Haemophilia in France: Modelisation of the Clinical Pathway for Patients

Process-of-care studies participate in improving the efficiency of the care pathway for patient with haemophilia (CPPH) and rationalize the multidisciplinary management of patients. Our objective is to establish a current overview of the different actors involved in the management of patients with haemophilia and to provide an accurate description of the patient trajectory. This is a qualitative exploratory research based on interviews of the principal health professionals of four haemophilia services, between November 2019 and February 2020, in France. Mapping of the CPPH processes within the different institutions and/or services, as well as the rupture zones, were identified. Treatment delivery and biological analyses were carried out exclusively in healthcare institutions. The main liberal health professionals solicited were nurses, physiotherapists and general practitioner. Obstacles and barriers within the specialized service, with other hospital services and external hospital or private services, community health care providers et community environment and individual one was complex and multiples. Our research identified potential concerns that need to be addressed to improve future studies to identify influential elements. Similarly, other qualitative studies will have to be conducted on the perceptions and literacy of patients with haemophilia to develop a global interactive mapping of their trajectories.

Accelerated hypofractionated radiotherapy for chest wall and nodal irradiation using hybrid techniques

Aim: This study compares three different hybrid plans, for left-sided chest wall (CW) and nodal stations irradiation using a hypofractionated dose regimen. Materials and methods: Planning target volumes (PTVs) of 25 breast cancer patients that included CW, supraclavicular (SCL) and internal mammary node (IMN) were planned with 3 different hybrid techniques: 3DCRT+IMRT, 3DCRT+VMAT and IMRT+VMAT. All hybrid plans were generated with a hypofractionated dose prescription of 40·5 Gy in 15 fractions. Seventy per cent of the dose was planned with the base-dose component and remaining 30% of the dose was planned with the hybrid component. All plans were evaluated based on the PTVs and organs at risk (OARs) dosimetric parameters. Results: The results for PTVs parameters have shown that the 3DCRT+IMRT and 3DCRT+VMAT plans were superior in uniformity index to the IMRT+VMAT plan. The OARs dose parameters were comparable between hybrid plans. The IMRT+VMAT plan provided a larger low dose volume spread to the heart and ipsilateral lung (p < 0·001). The 3DCRT+VMAT plan required less monitor units and treatment time (p = 0·005) than other plans. Conclusion: The 3DCRT+VMAT hybrid plan showed superior results with efficient treatment delivery and provide clinical benefit by reducing both low and high dose levels.

Estimating real snakebite incidence in Colombia by using mathematical modelling and statistical inference.

Snakebite envenoming is a Neglected Tropical Disease affecting mainly deprived populations. Its burden is normally underestimated because patients prefer to seek for traditional medicine. Thus, applying strategies to optimize disease' management and treatment delivery is difficult. We propose a framework to estimate snakebite incidence at a fine political scale based on available data, testing it in Colombia. First, we produced snakebite fine-scale risk maps based on the most medically important venomous snake species (Bothrops asper and B. atrox). We validated them with reported data in the country. Then, we proposed a generalized mixed effect model that estimates total incidence based on produced risk maps, poverty indexes, and an accessibility score that reflects the struggle to reach a medical center. Finally, we calibrated our model with national snakebite reported data from 2010 to 2019 using a Markov chain Monte Carlo (MCMC) algorithm and estimated underreporting based on the total incidence estimation. Our results suggest that 10.3% of total snakebite cases are not reported in Colombia and do not seek medical attention. The Orinoco and Amazonian regions (east of Colombia) share a high snakebite risk with a high underreporting. Our work highlights the importance of multidisciplinary approaches to face snakebite.

