Persons with serious mental illnesses (SMI) are involved in the criminal justice system at a disproportionately higher rate than the general population. While the exact causes remain unclear, it is accepted that a comprehensive strategy including mental health treatment is needed to reduce recidivism. This paper describes a unique jail diversion program coordinated by a county prosecutor's office in which individuals were diverted towards mental health services including case management, community-based services, and housing supports. Outcomes were studied over a five-year period, beyond the typical 12- to 24-month follow-up in other studies. Individuals who completed the program, compared to those who did not complete it, were at lower risk for being rearrested, arrested fewer times, and incarcerated fewer days. Gains were moderated by previous criminal justice involvement and substance use but, nevertheless, were maintained despite severity of history. The strongest gains were seen while the individual was still actively enrolled in the diversion services and these outcomes were maintained for up to four years. These findings suggest that completion of a jail diversion program facilitated by a prosecutor's office can lower recidivism and days incarcerated. Further research is needed to assess the unique contribution of prosecutor office facilitation.  The high rate of serious mental illnesses among people who are currently incarcerated poses moral, logistic, and financial concerns. A synthesis of the available data concludes that accurate prevalence rates of mental illnesses in jails and prisons are difficult to determine . ChallenPeople with mental illnesses in the jail and prison systems often go without proper mental health treatment . AdditioThe causes of criminal justice involvement among people with mental illnesses are not entirely clear. One hypothesis is that the behaviors that lead to the arrest of people with mental illnesses are, in large part, a consequence of their mental illness or related circumstances . This isEvaluation of these hypotheses has found support for both perspectives. The criminalization hypothesis is supported by evidence that mental illness symptoms are directly related to criminal behavior for a minority of individuals , 13, 14.Alternatively, there is evidence supportive of general risk factors that are related to criminal behavior for individuals with and without mental illnesses. Factors such as prior criminal history, criminal thinking patterns, substance abuse, antisocial traits, association with others involved in criminal activities, psychosocial factors, and sociodemographic variables are predictive of criminal behavior regardless of mental illness , 15, 16.Despite a lack of consensus regarding the causes of increased criminal justice involvement, there have been a number of efforts to divert persons with serious mental illnesses away from the criminal justice system and towards the mental health care system . RinghofA variety of diversionary criminal justice initiatives have been developed that vary in their structure and the points within the criminal justice system from which they operate , 18. TheWhile these programs have continued to proliferate over time, the research on the criminal justice outcomes of these diversionary programs has been mixed , 18. A sThis article seeks to add to the existing literature on jail diversion programs by evaluating the effectiveness of a program administered by a county prosecutor's office over a five-year follow-up period. Previous literature has only been able to report on recidivism and jail days up to 24 months after diversion. This evaluation is able to consider the longer-term impact of a diversion program. Additionally, the program evaluated is unique in that it originated from and is housed within the county prosecutor's office. While other programs rely on the involvement of the prosecutor, few are run out of the prosecutor's office. As a prosecutor-based diversion program, its unique feature was that the prosecutor's office itself coordinated the diversion effort, working with the court, defense counsel, and mental health providers. When these programs are not based in the prosecutor's office, typically defense counsel and a behavioral health care provider have to advocate with a potentially reluctant prosecutor to consider this option. By the nature of the court system, this is necessarily an adversarial process. Having a prosecutor's office philosophically committed to alternatives for persons with serious mental illness will result in a less adversarial approach to diverting the individual from incarceration to treatment alternatives. Additionally, the prosecutor's office has a significant amount of discretion regarding the disposition of the charge and can intervene earlier in the adjudication process. All of these factors help to ensure that appropriate individuals are considered for diversion and that diversion occurs as quickly as possible, potentially limiting the time an individual has to spend in jail.n = 95). Thirty-three percent of individuals (n = 44) had a diagnosis of schizophrenia or schizoaffective disorder, 40% (n = 52) had bipolar disorder, 17% (n = 22) had depression, 5% (n = 6) had anxiety, and 5% (n = 7) had other diagnoses. Fifty-seven percent (n = 74) also had a cooccurring drug and/or alcohol diagnosis.The jail diversion program began in April 2006 with the evaluation period concluding in April 2011. One hundred and thirty-one individuals participated in the program. Complete data sets were available for 125 participants and were included in this analysis. Cases with missing data for a particular analysis were excluded. The average age of participants was 40 years old (SD = 11.98) and the sample was 72.5% males . Violent offenses were considered on a case-by-case basis. If found legally appropriate and permission was secured from defense counsel, a clinical evaluation was conducted by an associated hospital and then by a community-based mental health program. If the individual was deemed appropriate for community-based services and was willing to participate in the program, a treatment plan was developed and incorporated into the disposition of the case. Mental health treatment could be a condition of bail, permitting the defendant's release without the need to post money, or could be a condition of probation, allowing a defendant to avoid a county jail or state prison sentence.The Union County Prosecutor's Office compiled data regarding the types of arrests and convictions, jail/prison days, dates of jail admission and release, and total jail days . County, state, and federal databases of arrests and incarcerations were accessed by the prosecutor's office to collect this data. Various measures of criminal justice outcomes after diversion were collected including arrests for different categories of charges, number of arrests, and community tenure before arrest regardless of arresting jurisdiction.The community-based mental health programs provided data regarding program participation including admission and discharge data and whether the prescribed program of treatment was completed. All participants received case management services, assertive outreach, and psychotropic medication monitoring if needed. In addition, housing services were provided to those who were homeless or at risk for homelessness. Other outpatient services and inpatient care were provided. Unfortunately, the details regarding the amount and type of services provided to individuals were not available as part of the database made available by the county prosecutor's office for this evaluation.Global level of functioning (GLOF) was also assessed at baseline and six months into the program. GLOF is a measure developed by the New Jersey Division of Mental Health Services (NJ DMHS) to provide an overall assessment of community functioning and coping with symptomatology. Persons with a score of three or less are typically in institutional settings. Those with scores of four through six are increasing their level of independent functioning and coping, although they may occasionally be hospitalized or in supervised settings. People with a score of seven or more are completely independent. While the GLOF is a required measure by NJ DMHS, there is limited reporting of its psychometric properties. There is no available data on the measure's interrater reliability. There is, however, support for its validity from one study . In a saInstitutional Review Board approval was obtained to analyze this existing data set provided by the Union County, NJ prosecutor's office. This is a naturalistic study in that it was not designed as a research experiment but grew out of a program evaluation of a local innovation. It includes pre-post analyses, between group comparisons, correlational analyses, and survival analysis. The preformed groups of “completers” versus “noncompleters” were used. Completers are those who finished the court-ordered treatment as originally recommended and prescribed by the mental health provider. Their reason for discharge from the program was that they completed the treatment ordered. Noncompleters are those who did not follow through with the prescribed treatment as originally ordered and were discharged for other reasons. Survival analyses tracking changes in the proportions of criminal justice outcomes were conducted for up to five years.n = 35) were diverted at the point of prison sentencing, 53.4% (n = 70) were diverted from jail stays , and 19.8% (n = 26) were diverted before arraignment or before trial by the prosecutor's office. The legal disposition of the diversions included reduced sentences (15%), dismissal of charges (13%), downgrading or reduction of charges to a less serious charge (58%), or pretrial interventions (14%).During the study period, a total of 131 persons were enrolled in the jail diversion program. Each person received both a legal disposition and a court-ordered treatment plan facilitated by a collaborating mental health provider. Treatment included initial evaluation and diagnosis, psychotropic medication monitoring if prescribed, and additional individualized treatments. These diversions took place at a variety of stages. Approximately 27% (t(129) = 1.97, p = .05). Participants who completed their prescribed program had significantly better outcomes than noncompleters. In the year prior to diversion, participants spent an average of 28.88 (SD = 70) days incarcerated. In the first 12 months after enrollment, this was reduced by 13 days to 15.82 days  than in the year prior to enrollment. However, for each follow-up period, noncompleters spent more days in jail than completers. A survival analysis examined length of community tenure spent unincarcerated as an outcome variable. In the first year, 42% of the noncompleters were reincarcerated compared to 14% among the completers. By the five-year mark, 67% of noncompleters had been incarcerated. In contrast, among those who completed the program, only 37% had been incarcerated even after 5 years. In F = 5.62, p < .05). The median point at which arrest has occurred for 50% of participants was 19 months for noncompleters, whereas for completers it was 48 months.Participants who are noncompleters are at significantly higher risk for reincarceration after entering the jail diversion program through year three see . During The survival curve illustrates the cumulative proportion of individuals who are not rearrested. In In order to better understand the pattern of changes, a hazard function is presented in t(81) = 6.72, p < .001). This indicates significantly increased community integration, better overall functioning, and management of symptoms. There was a larger increase in GLOF among completers  = 8.70, p < .001), compared to noncompleters (change score = .25). Nevertheless, this smaller pre-post difference among noncompleters was also statistically significant (t(39) = 2.69, p = .01).GLOF increased significantly to 5.31 from a baseline of 4.76, after 6 months in the jail diversion program (n = 37) refused services or were noncompliant, another 15% (n = 11) were lost to contact, 6% (n = 4) were deceased, and the remaining 28% (n = 20) were coded by the prosecutor's office as “other” reasons with no further details specified.Noncompleters received, on average, 19 weeks