Assessing professional competence in optometry - a review of the development and validity of the written component of the competency in optometry examination (COE).

BACKGROUND: Credentialing assessment for overseas-educated optometrists seeking registration in Australia and New Zealand is administered by the Optometry Council of Australia and New Zealand. The aim was to review the validation and outcomes of the written components of this exam to demonstrate credentialing meets entry-level competency standards. METHODS: The Competency in Optometry Examination consists of two written and two clinical parts. Part 1 of the written exam comprises multiple choice questions (MCQ) covering basic and clinical science, while Part 2 has 18 short answer questions (SAQ) examining diagnosis and management. Candidates must pass both written components to progress to the clinical exam. Validity was evaluated using Kane's framework for scoring (marking criteria, item analysis), generalization (blueprint), extrapolation (standard setting), and implications (outcome, including pass rates). A competency-based blueprint, the Optometry Australia Entry-level Competency Standards for Optometry 2014, guided question selection with the number of items weighted towards key competencies. A standard setting exercise, last conducted in 2017, was used to determine the minimum standard for both written exams. Item response theory (Rasch) was used to analyse exams, produce reliability metrics, apply consistent standards to the results, calibrate difficulty across exams, and score candidates. RESULTS: Data is reported on 12 administrations of the written examination since 2014. Of the 193 candidates who sat the exam over the study period, 133 (68.9%) passed and moved on to the practical component. Ninety-one (47.2%) passed both the MCQ and SAQ exams on their first attempt. The MCQ exam has displayed consistently high reliability (reliability index range 0.71 to 0.93, average 0.88) across all 12 administrations. Prior to September 2017 the SAQ had a set cutscore of 50%, and the difficulty of the exam was variable. Since the introduction of Rasch analysis to calibrate difficulty across exams, the reliability and power of the SAQ exam has been consistently high (separation index range 0.82 to 0.93, average 0.86). CONCLUSIONS: The findings from collective evidence support the validity of the written components (MCQ and SAQ) of the credentialing of the competency of overseas-educated optometrists in Australia and New Zealand.

Where and when adolescents are physically active: Neighborhood environment and psychosocial correlates and their interactions.

Female adolescents are less active than male peers in certain contexts including the neighborhood. Adolescents' physical activity can be explained by interactions between environmental and psychosocial factors, but few studies have tested such interactions in relation to context-specific behaviors. This study tested interactions between neighborhood environmental and psychosocial factors in relation to adolescents' context-specific physical activity. Data were collected in 2009-11 from 910 adolescents and a parent/guardian residing in the Baltimore/Seattle regions. Measures included adolescent-reported neighborhood leisure-time physical activity (LTPA) and non-neighborhood LTPA, accelerometer-based non-school moderate-to vigorous-physical activity (MVPA), psychosocial factors, and objective and parent-perceived neighborhood environmental factors. Gender-stratified mixed effects linear models tested associations of 6 environmental and 4 psychosocial factors and their interactions in relation to each physical activity outcome. The psychosocial factors had consistent associations with the physical activity outcomes but the environmental correlates were context-specific. Decisional balance (weighing of pros and cons of physical activity) moderated the association between recreation facility density and neighborhood LTPA among females, with a negative association only among those with high decisional balance (pros outweighed cons). Decisional balance also moderated associations of neighborhood walkability with non-school MVPA among females and non-neighborhood LTPA among males, with positive associations only among those with high decisional balance. Results support context-specific ecological models of physical activity. Targeting environmental factors that may promote opportunities for physical activity in specific contexts as well as adolescent decision-making may help promote their physical activity in those contexts, potentially leading to increased overall physical activity.

The Relationship Between Emotion Dysregulation and Error Monitoring in Adolescents with ADHD.

