AURKA gene promoter and negatively regulates its transcription. Cells lacking ARID1A show enhanced AURKA transcription, which leads to the persistent activation of CDC25C, a key protein for G2/M transition and mitotic entry. Inhibiting AURKA activity in ARID1A-deficient cells significantly increases G2/M arrest and induces cellular multinucleation and apoptosis. This study shows a novel synthetic lethality interaction between ARID1A and AURKA and indicates that pharmacologically inhibiting the AURKA–CDC25C axis represents a novel strategy for treating CRC with ARID1A loss-of-function mutations.ARID1A, a component of the SWI/SNF chromatin remodeling complex, is a tumor suppressor with a high frequency of inactivating mutations in many cancers. Therefore, ARID1A deficiency has been exploited therapeutically for treating cancer. Here we show that ARID1A has a synthetic lethal interaction with aurora kinase A (AURKA) in colorectal cancer (CRC) cells. Pharmacological and genetic perturbations of AURKA selectively inhibit the growth of ARID1A-deficient CRC cells. Mechanistically, ARID1A occupies the  ARID1A is highly inactivated in cancer. Here, the authors show that ARID1A has a synthetic lethal interaction with AURKA in colorectal cancer cells and that ARID1A deficiency activates the AURKA target CDC25C, whose inhibitors also cause cell death in the ARID1A-deficient cell lines. This complex exists as two major forms, BRG1-associated factor (BAF) and polybromo BAF2. Each complex contains 8–15 subunits, and many subunits have multiple isoforms. Mutations in these subunits lead to the aberrant control of lineage-specific differentiation and gene expression/repression, thereby contributing to tumorigenesis; these mutations have been observed in a number of cancer types1. AT-rich interactive domain 1A (ARID1A), a component of the BAF complex, has been identified by next-generation sequencing as one of the most frequently mutated genes in a variety of cancers, including ovarian clear cell carcinoma (OCCC)3, gastric cancer4, hepatocellular carcinoma5, esophageal adenocarcinoma6, breast cancer7, pancreatic cancer8 and colorectal cancer (CRC)9. In addition, loss of ARID1A expression has also been observed in different cancer types, such as uterine endometrioid carcinoma10 and renal cancer11. Genome-wide sequencing analyses of tumor samples revealed that 46–57% of OCCC cases harbored loss-of-function mutations in the ARID1A gene, implying the significant contribution of aberrant ARID1A functions to OCCC pathogenesis12. In CRC patients, a mutation frequency of approximately 10% was observed for the ARID1A gene13. However, clinico-pathological analyses of ARID1A protein levels in CRC tumor samples showed that 25.8% of CRC primary tumors did not express ARID1A, and 51.2% had low expression levels of ARID1A 14. The loss of ARID1A expression became even more significant as the tumor–node–metastasis (TNM) stage advanced. ARID1A loss was observed for 7.4% of TNM stage I samples, 24.1% of TNM stage II samples, 22.2% of TNM stage III samples, and 46.3% of TNM stage IV samples14. These data suggest that ARID1A loss in CRC is strongly associated with tumor progression and metastasis.The SWI/SNF chromatin remodeling complex remodels nucleosomes and modulates transcription in an ATP-dependent manner15. Recent studies have shown that ARID1A has a synthetic lethality interaction with genes involved in some epigenetic machinery, including EZH216, poly ADP-ribose polymerase 1 (PARP1)17, ATR18, and histone deacetylase 6 (HDAC6)19. Inhibiting the synthetic lethality targets resulted in selective vulnerabilities in ARID1A mutant OCCC, CRC, and breast cancer cells19. These studies suggested that ARID1A, as an epigenetic machinery component, may have various genetic and functional interdependencies with other epigenetic components to affect cell survival. Based on this notion, we initiated a systematic screening for druggable targets among human epigenetic machinery using an ARID1A isogenic CRC pair and epigenetics drug library. Among the epigenetics drugs screened, aurora kinase A (AURKA) inhibitors composed the majority of the synthetic lethality hits.Since the discovery of the high frequency of mutations and loss of expression of ARID1A in cancer, ARID1A deficiency has been exploited therapeutically for treating cancer according to an approach called synthetic lethality. Synthetic lethality is a genetic interaction between two or more genes where a single gene deficiency does not affect cell viability, but the combination of both gene deficiencies causes lethality. This concept has been widely exploited in cancer therapy because many types of cancer have loss-of-function mutations in tumor-suppressor genes that are not readily targetable. The pharmacological or genetic disruption of a synthetic lethality target of a tumor suppressor will cause selective lethality in the cancer cells that harbor the tumor-suppressor mutations22. During mitosis, AURKA phosphorylates several substrates, including polo-like kinase 1 (PLK1), to promote entry into mitosis at the G2/M phase by activating the nuclear localization of cell division cycle 25C (CDC25C)24. AURKA overexpression has been implicated in genetic instability and tumorigenesis25, which are observed in many cancers, including leukemia26, ovarian27, lung28, pancreas29, liver30, and CRC31. High AURKA expression has been associated with poor overall survival in patients with metastatic CRC32 and non-small cell lung cancer33, suggesting that it is an important therapeutic target for developing anticancer drugs.AURKA, also known as serine/threonine protein kinase 6, is a member of the mitotic serine/threonine kinase family, which has multiple functions in mitosis and non-mitotic biological processesIn this study, we show that AURKA inhibition causes selective vulnerability in CRC cells lacking ARID1A. We further explore a mechanism whereby the ARID1A and AURKA pathways converge on CDC25C to induce G2/M arrest and apoptosis in CRC cells.ARID1A isogenic CRC pairs using a clustered regularly interspaced short palindromic repeats (CRISPR)/Cas9-mediated gene knockout (KO). The use of ARID1A isogenic cell pairs will ensure that the synthetic lethality identified is dependent on the ARID1A status rather than other cellular factors. HCT116 CRC cells carrying wild-type ARID1A (ARID1A+/+) were transfected with a Cas-9 plasmid, single guide RNAs (sgRNAs) targeting the ARID1A gene and HDR (homology-directed repair) donor plasmids containing puromycin-resistant and red fluorescence protein (RFP) genes -mediated indel mutation in the other)   , a histone demethyltransferase inhibitor (GSK J4), a PARP inhibitor (PJ34), and a histone methyltransferase inhibitor (BIX 01294)  Fig. . Among t–3) Fig. , ARID1A−ls) Fig. . From tw94) Fig. . Since tlls Fig. . We alsoors Fig. . The EZHors Fig. , even wiors Fig. . This efors Fig. ; alternaARID1A isogenic cells treated with AURKAi. AURKAi treatment had negligible effects on ARID1A wild-type cells but markedly increased nuclear condensation and fragmentation, which are typical signs of apoptotic cell death, in all three ARID1A−/− clones  into the ARID1A isogenic cell pair, and cell viability was assessed. Similar to what was seen with AURKAi treatment, silencing AURKA with siRNA selectively inhibited viability in ARID1A−/− cells  injection, and the tumor volumes were measured periodically 38, it is important to test whether the synthetic lethality of AURKAi is also effective in cells with heterozygous mutations. Since we failed to isolate ARID1A+/− clones from the HCT116 ARID1A KO study, we knocked out ARID1A in SW480 cells, an ARID1A+/+ CRC cell line. Through CRISPR/Cas-9 gene editing, we successfully generated both homozygous (ARID1A−/−) and heterozygous (ARID1A+/−) KO clones from SW480 cells  analysis showed that all three of the HCT116 ARID1A−/− clones exhibited a significant increase in AURKA mRNA levels  assays of the AURKA promoter using specific antibodies against ARID1A and RNA polymerase II (RNA-Pol II) and a primer pair that targets the transcription start site (TSS) of the AURKA gene  and SNF5 (SMARCB1), in ARID1A+/+ and ARID1A−/− HCT116 cells. As shown by the ChIP results, the two core components were indeed recruited to the AURKA promoter in ARID1A+/+ cells but not in ARID1A−/− cells  domain and plays a crucial role in targeting the complex to gene promoters44. By changing the position of nucleosomes, ARID1A and the SWI/SNF complex are capable of activating or repressing the transcription of hundreds of target genes51, including p21 (CDKN1A)52, SMAD352, thrombospondin 1 (THBS1)44, and telomerase reverse transcriptase (TERT)53. HDAC6 has recently been identified as a target gene of ARID1A for transcription repression in OCCC; in fact, OCCC cells with ARID1A loss were shown to be sensitized to HDAC6 inhibition19.The SWI/SNF chromatin remodeling complex mediates diverse biological pathways by epigenetically regulating gene expressionAURKA is a target gene of ARID1A for transcription repression, and it interacts functionally with ARID1A in a synthetic lethal manner in CRC cells. Small-molecule inhibitors or siRNA silencing of AURKA caused strong synthetic lethality in ARID1A-deficient CRC cells. The synthetic lethality of ARID1A and AURKA was verified in three different ARID1A isogenic CRC pairs and three ovarian cancer cell lines with different ARID1A statuses; however, the synthetic lethality in ovarian cancer cells needs to be further investigated. Phenotypically, the inhibition of AURKA induced cellular G2/M arrest in both ARID1A+/+ and ARID1A−/− cells, but it generated considerable multinucleated ARID1A−/− cells, leading to the preferential induction of apoptosis. This phenotype is in agreement with previous observations that AURKA inhibition significantly delayed the cell cycle at the G2/M phase, followed by the induction of endoreduplication, aneuploidy, and apoptosis, depending on the cell type55. ARID1A is