The aim of the study was to investigate the clinical relevance of IgM deposition in patients with lupus nephritis (LN) in a large cohort.P < 0.001; r = 0.408, P < 0.001, respectively), and inversely correlated with plasma levels of C3 and CFH mildly . By multivariate analysis, we found that glomerular IgM deposition independently contributed to glomerular C3 deposition in patients with LN . In addition, we also found that patients with IgM 0–2+ had similar plasma CFH levels, but in patients with IgM3+–4+, plasma CFH levels were significantly lower . Furthermore, patients with high density of glomerular IgM and low levels of CFH had heavier proteinuria, higher serum creatinine and lower plasma C3 levels , comparing with those with low density of glomerular IgM and low levels of CFH.217 patients with renal biopsy-proven active LN were enrolled. The associations between glomerular IgM deposition and clinicopathological parameters were further analyzed. IgM deposition was positively correlated with glomerular C1q and C3 deposition moderately (r = 0.436, Our results suggested the involvement of glomerular deposited IgM in complement activation and renal injury in LN. Lupus nephritis (LN) is the most common complication of systemic lupus erythematosus (SLE). The pathogenesis of LN involves initiation by immune complexes, activation of the immune system in the kidney, and the responses of renal parenchymal cells to these insults. Although LN is characterized by a “full-house” pattern of immune deposits, it is mostly suggested to be initiated by the glomerular deposition of nephritogenic IgG type autoantibodies at present –4.Glomerular IgM deposition occurs in a wide range of glomerular diseases. It was previously considered to be passively trapped in areas of glomerulosclerosis. However, recent studies found that IgM specifically bound insulted glomeruli and exacerbated renal injury. In mice deficient in the complement factor H (CFH), a model of non-sclerotic and nonimmune-complex glomerular disease, IgM was identified as binding to glomerular epitopes and contributing to the progression of glomerular damage . In anotCFH−/− mice is also an interesting question.Since natural antibody IgM is suggested to bind to endogenous neoepitopes that are exposed after injury and exacerbates damage –13, whetIn this study, we firstly investigated the clinical relevance of renal IgM deposition and the relationship of plasma CFH levels with glomerular IgM deposition in a large Chinese LN cohort.In total, 217 consecutive patients with renal biopsy-proven active LN were enrolled. General clinical and renal histopathological profiles of the patients at renal biopsy are listed in Tables According to the 2003 classification of LN, 7 patients were classified as Class II (3.2%), 37 as Class III , 126 as Class IV , and 47 as Class V (21.7%). None were Classes I and VI in this study.Renal immunofluorescence profiles of the 217 patients at renal biopsy are listed in Table P = 0.201). It was found that the intensity of IgM deposition was correlated with the intensity of IgG and IgA deposition in glomeruli . IgM deposition was positively correlated with glomerular C1q and C3 deposition moderately , and inversely correlated with plasma levels of C3 and CFH mildly , but no correlation with plasma C1q levels . Among the pathologic indices, glomerular IgM deposition was positively correlated with subendothelial hyaline deposits mildly  and inversely correlated with interstitial inflammatory cell infiltration . There was no correlation between IgM deposition and proteinuria levels, serum creatine levels or SLEDAI scores , IV (including IV + V) and V were 14.3%, 13.5%, 16.7% and 8.5%, respectively. Although the percentage of stronger IgM deposition seemed to be lower in Class V, but the difference did not reach statistical significance  (shown in Table As shown in Table CFH−/− leads to glomerular IgM deposition −1.234 × age−0.179 ×  [The following clinical data were collected and analysed: gender, age, fever, anaemia, leucocytopenia, thrombocytopenia, haematuria, leukocyturia, 24-h proteinuria, serum creatinine and hemoglobulin. Clinical disease activity was assessed using the SLEDAI . eGFR wa female) .The criteria for clinical remission were the same as we reported previously . The remThe patients were followed up in our outpatient clinic specified for LN. The renal endpoints were defined as end-stage renal disease (ESRD) or doubling of serum creatinine.Plasma and sera from patients with LN were obtained from peripheral blood at the time of renal biopsy. All the blood samples were stored at − 80 °C until use.Serum ANAs, anti-dsDNA antibodies, anti-extractable nuclear antigen antibodies, including anti-Sm, anti-SSA, anti-SSB antibodies, were detected using immunodotting assays . Plasma C3 was determined using a rate nephelometry assay .Anti-C1q IgG autoantibodies were detected using a previously published ELISA method . The resPlasma concentrations of human complement components were determined by enzyme-linked immunosorbent assay, including plasma C1q, plasma CFH and soluble C5b-9 . The detection of plasma soluble C5b-9 was assayed in accordance with the manufacturer's instructions.2SO4. The results were recorded as the net optical absorbance at 450 and 570 nm in an ELISA reader .The method to detect plasma C1q was modified as previously described . Rabbit http://www.curveexpert.net/). All assays were run in duplicate, and when standard errors were > 10%, samples were routinely re-analyzed. Serial concentrations of commercially available highly purified human factor H were used to develop a standard curve. The linear portion of the curve was subsequently used for the measurement of plasma factor H.The method of detecting plasma CFH was the same as previously described . The CFHThe renal biopsy specimens were examined by light microscopy, direct immunofluorescence and electron microscopy. LN was re-classified according to the International Society of Nephrology/Renal Pathology Society (ISN/RPS) 2003 classification system . All renP < 0.001), Cohen's kappa = 0.951 (P < 0.001), respectively. The intra-rater reliability for immunofluorescence IgG and IgM scores from one pathologist was excellent, ICC = 0.962 (95% CI 0.952–0.971), ICC = 0.980 (95% CI 0.974–0.985), respectively. And the intra-rater reliability for immunofluorescence IgG and IgM scores from the other pathologist was also good, ICC = 0.946 (95% CI 0.931–0.958), ICC = 0.965 (95% CI 0.955–0.973), respectively.The two pathologists who undertook the analyses of the pathological data, were unaware of the patients’ details. Each evaluation was performed in triplicate and the mean of the values were reported. In addition, in each patient’s pathological data evaluation, two expert pathologists reported their results. The inter-rater reliability for immunofluorescence IgG and IgM scores was good, Cohen's kappa = 0.953 , periodic acid-Schiff, silver methenamine (Meth) and Masson’s trichrome.The intensity of immunofluorescence for IgG, IgA, IgM, C3, C1q, fibrin, kappa and lambda deposits were semi-quantitatively graded from 0 to 4, respectively. Staining intensity was expressed as follows: 0, invisible; 1+, ambiguous under a low-power lens and apparent under a high-power lens; 2+, apparent under a low-power lens and clear under a high-power lens; 3+, clear under a low-power lens and bright under a high-power lens; and 4+, dazzling under a high-power lens.Renal biopsy specimens were fixed in 2.5% paraformaldehyde for electron microscopy. After embedded in epon, ultrathin sections were mounted on metal grids and stained with uranyl acetate before viewed in a transmission electron microscope .P < 0.05.Statistical software SPSS 25.0  was employed for all the statistical analysis. Quantitative data were expressed as mean ± s.d., median with interquartile range (IQR), median with range, or number (%). One-way analysis of variance was used for the same continuous data in different groups. Differences of quantitative variables between groups were assessed using the t test  or Mann–Whitney U test . Logistic regression analysis was carried out to predict glomerular C3 deposition. Survival analysis was performed using the log-rank test. Statistical significance was considered as


Purpose of the Study: The purpose of this study was to examine the impact of the Caring Callers Program on older adults and volunteers. Our research team piloted this telephone reassurance program during the COVID-19 pandemic. In the Caring Callers Program, socially isolated older adults were paired with older adult volunteers from the Senior Companion Program (20 pairs). Methods: In the Caring Callers Program, Senior Companion volunteers provided the clients with emotional support through a weekly phone call over the 12 weeks period (May through July 2020). Prior to the intervention implementation, the volunteers received a two-hour group-based training through a teleconference platform. Program outcomes were measured through quantitative and qualitative approaches. Results: The clients (mean age=73.5) showed significantly increased overall self-rated health at post-test, compared to pre-test and they discussed social and emotional benefits. The clients were very satisfied with the program and indicated that the program met their expectations. Our individual, in-depth interviews with the volunteers (mean age=73.2) also revealed that the volunteers were able to develop their skills that are helpful for their Senior Companion volunteer activities and experience mutual benefits by spending their time more purposefully. Overall, our participants shared that they wanted to continue participating in the Caring Callers Program. Discussion: We learned the importance of training not only for the volunteers but also for the clients, prior information on their pair, making sure of the volunteer-client fit, and benefits of using telephone particularly in this group of vulnerable older adults.


