Studies dealing with the effectiveness of the Fédération Internationale de Football Association (FIFA) 11+ prevention program to improve performance outcomes in children aged < 14 years are limited. This study aimed to point out the effects of the application of short-term FIFA 11+ warm-up program on physical performance in young football players. Participants were 36 youth male football players, divided into a FIFA 11+  age: 11.15 (0.79) y) and a control group  y) and trained for 4 weeks. Before and after the training period, standing long jump performance, agility, repeated sprint ability, sit and reach, and “30–15” intermittent fitness tests were assessed. A mixed ANOVA showed significant differences between the groups in the standing long jump test (FIFA 11+: 5.6% vs. CG: −1.9%) in favor of FIFA 11+ over CG. Additionally, the FIFA 11+ performance of the Illinois agility test was significantly better compared to the CG performance (FIFA 11+: −1.9% vs. CG: 0.03%). The main findings of this study suggest that just 4 weeks of implementation of the FIFA 11+ improves physical performance compared with traditional warm-up routines in young soccer players. Fédération Internationale de Football Association (FIFA) 11+ is a complete, simple, and easy to implement warm-up program, comprised of 10 conditioning exercises. The application of the FIFA 11+ program has been primarily focused on preventing and lowering incidence of injuries in soccer players , but it Zarei et al. have shown superior results of 7.5% in vertical jump height, 2.6% in Illinois agility test in favor of the FIFA 11+ program compared to standard warming up, and possible positive effects have been found in 9.1 m sprint test of −3.1% . The samChen et al. aimed to determine acute effects of the FIFA 11+ program on physical performance . They coFurthermore, it has been shown that young boys (mean ± SD: age 10.4 ± 1.4) improved countermovement jump and 20 m sprint by 6% and 2%, respectively, following the 6-week-FIFA 11 warm-up program . In 11-yAlthough the main purpose of FIFA 11+ is injury prevention ,11, the Therefore, an evaluation of the effects of the original 11+ program on football athletes younger than 14 years of age is warranted. This study aimed to point out the effects of the application of short-term FIFA 11+ warm-up program on physical performance in young football players. We hypothesized that the FIFA 11+ program would show better effects on physical performance in comparison to the traditional warm up in football. The sample included 36 youth male football players, aged 10–12 years, and was divided into two groups (FIFA 11+ or control group). The FIFA 11+ group consisted of 19 football players  and the control group consisted of 17 football players . Subjects were recruited from two different soccer teams with similar competitive schedule (one competitive game per week) and soccer drills used during their weekly training sessions. There were four inclusion criteria: (1) subjects did not have history of injury or musculoskeletal disorder in the past 6 months prior to the study, (2) aged from 10 to 12 years, (3) with at least 1 year of soccer training experience, and (4) participated in soccer training session three times per week. In addition, the exclusion criteria were as follows: missed two consecutive training sessions and missed one testing session. The study was carried out following the Declaration of Helsinki and the experimental treatment was approved by the Institutional review board of Faculty of Sport and Physical Education, University of Novi Sad . The parents provided their written consent and agreed that their children can participate in this study. The initial and final measurements were carried out in March 2019 and April 2019, respectively. Subjects followed a familiarization session before testing to avoid any learning effects. Standardized tests were conducted 48 h after hard physical training to minimize the influence of fatigue, and performed under similar conditions before and immediately after the 4-week period over 2 days. All tests were administered in the same order before and after training, and recorded by the same person. On day 1, players’ characteristics (body height and body mass), and physical performance tests were conducted in the following order: Sit and Reach, Standing Long Jump, Sprint 20-m, Illinois Agility Test, and Repeated Sprint Ability tests. The “30–15” Intermittent Fitness Test was performed on day 2. High intra-class correlation coefficients were obtained for the different performance tests varying between 0.81 and 0.98.2)).Height was measured on the Seca 214 portable stadiometer , body mass was measured to the nearest 0.1 kg using a digital scale , and body mass index (BMI) was calculated (BMI = body weight (kg)/body height . Each sprint was initiated from an individually chosen standing position, 30 cm behind the photocell gate, which started a digital timer. Each player performed three maximal 20 m sprints interspersed with 3 min of passive recovery, and the fastest time achieved was retained.Standing Long Jump—the participant stood behind the starting line and was instructed to push off vigorously and jump as far as possible. The participant had to land with their feet together and to stay upright. Jump distance was measured from the take-off line to the back of the heel. After two familiarization tests, participants performed three repetitions. The best score of the three repetitions was selected for the analysis.Illinois Agility Test—the length of the zone was 10 m, while the width (distance between the start and finish points) was 5 m. Four cones were placed in the center of the testing area at a distance of 3.3 m from one another. The participants started the test lying face down, with their hands at shoulder level. The trial started on the “go” command, and the participants began to run as fast as possible. The trial was completed when the players crossed the finish line without having knocked any cones over. Time was measured using a photocell system (Witty). Each player performed three trials with the best score (time) used for analysis .Repeated sprint ability (RSA) test—a RSA test was used to assess repeated sprint ability ,18,19. TRSA best time—the best sprint running time out of six sprint runs;RSA total time—the sum of running times of all six sprint runs;TT is the sum of running times of all six sprint runs; PT is the best sprint running time out of six sprint runs; and N is total number of sprints completed.FI (fatigue index)—fatigue index was calculated according to the following formula, where 2max, was calculated according to the following formula: where VIFT is final running speed, G gender , A age, and W body weight (kg).“30–15” Intermittent Fitness Test—testing was performed in groups of up to 10 subjects. The subjects were asked to complete a run at each level of protocol given following the audio protocol . Each leBoth teams participated in the same weekly soccer training volume and methodology (three sessions/week of ≈90 min and one match/week). They were both visited at least once a week by our study assistants in order to monitor whether the groups used the same soccer training and if the control group did not use a structured injury prevention program but a regular warm-up. Additionally, players from both groups indicated their Rated Perceived Exertion (RPE) using the Borg’s CR-10 scale at the end of the sessions . A detaiwww.f-marc.com/11 plus). The CG performed their usual warm-up consisting of a combination of running exercises (4–5 min at light intensity), followed by 4–5 min of dynamic mobility emphasizing the lower-extremity muscle groups and technical exercises with the soccer ball (4–5 min).The FIFA 11+ warm-up program was performed in three parts with a total duration of 20 min with a precisely programmed exercise load as well as precisely scheduled rests between sets. The first part involved warming up through running with performing tasks; the second part included various strength development exercises, plyometrics and stabilization, and balance exercises, and the third part also covered running including specific tasks. The program according to the instructions contained in the FIFA 11+ manual comprises three levels of difficulty depending on the athlete’s age and level of preparedness. In this research, the experimental treatment followed the beginner level. For detailed instructions for the FIFA 11+ warm-up program the manual can be found on the official website , and are presented as mean and standard deviations. The Shapiro–Wilk test verified the normality assumption. To evaluate the effects of the FIFA 11+ program on the physical performance tests, we used a mixed ANOVA . The main effects of the group and time, and their interaction effect are reported. When the main effect of time/group was significant, the simple main effect of time/group was examined. The percentage of change from pre- to post-test was also calculated for each group, and, partial eta squared  and CG (5.9) for RPE, A mixed ANOVA showed that the mean performance of study outcomes was similar in the FIFA 11+ and CG . However = 23.81, p < 0.001,  = 7.21, p = 0.017, p ≤ 0.05) was not achieved for the interaction effect on VO2max, simple main effect of time showed that the mean VO2max significantly improved from pre- to post-test in the FIFA 11+  = 22.22, p < 0.001,  = 2.85, p = 0.112, Furthermore, simple main effect of time revealed that both groups improved performance in the Sit and Reach test, the FIFA 11+ (Fnificant .2max) measures of the physical performance parameters analyzed.Despite the great success of the FIFA 11+ Injury Prevention Program, it was difficult, in practical terms, to persuade coaches and players to apply this program regularly solely to prevent injuries, so the aim was to prove that it also has a positive and direct impact on players’ performance. The findings of the current study indicate that the training stimuli provided by the implementation of FIFA 11+ two times per week for 4 weeks appear to be sufficient to elicit significant improvements in some  but not all  for Illinois agility test after only 4 weeks of the FIFA 11+ program [Studies dealing with the effects of the FIFA 11+ in football have reported improvements in agility , balance program . Similar program .The reasons could be found in the fact that the FIFA 11+ program includes sprinting, agility, and plyometric exercises beside neuromuscular exercises . Moreovep = 0.001).Studies looking at the influence of the FIFA 11+ in adult males have reported improvements in jump performance . Positiv2, while a moderate intensity warm-up lasting 3–5 min is enough to significantly improve short-term performance [2max. Different warm up routines are commonly used to optimize football performance and prevent injuries with manipulation in the content , duration, and intensity ,30. Accoformance . The curThe limitations of the study are the short time available to investigate the effects of the FIFA 11+ program (4 weeks), and the absence of follow-up. A follow-up assessment of the PF could have addressed the FIFA 11+ warm-up program effects on retention of PF. The generalization of the results onto girls is also a limitation because the study only included boys, thus, it is not known whether it is applicable in girls. Moreover, future studies should investigate the effects of the FIFA 11+ program with a longer duration on several physical performance variables using randomized control trial designs. Additionally, although groups did not differ in study outcomes, a lack of randomization could have contributed to bias effects, therefore, future studies should randomize participants to overcome bias.However, the strength of the present study is that it demonstrated the plausible effects and suitability of the FIFA 11+ warm-up program even in boys aged less than 14 years. Thus, the FIFA 11+ warm-up program can be implemented in the training sessions in boys younger than 14 years old. This study supports previous findings that traditional warm-up programs could be replaced with FIFA 11+ in male youth soccer players based on its superior effects on physical performance. Moreover, this warm-up program does not require specific equipment, supports the performance development of young football players, and accordingly significantly contributes to the reduction in the injury risk. The main findings of this study suggest that just 4 weeks of implementation of the FIFA 11+ warm-up program improves physical performance compared with traditional warm-up routines in young soccer players. Therefore, the FIFA 11 + program can be considered appropriate for this age, as it seems to be adequate for inducing significant performance enhancements in young soccer players. Moreover, given the improvements in jump performance and agility, our study would advocate the introduction of these essential movement competency skills in children aged 10–12 years. Ultimately, due to evidence-based health benefits of the FIFA 11+ warm-up program, its primary target population could be expanded to recreational athletes and children in a school environment, while aiming to improve public health.


