BCR::ABL1 fusion transcript monitoring of chronic myeloid leukemia (CML). RT enzyme and reaction conditions may contribute to impairment of stoichiometry in cDNA synthesis potentially biasing in qRT-PCR data. We have comparatively investigated the performance of the MLV-RT and SuperScript IV with random-hexamer vs. target-specific priming by means of the Acrometrix™ BCR::ABL1 reference panel and 37 clinical specimens. Our experiments identified priming type and RT type as major factors for diagnostic data variation. Variation was mainly due to different efficacies of RT enzymes to process low- (<50) and high-copy targets. The impairment of the high-performing SuperScript IV in processing low- (BCR::ABL1) and high-copy-number (GUSB or ABL1) RNA targets equally was not reflected by the diagnostically relevant Log (BCR::ABL1/GUSB%) values. For improving BCR::ABL1 assay sensitivity with a faithful representation of diagnostic targets, increased RNA/cDNA amounts and distinct RT/priming combinations are highly recommended.Reverse transcriptases (RT) play a crucial role in BCR::ABL1 fusion transcript monitoring in chronic myeloid leukemia (CML). The RT type and cDNA priming method may impair the stoichiometry of cDNA synthesis, thereby potentially introducing a bias in BCR::ABL1 qRT-PCR data. Using the Acrometrix™ BCR::ABL1 reference panel and 37 clinical specimens, we have comparatively investigated the performance of the RTs MLV and SuperScript IV with random hexamer vs. target-specific priming. Quantitative RT-PCR results identified the priming type and RT type as major factors for diagnostic data variation, mainly due to the different efficacies of processing BCR::ABL1 low-copy-numbers (<50) compared to GUSB or ABL1 high-copy targets. The impairment of SuperScript IV in processing low- and high-copy-number RNA targets equally was not reflected by the diagnostically relevant Log (BCR::ABL1/GUSB%) values. Therefore, the correct representation of housekeeping and BCR::ABL1 target genes should have priority when aiming at as high a number of housekeeping gene copies as possible. Our data suggest that for improving BCR::ABL1 assay sensitivity, increased RNA/cDNA amounts and the use of distinct RT/priming combinations are advantageous. However, for inter-laboratory harmonization, the proper conversion factor according to the CML international standard (IS) has to be reevaluated each time the grade of RT is changed.Reverse transcriptases (RT) are essential tools in  BCR::ABL1 < 0.01% IS lasting for at least 2 years, is crucial for the decision of TKI treatment discontinuation. A strict technical standardization of BCR::ABL1 transcript measurements is mandatory, which also includes the selection of the most suitable control genes  = [number of molecules BCR::ABL1]/[number of molecules GUSB] × 100), in compliance with the guidelines of Foroni and coworkers .For nsidered . FurtherBCR::ABL1 panel, the first commercially available cell-based secondary reference panel for BCR::ABL1 quantification on the IS  = [total number of molecules BCR::ABL1]/[total number of molecules HKG] × 100, in compliance with the guidelines of Foroni et al., 2011 [BCR::ABL1 copies). This may lead to a diagnostic bias. As shown in BCR::ABL1 copies (=numerator) were detected, irrespective of the priming type, while the detection of the corresponding HKG GUSB turned out superior when specific priming was used. This yielded lower Log (BCR::ABL1/GUSB%) values when specific priming in combination with MLV RT was applied for reverse transcription  values) compared to random priming. In the case of SuperScript IV RT, we found that the overall performance superiority of random priming affects both the numerator and denominator quite equally, and therefore, the cDNA priming type may account for only minor changes in the diagnostic outcome.What may this mean for the resulting clinical diagnostic outcome? The Log  for the BCR::ABL1 target. At target copy numbers below 70, specific priming seems to become more and more superior  of 0.43 and 0.49 for GUSB and ABL1 targets, respectively (BCR::ABL1/GUSB%) values suggest a better diagnostic outcome than when patients are monitored with random-primed assays (BCR::ABL1 Log reduction step (random 0.1 = MMR vs. specific 0.0109 = MR4). Since at BCR::ABL1 target copy numbers below 70, random and specific priming seem to generate converging target numbers (BCR::ABL1/GUSB%) reduction differences (random vs. specific priming) becomes less and less prominent (mean random 0.0074 (range 0.0034 to 0.0111 vs. mean specific 0.0044 (range 0.0030 to 0.0064)). This is most visible for patient 8, for whom an identical Log (BCR::ABL1/GUSB%) of 0.0034 could be stated, irrespective of the type of priming. However, except for patient 1, the approximate two-fold differences observed in the Log (BCR::ABL1/GUSB) are in the acceptable range (up to three-fold) of variability observed when using a conversion factor (CF) [The detection of ectively B. Since,d assays C. In thetor (CF) .BCR::ABL1 reference panel  more molecules per 1 µg of RNA compared to specific priming  in the number of detected molecules for GUSB and ABL1, respectively. Thus, except for patients #12–14 and #20, the absolute assay sensitivity (per 1 µg RNA) seems to benefit from the combination of SSIV RT and random priming , a 3.1-fold (mean random: 0.0114 vs. mean specific: 0.0353) Log (BCR::ABL1/GUSB%) reduction was observed. This points to a general trend where the corresponding patients seem to respond better when assayed with specific priming  values) than when specific priming was applied in combination with SuperScript IV  that are representative for the types of samples regularly encountered by a routine diagnostic workflow. Sixteen samples  in this experiment. This enabled the execution of hexaplicate assays so that the complete amount of cDNA corresponding to 1 µg of the sample RNA was used up.In order to identify the best-performing reverse transcription procedure for monitoring therapy-free remission (TFR) and patients before stopping TKI treatment decisions, we performed analogous experiments with clinical specimens  as in the former experiment in BCR::ABL1 confirmed our former finding that, below a certain copy number cut-off , specific priming becomes superior to random priming for BCR::ABL1. This is depicted in n = 8) show random priming superiority , while at copy numbers <50 (patients #30 to #37), specific priming became more efficient . For GUSB, random priming always shows a higher efficacy in terms of target molecule detection  level quotient that clearly demonstrates that, in this experiment, the numerator (BCR::ABL1) and denominator (GUSB) follow different kinetics in reverse transcription depending on the priming type. At BCR::ABL1, copy numbers below the cut-off random priming result in lower Log (BCR::ABL1/GUSB%) quotients, making patients appear better-responding , while at copy numbers above the cut-off, an opposite trend could be observed . Although the acceptable range of variability observed when using a CF has been described approximately three-fold [BCR::ABL1 molecules detectable in a clinical specimen (per 1 µg RNA) may serve as an excellent basis for clinical decision making.These findings find expression in the diagnostic important Log  shown in BCR::ABL1 routine qRT-PCR assaying . As shown in 4.5 -> MR5). Specific priming performed quite similar . One patient (#21) reached MMR, although no MMR was diagnosed in routine diagnostics. Obviously, these Log level shifts were due to a higher cDNA amount used in general but also to the priming type-dependent RT reaction kinetics differing for low- (BCR::ABL1) and high-copy targets (GUSB). For example, in the case of patient #32 (compare GUSB (FC = 1.26) differ considerably from those of BCR::ABL1 (FC = 0.58). This concurs with the “better” diagnostic outcome (patient #32 in 4.5) when random priming was applied compared to specific priming. Specific priming increased the number of detected BCR::ABL1 molecules, resulting in a Log level shift MR4.5 -> MR4. This is an excellent example of how alternative priming can impact the Log level calculation, making the patient’s residual tumor load appear more or less eminent.In order to prove the potential benefit of the best possible RT efficacy in terms of  compare B, the foBCR::ABL1) and high-copy-number (GUSB or ABL1) targets should be proportionally processed with identical efficacy within a defined range of sample RNA concentrations. In particular, this is of great importance in CML routine BCR::ABL1 monitoring, as the number of BCR::ABL1 cDNA targets is considered to exactly reflect the tumor load.In diagnostic applications, it is assumed that RT enzymes perform a stoichiometrically correct reverse transcription. Low-  are major factors for diagnostic data variation, and it became clear that the influence of RT on the diagnostic outcome has been clearly underestimated so far.Our experiments with MLV RT and SuperScript IV on the Acrometrix™ f others ,20,21,22BCR::ABL1 RNA target copy number fell below a distinct threshold  combined with a much higher processivity according to the temperature coefficient Q10 rule given by the van’t Hoff equation, saying that the reaction rate can double for each 10 °C rise in temperature. Recombinant RTs that can work at elevated reaction temperatures were found to be superior to low-temperature-processing enzymes and have been recommended for low-RNA-input applications . IrrespeBCR::ABL1/HKG%) value, since a small numerator (BCR::ABL1) can be easily compromised by changes in the denominator (GUSB or ABL1). Patients with small BCR::ABL1 target numbers show deeper molecular responses (DMR) when assayed with random priming  values) than when specific priming was applied in combination with SuperScript IV , the resulting higher sensitivity can lead to individual Log level changes. Alternative priming may have an impact on the Log level calculation, making the patient’s residual tumor load appear more or less eminent. In other words, the goal must not be to have the highest amount of the housekeeping gene but to have the correct relation of the housekeeping gene and target gene. In our regular routine monitoring, this may be of minor importance, as a higher sensitivity of a lab-specific method will be corrected by the proper CF factor. The limits of variation can be up to three-fold when using a CF [Moreover, primer binding kinetics are highly dependent on the reaction temperature. At 37 °C, random primer target binding may be comparable to specific