Data are lacking regarding pulmonary rehabilitation (PR) programs in patients with lung cancer receiving radiation therapy. This study aimed to confirm the feasibility of an outpatient‐based PR program in lung cancer patients during radiation therapy.A retrospective chart review was performed of 40 patients with lung cancer who had undergone radiation therapy between July and December 2019. The patients received an outpatient‐based PR program for a total of eight sessions two times weekly comprising 60 min per session. Feasibility was assessed based on the completion rate, adverse events, and satisfaction with the PR program. Functional evaluations using 6‐min walk and grip strength tests were conducted before and after PR. Patient quality of life was assessed by the EORTC QLQ‐C30 questionnaire before and after PR.The completion rate for the PR program was 72.5% among the 40 patients. No adverse events related to PR were reported. The overall satisfaction was 5.7 ± 1.1 on a seven‐point Likert scale in all participants. The mean 6‐min walk test distance increased significantly from 419.1 to 446.2 m. The improvement in grip strength in the dominant hand after PR was not significant. The social functioning score in the EORTC QLQ‐C30 improved significantly.The results of this study showed the feasibility without serious adverse effects of a 4‐week outpatient‐based PR program for lung cancer patients undergoing outpatient‐based radiation therapy. This program might improve patient physical function and quality of life. The results of this study show the feasibility without serious adverse effects of a 4‐week outpatient‐based pulmonary rehabilitation program for lung cancer patients during outpatient‐based radiation therapy. Even though there is not sufficient evidence regarding the effects of PR in lung cancer patients receiving radiation therapy, some reports have shown that PR may improve pulmonary and physical function and quality of life. Therefore, our center developed an outpatient‐based PR program for lung cancer patients undergoing outpatient‐based radiation therapy. We expected that this outpatient‐based program would positively affect physical function and quality of life in these patients. This study aimed to confirm the feasibility of this program.This retrospective feasibility study reviewed the medical records of patients diagnosed with lung cancer from an outpatient clinic of the Rehabilitation Medicine Department in our hospital. According to pathology and stage, pulmonologists and radiation oncologists determined the radiation therapy plan, including definitive, palliative, salvage, preoperation, and postoperation radiation therapy. Before starting radiation therapy, the patients were referred to the rehabilitation department for the PR program. Eastern Cooperative Oncology Group performance status (ECOG PS) was evaluated by one physician at the first visit. All patients were over 19 years of age and received outpatient‐based PR between July and December 2019.This outpatient‐based PR rehabilitation program commenced from July 2019 for lung cancer patients who underwent outpatient‐based radiation therapy. The program was conducted simultaneously during the radiation therapy period. Functional evaluation was conducted using a 6‐min walk test (6MWT) and a grip strength test before and after PR. After functional evaluations, the 4‐week outpatient‐based PR program was started in conjunction with outpatient‐based radiation therapy. The outpatient‐based PR program lasted for four consecutive weeks, with two sessions per week. Each 60‐min exercise session was conducted under the supervision and guidance of a physical therapist. Most previous studies of PR in lung cancer patients administering aerobic and/or resistance exercise with or without inspiratory muscle trainingt‐tests were used to compare changes in the variables from baseline to the completion of the PR program. p values <0.05 were considered statistically significant.Statistical analysis was performed using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp.) and representative values were expressed as means ± standard deviation and percentages, respectively. Paired Twenty‐nine of the 40 patients who started the PR program completed the program . Nineteen patients were smokers and 26 were diagnosed with NSCLC. Among NSCLC patients, 53.8% and 30.8% had stage IIIA and IIIB disease, respectively. The baseline ECOG PS scores were PS1 (82.8% of patients) and PS 2 (17.2%). Eleven patients underwent lung resection surgery. Patients who underwent surgery received radiation therapy and participated in the PR program after surgery. The initial FVC predicted value (%) and forced expiratory volume in 1 s (FEV1)/FVC (%) were 76.11% and 0.72, respectively (Table The completion rate was 72.5% (29 out of 40 patients). The adherence rate was 81.25% . No adverse events related to PR were observed, including cardiac or pulmonary instability, dizziness, extreme fatigue, or musculoskeletal problems. Self‐reported questionnaires were obtained from 20 patients who completed the program, with scores of 5 or higher on all items Table .Our results showed that an outpatient‐based PR program was feasible and might improve physical function in lung cancer patients receiving radiation therapy. No serious adverse events were noted and the overall satisfaction was high. Most previous studies on PR in lung cancer patients were conducted in preoperative or postoperative conditions.Since our PR program included only outpatients, the completion rate was the most important outcome. Twenty‐nine of 40 patients (72.5%) completed all 4 weeks of the outpatient‐based PR program, indicating the program feasibility. Previous studies of outpatient‐based PR programs in COPD patients reported completion rates varying from approximately 40% to 66%.The median 6MWT distance increased significantly from 419.1 to 446.2 m. The grip strength of the nondominant hand improved significantly after the PR program. While the grip strength also improved on the dominant hand after the PR program, the difference was not statistically significant. Because our study had no control group, it is limited in showing the functional benefits of the PR program. However, one retrospective study using a control group also reported the improvement of 6MWT distance after a simultaneous PR program during thoracic radiation, which is in line with our result.Regarding the patient quality of life, significant improvement was observed in the social functioning scale of the EORTC QLQ‐C30, but not for the global health status, symptom scales, and functional scales except social functioning before and after the PR program. One study assessing patient quality of life after thoracic radiation therapy showed worsening for every score for global health status and symptom scales and for some of the functional scales  in the EORTC QLQ‐C30 after 6 weeks of radiation therapy.First, the main limitation of this study is the lack of a control group. Because this study was a single‐arm study limited to patients undergoing PR, it is difficult to give sufficient validity to the results, including the improvement in physical function and no deterioration of quality of life after PR. Second, we could not compare pulmonary function before and after the PR program, thus we were unable to evaluate the improvement in pulmonary function after the PR program. Further prospective studies with randomized controlled designs are needed to evaluate changes in pulmonary and physical function and quality of life after completing a PR program. Additionally, in this study radiation therapy and pulmonary rehabilitation were performed in the same building, therefore high compliance to the PR program, which is the main result of this study, may be difficult to generalize and apply to other regions and medical environments.The results of this study show that a 4‐week outpatient‐based PR program for lung cancer patients undergoing outpatient‐based radiation therapy is feasible, without serious adverse effects. Furthermore, this program might improve patient physical function and quality of life.None.None.


