Measure what matters: considerations for outcome measurement of care coordination for children with neurodevelopmental disabilities and medical complexity.

Introduction: Care Coordination (CC) is a significant intervention to enhance family's capacity in caring for children with neurodevelopmental disability and medical complexity (NDD-MC). CC assists with integration of medical and behavioral care and services, partnerships with medical and community-based supports, and access to medical, behavioral, and educational supports and services. Although there is some consensus on the principles that characterize optimal CC for children with NDD-MC, challenges remain in measuring and quantifying the impacts of CC related to these principles. Two key challenges include: (1) identification of measures that capture CC impacts from the medical system, care provider, and family perspectives; and (2) recognition of the important community context outside of a hospital or clinical setting. Methods: This study used a multilevel model variant of the triangulation mixed methods design to assess the impact of a CC project implemented in Alberta, Canada, on family quality of life, resource use, and care integration at the broader environmental and household levels. At the broader environmental level, we used linked administrative data. At the household level we used quantitative pre-post survey datasets, and aggregate findings from qualitative interviews to measure group-level impacts and an embedded multiple-case design to draw comparisons, capture the nuances of children with NDD-MC and their families, and expand on factors driving the high variability in outcome measures. Three theoretical propositions formed the basis of the analytical strategy for our case study evidence to explore factors affecting the high variability in outcome measures. Discussion: This study expanded on the factors used to measure the outcomes of CC and adds to our understanding of how CC as an intervention impacts resource use, quality of life, and care integration of children with NDD-MC and their families. Given the heterogeneous nature of this population, evaluation studies that account for the variable and multi-level impacts of CC interventions are critical to inform practice, implementation, and policy of CC for children with NDD-MC.

An eHealth Program for Insomnia in Children With Neurodevelopmental Disorders (Better Nights, Better Days): Protocol for an Economic Evaluation of a Randomized Controlled Trial.

BACKGROUND: Children with neurodevelopmental disorders have a high risk of sleep disturbances, with insomnia being the most common sleep disorder (ie, chronic and frequent difficulties with going and staying asleep). Insomnia adversely affects the well-being of these children and their caregivers. Pediatric sleep experts recommend behavioral interventions as the first-line treatment option for children. Better Nights, Better Days for Children with Neurodevelopmental Disorders (BNBD-NDD) is a 5-session eHealth behavioral intervention delivered to parents to improve outcomes (eg, Pediatric Quality of Life Inventory [PedsQL]) for their children (ages 4-12 years) with insomnia and who have a diagnosis of mild to moderate attention-deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, or fetal alcohol spectrum disorder. If cost-effective, BNBD-NDD can be a scalable intervention that provides value to an underserved population. OBJECTIVE: This protocol outlines an economic evaluation conducted alongside the BNBD-NDD randomized controlled trial (RCT) that aims to assess its costs, efficacy, and cost-effectiveness compared to usual care. METHODS: The BNBD-NDD RCT evaluates the impacts of the intervention on children's sleep and quality of life, as well as parents' daytime functioning and psychosocial health. Parent participants were randomized to the BNBD-NDD treatment or to usual care. The economic evaluation assesses outcomes at baseline and 8 months later, which include the PedsQL as the primary measure. Quality of life outcomes facilitate the comparison of competing interventions across different populations and medical conditions. Cost items include the BNBD-NDD intervention and parent-reported usage of private and publicly funded resources for their children's insomnia. The economic evaluation involves a reference case cost-effectiveness analysis to examine the incremental cost of BNBD-NDD per units gained in the PedsQL from the family payer perspective and a cost-consequence analysis from a societal perspective. These analyses will be conducted over an 8-month time horizon. RESULTS: Research funding was obtained from the Kids Brain Health Network in 2015. Ethics were approved by the IWK Health Research Ethics Board and the University of Calgary Conjoint Health Research Ethics Board in January 2019 and June 2022, respectively. The BNBD-NDD RCT data collection commenced in June 2019 and ended in April 2022. The RCT data are currently being analyzed, and data relevant to the economic analysis will be analyzed concurrently. CONCLUSIONS: To our knowledge, this will be the first economic evaluation of an eHealth intervention for insomnia in children with neurodevelopmental disorders. This evaluation's findings can inform users and stakeholders regarding the costs and benefits of BNBD-NDD. TRIAL REGISTRATION: ClinicalTrial.gov NCT02694003; https://clinicaltrials.gov/study/NCT02694003. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46735.

