Y360/Y177, BCR::ABL1Y360/Y177 and cytoplasmic ABL1Y412/T735 dephosphorylation thereby provoking the rescue of the BCR’s anti-oncogenic activities, nuclear accumulation of ABL1 with tumor-suppressive functions and consequently, growth inhibition of the leukemic cells and an ATO sensitization via BCR-MYC and ABL1-p73 signaling axes activation. Additionally, the allosteric activation of nuclear ABL1 was consistently found to enhance the anti-leukemic effects of the MEK1/2 inhibitor Mirdametinib, which when combined with ATO, significantly prolonged the survival of mice bearing BCR::ABL1-T315I-induced leukemia. These findings highlight the therapeutic potential of MEK1/2-inhibitors/ATO combination for the treatment of TKI-resistant leukemia.Resistance to tyrosine kinase inhibitors (TKIs) remains a clinical challenge in Ph-positive variants of chronic myeloid leukemia. We provide mechanistic insights into a previously undisclosed MEK1/2/BCR::ABL1/BCR/ABL1-driven signaling loop that may determine the efficacy of arsenic trioxide (ATO) in TKI-resistant leukemic patients. We find that activated MEK1/2 assemble into a pentameric complex with BCR::ABL1, BCR and ABL1 to induce phosphorylation of BCR and BCR::ABL1 at Tyr360 and Tyr177, and ABL1, at Thr735 and Tyr412 residues thus provoking loss of BCR’s tumor-suppression functions, enhanced oncogenic activity of BCR::ABL1, cytoplasmic retention of ABL1 and consequently drug resistance. Coherently, pharmacological blockade of MEK1/2 induces dissociation of the pentameric MEK1/2/BCR::ABL1/BCR/ABL1 complex and causes a concurrent BCR T315I mutation  imidazolidine-2,4-dione (DPH) from Sigma-Merck Saint-Louis, MO, USA.Highly specific MEK1/2 inhibitor (MEKi) Mirdametinib . Solid ultrapure arsenic trioxide (AsWT) and -resistant Ba/F3p210 mutant lines Ba/F3p210Y253F and Ba/F3p210T315I established from murine Ba/F3 cells were generated as previously reported [5 cells/ml) were seeded in fresh RPMI 1640 (Sigma-Merck) supplemented with 10% fetal bovine serum (FBS) (Sigma-Merck), 2 mM L-glutamine and penicillin G (100 U/ml)/streptomycin (100 mg/ml) (Sigma-Merck) in the presence of DMSO (vehicle) or PD325901 (0.5 μM) for 3 h and then were incubated with ATO at 2 μM or DPH at 10 μM. Human Ph+ ALL acute lymphoblastic leukemia cell line SUP-B15 [Imatinib-sensitive Ba/F3p210 wild-type . Primary Leukemia blasts were separated on a Ficoll-Hypaque density gradient. Patient characteristics are reported in Table 5 cells/ml) were seeded in complete IMDM medium and treated as described for cell lines.Freshly isolated or cryopreserved/thawed CD34+ leukemia blasts  and ATO using a fixed-ratio experimental design on Ph+ leukemia cell lines displaying different degrees of resistance to the first, second, and third generation of BCR::ABL1 TKIs , 21.Combined treatment of cells with PD plus ATO resulted in the synergistic induction of apoptosis in all the tested cell lines, regardless of their sensitivity to TKIs Fig. .Fig. 1PhAttachment of leukemia cells to the stroma-derived cell lines HS-5 (human) or MS-5 (murine) conferred a significant protection against ATO-induced cell death in three out of the six tested cell lines , but this protective effect was abrogated by the pharmacological inhibition of MEK1/2 Fig. .p < 0.001; n = 13), when treated either in the presence or absence of the stromal HS-5 cell line  and in four out of the five primary-derived leukemic samples (except for ALL#1), while PD treatment of the cells reduced the basal phosphorylation status of ERK1/2 and blunted the further activation of these kinases in response to ATO in all the analyzed samples  ratio observed in ATO-treated vs. other treatments Fig. . ConversBecause the different drugs treatments regulated the shuttling between the nucleus and the cytoplasm of the ABL1 but not that of BCR::ABL1 kinase Fig. , we wereY412 phosphorylation caused by PD in the two subcellular compartments can partly explain the relatively lower fold reduction in ABL1Y412 phosphorylation observed in whole-cell vs. cytoplasmic extracts derived from the same cancer cell samples exposed to PD treatment  increased PD-induced cell death in primary leukemic cells from patients clinically resistant to TKIs MEK1 (MEK1S218D/S222D) in K562 cells displaying a close to 3-fold lower basal MEK1/2 activity than K562-R  Supplem and asse207 Fig. . Convers207 Fig. .In accordance with the fact that MEK1 can elicit pro-survival signals in the leukemia cells we also found that (ca)MEK1-overexpressing cells were less sensitive to ATO-induced cell death as compared to vector control transfected cells and that genetic disruption of MEK1/2 functions in these (ca)MEK1-overexpressing cells was able to restore their responsiveness to ATO Fig. .The fact that genetic and/or pharmacological perturbation of MEK1/2 affected ABL1 and BCR activities suggested that either MEK1/2 or their downstream substrates could be directly responsible for the phosphorylation events in these two kinases. Reciprocal co-immunoprecipitation analysis showed that MEK1/2 were associated with BCR::ABL1, BCR and ABL1, and that these associations were abrogated upon the pharmacological blockade of MEK1/2 Fig. .All together these findings demonstrate that MEK1/2 can effectively enhance the oncogenic potential of BCR::ABL1 either by directly phosphorylating the fusion oncoprotein at the Y360 and/or Y177 residues , 37, 38 Y360/Y177 and ABL1T735/Y412 dephosphorylation in the BCR::ABL1-negative NB4 cell line , widely known to regulate several p53 target genes including p21, Bax, and p53-regulated apoptosis inducing protein 1 (p53AIP1), is translated as multiple transactivation competent (TA) pro-apoptotic and anti-proliferative COOH-terminal splicing isoforms  of which the two predominant forms are p73 α and p73β . In addiPD mono-treatment increased the ratio of TA/ΔN-p73 by either elevating TA-p73 and/or reducing ΔN-p73 in all but one of the 10 samples examined. ATO single treatment elevated TA/ΔN-p73 ratio in 7 out of the 10 samples analyzed. However, either of the single treatments were less efficient in affecting the TA/ΔN-p73 ratio as compared to the PD/ATO combined treatment except for ALL#2 Fig. . BecauseK321   and ATO treatments we tested the effect of these drugs in a mouse model of TKI-resistant, BCR::ABL1-dependent disease. We found that animal survival was significantly improved in mice treated with the combination PD/ATO vs. those that received monotherapies or Imatinib or vehicle alone (15) Fig. . Consist15) Fig. . Moreove15) Fig. .Fig. 6CoImmunohistochemical analyses of liver and spleen sections from PD/ATO-treated animals also revealed a significant reduction in the frequency of