known to interact with ATR and contribute to cellular DNA damage repair and G2/M checkpoint activity17. The lack of ARID1A activity allows cells with DNA damage to pass through the G2/M checkpoint, which potentially causes genomic instability17. AURKA inhibition impairs the spindle assembly checkpoint and induces abnormal chromatin segregation to cause chromosomal instability55. The combination of ARID1A deficiency and AURKA inhibition could cause severe genomic and chromosomal abnormalities, which are intolerable to cells and lead to apoptosis.In the present study, we show that AURKA transcription, making the cells addicted to AURKA signaling for their growth and survival. Cellular oncogene addiction due to high AURKA expression was evidenced by the persistent activation of CDC25C, a downstream effector of AURKA, in ARID1A−/− cells; in these cells, the pharmacological or genetic perturbation of AURKA was able to reverse the CDC25C activation. Inhibiting PLK1, a direct upstream target of CDC25C, or CDC25C itself recapitulated the synthetic lethality phenotype in ARID1A-deficient cells, further supporting the idea that the AURKA–PLK1–CDC25C axis is a key pathway activated in ARID1A-deficient CRC and that it could serve as a therapeutic target. CDC25C is also downstream of the DNA damage repair pathway in which ATR-activated checkpoint kinase 1 (CHK1) phosphorylates and inhibits CDC25C activity56. Cells lacking ARID1A exhibited impaired ATR and CHK1 activation upon DNA damage17. Therefore, ARID1A loss could also contribute to the persistent activation of CDC25C through inactivating the ATR/CHK pathway. Therefore, it can be postulated that ARID1A-deficient cells have persistent CDC25C activation through AURKA-mediated signal activation and the lack of ATR/CHK-mediated inhibitory signaling  cells that harbor inactivation mutations in BRG1, another SWI/SNF component protein. However, it is unclear whether each component of the SWI/SNF complex causes the synthetic lethality independently or whether they work as a complex. Our ChIP analysis of the AURKA promoter with antibodies against the two core components in ARID1A+/+ and ARID1A−/− cells demonstrated that SNF5 and BRG1 targeting to the AURKA promoter is dependent on ARID1A. ARID1A contains a DNA-binding (ARID) domain and is known to play a key role in targeting the complex to the target gene promoter44. On the other hand, SNF5 is essential for the formation of the SWI/SNF complex59, and BRG1 provides energy derived from ATP hydrolysis to the complex for the nucleosome remodeling activity60. Given the essentiality of the three components in nucleosome remodeling and the transcription regulation functions of the SWI/SNF complex, it is apparent that the entire SWI/SNF complex has a synthetic lethality interaction with AURKA in tumor cells in which mutations in the key components of the SWI/SNF complex causes the induced essentiality or the oncogene addiction of AURKA for cell survival. The observed synthetic lethality in CRC and ovarian cancer models, together with the reported synthetic lethality interactions between other SWI/SNF components and AURKA in rhabdoid tumors and NSCLC models, clearly indicate the potentially broad relevance of our findings to other cancer types where defective SWI/SNF components exist. Indeed, at least five components of the SWI/SNF complex, including SNF5, BAF180, ARID1A, BRG1, and BRD7, have been reported to be frequently mutated in a variety of tu~mor types, such as familial schwannomatosis (30–40% mutation frequency in SNF5), small-cell hepatoblastomas (36% mutation frequency in SNF5), epitheliod sarcomas (55% mutation frequency in SNF5), renal cell carcinoma (41% mutation frequency in BAF180), endometriod carcinoma (35% mutation frequency in ARID1A), and medulloblastoma (3% mutation frequency in ARID1A and BRG1), in addition to CRC, NSCLC, ovarian, and rhabdoid tumors (reviewed by Wilson and Roberts)1.Our findings are further strengthened by recent two reports showing that two other components of the SWI/SNF complex are involved in the downregulation of AURKA expression and cancer cell sensitivity to AURKA inhibitors. Lee et al.61 and a PIK3CA hotspot mutation (H1047R)35. Since EZH2-ARID1A synthetic lethality is mediated by PIK3IP1, which is an endogenous inhibitor of PIK3CA, the PIK3CA activating mutation in HCT116 cells may be another possible contributor to the synthetic lethality of the EZH2 inhibitor, in addition to the lack of PIK3IP1 expression regulation by ARID1A in this model. The BRG1 mutation (L1149P) in HCT116 cells has been well characterized previously62. This mutation does not affect SWI/SNF complex formation, and the BRG1 mutant complexes remain functional in the presence of BRM, another SWI/SNF component that is homologous and partially redundant to BRG162. Based on the findings of our group and others, BRG1 mutations in HCT116 cells do not affect the synthetic lethality interaction of ARID1A and AURKA or other known targets, including PARP117 and ATR18. However, the BRM compensation for BRG1 deficiency may occur in a gene-specific manner as they have different promoter preferences63. Therefore, it cannot be ruled out that BRG1 mutations could potentially affect the synthetic lethality interaction of ARID1A and other targets in the HCT116 model.The HCT116 CRC model used in this study has a BRG1 point mutation (L1149P)https://clinicaltrials.gov/). Alisertib (MLN8237) is the most clinically advanced AURKA inhibitor, and it is currently under phase I/II/III clinical investigation for treating leukemia and many other solid tumors64. The clinical efficacy of alisertib vary depending on the tumor type, and some cases of serious side effects have been described65. However, the potential clinical effect of alisertib is promising as it improved progression-free survival and the duration of disease stability for various tumor types, and the reported side effects were manageable in many cases66. To date, clinical studies of AURKA inhibitors in hematologic malignancies have moved fast, but there has been slow progress in solid tumor studies. Therefore, prompt clinical investigations of AURKA inhibitors for treating solid tumors with ARID1A or SWI/SNF complex deficiency where AURKA is highly expressed are warranted. In summary, our data demonstrate that AURKA is a target gene of the ARID1A-containing SWI/SNF nucleosome remodeling complex and is a target for inducing synthetic lethality in ARID1A-deficient CRC cells. Persistent CDC25C activation in ARID1A-deficient cells and its inhibition with AURKA inhibitors suggest that the AURKA–CDC25C axis could be a promising therapeutic target for treating CRC without ARID1A expression.AURKA has been increasingly recognized as a target for cancer therapy due to its high expression in many cancer types. Several small-molecule kinase inhibitors, such as alisertib, danusertib, MK-5108, and ENMD-2076, that target AURKA have entered clinical trials for cancer treatment (http://iclac.org/). HCT116, SW480, HCT15, and DLD1 cells were cultured in RPMI-1640 media supplemented with 10% fetal bovine serum (FBS) and 1% penicillin/streptomycin. RKO and LOVO cells were cultured in Dulbecco’s modified Eagle’s medium supplemented with 10% FBS and 1% penicillin/streptomycin. Cells were maintained in a humidified incubator adjusted with 5% CO2 at 37 °C. All the cell lines were regularly examined for mycoplasma contamination by the iPSC Core facility in the Faculty of Health Sciences, University of Macau (https://fhs.umac.mo/research/ipsc-core/). CDC25 Phosphatase inhibitor II (sc-202987) was purchased from Santa Cruz Biotechnology  and Aurora A inhibitor I (S1451) and tubastatin A (S8049) were from Selleck Chemicals . VE-821 and olaparib were kindly gifted by Dr. Chuxia Deng and EPZ-6438 was from Dr. Gang Li .CRC cell lines, HCT116, RKO, SW480, LOVO, HCT15, and DLD1, were obtained from American Type Culture Collection , which have been authenticated by the provider. These cell lines are not listed in the International Cell Line Authentication Committee (ICLAC)’s misidentified cell lines database  and exon 4 (5’-CCCCTCAATGACCTCCAGTA-3’) of ARID1A and HDR donor plasmid containing RFP, and puromycin-resistant gene were purchased from Santa Cruz Biotechnology. HCT116 cells were transfected with the ARID1A KO constructs using the Lipofectamine 3000 . The ARID1A−/− clones were selected with RFP fluorescence and puromycin (1 μg ml−1). The ARID1A−/− was verified with immunoblot and Sanger sequencing of the genomic ARID1A locus containing HDR insertion or indel mutations. The sequencing primers were designed to amplify the ARID1A exons 2 and 4 containing the 3 sgRNA target sites. The primer sequence is as follows: (exon-2 forward) 5’-TGGATCAGATGGGCAAGATG-3’; (exon-2 reverse) 5’-GCCAGTCAGGTCAAGAGAAA-3’; (exon-4 forward) 5’-GAGACAGTCCCATAACCCTTTC-3’; and (exon-4 reverse) 5’-AGGGAGACAGAACAGACATCTA-3’. The target region was amplified and the sequencing results are shown in Supplementary Fig. 52. pMDLg/pRRE, pRSV-Rev, and pMD2.G were gifts from Didier Trono 67. The lentiviral plasmids were transfected to 293FT cells with Lipofectamine 3000. The supernatant was collected and the lentiviral particles were concentrated using a Lenti-X Concentrator . RKO cells were transduced with the concentrated lentiviral particles and the ARID1A-overexpressing clones were selected with 1 μg ml−1 puromycin. The ARID1A overexpression was verified with immunoblot.pLenti-puro-ARID1A was a gift from Ie-Ming Shih (Addgene plasmid #39478)ARID1A+/+ or ARID1A−/− #1 cells were seeded at 2000 cells per well in the 384-well plates containing working dilution of the compound library and incubated for 72 h at 37 °C CO2 incubator. All the liquid handling was done with Liquidator-96 multi-well pipettor . For cell viability measurement, cells were incubated with AlamarBlue solution  at 10% for 3 h and the fluorescence signal (ex560/em590) at the bottom of the plate was measured with SpectraMax-M5 . The individual IC50 values of each compound against the ARID1A isogenic cell pair were calculated with GraphPad Prism 6.0 . The screening was done in duplicated and the average IC50 value from the two screenings were used to identify synthetic lethality hits. SI was calculated according to the following equation: SI = IC50ARID1A(+/+)/IC50ARID1A(−/−). Compounds with SI > 2 were selected as synthetic lethality candidates.Epigenetics Compound Library (L1900) containing 128 small-molecule inhibitors of epigenetics proteins was purchased from Selleck Chemicals. Each compound was arrayed in 384-well plates in an 8-dose, inter-plate titration format, ranging from 14 nM to 30 μM of final concentrations. HCT116 AURKA siRNA (siAURKA#1 and siAURKA#2) and a PLK1 siRNA were designed and synthesized from Integrated DNA Technologies  with following sequences: siAURKA#1, 5’-CUCUAUAAACUGUUCCAAGUGGUGCAU-3’, siAURKA#2, 5’- GCACAAUUCUCGUGGCUACUUUCACUU-3’, and siPLK1, 5’-GUACUAUUAAGAGGAGACUUGAAAA-3’. The siRNA transfection was performed with Lipofectamine-3000 according to the manufacturer’s instructions. Reverse transfection method was used for the silencing of AURKA in a 96-well plate. Briefly, in each well, 5 μL of siAURKA at an indicated concentration suspended in serum-free medium was mixed with 5 μL serum-free medium containing 0.1 μL Lipofectamine 3000 and the transfection mixture was incubated at room temperature for 20 min. Cells were trypsinized and 100 μL of cell suspension (5000 cells per well) was added to each well containing the transfection mixture. Cells were then incubated for 72 h in a CO2 incubator and cell images were taken with IncuCyte ZOOM . Integrated cell density was measured with the IncuCyte ZOOM software to assess cell viability. The silencing efficiency was assessed with immunoblot using an anti-AURKA antibody.Two different Whole-cell protein extracts were prepared with ice-cold RIPA buffer ) with Complete Protease Inhibitor Cocktail . Each aliquot of protein sample was run on a SDS-polyacrylamide gel electrophoresis and transferred onto a nitrocellulose membrane for immunoblotting with primary antibodies, including ARID1A , CDC25C , CDC2 , GAPDH , HSP90 , α-tubulin , p-CDC25C , p-CDC2 , AURKA , and cleaved caspase 3  antibodies, followed by horseradish peroxidase-conjugated secondary antibodies (Santa Cruz). Uncropped versions of all blots are shown in Supplementary Figs. 68. Six-week-old, female BALB/c nude mice were implanted with ARID1A+/+ (left flank) and ARID1A−/− (right flank) HCT116 cells suspended in Matrigel. When both tumors were palpable, mice were randomized into 3 groups (n = 5 mice per group) of equal tumor volume for treatment with vehicle and AURKAi, but the researchers were not blinded to the groups when performing the experiments. Mice were treated with vehicle  or AURKAi  via i.p. injection for 24 days. The sample size (n = 5 per group) in the animal experiment was chosen according to the report by Charan and Kantharia69. The similar procedure of xenograft experiments were conducted with RKO-ARID1A isogenic cell pair (n = 6 mice per group). The tumor size was periodically measured with a Vernier caliper and the tumor volume was calculated based on the modified ellipsoid formula (long axis × short axis2 × π/6). At the end of experiments, mice were sacrificed and the tumors were harvested for weighing and further analyses. Mice body weights were measured regularly during the drug injection period to assess potential drug toxicity.All animal procedures were approved by the Animal Research Ethics Committee of the University of Macau and were carried out according to ARRIVE guidelinesCells were seeded on a Nunc Lab-Tek II 8-Chamber Slide (Thermo Fisher Scientific) and treated with compound or siRNA for the indicated time. Cells were then fixed with 4% paraformaldehyde and permeabilized with 0.5% Triton X-100, followed by blocking with 2% bovine serum albumin for 1 h. Cells were incubated with primary antibodies, including AURKA , CDC25C , and α-tubulin  in the blocking buffer overnight at 4 °C, followed by the incubation with secondary antibodies conjugated with Alexa Fluor 488 or Alexa Fluor 647 for 1 h at room temperature. The nuclei were stained with Hoechst 33342 (Thermo Fisher Scientific). After washing with phosphate-buffered saline (PBS), cells were mounted with Immu-mount (Thermo Fisher Scientific) and observed under a Carl Zeiss LSM 710 confocal microscope .AURKA promoter region. Following are sequences of the primer pairs used to analyze ChIP DNA: Primer #1 (−1 to −75 bp from the AURKA TSS): forward primer 5’-ACAGGTCTGGCTGGCCGTTGGC-3’ and reverse primer 5’- GGCGCACACCGCGCGCAGGCG-3’; Primer #2 (−3892 to −3787 bp from the AURKA TSS): forward primer 5’-AGGACGACTAGGTGGTAGATAAA-3’ and reverse primer 5’-GTACTTGCATCCTCAGCAGAA-3’; Primer #3 (+3201 to +3296 bp from the AURKA TSS): forward primer 5’-CAAGGTCCTGATCCTTACTCAAC-3’ and reverse primer 5’-CCTTTATCATTTGGGCTGTTTCC-3’ (Integrated DNA Technologies); and Control primer (ORF-free region): forward primer 5’-CCTGGAGGGCTTGGAGATG-3’ and reverse primer 5’-GATCCTACGGCTGGCTGTGA-3’ (a kind gift of Professor Edwin Cheung at the University of Macau)70. The ChIP-qPCR data were expressed as fold enrichment (ΔΔCt method) according to the manufacturer’s instruction. Briefly, each ChIP DNA fraction’s Ct value was normalized to the input DNA fraction Ct value . The ΔCt for antibody ChIP was normalized to the IgG control ChIP ΔCt (ΔΔCt [antibody ChIP/IgG ChIP]). Fold enrichment of the specific site was calculated according to the following equation: fold enrichment = 2 (−ΔΔCt [antibody ChIP/IgG ChIP]).ChIP was performed with Imprint Chromatin Immunoprecipitation Kit  as per the manufacturer’s instructions. Briefly, cells were treated with 1% formaldehyde to crosslink DNA and proteins prior to prepare nuclear fraction. The nuclear pellet was sonicated with a Bioruptor Sonication System  to shear total DNA. Then the samples were immunoprecipitated with anti-ARID1A , anti-RNA polymerase II , anti-BRG1 , and anti-SNF5  ChIP-grade antibodies using the assay wells pre-coated with protein A. A normal mouse IgG was used as a non-specific antibody control for immunoprecipitation. After reverse crosslinking and protein degradation of the samples, the ChIP DNA were analyzed with qPCR against the Cell cycle and apoptosis were analyzed with a standard flow cytometry protocol. Briefly, for cell cycle analysis, cells were harvested and then fixed with 70% ethanol overnight at −20 °C prior to propidium iodide (PI) staining. For apoptosis analysis, FITC–Annexin V Apoptosis Detection Kit with PI  was used. Briefly, cells were washed with ice-cold PBS and re-suspended with Annexin V staining buffer. The cells were then stained with fluorescein isothiocyanate (FITC)–Annxin V and PI at room temperature for 15 min and then analyzed immediately with a BD Accuri C6 flow cytometer .Total cellular RNA was harvested with the RNeasy Mini Kit, followed by on-column DNAse digestion . RT was performed with the High-Capacity cDNA Reverse Transcription Kit (Thermo Fisher Scientific). AURKA transcription level was determined with SYBR Green Supermix  with the primer sequences as: forward primer 5’-CAGTACATGCTCCATCTTCCAG-3’ and reverse primer 5’-AAAGAACTCCAAGGCTCCAG-3’ (Integrated DNA Technologies).t test or one-sample t test using Graphpad Prism 6 . Statistical analysis of differences between two dose–response curves was determined by analysis of variance using Graphpad Prism 6. All statistical tests were two tailed. P values <0.05 were considered significant.All data were expressed as the mean ± standard deviation (s.d.). Statistical significance of differences between control and test groups was determined by Student’s All relevant data that are not present in the paper or Supplementary Data are available from the authors.Supplementary InformationPeer Review File


Programa Farmácia Popular do Brasil (PFPB – Brazilian Popular Pharmacy Program) on the indicators of hospitalizations and deaths by hypertension and diabetes.To evaluate the impact of the expansion of access to medicines by the Rede Própria (RP – Proprietary Network) and Rede Conveniada (RC – Partnership Network); the exposure time of the municipality to the program; intramunicipal density, measured by the number of accredited establishments; and the coverage spillover effect into patients from nonparticipating municipalities. Data from 5,566 municipalities were used, for the period from 2003 to 2016, including: (i) administrative records of the PFPB, Sistema de Informações sobre Mortalidade , and Sistema de Informações Hospitalares ; ii) other health data managed by the Departamento de Informática do SUS (DATASUS – Department of Informatics of SUS); iii) sociodemographic data produced by the Brazilian Institute of Geography and Statistics (IBGE); and iv) data from the Relação Anual de Informações Sociais .To estimate the impact of the Brazilian Popular Pharmacy Program, the statistical model of fixed-effect difference in differences was used, considering: the divisions The expansion of access to medicines for treatment of hypertension and diabetes resulted in a meaningful and statistically significant reduction (p < 0.05) of the number of hospitalizations and deaths by these diseases, in an average annual rate of 27.6% and 8.0%, respectively. The observed impacts were induced by the partnership network, highlighting the density of establishments per 100,000 inhabitants and, above all, the exposure time of the municipality to the program as relevant to the effect. Evidence of a spillover effect and of the maintenance of impacts on different age groups, especially older people, were also observed.The strategy to expand access to medicines through the PFPB was effective in reducing hospitalizations and deaths by hypertension and diabetes in Brazil during the investigated period. Better understanding the impacts of the program is important to improve the pharmaceutical