Systematic literature review of health economic models developed for multiple myeloma to support future analyses.

AIMS: The goal of this study was to review the economic evaluations of health technologies in multiple myeloma (MM) and provide guidance and recommendations for future health economic analyses. MATERIALS AND METHODS: A systemic literature review (SLR) was conducted on original economic assessment studies and structured review papers focusing on the studies in MM. The search was limited to English language papers published from 1 January 2000 onwards. Publications not applying any type of modelling methodology to describe disease progression and patient pathways over a specific time horizon were excluded. RESULTS: A total of 2,643 publications were initially identified, of which 148 were eligible to be included in the full-text review phase. From these, 49 publications were included in the final analysis. Most published health economic analyses supported by models came from high-income countries. Evaluations from middle-income countries were rarely published. Diagnostic technologies were rarely modelled and integrated care had not been modelled. Very few models investigated MM treatments from a societal perspective and there was a relative lack of evaluations regarding minimal residual disease (MRD). LIMITATIONS: Limitations of the publications included differences between trial populations and modelled populations, justification of methods, lack of confounder analyses, and small trial populations. Limitations of our study included the infeasibility of comparing MM economic evaluations due to the significant variance in modelled therapeutic lines and indications, and the relative scarcity of published economic evaluations from non-high-income countries. CONCLUSIONS: As published economic models lacked many of the elements of the complex and heterogeneous patient pathways in MM and they focused on single decision problems, a thorough, open-source economic whole disease modelling framework is needed to assess the economic value of a wide range of technologies across countries with various income levels with a more detailed view on MM, by including patient-centric and societal aspects.

[Quantitative Assessment of Human Health Risks Based on Soil Heavy Metals and PAHs Sources:Take a Polluted Industrial Site of Beijing As an Example].

In this study, 130 surface soil samples were collected at an industrial pollution site in Beijing and the contents of As, Be, Cd, Cu, Cr, Hg, Ni, Pb, Sb, Ti, Zn, and 16 PAHs were determined. The positive matrix factorization (PMF) model was used to analyze the sources of heavy metals and PAHs, and the contributions of these sources to carcinogenic risk and hazard index in the study area were calculated. The results showed that the contents of Cd, Cu, Pb, Hg, As, Zn, and Cr in the soil exceeded the background values in different degrees; Cd, Hg, Pb, Zn, and Cu exceeded the background values by>50%. Low molecular weight PAHs (two and three rings) and high molecular weight PAHs (four to six rings) accounted for 39.6% and 60.4% of the total content of 16 PAHs. The PAH content at 77% of the sampling points at the target site was more than 1000 µg ·kg-1, which suggests severe PAH pollution at the site. Heavy metals Be, Ti, As, and Ni mainly originated from natural sources. There are three major sources of 7 heavy metals and 16 PAHs at the site: coal combustion (Hg and ∑16PAHs), smelting (Cu, Cr, Pb, and Zn), and traffic (Sb and Cd). The contribution rates of these sources to the total average contents of seven heavy metals and sixteen PAHs at 130 sampling sites were 8.46% (coal combustion), 90.61% (smelting), and 0.94% (traffic). Human health risk assessment results showed that the carcinogenic risk of seven heavy metals and ∑16PAHs ranged from 4.17×10-6 to 39.38×10-4, and the hazard index ranged from 0 to 32.23. The maximum carcinogenic risk and hazard index values were calculated near the coking plant. Benzo[α]pyrene was the PAH that posed the highest carcinogenic risk and Zn was the heavy metal that had the highest hazard index value. The average carcinogenic risk of coal combustion was 2.16×10-4, accounting for 50.26% of the total average carcinogenic risk. The average hazard index of smelting was 0.834, accounting for 56.43% of the total average non-carcinogenic risk. These two pollution sources are responsible for the high levels of heavy metals and PAHs in the soil of the steel smelting sites that pose the most severe health risks. The results of this study can provide reference for soil remediation and process optimization at other heavily polluted industrial sites.

Computational Biomechanical Analysis of Postoperative Calcaneal Fractures with Different Placement of the Sustentaculum Screw.

