Interdisciplinary Team Of Experts Research Articles

Acute on Chronic Thromboembolic Pulmonary Hypertension: Case Series and Review of Management.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a distinct form of precapillary pulmonary hypertension classified as group 4 by the World Symposium on Pulmonary Hypertension (WSPH) and should be excluded during an episode of acute pulmonary embolism (PE). Patients presenting to emergency departments with sudden onset of signs and symptoms of acute PE may already have a pre-existing CTEPH condition decompensated by the new PE episode. Identifying an underlying and undiagnosed CTEPH during acute PE, while challenging, is an important consideration as it will alter the patients’ acute and long-term management. Differential diagnosis and evaluation require an interdisciplinary expert team. Analysis of the clinical condition, the CT angiogram, and the hemodynamic situation are important considerations; patients with CTEPH usually have significantly higher sPAP at the time of index PE, which is unusual and unattainable in the context of acute PE and a naïve right ventricle. The imaging may reveal signs of chronic disease such as right ventricle hypertrophy bronchial collaterals and atypical morphology of the thrombus. There is no standard for the management of acute on chronic CTEPH. Herein, we provide a diagnostic and management algorithm informed by several case descriptions and a review of the literature.

Abstract 5224: The PRecision Oncology For Young peopLE (PROFYLE) Program: A national precision oncology program for children, adolescents and young adults with hard-to-cure cancer in Canada

Abstract Background: Over 4,300 children, adolescents, and young adults (CAYA) are diagnosed with cancer each year in Canada, 1/3 of whom have refractory/metastatic disease or will relapse. A national collaborative program, PRecision Oncology For Young peopLE (PROFYLE), was created with the goal to develop and implement a pipeline providing access to tumor molecular profiling to identify novel targeted treatment options in a clinically relevant timeframe for CAYA with hard-to-cure cancers. Design: PROFYLE includes more than 20 institutions, building upon 3 pre-existing regional precision oncology programs (Personalized Oncogenomics (POG), SickKids Cancer Sequencing (KiCS), and Personalized Targeted Therapy in Refractory or Relapsed Cancer in Childhood (TRICEPS)). PROFYLE has united an interdisciplinary team of experts, leaders, research team, end-users and advocates from across Canada to form 14 domain specific nodes unified by a shared governance structure. PROFYLE includes genomic and transcriptomic sequencing of paired germline/cancer fresh/frozen samples. Inclusion criteria: ≤29y; treatment at a Canadian center; diagnosis of a hard-to-cure cancer. Profiling results are reviewed by multidisciplinary Molecular Tumor Boards. A report including a results/recommendations summary of actionable findings (therapeutic, diagnostic, prognostic, cancer predisposition), potential targeted therapy options including available clinical trials, clarification of diagnosis, and genetic counseling recommendations is provided to the treating oncologist. Results: To date, >900 CAYA are enrolled. Cancer diagnoses: 36% sarcoma, 16% leukemia/lymphoma, 16% CNS tumor, 13% neuroblastoma, 19% other. At study entry, 44% of participants had not relapsed, 40% had 1 relapse, 9% 2 relapses, 4% 3+ relapses. 17% had a cancer-predisposing pathogenic/likely pathogenic germline variant, 40% had ≥1 potentially actionable somatic alteration, 9.7% had a therapeutically targetable somatic alteration. The most frequent classes of therapeutic alterations were cell cycle (15%), RAS/MAPK (14%), epigenetic (13%), RTK (12%), PI3K/AKT/mTOR (10%), DNA repair (9%), immune checkpoint (8%). Of clinicians who reported the utility of results, 56% indicated the findings were useful for clinical management. Future Directions: With a comprehensive molecular view of cancer, PROFYLE will transform our understanding of underlying disease mechanisms, facilitate and improve diagnostic and prognostic indicators, and identify new therapeutic strategies and targets. Data from this interdisciplinary, multi-institutional research program will inform the development of a framework to innovatively link research, clinical and system considerations with Canadian values relevant to genomic profiling and drug access for CAYA in Canada. Citation Format: Stephanie A. Grover, Lesleigh Abbott, Jason N. Berman, Jennifer A. Chan, Avram E. Denburg, Rebecca J. Deyell, Conrad V. Fernandez, Cynthia Hawkins, Jan-Willem Henning, Meredith S. Irwin, Nada Jabado, Steven J. Jones, Philipp F. Lange, Michael F. Moran, Daniel A. Morgenstern, Antonia Palmer, Shahrad R. Rassekh, Donna L. Senger, Adam Shlien, Daniel Sinnett, Caron Strahlendorf, Patrick J. Sullivan, Michael D. Taylor, Suzanne Vercauteren, Anita Villani, James A. Whitlock, David Malkin, on behalf of the Terry Fox PROFYLE Consortium. The PRecision Oncology For Young peopLE (PROFYLE) Program: A national precision oncology program for children, adolescents and young adults with hard-to-cure cancer in Canada [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5224.

