Social isolation and disengagement fragments local communities. Evidence indicates that refugee families are highly vulnerable to social isolation in their countries of resettlement. Research to identify approaches to best address this is needed. Football United is a program that aims to foster social inclusion and cohesion in areas with high refugee settlement in New South Wales, Australia, through skills and leadership development, mentoring, and the creation of links with local community and corporate leaders and organisations. The Social Cohesion through Football study's broad goal is to examine the implementation of a complex health promotion program, and to analyse the processes involved in program implementation. The study will consider program impact on individual health and wellbeing, social inclusion and cohesion, as well as analyse how the program by necessity interacts and adapts to context during implementation, a concept we refer to as plasticity. The proposed study will be the first prospective cohort impact study to our knowledge to assess the impact of a comprehensive integrated program using football as a vehicle for fostering social inclusion and cohesion in communities with high refugee settlement.A quasi-experimental cohort study design with treatment partitioning involving four study sites. The study employs a 'dose response' model, comparing those with no involvement in the Football United program with those with lower or higher levels of participation. A range of qualitative and quantitative measures will be used in the study. Study participants' emotional well being, resilience, ethnic identity and other group orientation, feelings of social inclusion and belonging will be measured using a survey instrument complemented by relevant data drawn from in-depth interviews, self reporting measures and participant observation. The views of key informants from the program and the wider community will also be solicited.The complexity of the Football United program poses challenges for measurement, and requires the study design to be responsive to the dynamic nature of the program and context. Assessment of change is needed at multiple levels, drawing on mixed methods and multidisciplinary approaches in implementation and evaluation. Attention to these challenges has underpinned the design and methods in the Social Cohesion through Football study, which will use a unique and innovative combination of measures that have not been applied together previously in social inclusion/cohesion and sport and social inclusion/cohesion program research. Australia accepts more than 13,000 refugee and humanitarian immigrants annually. There iYouth account for a large overall percentage of the refugee population in New South Wales (NSW). For all refugee and humanitarian entrants arriving in NSW  in the last five years, 50% were under 20 years of age, with 69% of entrants under 30 years of age - these figures are even higher in the two program sites for the current study [In recent there has been an increase in programs addressing the social dimension of refugee settlement, but there is a paucity of robust impact assessment both in Australia and internationally on these programs . Well reThere is evidence of the positive impact of sport on individual participants' physical, mental and social health -12. At thow programs are developed and implemented to ensure that they promote team work, cross-cultural understanding and that they are socially inclusive rather than exclusive, including actively working to provide bridges to mainstream community organisations and structures and vice-versa [Moreover, while the positive impact of participation in sport on individuals and communities is widely promoted, the phenomena that can bond teams and groups around their sport can also exclude individuals and groups and further divide communities -22. Tontce-versa -10,25.Football programs for social and human development are on the increase both in Australia and internationally -10,17,26Football United (FUn) is a complex health promotion intervention that uses a football (soccer) development program as a mechanism for promoting individual health and well being, and fostering social inclusion and cohesion in areas of Sydney, Australia with high refugee settlement ,9,29. CoThe Program elements are integrated into three key focus areas:1. Football activities: These include regular Saturday and after school programs, gala days and school holiday camps. All activities are designed to foster maximum mentorship between coaches and players, between older and younger players, and between volunteers and participants.2. Capacity building: Youth and family members from the communities have opportunities to participate in courses and apply their learning in the following areas: coaching and refereeing, mentoring and life-skills, leadership, first aid, project management and volunteering.3. Fostering involvement with local football clubs and linkages between the program and partner agencies - government, community and corporate.The different activities have been designed to provide participants with skill sets that are transferable to other contexts such as fund raising, club management and development, volunteer management and support, and to promote linkages between newly arrived youth and families and other community members, families, community, corporate and sports organisations.The program is innovative because of its complexity in addressing many levels of social inclusion and cohesion thereby addressing the criticisms of past sport for social development programs as lacking such complexity ,21-23,25The Social Cohesion through Football study's broad goal is to investigate the implementation of FUn over a three-year period to analyse processes and impacts on individual health and wellbeing, social inclusion and cohesion. For the purpose of this study, the term social cohesion is defined as "the ongoing process of developing a community of shared values, shared challenges and equal opportunity ... based on trust, hope and reciprocity" . Our undThe study has four aims and two hypotheses.1. To determine the impact of Football United on participants' personal development, emotional health, resilience, social inclusion, peer relationships and other 'life skills'.2. To determine the impact of Football United on social cohesion in the school and broader community.3. To investigate issues arising from implementation of the program in order to inform future program implementation and replication of the program in other contexts, including other Australian and international sites.4. To establish guidelines for best practice sports-based social inclusion and cohesion programs.1. Participants in the Football United program will have significantly better emotional health, peer relationships and feelings of social inclusion and those who do not participate at all or who only participate minimally in the program.2. The Football United program will contribute to social cohesion in communities with high refugee settlement.The central element of the study will be a quasi-experimental cohort study design with treatment partitioning which will be used to accommodate the particular challenges of working with a study population that is changing (new immigrants arrive regularly and move locations) as well as ethical dilemmas related to excluding possible participants from the program. It employs what could be termed a 'dose response' model, comparing those with no involvement in the Football United program (at a single point in time enabling them to then participate in the program following measurement) with those with lower or higher levels of participation. Treatment partitioning involves separating the program group into low and high levels of participation in FUn activities. The study design reflects the reality that settlement is an ongoing process, and that different young people will access the program at different time. In addition, the program has already been running for more than two years in the study sites. The combination of these factors means that a true baseline measurement is precluded. A cohort study design with treatment partitioning is the best approach to enable causal inference and protect internal validity .The program group will be students in two Intensive English Centres (IECs) in Sydney, Australia who have participated in the FUn program in the study year. IECs are part of the school system in the state, and prepare newly arrived, secondary aged students for study in an Australian high school by providing intensive English tuition . At the A range of qualitative and quantitative measures will be undertaken with all consenting IEC participants in the study year. Study participants' emotional well being, resilience, ethnic identity and other group orientation, feelings of social inclusion and belonging will be measured using a survey instrument complemented by relevant data drawn from in-depth interviews, self reporting measures and participant observation.In designing the survey instrument, a number of existing instruments were considered for each key construct of interest based on a review of the literature around these constructs and their measurement. The composite survey instrument was agreed upon after a number of discussions among the research team where survey instruments were compared across a range of criteria, including match to construct of interest, previous use (including in other languages), availability of data on psychometric properties, such as reliability and validity, length, availability of national comparative data and cost to use. Instrument face validity was also considered by the researchers and key partners who work with the study population. For example, some instruments included colloquial Anglo-Saxon expressions which would not translate well into other languages and cultures. Table A range of demographic data are to be collected in the survey, such as age, country of birth, language spoken, date of arrival, country prior to arrival, level of English using the same questions, where possible, as the recent Good Starts Study in Victoria, Australia ,38. ThesFriendship Pairs (FP), where a selected participant chooses a friend to be interviewed with them, will provide a comfortable and supportive environment for the young people and encourage them to speak freely without undue peer pressure often apparent in focus groups . A firstA second interview will be undertaken with those from the program group two to three weeks following the first interview. In the second interview researchers will explore the narratives the participants construct about the scrapbooks and photographs, as well as consider the themes and perspectives the participants do not include . For parBetter outcomes for the program group could be explained by their participation in the research itself rather than the program, a phenomenon known as The Hawthorne Effect ,50. To aParticipant observation of Football United activities will include recording numbers of youth, parents, volunteers and community members engaged in FUn activities at the two schools and will document the different roles of the various participants and stakeholders and the dynamics of engagement. Interaction between youth, coaches, volunteers, community leaders and other significant stakeholders will be documented. This data will complement and add further depth to the data collected from other methods about impact and allow the research team to observe the experience of the program in real-time ,52. DireThe context and surrounding environment of each of the schools will be assessed primarily through Key Informant (KI) interviews at two points during the study period. Data from participant observation and FP interviews will also provide insights into contextual factors. KIs will include key people in the school, such as the principal and head teacher, as well as other