Increasing rates of childhood overweight and obesity highlight a need for the evaluation of lifestyle interventions. The purpose of the study was to determine the Reach, Effectiveness, Adoption, Implementation and Maintenance of a novel family-focused program targeting children with obesity  using the RE-AIM framework, an evaluation tool for community-based health interventions.n = 15; Mage = 10.6; 53% female) and/or Year 2 . Outcome variables were measured pre- and post-intervention, as well as 6- and 12-months following completion of the formal program.A single-centre, single cohort interventional feasibility study was conducted over the course of two years. Children with obesity and their families completed a 4-week group-based lifestyle intervention in Year 1 , body fat percentage, lean mass percentage, and child- and parent-proxy reported quality of life . Furthermore, a number of community partnerships were built, strengthened, and maintained prior to, during, and following implementation of the two-year program . Finally, the intervention was delivered as intended as evidenced by high adherence to the schedule, attendance rates, and cost effectiveness (implementation).Overall, C.H.A.M.P. had high Based on RE-AIM metrics, C.H.A.M.P. appears to be a promising childhood obesity program. The findings reported will inform researchers and practitioners on how to design and implement future community-based programs addressing pediatric obesity.ISRCTN13143236. Registered 27 March 2015.ISRCTN Registry, Study ID  Childhood obesity has reached epidemic proportions and is a major public health issue worldwide . Among CMulti-faceted treatment interventions integrating a family-based component have elicited significant and positive results among children with obesity -7. GenerIn their systematic review of obesity treatment interventions, Oude Luttikhuis and colleagues  examinedInterestingly, while multi-component e.g.,  behaviorA systematic review of the behavioral treatment of childhood obesity literature was conducted in 2012 to evaluate the extent to which external validity dimensions were reported . Of the The Children’s Health and Activity Modification Program (hereafter referred to as C.H.A.M.P.), a family-based lifestyle intervention for children with obesity, was designed on the basis of group dynamics theory and in response to the paucity of accessible community- and theory-based childhood obesity programs involving children and their parents e.g.,   children and families agreed to participate in the program in Year 1  and/or Year 2 ; 5 children/families were eligible and chose to participate in both years. One child from Year 1 was removed from the program during the second week due to behavioral and family issues, three children from Year 1 dropped out at the 6-month follow up, and five children (one from Year 1 and four from Year 2) dropped out at the 12-month follow up. Written informed consent and assent were obtained from parents and children, respectively, prior to program involvement.Families were recruited through advertisements placed in local media, posters displayed in libraries, community centers, hospitals, and family medical clinics, and physician referrals. The recruitment phase was approximately 3 weeks  and 3 months  in duration. The discrepancy in recruitment length between the two years was a result of administrative delays. Children in the London, Ontario census metropolitan area  were eligible to participate in the program if they: (a) were between the ages of 8 and 14; and (b) had a BMI-The project was a 4-week intervention delivered to two cohorts during the month of August over two years. C.H.A.M.P. included physical activity, dietary, and behavior modification components for children, as well as educational sessions reflecting similar content for families. Children attended camp on weekdays from 9am-4pm for four consecutive weeks, and family members  attended weekly group-based educational sessions on four consecutive Saturdays from 10am-2pm.A number of program-specific trained staff  and volunteers  were involved in the implementation of the intervention as program counselors and assistants, respectively. Five counselors and one volunteer were involved in both years. Potential staff were recruited via word of mouth and advertisements at Western University and a local YMCA. Candidates who were short-listed based on their credentials and experiences underwent initial screening and a two-phased interview process led by three members of the research team. All counselors, once hired, were required to complete a police background check, CPR/First Aid training, and a one-week counselor training program led by the Principal Investigator and Project Coordinator. This training included: (a) a detailed overview of the program, C.H.A.M.P. counselor manual, and research processes; (b) fine-tuning of the 4-week schedule for children and parents; (c) brainstorming sessions around various program-related topics; and (d) a one-day life coaching workshop that focused on effective and supportive communication. All counselors were certified school teachers, university students, and/or employees at the program delivery settings . Volunteers were university (graduate and undergraduate) students.Three researchers were responsible for the collection of data and supervision of the program for both years. Counselors ran the child-based portion of the intervention  and a number of guest speakers  facilitated the family-based sessions in addition to leading some camp sessions . Two-hour “booster sessions” were offered once every two months for one year following the formal intervention. These sessions were created to maintain contact among children and family members and to re-iterate, emphasize, and provide new information and resources pertaining to behavior modification strategies, physical activity, and healthy food choices.Although C.H.A.M.P. was funded externally, each family also paid a fee of $200.00 (CAD) upon entry into the program. Caregivers of potentially eligible children were informed of this fee when they contacted the researchers about the program . The fee contributed toward the cost of school bus transportation to and from camp and a one-month family membership at the YMCA. Ethical approval for all study procedures was obtained from The University of Western Ontario Research Ethics Board for Health Sciences Research Involving Human Subjects.In addition to a demographic survey completed by caregivers at the beginning of the 4-week intervention, children and family members completed a number of research assessments . For thereach of an intervention measures the participation rates and representativeness of individuals who participate in a program ); and (b) the Pediatric Quality of Life Inventory 4.0 ; 2) emotional (n = 5 items); 3) social (n = 5 items); 4) and school (n = 5 items) functioning. Individual-level maintenance was also assessed using participant attrition [The ectively . In rela-QL 4.0; ), a reli-QL 4.0; . The quettrition ,15.effectiveness referred to the evaluation of the abovementioned variables from pre- to post-intervention, whereas individual-level maintenance referred to the evaluation of these variables from pre-intervention to the 6- and 12-month follow-up periods. Effectiveness and maintenance data were analyzed using a series of one-way repeated measures ANOVAs. Effect size values (η2) were also calculated, and values of 0.01, 0.06, and 0.14 were considered small, medium, and large, respectively [Measurements were collected at baseline, post-intervention, 6-month, and 12-month follow-up assessments. For the purpose of the current study (and given the timeframe of the intervention and follow-up assessments), program ectively . Post-hoectively  requiredectively . Becauseectively . Missingectively . The 12-Adoption includes an assessment of the delivery settings  and the participation rate of delivery agents  involved in the implementation of a program ,28. AdopImplementation is measured by determining whether the intervention was delivered as intended [intended . The anaintended . The parintended ) checks In the present study, setting-level maintenance was assessed by calculating the percentage of community organizations (who participated in the first year of the intervention) that were both asked and agreed to participate in the second year of the program.A total of 85 families contacted the researchers regarding the potential involvement of 88 children. See Figure n = 44 inquiries), posters , attendees from the previous year , word of mouth , radio advertisements , physician referrals , television interviews , and school board referrals . Sixteen (16.3%) families who inquired about the program did not disclose their source of program information. For families that participated in the program, the most successful means of recruitment were newspaper advertisements , word of mouth , posters , previous attendance , and radio advertisements . Several families heard about the program through more than one source.In terms of total C.H.A.M.P. inquiries, the most successful means of recruitment were local newspaper advertisements  = 3.20, p < 0.05; η2 = 0.05). Post-hoc analyses revealed that BMI-z values decreased significantly from baseline to post-intervention and from baseline to the 6-month follow-up. Percentage of fat mass decreased significantly from baseline to post-intervention and was associated with a medium effect size  = 5.50, p < 0.05; η2 = 0.07), and percentage of muscle mass increased significantly from baseline to post-intervention with a large effect size  = 5.45, p < 0.05; η2 = 0.19). No changes in fat or muscle mass were sustained at the 6- or 12-month follow-up periods.Table Table physical QOL increased significantly  and was associated with a large effect size  = 6.62, p < 0.05; η2 = 0.13). Children’s emotional QOL improved significantly from baseline to post-intervention and from baseline to 12-months and was associated with a medium to large effect size  = 4.38, p < 0.05; η2 = 0.11). Additionally, significant improvements were observed in children’s self-reported social QOL from baseline to post-intervention and from baseline to 6-months  = 4.64, p < 0.05; η2 = 0.11).Children’s self-reported physical QOL increased significantly from baseline to post-intervention, baseline to 6-months, and