Background: Training programs must be evaluated to understand whether the training was successful at enabling staff to implement a program with fidelity. This is especially important when the training has been translated to a new context. The aim of this community case study was to evaluate the effectiveness of the in-person Small Steps for Big Changes training for fitness facility staff using the 4-level Kirkpatrick training evaluation model.Methods: Eight staff were trained to deliver the motivational interviewing-informed Small Steps for Big Changes program for individuals at risk of developing type 2 diabetes. Between August 2019 and March 2020, 32 clients enrolled in the program and were allocated to one of the eight staff. The Kirkpatrick 4-level training evaluation model was used to guide this research. Level one assessed staff satisfaction to the training on a 5-point scale. Level two assessed staff program knowledge and motivational interviewing knowledge/skills. Level three assessed staff behaviors by examining their use of motivational interviewing with each client. Level four assessed training outcomes using clients' perceived satisfaction with their staff and basic psychological needs support both on 7-point scales.Results: Staff were satisfied with the training . All learning measures demonstrated high post-training scores that were retained at implementation follow-up. Staff used motivational interviewing skills in practice and delivered the program at a client-centered level . Overall, clients perceived staff supported their basic psychological needs  and reported high staff satisfaction scores .Conclusion: The Small Steps for Big Changes training was successful and fitness facility staff delivered a motivational interviewing-informed program. While not all staff operated at a client-centered level, clients perceived their basic psychological needs to be supported. Findings support the training for future scale-up sites. Community fitness staff represent a feasible resource through which to run evidence-based counseling programs. The prevalence of diabetes continues to rise, with 1 in 3 Canadians affected . Large cThere have been multiple translations of T2D prevention programs into real-world settings with demonstrated effectiveness , 6. ManySeveral translational studies have been modeled on the United States Diabetes Prevention Program, adopting a group-based format. While group-based approaches demonstrate one method to reduce overall program costs , use of Training is a core component of implementation with implications on program fidelity and subsequent effectiveness . UnderstMotivational interviewing (MI) has been used in numerous health-related programs to help individuals change various health-related behaviors, including the management of diabetes and obesity , 13. WheRecently, Phillips and Guarnaccia  recommenThe Small Steps for Big Changes (SSBC) program uses an individual approach to deliver behavior change techniques coupled with MI techniques to bolster client's self-regulatory skills in an autonomy supportive manner . The proTranslating the program to be run by a community organization presents an ideal opportunity to supplement gaps in primary healthcare and provide a cost-efficient program using YMCA staff. Hosting the program in a community organization has numerous benefits including increasing reach to those underserved by the healthcare system and enabling clients to have ongoing access to facilities (including their staff) post-program. The YMCA of Okanagan was actively looking for a program to adopt and inquired whether SSBC could be implemented within their facility . YMCA stAs noted, SSBC centers on the delivery of diabetes prevention topics using MI skills and specific behavior change techniques  to support clients' basic psychological needs and program success. The goal of the training was to teach staff core program components and skills necessary to be successful in facilitating the program to clients. The Kirkpatrick Evaluation Model  is a freA 1-year collaborative planning process with the YMCA of Okanagan was undertaken to support uptake and sustainability of the program . Two locThe workshop included didactic teaching of intervention content , a variety of role-play activities to practice use of skills , demonstration of skills , videos of session content delivered using MI skills, and how-to videos for common program procedures . All staff were given an implementation manual, including standard operating procedures, sample session scripts and checklists for the six sessions, and had ongoing access to the training videos through an online platform. All staff were shadowed by a research team member for their first client and given feedback after each session. Finally, ongoing monthly meetings with staff from each site were led by the first author to provide study updates, support, and review successes, challenges, and lessons learned.Assessing training is an important fidelity assessment to gain confidence that staff are adequately trained to implement a program with high fidelity. This is a crucial step for effective program implementation, especially prior to scaling-up an intervention. Results will support refining a standardized training program for a community behavior change program for individuals at risk of T2D and support future scale-up of the training to other YMCAs.n = 8). Staff were, on average, 31.88 ± 9.05 years of age (range 24–51), predominantly self-identified as female (75%), and white (88%). There was a wide range in years of employment  and education  in staff. The eight staff facilitated clients (n = 32) through the program between August 2019 and March 2020. Clients were on average 59.56 ± 6.88 years of age (range 43–70), and predominantly self-identified as female (68%) and white (95%).All staff and clients provided written informed consent prior to participating. Staff who facilitated a minimum of three clients through the program were included in the present study (M = 5 months post-training). Clients were emailed a pre-program survey link after their baseline appointment and a post-program survey link after completion of the program. All surveys were hosted on Qualtrics. The following sections describe how each level was measured and with what measure . Second, staff MI knowledge was assessed using a modified MI knowledge test . The oriA third measure was used to assess staff knowledge of MI skills. The helpful response questionnaire (HRQ) is a brief measure to assess MI skills  and was To assess if staff used their program knowledge and skills in practice, an in-depth fidelity assessment was conducted and has been reported elsewhere [see ]. The stn = 32). Coders rated the staff's use of five MI intentions  and two MI strategies  on a 5-point scale from 1 (inconsistent with MI) to 5 (proficient with MI) for each audio recording. Items could be given a half-point. The five MI intentions aim to capture the overall spirit of MI. The coders also counted the frequency of two MI micro-skills (open-ended questions and reflections) within each coded session. A random 25% of sessions were double-coded. Based on the MICA double-coding standards  . The MICtandards , the codTo assess training outcomes, two client measures were examined post-program that reflected staff program delivery. The first measure was the 15-item learning climate questionnaire , 21, whiFinally, clients were asked to rate their overall satisfaction with their YMCA staff who facilitated them through the program. For this study, 1-item from a 10-item measure developed for this study on program quality (program and structures) was reported. The item measured overall staff satisfaction: “Please rate your satisfaction with your trainer?”. Staff satisfaction was chosen as a training outcome to represent whether clients felt their staff had delivered program components in a satisfactory manner. Clients were asked post-program to rate their confidence on a 7-point Likert scale from extremely dissatisfied to extremely satisfied. The entire 10-item program quality measure is available for reference in t-test was run to test for sustained effects on the program and MI knowledge measures, and the HRQ. As recommended, multiple agreement statistics were calculated for the HRQ including percent agreement, Cohen's kappa (K), and prevalence, and bias adjusted Kappa (PABAK) statistics  and 17 clients completing the program quality survey (53% response rate).M = 4.43, SD = 0.45). Staff agreed or totally agreed to 95% of all statements. Two statements had one staff responded neutrally to the items, “the topics were dealt with in enough detail and depth as the training allowed” and “the method of delivery was well-suited to the objectives and content.” Two staff disagreed to the item, “the length of the training was adequate for the objectives and content.”t-test  demonstrated staff's program knowledge test scores did not significantly differ between post-training  and implementation follow-up . Similarly, a paired-samples t-test  demonstrated staff MI knowledge test scores did not significantly differ between post-training  and implementation follow-up . Finally, a paired-samples t-test  demonstrated staff MI knowledge test scores significantly improved from pre- to post-training and there were no differences  between post-training and implementation follow-up .Similar trends occurred for all three learning measures; all demonstrated high post-training scores that were retained at implementation follow-up. A paired samples M = 6.34, SD = 0.83; Range: 3.75–7.80). Based on staff availability, staff facilitated between 3 and 6 clients during the study timeframe. When assessed at the individual staff level, 5 staff operated above a client-centered level and 3 were below . The mean for all the learning climate questionnaire sub-scales and the added empathy items obtained similar high results . Overall, clients reported high staff satisfaction scores .Training evaluations are an important component of assessing program fidelity and a vital implementation strategy during program translation and scale-up. Assessing training is a necessary factor to understand if a program was delivered as planned to have confidence in program outcomes . As a prPast diabetes prevention programs have used MI e.g., , 42], in, in42)],Although the fidelity of MI skills has not been examined in diabetes prevention programs, it has been examined in other fields. For pragmatic reasons, staff did not complete a pre-training audio recording of a counseling session. Therefore, comparisons of staff MICA scores from pre- to post-training were not done, which has been done in past training evaluations . Rather,Self-determination theory has been suggested as a potential conceptual framework for explaining how and why MI works , 19. WhiThis research was affected by COVID-19 (YMCA and associated programming were forced to close due to the pandemic), is limited by a small sample size and results may lack generalizability. A pre-training knowledge test was not administered as all staff were naïve to working with individuals at risk for developing