staff who will be identified as key informants using snowball sampling . People Process measures will be undertaken to document the issues arising from implementation and for future replication of the program. Measures will examine process issues at two levels: 1) local implementation of the program activities, and 2) program management at advisory group level. Data sources will include: participant observation, friendship pair interviews, self report data, KI interviews, meeting transcripts and minutes.Ethics approval has been received from the UNSW Human Research Ethics Committee and the NSW Department of Education and Training Student Engagement and Program Evaluation Bureau . The conThe survey sample for the program group (across the two schools) is estimated to be approximately 100-150 youth representing all youth who participate in the program and consent to inclusion in the study. With treatment partitioning in the program group, the sample will have power of greater than .80 to detect small to moderate effect sizes. Approximately 100 young people will be recruited as a comparison group for the survey. An additional benefit of the study design is that there will be no need to follow a large number of the program or comparison group for further survey measures meaning there will be no loss to follow-up.The recruitment of a subsample of the FUn program group to participate in in-depth interviews and self-reporting aspects of the study will employ purposeful sampling to ensure both diversity and richness of the data collected . ParticiInitial KI interviewees will be purposefully selected and snowball sampling then utilised to identify further key informants within and beyond the school context . ParticiDescriptive analysis of the demographic characteristics of the program and comparison groups and univariate analysis of measures, such as emotional well being, ethnic identity, and resilience will be undertaken. Although matching will be applied during the recruitment processes for the comparison group, it is recognised that the three groups  may differ on the distribution of factors impacting on outcomes, for example, length of time in Australia or age. Propensity score analysis will be used to balance any differences in groups ,56.To compare the impact measures across groups, Analysis of Variance (ANOVA) will be used for scale impact measures and Chi-square test will be used for proportional impact measures. In addition, factorial ANOVA will be used to determine interactive effects of demographic variables on measured impacts.Framework analysis will be used for qualitative data ,58. InteThe field researchers will first code a purposeful sample of data selecting information with rich and diverse content which will assist in the construction of theory ,61, befoThe research team has decided not to impose any particular theories in the qualitative data collection process or in the initial analysis, preferring to take an inductive approach . The resFrom our review of the literature, the proposed study will be the first prospective cohort impact study in Australia and internationally assessing the impact of a comprehensive integrated program using football as a vehicle for fostering social inclusion and cohesion in communities with high refugee settlement ,17,21,25The study will provide new knowledge on methodology and measures for assessing the impact of sport in vulnerable and culturally diverse populations. The study proposes a unique and innovative combination of measures which have not been applied together previously in social inclusion/cohesion and sport and social inclusion/cohesion program research ,15.Football United is a complex health promotion program which has been developed with the community over four years and its "active components" or key intervention functions ,63,64 hafunction that a component plays in an intervention should be standardised, rather than the form this component. This approach rejects the need for rigid standardisation of programs across various sites: "Indeed, the more complex an intervention becomes, the more it is necessary to have rigorous theory about the process and principles of the change process being tested, but to be flexible about the form that this takes in each site" [The goal in implementation is not to standardise the program across multiple sites, but allow it to respond and interact with context while ensuring the "active components" are present at each site. This is a similar approach to that taken by Hawe et al , who argch site"  (p267). ch site"  and the ch site" ,66. ThisComplexity poses challenges for measurement and evaluation because program impact will often not be straightforward or linear . Too heaFirstly, the overall evaluation design for this study must navigate a range of practical and ethical issues which are unavoidable in the 'real world' of intervention research whilst also providing the strongest design possible to allow causal inference. A cohort study design with treatment partitioning and propensity scoring provides the best approach to enable causal inference and protect internal validity whilst taking account of the specific community and program context . ContextSecondly, the study design must concurrently capture program impacts at a range of levels and document contextual factors at the school and community level that may influence program shape and implementation, and mediate impacts. Comparisons across the four schools will be critical to building understanding of the role of context as part of the intervention and to enable the context and plasticity of the intervention to be considered in interpreting impact data. The program operates in an ever-changing environment where predicting, let alone controlling variables that may affect the outcomes being studied, is impossible , and alsThirdly, the study design is not only focused on measuring outcomes, but will also document and examine the implementation of the program to inform the implementation of similar programs in other settings. In short, we need to keep an eye on what is happening, and how it is happening  - the "eIn conceptualising possible impacts, it is important to note that while we will build understanding of the processes of, and interactions between the program components, we also aim to measure outcomes of the whole program and not its constituent parts. This is best practice when evaluating an ecological program impacting on a range of areas at many levels ,70. ImpaAs a research team we have chosen to utilise multiple methods to try to capture change at the individual, school and community level as well as build our understanding of how the program works and interacts within each specific context. Figure Key informant as well as friendship-pair interviews will provide the research team with important insights into the school context and how Football United operates and affects participants and those who deliver the intervention in the two program schools. Interviewees will include the school participants, coaches, teachers, program workers and community agency staff involved, as well as community leaders. Others have noted the importance of such a dialogue with the participants and program workers, and the research team will question and further explore what intervention 'success' means and the role of the participants as active partners in implementation ,73.Careful recording of activities implemented and 'exposure' to the intervention has also been recommended in the field of evaluating complex interventions . ProcessKey informants will also tell us what is happening in the broader community that may impact on the young people and whether the program effects are felt beyond the school walls. Lastly, the media coverage of Football United will provide a measure of reach beyond the schools involved. The intensity of coverage of the issues of asylum seekers and refugee settlement in the media will also provide an understanding of the broader social and political setting within which the program is operating.This study of a complex health promotion intervention delivered at multiple sites addresses many of the documented failures of past studies to grapple with the "plasticity" of such interventions, which varies at each site. By plasticity we mean the ability, or not, to adapt and alter to accommodate the ever-changing conditions of possibility in which interventions are implemented and play out - economic, social, biological, cultural, political, spatial, and the like. Multiple lenses and methods are being deployed to cut through the inherent messiness of this movement, complexity and alteration, and provide rigour through triangulation. The implementation of the program and the role of participants in its success will be analysed. Multiple levels and measures of process and impact, including the individual, school and broader community are included in the study design, which provides a strong model to enable causal inference, but also the ability to analyse how the essence of the intervention responds in a real world context.The authors declare that they have no competing interests.SN, ABB, CE, LK, and RH all contributed to the study design. SN drafted the manuscript and all authors contributed to editing and refining the arguments presented in the final manuscript.SN is a social scientist who uses qualitative and quantitative methods in her research within a participatory framework where research participants are actively involved in the process of research and constructing meaning.ABB is a social scientist who specialises in design, implementation and evaluation of innovative community development and health promotion scientific and technical programmes at national and international levels. Her particular areas of intervention are youth, disadvantaged and vulnerable communities.CE researches gender, media, sport and cultural studies at the University of Nottingham, Ningbo, China. He's an active member of numerous community groups and editor of 'Altitude: An e-journal of emerging humanities work'.LK is a health equity researcher who focuses on mixed method trials of interventions to improve health and wellbeing outcomes for vulnerable communities and populations.RH is a psychologist who uses quantitative methods in his research, and is interested in the research of resilience processes in youth from different cultures.JM is a cultural researcher whose research interests include the interaction of gender, rights, and cultural difference.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/587/prepub


