In this paper, a practical application of theoretical developments found in our previous works is explored in relation to atmospheric lidar data. Multifractal structures, previously named “laminar channels”, have been identified in atmospheric profiles—these exhibit cellular and self-structuring properties, and are spatially ordered across the atmospheric profile. Furthermore, these structures have been connected to the spontaneous emergence of turbulent behavior in the calm atmospheric flow. Calculating the location and occurrence of these channels can help identify features of atmospheric evolution, such as the development of the planetary boundary layer (PBL). Employing this theoretical background to atmospheric lidar data, attempts are made to confirm this suggestion and extract information about atmospheric structure and evolution by analyzing turbulent vortex scale dynamics and scale-corresponding Lyapunov exponents that form the basis of identifying the laminar channels in atmospheric lidar profiles. A parameter named “scale laminarity index” is then introduced, which quantifies the relation between vortex scale and chaoticity throughout the profile. Finally, the algorithmic methods employed in this study are described and distributed for future use. In general, the attempt to model atmospheric dynamics is performed with a combination of physical theories and computer-aided simulation ,2,3,4,5.Recently, a new class of models to describe atmosphere dynamics based on scale relativity theory, either employing monofractal dynamics or using the multifractal dynamics as in the case of the multifractal theory of motion, has been developed ,9,10. ThHere, we consider the sequence of the values of the variable We can denote with Thus, let . itself . With thBy picking the second-simplest possible gauge, In this manner, the spontaneous breaking of scale invariance can become the mechanism through which the turbulent energy cascade operates from large to small scales.These theories are important because they represent foundations to practical applications of atmospheric modeling, with applications in various climate studies, meteorology, and atmospheric aerosol transport. Indeed, the set of theories presented in this work leads to a novel application of lidar data which can be used to estimate vertical atmospheric dynamics, which shall be shown in a later segment. Furthermore, they are important even on a purely theoretical basis, as potential avenues into offering a complete understanding of the mathematical apparatus, which describes atmospheric turbulence.In general, whatever scaling gauge is employed, energy is injected through vortices of length The common urdling” . In factdar data ,13. It hublished ,13. Furtublished ,13.Next, this model can be connected to a modified form of the logistic map, which approximates under certain conditions the behavior of a multifractal velocity mode of atmospheric flow. Usage of this model in the logistic map implies an associated Lyapunov exponent for each stage of the turbulent flow—in this manner, it is possible to determine whether for a given set of initial parameters and at a given altitude in an atmospheric column there exist stages in the turbulent cascade that present momentary laminar qualities. The manner in which the connection to the logistic map is done shall be shortly detailed in the following segment: following a Galerkin projection of multifractal type of the nondimensional Navier-Stokes equations of multifractal type, it is possible to write an arbitrary velocity Fourier mode of these equations with the iterative equation:position . Other sposition ,15. It iAfter this, the interpretation of the arbitrary wave vector sequence . Of courNow, if the differential equation used to yield Equation (10) is solved, the result is a Bernoulli equation solution that describes the velocity mode nt scale .Considering the connection between the logistic map and atmospheric turbulence scale models, the approach is quite novel. However, even regarding the connection between the logistic map and atmospheric turbulence studies, not much has been written; Frisch has discovered that a mathematical expression similar to the logistic map might be considered “a poor man’s Navier-Stokes equation” . A few oIn any case, after this connection to lidar data, scaling models and the logistic map has been performed, it is then possible to approximate whether or not certain stages of atmospheric turbulence, at a given altitude and time, present quasi-laminar behavior. Turbulent or laminar flow regimes can be identified in this manner throughout the atmosphere, because for certain initial values, and at certain scales and periods, it is then possible to arrive at such y index”:Sλ=〈λnln〉ed again .Experimental data obtained via a lidar platform are introduced in order to apply the theory written so far and verify the results. The method used to process these data is described in greater detail in our past works, however, they rely on obtaining the structure coefficient of the refraction index profile g manner ,19:(14) In the case of turbulent eddies that are situated in the inertial subrange, it is possible to approximate the refraction index profile from the definition of the structure coefficient:Now, once the outer and inner/dissipation scales have been obtained, it becomes feasible to use the modified beta model, and verify the hypotheses established in this work, however, given the previous presentation of the theories employed in this study, a final summary is required. We consider that atmospheric dynamics can be described by nondifferentiable yet continuous multifractal entities that evolve and bifurcate according to certain gauges. Then, these gauges can be used to construct scaling models that describe the evolution of these entities, and such models can be connected to the logistic map, given the fact that the logistic map itself can represent a velocity mode of a multifractal Navier-Stokes equation. With this connection in place, each scale becomes associated with a Lyapunov exponent, thus making it possible to determine whether or not certain scales at certain altitude exhibit chaotic or laminar channels—it will also be seen that laminarity does occur and that it occurs in an ordered manner, as channel-like structures.Remote sensing data can then be used to