of services less than those who complete the program . Their increase in jail days seems to follow termination from the mental health services, spiking in the second year of follow-up (13–24 months after entry). The reasons for noncompletion of the program varied. Among noncompleters, approximately 51% (t(121) = −.314, ns), gender  = .092, ns), and the frequency of psychiatric diagnoses (χ2(2) = 1.74, ns). However, noncompleters had histories that could be indicative of a poorer prognosis. Sixty-eight percent of the noncompleters have a substance abuse diagnosis compared to only 42% of the completers (χ2(1) = 7.06, p < .01). Noncompleters had significantly more total arrests prior to entry into the jail diversion program,  = 3.85, p < .001), more disorderly person's convictions  = 2.63, p = .01), and more total jail admissions prior to entering the program compared to completers  = 3.8, p < .001). In addition, noncompleters had a lower GLOF at program entry (t(121) = 2.57, p = .013).In many ways, completers and noncompleters were alike. There were no significant differences in terms of age  = .52, p < .05). These include (1) number of lifetime jail admissions prior to entering jail diversion: more lifetime admissions prior to diversion predict more postdiversion admissions (β = .39); (2) whether the individual completed the jail diversion program: completers were incarcerated less after diversion (β = −.24); and (3) age: younger people were more likely to be incarcerated more times after diversion (β = −.22). As indicated by the beta weights, the best predictor was number of previous jail admissions, followed by program completion.Consistent with other research findings, prior history contributes to the explanation of jail diversion program outcomes. In this study, the total number of jail admissions in the follow-up period was predicted by three variables in a multiple regression equation (multiple χ2(2) = 41.79, p < .001). Each additional day of prior jail admissions increased the likelihood of any postdiversion admission by 2.8% (odds-ratio = 1.028). Having completed the prescribed course of treatment reduced any instance of reincarceration by 82% (odds-ratio = .18). Thus, degree of previous criminal justice involvement is associated with poorer outcomes and, in some cases, explains more of the variance in outcomes than program participation.Using the dichotomous outcome variable of being incarcerated once or more in the follow-up period (1) or not incarcerated at all in the follow-up period (0), there were similar findings to those above. Program completion was the strongest predictor of incarceration followed by the number of days spent incarcerated during the 12 months prior to diversion as the second strongest predictor. Using logistic regression, forward stepwise method, both number of jail days in the prior year and program completion predicted whether someone was jailed or not on any occasion after diversion . Because completion of the jail diversion program is so strongly associated with more positive outcomes, assertive outreach and other attempts to keep service recipients actively participating are recommended.The best outcomes were found in the first follow-up year. By the fifth year of follow-up even among “completers” there is an increase in arrests. Thus, there is some question about the sustainability of gains after participation in jail diversion services. While we saw that the number of days incarcerated continues to decline over time, the hazard function for arrests and jail days seems to be rising for the completers later in the follow-up period, particularly in terms of disorderly persons arrests. Among those who completed the program, the risk of arrests peaks in the fourth year of follow-up (36–48 months). In addition, the cumulative proportion of persons still not arrested at 60 months is almost equal to that of noncompleters, although their incarceration days and incidence of incarceration remain significantly lower.Individuals with a longer length of participation in active treatment had better outcomes. This suggests that a longer length of participation and/or greater continuity of care with other community mental health services are needed. This could take the form of a jail diversion service that is longer in length or a follow-up community service with seamless continuity to the jail diversion program. Both groups (program completers and noncompleters) had their sharpest gains while still actively enrolled in the service and completers who received services for a longer length of time sustained these gains longer. In large part, this is not a surprising finding in light of other treatment services' research for persons with serious mental illness. All of the more effective, evidenced-based community services including assertive community treatment (ACT), supportive housing, and supported employment are long-term. They can provide several years of support, though often support is tapered off as need diminishes. Support can also be increased if need reemerges. Treatment gains seen when enrolled in ACT, in particular, rapidly diminish if the service is prematurely withdrawn.This study's findings are based on a nonexperimental design. Its pre-post and longitudinal features are similar to that of other jail diversion studies. Its follow-up period of up to 5 years was longer than most studies, which typically focus on the first 12 months and occasionally continue up to 24 months after diversion. The data analyzed were not collected prospectively but were based upon existing data sets. The post hoc grouping of completers versus noncompleters has its limitations because of the high degree of self-selection and other factors such as preexisting differences that contribute to whether someone remains in the program. In fact, completers and noncompleters had significant differences even before entering the service, with noncompleters having more extensive criminal justice histories and a higher likelihood of having a substance abuse diagnosis. Indeed, some of these so-called criminogenic features, including multiple jail admissions and substance abuse, are predictive of outcomes regardless of jail diversion program participation. This, too, is consistent with previous studies. Thus, this naturalistic design, an evaluation of a program as implemented over several years of operation, provides evidence of the generalizability of these approaches in “real world” and “routine” circumstances.


The Tier 1 Program of the Project P.A.T.H.S.  is a positive youth development program implemented in school settings utilizing a curricular-based approach. In the third year of the Full Implementation Phase, 19 experimental schools  and 24 control schools  participated in a randomized group trial. Analyses based on linear mixed models via SPSS showed that participants in the experimental schools displayed better positive youth development than did participants in the control schools based on different indicators derived from the Chinese Positive Youth Development Scale, including positive self-identity, prosocial behavior, and general positive youth development attributes. Differences between experimental and control participants were also found when students who joined the Tier 1 Program and perceived the program to be beneficial were employed as participants of the experimental schools. The present findings strongly suggest that the Project P.A.T.H.S. is making an important positive impact for junior secondary school students in Hong Kong.


The aim of this study was to assess the usefulness of endobronchial ultrasound transbronchial biopsy with guide-sheath (EBUS-GS-TBB) for the diagnosis of solitary pulmonary nodules (SPNs). One hundred and eighty patients, who were diagnosed with SPNs and underwent an endobronchial ultrasound procedure. The diagnostic yield, safety and the associated factors were analyzed. Mean EBUS-GS procedure time was 14±8 min. The average number of biopsy specimens obtained in each SPNs was 5±1.2. One hundred and thirty-four SPNs were diagnosed by EBUS-GS-TBB and the diagnostic rate was 74.4 %. The diagnosis rate of malignancy was 83.3 %, while that of benign disease was 56.7 %. The most important factors that helped enhance EBUS-GS diagnostic accuracy included lesion diameter greater than 20mm, EBUS probe within the lesions and central lesions. No pneumothorax, hemoptysis or other serious complications occurred with the diagnostic procedures. EBUS-GS-TBB is a safe and effective method for diagnosing SPNs. Bronchoscopy has been widely used in the evaluation of pulmonary lesions of the lung, however, the diagnostic yield of solitary pulmonary nodules (SPNs) is still low , 2. AlthA total of 180 patients with SPNs were eligible for inclusion in this study . One hundred and twenty patients were finally diagnosed of malignant diseases, including 106 cases of adenocarcinoma, 8 cases of squamous carcinoma, 2 cases of small cell carcinoma, 4 cases of lung metastatic nodule. Sixty patients were benign disease, of which pneumonia 18 cases, tuberculosis 20 cases, pulmonary abscess 2 cases, organizing pneumonia 8 cases, interstitial pneumonia 6 cases, pulmonary fungal infection 6 cases.Duration of EBUS-GS time was 14±8 min, and the mean number of specimens obtained from each SPNs was 5±1.2. Ultrasound images were available in 156 lesions under EBUS guidance. The mean diameter of the lesion was 25±4.8 mm. Eighty-four lesions (46.7 %) were < 20mm and 96 lesions (53.5 %) were of 20-30 mm in mean diameter. The localization of the SPNs was the right upper lobe in 28 (15.6 %), right middle lobe in 24 (13.3 %), right lower lobe in 48 (26.7 %), left upper lobe in 30 (16.7 %) and left lower lobe in 50 (27.8 %).One hundred and thirty-four of 180 patients were diagnosed by EBUS-GS-TBB, the diagnostic yield was 74.4 %, in which the diagnosis of malignant diseases was 83.3 % (100/120), benign diseases diagnostic yield was 56.7 % (34/60). One hundred malignant SPNs were composed of 92 adenocarcinomas, 4 squamous cell carcinomas, 2 small cell carcinomas and 2 metastatic carcinomas. For malignant lesions, the diagnosis of cytology and biopsy specimens was 66.0 % (66/100) and 76.0 % (76/100). Twenty false negative patients were confirmed after CT-PNB . Thirty-four of the 60 benign lesions were diagnosed through EBUS-GS-TBB, the rest 26 lesions, 15 lesions were diagnosed by CT-PNB , and the other were diagnosed by surgical procedure  . Lesion in which the probe was advanced to within the lesion, as determined from the EBUS image, had a higher diagnostic yield  than when the probe was adjacent to the lesion on the EBUS image    , while the diameter of 20 mm or less was 57.1 % (48/84), the difference was statistically significant . We screened 399 patients with SPNs, 219 patients were ineligible because they did not satisfy the inclusion criteria  were used, EBUS was performed by an endoscopic ultrasound system , equipped with a 30-MHz mechanical radial-type probe , having an external diameter of 2.0mm, and guide sheaths . A biopsy forceps or brush was inserted into GS before procedure adherence to guidelines, marked the position and then fixed probe into GS. The GS-covered probe was inserted through the work channel of the bronchoscope and advanced to the lesions to get the EBUS images. Adjust the probe to a suitable position where the lesions completely wrapped around the probe located. After obtaining the EBUS image, assistant helped to fix the bronchoscope and confirmed GS to entrance of working channel, then removed the probe and the GS remained in position. Biopsy forceps or brush acquired specimen via GS.A bronchial brush was introduced into the sheath until the point marked by the cellulose tape reached the proximal end of the sheath. When using the brush, a few vigorous back-and-forth movements were performed to collect the sample on the brush under fluoroscopic guidance.After the brushing forceps was withdrawn, the biopsy forceps was once again introduced into the sheath until the mark on the surface of the forceps reached the end of the sheath. Four to six biopsy specimens were obtained through the guide sheath using regular disposable biopsy forceps.The patients underwent CT in the prone, supine, or lateral position based on the shortest distance from the SPN lesion to the body chest surface. CT images were obtained from the region of interest by using a section thickness of 5 mm and were viewed by using lung window settings. After local anaesthesia with 2% lidocaine from the skin to pleura, a coaxial 18-gauge needle  was inserted under intermittent CT guidance with its trajectory pointing toward the lung lesion. CT image comfirmed the tip of needle had entered the lesion, a cutting needle was penetrated into the lesion via the introducter trocar. This procedure was typically performed once, and occasionally performed twice. The patients were instructed to hold their breath during the CT scanning and the biopsy process. The resected specimen was placed in 10% formaldehyde for pathological examination. After removal of the biopsy needle, CT scanning was carried out to detect if any complication such as pneumothorax and haemorrhage occur, for necessary intervene.The total time of EBUS-GS was defined as the time from the insertion of the probe to withdrawal of the guide sheath.If unable to obtain lesion images or biopsy specimens through EBUS, CT-PNB, following-up after treatment or surgery would be taken according to the patient's choice. And if the biopsy shows benign lesion, patient underwent follow-up after treatment. Two experienced pathologists read all the biopsy results, inconsistent results are determined by the discussion with the 3rd pathologist.2 test was used to compare the difference in percentages between groups. Value of P< 0.05 was considered statistically significant.Measurement data expressed by mean ± standard deviation, enumeration data expressed as a percentage. The analyses were carried out using SPSS 16.0 Statistics. χ


