Assertive community treatment for first-episode psychosis programs have been shown to improve symptoms and reduce service use. There is little or no evidence on whether these programs can increase access to income assistance and improve medication adherence in first episode psychosis patients. This research examines the impact of the Early Psychosis Prevention and Intervention Service (EPPIS) on these outcomes.We extracted data on EPPIS patients held in the Data Repository at the Manitoba Centre for Health Policy. The Repository is a comprehensive collection of person-level de-identified administrative records, including data from Manitoba’s health services. We compared income assistance use and antipsychotic medication adherence in EPPIS patients to a historical cohort matched on pattern of diagnosis. Confounders were adjusted through propensity-score weighting with asymmetrical trimming. Odds ratios (OR), hazard ratios (HR) and 95% confidence intervals were calculated.We identified a matched sample of 244 patients and 449 controls. EPPIS patients had a higher rate of income assistance use during the program . EPPIS patients were more likely to have been prescribed at least one antipsychotic medication than the control cohort, both during the program  and after the program ended . Patients in EPPIS were also more likely to adhere to their medication during the program , and after the program .Enrolment in the EPPIS program was associated with increased adherence to antipsychotic medication treatment and improved uptake of income assistance. Early intervention for psychosis and Assertive Community Treatment (ACT) programs have become increasing popular methods in the treatment of psychotic disorders –7. TheseLack of medication adherence among those with psychotic disorders is associated with poorer outcomes –17. ImprThe Early Psychosis Prevention and Intervention Service (EPPIS) was established in Winnipeg, Manitoba, Canada in 2003 as an ACT treatment program for first-episode psychosis patients. This program targets individuals aged 13 to 35 with a recent onset of psychotic symptoms within a single-payer integrated healthcare system with a population of about 650 000 people. Similar to other first-episode programs, EPPIS emphasizes adherence to medication and psychotherapy (including group therapy with family members and other clients), with the goal of promoting and maintaining social connectedness. EPPIS staff also work with guidance counsellors, employers, and other key individuals in the client’s environment, to assist with re-integration of clients into their communities. This may involve community psychoeducation to reduce the stigma of psychotic disorders, and/or developing flexible work and educational environments.Referrals are made directly to the EPPIS program by clinicians, at which time a Mental Health Clinician is assigned. If further follow-up is required, clients are assigned to a psychiatrist within one working day. An initial interview is conducted within 7 days of referral; however, cases considered urgent are seen within 3 working days. Cases of immediate risk are referred to the emergency department or a mobile crisis team. The initial interview is conducted in a non-clinical setting if necessary. At the initial interview, information is collected about basic demographics, personal history and experience, and assessment of general psychiatric symptoms. The Mental Health Clinician assigned at referral remains the clinician throughout the remainder of treatment in the program. Antipsychotic medication is considered a primary form of therapy in this program. However, clients retain the ability to refuse medication and still remain in the program. The program not only treats the individual client but aims to provide support for their family as well.This study used a unique population-based dataset of social and medical records to examine whether EPPIS affected medication use and access to income assistance. The specific outcomes assessed were medication prescriptions received, medication adherence, and receipt of income assistance. We hypothesized that the assertive nature of this program would improve medication outcomes and increase the use of available social assistance programs.This study used data from the PATHS Data Resource in the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy (MCHP). The Repth and 97·5th percentiles to reduce the effect of individuals with extreme weights [A matched-cohort design was used in this study. Individuals enrolled in the EPPIS program were identified using data provided by MATC which was responsible for administrating the program for the period assessed by this study. Individuals with 3+ visits in the program were considered to have been treated by the program. Data were available for the calendar years 2003 to 2012. Controls were then identified through matching for diagnostic pattern of psychotic disorders. EPPIS patients’ records were assessed for two years prior to program entrance for the occurrence of psychosis diagnoses. Matches were required to have received all of the same psychosis diagnosis codes but not have been treated by the program. In order to reduce differences between controls and cases, propensity scores were calculated using logistic regression and conditional probabilities for treatment were derived . These c weights . Trimmin weights . Standar weights . TreatedDescriptive statistics for age, sex, SES (grouped into quintiles), and follow-up length (years) were derived for both cohorts. For those in the program, information on total time in treatment (days) and number of visits to the treatment program were derived T-tests were used to determine if treatment days and visits differed significantly between low (quintiles 1 and 2) and high (quintiles 3–5) income groups.The first outcome was the use of income assistance. A binary variable was derived from these data for each group for the two-year period before treatment, during treatment and for a two-year period following the end of treatment, which identified individuals who were receiving income assistance at some point during those periods. A binary variable for ever being on income assistance after treatment was also derived. Time on income assistance was derived by measuring the years on income assistance per person year.The other outcomes pertained to the use of and adherence to antipsychotic medications (including depot medications) and included any first-or-second generation antipsychotic medications  at any dosage. The DPIN database was the data source for these outcomes We determined (i) whether individuals had ‘received any prescription for an antipsychotic medication’, and ii) whether individuals had ‘antipsychotic medication adherence’; which was defined as having a medication possession ratio  of at least 80% in a year . These oLogistic regression and Cox proportional hazards regression analyses were used to estimate odds ratios (OR), hazard ratios (HR) and 95% confidence intervals (95%CI). Analyses were performed for the treatment period, and during post-treatment. The post-treatment analysis was performed using two methods. First, ORs were determined for a two-year period following discharge from the program. Then HRs were estimated using all available follow-up years for each individual, without restriction to the two-year period. Age was included as a covariate in all of the regression models. Baseline use of income assistance was also included as a covariate for the income assistance analysis. Inverse probability of treatment weighting was applied so that the results would estimate the average treatment effect (ATE). Statistical analysis was performed using SAS 9.3 .Approval was obtained from the University of Manitoba’s Health Research Ethics Board (HREB #: H2011:294) and the Government of Manitoba’s Health Information Privacy Commission (HIPC #- 2013/2014–22). The study used de-identified administrative health data to protect the health information of those in the sample.MATC records contained data on 284 EPPIS patients, and an initial matched control group of 1036 individuals was identified based on diagnostic pattern. Trimming resulted in a sample of 244 cases and 449 controls. See Descriptive statistics on controls and EPPIS treatment group are shown in In this study, we evaluated the EPPIS program for its effect on access to income assistance and medication use and adherence. During and after the EPPIS program, clients were more likely than controls to be receiving income assistance. They were also more likely to be prescribed medication and adhere to that medication. Individuals from high-income areas stayed in the treatment program for a longer time period, but did not make more visits to the program than their lower income counterparts.Previous research on first-episode intervention programs has largely focused on clinical and health service outcomes. Some research has supported these programs as a method of reducing the severity of symptoms during the treatment phase . IndividIn our study, the use of antipsychotic medication was higher in the treatment group and remained higher after clients left the program. This suggests the program was effective in its goal of initiating and maintaining medication adherence. Poor medication adherence is a risk factor for poor prognosis among individuals with psychotic disorders ,16. AdheIndividuals with psychotic disorders not only have issues maintaining employment, but can also experience difficulty accessing social services available to them. The EPPIS program was associated with an increased use of income assistance. Enrolling in income assistance can not only help the patient in maintaining housing and other personal needs, but also improves their ability to adhere to their pharmaceutical treatment.The assessment of length of time treated and number of visits suggests that there could still be health disparity among patients of the program. Because we were unable to find a concurrent sample of controls, we cannot determine whether the program actually reduced disparity by income.The strengths of this study include the use of a large population-based sample, adjustment for a large variety of confounding factors, objective outcome measures, low levels of attrition, and capture of the entire population treated by EPPIS during the study years. These strengths reduce the likelihood of bias due to selection, attrition, or outcome detection (whether outcome events are more/less likely to be detected based on treatment group). We were also able to link the data across multiple sectors  and follow individuals over long periods of time. This improves our ability to control covariates and to detect differences in outcomes.Limitations include the lack of information about specific symptoms experienced by individual patients, both during the initial assessment of these patients and during treatment. This prevents us from adjusting for the severity of illness through the propensity-score weighting. It is possible that patients with more severe psychotic symptoms were more likely to be enrolled in the EPPIS program. This might have been why finding concurrent controls was difficult. Matching was done based on diagnostic patterns in an attempt to reduce the likelihood of there being a bias due to illness type and severity. However residual confounding may still exist. We were unable to find a group of comparable patients for matching in the time frame that EPPIS was operating. This could bias the results through the influence of secular trends, but expert clinicians in the Winnipeg area believe that EPPIS was the only significant change in treatment during this period. Our inability to locate a concurrent sample of controls may be a limitation to the study, but is also a sign that the program was effective at locating and enrolling its target population. Had there been a large number of eligible patients that were missed during the treatment period, then we should have been able to locate them through similarities in their medical records. Income groups were determined based on census dissemination area and are therefore not assessed individually. This reduces the accuracy of the income quintiles with respect to the individuals involved in this study. There was a parallel income assistance program run by the city of Winnipeg until April of 1999. Information on this program and its clients is not available and may be the cause of the initially low levels of assistance for the control group. However, any potential bias in the regression results due to this would be expected to be towards the null. Adherence and medication use measures in the administrative data cannot confirm that medications were taken properly, only that the medications were dispensed to the patients. The use of expensive antipsychotic medications which are covered by income assistance increases the likelihood that those individuals will be on income assistance. This may introduce some confounding for those outcomes.In conclusion, this study showed improvements in the treatment measures that we expected the EPPIS program to affect. This study provides additional support for the adoption of assertive treatment services targeted toward first-psychosis patients.