Objective: We review prior studies on the incidence of hypertension (HTN) after earthquakes and present a retrospective analysis of HTN after the 2010 earthquake in Haiti.Methods: Prior reports on HTN incidence were reviewed and a retrospective chart review for diagnosis of HTN in 4,308 patient charts was performed over a 7 year period (five clinics). A retrospective cohort study (RCS) was then performed on 11 patients with linear follow-up.Results: The Literature review revealed a significant increase in acute and subacute HTN following earthquakes. However, the chronic effects of earthquakes varied. Our chart review uncovered no significant difference in diagnosed HTN in a Fort-Liberté clinic 128 kilometers (km) distant and 4 weeks post-event. A secondary linear RCS for 11 individuals, prior to and after the earthquake, also did not detect a significant change in HTN prevalence.Conclusion: Prior studies demonstrate acute and subacute, increases in HTN after earthquakes, but late changes have varied. Retrospective studies in the Fort-Liberté clinic, 128 km distant and 4 weeks post-event, revealed no significant change in HTN, confirming prior findings that changes in HTN after earthquakes are early and local events. Further work examining HTN after earthquakes is needed to improve early health care after natural disasters. Populations are prone to various forms of stress including physical, psychological, and environmental stress. Environmental stress is defined as environmental changes, including pollution, climate change, and natural disasters that cause psychological and/or physical stress. Population-based stress associated with natural disasters is well-documented in the literature. Individuals respond to stress via internal physiologic mechanisms, called allostasis, that involve activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis, resulting in a release of high levels of catecholamines and cortisol in the blood . These sThe pathophysiology of earthquake-related cardiovascular events is believed to be induced by activation of the sympathetic nervous system together with HTN, endothelial dysfunction, increased platelet activation, and vascular thrombosis. Endothelial dysfunction is closely associated with activation of the coagulation cascades and enhanced inflammation as well as vasospasm. High levels of inflammatory biomarkers such as C-reactive protein (CRP), interleukins, tumor necrosing factor alpha, (TNFα), von-Willebrand factor (vWF), hematocrit, and D-dimer concentrations have been reported following natural disasters and earthquakes supporting this hypothesized mechanism for stress-induced cardiovascular complications including hypertension –6.Earthquakes, like most natural disasters, create cumulative community stress through the sheer magnitude of immediate loss of shelter, health, financial stability, and food security, but also have lasting impacts on communities for months or years. In prior reports, the onset of acute cardiovascular events occurring after earthquakes has been variable, with cardiovascular events occurring acutely on the day of the event or a few days after the disasters. Cardiovascular complications that have been reported include Takotsubo cardiomyopathy, coronary occlusion with myocardial infarction (MI), cerebrovascular occlusion with cerebrovascular accident , and sudden cardiac death. Subacute and chronic outcomes potentially include heart failure. Venous thrombosis with deep vein thrombosis, with or without subsequent pulmonary embolism is also reported . Sites iHaiti has been impacted by a series of natural disasters throughout its history. These natural disasters are superimposed on extreme poverty and limited health care, placing Haiti in a vulnerable position among Low-Income Countries (LICs). The location of Haiti also makes it vulnerable to various forms of natural disasters that have contributed to Haiti being considered the poorest country in the Western Hemisphere. The Haitian population has been exposed to stress during the Torrential rains in 2004, Tropical Storm Fay, Hurricanes Hanna and Gustav in 2008, the October 2010 Cholera epidemic as well as a major earthquake in January 2010, and Hurricane Matthew in 2016. The 2010 Haiti earthquake that occurred on January 12th, 2010 is considered to be the worst natural disaster to impact Haiti in terms of loss of life, with ~300,000 deaths being attributed to this earthquake. The epicenter of this 2010 earthquake was near Port-au-Prince. More than a million people were displaced, contributing to a population increase of 75% in Fort-Liberté, along the northern coast of Haiti, within 1 month of the earthquake. For the past 15 years, we have made yearly medical service trips to Haiti and examined a diverse population of local residents through a small church-sponsored clinic in Fort-Liberté .Reports of elevated BP and HTN have differed with variations in HTN incidence seen with proximity to the earthquake epicenter as well as the timing of HTN assessment after the event. Given prior variations in the reported incidence of HTN observed at later times after earthquakes and at sites remote from the epicenter, we have reviewed prior published literature examining the effects of earthquakes on the incidence of hypertension. We have also performed a retrospective analysis of the incidence of hypertension prior to and at 4–5 weeks or more after the 2010 earthquake in Fort-Liberté, Haiti, a site 128 km distant from the earthquake epicenter in Port-au-Prince. The review of prior literature is presented first providing the context for our retrospective analysis.Prior studies examining the effects of earthquakes on the incidence of HTN after earthquakes were identified. A literature search using the keywords of earthquake, BP, hypertension, and pregnancy was performed using PubMed, Google Scholar, Science Direct, UpToDate, and Research Gate searches to locate relevant articles. We identified 21 papers reporting changes in HTN incidence after earthquakes from China, Japan, the United States, and Italy from years 1995 to 2019.An initial retrospective chart review was performed using data from an outpatient clinic affiliated with the Jerusalem Baptist Church in Fort-Liberté, Haiti for each of 5 years where data was available from the clinic charts; 2007, 2009, 2010 (4–5 weeks or more after the earthquake), 2011, and 2014, that included 4,308 total patients. The clinic was interrupted in years 2008, 2012, and 2013 due to hurricanes, Cholera, and political unrest. This retrospective chart review was approved by the clinic director and all patient data were de-identified prior to collating and analysis.Data were collected in the local Fort-Liberté clinic charts and documented by volunteers. Basic demographic data and visit diagnoses were collected and reviewed, with a focus on a diagnosis of HTN. After review, patients younger than 18 years of age were excluded and a total of 2,876 patients were included in the analysis. BP was measured by a standard manual sphygmomanometer (BP cuff) with readings recorded during the clinic visits by either the visiting nurses or physicians on the medical team. Hypertension was defined as BP greater than systolic 130 mmHg and diastolic >90 mmHg. The prevalence of diagnosed HTN (BP ≥130/90 mmHg) was calculated and compared before and after the 2010 earthquake. Actual BP measurements were not provided in all of the charts.To examine linear changes in individual patients who were seen consistently before and after the 2010 earthquake, a subset of 11 patients in this clinic was identified with consistent documentation of BP measurements over a period of 6 years from 2007 to 2012. Data from this smaller subset of patients was analyzed for changes in mean systolic blood pressure (SBP), diastolic blood pressure (DBP), and the number of BP medications and compared before and after the 2010 earthquake.Data from the clinic documents were separated by date and included patients older than 18 years. The numbers and percentages of all patients with a diagnosis of HTN in the included cohort for each day and for the clinic charts for each year were calculated. Data from the initial retrospective chart review were analyzed by one-way Analysis of Variance (ANOVA) with a Fisher's LSD, Kolmogorov–Smirnov (KS) test, and Mann–Whitney using GraphPad Prism 8.4.3. For the linear cohort of 11 patients, a simple regression analysis was performed together with non-parametric Kolmogorov–Smirnov (KS) statistical test.Blood pressure changes and hypertension incidence post-earthquake have been reported in multiple studies  but haveIn prior reports, earthquakes have had an impact on BP readings. Elevated BP has been detected within minutes to days after the event. A study performed in Great Sichuan, China in 2008 at the time of the Wenchuan earthquake demonstrated acute changes in BP after the earthquake. This study measured the BP at the time of the earthquake in 11 patients who were undergoing ambulatory BP monitoring . Mean BPOther studies have revealed an early but a more sustained elevation in BP following earthquakes. Kario et al. have studied BP changes before and 7–14 days after the Hanshin-Awaji earthquake in China . In one n = 36) assessed near the epicenter when compared to those assessed over 50 kilometers from the epicenter  to baseline after 4–6 months . This was postulated to be due to the increased