Education in patient safety and quality of care is a requirement for radiation oncology residency programs according to accrediting agencies. However, recent surveys indicate that most programs lack a formal program to support this learning. The aim of this report was to address this gap and share experiences with a structured educational program on quality and safety designed specifically for medical physics therapy residencies. Five key topic areas were identified, drawn from published recommendations on safety and quality. A didactic component was developed, which includes an extensive reading list supported by a series of lectures. This was coupled with practice‐based learning which includes one project, for example, failure modes and effect analysis exercise, and also continued participation in the departmental incident learning system including a root‐cause analysis exercise. Performance was evaluated through quizzes, presentations, and reports. Over the period of 2014–2016, five medical physics residents successfully completed the program. Evaluations indicated that the residents had a positive experience. In addition to educating physics residents this program may be adapted for medical physics graduate programs or certificate programs, radiation oncology residencies, or as a self‐directed educational project for practicing physicists. Future directions might include a system that coordinates between medical training centers such as a resident exchange program. This is well‐recognized through the ACGME requirements on quality training for physiciansAlthough the need for quality and safety education is apparent, most residency programs currently lack a formal program for supporting this learning.The purpose of this report was to share experience with a patient safety and quality education program developed at the University of Washington specifically for medical physics residents. While the main focus of this report is on the medical physics residency program, the experience may be useful for physician residencies and may be relevant to Maintenance of Certification through the ABR and practice accreditation programs such as APEx, in which patient safety and quality of care is a key pillar.2The patient safety and quality educational program consists of a didactic component  coupled with practice‐based learning. The majority of this content is delivered in the form of a mentored rotation that is one month in duration, and there is also a component which extends throughout the residency and includes participation in the departmental incident learning program.In designing an educational program around a broad subject like patient safety and quality, it is important to select appropriate topic areas of focus. This is particularly important in the context of a medical physics residency program. Since most programs are 24 months, the total time dedicated specifically to patient safety and quality education will necessarily be limited. In formulating focus topics we consulted the following resources: AAPM Report No. 249 on guidance for CAMPEP‐accredited residencies,https://rpop.iaea.org/RPOP/RPoP/Content/News/e-learning.htm). This course consists of 12 modules, seven of which are focused on incident learning. A certificate is available after the course is complete.The topic focus areas in Table A project‐based learning component builds on and reinforces the base knowledge of concepts and content areas of the didactics. During the one‐month rotation each resident is expected to complete one project in one of the topic areas in Table In addition to the rotation project, the resident participates in the incident learning program of the department. This includes attendance at the weekly safety committee meetings where near‐miss events are discussed and analyzed. The department operates a high‐volume near‐miss incident learning system where approximately 25 quality reports are analyzed every week.Resident learning is evaluated and feedback provided in several ways: (a) A written quiz near the end of the rotation. (b) A presentation to physics faculty at the end of the rotation. These presentations are conducted at the end of every rotation in the medical physics residency and include the learning objectives for the rotation and a presentation of the rotation project. At least three physics faculty must be present and must include the rotation mentor and at least one member of the residency steering committee. (c) A written report about the rotation project. (d) A presentation of the RCA project at one of the monthly all‐staff departmental safety meetings. (e) Feedback about performance and the rotation from the mentor to the resident and also from the resident to the program director. If the resident fails to meet the educational objectives, a plan for remediation is in place which involves further study and project work. To date, however, this has not been necessary.3Table The program was developed in an iterative manner, with feedback from the residents being used to develop it into the form outlined here. One example of this was a request from the residents that they attend all weekly meetings of the departmental incident learning program starting from the beginning of the residency instead of only during the rotation since this was viewed as a rich learning environment. This is now a residency program‐level expectation. The residents start by observing these meetings and later, as their general clinical experience grows, they participate and contribute more actively to the discussion.Over the period of 2014–2016, five medical physics residents have completed the program described here. In all cases the rotation was successfully completed according to the educational evaluations listed above. The rotation projects generally consisted of FMEA exercises on various clinical processes including: treatment planning for SBRT lung cases, the final steps of preparing a treatment plan for treatment in dosimetry, and the process for the use and approval of patient in vivo dosimetry checks. In one case the project was reported as a manuscript,4The structured educational program on quality and safety described here has been in place since 2014 and is well‐received by medical physics residents. A key feature of the program is a concentrated rotation lasting one‐month with learning objectives focused on topic areas that are important for a medical physicist in clinical practice. The program also includes continuous learning through active participation in the departmental near‐miss incident learning system.This program is designed to address the gap in quality and safety education in residencies that has been reported in recent studies.One of the strong‐points of the program described here is the focus area of incident learning and root‐cause analysis (RCA). This aspect of the program benefits from the incident learning system operated by the department.The effectiveness of incident learning is supported by many educational theories and principles. For example, Experiential Learning, as described by KolbTo our knowledge, there is no report in the literature which describes the details of a formal patient safety educational program in radiation oncology residencies. Several related reports have appeared, however. Across healthcare in general there are reports about the experience of residents particularly in the realm of practice‐based quality improvement and associated metrics.A variety of challenges might be anticipated in implementing an educational program like the one described here. First, the mentor(s) might not have an extensive expertise in the topic and may feel uncomfortable teaching quality and safety concepts. This report may partially address this challenge by providing a baseline structure as well as references and background materials. It is also expected that the projects suggested here  provide a rich opportunity for learning for both the resident and the mentor(s). These activities can also serve for Maintenance of Certification activities for the American Board of Radiology. In particular, it may provide credit for a self‐directed educational program (SDEP) which is a type of Self‐Assessment Continuing Education credit available to medical physicists  to deliver didactic content. This facilitates a more interactive discussion of the topics during in‐person meetings. Programs may find it challenging to develop such content. However, recorded lectures may be borrowed from colleagues or may be easily developed using low‐cost screen‐capture software such as Camtasia . The AAPM virtual library is another resource for teaching materials.Scheduling may also represent a challenge. The program described here used a one‐month dedicated rotation. This was found to be a very compressed time scale and the rotation will be extended to 1.5 months in the future. Even with a compressed rotation, however, some residency programs may find it challenging to set aside this time from a typical 24‐month program, given the many other demands of the program. While there is no direct solution to this, it may be possible to deliver much of the learning described here outside of a rotation with a dedicated time period, such as in a weekly or monthly journal club.A final challenge may arise if the program does not have a departmental incident learning system and, related to that, does not have a strong culture of safety. For programs which do not have a departmental incident learning system, it may be possible to review case studies from the literature or from RO‐ILS™: Radiation Oncology Incident Learning SystemWhile this report has focused on medical physics residents, parts of the program described here may have a broader applicability. Parts of the program may be adapted to serve the continuing medical education needs of faculty and staff see Appendix ppendix AThere are some limitations to this study. One important limitation is that not all safety‐related topics can be included in an educational program like the one presented here, and Table https://rpop.iaea.org/RPOP/RPoP/Content/News/e-learning.htm).The program described here is expected to evolve and develop further. One future direction might be a distributed program that is coordinated between a few centers. This might include a combined teaching component, which leverages the expertise of faculty at various centers, and/or a resident exchange program which facilitates a shared learning experience. Another direction may be to encourage partnerships between physician and physics residents to conduct projects together. Any future effort would benefit from a certification process such as that eLearning course from the IAEA (The authors declare no conflict of interest.