care policy, to ensure access to cost-effective treatments. In Brazil, chronic noncommunicable diseases (CNCDs) were responsible for 73% of deaths in 2016Pharmacological treatment integrated to primary health care is one of the most cost-effective ways to address cardiovascular diseases, including hypertension and diabetes. Currently, the Brazilian Unified Health System (SUS) ensures pharmacological treatment for these diseases in two ways: Basic Pharmacies, which are basic dispensing units of the Brazilian Unified Health System (SUS) in primary health care; and the PFPB.The PFPB was thought of as a complement to the dispensation of medicines covered by Basic Pharmacies and operated in two divisions until 2017. The first was the Proprietary Network (RP), which came into operation in 2004 and was closed in 2017. It was managed by Fiocruz and included public pharmacies and drugstores installed by partnerships with municipal and state governments and nonprofit organizations to distribute medicines with copayment of a small portion or for free – which is the case of medicines for the treatment of diabetes, hypertension and asthma from 2011 on. The second is the Partnership Network (RC), which has been in operation since March 2006 and uses the capillarity of pharmacies from the private network to distribute medicines with copayment; since 2011, it also dispenses the medicines for hypertension, diabetes, and asthma for free.Despite being implemented for over a decade, studies on PFPB are still scarce, and reviews about its impact on the health conditions of its beneficiaries are even more rare. Regarding impact evaluations, we highlight the study of FerreiraDespite its importance, the analysis developed by FerreiraTo estimate the PFPB impact, the statistical model of fixed-effect difference in differences was used, considering: the divisions of RP and RC; the exposure time of the municipality to the program; intramunicipal density, measured by the number of accredited establishments; and the coverage spillover effect.Annual data from 5,566 Brazilian municipalities  were used. The initial research period is 2003, the year before the start of PFPB, and the final period was defined by data availability: 2016 for the analysis of the effects of the program on hospitalization rates and 2015 for mortality rates.The outcome variables, rates of hospitalization and mortality by diabetes and hypertension per 100,000 inhabitants, were constructed from data of SIH and SIM, considering the codes of the International Classification of Diseases (ICD-10) related to the two diseases on the quantification of hospitalizations and deaths, in addition to the population estimates of IBGE. The explanatory variables of interest for this evaluation are related to the specificities of the program coverage. To better characterize this coverage, administrative data of the PFPB were used regarding participating establishments, such as location, date of accreditation, division (RP or RC), and monthly transfer flow of the program.Thus, the impacts of the program were measured considering: 1) exposure time by type of division, defined by the amount of years in which the municipality had establishments of RC or RP with sales record of PFPB items; 2) coverage density, measured by the annual amount of establishments of the program per 100,000 inhabitants in each covered municipality; 3) the coverage spillover effect, measured by the number of municipalities, close to a noncovered municipality, that have establishments accredited to the program in a given period of time.If, on the one hand, the exposure time captures the maturation of the PFPB impacts on the health status of the population, on the other, one must consider the density of coverage within the municipality. For example, there may be locations with identical times of exposure, but with different numbers of proprietary or partnership establishments per 100,000 inhabitants, and this difference affects the probability of access to medicine. Furthermore, considering that most of the Brazilian municipalities are small, the absence of PFPB in a given municipality does not necessarily implies that its residents cannot have access to medicines in neighboring municipalities covered by the program.,To better estimate the effects attributable to the PFPB, other explanatory variables were used, which can be responsible for the differences in results not directly related to the program and that can also affect the participation decision of establishments. These control variables increase the precision of the estimates of the program effects and also reduce possible selection biases,In statistical terms, regression models with panel data were adjusted, using fixed effect and the difference in differences (DiD) estimator,Considering that individuals living in municipalities exposed longer to the PFPB, for having easier access, are more likely to adhere to the pharmacological treatmentit,kY represents the indicator of result k for municipality i at time t, with k including the indicators of hospitalization and mortality; j,itRC is a binary variable that takes a value of one if municipality i in year t had any private establishment with sales record in the partnership network of the program for j years; g,itRP is a binary variable that takes a value of one if the municipality i in year t had some establishment of RP with sales record for g years; itEstb captures the number of establishments of the program per 100,000 inhabitants, given that the coverage density can vary over time; itNB measures its spillover effect by the number of neighbors of municipality i, in a radius of 50 km, covered by the PFPB at a time itt; X represents a vector of control variables of the municipalities; iϕ is the fixed effect of the municipality, stμ represents temporal trends specific for the s-th federation unit of the municipality location; it,kϵ is the random error term.where Coverage density is an important variable in the analysis. The increase of a partnership establishment by 100,000 inhabitants, by itself, is able to reduce on average 0.69 hospitalizations per 100,000 inhabitants, with an equivalent elasticity of −1.6%. That is, a magnification of 1% in the number of establishments in a municipality decreases, on average, the rate of hospitalization by hypertension and diabetes in 1.6%.Additionally, the results show that municipalities without PFPB coverage that are neighbors of covered municipalities are also benefited, with an average reduction of 7.9 hospitalizations per 100,000 inhabitants and 0.6 deaths per 100,000 inhabitants, indicating spillover effect of the program coverage.To detail the previous results, Considering the two diseases, the effectiveness of RC on the reduction of hospitalizations is higher for the older age groups; is more significant for hypertension than for diabetes; and grows according to the exposure time of the municipalities to the PFPB . In 2016Regarding mortality, the effectiveness of the program is lower . The redThe PFPB spillover effect is also statistically significant for the estimated mortality reduction coefficients: in the case of hypertension, for all age groups; in the case of diabetes, only for older people. Regarding hospitalization, municipalities without program coverage, but neighbors of covered municipalities, can reduce the hospitalization rate in all age groups and for both diseases.The The effectiveness indicator is the percentage reduction rate of hospitalizations and deaths by hypertension and diabetes. The PFPB was able to reduce the number of hospitalizations and deaths in SUS, respectively, at 27.6% and 8.0% per year, on average, for the period investigated. By the disease-specific estimates, we observed a similar behavior on the trajectory of the program effectiveness. For hypertension, the annual average reduction of hospitalizations and deaths was respectively of 33.7% and 8.8%, and for diabetes, 21.8% and 7.5%, during the period of analysis.Although initially designed as a complement to the dispensation of continuous-use medicines in pharmacies of SUS primary health care services, the demand for medicines and the expense with PFPB have quickly grown in recent years. In 2016, the expenses with PFPB were over 2.7 billion reals, which corresponds to more than double the amount spent by the Ministry of Health with medicines dispensed in primary health care,,Some studies have shown that the costs of the provision of medicines in SUS pharmacies may be lower than by the PFPB,Given that there are problems of access to medicines by SUS patients, regardless of age or health group or evaluated health conditionFrom the PFPB divisions, RC was responsible for the impacts observed, being relevant to the effect the exposure time of the municipalities to the program and the density of establishments per 100,000 inhabitants. There is also evidence of program spillover effect, which means that even the population of municipalities that do not have accredited pharmaceutical establishments benefit from the program by having access to medicines in neighboring municipalities.Concerning the non-identification of impacts in RP, it is important to note that this finding may be related to its low capillarity (reduced coverage and density). In 2016, only 7.3% of the municipalities had pharmacies linked to RP, with less than one establishment per 100,000 inhabitants. On the other hand, RC was present in most municipalities, with 82% coverage and average density of 17 establishments per 100,000 inhabitants.Another issue is that RP may have a lower availability of medicines for hypertension and diabetes compared to RC,,Regarding the expressive effects induced by RC on hospitalization and mortality indicators, one observes this division presents high coverage on national territory – with high intramunicipal density –, variety of brands, and availability of medicines for usersPesquisa Nacional de Saúde , Costa et al.Using data from the 2013 