primer binding, whereas at 52 °C, random priming can be expected to be much less efficient ). Thus, during cDNA initiation with MLV RT, the abundancy of template-bound random hexamers (200 ng = 100 pmol) may outnumber the number of functional RT molecules and lead to a general underrepresentation of processed RNA targets (RT is a limiting factor). Of course, the amount of the primer and enzyme, i.e., the relation of the primer and enzyme, could be optimized with regard to the expected number of respective templates. The impairment of MLV RT and SuperScript IV RT in combination with specific or random priming may not be reflected by the resulting diagnostically relevant Log , thereby omitting the influence of denominators (HKG) varying with the RT and priming type. This approach would require the exact determination of the RNA quantity and quality, the latter to be analyzed by chip-based methods calculating RNA integrity numbers . Since the detection of single or sets of housekeeping genes also depends on the global RNA quality, more efficient and effective methods are imaginable, such as looking at the total levels of gene expression across all genes, as suggested by others [The sensitivity of a diagnostic laboratory is always normalized to that of the corresponding reference laboratory or its given standards—here, the Acrometrix™ 4368814; ). Howevey others .BCR::ABL1 monitoring method with the highest sensitivity is crucial. Our patients (4.5), stepped up one or two Log BCR-ABL/HKG % IS values when a more sensitive method was applied in monitoring after TKI discontinuation. Since, for these patients of our cohort, the real tumor load may be higher than that monitored by routine BCR::ABL1 assays (MR4.5), future follow-up may be informative. On the record, all four patients are still in TFR.The ELN panel agrees that TFR is the significant goal in CML management and that TKI treatment discontinuation should be considered in patients with durable DMR ,29,30,31BCR::ABL1 % IS values and potentially impacting the monitoring outcome if the proper CF will not be applied. In the case of BCR::ABL1 monitoring for TKI discontinuation, we consider BCR::ABL1 assays with the best possible sensitivity crucial but also underline the importance of inter-laboratory harmonization and the permanent validation of laboratory methods on the basis of a series of highly standardized reference samples . However, for inter-laboratory harmonization, the proper conversion factor according to the CML international standard (IS) has to be reevaluated, especially if the RT type or cDNA priming is changed.The employment of modern, convenient-to-use cDNA first-strand synthesis kits has led to a common disregard for the influence of cDNA synthesis in molecular methods. Varying efficacies of different RT enzyme grades for processing high- and low-copy-number RNA targets depend on the priming type and can introduce a bias into the resulting gene expression data, shifting Log


ARID1A) encodes a key component of the SWItch/Sucrose Non-Fermentable (SWI/SNF) chromatin remodeling complex that participates in gene expression. ARID1A alterations are quite common among cancer patients, although their role remains debated. The aim of this article was to study ARID1A-mutated cancer patients.AT-rich interaction domain 1A . Cancer patients with at least one molecular alteration in ARID1A gene were identified as ARID1A+.Molecular and clinical data of cancer patients evaluated at Phase 1 Unit of Fondazione Policlinico Universitario A. Gemelli IRCCS were collected. Molecular analyses were performed using FoundationOne+ population was higher compared to ARID1A– population (6 vs. 4), as well as tumor mutational burden (TMB) [20 mutations/megabase (mut/Mb) vs. 1.26 mut/Mb]. Phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA), phosphatase and tensin homolog (PTEN), catenin beta 1 (CTNNB1), and lysine methyltransferase 2D (MLL2) mutations were enriched in ARID1A+ population. In this cohort, ARID1A did not display any relation with response to platinum chemotherapy. Cancers with double alterations in ARID1A (ARID1A2+) were all gynecological cancers .Among the 270 patients undergoing molecular analysis, we found 25 (9%) with at least one pathogenic alteration in ARID1A. The vast majority of these patients were female (84%). The median age at diagnosis was 59; most of the cancers  were gynecological , diagnosed at an early stage. Frameshift alterations in ARID1A were the most common  alterations. The median number of mutations in ARID1A+ cancers, in particular the subgroup of gynecologic cancers. The high frequency of concurrent mutations in the phosphoinositide 3-kinase (PI3K) pathway among endometrioid endometrial cancers may support the proposal of a new treatment strategy based on the combination of ataxia telangiectasia and Rad3-related (ATR) inhibitor and PIK3CA inhibitor.This analysis provides clinical and molecular details about the phenotypes of ARID1A ARID1A) gene, also known as Brahma-related associated factor 250a (BAF250a), is located on chromosome 1p36.11. It encodes a key component of the SWItch/Sucrose Non-Fermentable (SWI/SNF) chromatin remodeling complex . ECOG PS, at the time of our evaluation, was good (0 or 1) in 92% of the study population although they were pre-treated with a median of 2 lines of chemotherapy.+ cancer have a high TMB (≥ 20 mut/Mb), with 12 (48%) showing stability of the microsatellite system. PIK3CA, TP53, PTEN, CTNNB1, and MLL2 were the most concurrent mutations  , the molecular analysis was performed on the archival sample referring to the diagnosis time (average time from sample collection 11 months). More than half of the patients with ARID1Actively) .Endometrioid cancer of endometrium was the prevalent tumor, representing 24% of the cases, followed by clear cell ovarian cancer . Among the pathogenic molecular alterations in ARID1A, frameshift alterations were the most common  . Interes+ population was significantly higher compared to ARID1A– population , as well as TMB . Also, the median number of VUS was higher in ARID1A+ cancers . In PIK3CA, PTEN, CTNNB1, and MLL2) in ARID1A+ population. On the contrary, TP53 was prevalent in ARID1A– population (63% vs. 48%), although not statistically significant.The median number of mutations in ARID1A+ tumors vs. ARID1A– tumors, the presence of alterations did not relate with a different time to platinum treatment failure . OS for ARID1A+ patients was 66 months.Comparing the response to platinum for gynecologic patients with ARID1A+ (ARID1A2+). They were all women with gynecological cancer, mainly of endometrial origin. Five (83%) had endometrioid endometrial cancer and the other one was diagnosed with clear cell ovarian cancer. ECOG PS was 0 or 1. TMB was 24.5 mut/Mb, the higher found among the ARID1A+ patients, with the majority  displaying microsatellite instability.Interestingly, the authors found six patients with 2 different alterations in ARID1AThe response to immunotherapy of the endometrial cancer patients was variable: two patients with high TMB (48/20 mut/Mb) and MSI-H progressed within 6 months; other two patients with MSI-H and TMB intermediate/high (14/29 mut/Mb) reached 14 months and 27 months of PFS, with one of them being still on treatment. The last patient with TMB low/MSS progressed after two cycles of immunotherapy. To note that one patient with MSI-H/high TMB endometrioid endometrial carcinoma progressed on immunotherapy very fast but showed a partial response to PI3K inhibitor lasting for 7 months.+ cancers, without any drug approval so far. These medicines include immune checkpoint blockades, PI3K/AKT/mTOR inhibitors, PARP inhibitors, ATR inhibitors, enhancer of zeste homolog 2 (EZH2) inhibitors, and pan-histone deacetylase (HDAC) inhibitors. In ARID1A is being configured as a potential new target for cancer treatments. A variety of compounds are being tested in ARID1AARID1A deficiency was defined as the absence of tumor expression of its gene product (BAF250a) by IHC staining. Of note, tumors harboring pathogenic mutations in ARID1A do not necessarily have a loss of expression of BAF250a, which was reported in 67% of the study population [In particular, a significant interest in this gene is rising in the gynecological field, due to the high percentage of ARID1A alterations among these patients. For instance, ATARI trial is a multicenter, international, phase II study (NCT0405269) testing the ATR inhibitor ceralasertib as a single agent and in combination with olaparib in ARID1A gynecological cancers. pulation . The intpulation .+ tumors may guide the design of future clinical trials targeting this gene. Therefore, we retrospectively analyzed our cancer population undergoing molecular evaluation with FoundationOne® CDx assay.A deeper insight into the clinical and molecular landscape of ARID1A+ cancers, a percentage comparable to that reported in the literature (6%) [+ population, especially in the ARID1A2+ group, whose median TMB reached 24.5 mut/Mb. PIK3CA, TP53, and PTEN were the most common concurrent mutations in ARID1A+ population, although TP53 was slightly increased in ARID1A– cancers (63% vs. 48%).In the population of patients being offered an NGS test for their advanced tumor, we found 9% of ARID1Aure 6%) . The sli% . The sure (6%) , endometPIK3CA or PTEN, frequently co-occurring, may cooperate with ARID1A loss to drive cancer and downstream activation of the PI3K/AKT pathway [Previous evidence suggested that ARID1A inactivation alone is insufficient to drive ovarian tumorigenesis . Defects pathway . Moreove pathway .TP53, Kirsten rat sarcoma viral oncogene homologue (KRAS), and adenomatous polyposis coli (APC) occurred most frequently in ARID1A+ GI cancers [In a previous experience with GI cancers , TP53, K cancers . This obIn our experience, ARID1A alterations were found both in solid tissue (primary diagnosis and relapsed disease) and blood. A recent report among 71,301 patients suggests that liquid biopsies identified ARID1A alterations at a frequency similar to that found in primary tumor material . If muta2+, among the patients who underwent liquid biopsy.Double alterations in ARID1A were observed only in solid tissues. Probably, it may be linked to the absence of gynecological cancers, the ones identified as ARID1A– tumors. Moreover, we observed a poor outcome among ARID1A+ tumors compared to the ARID1A WT cohort, consistently the largest report so far [With the limitation of the small sample size, our study did not show any differences in terms of duration of response to platinum-based chemotherapy among gynecological cancer displaying ARID1A alterations as compared with ARID1At so far .It is uncertain if monoallelic inactivations share the same phenotype (i.e. loss of ARID1A expression) as biallelic inactivations . This an+ cancers, no predictive role for platinum-based chemotherapy). In addition, we provide clinical and molecular details in both ARID1A+ and ARID1A2+ cohorts, highlighting Q372fs*19 as the most frequent alteration in solid tissue.In conclusion, this analysis confirms and strengthens existing literature , we propose to combine ATR inhibitor or PARP inhibitor with PIK3CA inhibitors in a new trial to test the synergic action of these drugs. Genomic analysis and protein expression of cancer tissue, as well as liquid biopsy, need to be performed and correlated with response to therapy.ARID1A among the key genes mutated in clear cell ovarian cancer may offer new treatment opportunities in this orphan disease, poorly responsive to chemotherapy. Moreover, among ARID1A2+ endometrioid endometrial carcinomas with a high value of TMB, a combination or new immunotherapies may be proposed in future studies.The identification of