Participation in Walk to School (WTS) programs has grown substantially in the US since its inception; however, no attempt has been made to systematically describe program use or factors associated with implementation of environment/policy changes.Describe the characteristics of schools' WTS programs by level of implementation.low), WTS Day and additional programs (medium), or making policy/environmental change (high).Representatives from 450 schools from 42 states completed a survey about their WTS program's infrastructure and activities, and perceived impact on walking to school. Level of implementation was determined from a single question to which respondents reported participation in WTS Day only , as was funding , years of participation , and use of a walkability assessment . Implementation level was modestly associated with increased walking (r = 0.18).Strong community involvement, some funding, repeat participation, and environmental audits are associated with progms that adopt environmental/policy change, and seem to facilitate walking to school. A recent literature review confirmed that physical activity (PA) is associated with important health benefits for children and adolescents, and recommended 60 minutes or more of moderate to vigorous PA daily . This reAlthough researchers have not observed a significant decrease in leisure time PA ,7, one ciwalk website describe how to implement a WTS Day event, activities that can extend the walking program throughout the year, and strategies for creating safe walking routes [In the United States, organized efforts to promote ATS, such as the Walk to School (WTS) program, emerged about 10 years ago and quickly spread from efforts in 2 cities in 1997 to all 50 states by 2002 . WTS prog routes . The WTSg routes -16. The Although two evaluations of Safe Routes to School (SRTS) programs in California examined the effect of programs with extensive education and traffic enforcement efforts  and engiUsing a cross-sectional approach, schools participating in WTS programs were surveyed about school and community characteristics; WTS activities, infrastructure, and resources; perceived level of program implementation; and perceived impact. A broad-based advisory panel (see Appendix) was convened to provide guidance on the evaluation process, including development of the initial survey. All procedures for the study were approved by the Institutional Review Board at the University of North Carolina at Chapel Hill.The study sample was recruited from the 2002 WTS registration database maintained by the Highway Safety Research Center (HSRC) at the University of North Carolina at Chapel Hill. This database, which allows schools to register their intent to participate in WTS Day activities , is the The database used for recruitment in the present study included 782 WTS coordinators who represented individual schools, multiple schools, or school districts from all 50 states. Surveys were distributed in spring of 2003 and 605 were completed and returned. Of these, 9 were from schools not in the 2002 registration database, 27 were duplicates from the same school, 48 represented multiple schools or school districts in a single survey, and 71 were from schools that registered but did not participate in the 2002 WTS Day event. Therefore, 155 surveys were eliminated before analysis, resulting in a total of 450 surveys in the analytic sample.School demographics. Six questions assessed the number of students enrolled, grade levels at the school, type of school , school organization , percentage of students who qualified for free or reduced-price lunches, and percentage of students provided bus service. (2) WTS program infrastructure and activities. Seven questions assessed type of coordinator , assignment of WTS coordinator duties , years of participation in the WTS program, number and type of engaged community groups, amount of funding available that year, use of a walkability assessment, and other activities  offered in support of the WTS program. (3) Level of program implementation. Implementation level was determined by the school coordinator's response to the following question: What activities or promotions did your school offer? Possible responses were (a) participated in WTS Day, (b) participated in additional promotions outside of WTS Day, and (c) made policy or environmental changes to support ATS. Coordinators could select one or more of the responses to indicate their level of implementation. Programs were classified based on the "highest" level of participation selected: low (participated only in WTS Day), medium , or high . (4) Perceived impact. Coordinators were asked:In your opinion, in the past 12 months has there been an increase in the number of children who walk to school? Responses included five levels,  which were collapsed into three levels for analysis .A preliminary survey was pilot tested with three active WTS coordinators to ascertain the relevance, clarity, and ease of survey administration. The final instrument is available from the primary author upon request. For this analysis, measures included: (1) Each of the 782 coordinators in the 2002 WTS database were invited to participate by e-mail or regular mail depending on information provided in the registration database. E-mailed invitations included a link to an online survey; mailed invitations included a paper copy of the survey with a postage-paid return envelope. Those who did not respond within 3 weeks were contacted by telephone to complete the survey. These techniques are consistent with procedures designed to ensure a high response rate as described by Dillman [t tests were used to compare survey responses across levels. In addition, Kendall's Tau-b statistic was used to determine the association between level of implementation and perceived impact of the WTS program on ATS since both variables are ordinal [Frequencies, means, and standard deviations were calculated for each question, and schools were classified into 3 levels  on the basis of the single question about program implementation. Chi-square and  ordinal .An exploratory proportional odds logistic regression model with a cumulative logit link was used to determine significant correlates of program implementation level. Nonsignificant variables were removed, one at a time, using a backward selection procedure at an alpha significance level of 0.05. To assess the relative importance of the remaining covariates, each was deleted, one at a time, from this reduced model, and change in log likelihood examined. Because the proportional odds assumption appeared to be violated for some covariates (p < 0.0001), a final "partial" proportional odds model , which aMost (87.4%) surveys were completed for elementary schools. Average enrollment was 547.3 (± 268.1) students. Nearly all schools were public (98.0%) and organized around a traditional calendar (89.9%). On average, 44.4% of the students at these schools qualified for free or reduced-price lunch; 31.4% were eligible for bus service. To assess validity of responses, a 10% random sample of WTS surveys was selected and matched to archival data from state and national sources for enrollment and percent of students qualifying for free or reduced-price lunch (%FRPL). Within this sample, enrollment data were missing from 3, % FRPL data were missing from 12, and reference data could not be obtained for 1. With regards to enrollment, 61.0% of respondents estimated enrollment within ± 25 students and 80.5% within ± 50 students. With regards to percentage of students qualifying for free or reduced cost lunch, 65.6% estimated the percentage within ± 5% and 75.0% within ± 10%.Overall, 88.8% of the respondents defined themselves as local WTS coordinators. Assignment of the WTS coordinator duties varied widely: 39.1% reported the WTS duties were incorporated into the responsibilities of an existing employee , 33.6% reported that duties were given to an unpaid volunteer, and 27.3% reported not having a designated person responsible for WTS. The majority (63.8%) had participated in the WTS program for 1–2 years. Over a third reported that 6 or more different groups were involved in their WTS efforts. WTS budgets ranged from none in 30.4% of schools to more than $500 in 10.1% of schools. When asked about specific WTS-related activities, the most commonly reported activities were poster campaigns and announcements (72.4%), pedestrian or bicycle safety training (48.2%), walkability or environmental assessments (47.5%), and designated safe routes for children's school travel (46.3%).Two hundred fifty-one schools (55.8%) were classified as low implementation, 105 (23.3%) as medium implementation, and 94 (20.9%) as high implementation.No significant differences in school demographics were found across the 3 levels of program implementation Table . HoweverAs noted in Table Overall, 147 coordinators perceived at least some increase in the number of children using ATS. A modest, but significant, association between perceived increase in ATS and implementation level was observed . In low implementation schools, only 27% noted an increase in the number of children using ATS compared to 35% of medium and 55% of high implementation schools, respectively.To understand the significant independent correlates of WTS program implementation associated with level of implementation, we conducted an exploratory analysis with the following covariates: years of participation in the WTS program, number of groups involved in planning and implementation, use of a walkability assessment, funding, and two-way interactions between these variables. Nineteen schools (4.2%) were deleted because of missing covariates or outcomes assumed to be missing completely at random, leaving a sample size of 431 . None of the 6 interaction terms was significant; therefore, the reduced model included the 4 main effect variables. Changes in log likelihood showed that that number of community groups involved had the most significant effect on the model, followed by funding, years of participation, and use of a walkability assessment (data not shown).Cumulative logit plots of each covariate showed that the number of community groups involved and the use of a walkability assessment appeared to violate the proportional odds assumption of homogeneity among the ordinal scales of these two variables analyzed by level. Hence, for these two covariates, two separate odds ratios were used. The first compared the odds of being classified as low versus a higher level of program implementation ; the second compared the odds of being classified as high versus a lower level of program implementation . For other covariates (years of participation and funding), proportional odds were assumed, so that the odds ratios were the same across all school level categories Table .versus OR 2 = low or medium implementation schools compared to high). As the number of community groups involved increased, the odds of being a higher level school also increased. The effect is most dramatic when comparing low implementing schools to medium or high implementing schools. Each additional community group involved increases the odds of having a medium or high implementing school by 78% . Conversely, each additional community group involved reduces the odds of being classified in the lowest level of program implementation by almost half (OR = 1 – 1/1.78 = 0.44). The effect is less dramatic as school level increases. For every additional community group involved, the odds of having the highest level of implementation increased by 56% . On the other hand, the use of walkability assessments appeared to be most associated with highest level schools. Schools that completed an assessment were 3 times as likely to have made environmental/policy changes than schools that did not (OR 2 = 3.22), although the confidence interval was quite wide . Again, these associations existed after adjustment for other covariates.High level schools were significantly associated with more funding (p < 0.0001) and more years of participation (p < 0.0001). For every increase in funding category, the odds of being in a higher WTS implementation level increased by an estimated 56% . Likewise, for every additional year of WTS participation, the odds of being in a school with a higher implementation level increased by about 44% . For number of community groups involved and use of a walkability assessment, both of which appeared to violate the proportional odds assumption of homogeneity, results depended on response categories compared  of the schools sampled implemented only a WTS Day event (low implementation), 23% implemented WTS Day and other activities (medium implementation), and 21% made policy/environmental changes to support walking to school (high implementation). Using multi-level modeling, we determined that number of community groups involved, amount of funding provided, years of participation, and use of a walkability assessment were significant, independent correlates of level of WTS program implementation. Additionally, we observed that programs making policy/environmental changes as part of their WTS program seemed to observe increased rates of ATS. These results have important implications for those who work with schools, communities, policymakers, and others to promote