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INTRODUCTION Pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) are severe but highly treatable postinfectious inflammatory brain conditions. Despite published diagnostic and treatment guidelines for this condition, there are long delays in obtaining appropriate care. The reasons for these delays are poorly understood. We sought to identify health care system barriers to timely treatment by examining cases of PANDAS/PANS occurring in children of health care professionals. METHOD We recruited families via e-mail request through the PANDAS Physicians Network. Participating parents completed a structured questionnaire and provided a written case description. RESULTS Eleven families completed data collection, representing a broad spectrum of disease (child disease onset age 4-15, 7 males/4 females, mild to severe). Parents included 11 physicians, 2 mental health professionals, 2 nurses, and a PharmD. Nine cases (82%) had "very delayed" diagnosis and treatment (>4 weeks after onset). The most commonly encountered causes for treatment delay were clinician lack of awareness (82%), clinician skepticism (82%), overdependence on diagnostic testing (91%), and out-of-pocket expenses >$100 US (82%). Other common challenges included difficulties finding a provider to spearhead care (64%), psychological misdiagnosis (55%), and children's suppression of behaviors during assessments (55%). CONCLUSIONS We found numerous barriers to treatment of PANDAS/PANS among children of health care providers. Our findings suggest that even among the medically sophisticated, PANDAS/PANS diagnosis and treatment remains challenging. Improvement in PANDAS/PANS education of clinicians who may encounter children with this disorder is 1 key step toward addressing our identified barriers. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

BACKGROUND: Access to health insurance and curative interventions [surgery/liver directed therapy (LDT)] affects survival for early-stage hepatocellular carcinoma (HCC). The aim of this multi-institutional study of high-volume safety-net hospitals (SNHs) and their tertiary-academic-centers (AC) was to identify the impact of type/lack of insurance on survival disparities across hospitals, particularly SNHs whose mission is to minimize insurance related access to care barriers for vulnerable populations. METHODS: Early-stage HCC patients (2012-2014) from the US Safety-Net Collaborative were propensity-score matched by treatment at SNH/AC. Overall survival (OS) was the primary outcome. Multivariable Cox proportional-hazard analysis was performed accounting for sociodemographic and clinical parameters. RESULTS: Among 925 patients, those with no insurance (NI) had decreased curative surgery, compared to those with government insurance (GI) and private insurance [PI, (PI-SNH:60.5% vs. GI-SNH:33.1% vs. NI-SNH:13.6%, p

PURPOSE In Canada, Indigenous peoples’ cancer rates have increased, but cancer screening rates tend to be lower. When coupled with poor cancer prognosis, treatment barriers, and inaccessible health care, Indigenous patients with cancer experience many unmet needs. Further complicating their journey is a multijurisdictional system that complicates cancer control services, treatments, patient supports, and cancer surveillance. To address these issues, the Canadian Indigenous Research Network Against Cancer (CIRNAC) was developed. This article describes the forerunners and consultative process that created the network and the consensus model developed to ground this network with, by, and for Indigenous peoples. METHODS A consultative workshop was held to (1) establish and increase network membership, (2) enhance partnerships with Indigenous communities and other researchers, and (3) develop an Indigenous-led research program, new funding, and related initiatives. RESULTS Participants viewed the CIRNAC as a reflective parallel network led by Indigenous peoples that would identify research priorities within Canada, assess how these priorities align with Indigenous patients’ cancer care and research needs, and cross-check to see if these priorities align with each other. The network would also advocate for Indigenous elders/knowledge holders and community grassroot processes to drive research and training, thus demonstrating the power of the community voice and lived experience in research. In addition, the network would foster research partnerships to investigate alternative Indigenous models for cancer prevention, care, treatment, and support. CONCLUSION The CIRNAC evolved as a viable vehicle to address cancer with, for, and by Indigenous peoples. The network is guided by a preamble, a set of aims, and an inclusion engagement circle model. It is evolving through major world initiatives, with the aim of formally becoming an internationally linked national network.

In this paper, a deterministic Lymphatic Filariasis (LF) model with preventive measures in human and treatment barriers is developed and analysed to assess the impact of treatment barriers on the transmission dynamics of LF in endemic areas. Qualitative analysis and numerical simulation are presented in terms of the reproduction number of the model in the absence and presence of treatment barriers. It is established that the treatment intervention has shown improvement in the reduction of LF infection in the population. Furthermore, in the absence of treatment barriers the model guaranteed disease extinction behaviour, while in the presence of treatment barriers the model shows disease persistence behaviour when . This means that in the presence of treatment barriers there is coexistence of the stable disease-free state and the stable persistent state of the disease when . The persistence behaviour may be due to plentiful infected individuals who accumulate in the community due to treatment barriers while the disease has no natural recovery. The numerical simulations are performed to complement the analytical results.

Background. Nutrition education is one of the most important factors determining the effectiveness of treatment and maintaining an adequate quality of life (QoL) in children and adolescents with type 1 diabetes. Objective. The primary objective was to compare the influence of two methods of nutrition education on the QoL. The secondary objective was to identify other determinants of the QoL. Material and Methods. A randomized single-blind study was conducted between October 2017 and April 2019 at the Children’s Clinical Hospital in Warsaw. The study included 170 patients (aged 8-17) with at least 1-year history of type 1 diabetes, treated with insulin pumps. The participants were randomly divided into two groups: a control group (C) – traditional/ informative education methods, and an experimental group (E) – modern/interactive methods. PedsQL Diabetes Module 3.0 questionnaire was used in the assessment of the QoL. Total PedsQL score was the primary outcome. The secondary outcomes included the results obtained in five subscales of the questionnaire. The relationships between selected variables and changes in scores were also verified. Results. Data obtained from 136 patients were analyzed. In both groups no significant changes regarding total PedsQL were noted 6 months after the intervention. However, a significant reduction occurred as regards the scores of ‘Communication’ subscale in group C. Analyzing other determinants of the QoL, significant dependencies were observed between: the level of physical activity and a change in ‘Diabetes symptoms’ subscale, and the level of parents’ education and a change in ‘Treatment barriers’ subscale. Conclusions. Both methods of nutrition education exerted a comparable influence on the total QoL. However, modern methods were more effective in terms of the improvement in the aspect of communication. Additionally, moderate physical activity and parents’ tertiary education constituted valid determinants of various aspects of the QoL in children and adolescents with type 1 diabetes.

