Women, with more vulnerabilities and less access to resources, are often seen as victims of natural disasters. Therefore, the present study aimed to investigate the experiences of rural women with damages resulting from an earthquake in Iran.In this research, a qualitative approach, as well as the conventional content analysis was employed. The study population consisted of rural women residing in the earthquake-stricken areas of Sarpol-e Zahab and Salas-e Babajani counties in Kermanshah Province, Iran. Semi-structured interviews were used for data collection. Moreover, sampling was purposeful, theoretical saturation was achieved by conducting 22 interviews, and the data analysis process was performed according to the steps proposed by Graneheim and Lundman. For the strength and transferability of the research, Lincoln and Guba’s Evaluative Criteria were used.There were seven categories regarding the experiences of rural women after the earthquakes including neglecting the health needs; tension in the family and marital relations; gender inequality in the provision of assistance; feeling insecure; ignoring the ruling culture of the region; concealing needs for fear of stigmatization, and incoherent mourning as well as two categories regarding their reactions to and interaction with the earthquake consequences including positive and negative interactions.Paying more attention to the needs of rural women, taking the culture governing the village into account at the time of service delivery, and helping them with positive adaptations are some indispensable measures that should be taken. Earthquakes, as the second deadliest natural disaster, have always existed throughout the life of the planet. These are unpredictable and out-of-control, which can cause extensive destruction, threaten many lives –4, and cRecent studies have shown that the damages caused by natural disasters are not equitable among different groups of people . In the One’s reaction to natural disasters is heavily influenced by his/her cultural, social, economic and political backgrounds , 17. HenNot to mention, women, with more vulnerabilities and less access to resources , 20, areThe study of Anwar et al. (2011) and Demirchyan et al. 2014) on Pakistani women stricken by earthquakes concluded that those women had multiple health problems and notable danger of depression and anxiety  on Pakis. Doris eMost studies conducted on earthquakes are quantitative and empirical, and a few previous studies have addressed the experiences of rural female survivors qualitatively. It should be noted that qualitative studies have a unique ability to understand phenomena and to describe life experiences, human interpretations and perceptions in the same cultural and social context . Hence, In this research, a qualitative approach and the conventional content analysis were employed to explain the experiences of rural women with damages resulting from an earthquake in Iran. Qualitative content analysis is one of the several research methods and a robust process that is used to analyze textual data and is intended to start the introductory meanings of the concept. It is also a systematic categorization and coding method. The main goal of this method is to satisfactorily understand the phenomenon being investigated .Moreover, the study population consisted of rural women residing in the earthquake-stricken areas of Sarpol-e Zahab and Salas-e Babajani counties in Kermanshah Province, Iran, who were there on the night that the earthquake rocked these two counties on November 12, 2017. Moreover, the inclusion criteria were consciousness, willingness to express their experiences of the earthquake, being female, residing in rural areas, ability to speak and willingness to participate in the research.To commence the study, the required permits were obtained from the Vice Chancellery for the Department of Research and Technology at Kermanshah University of Medical Sciences. For data collection, semi-structured interviews were used. However, given that the researchers were natives to the earthquake-stricken areas and served there as volunteers, the observation method was also used. Furthermore, the interviews were commenced two months after the earthquake and lasted for four months. Besides, the interviews were conducted based on some general questions Table . The intAfter asking the general questions that were the same for all participants, the following questions were developed concerning the answers that they provided. Any new code that emerged in the interview was attempted to be asked as a question in the subsequent interviews to check the codes repeatedly to find out whether or not other interviewees have had such an experience so that researchers can gain richer concepts.During the interviews, given that the researchers used local language of the interviewees, they were asked to speak in their local language to express their experiences comfortably, thereby creating a sense of trust and willingness to participate in the study. The time and place of the interviews were decided by the samples, which were mostly held in container homes and tents without anyone accompanying them since it was likely that other people would prevent them from communicating their experiences to the researchers smoothly. The average duration of the interviews was 37 min. After each interview, the researchers began to analyze and encode the data to use them as a kind of guidance in subsequent interviews. Moreover, sampling was purposeful, and theoretical saturation was achieved by conducting 22 interviews and the main and sub-categories were formed. In qualitative research, the sampling criterion is the theoretical saturation, and whenever there is no new code in interviews, it shows that saturation is reached and the researchers can interrupt the interview process and no longer need to increase the sample size . In factIn the present study, the data analysis process was performed according to the steps proposed by Graneheim and Lundman (2004). Additionally, the data analysis began simultaneous with data collection, and all interviews were recorded, and the contents were written verbatim. Besides, the entire material was reviewed several times to gain a correct understanding . At the Since qualitative research has slightly different paradigmatic principles than quantitative research, the methods of evaluating and generalizing results in qualitative research are different from quantitative research . TherefoTo observe the ethical considerations, the objectives of the present study were explained to the target subjects, and they were assured that their information would be kept confidential. They were also assured that their data would be encoded and published in such a way that they could not be identified by any means. Moreover, they were given the right to interrupt the interview at any time.In this research, different to most existing studies, the problems and needs of rural women after the earthquake were examined qualitatively, which can provide unique information and give us the needs and problems of rural women after the earthquake to prepare the grounds for intervention to improve their health condition. Similarly, since some of the authors of the article were indigenous to the studied areas and were working as a social worker there, they could establish a close relationship with the participants, could gain a comprehensive familiarity with the research field, and could get more complete and hands-on information from the research field for readers and, therefore, pave the grounds for further researches.In Table After encoding and analyzing the obtained data, there were seven categories regarding the experiences of rural women after the earthquakes, as well as two categories regarding their reactions and interaction with the earthquake consequences Tables  and 4.TNeglecting the Health Needs: Women have their own health needs, which in critical situations such as natural disasters need to be addressed to avoid health problems. However, after the earthquake, the most important health needs of women, such as access to baths and toilets, underwear, and sanitary napkin were ignored in the studied areas, and most of the rural women were in terrible conditions. After the earthquake, less attention was paid to the health needs of women in rural areas.Rural women are one of the most vulnerable groups against earthquake who can be affected by it in a different way than other groups. Below is a list of the experiences of earthquake-stricken rural women in Kermanshah“It was really hard to find a restroom in the first days of the earthquake and we couldn’t take a shower until two months after the earthquake”. (interviewee 3).“After the earthquake, many women in the village got their periods because of the horrible conditions they went through, but without any access to sanitary napkins.” (interviewee 15).“All of my clothes were buried under the debris, and after several weeks passing from the earthquake, I had only one dirty dress to wear.” (interviewee 8).2.Tension in Family and Marital Relations: The consequences of the earthquake were so extreme that the living conditions of survivors were influenced, thus possibly leading to tensions in the family and disruption of marital relations. As many of the participants stated, after the earthquake, there was tension in the family and their family relationships were not as strong as before, and the family atmosphere was affected by the earthquake, even the sexual relations between the couples.Despite the urgent need of earthquake-stricken rural women to sanitation stuff, this need was largely ignored, which could put their health at great risk and make the process of returning to normal life difficult.“After the earthquake, the atmosphere at our home was not like before and was tense. Plus, I could not make emotional affairs with my husband.” (interviewee 11).“Despite the passage of several months from the earthquake, nothing is like before, and I feel my husband and I are emotionally distant. We used to talk so much, but now he has changed into a different person.” (interviewee 8) “After the earthquake, I could not have sex with my husband for a few months. To be honest, I didn’t feel like it and he was not interested as well.” (interviewee 2). “After the earthquake, my husband was in a bad temper and shouted at me all the time. He was not like this before.” (interviewee 1). “After the earthquake, all family members were psychologically affected, we talk less and sometimes we fight together”. (interviewee 9).3.Gender Inequality in the Provision of Assistance: Since the earthquake-stricken areas were among the deprived areas of Iran and still dominated by the traditional patriarchal atmosphere, women possessed a low socioeconomic status and did not find the chance and appropriate conditions to receive aid.Since the family can play an effective role in dealing with post-earthquake issues, tensions within the family can make the process of returning rural women to normal life more difficult.“Although questions were asked only to men and they talked only about family problems and their problems, no one asked us about our problems and needs.” (interviewee 21).“The aid was given only to men, and only strong persons got more aid. Sad to say, women were the last to have the things which were left”. (interviewee 7).“Our problems were not given much attention, they gave everything first to men and if there was something left, they gave it to us” (interviewee 9).4.Feeling Insecure: After the earthquake, many Iranians volunteered to act spontaneously and went to the earthquake-stricken areas and stayed there for some time after the earthquake. Therefore, their presence disturbed the previous social atmosphere of villages, thereby creating a kind of insecurity in rural women.Reproduction of gender inequality after natural disasters can make conditions worse than before for women and bring about more limitations for them, making it difficult or even impossible to access the resources and assistance provided. Therefore, considering the needs of women and prioritizing their demands because of their circumstances can provide the basis for faster rehabilitation.