WTS programs in the US and may provide some direction for their work. Low implementation schools may be prime targets for intervention since they have demonstrated interest in ATS; however, more comprehensive programs should be encouraged to achieve maximum benefit from these efforts. This comparison of schools with different levels of program implementation has identified particular correlates that may guide intervention efforts to move low implementation schools toward more comprehensive programs.membership diversity was one of the six most commonly identified factors positively associated with coalition effectiveness [Community involvement is an important factor associated with making environmental- or policy-related changes to support ATS. Our findings show that for every additional community group involved, the odds of having a more comprehensive WTS program increases by 56% to 78% (depending on response categories compared). Thus, having multiple community partners as part of a school-based program is likely to enhance the program's reach and engagement, especially in moving a program beyond the one day event. Among schools with high levels of WTS program implementation, 57% reported that 6 or more different community groups were engaged in their WTS efforts, specifically groups such as police, media, local businesses, members of planning commissions, parents, corporate sponsors, and elected officials. It is likely that the type and quality of these partnerships, as well as their number, are important for greater implementation. These findings are consistent with literature on the use of coalitions in health promotion activities. A recent review article on coalition effectiveness by Zakocs and Edwards reported that tiveness . DespiteFunding is another important independent correlate of level of WTS program implementation. Although it is not surprising that "money matters," our results indicate that the absolute amount of funding needed to mount WTS activities is fairly modest. Even among schools that made policy/environment changes, less than 20% had budgets greater than $500. It may be that it is not the money itself that matters, but the endorsement that a funded project brings to the groups working to increase ATS . ResourcLength of involvement with the WTS program was also associated with higher levels of implementation. Almost half of the environment/policy group reported participation for three or more years compared to only 28% of the low implementation group. Although these data are cross-sectional and the cause-effect relation is unknown, we are encouraged to observe that experienced WTS Day participants are more likely to report activities that include additional programming and policy/environmental support. Sustainability of efforts to increase ATS is a key requirement for program success; however, maintaining such efforts is a major challenge . ParticiOur findings also suggest that an environmental assessment is important as schools attempt to promote ATS. A walkability assessment, such as the Walkability Checklist , may helAlthough the WTS program can be used to promote a number of different objectives, many health advocates suggest ATS as a way to promote lifestyle PA. Therefore, the observed association between level of implementation and increased ATS, although modest (r = 0.18), is of great interest. Of those making policy/environment changes, more than half perceived increased ATS. However, it is promising to see that even among the schools conducting only the WTS Day event, more than 25% perceived change in ATS. Obviously, these assessments should be viewed with caution. WTS programs typically are unable to conduct formal impact evaluations and WTS coordinators may not be suitably objective as to the program's effect.could participate in the WTS program do not.A sizeable number of surveys (n = 71) were eliminated from the analysis dataset because they failed to meet the inclusion criteria of participating in the 2002 WTS program. This group represents schools that thought they would participate, but failed to do so. Some had previously participated in WTS Day, while others were new to the program. Additional research is needed to elucidate why some schools that Our study has several strengths. We: 1) used a credible source to identify a large number of WTS program participants, 2) assembled a national advisory panel to help us construct a survey instrument, and 3) employed a multivariate modeling analysis to identify important program characteristics. Along with these strengths, however, were some limitations. We report data only from coordinators listed in the 2002 WTS registration database who responded (60%) to the survey. We do not know how many other schools engaged in WTS activities during 2002, but did not officially register. However, the schools surveyed generally are not dissimilar from other US schools based on a number of characteristics. Using data from the National Center for Education Statistics (NCES), average school enrollment for 2002–2003 was 439 for elementary schools, 617 for middle schools, and 754 for high schools . The majst Century (SAFETEA-LU), which authorized $612 million in funding over the next 5 years for Safe Route To School (SRTS) programs in all 50 states. This bill allows states to hire a SRTS coordinator, and sets aside at least 10% (and up to 30%) of the funds for non-infrastructure activities that encourage ATS. Programs such as WTS Day and its associated activities appear to provide an important gateway event that schools can use to initiate, motivate, and organize community participation. Caution obviously must be observed when drawing conclusions based on cross-sectional data from a select group of WTS participants. However, these findings are useful for emphasizing some of the characteristics associated with more comprehensive WTS programs. Policy and environmental changes are thought to have an important impact on behavioral outcomes for many health behaviors [Gaining a better understanding of characteristics and impact of WTS programs is needed, especially in light of the recent reauthorization of the Transportation Equity Act for the 21ehaviors , includiehaviors . Public The author(s) declare that they have no competing interests.DW served as the project's PI providing oversight for study design, data analysis, and manuscript development. LL served as a Co-I providing assistance with the planning of the study design, data analysis, and manuscript development. AV served as project manager providing oversight of data collection and contributing to manuscript development. BN served as the project biostatician conducting data analysis, assisting with data interpretation, and contributing to the manuscript development. SM and JF served as project officers providing guidance on study design, data analysis, and manuscript development. All authors read and approved the final manuscript.Marilyn Bull, Committee on Injury Prevention and Poison Prevention, American Academy of PediatricsKathie Carothers, Public Safety, City of ChicagoChristina Economos, School of Nutrition Science and Policy, Tuffs UniversityMark Fenton, walking consultantJanet Fulton, Centers for Disease Control and PreventionKaren Gerlach, Robert Wood Johnson FoundationDerek Graham, Transportation Services, NC Department of Public InstructionMary Pat Hanley, National SAFE KIDS CampaignDorothea Hass, WalkBostonWilliam Hall, Highway Safety Research Center, UNC Chapel HillChaun Hill, Transportation and Highway Safety, City of PhoenixWendi Kallins, Marin Safe Routes to SchoolsRich Killingsworth, Active Living By DesignMarilyn Leiber Governor's Council on Physical Fitness, Health and SportsLauren Marchetti, Pedestrian and Bicycle Information Center, UNC at Chapel HillSarah Levin Martin, Centers for Disease Control and PreventionPatrick McCormick, League of American BicyclistsTracy McMillan, Department of City and Regional Planning, University of California at IrvineBarbara Quinn, St. John's District Pedestrian Awareness ProjectGwyn Robertson, Cumberland County Schools (NC)Anne Seeley (deceased), University of California San FranciscoJessica Shisler, Centers for Disease Control and PreventionBill Smith, Parent RepresentativeCathy Thomas, Physical Activity and Nutrition Branch, NC Division of Public HealthJeff Tsai, School Transportation Group, NC State UniversitySally White, Palm Bay Elementary School (FL)* Affiliations listed are those at the time of the study.


A program has been developed for the control of Vapour PressureOsmometry (VPO) measurements. The output signal of a Vapour Pressure Osmometer is read by an A/D converter card installed in one of the expansion slots of a PC microcomputer. The stability of the measurements is checked by analysing the first derivative of the smoothed signals, which is calculated in real time. Sets of repeatedmeasurements are carried out under the supervision of a computer program as a check for their reproducibility. When the set is ended the program calculates the average and its standard deviation.The program is particularly valuable for evaluating VPO measurements for solution equilibria studies. This interfacing strategy may be applied to any kind of technique in which the time stability of the signals is the basis for defining measurement stability. The automated VPO has other advantages, including low cost and time saving.


Foundations and public agencies commonly fund focused initiatives for individual grantees. These discrete, stand-alone initiatives can risk failure by being carried out in isolation. Fostering synergy among grantees' initiatives is one strategy proposed for promoting the success and impact of grant programs. We evaluate an explicit strategy to build synergy within the Robert Wood Johnson Foundation's Southern Rural Access Program (SRAP), which awarded grants to collaboratives within eight southeastern U.S. states to strengthen basic health care services in targeted rural counties.We interviewed 39 key participants of the SRAP, including the program director within each state and the principal subcontractors heading the program's funded initiatives that supported heath professionals' recruitment, retention and training, made loans to health care providers, and built networks among providers. Interews were recorded and transcribed. Two investigators independently coded the transcripts and a third investigator distilled the main points.Participants generally perceived that the SRAP yielded more synergies than other grant programs in which they had participated and that these synergies added to the program's impact. The synergies most often noted were achieved through relationship building among grantees and with outside agencies, sharing information and know-how, sharing resources, combining efforts to yield greater capacity, joining voices to advocate for common goals, and spotting gaps in services offered and then filling these gaps. The SRAP's strategies that participants felt fostered synergy included targeting funding to culturally and geographically similar states, supporting complementary types of initiatives, promoting opportunities to network through semi-annual meetings and regular conference calls, and the advocacy efforts of the program's leadership. Participants noted that synergies were sometimes hindered by turf issues and politics and the conflicting perspectives and cultures of participating organizations and racial groups. Inadequate funding through the SRAP, restricting program involvement to only a few needy counties, and instances of over- and under-involvement by the program's leadership were sometimes felt to inhibit synergies and/or their sustainability.Participants of the SRAP generally perceived that the SRAP's deliberate strategies yielded synergies that added to the program's impact. Foundations and public agencies often support society's health and social goals by creating grant programs that fund