrate . Dps areubstrate . These pubstrate . The binubstrate . γ-glutamylcysteine (γ-GC) [γ-GC can chelate the toxic metal ions thereby conferring resistance. A unique phenomenon observed in archaea is the heavy metal-induced multimerization of metal chelating proteins such as CutA- and DpsA-like proteins that result in the precipitation of the protein-metal ion complex [Pyrococcus horikoshii. Substitution of Asp48 with alanine decreases the amount of aggregate formation [Halobacterium salinarum ensued from an assembly of 12 units and was found to sequester iron in response to the oxidative stress exerted by excess iron [dps that are upregulated under these conditions. It exhibits the features of non-haem bacterial ferritins that are expressed to sequester the excess iron. Their expression is repressed under conditions of iron starvation [Haloarchaea have e (γ-GC) , 68 whice (γ-GC) . The thi complex . This pr complex , 71. Altormation . Similaress iron . This prarvation . Overexparvation . MTs arearvation . Archaeoglobus fulgidus, was found to form a biofilm in response to toxic concentrations of metals, where the toxic metal was proposed to be trapped within the EPS matrix [Halobacterium salinarum CCM 2090 has a Ca(II)-dependent aggregation system, where the Ca(II) binds to certain aggregation factors present on the cell surface and induces ionic crossbridging between the EPS resulting in aggregation of the haloarchaeal cells. The presence of certain receptor proteins on the cell surface that interact with Ca(II) to form cell aggregates/flocs has also been demonstrated [Haloquadratum walsbyi, Haloarcula marismortui, Haloterrigena turkmenica, and Halobacterium sp. strain NRC-1, have been annotated with cbp encoding the cell surface calcium-binding acidic-repeat protein [Vibrio cholerae [Pseudomonas aeruginosa [Halobacterium, Haloferax, haloalkaliphilic Halorubrum, psychrotolerant Halorubrum, and a new genus of psychrotolerant haloarchaea isolated from Deep Lake, Antarctica [Pyrococcus furiosus, Sulfolobus solfataricus, and Methanococcus maripaludis involves cellular appendages such as archaeal type IV pili [Haloferax, Halobacterium, and Halorubrum [Biosorption of metals by the organisms at the surface or by the exopolysaccharides (EPS) secreted to form the biofilms enables organisms to tolerate metals , 76. BioS matrix . Thus, iS matrix , it has nstrated . Four ha protein –83 that cholerae  and Pseuruginosa . Ca(II) ruginosa . Thus, truginosa . Aggregaruginosa . Recentltarctica . Here Ca IV pili –90. Thes IV pili . Archaealorubrum , 92, 93.ars operon conferring arsenite and arsenate resistance in Halobacterium sp. strain NRC-1 is present on one of its two plasmids [1B-type ATPases involved in cation transport with a high diversity in the N-terminal metal-binding motifs were found to be distributed throughout the bacterial and archaeal lineages [Halobacterium salinarum NRC-1 was found to carry two distinct phylogenetic clusters, CopA1 (Cu(II) influx) and CopA2 (Cu(II) influx and efflux). These clusters were also found to span the entire diversity of the bacterial domain. Coombs and Barkay (2005) [1B-type ATPases and therefore concluded that divergence in consensus sequence of the N-terminal metal-binding motif might have been tolerated during evolution [Most bacteria carry the resistance determinants for metals as operons, on their plasmids . The metplasmids . A compalineages . Genome y (2005)  have provolution , 83. Butvolution .mer operon for mercury resistance [ars for arsenic resistance [cad operon for cadmium resistance [mer operon of the thermoacidophilic archaeon Sulfolobus solfataricus [ars operon of acidophilic archaeon Ferroplasma acidarmanus Fer1 [Thermoplasma acidophilum [cop operon for copper resistance of Sulfolobus solfataricus P2 [ars operon for arsenic resistance in Halobacterium sp. strain NRC-1 [Many metal resistance determinants have been characterized in the bacterial system –105, of sistance , ars forsistance , 98, andsistance  have beesistance , 107. Thataricus , 109, arnus Fer1  and Therdophilum , and thericus P2 –114. Altin NRC-1 .Halobacterium sp. strain NRC-1, harbors the arsADRC gene cluster, responsible for conferring arsenate (As(V)) and arsenite (As(III))/antimonite (Sb(III)) resistance [arsB, is present on the main chromosome. The arsADRC operon was annotated for As(III) transport due to its homology to previously characterized genes [arsC [arsA codes for P1B-type ATPase transporters that help in extrusion of As(III)/Sb(III) from the cell. arsR and arsD encode trans-acting repressors of the operon. ArsR and ArsD bind to As(III)/Sb(III) resulting in expression of the arsA and arsC. Arsenate reductase encoded by arsC is expressed weakly in Halobacterium sp. strain NRC-1, and therefore deletion of arsC and arsADRC was found to be ineffective in conferring arsenate sensitivity [arsADRC was found to be inducible by arsenite and antimonite [Most haloarchaea have large plasmids in addition to their genomes (chromosomes) known as minichromosomes/megaplasmids. These minichromosomes harbor genes for antibiotic resistance or metal resistance that may be essential for haloarchaeal survival . The pNRsistance . A fifthed genes , but lated genes . As(V) ced genes  or hexosed genes . As(V) ies [arsC . arsA cositivity . The opetimonite .Halobacterium sp. strain NRC-1 harbors a novel transporter unrelated to ArsB but with a similar function [In bacteria, ArsB, an inner membrane protein, along with ArsA, the membrane-bound anion-transporting ATPase, forms the anion-conducting channel for arsenite extrusion . Halobacfunction . Arsenicfunction . The unifunction , 121 /Sb(III) induce the expression of arsM [arsR2 is analogous to arsR and arsM encodes a