baseline to 12-months, and were associated with a large effect size  = 8.95, p < 0.05; η2 = 0.26). Parents’ proxy reported emotional QOL showed a significant increase from baseline to post-intervention, baseline to 6-months, and baseline to 12-months, and again, was associated with a large effect size  = 10.09, p < 0.05; η2 = 0.18). Similarly, parent’s perceptions of their child’s social QOL increased significantly from baseline to post-intervention, baseline to 6-months, and baseline to 12-months  = 14.55, p < 0.05) and were associated with a large effect (η2 = 0.32).Parents’ perceptions of their child’s Four delivery settings were involved in the implementation of the program. In Year 1, the child-based portion of the program was held at the Canadian Centre for Activity and Aging, a not-for-profit research and education center at Western University, as well as a local YMCA. Anecdotal feedback from caregivers, children, and program staff suggested that the YMCA was fundamental in providing participants with a family-friendly location in which they could be physically active both during and outside of the intervention. Thus, it was selected as the “home base” for the second year of the program; the YMCA was also selected because of the potential for program sustainability at the community level. Additionally, a nearby field at a local high school was utilized for the outdoor components of the program in Year 2. All family-based sessions took place at Western University because of the availability of classrooms, audiovisual equipment, specialized learning resources , and free parking. All delivery settings were carefully selected, and in some cases, the delivery agents who assisted with the implementation of the program were recruited from these sites.n = 12 individuals/organizations); (2) providing facilities to run the program ; (3) field trips ; and (4) providing resources for the program . Seven delivery agents participated in only one of the two years.All of the delivery agents that were approached to participate in the child and/or family component(s) of the 4-week intervention agreed to do so . The nature and extent of this participation varied and was divided into four categories: (1) guest presenters  were added on an as-needed basis. For the caregiver-focused portion of the program, 100.0% of the planned sessions were implemented.n = 25) retained a mean of 66.8% of the information presented over the course of the 4-week intervention. The overall mean of information retained by the children over the 4 weeks was 72.0%.Using the weekly “quizzes” as a measure of treatment fidelity, parents/guardians , for both years, was $141,642.32 (CAD). Salaries and benefits included salaries for the counselors, Project Coordinator, and health professionals involved in the delivery of the program . Supplies and services included: project-related materials and supplies; transportation; advertisement costs; DXA scans and other research-related expenses; administration costs; capital purchases including a laptop, printer, computer software, and a license for the PEDS-QL 4.0 inventory; evaluation costs; and other costs including t-shirts, backpacks, binders, and prizes. Dissemination costs for C.H.A.M.P. included conference registration and travel. As noted above, the $200 fee paid by each family was spent on a one-month family membership at the YMCA that could be used outside of the program ($85 each); the remainder was used for bus transportation. See Table The financial costs of C.H.A.M.P. were divided into three general categories: (1) salaries, wages, and benefits; 2) supplies and services; and (3) dissemination costs. The total  suppliesInsofar as attendance is concerned, the children’s overall attendance rate for the 4-week program was 91.0%. In total (for Years 1 and 2), the percentage of days attended was 93.3% in Week 1; 86.4% in Week 2; 93.8% in Week 3; and 90.3% in Week 4. In contrast, the overall mean attendance rate for parents was 69.2%. The percentage of weekend sessions attended by parents was 72.1% in Week 1; 53.6% in Week 2; 61.3% in Week 3; and 90.0% in Week 4.Twenty-three of the 26 original delivery agents involved in Year 1 of C.H.A.M.P. were approached for involvement in Year 2; 100% of these delivery agents agreed to participate. In addition, five new delivery agents agreed to participate in Year 2. New delivery agents were sought out as a means of improving the program based on feedback from children and families in Year 1.The purpose of the study was to conduct a preliminary investigation of C.H.A.M.P. using a validated, systematic framework . Using RC.H.A.M.P. addressed a number of barriers to healthy living by including supervised activities for children (including siblings) during caregiver sessions, providing transportation and free parking, and offering reduced pricing for a YMCA (family) membership following participation in the program. Moreover, many participants suggested that the camp format and culture were important in facilitating positive changes for children and families . In addieffectiveness and individual-level maintenance elements of RE-AIM showed that the children experienced significant improvements in fat and muscle mass from pre- to post-intervention, as well as a trend toward improvement at the 6- and 12-month follow-up assessments. In addition, BMI-z values decreased significantly from pre- to post-intervention, and these changes were sustained at 6-months following the intervention. In a similar vein, Owens and colleagues [Results pertaining to the lleagues  used DXAlleagues  showed tlleagues  identifiand social QOL following the intervention, and those improvements were all sustained at 12-months. Interestingly, while the parents in the Robertson et al. study reported improved perceptions of their children’s physical, emotional, and social QOL immediately following the intervention, only improvements in physical QOL were maintained. Despite these important findings, it would be worthwhile for future childhood obesity interventions to incorporate assessment periods that extend beyond 12 months [In their seminal paper on RE-AIM , Glasgow2 months ,11.preliminary evidence that the intervention may improve children’s body composition and QOL. Despite the small number of participants, the moderate and large effect sizes reported for the significant findings offer consistent support for the effectiveness of the theory-based intervention, despite the small number of participants. However, more robust research designs, such as a pragmatic or randomized controlled trial [Given that C.H.A.M.P. was a feasibility study and did not include a control arm, the effectiveness data presented above provide ed trial , are neeadoption, C.H.A.M.P. was successful at building strong community partnerships which were vital to the success of the program. According to Estabrooks and colleagues [With regard to lleagues , the inclleagues .implementation of C.H.A.M.P. was assessed by determining whether the program was delivered as intended. Although the percentage of planned activities implemented was high, treatment fidelity was moderate for both the children and parents. A variety of factors might have affected the proportion of knowledge retained including a possible lack of: (a) family commitment to the program; and/or (b) reinforcement of the lessons learned at C.H.A.M.P. while at home. Additionally, it is possible that too much information was provided to children and parents in a given week, or that the fidelity “quizzes” were overly comprehensive/difficult, poorly designed, or not ideally scheduled to facilitate recall/retention of information. In the future, interventionists should explore (and report) the use of additional methodological strategies  to assess and improve the reliability and validity of behaviorally-based pediatric obesity interventions [Generally speaking, the ventions .There should be a C.H.A.M.P. camp for parents!” [Although child attendance during the 4-week program was high, parental attendance during the family sessions was moderate. Despite this finding, our qualitative research has shown that many caregivers acknowledged the importance of role-modeling, and some expressed a desire for more involvement in the program arents!” ; thus, earents!” , next starents!” , in the Based on the thorough and systematic evaluation of C.H.A.M.P. using the RE-AIM framework, it can be concluded that this 4-week family-based program holds promise as a treatment intervention for children with obesity. Furthermore, the detailed reporting on several key elements within the RE-AIM dimensions provides important and pragmatic information that should assist researchers and practitioners in the design and implementation of future community-based pediatric obesity programs.


Diabetes mellitus type 2 (DM2) is a metabolic disease that involves complex multifactorial genetic and environmental factors . StudiesBauhinia forficata (paw-of-cow) registered in the SIS program Hiperdia/MS from 2009 to 2010, at the 16th Regional Health/RS". We analyzed some biochemical markers such as glucose, glycated hemoglobin (HbA1C) and C-reactive protein (CRP) using a Mindray BS120 analyzer. The variant rs7903146 (C/T) and rs12255372 (G/T) of the TCF7L2 gene were genotyped by Real Time PCR. A significance level of 5%.was used to declare associations. The study was approved by the Research Ethics committee at UNIVATES under number 110/11.The sample consisted of 61 adults diagnosed with T2DM, from in the SIS-Hiperdia patient follow-up program. This is characterized as a continuing research entitled: "Identification of risk factors in diabetic and hypertensive users and nonusers of herbal There were 61 subjects, of which 43 (70.5%) were female and 18 29.5%) males. It was found that the T allele frequency was 0.34 and 0.33 respectively for the rs7903146 and rs12255372. The genotypic frequencies are in agreement with the expected Hardy- Weinberg equilibrium. According to Wilfred et al (2012) [9.5% maleStudies indicate that the presence the T allele in these polymorphisms can influence in the risk of development and gravity of the T2DM. However, in this study, the allele T was not associated to outcomes biochemical in individuals with DM2. Failure to observe any significant result does not exclude the role of the gene as a modulator of disease severity.