Most gastrointestinal stromal tumors (GISTs) are caused by activating mutations of the KIT receptor tyrosine kinase. The small molecule inhibitor imatinib mesylate was initially developed to target the ABL1 kinase, which is constitutively activated through chromosomal translocation in BCR-ABL1-positive chronic myeloid leukemia. Because of cross-reactivity of imatinib against the KIT kinase, the drug is also successfully used for the treatment of GIST. Although inhibition of KIT clearly has a major role in the therapeutic response of GIST to imatinib, the contribution of concomitant inhibition of ABL in this context has never been explored. We show here that ABL1 is expressed in the majority of GISTs, including human GIST cell lines. Using siRNA-mediated knockdown, we demonstrate that depletion of KIT in conjunction with ABL1 – hence mimicking imatinib treatment – leads to reduced apoptosis induction and attenuated inhibition of cellular proliferation when compared to depletion of KIT alone. These results are explained by an increased activity of the AKT survival kinase, which is mediated by the cyclin-dependent kinase CDK2, likely through direct phosphorylation. Our results highlight that distinct inhibitory properties of targeted agents can impede antitumor effects and hence provide insights for rational drug development. Novel KIT-targeted agents to treat GIST should therefore comprise an increased specificity for KIT while at the same time displaying a reduced ability to inhibit ABL1. KIT receptor tyrosine kinase are the tumor-initiating event in the majority of gastrointestinal stromal tumors (GIST) [Oncogenic mutations in the s (GIST) . The ress (GIST) . Althougs (GIST) , 3. DissImatinib not only inhibits KIT, but also the activity of other tyrosine kinases, most prominently the BCR-ABL1 fusion oncoprotein and the native ABL1 kinase , 4. BCR-Abl [+ murine leukemia stem cells led to more aggressive disease, enhanced proliferation, inhibition of genotoxic stress-induced apoptosis and increased chromosomal aberrations [The non-receptor tyrosine kinase ABL1 was originally identified as the cellular counterpart to the Abelson murine leukemia virus oncogene v-Abl . NeverthAbl . MoreoveAbl . The rolAbl . Other rAbl . Similarrrations . Moreoverrations , 14. NotHerein, we demonstrate that ABL1 is co-expressed with KIT in the vast majority of GISTs. While this finding could point to a potential contribution of ABL1 inhibition to the therapeutic effect of imatinib treatment in these tumors, our results show that it may indeed have the opposite effect. Silencing of KIT in conjunction with ABL1 led to an attenuation of apoptosis induction and attenuation of cell cycle exit when compared to silencing of KIT alone. Importantly, depletion as well as chemical inhibition of ABL1 resulted in increased AKT S473 survival signaling that was mediated by activated CDK2. Taken together, our results indicate that improved future therapies for GIST may be more effective when not targeting ABL1 in conjunction with KIT.To determine whether ABL1 is expressed in GISTs, we stained imatinib-sensitive  and imatinib-resistant  GIST cell lines for ABL1 by immunoblotting in comparison to untransformed normal human fibroblasts , age  or gender . There was a weak correlation between ABL1 and KIT expression levels (correlation coefficient r = 0.354).Patient characteristics are shown in Table Taken together, ABL1 is co-expressed with KIT in the majority of GISTs. Because imatinib inhibits both, inhibition of ABL1 could contribute to the therapeutic effect of imatinib treatment of GIST.Having shown that GISTs express both KIT and ABL1, we aimed to assess their relative contributions to GIST cell proliferation and/or survival. siRNA-mediated knockdown of either KIT or ABL1 in GIST882 cells was used to mimic single inhibition of either of these proteins. In analogy, a combined knockdown of both KIT and ABL1 mimicked imatinib treatment.p < 0.0001) and increased apoptosis  when compared to transfection with non-targeting siRNA control in luminescence-based assays. By contrast, siRNA-mediated knockdown of ABL1 showed little to no effect on GIST882 proliferation or apoptosis .siRNA-mediated knockdown of KIT and ABL1 occurred within 24 to 48 hours of transfection in both single and combination experiments Figure . As expep < 0.02) and a strong trend towards a reduced induction of apoptosis (p < 0.08). Similar results were seen in a time course experiment over 72 hours when using the TUNEL assay for readout .To our surprise, depletion of KIT and ABL1 in combination did not lead to an increased effect when compared to depletion of KIT alone, but rather to a significantly attenuated reduction of cellular proliferation .Moreover, we could show that combined silencing of KIT and ABL1 resulted in a significantly attenuated increase of the sub-G1 fraction detected by flow cytometry when compared to silencing of KIT alone  or indirectly  involved in AKT dephosphorylation were detected after ABL1 knockdown Figure . TogetheA recent study reported that the cyclin-dependent kinase CDK2 has the capability to directly phosphorylate AKT thereby enabling its full activation . CDK2 acWe first tested whether siRNA-mediated knockdown of ABL1 leads to increased CDK2 activity. Indeed, silencing of ABL1 alone or in combination with siRNA-mediated knockdown of KIT resulted in increased levels of CDK2 that is phosphorylated at T160 Figure . SimilarTo test whether CDK2 could be directly responsible for the increased levels of AKT phosphorylation after functional loss of ABL1, we reduced CDK2 expression levels through siRNA-mediated knockdown alone or in combination with ABL1. As shown in Figure Taken together, a reduced ABL1 inhibitory capacity is likely beneficial for the effectiveness of KIT inhibitors in the treatment of GIST.KIT secondary mutations and likely also their broader kinase inhibitory spectrum, a reduced ability to inhibit ABL1 could be of additional benefit, as stated above.The multi-kinase inhibitors sunitinib and regorafenib are currently the only FDA-approved second- and third-line therapies for imatinib-resistant GIST, respectively . While tin vitro kinase assay to circumvent any unspecific phosphorylation that could be due to KIT activity in GIST cells  chromosomal translocation, is almost exclusively expressed in CML. By contrast, the native, non-translocated ABL1 kinase is a ubiquitously expressed protein. It is therefore conceivable that inhibition of ABL1 could contribute to the therapeutic effect of imatinib GIST. In the present study, we could show that ABL1 is indeed co-expressed with KIT in the majority of GISTs, including human GIST cell line models. However, co-depletion of KIT and ABL1 using siRNA-mediated knockdown – thus mimicking treatment with the KIT/ABL1 inhibitor imatinib – led to attenuated pro-apoptotic and anti-proliferative responses when compared to depletion of KIT alone. This effect was mediated, at least in part, by a novel mechanism that involves direct phosphorylation of the AKT survival kinase by the cyclin-dependent kinase CDK2.The majority of gastrointestinal stromal tumors is characterized by oncogenically activating mutations of the + murine leukemia stem cells led to more aggressive disease, enhanced proliferation, inhibition of genotoxic stress-induced apoptosis and increased chromosomal aberrations [Abl1−/− cells responded to the induction of ER stress with the induction of apoptosis [Our results may seem surprising, because the ABL1 kinase is often viewed as an oncoprotein that is driving proliferation and the evolution of a malignant phenotype. However, most of this notion stems from studies of the BCR-ABL1 fusion oncogene. By contrast, the native ABL1 protein kinase is a negative regulator of the cell division cycle . Early srrations . These frrations . Therefopoptosis . Similarpoptosis . Interespoptosis . It is tAbl−/− mouse embryonic fibroblasts (MEFs) with wildtype MEFs [We show here that depletion as well as inhibition of ABL1 leads to activation of the AKT pro-survival pathway. These results explain why co-depletion of KIT and ABL1 has an attenuated effect on apoptosis induction and inhibition of proliferation when compared to depletion of KIT alone. Interestingly, dissecting the mechanism of action leading to AKT S473 phosphorylation after functional loss of ABL1 showed that this effect was neither mediated by PDK1, the upstream activating kinase of AKT, nor by signaling cascades that regulate desphosphorylation of AKT. Instead, we found that AKT phosphorylation was mediated through the cyclin-dependent kinase CDK2. It is well-documented that CDK2 is negatively regulated by ABL1 . ABL1 isype MEFs . Our resype MEFs . This phype MEFs .+/CD38+). Similar results were noted by Belloc et al. when testing primary CD34+ CML cells [A recent report by Corbin et al. addressed a similar topic as our study . While wML cells . These fML cells . This efML cells . It is tin vitro kinase assay  and GIST-T1  were derpression . All celK562, a BCR-ABL1-positive chronic myelogenous leukeumia cell line, as well as the SK-UT1, SK-LMS leiomyosarcoma cell lines were obtained from ATCC and not further authenticated. Normal human dermal fibroblasts were obtained from Lonza and not passaged for longer than six months. All cells were maintained according to manufacturer's recommendations.For inhibitor treatments, cells were incubated in imatinib mesylate , the allosteric ABL1 inhibitor GNF-2 , the PDK1 inhibitor OSU-03012  or mock-treated with 0.1% DMSO for up to 72 hours, as indicated.6 cells were transfected with 5 μl of 10 μM annealed RNA duplexes using nucleofection (Amaxa/Lonza). Cells were then transferred to 35 mm tissue culture dishes with 2 ml RPMI1640 free of antibiotics and incubated for up to 72 hours. Knock-down efficiency was monitored by immunoblotting.For small interfering RNA (siRNA) experiments, pooled synthetic RNA duplexes  were used to reduce protein expression of KIT, ABL1 or CDK2 alone or in combination. Briefly, cells were trypsinized, and 3 × 10Fresh GIST tissue was collected from patients undergoing tumor resection at the University of Pittsburgh School of Medicine Presbyterian Hospital (IRB#0509050). The tissue was fresh frozen and protein extracts were prepared as described previously .For the tissue microarray, a total of 28 cores from primary and metastatic GISTs and seven controls (liver) were collected from the archives of the Department of Pathology at the University of Pittsburgh School of Medicine (IRB#0509050) .Protein lysates of cells growing as a monolayer were prepared as described previously . ProteinImmunohistochemistry of paraffin-embedded sections was performed as described previously . AntigenPrimary antibodies used for immunoblotting and immunohistochemistry were ABL1, CDK2, pTyr , actin (Sigma), pABL1 Y412, pAKT S473, AKT, pCDK2 T160, cleaved caspase 3, pCRKL Y207, CRKL, pKIT Y719, pMAPK p42/44 T202, pPDK1 S241, PDK1, PP2A, pS6K T389, S6K , CIP2A, PHLPP, SET , cyclin A (Novocastra), KIT (DakoCytomation) and MAPK (Invitrogen/Thermo Fisher Scientific).Apoptosis and cell viability studies were performed using the Caspase-Glo and CellTiter-Glo luminescence-based assays (Promega) . Cells wApoptotic cells were detected using the TUNEL assay (Roche) according to manufacturer's recommendations as described previously .2, 10 μg/ml RNase) and incubated at 37°C in the dark for 30 min. The analysis was performed in the University of Pittsburgh Cancer Institute Flow Cytometry Core Facility using a Gallios Flow Cytometer (Beckman Coulter) and the Kaluza 5 acquisition software.Cell cycle analysis was performed by measuring the amount of propidium iodide (PI)-labeled DNA in ethanol-fixed cells. In brief, cells were harvested by trypsinization, washed twice with pre-chilled PBS (containing 1% FBS), and fixed with ice-cold 70% ethanol. After the fixation step, cells were washed with PBS/1% FBS, resuspended in propidium iodide /RNase staining solution  and recombinant CRKL protein  as a substrate in 20 μl kinase buffer  containing 100 μM ATP. The reaction was incubated for 30 minutes at 30°C, stopped by adding loading buffer with β-Mercaptoethanol and heating the sample at 95°C. Proteins were separated by SDS-gel electrophoresis, and phosphorylation of ABL1 and CRKL was assessed by immunoblotting for phosphorylated tyrosine , phospho-ABL1 Y412 and phospho-CRKL Y207 . Antibodies against total ABL1 and total CRKL were from Santa Cruz and Cell Signaling, respectively. Band intensity was measured using LI-COR Image Studio Lite (LI-COR).A non-radioactive t-test, ChiSquare test, Fisher Exact Probability test or ANOVA analysis wherever applicable . P-values of p ≤ 0.05 were considered statistically significant.Statistical significance was assessed using the Student's