further apply the theory discussed thus far. Numerous studies have been performed strictly regarding environmental observation through remote sensing or other remote-controlled platforms; manned low Earth orbit platforms (MLEOPs) provide laboratories for scientific experiments in a wide range of disciplines, some of them even presenting lidar technology, such as the Lidar In-space Technology Experiment (LITE) developed by NASA . On the The RCS data used in this study have been obtained from the RALI Multiwavelength Raman Lidar Platform, which is a part of the National Institute for Research and Development in Optoelectronics INOE 2000 in Bucharest, Romania. The laser emission wavelengths are  studies ,23,24.An analysis of the chaotic behavior of the turbulent cascade in an atmospheric profile is then performed in the following manner: by obtaining  the PBL ,13. A caNow, in our previous studies, we have hypothesized that, because the turbulent cascade proceeds towards the dissipation scale, ascending channels represent upward transport and descending channels show downward transport. Thus, it stands to reason that a preliminary analysis should be made using the plots in order to confirm any such correlations. The first set of figures shows a time series plot of lidar profiles taken approximately from platform . The cho the PBL .The first zoomed-in figure of the time series shows multiple pollutant plumes and other structures associated with the PBL—it possible to confidently exclude the presence of clouds in the lower atmosphere, given the fact that Meteomanz.com displays clear conditions for the “BUCURESTI FILARET” station which is closest to the lidar platform, and also given the fact that ACTRIS lidar data collecting procedure demands that data collection start only during clear conditions . MeanwhiAfter the visual analysis of this RCS dataset, three significant points in the time series, namely termined . The posThe RCS profiles can also be used to provide a clearer picture of the atmospheric profile in comparison with the laminar analysis regarding various atmospheric formations, such as the PBL . The lam, 1500 m . Point C: Lidar data show that the atmospheric formation is only just appearing at this point; this might reflect indeterminacy. The analysis shows indeterminate, opposing V-shaped channels. There is some correlation between RCS data evolution and analysis  with a descending behavior instead of an ascending one. The analysis shows a weak descending laminar channel above the chosen altitude and a short descending laminar channel slightly above the chosen altitude, besides indeterminate horizontal channels. There is some correlation between RCS data evolution and analysis . Furthermore, such peaks are also very stable, not exhibiting fluctuations that are typical of the rest of the profile. This is further shown in the increase of the number of stages in the general laminar analysis corresponding to such areas . A largeOverall, our analysis has yielded ructures . These aNow, the study of atmospheric turbulence and laminarity intermittency and of various correlations between ascending and descending laminar channels can be fruitful, however, it is also a lengthy and difficult process. Any new theory that involves processes for which there is no set methodology, because of the novelty of the process, requires both interpretation and a certain level of speculation. However, beyond the act of interpreting this data, the sheer volume of possible laminarity data and the number of calculations necessary to obtain these data makes the experimentation stage an even more difficult task. Technically, as few as three lidar profiles are required in order to calculate a Opens a Windows Explorer tab which allows the user to select the desired lidar data;Displays emission channel wavelengths and index associated with channel, prompting the user to select one by typing the desired index;Displays the time and index associated with each lidar profile, prompting the user to select one by typing the desired index;Displays “Loading…” messages until the calculations are complete;Displays interactive plots.This fact prevents any ease of experimentation; furthermore, ideally, these theories should be tested on many more sets of lidar data. For these two issues, and to improve the dissemination of these ideas, the Python script used in this paper has been compiled, such that it can be used whether or not a researcher has installed the necessary Python libraries and packages. Compiling was performed using PyInstaller, first by adding Python to Windows PATH variable, and then inputting the command “pyinstaller ‘SCRIPTNAME’.py” with the flags “onefile” and “hidden-import cftime”. The dynamic link library “python38.dll” was also added in the same file as the executable. The program executes the following visible steps:A rough workflow and an example of the application interface are shown in The actual executable to be opened is titled “logistic_lidar_compile_script.exe” and it can be found in the “dist” file—obviously, the user has the possibility to create shortcuts. The input file itself has to be a NetCDF-type file, formatted by AERONET network standards; manipulating data contained in this file can be done in multiple ways, however in this case it is done through the “netCDF4” library for Python. The functionality of the produced plots is based on the library “matplotlib”, as such their size and margins can be modified, they can be zoomed-in or out in various areas, and they can be saved in multiple formats. The program produces four plots: an RCS time series of the whole dataset, a single RCS profile of the chosen index, the laminar channel analysis plot, and the scale laminarity index plot, which is to say it produces the same plots that were previously analyzed.Multiple useful functionalities can be found in the plots themselves; in the upper-left corners of the plot windows, the buttons “Reset original view”, “Back to previous view”, “Forward to next view”, “Pan”, “Zoom”, “Configure subplots”, “Figure options”  and “Save”. Many of these are self-explanatory, however, minor instructions are required for the sixth and seventh buttons. The “Configure subplots” button allows for instant modification of plot size or borders, or for establishing a “Tight layout” of the plot; the “Export values” button