Social support has been identified as a significant factor in addressing treatment barriers and facilitating treatment adherence. Using a descriptive design, this qualitative study aims at sharing personal feelings and social support-related experiences among pulmonary tuberculosis (TB) patients in Western India. A semi-structured interview guide was designed, and thirty-seven in-depth interviews were conducted. Descriptive thematic analysis was employed for reporting the themes and the results. The participants highlighted diverse social support experiences like empathy, compassion, trust, neglect, tangible aid, strained relationships with in-laws, health provider's support, strength, and motivation which influences their treatment adherent behaviour. Contrasting differences of social support experiences among adherent and non-adherent TB patients were also reported. The study has important ramifications for developing patient-centric social support intervention strategies, TB policy, and practice. The study has shown, 'if not for this support', patients would have left the treatment, and it is mainly because this debilitating disease robs people of their physical, social, economic, psychological, and emotional well-being far beyond the period when treatment is being administered. However, we resonate that addressing social support is not the only way, and TB elimination overall will require an optimal mix of enhanced biomedical, social, economic, and policy interventions.

Due to limitations in access to specialized eye care, the majority of people with diabetic retinopathy (DR) are not screened routinely. To increase screening for DR, the Utah Diabetes and Endocrinology Center clinic began to offer point-of-care retinal image screening for patients with diabetes who had not had a dilated eye exam in the last year. Retinal photos obtained with a digital non-mydriatic camera were interpreted by a vitreoretinal specialist. From 11/2017 to 12/2020, 320 people underwent point-of-care DR screening. Of these, 298 (93%) had retinal images that were of sufficient quality. Mild-moderate DR was identified in 63 participants (21%), moderate-severe DR in 29 participants (10%) and proliferative DR in 11 participants (4%). Patients with advanced DR were referred for in-person evaluation. Five of 11 patients with proliferative DR visited a University of Utah (U of U) ophthalmologist compared to 9 of 29 patients with moderate-severe DR. Four of 14 patients with advanced retinopathy seen by U of U ophthalmology began retinopathy-specific treatment (anti-VEGF injection/ photocoagulation). We conclude that initiation of point-of-care retinal screening to patients not routinely followed by ophthalmologists increased detection of mild, moderate and proliferative DR. These findings also identify follow-up with retinal specialists after referral as a potential treatment barrier. Disclosure M. Wahl: None. J. Neuberger: None. M. L. Litchman: Research Support; Self; Abbott Diabetes. G. S. Adjei-poku: None. A. Fagerlin: None. M. Hartnett: None. S. Fisher: None.

ObjectiveChronic pain is a prevalent and burdensome condition. Reboot Online was developed to address treatment barriers traditionally associated with accessing face-to-face chronic pain management programs. It is a comprehensive multidisciplinary online treatment program, based on an existing and effective face-to-face multidisciplinary pain program (the Reboot program).Design & ParticipantsA CONSORT-compliant randomized controlled trial was conducted, enrolling adults who had experienced pain for three months or longer.MethodsParticipants were randomly allocated to either an eight-lesson multidisciplinary pain management program, Reboot Online (N = 41), or to a usual care (UC) control group (N = 39). Clinical oversight was provided by a multidisciplinary team remotely, including physiotherapists and clinical psychologists. Participants were measured at baseline, post-treatment (week 16), and three-month follow-up (week 28).ResultsIntention-to-treat analyses revealed that Reboot Online was significantly more effective than UC at increasing pain self-efficacy (g = 0.69) at post-treatment, and these gains were maintained at follow-up. Similarly, Reboot Online was significantly more effective than UC on several secondary measures at post-treatment and follow-up, including movement-based fear avoidance and pain-related disability, but it did not significantly reduce pain interference or depression compared with UC. Clinician input was minimal, and adherence to Reboot Online was moderate, with 61% of participants (N = 25) completing all eight lessons.ConclusionsReboot Online presents a novel approach to multidisciplinary pain management and offers an accessible, efficacious alternative and viable treatment option for chronic pain management.

Background In 2017 the UK's Association of Children's Diabetes Clinicians (ACDC) launched a national educational package to provide training in the use of Freestyle Flash glucose monitoring (GM) to healthcare professionals. Objective To evaluate metabolic outcomes and quality of life (QoL) of children with T1DM trained in the use of the Freestyle Flash GM system adopting the ACDC guidelines. Methods Prospective study conducted at a single UK children's diabetes unit from 2017 to 2018.52 children with T1DM (age 5–18 yrs) were commenced on the Freestyle Flash GM system, received education and were followed up for 12 months. The Peds QL 3.2 diabetes questionnaire was used to assess QoL before and after the use of the system. HbA1c was measured at 3, 6 and 12 months pre and post use of Freestyle. Results 52 children (33 M,19 F) with a mean age of 11.6 yrs (range 4 m–17.2 yrs) were evaluated. Mean HbA1c 3 months post Freestyle Flash GM showed a significant improvement when compared with HbA1c values at 12, 6 and 3 months pre Freestyle (p-value 0.040, 0.040, 0.012 respectively). This improvement was not sustained at 6 and 12 months (p-value 0.15, 0.50). The PedsQL3.2 diabetes scores demonstrated significant improvement in patient QoL, reduction of diabetes symptoms and treatment barriers following the use of the new technology (p-values 0.014; 0.018; 0.035 respectively). Conclusions Freestyle Flash GM technology associated with appropriate education and regular support by healthcare professionals improves patient quality of life measures in children with T1DM.