T2D and the program's standard operating procedures prior to the workshop. Similarly, there was no pre-training audio recorded session to capture staff pre-training MICA scores. These decisions were made for pragmatic reasons. In evaluation research, data collection methods  can act as part of the training to increase the likelihood that staff demonstrate a minimum level of knowledge gained . In doinStaff praised the shadowing experience for providing comfort during their first experience implementing the program and an opportunity to receive direct feedback on their program delivery. However, it was difficult to coordinate scheduling and is not feasible for scale-up. Similarly, finding time for all staff to attend a 3-day in-person training workshop was challenging due to conflicting staff work schedules. Translating the training into a self-paced digital training may better support scale-up and sustainability of the training for broad scale-out. Future research should examine novel ways to mimic the reverse shadow experience to adequately prepare staff, such as incorporating a mock session.Conducting a training evaluation was invaluable to learn how the training was received and implemented by YMCA staff, and how clients were affected by their staff's execution of the program. The current study demonstrates that MI can be taught to fitness facility staff. Previous research has suggested MI was difficult to learn, with those struggling wishing to have more training . Indeed,Implementing a program as it was intended to be implemented gives confidence that program outcomes are a result of the program structure and delivery . All staThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Conjoint Health Research Ethics Board, University of British Columbia: H16-02028. The patients/participants provided their written informed consent to participate in this study.TD, CB, and MJ contributed to conception and design of the study. TD and KC completed the HRQ coding. KC and MM completed the MICA coding. TD organized the database, performed the statistical analysis, and wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.This research was funded by both a Social Sciences and Humanities Research Council Doctoral Scholarship (#767-2020-2130) and a Partnership Engage Grant (#892-2018-3065), the Canadian Institutes of Health Research (#333266), and Michael Smith Foundation for Health Research Reach Grant (#18120).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


As a result of working inside homes, city housing inspectors witness hidden and serious threats to public health. However, systems to respond to the range of problems they encounter are lacking. In this study, we describe the impact and enabling environment for integrating a novel Social Service Referral Program within the Inspectional Services Department in Chelsea, MA. To evaluate the first eight months of the program, we used a mixed-methods approach combining quantitative data from 15 referrals and qualitative interviews with six key informants . The most common services provided to residents referred by inspectors were for fuel, food, and rent assistance; healthcare; hoarding; and homelessness prevention. Half of referred residents were not receiving other social services. Inspectors reported increased work efficiency and reduced psychological burden because of the program. Interviewees described how quality of life improved not only for referred residents but also for the surrounding neighborhood. A simple referral process that made inspectors’ jobs easier and a trusted, well-connected service provider funded to carry out the work facilitated the program’s uptake and impact. Housing inspectors’ encounters with residents present a unique opportunity to expand the public health impact of housing code enforcement. Housing is more than physical shelter; it is a powerful social determinant of health . Poor hoA primary strategy for breaking the link between poor housing and poor health is the enforcement of housing codes . HousingHousing inspectors, by nature of their work inside homes, are often the only public officials to witness many serious health risks—some of which constitute code violations, but many of which do not. These risks include inadequate protection from the elements, hoarding disorders, and overcrowded conditions. While inspectors are in a unique position to intervene, they lack systems and training to respond to the range of public health problems they encounter: the only action available to them is enforcement through citations. While some housing-related problems are effectively addressed through enforcement alone , others require service provision paired with enforcement . Pairing code enforcement (an obligation encounter that imposes duties) with service provision (an encounter where assistance is provided) is an opportunity to address root causes of housing-related problems and improve the effectiveness, efficiency, and equity of code enforcement.There is growing evidence that collaboration between local governments, public health, and social service institutions has a synergistic impact on health outcomes . CollaboCollaborations like these can make housing code enforcement a more effective means to improve public health through early intervention. In fact, when housing inspection began in the late 1800s, code enforcement and public health went hand-in-hand. In modern times, formal collaboration between housing inspection and health and social service agencies are not the norm and existing programs are limited in the range of problems they address. Inherent tension between service-oriented professions and compliance-oriented professions can stymie collaboration . Yet, giIn the mid-19th century, rapid population growth among the urban poor and lack of affordable, adequate housing gave rise to overcrowded and severely substandard housing conditions . ConditiAs the 20th century progressed, budgets for public health departments in the U.S. shrank . Once paThe objective of this study is to describe the impact and enabling environment for integrating a novel Social Service Referral Program within the Inspectional Services Department in Chelsea, MA. Impact is measured in the quantity and quality of services provided to residents through the program, as well as how the program changed work processes for housing inspectors and social service providers.Chelsea is a small, densely populated, demographically diverse city located just outside Boston. Per-capita income is USD 23,240/year, making Chelsea one of the poorest cities in Massachusetts . The majIn 2015, Chelsea City Hall began a proactive rental housing inspection program to improve housing conditions . InspectIn 2017, the Harvard Kennedy School’s Innovation Field Lab partnered with five Massachusetts cities, including Chelsea, to develop innovative solutions to intractable housing problems . Based oIn 2019, the City of Chelsea, MA implemented a novel social service referral program within the housing inspectional services department. When inspectors identify a social or health problem that cannot be addressed through code enforcement alone, they can quickly and easily connect residents with a social service case manager. The case manager connects residents with a range of services from substance use disorder treatment to financial assistance with housing repairs.Significant change management work occurred prior to the initiation of the program. The Social Service Referral Program required more than collaboration across diverse agencies; it required pairing traditionally very separate types of encounters—one which imposes duties and one which provides assistance ,21,34. BPrior to the adoption of the program, a pilot program existed for several months to show proof of concept. In the pilot, inspectors could make referrals to a Community Engagement Specialist within City government who had connections with local social service agencies. The pilot convinced City leadership that inspectors would make referrals and residents would accept them. The pilot softened inspectors’ main objection to the program by reducing, instead of increasing, their day-to-day workload. However, the program lacked funding, accountability, and ultimately sustainability . RelyingChelsea’s Social Service Referral Program launched in earnest in July 2019, when the City contracted a local social service agency, CAPIC  to provide services to in-need residents identified during housing inspection. CAPIC had an existing contractual relationship with the City to provide crisis and outreach services but was not previously connected with inspectors. The agency serves an average of 14,000 low-income individuals and families annually in Chelsea and nearby cities . Their mDuring routine inspections, inspectors identify residents in need of support beyond what inspectors can provide, ranging from crisis assistance  to vital access to basic needs . Referrals can be made for landlords as well as tenants. No formal screening process is used in making referrals.To make a referral, inspectors obtain consent from residents and call a designated case manager at the social service agency, CAPIC. Inspectors received training from CAPIC’s case manager on this process.A case manager then contacts the resident, most often meeting them at their home, to determine what type of support is needed. If a resident accepts, the case manager connects them with services and provides follow-up care. Housing inspectors follow up to ensure housing code violations, if present, are corrected.CAPIC shares outcomes and progress with inspectors and the City Manager via monthly updates and quarterly reports.The Social Service Referral Program has four steps:To evaluate the impact of the first eight months of the referral program (July 2019 through February 2020), we used a mixed methods approach combining quantitative data from the first 15 referrals with qualitative interviews with six key informants.Case managers collected demographic data on referred residents, in addition to data on the number of refusals, services provided, and follow-up activities. We describe these data in summary statistics.n = 3 of 5); the lead social service case manager; and Chelsea’s City Manager and Deputy City Manager. Interviewees were selected based on their involvement in the Social Service Referral Program and interviews lasted 30 to 60 min. Interviews were completed in Fall 2020 via phone (N = 1), videoconferences (N = 4) or in person (N = 1) by the first and second authors. Interviewees were asked questions about the perceived impact of the program on their work and on residents, as well as conditions that enabled the program’s adoption. The study protocol originally included interviews with referred residents, with contact between residents and the research team facilitated through CAPIC’s case manager. However, this connection was not possible due to CAPIC’s ongoing response to the COVID-19 crisis.Semi-structured qualitative interviews  accepted services upon the first offer; 27% accepted after two or more offers; 7% declined services . For 20%Residents received, on average, nine visits or phone calls with a case manager  and three types of services (range 1–5). Inspectors reported routine encounters with families or individuals in crisis or in need of support. They described finding families living on enclosed porches, unfinished basements, or closets; the unhygienic conditions of homes where residents hoarded food or animals; bare cupboards; no heat in the winter; and seniors in need of assistance to live safely at home. Inspectors recounted how these problems impeded their work because they limited residents’ ability to resolve violations and caused repeat inspections. This reduced time available for other inspections and many violations were only temporarily resolved. Before the referral program, when inspectors tried to support residents in crisis, it often resulted in lengthy engagements with unattained or unstained resolution. Inspectors also shared the emotional toll of seeing human suffering on a regular basis; the fatalism they felt in trying to help people without support; and the blind eye they learned to give problems that were not specified in the housing code. In describing their work before the program, inspectors stated:So, we see all these social service problems. And there’s really not a lot we can do. It’s terrible… When you’re alone in the house, you see how people live. You see these people living with no food or you see this person that clearly has a mental health issue and, you know, that’s not our job. There’s not a lot we [could] do.”