allows for easy copying of plotting size parameters. Meanwhile, the “Figure options” functionality allows the user to modify plotting axes limits and scaling, from linear to logarithmic, and even to add or remove labels; in the “Images, etc.” tab it is also possible to instantly modify the colormap of the plot wherever possible, and to modify the minimum and maximum limits of the chosen colormap, thus fundamentally modifying the aspect of the plot and potentially highlighting important features. Of course, the authors of this work encourage other researchers to test these theories through multiple plot analysis and to communicate any error or desired functionality–the software used and discussed in this chapter can be found and downloaded through the link provided in the In this work, a more thorough practical examination of our previous research has been performed, with positive results that point to theoretical validity. After a compressed recapitulation of the required theory, and an explanation of the used theoretical procedures, plots were created that point not only to the existence of atmospheric laminar channels but also to the fact that such channels may dictate the vertical dynamics of macroscopic atmospheric structures, such as aerosol plumes or even the PBL itself. In comparison to RCS data evolution, laminar channel data have been found to mostly yield a positive correlation. Furthermore, the scale laminarity index analysis has proven to be helpful in identifying the PBLH, exhibiting clear and coherent peaks between the PBL and the superior segment of the atmosphere. Finally, acknowledging the difficulty of fully verifying such theories using large quantities of lidar data, software used to construct such plots is disseminated by compiling the Python code used to perform it. This executable and its associated resources are then distributed, and any researchers with access to access to lidar data of the type used in this study are invited to employ these tools in new studies. Further studies will need to be focused on finding ways to quantify the differences and similarities between laminar analysis and vertical atmospheric dynamics through correlation and to do so with much larger quantities of data.


Psychological trauma primarily affects children and adolescents; it mostly results from physical and sexual maltreatment. In the Medico-Judicial Unit Center for Sexual Violence Victims in Tours, France, which I joined in 1992 for research and to give treatment, underage patients represented about three-quarters of patients. At the same time, a national survey was conducted in collaboration with Marie Choquet’s “Adolescent Health” group (INSERM), which targeted several thousand adolescents representing the general population. It revealed that almost one out of five adolescents had experienced physical or sexual assault, and that although the number of sexual assaults probably does not exceed that of physical assaults, most of the time their psychological consequences do considerably exceed those of physical assaults. Several symptoms appear after experiencing rapes or assaults. They have a distinct semiology and independent evolutions. We isolated three of them: dissociative and phobic traumatic syndrome, re-experiencing traumatic syndrome, and borderline-like traumatic syndrome. They are generally triggered all at the same time or in close succession. Re-experiencing traumatic syndrome is profound, but the other two are often more worrying, particularly in relation to children and adolescents, because they generate disorders in their psychological development. Adolescent Unit at the University Hospital in Tours, which was followed by the Psychological Trauma Victim Consultation, which treated almost two hundred people a year . For the most part, this research proceeded in the following chronological order: they started from observations among two categories of female inpatients suffering from severe psychiatric disorders—schizophrenia and manic-depressive bipolar disorder—for which sexual violence is very frequent and has harmful consequences. These observations were then replicated with psychiatric inpatients, no matter what disorder they had been diagnosed with; this eventually led to two systematic studies of incestuous or non-incestuous rape victims from the general population. The first one was cross-sectional, while the other was prospective and lasted over a year. Until now, no other epidemiological study has been conducted on this topic in France.Psychological trauma in rapes and assaults is a serious public health issue. In France, the lack of epidemiological data on rapes and assaults led several research units to perform a series of collaborative studies from 1989 ,3,4, JeaThe purpose of this article is to provide a clinical approach to the aftermath of rapes and other physical maltreatments through an overview of decades of epidemiological and clinical research. While some patients recover quickly from trauma, most of them suffer from different forms of sequelae after these experiences, varying from subject to subject, especially according to their age and environment. This article will describe the distinct outcomes of these traumatic experiences.Hystérie [Hystérie traumatique [Dissociation hystérique [Neurotica; his theory states that the aetiology of dissociative hysteria lies in a traumatic occurrence [a passive sexual experience before puberty: thus is the specific aetiology of hysteria” [Clinical psychiatry and psychotraumatology were born together in France. This is demonstrated by the categories of Briquet’s Hystérie , Charcotumatique , and Janstérique . These pcurrence , the natysteria” . The facysteria”  or a denysteria” —does notysteria” ,17,18,19Etude médico-légale sur les sévices et mauvais traitements exercés sur des enfants [Etude médico-légale sur les attentats aux mœurs was published as early as 1857. In the 1878 edition of this work, he explained that in France between 1858 and 1869, a total of 11,576 people had been accused of rape or had attempted rape. Among them, 9125 had been accused of raping or attempting to rape children. Tardieu assessed 616 of these cases; of them, 339 were rapes or attempted rapes on children under the age of 11. Tardieu’s successor, Professor Brouardel, specialised in the study of child rape. He gave conferences on the