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Evidence for analgesic effects of parent-led pain management strategies during painful procedures in newborn infants exists; however, such strategies are inconsistently used in practice. A publicly available parent-targeted video demonstrates breastfeeding, skin-to-skin care, and sucrose during painful procedures. Australian parents' use and knowledge of this video and these strategies was unknown.To determine parents' use of pain management strategies, and perceived acceptability and usefulness of the parent-targeted video.A cross-sectional, online, anonymous survey with embedded video. Participants were recruited via social media channels of the Miracle Babies Foundation, an Australian parent support network. Target participants were parents or family members of infants currently or previously hospitalized in neonatal special and/or intensive care nurseries, or high dependency units.A total of 162 of 189 respondents provided sufficient data for analysis; all identified as mothers. Only 6 (4%) had previously seen the video; however, nearly all rated it as potentially useful and helpful (n = 124, 82%). Although most reported that sucrose had been used (n = 112, 84%), fewer reported having used skin-to-skin care (n = 50, 37%), or breastfeeding (n = 33, 25%). Most intended to advocate for skin-to-skin care (n = 108, 88%) or breastfeeding (n = 100, 81%) in future procedures. Perceived barriers to utilizing strategies included lack of information-sharing and organizational practices that excluded parent involvement.The video may be valuable in supporting mothers to advocate for their involvement during painful procedures in preterm and sick hospitalized infants. Further research is recommended to explore coordinated strategies targeting parents and healthcare professionals to overcome barriers to implementing parent-led infant pain management strategies.

Premature and sick neonates may require weeks of hospitalization in a noisy neonatal intensive care unit (NICU) environment with sound levels that may reach 120 decibels. The American Academy of Pediatrics recommends a maximum sound level of 45 decibels.To measure sound levels in a level III NICU and to describe contributing environmental factors.Descriptive quantitative study. Sound levels were measured using a portable sound meter in an open-bay level III NICU. Contributing environmental factors were recorded and analyzed.Mean sound levels for day, evening, and night shifts were 83.5, 83, and 80.9 decibels, respectively. Each period of time exceeded the recommended guidelines 90% of the time and was almost double the American Academy of Pediatrics' recommendation. Multiple linear regression findings demonstrated significant factors associated with elevated sound levels including number of neonates, number of people, number of alarms, acuity level, and shift type. Observational data explain 14.5% of elevated sound levels.An understanding of baseline sound levels and contributing environmental factors is the first step in developing strategies to mitigate excessive noise in the NICU.Research should focus on effective and sustainable ways to reduce sound levels in the NICU, including inside the isolette, in order to provide an environment that is conducive to optimal growth and neurodevelopment for preterm and sick infants.

Newborn screening is necessary for early detection of rare diseases, however, venipuncture and heel lance are painful for newborn infants. There are however effective evidence-based pain management strategies include breastfeeding or skin-to-skin care or giving a small volume of sweet solution. These strategies are demonstrated in a parent-targeted publicly accessible video titled Be Sweet to Babies, which has been produced and disseminated in multiple languages, including Farsi. We aimed to evaluate (1) the dissemination and reach of the Farsi video (using video analytics); and (2) viewers’ i) baseline knowledge and previous use of these pain management strategies; ii) intention to advocate for/recommend these strategies (using an online survey accessed from the video). Eight months after the release date, the video had 618,685 views and 202 viewers completed the survey. Almost half the participants knew about or used breastfeeding (n = 81, 40%), skin-to-skin care (n = 106, 53%) or sucrose (82, 41%) before viewing the video. After viewing the video, almost all participants (n = 195, 96%) intended to advocate for use or recommend these strategies to others. This study showed the acceptability, reach, and feasibility of the “Be Sweet to Babies” video, translated and voiced over in Farsi, as a parent-targeted and mediated knowledge translation tool.

Purpose Family-centred care (FCC) in the Neonatal Intensive Care Unit (NICU) is an aspect of high-quality neonatal nursing. The aim of this manuscript is to clarify the meaning of FCC in the NICU to inform future research. Methods Rodger's evolutionary concept analysis. Three databases were searched, each representing a different discipline: CINAHL, Medline, and PsycINFo. Results A total of 188 full-text papers were included. The concept of FCC in the NICU was defined according to its surrogate and related terms, antecedents, attributes, and consequences. Discussion Although interdisciplinary in nature, academic literature about FCC in the NICU is dominated by a biomedical perspective. Important conceptual departures, namely developmental care and family-integrated care are discussed. Conclusion Considering FCC as a model of care may be too reductionist; it should be regarded as a philosophy. Further work should explore the delivery of FCC for increasingly specialized NICU populations, such as perioperative infants.