“After the earthquake, many unknown people commute to/from our village, and we are too afraid to go outside.” (interviewee 15). “Most of the time, we just stay in our container homes and do not get out. Our village has become too packed with strangers, and we are afraid of verbal and physical harassment.” (interviewee 6). “I do not feel good about the messy conditions of the village, I used to go out more, but now I feel insecure.” (interviewee 12).5.Concealing Needs for Fear of Stigmatization: Given the traditional social and cultural fabric governing the earthquake-stricken areas, many women were reluctant to express their desires to avoid stigmatization. Therefore, providing conditions for rural women to help them more easily express their needs and access provided services could help them to be less vulnerable to earthquake damages.Therefore, despite the good intentions of people from elsewhere to support recovery by going tothe stricken areas to volunteer, the presence of a large number of volunteers and strangerscauses further disruption, and makes it harder for rural women’s lives to return to stability.“After a few days passed from the earthquake, sanitary napkins were brought to villages. Although I knew that several women were in dire need of sanitary napkins, they were too shy and afraid to say anything”. (interviewee 17).“I am the head of the family, and it’s been nearly eight years that I have lost my husband. So, after the earthquake, I didn’t have anyone to get the things we needed, and I was too shy and afraid. That is why I was the last to receive a tent.” (Interviewee 12).“To be honest, I had a yeast infection and I was too shy to speak about it or ask for anything.” (Interviewee 11).6.Ignoring the Ruling Culture of the Region: The earthquake rocked the Kurdish areas, where the cultural and social fabric is different from those in other areas of Iran. Unfortunately, ignoring this main factor at the time of aid provision caused some problems for relief efforts.Therefore, despite the severe needs of rural women to various facilities and services, these needs were often ignored and no one was trying to address them, this issue puts more pressure on these women.“After the earthquake, I had only one dress to wear for a month because the clothes they sent us did not fit our cultural fabric, so we couldn’t wear them.” (Interviewee 16).“We couldn’t wear most of the clothes and shoes that people had sent us, and once I wore one of those clothes, it was too noticeable. Thus, I was forced to take it off.” (Interviewee 18).“In the first days after the incident, we couldn’t eat some kinds of foods that people had sent us, such as a baguette.” (interviewee 12). “Several days after the earthquake, several bathrooms were built in the village, but many other women including myself were too shy to use them at all.” (Interviewee 1).7.Incoherent Mourning: In earthquake-stricken areas, people are buried after holding ritual and funeral ceremonies that may take several days and families may feel bad if this is not properly done. Since earthquakes take place very quickly and bring about horrible consequences, many families are forced to bury their loved ones quickly, thereby causing dissatisfaction in them.One of the main pillars of intervention in any society is the recognition of its culture and customs so that without sufficient knowledge and understanding of its culture, it is not possible to identify their needs properly or even the assistance and services provided may be contrary to their customs so that the locals will be reluctant to receive them. Since the people living in the earthquake-stricken areas were Kurds and had a different social and cultural structure than other geographical areas of Iran, ignoring this different structure in many cases made the aids sent back without any use.“My daughter was trapped under the rubble of our house, and when she was pulled out dead from the rubble, I was in the hospital. Sad to say, I was too late to arrive at her burial and couldn’t see her. I still get angry about why I couldn’t see her for the last time.” (Interviewee 4).“When my father died on the night of the earthquake, we buried him in the morning, and there were almost no relatives present at his funeral. However, now after two months passing from his death, everyone offers condolences and we all wish he had died normally so his death wouldn’t make us so miserable.” (Interviewee 11).Since the people who died from the earthquake were buried in different conditions, their families were unhappy with the situation and in fact, had a guilty conscience for not being able to hold a better funeral ceremony for them.After the earthquake, rural women selected specific strategies to cope with the earthquake which fall into two categories: positive and negative interactions.Getting Closer to God: In many cases, earthquakes are seen as an occurrence based on God’s will. Therefore, this natural occurrence can make changes in the connection between people and God, thereby making them closer to God.Positive Interactions: After the earthquake, some rural women tried to cope with the earthquake through a series of strategies and in fact found some kind of positive adaptation to the earthquake, which made them more relaxed and able to return to normal life. Positive interactions refers to the measures and approaches adopted by rural women, whereby they could better adapt themselves to the situation.“The earthquake reminds me of God and shows how weak we are. After the earthquake, I pray and try to be a better person.” (Interviewee 21).“After the earthquake, I do not know if I were afraid or it was because of anything else that I swore to God to say my prayers and to think of God more. I used to pray less, but now I say my prayers every day because it gives me peace of mind.” (Interviewee 20).2.Participation in Group Work: After the earthquake, the women who were residing in less affected areas tried to help others by baking bread or doing some other voluntary services for other villages.To do this, rural women sought to find a source of comfort for themselves by doing things such as praying and thus calmed themselves down this way.“Our village was ruined in the earthquake, but luckily nobody died. So, other women and I tried to bake bread for them and help with humanitarian aid. By doing so, I felt much better and thoughtless about the unpleasant conditions we were involved in.” (Interviewee 2).“Other women and I gathered our extra Kurdish dresses and sent them to the areas where there was more destruction.” (Interviewee 15).3.Comparing the Current Circumstances with Other Worse Conditions: The lives of all residents in Kermanshah were affected by the earthquake, which imposed more financial losses on some people. In some cases, the earthquake survivors tried to compare their own circumstances with the others who were more damaged.Participating in teamwork and being with other disadvantaged people made women less likely to think about their problems and this was a positive strategy to deal with this natural disaster.“Although our house is ruined, it is a blessing that at least my children are alive. Sad to say, my sister, lost her kid and her house was completely destroyed, too.” (Interviewee 10).“One of my sons was killed in the earthquake, and in spite of all the trouble that the earthquake has caused us, it’s a blessing that at least two of my kids and my husband are still healthy and I am not like my neighbor who lost his whole family in the earthquake.” (Interviewee 18).4.Sharing Feelings and Experiences: After the earthquake, the survivors were passionate about describing what the earthquake and its outcomes were like, thereby relieving themselves to some extent.One important psychological strategy that women chose to cope with their worse conditions in order to make it easier to tolerate awful conditions was comparing themselves to others who were far worse off.“After the earthquake, our only delight is sitting with other women in the village and thinking about the night when the earthquake occurred.” (Interviewee 13).“These days, the only thing that amuses me is sitting with other women in the village and speaking about the night when the earthquake occurred and its consequences. The good thing is that at least we understand each other.” (Interviewee 15).5.Heroizing the Dead: Many of the women who lost their relatives in the earthquake were proud of them and believed that their relatives would have God’s mercy on their souls because they lost their lives in the earthquake, thus making it easier for them to come to terms with the death of their loved ones more easily.In fact, sharing emotions and memories with other women makes rural women more likely to cope with post-earthquake events.“At first, I became desperately unhappy when my son died, but when I thought with myself that he was killed by the earthquake and God would forgive his sins for sure, I became calm and relieved”. (interviewee 2).“I am thankful to God that at least my innocent girl is dead in the earthquake, which is one of the best deaths because God himself will bless them. I believe that they are in heaven now.” (Interviewee 10).Rural women imagined a good place in the hereafter for their relatives who had died in the earthquake because they had died from natural disasters. This way, they could calm themselves down.Annoyance at God: After the earthquake, the survivors may feel that God has punished them. Therefore, they get annoyed and sulk.Negative Interactions: Despite some women who found positive ways to cope with the earthquake, some others were not able to react in the same way and chose ways to cope with the earthquake that could make their situation worse and more vulnerable. Negative interactions refer to the negative methods that lead to some kind of inappropriate adaptation to the events after the earthquake.“I had never missed a single prayer until the earthquake took my everything. So, I have decided not to say my prayers any longer.” (Interviewee 3).“After the earthquake, I cannot establish a close relationship with God because I feel he doesn’t see us anymore and I feel he likes us to die.” (Interviewee 8).2.The Phobic Display of a Greater Disaster: After the earthquake, rural women fell victim to a variety of local, national, and international propaganda and rumors, such as HAARP-triggered earthquakes. Therefore, they were obsessing over earthquakes with greater magnitudes.Since rural women blamed God for what was happening to them, some of them reacted to this by avoiding God and cutting off religious practices.“I have a gut feeling that a bigger earthquake happens and we all die.” (Interviewee 14).“I am positive there is going to be a bigger earthquake whereby everyone else will be killed. Every night, I think with myself that there may be another earthquake. So, I can’t sleep a wink all night long.” (Interviewee 6).3.Aggression towards the Others: Women are faced with a great deal of stress after the earthquake, possibly creating a kind of violence and aggression towards people around them, especially children.Despite warnings from national and local authorities that the HAARP phenomenon was not occurring, advertisements on social networks put more pressure on the earthquake-stricken people, and, in many cases delayed both their return home and starting the life over.“I had never hit my 10-year-old child before the earthquake, but I do not know why I lost my temper and slapped him.” (Interviewee 17).