Mauri Tu, Mauri Ora: A Process Evaluation

<p>Rates of violent reoffending amongst young offenders has been a cause of concern for those involved in the youth justice (YJ) system in New Zealand (NZ), and across the world. Although, the rates of youth offending in NZ appear to be declining, there is a trend of increasing violent youth offending (Ministry of Justice; MOJ, 2010, 2012). Therefore, the search for effective and generalisable treatment programmes for violent young offenders has been a focus for those involved in juvenile offending research (Caldwell & Van Rybroek, 2013). The Mauri Tu Mauri Ora programme (MTMO; Kilgour & Borg, 2016), was developed in 2014 to provide an “intensive rehabilitation option for youth between 16 and 20 years of age who are deemed to be at a high risk of re-offending” (p. 27). However, since its implementation, there has been no systematic evaluation of its effectiveness. This process evaluation investigated how the MTMO programme was operating so its strengths and areas of improvement could be better understood. This was achieved by detailing the characteristics of the programme; the extent to which it met the needs of key stakeholders; evaluating the specific components of the programme; the working relationship between staff; how well the programme was delivered; and identifying possible areas of improvement. The perspectives of participants resulting in 28 subthemes associated with: initial engagement and assessment; treatment delivery and engagement; the transition phase; unit environment; and staff services. Along with a discussion, these findings identify areas the MTMO programme can build on its strengths and areas it can make improvements.</p>

Mauri Tu, Mauri Ora: A Process Evaluation

<p>Rates of violent reoffending amongst young offenders has been a cause of concern for those involved in the youth justice (YJ) system in New Zealand (NZ), and across the world. Although, the rates of youth offending in NZ appear to be declining, there is a trend of increasing violent youth offending (Ministry of Justice; MOJ, 2010, 2012). Therefore, the search for effective and generalisable treatment programmes for violent young offenders has been a focus for those involved in juvenile offending research (Caldwell & Van Rybroek, 2013). The Mauri Tu Mauri Ora programme (MTMO; Kilgour & Borg, 2016), was developed in 2014 to provide an “intensive rehabilitation option for youth between 16 and 20 years of age who are deemed to be at a high risk of re-offending” (p. 27). However, since its implementation, there has been no systematic evaluation of its effectiveness. This process evaluation investigated how the MTMO programme was operating so its strengths and areas of improvement could be better understood. This was achieved by detailing the characteristics of the programme; the extent to which it met the needs of key stakeholders; evaluating the specific components of the programme; the working relationship between staff; how well the programme was delivered; and identifying possible areas of improvement. The perspectives of participants resulting in 28 subthemes associated with: initial engagement and assessment; treatment delivery and engagement; the transition phase; unit environment; and staff services. Along with a discussion, these findings identify areas the MTMO programme can build on its strengths and areas it can make improvements.</p>

Improving Mood Promoting Access to Collaborative Treatment (IMPACT) Program in Geriatrics Primary Care

Improving Mood Promoting Access to Collaborative Treatment (IMPACT) is a well-established model for the treatment of depression in primary care. The COVID pandemic has caused increased distress and depression among the older patients in our New York City geriatric practice. This paper describes the establishment of a virtual IMPACT model during the pandemic in which IMPACT services have been provided via telephone. This effort was a multidisciplinary collaboration among geriatric medicine, geriatric psychiatry, social work, and geropsychology. Our IMPACT program uses a brief form of Interpersonal Psychotherapy (IPT) for depression as the psychosocial component instead of Problem Solving Treatment. Delivery of IMPACT by telephone appears to have enhanced engagement and sustained involvement in the program compared with prior efforts to deliver it by in-person meetings. IPT as a psychosocial modality was well-received by patients. To date, treatment outcomes have been favorable and will be reported in this presentation.

From formative research to cultural adaptation of a face-to-face and internet-based cognitive-behavioural intervention for Arabic-speaking refugees in Germany