This qualitative study discusses barriers affecting female substance user’s treatment access to welfare services. The study consisted of seven group discussions and three individual meetings with 13 women in Helsinki, Finland. Institutional ethnography was used as the theoretical framework for the study. The research questions are: (a) What treatment barriers do women face?, (b) What reasons are there for them not receiving services?, and (c) How do the ruling relations coordinate women’s experiences? Women faced multiple barriers affecting their access to services. They could be interpreted as being: determined by the service system, such as a difficulty in meeting the various criteria in order to be granted access to services; determined by the lack of trust; or determined by personal choices. The study suggests that the service system should be organized according to the needs of the service users. Future research is needed to address the questions such as how social and health care services could better co-operate, and how the different sectors of the service system could break down the institutional barriers.

This study aimed to explore the experiences of clinicians working with fathers caring for a child experiencing an eating disorder. A phenomenological qualitative method was used to answer the quest...

Background Guidelines recommend a differentiation of difficult-to-treat asthma from severe asthma. However, this might be complex and to which extent this distinction is achievable in clinical practice remains unknown. Objective To evaluate to which degree a systematic evaluation protocol enables a differentiation between severe versus difficult-to-treat asthma in patients in specialist care on high intensity asthma treatment, i.e. potentially severe asthma. Methods All adult asthma patients seen in four respiratory clinics over one year were screened prospectively for asthma severity. Patients with difficult-to-control asthma according to ERS/ATS criteria (high–dose inhaled corticosteroids/oral corticosteroids) underwent systematic assessment to differentiate severe asthma patients from those with other causes of poor asthma control: objective confirmation of the asthma diagnosis as well as assessment of treatment barriers and comorbidities. Results Overall, 1034 asthma patients were screened, of whom 175 (16.9%) had difficult-to-control asthma. 117 of these accepted inclusion, and completed systematic assessment. Asthma diagnosis was objectively confirmed in 88%. Sub-optimal adherence (42.5%), inhaler errors (31.5%) and unmanaged comorbidities (66.7%) were common. After primary assessment, 12% (14/117) fulfilled strict criteria for severe asthma. Moreover, 56% (66/117) were instantly classified as difficult-to-treat asthma due to poor adherence/inhaler technique. Finally, an ´overlap' group of 32% (37/117) were identified with patients being adherent and displaying correct inhaler technique, but had unmanaged comorbidities —potentially fitting into both the difficult-to-treat and severe group. Conclusion Only a minority of patients with difficult-to-control asthma were found to have severe asthma after primary systematic assessment. Nevertheless, strict categorisation of severe vs. difficult-to-treat asthma seems to pose a challenge.

Engaging global key opinion leaders, the International Psoriasis Council (IPC) held a day-long roundtable discussion with the primary purpose to discuss the treatment goals of psoriasis patients and worldwide barriers to optimal care. Setting clear expectations might ultimately encourage undertreated psoriasis patients to seek care in an era in which great gains in therapeutic efficacy have been achieved. Here, we discuss the option for early treatment of all categories of psoriasis to alleviate disease impact while emphasizing the need for more focused attention for psoriasis patients with mild and moderate forms of this autoimmune disease. In addition, we encourage policy changes to keep pace with the innovative therapies and clinical science and highlight the demand for greater understanding of treatment barriers in resource-poor countries.

Objective Little is known about the treatment uptake rate for adults diagnosed with an eating disorder through formal assessment. This study aimed to identify psychological and eating disorder symptoms that predict whether individuals with diagnosed eating disorders start treatment after receiving a diagnostic assessment and recommendation to begin treatment. Identifying barriers to starting treatment can inform interventions to improve the uptake of treatment. Method After a diagnostic assessment at an eating disorder specialty clinic, 223 adults were recommended to begin treatment and completed self-report measures of psychological functioning, clinical impairment, and eating psychopathology. Patient attendance was assessed to determine rates and predictors of starting treatment within 3 months of the assessment. Results Of the 223 patients recommended to begin treatment, approximately two-third started treatment within 3 months of the assessment. Logistic regression identified greater avoidance of eating, greater laxative use frequency, more social eating concerns, and lower weight dissatisfaction as predicting lower likelihood of beginning treatment after assessment. A chi-square test for independence found no significant differences between diagnostic groups on starting treatment. Discussion Findings identify eating disorder symptoms that predict treatment enrollment after diagnostic assessment and recommendation to begin treatment. Assessing for these symptoms at the diagnostic assessment stage is recommended to address potential treatment barriers. Future research should identify strategies that increase treatment uptake at this stage of the process.