Project ECHO in Hospice and Palliative Care: Interdisciplinary Virtual Meeting to Address Needs and Critical Gaps in Our Field (FR218)

Outcomes 1. Compare and contrast the Project ECHO model with other forms of education, mentoring, and support for practitioners in our field 2. Assess practice needs and gaps in your organization or in our field and develop interdisciplinary techniques and curricula to address those concernsAs a response to the COVID-19 pandemic we created and executed an 18-month nationwide, interdisciplinary, virtual meeting project for hospice and palliative medicine team members. Through team expertise and collaboration, experience with the use of Project ECHO, and close monitoring of the impact the pandemic was disproportionately having on underserved communities and communities of color, we decided upon our focus areas for the project. We chose areas we thought were critical to the overall support of providers, patients, and our larger hospice and palliative medicine community. Areas to be addressed included knowledge gaps in treating people with COVID-19; advanced communication skillset needs with the rapid pivot to telehealth; and equity, diversity, inclusion, and racism in our field. Additionally, we wanted to build in techniques and methods we could use to foster strong interdisciplinary interactions toward building resilience and community in the face of the many unknowns of treating patients and caring for ourselves through the pandemic. We chose the model offered by Project ECHO, at the University of New Mexico School of Medicine, as the structure upon which we would build our project and to meet our objectives. The ECHO model uses virtual gathering to support mentorship, welcomes all levels of training with an “all teach, all learn” focus, and offers patient case–based learning in a way so as to democratize specialty knowledge. The virtual setting allows for participation regardless of location. We have gathered post-session survey data, participant data on moral distress, and data on provider views of their ability to affect equity, diversity, inclusion, and racism in our field. Our project is ongoing.Presenters are members of our project's interdisciplinary expert team, including MDs, an MSW/LCSW, a PharmD, and a PhD palliative care researcher. We will present data gathered thus far and will use interactive methods to teach and to elicit audience participation.

Protective Masks Utilizing Nonendangered Components.

At the beginning of the COVID-19 pandemic when traditional N95 respirators were in short supply in the United States, there was a need for alternative products that did not rely on traditional avenues of sourcing and manufacturing. The purpose of this research was to develop and test alternatives to N95 respirators that could be produced locally without specialized materials and processes. Through an interdisciplinary team of experts, new mask designs that use repurposed filtration media and commercially available components were developed and tested for filtration and fit against current N95 standards. Filtration efficiency test results showed that the filtration media can be used for high-quality facemasks and quantitative fit testing demonstrated that the new mask designs could be viable alternatives to traditional N95 facemasks when those masks are in short supply. Manufacturing viability was tested utilizing a workforce to create 6000 masks over 10 days. The ability to quickly produce masks at scale using a workforce without specialized skills demonstrated the feasibility of the mask designs and manufacturing approach to address shortages of critical healthcare equipment, mitigate risk for healthcare and essential workers, and minimize the transmission and spread of disease.

An Interdisciplinary Collaboration to Improve Hypertension Medication Adherence for Older Adults