putative As(III)-methyltransferase very similar to human methyltransferases and S-adenosyl methionine-dependent methyltransferases of Magnetospirillum magnetotacticum. ArsM is involved in converting As(III) to methylated species like dimethylarsinate (DMA), trimethylarsine oxide (TMAO), or trimethylarsine (TMA) gas [arsM exhibited as increased sensitivity to arsenite but not towards arsenate or antimonite [arsM. First, the generation of a concentration gradient results in the movement of methylated arsenite (negatively charged/uncharged) out of the cell. Second, the volatile trimethylarsine formed diffuses out of the cell thus eliminating As(III) [arsM gene functions independently and is not a part of ars operon [Halobacterium sp. strain NRC-1, the arsM gene is present as a part of the arsR2M operon involved in arsenite resistance [In  pNRC100 , where a of arsM . The arsTMA) gas . Deletiotimonite . Thus, t As(III) , 124. Als operon . Howeversistance . mer operon involved in detection, regulation, transport, and reduction of Hg(II) [merRHAI operon of thermoacidophilic archaeon Sulfolobus solfataricus [mer operons carry additional mer genes, notably merB, an organomercurial lyase, that cleaves the C-Hg bonds of organomercurials, and the released Hg(II) is reduced to Hg(0) by MerA [Halobacterium sp. strain NRC-1 and Haloterrigena turkmenica have been annotated with merA and merB genes, respectively [Mercury resistance in archaea and bacteria is conferred by the f Hg(II) , 126. Onataricus , 109. Thataricus , 109. Soectively , 127.Membrane transporters may act as the first line of defense against toxic or heavy metals. In order to exert their toxicity, metals need to gain entry within the cell. Thus, the organism may downregulate the transporters responsible for influx or induce the expression of efflux pumps to enable faster removal of toxic metals from within the cell . The useBoth influx and efflux types of transporters for various metals have been annotated in all haloarchaeal genomes sequenced to date . The fol1B-type ATPases are a large family of integral membrane proteins driven by ATP hydrolysis [The Pdrolysis . Membersdrolysis . A wide drolysis . These tdrolysis , 132. AlHalobacterium sp. strain NRC-1 genome [Halobacterium sp. strain NRC-1, the functionality and role of such transporters in metal resistance was shown [yvgX, a P1B-type ATPase, in response to Cu(II) and Zn(II) metal stress. In bacteria, the yvgX family is known to encode two kinds of CopA proteins, CopA1 and CopA2 [yvgX of Halobacterium sp. strain NRC-1 was found to be more specific for Cu(II) efflux family as the ΔyvgX strain was susceptible to Cu(II) and not to Zn(II) or Co(II) and therefore belongs to the CopA2 family of proteins. CopA2 is also found in other haloarchaea like Haloarcula marismortui, Haloarcula hispanica, and Haloquadratum walsbyi [A putative Cd(II)-efflux ATPase was annotated on 1 genome . In a syas shown . They exnd CopA2 . CopA1 ind CopA2 , 134. A nd CopA2 . It has nd CopA2 . The yvg walsbyi . 1B-type ATPase, ArsA discussed in Halobacterium sp. strain NRC-1, Halalkalicoccus jeotgali, Haloarcula hispanica, Natrialba magadii, Haloarcula marismortui, Haloquadratum walsbyi, and Natronomonas pharaonis [Halobacterium sp. strain NRC-1 [The As(III)/Sb(III) transporting Pharaonis . ArsB wain NRC-1 . 1B-type ATPases are of two types, that is, Cu-CPx-type-ATPases involved in efflux of monovalent cations, Cu(I) and Ag(I), and Zn-CPx-type ATPases involved in the efflux of divalent cations of Zn, Cd and Pb [cpx gene that encodes CPx P1B-type ATPases was found to be downregulated by Fe(II), Cu(II), and Ni(II) to avoid influx in Halobacterium sp. strain NRC-1 [Heavy metal cation-transporting CPx Pd and Pb –139. Howd and Pb , 141. Thin NRC-1 . This meHalobacterium sp. strain NRC-1 was annotated with putative CDF Cd (II) transporter ZntX, which confers resistance against Ni(II), Cu(II), and Zn(II) besides Cd(II) [ZntA in response to heavy metals (Cu and/or Zn) and poor growth of ΔzntA strain in presence of Ni(II), Cu(II), Zn(II), and Cd(II) have confirmed the role of this transporter in metal resistance [zntA based on charge and species rather than size [Haloarcula hispanica and Haloarcula marismortui have also been annotated with ZntA for Zn(II) transport. A putative CDF family protein has also been found on the chromosome of Natrialba magadii for inorganic metal ion transport [The CDF family of transport proteins is ubiquitously present in all three domains of life . Althougs Cd(II) . The rols Cd(II) . The uprsistance . The brohan size . Haloarcransport . The multisubunit ABC transporters are one of the largest protein families with a variety of physiological functions. These transporters are ubiquitously present in all living forms from bacteria to eukaryotes including archaea. They are involved in various functions such as nutrient uptake , oligopeHaloferax volcanii [Haloarcula marismortui [Halobacterium sp. NRC-1 [Natronomonas pharaonis [Haloquadratum walsbyi [Halobacterium sp. NRC-1 with their functions are listed in cbiNOQ for Co(II) transport [hemUV for iron uptake [nosFY for copper [zurMA for zinc transport (phoX (phosphate transport), appA (peptide transport), and ycdH (Mn(II) transport) along with two putative subunits of Fe(II) transport system does not prove deleterious for Halobacterium sp. NRC-1. Due to the large repertoire of ABC transport proteins, they concluded that deletion/mutation of a single ABC transporter is easily managed by the organism by substituting the deleted/mutated ABC transporter product with functional ABC transporter product of similar role.Although many ABC transporter genes for a variety of substrates have been annotated in all the 10 haloarchaeal