Coriolopsis gallica laccase immobilized on nitrogen-doped multiwalled carbon nanotubes (Lac/CNx-MWCNT) and on graphene oxide (Lac/GO) was used to measure the concentrations of catechol and catechin. Nitrogen-doped multiwalled carbon nanotubes (CNx-MWCNT) were synthesized by spray pyrolysis and characterized by scanning electron microscopy (SEM), transmission electron microscopy (TEM), and x-ray photoelectron spectroscopy (XPS). Covalently bonded hybrids with laccase (Lac/CNx-MWCNT and Lac/GO) were generated. Catalytic activity of free enzymes determined with syringaldazine yielded 14 584 UmL−1. With Lac/CNx-MWCNT at concentrations of 6.4 mmol L−1 activity was 9326 U mL−1, while enzyme activity measured with Lac/GO at concentration of 6.4 mmol L−1 was 9 234 U mL−1. The Lac/CNx-MWCNT hybrid showed higher stability than Lac/GO at different ethyl alcohol concentrations. The Lac/CNx-MWCNT hybrid can measure concentrations, not previously reported, as low as 1 × 10−8 mol L−1 by measuring the electric current responses.The use of nanomaterials allows the design of ultrasensitive biosensors with advantages in the detection of organic molecules. Catechol and catechin are molecules that occur naturally in fruits, and their presence in products like dyes and wines affects quality standards. In this study, catechol and catechin were measured at the nanoscale by means of cyclic voltammetry. The oxidation of  A few classical approaches are mass spectrometry, optical absorption spectroscopy and nuclear magnetic resonance (NMR). In general, these techniques require pre-treatments of samples before the analysis. Although these methods are very sensitive, they are difficult to miniaturize.On the other hand, the detection of organic molecules by the electrochemical approach does not have this limitation. A biosensor is a device that uses specific biochemical reactions mediated by isolated enzymes, immunosystems, tissues, organelles or whole cells to detect chemical compounds usually by electrical, thermal or optical signals . The sigFor biosensors based on direct electron transfer, redox proteins have to regenerate the electron transfer between the redox site and the electrode. Thus, substrate concentration is proportional to the current generated by the enzyme. Furthermore, the absence of a mediator is the main advantage, since no reactions interfere with the measurement .A challenging area for biosensors is the correct immobilization of the enzymes on the electrode surface and the maintenance of a high and stable rate of electron transfer . LaccaseLaccase belongs to the subgroup of multicopper oxidases. These enzymes have been studied in the industrial sector, such as the food, agriculture and bioremediation industries due to their high redox potential for molecules like mono-, di-, and poly-phenols .To optimize electron transfer, an important factor in biosensor construction is the conductive material between the macromolecule and the electrode. Carbon nanomaterials, such as carbon nanotubes, have been used in applications such as gas sensors, biosensors, cathodes and anodes, and fuel cells, among others . On the Carbon nanotubes and graphene may be modified by oxidation with sulfuric acid to obtain carboxylate derivatives. Complex molecules such as protein receptors, enzymes, DNA and nanoparticles can then be anchored to the surface of these nanostructured materials .in situ measurements. Table 1S of the Supplementary Materials lists the currently used enzymes and transduction systems  as reference electrode, glassy carbon as working electrode (3 mm diameter) and a platinum electrode as the counter electrode. The inks of CN2.6.x-MWCNT and Lac/GO under different concentrations of ethanol (v:v), 10 μL of the hybrids were diluted in succinate buffer, catechol (10 mmol L−1) and different percentages (V:V) of ethanol. The samples were measured in an a high-performance liquid chromatography (HPLC) system (Agilent) using acetonitrile as solvent and a wavelength of 260 nm with a C18 column .To determine the activity of Lac/CN2.7.μL. Protein concentration was determined by the Bradford method with the BioRad protein reagent and measured at a wavelength of 595 nm.Laccase (Lac) activity was measured with spectrophotometer (Perkin Elmer Lambda 25), using succinate buffer and different volumes of enzyme: 10, 15, 20 and 25 2.8.−5 to 10−9 mol L−1 in triplicate (figure Assays of limit detection were carried out using logarithmic concentration of catechin since 103.x-MWCNT and Lac/GO) used as biosensors to determine catechol and catechin concentration were obtained by anchoring laccase on two types of carbon nanostructured materials: lab-synthesized nitrogen-doped multiwalled carbon nanotubes (CNx-MWCNTs) and graphene oxide (GO).The hybrid samples .In order to predict the operational stability of the laccase hybrids in wine or alcoholic drinks, we used high performance liquid chromatography (HPLC) with different ethyl alcohol percentages. Results showed that Lac/CN% figure . The resUsing the Lineweaver–Burk equation in its electrochemical form, the Michaelis–Menten constants were calculated for catechol:Imax = maximum current (A)Iss = stable current (A)μmol L−1)C = substrate concentration (μmol L−1)μmol L−1, while for the hybrid Lac/CNx-MWCNT we obtained a dissociation constant of μmol L−1.For the hybrid Lac/GO, we observed a 3.4.x-MWCNT hybrid on catechol (figure ϕ) around 0.2 V indicates the reduction of catechol.Electrochemical assays were performed to determine the detection level of the hybrids regarding the oxidation and reduction of mono- and poly-phenolic compounds. The voltammograms obtained using the Lac/CNIn figure xMWCNT hybrid at different concentration of catechin (from 0.1 to 0.5 mmolL−1) in figure ϕ) around 0.0 V indicates the reduction of catechin, i.e. a thermodynamically reversible reaction. In the figure −1). The first peak (∗) around 0.55 V indicates the oxidation of catechin and the second peak (ϕ) around 0.0 V indicates the reduction of catechin, i.e. a thermodynamically reversible reaction.We show the voltammogram using the Lac/CNA linear relationship between catechol concentration and the current generated by the oxidation of the molecule was found .x-MWCNT. The results showed three defined peaks, two oxidation peaks at ∼0.25 and 0.5 V and the reduction peak at ∼0.15 V  and graphene oxide (GO) forming Lac/CN4.1.x-MWCNT hybrid activity remained about constant. The effect of ethanol on proteins is due to dehydration, though at 10% this cannot generate an abrupt change in the catalytic activity because laccases are stable in wines [In order to determine the detection efficiency for catechin, a molecule present in wine where the hybrids are intended to be used, and the effect of ethanol on the hybrids was studied. Figure in wines . It has in wines , so whenKM value 50.6 μmol L−1 [KM constant indicates a very low dissociative enzyme–substrate relationship [x-MWCNT and GO showed good affinity for phenolic derivatives  compared with the work of Li [One of the most recent works using non-doped carbon nanofibers reports a μmol L−1 . The caltionship . In contrk of Li .4.2.Cyclic voltammetry (CV) was used to investigate the catalytic and electrochemical behavior of both hybrids. The cathodic current in catechol was observed at 0.2 V using acetate buffer at pH 4.5  and 0.25x-MWCNT) and laccase covalently bonded to the edges [−1, which typically show a linear response [r of 0.992 for Lac/CNx-MWCNT and of 0.990 for Lac/GO.The electrochemical assays using cyclic voltammetry showed a linear relationship (figure 7S) between the oxidation peaks and catechol concentration. We used two hybrids, laccase covalently bonded to MWCNT , up to a concentration of 1 × 10nanotube , 29. Alsnitrogen .x-MWCNT) are preferred over non-doped MWCNT. Besides the electronic properties, the structure of the CNx-MWCNT may be hydrophilic, unlike MWCNT, which are hydrophobic. The nitrogen substituted in the nanotubes generates electronic donor states. The electrons of N use three of their valence electrons to form three σ bonds, and two electrons fill the π orbitals. The N in the CNx-MWCNT facilitates electron transfer between metalloproteins and gold electrodes [−1) related to the energy of the Fermi level.Regarding bioapplications, MWCNT doped with nitrogen  were more sensitive than graphene oxide (GO) regarding alcoholic beverages, because graphene oxide folds in the presence of ethanol and the enzyme is overlapped.Nitrogen-doped MWCNT  by the spray pyrolysis method at a temperature of 900 °C provided high-quality doped nanotubes with 5% atomic content of nitrogen in these nanomaterials. The donor states of the pyridinic nitrogen in the nanotubes conferred more sensitive properties to CNx-MWCNT than to graphene oxide due to the metallic character, easy dispersion and stability of CNx-MWCNT in water–ethanol solutions. When the immobilized laccase in the Lac/CNx-MWCNT hybrid starts to catalyze the substrate, nitrogen incorporated into the nanotubes improves the electronic transport, which may then be detected by cyclic voltammetry. The Lac/CNx-MWCNT hybrid is a promising candidate for polyphenol detection in fruit, the wine industry and for environmental control.The synthesis of nitrogen-doped multiwalled carbon nanotubes (CN