In-person and phone interviews were conducted with pharmacy stakeholders in Saskatchewan and across the country. (3) Results: Of the 265 students, 193 (72.8%) were present on the days the questionnaires were distributed, and they all completed the questionnaires. When asked if they would have pursued a combined degree if the U of S had offered it when they entered the pharmacy program, 16.6% (32/193) and 37.3% (72/193) either strongly agreed or agreed and 29.0% (56/193) were unsure. When pharmacists were asked if an MBA would be valuable or applicable in their current job, 42.2% (128/303) agreed and 13.9% (42/303) strongly agreed. When asked if they felt students graduating with a combined degree would be at an advantage for certain job opportunities upon graduation, 33.6% (100/298) strongly agreed and 55.4% (165/298) agreed. A total of 8 interviews were conducted with key stakeholders from across Canada. Of these 8 stakeholders, only 2 were aware that other combined programs were offered. All of the stakeholders were in favour of the idea of a combined degree. Some felt it was important for the program to have a clear value proposition and healthcare related content would be desirable. (4) Conclusions: Overall, pharmacist, pharmacy student, and stakeholder input indicate that a combined program could be supported at the University of Saskatchewan.(1) Background: Combined MBA programs are becoming increasingly popular, and it is anticipated that there will be 60 combined pharmacy–MBA programs across North America in 2015. We aimed to see if there would be support for a combined PharmD–MBA program at the University of Saskatchewan. (2) Methods: A questionnaire was distributed to 1st, 2nd, and 3rd year pharmacy students at the University of Saskatchewan. A separate questionnaire was developed and all practicing pharmacists in Saskatchewan were emailed a link to SurveyMonkey Pharmacy programs offered by Canadian schools are focused on producing high quality pharmacists with strong clinical skills. These clinical skills help manage decision-making processes in order to support therapeutic decisions in the best interests of the patient. However, not all pharmacists pursue careers in direct patient care. Many go on to have administrative positions in large teaching hospitals, work in the pharmaceutical industry, or own their own businesses. Intertwined throughout pharmacy programs are management or business classes, with the intent of providing some exposure to the business of pharmacy prior to entering the profession. However, business and management exposure is typically limited in pharmacy schools .A Master of Business Administration (MBA) is designed to help people develop the skills necessary to be successful in business. Combining an MBA with another degree is attractive for a number of reasons. The business skills learned in an MBA program complement the skills learned in one’s chosen profession so as to provide individuals with the greatest chance of having successful careers. Having both a pharmacy and MBA degree is considered desirable for those looking to work in academia, the pharmaceutical industry or large institutional settings . WhereasThroughout the past couple of decades, combined MBA degrees have increased in popularity. Between 1993 and 2001 the number of MD/MBA programs in the USA grew from 6 to 33 , and as Although the number of combined MBA programs is increasing and seemingly aligns with the vision of creating leaders in respective professions, to our knowledge, there has never been an assessment of the demand for combined pharmacy–MBA degrees. The merits and demands for MBA degrees across all fields have been debated in today’s business environment ,10,11. OSimilar to other pharmacy schools across Canada, the College of Pharmacy and Nutrition, University of Saskatchewan is currently undergoing curriculum change as it moves towards offering a PharmD as a first-degree program. As other Canadian pharmacy schools currently offer a combined pharmacy–MBA degree, this study aimed to determine if the pharmacy community felt it was worthwhile for the University of Saskatchewan to offer a combined PharmD–MBA program.A brief questionnaire was developed to determine pharmacy students’ awareness of MBA programs, and if they would have pursued a combined pharmacy–MBA degree if the opportunity had been offered to them. A hard-copy questionnaire was distributed to the 1st, 2nd, and 3rd year pharmacy students at the beginning of one of their lectures (4th year students were away on rotations). The questionnaire consisted of 12 questions which were either yes or no questions or utilized a 5-point Likert-scale where students were instructed to respond if they strongly agree, agree, disagree, strongly disagree, or were unsure. Students also had the ability to provide comments at the end. All questionnaires were completed between 24 March and 7 April 2015, and were completely anonymous with no means of identifying respondents.®. A notice for the study was emailed to all practicing pharmacists for whom the Saskatchewan College of Pharmacists has an email address. The initial email was sent 8 April 2015, and a follow-up email was sent 17 April 2015. The study was closed to responses 6 May 2015.A brief questionnaire was developed to determine the opinions of practicing pharmacists in Saskatchewan regarding their assessment of business preparedness and the value of an MBA degree. The questionnaire consisted of 10 questions, plus the ability to provide comments at the conclusion of the questionnaire. These questions utilized a 4-point Likert scale, where pharmacists were asked to respond if they strongly agreed, agreed, disagreed, or strongly disagreed. This was an online questionnaire available for completion through SurveyMonkeyPhone and in-person interviews were conducted with a few key pre-selected pharmacy stakeholders to determine their familiarity with and opinions on a combined pharmacy–MBA program. These interviews were performed by the same interviewer between 19 March and 6 April 2015. Interviews were semi-structured and consisted of 8 questions. These interviews were assessed by two separate reviewers.Basic descriptive statistics were performed for the questionnaires. An ethics exemption was granted by the University of Saskatchewan’s Behavioral Research Ethics Board.There are 265 pharmacy students in first, second, and third year at the College of Pharmacy and Nutrition, University of Saskatchewan (U of S). Not all students were present on the day the questionnaires were distributed, and overall 193 (72.8%) completed the questionnaires.The majority of students  reported that they did not have a previous business degree, and only 4.7% (9/193) have owned or managed a business in the past. Upon graduation, 12.4% (24/193) and 37.8% (73/193), respectively, strongly agreed or agreed that they were interested in owning a pharmacy upon graduation, and 32.1% (62/193) indicated they were unsure. The remaining 17.6% (34/193) either strongly disagreed or disagreed they were interested in owning a pharmacy. Similarly, 11.4% (22/193) and 42.0% (81/193) indicated they strongly agreed or agreed that they were interested in pursuing a career in management, whereas 30.6% (59/193) indicated they were unsure. The remaining 16.1% (31/193) either strongly disagreed or disagreed they were interested in pursuing a career in management.When asked if students felt their education prepared them for management or ownership positions, 42.0% (81/193) disagreed, 8.8% (17/193) strongly disagreed, 31.1% (60/193) were unsure, and 17.6% (34/193) and 0.5% (1/103) respectively either agreed or strongly agreed. 50.8% (98/193) felt an MBA would help them in their future career, whereas 11.4% (22/193) disagreed and 37.3% (72/193) were unsure.Only 6.2% (12/193) of students were familiar with other Canadian pharmacy schools that offered combined pharmacy–MBA programs, and only 2.6% (5/193) of students were familiar with pharmacy schools in the United States of America that offered combined programs. When asked if they would have pursued a combined degree if the U of S had offered it when they entered the pharmacy program, 16.6% (32/193) and 37.3% (72/193) either strongly agreed or agreed. 29.0% (56/193) were unsure, and 10.4% (20/193) and 5.7% (11/193) disagreed and strongly disagreed respectively. Upon graduation, 3.1% (6/193) and 11.9% (23/193) strongly agree or agree that they are interested in pursuing an MBA degree, whereas 31.6% (61/193) are still unsure.The online survey was emailed to 1529 practicing pharmacists in Saskatchewan; 304 completed the questionnaire for a 19.9% response rate. The majority of respondents identified themselves as staff community pharmacists  and having graduated more than 10 years ago . A complete list of pharmacist demographics is described in Most respondents strongly disagreed  or disagreed  that they were prepared business-wise for their career as a pharmacist upon graduation. When asked if an MBA would be valuable or applicable to their current job, 42.2% (128/303) agreed, 13.9% (42/303) strongly agreed, and 35.6% (108/303) and 8.3% (25/303) either disagreed or strongly disagreed, respectively.When asked if they would have been interested in pursuing a combined pharmacy–MBA degree if it had been offered when they were students, 17.6% (53/301) strongly agreed and 39.5% (119/301) agreed . When asA total of 8 interviews were conducted with representatives from pharmacy advocacy and regulatory bodies, large institutional  settings, and large retail chains. Participants were intentionally chosen from varied settings to obtain a broad spectrum of responses; to ensure individual identities are not revealed, all results are presented in aggregate. Thematic analysis and a full qualitative assessment were not performed, as these interviews were simply meant to get a feeling of acceptance or reluctance with respect to the introduction of a combined pharmacy–MBA program.To begin, these 8 stakeholders were asked if they were aware of any currently offered combined programs in either Canada or the USA. Of them, 2 were aware that other combined programs were offered. When asked, in general, if they felt a combined program was a good idea, all participants indicated yes. Some were emphatically in favour, whereas others felt there should be qualifiers, such as the number of students enrolled, and that it should not detract from patient care.All of the stakeholders were in favour of the idea of a combined degree. However, 2 respondents wanted to make sure it had a clear value proposition for students and the College of Pharmacy and Nutrition. Further, one respondent felt the number of students allowed to do a combined degree should be limited, and one person wanted to see a program that was affordable. It was also mentioned by one respondent that it should be differentiated from other Canadian schools offering a combined program, and another respondent mentioned that the combined program should bring value to the