“(Inspector 2).It would put a huge strain on my office. It would put a huge strain on each individual neighborhood. We have these issues that go on forever… And when we’re not working on it… there is no outcome, the neighborhood suffers, the family suffers, everybody suffers.”“(Inspector 3).When asked how the program changed their work, inspectors described increased efficiency and reduced psychological burden as a result of being able to refer residents whose problems would forestall bringing a home to code or whose problems they could not turn from with a clear conscience. They also described providing residents guidance on services when they felt case manager involvement was not required.[The Social Service Referral Program] took away the piece of the inspection for certain types of people that was causing problems for us. If people are going to be evicted or have mental health issues or can’t pay rent–these we can refer to CAPIC… CAPIC has time to case manage people’s needs. We still resolve problems in-house; we just refer our most challenging that are outside the scope of violations.”“(Inspector 1).There’s more free time … so once we do our inspection and write up our report and get CAPIC involved … you don’t have to have it in the back of your head the whole time and check in on it every day… it gives you peace of mind, it releases my inspectors to do other work… It’s a good feeling, takes a lot of stress off us.”“(Inspector 3).City leadership (the City Manager and Deputy City Manager) also noted the value of being able to rapidly and appropriately define a problem and assemble the needed resources and people from the beginning of an encounter. The program made leadership aware of the psychological toll social problems were exacting on inspectors and the resulting inefficiencies.What’s interesting is that now these problems that were experienced by inspectors, but didn’t necessarily come up to our level, now do… They were simply wrestling with these issues all on their own. Making phone calls, trying to find the resources to address the issues. Sometimes failing, sometimes succeeding, but in a really scattershot way. I think that was sort of an invisible workload down in [The Inspectional Services Department] that has now become part of an understood process of engagement… and given a form and a direction on how to solve these problem situations.”“(City Leader 1).The total number of referrals in the first eight months of the program was fewer than City leadership anticipated. When asked about the number of referrals, inspectors shared that they only referred the most “hopeless” and time-consuming cases, and that even this small number was valuable to them.When I challenge [inspectors] on the number of cases… it’s the intractable cases that can be time eaters for inspectors and endanger the client… So, I would say it makes [inspectors] more effective and therefore engenders a sense of actually assisting people to a solution that’s helpful to [residents] rather than punitive.”“(City Leader 1).I’m only going to refer people who really need the services–who are destitute or needs can’t be met otherwise.”“(Inspector 1).For most referrals, the case manager made home visits. In her typical work, clients come to her office. The Social Service Referral Program allowed her to view problems from a new vantage point within homes. She described the value of observing living conditions and building more personal relationships, which contributed to more nuanced assessments of what resources residents had and needed. Often, she found residents needed assistance for several problems, not just the problem that had precipitated a referral. She reported that the residents she helped through the program were unlikely to have connected with CAPIC on their own, especially physically disabled or elderly residents.I spend more time with them [residents referred by inspectors]. Sometimes a client comes in here [to CAPIC] and I’m issuing them a food gift card. I don’t really know about their background… or living situation. I don’t know what their issue is, apart from they’re coming in and they’re telling me, ‘I’m hungry.’ Through [the Social Service Referral Program], it’s a more personal connection I have with the clients.”“(Case Manager).Inspectors and City leadership described how the program improved residents’ quality of life, reduced the use of costly emergency services, and made neighborhoods safer.When you take the biggest problem of [residents’] lives … and it gives them a better-quality life … dealing with their medical issues, their families, and mental health issues, things like that.”“(Inspector 1).My first thought was to call the police. And now I’m thinking let me get [CAPIC] involved.”“(Inspector 2).If you have one bad building, everything else is so much worse. Once you fix that one building the rest of the neighborhood gets better. Kids are going out and playing on the sidewalk where they weren’t before because the guy had, you know, prostitutes and drug addicts living at his house. So, when he’s kept in check, it changes the whole neighborhood … So, in most of these [cases] we’ve referred … it’s almost like the whole neighborhood had a problem. So, it’s helping the whole neighborhood, not just one person or one person’s life.”“(Inspector 3).Inspectors and City leadership described two key components that enabled the program’s uptake and impact. First, the referral process is easy for inspectors and they see a meaningful difference in their work.As far as I’m concerned, it’s real successful because sometimes it just takes a phone call for me … And it’s like ‘tag, you’re it’ and [the case manager] carries the ball, and she’s really good.”“(Inspector 2).When I raised this as a budgetary issue with [the Director of Inspectional Services] or informally with his staff about moving forward with the program, there is no hesitation on their part … and they wouldn’t simply endorse something because it was there and occasionally it may be okay. So, I trust their judgements when they say to me, ‘This is really important for us to continue’.”“(City Leader 2).Second, the city contracted an effective and reliable service provider and provided funding to support their work. Inspectors frequently referenced their trust in the timeliness and quality of service CAPIC provides, as well as the benefit of CAPIC’s connections with other service providers in the City. City leadership described the importance of working with the right service provider and that part of what makes the program work is strong personal relationships between the inspectors and the case manager. This relationship did not exist prior to the program but was developed over time as inspectors learned that they could rely on CAPIC and that referring residents decreased their workload.You’ve got to identify the service provider who has the … case management experience to do something like this. … who understands all the connections, that has experience with all the resources that are out there on the state and nonprofit level and is able to bring those in to solve problems. … And on the day-to-day level, certainly making it as simple as possible. [Inspectors] didn’t want to have a complicated reporting system … so shifting the tracking and documentation of case management to the service provider so that it’s not an additional burden on the inspector was important to us.”“(City Leader 1).The main limitations described by interviewees were that (1) some people that need help refuse to accept help, and (2) some problems could not be addressed either because they were too expensive  or connections to the type of support needed were not readily available through CAPIC’s connections . However, to gain buy-in for the program from CAPIC and the inspectors, the requirements for documentation of referrals were limited. City leadership reflected that there was not a process to capture how many residents declined inspectors’ offers of a connection to CAPIC services. While there was a process to capture when residents declined services after meeting with CAPIC, there was not a process to document the number of people that needed a service that could not be provided by CAPIC, nor the type of service that could not be provided.Despite the limitations, all interviewees felt that the Social Service Referral Program could work in any city. Most added that Chelsea has unique characteristics that they thought contributed to the program’s adoption and success, namely its small geographic size and community-focused culture. No interviewees mentioned the City’s partnership with the Innovation Field Lab when asked what motivated the City to adopt the program. Instead, they described “social ills” that were inadequately addressed through obligation encounters alone and hypothesized that any city with similar problems could benefit.Integrating a novel Social Service Referral Program within housing inspection allowed for better alignment between the problems residents and inspectors faced and solutions to those problems . When inThe Social Service Referral Program also modified norms around how case managers at CAPIC engage with clients. Home visits through the program mirror the practice of physician house calls, once the primary mode of healthcare delivery in the U.S. Not only do home visits provide services for a population that might not otherwise access services on their own, but they also give providers an entry point to gather important qualitative information on environmental and social factors that can contribute to or help solve problems. The same is true of physician house calls and other home visiting