Ki67-positive cells and increased frequency of leukemic cells with activated Caspase-3, when compared to that seen in the organs of animals treated with vehicle or Imatinib Fig. . This obThe histopathological data shown in Fig. Additional molecular and immunohistochemical analyses on spleen and/or liver lysates and sections confirmed in vivo the decreased p-ABL1 (T735), p-CrkL (Y207), p-BCR (Y360), p-BCR (Y177) and c-Myc protein levels and nuclear localization of ABL1 in PD/ATO-treated mice vs. Imatinib- or vehicle-treated mice Fig. .n = 3 mice/group of treatments). We did not find any significant changes in total lymphocyte, granulocyte, and monocyte populations counts across the various treatments  in a non-transplanted mice group (In vitro and in vivo loss- or gain-of-function approaches on model cell lines and patient-derived leukemic samples were exploited to unveil an unprecedented role of MEK1/2 in sustaining and potentiating the oncogenic and pro-survival effects of BCR::ABL1.We demonstrate that this phenomenon is exerted through the impairment of the kinase activity of the negative regulator of BCR::ABL1, normal BCR and a concurrent elevation of the levels of activated cytoplasmic non-mutated ABL1.Consistent with these notions, we demonstrated that blockade of MEK1/2 functions reactivates the anti-oncogenic function of normal BCR kinase as well as converts normal ABL1 kinase from a cytoplasmic oncogenic to a nuclear tumor-suppressive effector thus enhancing the antitumor effects of ATO via activation of BCR-MYC and ABL1-p73 signaling pathways Fig. .MEK1/2 by phosphorylating at Y360 and Y177 residues turns off the tumor suppression functions of BCR , 44–47 aT735/Y412 phosphorylation are increased and correlated well with the MEK1/2 kinases activity in the leukemic cells, that is consistent with findings demonstrating that cytoplasmic retention drives ABL1 oncogenic function [ABL1 cytoplasmic/nuclear ratio and cytoplasmic ABL1function , 27.Y360/Y177, BCRY360/Y177 and ABL1T735/Y412 phosphorylations and drove resistance to ATO whereas functional disruption of MEK1/2 produced the reversed effects.Constitutively active forms of MEK increased BCR::ABL1Y360/Y177, BCRY360/Y177 and ABL1T735/Y412 phosphorylations thus enhancing the oncogenic activity of BCR::ABL1 and abrogating the tumor suppression functions of the non-mutated kinases; accordingly, the pharmacological blockade of MEK1/2 promoted dissociation of the pentameric complex and dephosphorylation of the mutated oncogenic and non-mutated counterparts thus leading to the rescue of the tumor suppressive properties of BCR and the nuclear translocation of ABL1.MEK1/2 form a pentameric complex with BCR::ABL1, BCR and ABL1 and contribute to the BCR::ABL1In this context the main findings of our investigation are:Our data identify MEK1/2 as the kinases responsible for the specific phosphorylation of ABL1 at T735 residue, which is critical for its cytoplasmic retention , therebyAdditionally, our demonstration that the MEK1/2 protein kinases can form a complex with and phosphorylate ABL1 and BCR kinases also in BCR::ABL1-negative leukemic cells, indicates that the functional interplay between these kinases can occur independently of the BCR::ABL1 oncoprotein and are consistent with previous findings showing a functional link between ABL kinases and the Ras-MAPK pathway components in other cell contexts .Further evidence to support this point stems from our previous findings demonstrating that in both BCR::ABL1-positive and-negative leukemia cell lines MEK1/2 inhibition induces the accumulation of tyrosine-phosphorylated endogenous p73 , a p53 pThese findings, taken together with previous studies demonstrating that normal ABL1 kinase not only counteracts the BCR::ABL1 oncogenic functions but also sensitizes CML cells to TKIs , 49 suggIndeed, by leveraging on the capability of the MEKi to promote normal ABL1 nuclear translocation, the subcellular compartment where it can exert its tumor suppressor functions, we could also demonstrate here that the allosteric activation of nuclear ABL1 kinase activity by DPH significantly potentiates the anti-leukemic effects of the MEKi Mirdametinib on model leukemic cell lines and patient-derived leukemic blasts.The fact that the efficacy of the PD/DPH combination was detected only in leukemia cells expressing ABL1 supports the concept that DPH exerted its activity by activating ABL1, but not by displacing HSP90 from BCR::ABL1 , 50.Furthermore, we have uncovered a novel role for MEK1/2 in the regulation of the tumor suppression functions of BCR that, in drug-resistant leukemia cells, has been demonstrated to be centered on the degradation of Myc , 34, a cIn this context MEK1/2 protein kinases, key elements of the MEK1/2/BCR::ABL1/ABL1/BCR signaling-centered feedback loop discovered in this study, by activating ERK  and inacBased on the present in vivo study and our previously reported in vivo findings demonstrating only a moderate inhibitory effect of PD/ATO combination on normal hematopoiesis  we expecSome MEKi, included the one used in our study, have been approved by the US Food and Drug Administration for clinical applications as a monotherapy and/or as a combination therapy with the B-Raf inhibitors in BRAF-mutated melanoma, non-small cell lung carcinoma and neurofibromatosis –61. TherSUPPLEMENTAL MATERIALS, METHODS and FIGURESSupplemental Table 1 IC50 Imatinib TKIs-resistant Ph+ leukemic cell linesSupplemental Table 2Supplemental Table 3


Exercise and healthy eating are known to reduce chronic disease risk; however, formerly incarcerated individuals  face significant social barriers when attempting to engage with existing community-based physical activity and nutrition programs. Given the high disease burden and unique educational needs of returning citizens, this proposed work fills an important gap in the support services currently offered to this population.This article describes a process for evaluating the feasibility and acceptability of a physical activity and nutrition intervention tailored to the needs of returning citizens via a partnership between an academic research organization and a community-based reentry program for returning citizens. Staff from the community-based reentry program will train four returning citizens as group fitness instructors and work with a nutritionist to design a 16-week nutrition education curriculum. Reentry program staff will enroll up to 15 formerly incarcerated adults (aged 18 +) in the exercise and nutrition program. Participants will take part in weekly nutrition classes led by the nutritionist and weekly group exercise classes led by a peer instructor. Research staff