“After the earthquake, I have lost my temper so much that I keep picking on my kids and hit them.” (Interviewee 5).4.Isolation: After the earthquake, the psychological and social conditions cause some women to stay away from the others, thus worsening their psychological problems.Having violent behaviors towards others was another reaction of women to the earthquake that could make the situation worse than it was and make their lives more stressful.“After the earthquake, I am not in the mood to do anything, and I don’t even feel like going out of the container home or seeing anyone.” (Interviewee 22).“Before the earthquake, I paid visits to my relatives once a week or so, but now, it has been nearly two months I have not gone out of the village. Besides, I don’t leave my house when I am at the village.” (Interviewee 11).5.Death Wish: The demolition and psychological burden of the earthquake were so extensive in Kermanshah that after the earthquake, some women thought of death all the time and preferred to die. Many rural women could not cope psychologically with the situation, and since there were no suitable programs for their mental rehabilitation, many had no hope of returning to normal life and were thinking of committing suicide, and some even did this.Staying away from one’s community and isolation can have far-reaching consequences for rural women, and if this is not resolved, it can create more psychological problems.“I see myself much closer to death than before, and I would like to die.” (Interviewee 16).“I can’t stand this much stress and pressure any longer. I used to be scared of death, but now I do not care about it anymore. For instance, I have thought of attempting suicide on many occasions, but just because of my family, I haven’t plucked the courage to do it.” (Interviewee 6).In fact, rural women were getting closer to death because of their hopelessness to improve, and this can make it harder for them to return to life and cope with the issues.In addition to destroying houses, earthquakes can bring about massive destruction and threaten the lives of many people, especially rural women, as one of the most vulnerable groups in the event of earthquakes. It should be noted that women’s ability to come to terms with natural disasters such as earthquakes relies on how well their needs and concerns are understood by health planners and policymakers . TherefoThe results of the present study demonstrated that the health needs of women were neglected in the earthquake, which could endanger their health. When natural disasters occur in third world societies, some of the vital needs are neglected due to the lack of a proper supportive structure, and the same case goes for Kermanshah Province, too. For example, the health needs of women were neglected for months after the earthquake. Similarly, in studies conducted by Nakhaei et al. (2015), Hirth et al. (2013), and Rahmani Bilandi et al. (2015), the neglect of women’s health needs has been reported , 33, 34.The results of the present study indicated that earthquakes could cause tensions in families, and since the circumstances of families are extensively affected by earthquakes, it can lead to tensions in marital relationships and disruptions in family functioning . Chan etGender inequity in the provision of services and aid was one of the other categories in the present study. Women in rural areas did not have access to resources due to the lack of sufficient literacy and restrictive culture in the village. Additionally, because of the dominant patriarchal culture in these areas, women did not have the opportunity to receive aids. Therefore, the lack of access to vulnerable groups, such as women, to services can impose irreparable damages to them. Research has shown that, compared to men, women’s health is more at risk during disasters due to personal, social, and health-related factors. In other words, the vulnerabilities of women’s health in the events of natural disasters deteriorates because of inequality in facing disasters and access to resources and opportunities . ProvidiFeeling insecure was another category in the present study. Since the presence of aid workers and volunteers changed the previous social atmosphere of villages, it created a kind of insecurity in rural women because of their unfamiliarity with the new situation, which made women decide not to go out. It should be noted that there was no report of sexual assault due to the specific cultural context of the target area and the sensitivities that exist in this respect among Kurds.The results of the present research revealed that the ruling culture of the region had been ignored when the survivors of the earthquake were provided with services. For this reason, most of the delivered services were not used due to the incompatibility of the sent clothing and food with the native culture of the region. For example, many bathrooms were built in villages, but most women did not use them because of the cultural conditions governing their villages. It should be noted that providing services to earthquake victims should be community-based and based on the culture of the region so that the needs of certain groups such as children, women and the elderly to be taken into account . In addiAnother result of the present research was about the rural women’s unmet needs, especially their health-related needs, due to concealing them for fear of stigmatization. Likewise, in a study done by Rahmani Bilandi et al. (2015), it was reported that indigenous beliefs and cultural taboos were the main reasons for earthquake-stricken women’s concealing their needs, thus exacerbating their health problems . The resThe incoherent mourning was another category in the present study. Those who lose their relatives during an earthquake suffer from the loss of their loved ones for a long time because they cannot mourn their deaths properly.One of the issues that matter after earthquakes is adaptability and coping with emergencies afterward. Some people have more adaptability and less vulnerability whereas there are some who cannot cope with this problem and are more exposed to damages. Adaptability and coping are the topics of interest to researchers who study the effects of natural disasters on communities , 38. AdaThe results of the present study revealed that rural women’s reactions to earthquake fell into two categories: positive and negative interactions. In the former, they approached this phenomenon by getting closer to God, participating in group works, comparing their current circumstances with other worse conditions, sharing feelings and experiences, and heroizing the dead.Getting closer to God through religious practices and prayers was one of the strategies that rural women adopted to come to terms with the earthquake, which created a kind of inner satisfaction in them. Likewise, the results of previous studies showed that religious practices were recognized as one of the strategies for coping with natural disasters –44.Participation in group works was another strategy adopted by rural women to come to terms with the earthquake and to make them too occupied with group works in the community to think about problems, thus having less stress.Another category of positive interactions among earthquake-stricken women was comparing their own circumstances with others’ worse conditions. Since earthquakes can lead to loss of many lives, everyone is exposed to this problem, and the majority of victims compare their problems with those of others to relieve their pain and psychological burden.Sharing of memories was another way whereby rural women could come to terms with the earthquake consequences. After the earthquake, rural women gathered around their tents and container homes and shared the memories of the night of the earthquake, thus encouraging them and reducing their post-earthquake stress . SimilarOne of the other ways that rural women came to terms with the death of their loved ones was to heroize them, and they were believing that their relatives would have God’s mercy on their souls because they lost their lives in the earthquake. On the other hand, having found themselves in tremendously difficult conditions, they supposed that the dead were finally relieved and adored by God too much to let them experience intolerable conditions. However, some rural women found it hard to come to terms with the consequences of earthquakes, and their reactions included annoyance at God, phobic display of a greater disaster, aggression towards the others, isolation, and death wish.Since earthquake is seen as something that occurs with the will of the Almighty God, its occurrence in some cases changes the relationship between the survivors and God, and because the earthquakes are regarded as a punishment by God, they find it an annoyance.The phobic display of a greater disaster was another issue that was obtained from the data. In the area under study, after the major earthquake, there were a lot of aftershocks that exposed people to high levels of mental pressure to the extent that the mental pressure of aftershocks was more irresistible than that of felt during the main earthquake itself. In the meantime, rural women fell victim to a variety of local, national and international propaganda and rumors, such as man-made earthquakes, due to insufficient media literacy. They also fell for rumors that there would be more destructive earthquakes at any time. Accordingly, they were obsessing over worse happenings. Consistent with the findings of the present study, previous studies revealed that worry and fear after a natural disaster were more common among female survivors than men .Aggression towards other people was another result of rural women’s negative interactions because they experienced a lot of stress after the earthquakes, thereby leading to aggression and violence. This finding was concurrent with the results of studies in which it was reported that aggression and violence were prevalent in the families after earthquakes , 24.Isolation was another alternative taken by rural women after the earthquakes, thereby excessively increasing their psychological burden and making it less likely to appear in community and to express in their desires and needs.Death wish was another category in the present study. The earthquake that occurred in Kermanshah destroyed lots of residential buildings and the subsequent damages led to psychological problems and hopelessness in women. Furthermore, since rural women in this area had little knowledge to deal with critical conditions, they got distressed and desperate, and thought of death and suicide. For example, in a study conducted by Hyodo et al. (2010) on the victims of an earthquake in Japan, the tendency towards death and suicide was on the rise among women . LikewisThe rural women, troubled by earthquakes are usually benefited from the fewest facilities and always in need of health and financial basics, which are affected by their social and cultural conditions, such as gender inequity in the provision of assistance, concealing needs for fear of stigmatization and ignoring the ruling culture in the area. Additionally, the results of the present study revealed that rural women’s reactions to earthquake fell into two categories: positive and negative interactions. In the former, they approached this phenomenon by getting closer to God, participating in group works, comparing their current circumstances with other worse conditions, sharing feelings and experiences, and heroizing the dead. However, most rural women found it hard to adopt such type of positive adjustment and negatively reacted to the consequences of earthquakes, including annoyance at the God, phobic display of a greater disaster, aggression towards the others, isolation, and death wish. Hence, in the event of natural disasters, such as earthquakes, paying more attention to the needs of rural women, taking the culture governing the village into account at the time of service delivery and helping them with positive adaptations are some indispensable measures that should be taken.