workload and stress during the long-term disaster relief operations performed by these workers specifically (n = 16), but much smaller increases at sites > 50 km from the epicenter (n = 20)  .Most studies investigating the influence of earthquakes on BP have established an increased incidence of hypertension at the time of the disaster and at sites near the earthquake center, however, the effects of earthquakes on populations at late follow-up times and sites remote from the epicenter have varied. There is also less information available for the impact of earthquakes on the prevalence of hypertension in a single site, select population across many years. One study observed a chronic elevation in BP only in public workers, but not in the general population . With ouHypertension was diagnosed as noted at 130/90 mmHg. The prevalence of diagnosed hypertension recorded in the clinic charts was 17, 20, 15, 16, and 19% in clinic years 2007, 2009, 2010, 2011, and 2014, respectively. The Fort-Liberté clinic was held 4–5 weeks after the earthquake. There was no statistically significant difference in the incidence of recorded HTN for each year, including for the year 2010 .P > 0.19). Linear regression of mean BP over the course of 6 years for these individual patients also revealed no association between the earthquake and altered BP (R2 < 0.02). Non-parametric Kolmogorov–Smirnov (KS) test analysis similarly did not reveal a statistically significant shift in mean SBP  activation of the HPA axis and its associated factors such as insulin resistance syndrome, accelerated atherosclerosis, and potential silent cardiovascular disease and (2) activation of the sympathetic nervous system responses. Both mechanisms have the potential to lead to endothelial dysfunction, increased blood viscosity, and platelet/hemostatic activation (Virchow's triad). Catastrophic stress is predicted to accelerate cardiovascular disease through hemodynamic changes such as HTN and thrombosis  activati.While we have examined a large number of charts, we should note that this study has some limitations; (1) the community studied is ~128 km from the epicenter and comparative analysis with Port-au-Prince was not available, (2) patient demographics were limited, (3) actual BP values were not consistently reported for all patients in the initial retrospective chart review thus a diagnosis of HTN was used for some charts, and (4) the data did not include all years from 2007 to 2014 due to interruptions in the clinic during major events such as political unrest (revolution), hurricanes, and epidemics; Data were available from years when the clinic was active. These recurrent instabilities in Haiti may have predisposed to mental and physiological resilience and make detection of changes in HTN incidence more difficult. It is important to note that while our acute care clinic is set up annually, presenting limitations on the true incidence of HTN in the total population, this data still presents accurate presentations of HTN in members of the community yielding partial data toward the true incidence of HTN of the encompassing population. Additionally, patient numbers do vary each year and our total patient number was higher in 2007, which may be due to many factors including attrition bias, voluntary response bias, or convenience.One could suggest that our detection of the stability of BP after the earthquake may have been due to an influx of aid with improved care after the 2010 earthquake event, there was no significant increase in the numbers of HTN medications noted in the charts. Multiple traumatic stress-inducing events have occurred in Haiti including political unrest with the overthrow of the government, a cholera epidemic, hurricanes, and earthquakes. In fact, the cholera epidemic also occurred in October 2010, just 9 months after the earthquake. Thus, effects on HTN may be difficult to correlate with a single environmental disaster such as the earthquake in January 2010.The reported prevalence of hypertension has varied in the Haitian population. Hypertension prevalence has been reported to be 43.6 and 42.3% in Léogâne . AnotherHypertension is an important risk factor to assess after earthquake events. Long-standing risk factors for the development of coronary artery disease (CAD) have typically included age, serum cholesterol levels, high-density lipoprotein (HDL), BP and specifically HTN, and cigarette use, and also men at younger ages . A priorKario et al. reported an increase in the incidence of coronary heart disease-related mortality in elderly patients for a few months following an earthquake in Japan . KabutoyIn conclusion, prior studies have examined both acute and subacute effects of earthquakes on BP elevation with variable correlations noted at sites removed from the earthquake epicenter and at later times after the event. Our retrospective study compares the impact of the 2010 Haiti earthquake on the prevalence of hypertension before and after the event and was the first to examine changes in BP in five different years over a 7-year period. There was no statistically significant difference in hypertension prevalence amongst patients from our clinic in Haiti from 2007, 2009, 2010, 2011, and 2014. Specifically, BP measured 4-5 weeks after the 2010 earthquake at a site 128 km (80 miles) north of the epicenter did not detect significant increases in BP, confirming prior work that has demonstrated less change in BP and less detected HTN at sites distant from the earthquake and at later follow up times. Furthermore, while many studies have demonstrated acute health impacts such as myocardial infarctions and strokes in victims of natural disasters, the chronicity of health issues such as HTN over several years in time may actually be preserved given the findings of this study.We would suggest that in future studies a careful analysis of larger numbers of patients both early and late after natural disasters should be conducted to determine the risk of significant elevations of BP. Analyses of other risk factors, such as endothelial cell-derived von Willebrand's factor (vWF), C reactive protein (CRP), fibrinogen, renin, aldosterone, and troponin among other acute reactants might be measured. Von Willebrand's factor has been reported to remain elevated at 4-6 months post events, and it may be important to examine the risks of an earthquake-induced chronic hypercoagulable state secondary to prolonged elevation of risk factors –30, it iThe raw data supporting the conclusions of this article will be made available by authors upon request, without undue reservation.ARL, JP, DG, JTJ, and PD collected data. ARF, AA, ARL, ASE, KSV, RNB, MJ, and JRY analyzed data. ARF, KSV, RNB, JRY, and ARL wrote the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


BCR-ABL1-like B-cell precursor acute lymphoblastic leukemia (BCP-ALL) remains poorly characterized in adults. We sought to establish the frequency and outcome of adolescent and adult BCR-ABL1-like ALL using a novel RNA-Seq signature in a series of patients with BCP-ALL. To this end, we developed and tested an RNA-Seq custom panel of 42 genes related to a BCR-ABL1-like signature in a cohort of 100 patients with BCP-ALL and treated with risk-adapted ALL trials. Mutations related to BCR-ABL1-like ALL were studied in a panel of 33 genes by next-generation sequencing (NGS). Also, CRLF2 overexpression and IKZF1/CDKN2A/B deletions were analyzed. Twenty out of 79 patients (12–84 years) were classified as BCR-ABL1-like (25%) based on heatmap clustering, with significant overexpression of ENAM, IGJ, and CRLF2 (P ≤ 0.001). The BCR-ABL1-like subgroup accounted for 29% of 15–60-year-old patients, with the following molecular characteristics: CRLF2 overexpression (75% of cases), IKZF1 deletions (64%), CDKN2A/B deletions (57%), and JAK2 mutations (57%). Among patients with postinduction negative minimal residual disease, those with the BCR-ABL1-like ALL signature had a higher rate of relapse and lower complete response duration than non-BCR-ABL1-like patients (P = 0.007). Thus, we have identified a new molecular signature of BCR-ABL1-like ALL that correlates with adverse prognosis in adult patients with ALL. BCR-ABL1-like. These 11 subtypes are based on specific molecular alterations, mainly chromosome rearrangements, that promote the formation of aberrant chimeric proteins and aneuploidies1. Next-generation sequencing (NGS) and array technologies have been instrumental in identifying new ALL subtypes, and have aided in the discovery of new leukemogenic mechanisms. It has been known for many years that a subset of patients with ALL (~25% of BCP-ALL) have no established abnormalities, commonly referred to as B-other ALL. The genomic landscape of B-other ALL is becoming increasingly clear, and the proportion of unclassifiable patients has declined significantly3. In this context, BCR-ABL1-like B-ALL has emerged as one of the most relevant new subtypes due to its frequency and the potential benefit of targeted therapies .The 2016 World Health Organization (WHO)classification of acute leukemias recognizes nine different entities within B-cell precursor acute lymphoblastic leukemia/lymphoma (BCP-ALL) and two new provisional entities, including BCR-ABL1 oncogene, a constitutively active kinase. This aberration is present in >95% of patients with chronic myeloid leukemia, and in 3–5% and 25% of pediatric and