Attention-deficit/hyperactivity disorder (ADHD) is emblematic of the limitations of existing diagnostic categories. One potential solution, consistent with the Research Domain Criteria (RDoC) initiative, is to interrogate psychological mechanisms at the behavioral and physiological level together to try and identify meaningful subgroups within existing categories. Such approaches provide a way to revise diagnostic boundaries and clarify individual variation in mechanisms. Here, we illustrate this approach to help resolve heterogeneity in ADHD using a combination of behaviorally-rated temperament measures from the Early Adolescent Temperament Questionnaire; cognitive performance on three difference conditions of an emotional go/no-go task; and electroencephalogram (EEG)-measured variation in multiple stages of error processing, including the error-related negativity (ERN) and positivity (Pe). In a large (N = 342), well-characterized sample of adolescents with ADHD, latent profile analysis identified two ADHD temperament subgroups: 1) emotionally regulated and 2) emotionally dysregulated (with high negative affect). Cognitive and EEG assessment in a subset of 272 adolescents (nADHD = 151) found that the emotionally dysregulated group showed distinct patterns of change in early neural response to errors (ERN) across emotional task conditions as compared to emotionally-regulated ADHD adolescents and typically-developing controls. Both ADHD groups showed blunted later response to errors (Pe) that was stable across emotional task conditions. Overall, neural response patterns identified important differences in how trait and state emotion interact to affect cognitive processing. Results highlight important temperament variation within ADHD that helps clarify its relationship to the ERN, one of the most prominent putative neural biomarkers for psychopathology.

Use of neighbourhood parks: does socio-economic status matter? A four-city study.

OBJECTIVES: To determine if neighbourhood socio-economic status (SES) is associated with park use and park-based physical activity. STUDY DESIGN: Cross-sectional study. METHODS: The use and characteristics of 24 neighbourhood parks in Albuquerque, Chapel Hill/Durham, Columbus and Philadelphia were observed systematically in three seasons (spring, summer and autumn), with nearly 36,000 park users observed. Twelve parks were in high-poverty neighbourhoods and 12 parks were in low-poverty neighbourhoods. In total, 3559 park users and 3815 local residents were surveyed. Park incivilities were assessed and park administrators were interviewed about management practices. RESULTS: The size and number of facilities in parks in high-poverty neighbourhoods were similar to those in parks in low-poverty neighbourhoods, but the former had more hours of programming. Neighbourhood poverty level, perception of safety and the presence of incivilities were not associated with the number of park users observed. However, programmed activities and the number of activity facilities were strongly correlated with park use and energy expended in the park. CONCLUSIONS: The finding that park programming is the most important correlate of park use and park-based physical activity suggests that there are considerable opportunities for facilitating physical activity among populations of both high- and low-poverty areas.

Physical activity for children in special school environment.

1. We assessed children's physical activity (PA) in structured (physical education) and unstructured (recess, lunch, before and after school) periods in special schools and examined its association with modifiable area contextual characteristics. 2. Children with disabilities were not highly active, but were more active during recess and lunch periods than at other times including physical education classes. 3. Areas were often not accessible during unstructured settings. Children were more active in areas when supervision and organised activities were provided. 4. Providing an interactive game during free play did not significantly increase group's PA. 5. Children's PA accrual is influenced by contextual characteristics of the school environment. There is a need to make areas more accessible and to use social marketing and programming to attract more users. School and health professionals should modify contextual characteristics by providing more direct supervision and organised activities during free play.

Evaluating a treatment without extinction for elopement maintained by access to stereotypy.

Elopement is a common and potentially dangerous form of problem behavior. Results of a functional analysis found that the elopement of a child with autism was maintained by access to stereotypy in the form of door play. We implemented functional communication training and contingency-based delays dependent on the absence of elopement and increased the amount of time the participant waited prior to engaging in stereotypy. We also conducted treatment-extension probes, with the participant waiting up to 10 min without elopement.

The relationship between alpha asymmetry and ADHD depends on negative affect level and parenting practices.

Atypical frontal alpha asymmetry is associated with the approach/withdrawal and affective processes implicated in many psychiatric disorders. Rightward alpha asymmetry, associated with high approach, is a putative endophenotype for attention deficit/hyperactivity disorder (ADHD). However, findings are inconsistent, likely because of a failure to consider emotional heterogeneity within the ADHD population. In addition, how this putative risk marker interacts with environmental factors known to increase symptom severity, such as parenting practices, has not been examined. The current study examined patterns of alpha asymmetry in a large sample of adolescents with and without ADHD, including the moderating role of negative affect and inconsistent discipline. Resting-state EEG was recorded from 169 well-characterized adolescents (nADHD = 79). Semi-structured clinical interviews and well-validated rating scales were used to create composites for negative affect and inconsistent discipline. The relationship between alpha asymmetry and ADHD diagnosis was moderated by negative affect. Right asymmetry was present only for those with ADHD and low levels of negative affect. In addition, greater right alpha asymmetry predicted severity of ADHD symptoms for those with the disorder, but only in the context of inconsistent parenting practices. Results confirm right alpha asymmetry is a possible endophenotype in ADHD but highlight the need to consider emotional heterogeneity and how biological risk interacts with child environment in order to fully characterize its relationship to disorder liability and severity.