will evaluate program success in four domains: reach, preliminary effectiveness, implementation, and maintenance.This feasibility study will allow us to design and test a program that can eventually be evaluated in a large, randomized trial. It also addresses the multitude of social determinants that impact the health of returning citizens and builds a framework for program sustainability. Individuals recruited as fitness trainers will acquire skills and certifications that may be used to sustain physical fitness activities within the reentry program.This feasibility study will test our ability to address social determinants that impact the health of returning citizens through a peer-led physical activity and nutrition programming. In the long term, study results may inform development and implementation of reentry programming and policy on a wider scale. The number of individuals released from state and federal prison has increased substantially in recent years. In the year 2000, roughly 600,000 individuals were released . By 2008Individuals who return to community settings after incarceration experience high rates of chronic disease and disability. Sixty-four percent of individuals ages 45 + in state and federal prisons report having a current medical problem . PersonsCurrently, there is little attention to chronic disease prevention and self-management in community reentry programs, despite high rates of chronic disease among returning citizens. Most community reentry programming focuses on mental health, substance abuse, work readiness, and/or education . The spaIncorporating health-related programming into community reentry programs is crucial for addressing physical health among returning citizens. Returning citizens often face a great deal of social stigma and isolation when attempting to re-integrate into society . ReturniExisting physical activity and nutrition programs fail to address the needs of returning citizens. Returning citizens face numerous barriers that are often not addressed by physical activity and nutrition programs designed for the general population. For example, housing insecurity is an ongoing problem in this population . ReturniThe purpose of the current study is to evaluate the feasibility and acceptability of a physical activity and nutrition program designed specifically to address the needs of returning citizens. This paper describes our planned process for an ongoing partnership between an academic research institution and a community-based reentry program . SpecifiIndividuals will be eligible for this study if they (1) are at least 18 years old, and (2) are current or former participants in the local reentry program implementing the project. Individuals will be excluded from participation if they (1) indicate that a doctor or nurse has told them not to engage in physical activity, (2) are unable or unwilling to provide informed consent.Individuals participating in the fitness instructor training program and/or the physical activity and nutrition program will complete an informed consent process. Study staff trained in human subjects protection will meet with potential participants to explain all aspects of the study, including the risks and benefits and obtain participants’ written informed consent. We will orally describe the material written in the informed consent document and answer any questions the participant may have. The participants will be reminded that they are not required to participate in the study and that their decision about whether to participate in the study will have no consequences. Participants who give their consent will sign a copy of the document and will be given a copy of the informed consent document. To accompany varying reading levels, consent forms will always be read aloud.CPR training will equip instructors to respond to breathing or cardiac emergencies that could occur during fitness classes. AED training will equip instructors to use a defibrillator to assist individuals who experience cardiac arrest. First aid training will prepare trainees to recognize and care for a variety of first aid, breathing, and cardiac emergencies involving adults, children, and infants. The course features an interactive simulation learning experience where participants will respond to real-world emergencies. CPR, first aid, and AED training are routinely offered via the local Red Cross [Staff from a community-based reentry program will identify four returning citizens  to be trained as group fitness instructors who can provide instruction to their peers. These individuals will agree to participate in a 36-h training program Table  that wiled Cross . All thrGroup Fitness Certification Program offered through the local YMCA [Trainees will participate in a cal YMCA . This prcal YMCA . This 12We will work with a local nutritionist to develop a 16-week nutrition education curriculum to later be implemented among 15 returning citizens involved in reentry programming. Members of our team previously developed a 16-week nutrition program that was successfully utilized among more than 250 adults who participated in the Church Challenge, a physical activity and nutrition program conducted in Flint’s African-American faith community . The ChuWe will modify this program in two important ways. First, given that many justice-involved individuals have basic or below basic literacy skills, we will reduce the reading level of the nutrition manual and use visual recipes, to ensure returning citizens with poor reading skills will be able to successfully use it . Second,Interactive activities will be important components of our program. From our previous experience in running a nutrition program, we learned that (1) participants learn best by preparing healthy meals in the classroom setting, and (2) competitive challenges encourage class attendance and positive behavior change. The program will, therefore, include cooking classes during which participants can practice preparing simple meals that do not require a kitchen. Additionally, the program will offer prizes  for participants who win weekly challenges .Eligible participants are formerly incarcerated adults aged 18 + who are current or former participants of a local community reentry program. This program provides wrap-around services for formerly incarcerated adults, including reentry care packages , transitional housing, job training, and life skills training . Formerly incarcerated adults aged 18 + who are current or former participants in the community-based reentry program will be eligible to participate in the physical activity and nutrition program. We will enroll up to 15 formerly incarcerated adults in