The importance of executive functions (EF) in childhood development, andtheir role as indicators of health, well-being, professional and academicsuccess have been demonstrated by several studies in the literature. FE arecognitive processes that aim to control and manage behavior to achievespecific goal and included skills planning, inhibition, cognitiveflexibility, (executive) attention and the central executive component ofworking memory (WM). In the context of education, the EF are crucial forcontinued learning and efficient academic performance due to theirinvolvement in several components of the educational process.The aim of this article was to describe the development and content validityof the CENA Program for Educational Training on the Neuropsychology ofLearning, with an emphasis on executive functions and attention.The study involved seven specialists , and was carried out in threestages:Background research: neuropsychology and education;Program development - author brainstorming andEvaluation by expert judges The goals, language and methods.CENA Program were considered adequate, attesting to its content validity as aschool-based neuropsychological intervention.Teacher training in school neuropsychology may be an important area forfuture investment and contribute to academic achievement and studentdevelopment in the Brazilian education system. The skills embedded in this construct include organization, planning,self-monitoring, cognitive and behavioral initiation and inhibition, cognitiveflexibility, the selection of problem-solving strategies, as well as (executive)attention and the central executive component of working memory (WM).8 More specifically, recent approaches highlight thatthe EF include constructs distinguishable from one another yetintercorrelated.10The importance of executive functions (EF) in childhood development, and their roleas indicators of health, well-being, professional and academic success have beendemonstrated by several studies in the literature.In the context of education, the EF are crucial for continued learning and efficientacademic performance due to their involvement in several components of theeducational process, such as:[a] the ability to handle new, unexpected and/orchallenging tasks, which require additional concentration for successfulcompletion;[b] organization and planning skills;[c] impulse control as well as behavioral and emotionalregulation;12[d] the ability to explore varied problem-solvingstrategies.15 As a result,executive dysfunction is associated with learning disorders ,and other clinical conditions with a negative impact on school performance,19 as wellas other neurodevelopmental disorders.The EF are also involved with the cognitive skills required for the acquisition ofreading, writing and mathematical skills.15These observations highlight the need for public policy regarding the development ofeducational interventions which move beyond the remediation  of learning difficulties , cognitive impairments and/or behavioral alterations. Preventiveinterventions involving the stimulation of the EF have become an increasinglyimportant tool for the promotion of better academic outcomes. The adequatestimulation of EF can optimize the acquisition of reading, writing and mathematicalskills.22As demonstrated by the current literature, significant investments have been made ininterventions targeting the cognitive and emotional skills (self-regulation andmetacognition) required for childhood development and learning. These interventionscontribute to educational practice, and promote the use of more effective strategiesand approaches in the teaching-learning process.27 and theSarilhos do Amarelo Program in Portugal.28 Most of these methods target preschool children, and weredesigned to be implemented by teachers under the supervision of interdisciplinaryteams. In Brazil, similar strategies with a more direct involvement in educationalprocesses have also been implemented. These include the NEUROEDUCA project, whichoffers teacher training in neuroscience and the management of learningdisorders.21Teacher-mediated interventions for the stimulation of the EF include the PIAFEXIntervention Program for Self-regulation and the Executive Functions(Programa de Intervenção em Autorregulação eFunções Executivas), developed for preschoolchildren.29 This programaims to improve executive functioning by stimulating executive and self-regulationskills.This claim is supported by previous studies in which programs targeting thestimulation of socio-emotional and self-regulation skills in the context of learningwere found to improve executive processing in schoolchildren. Examples of suchinterventions include the Head Start REDI program, the Chicago School ReadinessProject – CSRP, the Promoting Alternative Thinking Strategies (PATHS) Program andthe Tools of Mind intervention in the United States,33 Nevertheless, it must be ensuredthat the construction of neuropsychological interventions follows the same strictmethodological guidelines as the development of cognitive assessment tools.Unlike the development of assessment instruments, the construction of interventionprograms has received little attention in the neuropsychologicalliterature.nd and 3rd grade public school teachers,involving the stimulation of EF in children. The intervention developed in thisstudy was called the CENA Program for Educational Training on the Neuropsychology ofLearning, with an emphasis on EF and attention (Programa decapacitação de educadores sobre neuropsicologia da aprendizagemcom ênfase em FE e atenção).34 The program is unique in itsattempt to promote teacher autonomy by integrating the stimulation of EF into theprofessional practice. As a result, it may also be a useful tool for researchers andclinical practitioners seeking to develop educational strategies involving the EF asmediators of learning.In light of previously mentioned issues, including the scarcity of teacher trainingprograms and methodological articles in the field of school neuropsychology, the aimof this study was to describe the construction and content validity of a trainingprogram for 2Participants. A team of seven subject specialists took part in thepresent study. Three were involved in the brainstorming stage while four wereresponsible for judging whether the program achieved its ultimate objectives. Theacademic background of each participant and the lengths of their careers inneuropsychology are shown in Procedures and instruments. The stages involved in the construction ofthe CENA Program are displayed in 35Background research: neuropsychology and education. Thescientific and theoretical background of the intervention was constructedbased on a review of the literature on teacher training programs. Legalguidelines issued by the Ministry of Education and Culture (MEC) regardingthe skills required and the content explored in each school year were thenexamined.36 Thisprocedure was carried out with the following aims: [a] toidentify the goals of different stages in primary school education;[b] to identify the cognitive skills required by the teachingand assessment methods employed in different school years; [c]to adapt the techniques and contents of the CENA Program to the school yearsin question, and to the cognitive-developmental stage of the students atthese grades. An analysis of the national curriculum for Portuguese andMathematics in grades 1 through 4, as determined by the MEC, wasperformed.36School curricula were then analyzed to verify the educational goals and theresources available to teachers in grades 2 and 3. A brainstorming sessionwas then scheduled with specialists in order to reflect on the findings andmake arrangements for the next stage in the development of theintervention.Program development - author brainstorming. This stageinvolved the construction of a preliminary outline for the CENA Programbased on the information collected at stage 1. In addition, a brainstormingsession about knowledge regarding the types of task used to evaluatedifferent cognitive domains in childhood was conducted with threeexperts.38Activities were planned in two stages: [a] some activitieswere planned a priori, as a general model for thestimulation of the cognitive functions targeted in the program; and[b] other activities were developed aposteriori, over the course of the program, in response toteachers' demands. These activities were developed based on previouslymentioned sources and underlying cognitive constructs, as well as teachers'evaluations of their classroom applicability. This was a fundamental part ofthe program, since one of its major aims is to provide teachers with theresources to create and implement their own strategies based on relevanteducational and curricular objectives.The next step was the development of supporting materials, such as pamphletsdescribing EF-based teaching strategies, classroom management, and specificinstructions regarding the stimulation of the cognitive components targetedby the program. This was done to provide educators with additional knowledgeon childhood neurocognitive development, especially with regards to thecognitive skills involved in Portuguese and Mathematics: attention , language  and pragmatic development– at the comprehension and expression levels), memory , EF and self-regulation. Moreover, strategies were developed to encourage andpractice the use of these functions in the classroom using resources thatwere available to both teachers and students. Some of the tasks wereinspired by neuropsychological assessment tools, such as the Wisconsin CardSorting Test, the Trail Making Test, and the Stroop Color-Word Test, as wellas the Go/No-go, n-back and cancellation paradigms, in addition to teachingmaterials for grades 2 and 3.The next step was the organization of the program structure. This involvedthe development of additional content corresponding to the cognitive skillstargeted, and the organization of course materials into a schedule thatwould be adequate for the teachers enrolled in the program. Beforesubmitting the material to an evaluation by expert judges, a furtherbrainstorming session was scheduled with specialists for final reflectionsand arrangements.Evaluation by expert judges. The CENA was evaluated in twosteps, each with a different focus. The first was an assessment of itsspecific objectives and the extent to which these were covered by theprogram activities. The second consisted of an evaluation of the executivecomponents stimulated by the activities and strategies planned.37 Eachrater provides a score on a Likert scale ranging from 1 to 4, correspondingto the extent to which they believe the intended construct is represented bythe item/instrument in question . An instrument must have a minimum CVIof 0.90 to be considered representative.39Inter-rater agreement was examined using the Content Validity Index (CVI),which indicates the percentage of judges who agree on particular aspects ofan instrument when analyzed as a whole, and on an individual itembasis.The results of each stage in the construction process are described below.Background