The unmet burden of surgical disease represents a major global health concern, and a lack of trained providers is a critical component of the inadequacy of surgical care worldwide. Competency-based training has been advanced in high-income countries, improving technical skills and decreasing training time, but it is poorly understood how this model might be applied to low- and middle-income countries. We describe the development of a competency-based program to accelerate specialty training of in-country providers in cleft surgery techniques.t test.The program was designed and piloted among eight trainees at five international cleft lip and palate surgical mission sites in Latin America and Africa. A competency-based evaluation form, designed for the program, was utilized to grade general technical and procedure-specific competencies, and pre- and post-training scores were analyzed using a paired p < 0.01) and palate . General technical competency scores also improved . Among the procedural competencies assessed, surgical markings showed the greatest improvement , followed by nasal floor/mucosal approximation (15.0%) and hard palate dissection (17.1%).Trainees demonstrated improvement in average procedure-specific competency scores for both lip repairs (60.4–71.0%, Surgical delivery models in LMICs are varied, and trade-offs often exist between goals of case throughput, quality and training. Pilot program results show that procedure-specific and general technical competencies can be improved over a relatively short time and demonstrate the feasibility of incorporating such a training program into surgical outreach missions. Lancet Commission report “Global Surgery 2030” estimated that five billion people worldwide lack access to safe surgical care [Surgery is increasingly being recognized as an integral component of global health efforts. The recent cal care . Accordical care .” As thiGiven the overwhelming surgical need in LMICs, there exists a balance between immediate service and long-term investment in capacity building initiatives. As such, integrating educational programs into surgical aid must be implemented as effectively and efficiently as possible to maximize benefit to patients. One area of innovation in surgical education, particularly in high-income countries (HICs), has been the development of competency-based training. This approach has shown potential to reduce training time while simultaneously improving surgeon technical skill; , 6 howevTraditionally, trainees have been evaluated by the global impression of supervising staff, using number of years as a benchmark of competency. However, this type of non-criterion-based rating is largely subjective and unreliable , 8. MoreOver the last decade, HICs have increasingly moved toward this competency-based model in medical education. Initiatives through the Accreditation Council for Graduate Medical.Education (ACGME) in the USA, the Royal College of Physicians and Surgeons of Canada and a number of European and Australian counterparts have sought to increase documented competency as a way of improving public accountability , 12. MosThe educational theory of deliberate practice describes the essential components of acquisition of technical skills as intense, repetitive performance of an intended skill coupled with rigorous assessment , 15. HowThe program was piloted at five sites  between November 2016 and April 2017. At each site between one and three, local trainees were identified in collaboration with existing in-country senior surgeons and local medical foundations. Each individual had completed plastic or maxillofacial training in their respective country, but with minimal to no experience in cleft lip and palate surgery. These trainees were selected for their expressed commitment to deliver cleft surgical care within their countries and their ability to participate in the entirety of the training program. Prior to the mission, they were provided with a comprehensive cleft surgery manual, designed specifically for the program, as well as access to an online repository of surgical educational materials. During the week-long mission, they were formally paired with two different mentor surgeons on alternate days and worked on a designated operating room table.A core component of the program was the development of a competency-based evaluation instrument, which assessed a combination of general technical and procedure-specific skills. The general technical skill section was adapted directly from the objective structured assessment of technical skills (OSATS), a validated instrument in multiple specialties of surgery . The prot test with SPSS statistical software. Within procedure-specific criteria, individual technical components were analyzed for percentage improvement in unilateral lip and palate procedures, but there was insufficient data to analyze bilateral lip procedures.The evaluation was completed by the mentor surgeon after the first day to characterize baseline ability, and again after the last day of the program to track incremental improvement. Raw scores were converted into percentages based on the total possible score for each section, and pre- and post-training scores were analyzed using a paired p < 0.01) and as did procedure-specific competency scores for both cleft lip repairs, from 60.4 to 71.0% (p < 0.01), and cleft palate repairs, from 50.6 to 66.0% (p < 0.01). Postoperative care competencies improved from 64.8 to 72.8% (p < 0.05), while preoperative care competencies improved from 66.2 to 75.0%, trending toward significance (p = 0.06). Average percent scores, percentage improvement and p values for preoperative, postoperative, general technical and procedure-specific competencies are listed in Table A total of eight trainees participated in the program over the five pilot sites with all candidates demonstrating improvement in each of the evaluated competencies. Average general technical competency scores improved from 63.3 to 72.0% p < 0.0 and as dThere has been a call in the literature to link mission-based work with surgical training , but to It is estimated that participation with the program over three- to four-week-long experiences will be required to reach competency, based on the trainee’s baseline evaluation level. At this time, none of the trainees have completed scheduled follow-up training in order to assess skill retention between training sessions or to confirm the estimated trajectory to competency, and further data is expected to refine programmatic design. During the program, a case log is completed by the trainee each day, and this will be used in future analysis to draw associations between the number of cases necessary, on average, to reach an objectively evaluated level competency in different procedures. One of the advantages to competency-based evaluation is that allows for variable timing of skill progression, and it is expected that trainees will move through the program at different rates. Nonetheless, correlations with average case numbers may be helpful in setting expectations for trainees and mentors, aiding in organizational oversight and logistical planning and adapting the program to fit trainee needs. Finally, as the program progresses, information on case numbers outside of the formal education setting provided during the mission will be examined to demonstrate the impact of training on patients’ access to care.While the number of participants is limited and the results are early, the program shows promise in improving the skills of in-country surgeons in cleft-specialty procedures in an evidence-based fashion. Several characteristics of the program contribute to its potential. An emphasis on frequent, structured assessment of trainee skill progression allows for adaptation of the program to trainee needs as well as systematic program evaluation. While the intent of the program is the development of competency in cleft procedures in the trainees’ own local practice, additional summative evaluation with respect to Operation Smile credentialing encourages trainees to maintain connection to the organization. This facilitates long-term follow-up and closer monitoring of skill maintenance over time, which is essential to determining the program’s success and/or identifying additional training needs. Support from local surgical staff is also critical to the success of the program. The pilot utilized both US-based surgeons and Nicaraguan, Malawian, Guatemalan, Paraguayan and Mexican surgeons as its senior mentors, fostering investment from the local surgical community. Future steps include collaboration with national credentialing bodies to allow credentialing from the program to be recognized locally. This process is necessarily country-specific and will require additional data before formal agreements can be reached.Although promising, several challenges face the program. The length of the evaluation form was cited by mentors as a limitation. It is currently two pages but was still be felt to be time consuming, especially when required multiple times over the course of the mission. Future refinement will need to balance collection of robust data with minimization of paperwork. Additionally, the program is dependent on the commitment of both surgical mentors and trainees to engage in multiple training sessions over the course of several missions. Given the time away from existing practice responsibilities required to attend missions, consistent participation could be difficult, making appropriate participant selection essential. Finally, although the assessment tools are comprehensive, they are completed by the mentor surgeons and confounding factors such as observer bias cannot be excluded.As surgical disease is being brought into the global health spotlight, there is increasing recognition that education is key to addressing the vast burden of disease. Designing and evaluating educational initiatives in a complex field such as surgery is highly challenging, and the complexities of training only become further amplified in the global arena. Multiple educational initiatives have been previously implemented, each with their own strengths and limitations, but consensus is growing that these must continue to improve to keep pace with the increasing number of patients and the challenges of delivering care. To meet this challenge, Operation Smile and the University of Southern California propose a “fellowship without borders,” built on the principles of competency-based education and utilizing existing service platforms. This program leverages high patient volumes in the mission setting to more rapidly train in-country providers and gathers valuable data to systematically evaluate and improve the program. Further data collection is ongoing to determine the validity of the evaluation instrument, the generalizability of pilot results and the impact of training on surgical disease burden.


