Fibrillin-1 and asprosin, novel players in metabolic syndrome.

Fibrillin-1 is a major component of the extracellular microfibrils, where it interacts with other extracellular matrix proteins to provide elasticity to connective tissues, and regulates the bioavailability of TGFß family members. A peptide consisting of the C-terminal 140 amino acids of fibrillin-1 has recently been identified as a glucogenic hormone, secreted from adipose tissue during fasting and targeting the liver to release glucose. This fragment, called asprosin, also signals in the hypothalamus to stimulate appetite. Asprosin levels are correlated with many of the pathologies indicative of metabolic syndrome, including insulin resistance and obesity. Previous studies and reviews have addressed the therapeutic potential of asprosin as a target in obesity, diabetes and related conditions without considering mechanisms underlying the relationship between generation of asprosin and expression of the much larger fibrillin-1 protein. Profibrillin-1 undergoes obligatory cleavage at the cell surface as part of its assembly into microfibrils, producing the asprosin peptide as well as mature fibrillin-1. Patterns of FBN1 mRNA expression are inconsistent with the necessity for regulated release of asprosin. The asprosin peptide may be protected from degradation in adipose tissue. We present evidence for an alternative possibility, that asprosin mRNA is generated independently from an internal promoter within the 3' end of the FBN1 gene, which would allow for regulation independent of fibrillin-synthesis and is more economical of cellular resources. The discovery of asprosin opened exciting possibilities for treatment of metabolic syndrome related conditions, but there is much to be understood before such therapies could be introduced into the clinic.

A phage-encoded nucleoid associated protein compacts both host and phage DNA and derepresses H-NS silencing.

Nucleoid Associated Proteins (NAPs) organize the bacterial chromosome within the nucleoid. The interaction of the NAP H-NS with DNA also represses specific host and xenogeneic genes. Previously, we showed that the bacteriophage T4 early protein MotB binds to DNA, co-purifies with H-NS/DNA, and improves phage fitness. Here we demonstrate using atomic force microscopy that MotB compacts the DNA with multiple MotB proteins at the center of the complex. These complexes differ from those observed with H-NS and other NAPs, but resemble those formed by the NAP-like proteins CbpA/Dps and yeast condensin. Fluorescent microscopy indicates that expression of motB in vivo, at levels like that during T4 infection, yields a significantly compacted nucleoid containing MotB and H-NS. motB overexpression dysregulates hundreds of host genes; ∼70% are within the hns regulon. In infected cells overexpressing motB, 33 T4 late genes are expressed early, and the T4 early gene repEB, involved in replication initiation, is up ∼5-fold. We postulate that MotB represents a phage-encoded NAP that aids infection in a previously unrecognized way. We speculate that MotB-induced compaction may generate more room for T4 replication/assembly and/or leads to beneficial global changes in host gene expression, including derepression of much of the hns regulon.

Interpregnancy Body Mass Index Change and Offspring Mortality Risk following the Second Pregnancy.

OBJECTIVE: The aim of the study is to examine the impact of maternal interpregnancy body mass index (BMI) change on subsequent offspring mortality risk. STUDY DESIGN: This is a retrospective cohort study of women who had two consecutive live singleton deliveries of at least 20 weeks' gestation from the Utah Population Database. Our exposure was defined as interpregnancy BMI change from the date of first delivery to the conception date of subsequent pregnancy. We categorized BMI change as: < - 1, -1 to 0, 0 to <1 (reference), 1 to 2, 2 to 4, ≥4 kg/m2. Our primary outcome was all-cause age-specific mortality during four time periods: neonatal (≤28 days), infant (29 days to <1 year old), childhood ((≥1 to <5 years old), and late childhood (5 to <18 years old). We also examined mortality specifically attributed to congenital anomalies. Analyses used Cox proportional hazard models stratified by full term (≥37 weeks) and preterm (<37 weeks) deliveries. All models were adjusted for relevant confounders. RESULTS: Of 266,752 women, among full-term deliveries, women with a BMI increase of 4 kg/m2 or more had an increased risk of neonatal mortality in their subsequent pregnancy (hazard ratio or HR = 1.72, 95% confidence interval or CI: 1.23-2.41) Women who lost 1 kg/m2 or more between deliveries also had increased neonatal mortality (HR = 1.46, 95% CI: 1.04-2.05). There were no differences in infant, early, or late childhood mortality by interpregnancy BMI change. Maternal interpregnancy interval weight loss of 1 kg/m2 or more and weight gain of ≥4 kg/m2 also had increased risk of mortality associated with congenital anomalies or conditions arising during the neonatal period following their subsequent delivery. CONCLUSION: Women with significant interpregnancy weight gain and modest weight loss have a significant increased risk of neonatal mortality following their subsequent pregnancy. KEY POINTS: · Significant weight gain between deliveries increases the risk of neonatal death.. · Modest weight loss between deliveries increases the risk of neonatal death.. · This risk may be partially explained by increased risk of congenital malformations..