research: neuropsychology and education. The investigation ofexisting programs showed that the majority of early/preventive interventions focusedon EF and self-regulation in pre-school children, emphasizing the development ofself-regulation, metacognition, WM, inhibition and cognitive flexibility skills.The improvement of these abilities facilitates the acquisition of reading, writingand mathematical skills. The guiding principle of these interventions is that thecognitive skills targeted can be taught within the school environment. To achievethis goal, these programs employ a series of strategies and activities targetingeach individual executive component. Schoolteachers take on the role of mediators ofthe psychoeducation process for their students. These programs were used as thebasis for an intervention which involved the stimulation of EF in primary schoolchildren, but had the teachers themselves as the target population. The literatureon interventions for the stimulation of EF in school-age children is summarized inThe contents and materials involved in the psychoeducation and training program weredrawn from the review of MEC parameters and school curricula. As a result, the CENAwas structured around the following objectives:[a] general primary education goals; and[b] goals and contents of the Portuguese and Mathematicscurricula for grades 1 and 2.Primary education goals include the development of the following skills:[a] the ability to take a critical, responsible and activestance in situations requiring conflict mediation and decisionmaking;[b] the perception of oneself as an agent of change,attentive to the elements in the environment and the interaction betweenthem;[c] the use of different forms of language to produce,express and communicate ideas; and[d] the ability to question, as well as formulate and solveproblems, using logic, creativity, intuition and critical thinkingskills.Additional achievements are listed in the Portuguese and Mathematics curricula. Theseinclude the following:[a] to expand and adjust the use of spoken and writtenlanguage to address different goals, topics and audiences;[b] to comprehend oral and written text, as well asinterpret and infer the intentions of others across different socialcontexts;[c] to use language as a learning tool, knowing how toextract and use textual information ;[d] to perceive mathematics as a way to understand andtransform the environment;[e] to see intellectual work (mathematics) as an incentivefor interest, curiosity, inquisitiveness and problem-solving;[f] to establish relationships between quantitative andqualitative concepts using different types of mathematical knowledge; to use different logical and reasoningmethods  to solve problems andformulate results; and[g] to describe, represent and present results in anaccurate manner, discuss inferences, and make adequate use of orallanguage and its association with mathematical concepts.The review of the national curriculum and teaching standards for grades 2 and 3,especially for Portuguese and Mathematics, also helped establish the goals andcontents of the CENA Program. This information was used to teach participants aboutthe cognitive functions underlying different school activities, and help teachersmake more effective use of available resources to stimulate EF in the classroom. Thereview of curricular contents and activities also helped define the role of theteachers in the CENA Program, as did the education expert who contributed to theplanning and structuring of the intervention.Program development - author brainstorming. The structure of the CENAProgram was based on a group cognitive-behavioral therapy (GCBT) approach involvingthe use of modeling.42 Theintervention took place over11 aseries of four-hour sessions held every other week. The first two sessions provideda theoretical introduction to neuropsychology and education, as well as thecognitive constructs addressed in the program .The following two meetings involved an in-depth study of each cognitive skilltargeted in the intervention . This stage was divided into modules corresponding to each targetcomponent. Each module, in turn, involved the introduction of several stimulationstrategies of increasing complexity targeting the cognitive skill in question. Assuch, the contents of each module, as well as the order of the modules themselves,were organized based on a hierarchy of cognitive complexity. The logical sequencingtask - organizing ideas and information, for instance, was less complex than theturning the story backwards task, and was therefore introduced earlier. The lattertask consisted of a series of activities involving story-telling and repetition,which required several executive skills such as organization, planning, WM andcognitive flexibility.The aim of these activities was to provide teachers with a first-hand opportunity tosee how classroom activities could be used to stimulate the EF, especially thoseinvolved in the achievement of educational goals and learning objectives. Some ofthe tasks are very well known, and similar to activities which are freely availableon the internet. Each session began with a discussion of the contents introduced in the previousmeeting, and ended with an oral and written assessment of the session. Aquestionnaire was developed for teachers to provide their opinion on the topicsdiscussed and activities performed in each meeting. Additional details regarding thecontents of each session are described in Pureza & Fonseca (2016).Evaluation by expert judges. The inter-rater agreement (CVI) on theadequacy of the structure (language and methods) of the CENA Program, and itsability to achieve its intended goals, was 1.0. Although judges achieved anagreement rate of 100%, they also provided suggestions for improvement. Theseincluded the order in which cognitive skills were presented in the introductionsection , and the need for clearer and morespecific instructions for the practical activities.A selection of twenty such tasks was rated by three judges, who also reached 100%agreement with regards to their content validity. Slight changes were then made tothe program to accommodate the following suggestions:[a] providing more specific distinction between thedifficulty levels of some activities, especially the connecting pathstask;[b] implementing some of the activities, such as organizingthe classroom, during the actual sessions;[c] improving the clarity and objectivity of taskinstructions.The construction of the CENA followed all methodological guidelines for theconstruction and/or adaptation of assessment instruments. Three stages in itsdevelopment were especially important, namely:[a] the review of existing teacher training programs forthe stimulation of EF in school-age children;[b] the examination of national curricula and schoolsyllabi; and[c] brainstorming and expert judge analyses.29 The examination of MEC parameters and schoolcurricula allowed the contents of the intervention to be adjusted to the educationalgoals of the targeted school years.The theoretical background for the CENA Program was drawn from the literature on theimpact of stimulating the EF on childhood development and learning.21We hope that the ideas and insights inspired by the CENA Program contribute to thedevelopment of creative and systematic strategies for the stimulation of EF inschoolchildren. Teachers often become responsible for the stimulation of EF andother cognitive skills in children as a result of schooling. The main differencebetween the CENA and other neuropsychological programs for teachers is the fact thatthis intervention focuses specifically on psychoeducation regarding studentcognitive stimulation.According to the literature, classroom activities developed by teachers can stimulatechildhood cognitive development.26 The only exceptions appear to bethe Sarilhos do Amarelo program, which targets children aged 7 to 10, and themetacognitive stimulation program, which was developed for grade 5students.41 Although the majority ofinterventions described in the literature target preschool children,40 they still provided important theoreticalcontributions to the development of the CENA Program.The majority of existing interventions focus on the stimulation of EF andself-regulation in preschool children, with teachers taking on the role ofmediators.43A methodological assessment of existing interventions also revealed a lack ofpublished studies on the stages involved in the construction of these programs. ThePIAFEX appears to be the only intervention for which detailed construction data andvalidity evidence is available.44 The inter-rater analysis performed in the presentstudy allowed for an assessment of the congruence between the main objectives of theCENA Program and its structure, language and methods, as well as the extent to whichthe intended goals were achieved by the intervention. The high levels of inter-rateragreement (CVI – 1.0) also provided important evidence of content validity for theCENA, confirming the contribution of methods and strategies drawn fromneuropsychological assessment to the field of cognitive intervention. Methodologicalinvestment is essential to obtain future evidence of the applicability, efficacy andeffectiveness of an intervention.Methodological guidelines are essential for the development of assessment and/orintervention tools, and crucial for the verification of constructs such as contentvalidity and reliability.42 This format was selected to provide an opportunityfor participants to discuss and develop their own strategies, and allow forobservation-based modeling.45 Group interventions also benefit alarge number of participants in a short period of time and at a lower cost , in addition to being moreeasily replicable and having lower infrastructure demands.42The CENA was structured according to a GCBT model.The CENA Program was structured to contain both a general theoretical introduction toeducational neuropsychology and cognitive abilities, as well as opportunities forthe discussion of individual cognitive components. Each session began with adiscussion of the topics introduced in the previous meeting, and ended with a finaldiscussion which summarized psychoeducational contents and provided a systematicopportunity for the assessment of session contents and activities by theteachers.In light of the importance of educational interventions for the cognitive stimulationof school-age children, future studies should examine the effectiveness of teachertraining programs for the stimulation of EF in typically developing children acrossdifferent age groups. These studies may contribute to the development ofinterventions which address more specific educational demands, such as reading,writing and mathematical difficulties, as well as neurodevelopmental conditions suchas ADHD and communication disorders. In conclusion, teacher training in schoolneuropsychology may constitute an important preventive policy measure, which couldcontribute to academic development and educational attainment in Brazil, paving theway for progressive improvements and solid education.