The underestimation of the program effects in the absence of the variable that captures the overflow of its coverage may be related to the contamination of the group of non-covered municipalities, since the people living there can access the medicines in PFPB establishments from other municipalities. Considering that Brazil is formed by a large number of small municipalities (about 70% have less than 20000 inhabitants), and that there is a growing trend of commuting, it is likely that there is a potential demand for medicines and other items provided in neighboring municipalities. The inclusion of this variable in the model proved to be important.The results of this study confirm the findings of FerreiraRelação Nacional de Medicamentos Essenciais In general, the findings show positive aspects of the program. However, even if its effectiveness is proven, the impacts of the replacement of pharmaceutical care for PFPB in primary health care must be investigated in further studies. Since most medicines of the program are on the The limitations of this study include the fact that hospitalizations by hypertension and diabetes in the private health subsystem were not considered, which creates some uncertainty about the effectiveness of the program measured by the number of hospitalizations averted, unlike the effectiveness estimated as reduction of deaths, which is methodologically robust. Another limitation concerns the data used, which were not able to properly evaluate the effectiveness of RP, considering its low capillarity in the municipalities.,Finally, it should be noted that the analysis can be improved by future research. For instance, it would be possible to estimate disability-adjusted life years (DALYs), from data of individuals, and measure the effectiveness of the program by the number of averted DALYs. Based on this indicator and on information about the costs of the program, it would be possible to estimate its cost-effectiveness ratio and apply the parameter of the World Health Organization to evaluate the PFPB in this regard


Intimate partner violence can have a devastating impact on victims’ psychological and physical health and ability to maintain and preserve interpersonal relationships. The aim of the current study is to empirically test the effectiveness of Strong Through Every Mile (STEM), a 10-week structured running (exercise) program designed to increase psychological, social, and physical well-being among survivors of intimate partner violence. To the authors’ knowledge, STEM is the only community-based structured running program designed to improve the quality of life of survivors of intimate partner violence. This paper will describe the STEM program and present the theoretical basis of the program and the program evaluation design.The current study will utilize an interdisciplinary lens to evaluate a community-based intervention aimed at decreasing the negative effects of intimate partner violence on women’s lives. The study will use a mixed method approach , including a pre- and post-test evaluation of the STEM running program. Primary data will be collected using paper and pencil surveys which assess women’s psychological, social, and physical well-being prior to participation in the program and following the completion of the program. Qualitative data from focus groups will also be collected and allow for a more rich understanding of the changes that women experience over the course of the program and specific mechanisms underlying these changes.The current study will employ an interdisciplinary lens to examine the extent to which a structured exercise program, specifically running, impacts the psychological, social and physical well-being of women survivors of intimate partner violence. Findings of this study can influence the development and implementation of similar programs for survivors of intimate partner violence and other types of trauma by identifying mechanisms central in achieving positive outcomes for participants. Violence and trauma affect all aspects of a woman’s life including her physical and psychological health, self-sufficiency, employment, and ability to maintain social relationships . While cSport-for-development, using sporting activities to support opportunities beyond physical activity , is a prDoes participation in a structured running program positively impact the psychological health  of female survivors of intimate partner violence?Does participation in a structured running program positively impact the social well-being  of female survivors of intimate partner violence?Does participation in a structured running program positively impact the health behaviors  and physical health  of female survivors of intimate partner violence?This paper describes a “Couch-to-5 Kilometer” (C25K) running program developed specifically for survivors of intimate partner violence and the evaluation protocol that will be employed to assess program effectiveness. Such an evaluation is novel and theoretically informs our understanding of the complexities of survivors’ recovery and the ways in which community-based exercise programs can improve women’s overall well-being and interpersonal relationships. While STEM focuses directly on running and increasing physical fitness among participants, it is believed that the indirect benefits to participants span the spectrum of health. It is hypothesized, based on existing literature, that this program will have a positive effect on participants’ psychological, social, and physical well-being. This research project seeks to answer the following three research questions:The World Health Organization defines health as “…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” . IntimatJohnson and colleagues , 8–14 haJohnson’s largely control-based typology defines violence types on the basis of the underlying motivation to use physical violence, as demonstrated in a general framework of controlling behavior . For an intimate terrorist, the control tactics serve to establish and demonstrate his own power while at the same time continuously weakening his partner’s power. For example, intimate terrorists entrap victims in the relationship by creating tremendous fear of further physical and sexual violence, by diminishing victims’ personal and financial resources, and by creating an environment for victims in which social support networks may be geographically and socially inaccessible . IntimatThe negative consequences of highly-controlling intimate partner violence  on women’s well-being is well documented. In addition to violence-related injuries, there are psychological and physical health effects, as well as negative psychosocial and economic outcomes. The psychological effects of intimate terrorism include post-traumatic stress disorder (PTSD), anxiety, long- and short-term depression, lowered self-esteem, self-blame, and increased suicidality , 15–17. Intervention strategies to counteract the harmful effects of highly-controlling intimate partner violence focus largely on providing immediate physical safety for women and their children , and short- and long-term interventions to improve women’s psychological health  and high density lipoprotein cholesterol [Physical activity is positively associated with health-related quality of life –26. Reselesterol .Additionlesterol , 32 incllesterol –38, redulesterol , 39–41, lesterol , 43, implesterol , and implesterol . Runninglesterol , 47. Simlesterol . Exercislesterol .With regard to clinical populations of adults, physical activity is consistently and positively linked to psychological and social well-being . Physicastructured running programs to determine their impact on well-being. Several community-based running interventions exist for adolescents . To the authors’ knowledge, only Girls on the Run and Students Run Philly Style have been empirically evaluated. Girls on the Run is designed for pre-teen girls and combines training for a 5-km (5 K) (3.1 mile) run with a three-part curriculum that focuses on increasing self-awareness, self-care, team- and community-building, communication, and social engagement and awareness. Evaluation findings indicate that following the program, participants exhibit decreased body dissatisfaction and increased self-esteem [Students Run Philly Style uses distance running to promote healthier living and high school completion among mostly minority and low socioeconomic status students aged 12 to 18. Students train to complete races of differing lengths including the Philadelphia Marathon or Half Marathon. Participation in the program is positively linked to motivation for running, general self-efficacy, attitude toward a healthy lifestyle, and engaging in higher levels of non-threatening behavior [Despite strong evidence demonstrating the positive effects of physical activity on various components of well-being, few studies have specifically evaluated f-esteem . Continuf-esteem . Studentbehavior .Back on My Feet (BoMF) (http://www.backonmyfeet.org/) is a running program specifically for individuals experiencing homelessness. An evaluation of the BoMF program found that following program completion, participants reported increased self-sufficiency, self-esteem, self-confidence, and perceived productivity [To the best of the authors’ knowledge, only one structured running program specifically focused on adults at-risk for psychosocial difficulties has been evaluated. uctivity . The curww.stemrunning.com/). A C25K running program is one that is designed for novice runners or those who are not consistent runners. Program participants alternate between running and walking during a 30-minute period. Over the course of several weeks, the duration of the running segment increases while the walking segment decreases until participants are entirely, or almost entirely, running. The STEM program, developed in 2013, consists of three (two week day and one weekend) organized group workouts per week for 10 weeks and