At 21.19 on 8 August 2017, an Ms 7.0 earthquake struck the Jiuzhaigou scenic spot in northwestern Sichuan Province, China. The Jiuzhaigou earthquake is a strike-slip earthquake with a focal depth of 20 km at 33.20° N and 103.82° E, and was caused by two concealed faults. According to emergency investigations and remote sensing interpretations, the Jiuzhaigou earthquake triggered 1780 landslides, damaged one dam  and broke one dam (Huohua Lake). The landslides mainly occurred in the Rize Valley and Shuzheng Valley and in Jiuzhai Paradise. The landslides involved hanging wall and back-slope effects, and the slope angle, slope aspect, seismic faults and valley trend were obviously related to the occurrence of the landslides. Specifically, most of the landslides were shallow landslides, rockfalls and rock avalanches and were small in scale. The failure modes of landslides mainly include wedge rock mass failure, residual deposit failure, relaxed rock mass failure and weathered rock mass failure. The initial low stability of the dam coupled with the topographic effect, back-slope effect and excess pore water pressure led to damage to the Nuorilang Waterfall dam. This earthquake had a magnitude of Ms 7.0 and a focal depth of 20 km at 33.20° N and 103.82° E ..b) [10].b, there is an obvious seismic belt along the boundaries of the Minjiang block; many great earthquakes (Ms ≥ 7.0) occurred along the boundaries of Minjiang block, such as the 1933 Diexi Ms 7.5 earthquake (east boundary), 1976 Songpan Ms 7.2 earthquake (west boundary) and 2008 Wenchuan 8.0 earthquake (south boundary).As shown in figure 1b). Although several earthquakes were distributed along the northern edge of the Minshan Block, no large earthquakes occurred. At 21.19 local time (13.19 UTC) on 8 August 2017, an earthquake with a magnitude of Ms 7.0 and a focal depth of 20 km occurred at the north edge of the Minshan Block (b).The Jiuzhaigou earthquake is located at the north edge of the Minshan Block b. Althouan Block b.2.2.According to the focal mechanism solution of the Jiuzhaigou earthquake, the Jiuzhaigou earthquake is a strike-slip earthquake with a focal depth of 20 km at 33.20° N and 103.82° E, as shown in F1 and F2 in F1 and F2 are approximately 23.0 km and 19.0 km, respectively [The active faults in the northern section of the Minshan Block include the Tazang fracture and the Minjiang fault . Based oectively .Figure −2, NS: 185.0 cm s−2, UD: −124.7 cm s−2 and east–west (EW): 3.9 cm s−1, north–south (NS): 6.6 cm s−1, up–down (UD): 2.5 cm s−1 [The PGA (peak ground acceleration) and peak velocity are listed as follows: EW: 129.5 cm s5 cm s−1 . As of 15 cm s−1 . Among tThe area affected by the Jiuzhaigou earthquake was mountainous with elevations from 1600 to 4500 m, as shown in 2.3.Based on field investigations and remote sensing interpretations , the ba−2). Other distribution laws can be summarized as follows:Hanging wall effect. Most geohazards are distributed in the hanging wall of the main seismic fault (F1). Relative studies indicate that the dynamic conditions in hanging walls are better than those in footwalls [(1) ootwalls ,17.Back-slope effect. The geohazards in the Rize Valley and Shuzheng Valley mainly occurred on the back slopes and not at the epicentre , as shown in figures (2) From (1) landslides,(2) damage to the Ruorilang Waterfall dam, and(3) breaking of the Huohua Lake dam.The Jiuzhaigou earthquake-triggered geohazards can be classified into three broad categories:3.3.1.3.1.1.Overall, 1780 landslides were triggered by the Jiuzhaigou earthquake. Most of these landslides are small, with scales of a few cubic metres to thousands of cubic metres and few reached hundreds of thousands of cubic metres.a), rockfalls from steep slopes (b) and rock avalanches (c), which typically involve the top few metres of the weathered bedrock, regolith and colluvium.Most of the landslides were shallow landslides a, rockfap slopes b and rocalanches c, which Low-position landslides. This type of landslide is distributed along the bank slope of the Rize Valley and Shuzheng Valley and is associated with engineering activities at elevations between 5 and 100 m above the road. This type of landslide is the main type of rockfall and involves shallow surface sliding. The volume of the accumulation is almost tens to thousands cubic metres.(1) High-position landslides. Compared with the low-position landslides, the high-position landslide is distributed on the upper part of the mountain or on the convex topography of the slope, and the elevation is between 100 and 400 m above the valley floor. This slope failure mainly includes rock avalanches and shallow landslides.(2) The landslides were distinguished as low-position or high-position landslides based on their position.3.1.2.a), (ii) residual deposit failure (b), (iii) relaxed rock mass failure (c) and (iv) weathered rock mass failure (d).Wedge rock mass failure. The structure planes cut the rock mass from different directions and turn it into a wedge rock mass. Owing to the structure planes, the wedge rock mass is in a potentially unstable state. Thus, the earthquake finally triggered the movement of these unstable rock masses (a).(1) k masses a.Residual deposit failure. In the earthquake area, the residual deposits were distributed widely, and their poor properties (low shear strength and low tensile strength) [b). Many shallow landslides follow this mode.(2) trength)  result iRelaxed rock mass failure. In earthquake areas, many steep slopes with large amounts of relaxed rock mass are very fractured and are accompanied by developed structural planes. These rock masses collapse suddenly during earthquakes, as shown in figure 6c. This failure mode can trigger larger scale landslides. Most rock avalanches follow this failure mode.(3) Weathered rock mass failure. Steep slopes with strong weathered rock masses appear in many road slopes. During earthquakes, these strong weathered rock masses slide down (d).(4) ide down d.Based on field investigations and comprehensive analysis, the failure modes of landslides in earthquake areas can be summarized as follows: (i) wedge rock mass failure a, (ii) r failure b, (iii)  failure c and (iv failure d.(1) We3.2.2O3 (0.31%), FeO (0.47%), MgO (2.19%), CaO (47%), K2O (0.36%), Na2O (0.19%), Ti2O (0.09%), P2O5 (0.05%), MnO (0.01%), CO2 (36.6%) and H2O+ (2.15%) [The Jiuzhaigou earthquake damaged the Nuorilang Waterfall dam, resulting in its partial collapse and in many shear cracks . The Nuo), MgO 2.%, CaO , and the ejection length exceeded 40 m . When mag et al.  indicateThe earthquake also caused the dam to produce many fractures, and the lake water flowed out through these fractures . In thes3.3.5 m3. The Huohua Lake dam is a thin ridge dam bonded by algae and has a very loose structure.The Jiuzhaigou earthquake caused the Huohua Lake dam to break . The HuoThe distance from Huohua Lake to the epicentre is only 5.3 km. During the earthquake period, the dam broke at its weakest part, which was approximately 50 m in length, 20 m in width and 12 m in height.3 s−1 to a maximum of 21.5 m3 s−1, and several hours later, the beautiful natural lake was gone. During the rapid descent of the water level in Huohua Lake, many collapses occurred along the dam . However, the occurrence of the steepest inclinations (over 70°) is underrepresented. The maximum slope retrieved from the 30 m DEM did not exceed 70° [et al. [et al.  and Qi e [et al.  for co-sceed 70° . As note [et al. , this ma4.3.The statistical results  show thaIn the NW direction, the landslide percentage was obviously lower although this was the direction of the seismic fault. One possible explanation for this result is that two transverse valleys  exist in the NE direction in the southern section of the epicentre. Thus, many slopes are parallel to the direction of seismic wave movement. The back-slope effect caused the landslides to be concentrated on the back slopes of the two valleys, and this obvious distribution can be found in 4.4.4.4.1.F1), while the Zhangza Valley follows the NW direction, which is approximately parallel to the seismic fault. The field investigation and interpretation show that the landslide concentration of the Shuzheng Valley is obviously higher than that of the Zhangza Valley . From These results indicate that the dynamic response at the surface of the upper mountain is the most obvious. In the upper mountain, the larger PGA coupled with the longer action time (lower frequency) makes the upper mountain more unstable.In addition, based on our previous studies, the PGA of the back slope is approximately 2–3 times greater than that of the face slope . When th5.2.(1) Mountains around the epicentre are mainly vigorous ridges with mainly compact limestone lithology. In addition, sparse vegetation and bare bedrock result in a low geohazard distribution in this area.(2) The valley trend is parallel to seismic faults in a NW direction, and the earthquake is a strike-slip earthquake. Thus, the main earthquake force acts on the lateral fixed boundaries rather than the free boundaries; this dynamic condition is unfavourable for the occurrence of landslides. In addition, not much engineering activity occurred in the region, which reduced the number of potential unstable slopes.(3) The elevation of this region is generally higher than 4000 m, and some places are covered by snow or clouds, which can cause some interference in the interpretation of the results.In addition, the geohazards around the epicentre are mainly focused on the mountain top and prominent ridge, potentially due to topographic amplification. According to our previous studies, the PGA of prominent ridges after topographic amplification is approximately 4–11 times greater than that at the foot of the mountain [As shown in mountain .The influencing factors of dam damage  are different from landslides' partially. For dam damage, except for dynamic condition (topographic amplification), their special dam structure also plays an important role.(1) The dam has low stability. The mechanical tests show that the dam consisted of a poor material with high porosity and low mechanical strength, which made the dam have a low stability that resulted in some rockfalls from the nearly vertical dam (with a height of more than 20 m) from time to time during the non-earthquake period.(2) The nearly vertical dam can produce obvious topographic amplification at its upper part, and because the dam is located in the influence area of the back-slope effect, the amplification effect is strengthened further. The excess pore water pressure can also be produced in the dam mass in the dynamic process. In addition, the free surfaces provide enough space for deformation and final collapse.The causes of the Nuorilang Waterfall failure can be summarized as follows:Coupled with these influencing factors, the Nuorilang Waterfall dam collapses from the top.(1) Excess pore water pressure makes the stability of dam decrease greatly. Because the dam is made up of loose soil, the shaking caused by earthquake makes the pore water pressure increase rapidly and this decreases the shear strength of dam soil.d).