the program. This is a non-randomized feasibility study; thus we did not perform formal sample size calculations. Rather, we will aim for a sample size of 15 participants as a pragmatic decision based on availability of resources. Participants will not be restricted from participating in any other community programs or interventions while participating in this program.Participants will participate in weekly nutrition classes that will take place at the community-based reentry program’s office. Classes will be run by a local nutritionist using an apprenticeship model, where one to two participants assist and provide support during the class. We expect that this apprenticeship model will boost local program capacity to support nutrition education for returning citizens in the future. Of the 16 1-h classes in the program, eight classes will focus on general nutrition education, four classes will be food preparation classes, and four classes will be special topics geared toward the unique needs of returning citizens . We will offer options for day and evening classes to accommodate the schedules of program participants. Program participants will be given city bus passes to ensure their ability to attend classes.Physical activity classes will take place weekly over the 16-week program period. The four individuals trained as group fitness instructors will lead two classes a week that include a warm-up, moderate intensity aerobics, resistance training with cuff weights, flexibility training, and a cool down. Additionally, participants will be asked to engage in at least 30 min of physical activity twice a week in addition to the weekly physical activity class. We also will provide participants with six-month memberships to a local fitness center.We will discontinue or modify fitness program components if participants develop medical conditions during the study that limit their ability to exercise safely. For example, participants will have the option to engage in seated and/or low impact versions of all exercises. Unexpected adverse events (AEs) that occur during the intervention period will be reported to the study team. Serious adverse events will be reported to the Principal Investigator and the IRB immediately in order to determine whether participants should withdraw from the study.Social support is an important predictor of chronic-disease related lifestyle change , 22. We Research staff will lead program evaluation efforts for the project. Primary outcomes include reach, preliminary effectiveness, adoption, implementation, and maintenance Table .Table 2SWe will evaluate the reach of the fitness instructor training program and the physical activity and nutrition program. Reach-related outcomes for the fitness instructor training program include the number of potential fitness instructors who complete fitness instructor certification and the number of fitness instructors who successfully teach in the program. Reach-related outcomes for the physical activity and nutrition program will include the number of community-based reentry program participants reached, the representativeness of program participants reached, the mean number of physical activity and nutrition program sessions attended by participants, and the number of participants who complete the program.We will collect survey and physical measurement data at baseline, 16 weeks (end of program) and at a six-month follow-up Table . ParticiAfter informed consent, participants will be asked to complete a 20-min survey that collects psychosocial data, information on health behaviors  and health status. As needed, surveys will be read aloud to accommodate all reading levels. Physical measurements will be collected by research project staff. Program participants will provide their contact information to study staff at baseline. Those who discontinue the program will be contacted by phone and asked to complete outcome assessments either by phone  or in-person .Demographic measures will include age, gender, marital status, parental status, education, and employment status. Psychosocial measures will include measures of depressive symptoms, anxiety, self-efficacy for physical activity and nutrition, and social support for physical activity and nutrition.Health behaviors will be assessed, including tobacco use, alcohol use , and sleep behaviors . Health status measures will include self-reported health conditions , self-reported chronic pain, overall self-rated health, and health-related quality of life.Physical activity measures will include minutes of vigorous/moderate/light exercise per week, and frequency of physical activity. Diet and nutrition measures will include evaluation of fruit and vegetable intake, water consumption, food security , and fast food consumption.Systolic and diastolic blood pressure, weight, height, and waist circumference will be collected by research staff. Weight and height data will be collected from participants without shoes, and participants will be asked to wear no more than one lightweight layer of clothing during weight measures. After resting quietly in a seated position for 5 min, three consecutive heart rate and blood pressure readings will be obtained using an automated oscillometric blood pressure measuring device. If a blood pressure measurement is interrupted or incomplete, a fourth attempt may be made. Weight will be ascertained using digital scales. Height and waist circumference will be measured using a fiberglass measuring tape.We will use qualitative methods to understand adoption. We will participate in weekly meetings with program staff before and after initiation of the fitness training program and the physical activity and nutrition program. We will use information from these meetings to gather information on adotpion barriers and facilitators. Meetings will be recorded, and barriers and facilitators will be documented in meeting minutes.We will evaluate implementation of both the fitness instructor training program and the physical activity and nutrition program.After completing informed consent, trainees will complete surveys that assess their (1) overall satisfaction with instructor training, and (2) perceived ability to handle the tasks, obligations, and challenges associated with group fitness instruction (self-efficacy). Self-efficacy assessments will, in particular, assess their confidence in their ability to perform tasks related to the five components of our training program .We will calculate means and standard deviations for all domains of the quantitative assessments. Quantitative data will then inform the direction of the trainee focus group. In particular, we will use the scores on the