topic, and his book titled Les attentats aux moeurs was published within a collection of forensic medicine lectures from the Faculté de Médecine de Paris after he died [In order to explore this, let us recall what the state of knowledge was like at the time. In 1860, Tardieu published an article entitled  enfants  in a sci he died . The exiTraumatic assaults on the subjects that we are tasked with treating consist of physical or sexual violence; either with a mainly utilitarian goal (theft) or a perverse one (an assault with no other aim than itself); either in a professional context  or a civil one (“suburban uprising”); either in an international setting (war) or a societal one ; either on isolated subjects (rape) or on groups (hostages); and they can be further complicated by facts of another nature (traumatic loss and/or separation). As there is an intersubjectivity between a victim and an aggressor, these events stand out from other potentially traumatic situations, such as natural disasters for instance, in which traumatised subjects do not feel that they have been objectified by an aggressor through a sadistic relationship.Medico-Judicial Unit Center for Sexual Violence Victims in Tours, about three-quarters of the patients are underage. A national survey was conducted among several thousand adolescents representing the general population, in collaboration with Marie Choquet’s “Adolescent Health” group (INSERM U472). It revealed that almost one out of five adolescents had experienced physical or sexual assaults, and that although the number of sexual assaults probably does not exceed that of physical assaults, most of the time their psychological consequences do considerably exceed those of physical assaults [Psychological traumas predominantly involve children and adolescents; moreover, they mainly consist in physical and sexual maltreatment . In the assaults . Indeed, not all of the various situations which are likely to generate traumas have the same intensity levels in their consequences, just as not all subjects have the same resistance levels. Moreover, the context or sequence in which the trauma occurs influences its psychopathological evolution. In particular, on top of the usual psychotraumatic clinical consequences, the chronic reiteration of trauma creates other specific clinical manifestations of its own. Therefore, suffering from a car accident but then being warmly supported by family or friends is not the same as suffering from war abuse for several years ; similarComité Français d’Education pour la Santé [Ultimately, like Edna Foa , we intrla Santé . It is ala Santé . Indeed,la Santé ,25. In fdissociative and phobic traumatic syndrome, re-experiencing traumatic syndrome, and borderline-like traumatic syndrome. They are generally triggered all at the same time or in close succession. Re-experiencing traumatic syndrome is profound; however, by many accounts, the other two are much more worrying, particularly in relation to children and adolescents, because they generate severe disorders in their psychological development [Several psychotraumatic syndromes appear after experiencing rapes or assaults . They eaelopment .Dissociative and phobic traumatic syndrome represents the way subjects defend themselves during the traumatic event and then attempt to treat both their identity wound and their re-experiences, respectively, by fragmenting their memory and psyche and by avoiding the world. What we call “dissociation” is a phenomenon that is both intra-psychological and somato-psychological [re-experiencing syndrome has disappeared, the only disorder that still remains consists of psychogenic amnesia or panic disorder with agoraphobia [ological . Intra-pological . Table 1raphobia . These rraphobia .Dissociative and phobic traumatic syndrome is the first traumatic syndrome to appear after the traumatic event takes place. It can become chronic. In that case, everything seems to indicate that experimenting with this defence mechanism during the traumatic event leads to using the same mechanisms with a much higher frequency later, during other hostile but non-trauma-inducing events, when other people could have reacted, for example, with depression symptoms. Its persistence must come as a warning that re-experiencing syndrome may be present for a long period of time [ of time . re-experiencing traumatic syndrome include reminiscences, nightmares, and trigger associations which set off a re-experience of the pain tied to the traumatic experience, or even the illusion of the traumatic experience itself. They are the most specific and sensitive out of all post-trauma symptom groups [The clinical features of m groups . The Amem groups . The diam groups ,32, and In spite of how frequent it is among traumatised people (one out of two people are affected), highlighting their depression symptoms could lead to assumptions that treating such patients is not any more difficult than treating isolated depression. However, let us point out that the British psychiatry professor Sir David Goldberg, who dedicated his entire life to studying depression vulnerability factors, has no hesitation in claiming that sexual assaults are the first aetiological factors of depression . Borderline-like traumatic syndrome can manifest in more psychological ways or more behavioural ways, depending on the cases or the moments in time. At first, “identity instability” is expressed on a psychological level and as a narcissistic depression  which can be so severe that it could evoke melancholy if its traumatic aetiology is not identified. The alteration of psychological development often complicates the identity disorder afterwards, sometimes quickly, particularly among children and adolescents. Indeed, an identity rebuilding process appears, with paranoid omnipotence fits or acting-out behaviours of various kinds. These well-documented borderline personality characteristics are rather typical of traumatic interactions between individuals [Borderline-like traumatic syndrome is a pathology that damages the representation of the future. ividuals ,36. Thisividuals . One shoSome situations are characterised by a particular end to trauma. We have already mentioned the symptomatic differences between boys and girls ,37 and tThanks to mental disorder classifications among other things, clinical researchers know