culminates with a 5 K road race. The program is designed to build participants’ physical endurance and confidence, thus resulting in mastery experience.Strong Through Every Mile (STEM) is a Couch-to-5 Kilometer (C25K) running program designed specifically for individuals receiving services through several domestic violence shelters in the Capital Region of New York  and embraces an ecological framework for prevention , 64. STEThe program was not developed to directly address past trauma, however there is an acknowledgment that prior traumatic experiences impact perceptions, behaviors, and thoughts – a central component of trauma informed approaches . Trauma-STEM is implemented and maintained entirely through volunteer efforts, and is funded solely through donations. To date, STEM has partnered with four local domestic violence shelters that provide residential and non-residential services for survivors of intimate partner violence. Each shelter has a designated staff member who serves as a STEM liaison/coordinator. The liaison works with STEM staff to explain the program to shelter clients. Interested individuals self-enroll in the program and are partnered with a “mentor”, a community volunteer who runs with participants during training sessions and the target race and provides support and encouragement.Women must receive medical clearance prior to participating in STEM – shelter staff assist participants with receiving clearance if they do not have an established relationship with a medical provider. Once women are identified and medically cleared for participation, the liaison/coordinator works with STEM staff to schedule running sessions and identify a training location. The partner domestic violence shelters provide transportation to and from the training location and a shelter representative attends training sessions to provide support if needed. It is important to note that the women’s safety during training sessions is paramount. Research consistently shows that the escaping and help-seeking process can be extremely dangerous and involve a high degree of risk for victims entrapped by intimate terrorists. Indeed, escaping or trying to end the relationship is an immediate precipitating factor in 45% of cases in which men kill female partners . Given tInitially, STEM provides participants with donated running shoes and athletic wear if necessary. Later, women who participate in the program for the first month are accompanied to a local running store and provided exercise clothing and a pair of new running shoes. A local athletic business has partnered with STEM to provide these supplies at a discounted rate. STEM provides team shirts for participants and pays the race registration fees for them. After the completion of the race, STEM participants gather for an end-of-session celebration.The STEM program focuses on tertiary prevention, coping and recovery from intimate partner abuse . STEM’s Self-determination theory (SDT) explains human motivation and personality. SDT postulates that three key psychological needs  foster well-being . CompeteSDT proposes that these psychological needs are strongly associated with autonomous motivation . AutonomIt is predicted that programs like STEM promote autonomous motivation by satisfying the basic needs described by self-determination theory  by offering a non-judgmental and voluntary framework which supports the development of autonomy orientation . ParticiRelated to self-determination theory, self-efficacy theory is based in social learning theory  and focuLocus of control (LOC)  describeInternal locus of control is central to survivors of intimate partner violence, particularly intimate terrorism, because of the nature of this type of violence. As discussed previously, intimate terrorists use economic control, intimidation, isolation, emotional abuse, and physical and sexual violence to gain and maintain control over their partner. Through entrapping a victim in the relationship, an intimate terrorist forces a sense of powerlessness upon the victim as he literally takes control of her life. Among survivors of intimate terrorism, trauma hinders perceptions of internal control and may subsequently lower perceptions of hope .It is predicted that the STEM program will increase participants’ sense of accomplishment and internal control as participants are encouraged and empowered to set their own goals and create their own path to success. While the program determines the race, training schedule, and distance, the participants decide to join the program and control their training frequency and intensity. This type of control increases beliefs of personal control over one’s life and adoption of healthy behaviors .Social capital refers to the available resources, either actual or potential, resulting from one’s social network or ties between individuals  and the The theory of social capital suggests that one’s position within a particular group or social network provides certain benefits. Findings indicate a positive correlation between social capital and psychological health , 88. MorMindful individuals are aware of and pay attention to what is occurring in their internal and external environment  rather tThe evaluation of the STEM program will be conducted in a two phases. In the first, the research team conducted focus groups with previous program participants, reviewed program material, and reviewed scientific literature to identify potential program outcomes and develop a theory- and data-driven program logic model Fig. . The secPhase I of the program evaluation included development of the program logic model, review of program documents, and focus group data collection. Individuals unable to participate in focus groups but wishing to speak with researchers were interviewed in-person. All focus groups and interviews were recorded and transcribed by a research assistant. Transcripts were reviewed for themes related to participation in and examples of theoretical components of the program. All participants provided written informed consent.The second phase of the evaluation is an impact evaluation to test hypothesized short- and medium-term outcomes. The goal is to collect data from all STEM participants with maximum efficiency and minimal intrusion of research staff in the STEM program or the partner agency service delivery. Principal investigators will coordinate pre- and post-test data collection times with partner agency staff. Individuals will complete the survey independently, or if requested, have the survey read to them by a member of the research team or partner organization. Participants will receive a running belt after completing the post-test survey. To protect confidentiality and to match pre-and post-test data, participants will be given a unique identification number. All participants will provide written informed consent prior to completion of the survey.Respondent relationship and sociodemographic characteristics will be recorded. These variables include age, race, education level, employment status, relationship status, length of relationship, and number of children.Eight measures will be used to assess respondent psychological well-being: the 21-item Depression, Anxiety and Stress Scale (DASS 21)  assessesParticipants’ social well-being will be measured by the 14-item Interpersonal Support Evaluation List (ISEL)  which asThe World Health Organization Quality of Life instrument  will be Future behavior will be assessed by asking participants about their behavioral intentions. Intention is a reliable predictor of behavior , 116, thThe target sample size for this study was calculated using G*Power . To calcSPSS will be used to conduct descriptive and other analyses. Chi-squared or t-test analyses will be used to compare baseline and post-test samples. Participant pre-test data will be compared to post-test data using a paired T-test. Sensitivity analyses will be conducted to assess robustness of the results.The intervention being studied incorporates multiple psychological and sociological theories including self-determination theory, self-efficacy theory, locus of control, social capital, empowerment, happiness, and mindfulness. The STEM running program engages community members as mentors, collaborates with local domestic abuse assistance agencies, and elicits financial support for running apparel from area businesses, including a local running specialty store. Through community engagement, the program has the unintended consequence of raising awareness of the issue of intimate partner violence and survivors’ ability to thrive.The current study seeks to provide a multifaceted, empirically-derived understanding of the impact of a structured running program on survivors of intimate terrorism. The program evaluation will inform future research directions and program expansion and delivery. The interdisciplinary nature of this study establishes a dynamic collaboration between the fields of family science, psychology, and public health and bridges an often ambiguous gap between these disciplines. A future step will be to determine STEM’s effectiveness compared to other common interventions including non-physical activity based programs such as support groups, book clubs, and sewing circles. Additionally, long term studies can examine the physiological markers of stress experienced by survivors of intimate partner violence over the course of the STEM program. The incorporation of physiological data into this work will help elucidate the underlying mechanisms responsible for STEM’s beneficial effect on participants.The findings have important implications for informing and influencing practice regarding community responses to survivors of violence and ultimately improving the provision of services for survivors. If the current study, and future multi-group studies, demonstrate STEM’s effectiveness, robust evidence will exist for a unique, low-cost community-based intervention to promote survivor well-being.