Hypertension is highly prevalent in older adults (74.5% in ≥60 years) with dire consequences, and adherence to hypertension medications is low (approximately 50%). With increased smartphone use among older adults (81% for 60-69 years, 62% for ≥70 years), technology innovations can improve medication adherence. This symposium highlights the efforts of an innovative interdisciplinary team of experts (clinical, cognitive aging, human factors, health technology) to develop and implement the Medication Education, Decision Support, Reminding, and Monitoring (MEDSReM) system to improve hypertension medication adherence for older adults. MEDSReM is a theory-based, integrated mobile application (app) and companion web portal that educates, supports missed dose decisions, reminds, monitors adherence, and incorporates blood pressure feedback. In this symposium, we describe the interdisciplinary development efforts. Insel et al. will present the theory-based intervention, technology translation, and advancement of the MEDSReM system. Lee et al. will describe the interdisciplinary team and describe the work by the decision support subteam that created the medication formulary and generated an algorithm to guide missed-dose decisions based on pharmacology of aging. Rogers et al. will discuss the education subteam’s development of educational information about hypertension, medications, and adherence for the MEDSReM system. Mitzner et al. will illustrate the instructional support sub-team’s efforts to ensure older adults can interact with both the smartphone app and online portal. Lastly, Hale et al. will describe the user testing subteam’s usability processes including the integration of blood pressure self-monitoring. These efforts will provide insights for other interdisciplinary teams developing technology interventions for older adults.

Preoperative diagnostics and typing of abdominal soft tissue sarcomas

Abdominal sarcomas are aheterogeneous group of rare soft tissue tumors and can be localized intraperitoneally or retroperitoneally. Apretherapeutic differentiated subtyping is essential for planning an individual, multimodal treatment concept in an interdisciplinary team of experts. The central aspects of histology acquisition, imaging diagnostics and (molecular) pathological subtyping of abdominal soft tissue sarcomas are described in detail. Imaging and pathological diagnostics are depicted based on the German S3 guidelines on adult soft tissue sarcomas, acurrent literature search and personal experiences at the Sarcoma Center at the National Center for Tumor Diseases in Dresden (NCT/UCC). Preoperative imaging and (molecular) pathological subtyping of abdominal soft tissue sarcomas place high demands on surgeons, radiologists and pathologists. Genome analyses of sarcomas have the potential to identify points of attack for individualized treatment options. The limitations of resectability can only be assessed by experienced sarcoma surgeons at specialized centers. The treatment of abdominal soft tissue sarcomas at an experienced center is associated with abetter prognosis. Even at the first suspicion of an abdominal sarcoma, areferral to an experienced center should be made in order to guarantee optimal expertise in diagnostics and treatment.

PH Professional Network: 360-degree Care for the Bronchopulmonary Dysplasia Infant with Pulmonary Hypertension: A Comprehensive Review

Premature infants are at risk of developing bronchopulmonary dysplasia and associated pulmonary hypertension. These infants make up a complex group of patients with unique considerations regarding development of lung and vascular disease, comorbidities, and care plans. They are high risk for many complications and poor outcomes due to the severity and complexity of disease. Because of this, a comprehensive approach to care with consideration for multiple organ systems and with an interdisciplinary team of experts is the preferred approach. Here we describe in detail the major considerations in care for these infants.

Editor’s Memo

Hello to all! This summer proved again to be challenging, however, hope is everywhere for a brighter fall and winter of 2021. The resilience of our healthcare teams around the country has been incredible. I would like to thank everyone involved in Advances in Pulmonary Hypertension, who over the 20 months, have worked day and night to get the issues out during the pandemic. The guest editors, editorial board, authors and everyone at PHA have been truly phenomenal. Every issue and article published has been outstanding. Thank you and congratulations. All of these issues are state of the art resources that will be the backbone of each topic for years to come.Our current issue is no different. The issue is focused on PH-ILD, a topic that has fascinated our field forever. This issue delves into the pathophysiology, etiology and management of this difficult disease state. Congratulations to all involved in this work which is so timely to our field.In the first article of this issue, Drs. Farbod and Franck Rahaghi introduce the topic discussing the pathogenesis, identification, evaluation, and monitoring of PH-ILD. The authors reveal what is known about the clinical impact of PH in ILD. They move on from there to the actual evaluation and considerations in management of the disease.In the next article, Drs. Denise Gabrielle Sese and Kristin Highland discuss the difficult topic of Connective Tissue Disease, Interstitial Lung Disease, and Pulmonary Hypertension (CTD PH-ILD). They review the differences (both in terms of severity and management) between CTD PH-ILD and PH-ILD. It is a topic that is so important for us all to recognize while caring for these patients.In our third article, Dr. Eileen Harder and Dr. Aaron Waxman take us through the management strategies from the past, present and what we can look forward to in the future for PH-ILD. Discussions of therapies, transplant evaluation and future clinical trials are all discussed in detail.Our PHPN article for this issue discusses the care of the infant with bronchopulmonary dysplasia and PH. Claire Parker, Natalie Villafranco, Nidhy Varghese and Elise Whalen give us a thorough overview of the comprehensive approach to care with consideration for multiple organ systems and with an interdisciplinary team of experts for these infants.And lastly, but certainly not least, Dr. Jeff Edelman leads an extraordinary round table on the conundrums and controversies in PH-ILD discussing when and how to treat patients. The roundtable included world-class experts discussing their experience, opinions and the published literature on this topic. I would like to thank Drs. Jean Elwing, MD, Anjali Vaidya, MD and Steve Mathai, MD, for this up to date and incredibly important discussion.Thank you to all of the authors, and everyone at PHA and Allen Press who have worked so hard to bring this outstanding issue to all of us.Thank you again for joining us for this issue.