Background Despite the wealth of evidence demonstrating the efficacy of treatment intensification beyond androgen-deprivation therapy (ADT) among patients with de novo metastatic castration-sensitive prostate cancer (mCSPC), little is known of its real-world use. This study examined the real-world uptake of ADT treatment intensification among older men in a large Canadian province. Methods We performed a retrospective population-based cohort study using province-wide linked administrative data in Ontario, Canada. Patients 66 years of age and older with de novo mCSPC were included and their treatment with conventional ADT-based regimens, ADT plus next-generation androgen receptor axis–targeted therapy, and ADT plus docetaxel were identified and stratified by time. Results From 2014 to 2019, 3556 patients were identified with de novo mCSPC. Most patients (n = 2794 [78.6%]) were treated with a conventional ADT regimen, whereas 399 (11.2%) patients received ADT intensification with docetaxel and 52 (1.5%) patients received abiraterone acetate plus prednisone. In a time-stratified analysis of ADT intensification before and after the pivotal AA+P trial (LATITUDE), AA+P uptake increased from 0.5% to 3.0%, whereas docetaxel use dropped from 12.0% to 10.0%. The median survival of the study population was 18 months (interquartile range = 10-31). Conclusions The majority of patients with de novo mCSPC are treated with ADT alone in the Canadian real-world setting, despite randomized clinical trial evidence of benefit with the use of ADT-intensified regimens. As ADT treatment intensification is substantially underused, better understanding of the barriers to treatment and targeted education to address them are needed.

Brain abscesses are difficult to manage clinically and often result in a poor outcome. Although surgical and medical therapeutics have progressed, there are still challenges that make treating intracranial abscesses problematic. One of these treatment barriers is the poor penetration of intravenous antibiotics to the infection source through the blood-brain barrier. In this case report, we will discuss the use of a surgical drain as a conduit for direct antibiotic administration for a rare, recurrent Streptococcus intermedius infection. This technique allows us to bypass the blood-brain barrier while also reducing the systemic effects of antibiotics. When used in conjunction with craniotomy and resection, direct antibiotic administration via a surgical drain proved to be effective at treating our patient's abscess and preventing recurrence.

Background Many individuals misusing opioids do not enter into treatment. The question of who enters into treatment for their opioid abuse and under what circumstances is complex and shaped by multiple factors. The objective of the current study is to explore the risk factors for wide-ranging and numerous barriers to treatment among social media users. Method Opioid-related forums within a popular social media platform were used to recruit non-treatment engaged individuals (≥15 years) who had misused opioids in the past month ( n = 144; 66% male; median age 28). Four treatment barrier factors were identified utilizing principle component analysis: (1) stigma, (2) awareness, (3) attitudinal, and (4) denial. A structural equation model (SEM) was then created to explore the risk factors for different types of barriers to OUD treatment. Results The most common barriers among participants not engaged in treatment for their opioid misuse were the belief that one should be able to help themselves with their condition (66%), treatment was too expensive (63%), and worries about being labeled or judged (57%). Additionally, SEM results demonstrate stigma barriers, awareness, and attitudinal barriers were associated with mental health comorbidities, opioid abuse and dependence severity, and treatment history. Denial barriers, however, were only associated with treatment history, and structural/financial barriers were only associated with opioid abuse and dependence severity. Conclusions Our research findings are relevant for underscoring the wide-ranging and numerous barriers to treatment faced by individuals misusing opioids that are especially concentrated among those who also struggle with comorbid mental illness.

The opioid epidemic in the United States, along with a lack of adequate harm reduction services, has contributed to a sharp rise in hepatitis C virus (HCV) infections. Despite considerable evidence of the effectiveness of HCV treatment in people who inject drugs (PWID), and recommendations from clinical guidelines to prioritize treatment in PWID, there are multiple barriers to broad uptake of HCV treatment. These barriers exist at the systems level, as well as at the level of medical providers and patients. Interventions to remove treatment barriers in the United States include harm reduction services, simplifying HCV testing algorithms, improved linkage to HCV care services, and application of new treatment models including colocating services at substance use disorder treatment programs. By following the lead of other countries who have addressed the barriers to HCV treatment, the United States has opportunities to do better in addressing the consequences of the opioid epidemic, including chronic HCV infection.

Background:Individuals with mental health concerns face many barriers when accessing psychological treatment. Even when patients overcome these barriers, they often do not receive an evidence-based treatment. Although the current literature highlights these issues clearly across psychological disorders, the research is limited in relation to body dysmorphic disorder (BDD).Aim:The aim of this study was to examine psychological treatment barriers, treatment delivery preferences and treatment histories of individuals with symptoms of BDD.Method:A total of 122 participants with clinically significant BDD symptoms (94% female; mean age = 34.19 years, SD = 10.86) completed the cross-sectional study.Results:The most frequently reported barriers to accessing psychological treatment for individuals with BDD symptoms were the cost of treatment (41%) and the belief that the symptoms did not warrant treatment (36%). Although 69% of treatment-seeking participants reported previously receiving cognitive behavioural therapy (CBT) for BDD, only 13% of participants appeared to receive best-practice CBT. The preferred modality of future psychological treatment delivery was face-to-face treatment with a therapist once a week (63%), rather than accelerated or remote treatment approaches.Conclusions:The study suggests that there are significant barriers to accessing CBT for BDD. Reducing these barriers, as well as increasing consumer mental health literacy, is required to improve treatment access and treatment outcomes for individuals with BDD.

OBJECTIVE A lack of resources and cultural stigma associated with mental health treatment necessitate the development of innovative and economical individualized treatments. This study evaluated the efficacy of delivering computer-based cognitive behavioral therapy (e-CBT) presented through Microsoft PowerPoint and delivered via email in the treatment of generalized anxiety disorder (GAD) to Iranian patients, as a means of overcoming treatment barriers. METHODS Participants (N=80) of Iranian descent were recruited through announcements on psychology websites, Iranian organization websites, weblogs, and in flyers. Participants were randomly assigned to either an e-CBT or a control group. The e-CBT group received 12 weekly modules and homework assignments through email, presented using PowerPoint. The control group received no treatment (individuals in the control group were able to pursue another treatment, but would then be excluded from the study although they could continue with the program). All emails were sent by an attending or resident psychiatrist, who also provided feedback on weekly homework via email. The Beck Anxiety Inventory was used to measure levels of anxiety before study onset and changes in levels of anxiety upon completion of the program at 12 weeks, and at 6-month and 1-year follow-up in both groups. RESULTS Beck Anxiety Inventory scores were significantly reduced in the group who received PowerPoint e-CBT modules delivered via email, compared with the control group, following 12 weeks of treatment, and the reductions were maintained at both follow-up points. CONCLUSIONS Delivery of PowerPoint e-CBT modules via email was found to be a viable method for delivering CBT to individuals with GAD and a simple method for overcoming language, cultural, and travel barriers to accessing mental health resources. This simplified approach to the individualization and delivery of treatment modules has the potential to improve access to CBT as a treatment option throughout the world.