Understanding the mediated relationship between moral distress, depression, and suicide risk in undergraduate nursing students.

BACKGROUND: Nursing students are at higher risk for depression, suicide, and other mental health concerns as compared to the general college student population. Moral distress and other ethical issues may be a significant source of psychological harm within nursing student experiences and warrants further attention. PURPOSE: The purpose of this study was to understand the mediating effect of depression on the relationship between moral distress and suicide risk among undergraduate nursing students. METHODS: This cross-sectional analysis was derived from a larger sequential mixed methods study. The first phase was an online survey completed by a national sample of N = 679 nursing students in the United States. FINDINGS: The relationship between moral distress and suicide risk was fully mediated by depression and statistically significant at the alpha = 0.05 level. CONCLUSION: All three psychological variables (depression, moral distress, suicide risk) impact nursing students and require innovative solutions within nursing and educational programs.

Rural Community Pharmacy Approaches to Lethal Means Management for Suicide Prevention.

INTRODUCTION: Medications are common means of suicide. Rural areas have high suicide rates, greater proportions of older adults and veterans, and few providers. We assessed the implementation potential of community pharmacy interventions for lethal means management (LMM). METHODS: The feasibility, acceptability, and appropriateness of 8 LMM interventions were assessed by pharmacists in seven southeastern states via an online survey. Descriptive statistics were calculated. RESULTS: Pharmacists (N = 61) responded from 42 zip codes. The majority indicated that five (62.5%) interventions were very/extremely feasible, appropriate and acceptable. The greatest proportion rated medication therapy management (MTM) as very or extremely feasible, appropriate and acceptable (82%) followed by limiting prescription drug days' supplies (75.4%), blister packaging (68.9%), dispensing naloxone (62.3%), and suicide prevention training (59.0%). No pharmacies were currently distributing gun locks; however, some were already managing suicide risk with limited days' supply (31.7%), MTM (26.7%), naloxone distribution with every opioid dispensed (15.0%), monitoring patients for suicidal adverse events (16.7%), limits on sales or stock of non-prescription products (16.7%) or blister packaging (1.7%). DISCUSSION: Pharmacists endorsed LMM interventions, and most were already offering the endorsed interventions but not for LMM. CLINICAL IMPLICATIONS: The rural community pharmacists in this study believed several LMM services were highly feasible, acceptable and appropriate for use in preventing suicide.

Community pharmacies offer services that may support clinicians managing patients at risk of suicide or with a history of suicidal behavior, including MTM, blister packaging, limited days' supply/more frequent refills to support monitoring of patient outcomes and suicide warning signs, distribution of naloxone and gun locks and training pharmacy staff in Pharm-SAVES gatekeeping.The majority of rural community pharmacists reported that 5 of 8 lethal means management (LMM) interventions were appropriate, feasible and acceptable with common barriers being lack of both reimbursement and time.Interprofessional training and protocols for LMM interventions and indications could support implementation by pharmacists in support of patients.

The impact of Marfan syndrome on an Aboriginal Australian family: 'I don't like it as much as I don't like cancer'.