A Rome Working Team Report on Brain-Gut Behavior Therapies for Disorders of Gut-Brain Interaction

This Rome Foundation Working Team Report reflects the consensus of an international interdisciplinary team of experts regarding the use of behavioral interventions, specifically brain-gut behavior therapies (BGBTs), in patients with disorders of gut-brain interaction (DGBIs). The committee members reviewed the extant scientific literature and, when possible, addressed gaps in this literature through the lens of their clinical and scientific expertise. The Delphi method was used to create consensus on the goals, structure, and framework before writing the report. The report is broken into 5 parts: 1) definition and evidence for BGBT, 2) the gut-brain axis as the mechanistic basis for BGBT, 3) targets of BGBTs, 4) common and unique therapeutic techniques seen in BGBT, and 5) who and how to refer for BGBT. We chose to not only review for the reader the 5 existing classes of BGBT and their evidence, but to connect DGBI-specific behavioral targets and techniques as they relate directly, or in some cases indirectly, to the gut-brain axis. In doing so, we expect to increase gastrointestinal providers' confidence in identifying and referring appropriate candidates for BGBT and to support clinical decision making for mental health professionals providing BGBT. Both gastrointestinal medical providers and behavioral health providers have an opportunity to optimize care for DGBIs through a collaborative integrated approach that begins with an effective patient-provider relationship, thoughtful communication about the brain-gut axis and, when appropriate, a well communicated referral to BGBT.

"Closing the chasm" - guidelines bridge the gap from evidence to implementation.

"Closing the chasm" - guidelines bridge the gap from evidence to implementation.

The patient journey map: Improving the emergency department communication experience for patients and their family and friends

The patient journey map: Improving the emergency department communication experience for patients and their family and friends. Stephanie VandenBerg, Heather Hair, Gillian Harvey, Eddy Lang, David Stringer Background: The 2013 Urban and Regional Emergency Department (ED) Patient Experience Report indicates that the most important factor influencing a patients’ ED experience is a combination of staff care and communication. Lack of communication in the emergency room experience can be addressed by design methods and processes. The Emergency Strategic Care NetworkTM assembled an interdisciplinary team of experts from various clinical, academic, and information design backgrounds to engage patients, families and providers to improve the ED intake experience. This innovative partnership resulted in the development of a graphic information system that directs, informs and educates patients in EDs in Alberta. Implementation: Using the Plan-Do-Study-Act (PDSA) framework, focus groups were conducted to understand the communication needs of emergency department patients. An information design specialist co-created a graphic information system (the patient journey map) and worked with AHS communications to ensure it met AHS guidelines. Patients were then approached to participate in a 14-question survey about the usability and accuracy of the journey map as well as the impact it had on their ED visit. Our team consisted of Heather Hair, Executive Director of the (ESCN) who provided leadership in identifying communication as a key area for improvement and coordinating ED partners and patient involvement. Gillian Harvey is an assistant professor of Design Studies at the University of Alberta. She used the data collected in focus groups to design a 2-D communication map. David Stringer acted as project manager for the implementation and evaluation of the journey map. Stephanie Vandenberg is an emergency physician and was responsible for designing the evaluation strategy including research methods and data analysis. An official journey map is now available to print for emergency departments across Alberta. Evaluation Methods: The objective was to understand what information ED patients require during their visit to better understand the process by which they are triaged and receive care. Data collection consisted of a 10-minute, 14 question interview. Each question allowed for positive, neutral or negative feedback to capture unintended consequences of the journey map. Quantitative demographic and journey map-specific variables were collected and reported as frequencies. Qualitative data was analyzed using thematic analysis with thematic codes developed and assigned to the qualitative responses. Both quantitative and qualitative analysis was undertaken by two members of the research team. Responses were analyzed against the demographic variable of age category to determine if age impacts communication needs and desired medium of communication in the ED. Results: Seven hospitals took part in this survey, conducted between September 1, 2019 and May 5, 2020. 162 emergency department patients participated. Most people agreed that the journey map clarified the ED patient process and accurately reflected their experience of the ED journey. The journey map did not seem to make the wait less confusing. Participants reported the journey map was good at helping them understand the overall emergency department intake process and did a good job of helping them understand the reason for waiting/delays. The journey map was excellent at helping the participant understand why specific tests/treatments were needed but was poor at helping them to understand the total time it would take them to be seen.