The holotropic mind perspective, an integral part of the framework of transpersonal psychology, has been considered a revolutionary approach to a certain spectrum of experiences in Non-ordinary states of consciousness (NOSC) which conventional approaches tend to treat indiscriminately as pathological processes, because PHM recognizes in these experiences their healing and evolutionary potential. This article describes the needs assessment, implementation, and evaluation of an experiential and educational program on the holotropic mind perspective and its praxis, Holotropic Breathwork® (HB), with students and professionals from the Group for Early Intervention in First-Episode Mental Crisis of a Psychotic Type of the University of Brasilia. The intervention aimed to establish change goals and objectives that would promote the adoption of the holotropic mind perspective’s elements, such as a framework to broaden and strengthen mental health programs that assist people experiencing NOSC. The stages developed, inspired by the Intervention Mapping protocol, included a needs assessment; elaboration of change objective matrices; selection and description of methods based on theory and their applications; conception, planning, and implementation of the intervention; and results evaluation. Participants reported that the intervention allowed the expansion of their theoretical-conceptual and technical frameworks, giving them a less pathologizing understanding of and approach to NOSC and allowing them to perceive and manage such states, not as indiscriminately pathological expressions, but as phenomena inherent to the human condition that can be accepted and cared for without the exclusionary and exhaustive bias of mental disorders. Limitations and practical implications are discussed. Human history presents, in every society and culture, a wide array of therapeutic approaches toward health and illness, including the psychological. The first investigations of psychology and psychiatry strongly emphasized the field of neuroscience, presuming that one could find in the body the causes of various psychological phenomena as well as the solutions to these problems—something that has only been reinforced by the advent of psychopharmacology Costa, . While rIn this scenario, the holotropic mind perspective (HMP), proposed by Czech psychiatrist Stanislav Grof, becomes important, as it advocates stepping back from this pathologization bias and taking a certain spectrum of NOSC experiences as qualitative changes that may hold developmental potential when well-managed and should not, a priori, be considered anomalous mental digressions Grof, , 2015. TTaking HMP as a starting point, the stages of an educational and experiential program around HMP and its praxis, HB, were recorded. HB’s development was inspired by the intervention mapping protocol and stresses the stages of needs assessment; the intervention’s expected results; selection and description of methods based on theory and their applications supported by evidence for their success; conception and implementation of the intervention carried out; and results evaluation , with students and professionals from the Group for Early Intervention in First-Episode Mental Crisis of a Psychotic Type of the University of Brasilia.The stages of the educational and experiential program in HMP that were performed inspired by IM, from needs assessment to results achieved, are presented as follows Fig. . The stuIn the needs assessment stage, the problem the intervention focuses on should be scrutinized, seeking an approximation with reality into which is inserted, along with the actors involved in it, the interactional dynamics that occur in the scenario, and related behaviors. This investigation can be carried out with qualitative methods, such as interviews or focus groups Köche, . This inThe sample who participated from needs assessment was composed by 30 people linked to GIPSI Program, among interns, volunteer professionals, and researchers. GIPSI is a Standing Extension Program of the Department of Clinical Psychology of the Institute of Psychology at the University of Brasilia. It consists of an interdisciplinary team of professionals, volunteers, interns, and researchers from the fields of psychology, psychiatry, nursing, social service, occupational therapy, and others. This program focuses on the welcoming and care of people in their first mental health crisis and their relatives as well as on the development of research related to severe psychological distress and its management .The needs assessment was performed via a set of methods  and Brazilian Coordination Portal for the Improvement of Higher Education Personnel  was one article and, at Google Scholar, one article and one citation, whose original article was recovered at the Pluralities in Mental Health Journal website. For the observation and interview, a script was prepared, adapted from IM , were requested for this activity. The choice of these individuals was due to the nature of the work, developed by the GIPSI Program, in which they welcomed and followed-up with people in psychological distress, a phenomenon which, in the scope of this program, is taken as an integral aspect of existence. To be avoided at all costs is its a priori framing as a nosographic classification of mental disease. Instead, it seeks to understand it from a broader phenomenological perspective that suggests a more integrative management of these experiences  in the initial planning actions of GIPSI. However, these groups have a privileged space to talk during the therapeutic process and group activities, in which they “can offer their impressions,” having been invited to evaluate the care and the propositions for improvement of the initiatives connected to the program.Regarding the program development, it was observed that the model of early intervention in psychotic crises developed by GIPSI, albeit inspired by the English experience of early intervention in psychotic crisis Among the barriers to the program’s development, the precariousness of the psychosocial care network of the Federal District, which lacks sufficient psychosocial assistance centers thus resulting in GIPSI being overloaded, was cited. As barriers, paradigm divergences in the assistance model were noted, as the caregivers entering the program often bring from their background a hospital and medical perspective concerning the management of people in mental health crisis. It was mentioned that approximately 20% of the people and families who begin their treatment in the program quit, making adherence a challenge. Regarding these challenges, the interviewee reveals:Some other challenges are posed for the program, such as those related to interdisciplinary and interprofessional work, integration between theory and practice, and the need for openness to a paradigmatic deconstruction. To overcome the identified barriers, the program proposes methodological workshops to discuss aspects of the program’s structure, process, concepts and results, and experiential workshops in which relational aspects between group members and care with the caregiver are addressed. These workshops are held every 6 months and can be organized on special dates if there is a need for technical and methodological alignment. In addition to this strategy, the whole team undergoes individual and collective supervision by the program staff. This includes the evaluation of the work process, the survey of limitations and needs, the sharing of experiences overcoming barriers, and the formulation of propositions to overcome them.Regarding the program’s evaluation methods, it was observed that GIPSI members use internal and external strategies. In addition to the previously mentioned workshops and team supervision, evaluation has been carried out through assessment by research funding organizations, such as the Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES). Also, through publications—be they books, articles, theses, or dissertations—GIPSI members raise visibility of the program experience and boost its recognition by the scientific and care-giving communities. One final evaluative strategy is the organization of scientific and cultural events, where this small community presents its products and services, open to public judgment. Today, around 40 people work at GIPSI, including professionals, volunteers, interns, researchers, and graduate students (masters and doctorate candidates). The evaluation of the GIPSI program, considering the steps proposed for the planning and development of health interventions, allowed greater appropriation of the context in which the educational and experiential program in HMP and its praxis, HB, to be developed.® to formalize the invitation to conduct HB workshops. Plane tickets and lodging were provided as the implementers lived outside Brasilia. All equipment and materials needed to fulfill the educational and experiential program were provided. The partnership with the Institute of Mental Health for the assignment of the facilities was secured after a visit to the unit, and formalization of the reservation request was made via the Federal District Health Authority’s Electronic Information System. As a counterpart to the partnership with the institute, vacancies were reserved for service professionals and volunteers interested in the holotropic approach. Visits to GIPSI and the institute were made during team meetings to present the educational and experiential program, including awareness-raising and invitations to participate in the initiative.Based on the needs survey and according to the planning established, the envisaged educational and experiential program was conducted. Telephone and e-mail communication were carried out with facilitators certified by Grof Transpersonal TrainingThe educational and experiential program took place in two workshops, the first on April 26–28 and the second on June 15–17, 2018. The structure of the workshops was identical. On the first day of each workshop, the activities were focused on expository dialogues "It was for me an experience that promotes self-knowledge and development." (P4)"I had a huge increase in my personal analysis from my holotropic breathwork experiences. From these experiences, I managed to advance my therapeutic process a lot. It is much more intense and is giving very nice results. (P11)To begin the evaluation of intervention outcomes, it should be noted that of the 28 people who participated in the workshops, 22 of them answered the interviews, of which 11 were professionals, seven were students, and four were volunteers. For the objectives of the following analyses, it was decided not to use with the volunteers’ responses as they were not clinical practitioners and thus lack this point of view. In fact, of the 18 professional (P) and student (S) respondents, only five (27.75%) reported they had had experienced NOSC before the HB practice offered in the program. As for the NOSC experiences that occurred during the HB workshops, all 18 (100%) respondents stated that it was a transformational experience that impacted their personal and professional development:We recognize that the realization of the present educational and experiential program, built upon and inspired by the Intervention Mapping Protocol, was successful in choosing and implementing the methods and their outcomes. Active learning methods The program provided an environment for participants to express themselves regarding the evaluation of the activities developed as well as for self-evaluation The practice of HB Grof,  has showThe practice of HB has successfully allowed the exercise of action-reflection-action within the explanatory model of mind proposed by psychiatrist and researcher Stanislav Grof, wherein the existence of an expanded mental cartography includes remembrance levels beyond that of biographical memory, commonly studied by the traditional psychological schools. These different levels in the perinatal and transpersonal remembrance dimensions can be accessed when experiencing, in a spontaneous or induced way, NOSC. Such experiences, when well-received in an appropriate therapeutic environment, as proposed by the practice of HB, can be promoters of healing and personal development Yes, mainly for not judging the psychological phenomena that need to be manifested. (P8)Undoubtedly, first, it does not treat psychological demands as diseases, but as part of the human being. In addition, it refers a lot to the phenomenological approach that brings us precisely this idea of going against the pathologization of mental suffering. (S1)At this point in the analysis, resuming the action planning, it can be stated that the development of this educational and experiential program achieved the proposed goals, resulting in 16 (88.8%) of the respondents recognizing that the holotropic mind perspective is a less pathologizing approach to NOSC phenomena than conventional psychological approaches, which is represented in the following statements:Very interesting technique of self-knowledge, making it possible to experience deep levels of consciousness, as I observed. (P4)The other conventional practices in mental health do not have such an ability to access our subconscious mind so assertively, to the point that we ourselves are the authors of our emotional and physical healings. (S1)Only two (11.2%) of the respondents did not comment on this topic. Seventeen (94.35%) respondents agree with the statement that the practice of HB is a valid, important, and recommendable mental health tool for people who experience NOSCs. Here are some statements regarding HB practice:I could not come to a 100% conclusion. (P1)One (5.55%) of the respondents did not categorically state a standing:I will use many of its elements. It certainly prepared me better to welcome the user. (P5)In fact, the perinatal stages (levels reminiscent of the Grofian perspective) are something to pay attention to; I have even reflected a lot on how this (re)birth process reverberates in my own life. (P8)I would consider other dimensions, such as the perinatal and the perspective regarding the subject's relationship with reality. (P10)In particular those [elements] that understand spiritual emergencies and the transpersonal scope of consciousness may be very relevant in dealing with the 'unspeakable' suffering of the people I treat in the future (S7)Of the 18 professionals and students respondents, 17 (94.35%) expressed interest in deepening their knowledge and willingness to include elements of HMP in their theoretical framework and clinical practice with people reporting NOSC experiences. The following statements are representative:Concluding the evaluation of the educational and experiential program implemented by us and underpinned by the IM protocol, it is notable that the participants’ acquisition of HMP allowed the expansion of their theoretical-conceptual and technical frameworks, making them aware of a less pathologizing understanding of and approach to NOSC phenomena. This in turn allowed the perception and management of such phenomena, not indiscriminately as pathological expressions, but as phenomena inherent to the human condition that can be accepted and cared for without the exclusionary and exhaustive bias of mental disorders.One of the limitations of the educational and experiential program described here is the fact that the needs assessment for the GIPSI Program was conducted based on the few documents available in academic databases, one participant observation session, and one interview, though it was with a key informant. The low adherence of GIPSI Program members to the initiative, the target group of our study, also set a limitation. Although it was overcome by the inclusion of members of the ISM mental health program, and, in the end, the results of the initiative were broader and more positive than those initially envisioned, as two mental health programs were included in the process, rather than the single one originally planned.The experience of using the IM approach was of crucial importance for the success achieved by the initiative as it enabled the program to foster knowledge capable of guiding a clinical and social practice that offers greater support and care to the subjects and collectives in mental health care programs, such as those of GIPSI and ISM. The present exercise of using the Intervention Mapping protocol instrumentalized, in a less intuitive way, our intervention propositions, grounding them in theoretical and methodological bases and in evidence for their successful practical applications. Likewise, the unconstrained validation of participants of the value of the holotropic mind perspective shows that these contributions can be added to those already achieved by clinical psychology, expanding theoretical support for the deconstruction of discourse between normalcy and pathology, favoring a more respectful and dignified treatment of people who experience unique psychological phenomena such as NOSC.