In 2023, Türkiye experienced a significant earthquake disaster that profoundly impacted 11 provinces. The enduring consequences of these earthquakes on daily life triggered widespread fears and anxieties in society, leading to scholarly investigations in this field.The primary objective of this study was to create and evaluate the psychometric properties of the Fear of Earthquake Scale (FES), a modified adaptation of the Fear of COVID-19 Scale (FCV-19 S), tailored to measure earthquake-related experiences in Türkiye.A total of 315 Turkish adult participants , with a mean age of 37.71 years, completed the FES, along with the Brief Psychological Resilience Scale (BPRS). Psychometric analyses included confirmatory factor analysis as well as the evaluation of alternative factor structures, internal consistency, convergent validity, and criterion validity with respect to resilience.The findings indicate that the Turkish version of the Fear of Earthquake Scale has strong psychometric properties in terms of validity and reliability. After assessing various factor structures, it was observed that the two-factor model which represents the emotional and somatic response to fear, exhibited the best-fit values The Cronbach’s alpha coefficients were calculated as 0.89 for the overall FES, 0.84 for the emotional subscale and 0.86 for the somatic subscale, indicating high internal consistency. Additionally, the negative correlation between resilience and the FES supports the criterion validity of the scale, and multi-group confirmatory factor analyses proved that measurement invariance held across genders and whether they experienced an earthquake or not for all groups. Furthermore, the results of the study revealed that women and individuals with prior earthquake experience reported higher levels of fear of earthquakes.The FES emerged as a reliable and valid tool for assessing earthquake-related fears among the Turkish population. Earthquakes, characterized by their suddenness and lack of forewarning, present an immediate and significant danger to individual’s lives and well-being, with the extent of their impact determined by their intensity . NumerouThe traumatic impacts of such occurrences may spread outside the disaster zone, and symptoms may linger for a long time after the incident . For insNumerous studies –12 invesFear is an emotional response that emerges in the face of immediate and tangible danger . It servExtensive research indicates that individuals who harbor a high fear of earthquakes tend to experience adverse psychological conditions, including anxiety –20, deprConducting research on earthquake fear in diverse populations holds significant importance. Considering the unavailability of measurement tools specifically designed for assessing earthquake fear in Türkiye, the present study sought to develop the Fear of Earthquake Scale (FES). In pursuit of this goal, the study draws from the Fear of COVID-19 Scale (FCV-19 S), which was adapted and employed to measure earthquake fear in a Croatian sample . The FCVGiven the diverse findings in studies exploring factor structure-related scales such as the FCV-19 S, it becomes evident that understanding the complex nature of fear is crucial. With this perspective in mind, our study pursued two primary objectives. First, we aimed to construct and assess the psychometric properties of the Fear of Earthquake Scale (FES), which is a modified adaptation of the FCV-19 S , specifiThe participants of the study consist of 315 adults aged 18 and above living in Türkiye who have experienced earthquake events and those who have not. The enrollment of these participants was accomplished through the utilization of the convenience sampling method. Among the participant group, 209 (66%) were female and 106 (34%) were male. There were 182 (58%) participants who had experienced earthquake events and 133 (42%) participants who had not. Furthermore, among the participants, 81 individuals (26%) fell within the age range of 18–29, 97 individuals (31%) fell within the age range of 30–39, 86 individuals (27%) fell within the age range of 40–49, 41 individuals (13%) fell within the age range of 50–59, and 10 individuals (3%) were 60 years old and above. The distribution of participants based on their perceived economic status as low-income, middle-income, and high-income was as follows: 32 individuals (10%) reported low-income, 260 individuals (83%) reported middle-income, and 23 individuals (7%) reported high-income , originally developed by Smith et al.  and lateTo initiate the study on the scale by modifying the items of the Fear of COVID-19 Scale, we first contacted the authors of the FCV-19 S via email. In our communication, we requested permission to modify the items of the Fear of COVID-19 Scale to measure the fear of earthquakes. We obtained permission to adapt the scale by replacing the expressions associated with COVID-19 fear in the FCV-19 S with earthquake-related fear expressions. After replacing the COVID-19 fear expressions in each item of the FCV-19 S with earthquake-related fear expressions, the translation process from English to Turkish was initiated. The initial translation was conducted by the first author, who is proficient in both Turkish and English. Expert opinions were then obtained from three academics specializing in this field. Based on the feedback received, revisions were made to the scale items, and the final version was determined. The forward translations were compared by the initial and the second authors, leading to a reconciliation. The scale was then translated back into English by the first author. In the final phase, the three researchers reviewed each item in both Turkish and English. The authors’ university then authorized the submission of an application to the ethics committee. Before participating, all individuals were informed about the study’s objectives, and each participant provided informed consent.Data collection for the study took place after a significant seismic event on February 6, 2023, which resulted in a 7.8 magnitude (Mw) earthquake. The data were collected from April to June. The Google Form was organized in the following order: Demographic Information Form, Brief Psychological Resilience Scale, and Fear of Earthquake Scale (FES). The researchers utilized social media platforms to share the online forms they had prepared with their social circles, as well as with undergraduate and graduate students. The snowball sampling technique was used to ensure a diverse participant tool, including individuals from various cities. The application link was specifically shared with volunteer participant groups in different cities, including those residing in earthquake-affected areas.All analyses, except for CFA were conducted using IBM SPSS Statistics 25. For CFA, IBM SPSS Amos 23 was employed. Before conducting validity and reliability tests, the normality assumptions of the scale items were checked and met. A CFA was performed to test the construct validity of the five-item single-factor model of the scale. Additionally, the criterion-related validity of the scale was examined by assessing its relationship with the Brief Psychological Resilience Scale.CFA was conducted on different models for the FES in our study. These models include the one-factor structure model (M1), an alternative one-factor model with three correlated pairs of residuals (M2), a two-factor model with emotional response and somatic response factors (M3), and an alternative two-factor model with one correlated pair of residuals (M4). The chi-square (χ2) value divided by degrees of freedom (df) was calculated to evaluate the fit of the one-factor structure model . A chi-sIn this study, descriptive statistics were generated to identify the number of missing values for each variable in the dataset. No missing data were found. Z-scores were calculated, and a comprehensive analysis of histogram and box-plot visuals was conducted to determine both univariate and multivariate outliers, as well as to assess the normality of distributions. After this examination, three participants were identified as outliers and excluded from the study. The univariate skewness and kurtosis values suggest that the responses were relatively normally distributed . The desTable The two-factor model (M3) CFA demonstrated an acceptable model fit. Upon analyzing the modification indices, substantial error correlations were identified between item 1 and item 2. After analyzing the data with the modification, notable improvements were observed in the goodness-of-fit indicators, as indicated by the χ2/df value of 2.173 for the alternative two-factor model with one correlated pair of residuals (M4). The fit indices of the alternative two-factor model with one correlated pair of residuals (M4) support model fit.All measurement models were compared using ECVI and BIC values. Among them, the alternative two-factor model with one correlated pair of residuals (M4) demonstrated the lowest ECVI and BIC values . The emotional response and somatic response subscales also showed negative correlations with the BRS. The correlation for the somatic response subscale was − 0.324 (p < .001), while it was − 0.373 (p < .001) for the emotional response subscale.We conducted a bivariate correlational analysis to examine the relationship between the overall score of the FES and