Leitliniengerechte Diagnostik der Pankreatitis

There is currently no S3guideline that contains statements on the diagnosis and treatment of acute, chronic and autoimmune pancreatitis in asingle guideline. This article presents the most relevant recommendations relating to radiological imaging from the new "S3guideline for pancreatitis". The guideline was developed by the DGVS (German Society for Digestive and Metabolic Diseases). After an online-based Delphi survey, the statements were discussed by an interdisciplinary expert team at a3-day consensus conference and then agreed upon. The level of evidence scheme (version2) of the Oxford Centre for Evidence-based Medicine was used. The new German "S3guideline pancreatitis" comprises for the first time all entities of pancreatitis, acute, chronic and autoimmune pancreatitis and contains alarge number of innovations with regard to diagnostic imaging and therapy. In addition to the evidence-based recommendations for diagnosis and therapy, aGerman-language glossary of the revised Atlanta classification on acute pancreatitis was adopted by consensus of the interdisciplinary guideline expert team. Furthermore, protocol recommendations for the performance of computed tomography (CT) are provided for the first time. In this article we introduce the key recommendations and innovations in the field of diagnostic radiologic imaging for acute, chronic and autoimmune pancreatitis. In the future, every radiologist should have deep knowledge of the recommended time intervals for radiological imaging in acute pancreatitis and know the German terms for the description of acute pancreatitis; furthermore they should be able to classify the morphologies to the appropriate stages.

Multi-criteria risk evaluation model for developing ventilator-associated pneumonia.

Ventilator-associated pneumonia is a hospital-acquired infection of the lungs occurring in mechanically ventilated patients. An active risk management approach can prevent the occurrence of the disease and promote positive organizational changes, subsequently decreasing mortality and hospitalization costs. Using scientific and clinical practice knowledge, a risk evaluation model was developed to identify patients more at risk of developing the disease. For this purpose, a Decision Expert qualitative multi-criteria decision method was used, in which alternatives are evaluated according to predetermined hierarchically arranged criteria. Characteristics of each evaluated alternative are described by the members of an interdisciplinary expert team and are represented by the values of the basic criteria. Values of hierarchically higher aggregated criteria are computed in an upwards fashion according to utility functions, which are defined as simple logical rules. This method is integrated into a software solution, DEXi. The approach is applicable to vastly diverse decision problems and has been successfully used before for health-related decision support. The designed model was tested using actual clinical data. Evaluations of alternatives that most distinctly demonstrated the functionality of the evaluation model were selected and are presented in the results. The evaluation model is intended to assist a holistic evaluation of the risk of developing ventilator-associated pneumonia, by considering patient-related risk factors and the use of preventive measures. The model incorporates nursing-specific data that have hitherto been poorly utilized in preventing ventilator-associated pneumonia and promotes the active engagement of nurses in confronting this interdisciplinary healthcare problem, which has gained more prominence with the onset of COVID-19 disease.

Consensus Parameter: Research Methodologies to Evaluate Neurodevelopmental Effects of Pubertal Suppression in Transgender Youth.