OBJECTIVE: To evaluate the computational biomechanical analysis of intra-articular calcaneal fractures with different fixation status of the sustentaculum plate screw, when the finite element modeling of calcaneal fractures were fixed by the lateral locking plate. METHODS: The normal right foot of a male (age: 36 years; height: 174 cm; body weight: 65 kg) was scanned by the CT scanner. As the computational biomechanical study, the three-dimensional finite element model of the simplified Sanders type-II calcaneal fracture was built. Fixation with the lateral calcaneal locking plate and screws was simulated using a finite element software package according to clinical operation. According to the different placement of the sustentaculum plate screw, the models were categorized as the accurate fixation group, marginal fixation group, and non-fixation group. The loading of 650 N with the vertical axial compression was applied to simulate the standing phase with single foot. The Von Mises stress distribution, maximal displacement, and contact area of the subtalar joint were analyzed among three groups. RESULTS: The pressure distribution of the subtalar joint facet was inhomogeneous. The stress concentration of the calcaneus was located at the medial zone of the posterior subtalar joint facet. The peak Von Mises stress distribution in three groups was similar at the subtalar joint facet of 4.9 MPa, 5.1 MPa, and 5.4 MPa. In the accurate fixation group, the contact area on the posterior articular facet was 277.1 mm2 ; the maximal displacement was 0.18 mm. The contact area of the marginal fixation group was 265.3 mm2 on the posterior facet, where the maximal displacement was 0.23 mm. In the non-fixation group, the contact area was 253.8 mm2 ; the maximal displacement was 0.25 mm. There was a slight change in the contact area of the subtalar joint and no prominent displacement of the calcaneus could be detected among the three groups. CONCLUSIONS: The biomechanical results, including the peak stress distribution, contact area, and maximal displacement of subtalar joint, were similar whether the screw is placed exactly within the sustentaculum tali or not, when the calcaneal fractures were fixed by the lateral locking plate. The sustentaculum plate screw had less effect on the biomechanical performance of the calcaneus.

Postoperative Evaluation of Reduction Loss in Proximal Humeral Fractures: A Comparison of Plain Radiographs and Computed Tomography.

OBJECTIVE: To compare postoperative CT images with plain radiographs for measuring prognostic factors of reduction loss of fractures of the proximal part of the humerus. METHODS: A total of 65 patients who sustained fractures of the proximal humerus treated with locking plates from June 2012 to October 2015 were retrospectively analyzed. There were 24 men and 41 women, with a mean age of 60.0 years (range, 22-76 years). According to the Neer classification system of proximal humeral fracture, there were 26 two-part, 27 three-part and 12 four-part fractures of the proximal part of the humerus, and all fractures were treated with open reduction and internal fixation (ORIF) using locked plating. All postoperative CT images and plain radiographs of the patients were obtained. Prognostic factors of the reduction loss were the change of neck shaft angle (NSA) and the change of humeral head height (HHH). The change of NSA and HHH were evaluated by the difference between postoperative initial and final follow-up measurement. Reduction loss was defined as the change ≥10° for NSA or ≥5 mm for HHH. The NSA and HHH were measured using plain radiographs and 3-D CT images, both initially and at final follow-up. The paired t-test was used for comparison of NSA, change of NSA, HHH, and change of HHH between two image modalities. The differences between two image modalities in the assessment of reduction loss were examined using the χ2 -test (McNemar test). Intraclass correlation coefficients (ICC) were used to assess the intra-observer and inter-observer reliability. RESULTS: 3-D CT images (ICC range, 0.834-0.967) were more reliable in all parameters when compared with plain radiographs (ICC range, 0.598-0.915). Significant differences were found between the two image modalities in all parameters (plain radiographs: initial NSA = 133.6° ± 3.8°, final NSA = 130.0° ± 1.9°, initial HHH = 17.9 ± 0.9 mm, final HHH = 15.8 ± 1.5 mm; 3-D CT: initial NSA = 131.4° ± 3.4°, final NSA = 128.8° ± 1.7°, initial HHH = 16.8 ± 1.2 mm, final HHH = 14.5 ± 1.1 mm; all P < 0.05). In the assessment of reduction loss, the percentage was 16.9% (11/65) for the plain radiographs and 7.7% (5/65) for the 3-D CT scans (P < 0.05). For the 5 patients with reduction loss, which were observed by two imaging modalities, the mean Constant-Murley score was 61.0 ± 1.6. The patients with reduction loss, observed only in plain radiographs but not CT images, had good shoulder function (Constant-Murley score: 82.7 ± 1.0). CONCLUSIONS: Our data reveal that 3-D CT images are more reliable than plain radiographs in the assessment of the prognostic factors of reduction loss of fractures of the proximal part of the humerus with treatment of locking plates; this reliable CT technique can serve as an effective guideline for the subsequent clinical management of patients.