Association of LY9 in UK and Canadian SLE families.

Systemic lupus erythematosus (SLE) is a complex disease trait of unknown aetiology. Genome-wide linkage studies in human SLE identified several linkage regions, including one at 1q23, which contains multiple susceptibility genes, including the members of the signalling lymphocyte activation molecule (SLAM) locus. In mice there is a syntenic linkage region, Sle1. The SLAM genes are functionally related cell-surface receptors, which regulate signal transduction of cells in the immune system. Family-based association study in UK and Canadian SLE families identified variants in the promoter and coding region of SLAMF7 and LY9 contributing to SLE disease susceptibility. The strongest association was from rs509749, in exon 8 of LY9 (P=0.00209). rs509749 encodes a Val/Met nonsynonymous change in amino acid 602 in the cytoplasmic domain of LY9. In the parents and affected individuals from the Canadian SLE families, the risk allele of rs509049 skews the T-cell population by increasing the number of CD8+ memory T cells, while decreasing the proportion of CD4+ naïve T cells and activated T cells. Since rs509749 lies within the consensus binding site for SAP/SH2D1a, which influences downstream signalling events from LY9, the mechanism for increased CD8+ memory T cells may include differential binding SAP/SH2D1a to the cytoplasmic domain of LY9.

Perceived Neighborhood Environmental Factors That Maximize the Effectiveness of a Multilevel Intervention Promoting Physical Activity Among Latinas.

PURPOSE: This study tested whether a multilevel physical activity (PA) intervention had differential effects on PA according to participants' perceptions of their neighborhood environment. DESIGN: Two-group cluster randomized controlled trial. SETTING: San Diego, California. SUBJECTS: Analytical sample included 319 Latinas (18-65 years) from churches randomized to the following conditions: PA (n = 8 churches, n = 157 participants) or attention control (n = 8 churches, n = 162 participants). INTERVENTION: Over 12 months, PA participants were offered free PA classes (6/wk), while attention control participants were offered cancer prevention workshops. MEASURES: Baseline and 12-month follow-up measures included self-report and accelerometer-based moderate to vigorous physical activity (MVPA), sociodemographics, and perceived neighborhood environment variables. ANALYSIS: Mixed-effects models examined each PA outcome at 12-month follow-up, adjusted for church clustering, baseline PA, and sociodemographics. We tested interactions between 7 baseline perceived environment variables and study condition. RESULTS: Neighborhood esthetics was the only significant moderator of intervention effects on accelerometer-based MVPA and self-report leisure-time MVPA. Participants in the PA intervention had significantly higher PA at follow-up than attention control participants, only when participants evaluated their neighborhood esthetics favorably. CONCLUSION: Perceived neighborhood esthetics appeared to maximize the effectiveness of a multilevel PA intervention among Latinas. For sustainable PA behavior change, the environments in which Latinas are encouraged to be active may need to be evaluated prior to implementing an intervention to ensure they support active lifestyles.

Diabetic and idiopathic gastroparesis is associated with loss of CD206-positive macrophages in the gastric antrum.