stand-alone "categorical" initiatives. Experience has shown, however, that single, narrowly-targeted initiatives operating in isolation often gain little visibility, do not have sufficient impact to achieve their programmatic goals and do not attain sufficient momentum or attract enough other support to become self-sustaining . For exaPromoting synergy – when two or more organizations work together so their combined effect is greater than the sum of their individual effects – may be a useful approach to overcoming the common limitations of categorical grant programs. In its richest form, synergy entails more than creating relationships and exchanging information; it involves the merging of complementary perspectives, resources and skills in ways that produce new and greater value than would otherwise be achieved. The vitality, impact and sustainability of grant-funded initiatives might be strengthened if, from the outset, they are structured to make use of synergies and grantees are provided with opportunities and the means for linking with other grantees, initiatives and organizations. Synergy might help funded initiatives avoid the pitfalls of isolation.The Robert Wood Johnson Foundation's Southern Rural Access Program (SRAP) was a grant-funding program that supported four related types of initiatives to bolster basic health care services within select rural counties in eight states in the southeastern U.S. The SRAP intentionally sought to promote synergy to increase program impact; it helped funded initiatives link with other initiatives within and across states and with other initiatives in their states.Despite its promise, there has been little formal study of how grant programs can best foster synergies among their grantees and of whether synergy, indeed, promotes program outcomes. The goals of this evaluation were to assess the kinds of synergy that developed, and failed to develop, over the SRAP's eight years and to identify the design-features of the program that participants felt promoted synergies. This evaluation also assessed participants' perceptions of how synergies contributed to program success. Data for this evaluation were from telephone interviews with the SRAP's key participants conducted shortly after the program ended.Synergy refers to cooperative interaction among groups that creates an enhanced combined effect. In business, the potential for synergy is typically conceived as the closeness or relatedness of the resources or capabilities of two enterprises, such as acquired subsidiaries or merged parts of a corporation -6. EconoIn the health field, synergy has been conceived broadly as the advantages that groups and organizations realize when they collaborate through partnerships, networks, and alliances -20. The Although much work has been done to advance knowledge of synergy in community health partnerships, this article seeks to fill two important gaps. First, the emphasis that Lasker and her colleagues place on new and better ways of thinking obscures other forms of synergy that partnerships could produce, which may be as or more valuable. Second, the emphasis they place on partnership-level determinants of synergy obscures the potentially powerful role that foundations and other funding agencies can play in promoting or inhibiting synergy in partnerships. As a condition of funding and through ongoing interactions with grantees, foundations and public agencies can influence the goals that partnerships choose, the groups and organizations that are brought to the table, the governance and administrative processes they use, and the activities they perform. Given the time, energy, and resources that foundations and public agencies invest in partnerships, a stronger knowledge base about programmatic design features that support synergy development could strengthen efforts to improve health through collaboration.In the mid-1990s it was well known that health indices in the rural Southeastern U.S. lagged behind other regions of the country and that poverty and lack of health insurance were more common. Shortages of physicians and other health care professionals plagued the efforts of many southern rural communities to provide health care locally.The Robert Wood Johnson Foundation, the largest health philanthropy in the U.S., created the Southern Rural Access Program to address the chronic health care delivery problems of selected needy rural counties in eight Southeastern states – Alabama, Arkansas, Georgia, Louisiana, Mississippi, South Carolina, Texas and West Virginia . The staThe SRAP's work was initiated in 1997 when staffs of the Foundation and the NPO invited health care leaders within each of the eight states to submit proposals for four types of initiatives: (1) "pipeline" initiatives to prepare and guide middle school, high school and college students into health careers, (2) recruitment and/or retention initiatives to help physicians and other health professionals find work in the program's targeted rural areas and then remain there, (3) rural health network initiatives to link local health care organizations – typically hospitals and practices in adjacent counties – to promote service coordination, group purchasing, and other collaborations as they saw advantageous, and (4) revolving loan initiatives to offer low interest loans to help rural providers afford needed capital equipment. Initial three-year awards were made in 1998 to consortia in all eight states, with subsequent continuation awards made every two to three years. Funding for the program formally ended in the spring of 2006, after a total investment of $36 million. Among the findings of evaluations of various aspects of the SRAP were that (1) primary care physician numbers in the SRAP's high-poverty rural counties grew faster than in these states' other, non-targeted high-poverty rural counties ,38, and Building synergy was a central strategy of the SRAP. The overarching planned approaches for stimulating synergy were to layer related types of initiatives within geographically bounded areas where the staffs of initiatives would naturally come in frequent contact, and to promote partnerships among the program's numerous participating organizations within and across states. A key management approach was to create many opportunities for all possible partners – local health care organizations, community leaders, state agencies, funding institutions, policy experts and policy makers – to come together around their shared goals with the expectation that synergies would emerge.Specific features of the program's design and management intended to foster synergy included:Unlike most grant programs sponsored by national philanthropies and federal agencies, only eight southeastern states were invited to participate in the SRAP: there was no wider open competition for funds. It was thought that a regional approach would help participants from states with similar cultures, policy environments, strengths and challenges develop trust, learn from one another and build cohesion.The SRAP funded four types of related initiatives anticipating that they would be more effective together than operating individually.As initially envisioned for the SRAP and reinforced during states' 2002 grant renewal process, each grantee targeted its initiatives to a group of 16 to 31 contiguous counties that were generally among their most socio-economically disadvantaged.The program required grantees in each state to enlist a broad coalition of health care organizations and policy makers that was to prepare a single proposal for their state . Proposast Century Challenge Fund" through which SRAP participants could request additional funding from the RWJF for new, innovative initiatives if they secured co-funding from local and regional philanthropies  helped us with the underwriting and the servicing of the loans. They helped us pretty much set up the little details of the program, plus they furnished some of the funding for the projects that we worked on, so they were a key partnership. We also developed a partnership with the Rural Development arm of the USDA. We were able to get two grants from them; one was a direct grant for $900,000 and one was an Intermediary Relending Program grant for $500,000."Interviewees felt that the SRAP's semi-annual all-grantee meetings, monthly conference calls and NPO guidance all helped participants identify and learn how to work with new funding partners.Participants noted various ways in which the availability of the complementary services of the SRAP's several initiatives augmented the impact of each. This happened most often when the staff of one initiative referred clients – health professions students, physicians and medical practices – to another SRAP initiative. Cross-initiative referrals augmented the visibility of initiatives and promoted the use of their services. As intended in the program's design, participants felt that specific local health care providers sometimes benefited from the services of more than one initiative."So, I guess the combination between practice management, locum tenens, and recruitment and retention all helped strengthen the rural physician base in the community."About one-quarter of participants cited synergies that stemmed from combining the voices and power of participating organizations to gain greater recognition from legislators and funding agencies. This happened both within and between states. Instances of shared voice were not attributed to specific aspects of the SRAP's design but were more loosely seen as emerging from people and organizations with shared goals coming together through the program."The political influence has probably been the most important... this group has provided a cohesive rural voice that has always said... we are speaking for rural Alabama and we say, "You ought to do this", and that helped."About one-third of participants noted instances where interactions between SRAP organizations, or between SRAP-supported organizations and other organizations in their states, led to the identification and then filling of gaps in services within communities. Gap spotting and closure were fostered by the SRAP's approach of funding several initiatives addressing the same or related health care problems within geographically circumscribed areas and by the assistance that NPO staff provided to grantees.avoid duplicating services, that is to recognize and reduce redundant and wasteful capacity when two organizations are offering similar programs. Also, only two participants gave examples of benefiting from economies of scale, where program unit costs of production are reduced by two organizations coming together to jointly produce a larger volume of services. We suspect that these two types of synergy were seldom realized because the SRAP's targeted counties were profoundly poor and their resources scarce, so there were few redundant services that needed to be scaled back. Also, the SRAP's initiatives generally provided personally delivered services, which less often lend themselves to economies of scale.Fewer than 5 to 10 of the 39 SRAP participants we interviewed mentioned some of the types of synergies that figure prominently in the corporate literature on synergy. We heard only a few mentions that collaborations allowed participants to creating spin-off initiatives and organizations from parent collaborating organizations – was reported from only two kinds of collaborations within the SRAP. The first was the creation of the Southern Regional Health Consortium (SRHC), which emerged from the relationships that formed among the lead agencies of the eight states. The second was the handful of instances where relationships that formed with state governmental agencies eventually led these agencies to assume the ongoing funding and, in some cases, administrative control of the initiatives as the SRAP's funding ended.Another type of synergy popular in business – Most