Marfan syndrome (MFS) is an autosomal dominantly inherited connective tissue disorder. Aortic dilatation/dissection and ectopia lentis are the most severe features, which affect physical functioning and psychological well-being. In Aboriginal Australians, there is little psychosocial research on genetic conditions. This study explored the physical, psychological, and practical impacts of MFS on Aboriginal Australians. Eighteen (8 affected and 10 unaffected) members of a large Aboriginal Australian family with MFS participated in an ethically approved study. Semi-structured qualitative interviews were conducted, transcribed verbatim, and analyzed thematically. All individuals reported challenges from MFS, negatively affecting day-to-day living. Severe vision impairment was perceived as the greatest challenge, contributing to feelings of stigma and exclusion. With aging, concerns shifted toward cardiac complications. The unpredictability of lens dislocation and aortic dissection was reported to be psychologically challenging. Participants described MFS-related barriers to obtaining and retaining employment, especially following cardiac surgery; with consequential psychological and financial hardships. Participants articulated that their cultural drive to support the ill and respectfully mourn the deceased, regardless of distance, resulted in a significant financial burden. Additionally, when hospitalization and/or funerals occurred, financially solvent individuals were expected to share resources, without any expectation of repayment or reciprocity (i.e., 'demand sharing', common in Aboriginal Australian culture). This study documents the nature and pervasiveness of uncertainty for both affected and unaffected members of an MFS family. Many reported challenges are consistent with other MFS cohorts (including stigma, social exclusion, and unemployment). However, our findings suggest that cultural values may exacerbate the financial costs of MFS for Aboriginal Australians.

Gold nanoshell-localized photothermal ablation of prostate tumors in a clinical pilot device study.

Biocompatible gold nanoparticles designed to absorb light at wavelengths of high tissue transparency have been of particular interest for biomedical applications. The ability of such nanoparticles to convert absorbed near-infrared light to heat and induce highly localized hyperthermia has been shown to be highly effective for photothermal cancer therapy, resulting in cell death and tumor remission in a multitude of preclinical animal models. Here we report the initial results of a clinical trial in which laser-excited gold-silica nanoshells (GSNs) were used in combination with magnetic resonance-ultrasound fusion imaging to focally ablate low-intermediate-grade tumors within the prostate. The overall goal is to provide highly localized regional control of prostate cancer that also results in greatly reduced patient morbidity and improved functional outcomes. This pilot device study reports feasibility and safety data from 16 cases of patients diagnosed with low- or intermediate-risk localized prostate cancer. After GSN infusion and high-precision laser ablation, patients underwent multiparametric MRI of the prostate at 48 to 72 h, followed by postprocedure mpMRI/ultrasound targeted fusion biopsies at 3 and 12 mo, as well as a standard 12-core systematic biopsy at 12 mo. GSN-mediated focal laser ablation was successfully achieved in 94% (15/16) of patients, with no significant difference in International Prostate Symptom Score or Sexual Health Inventory for Men observed after treatment. This treatment protocol appears to be feasible and safe in men with low- or intermediate-risk localized prostate cancer without serious complications or deleterious changes in genitourinary function.

Microdeletion of 9q22.3: A patient with minimal deletion size associated with a severe phenotype.

Basal cell nevus syndrome (also known as Gorlin Syndrome; MIM109400) is an autosomal dominant disorder characterized by recurrent pathological features such as basal cell carcinomas and odontogenic keratocysts as well as skeletal abnormalities. Most affected individuals have point mutations or small insertions or deletions within the PTCH1 gene on human chromosome 9, but there are some cases with more extensive deletion of the region, usually including the neighboring FANCC and/or ERCC6L2 genes. We report a 16-year-old patient with a deletion of approximately 400,000 bases which removes only PTCH1 and some non-coding RNA genes but leaves FANCC and ERCC6L2 intact. In spite of the small amount of DNA for which he is haploid, his phenotype is more extreme than many individuals with longer deletions in the region. This includes early presentation with a large number of basal cell nevi and other skin lesions, multiple jaw keratocysts, and macrosomia. We found that the deletion was in the paternal chromosome, in common with other macrosomia cases. Using public databases, we have examined possible interactions between sequences within and outside the deletion and speculate that a regulatory relationship exists with flanking genes, which is unbalanced by the deletion, resulting in abnormal activation or repression of the target genes and hence the severity of the phenotype.

Synthetic ECM: Bioactive Synthetic Hydrogels for 3D Tissue Engineering.

The specific microenvironment that cells reside in fundamentally impacts their broader function in tissues and organs. At its core, this microenvironment is composed of precise arrangements of cells that encourage homotypic and heterotypic cell-cell interactions, biochemical signaling through soluble factors like cytokines, hormones, and autocrine, endocrine, or paracrine secretions, and the local extracellular matrix (ECM) that provides physical support and mechanobiological stimuli, and further regulates biochemical signaling through cell-ECM interactions like adhesions and growth factor sequestering. Each cue provided in the microenvironment dictates cellular behavior and, thus, overall potential to perform tissue and organ specific function. It follows that in order to recapitulate physiological cell responses and develop constructs capable of replacing damaged tissue, we must engineer the cellular microenvironment very carefully. Many great strides have been made toward this goal using various three-dimensional (3D) tissue culture scaffolds and specific media conditions. Among the various 3D biomimetic scaffolds, synthetic hydrogels have emerged as a highly tunable and tissue-like biomaterial well-suited for implantable tissue-engineered constructs. Because many synthetic hydrogel materials are inherently bioinert, they minimize unintentional cell responses and thus are good candidates for long-term implantable grafts, patches, and organs. This review will provide an overview of commonly used biomaterials for forming synthetic hydrogels for tissue engineering applications and techniques for modifying them to with bioactive properties to elicit the desired cell responses.