Summary Pancreatic ductal adenocarcinoma is the seventh leading cause of cancer death worldwide with an estimated 432 242 deaths occurring in 2018. This estimate, in conjunction with the findings that pancreatic ductal adenocarcinoma incidence is rising and that pancreatic ductal adenocarcinoma has the highest case-fatality rate of any solid tumour, highlights the urgency for designing novel therapeutic strategies to combat this deadly disease. Through the efforts of the global research community, our knowledge of the factors that lead to the development of pancreatic ductal adenocarcinoma, its progression, and the interplay between tumour cells and their surrounding microenvironment have improved substantially. Although these scientific advances have not yet translated into targeted or immunotherapy strategies that are effective for most patients with pancreatic ductal adenocarcinoma, important incremental progress has been made particularly for the treatment of specific molecular subgroups of tumours. Although PD-1 inhibitors for mismatch-repair-deficient tumours and NTRK inhibitors for tumours containing NTRK gene fusions are the most recent targeted agents approved by the US Food and Drug Administration, olaparib for germline BRCA-mutated pancreatic ductal adenocarcinoma is expected to be approved soon in the maintenance setting. These recent advances show the accelerated pace at which pancreatic ductal adenocarcinoma drugs are achieving successful clinical outcomes. Here we review the current understanding of the pathophysiology of pancreatic ductal adenocarcinoma, recent advances in the understanding of the stromal microenvironment, current standard-of-care treatment, and novel therapeutic targets and strategies that hold promise for improving patient outcomes. We predict that there will be major breakthroughs in the treatment of pancreatic ductal adenocarcinoma in the next 5–10 years. These breakthroughs will result from the increased understanding of the treatment barriers imposed by the tumour-associated stroma, and from the development of novel approaches to re-engineer the tumour microenvironment in favour of effective anticancer responses.

Background Although effective treatments are available, most individuals with body dysmorphic disorder (BDD) do not receive an appropriate diagnosis or treatment. We aimed to examine treatment utilization and barriers to treatment, and to identify associated socio-demographic and clinical characteristics. Methods German individuals completed an online self-report survey of appearance concerns. A sample of N = 429 individuals met criteria for BDD. We examined the frequency of treatment utilization and barriers, analyzed comparisons between treated and untreated individuals and assessed the relationships of socio-demographic and clinical features with mental health treatment utilization and treatment barriers, respectively. Results Only 15.2% of the individuals with BDD had been diagnosed with BDD, and lifetime rates of mental health treatment were low (39.9%). Individuals endorsed multiple barriers to mental health treatment, especially shame, low perceived need and a preference for cosmetic and medical treatments. Associated features were identified, including age, a BDD diagnosis, body dysmorphic symptom severity, a likely major depressive disorder, prior cosmetic surgery, and insight. Conclusions The results of this largest study to date highlight that BDD is still underrecognized and undertreated even in a country with extensive mental health care and few financial barriers. We discuss modifiable factors and strategies to foster awareness of BDD in sufferers and professionals to improve treatment dissemination and to reduce treatment barriers.

Retaining HIV patients in clinical care is a critical component of the HIV care continuum, impacting not only patients' virologic suppression, but their overall health and wellbeing. Understanding reasons for patient drop-out is therefore important to improve HIV outcomes and reduce transmission. This study used qualitative in-depth interviews with patients who dropped out of HIV care (n = 16) from the Atlanta Veterans Affairs Medical Center, to explore their reasons for drop-out and how they negotiate barriers to return to care. Results show three interlinked “pathways” leading to patient drop-out —wellness, illness, and medication pathways. These pathways encompass both barriers to retention and triggers to resume clinic visits, with patients following different pathways at different times in their lives. Perhaps the strongest deterrent to continuing clinic visits was participants' self-perception of wellness, which often outweighed clinical indicators of wellness. These pathways suggest that multiple approaches are needed to improve treatment retention, including reducing clinic-based barriers, addressing basic needs that are barriers to clinic visits, and empowering patients to view clinic visits as a facilitator to maintaining their overall health rather than only a reaction to illness.

Subclinical eating disorders, though considered less severe, are associated with clinically significant impairment in functioning. Guided by feminist theory, the purpose of the present analysis was to identify barriers and facilitators to seeking treatment for those with subclinical eating disorders. Fifteen women between the ages of 18 and 25, with subclinical eating disorder symptoms, and no treatment history were interviewed. Barriers to seeking treatment included a lack of openness with support system, misperceptions regarding subclinical symptoms, and stigma. Supportive relationships are highlighted as a significant facilitator in the process of treatment-seeking. Clinical implications for future research and practice are discussed.