quantitative assessments to identify the areas where trainees felt most challenged during the training process and solicit recommendations for handling those challenges going forward.We will conduct three, 1-h focus groups with the four trainees who participated in fitness instructor training program. We will develop a structured interview guide that allows fitness trainees to expound on their satisfaction with the training process. We will also query them regarding any difficulties they experienced in getting trained, and any changes to the training process that would be beneficial. We will discuss potential approaches for increasing self-efficacy across the various components of the training program.We will conduct two focus groups with the fitness coach, the project research assistant, and community-based reentry program staff. We will use these focus groups to get trainer/staff perspectives on (1) trainee readiness to serve as fitness trainers and (2) the process of working with trainees during the training process. We also will share with this group the key findings gleaned from the trainee focus group, including their recommendations for improving the training process and increasing trainee self-efficacy.All qualitative interviews will be recorded, transcribed verbatim, and de-identified prior to analysis. We will use the domains covered by our survey measures as a deductive coding framework and then identify inductive codes as they arise. Data will be coded using Dedoose, a web-based qualitative data analysis program . Two codWe will use our quantitative and qualitative data to identify areas where trainees may need additional support to maximize their skills as trainers. As needed, the fitness consultant will work with the trainees to provide supplemental “booster” training to sharpen trainees’ skills. Additionally, we will use these data to develop recommendations for addressing any challenges that arise from training returning citizens as fitness instructors. This information will be useful for future replication efforts.satisfaction with and usage of various program components. This includes satisfaction/usage of: support mentors, the nutrition smartphone app, fitness classes, the nutrition curriculum, pantry usage and grocery shopping tips, and meal preparation strategies learned in cooking workshops. This will be done in two ways: first, participants will complete brief quantitative measures that capture data on usage and satisfaction. Second, research staff will conduct short focus groups with program participants at weeks 4, 8, and 16 of the intervention to discuss program components and ways to improve the intervention.To monitor implementation, we will create fidelity checklists to evaluate the extent to which the physical activity and nutrition programming is delivered as attended , 32. TheTo evaluate maintenance with respect to the fitness instructor training program, we will evaluate the extent to which trained fitness instructors continue to be engaged as group fitness instructors at the 6-month data collection point. We will use survey and physical health assessment data collected at six months to evaluate maintenance with respect to the physical activity and nutrition program.Data management will be conducted by an experienced team, directed by the Principal Investigator. Each study participant will be issued an ID number that will be used for data collection. Quantitative survey data will be collected electronically and will only be identified with the study ID number of the participant. Codes linking participant names with study ID numbers will be kept confidential in secured electronic files on password-protected servers only accessible to the research team. We will collect quantitative data via direct electronic data capture using Qualtrics, a secure, HIPAA compliant, web-based application. In circumstances where direct electronic data capture is not possible, we will use paper-based study forms. Completed study forms will be stored in a locked drawer in the PI’s locked office. We will use standard data checking procedures to check all forms for missing data. Standard data checking procedures will include checking forms for missing data, double entry with discrepancy resolution, daily back-up copies of computer files, and examination of key variables for skewness, variability, missing data, and outliers.Qualitative interviews and focus groups will be audio-recorded using a password-protected encrypted digital voice recorder. All recordings will be stored on a password-protected computer.After interviews are complete, recordings will be de-identified, encrypted and sent to a third-party transcription service.All protocol changes will be submitted to the IRB as modifications prior to implementation. Changes will also be communicated during dissemination to both academic and lay audiences see “” sectionWe will disseminate study findings to academic and lay audiences. We will create one-page fact sheets that summarize major findings. These fact sheets will be given to study participants and posted on the reentry program’s website. Additionally, we will invite participants to a culminating event at the end of the study where we will share study findings. We will disseminate study findings at academic conferences and via academic publications. The sponsor has imposed no publication restrictions.Progression criteria for this study are related to recruitment, acceptability, and completeness of outcome data. The next step from this study will be a pilot randomized controlled trial (RCT) comparing the physical activity and nutrition program to a treatment-as-usual control. We will continue to a pilot RCT if (1) we recruit and consent at least 15 participants in the feasibility study, (2) 70% of enrolled participants report satisfaction with the program via survey assessments, and (3) we obtain complete outcome data from at least 70% of enrolled participants at 16 week follow-up.This project is innovative in several ways. It will be one of only a few studies designed to specifically address preventive and non-pharmaceutical physical health improvement among returning citizens. Few programs and research studies focus on physical health among returning citizens. Most interventions conducted in this population focus on mental health, substance abuse, and job readiness . When phOur project is designed to increase the capacity of returning citizens (and the organizations serving them) to promote physical health. One of the project’s core components is increasing individual and organizational capacity to support physical activity and nutrition programming among returning citizens. By training returning citizens to provide group fitness instruction and working with reentry programs to develop and implement an appropriate nutrition program for this population, we are investing our efforts and resources in activities that can be sustained after project funding is complete.This project promotes health equity by addressing the unique nutritional needs of returning citizens. Traditional community-based nutrition programs fail to consider how housing insecurity and poverty impact an individual’s ability to engage in healthy eating. By developing and implementing a nutrition curriculum that intentionally addresses these issues, we remove some of the obstacles to heathy eating, thus increasing healthy equity in this population.Healthy eating and physical activity depend on numerous social determinants of health, including food access, adequate housing, community/social support, health literacy, and income . Returni