Chemically Orthogonal Protein Ligation Domains for Independent Control of Hydrogel Modification with Adhesive Ligands and Growth Factors.

The twin, chemically orthogonal protein ligation domains, SpyCatcher and SnoopCatcher, were used to link two engineered proteins into poly(ethylene glycol) (PEG) hydrogels in order to control both endothelial cell adhesion and material-mediated pro-mitotic stimulation. SpyCatcher was appended with an N-terminal adhesion ligand RGDS to form RGDS-SC, and SnoopCatcher was appended with the vascular endothelial growth factor (VEGF)-mimetic peptide QK to form QK-SnpC. QK-SnpC formed a spontaneous covalent bond with SnoopTag peptide with 40% reaction efficiency, both in solution, in a PEG gel containing SnoopTag peptide, and in a PEG gel with both SnoopTag and SpyTag sites. QK-SnpC added to cell culture media enhanced endothelial cell proliferation compared to a negative control, and was statistically indistinguishable from the positive control of 130 pM VEGF165. Endothelial cells seeded onto PEG gels presenting both RGDS-SC and QK-SnpC showed ∼50% of cells actively proliferating (defined as Ki67+), compared to ∼31% of cells seeded on gels presenting RGDS-SC alone. These results show that complementary nondiffusing biochemical signals can be linked into PEG-DA hydrogels simultaneously using 'Catcher-based ligation strategies, thereby inducing more nuanced cell-material interactions.

Cell-Compatible, Site-Specific Covalent Modification of Hydrogel Scaffolds Enables User-Defined Control over Cell-Material Interactions.

SpyCatcher, a 15 kDa protein domain that spontaneously forms a site-specific covalent bond with the 13 amino acid peptide SpyTag, was used to covalently link a model recombinant protein containing a SpyCatcher domain and the adhesive ligand Arg-Gly-Asp-Ser (RGDS) (RGDS-SC) into SpyTag-containing poly(ethylene glycol) (PEG) hydrogels. This new strategy for covalent immobilization of proteins or peptides provides an easy and gentle mechanism for biochemical modification of hydrogels. Labeling efficiency was approximately 100% when soluble RGDS-SC was applied to SpyTag-containing hydrogels at a 1:1 molar ratio. RGDS-SC remained stably bound throughout the 5 days of rinsing, and 3T3 fibroblasts were able to adhere to PEG gels presenting RGDS-SC, but did not adhere when the scrambled amino acid sequence RDGS was presented instead. Fibroblasts encapsulated within 3D cell-degradable PEG hydrogels containing SpyTag did not spread until RGDS-SC was added to the gels, at which point cell spreading was induced. This cell-friendly site-specific ligation strategy could have great utility in driving specific cellular outcomes using biochemically dynamic hydrogels.

A randomized controlled trial of suicide prevention training for primary care providers: a study protocol.

BACKGROUND: Suicide is a national public health crisis and a critical patient safety issue. It is the 10th leading cause of death overall and the second leading cause of death among adolescents and young adults (15-34 years old). Research shows 80% of youth who died by suicide saw their primary care provider within the year of their death. It is imperative that primary care providers develop the knowledge and skills to talk with patients about distress and suicidal thoughts, and to assess and respond in the context of the ongoing patient - primary care provider relationship. METHODS: This study examines the effectiveness of simulation on suicide prevention training for providers-in-training by comparing two conditions: 1) a control group that receives online teaching on suicide prevention in primary care via brief online videos and 2) an experimental group that includes the same online teaching videos plus two standardized patient (SP) interactions (face-to-face and telehealth, presentation randomized). All SP interactions are video-recorded. The primary analysis is a comparison of the two groups' suicide prevention skills using an SP "test case" at 6-month follow-up. DISCUSSION: The primary research question examines the impact of practice (through SP simulation) over and above online teaching alone on suicide prevention skills demonstrated at follow-up. We will assess moderators of outcomes, differences among SP simulations (i.e., face-to-face vs. telehealth modalities), and whether the experimental group's suicide prevention skills improve over the three SP experiences. TRIAL REGISTRATION: The study was registered on Clinical Trials Registry ( clinicaltrials.gov ) on December 14, 2016. The Trial Registration Number is NCT02996344 .