The United Republic of Tanzania is at a crucial stage in the development of its mental health system. As of 2009, there were 18 psychiatrists serving this nation of 51 million people despite depression ranking as Tanzania’s number one cause of disability. Modest efforts have been made to expand services, but few studies have documented the state of mental health treatment in the nation. The current research represents a formative effort to assess mental health needs in northern Tanzania and inform the investment of resources to improve care. To achieve these aims, we conducted semistructured interviews with 29 mental health providers examining their perceptions of the treatment currently offered, characteristics of patient populations, and future directions in treatment. Responses were analyzed using consensual qualitative research, and these offer nuanced insights into the Tanzanian context. Alcohol and substance abuse, schizophrenia, and stress related to social challenges were the most commonly described mental health concerns. Interviewees acknowledged critical shortfalls in providers, facilities, or resources dedicated to mental health; little coordination among services; and multiple barriers that prevent all but the most severely impaired patients from receiving care. Despite these challenges, the majority of the providers believed that treatment would improve in the future. Implications of these results for the development of the mental health system in Tanzania include the necessity for: (a) improving the availability and quality of services by dedicating new resources, (b) maximizing existing resources through task-shifting and improved training, and (c) addressing barriers to treatment via public education and community outreach.

Risk factors associated with developing opioid use disorders (OUD) are documented, but less is known about different pathways to initiation of opioids or opioid dependence, or how such pathways affect treatment engagement.We recruited 283 adults with electronic medical record (EMR) evidence of opioid dependence diagnoses. Open-ended and structured interview items focused on prior opioid treatment experiences, barriers to and knowledge of treatment options. Interviews were audio-recorded, transcribed, and coded. In exploratory analyses, we used a modified grounded theory approach to organize emergent, patient-reported themes describing participants' perceived pathways to opioid dependence.121 participants described one or more pathways to OUD. Qualitative analyses revealed five pathway themes. Three pathways were related to pain control: inadequately controlled chronic pain, exposure to opioids during acute pain episodes, and chronic pain among individuals with prior substance use disorders. A fourth pathway included individuals for whom opioids provided relief from emotional distress; the fifth related to recreational or non-medically supervised opioid use. We identified pain-related barriers to reducing/stopping opioids and treatment engagement barriers among individuals who perceived themselves solely as pain patients.Patients' perceptions of inadequately controlled pain, patients' previous substance use disorders, and the relief from emotional distress that some patients feel while using opioids are relevant when making clinical decisions about whether to initiate or sustain opioid therapy, and for how to monitor certain individuals. Among individuals with pain and OUD, treatment barriers include fear of uncontrolled pain, and stigmatization of being treated alongside people with non-medical opioid use.

To investigate perceptions of surgical participants and their caregivers regarding novel nerve transfer surgery to restore upper extremity function in cervical level spinal cord injury.A qualitative study design was used. A multidisciplinary team developed semi-structured interview guides. Interviews were recorded, transcribed and analyzed using basic text analysis.Participants had limited information about procedures to improve function after spinal cord injury. When discussing their choice to undergo nerve (as compared to traditional tendon) transfer surgery, they describe a desire to avoid post-operative immobilization. Barriers included the pre-operative testing, cost and inconvenience of travel for surgery, and understanding complex health information related to the procedure. While expectations matched descriptions of outcomes among participants and were generally positive, caregivers expressed disappointment. The long time interval for gains in function to be realized and relatively incremental gains achieved were frustrating to all.People with cervical spinal cord injury and their caregivers need more information about options to restore function and about realistic range of improvements with treatment. Further work to mitigate barriers and develop health information materials around nerve transfer surgery may improve medical decision making around and appropriate use of this newer treatment option.IMPLICATIONS FOR REHABILITATIONNerve transfer surgery is a novel and acceptable means of improving upper extremity function in the setting of cervical spinal cord injury.People with cervical spinal cord injury and their caregivers need information about options to restore hand and arm function and mitigation of barriers around these treatment options.

This study aims to assess the perceived practice and barriers towards the provision of asthma management services among urban community pharmacists in Selangor, Malaysia. The study also highlights both pharmacist and patient-related barriers in asthma counseling. One hundred fifty urban community pharmacists in Selangor, Malaysia, were randomly selected and recruited for the present cross sectional baseline study. Previous studies have explored pharmacists’ perception on their roles in asthma management in different parts of the world. The data was collected through self-explanatory questionnaires (containing 47 items). The extracted data from the completed questionnaires were analyzed descriptively and inferentially using Statistical Package for Social Science (SPSS) version 19. Results showed that pharmacists perceived their roles in asthma management along three major dimensions: ‘patient self-management’, ‘medication use’ and ‘asthma control’, mean (±SD) score of the perception towards asthma management was 99.29 ± 4.58 over a maximum possible score of 110 with 90.26%. There were significant differences between the pharmacy education level and perceived practice of asthma management while there were insignificant differences between age, gender, ethnicity, number of practicing year and perceived practice of asthma management among respondents. Most common barriers towards asthma counselling including lack of time, lack of asthma knowledge, lack of counselling space and cost of asthma drugs. Conclusively, urban community pharmacists in Selangor, Malaysia, demonstrate good perceived practice of better management of asthma with multidimensional dimensional role against in disease care.

Opioid use disorder (OUD) refers to the physical and psychological reliance on opioids. OUD costs the US healthcare systems $504 billion annually and poses significant mortality risk for patients. Understanding and mitigating the barriers to OUD treatment is a high-priority area for healthcare and IS researchers, practitioners, and policymakers. Current OUD treatment studies largely rely on surveys and reviews. However, the response rate of these surveys is low because patients are reluctant to share their OUD experience for fear of stigma in society. In this paper, we explore social media as a new source of data to study OUD treatments. Drug users increasingly participate in social media to share their experience anonymously. Yet their voice in social media has not been utilized in past studies. We develop the SImilarity Network-based DEep Learning (SINDEL) to discover barriers to OUD treatment from the patient narratives and address the challenge of morphs. SINDEL significantly outperforms state-of-the-art baseline models, reaching an F1 score of 76.79%. Thirteen types of OUD treatment barriers were identified and verified by domain experts. This study contributes to IS literature by proposing a novel deep-learning-based analytical approach with impactful implications for health practitioners.