Teaching Point: This clinical case shows the importance of also examining the arteries when investigating suspected deep venous thrombosis. A 54-year-old patient, very active and a smoker, was sent for ultrasound of the knee and calf to exclude deep venous thrombosis (DVT). Upon specific questioning, the patient revealed that for four days he had been suffering from constant posterior knee pain while calf pain actually occurred only during walking. The popliteal vein was depressible and DVT was excluded, as was rupture of a popliteal cyst. Incidentally on Doppler ultrasound, the popliteal artery showed flow acceleration up to 350 cm/sec, due to a tight stenosis Figure . It was Adventitial cyst is a rare vascular disease that causes peripheral artery stenosis or occlusion by luminal compression. It mainly affects men aged 40 to 50 years old, and the popliteal artery is the most frequently involved vessel (85%). The incidence is estimated at 1:1200 in the case of arterial stenosis around the knee. Usually it affects the popliteal artery unilaterally. The clinical presentation is often intermittent claudication in patients at low risk of vascular disease whose clinical diagnosis is therefore difficult [Contrast CT and magnetic resonance imaging are useful for assessing the detailed morphology of the cysts and the stenosis and can additionally reveal a communication between the cyst and an adjacent joint. On contrast CT, the cyst is commonly of “water density”, causing an “hourglass” or “scimitar” narrowing of the vessel lumen. The cysts appear respectively hypointense and hyperintense on T1- and T2-weighted magnetic resonance imaging.


Since 2015, we have run a free 9-week summer program that provides non-computer science (CS) undergraduates at San Francisco State University (SFSU) with experience in coding and doing research. Undergraduate research experiences remain very limited at SFSU and elsewhere, so the summer program provides opportunities for many more students beyond the mentoring capacity of our university laboratories. In addition, we were concerned that many students from historically underrepresented (HU) groups may be unable to take advantage of traditional summer research programs because these programs require students to relocate or be available full time, which is not feasible for students who have family, work, or housing commitments. Our program, which is local and part-time, serves about 5 times as many students as a typical National Science Foundation (NSF) Research Experiences for Undergraduates (REU) program, on a smaller budget. Based on our experiences, we present 10 simple rules for busy faculty who want to create similar programs to engage non-CS HU undergraduates in computational research. Note that while some of the strategies we implement are based on evidence-based publications in the social sciences or education research literature, the original suggestions we make here are based on our trial-and-error experiences, rather than formal hypothesis testing. The structure of the program is its most important characteristic. The first 6 rules are related to ways in which the structure of the program and the application process promote inclusivity and garner engagement.am to 12 pm four days a week, in addition to an all-hands lunch meeting from 12 pm to 2 pm one day a week. So far, while the program is free to participants , we have not been able to offer participants stipends. While we would prefer to offer students financial support, since we do not offer a federally funded stipend, we avoid any need to talk about citizenship. This makes our program more accessible to undocumented students compared with most federally funded summer research programs.Since many students at our campus (San Francisco State University [SFSU]) have a job or jobs, commute long distances, take care of family members, take summer classes, or volunteer in their community, our program is part-time (10 hours per week). The part-time nature allows students to participate while still tending to these other obligations. We decide on and set all meeting times at the time of application and have students apply to their desired meeting times. We make it clear that no work is expected outside of these hours. Once accepted to the program, students know their time obligation and schedule. For example, an applicant might be offered a spot on a team that meets from 10 Our application process starts early in spring and aims to attract a diverse cohort of students. We use a number of evidence-based recruitment strategies, including the following.We emphasize that no prior knowledge is expected, there are no grade point average (GPA) or prerequisite requirements, and no letters of recommendation are needed.We make it clear that the program is free.On the flyer we use to advertise the program, we feature a visibly diverse group photo including virtually all of the previous year’s participants  and logistics (whether they are available for possible team meeting times). Perhaps in part because of these strategies, our applicant pool and selected student body have always consisted of large numbers of historically underrepresented (HU) groups (approximately 70% in 2018) and women and gender nonconforming (approximately 80% in 2018) students. These percentages are much higher than those for SFSU’s biology, chemistry, and economics departments, from which the program draws most of its applicants.When working alone, we’ve often seen students learning computer science (CS) and programming get stuck on technical problems, leaving many feeling lost and inadequate and wanting to discontinue learning this new skill. Working in a mentored team, however, students have access to immediate support from their peers and mentor. This helps them learn technical skills more efficiently, develop relationships with each other, and cultivate a shared sense of belonging in computational research . We recoOver the years, we have found that near-peer mentors are incredibly useful for a number of reasons, including that (1) student participants are more likely to ask for help from a near-peer mentor than from a faculty advisor, (2) near-peer mentors serve as role models, giving participants an idea of what they can aim for in the next year or two, and (3) the use of mentors allows the program to serve many more participants than it could if it relied on a few time-pressed faculty advisors. Our selection criteria for mentors include essential knowledge , mentoring experience or potential, logistical availability, and having a similar demographic background as the participants. Mentors don’t need experience with the specific coding language or research topic they will work on with their team. Rather than being the expert in the room, they are expected to help team members work together to find solutions or formulate questions for the faculty advisor. The application for mentors is similar to that for program participants, but includes more information about research, programming, and mentoring experience. Thanks to the large number of mentor applications we have received each year, we have easily been able to select excellent mentors, most of whom are HU and/or women or gender nonconforming. Mentors are crucial for the success of the program and need to be paid well for their work. Each week of the program, we pay our mentors a competitive wage for 8 contact hours with their team, a 2-hour all-hands lunch meeting, a 2-hour mentor meeting, and 4 additional hours to account for preparation.https://www.datacamp.com/], Udacity [https://www.udacity.com/], or Coursera [https://www.coursera.org/]) motivate and engage students better than books or online texts. Yet, when working individually, most students—especially beginners and HU students—don’t finish online classes [We have found that when learning basic programming skills, interactive online classes to learn computer programming . In this training, mentors are equipped with tools for working with their team. For example, they learn to frequently gather anonymous feedback from their students (the mentor might prompt “write down one thing you learned and one thing that confuses you this week”). In addition, an experienced mentor advisor leads the mentors in a 2-hour weekly meeting to troubleshoot group dynamics and project hang-ups, discuss pedagogy, and respond to weekly student evaluations. These meetings are a crucial time for mentors to get feedback, hear from others running into similar issues, and share solutions. We have had the most success when an experienced advisor who is not a faculty advisor of any of the summer teams runs the mentor meetings, as it alleviates any pressure that some mentors may feel to hide their challenges. We also encourage mentors to communicate with their faculty advisor openly and regularly.The first time we ran our summer program with multiple teams, we received overwhelming feedback that participants wanted to get to know students from other teams. Therefore, we instituted a weekly all-hands meeting during which all participants and mentors in the program get to meet and mingle. Importantly, we provide the food at these meetings and plenty of time for students to eat and chat. Sometimes we invite external speakers from nearby companies or universities to these meetings. We also use these meetings for the faculty involved in the program to talk about their research, and for a workshop on coping with stereotype threat that can lift the performance of women and minorities in STEM . Our oveDuring the last week of our summer program, each team creates and prints a scientific poster describing their research. They present these posters at a fairly large end-of-summer symposium where students from many summer programs on our campus share their work. This conference is a lively event with many students, faculty, and family members in attendance. Participants seem to develop a stronger identity as a scientist by preparing posters, seeing the professional printed products, and proudly presenting their work . In factMany students are excited to do more coding, research, or both after the program ends. To connect students to future research opportunities, we dedicate the last all-hands lunch meeting to a networking session with principal investigators (PIs) on campus, many of whom are interested in meeting the summer students who now have 90 hours of coding and research experience. Each PI has 3 minutes to pitch a project. Then the faculty sit at tables, where students can approach them to talk about the projects. All interested alumni of the 2018 summer program joined research groups the following fall. In addition, we give students information about relevant courses at SFSU they can take that include some coding . SFSU also offers a 5-course CS minor for biology and chemistry minors, which is a great option for alumni from the summer program .Using these 10 simple rules, we have been able to set up a popular and effective program that uses few resources. The influx of students trained in our program has had a substantial impact on our primarily undergraduate-serving institution, allowing faculty and students to carry out many new research projects together. The program originally started in the Biology Department, but as our program has expanded, we have found it possible, though more complicated, to include projects that are of interest to students from economics, public health, and ethnic studies.Our end-of-the-program survey, given to both participants and mentors, is used internally to improve the program year over year. We decided to write this 10-rule paper to share the ideas we have developed from our experiences running this program over a number of years. If you are planning to start a similar program on a low budget, know that you can start with just one team of students (4–5 undergrads). We hope you are inspired to adopt whichever of our rules make sense to create your own program customized to your specific institution. We would love to hear about your program as it develops!