programs  ,41. RefeTwo conditions of an enabling environment for the program were identified through the interviews: (1) A simple referral process that made inspectors’ jobs easier and (2) a trusted, well connected social service agency, funded to carry out its work. The development of a pilot referral program that preceded the formal program also helped facilitate adoption. The program showed that while housing inspection and social service providers employ very different methods, they ultimately have shared goals—housing stability, safety, health, and social welfare. However, these two groups lacked operational alignment. While their integration was facilitated through the Harvard Kennedy School Innovation Field Lab, connections like these do not require a third party to facilitate. However, role reimagining and adaptive leadership are required to achieve alignment between problems and solutions.Equipping code enforcement officers, or other frontline staff, to be sensors of at-risk households has the potential to transform the way cities identify and provide services to those in-need. This role re-imagining, within existing structures, can be built upon in other locations and by other professions. By leveraging existing encounters and networks, hard-to-reach or at-risk populations can often be reached more efficiently than through the creation of new channels .Further, we demonstrate how greater value is delivered to the public when enforcement work is problem-oriented to identify and resolve risks through critical engagement, rather than simply applying a rule-driven approach . This tyThis study represents a steppingstone toward larger, more robust studies on the effectiveness of multisector collaboration to address housing and health problems and other intractable urban health challenges.Inspectors referred only 15 residents to the Social Service Referral Program during the eight-month study period. While inspectors were pleased with this total and City leadership has continued to fund the program, the number of referrals was lower than anticipated at the program’s inception. Prior to the program, inspectors reported encountering at-risk residents on a weekly basis. It is possible that inspectors only referred residents who they thought would accept services (given the high acceptance rate) or when they were confident CAPIC would be able to help—though inspectors denied this type of screening. It is also possible that inspectors felt more equipped and motivated to address less complex social needs on their own through providing information or connections to services without going through the CAPIC case manager, as was described by two inspectors. It is a limitation of the program that there were not specific criterial for what should constitute a referral and a mechanism to document refusals of referrals. It was also not possible to extend the study period past February 2020 due to the COVID-19 pandemic. In March 2020, proactive rental housing inspection ceased. The nature of the referrals and data quality differed substantially after February 2020.Another important limitation is that it was not possible to interview residents referred to the program due to the COVID-19 pandemic and therefore this evaluation lacks their perspective. Additionally, we cannot quantify the impact of the referral program on the efficiency of housing inspection  because the former is not tracked, and the latter is not available for 2019–2020 due to a change in reporting systems. However, if we use the number of inspections from July 2017 to February 2018 as guidance, approximately 300 housing inspections occurred (excluding tenant turnover inspections when residents are unlikely to be home), only 5% of inspections resulted in a referral.Among the residents referred, 40% were White (non-Hispanic/Latino). This group makes up only 20% of the total population in Chelsea. The disparity in referrals by race may be due to the age structure of the population. Most elderly residents are White and elderly residents are more likely to be home and encounter housing inspectors . HoweverLastly, interviewers (first and second authors) were known to the interviewees, having worked together a year prior to the interview. This was both a benefit—because good rapport and candor had been established—but also a limitation. Interviewees may not have felt comfortable critiquing a program the interviewers had helped initiate. To mitigate this, interviewees were encouraged to share their sincere views, both positive and negative and several follow up questions were asked regarding limitations and challenges of the program.Fulfilling housing inspector’s mandate to protect the health and safety of residents requires novel approaches. Through the Social Service Referral Program implemented in Chelsea, MA, when inspectors encounter threats to health and safety that cannot be addressed through code enforcement alone, they have a system to link residents to the services they need. This not only allows for timely and appropriate intervention for residents but improves workflow for inspectors. Given the central role that housing plays in the health of individuals and communities, integrating social services within housing code enforcement is a catalyst to improve community health.


A damaging Mw5.5 earthquake occurred at Pohang, South Korea, in 2017, after stimulating an enhanced geothermal system by borehole fluid injections. The earthquake was likely triggered by these operations. Current approaches for predicting maximum induced earthquake magnitude ( Here, authors find scaling of maximum magnitudes of earthquakes triggered by underground fluid injections with logarithmic event-occurrence times. This also applies to the Pohang Earthquake, the high probability of which was predictable using an approach based on monitoring of the Seismogenic Index. The earthquake was likely triggered by the EGS-stimulation operations27 in developing strategies to forecast Vf, as the controlling parameter25. Some approaches29 implicitly assume that fluid injection is the sole source of strain in the surrounding rocks, and conclude that the seismic moment of the largest induced earthquake , 27.There is considerable active research25 that was induced by pore-fluid pressure perturbation in the layer around an area of the earthquake fault plane. A comparison of the stress intensity factor (a function of the pore-pressure perturbation) and fracture toughness yields a different power law25, 25 depends on the background stress drop, friction, elastic properties and thickness of the pressure-perturbed layer, with the seismic moment of the maximum arrested rupture eventually being controlled by the injection-induced pressure perturbation. Such a perturbation is independent of the existing tectonic stresses at the injection site. Thus, such an approach has a  potential for failing in tectonically active regions and areas situated near critically stressed faults. However, one can adjust the proportionality coefficient of the power law 25 by relating it to the seismogenic index, Σ, which quantifies the induced seismicity that may be produced at a given injection site in response to a unit injected volume31 (see ‘Methods’ section).Another approach is to compute the moment of the largest arrested rupture31 to the largest earthquake in a time series of fluid-induced seismicity has also provided an estimate24 of A direct application of the seismogenic index model19, whereas case histories25 have shown that Vf. However, magnitude scaling with ΔVf is a function of the geometry of the processes under consideration, as three22- and two25-dimensional pore-pressure-diffusion-based approaches have yielded various power-law dependencies of Vf is closely related to the elapsed time ΔT from the beginning of fluid injection to the Recent studies on the 2017 Pohang Earthquake have emphasised that none of the abovementioned approaches are adequate in describing this earthquakeVf. However, ΔT is unknown a priori; therefore, the seismogenic response of the surrounding rocks due to fluid injection should be monitored in real-time to address the Here, we analyse published case histories and show that 29 of published T data from corresponding and some additional literature sources58. In some publications times, ΔT can be directly found. However, in the other cases, we estimated ΔT from published plots. We provide ΔT values up to the second digit in the leading order. This precision is sufficient for our consideration below. The data and corresponding references are given in the Supplementary Data We used existing compilationsmentclass2pt{minimVf, and the elapsed times, ΔT,  due to fluid injections can be governed by various processes, such as (non-)linear pore-pressure relaxation23, which sometimes includes a significant portion of the poroelastic coupling59, aseismic deformation61, and/or a diffusion-driven event interaction11. The growth of L can be approximated as a power-law function, ΔTξ, where ξ is indicative of the physical process(es) controlling this growth. For example, ξ = 1 in the case of a ballistic propagating perturbation, ξ = 1/2 in the case of a linear pore-pressure relaxation , and 1/3 ≤ ξ < 1/2 in the case of a non-linear diffusion-like process  of opening additional 3-D pore space23. Asymptotically, such power laws apply to both the triggering front and backfront62 . L also continues to grow after the termination of injection62. The size L influences the frequency–magnitude statistics of the induced seismicity23, because the length statistics of triggered rupture surfaces that are related to the stimulated volume  are controlled by this size23. The probability of a triggered earthquake with a large rupture length, L. This is also the case for so-called runaway ruptures because increasing the stimulated volume raises the probability that it will contact a large fault25. This relationship can be approximated as 23 is a function of R of an earthquake and its seismic moment, M0 ∝ R3, and between the seismic moment and the moment magnitude25, MwL ∝ ΔTξ into these relationships yields the following scalings: Our findings suggest the following. The growth of the characteristic size, L ∝ ΔT1/2, which is typical for the size-time dynamics of rock volumes stimulated by normal pressure diffusion processes. Thus, our observations indicate a statistically dominant role of linear pore-pressure diffusion in triggering 23 can be relevant for such earthquakes: (i) the rupture surface of the earthquake is contained within the stimulated volume ; or (ii) the nucleation domain of the rupture surface and its part are contained within the stimulated volume; or finally, (iii) the rupture surface is touched or slightly intersected by the stimulated volume  and (iii) are called triggered ones23). The cases of ruptures arrested inside or outside of the stimulated volume as well as runaway ruptures are parts of these scenarios. At least in the scenarios (ii) and (iii), magnitudes of triggered earthquakes are very likely controlled by tectonic features of corresponding geological sites rather than by the scale L of the stimulated