ETV6-ABL1 fusion gene are rare in AML and other hematologic malignancies with only thirty-two previously reported cases in the literature, five of which were AML.Acute myeloid leukemia (AML) is commonly characterized by several chromosomal abnormalities resulting in the formation of chimeric genes that play various roles in leukemogenesis. Translocations resulting in the PDGFRA and PDGFRB, positive for bone marrow eosinophilia, rash, and marked fluid retention, which improved dramatically with imatinib therapy. Conventional cytogenetics revealed a t, t, and additional material of unknown origin at 12p11.2 in 2 out of 10 metaphases analyzed. Interphase FISH studies showed evidence of ETV6 (12p13) and ABL1 (9q34) rearrangements in 41.3 % and 5.7 % of the cells respectively. FISH studies on previously G-banded metaphases showed colocalization of ABL1 and ETV6 signals to the short arm of chromosome 3 at 3p25 suggesting a possible ETV6-ABL1 fusion. Subtelomeric metaphase FISH studies also showed the presence of a subtelomere 3p signal on the long arm of the derivative 9, and no subtelomere 3p signal on the derivative chromosome 12.Herein, we report the case of a 73-year-old male with acute myeloid leukemia arising from MDS, negative for ETV6 into 3p25 followed by a reciprocal translocation involving 3p25 and 9q34, resulting in a possible ETV6-ABL1 fusion. This case highlights the importance of FISH to characterize complex rearrangements in myeloid malignancies, particularly those resulting in clinically significant chimeric genes.These findings suggest a complex rearrangement involving an insertion of  ETV6-ABL1 fusion gene is uncommon in hematological malignancies, including chronic myeloid leukemia (CML), acute myeloid leukemia (AML), and acute lymphoblastic leukemia (ALL), and has been reported in only thirty-two patients nuc ish(ETV6x2)(5'ETV6 sep 3'ETV6x1)[124/300]Interphase FISH studies confirmed a rearrangement in 41.3 % 124/300) of nuclei examined involving 4/300 of ABL1 and ETV6 signals to the short arm of chromosome 3, suggesting the presence of an ETV6-ABL1 fusion gene. Subtelomeric metaphase FISH studies also showed the presence of a subtelomere 3p signal on the derivative 9q, and no subtelomere 3p signals on the derivative 12. In light of conventional cytogenetic findings, the karyotype was conveyed as follows inst,t5;18),der(9)t,der(12)insadd(12)(p13)[2]/46,XY[, resulting in the potential fusion gene. The breakpoint on chromosome 3 at which the aforementioned rearrangements occurred - 3p25 - harbors ANKRD28 (3p25.1), which has been implicated in AML in the context of t involving NUP98 (11p15) [This case highlights the formation of a potential  11p15) . In othep15 . In ETV6-ABL1 fusion gene in numerous hematologic malignancies including eleven cases of acute lymphoblastic leukemia, five cases of acute myeloid leukemia, and sixteen cases of myeloproliferative neoplasms (including CML)  domain of ETV6 and tyrosine kinase domain of ABL1, and each domain is necessary for constitutive phosphorylation to occur [ETV6-ABL1-positive hematopoietic stem cells developed CML-like myeloproliferative disease, and that the TEL pointed homology oligomerization domain was essential to ETV6-ABL1-driven leukemogenesis [ABL1 kinase has altered catalytic specificity in human leukemia. Co-immunoprecipitation studies show that the ETV6-ABL1 fusion protein tends to form complexes with CrkL in Ba/F3 cells, and this interaction phosphorylates CrkL and possibly CrkII [Crk and CrkL adaptor proteins show that they play an essential role in integrating signals from a wide variety of sources such as apoptotic cells, extracellular matrix molecules, and growth factors, and there is mounting evidence to indicate that these proteins are associated with human diseases including susceptibility to pathogens and cancer [The to occur . Millon ogenesis . It is wly CrkII . Howeverly CrkII . Furtherd cancer .ETV6 along with five other genes, BCR, ZMIZ, EML, and Nup21 form chimeric transcripts with ABL1. There must be a joining of the 3’ sequence of ABL1 with the 5’ end of the partner genes, and most of these genes are associated with a wide spectrum hematologic malignancies. Despite this heterogeneity, there is likely a common pluripotent stem cell that gives rise to similar transduction pathways and transforming activity [ETV6-ABL1-positive myeloid malignancies [ETV6-ABL1 positive cases, three out of the five were reported to have an increased abnormal eosinophil count, consistent with the findings in the present case. Another finding common to most of the patients was leukocytosis and out of those three cases, two had both leukocytosis and eosinophilia [ETV6-ABL1-positive AML patients with eosinophilia and leukocytosis [Eosinophilia is a recurrent morphologic finding in gnancies . Of the nophilia , 13, 14.ETV6-ABL1, chronic myeloid leukemia (CML) positive for BCR-ABL1 has been well studied and the molecular mechanisms of leukemogenesis and courses of clinical management are established. Tyrosine kinase inhibitors (TKI) such as imatinib are effective agents for inhibiting the constitutively activated BCR-ABL1 tyrosine kinase in CML [ETV6-ABL1 is also known to constitutively activate the ABL1 tyrosine kinase, leading to cell cycle deregulation and leukemogenesis [BCR-ABL1 and ETV6-ABL1 driven leukemogenesis, TKIs have also been considered in the treatment of patients bearing the ETV6-ABL1 fusion. Six out of eleven CML patients positive for ETV6-ABL1 reported in the literature were treated with imatinib: three patients showed a transient favorable response followed by relapse, one patient showed significantly decreased levels of leukemic clones, and two patients treated with 400 mg/day during the chronic phase achieved complete remission [ETV6-ABL1 transcript became undetectable, the white blood count normalized, and expression of C-MYC, ID1, BCL-XL, and NUP-98 had decreased significantly [ETV6-ABL1 and BCR-ABL1 have significant overlaps that warrant further investigation to elucidate the effectiveness of TKIs on ETV6-ABL1 positive hematologic malignancies.Although there is limited information about the pathogenesis of myeloid neoplasms positive for e in CML . Similarogenesis . Due to emission , 20–22. ETV6-ABL1 fusion gene and provides additional insight into the pathogenesis of this subset of malignancies. It is particularly important to utilize complimentary cytogenetic methodologies - namely conventional cytogenetics and FISH - in order to elucidate cryptic abnormalities, which occur more frequently in this context, and to properly characterize karyotypic changes. Additionally, screening using RT-PCR as well as other methodologies has proven useful when cytogenetic analysis is unavailable or yields negative results and in the context of broad molecular screening to identify previously unreported cases. Finally, the consideration of tyrosine kinase inhibitors, particularly second-generation ones, in the treatment of ETV6-ABL1-positive hematological malignancies has shown varying responses, and further investigation of its utility and clinical efficacy is warranted.All in all, this is the sixth reported case of AML bearing the in situ hybridization; HLH, helix loop helix; MDS, myelodysplastic syndrome; MPD, myeloproliferative disorder; RT-PCR, reverse transcriptase-polymerase chain reaction; TKI, tyrosine kinase inhibitorALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; CML, chronic myelogenous leukemia; FISH, fluorescence


There are two tiers of programs in the Project P.A.T.H.S. . In the Tier 1 Program, teaching units based on different positive youth development constructs are covered. Pre- and post-test data utilizing the Chinese Positive Youth Development Scale (CPYDS) and post-test subjective outcome evaluation data were collected from 546 students who participated in the 20h Tier 1 Program of the P.A.T.H.S. Project. Results showed that high proportions of the respondents had positive perceptions of the program and the instructors, with 85.3% of the respondents regarding the program as helpful to them. Positive changes in the program participants in many measures of positive youth development were also observed. Although there were some increases in problem behavior in some areas, adolescent problem behavior was generally stable. The present study provides preliminary support for the effectiveness of the Tier 1 Program of the Project P.A.T.H.S. in Hong Kong.


Background: Hypertension is characterized by sympathetic overactivity, which is associated with an enhancement in angiotensin receptor type I (AT1R) in the rostral ventrolateral medulla (RVLM). β-arrestin1, a canonical scaffold protein, has been suggested to show a negative effect on G protein-coupled receptors via its internalization and desensitization and/or the biased signaling pathway. The major objectives of the present study were to observe the effect of β-arrestin1 overexpression in the RVLM on cardiovascular regulation in spontaneously hypertensive rats (SHR), and further determine the effect of β-arrestin1 on AT1R expression in the RVLM.Methods: The animal model of β-arrestin1 overexpression was induced by bilateral injection of adeno-associated virus containing Arrb1 gene (AAV-Arrb1) into the RVLM of WKY and SHR.Results: β-arrestin1 was expressed on the pre-sympathetic neurons in the RVLM, and its expression in the RVLM was significantly (P < 0.05) downregulated by an average of 64% in SHR than WKY. Overexpression of β-arrestin1 in SHR significantly decreased baseline levels of blood pressure and renal sympathetic nerve activity, and attenuated cardiovascular effects induced by RVLM injection of angiotensin II (100 pmol). Furthermore, β-arrestin1 overexpression in the RVLM significantly reduced the expression of AT1R by 65% and NF-κB p65 phosphorylation by 66% in SHR. It was confirmed that β-arrestin1 overexpression in the RVLM led to an enhancement of interaction between β-arrestin1 and IκB-α.Conclusion: Overexpression of β-arrestin1 in the RVLM reduces BP and sympathetic outflow in hypertension, which may be associated with NFκB-mediated AT1R downregulation. Accumulating