about the specific semiologies of trauma re-experiences in children . It is easy to investigate children’s trauma re-experiences verbally. Children will give an account of reminiscences or nightmares very simply, when prompted to do so. Most of the time, just like with adults, they would not spontaneously do so; therefore, stating the importance of verbal interaction during the child witnesses and their mother’s consultation does not have much inherent worth. dad and mom are separated”—as well as what was implicitly fantasised about—“this wouldn’t have happened if my father had been there”. Indeed, when a little girl who has been asked to represent the time frame when her mother was in danger—raped in her car under the threat of her children getting hurt—she will draw a car. We will use her drawing as a starting point to make associations, in front of her brother and mother, through our remark that a woman’s face seems to be surrounding the car. As for the little brother, after we requested for him to draw his family before difficulties started, he also represented a car. “This car belongs to everyone”, he says, which allows me to say something that is implicit for him but left unsaid between the two children and the mother. I tell him “that’s impossible, since your father and mother are separated”. In that way, two ideas that were being verbally avoided in this family, which has been reduced to the mother and her two children, are reintroduced in their three-way relationship—“the world is dangerous” for phobic avoidance; “I am worthless” for suicide attempts, scarification, and self-harm; or “never again will I surrender” for tantrums from children identifying the aggressor. In the worst cases, masochism can be eroticised up to the point that they look for all sorts of potentially trauma-inducing situations . This is the reason why we stress the importance of looking for behavioural alerting in adolescents who have previously been involved in an assault; furthermore, their running away must always lead to an inspection for sexual assault histories [Above all else, it is the children’s psychological development that is at stake after they witness rapes or assaults. That psychological dead end often leads to acting out according to various thought processes, for example, the birth of a fantasy or a thought such as “istories ,32,35.Precocious affective development and a disproportionate investment in education can sometimes be observed. What will I do if my mother dies?”. The behavioural response was characterised by learning a lot and quickly; growing up in order to be ready in case his mother died. I had to take care of a four-year-old child who had witnessed his father’s attempt to murder his mother. When he came to my office with his mother, he always asked me for my keys and went to lock the door. So much so that when his mother one day asked me, “when will his disorders end?”, it seemed appropriate to answer, “when he will no longer ask for my keys in order to lock the office”. Indeed, by acting in such a way, this wary little boy for the first time tried to recreate the safe place that he had been lacking ever since the traumatic event, because he confusedly felt that he needed it in order to grow up. In school and at home, he was manifesting an irrepressible thirst for knowledge because his actual fantasy was: “The maniac defence from children attempting to resist their new world-representation, which they experience as hostile, with accelerated psychological development must not be related either to the diagnosis setting of real maniac conditions or to the diagnosis of attention-deficit disorder hyperactivity.Borderline-like traumatic syndrome exists along a continuum, with the severe end consisting of severe narcissistic depression, sometimes transforming into dangerous acts against oneself or others, and the benign end consisting of non-conformist behaviour. In those who have been able to perlaborate their narcissistic wound from a traumatic experience, atypicality and fearlessness to the world—which have become less phobogenic than before the traumatic experience—are common ways to move beyond trauma. Indeed, “healing” from trauma cannot happen within a conformist frame. In order to move beyond phobia, the subject has to go through contra-phobic defiance, which does not always worsen and turn into a characterised borderline pathology. Therefore, the subject’s evolution proves to be similar to that of the traumatised child’s, who wants to grow up quickly, or disproportionately thirsts for knowledge. This is why trauma partly works in favour of life: without contra-phobic defiance, we would all still be in our cribs. In summary, subjects whose trauma refers to an intersubjective relationship with others placed in the sadistic position most likely suffer from re-experiences, but also resort to intra- and somato-psychological dissociations and phobic avoidance of the world in order to prevent the pain brought about by panic attacks; at the same time, they also transform—in a harmful or benign way—their identity and narcissistic equilibrium. re-experiencing traumatic syndrome, the traumatic memory is reduced to proto-representation, for example, just the image of the rapist’s eyes; the pain experienced from the entire traumatic experience comes to be associated with this proto-representation. Rapes and assaults alter the usual way of representing the past. Indeed, with borderline-like traumatic syndrome, the wounded subject aims for a neo-identity, which implies new thought processes and new behavioural patterns in the future, for example, with an identification to the aggressor. Rapes and assaults alter the usual way of representing the future. Indeed, with dissociative and phobic traumatic syndrome. Indeed, on the one hand, phobic avoidance revives the traumatic past day after day; on the other hand, phobia also brings a projection into the future: contra-phobic defiance. Similarly, above all else, both amnesia and conversion allow the subject to ignore the past, utilising personality fragmentation. Nevertheless, these dissociations also stimulate the emergence of neo-identities which are supported by new ideals and expectations for the future. With those, subjects attempt to adapt themselves to the world that has emerged after the trauma.The way in which a subject transitions from the first register to the second is determined by the defence mechanisms used in the traumatic experience, which we have gathered under the name of