BACKGROUND: Animal studies have increasingly highlighted the role of macrophages in the development of delayed gastric emptying. However, their role in the pathophysiology of human gastroparesis is unclear. Our aim was to determine changes in macrophages and other cell types in the gastric antrum muscularis propria of patients with diabetic and idiopathic gastroparesis. METHODS: Full thickness gastric antrum biopsies were obtained from patients enrolled in the Gastroparesis Clinical Research Consortium (11 diabetic, 6 idiopathic) and 5 controls. Immunolabeling and quantitative assessment was done for interstitial cells of Cajal (ICC) (Kit), enteric nerves protein gene product 9.5, neuronal nitric oxide synthase, vasoactive intestinal peptide, substance P, tyrosine hydroxylase), overall immune cells (CD45) and anti-inflammatory macrophages (CD206). Gastric emptying was assessed using nuclear medicine scintigraphy and symptom severity using the Gastroparesis Cardinal Symptom Index. RESULTS: Both diabetic and idiopathic gastroparesis patients showed loss of ICC as compared to controls (Mean [standard error of mean]/hpf: diabetic, 2.28 [0.16]; idiopathic, 2.53 [0.47]; controls, 6.05 [0.62]; P=.004). Overall immune cell population (CD45) was unchanged but there was a loss of anti-inflammatory macrophages (CD206) in circular muscle (diabetic, 3.87 [0.32]; idiopathic, 4.16 [0.52]; controls, 6.59 [1.09]; P=.04) and myenteric plexus (diabetic, 3.83 [0.27]; idiopathic, 3.59 [0.68]; controls, 7.46 [0.51]; P=.004). There was correlation between the number of ICC and CD206-positive cells (r=.55, P=.008). Enteric nerves (PGP9.5) were unchanged: diabetic, 33.64 (3.45); idiopathic, 41.26 (6.40); controls, 46.80 (6.04). CONCLUSION: Loss of antral CD206-positive anti-inflammatory macrophages is a key feature in human gastroparesis and it is associates with ICC loss.

A benzothiophene-carboxamide is a potent inhibitor of IL-1beta induced VCAM-1 gene expression in human endothelial cells.

Vascular endothelial cells respond to cytokines such as IL-1 beta or TNF-alpha by undergoing a number of functional alterations. Among these alterations is the induction of cell surface adhesion molecules, including VCAM-1. In this report, we investigated the effects of a 3-alkoxybenzo[beta]thiophene-2-carboxamide (BZT) on the cytokine induction of VCAM-1 expression and activation of the transcription factor NF-kappa B in human endothelial cells. BZT blocked the IL-1 beta induced cell surface expression of VCAM-1 in human endothelial cells but did not prevent nuclear translocation of NF-kappa B. This study demonstrates that BZT is a potent inhibitor of VCAM-1 expression in human endothelial cells.

5-Aryl-3-azabicyclo[3.2.0]heptan-6-one ketals, compounds with morphine-like analgesic activity.

A series of 5-aryl-3-azabicyclo[3.2.0] heptan -6-one ketals 6 were synthesized by hydride reduction of 1-aryl-4, 4-dimethoxy-1,2- cyclobutanedicarboximides 5. Imides 5 were obtained as the sole, regioselective products of the [2 + 2] photocycloaddition of 1,1- dimethoxyethylene to 2- arylmaleimides . The m-methoxyphenyl-N-methyl analogue 6a was demethylated to phenol 7 with EtSNa -DMF. Both 6a and 7 were similar to morphine in analgesic potency in rats and mice and showed physiological effects that were identical with those of morphine and that were completely reversed by naloxone. Compound 7 was identical with morphine in its ability to displace [3H]naloxone from homogenates of rat brain minus cerebellum. A molecular mechanics analysis of the m-methoxyphenyl analogue 6a showed that the nitrogen atom, the methoxyphenyl group, and the methoxyl oxygen cis to the phenyl group can be superimposed on the corresponding features of the morphine molecule, and perhaps this accounts for the observed opiate-receptor binding properties of 7.

1-Aryl-3-azabicyclo[3.1.0]hexanes, a new series of nonnarcotic analgesic agents.

A series of 1-aryl-3-azabicyclo[3.1.0]hexanes was synthesized by hydride reduction of 1-arylcyclopropanedicarboximides. Hydroxyphenyl analogues 20, 22, and 24 were prepared by EtSNa--DMF ether cleavage of the corresponding methoxyphenyl analogues 2m, 2n, and 23, respectively, with the secondary amines 20 and 22 going through the N-formyl intermediate 19 and 21. The p-ethoxy analogue 26 was obtained by O-ethylation of 19, followed by base hydrolysis of the amide 25. The greatest analgesic potency in mouse writhing and rat paw-pain assays was observed for para-substituted compounds. Bicifadine, 1-(4-methylphenyl)-3-azabicyclo[3.1.0]hexane (2b), was the most potent member of the series and is presently undergoing clinical trials in man. Analgesic activity of 2b is limited to the (+) enantiomer 2v, which has the 1R,5S absolute configuration as determined by single-crystal X-ray analysis. The N-methyl analogue (27d) of 2b showed significant analgesic potency, whereas the N-allyl (27a), N-(cyclopropylmethyl) (27b), and N-(n-hexyl) (27c) analogues were inactive. Bicifadine (2b) showed a nonnarcotic profile different from analogous azabicycloalkane and 3-phenylpyrrolidine analgesics.