students and not be just a token add-on program. Overall, the idea of a combined degree was supported, with an overarching sense that it should bring value to the students enrolled.When asked which type of students they felt would benefit from a combined degree, the majority indicated them to be those looking at ownership or any senior management position. It was mentioned by 2 respondents that higher level positions within large companies and large healthcare institutions now often require an MBA, and that senior level positions would no longer be attainable without one. Respondents also expressed that those entering academia, advocacy organizations, the pharmaceutical industry or doing policy analysis would benefit from a combined degree as well. One respondent felt that any pharmacist would benefit, as there are skills learned in the MBA program that will help make people successful regardless of their position.Several respondents expressed that pharmacy is only one small piece of the healthcare system, and if pharmacists are to play a larger role, it is vital to understand the business of healthcare and how pharmacists fit in. Numerous respondents mentioned that ‘pharmacy’ is often on the outside looking in, and that pharmacy leaders with business acumen are needed to understand the broader context of health care  and that would be the value of an MBA to pharmacy. When asked if they were able to have any input into the design of the MBA program, the majority of respondents expressed they would like to see some business-course content which is health care related.Finally, when asked from a high-level view if a combined program is something the College of Pharmacy and Nutrition should consider as they undergo a transition to the PharmD program, all of the respondents indicated yes.Combined MBA programs are increasing in popularity and are already offered at two pharmacy schools in Canada. With the College of Pharmacy and Nutrition undergoing curriculum redesign towards a PharmD as a first-degree, the timing is ideal to evaluate whether a combined PharmD–MBA program could be supported at the University of Saskatchewan.The results of the student and pharmacist questionnaires indicate that there is a level of demand for a combined PharmD/MBA program. When asked if they would have pursued a combined pharmacy–MBA degree had it been offered to them, 54% of pharmacy students and 58% of pharmacists either agreed or strongly agreed. Granted, this amount would not be expected to actually apply for a combined program, but this does indicate some level of interest on behalf of both future and present pharmacists. From a stakeholder perspective, it was felt that the College of Pharmacy and Nutrition should entertain looking into a combined degree. The responses from these 3 groups are important for program planners and developers, as it is the only known published assessment of demand that we are aware of.It is important to examine the number of applicants when considering how many students a combined degree program may be able to accommodate. The combined program at the University of Alberta has had 4 students go through the program since 2012, and although the University of Toronto had 5 applicants in its inaugural year, it has not had any students complete the combined program to date . A 2014 graduation survey of pharmacy students in the USA showed that 2% (191/9524) of students graduated with a combined PharmD–MBA degree [Overwhelmingly, there was very little knowledge of combined pharmacy–MBA programs with current pharmacy students, pharmacists, and key stakeholders alike. Further, current pharmacists were generally not familiar with the MBA program at the University of Saskatchewan. This is significant as the College of Pharmacy and Nutrition accepts a significant proportion of its students from both in-province and out of province. Hence, creating awareness and marketing a combined program will become a key factor for any school looking to attract potential applicants. Another important consideration is the financial cost of a combined program for students, and hence it was identified that it is important to have scholarships in place for prospective students so that the tuition amount is not a significant burden when attracting applicants .Currently available pharmacy–MBA combined programs are diverse in nature, and provide business-development opportunities for a limited number of students per year. At the University of Alberta, students take time off between 3rd and 4th year pharmacy to enroll in the MBA , and UniWith partnerships already established with the College of Medicine and Western College of Veterinary Medicine, the Edwards School of Business is presented an opportunity to offer classes that may be focused on health care administration, particularly as there is still significant interest from current pharmacists in the traditional MBA program as evidenced by our survey results and the number of pharmacists currently enrolled in the MBA program at the University of Saskatchewan. Some external stakeholders felt it was important for a combined PharmD–MBA to have healthcare-related content within the MBA program, and hence this could be seen as an opportunity for the University of Saskatchewan to differentiate itself from the other Canadian schools that either currently offer a combined program or are in the contemplation stage.Finally, around 50% of pharmacy students indicated they are either interested in owning a pharmacy upon graduation or interested in a career in management. These are the positions many stakeholders felt would most benefit from an MBA degree, and this aligns with the skills MBA programs are trying to develop. Just over half of all pharmacists who responded to our questionnaire felt that an MBA degree would be valuable to their current job, which is significant given that over half of all respondents identified as staff pharmacists not in managerial positions. Combined with the fact that nearly 90% of pharmacists indicated that those students graduating with a combined degree would be at an advantage for career opportunities, this indicates some degree of value which pharmacists place on an MBA degree and how it aligns with pharmacy careers.The questionnaires distributed were to Saskatchewan students and pharmacists only, hence it is unknown how applicable these results are outside of this province. Also, just less than 20% of all Saskatchewan pharmacists completed the online questionnaire, and so the results are not totally representative of all Saskatchewan pharmacists. Further, although pharmacy students showed significant interest in a combined program, the questions were theoretically based, and it is unknown if interest in a program would translate into actual applications.The interviews conducted were only with a select number of key stakeholders identified by the researchers, and hence not representative of all stakeholder groups. This could also lead to selection bias. Although there was unanimous support from a high-level overview, it would be appropriate to re-engage these groups as well as a broader scope of stakeholders once program specifics were developed.Overall, pharmacist, pharmacy student, and stakeholder input indicate that a combined program could be supported, and the program could likely accommodate a small number of students per year. In order to extrapolate these findings to other pharmacy schools across Canada, each of the other schools should perform their own analysis to determine if pursuing a combined degree is something they want to consider.


Plasmodium falciparum (Pf)-specific T- and B-cell responses may be present at birth; however, when during fetal development antibodies are produced is unknown. Accordingly, cord blood samples from 232 preterm (20–37 weeks of gestation) and 450 term (≥37 weeks) babies were screened for IgM to Pf blood-stage antigens MSP1, MSP2, AMA1, EBA175 and RESA. Overall, 25% [95% CI = 22–28%] of the 682 newborns were positive for IgM to ≥1 Pf antigens with the earliest response occurring at 22 weeks. Interestingly, the odds of being positive for cord blood Pf IgM decreased with gestational age ; however, preterm and term newborns had similar levels of Pf IgM and recognized a comparable breadth of antigens. Having cord blood Pf IgM was associated with placental malaria (adjusted OR [95% CI] = 2.37 [1.25–4.54]). To determine if in utero exposure occurred via transplacental transfer of Pf-IgG immune complexes (IC), IC containing MSP1 and MSP2 were measured in plasma of 242 mother-newborn pairs. Among newborns of IC-positive mothers (77/242), the proportion of cord samples with Pf IC increased with gestational age but was not associated with Pf IgM, suggesting that fetal B cells early in gestation had not been primed by IC. Finally, when cord mononuclear cells from 64 term newborns were cultured in vitro, only 11% (7/64) of supernatants had Pf IgM; whereas, 95% (61/64) contained secreted Pf IgG. These data suggest fetal B cells are capable of making Pf-specific IgM from early in the second trimester and undergo isotype switching to IgG towards term. Plasmodium falciparum (Pf) antigens (Ags) that cross the placenta. Pf-infected erythrocytes (iE), DNA and/or soluble parasite proteins have been detected in umbilical cord blood samples of <1% to 55% of newborns in sub-Saharan Africa  was 1.7% [0.6–6.1%] for preterm and 1.0% [0.3–3.4%] for term mothers, p = 0.042), suggesting that maternal malaria contributed to preterm births. Other maternal factors associated with preterm delivery were younger maternal age  of Cameroonian newborns were IgM positive for MSP1-FVO, 8% (5–9%) for MSP1-3D7, 18% (15–21%) for MSP2-FC27, 17% (15–21%) for MSP2-3D7, 6% (4–8%) for AMA1, 7% (6–9%) for EBA175 and 9% (7–11%) for RESA. Overall, 169/682, i.e., 25% (22–28%) had IgM to one or more Pf Ags.As expected, some Cameroonian newborns had IgM to Pf Ags , indicatTo confirm the IgM responses were Pf Ag-specific, cord plasma from 45 newborns who tested positive for IgM to MSP1-FVO were re-screened for IgM to an irrelevant Ag (BSA) and a viral pathogen (DENV) that is uncommon in Yaoundé, Cameroon  and doesStratification of the IgM response by GA showed a strong trend for a decrease in the proportion of IgM+ newborns with increasing GA, i.e., the highest percentage of Pf IgM+ were in the extremely preterm, followed by very preterm, moderate to late preterm, and term newborns . The proSince the overall B cell repertoire increases during fetal development, the number of Pf Ags recognized with increasing GA was evaluated . Among tIn summary, these data demonstrate that preterm fetuses can produce similar amount of IgM to as many Pf Ags as term fetuses. Interestingly, the proportion of IgM responders to at least one Pf Ag significantly decreased with GA.Plasma samples from 242 mother and neonate pairs were tested for IC containing MSP1 and IC containing MSP2. Overall, 77/242 mothers (32%) had MSP1or MSP2 IC. Since these mothers had the potential of transferring IC to their fetuses, cord IC data from newborns of IC+ mothers were analyzed in relation to GA . ResultsTo determine which factors were associated with presence of IgM to Pf Ags in cord blood, a logistics model was employed comprising the variables GA, PM status, presence of IC, and maternal anemia (which was associated with breadth of the IgM response) . In the in vitro IgM levels correlated with the plasma IgM levels  supporting the conclusion that IgM in cord plasma was produced by B cells of fetal origin. No significant difference in the proportion of in vitro cultures containing Pf IgM or IgG was found between neonates of PM+ and PM–mothers. The finding of Pf IgG responses in newborns of PM–mothers shows that some of the women that were negative for Pf at delivery had been infected during pregnancy and their fetuses were exposed to Pf in utero.When CBMC from 64 Cameroonian term