Minds in Motion® addresses many of the barriers often linked to poor physical activity participation in chronic diseases (such as inclusion of the care partner), to ensure the best program uptake. The Minds in Motion® program has anecdotally been successful in helping to increase physical function and social skills in those living with dementia. However, it is important to connect community-driven programs with the academic research community, to create an opportunity for high quality evaluation metrics that can be disseminated at multiple levels: to research audiences, clinical audiences, and to those in the community. With ongoing collaborations between research and community programs, there is a greater opportunity to understand the positive impact of a program, which ultimately increases the chance of funding for the program. In this editorial, we highlight that community-integrated research is an important priority for future collaborations.Alzheimer’s Disease (AD) and other dementias are prevalent neurodegenerative diseases characterized by decreased cognition, physical function, and quality of life. Currently, millions of people are living with AD and other dementias. With no cure, research has examined the use of non-pharmacological treatment options including exercise. Many high-quality studies demonstrate that physical activity slows the progression of AD’s many outcomes, and is beneficial to overall quality of life in those living with AD. However, creating exercise interventions at the community level that individuals will adhere to is often a challenge. The Alzheimer’s Society of Canada developed a unique program that combines physical activity with cognitive stimulation in a social atmosphere: The Minds in Motion Alzheimer’s Disease (AD) is the most common form of dementia and is a progressive neurodegenerative disease that is characterized by many neurological components including behavioral changes, cognitive decline, as well as physical impairments . ApproxiIt is well known that AD has many symptoms associated with cognitive decline including poor memory, judgement, orientation, reasoning, as well as behavioral changes such as frustration and depression. Reductions in physical function are also common ,5. CharaPharmaceutical medications such as cholinesterase inhibitors  and Memantine (Namenda) can be used to aid in the treatment of AD . HoweverWhile data clearly demonstrates that exercise is beneficial to those living with dementia and AD, figuring out how to deliver exercise programing at a community level is challenging . There a® (MiM), targeted towards persons living with symptoms of early to mid-stage dementia. So, what exactly is MiM? MiM is an eight week program that combines physical activity and mental stimulation into a two hour session once per week [In 2009 The Alzheimer’s Society of Canada developed an innovative program named Minds in Motionper week . The insper week . The phyper week . The proper week . TherefoThe MiM program has a number of important goals: to increase the number of programs available that provide mental health services and support; to increase the awareness and support to individuals, families, and care partners regarding mental health education; to increase community awareness and partnerships to sustain the MiM initiative; and to improve physical funcitoninig and general well-being of program participants. Anecdotally, and thorugh pilot data, the MiM program has been well recevied and is an effective program for those living with mild to moderate dementia. Individuals who particpate in the MiM program report improved mental functioning following a MiM session, gains in their confidence and comfort with their life, as well as improved balance, mobility, strength, endurance, and increased flexibility .However, more hypothesis-driven research that demonstrates the impact of MiM on multiple outcomes  is still needed. High-quality research followed by an advanced knowledge-mobilizaton plan that targets medical professionals in the community , research scientists , as well as reports to families within communities are ways to effectively disseminate the results. Incorporating high quality research outcomes within a community delivered program such as MiM will provide key evaluation metrics that demonstrate effectiveness  in an increasingly evidence-savvy culture. The ultimate goal is to encourage increased program participation and uptake, as well as solidify funding from public and private sectors.® program) are necessary initiatives that lead to an improved quality of life in those living with AD. However, we believe that it is critical for members of the scientific community to join forces with community program teams, and assist with developing and implementing research-driven outcomes that demonstrate program effectiveness. Reliable program effectiveness data increases the opportunity for funding (both public and private), and ultimately increases program availability to more individuals. For example, our research team is commited to working with our local Alzheimer Society  to assist in creating appropriate evaluation metrics for the above stated reasons. We look forward to continuing to bridge the connection between academic research driven outcomes and community-based programming; and in the end improving care and health outcomes for persons living with dementia.In conclusion, with the incidence of dementia on the rise, there is a continued need to explore and implement non-pharamcological treatment options including exercise ,24,25,31


The success of tyrosine kinase inhibitor (TKI) therapy has greatly prolonged the survival time of patients with chronic myeloid leukemia (CML), harboring the characteristic Philadelphia (Ph) chromosome. However, a fraction of patients, achieving complete cytogenetic response after TKI therapy, develop a myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML) with additional clonal chromosomal abnormalities in Philadelphia-negative cells (CCA/Ph–).A 56-year-old woman with AML, developing from Philadelphia-negative CML after TKI therapy. She showed 6 kinds of somatic variants—CEBPA, ATRX, WT1, CSMD1, IKZF1, and LRP1B mutation after diagnosed as AML.The patient was diagnosed with chronic phase CML that developed to AML after achieving durable complete cytogenetic response (CCR) and major molecular response (MMR).The patient was treated with TKI therapy at the period of CML. When diagnosed with AML, she received induction chemotherapy regimens, consolidation therapy, and allogeneic hematopoietic stem cell transplantation subsequently.The patient has been CCR and MMR for nearly 4 years, and has achieved complete remission after intervention related to AML. She is now preparing for allogeneic hematopoietic stem cell transplantation.These rare occurrences highlight the importance of exploring the relevant pathogenesis of AML developing from CML after TKI therapy. In addition to monitoring molecular changes in the course of CML, cytogenetic analysis, or next-generation sequencing of CML patients should be performed. As is shown in some reports, the overall prognosis of CCA/Ph– CML is good and depends on the response to imatinib therapy. Rare cases of CML treated by TKIs, including imatinib, dasatinib, and nilotinib, progressing to myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML) from CCA/Ph–have been reported,–8 even though they are in complete cytogenetic response with no Ph-positive metaphases and in major molecular response (MMR) with BCR-ABL1 negative. According to the National Comprehensive Cancer Network, all TKIs are highly effective in the newly diagnosed chronic phase of CML, and the vast majority of CML patients can achieve complete molecular remission with no BCR-ABL1 rearrangement using reverse transcription quantitative polymerase chain reaction (RT–qPCR) after TKI therapy.Chronic myeloid leukemia (CML), harboring the characteristic Philadelphia (Ph) chromosome, a translocation between chromosome 9 and 22, is associated with a significantly improved overall survival rate after tyrosine kinase inhibitor (TKI) therapy. TKIs, which originally inhibited the activity of BCR-ABL1 fusion gene product, have been performing an extremely important role in CML patients.22.1 After the BCR-ABL1 positive clone was not detectable for the first time in July 2015, the patient has achieved durable CCR and MMR. The monitoring of BCR-ABL1 using RT–qPCR (IS) has been performed continuously, after achieving BCR-ABL1 (IS) ≤1% (>0.1–1%), every 3 months for 2 years and every 3 to 6 months thereafter  immediately after diagnosis and then monitored for durable MMR for nearly 3 years. The sole abnormal karyotype was tq34;q11)[12] at original diagnosis in January 2014. Bone marrow aspiration showed 4% blasts, and fluorescence in situ hybridization analysis of bone marrow cells revealed that the patient had 189 cells bearing BCR-ABL1 fusion (p210) from among 200 counted. At the same time, the ratio of BCR-ABL1 to ABL1 transcript numbers was 24.000%, standardized by an international scale (IS) using RT–qPCR. The patient first received TKI therapy (imatinib 400 mg/day). The patient's BCR-ABL1/ABL1 transcripts as monitored by RT–qPCR (IS) were 0.400%, 2.400%, and 2.200% at the 3-, 6-, and 12-month evaluations, respectively. After failing to achieve BCR-ABL1 transcripts <0.1% at 1 year after first-line therapy with imatinib, the therapy was changed to nilotinib 400 mg twice daily, which is associated with superior cytogenetic and molecular response rates compared with imatinib.1[12] at  was seen  or mutational types of BCR-ABL1. Additionally, a sole karyotype abnormality other than Ph chromosome, a translocation between chromosome 1 and 19, t,2 d1–d3, cytarabine 100 mg/m2 d1–d7 continuous infusion). The patient, subsequently, has been treated with consolidation therapy of high dose cytarabine after she achieved complete response of AML. In addition, the woman has accepted nilotinib 400 mg twice daily for CML at the intermission of the chemotherapy before preparing to receive allogeneic hematopoietic stem cell transplantation from an HLA-matched donor.Next-generation sequencing of peripheral cells to screen for 42 kinds of genetic mutations of leukemia showed CEBPA mutation at 67.63% and IKZF1 mutation at 50.20%. Since the novel mutation appeared after achieving MMR, we analyzed the patient's whole exome sequence. The results revealed 6 kinds of somatic variants—CEBPA, ATRX, WT1, CSMD1, IKZF1, and LRP1B mutation—accounting for 74.00%, 46.00%, 45.00%, 44.00%, 52.00%, and 39.00%, respectively. In other words, the patient newly developed AML with CCA/Ph– after achieving MMR of CML, and showed complete remission state of 4% myeloblast cells in bone marrow after receiving induction chemotherapy  may already exist, according to 1 hypothesis, unknown, which then leading to AML after cooperating with BCR/ABL. On account of the prior attraction of BCR-ABL1 fusion, the latent clone mutation may play a leading role, developing into MDS/AML when the BCR-ABL1 fusion oncogene disappears or the Ph chromosome becomes negative. In addition, the study also suggested that abnormal bone marrow stroma may result in the acquisition of BCR–ABL1 and other genetic aberrations, leading to MDS or AML. Therefore, in addition to the molecular detection of BCL/ABL in CML, which used to be the main monitor for response to TKI therapy, cytogenetic analysis or next-generation sequencing of CML patients should be performed.Cases of CML progressing to CCA/Ph–MDS/AML after treatment with imatinib, dasatinib, or nilotinib have been reported.Formal analysis: Jia Liu.Methodology: Bin Yang.Resources: Yun Ling.Software: Wei Wu.Writing – original draft: Huan Zhu.Writing – review & editing: Yun Ling.