volume. However, the occurrence probability of such earthquakes depends on this scale, as it follows from our consideration above. The Pohang Earthquake is an example of such an event. Figure 18 that the Pohang Earthquake was triggered by an EGS-stimulation impact on the earthquake hypocenter domain. This impact could have various forms, for example, a direct injection-produced pore-pressure perturbation or a combined pore-pressure and stress perturbations11 of induced earthquakes in the stimulated volume.We find that the scalings mentclass2pt{minimons Fig. . These rL ∝ ΔTξ, also describes the continuing growth of the stimulated rock volume after the termination of injection62. These magnitude scalings are therefore more adequate than those with ΔVf. Large earthquakes have an enhanced occurrence probability at or shortly after the termination of fluid injection (a finite time period after the termination of injection is characterised by a significant number of induced earthquakes63), because L increases with ΔT. This also contributes to the fact that The abovementioned magnitude scalings naturally include situations of earthquake triggering after the termination of fluid injection since the law, Vf is approximately proportional to the injection time. Therefore, ΔT and ΔVf will be approximately interchangeable if the highest magnitude earthquake occurs before the termination of fluid injection (observed in a majority of the case histories). These quantities are indeed strongly correlated elastic stresses are still significant . Thus, the scaling t0, (see ‘Methods’ section). Then, the corresponding realistic scale of the spatial domain where the earthquake triggering will be probable is limited by the size of the order of several characteristic lengths D is a representative hydraulic diffusivity of hydraulic paths to the critically stressed faults.In respect to the post-injection growth of the size T are unknown a priori parameters for a particular fluid-injection experiment. However, one could estimate the exceedance probability of an assumed critical 64, with their frequency–magnitude distribution given by the Gutenberg–Richter statistic of the tectonic environment. However, their probability is enhanced due to the fluid injection. We take this into account by combining the occurrence probability of an earthquake with a magnitude 30 (see ‘Methods’ section). This model contains the seismicity parameters, Σ and b, which are functions of the seismotectonic features of the surrounding fault systems. A more or less seismically active fault system will potentially be activated if these parameters exhibit non-stationary behaviour during rock stimulation. Therefore, Σ and b should be monitored in real-time. We propose to monitor the worst-case probability based on the real-time evolution of these parameters:t: t counted from the start of injection operations (the time moment 0). Simultaneously, the quantity t (see Methods). Thus, we call the quantity b-value is challenging during the early stages of injections, especially when an imperfect monitoring system is used. A potential alternative is to obtain a realistic estimate of the b-value from (a priori) available regional seismicity data. However, real-time monitoring of Σ is feasible, such that the observation of significant events then becomes sufficient (see ‘Methods’ section and Supplementary Information file).Maximum induced magnitude and Δmentclass2pt{minimmentclass2pt{minim18 was 510 m from the site of the Pohang-EGS project and ~15 km away to the north-northeast from the centre of Pohang, a city with a population of ~500,000. The earthquake occurred on 15 November 2017, after a series of water injections into two deep boreholes, PX-1 and PX-2, that were drilled into granodioritic rocks to 4215 and 4340 m depth, respectively . Σ is approximately between −2 and −1 Fig. . We obse66 (early aftershocks). It has been observed that the initial propagation of the main rupture segment and its subsidiary segment was likely arrested by two other fault segments, one to the northeast and another one to the southwest from the hypocenter domain. However, our estimates of Σ indicate a dangerous tendency of non-stationarity in the temporal evolution of the seismogenic index, and thus an enhanced probability of triggering a runaway large-scale earthquake rupture. We use Eq. , the real probability of the Pohang Earthquake could be even higher. A strong indication of a possibility of a runaway rupture can also be seen from a very high worst-case probability of an event of the stimulation-zone size (this is a largest event for which Eq. (3m and the stress drop in the range 1–5 MPa). The temporal behaviour of the probability of a stimulation-zone size event during the Pohang-EGS-stimulation activity is similar to that calculated for the Pohang Earthquake  than the Pohang one, yielded a significantly higher corresponding Σ (~0.25). However, the b-value (~1.44) was also higher, such that the probability of a Mw5.5 event at Basel was highly unlikely. However, the probability of a Mw3.4 event (such an earthquake led to the termination of the Basel EGS project12) was ~15% .The low ~11,500 m than the68 are another example of how the induced seismicity could be predicted, with the large ΔVf being the main driver in this instance. Approximately 630,000 m3 of wastewater was injected down a single 3671-m-deep well that was drilled into the fractured Precambrian crystalline basement below the Rocky Mountain Arsenal44. The fluid injection began under pressure on 8 March 1962. It was interrupted from October 1963 to August 1964, and then resumed as a gravity flow in September 1964, with continued fluid injection under pressure commencing on 6 April 1965. Fluid injection was terminated on 20 February 1966 due to the induced seismicity68  for the Denver site by assuming a continuous injection experiment. This provides 68 none of the Denver earthquakes were larger than Mw5.3 or even Mw4.85. We assume b = 0.85, based on the published data4, and observe that even for the lower estimate of the seismogenic index, the probability of such a high magnitude event (>20%) was higher than that in Pohang  occurred on 9 August 1967.The 1962–1968 Denver earthquakesVf and high b-value) in Basel, a very low b-value (with a moderate to high Σ and very moderate ΔVf) in Pohang, and an extremely high ΔVf  in Denver. The interplay between these parameters takes the form of Eq. . The elapsed injection time ΔT is also an important implicit parameter of Eq. ))Vf and h31 to analyse the case histories. Σ quantifies the potential for an earthquake to occur at a particular geologic site due to fluid injection. This model has been used to characterise induced seismicity in various studies, such as water-disposal-related seismicity8, seismicity triggered by hydraulic fracturing operations70, and seismicity related to the Pohang-EGS activity20.We use the seismogenic index model30 follows from the mass conservation of an approximately incompressible pore fluid (i.e. approximately pressure independent density). In the approximation of a monotonic non-decreasing injection pressure, this model describes the cumulative number of induced earthquakes, NM≥(t), with moment magnitudes ≥M, that occur during the injection period t as:M induced events, a and b are the parameters of the Gutenberg–Richter distribution. Σ is the seismogenic index of the rock volume stimulated by the injection. Conventionally, Vf(t) is given in m3. Σ can be estimated using Eq. (t) directly by assuming that all of the injection phases are a single continuous injection experiment. This results in a somewhat underestimated Σ (an approximate lower bound) because the fluid volume was also accounted for during the intervals where the pore pressure was lower than those reached in the previous injection phases. We then assume that all of the injection phases are independent experiments and compute the corresponding values of Σ(t) (Supplementary Information file). This calculation results in a somewhat overestimated Σ (an approximate upper bound) because some events that were induced by previous injection phases can influence the number of induced events in the later injection phases. During long-term bleed-off phases of the injected fluid, the relation between these two Σ estimates can turn round because of possible late triggered events and resulting lower injected volumes at occurrence times of such events  into Eq. , after the termination of an injection at a constant rate (at least for τ0 = O(1)):t0 is the duration of the fluid injection and τ0 = t/t0 denotes the normalised time after the termination of the injection (τ0 ≥ 1).A specific model of the seismicity triggering process is required to predict the seismicity rate after the termination of a fluid injection. One can calculate the seismicity rate after the termination of injectionRev(t0) for events with magnitudes ≥M can be directly obtained from Eq. (63 have shown that pd approaches 2 for long durations (τ0 on the order of 2 and larger). This is also supported by studies of the seismicity induced by large-scale massive fluid disposals in Oklahoma8. The estimated seismicity rates for the Fenton Hill and Soultz case studies63 (τ0 on the order of 1) have provided high values of 7.5 and 9.5, respectively, for the pd exponent.The following approximation of from Eq. :7\documeM that were triggered during the time range  (fluid injection starts at the time moment 0):pd ≥ 2. Therefore, the event probability after the termination of fluid injection is roughly limited by its probability during the period . The short elapsed time of Δt  after an injection termination causes the event number to increase as We obtain the following relationship when we use Eq.  for the Mcr event  that occurred at t0. We can then use right-hand side of Eq. .Let us assume that the injection was terminated immediately after a magnitude e of Eq.  with N≥MThe event probabilities corresponding to Eqs.  and 9)  9) are dSupplementary InformationPeer Review FileDescription of Additional Supplementary FilesSupplementary Data 1Supplementary Data 2