The aim of this scoping review was to evaluate and summarise the measurement properties of nursing research competence instruments and provide a summary overview of the use of nursing research competence instruments.Increasing nursing research competence instruments have been developed. However, a systematic review and evaluation of nursing research competence instruments is lacking.This scoping review was conducted following the Joanna Briggs Institute updated methodology for scoping reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Reviewers searched articles in Eight English databases and two Chinese databases between April 1st, 2022, and April 30th, 2022. An updated literature search was conducted between March 1st and March 4th, 2023. The literature screening and data extraction were conducted by two reviewers, independently. A third reviewer was involved when consensus was needed. The COnsensus-based Standards for the selection of health Measurement Instruments methodology was used to evaluate the methodological quality and measurement properties of the nursing research competence instruments.Ten studies involving eight nursing research competence instruments were included. None of the existing instruments have assessed all measurement properties. A total of 177 empirical studies have utilized a nursing research competence instrument with tested measurement properties.‘Self-evaluated Nursing Research Capacity of Questionnaire (refined)’ was identified as the most appropriate nursing research competence instrument in existing instruments. However, reviewers need to conduct further measurement properties studies on the existing nursing research competence instruments.This study could guide the selection of appropriate nursing research competence instruments which could help to evaluate the nursing research competence of nurses and inform the development of intervention plans to enhance nursing research competence.The online version contains supplementary material available at 10.1186/s12912-023-01572-7. Nursing research competence (NRC) refers to the individual nurse’s ability to conduct nursing research activities , 2. EvidMeasuring the NRC of nursing staff is important for research, education, and management purposes. Research has shown that clinical nurses are the end users and producers of nursing research, and nurses with research competence can promote the development of nursing discipline . The preRecently, many NRC instruments have been developed, such as the Self-evaluated Nursing Research Capacity Questionnaire for nursing staff by Liu , later rResearch performed with outcome measurement instruments of poor or unknown quality constitutes a waste of resources and is unethical . SelectiThis scoping review could answer the following questions : (1) Whi(1) To identity, evaluate, compare, and summarize the validated instruments developed to measure nursing research competence.(2) To provide an overview of the use of all NRC instruments.This scoping review was conducted following: (1) the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) guidance , (2) JoaReviewers searched for articles in eight English databases, including the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), PubMed, PsycINFO, Scopus, Education Resource Information Center (ERIC), and ProQuest Dissertations & Theses Global as well as two Chinese databases, namely the China National Knowledge Infrastructure (CNKI) and WANGFANG DATA between April 1st, 2022, and April 30th, 2022. An updated literature search was conducted between March 1st and March 4th, 2023, covering the literature during the period from April 1st, 2022, to March 1st, 2023. Our search methodology was guided by the COSMIN guideline. It encompassed three primary components: (1) the target demographic , (2) the focal concept , and (3) the measurement attributes . Elaborate search strategies for each database could be found in Tables Supplementary 4–13 (Tables S.The scoping review aimed to (1) summarize the instruments developed to measure NRC and (2) provide an overview of their use . The incAll studies were exported to an EndNote X9 library , and duplicates were removed using its deduplication function. Two reviewers (YX and HH) independently screened the titles and abstracts, followed by assessment of full tests of potentially eligible articles. Disagreements between the two reviewers were resolved by a third reviewer (QC). Any articles that were not available online or through author contact were excluded, and The references of the included studies were also screened using the same process.Two reviewers (YX and HH) independently extracted data from Tables SFor all eligible studies of objective 1), we extracted information including the development and verification of instruments, measurement properties of the included the development and verification of instrument. However, none of the self-designed scales provided details about the development of NRC instruments or psychometric testing. Furthermore, the evaluation of these scales did not adhere to the COSMIN methodology nor was their data extracted in this study. The extracted data are shown in Table S, we extrFor all eligible studies of objective (2), we extracted the information including author, year, location, study aim, design (intervention), participants, sample size, the instrument of NRC used, and results related to NRC. The information is shown in Table STwo reviewers (YX and HH) appraised the quality of the studies, with a third reviewer (QC) resolving any disagreement. First, the content validity  was considered the most important section to determine whether the instrument items were suitable for the construct of interest and target population. Next, evaluating