Purpose: Pubertal suppression is standard of care for early pubertal transgender youth to prevent the development of undesired and distressing secondary sex characteristics incongruent with gender identity. Preliminary evidence suggests pubertal suppression improves mental health functioning. Given the widespread changes in brain and cognition that occur during puberty, a critical question is whether this treatment impacts neurodevelopment.Methods: A Delphi consensus procedure engaged 24 international experts in neurodevelopment, gender development, puberty/adolescence, neuroendocrinology, and statistics/psychometrics to identify priority research methodologies to address the empirical question: is pubertal suppression treatment associated with real-world neurocognitive sequelae? Recommended study approaches reaching 80% consensus were included in the consensus parameter.Results: The Delphi procedure identified 160 initial expert recommendations, 44 of which ultimately achieved consensus. Consensus study design elements include the following: a minimum of three measurement time points, pubertal staging at baseline, statistical modeling of sex in analyses, use of analytic approaches that account for heterogeneity, and use of multiple comparison groups to minimize the limitations of any one group. Consensus study comparison groups include untreated transgender youth matched on pubertal stage, cisgender (i.e., gender congruent) youth matched on pubertal stage, and an independent sample from a large-scale youth development database. The consensus domains for assessment includes: mental health, executive function/cognitive control, and social awareness/functioning.Conclusion: An international interdisciplinary team of experts achieved consensus around primary methods and domains for assessing neurodevelopmental effects (i.e., benefits and/or difficulties) of pubertal suppression treatment in transgender youth.

Primary Prevention of New Pandemic and Biomimetic-Based Adaptation to Situation Connected with COVID-19 Pandemic

Acceleration of worldwide infection with mutant of coronavirus SARS CoV-19 require new paradigmatic of human activity based on negative feed-back system following basic mechanism of Homeostasis of all living organisms and ecosystems. Condition of efficient primary prevention is better integration of cooperation of interdisciplinary teams of experts, knowledge-based society and decision-makers on local scale with working global network focused on common action for efficient protection against contamination of the Human environment with mutagens for reduction risk of incidence new mutants [Ex: Coronaviruses and new pandemics]. Key factor for primary prevention is reduction at the sources emission of immune suppressors, carcinogens and teratogens. Efficient prevention is depended on without delay worldwide introduction of complementary good practice in innovative environmental biotechnology integrated with ecological engineering and circular bioeconomy-driven sustainable development adopted to different kind of regions. Let us recommend heuristic approach, better financial support of transdisciplinary innovative basic and research-developing studies, improvement application of new IT tools for speed dissemination of scientific and technical progress, elimination of bureaucratic barriers and progress in distance problem-solving training and lifelong learning focused on sustainable, knowledge-based society selecting decision-makers with proper imagination and responsibility. Introduction on wider scale innovative biotechnologies [Ex: Recommended by our team modern environmental ecological engineering integrated with renewable sources of energy, laser biotechnology for better adaptation to climate change, aquaculture, apiculture etc.] focused on better prevention against contamination of the air, water and food; would be beneficial for environmental health. It would be also useful for creation in the near future many green jobs all over the world and for reduction risk of unemployment and hunger. International action for greening cities adopted to climate change could be supported by introduction of proposed new generation of eco-buildings and green habitats. The most important eco-innovation would be designing and construction underground centres integrating innovative biotechnologies for waster, wastes management to biogas; useful for also underground greenhouses for wide scale hydroponic production pollutants-free vegetables, mushrooms, supported by laser biotechnology, apiculture and aquaculture. Such life-supporting system would be following ecosystems structure and function as new contribution to circular bioeconomy, especially useful for big cities. In the case of new epidemic, self-supporting in water and food green-habitats; could be more efficient in protection inhabitants against infectors. Taking into consideration synergistic effects of chemical, physical, biological pollutants of the human environment as well as impact of immune suppressors decreasing resistance of humans to infections and carcinogenic effects; is necessary for proper evaluation of existing health hazard as well as for prognostic study and efficient primary prevention against risk of new pandemics.

Development of a Practice Tool for Primary Care Providers: Medication Management of Posttraumatic Stress Disorder in Veterans with Mild Traumatic Brain Injury.