evidences have demonstrated that excessive sympathetic outflow is an important contributor to essential hypertension , has been identified as a scaffold protein that mediates G protein-coupled receptors (GPCRs) desensitization and internalization  rats and spontaneously hypertensive rat (SHR). Second, we investigated the effect of β-arrestin1 overexpression in the RVLM on cardiovascular function in SHR. Finally, we observed the effect of β-arrestin1 overexpression on AT1R expression in the RVLM.Sixteen-week-old male WKY rats and SHR were purchased from Sino-British SIPPR/BK Laboratory Animal Ltd., (Shanghai China) in these procedures. All experiments were approved by the Animal Care and Use Committee of Second Military Medical University, and were conducted to the principles of the Institutional Animal Care.NM_012910). The control vector (AAV-GFP) contained all sequence elements except the target gene (Arrb1). The final infectious titer was 3.7 × 1012 vector genomes/ml.The virus packaging was supported by Obio Technology company (Shanghai). The serotype 9 adeno associated virus (AAV9) was used as the vector to carry the rat Arrb1 cDNA  and fixed in the stereotaxic instrument. After the dorsal laminectomy, the Fluorogold  was injected into intermediolateral cell column (IML), as previously described  in conscious rats were measured by noninvasive tail-cuff system every 4 days after treatments  according to our previous study . RT-PCR were performed to obtain cDNA templates by All-in-one cDNA Synthesis Supermix  containing the necessary components for reverse transcription. The quantification of target gene expression (AT1a and AT1b) was manipulated using 2x SYBR Green qPCR Master Mix  and the amplification reaction was conducted on a CFX Connect real-time PCR System  using the following parameters: 95°C for 5 min, 95°C for 15 s, 60°C for 30 s, 72°C for 30 s, step 2,3, and 4 were repeated for 40 cycles followed by 5 s at 65°C. The special oligonucleotides were used for gene detection, and here shows the oligonucleotide sequences as previously described . P < 0.05 was selected as the value to determine statistical significance.All of the values are expressed as mean±SE. Differences in β-arrestin1 expression between WKY and SHR were analyzed by unpaired P < 0.05) in SHR compared with WKY  after overexpression of β-arrestin1 in the RVLM of SHR, whereas AT1b mRNA was not changed. Similarly, protein level of AT1R was notably decreased by an average of 66%  in SHR+AAV-Arrb1 compared with SHR+AAV-GFP.As shown in Figure P < 0.05, n = 5) and p65 phosphorylation  in SHR  was significantly diminished by the pretreatment with β-arrestin1 overexpression in the RVLM. Interestingly, in some cases, β-arrestin1 overexpression reversed the Ang II-induced cardiovascular excitation.In order to confirm the effect of β-arrestin1 on AT1R function, Ang II (100 pmol in 100 nl) was microinjected into the RVLM of SHR after treatment with β-arrestin1 or GFP. As shown in Figure In the present study, the major findings were observed: (1) β-arrestin1 was expressed in the pre-sympathetic neurons in the RVLM and its expression was significantly decreased in hypertensive rats, (2) overexpression of β-arrestin1 in the RVLM significantly decreased the level of BP and RSNA of SHR, and (3) overexpression of β-arrestin1 in the RVLM decreased AT1R expression and NF-κB activation. Taken together, these findings suggest that β-arrestin1 in the RVLM reduces sympathetic tone and BP in hypertension, which is associated with NF-kB-mediated AT1R downregulation.β-arrestin1 is ubiquitously expressed in organs and tissues of mammalian animals. In this study, we mainly focused on the pre-sympathetic neurons in the RVLM which exhibit firing patterns to sympathetic nerve activities (Turner et al., β-arrestin1 has long been identified as the protein that regulates GPCRs desensitization, internalization, trafficking and signaling (Ferguson, In summary, the present study has shown that overexpression of β-arrestin1 in the RVLM reduces BP and AT1R expression in SHR. Furthermore, the β-arrestin-mediated NF-κB inactivation may be responsible for the decreased AT1R expression in hypertension. Our current data highlight an importance role of β-arrestin1 in central regulation of BP and AT1R in hypertension. It is worth to further determine the possible significance and mechanism of the β-arrestin1-biased signaling pathway in central control of cardiovascular activity in hypertension. The selective central β-arrestin1 biased agonist for AT1R may be a potential strategy for reducing BP and sympathetic outflow in hypertension.Study design: J-CS and W-ZW. Performing experiments: J-CS, BL, R-WZ, P-LJ, and XT. Data collection and analysis: J-CS, R-WZ, Y-KW, and W-ZW. Drafting manuscript: J-CS. Revising manuscript content: Y-KW and W-ZW. Approving final version of manuscript: J-CS, BL, P-LJ, XT, Y-KW, and W-ZW.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


BCR and ABL1 genes. Quantitative RT-PCR (qRT-PCR) is a routinely performed screening technique to identify BCR-ABL1 fusion genes, but a limitation of this method is its inability to recognize novel fusions that have not been previously characterized. Next-generation sequencing (NGS) is an effective and sensitive detection method for the determination of novel BCR-ABL1 fusion genes as well as previously characterized ones. The oncoprotein tyrosine kinase BCR-ABL1 is a constitutively active kinase involved in the activation of a number of signaling pathways, and it has been the therapeutic target for tyrosine kinase inhibitors (TKIs) such as imatinib. Reports have presented opposing viewpoints about the effect of the disrupted Src homology 3 (SH3) domain on TKI efficacy.Chronic myelogenous leukemia (CML) is a pluripotent hematopoietic stem cell disorder caused by the fusion of the BCR-ABL1 fusion gene with breakpoints in the BCR intron 14 and the ABL1 intron 2, leading to partial deletion of its SH3 domain. In the present case, the patient received targeted therapy with the TKI imatinib at 400 mg/day and no adverse reaction was reported. The patient eventually entered remission with decreased proliferation of karyocytes and granulocytes. We also identified mutations in genes, including TP53, FLT3, ASXL1, SETBP1, CEBPA and CBL, that seemed to have an influence on the outcome of TKI therapy targeting the BCR-ABL1 protein.We here report that using NGS we identified a novel Together with previously reported results, it is clear that the genetic heterogeneity of CML patients significantly affects the presentation of the disease and its progression and therefore should inform the design of the therapeutic strategy. ABL1) on chromosome 9q34 with the breakpoint cluster region (BCR) gene on chromosome 22q11.2, which is known as the Philadelphia translocation [BCR-ABL1 oncogene. Its translation product, oncoprotein BCR-ABL1, shows enhanced tyrosine kinase activity and plays a critical role in the transformation of hematopoietic stem cells through activation of a number of signaling pathways [BCR and ABL1 genes, fusion genes are divided into many known species, such as e13-a2, e14-a2, e19-a2 and e1-a2 [BCR-ABL1 fusion transcripts and, thus, have limited ability to detect novel ones. That problem can be resolved with the application of NGS technology since it can identify these novel mutations undetectable by routine screening procedures [CML, a clonal hematopoietic stem cell disorder, is characterized by the fusion of the Abelson gene ABL on chromnd e1-a2 , as wellocedures –8, as weBCR-ABL1 fusion gene identified by next-generation sequencing in chronic myeloid leukemia” has been published recently. Here, we report that we have also identified this novel BCR-ABL1 fusion gene in another patient using NGS technology. We also report that this patient carries a different set of genetic mutations than those that impacted the outcome of TKI imatinib treatment in the Lyu et al. report [An article  entitled. report . CompariOur patient is a 62-year-old male who presented at our hospital in February 2016 with intermittent nasal bleeding that had exceed 1 month in duration. After hospitalization, we determined the patient had a significantly elevated platelet level that increased the risk of bleeding and thrombosis to a life-threatening level. No superficial lymph nodes were detected anywhere in the body. The patient was diagnosed with CML through blood and bone marrow examinations. Peripheral blood smear analysis indicated elevated levels of total white blood cells , neutrophils (34.58 g/L), thrombocytes (2597 g/L), and a normal level of hemoglobin (103 g/L). Bone marrow aspiration analysis revealed the active proliferation of bone marrow nucleated cells (BMNCs) and elevated proportions of eosinophils and basophils. Granulocytes accounted for 88% of WBCs due to the excessive proliferation of band granulocytes and segmented granulocytes Table . We alsoBCR and ABL1 genes, which were demonstrated as dots of yellowish fluorescent signals formed from the colocalization of the green (BCR) and red (ABL1) fluorescent signals. We found at least one yellowish fluorescent dot per cell in 44% of cells, representing the tumor cells with BCR-ABL1 fusions , p210 (e13-a2 and e14-a2) and p230 (e19-a2). To further clarify the existence of a BCR-ABL1 fusion in this patient, we conducted whole genome sequencing (WGS) analysis on a NGS platform. We detected a BCR-ABL1 fusion gene with novel breakpoints in BCR intron 14 and ABL1 intron 2  and ABL1 exon 3 (a3). The corresponding BCR-ABL1 hybrid mRNA was eventually identified by RT-PCR with a pair of custom primers targeting e14 and a3, followed by Sanger sequencing q34;q11.2) (Data not shown). Fluorescence in situ hybridization (FISH) analysis was then used to detect the fusion between ons Fig. . Howevern 2 Fig. , confirming Fig. . After 71.2  domain in the ABL protein plays a crucial role in regulating its tyrosine kinase activity [ABL1 exons 2 and 3, remains controversial. The report from Lyu et al. showed that their patient was intolerant to a normal dosage of imatinib, indicating an interaction between this unusual