the internal structure  was crucial to understand how the items were combined into a scale or subscale. Finally, the remaining measurement properties  were also taken into account . Based oCOSMIN Risk of Bias Checklist was used to evaluate the risk of bias of 10 measurement properties  . The COSThe methodological quality ratings of instrument development and reviewer's ratings were used to evaluate content validity against the 10 Criteria for Good Content Validity, scoring each measure as "sufficient ( +)", "insufficient (-)", or "inconsistent ( ±)" . The oveThe modified GRADE approach was used to rate the quality of evidence, based on the number and quality of available studies, their results, reviewer ratings, and consistency of results. The overall quality was graded as "High", "Moderate", "Low", or "Very low" . EvidencStudies that only used the NRC instrument as a variable without testing its properties would not be evaluated, but their characteristics would be extracted.Instruments were categorized using COSMIN guidelines into three groups: (A) Instruments with evidence for sufficient content validity (any level) AND at least low quality evidence for sufficient internal consistency; (B) Instruments categorized not in A or C; (C) Instruments with high quality evidence for any an insufficient measurement property .Instruments categorized as (A) could be recommended for widely use. Instruments categorized as (B) have potential to be recommended for use, but further research was needed to assess the quality of this instrument. Instruments categorized as (C) should not be recommended for use.A total of 3265 articles were retrieved, 920 duplicates were removed, and 454 were screened for eligibility. From these, 10 studies on NRC instrument development and psychometric properties, 177 empirical studies using a psychometric tested NRC instrument, and 23 empirical studies using a self-designed NRC questionnaire (without describing the development or/and the psychometric testing) were identified  was rated as 'inconsistent ( ±)' and NRC instruments (⑤⑦⑧) was rated as ‘sufficient ( +)’. The assessment of structural validity for two NRC instruments (③⑦) was rated as 'sufficient ( +)’, the assessment of the structural validity of these four NRC instruments (④⑤⑥⑧) was ‘indeterminate (?)’. The assessment of internal consistency for three NRC instruments (②④⑥) was rated as ' sufficient ( +)', two NRC instruments (①③) was rated as ‘insufficient (-)’, and three NRC instruments (⑤⑦⑧) was rated as ‘indeterminate (?)’. The measurement properties of reliability for seven NRC instruments (①③④⑤⑥⑦⑧) was rated as ‘indeterminate (?)’. The assessment of the hypotheses testing for construct validity for NRC instruments ④ and ⑧ was rated as 'sufficient ( +)'. More details were shown in Table As present in Table Based on the evaluation results, three NRC instruments (⑤⑦⑧) were rated as ‘sufficient ( +)’ for content validity, but their internal consistency was rated as ‘indeterminate (?)’ Table . Thus, tMost studies on NRC instruments were conducted in China , with cross-sectional studies , randomized controlled trials , a quasi-experimental study  and before-after studies being the predominant study designs . All the studies (100%) were published after 2009, with most studies targeting either nurses  or nursing students  as the target population. Further details on objective (2) can be found in Table S3.This scoping review evaluated eight NRC instruments using the COSMIN checklist, but none of them have assessed all measurement properties. Among the existing eight NRC instruments, NRC instrument ⑦ is the most widely used, and it has only been used by Chinese scholars as of now. This may be because the NRC instrument ⑦ was developed by Chinese scholar Pan et al. In addition, NRC instrument ⑦ was developed in 2011 and was one of the earliest NRC instruments developed in China.Lack of reference to the target population during development was an important disadvantage in developing NRC instruments. The items in NRC instruments should be both relevant and comprehensive for the "construct" being measured, as well as comprehensible for the study population. These elements are crucial for ensuring content validity, which is crucial for ensuring an instrument's psychometric properties, and? requires cognitive interviews with the target population , 20. HowConfirmatory factor analysis (CFA) and exploratory factor analysis (EFA) were performed on six NRC instruments (③④⑤⑥⑦⑧), with two instruments (③⑦) reporting CFI values of 0.98 and 0.97, respectively. These NRC instruments (③④⑤⑥⑦⑧) are capable of reliably capturing the theoretical structure and idiosyncratic degree . In otheMost studies focused on internal consistency, which reflects the correlation of items in the NRC instrument or subscales. However, some NRC instruments ①②④⑤⑥ and ⑧ did not meet the criterion for sufficient structural validity . TherefoThe prerequisite for widespread use of NRC instruments is to ensure reliability, minimal measurement error, and sensitivity to changes. Except 'The Nurse Research Questionnaire among Nurse Clinicians ②', all NRC instruments have been evaluated for reliability. The reported ICC values were not clearly documented in the literature, indicating that their reliability was not satisfactory. Although reliability and measurement error are interrelated measurement properties , there iCriterion validity of NRC instruments ④ and ⑧ was reported using the author-defined gold standard in the respective articles. However, we question the appropriateness of using 'The Anxiety Scale Towards Research and the Attention Scale Towards Scientific Research' and 'General Self Efficiency Scale' as the gold standard in the studies, as they may not be ideal measures for NRC instruments ④ and ⑧, respectively . AccordiHypotheses testing for construct validity is defined as the relationships of scores on the instrument of interest with the scores on other instruments measuring similar constructs  or dissimilar constructs , or the difference in the instrument scores between subgroups of people  . The stuNo studies evaluated the cross-cultural validity of the NRC instruments. Cross-cultural validity refers to the degree to which the performance of the items in the translated or culturally adapted instrument adequately reflects the performance of the items in the original version of the instrument , 31. CroThe study recommended all NRC instruments as Grade B. However, the lack of specific information regarding the evaluation of content and construct validity may have influenced this rating. Although all NRC instruments could be recommended for use, but