Nurses Improving Care for Healthsystem Elders (NICHE) is a geriatric care model that positions nurses as leaders to address the unique care needs of older adults. From 2016 to 2019, we developed and piloted the NICHE-LTC program. NICHE-LTC program includes the three interrelated components of 1). the Geriatric Resource Nurse (GRN) and Geriatric Certified Nursing Assistant (GCNA) clinical leadership roles; 2) research-based clinical protocols and assessment tools; and 3). staff development, quality improvement (QI), and care coordination models to build clinician and organizational capacity in geriatrics. We report the results of a summative program evaluation of the NICHE-LTC program. We collected data on organizational and participant demographics, facility enrollment and retention, program completion rates, clinical quality improvement project plans, and participant satisfaction data from 369 individuals working in 79 facilities participating in NICHE-LTC program from January 2016 to February 2019. The majority of participants (80%) reported a positive learning outcome after completing NICHE-LTC program. Additionally, 80% reported they agreed or strongly agreed that their knowledge and ability to implement quality improvement initiatives in their facilities improved. The NICHE-LTC supported facilities ability to move from process-oriented QI priorities to patient-based outcome QI priorities such as falls, pain management, and managing behaviors of dementia. Over the three-year pilot period, NICHE-LTC program maintained an 89.4% annual retention rate. The high annual retention rate suggests that members value the program as an approach to address the clinical quality and nursing workforce development needs in LTC settings.


W 7.9 strike-slip Gulf of Alaska earthquake ruptured an oceanic fracture zone system offshore Kodiak Island. Bathymetric compilations show a muted topographic expression of the fracture zone due to the thick sediment that covers oceanic basement but the fracture zone system can be identified by offset N-S magnetic anomalies and E-W linear zones in the vertical gravity gradient. Back-projection from global seismic stations reveals that the initial rupture at first propagated from the epicenter to the north, likely rupturing along a weak zone parallel to the ocean crustal fabric. The rupture then changed direction to eastward directed with most energy emitted on Aka fracture zone resulting in an unusual multi-fault earthquake. Similarly, the aftershocks show complex behavior and are related to two different tectonic structures: (1) events along N-S trending oceanic fabric, which ruptured mainly strike-slip and additionally, in normal and oblique slip mechanisms and (2) strike-slip events along E-W oriented fracture zones. To explain the complex faulting behavior we adopt the classical stress and strain partitioning concept and propose a generalized model for large intra-oceanic strike-slip earthquakes of trench-oblique oriented fracture zones/ocean plate fabric near subduction zones. Taking the Kodiak asperity position of 1964 maximum afterslip and outer-rise Coulomb stress distribution into account, we propose that the unusual 2018 Gulf of Alaska moment release was stress transferred to the incoming oceanic plate from co- and post-processes of the nearby great 1964 MW 9.2 megathrust earthquake.Large intraplate earthquakes in oceanic lithosphere are rare and usually related to regions of diffuse deformation within the oceanic plate. The 23 January 2018 M W 9.2 earthquake . Oceanic lithosphere strike-slip earthquakes near subduction zones are rare. Two major Pacific Plate N-S trending strike-slip earthquakes  ruptured a composite length of ~250 km in the central Gulf of Alaska3. This region has hosted a spatially persistent cluster of diffuse seismicity since then6 where complex N-S aftershock patterns dominate and additionally ENE – WSW trending aftershock clusters reactivated fracture zones (FZs)4. This cluster of seismicity resulted from a combination of enhanced tensional stress in the Pacific Plate following the 1964 great Alaska earthquake and compressional stress resulting from the collision of the Yakutat Terrane with North America5. Additionally, the rupture occurred in a zone of weakness in the crust inherited from processes of plate formation5. Convergence of the Pacific Plate with the North America Plate is currently 60 mm/yr and almost trench-normal . For both regions plate convergence is oblique and the high level of moment release can be explained by diffuse deformation associated with microplates7.Worldwide, only two other regions have hosted numerous major and great strike-slip ocean lithosphere earthquakes near subduction zones in the documented era: Macquarie Ridge near the Puysegur Trench in the southern Tasman Sea and offshore Sumatra9). Several large (MW > 7.5) intra-oceanic plate strike-slip earthquakes  intersperse with great interplate strike-slip (e.g. 1989 great MW 8.2 Macquarie Ridge13) or thrust earthquakes . These large earthquakes with different rupture mechanisms show triggering interactions of interplate thrust earthquakes with intraplate strike-slip events on nearby FZs and oceanic fabric, or vice versa14.A long record of ongoing major and great strike-slip intraplate earthquakes from the southern Tasman Sea documents the complex tectonic setting ~150 km seaward of the obliquely subducting Australia Plate (Puysegur Block) beneath the Pacific Plate where strike-slip motion along the Macquarie Ridge changes to convergence at the Puysegur Trench  seaward of coseismic peak slip that occurred during the great 2004 Sumatra megathrust earthquake. This earthquake sequence most likely triggered by the MW 9.2 2004 earthquake (e.g.16), ruptured a network of en échelon faults orthogonal and parallel to the 90°E Ridge15.The other region of previous intra-oceanic earthquakes near a subduction megathrust is located offshore northern Sumatra and includes the largest recorded strike-slip intraplate great earthquakes  1964 earthquake17 . There, the rupture was re-directed and propagated in E-W direction, mainly to the east along the Aka FZ. Such a transfer or termination of great earthquake slip is not commonly reported. After ~50 s the main shock terminated at the easternmost location of the aftershock distribution near ~148°W, on the Aka FZ. For two months after the main shock, aftershocks were distributed along two major tectonic trends  constriction in the Alaska Trench axis and (2) the E-W oriented FZ system (56°N FZ and Aka FZ).Back-projection reveals that the main shock ruptured an area of ~150 × 60 km Fig. . Initial020 Figs . Rupture21 , images broad areas of bend faults24 along the trench seaward flank  aftershocks are aligned along one single lineament of oceanic fabric . The triggering farfield stresses of the 1987–1992 GASZ earthquake sequence, most likely, originate in the collision/subduction of the Yakutat Terrane5.The 2018 M18. Additionally, rupture along normal faults in the outer-rise region may be explained by a shallow rupture of the 1964 great Alaska earthquake, which then would have increased the Coulomb stress in the outer-rise region31. Therefore, we prefer a stress transfer from the subduction zone into the outer-rise region of the 2018 Gulf of Alaska earthquake sequence.However, postseismic deformation model predictions for the 1964 great earthquake show maximum values in the Kodiak asperity32. This required large adjustments of fractures to accommodate that change33. The downward flexure of the Pacific Plate into the Alaska Trench produces bending-related stresses in the lithospheric oceanic plate. To accommodate these stresses, the prevailing tectonic mechanism is an activation of pre-existing ocean-lithospheric structures rather than the creation of new faults resulting in outer-rise normal faulting (e.g.34). Plate bending stresses that are commonly accommodated by trench-parallel outer-rise extensional faulting are aligned N-S parallel to magnetic anomalies in the Alaska Trench outer-rise region, indicated by multichannel seismic (MCS) data24 and multibeam bathymetry24  and Macquarie/Puysegur (e.g.14), that produced similar earthquake patterns. All three events  resulted in complex aftershock distributions following fault systems parallel and orthogonal to major FZs in the outer-rise region where extension usually occurs16.As unusual as this strike-slip intra-oceanic lithosphere earthquake was, it is not unique and has several features