therapy outcome and the incomplete SH3 domain caused by the deletion of ABL1 exon 2 [BCR-ABL1 fusion gene was not refractory to or intolerant of imatinib treatment. The patient achieved both hematologic and molecular remission after 4 months of imatinib treatment. A previous study [BCR-ABL1 leukemogenesis. Thus the truncation of the SH3 domain caused by deletion of ABL exon 2 may result in the reduction of leukemogenesis. CML patients with an e13a3 fusion gene were found to have a good response to imatinib, and could achieve complete hematologic and cytogenetic remission [The introduction of small molecule TKIs has contributed to marked improvements in the therapeutic outcomes of CML by forcefully blocking phosphorylation by the BCR-ABL1 oncoprotein and inhibiting its cell signal transduction activity –12. Imatactivity . The fun1 exon 2 . Our casus study  reportedemission .TP53 (c.C215G: p.P72R) and FLT3 (c.C680T: p.T227M) through NGS. Furthermore, we also found mutations in ASXL1 (c.T2444C:p.L815P), SETBP1 (c.G664A: p.A222T) (c.G3301A: p.V1101I) (c.C3388A: p.P1130T), CEBPA (c.570_571insCACCCG: p.H191delinsHPH) and CBL (c.C1858T:p.L620F) that co-existed with the BCR-ABL1 fusion in our patient. ASXL1 mutations are common in myeloid neoplasms, including myelodysplastic syndrome (MDS) [SETBP1 mutations have been identified in atypical chronic myeloid leukemia (aCML), which is a rare disorder of hematopoietic stem cells and shares clinical and laboratory features with CML but lacks the BCR-ABL fusion gene [SETBP1. Despite the fact that mutations in both ASXL1 and SETBP1 are generally associated with an adverse prognosis [CEBPA results in dysregulation of transcription, translation or post-translational modifications. These disruptions cause disorders of differentiation and over proliferation of immature hematopoietic cells [BCR-ABL1. More research is needed to illuminate the interactions between these uncommon mutations and the variety of BCR-ABL1 fusion genes in CML.Similar to previous results, we also detected nonsynonymous mutations in leukemic genes such as me (MDS) . SETBP1 ion gene –29, are rognosis , 30, ourrognosis  plays a ic cells , 33. In BCR-ABL1 fusion that disrupts the SH3 domain, as Lyu et al. [TP53, FLT3, ASXL1, SETBP1, CEBPA and CBL, suggesting that CML may be more highly heterogeneous than previously appreciated. Our findings show that such genetic heterogeneity may significantly affect treatment outcomes and should therefore inform the therapeutic strategy. Since these conclusions remain speculative, more studies should be performed to characterize the various interactions between BCR-ABL1 gene rearrangements and mutations in other oncogenes.We report this case to demonstrate that by NGS we have detected the same u et al. . MeanwhiBCR-ABL1 fusion, we performed FISH analysis with dual color, single fusion probes on the patient’s bone marrow aspiration sample using the BCR-ABL FISH Probe kit  according to the manufacturer’s instructions. DNA probes targeting the BCR (chromosome 22q11.2) and ABL1 (chromosome 9q34) genes were labeled with green and red fluorescent dye, respectively. In normal cells, two green signals and two red signals were separated, representing that two probe-targeted sequences were located on different chromosomes. The presence of yellowish signal dots indicated the fusion events that resulted from the colocalization of BCR-targeting green fluorescent signals and ABL1-targeting red signals. The percent of cells with BCR-ABL1 fusions was counted and the cutoff value for the BCR-ABL1 fusion was set at 3% in our hospital.To validate the presence of BCR-ABL1 fusion transcripts. RNA from patient bone marrow aspiration samples was extracted using an RNeasy Kit , following the protocol provided by the manufacturer. RNA was purified by DNase I  digestion and was then subjected to one-step RT-PCR by a Leukemia Related Fusion Gene Detection Kit for BCR-ABL p210, p190, or p230 . In each PCR process, a total volume of 25 μl reaction solution contains 3 μl template RNA, 2 μl multiplex Enzyme and 20 μl multiplex RT-PCR buffer. Amplification and detection were performed on a 7300 Real Time PCR System . PCR procedure parameters were as follows: reverse transcription at 42 °C for 30 min, inactivation at 94 °C for 5 min, followed by 40 cycles of fluorescence detection at 94 °C for 15 s, and annealing at 60 °C for 60 s.Routine fluorescence one-step RT-PCR was carried out to detect A genomic DNA (gDNA) library was constructed for sequencing following protocols of the TruSeq Nano DNA Library Preparation Kit . Adaptors were ligated to library fragments sheared by Covaris  and were then subjected to PCR amplification. The quantitation and abundance determination of PCR amplicons were performed on Qubit 3.0 Fluorometer  and Agilent 2100 Bioanalyzer , respectively. WGS was performed on HiSeq X , with the use of Illumina bcl2fastq software version 2.15 for base calling analysis.


Compared to a lower-resolution model, submesoscale heat transport warms the sea surface up to 0.3 °C and produces an upward annual-mean air–sea heat flux anomaly of 4–10 W/m2 at mid-latitudes. These results indicate that submesoscale dynamics are critical to the transport of heat between the ocean interior and the atmosphere, and are thus a key component of the Earth’s climate.Recent studies highlight that oceanic motions associated with horizontal scales smaller than 50 km, defined here as submesoscales, lead to anomalous vertical heat fluxes from colder to warmer waters. This unique transport property is not captured in climate models that have insufficient resolution to simulate these submesoscale dynamics. Here, we use an ocean model with an unprecedented resolution that, for the first time, globally resolves submesoscale heat transport. Upper-ocean submesoscale turbulence produces a systematically-upward heat transport that is five times larger than mesoscale heat transport, with winter-time averages up to 100 W/m Oceanic motions associated with horizontal scales smaller than 50 km remain unresolved in climate models. Here the authors show that motions in this scale range are critical to the global transport of heat between the ocean interior and the atmosphere, and are thus a key component of the Earth’s climate. Turbulent motions in the upper ocean (down to ~300 m depths) occur across a broad range of spatial scales, from ~1000 km down to ~1 km and even smaller scales, and influence the partitioning of heat between the ocean and atmosphere as suggested by local studies4. Satellite images during the past four decades reveal broadly distributed submesoscale (~0.1–50 km) turbulence over the global ocean5, typically characterized by surface frontal structures in the form of eddies and elongated filaments 12, the opposite sense of traditional subgrid-scale parameterizations (down-gradient) in climate models. This unique property is not captured in climate models that have insufficient resolution to simulate these submesoscale dynamics. Useful parameterizations13 have been proposed and implemented for certain submesoscale processes, although these involve sometimes-unsettled coefficients while other submesoscale processes remain uncaptured, e.g., wind-front interactions and frontogenesis. The full impact of submesoscale turbulence on ocean vertical heat transport and air–sea heat exchange has not previously been directly quantified on a global scale, representing a potential gap in our understanding of the evolution of global oceanic and atmospheric heat content13. Accurately assessing the impact of submesoscale turbulence requires explicit resolution of motions at these scales, which remains computationally challenging for global ocean simulations.Variations in the heat content of the ocean–atmosphere-coupled system influence Earth’s climatents Fig. . Only re2 across most of the mid-latitudes, peaking at 500–1000 W/m2 over shorter intervals of days to weeks. These amplitudes, consistent with recent in situ observations11, are comparable to air–sea heat fluxes, and are more than five times larger than the mesoscale vertical heat transport in most regions of the ocean. Comparison with a lower resolution simulation shows that submesoscale vertical heat transport warms the sea surface by 0.06–0.3 °C and produces an upward annual mean air–sea heat flux anomaly of 4–10 W/m2 in most mid-latitude areas. The latter is comparable to climatological air–sea heat fluxes. These results suggest that submesoscale processes are critical to setting the magnitude of the vertical heat flux between the interior ocean, the surface ocean, and the atmosphere, as well as the geographic location and temporal variability of these fluxes over days to months, and are therefore a key component of the global heat budget.In this study, we make a major advance toward realizing this challenge by using a novel global ocean simulation with an unprecedented ~2 km horizontal resolution that, for the first time, globally resolves the ocean submesoscale heat transport at the 10–50-km scale range. We find that submesoscale turbulence produces a large and systematically upward heat transport globally throughout the upper ocean: the winter-time averages are 20–100 W/m15. This ocean simulation has been evaluated, locally, using in situ observations in terms of the kinetic energy levels at different wavelengths and frequencies15. The simulation is progressively spun up from coarser resolution , observationally constrained model solutions16, which results in a quasi-equilibrated and realistic upper ocean state above the first 500 m (see “Methods”). Throughout this manuscript, we use the term submesoscale to designate a spatial scale smaller than the mesoscale: a horizontal scale ≲0.5° in terms of longitude (~50 km at mid-latitudes), roughly below the first deformation radius in most of the global ocean22 (in terms of wavelengths). Our simulation can resolve the 10–50 km submesoscale range (see “Methods”); we discuss the potential impact of the still unresolved submesoscale range below.Here, we use a global ocean model with unprecedented resolution . The horizontal resolution, ~2 