adult ALL cases, respectively. In 2009, the DCOG/Erasmus and COG/St. Jude groups independently discovered a high risk BCR-ABL1-negative subgroup in children with B-ALL, exhibiting a gene expression signature similar to that of BCR-ABL1 positive-ALL but lacking the BCR-ABL1 rearrangement4. This subtype is associated with downregulation of B-cell development genes and overexpression of stem- and progenitor-cell genes. Clinically, this ALL subtype presents with high-risk clinical features such as high white blood cell (WBC) count, poor response to induction chemotherapy, higher measurable residual disease levels, and low probability of survival8.Philadelphia chromosome-positive ALL is defined by the t translocation that encodes BCR-ABL1-like ALL has been reported as 20–30% in adults, with a peak of incidence in the adolescent and young adult population (up to 42%)12. The BCR-ABL1-like ALL subtype shows deletions in several transcription factors involved in B-cell development, including IKZF1, E2A, EBF1, and PAX513. Additionally, the main molecular characteristics of BCR-ABL1-like ALL are the multiple translocations in different cytokine receptor and kinase signaling genes such as ABL1 (excluding BCR association), JAK2, ABL2, PDGFRB, TYK2, CSF1R, CRLF2, and EPOR. These mutations trigger the activation of growth promoting kinase or cytokine signaling pathways14. CRLF2 translocation and mutations in the JAK family genes are recurrent and result in the activation of JAK-STAT pathways in patients with BCR-ABL1-like B-ALL17.The frequency of BCR-ABL1-like ALL. Patients were classified using hierarchical clustering on a gene expression array in early studies8. A simpler approach was subsequently optimized based on Low Density Arrays carrying a small number of genes selected by microarray prediction analysis18. In the present study, we designed a targeted NGS RNA-Seq panel of 42 genes to classify patients with BCR-ABL1-like ALL. We sought to identify the BCR-ABL1-like ALL signature by targeted expression in a series of adolescent and adult patients with BCP-ALL, but without recurrent genetic abnormalities defined by the WHO classification (henceforth B-other ALL), and to evaluate its clinical, prognostic and therapeutic relevance.Several different approaches have been employed for the characterization of Programa Español de Tratamientos en Hematología) ALL risk and minimal residual disease (MRD)-oriented trials20. A first series of patients treated between 2002 and 2012 was evaluated for the identification of the BCR-ABL1-like signature (n = 49), and a second series of patients treated between 2012 and 2017 was used for validation (n = 100).We examined bone marrow (BM) or peripheral blood (PB) samples from adolescent and adult patients newly diagnosed with B-other ALL and treated between 2003 and 2017 in several Spanish hospitals. Patients received frontline chemotherapy according to PETHEMA , undifferentiated acute leukemia (n = 2), ALL with MLL rearrangements (n = 2), TCF3-PBX1 (n = 1), ETV6/RUNX1 (n = 1), hyperdiploidy (n = 3) and hypodiploidy (n = 1) not classified as BCR-ABL1-like based on the RNA-Seq signature, and two patients with low quality clinical data]. The remaining 84 patients, classified as B-other ALL, were considered valid for BCR-ABL1-like signature identification by RNA-Seq. Of these, 28 were discarded for survival analysis due to the heterogeneity of treatment protocols  and the absence of MRD assessment. Therefore, the prognostic relevance of the BCR-ABL1-like signature was investigated in a cohort of 56 homogeneously treated patients . The main clinical characteristics and prognosis of patients with BCR-ABL1-like B-ALL are shown in Table The study design is shown in Fig.Details for patient samples are provided in Supplementary Table −4. MRD level was considered positive when exceeded 0.01% or 1 × 10−4 at the end of induction and after consolidation.BM MRD levels were centrally assessed at the end of induction (weeks 5–6) in complete remission (CR) patients and at the end of the third consolidation cycle (weeks 16–18) by multiparameter flow cytometry. MRD levels at this latter time point were used to assign post-consolidation therapy . The detection limit of the method was 1 × 10CRLF2 relative to GAPDH, by real-time quantitative PCR (qPCR). The probes were acquired from Gene Expression Taqman Assays : Hs00845692_m1 (CRLF2), and Hs02786624_g1 (GAPDH). Overexpression was determined by means of 2−ΔΔCt method21, and was defined as positive when it was ≥0.1% relative to GAPDH gene expression.One microgram of RNA was retrotranscribed to evaluate the expression levels of EBF1, JAK2, CDKN2A, CDKN2B, PAX5, ETV6, BTG1, RB1, IKZF1/2/3 genes, and genes of the X/Y PAR1 region . The second Kit SALSA MLPA P202 probemix kit contains 59 MLPA probes with amplification products between 118 and 504 nucleotides, which span IKZF1 and CDKN2A-B genes .One hundred ng of DNA was used for MLPA according to manufacturer instructions . Two different kits have been used, one of them SALSA MLPA P335-C1 ALL-IKZF1 probemix kit contains 57 MLPA probes with amplification products between 120 and 504 nucleotides of the main exons of GUSB Taqman probe (Hs00939627_m1) (Thermo Fisher Scientific), discarding cDNA with a Ct>25 at a threshold of 0.1. A barcoded cDNA library was then generated by amplification using Ion AmpliSeq® (Thermo Fisher Scientific) technology to precisely maintain expression levels of the targeted genes. A targeted RNA-Seq customized panel was designed with 38 genes plus 4 housekeeping genes, generating 42 primer pair amplicons. The tested genes were as follows : ABCA9, ARHGEF12, BMPR1B, CA6, CD99, CHN2, CRLF2, DCTN4, DENND3, ECM1, ENAM, GAB1, GBP5, GPR110, IFITM1, IGJ, IL7R, LDB3, MDFIC, MMP28, MUC4, NRXN3, PON2, RBM47, RNF157, S100Z, SEMA6A, SCHIP1, SH2B3, SLC2A5, SLC37A3, SOC2, SPATS2L, TAF5L, TMEM154, TP53INP1, TTYH2, and WNT9A22. The control genes were GUSB, JUN, PBGD, and TBP. Two of the 42 genes (SCHIP1 and IFITM1) were discarded from analysis due to the low number of reads in each of the runs.cDNA was obtained after reverse transcription of 1 µg of RNA. cDNA integrity was checked by qPCR with a GUSB because it was the housekeeping gene with the higher Spearman correlation coefficient (ρ) of the reads between patients within the matrix data, compared to the other three genes. A final analysis was performed using the web-based tool Morpheus (https://software.broadinstitute.org/morpheus/), a matrix visualization and analysis platform, obtaining an unsupervised hierarchical cluster heatmap using one minus Pearson correlation as a metric, and an average of the data as the linkage method. The raw RNA-Seq sequencing data were uploaded to NCBI with BioProject ID: PRJNA613841.The quality of the amplified cDNA libraries was evaluated using Bioanalyzer High Sensitivity chips  and quantified with Ion Library TaqMan™ Quantitation Kits (Thermo Fisher Scientific). Libraries were diluted to 100 pM and pooled equally, assigning 150,000 reads per sample. Pooled libraries were amplified using the Ion Chef System with the Ion 540 Sequencing Kit (Thermo Fisher Scientific). Enriched libraries on a chip were sequenced on the Ion GeneStudio S5 System using the Ion S5 Sequencing Kit (Thermo Fisher Scientific) with 500 flows. The absolute normalized Reads Per Million (RPM) matrix was obtained from RNA-Seq Analysis plug-in (v5.4.0.1) within Torrent Suite software (v5.10) (Thermo Fisher Scientific). The matrix was subsequently normalized intra-patient relative to JAK1, NRAS, XPO1, CXCR4, SF3B1, MYD88, KLHL6, WHSC1, FBXW7, IRF4, IKZF1, CRLF2, BRAF, EZH2, JAK2, CDKN2A, PAX5, NOTCH1, ATM, KRAS, KMT2D, CREBBP, TP53, STAT5B, STAT3, TYK2, and JAK3 genes, and selected exons of RAB39A, CUL5, EXPH5, DLEU1, SAT2, and EFNB3.A total of 33 lymphoid-related genes were sequenced by targeted NGS using an Ion Ampliseq® On Demand panel (Thermo Fisher Scientific), consisting of a custom mixture of oligonucleotides that generated 892 amplicons in two pools, covering 182 kb. The design includes whole exons of 23. The raw DNA-Seq sequencing data were uploaded to NCBI with BioProject ID: PRJNA614523.Libraries were prepared following the Ampliseq® protocol using at least 10 ng of template DNA per reaction. Multiple indexed libraries were pooled and sequenced on the Ion GeneStudio S5 System using Ion S5 Sequencing Kit, with 500 flows. Samples were sequenced to an average 1900× coverage. Alignment and variant detection were performed using Ion Reporter v5.10 using the human reference genome (hg19). Variants were manually reviewed in Integrated Genome Viewer v2.3.81 . Variants were classified as benign, unknown significance, pathogenic or likely pathogenic according to VARSOME software2 test, Fisher’s exact test, or the nonparametric median test as appropriate. Overall survival (OS) was measured from the time of diagnosis to the time of death from any cause. Disease-free survival (DFS) was measured from the date of achievement of the first remission until the date of relapse or death from any cause. Cumulative incidence of relapse (CIR) was calculated from the date of achievement of the first remission until the date of relapse. Patients who died without relapse were counted as a competing risk. Patients not known to have relapsed ordied at last follow-up were censored on the date they were last examined. OS and DFS curves were performed using the Kaplan–Meier