Project SPARK. Effects of physical education on adiposity in children.

Project SPARK evaluates multiple effects of a health-related physical education (PE) program for elementary school students. Seven schools were randomly assigned to one of three conditions: usual PE or control, trained classroom teachers, or PE specialists. The intervention was implemented throughout the fourth and fifth grades. Data are available from one cohort of 550 children who were measured in the fall and spring of both grades. Adiposity was assessed by triceps and calf skinfolds, and body mass index (BMI) was also measured. Data at each measurement point were analyzed by ANOVAs, covarying for baseline values. At no measurement point were there significant group differences in total skinfold. At both fifth grade measurement points for boys and girls, however, there was a trend for the control group to have higher skinfold values than the two intervention groups. At the final measure, the difference between the highest and lowest groups was about 3 mm for girls and 2 mm for boys. BMIs were significantly lower at some measurement points for boys and girls, but this could be due to increased lean body mass in intervention students. After two years, there was a trend for the children exposed to the PE intervention to have lower levels of body fat, but the differences were not significant.

Factors parents use in selecting play spaces for young children.

BACKGROUND: The amount of time children spend in play spaces (ie, physical locations that are appropriate for children's physical activity) near their homes is correlated with their level of physical activity. OBJECTIVE: To examine factors used in parents' decisions about the selection of play spaces for their children. SUBJECTS: Parents (primarily mothers) of 178 Mexican American and 122 white children who were a mean age of 4.9 years old at the first measurement. MEASURES: In individual interviews, parents rated 24 factors on their importance in selecting for their children a play space that is away from their home or yard. Decision factors were rated from 1 (ie, not important at all) to 5 (ie, very important). RESULTS: The most important factors, with ratings ranging from 4.8 to 4.2, were safety and availability of toilets, drinking water, lighting, and shade. Mexican American parents rated 8 of 24 items significantly higher than did white parents, including lighted at night, organized activities, play supplies, and drinking water. White parents rated 5 of 24 items significantly higher than did Mexican American parents, including distance from home, cost of admission, and child's friends go there. The rated importance of 7 of 24 items increased during 1 year, including play supplies, drinking water, distance from home, and parents' friends or relatives go there. CONCLUSIONS: These results indicate that parents can identify factors they use in selecting places for their young children to play, and selection factors differ somewhat by ethnicity or socioeconomic status. Further studies are needed to determine whether improvements on the most important selection factors might be effective in increasing the use of play spaces by children and their parents. Clinicians may be able to use the most highly rated decision factors to help parents assess the acceptability of play spaces in their areas.

Dissection of an allograft ascending aorta after aortic root replacement.

THe case of a 57-year-old man with dissection of an allograft ascending aorta 2 months after aortic root replacement is presented. Most likely traumatic in origin, this unusual complication was managed by Dacron graft replacement of the ascending aorta using hypothermia and circulatory arrest.

Effects of physical activity interventions in youth. Review and synthesis.

INTRODUCTION: Physical inactivity has been identified as an important public health concern for youth. School and community settings can be important infrastructures for promoting physical activity (PA). This paper reviews studies of physical activity in school and community settings among preschool through college-aged persons to determine characteristics and effects of interventions. Studies in progress are included. METHODS: Studies from 1980 to 1997 testing physical activity interventions in schools and community settings were identified by computerized search methods and reference lists of published reviews. Studies needed to have used a quantitative assessment of PA, used a comparison or control group, included participants who were preschool through college age, and be conducted in the United States or foreign school or community settings. Significance of effects was examined overall and for various types of interventions. RESULTS: Twenty-two school-based studies were reviewed, 14 completed and 8 in progress. Three studies were in countries other than the United States. The 8 studies in progress were all in the United States. Only 7 community studies were reviewed, all in the United States. Four studies were in progress. Several community studies involved a high percentage of African-American or Hispanic youth and their families. Studies showing the best results used randomized designs, valid and reliable measurements, and more extensive interventions. Some follow-up results showed PA was sustained after interventions ended. CONCLUSIONS: The collection of school and community studies is limited for several age groups with none below third grade and only three at college age. There are few community studies. The most is known about upper-elementary-age-students, including the first multicenter randomized trial to report significant results for increasing moderate to vigorous physical activity (MVPA) in physical education (PE) and increase vigorous PA outside of school. A number of older study designs were weak and assessments less than optimal, but studies in progress are stronger. Special attention is needed for girls, middle schools, and community settings for all youth. More objective assessments are needed for measuring PA outside of school and in younger children, since they cannot provide reliable self-report.