BCR‐ABL1 kinase domain (KD) is a common mechanism of resistance to tyrosine kinase inhibitor (TKI)‐based therapies in Philadelphia chromosome‐positive (Ph+) acute lymphoblastic leukemia (ALL). Sanger sequencing (SS) is the most frequently used method for diagnostic BCR‐ABL1 KD mutation screening, but it has some limitations—it is poorly sensitive and cannot robustly identify compound mutations. Next‐generation sequencing (NGS) may overcome these problems. NSG is increasingly available and has the potential to become the method of choice for diagnostic BCR‐ABL1 KD mutation screening. A group discussion within an ad hoc constituted Panel of Experts has produced a series of consensus‐based statements on the potential value of NGS testing before and during first‐line TKI‐based treatment, in relapsed/refractory cases, before and after allo‐stem cell transplantation, and on how NGS results may impact on therapeutic decisions. A set of minimal technical and methodological requirements for the analysis and the reporting of results has also been defined. The proposals herein reported may be used to guide the practical use of NGS for BCR‐ABL1 KD mutation testing in Ph+ ALL.Emergence of clones carrying point mutations in the  BCR‐ABL1 kinase domain mutation screening in Philadelphia‐positive acute lymphoblastic leukemia patients receiving tyrosine kinase inhibitor‐based therapies. Minimal technical and methodological requirements for the analysis and the reporting of results have also been proposed.This consensus paper presents the results of an initiative by an expert panel to define a set of indications for the practical use of next‐generation sequencing for  Mutation testing is commonly performed by bidirectional Sanger sequencing (SS) of the entire BCR‐ABL1 KD amplified by polymerase chain reaction.BCR‐ABL1 transcripts.BCR‐ABL1‐positive cells.BCR‐ABL1 KD mutation testing by NGS in patients with Ph+ ALL, and this does not allow the formulation of evidence‐based recommendations. The aim of this project was thus to generate consensus‐based indications for the possible clinical use of NGS in Ph+ ALL.There is increasing evidence that a rational use of minimal residual disease (MRD) monitoring and 2A Panel of Experts was appointed on the basis of their nationally and internationally recognized expertise in the treatment and molecular monitoring of ALL. An initial meeting was held in June 2018, during which the outline of the project was defined and the topics of the expert discussion were decided. A series of key questions were identified and addressed through questionnaires. Each panelist drafted statements related to one or a few questions, while the remaining panelists scored their agreement with those statements or provided suggestions for modifications. Subsequently, the Panel convened for a consensus conference in Milan in November 2018, where final proposals were defined using the nominal group technique.33.1BCR‐ABL1 KD mutations have been identified in de novo Ph+ ALL.When using highly sensitive methods of detection, Using denaturing high‐performance liquid chromatography (D‐HPLC), Pfeifer et alRousselot et alBCR‐ABL1 transcript levels in Ph+ ALL patients is universally accepted as a strong prognostic factor and is performed at regular intervals during treatment.BCR‐ABL1 KD mutations.BCR‐ABL1 mutations in parallel to MRD assessment may thus provide meaningful information on the subclonal sensitivity of Ph+ leukemic cells to the current therapy. As a matter of fact, a strikingly rapid expansion of the mutated clones as early as after 4 weeks since TKI initiation was observed,Real‐time PCR‐based assessment of residual 3.1.1BCR‐ABL1 KD mutation testing by NGS is indicated in patients with Ph+ ALL before frontline treatment. The Panel argued that the detection of BCR‐ABL1 KD mutations that might lead to the emergence of TKI‐resistant clones could allow the identification of patients at a higher risk of MRD persistence and early relapse, and help in planning an individualized molecular and mutation monitoring.BCR‐ABL1 transcript levels decrease below 0.1%, or until the increase in mutation and BCR‐ABL1 transcript levels leads to therapeutic intervention.In patients with pretherapy low‐level mutations known to confer resistance to one or more TKIs, monthly retesting should be performed to monitor mutation kinetics, until residual 3.2BCR‐ABL1 KD mutation status is important for treatment decision‐making.Relapses after therapy may be associated with the emergence or persistence of clones harboring mutations that confer resistance to the TKI incorporated in the treatment regimen. Since for each TKI there is a well‐defined spectrum of sensitive and resistant mutations, an accurate assessment of BCR‐ABL1 KD mutational status in 55% of samples. Indeed, low‐level mutations were detected not only in SS‐negative patients, but also in addition to the dominant clone(s) detected by SS. Compound mutations were frequent in advanced phase CML and in Ph+ ALL, and could easily be recognized by NGS in the majority of cases. In another study,BCR‐ABL1 KD proved capable of anticipating an impending recurrence with a median of 5 weeks  compared to the classical SS‐based analysis.Using NGS, Soverini et al3.2.1BCR‐ABL1 KD mutation testing by NGS is indicated in patients who do not reach a CHR after induction therapy.BCR‐ABL1 KD mutation testing by NGS is also indicated in patients who do not reach a complete molecular response after induction therapy. In the latter, however, the BCR‐ABL1 transcript level should be >0.1% to ensure the feasibility of NGS library preparation. Given the variability of the induction protocols, at least 4 weeks of induction therapy should be completed before NGS testing.BCR‐ABL1 KD mutation testing by NGS testing is indicated in patients with a relapsing disease before receiving salvage therapy. The Panel argued that the information provided by NGS testing in refractory and relapsing patients may allow the personalization of an optimal TKI treatment choice.3.3Allogeneic hematopoietic stem cell transplant  is still considered the best option in attempting to pursue long‐term disease control in Ph+ ALL.Several retrospective, comparative analyses have been performed with the aim of evaluating the impact of the use of TKIs after allo‐SCT on outcome. The largest analysis, restricted to patients treated with allo‐SCT in first complete remission, showed that imatinib or dasatinib for primary prophylaxis against relapse resulted in an improvement of OS and leukemia‐free survival along with a lower incidence of grade 2‐4 acute graft versus host disease.BCR‐ABL1 KD mutations before allo‐SCT predominantly relapse with the same mutation. Therefore, empiric selection of any one TKI in the posttransplant management will almost certainly result in predictable treatment failures in a subset of patients with preexisting mutations. In addition to considerations of cost and toxicity, the pretransplant mutation status of patients with detectable residual disease should thus be considered when choosing the TKI for posttransplant prophylaxis.Unfortunately, TKI resistance mechanisms in the transplantation setting have not been extensively investigated; indeed, there are very few data about the mutational status of MRD‐positive patients both before and after allo‐SCT, as well as about the patterns of clonal evolution of preexisting mutations. Egan et al3.3.1BCR‐ABL1 KD mutation status prior to an allo‐SCT could provide useful information about the risk of recurrence of the disease after transplant and about the posttransplant TKI to be utilized. Thus, patients who did not have NGS testing done at the time of transplant decision should have it carried out prior to the transplant (if the BCR‐ABL1 transcript level is greater than 0.1%).The Panel agreed that knowledge of the BCR‐ABL1 KD mutation screening by NGS should be performed whenever a patient tests MRD positive, with BCR‐ABL1 levels greater than 0.1%. If a low‐level mutation is detected, mutation kinetics should be monitored at monthly intervals, and the TKI to which the mutation is known to confer resistance should be avoided.After transplant, 3.4BCR‐ABL1 mutation profiling may be useful before changing therapy since the detection of specific mutations may influence the choice of the second‐generation TKI.In Ph+ ALL patients who fail imatinib treatment, The setting in which the greater sensitivity of NGS could be most useful is when a Ph+ ALL patient with a nonoptimal response to imatinib has to be shifted to second‐line therapy, and in the transplant setting. Typically, patients candidate for the use of second‐generation TKIs in the pretransplant or posttransplant setting are represented by those who have experienced resistance to pretransplant treatment with imatinib. In fact, in the posttransplant setting, early prophylactic or MRD‐triggered imatinib was not always effective in reducing the risk of clinical or molecular relapse.3.4.1In general, the interpretation of NGS testing results and the therapeutic decisions should involve both biologists/biotechnologists and physicians expert in Ph+ ALL monitoring and treatment, respectively.Since there is no established evidence of a real clinical advantage of a personalized therapy tailored according to the detection of low‐level mutations, at the present time, any therapeutic decision based on the results of NGS testing may only derive from inductive reasoning.The majority of Panel members agreed that the NGS results obtained prior to front‐line therapy should restrain from modifying the approved conventional treatment, but should rather trigger monthly evaluation of mutation kinetics (in the presence of quantifiable disease).BCR‐ABL1 KD mutation by NGS in patients who are MRD‐positive after TKI‐based induction or consolidation should prompt to consider switching TKI when the mutation is known to be not sensitive to the TKI currently used by the patient. In this case, the detection of mutations by NGS should encourage an individualized therapy or a therapeutic switch that depends on the type and level of mutation(s) and on the toxicity profile of the various options.On the contrary, the identification of a low‐level BCR‐ABL1 KD mutation testing by NGS has an important role in patients who are candidate for the posttransplant use of TKIs in order to reduce the risk of relapse. In