Posttraumatic stress disorder (PTSD) and comorbid mild traumatic brain injury (mTBI) are highly prevalent in veterans who served in Iraq [Operation Iraqi Freedom/Operation New Dawn] and Afghanistan [Operation Enduring Freedom]. Complicated psychotropic medications are used for treatment of PTSD and comorbid mTBI symptoms lead to polypharmacy related complications. Primary care providers (PCPs) working in Community Based Outpatient Clinics (CBOCs) are usually burdened with the responsibility of managing this complicated medication regimen or relevant side effects. The PCPs do not feel equipped to provide this complicated psychopharmacological management. Thus, there is a need for a comprehensive yet concise tool for the medication management of PTSD in veterans with comorbid mTBI. (1) To conduct focus groups of interdisciplinary team of experts and other stake holders to assess need, (2) To carefully review current VA/Department of Defense practice guideline to identify content, (3) To develop an evidence based, user friendly, and concise pocket guide for the PCP's. Content was identified by review of current guidelines and available literature and was finalized after input from stakeholders, multidisciplinary team of experts, and review of qualitative data from focus groups/interviews of clinicians working in remote CBOCs. The pocket tool was formatted and designed by multimedia service. A pocket guide in the form of a bi-fold, 4″ × 5.5″ laminated card was developed. One thousand hard copies were distributed in the local VA medical center. This product is available online for download at the South-Central Mental Illness Research, Education, and Clinical Center website ( https://www.mirecc.va.gov/VISN16/ptsd-and-mtbi-pocket-card.asp ). This pocket card provides PCPs an easy to carry and user-friendly clinical decision-making tool to effectively treat veterans with PTSD and comorbid mTBI.

Optimizing Child Nutrition Education With the Foodbot Factory Mobile Health App: Formative Evaluation and Analysis.

BackgroundEarly nutrition interventions to improve food knowledge and skills are critical in enhancing the diet quality of children and reducing the lifelong risk of chronic disease. Despite the rise of mobile health (mHealth) apps and their known effectiveness for improving health behaviors, few evidence-based apps exist to help engage children in learning about nutrition and healthy eating.ObjectiveThis study aimed to describe the iterative development and user testing of Foodbot Factory, a novel nutrition education gamified app for children to use at home or in the classroom and to present data from user testing experiments conducted to evaluate the app.MethodsAn interdisciplinary team of experts in nutrition, education (pedagogy), and game design led to the creation of Foodbot Factory. First, a literature review and an environmental scan of the app marketplace were conducted, and stakeholders were consulted to define the key objectives and content of Foodbot Factory. Dietitian and teacher stakeholders identified priority age groups and learning objectives. Using a quasi-experimental mixed method design guided by the Iterative Convergent Design for Mobile Health Usability Testing approach, five app user testing sessions were conducted among students (ages 9-12 years). During gameplay, engagement and usability were assessed via direct observations with a semistructured form. After gameplay, qualitative interviews and questionnaires were used to assess user satisfaction, engagement, usability, and knowledge gained.ResultsThe environmental scan data revealed that few evidence-based nutrition education apps existed for children. A literature search identified key nutrients of concern for Canadian children and techniques that could be incorporated into the app to engage users in learning. Foodbot Factory included characters (2 scientists and Foodbots) who initiate fun and engaging dialogue and challenges (minigames), with storylines incorporating healthy eating messages that align with the established learning objectives. A total of five modules were developed: drinks, vegetables and fruit, grain foods, animal protein foods, and plant protein foods. Seven behavior change techniques and three unique gamified components were integrated into the app. Data from each user testing session were used to inform and optimize the next app iteration. The final user testing session demonstrated that participants agreed that they wanted to play Foodbot Factory again (12/17, 71%), that the app is easy to use (12/17, 71%) and fun (14/17, 88%), and that the app goals were clearly presented (15/17, 94%).ConclusionsFoodbot Factory is an engaging and educational mHealth intervention for the Canadian public that is grounded in evidence and developed by an interdisciplinary team of experts. The use of an iterative development approach is a demonstrated method to improve engagement, satisfaction, and usability with each iteration. Children find Foodbot Factory to be fun and easy to use, and can engage children in learning about nutrition.

Effectiveness of the Extension for Community Health Outcomes Model as Applied to Primary Care for Autism