newborns  women in high transmission areas test positive for Pf in peripheral blood smears an average of 4–5 times during the second and third trimester , ii) iE in utero exposure to Ag. However, IgM in some exposed fetuses may have waned just before delivery, thus the actual prevalence of fetal IgM+ could be higher than 25%. Samples from MSP1 IgM+ newborns did not react with Ags such as BSA and DENV that the newborns were unlikely to be exposed to in utero  were usarasites  reportedMaternal anemia was associated with increased breadth of Pf IgM independently of GA. Maternal anemia has previously been linked with higher placental weight to birth weight ratios ,72, meanin utero exposure to Pf occurring from this early age can elicit a B-cell response. However, 22 wks may not be the earliest time point because only one newborn in this study was younger (20 wks) and babies born before 20 wks were excluded from the study. Because, Pf iE begin sequestrating in the IVS from ~12 wks and fetal spleens are seeded with B cells over the next 2 months, it is plausible that Pf IgM would be produced by some fetuses aged 14–20 wks.Pf IgM was detected in cord plasma from 22 weeks of gestation through term, demonstrating that in vitro experiments  SPs. Gel C shows one (SP8) of the two SPs that were not informative after genotyping of all three VNTR loci .Bands represent peripheral maternal blood (M) and cord blood (C) VNTR alleles for mother-stillborn sample pairs (SP). Eight SPs  are represented. (TIF)Click here for additional data file.S1 File(XLSX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Twice-daily caregiver-supervised toothbrushing with fluoridated toothpaste is an effective and widely recommended strategy to prevent tooth decay in children. Qualitative research suggests that low-income caregivers know the recommendation but would benefit from toothbrushing supplies and advice about how to introduce this health behavior especially as the child becomes older and asserts autonomy to do it “myself.” Our objective is to assess consumer satisfaction with the evidence-based theory-informed campaign and usefulness of materials that were home delivered. The focus of the evaluation was families with children <36 months of age because of the high incidence of disease in this population.Everybody Brush! in three counties of Central Oregon. Participants were families of Medicaid-insured children <21 years of age. Participants were randomly assigned to one of the three study groups: test , active (supplies), and a waitlist control. Program materials were in English and Spanish. Caregivers of children <36 months were interviewed at the beginning and end of the program.A dental care organization designed and implemented A total of 83,148 toothbrushing kits were mailed to 21,743 families. In addition, 93,766 printed messages and 110,367 recorded messages were sent to half of the families. Caregivers were highly satisfied. On a global rating scale from 0 to 10 (worst to best program possible), they rated the program 9.5 on average . On a scale from 0 to 10 , mean ratings for usefulness of the toothbrushing supplies was 9.5 (SD = 1.5), for the printed postcard messages was 7.2 (SD 3.6), and for the voice telephone messages was 6.5 (SD 3.9).Everybody Brush! program and toothbrushing supplies were considered the most useful, followed by printed messages. Voice telephone messages were rated least useful. Further evaluation of the impact of the program on toothbrushing behavior and dental-care utilization is underway.A dental care organization carried out a complex community intervention designed to address excess tooth decay among low-income children. Caregivers were highly satisfied with the  Widespread availability of fluoridated toothpaste is one reason the U.S. has seen a decline in tooth decay over the past several decades. Regular brushing with fluoridated toothpaste maintains a low level of fluoride in the saliva. The fluoride helps repair tooth surfaces demineralized by acid by-products from the dietary sugar metabolism of bacteria that colonize the teeth . EvidencBarriers to putting the toothbrushing recommendation into practice, especially for parents with limited access to pediatric dental care, include parents’ uncertainty about when to initiate brushing, the cost of toothbrushing supplies, and children’s resistance to brushing . The U.SOutside of the U.S., toothbrushing campaigns with free distribution of toothpaste and toothbrushes—at a child health visit and by mail—have showed positive effects on parents’ behaviors. Parents who participated in such a campaign, compared to those who did not, were significantly more likely to report twice-daily toothbrushing of their children . When acMobile health  is a logical approach to deliver health education and services. Because of its wide reach, small investment on time and money on the part of participants, mHealth is suitable to accompany broad-based public health campaigns. Most mHealth interventions for behavior change have focused on general health and well-being related behaviors such as parenting skills, physical activity, smoking cessation, sunscreen use, prevention of sexually transmitted diseases and diabetes , most ofvia text or video trough mobile phones  enrolled in Medicaid and assigned by the State of Oregon to a single dental care organization  who resided in the three largely rural counties in Central Oregon . The counties, served by the Pacific Source Community Solutions Coordinated Care Organization, are part of a statewide Center for Medicaid and Medicare Transformation Project that provided the majority of the funds for the evaluation of the project. Medicaid enrollees represent 12–19% of all children ages 1 to <21 years old in these three counties. The median per capita annual income across the counties is US$50,000 to $60,000. Most homes are served by public water systems without fluoridation. The dental care organization has primary care dentists in individual rural practices and clinics throughout the three-county area.Everybody Brush! reflected theories of behavior change and foci for behavioral change interventions, including those described by Fishbein et al.  and one “cling sheet” that could be affixed to a mirror or other smooth surface. The toothbrushing supplies were 7 tubes of fluoridated toothpaste (0.85 oz.), 3 adult-size toothbrushes, 1 toothbrush each for a child ages 4–24 months, 2–4 years, and 5–7 years. The cling sheet contained instructions to brush twice a day with an age-appropriate amount of fluoride toothpaste depicted by illustration as well as information about how to request additional supplies. Instructional materials were provided in both English and Spanish and were written at 6th-grade reading level.via automated telephone calls and printed messages were delivered via mailed postcards every 2 weeks for 9 months, so that the voice and print messages were intercalated. The messages were written to reflect universal health literacy considerations  culturally competent staff members trained in oral hygiene and behavioral change techniques were available to support families who used the help line to ask for additional support.For purposes of evaluation, participants were assigned to one of three study groups: a test, an active, and a waitlist control. The test group received the toothbrushing supplies, the voice and printed messages, and the telephone support. The active control group received only the toothbrushing supplies and the waitlist control group did not receive supplies or messages and were placed on a waiting list to receive the supplies after the end of the evaluation period.Participants who met the inclusion criteria were randomly allocated to the groups using a computer-generated allocation schedule. First, we randomly allocated the 450 families with children less than 36 months who participated in the baseline interview to the three groups: test, active control, and waitlist control. We then randomly allocated with equal probability the remaining families to one of two groups: test or active control. The final sample size per group was 10,797 families in the test group, 10,796 in the active control group, and 150 in the waitlist control group.Caregivers of children less than 36 months of age were invited to participate in an interview before the implementation of the intervention. A list of the families meeting the inclusion criteria was randomly ordered and the caregivers were telephoned and invited to participate in an interview. Invitations were made until 450 caregivers agreed to participate. After the interview, the families were randomly assigned to one of the three groups. At the end of the intervention period, the same caregivers were re-contacted and invited to participate in an exit interview.Data were collected through telephone interviews conducted by bilingual staff  from the customer service department of the dental care organization before the start of the intervention (baseline) and after the intervention period (exit interview). At least five attempts were made to reach the caregiver. Interviewers were unaware of caregivers’ group assignment.Everybody Brush! program were collected using a single question in which the caregiver was asked to rate the program on a scale from 0 to 10, from worst to best program possible. Additionally, caregivers were asked if they and their children used the toothpaste and toothbrushes from the kit and if they received the print and voice messages. Usefulness of these sets of materials were assessed on a 11-point scale (0–10) from not at all useful to very useful in three questions: toothbrushing supplies, printed postcards messages, and voice telephone messages. The interview concluded with an open-ended question asking if there were anything to note about their feelings about the Everybody Brush! program.Data on overall satisfaction with the Descriptive statistics were used to describe implementation process, participants’ characteristics, and perceptions of the program. Continuous variables were expressed as means and categorical variables as frequencies and percentages. We compared caregivers’ ratings and reported use of the different program elements between the test and active control groups using Wilcoxon Rank Sum tests for continuous variables and Chi-square and Fisher exact tests for categorical variables at a statistical significance level of 0.05.Everybody Brush! was implemented over a 9-month period from August 2014 through April 2015. The project manager from the dental care organization purchased the supplies from the toothbrush and toothpaste manufacturer and contracted with an outside fulfilment company to store, assemble, address, and mail toothbrush kits.via automated telephone calls and 93,766 printed postcards via mail. The toothbrushing kits were sent in August and November 2014 and February 2015. Postcards and telephone messages were delivered through April 2015. The helpline and other telephone service to request additional supplies were available throughout the intervention period from August 2014 through April 2015.Over the course of the intervention, 83,148 toothbrushing kits were mailed to 21,743 families. The group of 10,797 families assigned to receive additional support (the test group) were sent a total of 110,367 pre-recorded voice messages The overall direct cost of the intervention, exclusive of costs to design and evaluate the program, was US$ 42.50 per family in the test group and US$ 37.62 per family in the active control group over the 9 months. With about four Medicaid enrolled children per family, the cost per child ranged roughly from $9.41 to 10.60 per child per year. The overall cost includes the cost of the materials, fulfillment, freight, and postage of the toothbrush kits and graphic design and printing of the cling sheet. Additional costs for the test group include graphic design and printing