A family health history-based risk assessment is particularly valuable for guiding cancer screening and treatment strategies, yet an optimal implementation depends upon end-users’ values and needs. This is not only true prior to disease development, but also for those already affected. The aim of this study is to explore perceptions of the value of knowing one’s family health history (FHH)-based risk, experience using a patient-facing FHH tool and the potential of the tool for wider implementation. Twenty multi-ethnic Asian patients undergoing breast cancer treatment in Singapore completed an FHH-based risk assessment. Semi-structured one-on-one interviews were conducted and data were thematically analyzed. All participants were female and slightly more than half were Chinese. The acceptance and usage of an FHH risk assessment tool for cancers and its broader implementation was affected by a perceived importance of personal control over early detection, patient concerns of anxiety for themselves and their families due to risk results, concerns for genetic discrimination, adequacy of follow-up care plans and Asian cultural beliefs toward disease and dying. This study uniquely sheds light on the factors affecting Asian breast cancer patients’ perceptions about undergoing an FHH-based risk assessment, which should inform steps for a broader implementation in Asian healthcare systems. Family health history (FHH) is not only the strongest risk factor for rare diseases, but is well known to impact chronic disease risk as well ,2. An FHIn order to overcome some of these barriers, patient-facing FHH collection tools have been developed to improve risk stratification and disease prevention efforts ,9,10. ThA risk assessment is not only of value to patients prior to disease diagnosis, but is also critical for identifying hereditary syndromes in those already affected. The potential benefits are for both the individual and their family. For example, a cascade testing of healthy relatives to identify others at high risk for disease, and managing the already affected individual’s risk of developing additional diseases associated with the hereditary syndrome. In cancer hereditary syndromes, this frequently manifests as developing a second primary cancer, either of the same type  or a different type , which can occur sometimes several years later . If thesWhile the use of FHH-based risk assessment platforms has been well established in primary care environments, less has been performed to understand its utility in cancer clinics among individuals already affected. Additionally, the majority of these studies have been conducted in largely Caucasian populations. Given that implementation, particularly around genetic interventions, is very context specific, an evaluation of such interventions in diverse populations is imperative ,19,20. WThis was a hybrid type III implementation effectiveness trial conducted at two breast surgical oncology clinics in Singapore, a multi-ethnic city-state in Asia . The stuFull details of the methods have been described elsewhere . BrieflyFor this qualitative sub-study, participants enrolled in the trial were asked to participate in a qualitative interview to explore the perceived value of risk assessment, the usability of the risk assessment platform, and the perceived benefit of broader implementation in primary care settings in Singapore. We used a purposive sampling technique to recruit participants at a range of ages, ethnicities and cancer stages to maximize the diversity of experiences and opinions.The risk assessment platform is a web-based, patient-facing platform, MeTree, that collects personal characteristics, medical history and family health history on 90 diseases and provides risk assessment and clinical decision support (CDS) for 30 based on commonly accepted guidelines for disease identification, prevention and surveillance . MeTree A semi-structured interview guide was developed based on the study team’s expert knowledge and relevant literature ,29. The All interviews were audio-recorded and transcribed verbatim. We used grounded theory for thematic data analysis ,31. The A total of twenty patients participated in one-to-one interviews. Data saturation was reached after the eighteenth interview, with no new themes emerging from subsequent interviews. We conducted two additional interviews beyond data saturation to ensure that the point of information redundancy was achieved. All participants were female with varying stages of breast cancer, nearly half (45%) were stage 2, and the majority were of Chinese ethnicity (55%). The mean age was 51.1 (±6.9) years old, with 85% falling between 40 and 59 years old. Mean years since cancer diagnosis was 4.4 (±2.1) years and 25% of the patients were referred to genetic counselling following the intervention .When asked about the benefits of knowing one’s genetic risk, many participants stated that understanding genetic risks would enable them to cultivate an internal locus of control to prepare for future adversity and, thus, respond to such situations with ‘peace of mind’.“Knowing the risks will make me more mentally prepared to handle the issues should they arise”. 43 Chinese, Stage 0.An FHH-based risk assessment was also viewed as prompting early financial planning to ensure family affordability for cancer treatment. As one participant mentioned,“Cost of cancer treatment can be exorbitant, and not many people can actually afford [it]. So, I think it’s good to have this preliminary assessment, so if they fall under this high-risk group, then they can go for a further test and be financially prepared if results show positive”. 43 Chinese, Stage 0.Some participants added that a genetic risk assessment would heighten the awareness of their family’s genetic risks which in turn could improve their health-seeking behaviors.“So, for example, I will be more health-conscious in a sense, do go for regular check-ups? I think this [knowing one’s risk] will be helpful”. 44 Chinese, Stage 1.Despite the perceived utility and value of the risk assessment by many, a few participants were more skeptical and raised some concerns. The most commonly noted hindrance was related to the emotional and psychological repercussions. Participants worried that information generated from an FHH-based risk assessment tool might cause undue distress for themselves and their families.