its two subscales  as well as the overall score of the Brief Resilience Scale (BRS) to assess criterion validity. The correlation analysis revealed a statistically significant negative association between the FES and BRS total scores, with a correlation coefficient of − 0.383 (p < .05) for all groups. In summary, these findings suggest that the two-factor structure of fear of earthquakes adequately explains the FES in both gender and earthquake experience groups.In our study, we investigated whether the two-factor structure of the FES could adequately describe the fear of earthquakes across different groups using the configural invariance model (M4). For gender groups, the results showed that χ2/df = 1.42, AGFI = 0.93, GFI = 0.97, CFI = 0.99, RMSEA = 0.036, and RMR = 0.026. For earthquake experience, the results showed that χ2/df = 2.37, AGFI = 0.90, GFI = 0.97, CFI = 0.97, RMSEA = 0.064, and RMR = 0.37. Additionally, all factor loadings reached a significant level  compared to males ; p = .014; d = − 0.294). Furthermore, females exhibited a higher usage of emotional responses to fear  than males ; p = .006; d = − 0.347).We also examined potential gender and earthquake experience differences in our study. The results revealed significant differences in both gender and earthquake experience. Specifically, females reported a significantly higher overall FES score  scored higher on the somatic response subscale compared to those who had not experienced earthquakes , p = .021; d = − 0.260). These findings indicate that individuals who have experienced earthquakes report a significantly higher frequency of somatic responses to fear compared to those who have not experienced earthquakes.In terms of earthquake experience, we found statistically significant differences in the somatic response subscale of the FES. Participants who had experienced earthquakes , we designed the Fear of Earthquake Scale (FES) which incorporates relevant items capturing various aspects of fear responses related to earthquakes.In this study, we investigated the measurement models of the FES and explored its psychometric properties. Four different models were evaluated using a competing model approach. These models included the one-factor structure model proposed by Ahorsu et al. , an altePrizmić-Larsen et al.  used theThe item-total statistical analysis for the FES revealed strong corrected item-total correlations for all items, ranging from 0.63 to 0.77. These values indicate a solid relationship between each item and the total scale score, confirming the measuring power of the items in capturing earthquake fear responses effectively. Furthermore, the internal consistency of the FES was assessed using Cronbach’s alpha coefficient, which demonstrated high reliability for the overall scale (α = 0.89). This result closely resembles the findings reported by Prizmić-Larsen et al.  in CroatCriterion validity was evaluated by examining the associations between the FES total scores and its subscales  and the Brief Resilience Scale (BRS) total score. The results indicated a significant negative link between the FES and BRS scores, suggesting that higher FES scores were associated with lower resilience. This supports the FES’s criterion validity, capturing fear responses and resilience levels. Similar findings were found in the Croatian study Prizmić-Larsen et al. . AlthougIn this study, we also investigated the differences in earthquake fears between individuals based on two variables: gender and earthquake experience. The results highlighted significant variations in both gender and earthquake experience groups, offering insights into their influence on coping strategies. Regarding gender disparities, our findings indicated that females reported more earthquake fear and higher emotional fear response levels than males. Gün Çinği and Yazgan , KaranciThe study’s findings also demonstrated that individuals who had experienced an earthquake responded to fear considerably more somatically than those who had not. This emphasizes the significance of physical responses to fear associated with earthquakes. Increased heart rate, sweating, shaking, and a sense of restlessness or unease are physical signs of dread and anxiety brought on by earthquakes , 59, 60.Although the Turkish version of the FES has shown promise in terms of validity and reliability, further evaluation and development in different populations and circumstances are necessary to improve its generalizability. Future research could explore how the FES relates to real earthquake experiences and evaluate its sensitivity to changes in anxiety levels over time. The lack of test-retest repeatability is a limitation of this study, which could be addressed in future studies to determine the consistency and reliability of the FES.In conclusion, despite certain limitations, our study successfully created the Fear of Earthquake Scale, a useful instrument for evaluating earthquake-related fear in seismically active regions like Türkiye. The validity and reliability of the FES are supported by our findings, making it an effective tool for comprehensively assessing earthquake fear. The integrated and reliable two-factor structure of the FES provides a comprehensive understanding of how people respond to earthquake fear. Researchers can utilize the FES to gain insights into both the physiological and emotional reactions associated with earthquake fear, aiding in the selection of appropriate intervention strategies for those affected by earthquakes. The FES is a valuable resource for researchers and professionals in mental health care, disaster preparedness, and community resilience development in Türkiye. Its applicability extends to studies conducted across different cultures, providing a broader perspective on coping with earthquake fear.


Social anxiety disorder (SAD), also known as social phobia, is one of the most common mental disorders worldwide. In Hong Kong, the prevalence of SAD is high, but its treatment rate is low. SAD has immense impact on academic or work performance, social life, career development, and quality of life. One of the most effective treatments for SAD is cognitive behavioral therapy (CBT), with internet-based CBT (iCBT) and virtual reality exposure therapy (VRET) showing promise in treating SAD. However, internet interventions are underdeveloped in Chinese communities including Hong Kong.This study aims to develop an iCBT program that includes VRET, called “Ease Anxiety in Social Event Online” (Ease Online), for Hong Kong adults with SAD in a randomized controlled trial.The 14-week Ease Online program is a guided self-help iCBT program with a blended mode of service delivery. The program comprises 9 web-based modules and 5 individual counseling sessions (including 2 VRET sessions) conducted remotely or face-to-face with a therapist to provide therapist support, as guided iCBT shows superior effects than unguided iCBT. Other program components include therapist feedback on assignments, internal messages, forums, client portfolios, web-based questionnaires, reminders, and web-based bookings. The program can be accessed either through a mobile app or program website through a PC with an internet connection. The participants are openly recruited and screened using a questionnaire and through an intake interview. Eligible participants are randomized by placing them into a web-based iCBT group, app-based iCBT group, or a waitlist control (WLC) group. Participants in the WLC group are assigned to the app-based program upon completion of the service of the 2 experimental groups. Measurements of social anxiety, depression and anxiety symptoms, psychological distress, automatic thoughts, and quality of life are administered at pretest, posttest, and 3- and 6-month follow-ups. Multivariate ANOVA with repeated measures will be performed to determine the intervention effectiveness on the continuous variables over time.Participant recruitment commenced in January 2021. As of February 2023, a total of 1811 individuals applied for the Ease Online program. In total, 401 intake interviews have been completed, and 329 eligible participants have joined the program, among whom 166 have completed the service. Data collection is still ongoing, which is expected to be completed in March 2024.This study is the first of its kind in combining iCBT and VRET for the treatment of SAD in Hong Kong. At a theoretical level, this study contributes to the development and evaluation of internet-based psychological interventions in Hong Kong. At a practical level, the Ease Online program may serve as an alternative service option for SAD clients in Hong Kong if proven effective.ClinicalTrials.gov NCT04995913; https://clinicaltrials.gov/study/NCT04995913DERR1-10.2196/48437 Social anxiety symptoms have increased significantly during the COVID-19 pandemic . IndividPeople with SAD face certain treatment barriers that prevent them from seeking mental health services, including fear of judgement, uncertainty of the resources for receiving help, and skepticism regarding anxiety disorders . In HongCognitive behavioral therapy (CBT) is the first-line treatment for SAD . Clark aiCBT is used to deliver CBT on the web or through a mobile app. In a recent meta-analysis study, Andrews et al  showed tThe intervention skills in the various iCBT programs for SAD generally include psychoeducation, cognitive restructuring, behavioral experiments, exposure and reality testing, modifying attention bias, social skills training, developing healthy lifestyles, problem-solving, and preventing relapses ,20,21. TOne of the central components of CBT for SAD is exposure therapy in which clients are exposed to social stimuli that cause anxiety while eliminating safety behaviors so that they learn and understand that the anticipated negative consequences are ill-founded . ExposurMeta-analyses have consistently found a significantly large effect size for VRET compared to a waitlist or psychological placebo conditions for SAD treatment, and no significant difference in effect size between VRET and in vivo or imaginal exposure therapy ,28, thusBoth psychological and physiological indicators are measured in VRET studies. The commonly used psychological indicators include self-reported anxiety and fear, distress, and self-confidence ,34. As aTechnology-assisted CBT programs have great potential to extend mental health services to people with social anxiety who are unwilling or unable to seek face-to-face therapy . HoweverTo be included in the study, participants should