estimation, and the log-rank test was used for comparisons between groups. CIR curves were estimated using cumulative incidence rates and were compared by Gray’s test. Two-sided P-values < 0.05 were considered statistically significant. Multivariable analyses were performed using the Cox proportional hazards model for OS and DFS, and the Fine and Gray model for CIR. The statistical package SPSS version 24.0  and R 3.4.2 software were used for all analyses.Baseline characteristics were reported as frequency and percentage for categorical variables and as median and range for quantitative variables. Comparisons of proportions and the medians of variables between different groups were performed using the χBCR-ABL1-like B-ALL, we examined a dataset from patients with B-other ALL (n = 49) by targeted RNA-Seq that, after clustering, grouped a subset of patients with overexpression of CRLF2 and mutations in several genes related to the BCR-ABL1-like signature. Thirteen of these patients (27%) were classified as BCR-ABL1-like based on heatmap clustering, with all equally showing overexpression of ENAM and IGJ. Also, most of the patients with high CRLF2 expression (CRLF2+) were classified into the BCR-ABL1-like ALL subgroup: 11/13 (85%) versus 7/36 (19%) non-BCR-ABL1-like, P < 0.001. Mutations of IKZF1, KRAS, JAK2, CRLF2, NRAS, JAK1, TYK2, and PAX5 genes related to BCR-ABL1-like genotype were present in 7/11 BCR-ABL1-like patients (64%) versus 3/20 non-BCR-ABL1-like patients (15%), P = 0.013. This signature identified BCR-ABL1-like patients who showed significantly shorter DFS probability at 5 years .To identify a specific molecular signature for BCR-ABL1-negative patients  . By contrast, MDFIC was underexpressed in 100% of patients with the BCR-ABL1-like signature (P = 0.001). In addition, this group was enriched inpatients who were CRLF2+ ; and in mutations related to the BCR-ABL1-like signature16 such as JAK2 and RAS, or PAX5 and IKZF1 genes ; and both alterations . Most of the BCR-ABL1-like patients agree on the result of CRLF2 overexpression (17/20: 85%) by both techniques qPCR and RNA-Seq.We next validated the reproducibility of the identified signature by extending the study cohort to 100 Outcome analysis was performed in patients between 15 and 60 years of age treated in PETHEMA trials with intermediate  and high-risk  protocols, in order to ensure homogeneity between treatments. With a median follow up of 3.8 years , the 4- and 8-year OS of the 56 patients with BCP ALL were 58%  and 37% , respectively; the 4- and 8-year DFS were 47%  and 39% , respectively; and the CIR was 45%  for both time points. A summary of the clinical data is shown in Table BCR-ABL1-like in the heatmap .Sixteen of the 56 patients (29%) were classified as BCR-ABL1-like patients in comparison with the remaining patients in the B-other ALL subgroup. However, significant differences were observed in the median percentage of blasts in PB between BCR-ABL1-like and non-BCR-ABL1-like groups , and WBC counts .There were no significant differences in baseline characteristics such as age, gender, ALL phenotype, % BM blasts, cytogenetics, and risk classification in BCR-ABL1-like patients had a tendency for a poorer response to induction treatment than non-BCR-ABL1-like patients . In addition, BCR-ABL1-like patients showed a higher proportion of positive MRD than non-BCR-ABL1-like patients  at the end of induction phase. Interestingly, among patients with postinduction negative MRD (MRD-) (n = 26), BCR-ABL1-like patients (n = 6) had a higher rate of relapse and lower CR duration than non-BCR-ABL1-like patients (n = 20) (P = 0.007)  vs 7/38 (18%), respectively, P = 1.000].Although there were no significant differences in CR achievement, BCR-ABL1-like patients showed poorer OS than the remaining BCP-ALL patients , with a higher frequency of relapses  and the consequent lower DFS  as the main reasonsfor the poorer OS  vs 9/40(22%) non-BCR-ABL1-like patients, P < 0.001]. There were available samples for NGS molecular studies of DNA for 42/56 patients (14/16 BCR-ABL1-like and 24/40 non-BCR-ABL1-like). A total of 57 non-synonymous variants affecting 15 genes were identified among the 42 patients. At least one variant could be identified in 79% (33/42) of the patients, and at least one pathogenic mutation was identified in 57% (24/42). The distribution of the mutated genes is shown in Fig. BCR-ABL1-like ALL patients . The distribution of JAK2 mutations across the protein domains is shown in Fig. Among the 56 B-other ALL patients with clinical data, most of the CRLF2 were found between BCR-ABL1-like and non-BCR-ABL1-like groups (see Supplementary Table P < 0.001), and additional mutations were found in JAK-STAT, RAS, and transcription factors such as IKZF1 or PAX5. Statistically significant differences were found in the rate of JAK/STAT mutations between BCR-ABL1-like patients and the remaining B-other ALL patients , but not for RAS genes or lymphoid transcription factors.Significant differences in overexpression of P = 0.006] . CRLF2+ patients had higher 4- and 8-year CIR than patients with no CRLF2 overexpression  . Although CRLF2+ patients showed lower OS than those without overexpression, the differences were not statistically significant .We found significant differences in DFS for CRLF2 overexpression . However, these differences showed a trend for DFS and were not statistically significant for CIR, in which patients with CDKN2A/B loss had higher relapse incidence in both subgroups individually. By contrast, the prognostic differences on OS and DFS observed for BCR-ABL1-like were not observed within the non-BCR-ABL1-like patients, although non-BCR-ABL1-like patients with CDKN2A/B deletion showed a trend towards higher CIR than those without CDKN2A/B loss (data not shown).As shown in univariable and multivariable analysis  showed poorer OS than those without both deletions (n = 33) . The same scenario was observed for DFS  and CIR .IKZF1 and CDKN2A/B had adifferent prognosis in BCR-ABL1-like and non-BCR-ABL1-like cohorts individually. Again, although the patient numbers were low, we observed that within the BCR-ABL1-like subset, patients harboring both deletions experienced significantly lower probability of survival than those without both alterations , mainly due to a higher relapse rate   Fig. . Within BCR-ABL1-like ALL in a series of homogeneously treated adolescent and adult patients with B-other ALL, and analyze its prognostic impact. We demonstrate the capacity of a simplified targeted RNA-Seq signature to segregate BCR-ABL1-like patients within a BCP-ALL adult population. This approach enabled us to confirm that BCR-ABL1-like is a high-risk ALL subtype also in young, adolescent, and older adults despite treatment with modern MRD-oriented protocols.We sought to identify an RNA-Seq signature for BCR-ABL1-like subtype has been mainly reported in pediatric and adolescent populations, and studies in adult BCP-ALL are scarce16. The DCOG/Erasmus and St Jude groups used different gene profiles to define the BCR-ABL1-like subtype and, consequently, there is a lack of standardization and comparability regarding the best strategy to identify these patients. The frequency (29%) and clinical outcome of BCR-ABL1-like ALL found in this study is in accord with that of the MD Anderson and St. Judereports11: Roberts and coworkers11 characterized 194/798 (24%) patients (age range 21–86 years) as BCR-ABL1-like, and Jain et al.9 identified 49/148 (33%) patients (age range 15–71 years). Regarding IKZF1 deletions, the MD Anderson group classified 73% of patients within the BCR-ABL1-like population as positive, St. Jude reported 81% of IKZF1 losses, and we found 64% of mutated patients. In our study, we identified 75% of patients CRLF2+ and 57% with mutated JAK2, similar to the published results. Indeed, 61% and 51% of CRLF2+ and 45% and 27% of mutated JAK2 have been reported within BCR-ABL1-like patients in the St. Jude and MD Anderson studies, respectively.The prognostic impact of the BCR-ABL1-like ALL subtype in adults homogeneously treated within MRD-oriented trials remains still unclear. In our series, these patients had higher WBC and blast counts than non-BCR-ABL1-like patients, suggesting a greater degree of cell proliferation with a strong capacity for dissemination—an essential characteristic related to a higher degree of clonal heterogeneity and treatment resistance. Interestingly, a high degree of cell cycle deregulation (57% CDKN2A/B deletion) and stem cell-like characteristics as a result of IKZF1 losses (64%) might play an important role in the aggressiveness and resistance seen in the present and other series of BCR-ABL1-like patients. As mentioned, 75% of BCR-ABL1-like patients overexpressed CRLF2 and 64% had mutations in the JAK-STAT pathway , supporting the idea that this is an essential pathway in this aggressive subtype. Most JAK2 mutations identified in the present study were pathogenic and involved the tyrosine-kinase domains 1 and 2, close to the nucleotide binding site for ATP-ADP exchange (residues 855–863), and structurally distant from the self-regulatory tyrosine 1007 and 1008. Currently, several clinical trials are evaluating the efficacy of JAK and mTOR inhibitors (in addition to TKI inhibitors), alone or in combination with other drugs based on this genetic rationale26.The prognostic impact of the IKZF1 and CDKN2A/B deletions