genomes sequenced to date, experimentally, very few have been shown to be functional. ABC transporters for sugar and polypeptide have been found in volcanii , Haloarcismortui , Halobacp. NRC-1 , Natronoharaonis , and Hal walsbyi . All halransport , hemUV fn uptake , 159, nor copper , and zurransport . Althoug1B-type ATPases and CDF family have a greater role in maintaining metal homeostasis than the ABC transporters in haloarchaea [The differential regulation of all three classes of metal transporters discussed above is in congruence with the general norm of micro-organisms utilizing enhanced efflux or decreased influx to resist metals. However, the Poarchaea . Under unfavourable conditions of growth, all organisms make adjustments at the system level to overcome the stress imposed by the stressor. Presence of heavy metals in their environment triggers global transcriptional regulations either to prevent their entry into the cell or to transform the metal to nontoxic form. This response can be transitory, with perturbations of a few genes within minutes of metal exposure, but once the cell acclimatizes to the new environment, the transcript levels of some early response genes return to preperturbation levels. The early response to a stressor usually results in the upregulation of transcription and translation. As a consequence, the transcripts damaged due to the stressor are replaced and new proteins are synthesized , 162.Halobacterium sp. strain NRC-1 has been reported [In haloarchaea, only one study on transcriptional changes in response to heavy metal stress (Fe(II), Cu(II), Co(II), Ni(II), Zn(II), and Mn(II)) in reported . Besidesreported  elucidatreported .Halobacterium salinarum and Haloferax volcanii, have been annotated with SOD [Halobacterium sp. strain NRC-1 [One of the major toxic effects elicited by heavy metals is the rapid generation of reactive oxygen species (ROS) that damages the cellular machinery , 163. Thwith SOD  and catawith SOD . Metal-iin NRC-1 .tfbB and SirR. TfbB is the transcription initiation factor IIB. Its upregulation indicates a global response towards stress by increasing the rate of transcription to increase protein turnover. Similarly, the upregulation of SirR (silent information regulator) repressed the active uptake of Mn(II), thus providing the organism the ability to overcome the stress. Similar upregulation has also been observed in certain bacteria and yeast [Staphylococcus aureus and Staphylococcus epidermidis were shown to carry several copies of sirR genes that act as divalent metal cation-dependent transcriptional repressor [cbiN, cbiM, and cbiQ involved in cobalt transport and zurM, zurA, and ycdH that encode Mn/Fe ABC-transporters were predicted to be putatively regulated by sirR in Halobacterium sp. strain NRC-1 [sirR is essential for survival during metal-induced stress. This was evident from the upregulation of Mn(II) uptake genes zurM, zurA, and ycdH in ΔsirR strain as compared to parent strain in Halobacterium sp. strain NRC-1. Thus, in the haloarchaeon Halobacterium sp. strain NRC-1, sirR acts as a Mn(II)-dependent autorepressor [Few of the early response genes found to be differentially regulated were transcriptional regulators like nd yeast , 168. Stepressor . cbiN, cin NRC-1 . This waepressor . 1B type ATPases gene yvgX in Halobacterium sp. strain NRC-1 [yvgX as well as the metallochaperones, thus providing Cu(II) resistance to Halobacterium sp. strain NRC-1. A similar pattern involving a metallochaperone (CopM), a transcriptional regulator with C-terminal TRASH domain (CopT), and a P-type Cu(II) exporting ATPase (CopA) forming the cop gene cluster for Cu(II) resistance has been described in Sulfolobus solfataricus, a thermoacidophilic crenarchaeon [A putative Lrp (leucine-responsive regulatory protein) family protein VNG1197C was reported to upregulate the Cu(II)-Pin NRC-1 . VNG1197in NRC-1  proposedarchaeon , 114.Halobacterium sp. strain NRC-1 is an example of how metal homeostasis is maintained. Transient changes in transcripts to resist metals may play a major role in haloarchaea.Thus, organisms have the ability to differentiate between metal ions and therefore elicit responses that enable better survival. These responses could be local or global but in effect would be to efficiently handle the stress. The transcriptional regulation exhibited by Halobacterium sp. strain NRC-1 show that they have the ability to elicit a tailor-made response to metal stress. Other genera of the halophilic Euryarchaeota have not yet been subjected to such detailed studies with regard to metal homeostasis and resistance. The development of standard molecular and genetic tools for haloarchaea may facilitate better understanding of the various components involved in metal resistance including detoxifying enzymes, metallochaperones, and metal chelators and transporters. While assessing metal resistance in haloarchaea, the metal speciation should be given importance, as the metal might be unavailable to the cell for uptake, thus giving a higher MIC value. Therefore, beside understanding the molecular mechanisms underlying the resistance to metals, metal speciation and bio-availability studies should be carried out to obtain a complete picture. Further, this could facilitate the use of haloarchaea for bioremediation of metal-polluted hypersaline environments. Haloarchaea encounter metals in their natural environment and utilize some of these metals for various key physiological functions. However, at higher concentrations, these metals can be toxic, and thus haloarchaea exhibit metal resistance mechanisms. Knowledge about metal physiology in haloarchaea is cursory, and therefore global studies for gaining insights into the metabolic regulations in response to metal stress are required. Metal physiology studies in model haloarchaeon