be Hong Kong residents who (1) are fluent in Cantonese, (2) are aged between the 18 and 70 years, (3) obtained a score of 24 or higher on the Chinese version of the Social Phobia Inventory (SPIN) , (4) havOutcome Measures section). The α value was set at .01. The calculations resulted in a minimum sample size of 139. This study aims at recruiting 330 eligible participants, with 110 in each experimental group and the waitlist control (WLC) group, respectively.The sample size was calculated by using a computer program called G*Power . The statistical method used was a multivariate ANOVA with repeated measures (within-between interactions). The effect size was assumed to be 0.40 (large) [Participants were recruited from the general population on an ongoing basis through various means, such as advertisements on social media (Facebook and Instagram) and Google, press conferences, posters, and referrals from local nongovernmental organizations. Interested participants were asked to complete a screening questionnaire that includes the Chinese version of the Beck Anxiety Inventory (C-BAI), BDI-II, and Chinese version of the SPIN on the program website . InitialAlthough deterioration in a control condition can take place , SteinerThere were 2 experimental groups that joined either the web-based or app-based iCBT program (Ease Online). The WLC group received the app-based treatment immediately after the 2 experimental groups completed the program. All 3 groups completed the same web-based questionnaire at pretest, posttest, and 3- and 6-month follow-ups. The WLC group completed the questionnaire one more time at posttest after the 2 experimental groups completed the program. To increase the submission rate of questionnaire, participants were given 2 more weeks to submit an email questionnaire after the submission deadline in the program system. The RCT was conducted in cohorts for implementation feasibility. Specifically, in each cohort, around 30 qualified participants were randomized into one of the 3 groups through computer-generated random numbers, with approximately 10 in each group. The program evaluators were blinded to the allocation of the participants. The participant recruitment flowchart is shown in The Ease Online program is 14 weeks in duration. The program adopts a blended mode of service delivery as guided self-help iCBT has demonstrated lower attrition than nonguided self-help iCBT , and theA VR system for exposure therapy has also been developed for this program, which includes 5 virtual scenarios: (1) interviewing for a job, (2) delivering a presentation, (3) participating in work performance evaluation, (4) expressing disagreement, and (5) drinking in public. The VR system uses an 180° video of real humans. There is a storyline for each VR scenario and a couple of interactions between the client and the VR environment, which are guided by a prerecorded voice-over. The clients wear a head-mounted display and respond by moving their head. The voice responses of the clients are recorded in the VR system for replay. The technologies used for the development of the VR system include voice recording, VR180 stitching, VR game engine development, VR motion tracking on the target point, and an auto-trigger based on the user’s headset direction. An administration control panel has been developed for the therapist to control the VR interaction. In the beginning of each VRET session, the therapist provides a short briefing and asks the client to choose one VR scenario. Then, the client participates in the VRET for no longer than 15 minutes. The therapist then proceeds to debrief the client upon completion of each VRET session and submits a session report on the Ease Online system. Examples of VRET photographs are shown in The program sessions outlined in The therapist for the Ease Online program has a master’s degree in counseling  and is registered as a certified counselor in both the United States and Canada. She has 9 years of counseling experience in Hong Kong. The intake worker is a registered social worker in Hong Kong who has a bachelor’s and a master’s degree in social work and counseling experience that spans more than 30 years in a variety of settings. The intake interviews were conducted by both the therapist and the intake worker, and all the service and initial screenings were delivered and conducted by the therapist—both are native Cantonese speakers.Several strategies were adopted to ensure compliance with the intervention: (1) progress reports were completed and submitted by the therapist after each individual counseling session to record the understanding of the clients of the web-based modules and their difficulties in learning them, and applying CBT skills to cope with their own social anxiety; (2) the therapist completed and submitted a progress report in the system after each VRET session to record the session contents, including the VRET experience of the client, skills that the clients have learned to cope with social anxiety, and client feedback; the VRET process was recorded for debriefing in each VRET session; and (3) all the tasks completed by the clients were recorded in the system. A reward score was assigned to clients when they completed a task. Clients were provided a program workbook as an incentive if they completed 80% of the intervention contents.The Chinese version of the SPIN ,47 was uThe C-BAI ,49 was uThe Chinese version of the BDI-II ,50 was uThe Chinese version of the General Health Questionnaire-12  was adopThe Chinese Automatic Thoughts Questionnaire  containsThe Chinese adaptation of the abbreviated version of the World Health Organization Quality of life Scale  was usedThe Chinese version of the Internalized Stigma of Mental Illness scale ,56 was uIn addition, before and after each VRET session, physical arousal through heart rate and blood oxygen levels were measured with a smart watch that the clients wore on their wrist.Ethics approval was granted by the Human Research Ethics Committee (REC/18-19/0241) of the Hong Kong Baptist University. Participation in this study is voluntary and free of charge. Participants could withdraw at any time without any repercussions. High-risk cases identified at the screening stage were referred to local nongovernmental organizations or governmental social service sectors upon the consent of the applicant. Each participant was assigned a code number for identification in the program database to protect their privacy and anonymity.d will be calculated as the index of the effect size both within and between groups.Intent-to-treat analysis, which is the least biased way to estimate an intervention’s effects , was useThe Ease Online program was developed between July 2019 and December 2020 and officially launched in a press conference on January 18, 2021. The principal investigator and project staff have since been involved in promoting the program and recruiting, screening, and referring participants, taking part in intake interviews and case meetings, conducting service delivery and monitoring duties, collecting data, modifying and enhancing the system, providing technical support, responding to enquiries, and other tasks. As of February 2023, a total of 1811 individuals were enrolled in the Ease Online program. A total of 401 intake interviews have been completed, and 329 participants have joined the program, among whom 166 have completed the intervention. A total of 1924 written comments have been provided for client assignments, 604 individual counseling sessions have taken place, and 392 VRET sessions have been conducted. Data collection is still ongoing, which is expected to be completed in March 2024.SAD often has a high prevalence and low treatment rate. People with SAD often underperform and underachieve. Treatment of SAD can not only improve their achievement and quality of life, but also increase productivity in the society as a whole. This study is the first of its kind in combining iCBT and VRET for the treatment of social anxiety in Hong Kong. At a theoretical level, this study will contribute to the development and evaluation of internet-based psychological interventions in Chinese communities. At a practical level, if proven to be effective, this study will provide an alternative e–mental health service option for people in Hong Kong with easy access. In addition, if adopted by local social service sectors, the Ease Online program will fill in a large service gap between the overwhelming service demand by mental health clients and the insufficiency of mental health professionals in Hong Kong.In the process of developing the Ease Online program, several lessons have been learnt: (1) considering the extremely low treatment rate of SAD in Hong Kong (8.7%) , iCBT seThere are several limitations of this study that should be considered. First, only completed tasks are recorded in the system, but there are no records of therapist time and use time of the client in the system. User time can be recorded in the system in future research to calculate the average therapist time spent and the amount of time for which the clients use the system. Second, the number of missing data at posttest and follow-up is quite high—this may be related to the busy lifestyle in Hong Kong and nature of free services provided in this study, although various means including email and phone calls have been used to remind clients to complete the web-based questionnaires after the intervention. Different approaches need to be used in future research to increase the response rate of postintervention assessments. Third, although several strategies are adopted ensuring compliance with the intervention, future research may include independent ratings by certified cognitive behavioral therapists of a random selection of the progress reports of the individual counseling and VRET sessions as well as assignment feedback. Fourth, participants are mainly recruited via open recruitment, which may cause recruitment difficulties and a high nonresponse rate after enrollment. Collaboration with local social service sectors is suggested in future research for participant recruitment and follow-up with service delivery and data collection. Fifth, in the VR system, 180° videos are produced, which may limit the view of clients in the VR environment. Future research may aim to develop 360° videos for the VRET system. Finally, 5 VR scenarios are developed in this study; future research may aim to develop more VR scenarios to allow clients to choose social situations that are more relevant to them.