are known to be associated with poor prognosis in pediatric and adult B-ALL populations29, mainly in the BCR-ABL1 B-ALL subpopulation. Our results suggest that, despite the low number of cases analyzed, CDKN2A/B deletions are markers of poor survival in B-other ALL, and the association between CDKN2A/B and IKZF1 deletions might also contribute to the dismal prognosis of BCR-ABL1-like. Finally, the survival analysis suggests that all CRLF2+ patients show poor response to standard treatment and bad prognosis whether or not they are BCR-ABL1-like. Unfortunately, we did not have enough samples to evaluate the prognostic significance of additional alterations  in the cohort of 56 B-other ALL patients or within the subgroups of patients with and without CRLF2 overexpression.BCR-ABL1-like patients in our series, the difference in CR achievement between BCR-ABL1-like and non-BCR-ABL1-like patients did not reach statistical significance, although there were four times as many patients not achieving CR in the BCR-ABL1-like subgroup. Taken together with the low MRD clearance at the end of induction seen in BCR-ABL1-like patients (three-quarters of BCR-ABL1-like patients were MRD-positive at the end of induction compared with one-third of non-BCR-ABL1-like patients), this indicates higher treatment resistance. Given the small number of B-other patients (n = 10) MRD-positive at the end of consolidation, we could not evaluate the role of HSCT on BCR-ABL1-like and non-BCR-ABL1-like patients.Due to the limited number of BCR-ABL1-like patients and, more importantly, those who were MRD-negative at the end of induction, suggests that standard treatments are not less efficient for this ALL subtype. Also, while MRD has become the most powerful outcome predictor in ALL, it is not fully predictive, and other factors beyond MRD  also impact patients’ prognosis, especially in the B-other subpopulation.In addition to treatment resistance, the high degree of relapse observed in BCR-ABL1-like signature methodology clearly distinguishes the outcome of patients in whom no recurrent genetic abnormalities could be identified by standard methods. Specifically, loss of CDKN2A/B identifies patients at high risk of disease progression among those with non-available genetic risk categorization. We also provide more detailed information on the prognostic impact of IKZF1 and CDKN2A/B deletions (together and separately), specifically within the BCR-ABL1-like subtype, where they seem to confer poor outcome. By contrast, the prognostic relevance of these alterations in the non-BCR-ABL1-like subgroup is less clear. Due to the paucity of samples, more studies are needed to address these issues.The BCR-ABL1-like is expensive and laborious. The multiple rearrangements present in this subtype and the constellation of other molecular alterations characteristic but not exclusive of this entity make NGS an attractive option, although this requires complex bioinformatic analysis. Interestingly, the approach shown here enables the identification of the BCR-ABL1-like signature by targeted RNA-Seq in 3 days upon sample arrival with a simple and fast NGS library protocol and subsequent sequencing. It is also reproducible, as we have shown in the validation cohort. Finally, a simple computer plug-in will output a normalized matrix that will predict patient outcome in the hierarchical clustering heatmap.Currently, methodical characterization BCR-ABL1-like ALL in BCP-ALL patients. This methodology is inexpensive, available, and feasible, and could be introduced in the routine clinical workout for ALL patients. We have also confirmed the poor prognosis of BCR-ABL1-like ALL in the adult setting. An early diagnosis of BCR-ABL1-like ALL could be critical to initiate appropriate treatment depending on the kinase profile . These results endorse the inclusion of these molecular approaches in further clinical protocols for adopting early clinical decisions with the goal to better manage patients with ALL.In summary, our study demonstrates that targeted RNA-Seq correctly identifies Blood Cancer Journal website.Supplementary information is available at Supplementary Tables S1, S2, S3, and S5Supplementary Table S4Figure S1 and Figure S2


P waveforms to obtain a detailed rupture process of a complex multiple-fault earthquake. We estimate the distribution of potency-rate density tensors on an assumed model plane to clarify rupture evolution processes, including variations of fault geometry. We applied our method to the 23 January 2018 Gulf of Alaska earthquake by representing slip on a projected horizontal model plane at a depth of 33.6 km to fit the distribution of aftershocks occurring within one week of the mainshock. The obtained source model, which successfully explained the complex teleseismic P waveforms, shows that the 2018 earthquake ruptured a conjugate system of N-S and E-W faults. The spatiotemporal rupture evolution indicates irregular rupture behavior involving a multiple-shock sequence, which is likely associated with discontinuities in the fault geometry that originated from E-W sea-floor fracture zones and N-S plate-bending faults.We developed a flexible finite-fault inversion method for teleseismic  MW 7.91) struck offshore Kodiak Island , in the seaward-region of the Alaska-Aleutian subduction zone. The Global Centroid Moment Tensor (GCMT) project3 reported that the 2018 Gulf of Alaska earthquake had strike-slip faulting with a large non-double-couple component (47%). Aftershock seismicity determined by the AEC1 shows a lineation extending about 120 km N-S near the epicenter and two aftershock clusters centered about 60 km northeast and about 50 km west from the epicenter  recorded at stations with epicentral distances of 30–90° (downloaded from the Incorporated Research Institutions for Seismology Data Management Center). Of these, we selected 78 stations, ensuring a high signal-to-noise ratio and an azimuthal coverage26   P wavefo=1 Table .Figure 28. To cover the high point density area of aftershocks within one week of the event1 . The synthetic waveforms from the obtained source model well reproduce the observed waveforms  after about 9 s , started at the hypocenter and propagated bilaterally northward and southward with strike-slip focal mechanisms  started about 50 km northeast of the epicenter at around 7 s after the origin time and propagated west along the Aka FZPhase A3 (16–27 s), started about 40 km northwest of the epicenter, near the 56°N FZ, around 16 s after the origin time  affected segments oriented both N-S and E-W, suggesting that the 2018 Gulf of Alaska earthquake ruptured a conjugate fault system, as proposed in previous studies33, we interpret that this fault step over caused the rupture to stagnate at around 9 and 12 s.A notable irregular rupture propagation highlighted by our inversion results is the northward rupture at around 9 s in phase A1 and the southward rupture at around 12 s in phase A2, both of which stopped near the 56° N FZ  and pre-existing bathymetric features by resolving both the rupture evolution and variation of fault geometry using only teleseismic body waves. Similar observations were made during the MW 8.6 2012 Sumatra earthquake in the Wharton basin. That earthquake involved multiple MW > 8 sub-events along a conjugate fault system39, which developed by deep ductile shear localization beneath the brittle upper lithosphere of the oceanic plate40.Multiple sub-events occurring in a conjugate strike-slip fault system have been reported in previous studies12 (Fig. We evaluated how the newly developed method improved the source model of the 2018 Gulf of Alaska earthquake by performing the inversion analysis with the conventional smoothness constraints12 Fig. . The inv12 Fig. . Howeverake Fig. , which pake Fig.  and S7.44. We evaluated this possibility by using empirical Green’s functions46 and confirm that it is unlikely that the multiple rupture stages originated from such reverberations (see Supplementary Material It is possible that the complex waveforms observed during the 2018 Gulf of Alaska earthquake were contaminated by reverberations due to the bathymetric setting that cannot be reproduced by the theoretical Green’s function, resulting in dummy multiple events47. Although it is difficult to distinguish whether such early near- to intermediate-field aftershocks were dynamically or statically triggered47, it is noteworthy that the rupture propagated from A1 to A2 at more than 5 km/s (see Supplementary Material The sub-events that occurred after the main A1 phase can be regarded as early aftershocks missing from global catalogsP waveforms with improved smoothness constraints to obtain source processes for earthquakes with complex multiple-fault ruptures. We applied our inversion method to the 2018 Gulf of Alaska earthquake and estimated its spatiotemporal rupture process. Although the observed waveforms are very complicated, reflecting the complex rupture process and fault geometry, the waveforms calculated from our source model fit well. The obtained source model suggests a complex multiple-shock sequence on a conjugate fault system, consistent with pre-existing bathymetric features. Irregular rupture stagnation about 20 km north of the epicenter may have been promoted by a fault step across a sea-floor fracture zone.We developed a finite-fault inversion method for teleseismic Supplementary information.