the case of persistence or reappearance of MRD positivity after allo‐SCT, the choice of an alternative TKI should be based on the results of NGS analysis.The Panel claimed that 3.5BCR‐ABL1 KD mutation issued by this document should be for clinical centers that do not have access to the NGS technology. The Panel agreed that NGS testing should be encouraged, in the proper indications of use, in all the clinical centers caring for patients with Ph+ ALL. However, the Panel also acknowledged that there is currently no evidence demonstrating that the lack of NGS testing hampers the possibility to properly manage Ph+ ALL patients, thus failure to use NGS because of the lack of access to it, at present, should not be regarded as an inappropriate clinical management.The Panel addressed the matter of how mandatory the indications for the use of NGS testing for The Panel also advocated that NGS testing should be performed in a restricted number of highly qualified laboratories within regional or national networks, already engaged in MRD monitoring of Ph+ ALL patients. Important aims of these networks should be: centralization of the analysis in a few highly specialized laboratories; harmonization of techniques among the network laboratories; central coordination for continuous technology development and also through worldwide collaborations with other reference laboratories; development of an inter‐lab quality control system for sensitivity, accuracy, and reproducibility of the results; organization of periodical quality control rounds.3.6BCR‐ABL1 mutation testing in CML underlined the importance of using sequencing approaches rather than mutation‐specific assays, enabling screening for a limited number of mutations only. No commercial assay is, as yet, available.ABL1, implemented on various NGS platforms.BCR‐ABL1 KD mutation screening by NGS is feasible in expert laboratories, and that NGS results are accurate and reproducible down to variant frequencies of 1%BCR‐ABL1 KD mutation screening is presented in Figure Although in Ph+ ALL P‐loop mutations and T315I are the most frequent,3.6.1BCR‐ABL1 KD mutation screening in Ph+ ALL. At least 5 mL of BM should be obtained using ethylenediaminetetraacetic acid or sodium citrate as an anticoagulant; heparin must be avoided. RNA from mononuclear cells is the recommended template. Selective amplification of the ABL1 KD of the fusion BCR‐ABL1 allele is recommended. This may be accomplished using either of two forward primers, on BCR exon 1  or on BCR exons 12/13  and a reverse primer on ABL1 exon 10. The resulting amplicon may be either used as a template for a nested PCR or may be fragmented, provided that the final amplicons or fragments are not shorter than 300‐400 bp, to maximize the likelihood to detect compound mutations. Accordingly, sequencing chemistries/cycles producing reads shorter than 400 bp are not recommended. For the above reasons, commercial gene panels incorporating ABL1 but using genomic DNA as input material and sequencing short fragments are not recommended.Bone marrow (BM) should be the preferred specimen for ABL1 1a protein isoform, known to correspond to the KD (reference Genbank sequence: NM_005157.5). No mutations should be reported outside this region.The minimal mRNA region to be screened for mutations is that encoding amino acids 235 through 498 of the ABL1 KD of the BCR‐ABL1 transcript);whether the sample is evaluable or not and why  to whom the variant is known to be insensitive should be clearly indicated.The recommended minimum depth of coverage is 1000×. Unless commercial kits become available, each individual laboratory will be responsible for the optimization of assay conditions and for the evaluation of accuracy, precision and analytical sensitivity. Given the inherent differences between NGS platforms, chemistries, and bioinformatics tools, specific recommendations on ranges and thresholds cannot be provided. To ensure optimal analytical performance, each laboratory will have to define means and criteria for quality control and to engage in regular proficiency testing programs. The Panel suggests that mutations with a variant allele frequency below 3% should not be reported. Any variant >3% should be reported irrespective of the availability of experimental or clinical information regarding its sensitivity profile. Laboratory reports should include the following minimal set of information:The turnaround time for reporting results should be 2 weeks or shorter.4BCR‐ABL1 KD mutation testing in Ph+ ALL and judged whether it was sufficiently robust to provide recommendations. So far, there has been no randomized clinical trial formally assessing the efficacy of a proactive change of therapy based on the detection of low‐level mutations by NGS, and considering the low incidence of Ph+ ALL cases and the heterogeneity of TKI and chemotherapy combination regimens used by different cooperative study groups, such a trial will hardly be feasible. This forced the expert Panel to use the method of consensus to shape the statements herein presented.Many laboratories are currently in the process of introducing NGS into their routine diagnostic procedures since it has proven a robust, reproducible and, in the case of gene panels, cost‐effective alternative to SS. Here, Ph+ ALL experts analyzed the body of data on the use of NGS for The Panel assessed the potential value of NGS testing in three distinct settings: before and during first‐line TKI‐based treatment; in relapsed/refractory cases; before and after allo‐SCT. The first was the most debated setting. The Panel discussion highlighted the lack of prospective data and the paucity of retrospective data—all obtained with other technologies  characterized by variable levels of sensitivity, accuracy, and reproducibility. In the great majority of cases, the same TKI‐resistant mutation detected at low levels at diagnosis coincided with that harbored by the dominant clone detected at relapse, although some exceptions (patients not relapsing or relapsing with a different mutation) have been reported.BCR‐ABL1 KD mutation screening may be activated in a timely manner on the same RNA or cDNA samples used for MRD analysis whenever necessary. The centralization of testing will also be required for cost‐effectiveness. Several regional or national networks of expert laboratories are already in place, which in turn are involved in worldwide cooperative efforts . It would be advisable for such networks to take the lead in future standardization and organization of periodical quality control rounds. Harmonization of protocols and coordinated definition of standard requirements for sensitivity, accuracy, and reproducibility of the results are particularly critical issues. At present, unfortunately, no commercial kit for NGS‐based BCR‐ABL1 KD mutation testing yet exists. A common NGS kit to be standardized across centers is eagerly awaited, since that would increase the number of centers that can perform in house analyses.The Panel, that also included experts in molecular biology and NGS testing, additionally engaged in the definition of a set of minimal technical and methodological requirements for analysis and result reporting. They also underlined that NGS should be implemented only in a limited number of highly qualified laboratories already involved in MRD monitoring of Ph+ ALL patients, so that BCR‐ABL1 KD mutation screening can be performed on the same RNA or cDNA used for MRD testing. Indeed, real‐time PCR should always be performed first, and MRD results should guide the decision of whether to proceed to NGS testing. It has been reported that MRD persistence in Ph+ ALL patients may hide emerging clinically actionable mutations that NGS may timely identify, thus enabling treatment optimization aimed to prevent hematologic relapse.BCR‐ABL1 transcript levels is also important to assess the feasibility of NGS testing. In CML samples, it has been reported that at values below 0.1% library preparation is not always successful, and even when it is successful, repeatability is reduced, and false negative results are not infrequent.From a technical point of view, NGS‐based BCR‐ABL1 KD mutation screening in Ph+ ALL. Table BCR‐ABL1 KD mutation testing in CML.In conclusion, we here report the first attempt at defining indications for the use of NGS for BCR‐ABL1 KD mutation monitoring of Ph+ ALL patients in the framework of TKI‐based clinical trials. Such studies, that would greatly benefit from the international cooperation of different study groups, would help to establish the role of NGS at diagnosis and to find the best timing and integration of MRD and mutation testing into the clinical decision algorithms.Although a consensus on a series of position statements was reached, the literature review and the Panel discussion highlighted the strong need for prospective studies aimed at systematically applying NGS for Simona Soverini has received honoraria from Incyte Biosciences, Novartis, Bristol‐Myers Squibb. Francesco Albano has received honoraria for advisory board from Incyte. Renato Bassan has received honoraria advisory board from Amgen, Pfizer, Shire, Servier, Jazz, Incyte. Francesco Fabbiano has received honoraria for advisory board from Incyte. Robin Foà has received honoraria for consultancies/advisory board from Janssen, Novartis, Amgen, Abbvie, Roche, Incyte, Shire, Pfizer. Attilio Olivieri has received honoraria for advisory board from Incyte. Alessandro Rambaldi has received honoraria for travel, accommodation expenses and fees for consultancies and participation to meetings, boards and symposia sponsored by Amgen, Pfizer, Incyte, Italfarmaco, Astellas, Celgene, Novartis, Roche, Jazz. Giuseppe Rossi has received honoraria from Novartis, BMS, Incyte and participated to advisory boards from Amgen, Pfizer. Simona Sica has received honoraria for advisory board from Incyte, Sanofi, Alexion. Adriano Venditti has received personal fees from Pfizer, Novartis, Astellas, Jazz Pharmaceuticals, Amgen, Incyte and Daiichi‐Sankyo outside the submitted work. Fabrizio Pane has received honoraria for advisory board from Amgen, Pfizer. The remaining authors have no conflicts of interest to disclose.All authors contributed to conception and design of the work, analysis, and interpretation of the literature and manuscript drafting and gave final approval for submission.