participants could readily identify specific barriers to synergy, which were principally of three types Table :1. Turf issues and politics, which arose from concerns over who would "get credit" for the successes of collaborative efforts.2. Differences in organizational type, structure and agendas between collaborating organizations, which led partners to view the world differently and make them responsive to different incentives.3. Racial differences in perspectives and racial tensions, which inhibited communications, trust and the functioning of some groups.A number of factors about the SRAP itself were also noted to sometimes inhibit synergies Table :1. A few participants cited instances when the NPO needed to have been more actively involved to push collaborations forward, and others cited instances when they felt the NPO was over-involved and attempting to micro-manage collaborations.2. Some participants felt that the program sometimes provided too few dollar incentives to support collaboration, which reduced the motivation of partners to work together. Similarly, participants noted that some previously successful collaborations weakened towards the end of the program as funding was weaned.3. Several participants felt that geographically focusing the SRAP's initiatives on specific contiguous counties within each state was, on balance, counterproductive because it introduced a sense of exclusion, caused resentment in non-included counties within some states which hampered the program's external collaborations, and created problems for some state agencies and organizations otherwise responsible for statewide programs.Participants were asked how the synergies they saw within the SRAP compared to what they have experienced through other foundation and public grant programs. Most had participated in other grant programs and felt the SRAP yielded more and more effective synergies. Individuals attributed the SRAP's success with synergies to each of its features intended to foster them, particularly its restriction to states within only a specific region, its requirement for joint leadership and planning, and the effectiveness of its grantee meetings."I think the synergies in the SRAP were very evident across state lines and across organization lines. It was much more than what I've seen with other types of programs."This study assessed synergy within the SRAP only as viewed by individuals who directly participated in the program; individuals outside the SRAP who interacted with its participants and initiatives might have perceived things differently. Also, we cannot confirm participants' perceptions that synergies enhanced the reach of the SRAP. As in any study that relies on subjects' reports, social desirability might have prompted this study's participants to portray their experiences and opinions in an overly positive light and withhold negative views. It seemed, however, that subjects were quite willing to share their full opinions, both positive and negative; only a few seemed to pull their punches.Events and factors that stand out prominently and are directly relevant to people are more likely to come to mind and be volunteered when they are interviewed with open-ended queries. SRAP participants might have overlooked some types of synergies that were less salient to them. Therefore, for example, if economies of scale were not important in the thinking of SRAP participants, then this may explain why we heard little about them in the interviews. We might have learned of more instances of economies of scale had we explicitly asked for examples of this type of synergy. Further, we might have missed some types of synergies that were difficult for subjects to describe or difficult for us, in coding, to discern from other, more commonly reported types of synergy.According to these reports from key participants of the Southern Rural Access Program, synergy was a broadly recognized feature of the program. Participants knew the SRAP was designed to foster synergy. Virtually all participants could name one or more examples of synergy they saw grow out of their states' involvement in the program and nearly all could identify features of the SRAP's design they felt promoted these synergies. As a whole, participants felt that the SRAP yielded more and richer synergies than other grant-funded initiatives in which they had participated and they felt that synergy contributed to the program's successes.These findings for the SRAP do not mean that synergy should be promoted in all grant-funded programs. Synergy is not always needed or appropriate. If an organization can do something well on its own, forcing synergy can be counterproductive . PromotiSynergy is also not always feasible . Some SRObservations from the SRAP's participants suggest that if foundations and other agencies intend to promote synergy among the initiatives they fund, then it should be built into the fabric of the program and pursued through multiple strategies: synergy doesn't just happen. Able program leadership is also key. Many of the SRAP's successful synergies came about because the National Program Office staff adeptly spotted opportunities and resources to support synergy, brokered relationships, and more generally helped grantees understand, value and learn how to create synergies.Finally, promoting synergy in grant programs may require investments in education and training to enhance grantees' collaborative competence. As Liedtka observed:Collaboration calls upon skills that have been rarely rewarded in most organizations – listening with an open mind to the proposals of others versus selling one's own solutions harder; acknowledging and using conflict productively versus suppressing and ignoring it; leading by supporting and facilitating versus managing through authority and fiat; and designing new end-to-end value systems rather than tinkering with incremental fixes to current processes. Fortunately, the skills needed to create synergies can be acquired and sharpened. Investing in education and training of grantees, typically through technical assistance, can enhance their ability to collaborate and not only increase the level and effectiveness of synergy within a grant program, but also create an enduring community capability. The relationships formed within the SRAP and the enhanced capacity of its participants to collaborate and find synergies may be the program's most important and lasting legacy. These strengthened capacities have placed the SRAP's states and rural counties in a better position to solve their health care problems, one of the program's original goals.The authors declare that they have no competing interests.DEP conceived of the study, contributed to its design and coordination, participated in data coding and helped draft the manuscript. EC assisted in the design and refinement of the interview guide, recruited study subjects, conducted the study's interviews, participated in data coding and helped draft the manuscript. BJW assisted in the design of the study and its coordination, participated in data coding, and helped draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:Interview guide for SRAP synergy assessment. This guide was used by EC during phone interviews to standardize the questions posed to study participants.Click here for file


We report the case of a 45-year-old male who presented with a 5-year history of shoulder pain following an injury. Clinical and radiological investigations revealed a ruptured long head of the biceps and a meso-os acromiale. We performed an arthroscopic resection of the intra-articular stump of the long head of the biceps, followed by internal fixation of the mobile os acromiale using a tension band technique. Rupture of the long head of the biceps associated with a symptomatic os acromiale has not been previously described. This case reinforces the importance of routine shoulder arthroscopy in the treatment of symptomatic os acromiale. Os acromiale is an unfused epiphysis of the anterior part of the acromion in a mature individual. It is prTo the best of the authors' knowledge a case of a symptomatic os acromiale associated with rupture of the long head of biceps (LHB) has not been reported in the literature to date. We describe the appropriate treatment and discuss the likely mechanism of the lesion and its clinical relevance.A 45-year-old right-handed gentleman presented with a 5-year history of chronic left shoulder pain. The symptoms had begun after a fall on ice, with the patient landing directly on his shoulder. At the initial consultation the patient presented with pain over the anterolateral and superior aspect of the shoulder that was exacerbated by overhead activities. He scored 6/10 on a pain visual analogue scale and 4/12 on the Simple Shoulder Test. An x-rayOn clinical examination there was reduced range of motion, with active forward elevation up to100° (passive 110°), active abduction up to 120° (passive 130°), external rotation up to 35°, and functional internal rotation to the level of L5. The acromion was tender and mobile; there was tenderness also on palpation of the bicipital groove. There was clinical evidence of a ruptured LHB. Radiological investigations confirmed the presence of an os acromiale, with AP and axillary views demonstrating the unfused epiphysis Figures .Shoulder arthroscopy revealed a 1.5-cm long, hypertrophic, and mobile LHB stump. There was also synovitis of the rotator interval and fraying of the anterior labrum. Excision of the stump was performed using the technique described for a tenotomy of a hypertrophic LHB tendon. The arthAfter completion of the arthroscopy, a limited anterosuperior approach was made, elevating the deltoid at the level of the unfused physis. The cartilaginous apophysis was excised, exposing cancellous bone anteriorly and posteriorly. The bone ends were compressed and fixed with two Kirschner wires and a figure-of-eight tension band technique. The deltoid was repaired with sutures.Union was achieved by 9 weeks postoperatively. Postoperative x-ray demonstrated the tension band wires holding the fixation . At the When conservative measures for symptomatic os acromiale fail to relieve symptoms, surgical intervention should be considered. Options include excision of a meta-acromion, open reduction and internal fixation of meso- and pre-acromia, and arthroscopic decompression.Literature review showed that trauma was associated with 42% of the cases of os acromiale that required internal fixation. The presOs acromiale is a recognised associated finding in patients with subacromial impingement and rotator cuff tears. Rotator 5In our patient, bone grafting was not necessary. Internal fixation without bone grafting has shown good results, with satisfaction rates being as high as 92%.The association of an os acromiale with a ruptured LHB has not previously been described. In this case, the patient presented with the clinical features of a symptomatic os acromiale and LHB pathology. We cannot be certain when the tendon rupture occurred, although its location at the entrance of the bicipital groove as well as the presence of tendon hypertrophy are suggestive of a rupture caused by persistent impingement and degenerative attrition. It is uncommon for a ruptured LHB to leave a significant intra-articular stump; in this case it was evidently the source of his ongoing symptoms.Long head of the biceps tenotomy, with excision of its intra-articular portion, has been described for hypertrophic LHB tendons and thisAwareness of this association is required to prevent failures of surgical treatment for os acromiale. MRI in this case demonstrated the LHB pathology; a simple ultrasound may have been difficult to interpret. In cases with an intact rotator cuff on imaging studies, arthroscopy may not routinely be performed. We suggest that diagnostic arthroscopy be performed in all cases scheduled for surgical treatment for os acromiale.