km at mid-latitude, captures physical processes at wavelengths down to a scale of ~10 km23 strong and wide-spread vertical velocities in the upper ocean: in the 20°–60° mid-latitude band during the winter, about 51% and 2% of ocean area at 40 m depth has magnitudes larger than 10 m/day and 40 m/day, respectively  embedded in the larger-scale ocean circulation , where 61% and 19% of ocean area has amplitudes larger than 20 W/m2 and 100 W/m2, respectively, at 200 m depth. During the summer, submesoscale fluxes are still positive but have a smaller amplitude and more limited spatial coverage. Only the region between 40°–60°S, as well as 40°–60°N in the Atlantic, still have significant submesoscale fluxes, where 32% and 46% of the area in these respective latitude bands have amplitudes larger than 10 W/m2 at 200 m depth  and mesoscale vertical fluxes , and exceeds 10 W/m2 over a greater proportion of the ocean (~3 times greater), as compared to studies that parameterize submesoscale motions26.Importantly, in most regions the amplitudes of the submesoscale heat transport, 20–100 W/m2 and 10 W/m2 stronger, respectively  in the 1/48° model  and therefore produce an upward heat flux. Other process studies31 suggested similar behavior. A more recent study32, using a non-hydrostatic model in a 200-km square domain, found that physical scales from 10 km down to 250 m lead to upward buoyancy fluxes and therefore upward heat fluxes, with a magnitude comparable to our estimate. Extrapolation of these localized or process-based results to the global ocean still needs to be examined.Our numerical simulation of the global ocean has permitted an estimate of the vertical heat fluxes caused by submesoscale motions at ~10–50 km range . This global ocean simulation is state of the art in terms of resolution; at the time of writing this manuscript, it remains impractical to go beyond a ~2 km resolution in a global model. We acknowledge that the heat flux contributions from submesoscale motions not resolved by this model (~0.1–10 km) could be significant and could quantitatively alter the values presented in this study. However, recent studies provide strong evidence that the total heat flux, including the full range of submesoscale motions, should remain upward (positive) and, if anything, are likely to be even larger than the values reported here. Indeed, a process study33. However, atmospheric variables, such as surface wind, air temperature, and humidity that also impact air–sea fluxes, are prescribed in our model, rather than being influenced by SST as they are in a fully coupled system. Thus, there is an additional uncertainty related to our calculated submesoscale and surface heat fluxes due to air–sea coupling. Submesoscale fluxes may modulate atmospheric dynamics that in turn lead to feedback on ocean dynamics. Indeed, multiple studies have pointed out the impact of eddy-driven SST anomalies on the stability of the overlying atmosphere34 and surface pressure anomalies35. These interactions may significantly influence wind stress38 and the location and strength of the atmospheric jet streams41, as well as mid-latitude storms42. This raises the possibility that SST changes reported in our study—most significant at mid-latitudes—may impact atmospheric storm-tracks, and therefore produce a feedback on the large-scale ocean circulation as well as on ocean submesoscale motions. This feedback may also include wind-front interactions43, wind-driven changes in mixed layer depth44 and ocean stratification,45 the change of wind energy input to the ocean46, and changes in air–sea turbulent fluxes47.An acknowledged limitation of this study is that the atmosphere and ocean are not fully coupled. In our global ocean simulation, modifications to sea surface temperature (SST) by submesoscale heat fluxes necessarily impact air–sea fluxes since the latter are parameterized using bulk formulae involving SSTThese results indicate that the oceanic submesoscale heat fluxes may impact ocean dynamics at both larger and smaller scales through the interaction with atmospheric dynamics. This impact may only be assessed and quantified through a global ocean–atmosphere-coupled model with a spatial resolution similar to the one considered in the present study. This simulation does not yet exist due to its computational expense.48, e.g., the Southern Ocean and high-latitude North Atlantic, as well as regions that influence the atmospheric storm tracks, e.g., the Kuroshio Extension and Gulf Stream, are particularly affected by the strong submesoscale heat transport . We also use the LLC2160 simulation for the results presented in Fig. 14 that the effective resolution of LLC4320 and LLC2160 is about 10 km and 20 km, respectively. The 1/48° simulation spans 14 months from September 10, 2011 to November 15, 2012. The spin-up of this simulation is described in Appendix D and Table D2 of ref. 16; it progresses from a 1/6° global ocean state estimate generated by the Estimating the Circulation and Climate of the Ocean, Phase II (ECCO2) project16, to 1/12° and then 1/24° simulations. The 1/12°, 1/24°, and 1/48° simulations are forced with six-hourly surface atmospheric fields  from the 0.14° European Centre for Medium-Range Weather Forecasting (ECMWF) atmospheric operational model analysis, starting in 2011. These three simulations also include tidal forcing for the 16 most significant components, applied as additional atmospheric pressure forcing. Vertical mixing is parameterized based on the critical value of Richardson number and is implemented using the K-Profile Parameterization (KPP) scheme52 that has been extensively used and evaluated in ocean modeling studies54. The 1/48° simulation has been evaluated using in situ observations in terms of the kinetic energy level at different wavelengths and frequencies15. This simulation’s air–sea fluxes have similar magnitudes as climatological fluxes. This is because our model’s global SST distributions are in realistic range and the air–sea fluxes in our model depend on SST and the prescribed reanalysis of atmospheric state such as near-surface air temperature, humidity, and wind speed according to the bulk formulae of ref. 33. This study focuses on submesoscales and its seasonality. The current integration of this simulation is able to reach the equilibrium state for submesoscale dynamics because of their short timescales. We are aware that it would take longer integration to reach the equilibrium state for the larger-scale ocean dynamics in the global ocean, which is beyond the capacity of the most powerful computers at the current time50. Note that the 1/48° simulation is integrated using primitive equations . The horizontal grid spacing and the hydrostatic assumption indicate that the 1/48° simulation cannot adequately resolve symmetric instability. But to a large extent, we expect the 1/48° simulation to resolve some other crucial sources for generating submesoscale turbulence, such as the mixed layer instability26, wind-front interactions43, and strain-induced frontogenesis28.We use a set of global, full-depth ocean and sea ice numerical simulations carried out using the Massachusetts Institute of Technology general circulation model (MITgcm) on a Latitude-Longitude polar Cap (LLC) gridvx − uy, with u and v the zonal and meridional velocities and x and y the zonal and meridional coordinates; subscripts here imply partial differentiation. Here, ζ is a measure of the spin of a fluid parcel. A useful non-dimensional number characterizing the surface frontal structure is ζ/f, where f is the Coriolis parameter due to the Earth rotation. When this non-dimensional number  has a surface |Ro| ~0.4 . The lower bound of submesoscales is often considered3 as O(0.1 km), but in our model is ~10 km, which is the effective resolution of our model14 since our numerical resolution is 1/48°, ~2 km at mid-latitudes . Therefore, submesoscale in this study refers to the range 1/10°–0.5° (~10–50 km). To focus on submesoscale processes, for all fields analyzed, we apply daily averaging to filter out most of the internal gravity waves14. The submesoscale component of ζ, denoted as ζ′, are the anomalies of the daily mean ζ from its 0.5° × 0.5° spatial mean (averaging over a 0.5° × 0.5° square box). Therefore, ζ′ is a spatial-temporal variable and approximately represents the component of ζ in the 1/48°–0.5° scale range (~2–50 km). Similarly, we can define the submesoscale component for other quantities such as temperature and vertical velocity. In our test, it yields essentially the same results when using 1° instead of 0.5° as the upper bound for defining submesoscales. The vertical heat flux 22.We use the term submesoscale to designate a spatial scale just smaller than the mesoscale: a horizontal scale ≲0.5° in terms of longitude (~50 km at mid-latitudes), roughly below the first deformation radius in most of the global ocean14 (~10–50 km vs ~20–50 km). This powers a stronger global submesoscale field in the 1/48° model , S is the heating source, and –λT is the negative feedback from air–sea heat flux, where λ can be approximated as a positive constant locally59. In the 1/48° model, S is larger due to a stronger incoming submesoscale heat flux from below . In this case for the upper 40 m ocean59, λ is ~15 Wm2/K and C is ~16 × 107 Jm2/K. Therefore, the timescale C/λ is about a few months, which means that the air–sea flux (−λT) can respond to the forcing S by a timescale of months. This is captured in our simulations . The 1/48° model resolves submesoscale instabilities over slightly broader wavelengths than the 1/24° modellow Fig. . From Eq. T Fig. , and henons Fig.  vs 4a suThe instructions and code for running the 1/24° and 1/48° simulations are available by the following websites:http://wwwcvs.mitgcm.org/viewvc/MITgcm/MITgcm_contrib/llc_hires/llc_2160/http://wwwcvs.mitgcm.org/viewvc/MITgcm/MITgcm_contrib/llc_hires/llc_4320/The authors declare that the data supporting the findings of this study are available within the article and its Supplementary Information Files, or from the corresponding authors on request.Supplementary Information