Persistent low-grade systemic inflammation has been increasingly recognized as a common pathological process, and an important contributing factor to cardiovascular diseases and its risk factor, metabolic syndrome. Immunoglobulin M is reactive to multiple autoantigens and is inferred to be important for autoimmunity, implying that immunoglobulin M may be a potential risk factor for metabolic syndrome. However, few epidemiological studies are available which are related to this potential link. Therefore, we designed a cross-sectional study of 9,379 subjects to evaluate the relationship between immunoglobulin M and metabolic syndrome in an adult population. Subjects who received health examinations were recruited from the Tianjin Medical University General Hospital-Health Management Center in Tianjin, China. Immunoglobulin M was determined with an immunonephelometric technique. Metabolic syndrome was defined according to the criteria of the American Heart Association scientific statements of 2009. Multiple logistic regression analysis was used to examine the relationships between the quartiles of immunoglobulin M and the prevalence of metabolic syndrome. After adjustment for covariates, the odds ratio of having metabolic syndrome in the fourth quartile compared with the first quartile of immunoglobulin M was 1.19 times for males  and 1.39 times for females . Immunoglobulin M levels also showed positive relationships with the ratio of elevated triglycerides and reduced high-density lipoprotein cholesterol in males. The study is the first to show that immunoglobulin M is independently related to metabolic syndrome and its individual components (elevated triglycerides and reduced high-density lipoprotein cholesterol) in males, whereas immunoglobulin M is independently related to metabolic syndrome in females but not to its individual components. Further studies are needed to explore the causality and the exact role of immunoglobulin M in metabolic syndrome. Chronic diseases, such as cardiovascular diseases (CVD), cancer, and age-related diseases have long been considered among the most important global public health issues Over the past few decades, there has been a steep increase in obesity throughout the world On the other hand, Immunoglobulin M (IgM) is the first antibody to be produced during an immune response after an initial antigen encounter, and is the predominant isotype secreted in T-cell independent immune responses This cross-sectional study aimed to investigate how serum IgM concentration is related to the prevalence of MS in an adult population.The Tianjin Chronic Low-grade Systemic Inflammation and Health (TCLSIH) Cohort Study is a large prospective dynamic cohort study focusing on the relationships between chronic low-grade systemic inflammation and the health status of a population living in Tianjin, China. Tianjin is a city of approximately 10.43 million inhabitants, located in the northeastern part of the North China Plain, facing the Bohai Sea This cross-sectional study used baseline data from the TCLSIH. During the research period there were 10,015 participants who had received health examinations including serum-immunological tests. We excluded participants who did not complete data collection on any components of MS (n = 41), body height and/or body weight measurements (n = 1), or those with a history of CVD (n = 513) or cancer (n = 81). Owing to these exclusions, the final cross-sectional study population comprised 9,379 participants . The blood sample was routinely drawn 12 ml of whole blood for 2 ml of plasma and 10 ml of serum from each subject. The protocol of this study was approved by the Institutional Review Board of the Tianjin Medical University and participants gave written informed consent prior to participation in the study.Serum-immunological tests were measured as a health examination item. Serum levels of immunoglobulins  were determined by the immunonephelometric technique using the automated IMMAGE 800 immunochemistry system , and expressed as mg/dL. The detection limit of the assay was: IgM 4.2 mg/dL, IgA 6.7 mg/dL, IgG 33.3 mg/dL; the measurement range was: IgM, 4.2–14,400 mg/dL, IgA 6.7-25,200 mg/dL, IgG 33.3-21,600 mg/dL; and the intra- and inter-assay coefficients of variation (CV) were less than 6% for three classes of immunoglobulins. The manufacturer indicates the following reference intervals for healthy adults: IgM 46–304 mg/dL, IgA 82–453 mg/dL, and IgG 751–1,560 mg/dL.Waist circumference was measured at the umbilical level with participants standing and breathing normally. Blood pressure (BP) was measured twice from the upper left arm using a TM-2655P automatic device  after 5 minutes of rest in a seated position. The mean of these 2 measurements was taken as the BP value. Blood samples for the analysis of fasting blood sugar (FBS) and lipids were collected in siliconized vacuum plastic tubes. FBS was measured by the glucose oxidase method, triglycerides (TG) were measured by enzymatic methods, low-density lipoprotein cholesterol (LDL) was measured by the polyvinyl sulfuric acid precipitation method, and high-density lipoprotein cholesterol (HDL) was measured by the chemical precipitation method using reagents from Roche Diagnostics on an automatic biochemistry analyzer .MS was defined in accordance with the criteria of the American Heart Association scientific statements of 2009 2 (kg/m2). Sociodemographic variables, including gender and, age were also assessed. A detailed personal and family history of physical illness and current medications were noted from “yes” or “no” responses to relevant questions. Information