Effects of Fluorescent Lighting Versus Sunlight Exposure on Calcium, Magnesium, Vitamin D, and Feather Destructive Behavior in Hispaniolan Amazon Parrots (Amazona ventralis).

Low exposure to ultraviolet light, and resulting vitamin D deficiency, has recently been linked to autism spectrum disorder in people. Captive psittacine birds that exhibit feather destructive behavior share similarities with people affected by autism spectrum disorder, such as repetitive (stereotypies) and self-harming behaviors. The metabolic and psychological effects of housing pet parrots indoors without ultraviolet B lighting are not typically considered in animal husbandry or veterinary care. Calcifediol (serum vitamin D), ionized calcium, and ionized magnesium levels were compared between 10 Hispaniolan Amazon parrots (Amazona ventralis) housed indoors and 10 Hispaniolan Amazon parrots historically housed outdoors. Although ionized calcium and magnesium levels were not significantly different, calcifediol levels were significantly greater in the colony of birds housed outdoors. Further, these 2 research colonies of individually housed birds were feather scored. Subjectively, the birds that were housed indoors had greater self-inflicted feather damage than did those housed outdoors; however, the difference was not statistically significant.

Dynamic Ligand Presentation in Biomaterials.

The native cell microenvironment is extraordinarily dynamic, with reciprocal regulation pathways between cells and the extracellular matrix guiding many physiological processes, such as cell migration, stem cell differentiation, and tissue formation. Providing the correct sequence of biochemical cues to cells, both in vivo and in vitro, is critical for triggering specific biological outcomes. There has been a diversity of methods developed for exposing cells in culture to spatiotemporally varying cues, many of which have centered on dynamic control over cell-material interactions in an attempt to recapitulate the role of the extracellular matrix in cell signaling. This review highlights several mechanisms that have been employed to control bioactive ligand presentation in biomaterials, and looks ahead toward the potential for genetically encoded approaches to dynamically regulate material bioactivity using light.

Trauma Sensitive Yoga as a complementary treatment for posttraumatic stress disorder: A Qualitative Descriptive analysis.

Research on Posttraumatic Stress Disorder and chronic childhood abuse has revealed that traditional trauma treatments often fail to fully address the complicated symptom presentation, including the somatic complaints, loss of awareness of one's emotional and physical being in the present moment, and overall lack of integration between the self and the body. The mindfulness-based intervention of hatha yoga shows promise as a complementary treatment, and focuses on personal growth in addition to symptom reduction. This qualitative study explored the experiences of thirty-one adult women with PTSD related to chronic childhood trauma who participated in a 10-week Trauma Sensitive Yoga class, specifically examining perceived changes in symptoms and personal growth. Five themes were identified that reflect participants' feelings of Gratitude and compassion, Relatedness, Acceptance, Centeredness, and Empowerment. Results and implications for research and clinical work are presented.

Bioactive poly(ethylene glycol) hydrogels to recapitulate the HSC niche and facilitate HSC expansion in culture.

Hematopoietic stem cells (HSCs) have been used therapeutically for decades, yet their widespread clinical use is hampered by the inability to expand HSCs successfully in vitro. In culture, HSCs rapidly differentiate and lose their ability to self-renew. We hypothesize that by mimicking aspects of the bone marrow microenvironment in vitro we can better control the expansion and differentiation of these cells. In this work, derivatives of poly(ethylene glycol) diacrylate hydrogels were used as a culture substrate for hematopoietic stem and progenitor cell (HSPC) populations. Key HSC cytokines, stem cell factor (SCF) and interferon-γ (IFNγ), as well as the cell adhesion ligands RGDS and connecting segment 1 were covalently immobilized onto the surface of the hydrogels. With the use of SCF and IFNγ, we observed significant expansion of HSPCs, ∼97 and ∼104 fold respectively, while maintaining c-kit(+) lin(-) and c-kit(+) Sca1(+) lin(-) (KSL) populations and the ability to form multilineage colonies after 14 days. HSPCs were also encapsulated within degradable poly(ethylene glycol) hydrogels for three-dimensional culture. After expansion in hydrogels, ∼60% of cells were c-kit(+), demonstrating no loss in the proportion of these cells over the 14 day culture period, and ∼50% of colonies formed were multilineage, indicating that the cells retained their differentiation potential. The ability to tailor and use this system to support HSC growth could have implications on the future use of HSCs and other blood cell types in a clinical setting.