Tobacco mosaic virus (TMV)-based vectors are much higher than those possible from plant promoters. However the common TMV expression vectors are costly, and at times technically challenging, to work with. Therefore it was a goal to develop TMV expression vectors that express high levels of recombinant protein and are easier, more reliable, and more cost-effective to use.Plants are increasingly being examined as alternative recombinant protein expression systems. Recombinant protein expression levels in plants from Cauliflower mosaic virus (CaMV) 35S promoter-driven TMV expression vector that can be delivered as a T-DNA to plant cells by Agrobacterium tumefaciens. Co-introduction (by agroinfiltration) of this T-DNA along with a 35S promoter driven gene for the RNA silencing suppressor P19, from Tomato bushy stunt virus (TBSV) resulted in essentially complete infection of the infiltrated plant tissue with the TMV vector by 4 days post infiltration (DPI). The TMV vector produced between 600 and 1200 micrograms of recombinant protein per gram of infiltrated tissue by 6 DPI. Similar levels of recombinant protein were detected in systemically infected plant tissue 10–14 DPI. These expression levels were 10 to 25 times higher than the most efficient 35S promoter driven transient expression systems described to date.We have constructed a These modifications to the TMV-based expression vector system have made TMV vectors an easier, more reliable and more cost-effective way to produce recombinant proteins in plants. These improvements should facilitate the production of recombinant proteins in plants for both research and product development purposes. The vector should be especially useful in high-throughput experiments. Tobacco mosaic virus (TMV)-based vectors express the highest levels of foreign protein in plants . Alth. Alth2]) Review ,4). TMV'. TMV'Tob  the deletion of the TMV coat protein (CP) gene, (2) generating nearly 100 point mutations to destroy cryptic introns in the viral cDNA, and (3) inserting multiple (up to 24) plant-gene introns into the TMV cDNA sequences in a binary vector .A. tumefaciens cultures carrying intron-modified TMV sequences in a binary vector. While the magnifection process is very efficient, it is not easily adapted to a high throughput workflow. Also, the increased size of the intron-modified vectors can make cloning into these vectors more challenging. In addition, it is not clear if the intron-modified vectors are absolutely required for efficient agroinfection of local and systemic infection of plant tissue with a TMV vector.The point mutations and inserted introns dramatically improved the infectivity of the TMV replicon delivered to plants by agroinfection. However, because of the deletion of the CP gene, this replicon cannot move systemically in plants. Plants were therefore infected in a process called "magnifection" ,15 in whTherefore, there is a need for TMV expression vectors with the following features: 1) contains convenient cloning sites for genes of interest 2) can be used to infect plants in an easy and cost-effective manner, and 3) leads to efficient local and systemic infection of inoculated plants. To address these needs, a 35S promoter driven version of a commonly used TMV expression vector (containing the TMV CP gene)  was consNicotiana benthamiana plants via agroinfection. Using GFP-expressing TMV vectors, it was determined that the agroinfection efficiency of 35S driven TMV clones was significantly increased by ectopic expression of a protein with RNA silencing suppressor ability. This high-efficiency agroinfection procedure made it possible to express approximately 600 to 1200 μg of recombinant GFP per gram of agroinfiltrated tissue, and to reliably obtain plants that expressed GFP in systemically infected tissue. These results significantly extend the utility of the TMV expression vector system. The cloning and/or agroinfection procedure modifications described here can be readily applied to other cloning and expression vector systems and are especially amenable to high-throughput cloning workflows. These improvements should make it easier and more cost effective to use TMV-based plant expression vectors in research and development.The various 35S promoter-driven TMV vectors constructed reliably infected gfp) gene and the p19 (RNA silencing suppressor) gene from TBSV were constructed for this experiment  driven TMV vectors, as well as 35S driven versions of the green fluorescent protein (A. tumefaciens (A.t.) transformed with pJL43:GFP were prepared essentially as described in Johansen and Carrington )p19 is expressed in the plant cell the P19 protein binds 21 nt duplex RNAs  containing the coding sequence for two SapI restriction endonuclease sites (gctcttc), the V5 epitope (amino acid sequence GKPIPNPLLGLD) and a hexa-histidine (His6) tag coding sequence was inserted downstream of the additional TMV subgenomic promoter.To construct pJL43 Figure  the ds DTo prepare pJL-43 for sticky RICE cloning, plasmid DNA was digested with the restriction endonuclease SapI, treated with calf alkaline intestinal phosphatase and column purified.For sticky RICE cloning of PCR products into SapI cut pJL 43 the 5' end of the forward PCR direction primer must have the following sequence: 5' GGCCWW. The 5' end of the reverse direction PCR primer should be 5' GCWW. In the primer sequences W = A or T. The T and A residues in the primers will serve as "stop nucleotides" during the sticky RICE reaction, in which PCR products were incubated in the presence of a DNA polymerase with 3' to 5' exonuclease activity and dATP and dTTP. The DNA polymerase removed nucleotides from the 3' ends of each strand until an A or T residue was present in the template stand. This resulted in 5' overhangs on each end of the PCR products Figure .gfp gene was amplified by the PCR from a pUC-based plasmid with forward direction primer JAL 286 (GGCCT aaa atggctagcaaaggagaag) and reverse direction primer JAL 287 (GCttatttgtagagctcatccat). The primer nucleotides that were converted to sticky ends by T4 DNA polymerase are in bold. PCR reactions using either non-phosphorylated or 5' phosphorylated primers were performed. PCR products were purified to remove unincorporated dNTPs and primers and eluted in dH20.Using these guidelines for primer design, the gfp gene PCR product was combined with 50 ng SapI cut and phosphatase treated pJL 43 DNA in a 10 ul reaction volume composed of: 1 × ligase buffer, 0.1 mM (each) dATP/dTTP, 0.25 Units T4 DNA Polymerase, and 400 Units T4 DNA ligase. Enzymes, buffers and unit definitions were all from New England Biolabs. The assembled reaction was incubated at room temperature for 30 minutes.A three-fold molar excess of phosphorylated gfp gene PCR products were also cloned using the same reaction conditions except that 0.5 Units T4 polynucleotide kinase were also included in the Sticky RICE cloning reaction. The cloning of the gfp gene into pJL 43 resulted in plasmid pJL43:GFP.For purposes of comparison, non-phosphorylated E. coli . Transformation conditions were essentially as per manufacturers instructions. Transformed cells were plated on LB plates with 50 ug/ml Kanamycin.Two microliters of a sticky RICE ligation reaction was added to 25 ul of chemically competent E. coli, individual colonies were used to inoculate LB broth with 50 ug/ml Kanamycin. Plasmids were purified from overnight liquid cultures. Because the forward-direction primer used for PCR began with the sequence "GGCCT" a StuI restriction enzyme recognition site was generated upon sticky RICE joining of PCR product to pJL 43. Therefore plasmids were screened by digestion with StuI and digested DNA separated on 1% agarose gels to identify clones that had inserts  samples were ground in the presence of 4 volumes (per gram fresh weight) 50 mM Tris, pH 7.5, 150 mM NaCl, 0.1% Tween-20, 0.1% beta-mercaptoethanol. Extracts were clarified by centrifuging for 15 minutes at 12–15 K × g. Samples of clarified extract were combined with SDS-PAGE loading dye and analyzed on 4–20% SDS-PAGE gels. Gels were stained with coomassie blue to visualize proteins.Healthy and TMV:GFP infected plant tissue (from TMV vector launched from the Plant protein extracts (prepared as described above) were diluted in 50 mM Carbonate buffer (pH 9.6). Samples were assayed for GFP activity with a Perkin-Elmer HTS 7000 BioAssay Reader using filters of 405 nm excitation/535 nm emission. A standard curve was prepared from purified His-6 tagged GFP (purified from plants).TMV- Tobacco mosaic virus.GFP- Green Fluorescent Protein.MW- Molecular Weight.DPI- Days Post Infiltration.ds- Double stranded.MP- Movement protein.CP- Coat (capsid) protein.  JAL conceived of this study, designed and performed all experiments and wrote the manuscript. All authors read and approved the final manuscript.