on alcohol and tobacco use were obtained from a questionnaire survey.Anthropometric parameters (height and body weight) were recorded using a standard protocol. Body mass index (BMI) was calculated as weight/heightP values were used for comparisons between IgM quartiles. Multiple logistic regression analysis was used to examine relationships between IgM categories and the prevalence of MS after adjustment for covariates: age, sex, BMI, smoking status, drinking status, family history of CVD, hypertension, hyperlipidemia, or diabetes, and serum IgA and IgG concentrations. Odds ratio (OR) and a 95% CI were calculated. Moreover, a developed multivariable logistic model was obtained using stepwise variable selection methods applied to the variables with a P value of <0.20 based on the univariable analysis. A linear trend across increasing quartiles was tested by using the median value of each quartile as an ordinal variable. All tests were two-tailed and P<0.05 was defined as statistically significant.All statistical analyses were performed using the Statistical Analysis System 9.3 edition for Windows . Because the prevalence of MS was significantly higher in males, and their IgM serum concentration was also significantly different (see the results section), males and females were analyzed separately in this study. Descriptive data are presented as the mean (range) for continuous variables, and as percentages for categorical variables. Differences in serum IgM levels and the MS prevalence between genders were examined by t-test or chi-squared test, respectively. Because the distribution of serum IgM levels was non-normal, the natural logarithm was applied to normalize the data before analysis of the t-test, and the descriptive data is presented as the geometric mean  for it. For further analysis, the prevalence of MS was used as a dependent variable, and the quartiles of IgM as independent variables. For participant characteristics analysis, the differences among IgM categories were examined using analysis of variance (ANOVA) for continuous variables, and logistic regression analysis for proportional variables. Bonferroni-corrected P<0.0001). In contrast, the levels of IgM were significantly lower in males .In this study, 60.5% of participants were males and 39.5% females, with mean ages (SD) of 46.3 (10.4) and 47.1 (11.6) years, respectively. The overall prevalence of MS was 34.9% . The prevalence of MS was significantly higher in males than in females . Otherwise, no significant difference was observed between different quartiles of IgM.Characteristics of male participants across quartiles of IgM are presented in P for trend <0.001). Mean IgG was significantly higher across IgM quartiles (P for trend <0.0001). The percentage of subjects with a family history of CVD, and who were current smokers were significantly lower in the highest IgM quartile . No significant differences in HDL, drinking status, family history of hypertension, hyperlipidemia, or diabetes were observed across quartiles of IgM.P for trend  = 0.07), respectively. Similar results also were observed in females (P for trend  = 0.0001) in male, in the final model (P for trend  = 0.09), the highest proportion of participants with reduced HDL was in the highest IgM quartile   In contrast to our observations, a previous study has shown that elevated levels of IgA, IgE, and IgG, but not IgM, are related to myocardial infarction and cardiac death in males with dyslipidemia P<0.0001), differences in TG levels may partly explain these observations. Furthermore, despite being positively and significantly related to MS in females, IgM levels were not significantly related to any one of the individual components of MS. We speculate that in females, IgM may be strongly related to a constellation of risk factors rather than a simple risk factor.Consistent with previous studies, our study also found that females have higher IgM levels than males A large number of studies have established that most autoimmune diseases occur significantly more frequently in females than males It is increasingly recognized that MS is a low-grade inflammatory condition and central abdominal fat is a contributing factor The present study has two limitations. Firstly, because this is a cross-sectional study, further prospective studies and intervention trials should be undertaken to establish a causal relationship between IgM and MS. Secondly, although we adjusted for a considerable number of potentially confounding factors, we cannot exclude the possibility that MS is affected by other lifestyle variables which are intrinsically related to serum IgM concentration.This large-scale epidemiological study has shown that the highest immunoglobulin M quartile is independently related to the highest prevalence of MS in males. But, IgM only was significantly related to elevated TG and reduced HDL, but not waist circumference, BP and FBS. This suggests that IgM may be involved in the pathological process of MS through lipid metabolism disorder. In females, serum IgM levels were independently related to a higher prevalence of MS, but not its components, suggesting IgM may be strongly related to a constellation of risk factors rather than a simple risk factor. To conclude, this study is the first to show that IgM is independently related to MS and its individual components (elevated triglycerides and reduced high-density lipoprotein cholesterol) in males, whereas IgM is independently related to MS in females but not to its individual components. The present study also implied that IgM might be a useful predictive factor for MS in an adult population. Further studies are needed to explore the causality and exact mechanisms of IgM in MS.