in common with two other tectonic settings: Sumatra  or upper plate (Sumatra15) strike-slip events. In contrast, plate convergence along this portion of the Alaskan subduction zone is trench-normal with inherited ocean-lithospheric magnetic anomalies at ~30–35° to the trench axis as well. Here, we expand the strain partitioning model36 for more general and complex cases to accommodate the oblique alignment of inherited ocean-crustal fabric and FZs instead of oblique plate convergence. We propose that a significant condition promoting large orthogonal intra-oceanic strike-slip earthquakes near subduction zones may be the oblique alignment of FZ systems and crustal fabric ~30–35° to the trench axis  to the trench axis. Proposed strain partitioning that accommodates oblique plate convergence° to the 37). Thus, proximity to a subduction zone may be significant to understanding oceanic intraplate earthquakes in Paleogene crust. A driving mechanism to produce major earthquake slip in intra-oceanic lithosphere may be stress transfer from the subduction zone. This could either be due to stress release along the subduction megathrust after a great earthquake, or stress accumulation along the subduction megathrust late in the seismic cycle prior to a great subduction earthquake. The result could be an earthquake doublet involving an interplate thrust event and an intra-oceanic plate strike-slip event, described by two triggering mechanism models8: In the first model the initial great rupture occurred along the plate interface and triggered the intraplate strike-slip event, whereas in the second model, the triggering interaction occurred in reverse order. The first triggering mechanism occurred after the 2004 Sumatra great megathrust earthquake which initiated increased (strike-slip) seismicity in the adjacent oceanic lithosphere16. Due to the high levels of interspersed intra- and interplate seismicity in the Macquarie/Puysegur region (e.g.14) changing triggering interaction between intra- and interplate events is inferred, hence the combination of the two above proposed triggering mechanisms8. The 2018 Gulf of Alaska earthquake might have occurred either as a delayed postseismic response to the 1964 great earthquake or during the interseismic period as a result of stress accumulation and strain release from compressional convergent forces and locking of the adjacent subduction megathrust. We favor stress transfer from the subduction zone as the driving mechanism for the current main and aftershock sequence since the orientation of moment-tensors is left-lateral in the E-W direction  extends locally into the subduction system at the prolongation of the Kodiak Bowie Seamount chain  relocation of the weak seismicity observed in the upper plate. A local seismic network might record the weak seismicity from rupture of the FZ system (intraplate in the subducting slab) beneath the upper plate or alternatively from induced seismicity along the subduction thrust (interplate) or stress transfer into the upper plate.Weak seismicity .The 2018 Gulf of Alaska earthquake is a third recorded, global, large intra-oceanic plate strike-slip event. It is likely that historic events with the same mechanisms have occurred before instrumental seismology. Also, this probably is not the last major or great strike-slip event. Other active margins satisfy the requirements of having magnetic anomalies trending ~30° oblique to the trench axis: i.e. Aleutian, Ecuador, Guatemala, Kuril, Solomon (Woodlark), with some that produced great megathrust earthquakes in the shallow part of the subduction zoneW 7.9 strike-slip oceanic lithosphere earthquake is a rare example of an oceanic intraplate strike-slip rupture. Its occurrence was unexpected because the structures involved are covered by thick turbidites that smoothed the underlying seafloor bathymetry. Despite few ship survey data, the combination of several regional geophysical observational datasets gives insight into the complex tectonic setting/history of this earthquake and its aftershock distribution.The 23 January 2018 M8 and references therein). Instead of oblique convergence, a key tectonic feature that leads to strain partitioning for such events is the trend of the ocean plate fabric at ~30–35° to the trench axis and orthogonal FZs. Similar scenarios may occur in other subduction systems that ruptured in great megathrust earthquakes where oceanic fabric on the incoming oceanic lithosphere trends ~30–35° obliquely to the trench axis .Given the global history of such unusual strike-slip intra-oceanic plate earthquakes, one common feature is proximity to a subduction zone that produces great earthquakes with rupture close to the trench. All three rare events, Macquarie/Puysegur, Sumatra and Gulf of Alaska, resulted in complex en échelon and orthogonal fault rupture of pre-existing ocean plate fabric and FZ systems  and a recently acquired line with RV Marcus G. Langseth  were processed. The processing procedure involved frequency filtering, multiple suppression and trace interpolation for the legacy data. MCS data were sorted for common image gathers, which were used for iterative semblance velocity model-building. Velocity model-smoothing was applied to reduce small scale artefacts. Pre-stack depth migration with the final velocity model and stacking provided the subsurface image.USGS legacy multichannel reflection seismic (MCS) lines acquired with USGS vessel RV 41, building on a large body of earlier work (e.g.43) to evaluate the high-frequency emissions of the 23 January 2018 Mw 7.9 strike-slip Gulf of Alaska Earthquake. The back-projection method analyzes the coherence of multiple signals arriving at a seismic array within narrow windows during the rupture of a larger event, assuming as sources candidate locations on a  2D grid around the hypocenter. For each potential source point the theoretical arrival times to each receiver of the array are calculated based on a 1D velocity model (here IASP9144). The signals within a narrow sliding window of length L are aligned according to these calculated travel times and finally summed to form a beam trace. Finally, the source point with the largest total beam power in each time window is selected as the most likely emission point for seismic waves for this time window. We additionally carry out a semblance (S) analysis46, which measures the coherence of waveforms and is less likely to be dominated by the most energetic part of the rupture but loses information on the relative importance of various rupture phases (S = 1 corresponds to a perfect coherence).We implemented a time-domain back-projection47. A zero-phase fourth order Butterworth filter with a pass band between 0.5 and 2.0 Hz was applied to the data48. The back-projection assumes a source grid with a spacing of 4 km around the hypocenter area at a constant depth of 25 km, a time window of L = 6 s with time steps of 0.5 s. Both arrays were back-projected separately and the maps of beam energy or semblance were obtained by multiplying such independent back-projections results in space (2D grid) and time for our final results  and 176 stations from Europe (most stations between 65° and 89°). Back-projection data were provided by the Data Management Center (DMC) of the Incorporated Research Institutions for Seismology (IRIS)49. Based on this method, the north-central America data set was aligned using the first 6 s after the theoretical P-phase arrival (filtered between 0.5–2.0 Hz). As the European data were at a larger distance and thus noisier, a wider window of 8.5 s had to be used (filtered between 0.5–2.0 Hz). The coherence of the selected waveforms and the time-shift values estimated are shown in Figure To take into account the 3D Earth heterogeneity and its effects on the arrival times and consequently, on the constructive interference necessary to illuminate the rupture, the back-projection method includes static station corrections. The station statics supply station-specific time-shifts relative to the theoretical arrival times to maximize the correlation between the waveforms registered at the array. In order to determine these statics a pilot time window with known event parameters is needed. Here, we calculated the time-shift values based on the hypocenter using the adaptive stacking process29.Finally, part of the North America waveforms were affected by polarity flips as the array is bisected by the nodal plane Fig. . TherefoSupplementary InformationSupplementary MovieS1