Realtors match home-seekers with neighborhoods that have built and social characteristics they desire to pursue active lifestyles. Studies have yet to explore realtors’ perspectives on neighborhood design that supports active living. Using qualitative description, our study was to explore the perceptions and understandings of neighborhood design  among urban residential realtors. Nineteen  self-identified residential realtors from Calgary, Edmonton, and Lethbridge (Canada) completed semi-structured telephone interviews. Content analysis identified themes from the interview data. Specifically, walkability was described as: perceived preferences, destinations and amenities, and connections; a healthy community was described as: encourages outdoor activities, and promotes social homogeneity; bike-ability was described as: bike-ability attributes, and was controversial; vibrancy was described as: community feel, and evidence of life; and livability was described as: subjective, and preferences and necessities. Our findings can inform the refinement of universal definitions and concepts used to in neighborhood urban design. There is growing interest in the role that neighborhood environments have in supporting active living and health ,2. The eHome-seekers (buyers and renters) demand certain neighborhood characteristics, and land developers supply neighborhoods with particular built characteristics, however it is realtors who are vital in matching home-seekers with their desired neighborhoods. In the U.S., 89% of buyers purchase their home through a realtor ,11. ThusThe underlying reasons for relocating to a new neighborhood are complex and numerous, but often relate to housing characteristics such as affordability and size . NeverthThere is a lack of consensus in the terminology and definitions used among stakeholders when describing neighborhood characteristics related to health and active living ,23. ThusQualitative description, as described by Sandelowski , was thehttps://www.albertarealtor.ca/), there are over 10,500 licensed realtors in the province of Alberta. Recruitment materials were also distributed to realtors via several Real Estate Agencies located within the three cities. Interested participants contacted the research coordinator who screened them for eligibility  and scheduled eligible participants for a telephone interview. Using snowball sampling , but you couldn’t walk to a store. So… it just depends what people mean by walkability, I guess”.Given the subjectivity of the term, Angela described the importance of asking home-seekers questions about walkability. She said, “If I am talking to clients I will get into what walkability means to them… Do you like to go for a walk, or walk to amenities in any season?” Recognizing that walkability means different things to different people, Franny argued that there is a need for consistent messaging around the term. She said, “I have seen it [the term walkability] in a lot of contexts, and it is not necessarily very consistent for the consumer. If the term was used with a very clear point A to point B, I think the message would be clearer to consumers”.Realtors described how access to various services and amenities contributes to neighborhood walkability. For instance, access to stores, restaurants, transit, and parks or greenspace were described as key features of walkability. Participants also described how safety and aesthetics are important to consider within the context of access to services and amenities. Angela’s description of walkability serves a detailed example of the importance of access to services and amenities: “I would say the ability to walk to several different amenities within a community. So not just walking paths, but being able to walk to a grocery store, not just a corner store, but drug stores, restaurant, pubs, schools, transit. In addition to having some nice streetscapes, parks, or areas like that to walk around… I think with walkability there are a lot of factors, but I think it does have to have the 5 main things: grocery stores, transit, restaurants, shops, and parks that kind of public spaces. I think it is really important”. Similarly, Debbie echoed this sentiment in her description of walkability: “A walkable neighborhood is just minutes to where you are going to take your children to school, to dentist, to doctors, to community activities. If you are in the inner city and you do not have access to a vehicle it is really important for work”.While some realtors described walkability in detail, others were succinct. For instance, Kristen described walkability as “the access that someone has to services within a neighborhood by simply walking”. Similarly, Gina explained how walkability means that people have access to amenities, pathways, and transit opportunities. Gina also suggested that the term “accessibility” might be a more useful term because “walkability comes with the assumption that you can walk”.Within the context of access to services and amenities, LeAnne also explained how safety is a key feature of neighborhood walkability. She explained: “Walkability in my mind would be a location that is safe, developed, or close to green spaces. Generally, something that is inviting for your health and your sense of community. I would expect it to be something with trees, and shops, and a welcoming feel”. Safety of pathways was also mentioned by various realtors. As LeAnne explained, “when I mention walkability to my clients, there is an element of safety”. Safety was discussed in terms of well-lit pathways and neighborhoods at night, cleared pathways in the wintertime, and smooth and continuous routes.The realtors suggested that connection, including both physical and social connections, are an important feature of walkability. In terms of physical connections, Keith explained that a walkable neighborhood means that “there are great pathways, shared use pathways, very clear and numerous pathways for pedestrians and cyclists connecting streets through green strips and parks leading you out to different service areas and different facilities”. Additionally, Shannon and Michelle suggested that such physical connections support necessary transit options. Shannon indicated that for neighborhoods to be walkable, they need to facilitate the ability to get to a destination “via public transit, as it could take care of any other leg of the journey you might need” when not on foot. Similarly, Michelle explained that “transit would go hand in hand with walkability”.In addition to the physical connections, social connections were also described as a key feature of a walkable neighborhood. For instance, walkable neighborhoods encouraged a sense of community. As Rob suggested, “the more that you get out and about the more that you’ll chat with neighbors and foster a sense of community in the neighborhood”. Similarly, LeAnne explained how a neighborhood that has low walkability would be “empty of personality” because the neighborhood would be void of people walking around and there would be “no participation in the neighborhood”.The term healthy, within the context of neighborhoods, was difficult for the realtors to describe. They suggested that the term healthy was not typically used when referring to neighborhoods, but used more often in describing a house or property. As Lana stated, “I don’t think they [real estate professionals] would use the word healthy, but they might advertise a lifestyle”. Despite the challenges in describing the term, participants’ shared experiences suggest that a healthy neighborhood: (a) encourages outdoor activities, and (b) promotes neighborhood social homogeneity.When referring to a healthy neighborhood, the realtors emphasized the health benefits of being able to walk or bike to local services and amenities. They argued that healthy neighborhoods have accessible amenities and aesthetic and appealing features. Beviel said, “I would think one that has a lot of vegetation. Trees and plants. Because that helps the environment, but it also helps people both aesthetically and with how they perceive it affects their lifestyle”. Several realtors discussed the condition of neighborhood parking as a deterrent of health. As Shannon suggested, “healthy to me would be making sure that we don’t have over-parked streets”. She argued that having too much traffic in a “tighter neighborhood” is not healthy.When asked about what constitutes a healthy neighborhood, Rob stated, “the first thing that comes to mind for me, does the neighborhood design encourage people to be outside on a regular basis? Going for walks, biking, being outdoors”. Similarly, Wayne explained: “A healthy community is the pathways are accessible. Walking to a neighborhood pub, park, coffee shop… it’s accessible. The areas that people want to go to are accessible by bicycle. A neighborhood that encourages people to get out and move, by bike or walking, to amenities in their community rather than driving. For a community to be healthy it needs to be accessible and planned properly… older areas are limited to what they can do to get that to a higher level of healthy”. Keith shared similar sentiments to Wayne, but Keith also highlighted the importance of safety. He said, “You have to feel safe, be inviting. It’s going to attract you and motivate you to get out and move and go for a walk. I guess a part of health is feeling safe as well”.Realtors provided numerous examples to suggest that neighborhood social homogeneity is a key feature of a healthy neighborhood. As Beviel suggested, “I think a healthy neighborhood would have conveniences that are fairly close, and similar houses… You don’t want to have a $200,000 home next to a $600,000 house. [Our city] has tried that, and it just doesn’t work. So, if you have a grouping of say $250,000 houses, most of the people who are buying in that area are in a like frame of lifestyle. They might have families; they might have pets. Whereas people, perhaps my age… I don’t want to be living by a bunch of screaming kids (laughs)”. Tabitha argued that she does indeed appreciate when houses are not all of the same design within a community but, similar to Beviel, she said, “I don’t think you should have a house worth $300,000 and a house worth $800,000 on the same street. Maybe a $100,000 to $200,000 spread but not an $800,000 spread”.When describing healthy neighborhoods, Keith explained how he tries to describe the overall “condition of the neighborhood”. He explained, “Nobody really says, ‘I want to live in a healthy neighborhood’. But if we are talking about the attributes, we might talk about neighborhoods that are, or homes that are, clean and well kept. There is a sense of pride of ownership in neighborhoods, uncluttered. That all speaks to a sense of healthiness. So, I guess on that front we, in a roundabout way, talk about healthy neighborhoods with just about every buyer or client that we sit down with”. Mary further elaborated by suggesting that the condition or health of a neighborhood can be compromised when there are rental properties or multi-family homes. In describing what constitutes a healthy neighborhood she said, “When properties all conform to the same ideals and you know that even if there is a vacant lot beside you, which sometimes there is, the likelihood of a duplex or a multifamily being built on that lot next to you is slim to none. Because that is important as well, because people that spend good money for a nice home do not want a rental property next to them”.The realtors described how bike-ability is very similar to walkability. When describing bike-ability Keith asked if it was “similar to walkability but are there cycling or multi-use paths that help a cyclist move with, or through, traffic with a sense of purpose or direction?” Specifically, bike-ability was described by participants as: (a) bike-ability attributes, and (b) controversial.Bike paths and multi-use trails were key features that the realtors described as necessary for a neighborhood to be bike-able. For example, Beviel suggested: “I think it has to do with designated pathways for bikers, and places they can be parked if you are going somewhere on a bike. For instance, bike stands in locations. But mostly I believe it is having the road work and the plan, so bikes can maneuver around the city”. Similarly, Rob explained how a bike-able neighborhood would have a “paved trail system nearby, with access to the neighborhood. Close enough proximity so you can bike to amenities maybe connecting other neighborhoods as well”. In describing how she refers to bike-ability with home-seekers, Debbie explained how “we talk about it for recreational purposes, for exercise. They want to be able to go out for a ride”. Realtors also acknowledged that some people want a bike-able neighborhood for more than just exercise. As stated by Angela, “I have a lot of friends that are into cycling and they love the coffee shops that are popping up for people on bikes to stop and hang out and have a coffee”.Realtors described how promoting a neighborhood as bike-able is sometimes controversial. For instance, participants voiced how some home-seekers are frustrated about the infrastructure that supports biking. For example, Tamera shared: “Our bike lanes here are fairly new and extremely controversial… there is less parking now and maybe a few more minutes added to a commute because of light and traffic changes. We have lost two traffic lanes and several parking spots. There is also that you have to look for bikers when turning right. So, it adds a few minutes and is a little bit annoying. But in my opinion, it is for the better. But it is something that is discussed often”.Taking a similar stance, Chris said “I’m not a big fan of losing a lane for a bike lane, but I think it is important to feel safe so you can cycle”.Overall, a vibrant