Although this flash flood caused property damage of about $21 million  to the metro especially its electrical system, fortunately no death and injury ensued ,,,On 15 April 2012 at around 13:00 local time, following a heavy rainfall in Tehran, a break in the channel wall of Kan River caused a flash flood in the Tehran metro tunnels. Consequently, line 4 of the metro went out of operation for about two weeks 3 of debris and precipitants were removed from the stations and trains. Finally, damaged stations were repaired and got back to the operation in 12 days Quick measures were taken to disconnect electricity and evacuate more than 1,500 passengers and staff from the adjacent stations while simultaneously the water was draining. For a few days, more than 10 thousands mImmediate disconnection of the electricity system prevented electrocutions. Timely emergency evacuation in this event saved hundreds of lives. All trains were stopped in adjacent stations and the passengers were instructed by the staff to safely evacuate the metro. In addition, dwellers near at risk stations were relocated to safe buildings.Here, we wish to address some challenges along with corresponding lessons learned that have a bearing on revisions to the emergency plan of Tehran in general and Tehran’s metro in particular:Experts believe that over excavation near the river channel was the main reason for this event Tehran’s early warning system (EWS) for flash floods must be improved. City’s inhabitants and the infrastructures including Tehran’s metro, in particular, will benefit from this system. A timely and effective EWS prevents the loss of lives and unnecessary functional and economical damages. It however requires further collaboration among Tehran’s Disaster Management Center, Meteorological Organization and Water and Sanitation Organization.Risk transfer is a key component of disaster risk management. Tehran's metro system was insured up to $8 million , but the damage caused by the flash flood far exceeded that amount Tehran’s metro needs a paratransit system in case of major emergencies. This system will be also useful in case of daily incidents. Once the metro service was disrupted, a large crowd of passengers was wandering in the streets looking for taxies.While fortunately no death was reported in this event, but it is worth emphasizing continuous education of metro’s passengers in term of safety issues especially risks of electrocution during the flooding and stampede toward the exit doors. This will save lives and assist the metro operators for safer and quicker response.The authors received no fund for this study.The authors have declared that no competing interests exist.Ali Ardalan MD, PhD. Tehran University of Medical Sciences. Harvard Humanitarian Initiative. Email: ardalan@hsph.harvard.edu


Falls are among the most common problems affecting older adults. At least 50% of those over the age of 80 fall annually. The goal of this pilot was to assess the safety and feasibility of structured yoga in an elderly population with fall risk.Seniors at risk for falls were identified and enrolled in a single arm pilot trial. A chair based yoga program was provided twice a week for 8 weeks. The program was designed from previous published pilot data. A battery of validated instruments was administered at baseline and week eight and was used to identify which instrument may be sensitive to change as a result of a yoga program.Among sixteen seniors (median age of 88) with a previous history of falls, 87% provided data for assessment at the end of the intervention. Two patients withdrew, one due to a fall outside the institution and the other due to lack of time and interest. There were no adverse events during the yoga sessions. Paired-t tests compared pre-post changes and gains were noted in Fear of Falling  and the SPPB sit to stand subscale . Improved trends were noted in the anxiety subscale of the Hospital Anxiety and Depression  and the Timed Up and Go  assessments.We found the modified chair-yoga program is safe and recruitment is feasible. To provide a skillful framework for teaching yoga to seniors, specific principles of practice are important to ensure safety of this intervention. Our data suggest that yoga may be beneficial in improving mobility and reducing fear of falling which warrants additional research via randomized controlled trials.