(2) Loose soil also has topographic amplification. One time we put 1# station on the nearby accumulations and we obtained a set of seismic data, as listed in figure 9Coupled with the above points, these influences of excess pore water pressure, topographic amplification and kinetic energy difference etc., the dam of Huohua Lake collapsed finally.Causes of Huohua Lake dam failure can be summarized as follows:5.3(1) Compared with the 2008 Wenchuan Ms 8.0 earthquakeIn the last 10 years, the 2008 Wenchuan Ms 8.0 earthquake and the 2013 Lushan Ms 7.0 earthquake occurred along the Longmenshan fault zone at the eastern edge of the Qinghai-Tibet Plateau and caused several landslides. However, the features of landslides induced by the Jiuzhaigou earthquake are different from those by these two earthquakes.The PGA recorded in the valley bottom, the meizoseismal area of a strong earthquake in the Wenchuan earthquake, is over 0.5 g . If the 3. The reason for the lack of large, deep landslides triggered by the Jiuzhaigou earthquake probably relates to the differences in duration and frequency between the two earthquakes. The Wenchuan earthquake had a much larger magnitude, which resulted in a longer duration and longer period of shaking than the Jiuzhaigou earthquake.(2) Compared with the 2013 Lushan Ms 7.0 earthquakeIn the Jiuzhaigou area, most of the landslides were relatively small, and no landslides had a volume exceeding 1 million m2 were induced by the Lushan earthquake [2 were induced by the Jiuzhaigou earthquake. Although the earthquake area and landslides of the Lushan earthquake are both much larger than those of the Jiuzhaigou earthquake, the landslide concentration of the Jiuzhaigou earthquake is higher than that of the Lushan earthquake. In addition, the hanging wall effect and back-slope effect of the Jiuzhaigou earthquake are also more obvious than those of the Lushan earthquake.Although the 2013 Lushan earthquake and the 2017 Jiuzhaigou earthquake are both Ms 7.0 earthquakes, the Lushan earthquake is a thrusting earthquake, and the Jiuzhaigou earthquake is a strike-slip earthquake. The Lushan earthquake is more intense than the Jiuzhaigou earthquake . Approxirthquake , and app6.The 2017 Jiuzhaigou earthquake with a magnitude of Ms 7.0 occurred in the eastern segment of the Tazang fault zone in Sichuan, China. The epicentre is located in the Jiuzhaigou scenic spot.The seismic fault is a branch of the Tazang fault following the NW direction and is made up of two concealed faults with lengths of approximately 23.0 and 19.0 km. The earthquake triggered 1782 geohazards, including 1780 landslides, one damaged dam  and one broken dam (Huohua Lake). The main types of landslides included shallow landslides, rockfalls and rock avalanches, whose scales were mainly from a few cubic metres to thousands of cubic metres, and a few landslides reached a scale of hundreds of thousands of cubic metres. Most of the landslides occurred along valleys and were concentrated on the hanging wall of the seismic faults. The landslide concentration was positively correlated with the slope angle and the distances from the seismic fault and valleys.In addition, the Jiuzhaigou scenic spot is a world natural heritage site and is famous for its beautiful scenery. Although this earthquake produced some damage to the Jiuzhaigou scenic spot, such as Huohua Lake and the Nuorilang waterfalls, which may take a long time to recover, most other scenic spots remain intact. In addition, after this earthquake, many mountains may produce dangerous rock masses; thus, detailed geological investigation is necessary in the future.


N = 293) from the United States were recruited via Amazon’s Mechanical Turk and were randomly assigned to read one of several contrastive vignettes in which a 13-year-old child is described as bullying another student in school and then is offered an empathy-enhancing program. The empathy-enhancing program is described as either involving taking a pill or playing a video game on a daily basis for four weeks. In addition, participants were asked to imagine either their own child bullying another student at school, or their own child being bullied by another student. This resulted in a 2 × 2 between-subjects design. In an escalating series of morally challenging questions, we asked participants to rate their overall support for the program; whether they would support requiring participation; whether they would support requiring participation of children who are at higher risk to become bullies in the future; whether they would support requiring participation of all children or even the entire population; and whether they would be willing to participate in the program themselves. We found that people were significantly more troubled by pharmacological as opposed to non-pharmacological moral enhancement interventions. The results indicate that members of the public for the greater part oppose pharmacological moral bioenhancement, yet are open to non-biomedical means to attain moral enhancement. [248 words].To gain insight into the reasons that the public may have for endorsing or eschewing pharmacological moral enhancement for themselves or for others, we used empirical tools to explore public attitudes towards these issues. Participants (The online version of this article (doi:10.1007/s12152-017-9340-9) contains supplementary material, which is available to authorized users. Moral competence is universally valued. Religious texts and the virtue ethics traditions all valorize the attainment of moral fluency. The Enlightenment brought its own contributions to the project, with deontology and consequentialism imparting ‘rational’ means of defining what it means to be a moral person .bioenhancement . Both programs were described as being equally safe and effective. We took pains to insure that the pharmacological moral bioenhancement was as innocuous as possible, describing it as a pill “based on the natural hormone oxytocin”, as we did not want to bias our results with off-putting interventions such as genetic modification or deep brain stimulation. A second form of contrast built into the vignettes compared the closeness to the subject of the individual who is under consideration for moral bioenhancement: participants were asked to imagine either their own child bullying another student at school, or their own child being bullied by another student at school [closeness to subject: other’s child or own child]. This resulted in a 2 × 2 between-subjects design.One form of contrast involved the In an escalating series of morally challenging questions, we asked participants to what degree they thought that it would be a good idea for the bully to participate in the program ; to what degree they thought that it would be a good idea for the bully to be required to participate in the program (question 3); to what degree they thought that it would be a good idea for children, identified by a test to be at higher risk of being bullies in the future, to be required to participate in the program (question 5); to what degree they thought it would be a good idea for all children to be required in the program, given that the program increases empathy (question 6); to what degree they thought society would be better off if the general population was required to participate in the program ; and to what degree they would be willing to participate in the program themselves .alternative empathy-enhancing program: participants who were initially presented with a program that involved taking a pill daily for four weeks, were now reading about an alternative program that involves playing a video game for four weeks – and vice versa. We presented them with the rating they gave in response to question 3, and asked them to what degree they thought that it would be a good idea for the bully to be required to participate in this alternative program.In the second part of the experiment, we asked participants to read a second vignette describing the same 13-year-old child bullying another student at school , but this time is being required to participate in an the optionally tell us whether they or their family members had been bullied or been bullies themselves.We asked participants to explain the rationale for the answers they had given to questions 1, 3, and 9, in open response boxes , which were coded using Contrastive Quantitized Content Analysis . A comprThe vignettes and questions can be found in the supplemental information. The University of British Columbia’s Behavioural Research Ethics Board approved the study.Participants were recruited via Amazon’s Mechanical Turk , 46. ParData were analyzed using SPSS. Quantitative questions were analyzed using a two way independent Analysis of Variance (ANOVA) to identify significant main and interaction effects of the two independent variables on vignette measures. We analyzed significant effects with independent sample t-tests. Descriptive statistics were used to characterize the composition and properties of the sample. The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.Answers entered into the free-response box in question 2 were analyzed using the mixed-methods strategy called Contrastive Quantitized Content Analysis (CQCA) . The tecA total of 384 participants from the United States completed the survey; 91 participants failed the comprehension test resulting in a final sample of 293 respondents from 38 states and the District of Columbia . The mean age was 35.7 years old (with a standard deviation of 11.8 years). Frequencies of sample demographics are summarized in Table 1 in Appendix B.An often-cited argument as to why we should explore the possibilities of moral bioenhancement is the lack of effectiveness of so-called traditional methods of moral enhancement, such as upbringing, socialization, and education , 48. A rOther commentators have argued that there are in fact morally relevant differences between traditional and biomedical moral enhancement, for example because education is characterized by a fundamental moral equality between educator and educated, an equality that is lacking in the case of biomedical interventions aimed at reshaping the moral agency of others . Or, alopharmacological moral interventions in particular. We tested these hypotheses with an escalating series of morally challenging questions.In this study, we hypothesized that members of the public would be less supportive of pharmacological than of non-pharmacological programs, even if in the programs were described as being equally safe and effective. Moreover, we expected that the public would be uncomfortable with mandating moral enhancement interventions and with mandatory participate in the program as described in the vignette. A two way independent ANOVA showed a significant main effect of version of program (F(1289) = 141,57, p < 0.001). An independent sample t-test revealed that respondents were significantly more supportive of an anti-bullying program that involved playing a video game than one that involved taking a pill   = 147.26, p < 0.001). An independent sample t-test revealed that respondents were more supportive of a mandatory anti-bullying program that involved playing a video game than of a mandatory program that involved taking a pill; Mdiff = 44.68, 95%CI , p < 0.001, d = 1.39  = 51.702, p < 0.001). An independent sample t-test revealed that respondents supported a preventive anti-bullying program that involved playing a video game more than a program that involved taking a pill; Mdiff = 27.21, 95%CI , p < 0.001, d = 0.84  to be required to participate in the empathy-enhancing program. A two way independent ANOVA showed a significant main effect of version of program on the support rates for a mandatory empathy-enhancing program for all children (F(1289) = 131.005, p < 0.001). An independent sample