Predictors of change in children's physical activity over 20 months. Variations by gender and level of adiposity.

BACKGROUND: Physical activity declines during childhood and determinants of this decline are poorly understood. The purpose of this prospective study was to examine modifiable psychological and social correlates of physical activity change over 20 months. SUBJECTS: 370 girls and 362 boys in public schools, studied through the 4th and 5th grades. MEASURES: A physical activity index was computed from child reports, parent reports, and objective activity monitoring. Predictor variables were assessed by child and parent surveys. RESULTS: In multiple regressions, after adjustments for demographic variables, psychological variables explained 4% of the variance in boys' physical activity change, parent variables explained 8%, and interactions with skinfolds explained 3%, for a total of 15% (unadjusted). Regarding change in girls' physical activity, psychological variables explained 3%, parent variables explained 1.5%, and interactions with skinfold explained 1.5%, for a total of 6% explained variance (unadjusted). There were differences in predictors among children with high and low levels of body fat. CONCLUSIONS: Children's preferences for physical activity and frequency of parents transporting children to activity locations explained significant proportions of variance for girls and boys. The results support a dynamic model of the determinants of children's physical activity, but most of the variance was left unexplained.

Parental provision of transportation for adolescent physical activity.

BACKGROUND: Physical activity (PA) is important to adolescents' health. Parent transportation to activity locations is a practical strategy for increasing youth PA that has rarely been examined. DESIGN: Cross-sectional surveys of students and parents. SETTING/PARTICIPANTS: Ethnically diverse students (N=1678; 712 boys, 966 girls; M age=13.0 years) from 24 middle schools (grades six to eight) and their parents completed surveys (response rate=72%). MAIN OUTCOME MEASURES: Frequency of parents transporting adolescents to PA locations was studied in relation to adolescents' reported participation in PA during the previous week and their involvement in sports and activity lessons during the past year. RESULTS: Parents transported adolescents to PA locations 2.13 times per week, with boys being transported more often than girls (p=0.03). Ethnic/racial differences in frequency of transport were evidenced (p=0.002). Parent transportation for PA significantly contributed to girls' total PA (p=0.001) and their participation in sports/activity lessons (p=0.001). Transportation contributed marginally (p=0.06) to boys' total PA, but significantly to their participation in sports/activity lessons (p=0.001). CONCLUSIONS: Parent provision of transportation to activity locations is associated with out-of-school PA in a diverse adolescent population. This variable should be targeted for intervention.

Effects of the CATCH physical education intervention: teacher type and lesson location.

BACKGROUND: Substantial differences exist in how and where physical education (PE) is conducted in elementary schools throughout the United States. Few effectiveness studies of large-scale interventions to improve PE have been reported. DESIGN: Multicenter randomized trial. SETTING/ PARTICIPANTS: The Child and Adolescent Trial for Cardiovascular Health (CATCH) was implemented in PE classes in 96 schools (56 intervention, 40 control) in four study centers: California, Louisiana, Minnesota, and Texas. INTERVENTION: The 2.5-year PE intervention consisted of professional development sessions, curricula, and follow-up consultations. MAIN OUTCOME MEASURES: Intervention effects on student physical activity and lesson context in PE were examined by teacher type (PE specialists and classroom teachers) and lesson location (indoors and outdoors). RESULTS: Differential effects by teacher type and lesson location were evidenced for both physical activity and lesson context. Observations of 2016 lessons showed that intervention schools provided more moderate-to-vigorous physical activity (p=0.002) and vigorous physical activity (p=0.02) than controls. Classroom teachers improved physical activity relatively more than PE specialists, but PE specialists still provided longer lessons and more physical activity. Classroom teachers increased lesson length (p=0.02) and time for physical fitness (p=0.03). CONCLUSIONS: The intervention improved PE of both specialists' and classroom teachers' lessons. States and districts should ensure that the most qualified staff teaches PE. Interventions need to be tailored to meet local needs and conditions, including teacher type and location of lessons.