of postcards, telephone messaging charges, and support for the advice line. For the test group, costs were US$ 5.41 per family for printing, addressing and mailing of postcards and US$ 1.48 per family for the telephone calls for the recorded voice messages. These costs do not include internal company resources required to establish and administer the program.Of the subsample of 450 caregivers who interviewed at baseline, 223 (49.6%) completed the final interview. At the time of the final interview, 33% of children were 1 year old, 37% were 1 to 2 years old, and 30% were 3 years old. Caregivers interviewed were fairly typical of the Medicaid client population in Oregon: 26% of caregivers had less than a High School (HS) diploma, 26% had a HS diploma, and 48% had completed formal education beyond high school; 44% had three or more children less than 21 years old in the household.Of the 153 participants in the test and active control groups, 90% reported that they received the kits. Of the participants in the test and active control groups who reported receiving the kits, approximately two-thirds of caregivers reported their children used the toothbrushes (68%) and the toothpaste (62%) from the kits. More than half said they or other family members used the adult toothbrushes (58%) or toothpaste contained in the kits (52%). Within the test group, 84% of the children were reported to have used the toothbrushes and 78% used the toothpaste, 70% of the caregivers said they used the toothbrushes and 61% used the toothpaste. Within the active control group, 95% of the children were reported to have used the toothbrushes and 89% used the toothpaste, 84% of the caregivers said they used the toothbrushes and 76% used the toothpaste. Differences between groups were not statistically significant.Table Caregivers in the test group  were asked to rate the usefulness of the postcards and telephone messages. On a scale from 0  to 10 (very useful), caregivers rated the postcards on average a 7.2 (SD = 3.6). The telephone messages were rated lower, 6.4 (SD = 3.9), on average. Sixty-seven percent rated the usefulness of the postcards as a 7 or above, and 59% rated the usefulness of the telephone messages as a 7 or above.Using a global rating scale from 0 (worst) to 10 (best program possible), the average rating by caregivers was 9.5 points . The satisfaction with the program was rated 9.5 (SD = 1.1) by the test group and 9.5 (SD = 0.9) by the active control group. We found 97% of the test group and 99% of the active control group gave a favorable rating of 7 points or higher. The average rating by caregivers in the test and active control groups were not statistically significant.Everybody Brush! program. Nine caregivers suggested items to add to the supply kit; one said the supply kit contained too many items. Three thought that the telephone calls or postcards were not useful. The majority (50 of 66) shared very positive comments. Most comments were of general praise  and others reflected favorably on the dental care organization specifically. Sample comments are provided in Table Sixty-six caregivers offered a response to the open-ended question asking their opinion of Everybody Brush! was a family-level mHealth effort with free distribution of fluoridated toothpaste and toothbrushes to address gaps in knowledge and self-efficacy about toothbrushing among families with low-income children. Consumers (parents) were very satisfied with the program and considered the supplies useful. Consumers rated the toothbrushing supplies more highly than the written oral health promotion messages, and the telephone messages were rated lowest of all.Studies reporting on consumer satisfaction from mHealth health promotion campaigns are scarce. Previous studies on the perceptions of consumers with dental services have been focused on dental care received at dental practices –31. Few The studies on health promotion campaigns with free distribution of toothbrushing supplies reported positive results on oral health outcomes –10 and bImplementation of this large-scale health promotion program was challenging not only to the dental care organization. Assembly of the kits was outsourced to a fulfillment center after the initial kit was completed within the dental service organization itself and proved to require resources beyond the capability of the organization. In response, the organization had to identify and hire a fulfillment center to complete the assembly of the remaining kits. The postal system in the three rural counties was slowed by the large number of kits and postcards that had to be delivered to homes in this intensive campaign. There were also challenges in carrying out the evaluation at the end of the program. After the implementation period, 12 months from its initiation, many household’s phone numbers were no longer in service. Other parents with working numbers were not successfully interviewed despite the repeated attempts.Everybody Brush! was well received by the dental care organization and its members and the value of the lessons learned were perceived to outweigh the implementation challenges. As a quality improvement project, the organization had the opportunity to collaborate with university researchers, health departments, and community organizations. It also used in-house resources including a project coordinator, the communication and graphic arts staff, and the customer service staff who were trained to provide social support and advice to families asking for additional tips to overcome barriers to toothbrushing. Customer service staff members were responsible for conducting the telephone interviews used for evaluation. The use of bilingual and multicultural staff and materials and the delivery of supplies strengthened the commitment to population health and reduction of rural and ethnic disparities in health by serving families at their homes and using communication in both English and Spanish.Everybody Brush! program. The cost per child was about $10. To put this in perspective, 52% of the children 6–9 years of age have had at least one cavity and 20% have untreated decay in this population (Community-based primary prevention has largely been seen as separate and apart from the U.S. dental-care delivery system. With the expansion of Medicaid and evolution of capitation payment by states, however, dental care organizations are being required to care for a panel of clients and assume full risk for the cost of defined care benefits. These organizations can use global budgeting to allocate resources for primary prevention programs like the pulation . The cosEverybody Brush! program will examine toothbrushing behavior, utilization of care, and oral health associated with the program. In conclusion, consumers were satisfied with the program, particularly with the free distribution of the toothbrushing supplies.In this quality improvement program, the dental care organization adapted an environmental and mHealth strategy shown to increase the adoption of the behavior and improve health outcomes –10. FurtConsistent with U.S. Federal regulations, this quality improvement project did not meet the definition of research and therefore program participants are not considered research subjects. University of Washington personnel have access only to evaluation data that contain no information that could identify individual participants.The quality improvement project was conceived and designed by J-CC, CH, SL, JS, JD, MM, GA, RS, JS, and PM and all of the authors contributed to the data collection, analysis, and interpretation; contributed to the synthesis of the findings reported here, critically revised the manuscript for important intellectual content, approved the final version, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.SL, JD, MM, GA, and RS are employed by Advantage Dental Services, LLC. All other authors declare no competing interests. This quality improvement project was funded by Pacific Source Community Solutions, Inc., and Advantage Dental Services, LLC. Pacific Source Community Solutions, Inc. was not involved in the quality improvement project design or collection, analysis, or interpretation of the evaluation data.


Infants whose parents and/or siblings have a history of asthma or allergy may profit from receiving exclusive breastfeeding during the first 6 months of life. This is expected to diminish the chance of developing childhood asthma and/or atopic disease. Ongoing breastfeeding for 6 months seems challenging for many women. An educational program was developed using Intervention Mapping as a logic model to guide development and was found successful in improving breastfeeding rates at 6 months postpartum, improving knowledge and beliefs about breastfeeding for 6 months, after exposure to the program compared to controls. Intervention elements included an evidence- and theory-based booklet addressed during pre- and postnatal home visits by trained assistants. This paper elucidates the inner workings of the program by systematically describing and illustrating the steps for intervention development. Complex behavior change interventions need evidence regarding the effectiveness of individual components to understand how these interventions work. The objective of this paper is to identify, guided by the Intervention Mapping (IM) protocol, the effective elements of an existing educational program, which were shown to be effective in increasing exclusive breastfeeding.Exclusive breastfeeding during the first 6 months after birth is expected to diminish the chance of developing childhood asthma and/or atopic disease , 2. ThisLike educational or health promotion programs for other problems, it is difficult to know what parts of these programs have contributed to effectiveness or ineffectiveness. Failure to report adequately about the program theory, theory- and evidence-informed behavior change techniques, and practical delivery strategies hampers the growth of the science of health promotion. A number of researchers have called for better reporting , 11. ProIn the first step, the planner puts together a planning group to assess the health problem, the behavioral and environmental factors influencing the health problem, and determinants of behavioral and environmental causes, which are then depicted in a logic model of the health problem. Step 2 specifies program outcomes and objectives in a logic model of change. In step 3, a coherent, deliverable intervention is designed. Theory-based intervention methods and practical applications to change (determinants of) behavior are selected, and program themes, components, scope, and sequence are generated. Step 4 comprises the actual production of the program. In step 5, a program implementation plan is generated. In step 6, a plan is generated for effect and process evaluations. Activities for steps 5 and 6 start as early as possible in the planning process. Although IM is presented as a sequence of actions, the authors see the planning process as iterative rather than chronological.In this article, we use IM to describe the successive steps of the program development, especially the theoretical change methods and practical delivery applications used in our program to promote breastfeeding.The intervention described in this report and its evaluation was a sequel to a Dutch prospective birth cohort study called PREVASC . In thisNeeds assessment: the logic model of the problem. Improvement of breastfeeding adherence was the interest of this project. Our needs assessment comprised two studies: a review of the literature and a qualitative study (ve study . Both stProgram outcomes and objectives: the logic model of change. We developed the program plan by specifying who and what will change as a result of the intervention. We combined performance objectives for each target group (women and partners) with chosen determinants to produce