further studies are necessary to confirm the reliability of all NRC instruments. It is also important to note that the stringent evaluation method of COSMIN bases the score of each measurement property on the lowest-scoring item across all items. This approach may result in lower evaluations for instruments with insufficient information , 34, 35.We have observed that even though the of developers these NRC instruments have limited the target population (nurses/nursing students) and provided clear definitions of NRC, there was no significant difference in their definitions of NRC for nurses and nursing students. Furthermore, minimal discrepancies exist among the NRC instruments developed for distinct populations . Therefore, further research should investigate whether a distinction in NRC between different populations (nurses and nursing students) is necessary. If different populations need to have different NRC, it becomes imperative to delineate the precise implications and extent of NRC for each distinct group. Conversely, if there is no difference, all the NRC instruments can be universally used without limiting the target population.All the NRC instruments were recommended for use under category B. Considering that the COSMIN guidelines recommend using instruments categorized as (B), and given the current widespread used of NRC instruments, it was not recommended to develop new NRC instruments. Instead, existing NRC instruments that were recommended as category (B) could be optimized to the greatest extent possible. For example, it's worth noting that the evaluation on content validity of NRC instruments ①②③④⑥ did not encompass nurses and/or nursing students (the main reason why these NRC instruments cannot be recommended as category (A)). Therefore, it is possible to consider conducting additional interviews with nurses and/or nursing students, comparing the NRC instruments ①②③④⑥ items with the interview results to estimate which NRC instruments have very good content validity. Furthermore, the evaluation results suggest the Cronbach's alpha values of some dimensions of NRC instruments ⑤⑦⑧ are below 0.70. It's imperative to undertake large-scale studies that validate these dimensions comprehensively. If the Cronbach's alpha values for all dimensions fail to reach the desired threshold even within a large-scale study, a revision of the dimensions and entries within the existing NRC instruments should be deliberated. In a broader context, future researchers are encouraged to develop novel measurement instruments guided by the COSMIN framework. Notably, the development process should incorporate qualitative interviews with the target population, specifically focusing on gauging reliability, comprehensiveness, and understandability of content validity within these instruments. Subsequently, extensive validation of internal consistency within a sizable sample of the target population is pivotal, ensuring that instruments could be categorized as (A) merit recommendation for practical use.By summarizing the usage of all NRC instruments, we found that nurses and nursing students were currently the main focus of research using NRC instruments, and more than 50% of the research was cross-sectional. This provides a theoretical basis for nursing researchers to understand the current situation of nurses and nursing students' NRC and develop precise intervention plans to improve their NRC. It is worth noting that although RCT and Before-after study in the same patient have been conducted, there were few studies with a large sample size and a lack of longitudinal evaluation of the effectiveness of NRC intervention by nurses and/or nursing students. In addition, almost all research was conducted in China, which may be due to the fact that the majority (87.5%) of NRC instruments were first developed by Chinese researchers. Therefore, in the future, nursing researchers from different countries should improve existing NRC instruments, select appropriate NRC instrument based on specific contexts and cultural backgrounds, and conduct cross-cultural testing to clarify the NRC competence of nursing staff from different countries and provide a theoretical basis for formulating intervention measures.The study has three strengths: (1) it followed the COSMIN guideline, JBI methodology, and reported following PRISMA-ScR checklist; (2) it comprehensively searched and retrieved relevant literature from English and Chinese databases; and (3) it evaluated the methodological quality of studies and instruments according to the COSMIN guideline.Limitations of the study include the exclusion of NRC instruments published in languages other than English and Chinese, and the possibility of missing relevant literature not included in the selected databases. In addition, the NRC instruments in this scoping review were designed for nurses and/or nursing students, not for patients. Therefore, we replaced all patients with nursers/nursing students during the evaluation. COSMIN guideline suggested that it could be used as a guidance for reviews of non-PROMs. However, COSMIN guideline did not mention how to make specific modifications to steps 5–7 , and remaining measurement properties  for non-PROMs.The study recommended NRC instrument ⑦ as the most suitable among existing instruments, but calls for further research on the measurement properties of NRC instruments, especially cross-cultural validity, measurement error, and criteria validity. Additionally, researchers should evaluate and report on the interpretability and feasibility of NRC instruments, and explore the development of more reliable and feasible instruments for different nursing populations based on a unified concept of nursing research competence.This study evaluated NRC instruments' measurement properties and provides recommendations for selecting appropriate instruments. Valid and reliable NRC instruments can accurately evaluate nurses' NRC in clinical settings and provide evidence for intervention plans to improve their competence.Additional file 1: Table S1. The characteristics of eligible NRC instruments. Table S2. The characteristics of study populations involved in the development and validation of eligible NRC instruments. Table S3. An overview of the uses of all the NRC instruments. Table S4. Search strategy for Pubmed. Table S5. Search strategy for Embase. Table S6. Search strategy for Scopus. Table S7. Search strategy for Cochrane. Table S8. Search strategy for CINAHL. Table S9. Search strategy for PsycINFO. Table S10. Search strategy for ERIC. Table S11. Search strategy for ProQuest. Table S12. Search strategy for Wanfang. Table S13. Search strategy for CNKI.