Local humanitarian workers in low and middle-income countries must often contend with potentially morally injurious situations, often with limited resources. This creates barriers to providing sustainable mental health and psychosocial support (MHPSS) to displaced individuals. Clinical supervision is an often neglected part of ensuring high-quality, sustainable care. The Caring for Carers (C4C) project aims to test the effectiveness and acceptability of online group-based supportive supervision on the well-being of MHPSS practitioners, as well as service-user-reported service satisfaction and quality when working with displaced communities in Türkiye, Syria, and Bangladesh. This protocol paper describes the aim, design, and methodology of the C4C project.A quasi-experimental, mixed-method, community-based participatory research study will be conducted to test the effectiveness of online group-based supportive clinical supervision provided to 50 Syrian and 50 Bangladeshi MHPSS practitioners working with Syrian and Rohingya displaced communities. Monthly data will be collected from the practitioners and their beneficiaries during the active control (six months) and supervision period (16 months over two terms). Outcomes are psychological distress (Kessler-6), burnout (the Copenhagen Burnout Inventory), compassion fatigue, compassion satisfaction, and secondary traumatic stress , perceived injustice, clinical self-efficacy , service satisfaction, and quality (Client Satisfaction Questionnaire and an 18-item measure developed in this project). A realist evaluation framework will be used to elucidate the contextual factors, mechanisms, and outcomes of the supervision intervention.There is a scarcity of evidence on the role of clinical supervision in improving the well-being of MHPSS practitioners and the quality of service they provide to displaced people. By combining qualitative and quantitative data collection, the C4C project will address the long-standing question of the effectiveness and acceptability of clinical supervision in humanitarian settings.The online version contains supplementary material available at 10.1186/s12888-023-05246-1. The number of people who have been forcibly displaced due to ongoing conflicts, violence, and persecution is currently at an all-time high. Displaced individuals are at a higher risk of experiencing mental health problems and functional impairment as a result of the various stressors they face before, during, and after displacement . The majOne novel approach to addressing the burden of needs in low resource contexts is called ‘task-sharing’ in which tasks typically performed by specialized mental health professionals are transferred or shared with individuals who have little or no formal mental health education, such as community health workers. These individuals receive brief training in order to provide mental health care . ClinicaSupportive clinical supervision is a collaborative, emotional, and practical professional support that can help practitioners cope with the stress of working in displacement contexts. It is a vital aspect of mental health practice, providing practitioners with the support they need to improve their skills, maintain quality of care, and ensure the sustainability of psychosocial services . By reduIn addition, there is a well-established link between contextual stressors such as occupational stress, structural injustice and high workloads and negative psychological outcomes such as distress and burnout. There has been little research to date on how to protect practitioners involved in task-sharing from these negative psychological outcomes.To ensure that practitioners can provide high-quality, sustainable care, it is essential to prioritize supervision in displacement contexts. Furthermore, there is a lack of research investigating the impact of supervision on the mental health outcomes of displaced communities who use psychosocial services . DespiteThe aim of the Caring for Carers (C4C) project is to evaluate the impact of online supportive clinical supervision on the well-being of mental health and psychosocial support (MHPSS) practitioners, as well as service-user reported service satisfaction and quality, when working with Syrian and Rohingya displaced communities in three prolonged displacement contexts: Türkiye, Syria, and Bangladesh. By considering the perspectives of various stakeholders, including mental health practitioners, Syrian and Rohingya mental health service users, supervisors, and organizations, the project also aims to assess the acceptability and appropriateness of the supervision program.Drawing on a realist evaluation framework ; we aim Objective 1: Characterise the relationship between contextual stressors  and psychological outcomes  and PTSD (PTSD8) and burnout.During the active control period, contextual stressors will be positively associated with psychological outcomes among MHPSS practitioners working with displaced communities, both at baseline and longitudinally. Compassion satisfaction will mediate the relationship between contextual stressors and psychological outcomes.Objective 2: To evaluate whether the 16-month online supervision program ameliorates the negative impact of contextual stressors on psychological outcomes.The negative relationship between contextual stressors and psychological outcomes during the intervention period will be weaker, compared to the active control period,Practitioner clinical self-efficacy will increase at a greater rate during the intervention period compared the active control period, controlling for contextual stressors and psychological outcomes,Objective 2: To evaluate the effectiveness of the 16-month online supervision program (2 8-months terms) on perceived service satisfaction, acceptability, and appropriateness of the service provided to Syrian and Rohingya displaced communities in Türkiye, Syria, and Bangladesh compared to a 6-month active control period.Objective 3: To identify supervision group content and processes associated with greater improvements in practitioner wellbeing and service user satisfaction.The current project is a mixed-method, longitudinal, quasi-experimental, and community-based participatory research study using a realist evaluation framework. This design is feasible in a low-resource setting and does not require withholding the intervention from anyone.The realist evaluation (RE) framework is a theory-driven approach that aims to uncover how, for whom, and under what circumstances an intervention, or a program works . This apThe application of the RE framework in the scope of this project is depicted in Fig. The contextual factors are given under three categories: (1) Study Location; (2) Work-related Factors; and (3) Supervision Program-related Factors.Conducting psychosocial work with communities who have experienced conflict, persecution and displacement can increase the risks of experiencing moral injury and burnout . This isThe Syrian crisis led to the displacement of 13.3 million Syrians, of which 6.6 million were forced to leave the country and 6.7 were internally displaced . Many ofAmong Syrians who sought refuge in other countries, the majority or roughly 3.6 million people, live in Türkiye under temporary protection status. Türkiye limits refugee status to those escaping from European countries; therefore, Syrians are given temporary protection status, which provides limited access to basic services including health, education, and employment . In addiRohingya people have a long history of human rights violations, oppression, and persecution. They became stateless following the Citizenship Act of 1982, which denied citizenship to the Rohingya people in Myanmar . ApproxiWorking in direct contact with people who have experienced significant adversity in resource constrained environments can pose psychological and social hazards to humanitarian workers. Work conditions represent the main proximal context factors that can hinder or promote supervision . ExcessiHumanitarian workers providing support to displaced people are at higher risk of a wide range of mental health problems. Recent research has shown that at least one-third of MHPSS practitioners working with Syrian refugees in Türkiye and the Syrian border are likely to experience depression, anxiety, burnout, and secondary traumatization due to the stressful nature of their jobs . The risThus, in the present study, we will examine work conditions  to understand the enablers and barriers of our supervision program.In addition to contextual factors, we hypothesize that supervision-related factors will impact on outcomes. This includes operational supervision factors, such as the number of supervision sessions attended and session structure  are likely to impact the outcome of the supervision program. Clinical supervision factors could include the working relationship between the co-supervisors; group cohesion; working alliance between the supervisees and supervisors; cultural sensitivity of the group members; disparities in relative experience and clinical frameworks among group members.Within the RE framework, ‘mechanisms’ refer to the underlying processes whereby the intervention results in the observed outcome. An intervention triggers specific mechanisms/processes in a particular context, thereby producing the outcome . We propAs the current project focuses on group supervision, competencies of the supervisors related to group facilitation  will beAs the last element of the C-M-O configuration, we propose the following outcomes for our supervision program:The relationship between psychological hazards presented by the context and work -related factors will be ameliorated by the introduction of clinical supervision. That is, relative to adversities experienced, practitioners will show reduced distress, PTSD and burnout during the supervision program compared to during the active control period.Improvement in MHPSS service satisfaction of Syrian and Rohingya displaced communities relative to the active control period.RE framework entails an iterative process of testing C-M-O configurations and refining the initial theory by collecting and analysing empirical data . To bettA quasi-experimental multiple-baseline design will compare repeated measurements of the same individual during an active control period to those during the intervention, eliminating the need for a control group . During MHPSS practitioners will be asked to complete online surveys during the active control component and intervention component to examine the effect of the supervision program on the well-being, burnout level, and counseling self-efficacy of MHPSS practitioners (Objectives 1 & 2). MHPSS service users will be interviewed by trained research assistants to rate service satisfaction and quality (Objective 3).The intervention was designed by an Australian clinical psychologist and clinical supervisor with experience providing supervision in both Australia and in humanitarian contexts (SW). The program aims to develop key competencies in mental health practice based on professional practice standards outlined in Supplementary material The program uses Australian mental health professionals with specialized training in supervision, along with local supervisors who have professional experience and cultural