Cadmium exposure via diet and its implication on the derivation of health-based soil screening values in China.

The cadmium (Cd) intake rates via diet of adults from different regions in China were between 0.160 and 0.557 µg/(kg BW·day), which were less than the provisional tolerable monthly intake (0.833 µg/(kg BW·day)) issued by Food and Agriculture Organization/World Health Organization in 2010, but higher than the one (0.365 µg/(kg BW·day)) issued by the European Food Safety Authority in 2011, to protect children, vegetarians and people living in heavily contaminated regions, and the intake rate of children (1.007 µg/(kg BW·day)) at the national scale was higher than the values recommended by the above institutes and those of adults. Vegetables were the critical contributors, followed by rice, flour, meats and aquatic products. Cd concentration in vegetable was the most sensitive factor in calculating the intake rate, followed by its contents in rice and aquatic products, and the intake rate of flour, indicating that more attention should be given to these parameters in future total diet surveys. When dietary exposure was incorporated, the derived national screening value of Cd under commercial scenario was reduced from 825 to 458 mg/kg, while the values of the north, south, Beijing and Shanghai were reduced to 627, 365, 693 and 489 mg/kg, respectively, indicating that the hazard would be underestimated if dietary exposure was not taken into account, especially for the south. The great variance between the screening values was due to the varied Cd intake rates, which indicated that deriving a screening value for each specific area based on its corresponding exposure characteristics was more appropriate. The national screening level for the residential scenario derived theoretically based on the dietary exposure characteristics of children was a negative value, meaning that the dietary intake rate was above the tolerable value. The method used in the United Kingdom to derive soil guideline values when non-soil exposure accounted for more than half of the maximum tolerable daily intake dose may be an appropriate estimate, but the exact ratio assigned to soil exposure should be assessed comprehensively based on a more sophisticated dietary exposure survey and the corresponding economic implications.

[Case study on groundwater health risk assessment and remediation strategy based on exposure pathway].

The carcinogenic risk originated from benzene in contaminated groundwater of a large-scale coke plant in Beijing was analyzed and assessed for different land use zones according to the site redevelopment plan. The results revealed that indoor vapor inhalation was the key exposure pathway for all the three zones. The carcinogenic risk in zone A as commercial area was 6.37 x 10(-8), below the maximum allowable level (1.0 x 10(-6)), but was 2.20 x 10(-4) in zone B as industrial park and 7.49 x 10(-5) in zone C as residential/commercial area, both beyond the acceptable level. Further, the remediation target for benzene was calculated at 118 microg x L(-1) and the corresponding remediation area was contoured to be 165 000 m2. Given the high permeability of the aquifer and the excellent volatility of benzene, air-sparging with a combination of engineering control measure was recommended to mitigate the risk of the groundwater contamination.

[Simulation on remediation of benzene contaminated groundwater by air sparging].

Air sparging (AS) is one of the in situ remedial technologies which are used in groundwater remediation for pollutions with volatile organic compounds (VOCs). At present, the field design of air sparging system was mainly based on experience due to the lack of field data. In order to obtain rational design parameters, the TMVOC module in the Petrasim software package, combined with field test results on a coking plant in Beijing, is used to optimize the design parameters and simulate the remediation process. The pilot test showed that the optimal injection rate was 23.2 m3 x h(-1), while the optimal radius of influence (ROI) was 5 m. The simulation results revealed that the pressure response simulated by the model matched well with the field test results, which indicated a good representation of the simulation. The optimization results indicated that the optimal injection location was at the bottom of the aquifer. Furthermore, simulated at the optimized injection location, the optimal injection rate was 20 m3 x h(-1), which was in accordance with the field test result. Besides, 3 m was the optimal ROI, less than the field test results, and the main reason was that field test reflected the flow behavior at the upper space of groundwater and unsaturated area, in which the width of flow increased rapidly, and became bigger than the actual one. With the above optimized operation parameters, in addition to the hydro-geological parameters measured on site, the model simulation result revealed that 90 days were needed to remediate the benzene from 371 000 microg x L(-1) to 1 microg x L(-1) for the site, and that the opeation model in which the injection wells were progressively turned off once the groundwater around them was "clean" was better than the one in which all the wells were kept operating throughout the remediation process.