change objectives, the most proximal focus of an intervention.Program design. Based on the change objectives, we sought theory-based methods and practical applications to change the factors that influence the target behaviors. An intervention method is a technique or procedure that is expected to change one or more factors that influence a target behavior of individuals, groups, or social structures while a practical application concerns the way methods are delivered to fit the context of the target population. We created a sketch of the program elements, their purpose and arrangement, the final program materials, and the program protocols.Program production. All program components were pretested. We did this by presenting the booklet to eight women, by means of the plus–minus method. The plus–minus method involved asking participants to read the booklet from beginning to end and to indicate their positive and negative experiences in the margin with pluses and minuses, respectively. Pluses and minuses may be assigned to all sorts of text elements (from chapters to words) and for various reasons . After that, we interviewed the participants to elicit the reasons for every plus and minus. We followed the interviews with a short semistructured questionnaire focusing on the macrostructure and a general evaluation of the text in the brochure (brochure .Program implementation plan. This step includes program adoption and implementation (including consideration of program maintenance). We did not perform this step here because the program was implemented as a part of a research study by research personnel (efficacy study). Implementation after the RCT will focus on professionals and organizations specialized in pregnancy and/or breastfeeding, e.g., midwives and gynecologists, who have personal contact with pregnant women, which is important since preparation to breastfeed during pregnancy is considered prerequisite. These potential intermediaries will be approached to discuss their role in this breastfeeding program. In this way, providing the intervention materials to the target population and subsequent dialog occurs during health provider contacts and best resembles the RCT context.Evaluation plan. The evaluation consisted of assessing the impact of the program provided on behavior adherence, exclusive breastfeeding for 6 months, using diaries as a source for the behavioral outcome in survival analysis. Furthermore, changes in related determinants of exclusive breastfeeding were assessed by a determinant-questionnaire filled-out by participants before and after the preventive program was provided and was compared with determinants in the control group. The analysis was performed to examine distal program objectives . Process evaluation criteria were formulated .Intervention mapping guided the identification of determinants of breastfeeding (and postponement of solid foods), the formulation of intervention objectives, the choice of methods and practical applications for inducing a change in determinants and feeding behaviors, and creation of ideas for program implementation and evaluation. In this article, the first four IM steps will be illustrated in more detail.The needs assessment focused on barriers and facilitators to providing exclusively breast milk to newborns the first 6 months after birth. Thulier and Mercer  reviewedThe focus group interviews suggested that threats to the continuation of breastfeeding vary by three time periods—the prenatal preparatory phase, the postnatal initiation phase, and the postnatal continuation phase. In the prenatal phase, a woman and her partner may or may not have learned how to correctly breastfeed their child. Some parents became breastfeeding “experts” in solving breastfeeding problems that turned up during the initial 6 months after birth while others did not gain the knowledge and skills to deal with problems that arose after the birth. Interviews revealed that looking for solutions only happened when problems had occurred, which often resulted in breastfeeding failure since child feeding could not be postponed. Parents stated that they had lacked the self-confidence to stand up to “discouraging advice” from family and friends. Parents had to practically obtain a “fighting spirit” to maintain breastfeeding for 6 months.The next critical period started after delivery. Certain problems, such as difficulty helping the baby to latch-on, sore nipples, and worries over whether the baby was feeding adequately, undermined efforts to breastfeed. Parents, who learned about breastfeeding prior to the birth and had been mentally exposed to thinkable risk scenarios, were better prepared to cope with such situations. In addition, parents talked about a strong perceived social pressure/criticism against breastfeeding and the postponement of solid food. This was considered a risk situation one really needed to be prepared for since this hindrance appeared rather unexpected. For the women, it was very important that their partners supported them.The final precarious period was the return to work. Many women reported they did not prepare very well for the tasks during this period. For example, the mothers did not plan ahead with arranging for a breast pump and a room at work to express milk. Women who were not aware of these tasks and who did not know of the law regarding expressing milk during work time seemed to have been more vulnerable to quitting prematurely.Based on the needs assessment, we formulated four main program objectives regarding breastfeeding and postponement of solids until 6 months: Women will 1. Give exclusive breastfeeding for 6 months; 2. Postpone solid food for 6 months; 3. Recognize social pressure and cope with it; and 4. Recognize risk situations and cope with them. From these objectives, we developed performance specifications. These overall objectives were split into intermediate objectives such as acquiring information by reading the booklet as a preparatory action before delivery. We then combined these performance objectives with the determinants of breastfeeding that were under control of the mother and partner, and subject to change. Other, environmental factors, such as social norms or social support may directly influence the desired health behavior as well, but they are in this setting very difficult to address. We addressed only one relevant external agent, the newborn’s father; a key person in breastfeeding support.As an alternative to making other external agents direct targets of the program, we sought to address these environmental factors through change objectives for the women. For example, the social influence by grandmothers was dealt with through a change objective for the women dealing with perceived social influence and a change objective for the partner to support the mother when she is confronted with opinions against breastfeeding.The performance objectives are mentioned in Table The eight women who pretested the brochure were multiparous women. Two of them had no experience with breastfeeding, three women breastfed an earlier child for 2–3 months, and three women breastfed an earlier child for more than 6 months. The results of the plus–minus method showed that the overall opinion about the brochure was very positive. The women thought that the brochure was interesting to read, attractive, and contained not too much or too little information. The used language appeared to be clear, and women appreciated examples and pictures. Despite the overall positive comments, the women had several suggestions to improve the brochure. Some women would like to have more information in the brochure about expressing milk and more focus on the social pressure of the environment. Other suggestions were a different title of the brochure and more pictures. We used information from these pretests to revise the program materials prior to implementation.We present Steps 3 and 4 together so that the reader can readily understand the relations among theoretical behavior change methods, how the methods were delivered to parents and what specific topics and communication messages were conveyed. Table To change the determinants in step 2 and enable the performance objectives, we used a number of theoretical change methods from different theories. For example, looking at the first row of Table The key messages of the program were related to the central theme that exclusive breastfeeding (including the postponement of solid food) is the optimal and most normal/natural nutrition for newborns, but that it is hard work, and several barriers can make you quit before the intended 6 months. Therefore, preparation is needed. Presenting messages like this should increase the likelihood that readers process the content actively and stimulate an increase in their knowledge about the subject . Since kFurthermore, risk awareness messages (your child might be predisposed to asthma) underlined the child’s vulnerability to the threat , but at p < 0.03) (A description of the study design has been published elsewhere . At 6 mo < 0.03) . Substan < 0.03) .Parents in the intervention group completed a questionnaire about the usefulness of the breastfeeding booklet and home visit. Almost all women (98%) read the booklet in whole or parts of it. The booklet was evaluated accessible, easy to read, and attractive. The overall appreciation of the program on a 10-point scale was rewarded with an 8.1 (range 6–10). The main comments reflected a generally positive view of the program.In this paper, we described the development, theoretical behavior change methods, and content of a program that effectively increased the proportion of women who were able to sustain breastfeeding . The proMany breastfeeding promotion programs to extend the duration of breastfeeding have been evaluated, but the majority of the studies are not comparable with each other due to several different basic assumptions –34. For In conclusion, strong points of our program are the systematic development based on theoretical models, pre- and postnatal home visits, intervention starting in mid-pregnancy, and the supportive role of the home visitor, stressing partner support and resistance to social influence in combination with the written material.Intervention Mapping helps programs development and it also helps to describe existing interventions explaining what is “inside the black box” . In thisAbove examples illustrate that IM can be complex, elaborate, tiresome, expensive, and time-consuming. However, IM also assists in bringing the development of interventions to a higher level, and it helps intervention planners develop the best possible intervention.At a national level, important organizations such as the professional organization for midwives and the health home care services adopted the national feeding guidelines for newborns to promote exclusive breastfeeding for the first 6 months. Also, the Dutch government promotes breastfeeding for 6 months because of the many proven health benefits for mother and child. Our effective breastfeeding promotion program was evaluated positively by participating families who graded the program with an eight on a scale from 0 to 10. We believe this program holds a promise for future care to coach women and their partner, pregnant of a predisposed child, toward adherence to breastfeeding for 6 months and improve health in high-risk newborns. Therefore, an attempt must be made to implement the program in the daily practice of health professionals, especially in prenatal care.Medical ethics review committee Maastricht University Medical Center and Maastricht University.IM and BG are the investigators of this study and developed the breastfeeding intervention. KB was the external consultant on Intervention Mapping. All authors contributed to writing the article submitted. KB passed away in February 2016.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.