Portopulmonary hypertension (PoPH) is a form of pulmonary arterial hypertension (PAH) that can develop as a complication of portal hypertension. Treatment of PoPH includes PAH-specific therapies, and in certain cases, such therapies are necessary to facilitate a successful liver transplantation. A significant number of barriers may limit the adequate treatment of patients with PoPH and explain the poorer survival of these patients when compared to patients with other types of PAH. Until recently, only one randomized controlled trial has included PoPH patients, and the majority of treatment data have been derived from relatively small observational studies. In the present article, we review some of the barriers in the treatment of patients with PoPH and implications for liver transplantation.

BACKGROUND American Indian and Alaska Native (AI/AN) breast cancer survivors experience disparities in breast cancer incidence and age-adjusted mortality compared with non-Hispanic white (NHW) breast cancer survivors. In addition, mortality-to-incidence rates indicate that AI/ANs continue to have the poorest survival from breast cancer compared with other racial groups. “Native American Cancer Education for Survivors” (NACES) is a cultural education and support intervention for AI/AN patients with cancer that collects data from voluntary participants through the NACES quality-of-life (QOL) survey regarding their cancer experience and survivor journey. METHODS Data from the NACES QOL survey were analyzed to determine whether barriers accessing and during initial cancer treatment impacted QOL domains for AI/AN cancer survivors. Exploratory analyses of selected variables were conducted and were followed by Kruskal-Wallis tests to determine whether these barriers influenced survivorship QOL for AI/AN breast cancer survivors. RESULTS AI/AN breast cancer survivors' social QOL was significantly affected by barriers to accessing cancer treatment. Many respondents experienced barriers, including a lack of cancer care at local clinics and the distance traveled to receive cancer care. During treatment, too much paperwork and having to wait too long in the clinic for cancer care were the most frequently reported barriers. CONCLUSIONS Treatment barriers influence AI/AN breast cancer survivors' social QOL. Mediating these barriers is crucial to ameliorating AI/AN survivors' disparities when accessing and completing cancer treatment and improving survivorship QOL. Cancer 2017;123:861–68. © 2016 American Cancer Society.

Despite the introduction of direct-acting antivirals which simplified treatment and significantly increased cure rates, hepatitis C virus (HCV) treatment barriers persist. The number of HCV specialists is limited, particularly in rural and medically underserved areas, and patients often do not have access to care and treatment. Project ECHO was developed to increase the number of patients optimally treated for HCV through their local primary care clinics. Since its inception, the ECHO model has been used to improve HCV access across the USA and globally. Project ECHO and the ECHO model represent a revolutionary approach to expanding access to treatment for HCV.

Non-gay-identified men who have sex with men and women and who use alcohol and other drugs are a vulnerable population. Little is known about health and medical service provider interaction with these underserved clients. This article presents a thematic analysis of two focus groups undertaken with social and medical service providers regarding the needs of non-gay-identified men who have sex with men and women. Four emergent themes (labeling, constructions of masculinity, HIV/AIDS awareness, and treatment success) illustrate perceived barriers to HIV/AIDS prevention and treatment, as well as treatment success. Implications for policy, practice, and future research are discussed.

Historically, patients diagnosed with metastatic pancreatic cancer have faced a grim prognosis. The survival benefit seen with systemic chemotherapies and even combinations thereof have been disappointing. However, growing data suggest that the microenvironment of pancreatic cancer may be contributing to this poor prognosis. This microenvironment has a dense fibrotic stroma, and is hypoxic and highly immunosuppressive, all of which pose barriers to treatment. Newer strategies looking to disrupt the fibrotic stroma, target hypoxic areas, and improve local immune responses in the tumor microenvironment are currently undergoing clinical evaluation and seem to offer great promise. In addition to these therapies, preclinical work evaluating novel cytotoxic agents including nanoparticles has also been encouraging. While much research still needs to be done, these strategies offer new hope for patients with pancreatic cancer.

Aims: To identify fistula treatment barriers and increase treatment access in Kalungu, Uganda.Methods: Responding to treatment barriers identified through formative research, the USAID-funded Fistula Care Plus (FC+) Project is implementing a comprehensive intervention to address fistula treatment barriers. The intervention utilizes multiple communication channels (free fistula screening hotline, health workers, and community agents), a consistent screening algorithm for fistula screening, and a transportation voucher to enable positively-screened women to travel to and from the fistula treatment facility.Results: FC+ trained and oriented 42 health workers and 275 community agents across Kalungu District to raise awareness and identify suspected fistula cases; trainees were provided with fistula hotline advertisements and data collection and referral tools. Thirty drivers were also trained and oriented on the transportation voucher system. From July 2017 to July 2018, the hotline received 120 callers from Kalungu; 88 screened positively. 37 women from Kalungu used the voucher system for free transport. In all, 51 women from Kalungu were referred to the fistula facility through the intervention’s referral channels. Facility records indicate that the number of women seeking fistula treatment from Kalungu District increased during the intervention period compared to the prior year. Conclusions: Applying client-centered communication, screening, referral, and transportation mechanisms enabled FC+ to address treatment barriers in Uganda. This approach may be replicated in other settings where the backlog of unidentified/untreated fistula cases persists. Keywords: approach, barrier, fistula, treatment