Background This study aims to provide a transparent and replicable documentation approach for the cultural adaptation of a cognitive-behavioural transdiagnostic intervention (Common Elements Treatment Approach, CETA) for Arabic-speaking refugees with common mental disorders in Germany. Method A mixed-methods approach was used, including literature review, interviews, expert decisions and questionnaires, in order to adapt the original CETA as well as an internet-based guided version (eCETA). The process of cultural adaptation was based on a conceptual framework and was facilitated by an adaptation monitoring form as well as guidelines which facilitate the reporting of cultural adaptation in psychological trials (RECAPT). Results Consistent with this form and the guidelines, the decision-making process of adaptation proved to be coherent and stringent. All specific CETA treatment components seem to be suitable for the treatment of Arabic-speaking refugees in Germany. Adaptations were made to three different elements: 1) Cultural concepts of distress: a culturally appropriate explanatory model of symptoms was added; socially accepted terms for expressing symptoms (for eCETA only) and assessing suicidal ideation were adapted; 2) Treatment components: no adaptations for theoretically/empirically based components of the intervention, two adaptations for elements used by the therapist to engage the patient or implement the intervention (nonspecific elements), seven adaptations for skills implemented during sessions (therapeutic techniques; two for eCETA only) and 3) Treatment delivery: 21 surface adaptations (10 for eCETA only), two eCETA-only adaptations regarding the format. Conclusion The conceptual framework and the RECAPT guidelines simplify, standardise and clarify the cultural adaptation process.

A bi-institutional multi-disciplinary failure mode and effects analysis (FMEA) for a Co-60 based total body irradiation technique

Background We aim to assess the risks associated with total body irradiation (TBI) delivered using a commercial dedicated Co-60 irradiator, and to evaluate inter-institutional and inter-professional variations in the estimation of these risks. Methods A failure mode and effects analysis (FMEA) was generated using guidance from the AAPM TG-100 report for quantitative estimation of prospective risk metrics. Thirteen radiation oncology professionals from two institutions rated possible failure modes (FMs) for occurrence (O), severity (S), and detectability (D) indices to generate a risk priority number (RPN). The FMs were ranked by descending RPN value. Absolute gross differences (AGD) in resulting RPN values and Jaccard Index (JI; for the top 20 FMs) were calculated. The results were compared between professions and institutions. Results A total of 87 potential FMs (57, 15, 10, 3, and 2 for treatment, quality assurance, planning, simulation, and logistics respectively) were identified and ranked, with individual RPN ranging between 1–420 and mean RPN values ranging between 6 and 74. The two institutions shared 6 of their respective top 20 FMs. For various institutional and professional comparison pairs, the number of common FMs in the top 20 FMs ranged from 6 to 13, with JI values of 18–48%. For the top 20 FMs, the trend in inter-professional variability was institution-specific. The mean AGD values ranged between 12.5 and 74.5 for various comparison pairs. AGD values differed the most for medical physicists (MPs) in comparison to other specialties i.e. radiation oncologists (ROs) and radiation therapists (RTs) [MPs-vs-ROs: 36.3 (standard deviation SD = 34.1); MPs-vs-RTs: 41.2 (SD = 37.9); ROs-vs-RTs: 12.5 (SD = 10.8)]. Trends in inter-professional AGD values were similar for both institutions. Conclusion This inter-institutional comparison provides prospective risk analysis for a new treatment delivery unit and illustrates the institution-specific nature of FM prioritization, primarily due to operational differences. Despite being subjective in nature, the FMEA is a valuable tool to ensure the identification of the most significant risks, particularly when implementing a novel treatment modality. The creation of a bi-institutional, multidisciplinary FMEA for this unique TBI technique has not only helped identify potential risks but also served as an opportunity to evaluate clinical and safety practices from the perspective of both multiple professional roles and different institutions.

Multitiered Systems of Support, Adaptive Interventions, and SMART Designs

This article introduces the special section on adaptive interventions and sequential multiple-assignment randomized trial (SMART) research designs. In addition to describing the two accompanying articles, we discuss features of adaptive interventions (AIs) and describe the use of SMART design to optimize AIs in the context of multitiered systems of support (MTSS) and integrated MTSS. AI is a treatment delivery model that explicitly specifies how information about individuals should be used to decide which treatment to provide in practice. Principles that apply to the design of AIs may help to more clearly operationalize MTSS-based programs, improve their implementation in school settings, and increase their efficacy when used according to evidence-based decision rules. A SMART is a research design for developing and optimizing MTSS-based programs. We provide a running example of a SMART design to optimize an MTSS-aligned AI that integrates academic and behavioral interventions.