Bacillus subtilis, the model system for spore formers. Adsorption on B. subtilis spores has then been proposed as a non-recombinant approach for the development of mucosal vaccine/drug delivery vehicles, biocatalysts, bioremediation, and diagnostic tools. We used spores of B. megaterium QM B1551 to evaluate their efficiency as an adsorption platform. Spores of B. megaterium are significantly larger than those of B. subtilis and of other Bacillus species and are surrounded by the exosporium, an outermost surface layer present only in some Bacillus species and lacking in B. subtilis. Strain QM B1551 of B. megaterium and a derivative strain totally lacking the exosporium were used to localize the adsorbed monomeric Red Fluorescent Protein (mRFP) of the coral Discosoma sp., used as a model heterologous protein. Our results indicate that spores of B. megaterium adsorb mRFP more efficiently than B. subtilis spores, that the exosporium is essential for mRFP adsorption, and that most of the adsorbed mRFP molecules are not exposed on the spore surface but rather localized in the space between the outer coat and the exosporium.Bacterial spores spontaneously interact and tightly bind heterologous proteins. A variety of antigens and enzymes have been efficiently displayed on spores of  Bacillus and Clostridium genera can differentiate to form an endospore (spore), a metabolically quiescent cell produced in response to conditions that do not allow cell growth  and spores (length up to 3 μm and diameter of 1 μm)  of the coral soma sp. , to evalof 1 μm) . Spores B. megaterium. This strain carries about 11% of its genome on seven indigenous plasmids .The ve PV361 . The B. was PY79 . Sporulan method . After 3Escherichia coli strain RH161 . Purified protein was desalted using a PD10 column  to remove high NaCl and imidazole concentrations.For mRFP production, cells of in RH161 , bearing protein . The His8) in 50 mM Sodium Citrate pH 4.0 at 25°C in a final volume of 200 μl. After 1 h of incubation, the binding mixture was centrifuged  to fractionate mRFP bound-spores in the pellet from free mRFP in the supernatant.Unless otherwise specified 5 μg of purified recombinant mRFP was added to a suspension of spores . Immunofluorescence was performed as described by 6 RFP-adsorbed spores of QM B1551 and PV361 B. megaterium strains were pretreated with 1% bovine serum albumin (BSA) – 1x PBS pH 4.0 for 30 min prior to 2 h-incubation at 4°C with the anti-polyHistidine antibodies  diluted 1:20 in 1x PBS pH 4.0–1% BSA. As a control of the specificity of this technique, non-adsorbed spores were directly treated with anti-His antibodies. After three washes, the samples were incubated with a 64-fold diluted anti-mouse secondary antibody conjugated with fluorescein isothiocyanate, FITC  and washed four times with 1x PBS pH 4.0. Washed samples were resuspended in 20 μl of 1x PBS pH 4.0 and 10 μl were analyzed. All samples were observed with an Olympus BX51 fluorescence microscope fitted with a 100× UPlan F1 oil objective; U-MNG or U-MWIBBP cube-filters were used to detect the red fluorescence emission of mRFP or the green emission of FITC-conjugated antibodies, respectively. Exposure times were in the range between 200 and 3000 ms. Images were captured using an Olympus DP70 digital camera and processed with Image Analysis Software (Olympus) for minor adjustments of brightness, contrast and color balance  were incubated with 5.0 × 108 purified spores. The adsorption reaction was performed in 50 mM sodium citrate at pH 4.0, as previously described . A densitometric analysis of the dot blot (Supplementary Table 1) showed that when 5 μg of mRFP was used in the adsorption reaction less than 1% was left unbound, indicating that about 99% of the heterologous protein was adsorbed to B. megaterium spores.To verify whether spores of escribed . After tFigure 1C, and supported by densitometric analysis of the dot blot (Supplementary Table 2), the washes at pH 3.0 did not cause any release of the adsorbed mRFP, while the washes at pH 7.0 or with 1M NaCl, 0.1% Triton X-100 caused a minimal, less than 1%, release of mRFP molecules. Therefore, results presented in Figure 1 suggest that mRFP was efficiently adsorbed and tightly bound to B. megaterium spores. To assess whether spore-adsorbed mRFP molecules retained their fluorescence properties, we performed a fluorescence microscopy analysis. As shown in Figure 2, post-adsorption reaction spores were associated with a strong fluorescence signal visible around the entire spore surface.To analyze whether adsorbed mRFP molecules were tightly bound to the spore surface, post-adsorption reaction spores were washed twice with PBS buffer at pH 3.0 or pH 7.0, or with a 1M NaCl, 0.1% Triton X-100 solution as previously described . As showB. megaterium contains seven indigenous plasmids . A densitometric analysis of the dot blot of Figure 3B (Supplementary Table 3) indicated that PY79 and PV361 spores adsorbed about 90% of the total mRFP while QM B1551 spores adsorbed almost all (over 99%) purified mRFP.Strain QM B1551 of plasmids  and plasplasmids . PV361 iplasmids . We usedorb mRFP . To compFigure 4A and Supplementary Figure S1). Microscopy images were analyzed by ImageJ software  to perform quantitative fluorescence image analysis and spore fluorescence was calculated as described in Materials and Methods. The analysis of 80 spores of each strain indicated an average fluorescence value per pixel of 52.43 (± 5.94), 20.81 (± 2.71), and 32.33  for QM B1551, PV361, and PY79, respectively , conferring further evidence that QM B1551 spores adsorbed more mRFP than spores of the other two strains.The adsorption efficiency of spores of the three strains was also analyzed by fluorescence microscopy .In addition, results of Figure 3B) indicated that when 5 μg of purified mRFP was used in adsorption reactions with 5.0 × 108 spores of the QM B1551 strain almost all heterologous protein was bound to the spore. In order to define the maximal amount of mRFP that can be adsorbed to QM B1551 spores, we repeated the reactions with increasing concentrations of purified mRFP, i.e., 5.0 × 108 QM B1551 spores were reacted with 5, 10, 20, 40, 80, and 160 μg of purified mRFP. After the reactions spores were collected by centrifugation and the supernatants containing unbound mRFP were serially diluted and analyzed by dot blotting . Figure 5B displays the results of a densitometric analyses of the dot blot (??), which indicates that when 5–80 μg of mRFP was reacted with 5 × 108 spores, the percentage of protein bound to spores was over 90%. A decrease of bound mRFP was observed when 160 μg of purified protein were used in the reaction. However, even when 160 μg of purified mRFP was used over 60% of the protein was absorbed, indicating that 5.0 × 108 spores of QM B1551 can adsorb about 100 μg of mRFP.Dot blot experiments  and observed under the fluorescence microscope . With the lowest amount of mRFP used in this experiment (2 μg) the mRFP fluorescence signal (red) was observed all around the spore while the immunofluorescence signal (green) was weak and mainly concentrated at the spore poles, suggesting that only in those points mRFP was exposed on the spore surface. Increasing the amount of mRFP used in the reaction the number of green spots increased (5 and 10 μg) and with highest amount of mRFP used in the reaction (20 μg) an almost complete green ring was observed around the spores. Based on the results presented in Figure 6, we hypothesized that mRFP molecules infiltrate through the exosporium and localizes in the inter-coat space between the outer coat and the exosporium, i.e., when a low amount of mRFP is used almost all protein molecules are internal to the exosporium and are available to the antibody at only a few locations. Increasing amounts of mRFP in adsorption reactions results in the inter-coat space “filling up,” until ultimately more mRFP molecules are available to the antibody on the spore surface. This hypothesis implies that if the exosporium is lacking then all mRFP should be available to the antibody. To test this, we compared by immunofluorescence microscopy equal numbers of spores of QM B1551 (with exosporium) and of PV361 (without exosporium) incubated with the same amount of mRFP (5 μg). When the exosporium was present (QM B1551) mRFP was only partially available to the antibody and green spots were observed . When the exosporium was not present (PV361) adsorbed mRFP was available to the antibody all around the spore and a complete green ring was formed, supporting the hypothesis that mRFP is internal to the exosporium in QM B1551 spores.An immuno-fluorescence microscopy approach was employed to assess whether adsorbed mRFP molecules were exposed on the surface of Figure 7 showed a complete red fluorescent ring as in Figure 2, PV361 spores showed a very weak red fluorescent signal. With PV361 spores a red signal was only observed using long exposure times at the fluorescence microscope . Since mRFP is present around PV361 spores , we conclude that mRFP fluorescence is weakened when the protein is adsorbed to PV361 spores. Further experiments will be needed to fully address this point.While QM B1551 spores used in the experiments of B. megaterium are extremely efficient in adsorbing the heterologous model protein mRFP, that the exosporium has an important role in this process, and that mRFP molecules infiltrate through the exosporium localizing between the outer coat and the exosporium. These results expand previous work performed on spores of B. subtilis and demonstrate that spores of a different species may also be used to deliver heterologous proteins via the adsorption method. The high efficiency of adsorption observed with B. megaterium spores is in part due to the large size of its spore compared with that of B. subtilis. Indeed, the B. megaterium spore surface area is about 2.5-fold larger than the B. subtilis spore, with a surface of 5.33 μm2 (h: 1.60 ± 0.16 w: 0.84 ± 0.07) vs. 1.98 μm2 (h: 1.07 ± 0.09 w: 0.48 ± 0.03). The large dimensions allow the adsorption of up to 100 μg of mRFP when 160 μg of protein are reacted with spores.The main findings of this report are that spores of B. megaterium QM B1551 exosporium was suggested to represent a permeability barrier to molecules with molecular weights greater than 100 KDa, while influencing the passage of molecules with masses somewhere between 2 and 40 kDa  in the inter-coat space are sufficiently occupied. This implies that the adsorption approach to surface display can be used with olecules , our datML and GD – performed most of the experiments; RA and AS – contributed to interpretation of data for the work; GiC, LB, and GrC – contributed to drafting the work and revising it critically; ER – contributed to discussions and suggestions during the work and contributed to writing the manuscript; RI – led the work and contributed to writing the manuscript. All authors read and approved the final manuscript.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.


The U.S.-Japan Panel on Wind and Seismic Effects provides for cooperative activities of 15 U.S. and 6 Japanese Agencies to reduce damage from strong winds and earthquakes. The Panel is part of the U.S.-Japan Natural Resources Development Program under the aegis of the U.S.-Japan Cooperative Science Program of 1961. The National Bureau of Standards (NBS) provides the U.S.-side chairman and secretariat; Dr. Richard N. Wright, Director of the Center for Building Technology (CBT) and Noel J. Raufaste of CBT, respectively. Annually, the Panel conducts a 1-week joint technical meeting where recent research results are discussed. A technical study tour follows the Panel meetings.This year (1988) the United States hosted the 20th joint meeting and visits to U.S. laboratories and construction projects. The meeting was held at NBS during 17–20 May. Technical presentations focused on: Wind Engineering; Earthquake Engineering; Storm Surge; Tsunamis; U.S.-Japan Cooperative Research Program (where NBS is performing cooperative research in seismic behavior of large concrete bridge piers); summaries of recent Panel Workshops; and a report from each side on Two Decades of Panel Accomplishments and Future Work.During 1988–89, the Panel members agreed to performing large-scale testing of precast seismic structural systems, advance technologies in application of active and passive control of buildings and other structures, improve knowledge of strong motion data on performance of buried pipeline systems, and verify the effectiveness of retrofitting and strengthening methods for structures and soils. Five workshops are being planned on: repair and retrofit of buildings, sensor technology applied to large engineered systems, earthquake hazard and risk assessment, disaster prevention for lifeline systems, and loads on bridges. Also, a planning meeting will address remedial treatment of liquefiable soils.Manual for Repair Methods of Civil Engineering Structures Damaged by Earthquakes. This report is a valuable reference for development of U.S. building practices. The data produced by the joint Panel influence on-going U.S. and Japan structural engineering research, and guide improvements of building codes and standards of both countries.Panel accomplishments during the past year included: more than six guest researchers exchanged between U.S. and Japanese laboratories; correlation of data from the Whittier Narrows and the Mexico City earthquakes with Japanese and U.S. design practices; joint research in large-scale testing of masonry and lifeline structures; sharing repair methods for civil engineering structures; exchanged data from strong motion arrays to study causes and effects of horizontal variations in ground motions and effects of overburden on intensity of ground shaking; and translated into English and published the Japanese publication,