Hyaluronan Hydrogels for a Biomimetic Spongiosa Layer of Tissue Engineered Heart Valve Scaffolds.

Advanced tissue engineered heart valves must be constructed from multiple materials to better mimic the heterogeneity found in the native valve. The trilayered structure of aortic valves provides the ability to open and close consistently over a full human lifetime, with each layer performing specific mechanical functions. The middle spongiosa layer consists primarily of proteoglycans and glycosaminoglycans, providing lubrication and dampening functions as the valve leaflet flexes open and closed. In this study, hyaluronan hydrogels were tuned to perform the mechanical functions of the spongiosa layer, provide a biomimetic scaffold in which valve cells were encapsulated in 3D for tissue engineering applications, and gain insight into how valve cells maintain hyaluronan homeostasis within heart valves. Expression of the HAS1 isoform of hyaluronan synthase was significantly higher in hyaluronan hydrogels compared to blank-slate poly(ethylene glycol) diacrylate (PEGDA) hydrogels. Hyaluronidase and matrix metalloproteinase enzyme activity was similar between hyaluronan and PEGDA hydrogels, even though these scaffold materials were each specifically susceptible to degradation by different enzyme types. KIAA1199 was expressed by valve cells and may play a role in the regulation of hyaluronan in heart valves. Cross-linked hyaluronan hydrogels maintained healthy phenotype of valve cells in 3D culture and were tuned to approximate the mechanical properties of the valve spongiosa layer. Therefore, hyaluronan can be used as an appropriate material for the spongiosa layer of a proposed laminate tissue engineered heart valve scaffold.

3D biofabrication strategies for tissue engineering and regenerative medicine.

Over the past several decades, there has been an ever-increasing demand for organ transplants. However, there is a severe shortage of donor organs, and as a result of the increasing demand, the gap between supply and demand continues to widen. A potential solution to this problem is to grow or fabricate organs using biomaterial scaffolds and a person's own cells. Although the realization of this solution has been limited, the development of new biofabrication approaches has made it more realistic. This review provides an overview of natural and synthetic biomaterials that have been used for organ/tissue development. It then discusses past and current biofabrication techniques, with a brief explanation of the state of the art. Finally, the review highlights the need for combining vascularization strategies with current biofabrication techniques. Given the multitude of applications of biofabrication technologies, from organ/tissue development to drug discovery/screening to development of complex in vitro models of human diseases, these manufacturing technologies can have a significant impact on the future of medicine and health care.

Observational measures of implementer fidelity for a school-based preventive intervention: development, reliability, and validity.

Current measures of implementer fidelity often fail to adequately measure core constructs of adherence and competence, and their relationship to outcomes can be mixed. To address these limitations, we used observational methods to assess these constructs and their relationships to proximal outcomes in a randomized trial of a school-based preventive intervention (Rochester Resilience Project) designed to strengthen emotion self-regulation skills in first-third graders with elevated aggressive-disruptive behaviors. Within the intervention group (n = 203), a subsample (n = 76) of students was selected to reflect the overall sample. Implementers were 10 paraprofessionals. Videotaped observations of three lessons from year 1 of the intervention (14 lessons) were coded for each implementer-child dyad on adherence (content) and competence (quality). Using multilevel modeling, we examined how much of the variance in the fidelity measures was attributed to implementer and to the child within implementer. Both measures had large and significant variance accounted for by implementer (competence, 68 %; adherence, 41 %); child within implementer did not account for significant variance indicating that ratings reflected stable qualities of the implementer rather than the child. Raw adherence and competence scores shared 46 % of variance (r = .68). Controlling for baseline differences and age, the amount (adherence) and quality (competence) of program delivered predicted children's enhanced response to the intervention on both child and parent reports after 6 months, but not on teacher report of externalizing behavior. Our findings support the use of multiple observations for measuring fidelity and that adherence and competence are important components of fidelity which could be assessed by many programs using these methods.