Orientia tsutsugamushi between paired samples were 23.8%  and 86.2% (95% CI = 84.1–88.6%), respectively. Sensitivity and specificity for the ST ICT determined by using an admission IgM titer ≥ 1:400 were 39.1% (95% CI = 34.1–44.2%) and 99.5% (95% CI = 98.7–99.9%), respectively. Sensitivity and specificity for the MT IBT determined by using the criteria of a four-fold increase in IgM against Rickettsia typhi between paired serum samples were 61.2% (95% CI = 53.7–68.3%) and 86.5% (95% CI = 84.1–88.8%), respectively. Sensitivity and specificity for the MT IBT determined by using an admission IgM titer ≥ 1:400 were 54.6% (95% CI = 49.1–60.0%) and 94.1% (95% CI = 92.0–95.7%), respectively. Both assays had relatively good specificity but low sensitivity and thus have limited utility for admission diagnosis.We studied the diagnostic accuracy of a rapid immunochromatographic test (ICT) for detection of IgM against scrub typhus (ST ICT) and an immunoblot test for the detection of IgM against murine typhus (MT IBT) by using admission serum samples from 1,030 febrile patients in Laos. Sensitivity and specificity for the ST ICT determined by using the diagnostic criteria of a four-fold increase in IgM against  Orientia tsutsugamushi, and murine typhus, caused by Rickettsia typhi, are important acute febrile illnesses in the Asia–Pacific region.O. tsutsugamushi and R. typhi, and the gold standard assay is the indirect immunofluorescent antibody (IFA) assay.6Scrub typhus, caused by O. tsutsugamushi and an IBT for detection of IgM against R. typhi to aid the diagnosis of acute scrub and murine typhus infection in patients in the tropical and disease-endemic environment of the Lao People's Democratic Republic (Laos).We assessed the diagnostic capacity of a commercially available rapid ICT for detection of IgM against The study was conducted at Mahosot Hospital in Vientiane, Laos during March 2003–May 2007. Ethical clearance was granted by the Ethical Review Committee of the Faculty of Medical Sciences, National University of Laos, Vientiane, Laos, and by the Oxford University Tropical Ethics Research Committee, United Kingdom. After informed written consent was obtained, consecutive inpatients of any age were recruited if the responsible physician suspected typhus, characterized by a minimum of fever, headache, and/or myalgia. Venous blood samples were collected on the day of admission and during convalescence at or after discharge from the hospital. Serum was divided for immediate use and for storage at –80°C.O. tsutsugamushi pooled Karp, Kato, and Gilliam antigens) and murine typhus (R. typhi Wilmington strain antigen) IgM was detected by using an IFA assay.IgM against scrub typhus  (ST ICT) was performed on admission-phase specimens according to the manufacturer's instructions. Briefly, 5 µL of serum was applied to the reagent pad of the ICT strip and two drops of buffer was added. Results were read visually 10 minutes later. Results were recorded as positive, equivocal, or negative for the IgM against R. typhi and thus negative. Samples that resulted in 3 or 4 dots were considered seroreactive with IgM against R. typhi.The Murine typhus Dip-S-Ticks IBT (Panbio) (MT IBT) was performed on admission specimens according to the manufacturer's instructions with the modification that the manufacturer provided goat anti-human IgG and alkaline phosphatase–conjugated goat anti-human IgM to make the assay specific for detection of IgM. Samples were assessed by trained staff in a routine hospital laboratory, as described above. Using the interpretation provided by the manufacturer, the presence of ≤ 2 dots was considered not seroreactive with IgM against P < 0.05) between rapid test positivity rates and days of fever and IgM IFA assay titer and assay cross-reactivity using different diagnostic criteria were calculated by using Pearson's chi-square test.Diagnostic accuracy was calculated using ST ICT and MT IBT results compared with the gold standard reference IFA assay results for each patient sample. The gold standard reference IFA assay result used in this study was that an admission-phase sample IgM IFA assay titer ≥ 1:400To examine the true diagnostic utility of the rapid tests in a clinical setting, four questions were posed.1) In a patient with suspected acute typhus infection, how accurate were the ST ICT and MT IBT for diagnosis of scrub and murine typhus, respectively, in absolute terms when compared with the above mentioned established IFA diagnostic criteria?O. tsutsugamushi and R. typhi admission-phase IgM IFA assays?2) What is the relative accuracy of the admission ST ICT and MT IBT for the detection of IgM compared with the gold standard O. tsutsugamushi and R. typhi on the diagnostic utility of ST ICT and MT IBT compared with gold standard IFA assays for antibodies against O. tsutsugamushi and R. typhi?3) What is the effect of cross-reactivity between antibodies to O. tsutsugamushi and R. typhi IFA assay-positive patients?4) What is the effect of sample timing, in relation to the duration of illness, on the ST ICT and MT IBT positivity rates for IgM against O. tsutsugamushi and R. typhi IgM IFA reference serologic analysis to determine scrub and murine typhus antibody status of the patients. A total of 8.3%  of the patients were children (age < 15 years). All patients were assessed by using the ST ICT and the MT IBT. Median number of days of fever at the time of collection of the admission-phase sample was 6 (IQR = 5–10 days), and median interval between obtaining admission-phase and convalescent-phase samples was 7 days (IQR = 5–10 days).Admission-phase and convalescent-phase serum samples  from 1,030 patients  were evaluated by O. tsutsugamushi IFAs, and 376 (36.1%) of 1,030 patients had admission-phase IgM titers ≥ 1:400. Four hundred twenty-six (41.4%) of 1,030 patients had admission-phase IgM titers ≥ 1:400 or a ≥ 4-fold increase in titer between paired specimens  of 1,030 patients had a ≥ 4-fold increase in titer between paired specimens in pecimens .R. typhi IFAs, and 339 (32.9%) of 1,030 patients had admission-phase IgM titers ≥ 1:400. Four hundred nine (39.7%) of 1,030 patients had admission-phase IgM titers ≥ 1:400 or a ≥ 4-fold increase in titer between paired specimens  of 1,030 patients had a ≥ 4-fold increase in titer between paired specimens in the pecimens .1) In a patient with suspected acute typhus infection, how accurate were the ST ICT and MT IBT in diagnosis of scrub and murine typhus, respectively, in absolute terms, when compared with previously established diagnostic criteria for scrub typhus?For the ST ICT, when we used the stringent ≥ 4-fold increase in IFA titer between paired serum samples as the diagnostic criterion, sensitivity of the ST ICT for admission-phase samples was 23.8% . For patients with an IgM IFA titer ≥ 1:400, sensitivity was 39.1% . Specificities were 86.2%  and 99.5% , respectively. For samples with a ≥ 4-fold increased IFA titer between paired serum samples or IgM IFA titer ≥ 1:400, sensitivity was 34.7%  and specificity was 99.7%  .For the MT IBT, when we used the stringent ≥ 4-fold increase in IFA titer between paired serum samples as the diagnostic criterion, sensitivity of the MT IBT for admission-phase samples was 61.2% . For patients with an IgM IFA titer ≥ 1:400, sensitivity was 54.6% . Specificities were moderately high at 86.5%  and 94.1% , respectively. For samples with ≥ 4-fold rising IFA titer between paired serum samples or IgM IFA titer ≥ 1:400, sensitivity was 48.4%  and specificity was 95.5%  .O. tsutsugamushi and R. typhi admission-phase IgM IFA assays?2) What is the relative accuracy of the admission ST ICT and MT IBT for the detection of IgM compared with the gold standard 2 = 697.2 and 445.4, respectively; both P < 0.00005)  and the specificity was 96.8% (95% CI = 95.4–97.9%). For the MT IBT (n = 74) sensitivity for antibody to R. typhi was 94.6% (95% CI = 86.7–98.5%) and specificity was 83.7% (81.2–86.0%).There was a significant association between ST ICT and MT IBT positivity rates and increasing IFA IgM titers (ST ICT and MT IBT Pearson's χ0.00005) . The MT ectively . Importaectively . This fiO. tsutsugamushi and R. typhi on the diagnostic utility of ST ICT and MT IBT compared with gold standard IFA assays for antibodies against O. tsutsugamushi and R. typhi?3) What is the effect of cross-reactivity between antibodies to We investigated the utility of the ST ICT and MT IBT to detect heterologous antibodies for detection of both typhus diseases. Cross-reactivity in the MT IBT for detection of antibodies to scrub typhus ranged from 16.7% to 17.8% depending on the diagnostic criteria used . When weO. tsutsugamushi and R. typhi IFA assay-positive patients?4) What is the effect of sample timing, in relation to the duration of illness, on the ST ICT and MT IBT positivity rates for IgM against Rapid test positivity rates for the three reference diagnostic criteria were largely constant with increasing days of illness for both rapid tests until day 10 or 12 of fever when there was a marked increase in positivity . The ST This study examined the accuracy of the Panbio scrub typhus ICT and the murine typhus IBT in IgM formats for diagnosis of scrub and murine typhus in a prospectively recruited series of patients with typhus-like illness in an area where scrub and murine typhus are common.2The ST ICT and MT IBT had low sensitivity for accurate diagnosis of typhus for admission-phase specimens, which suggested that these rapid assays have limited usefulness for diagnosis of typhus-like illness in this disease-endemic setting. Comparison with reference IFA techniques demonstrated that much higher antibody titers than patients would normally have on admission  were required to generate positive results in the rapid assays. Sensitivity of these assays may be improved by increasing the amount of antigen on the test strips.The time when the sample was obtained was an important factor in accuracy of the rapid tests. The ST ICT did not show acceptable levels of sensitivity until well after the median day of presentation in this study (seven days), which was reflected in poor overall sensitivity results. This effect was less pronounced for the MT IBT.Given that the current recommendations for treatment of scrub and murine typhus are similar, oral doxycycline for seven days,For the scrub typhus ICT, accuracy estimates were lower than those in previous studies with the same product; sensitivities ranged from 74% to 96% and specificities ranged from 86% to 99%.In this study, we used three diagnostic reference standards; the four-fold increasing antibody titer in paired samples, an admission IFA IgM titer ≥ 1:400,7O. tsutsugamushi in Laos are antigenically diverse,R. typhi diagnosis, but there are few data to make this judgment.An additional issue affecting sensitivity is that it is likely that This study has demonstrated that in a low-resource, typhus-endemic setting, the Panbio scrub typhus ICT and murine typhus Dip-S-Ticks IBT for detecting IgM have potential for diagnosing acute infections. With a high specificity a positive result in either test is a reliable marker of scrub typhus or murine typhus but, in their current format, they have low sensitivity to be clinically useful. Further development of these tests, perhaps with a lower antibody cut-off value, as expressed visually, may increase the sensitivity.