“After I was diagnosed with cancer, I realized that some of my friends feel very emotional about it. Although knowing my risk is good, but it tends to give me the impression that people around me tend to get more emotional if the results are not ideal and I don’t want to face certain feelings”. 51 Malay, Stage 2.Given the absence of legal protections in Singapore at the time of data collection  so many pages, like three pages, I didn’t go through every page. I only read the first page. Besides, those medical terms are not helping either”. 49 Indian, Stage 2.It is well established that patients need coaching on what and how to collect FHH information . While t“I realized I couldn’t complete the form when I was asked about my parents’ and relatives’ health condition[s]. It would be better if I can bring it back and discuss it with my family for a more accurate result”. 55 Chinese, Stage 2.Some participants experienced some challenges during the information entry due to a limited comprehension of the instructions provided by the MeTree platform, but appreciated the presence of the support staff, who helped with data entry and clarified concerns that emerged during the information entry process.“This [family genogram] is very hard to fill in. At least, the symbols and shapes on the genogram should be clearly stated. For example, square representing male and circle for female”. 65 Malay, Stage 3.“Throughout the session, I needed guidance from the [research] coordinator. She helped to clear my doubts on ambiguous terms or questions. I need more instructions. I cannot do this at home alone”. 43 Chinese, Stage 0.Most participants liked the idea of being able to obtain their risk scores immediately upon submission of their data, which displayed their individualized risks based on their FHH. Participants also mentioned that having the results printed for their own record or for future discussion with a specialist was particularly valuable. There were cases where this was not possible or the records were misplaced. Participants particularly commented on the importance of maintaining that record.“Although the result is available immediately, I am not provided with the result for record-keeping purposes, which I can show to the doctor next time during the consultation”. 49 Others, Stage 2.others” and (2) for their “own family members”.Many participants mentioned the importance of becoming aware of the genetic risks, yet we found two subtly different reactions to a wider implementation in primary care settings: (1) for “others, a recurrent theme was that the risk assessment could be beneficial for people, facilitating early detection and mitigating the risks of diseases that might present later. The following response from a participant was typical of many.For the recommendation for “I think this [MeTree] is beneficial. I think everyone should go for it because five years ago, when I was diagnosed [with breast cancer], I did not fill [in] any of this questionnaire. So, I was actually thinking, “Could it be family history?” because my father was adopted, so we don’t know anything about his family history. I think this, it’s quite a good questionnaire so that people would know their family history, whether they are (considered) high risk, and if they are, they can go for further genetic tests”. 43 Chinese, Stage 0.However, a few participants were more skeptical about the implementation of a risk assessment in primary care and expressed reluctance. One of the reasons cited was the perceived high level of awareness and knowledge of cancer risk among the public in Singapore. Participants felt that in light of high-profile campaigns and the local media coverage of cancer, people become more aware of genetic and non-genetic determinants of cancer. Hence, the uptake of a risk assessment in primary care patients would be limited.“I don’t feel it really helped people in primary care. I think most Singaporeans already generally know if they are at risk. There are so many campaigns and programs. So, they will not use it [MeTree]” 45 Others, Stage 2Participants also pointed out cultural barriers that might hinder the uptake in primary care. As one participant stated, there are prevailing beliefs in Asian culture that discussion of future perils is often considered a taboo subject.“A lot of people are very sensitive. You can’t even mention the word “death” in front of them, not to mention asking them to take a survey that reveals their risk of developing diseases? That’s a big no-no”. 55 Chinese, Stage 2.Other participants were uncertain of the follow-up procedure upon the completion of the risk assessment. The perceived absence of systematic follow-up plans at a healthcare system level generated a sense of uncertainty, and these perceptions led to their hesitation to recommend the risk assessment to others.“So what can be expected after completing MeTree? The follow-up process is not made clear to us. Not so nice to leave us in a lurch. If resources allow, it will be nice to have a complete [follow-up] package. Otherwise, I don’t think people will find it helpful”. 52 Chinese, Stage 1.family members centered around the improvement of clinical outcomes as a result of early detection and diagnosis. It was believed that the completion of MeTree would prompt health-seeking behaviors among family members and empower them to make an informed decision.Similar to the theme for “others”, reasons cited for the recommendation to “I will definitely recommend it to my husband. Like my husband, whose father and mother have a lot of medical problems. So, once he knows his risk of developing diseases, he will take precautions to take care of his health”. 50 Chinese, Stage 4.However, many participants expressed concerns that the results of MeTree might create anxiety and felt conflicted as to whether one should share the genetic risks identified with other family members. To pre-empt these dilemmas, they expressed unwillingness to recommend the risk assessment to family members. As a patient articulated,“People are very sensitive. They don’t want to know. If you ask my husband, he wouldn’t want to know either. Instead of thinking about all these unhappy and uncertain things, he would rather not know anything. So, I don’t think I will recommend him for this genetic test so as not to generate more worries”. 