Background. The goals of this project were to evaluate the current perspective on letters of recommendation and to assess the need for, and acceptance of, a more standardized letter of recommendation (LOR). Methods. An eight-question survey was distributed to plastic surgery program directors. A five-point Likert scale was selected as a means of quantifying the participants' responses to the survey. Results. Twenty-eight of 71 program directors (39.4%) completed the survey. The majority of participants felt that current LOR did not offer a realistic way to compare applicants . While most agreed that increasing the objectivity of LOR would be valuable in comparing applicants , the overall average response to whether a more standardized letter format would improve the resident selection process remained only slightly better than neutral . Most of the chairmen supported the notion that familiarity with the author of the LOR strengthened the recommendation . Conclusion. The majority of plastic surgery program directors would like more objectivity in comparing applicants but are ambivalent about a standardized letter of recommendation. Plastic surgery residency candidates are increasingly competitive which, in turn, raises the complexity of selecting the most qualified applicants. Rating applicants is a multifactorial process involving the assessment of many variables including grades, class rank, performances at subinternship rotations, USMLE scores, AOA and other honors, research accomplishments, and letters of recommendation.In a recent study by Janis and Hatef, a survey was conducted to assess the current method of plastic surgery resident selection and program directors' satisfaction with the process. The study demonstrated that although many directors were displeased with the current system, few changes have been made towards improvement. Interestingly, letters of recommendation were found to be a valuable criterion for selection, yet letters of recommendation remain primarily a subjective measure of a candidate's character and quality. Attrition rates from residency programs were deemed unacceptably high, which may reflect a problem with applicant selection. It was concluded that increasing objectivity might raise overall satisfaction .Recently, letters of recommendation have been under scrutiny across many specialties. While some feel that letters of recommendation are an invaluable component in the overall evaluation of each applicant, others argue that, as the number and quality of applicants rise, current letters fail to distinguish excellent applicants from the average –6. Studihttp://acaplasticsurgeons.org/multimedia/files/Letter-of-Recommendation-Form.doc; see Supplementary Material available online at doi: 10.1155/2012/728981). Although other studies have looked at the overall candidate evaluation and resident selection process, no study has focused on LOR in plastic surgery. The goals of this project were to evaluate the current perspective on letters of recommendation among plastic surgery program directors, to measure the utility and ease with which directors are able to extract information and draw accurate conclusions about the various residency candidates, and to assess the need for, and acceptance of, a more standardized letter of recommendation. The ambiguity and seeming lack of specificity of the current narrative LOR led to the development of a standardized letter of recommendation (SLOR) now used by the specialty of emergency medicine , 9. EmerAn eight-question survey was created to assess the current perception of LOR in the plastic surgery resident selection process. The questions focused on either the utility of LOR in the resident selection process or the program directors' assessments of the benefits of a more standardized letter format. The questionnaire was distributed and collected at the ACAPS annual meeting prior to the presentation of the SLOR prototype. Each member was asked to complete the survey upon entering the meeting.A five-point Likert scale was selected as a means of quantifying the participants' responses to the survey. A “5” meant that they strongly agreed, while “1” was strongly disagree. A rating of “3” represented a neutral stance, “2” meaning somewhat disagree, and “4” for somewhat agree. At the end of the survey, an area was allotted for comments.Refer to  for the list of eight ranked survey statements.P value of less than 0.05 indicated a statistical significance. SAS version 9.2  was used for data analysis.Response scales of each of eight questions were summarized using the mean plus or minus the standard deviation for the entire group and according to the type of program. Integrated and independent programs were compared in each of eight questions utilizing the Wilcoxon rank-sum test. Q1, Q5, and Q8 were selected for further analysis in an attempt to compare perceived quality of LOR with desire for an SLOR. Response scales of three or less were merged, and response scales of four or five were merged for questions Q1, Q5, and Q8. The homogeneity of the marginal distributions of Q1 and Q5 with Q8 were assessed using McNemar's test. Association of Q1 and Q5 with Q8 was assessed utilizing Fisher's exact test.  A total of 28 of all 71 program directors nationwide (39.4%) completed the survey. Not all 71 program directors were in attendance at the ACAPS meetings at the time of the survey. The majority of program directors felt that current LOR failed to definitively offer a realistic way to compare applicants (2.9 ± 0.8). While most agreed that increasing the objectivity of LOR would be valuable in comparing applicants (4.1 ± 0.9), the overall average response to whether a more standardized letter format would improve the resident selection process remained only slightly better than neutral (3.5 ± 1.2). However, upon further stratifying the responses, there was a significant difference in the proportion of those that strongly or somewhat agreed with statement five versus statement eight. Thus, more participants strongly or somewhat agreed that increasing the objectivity of LOR would be valuable than that a standardized letter format would improve the overall selection process. However, no significant association was detected between responses to Q5 and responses to Q8 .Most of the program directors supported the notion that familiarity with the author of the LOR strengthened the recommendation (4.5 ± 0.6). Increasing the number of letters of recommendation did not allow for a more accurate assessment of the applicant (2.8 ± 1.0). Most respondents remained neutral in their stance on the LOR as a predictor of resident performance (3.1 ± 0.9). When further stratifying the results based on ratings for statements one and eight, there was no significant difference in the proportion of those who strongly or somewhat agreed that LOR were valuable predictors of resident performance compared to those who strongly or somewhat agreed that SLOR would enhance the overall resident selection process.P values were greater than 0.05).Survey results recently published by the National Resident Matching Program illustrated the importance of letters of recommendation in the plastic surgery resident selection process . SeventyMorgenstern et al. looked at ways to improve the LOR, noting that “superlative inflation” has become the norm in letter writing. Many authors find it necessary to use extreme diction in order to avoid potential disservice to students by providing insufficient