OBJECTIVE(S): To examine patient- and provider-level factors associated with receiving attention-deficit/hyperactivity disorder (ADHD) medication treatment in community care setting. We hypothesized that the likelihood of ADHD medication receipt would be lower in groups with specific patient sociodemographic (eg, female sex, non-white race) and clinical (e.g., comorbid conditions) characteristics as well as physician characteristics (e.g., older age, more years since completing training). STUDY DESIGN: A retrospective cohort study was conducted with 577 children (mean age=7.8 years, 70% male) presenting for ADHD to 50 community-based practices. The bivariate relationship between each patient- and physician-level predictor and whether the child was prescribed ADHD medication was assessed. A multivariable model predicting ADHD medication prescription was conducted using predictors with significant (P < .05) bivariate associations. RESULTS: 69% of children were prescribed ADHD medication in the year following initial presentation for ADHD-related concerns. Eleven of 31 predictors demonstrated a significant (p

Most individuals with eating disorders do not receive treatment for their eating disorder. Closing this "treatment gap" requires a quantitative examination of individuals' attitudes towards accessing various types of treatment and of individuals' perceived barriers to seeking treatment. Thus, we recruited a sample of 425 individuals with either diagnosed or undiagnosed eating disorders and asked them to complete a survey assessing treatment attitudes, treatment barriers, and eating disorder symptom severity. Undiagnosed individuals reported more positive attitudes towards novel Internet- and smartphone-delivered treatments, and stronger barriers relating to eating disorders mental health literacy, than diagnosed individuals. Nevertheless, both diagnosed and undiagnosed individuals were broadly more positive towards established (i.e., non-novel) treatments than novel treatments. The strongest barriers to seeking treatment were fear of losing control, fear of change, and finding motivation to change. Eating disorder symptoms were positively associated with the strength of most treatment barriers. Results were broadly unchanged after adjusting for individuals' past experiences of treatment. In conclusion, the development and dissemination of novel treatments and the provision of eating disorders mental health literacy may offer promising potential pathways into treatment for individuals with undiagnosed eating disorders. Nevertheless, researchers must pay attention to and improve, individuals' attitudes towards accessing these novel treatments. The positive correlations of symptom severity with treatment barrier strength highlights the importance of early intervention for individuals with eating disorders. Finally, the fear of losing control may be a uniquely salient treatment barrier for individuals with eating disorders that requires greater attention in future research on eating disorder treatment seeking.

BACKGROUND: HCV-related liver disease in people who inject drugs (PWIDs) carries a heavy personal, healthcare and societal burden. Current HCV treatment uptake in PWIDs is low and related to barriers at the individual, provider and healthcare system levels. AIMS: Collect data related to demographic, medical and behavioral variables in HCV-infected PWIDs already engaged in care in Canada to help define treatment barriers. METHODS: This multicenter observational study used retrospective chart review to collect data on patients receiving care from 12 Canadian centers. Patients with chronic HCV infection (HCV RNA+) and a history of injection drug use (in the previous 12 months) were included; HIV co-infection was excluded. Data were collected from October 2015 to February 2016. RESULTS: Of 423 participants: 74% were male, 65% Caucasian, 12% Aboriginal, with a median age of 42 years. All clinical sites provided multidisciplinary care and 11/12 had harm reduction programs. 33% of patients injected daily and 20% recently shared needles. Most frequent HCV genotypes were 1a (47%) and 3 (29%). When the fibrosis score was known (65% cases), 55% had F0-F1 and 14% had F4. The majority of patients were not yet being treated for HCV (83%). Of the 71 patients who received treatment, 37% (26/71) received IFN-free regimens. In the multivariate analysis, increasing age (OR = 1.10, 95% CI [1.03, 1.08]), not using a needle exchange program (OR = 6.95, 95% CI [1.73, 27.97]), moderate alcohol consumption (males ≤ 15 or females ≤ 10 drinks per week) vs. other (OR = 3.70, 95% CI [2.05,6.69]) and a recent fibrosis assessment with F4 vs. F0-F3 (OR = 4.91, 95% CI [2.18,11.09]) were associated with a higher likelihood of receiving treatment. CONCLUSIONS: A large number of HCV-infected PWIDs are engaged in care in Canada. Treatment rates are still low and patients are being prioritized for treatment. Barriers to treatment identified in this analysis will help to design targeted interventions for this group. FUNDING AGENCIES: Merck Canada Inc.

Children with Tourette’s Disorder (TD) and other forms of tic disorders display a range of academic and psychosocial impairments that place them at risk for experiencing long-term negative life outcomes. Fortunately, effective treatments and interventions such as habit reversal training (HRT) have been developed and implemented in clinical settings to help these children. However, relatively few youth with tics and related sequelae receive effective treatments for their symptoms, often because of various treatment barriers (e.g., travel difficulties, limitations in trained practitioners). To overcome some of these barriers, educators and school-based mental health practitioners can provide a range of academic, social-emotional, and mental health supports to address the needs of youth with tics in school settings. In support of this notion, this article discusses various ways that members of school communities can help support the academic and social-emotional success of students with tics and related impairments.

Delayed treatment seeking for people experiencing symptoms of mental illness is common despite available mental healthcare. Poor outcomes are associated with untreated mental illness and caregivers may eventually need to seek help on the service user's behalf. More attention has recently focused on the role of stigma in delayed treatment seeking. This study aimed to establish the frequency of stigma- and non-stigma-related treatment barriers reported by 202 service users and 80 caregivers; to compare treatment barriers reported by service users and caregivers; and to investigate demographic predictors of reporting stigma-related treatment barriers. The profile of treatment barriers differed between service users and caregivers. Service users were more likely to report stigma-related treatment barriers than caregivers across all stigma-related items. Service users who were female, had a diagnosis of schizophrenia or with GCSEs (UK qualifications usually obtained at age 16) were significantly more likely to report stigma-related treatment barriers. Caregivers who were female or of Black ethnicities were significantly more likely to report stigma-related treatment barriers. Multifaceted approaches are needed to reduce barriers to treatment seeking for both service users and caregivers, with anti-stigma interventions being of particular importance for the former group.