55 Chinese, Stage 2.Some participants also questioned the reliability of the cancer risk assessment provided by MeTree, and this led to their reservation on recommending it to family members, if implemented in primary care. They questioned whether the likelihood of developing a condition in one’s lifetime could be determined by an FHH alone. Participants often mentioned their experience with close family members, highlighting the potential for MeTree or similar risk assessment tools to miss certain factors that contribute to disease risk.“I know the results will not be deterministic because every individual is different. If the person has a good lifestyle, maybe s/he won’t get cancer at all, right? Like me, I have seven sisters; three of us have (cancer), whereas the other four are perfectly fine. Do you get what I mean? Not hundred percent I will have cancer even if I’m high risk”. 43 Malay, Stage 4.This qualitative study explored breast cancer patients’ perceptions toward knowing their FHH risks, the experience of using a web-based patient-facing FHH risk assessment tool and its perceived potential value in broader patient populations.An individual’s likelihood to undergo an FHH-based risk assessment is often dependent on whether the assessment meets one’s outcome expectancy. Overall, participants in our study viewed the risk assessment as important for fostering personal control over early detection as a way to prepare for future adversity and financial planning for treatment. The risk assessment was also seen as a way to encourage preventive health behaviors. This was in line with previous literature that patients are motivated to undergo a genetic risk assessment to assert control over health outcomes ,37. HencAt the same time, participants expressed concerns about the potential for unnecessary anxiety for them and their family members as a result of the risk assessment. Multiple studies show that knowing familial susceptibility for cancer can engender a range of psychological responses, including increased anxiety and distress, which might hinder subsequent health-seeking behaviors ,40. ThesOur study explored user experience, specifically the usability of MeTree as a potential risk assessment tool in Singapore. The use of a simple layout and visual content enhanced participant receptivity, while the length of the data input, unfamiliar medical terminology and limited understanding of the instructions hampered women from completing the tasks. It was also apparent that, for a minority of participants, navigating the MeTree platform independently was daunting. These findings suggest that additional modifications are likely necessary to improve the platform’s usability in the context of current oncology practice and beyond.others”, the main benefit identified was early detection and the mitigation of risks, while key barriers were related to a perceived high level of awareness of genetic risks among the public, cultural taboos around the discussion of disease or death, and unclear follow-up care plans. This was consistent with prior literature demonstrating that follow-up procedures for high-risk patients remain suboptimal [A novel finding from this study was that participants’ opinions regarding a wider implementation of MeTree or similar FHH-based risk assessment tools in primary care differed depending on the target recipients. For recommendations to “boptimal . It willboptimal ,49.family members”, risk mitigation through early detection and preventive behaviors was the main perceived benefit, which was similar to the reasons espoused for recommendation to “others”. However, a major theme running through the interviews was an overall reluctance to recommend the risk assessment to family members, citing concerns about negative emotional ramifications and the impact on familial relationships. Intriguingly, a Dutch study reported an improved familial relationship upon the disclosure of genetic testing results. It brought families closer as a result of more frequent communication, improved support systems, and the obligation to ride out the storm together [For recommendations to “together . Similartogether . Asian ctogether . Nonethetogether .This study had several limitations. Participants were patients being actively treated for breast cancer in an oncology setting and, therefore, findings may not be generalizable to other clinical settings or conditions. They may not be generalizable to those who were previously treated for breast cancer, as active cancer treatment comes with an enormous emotional and psychological burden that may significantly influence perceptions. However, the interview topics covered were sufficiently broad to have potential applicability to other potentially heritable health conditions. There was also the potential for selection bias, where women with a greater interest in expressing their opinions about MeTree may have been more likely to participate, which could have affected the findings of this study. Additionally, there was a time lapse of a week to 18 months between the administration of MeTree and qualitative interviews, owing to patients’ personal commitments, competing health priorities and psychological issues. This might have engendered the recall bias when assessing specific aspects of MeTree. Lastly, patients’ perceptions might have been affected by the time elapsed since diagnosis; it is possible that some patients who had survived long-term, had already learned of genetic risks through their own education and research prior to MeTree administration and, hence, saw the tool as less useful.This study adds important empirical evidence to the literature by understanding the user experience of a risk assessment platform among multi-ethnic patients in an Asian oncology setting and their perceptions of the potential impact of a wider implementation in primary care in Asia. Most studies in Asian populations were still within Western societies and often were conducted among patients not currently affected by the disease . FurtherWith the potential health impact of a systematic risk assessment becoming increasingly evident, the need for access to such services is more apparent than ever ,27,53. H