The Extension for Community Health Outcomes (ECHO) model is a widely adopted technology-based model for training primary care physicians and practitioners (PCPs) to care for patients with complex conditions. Despite its popularity, to our knowledge, direct effects of ECHO on clinical practice have not been tested in a large-scale study. To test the effectiveness of the ECHO model as applied to primary care for autism and whether it resulted in improved clinical practice, knowledge, and self-efficacy regarding autism screening and comorbidity management. Primary care physicians and practitioners were recruited to participate in a 6-month ECHO Autism program delivered by 1 of 10 academic medical center sites. A sequential, staggered rollout of ECHO Autism was delivered to 5 cohorts of participants (15 per site; 2 sites per cohort). Sites were randomized after recruitment to cohort/start time. Cohorts launched every 3 months. The ECHO Autism program used videoconferencing technology to connect community-based PCPs with interdisciplinary expert teams at academic medical centers. There were 148 participants (PCPs [family practice physicians, pediatricians, nurse practitioners, and physician assistants] providing outpatient services to underserved children) studied between December 2016 and November 2018. The 6-month ECHO Autism program included twelve 2-hour sessions connecting PCP participants with an interdisciplinary expert team. Sessions included didactics, case-based learning, guided practice, and discussion. Coprimary outcomes were autism screening practices and comorbidity management (assessed by medical record review). Secondary outcomes were knowledge (assessed by direct testing) and self-efficacy (assessed by self-report survey). Assessments were conducted at baseline, mid-ECHO, post-ECHO, and follow-up (3 months after ECHO). Ten sites were randomized to 1 of 5 cohorts. Participants were 82% female (n = 108), 76% white (n = 100), and 6% Hispanic or Latino (n = 8); the median age was 46 years (interquartile range, 37-55 years). Significant changes in autism screening and treatment of comorbidities in children with autism were not observed. Participants demonstrated significant improvements in knowledge (9%; 95% CI, 4-13; P < .001) and self-efficacy (29%; 95% CI, 25-32; P < .001). The ECHO model was developed to increase access to high-quality health care for underserved patients with complex conditions. Study results provide support for the model in improving clinician knowledge and confidence but little support for achieving practice change. ClinicalTrials.gov Identifier: NCT03677089.

Multidisciplinary investigation of two Egyptian child mummies curated at the University of Tartu Art Museum, Estonia (Late/Graeco-Roman Periods).

Two ancient Egyptian child mummies at the University of Tartu Art Museum (Estonia) were, according to museum records, brought to Estonia by the young Baltic-German scholar Otto Friedrich von Richter, who had travelled in Egypt during the early 19th century. Although some studies of the mummies were conducted, a thorough investigation has never been made. Thus, an interdisciplinary team of experts studied the remains using the most recent analytical methods in order to provide an exhaustive analysis of the remains. The bodies were submitted for osteological and archaeothanatological study, radiological investigation, AMS radiocarbon dating, chemical and textile analyses, 3D modelling, entomological as well as aDNA investigation. Here we synthesize the results of one of the most extensive multidisciplinary analyses of ancient Egyptian child mummies, adding significantly to our knowledge of such examples of ancient funerary practices.

Appropriate approaches for improving health promotion literacy in adolescents – a systematic review

Abstract Background Adolescents are exposed to various risks for their health: substance use, Internet overuse, video game addiction, unhealthy diet (reduced intake of fruits and vegetables, fast food culture), low physical activity, overweight, stress, violence, unsafe sexual behaviours, self-medication. Health literacy is defined as the knowledge, motivation and competence to access, understand, appraise and apply right information to make decisions in terms of healthcare, disease prevention and health promotion. Despite the advancement of theoretical models, many national and international health promotion programs, the percentage of unhealthy behaviours still persist in young age. Objective: Current review proposes to assess the implementation and effectiveness of various interventions in order to identify possible success or failure factors. Methods Comprehensive Systematic review was performed. After three steps data searching (in PubMed, SCOPUS, Cochrane, PsycINFO, Google Scholar) and critical appraisal, 63 studies out of 739 were fully retrieved. Results Implementation aspects as intervention types (single or combined targeted risk factors), type of audience (students, parents, school staff, communities), settings (home, school or outdoor), type of organization (face to face, groups, online), professional or peer-led, communication type (written materials as brochures, posters or videoconferencing) or effectiveness measures were extracted and synthesized. Important features of context such as funding, European or government programs were used for clustering the studies. Conclusions Health literacy interventions in adolescents need the involvement of education staff and parents participation. Health literacy for adolescents has to take into account cultural context, language, psychological features of each age; either digital or non-digital interventions cannot elude face to face communication between adolescents and their parents, academics or peers. Key messages Health literacy school-based interventions are effective but the content for adolescents audience should rely on guidelines provided by interdisciplinary teams of experts. Health Literacy interventions in adolescents should be age-appropriate and do-not-harm precautions must always be taken in order to avoid prejudices, body-image or self-esteem concerns.