insight. Supervision will be in groups of 4–6 supervisees, 2 co-supervisors , and a research assistant. Sessions will run for 90 min on Zoom, fortnightly, for 16 months, split into two terms as per postgraduate mental health programs. Groups will be closed once they start, to allow for cohesion and safety. At the end of the first term, participants will be reassigned to a different group with new supervisors and co-supervisees. Supervisor dyads are then placed into a Whatsapp group with a Research Assistant/translator two weeks prior to the supervision groups commencing and will be encouraged to begin a dialogue. The supervisors will be provided with the written guidance and asked to discuss and share ideas with each other.The supervision models built on reflective and supportive supervision. Reflective supervision helps supervisors guide supervisees to better understand clinical issues. It involves two-way communication and draws on the supervisee’s expertise. This approach is suitable for cross-cultural programs where Australian supervisors may not understand cultural and contextual dynamics. The program also draws on the Integrated Model for Supervision by the International Federation of Red Cross and Red Crescent Societies (IFRC) . SuperviThe total sample size for the project is 2,300 comprised of the following samples from each of the participant groups:Participant Group 1 MHPSS Clinicians: 100 . Participant Group 1 will be equally split between the two data collection sites i.e. 50 practitioners sampled from Türkiye and Northwest Syria, and 50 practitioners sampled from Bangladesh.Participant Group 2 Beneficiaries: 2,200 .This sample size is sufficient to meet the research aims and answer the research questions because in longitudinal growth modelling, sample size is calculated based on the number of assessment occasions and does not require large numbers of participants to achieve sufficient statistical power. We have previously conducted Monte Carlo simulations using the same primary outcome to determine that a sample size of 80 is sufficient to achieve a power of 80% with a similar multiple baseline design with 10 measurement occasions . We haveMHPSS practitioners will be recruited via the network of the project partners  in Türkiye/Syria; Suicide Prevention Sub-Group (SPSG) of the MHPSS Working Group in Bangladesh). MHPSS organisations will be invited to participate in the study. Upon approval to participate in the study, those organisations will be asked to provide a list of consenting MHPSS practitioners in their organisations who have indicated interest in the study. The research team will oversee the recruitment of the practitioners. Recruitment will be open to new participants during the 6-month baseline period and cease once the first term of the supervision program starts. If appropriate (others have dropped out and new practitioners have joined the organisation), new practitioners may join in the break between the two supervision terms when new groups are formed.MHPSS practitioners are: (1) 18 years or over; (2) self-identify as Syrian or Bangladeshi; (3) working as an MHPSS practitioner  with displaced Syrian (in Northwest Syria or Türkiye) or Rohingya community (in Bangladesh). Rohingya MHPSS practitioners cannot be included in the study due to Bangladesh Telecommunication Regulatory Commission restrictions on internet access for Rohingya living in Cox’s Bazaar refugee camps since 2019 [Inclusion criteria for the nce 2019 .MHPSS service users are: (1) 18 years or over; and (2) receiving MHPSS services from an MHPSS practitioner recruited in the study. MHPSS service users will be recruited among the beneficiaries of the practitioners involved in the study.Inclusion criteria for Inclusion criteria for Australian supervisors are: (1) 18 years or older; (2) psychologists, clinical psychologists, social workers or counsellors; (3) completed tertiary training in clinical psychology, social work or counselling or Registered Psychologists.Inclusion criteria for local supervisors are: (1) Completed a university degree in psychological counselling, psychology or psychiatry; and, (2) to have participated in the pilot supervision program since the beginning of 2020 or have other supervision experience.Syrian and Bangladeshi supervisors and clinicians will be offered two free online short courses to support their participation in the program. Upon completion, they will receive two accredited certificates and digital badges stating that they have completed two short courses at the University of New South Wales Faculty of Medicine and Health, Sydney, Australia. These two certificates confirm participation in a 16-month supervision program.For practitioners participating in the supervision program, the five people who answer the highest number of questionnaires closest to the date they are sent out will be awarded $50 for each supervision term.The Kessler-6  ), a 6-iService satisfaction and quality among MHPSS service users will be measured by the Client Satisfaction Questionnaire (CSQ-8)  and an 1The data collection plan with an overview of measures for each participant group is given in Table Each month, field research teams for each site contact all currently eligible practitioners (WhatsApp and email) and provide them with an online survey link containing all planned measures for that cross-section of the overall program. Surveys are delivered using the online KoBoToolbox platform . KoBoTooBeneficiary data collection for description of interview cycles). Beneficiaries are eligible for an interview up to 21 days after their session with their MHPSS practitioner.Practitioners who deliver MHPSS services directly to beneficiaries are eligible for enrolment in our beneficiary interview data collection program. Note, not all practitioners enrolled in our supervision program are eligible for beneficiary interviews for a range of circumstances. Agreements with the MHPSS service organisations are required to contact beneficiaries, with some organisations not able to agree to this process, other reasons for not collecting beneficiary data include: practitioner has changed jobs into a non-service delivery role (i.e. line manager/supervisor); fractional unemployment; as well as illness or holiday. For each eligible practitioner, field researchers at each site will attempt to conduct an interview with one of the beneficiaries of their MHPSS services, on a one-to-one basis per interview cycle . Cross-sectional data drawn from the beneficiary interviews will be nested within practitioner from the longitudinal data drawn from the online practitioner surveys, cross-classified across time. Supervision program participation data may also be incorporated following qualitative analysis.To address Objective 1, data from the active control period will be used to model the relationships between psychological hazards and outcomes, using the hierarchical model structure described above. This model will take into account sociodemographic characteristics, organizational factors, group allocation, exposure to the intervention, and other contextual factors that may be identified over the course of the intervention program. To address Objective 2, the same model will be applied to data from the supervision terms to determine whether the introduction of supervision moderates the relationships between psychological hazards and outcomes identified in Objective 1.Data may be transformed and/or combined in order to achieve appropriate variance partitioning , informed by gold-standard approaches . All canPlanned statistical analyses will primarily be carried out in the R language ecosystem  within tPlanned reporting will be performed in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines .Video recordings of the supervision sessions will be analysed using content analysis  to identThematic analysis , 80 willClinical supervision has been identified by international consensus as a key global research priority for promoting quality mental health care for displaced communities . ClinicaBelow is the link to the electronic supplementary material.Supplementary Material 1: Supervision Resources and Framework.Supplementary Material 2: C4C Project R Workbook Setup.


Two bacterial strains, Streptococcus mutans  and Fusobacterium nucleatum (secondary colonizers), were used. A zone of inhibition test, microbial colony forming units assay, and crystal violet staining assay were used to evaluate bacterial cell viability. Surface characteristics and antimicrobial efficacy were examined by scanning electron microscopy with energy dispersion X-ray spectroscopy. SPSS  version 21.0 was used to analyze the results. The data were analyzed for probability distribution using the Kolmogorov-Smirnov test, and a non-parametric test of significance was applied. An inter-group comparison was done using the Mann-Whitney U test. A statistically significant increase was observed in the bactericidal action of BN-coated discs compared to uncoated discs against S. mutans, but no statistically significant difference was found against F. nucleatum.This in vitro study evaluated bacterial cell proliferation and biofilm adhesion on titanium discs with and without antibacterial surface treatment to reduce the chances of peri-implant infections. Hexagonal boron nitride with 99.5% purity was converted to hexagonal boron nitride nanosheets via the liquid phase exfoliation process. The spin coating method was used for uniform coating of h-BNNSs over titanium alloy (Ti6Al4V) discs. Two groups of titanium discs were formed: Group I ( A dental implant’s success or failure can be greatly influenced by both osseointegration, which occurs when an implant integrates with the bone, and bacterial aggregation surrounding the implant  Even wheTitanium alloy (Ti6Al4V) is the most commonly used implant material due to its favorable mechanical properties and biocompatibility, high corrosion resistance, lack of cell toxicity, and the minimal inflammatory response it causes in the tissues around the implant. Positive regulation of biological processes cannot be fully achieved with titanium alloy since it cannot cause bone apposition. Additionally, because biological processes at the bone-implant interface proceed more slowly on smooth surfaces, titanium alloy surfaces are treated to improve their surface characteristics, shorten healing time, and increase bone-implant contact areas and osseointegration .In boron nitride (BN), boron and nitrogen atoms have a honeycomb structure resembling that of graphene. Specifically, strong sp2 covalent in-plane bonding and weak van der Waals forces between layers make up the structure ,6,7,8,9.Escherichia coli and Staphylococcus aureus  to produce h-BNNSs  in large quantities by ultrasonication in a 3:7 ratio  After that, the liquid phase exfoliation method was used to synthesize h-BNNSs. The exfoliation of h-BN is caused by electron-deficient boron atoms, which result from the Lewis acid-base interaction mechanism. The prepared solution was kept in in 6 test tubes in a centrifuge . The first centrifugation was done at 1000 rpm for 10 min, followed by 3000 rpm for 10 min, followed by 5000 rpm for 10 min. Thus, h-BNNSs were achieved.Samples of the Grade 5 Ti6Al4V titanium alloy discs  were taken. Discs were ultrasonically cleaned for 2 min. The spin coating method was used to add a uniform coating of h-BNNSs over the titanium discs. First, h-BBNSs solution was dropped over each disc with a micropipette at a speed of about 500 rpm. For each disc, 5 cycles were done at 500 rpm for 1 min each. At a fixed rate, a stage of substrate spinning takes place, and the behavior of the fluid is dominated by viscous forces, while that of the coating is dominated by solvent evaporation. Discs were air-dried for 1.5 h and kept in a petri dish over the slide to prevent dust contamination.Samples were examined under a scanning electron microscope  to both obtain coating thickness and to ascertain the impact of BN coating on roughness and wettability; these measurements were conducted on both the uncoated and BN-coated implants.The Micro Scratch Tester  was used to evaluate the BN films’ quality of adhesion. Starting at 0.5 N, the load was gradually raised to 30 N. A 100 m-radius Rockwell diamond indenter tip was employed. When the indenter moved at a rate of 4 mm per minute, a scratch of two millimeters was created. 