t-test showed that respondents supported a mandatory preventive empathy-enhancing program for all children that involved playing a video game more than one that involved taking a pill; Mdiff = 43.13, 95%CI , p < 0.001, d = 1.33 , or that their own child is being bullied by another student in school (other’s child). Second, we compared responses to two questions in which we asked respondents about their support for a population-wide empathy-enhancing program (everyone else) and their willingness to participate in such a program themselves (self).participation (F(1289) = .451, p = .502), mandatory participation (F(1289) = 1.473, p = .226), or preventive approaches to the anti-bullying program (F(1289) = .994, p = .320)  versus those in which someone else’s child had been bullying the respondent’s child (other’s child). Two way independent ANOVAs demonstrate that there was no significant main effect of closeness to subject on the support rates for either ation (F189 = .451p = .033) between version of program and closeness to subject when the respondents were probed on children being required to participate in the program, indicating that the mean difference between other’s child and own child differs depending on whether the program involves a pill or a video game. Pairwise comparisons using an independent sample t-test revealed that people were more supportive of a mandatory empathy-enhancing program that involved taking a pill when they imagined the child participating in the program to be an other’s child rather their own child; Mdiff = 12.55, 95%CI , p = .023, d = 0.38  = 4.4611, 89 = 4.46In one of the first articles discussing moral enhancement, Thom Douglas argued that unlike other types of enhancement, moral enhancement primarily benefits others: “on any plausible moral theory, a person’s having morally better motives will tend to be to the advantage of others” . Others moral enhancement. A fundamental question is how to weigh the interests and preferences of the individual and the interests of others (in view of public safety and managing public risk) , p < 0.001, d = 0.82 . An independent sample t-test revealed that respondents were more willing to participate in an empathy-enhancing program that involved playing a video game than one that involved taking a pill; Mdiff = 39.02, 95%CI , p < 0.001, d = 1.13  = 67.808, n = 99) of the respondents indicated that they had been bullied in the past to such a degree that it interfered with their daily activities. 64.8% (n = 190) indicated that they hadn’t been bullied (to such a degree), and 1.4% (n = 4) chose to not answer this question. 7.8% (n = 23) of the respondents indicated that they had bullied in the past to such a degree that it interfered with someone else’s daily activities. 89.8% (n = 263) indicated that they hadn’t bullied someone else (to such a degree), and 2.4% (n = 7) chose to not answer this question. Age, gender, and whether participants had been bullied or were bullies themselves had no influence on any of our parameters.Finally, we asked whether participants had a history of bullying, either as perpetrators or victims of bullying. We found that 33.8% (good to bad idea (question 1), participants were asked to explain why they answered as they did in a free-response format (question 2). Responses were analyzed using contrastive qualitative content analysis (see methods). The themes that emerged represented reasons that fell into four main categories: Good idea, Bad idea, Ambivalent, and Appropriate reaction to bullying (see appendix C for the code sheet).After rating the empathy-enhancing anti-bullying program described in the vignette on a sliding scale ranging from Good idea category, the following reasons in support of the empathy-enhancing anti-bullying program were given most frequently  , the program’s SAFETY , the notion that the program provides a GOOD ALTERNATIVE to other approaches (such as ignoring the problem or punishment) , the idea that the OBJECTIVE JUSTIFIES MEANS  , the program’s POSITIVE IMPACT ON THE BULLY  , and the idea that the PROGRAM IS ENJOYABLE (and that this will motivate the bully to participate) .In the te) Fig. : the proχ2 = 57.49, df = 1, p < 0.001) and SAFETY , the notion that the program provides a GOOD ALTERNATIVE to current interventions , and the notion that the PROGRAM IS ENJOYABLE  were significantly more commonly mentioned in support of the non-pharmacological than the pharmacological program. No difference was found between version of the program and the following reasons in support of the program: the notion that the OBJECTIVE JUSTIFIES MEANS , the program’s POSITIVE IMPACT on the BULLY . We found no relationship between reasons in support of the program and closeness to subject (own child or other’s child), even when accounting for version of the program (pill or video game).The program’s EFFICACY , the program’s SUPERFICIALITY  , EFFICACY DISBELIEF  , the notion that ALTERNATIVE APPROACHES should be tried FIRST (and that the program should be a last resort) , SAFETY CONCERNS  .In the tly Fig. : the notpharmacological program compared to the non-pharmacological program: the notion that DRUGS SHOULD NOT BE USED , the SUPERFICIALITY of the program , the notion that ALTERNATIVES should be tried FIRST , and SAFETY CONCERNS . No difference was found between versions of the program for EFFICACY DISBELIEF .The following concerns were more commonly brought up against the χ2 = 5.930, df = 1, p = 0.015) and SAFETY CONCERNS  were more commonly mentioned as reasons against the program when the program described in the vignette was a pharmacological program intended for one’s own child. Moreover, we found that comments by respondents imaging their own child participating in a pharmacological program were more often coded as AMBIVALENT .Chi-squared tests were performed to determine whether there was a relation between reasons why respondents rated the program as a bad idea and their imagined closeness to the bully (own child or other’s child). We found no significant relationship between closeness to subject (own child or other’s child) and particular reasons provided against the program without stratifying for version of program . However, the notion that ALTERNATIVES should be tried FIRST , EMPATHY , UNDERSTANDING , HELP , PUNISHMENT , and moral AGENCY   (data not shown). We found no significant relation between version of program and respondents indicating that the bully needed TEACHING, EMPATHY, UNDERSTANDING, PUNISHMENT, or AGENCY.Moreover, respondents frequently made explicit whether they thought the program as described in the vignette indeed consisted of the strategy to alleviate bullying that they preferred or found to be most promising Fig. . Chi-squχ2 = 8.502, df = 1, p = 0.004), while when the program involved taking a pill, respondents more commonly indicated that they did not consider the program an adequate reaction to bullying   Fig. .In conclusion, the difference between self and other  influences the public’s support for moral enhancement. For the pharmacological empathy-enhancing program, respondents were more critical when they imagined their own child rather than an other’s child to be the one subjected to the program. They more often expressed ambivalence, mentioned safety concerns, and argued that alternatives should be tried first. And as regards the pharmacological program, respondents were more open to requiring the general population to participate in the program, but were less willing to participate themselves. However, the difference between self and other was largely absent for vignettes describing a non-pharmacological program, suggesting that this distinction is morally salient only when safety and risk concerns come into play.means matter morally. For when it comes to moral enhancement, members of the public generally eschew pharmacological moral bioenhancement yet are open to non-biomedical means to attain moral enhancement. Both the quantitative and the qualitative data confirm that the public disapprove of biomedical interventions for moral enhancement. These findings were confirmed convincingly across a range of questions and in all versions of the vignettes.This study provides empirical evidence that These findings are in line with previous research demonstrating a considerable bias against or mistrust of “pills” in general –60. The learned something on a deeper level and in the longer run.Moreover, many respondents explained that the reason why they did or did not support the empathy-enhancing program in the vignette was related to whether or not they were under the impression that the program offered an appropriate pedagogical response to the problem behaviour (bullying). This might be interpreted as an indication that the public values fostering in children deeper understanding of and insight into why certain behaviour is morally wrong rather than mere conformity to  rules. The public appears concerned not only about effectiveness  but also about whether the one participating in the program will, as a result of the intervention, have One important consideration in interpreting these results is the fact that the scenario in our vignettes concerns bullying by a 13-year-old child. People might be particularly resistant to giving pharmacological substances to children, and different ethical considerations may come into play, for example about the responsibility of parents and schools. However, comments given in the open-response boxes indicate that the concerns respondents have go beyond mere ‘pills are bad’-considerations. Moreover, next to empathy enhancement in children, we also asked respondents about their support for empathy enhancement for the general population and for themselves.doing the right thing, period as opposed to doing the right thing for the right reasons are also raised in the ethical debate on moral bioenhancement. Douglas [brute as opposed to deliberate [deep moral understanding and deep moral improvement because these kinds of interventions fail to provide any moral content.Concerns about the importance of  Douglas  discusseliberate , becauseliberate . Douglasliberate ; Perssonliberate . Other c“On my analysis, I conclude that moral neuroenhancement is unlikely to morally enhance people in the true meaning of the word. The development of neurotechnologies will allow us to control moral emotions but not to generate any content for moral reasons for actions. Without a systematic reflection on the nature of the good, the right and the just, one would end up, using MacIntyre’s language, in bad character because of intellectual blindness. Moral agency requires understanding and the formation of right moral emotions. (…) The hope of controlling human moral emotions is insufficient for the formation of virtuous people. Moral agents are not engineered but trained through the development of a vision of the good life and an understanding of human flourishing.” These comments suggest that at least some philosophical positions in the ongoing debate align with public opinion. Indeed, the reasons participants offered in their free responses reflect to large extent key themes discussed in the neuroethics literature.Harris maintains that to be a moral agent is to consider moral reasons for action. He argues that direct, reason-bypassing interventions “might well take the conduct of the affected individual beyond moral review and certainly out of the realm of things that might be right all things considered” . JotteraESM 1(PDF 603 kb)