neighborhood was described using adjectives such as active, interesting, and new. Young first-time and senior home-seekers were said to be the most interested in living in vibrant communities. Although participants acknowledged that the concept of vibrancy might be somewhat subjective, their shared experiences suggest that vibrancy includes: (a) community feel, and (b) evidence of life.In terms of the feel of a community, Rob explained, “I guess with vibrant, they [houses] are generally quite new. I look at my neighborhood and some of the houses are getting old so that would be the number one reason I would describe it as not vibrant, just because it is not up and coming”. Similarly, Tamara described neighborhood vibrancy as “the look, the flow, and the feel of a community. It is brand new, with that new modern style; the look of the building catches your eye. It pops”.Lana shared Tamara’s sentiments that a vibrancy suggests a new community but also noted the preference of vibrant communities among younger adults: “They will say it is a vibrant new neighborhood… it’s typically marketed towards younger families as being something that is exciting, something that young people can get their teeth into… y’ know, even condominiums will sometimes use that in new neighborhoods… Saying that it’s a really vibrant community, it has a lot of amenities and things for them to do”. Similarly, Devon said that a “higher vibrancy might mean more younger people, more educated professionals. I also think about is it close to bars and nightlife? Those are the two things that come to mind in terms of vibrancy”.Although some of the participants explained that vibrant neighborhoods typically consist of “younger” people, Tamera argued that this is not always the case. In working with seniors, Tamera explained, “Especially those who don’t feel like they are ready to settle down yet but are looking to downsize… They don’t want to be in an old folk’s community because they want more young things to do. Even if there are seniors’ leagues, like bridge I don’t think that would be vibrancy per se… vibrant would be more like clubs, community, or social events”. While not referring specifically to a target population, Shannon did acknowledge that a vibrant neighborhood is one in which there is “lots to do”. She said, “vibrancy is being able to pop out of your home and be able to get to a nice little restaurant”.Participants described vibrant neighborhoods as those that have numerous amenities and services, and those that have “evidence of life”. They explained how services, amenities, and design features comprise a vibrant community. As stated by Franny, it is the “proximity to different types of amenities that kind of brings the community to life”. Franny further explained that the concept of vibrancy is quite ambiguous, however she provided examples of what constitutes a vibrant community. She said, “Although the word vibrancy specifically, would lend more to the faster paced side but I guess it would depend on the context of the person writing the ad. This one [the term vibrancy] has more ambiguity; it is more arbitrary. It is too subjective. More of an adjective than a term to rate the community. It is an advertisement word. It is the tourism of the community. That is what I would define it as. The opportunity for livelihood. Amenities that foster livelihood in the community”. Beviel shared similar sentiments to Franny. However, while Beviel did not highlight the ambiguous nature of vibrancy, she explained how vibrancy is related to the “life” of a community: “Many older areas just have rows and rows of streets. There is no life to it, there is no reason for people to be out of their homes and associating outside. So, it just seems it is just houses. Whereas if you have a community that is designed where there are parks, places for people to go and perhaps picnic outside. There is more life that seems to be going on, and people are spending time in a community”.While some participants were focused on the specific amenities and services that contribute to vibrancy, others focused more on the design features of a community. As Keith explained, “To me when you say that I think of neighborhoods that have visually attractive features. I think architecture… When I think of vibrancy, I think of going through a neighborhood and seeing people enjoying the neighborhood and features—out there doing activities. Evidence of life”. While Keith’s initial description of vibrancy was focused on the attractiveness of a neighborhood, he also explained how vibrant communities have “lots of community events, lots of events that engage the community. Vibrancy… that’s the first thing that comes to mind. Different events, community events, festivals. That kind of thing”. Expanding on this, LeAnne suggested that “what creates vibrancy is people’s awareness of what it is going on in a community. Y’know people are aware of events that they can go to and participate in. It is what brings people out”. Similarly, Franny suggested that a vibrant neighborhood “promotes interaction between residents like a lake or a restaurant. That the community only consists of residents would be non-vibrant not close to anything”.Realtors suggested that the concept of livability is an all-encompassing term, which includes walkability, bike-ability, vibrancy, and healthy. When asked about livability, many participants did not have much to say because they felt that this concept was covered by discussion of the other concepts, although some realtors did suggest that that concept of livability was linked with the age or life-stage of the home-seeker. Beviel states, “I would think that it incorporates all the things that we have talked about. If it’s a livable neighborhood you have all of those amenities you have a combination of everything it makes it more enjoyable to live there”. Wayne further expanded by saying: “I think that the problem here is that we have already covered this”. Despite the participants’ acknowledgement that livability was discussed within the context of the other concepts, participants described livability as: (a) subjective, and (b) preferences and necessities.Livability is a concept that realtors described as subjective, and that typically depends on a person’s stage of life. As Keith stated, “Livable is relative to where you are in your life. I am speaking from a midlife more established perspective and less congestion is more livable…the definition changes as you go through the life cycles”. Michelle shared similar sentiments: “All of my clients would define this [livability] differently. Livability for some young people would be close to a bar, livable for some older people would be close to an amenity where they can make new friends like a movie theatre or library. Like I said, in my late 30s I want green space or park space for my children. I don’t think that I have one way of defining it that is right or overarching”. Recognizing that livability is a concept rather than just a word, Beviel said, “I think it is more of a concept rather than what some people… y’know when they walk into a neighborhood they say ‘this is nice, I like it here’ but they don’t say the term livable. So, it’s more of a concept in your head. Again, a lot of it depends on age, lifestyle, things that people do for hobbies… all of that is wrapped up into it, whether they think a neighborhood is livable or not”.When describing the term livability, realtors provided numerous examples to suggest that the concept comprises preferences and necessities. Notably, some realtors viewed livability as what some scholars might describe as the “habitability”  of the nOur study explored realtor perspectives on concepts commonly used in public health, urban design, transportation planning, and geography to describe neighborhood design associated with active living. Among realtors, multiple themes emerged for the neighborhood design concepts of walkability , healthy , bike-ability , vibrancy , and livability . Our findings, which are grounded in the experiences of the participants, highlight important considerations for developing consistent definitions and awareness of concepts among realtors to ensure home-seekers are matched with neighborhoods that support their preference for an active lifestyle.Among realtors there was general agreement in the meaning and understanding of concepts related to the neighborhood environment. Despite realtors reporting they did not often use terms such as walkability, bike-ability, healthy, vibrancy, and livability when communicating with home-seekers, they did identify specific neighborhood built and social characteristics that support physical activity, sense of community, and health of residents. For instance, the realtors identified proximity to services and amenities, availability of greenspace and parks, availability of transit, and safety (lighting and cleared paths) as important built characteristics contributing to neighborhood walkability. These built characteristics were similar to those identified by Edmonton residents as contributing to walkability  . Realtor®, Transit Score®, and Bike Score®, respectively) are available to North American realtors via real estate websites . The extent to which realtors use these metrics when communicating with home-seekers remains unknown.Realtor perspectives on the built characteristics that contribute to walkability and bike-ability align with those characteristics found to be supportive of walking and cycling in previous studies ,48,49,50Relative to the other concepts, healthy, vibrancy, and livability took on more abstract meanings for realtors. Realtors noted that the concepts of healthy and livability reflect a neighborhood’s propensity to allow residents to achieve a self-determined lifestyle. Healthy neighborhoods were considered to be those with built characteristics that encouraged walking and cycling and other outdoor activity, and those with trees and vegetation, low traffic, and maintained homes. Several reviews report associations between neighborhood built characteristics and health outcomes including chronic disease and quality of life ,47,53,54Like healthy and livability, realtors associated vibrancy with the social characteristics of a neighborhood. They noted that more vibrant neighborhoods seemed to have newer homes with younger and highly educated residents. Vibrant neighborhoods included those that had clubs and community events, where residents were happy and enjoying activities in and around the neighborhood. Vibrancy was related to local amenities, because they facilitated socializing. Realtors’ perspectives on vibrant neighborhoods having a community feel and demonstrating evidence of life is congruent with traditional notions of neighborhood or urban vibrancy which reflects levels of street life, intensity of activity, and concentrations of people, facilitated by higher densities and a mix of local amenities and services ,60. LikeOur study has several limitations. Realtors self-selected to participate in the study, and therefore our findings may reflect the perspectives of those with the strongest opinions on the study topic. Our sample included urban realtors from three major cities in a western Canadian province, and therefore the perspectives of realtors in our study may not be transferrable to rural areas or other countries. For instance, walkability, bike-ability, healthy, vibrancy, and livability may have different meanings for realtors (and home-seekers) in different cities because of differences in urban designs, norms , and health behaviors . Moreover, the terminology used in our study may not be universal to all populations or contexts. Our interview questions focused on walkability, healthy, bike-ability, vibrancy, and livability, however other concepts and terminology exist for describing neighborhood design in relation to active living  that might be used more frequently used among realtors and their clients. Due to our geographically dispersed population and the nature of our interview questions, we used telephone-administered semi-structured interviews. Although outside the scope of our study, focus groups might be a useful qualitative approach for identifying and developing common terminology and concepts related to neighborhoods among groups of realtors.Our findings suggest that realtors consider built and social environmental characteristics important for creating walkable, bike-able, healthy, vibrant, and livable neighborhoods, but the nature of these characteristics might differ depending on home-seeker sociodemographic characteristics and stage of life. Our findings also suggest that realtors do attempt to match home-seekers with their desired neighborhoods, including home-seekers wanting to reside in walkable, bike-able, healthy, vibrant, and livable neighborhoods, however, realtor biases regarding home-seeker sociodemographic characteristics  and the belief that neighborhood social homogeneity is an indicator of a healthy neighborhood has the potential to undermine the matching of home-seekers with neighborhoods that support active living. Future studies should explore how realtor perspectives on neighborhood characteristics inform neighborhood choice decisions among home-seekers and in turn how these decisions affect home-seeker health. Future studies with home-seekers might provide interesting and complementary insights into how this group perceives walkable, bike-able, healthy, vibrant, and livable neighborhoods, perceived influence of realtors, and how these perspectives contribute to their neighborhood choice decision-making. Our findings contribute knowledge that can inform the development of universal definitions and understanding of terminology and concepts used to describe neighborhood urban design among stakeholders, including realtors and home-seekers.