59.94 N min1 was the loading rate.Surface roughness was measured using profilometer equipment, which also provides the difference between a surface’s high and low points. During profilometer operation, a diamond stylus was moved vertically while in contact with a sample. The diamond stylus was then moved laterally across the sample for a predetermined distance at a predetermined contact force. Outcomes were assessed using the Image Plus program.Streptococcus mutans [Strain: MTCC 890] and Fusobacterium nucleatum [Strain: ATCC 25586] strains were purchased from the Institute of Microbial Technology  and American Type Culture Collection , respectively, for use in the biofilm formation.Incubation:Specimens were divided into these two groups:Group I: BN-coated titanium discs [BN],Group II: Uncoated titanium discs [Control].Streptococcus mutans [Strain: MTCC 890] and Fusobacterium nucleatum [Strain: ATCC 25586] and then incubated . The sample groups were divided into coated and uncoated BN for 24–48 h of analysis. The discs were sterilized by dipping them in 70% ethanol  for 1 min. After sterilization, the samples were placed in the broth medium  for incubation and analysis.BHI (brain heart infusion) broth was prepared to inoculate Streptococcus mutans and Fusobacterium nucleatum were tested using the disc diffusion method. About 100 μL of pre-cultured test organisms were spread onto the agar plates, and then the discs were put on the agar plates. Bacterial plates of S. mutans were incubated for 24 h at 37 °C, whereas Fusobacterium nucleatum plates were incubated at 37 °C for 24 h with 85% N2, 5% CO2, and 10% H2. The zone of inhibition was measured and tabulated. The antimicrobial activity of both BN-coated and control disc samples against One set of samples was used for colony counting after incubation, whereas another set was used for crystal violet staining and a UV spectrophotometer test.3; for uncoated control discs, it was taken as 1 × 106.Microbial colony forming units (CFUs) assay: The specimens were placed in BHI agar plates. After being incubated for 48 h, the bacteria were counted . For BN-coated discs bacterial concentration was taken as 1 × 10Crystal Violet staining assay: PBS  was autoclaved and stored. The culture broth was carefully decanted, and the disc was given two minutes to dry. Following that, a few drops of crystal violet (Himedia) was added, and the mixture was left alone for five minutes. Next, the disc samples were rinsed in 3 mL of PBS. After being cleaned, the samples were dried and photographed. The absorbance of the washed PBS samples was then determined using a UV spectrophotometer  at 530 nm. The bacteria’s growth phase was measured using a UV-visible spectrophotometer at 660 nm to determine whether BN coating on the surface of Ti discs affected the growth rate of the microorganisms., and 0.1 M phosphate buffer were applied for an additional hour. After that, post-fixation with osmium tetroxide and cacodylate phosphate buffer (Himedia) was done for an hour. Then samples were washed with deionized water. After that, a series of graded acetonitrile (Himedia) concentrations  was applied.We used Zeiss FIB-FESEM (field emission scanning electron microscopy) with EDS (energy dispersion X-ray spectroscopy) for analysis. To prepare the samples for SEM, Karnovsky’s glutaraldehyde fixative (Himedia) was used for at least one hour, then 2% paraformaldehyde (Himedia), 2% glutaraldehyde (Himedia)p value < 0.05.First, data were entered into an Excel sheet. SPSS  version 21.0 was used to analyze the data. To determine the probability distribution of the data, the Kolmogorov-Smirnov test was used. It was discovered that the data were not normally distributed, therefore; non-parametric tests of significance were used. The Mann-Whitney U test was used to compare individuals from different groups. Median, interquartile range, and Z value were all measurements of interest. Statistical significance was defined as a Under the scanning electron microscope, a thin and uniform coating of 13–14 μm was observed at 25 KV accelerating voltage for the electrons. These surfaces were smooth, as evidenced by the profilometer’s roughness results. The uncoated and coated discs had different properties, discovered in the 0.11–3.44 μm range, which showed that the BN coating did not change the surface roughness. The hydrophobicity or hydrophilicity of implant surfaces was examined via contact angle measurements using distilled water. The contact angles of the implants ranged from 63 degrees to 79 degrees before BN coating. When coated with BN, however, all of the implants’ contact angles were between 46 and 67 degrees. This demonstrated how, despite its thinness, BN coating helped produce a hydrophilic surface with a similar contact angle. In addition, no cracks were found and the BN coatings showed good adhesions. Adhesion measurements were carried out to estimate a critical load; these adhesions could be seen clearly in SEM images.S. mutans and F. nucleatum with control and BN-coated discs showed 11–13 mm in all BN-coated discs for S. mutans, p < 0.001 ] as compared to those in group I [4.0 × 103 (3.0 × 103–7.25 × 103)]  (F. nucleatum were significantly greater in group II samples [555.5 × 106 (534.0 × 106–566.25 × 106)] as compared to those in group I [540.0 × 103 (451.0 × 103–558.25 × 103)]   assay, the colony forming units of  < 0.05) A. The co < 0.05) B. Which S. mutans, which means the growth phase of S. mutans bacteria was considerably less in BN-coated discs because more bacterial death occurred due to the physical characteristics of BN. However, the results against F. nucleatum were not significant  vs. 0.2725 (0.2558–0.2898)]  (In the  < 0.05) . Similar < 0.05) .F. nucleatum samples, the optical density at 660 nm was greater in group I [1.7230 (1.6280–1.7990)] as compared to that in group II [1.6970 (1.6250–1.7260)]; however, the difference was statistically non-significant )  (In the > 0.05)) . The opt > 0.05) .S. mutans showed activity, we performed SEM for the same in uncoated and coated samples. Uncoated sample discs showed a mat layer of biofilm formed on the surface , was performed for elemental analysis and chemical characterization of the boron nitride coating on the titanium alloy discs. EDS results of BN-coated discs with and without microbial treatment showed marked results of BN coating %. , Table 427, polydopamine, silver nanoparticles [As the world’s population ages, the number of operations involving orthopedic implants for the hip and knee, as well as dental implants, is continuously rising. Dental implants in particular have been utilized for a wide range of purposes, including aesthetic treatment and the restoration of masticatory functions. Titanium and its alloys are frequently utilized as implant materials in orthopedic surgery and dentistry due to their superior mechanical qualities, great corrosion resistance, and biocompatibility . Howeverarticles , BBF . As a significant producer of biofilms, it is essential to prevent the formation of is sites ,32. ThusS. mutans and F. nucleatum with control and BN-coated discs. It showed activity for S. mutans but no activity for control and F. nucleatum samples, which means S. mutans is susceptible to the action of BN-coated discs  and helped to prevent initial biofilm formation. However, a limitation of the study was that BN was not able to significantly damage the cell wall of F. nucleatum. Uncoated discs also did not show any antibacterial action against F. nucleatum. However, in this study change in surface characteristics of titanium implants by BN coating did demonstrate significant antibacterial action. Thus, boron nitride nanosheet-coated titanium implants may be a promising antibacterial coating to help prevent both initial colonizers and biofilm formation, and thus reduce chances of peri-implantitis.Previous studies have shown that the sharpness and orientation of nanoparticles are critical elements to achieving significant bactericidal effects . The cur(1)Thin and uniform hydrophilic BN coating of 13–14 μm was achieved. In surface characterization, boron nitride showed good adhesion properties on the surface of titanium alloy discs.(2)S. mutans and F. nucleatum with control and BN-coated discs showed 11–13 mm in all BN-coated discs for S. mutans.Zone of inhibition tests done for (3)S. mutans and F. nucleatum were significantly greater in uncoated TI discs as compared to BN-coated discs.In microbial colony forming units (CFUs) assays, the CFUs of (4)S. mutans bacteria was considerably less compared to F. nucleatum in coated discs. The optical density of BN-coated discs was less in S. mutans.In crystal violet assays, the growth phase of (5)In SEM analysis, uncoated discs showed a mat layer of biofilm on the surface of the disc. Coated discs showed the characteristic nanospike-like structures of BN formed on the surface of the coating. This characteristic feature is responsible for bacterial cell wall damage.(5)EDS results showed a prominent release of boron and nitride elements. 1.1% by weight in B and 2.4% by weight in N elements were released from BN-coated discs with treatment. Without treatment, BN-coated discs released 1.2% by weight in B and 2.6 % by weight in N elements.The present in vitro study aimed to compare the antimicrobial efficacy of boron nitride-coated titanium alloy discs with that of uncoated titanium alloy discs for dental implant applications. In this study, titanium alloy discs were coated with h-BNNSs through the spin coating method. Subsequently, zone of inhibition tests, microbial colony forming units assay, crystal violet assay, and SEM, along with EDS analyses, were done to check antibacterial efficacy.S. mutans; however, its antibacterial activity against F. nucleatum was not significant. Thus, boron nitride nanosheets may have potential as an antibacterial coating for titanium implants that will inhibit initial colonizer and biofilm growth, but further in vivo study needs to be done to assess future clinical implications.This in vitro investigation showed that boron nitride-coated discs were able to reduce bacterial adhesion and several microbial colonies in an in vitro biofilm compared to uncoated discs. However, it showed more prominent bactericidal activity against