BackgroundPediatric to adult health care transition (HCT) is an essential process in the care of youth with special health care needs (YSHCN). Many internal medicine-pediatrics (med-peds) residency programs have developed curricula to teach transition knowledge and skills for the care of YSHCN.ObjectiveUsing a national med-peds program director quality improvement collaborative to improve transition curriculum, we aim to identify curricular content areas of improvement by describing baseline trainee knowledge and skills taught through existing transition curricula in med-peds programs.MethodsWe analyzed data collected during the 2018-2019 national med-peds program director quality improvement collaborative to improve transition curriculum. Program directors assessed their programs, and trainees assessed themselves on five transition goals by completing a Likert-scale questionnaire. In addition, trainees received an objective assessment of their knowledge through a multiple-choice questionnaire (MCQ).ResultsAll 19 programs in the collaborative, and 193 of 316 trainees from these programs, completed the questionnaires. Most programs were based at academic centers (68%) and provided transition training via didactics (63%) and/or subspecialty rotations (58%). More programs had high confidence (95%) than trainees (58%) in goal 1 (knowledge and skills of the issues around transition), whereas more trainees had high confidence (60%) than programs (47%) in goal 2 . Programs and trainees self-assessed lower in goals related to health insurance, educational and vocational needs, and application of health care system knowledge to the practice environment .ConclusionsUsing the assessments of the program directors and resident trainees, we identified subject areas for improvement of transition curricula, including health insurance and the application of health care system knowledge to the practice environment. The entrance to adulthood can be a perilous time for all patients, especially for those with special health care needs. The young adult years are often marked with complex changes to social structure and needs, declining health, and increased acute care utilization -6. TherePhysician training programs are tasked with providing the education and experiences necessary to teach physicians how to facilitate the transition for their patients. A framework for resident trainee competencies has been described, which accounts for the numerous and complex needs during transition to adulthood . The HeaOur study aims to identify areas of curricular improvement by analyzing the results of program director and resident assessments of knowledge and skills of pre-defined HCT topics.Study design and sampleThis is a descriptive study of the baseline data collected as part of a prospective quality improvement learning collaborative. The results of the learning collaborative have not been published. The HCT-CoIN emerged from the larger University of California, Los Angeles (UCLA) Health Care Transition Research Network, funded by the Maternal and Child Health Bureau of the Health Research Services Administration. The UCLA med-peds residency program served as the coordinating and administrative site for all study procedures. The purpose of the HCT-CoIN was to create a toolbox of resources for residency program directors to implement or enhance HCT curricula at their own institutions from June 2018 to February 2019. An incentive of $1000 was provided to all program directors who agreed to participate in the HCT-CoIN. They had the discretion to use the incentive in any way to improve participation in and/or success of the study. Program directors from 22 med-peds residency programs across the country elected to participate in the collaborative at the end of the 2018 Medicine-Pediatrics Program Directors Association (MPPDA) meeting. Three programs withdrew prior to data collection. Data from 19 programs are included in the current analysis. Programs were diverse in geographic location.Data collection and measuresWe analyzed data collected during the 2018-2019 national med-peds program director quality improvement collaborative to improve transition curriculum. Study measures and data collection tools for the HCT-CoIN were developed by the project director (a med-peds residency program director), the quality improvement consultant (a preventive medicine physician), and the project coordinator of the study team at the coordinating site, UCLA. Data collection tools including the self-assessment surveys and multiple-choice questions (MCQ) were designed by the aforementioned study team. The trainee self-assessment and MCQs are provided in the Appendix. The main outcome measure for the current study was an assessment score with regards to five transition goals outlined previously using a modified Delphi model, and this was collected prior to the initiation of the activities of the improvement collaborative . The traThe second source of baseline data was collected from resident trainees in the 19 programs. The resident trainee survey consisted of a self-assessment of their current knowledge of transition care and 15 MCQs created by the study team as no other validated survey was available or applicable to the study. The MCQs were mapped to the transition goals used in the program director and resident self-assessments. MCQs that mapped to more than one goal were questions 1 , 6 , 13 , 14 , and 15 . Each MCQ had one right answer as determined by the coordinating site expert panel. The self-assessment for resident trainees used a Likert scale, similar to the program director assessment, where trainees rated their preparedness on each of the objectives within the five goals of transition care on a scale of 1 to 4. A higher score reflected greater preparedness for the goal. Eighteen of the 19 programs administered the online version of the survey to all their current resident trainees. One program administered a paper-version of the survey to their trainees to improve the response rate. Survey responses were received over the period of June 2018 to October 2018, and those that did not have at least one self-assessment or question answered were excluded from the final analysis.Statistical analysisFor the purpose of this study, assessment data from program directors and resident trainees were recoded to a binary variable of low-confidence and high-confidence. For program directors, assessment scores of 1-2 were categorized as low confidence, and scores of 3-5 were categorized as high confidence. This mimicked the ACGME Milestones grading in which a resident at a level 3 suggests competency, and anything higher suggests greater proficiency in the Milestone . For resThe host institution and all participating programs received an exemption from their individual institutional review boards.Response ratesWe received responses from all 19 program directors (100% response rate) which represent 24% of the total med-peds programs in the US in 2018-2019. We received 231 responses from a total of 316 resident trainees (73% response rate). Only 193 were included in the final analysis (61% response rate for completed surveys), because 38 responses were incomplete in that none of the self-assessment questions or the MCQs were answered.Program and trainee characteristicsTable Multiple-choice question responses by goalThe percentage of resident trainees with correct responses to each MCQ can be found in Table Self-assessment responses by goalFigure Trainee self-assessments were also analyzed by post-graduate year level. For all five goals, a larger proportion of trainees had high confidence in each subsequent training level Table .Program directors and residents differed in their self-assessed confidence of transition skills and knowledge. Understanding how YSHCN and their families are impacted by insurance policies and social services as they age  and improving patient care and policies for youth and young adults (YYA) with special health care needs by improving the application of knowledge of health care systems to practice environment and beyond  are two subject areas of residency transition curriculum needing improvement, as evidenced by low self-assessment scores by program directors and residents.There is a growing literature showing the importance of transition to adult care within specific disease conditions -15. OursPrevious studies have not evaluated both self-assessment and objective measurement of knowledge related to transition goals. Our study showed discordance between resident self-assessment and objective measurement of knowledge related to transition goals. The discordance was most pronounced for goal 4 , in which residents self-assessed as having low confidence, though most residents correctly answered the MCQs related to the goal. This observation may suggest that the teaching modalities utilized by many combined med-peds residency training programs are effective in teaching knowledge regarding HCT for YSHCN. Transition-related curricula variably consist of didactic teaching and experiential learning in a variety of settings . There may be a difference in the perceived mastery of transition care that is learned outside of a defined transition-specific experience or that is only presented in traditional didactic methods. Graduate medical educators could incorporate multiple modalities of transition curriculum delivery throughout residency and highlight informal curricula where it exists to ensure concordance between subjective and objective assessments of resident trainees.There were several limitations to our study. Programs and residents of only one specialty (combined medicine-pediatrics) were surveyed and did not include other primary care specialties that play a role in HCT such as pediatrics, internal medicine, and family medicine. The sample was biased towards med-peds programs with pre-existing HCT curricula or plans to develop one. Although the transition goals were the same, the program self-assessment scale was slightly different than the resident self-assessment, making comparisons between the two groups not ideal. We addressed this limitation by grouping the self-assessments into high and low confidence categories rather than comparing the raw scales.The differences between the self-assessments of program directors and resident trainees for transition goals may suggest problems with results validity. However, as medical educators, we believe those differences to be true. The differences in self-assessments may be from a lack of standard competencies on which to assess learners in their transition knowledge and skills. Competency-based medical education (CBME) centers on education and training using standard practices across training programs. Up to this point, many med-peds residency programs have created and implemented their own curriculum to teach HCT utilizing various teaching modalities including didactics, online modules, electronic health record tools, small group discussions, case studies, pediatric and internal medicine dyads, or direct patient care activities -19. HoweStudies have shown that ACGME milestones have played an important role in identifying holes in existing curricula, actively engaging resident trainees in their own learning, and assessing the progress of trainees over time -22. IndeOptimal health care for YSHCN depends on high-quality transition, which requires education and training. Having clear goals and objectives at the outset of curricular delivery, preferably adopted from nationally recognized ones, is important to ensure alignment between program directors’ and trainees’ expectations. Future research should be done on assessment methods of transition skills and knowledge beyond self-assessments, ideally those that could be applied within clinical practice to directly observe activities that support comprehensive HCT. This study provides assessment data of med-peds trainee knowledge and skill acquisition from the existing transition curriculum and reveals that further instruction is needed regarding health insurance and the application of health care system knowledge in order to provide quality transitional care to YSHCN.