praise . Such seIn 1995 the specialty of emergency medicine adopted an SLOR model in attempt to curtail “adjective inflation” and increase accurate information about each applicant. The standardized format has been positively received by emergency medicine program directors and is now commonly used in evaluating prospective residents. A survey of the program directors after its implementation highlighted a few of the perceived values of the SLOR. Results of the poll suggested that it was easier than traditional LOR to read and incorporate into a ranking scheme. Readers of the SLOR were better able to discriminate differences between candidates, and evaluators found it easier to complete. Other studies suggest that the emergency medicine SLOR has resulted in better interrater reliability and requires less time to interpret .The present study indicates that, while a majority desire more objectivity, most plastic surgery program directors remain neutral in their perception of the need for a standardized letter of recommendation. Letters of recommendation by authors familiar to the reader and from within the plastic surgery field remain a valuable part of applicant evaluation. A more standardized letter format may serve to supplement the narrative letters of recommendation currently used, particularly when an unfamiliar author outside of the plastic surgery field writes the letter.Two major training models exist for plastic surgery, independent and integrated. In the integrated model, residents are accepted directly from medical school to begin their six-year training which consists of a primarily general surgery focus and transitions into plastic surgery exclusively the final few years. The independent model requires prerequisite training prior to joining the program. The resident must first complete either 36 months of general surgery training or complete a formal training in general surgery or a number of other surgical subspecialties. Surprisingly no statistically significant difference was detected between responses from program directors of the two different program types. It was hypothesized that program directors of independent programs would find greater value in current LOR in predicting resident performance, given the far greater surgical resident experience for the letter writer to critique. However, the responses suggest that neither subset of program directors, on the average, felt that LOR were good predictors of resident performance or offered a realistic way to compare applicants.The survey used was completed prior to the introduction of the SLOR, thus the respondents' opinions represent those prior to the approval of the proposed change. It is unknown whether responses would have changed if the survey was conducted after the standardized letter model was available to program directors. An additional limitation to the present study is the low response with approximately 28 completed surveys of the 71 program directors nationwide. Although most program directors indicated that they were involved in reviewing LOR, the chair of the division/department for 21 of the 28 programs also reviewed LOR. The current study did not survey the opinions of the chairs; their perspectives may prove valuable and should be studied in the future. Further studies are necessary to assess changes in perspectives as the field of plastic surgery evolves, competition for residency positions increases, and program directors become more familiar with the standardized letter prototype. Potentially useful long-term follow-up studies include looking at the number of authors/programs that use the SLOR format and opinions and experiences regarding its use. Long-term prospective studies comparing traditional LOR to SLOR for individual plastic surgery applicants should be conducted to assess predictive value of resident successful completion of residency.Despite the subjective nature of LOR, they remain a vital component of the applicant evaluation. Although plastic surgery program directors desire more objective data on which to base their resident selection, many remain ambivalent to moving to a standardized format. The recently proposed SLOR should be considered as a supplement to current LOR, particularly when unfamiliar authors outside the field of plastic surgery write letters.The letter of recommendation template was created by ACAPS in an effort to help residency programs compare across candidates. There are both objective and subjective sections as many authors desired a section where they could still add subjective content.Click here for additional data file.Click here for additional data file.


A one-sided paired t test was used to compare pre- versus post-test scores from the instrument under the hypothesis that the educational module improved post-test scores. The standard for statistical significance was p<0.05.This was a mixed methods design. Pre-and-post program semi-structured focus groups with students were conducted to explore satisfaction with the program, and perceptions of program impact on the acquisition of collaborative competencies in MSK care. Key informant interviews with teachers were conducted to determine program content and the different educational approaches to be used. Inductive thematic analysis and triangulation of data sets was utilized to evaluate qualitative data. A new quantitative tool, the Health Professional Collaborative Competency Scale Thirteen students from 6 different programs and 5 institutions participated, their year of study within their program varying to some degree. Learners also had variable levels of MSK training/experience with IPE. The students were satisfied with the program and discussing their own experiences and ideas as well as to learn from other students. Twenty-two facilitators participated from 11 professions and felt that best teaching was thought to occur through role modeling.A 4-day interprofessional educational module can enhance the collaborative abilities of mixed health professional learners. Role modeling (by mentor facilitators) and discussion/interactive activities appear to be important key features of such programs.


The Paediatric Unit at Flinders Medical Centre in South Australia caters for children aged between 0 - 18 years of age, within a large general metropolitan hospital. Consistent with national trends we have experienced a significant increase in adolescents admitted with an eating disorder. In response a core eating disorder group visited other hospitals within the Room: State and interRoom: State in the hope of gaining insight into how to best manage this cohort. We formed a management team consisting of Paediatric Consultant, Psychiatrist, Nursing and Allied Health, CAHMS, School Teacher and Diversional Therapist. With much trepidation, February 18th 2013 saw the launch of our Eating Disorder program, heavily based on the Westmead Children's Hospital model with their on-going guidance and support. Our immediate focus has been on delivering education sessions for all staff; developing written resources for staff, patients and families. Imperative to the success of this program has been setting up a weekly activity program, family meetings, team management meetings and addressing ward management issues.This presentation will describe our journey and specific challenges we met along the way to ensure we are meeting not only the needs of these complex patients but also empowering staff and families to deal with concerns on a daily basis.