Introduction Nurses' use of evidence-based pain treatments for newborns during needle-related procedures in China was unknown. This study aimed to ascertain knowledge and use of pain management strategies and usefulness of a publicly accessible 'BSweet2Babies' video, produced in Mandarin, demonstrating the use of breastfeeding, skin-to-skin care (SSC), and sweet solutions during painful procedures. Methods An online survey was conducted during six nursing conferences in China ascertaining nurses' previous viewing of the video and knowledge and use of the demonstrated strategies. Results 221 nurses participated. Only 25 (11.3%) had previously seen the video. Over half knew that breastfeeding (n = 138, 62.4%) and SSC (n = 173, 78.3%) reduced pain, and 89 (40.3%) knew that sucrose reduced pain, but these strategies were infrequently used. Most intended to use the strategies in the future. Discussion A knowledge-to-action gap for newborn pain management was identified. Future research is needed to improve the implementation of effective pain treatment for newborns.

Background The World Trade Center (WTC) general responder cohort (GRC) was exposed to environmental toxins possibly associated with increased risk of developing autoimmune conditions. Objectives Two study designs were used to assess incidence and risks of autoimmune conditions in the GRC. Methods Three clinically trained professionals established the status of possible GRC cases of autoimmune disorders adhering to diagnostic criteria, supplemented, as needed, by specialists' review of consenting responders' medical records. Nested case-control analyses using conditional logistic regression estimated the risk associated with high WTC exposure (being in the 9/11/2001 dust cloud or ≥median days' response worked) compared with low WTC exposure (all other GRC members'). Four controls were matched to each case on age at case diagnosis (±2 years), sex, race/ethnicity, and year of program enrollment. Sex-specific and sensitivity analyses were performed. GRC age- and sex-adjusted standardized incidence ratios (SIRs) were compared with the Rochester Epidemiology Project (REP). Complete REP inpatient and outpatient medical records were reviewed by specialists. Conditions meeting standardized criteria on ≥2 visits were classified as REP confirmed cases. Results Six hundred and twenty-eight responders were diagnosed with autoimmune conditions between 2002 and 2017. In the nested case-control analyses, high WTC exposure was not associated with autoimmune domains and conditions (rheumatologic domain odds ratio [OR] = 1.03, 95% confidence interval [CI] = 0.77, 1.37; rheumatoid arthritis OR = 1.12, 95% CI = 0.70, 1.77). GRC members had lower SIR than REP. Women's risks were generally greater than men's. Conclusions The study found no statistically significant increased risk of autoimmune conditions with WTC exposures.

To assess and improve pain management practices for hospitalized children in an urban tertiary pediatric teaching hospital. Methods Health Quality Ontario Quality Improvement (QI) framework informed this study. A pre (T1) – post (T2) intervention assessment included chart reviews and children/caregiver surveys to ascertain pain management practices. Information on self-reported pain intensity, painful procedures, pain treatment and satisfaction were obtained from children/caregivers. Documented pain assessment, pain scores, and pharmacological/non-pharmacological pain treatments were collected by chart review. T1 data was fed back to pediatric units to inform their decisions and pain management targets. Results At T1, 51 (58% of eligible participants) children/caregivers participated. At T2, 86 (97%) chart reviews and 51 (54%) children/caregivers surveys were completed. Most children/caregivers at T1 (78%) and T2 (80%) reported moderate to severe pain during their hospitalization. A mean of 2.6 painful procedures were documented in the previous 24 h, with the most common being needle-related procedures at both T1 and T2. Pain management strategies were infrequently used during needle-related procedures at both time points. Conclusion No improvements in pain management as measured by the T1 and T2 data occurred. Findings informed further pain management initiatives in the participating hospital.

Author(s): Hu, Jiale; Gifford, Wendy; Ruan, Hong; Harrison, Denise; Li, Qingge; Ehrhart, Mark G; Harrison, Mary-Ann; Barrowman, Nick; Aarons, Gregory A | Abstract: AimThis study aimed to evaluate the validity, reliability and acceptability of the Implementation Leadership Scale in the Chinese nursing context.DesignThis study utilized a cross-sectional design.MethodsThis study was conducted in one general tertiary hospital with 234 nurses (85.3% response rate) from 35 clinical units in China. Content validity, structural validity, convergent validity, reliability (internal consistency), agreement indices and acceptability were evaluated. The data collection was from December 1st, 2017 to June 30th, 2018.ResultsConfirmatory factor analysis demonstrated a good model fit to the four-factor implementation leadership model. The psychometric testing also indicated good convergent validity, high internal consistency and acceptable aggregation. Most participants completed the scale in two minutes or less and agreed or strongly agreed that the questions were relevant to implementation leadership, clear and easy to answer.ConclusionsThis study demonstrated that the Chinese Implementation Leadership Scale is a valid, reliable and pragmatic tool for measuring strategic leadership for implementing evidence-based practices.

Twelve years ago, the paper ‘Oral sucrose for pain management in infants: Myths and misconceptions’ was published in the Journal of Neonatal Nursing. At this time, eight myths or misconceptions were addressed. Since this time there has been more than 100 studies published reporting on analgesic effects of sweet solutions in newborns, which have been synthesised and included in systematic reviews. There has also been a growth of literature to support analgesic effects of breastfeeding and skin-to-skin care as well as concerning evidence of adverse long-term neurobehavioural outcomes associated with painful procedures. Yet, ongoing studies of pain management practices continue to report inconsistent use of these strategies during painful procedures. We are therefore at a cross-roads of evidence – there is knowledge of effective treatments, knowledge of harm of untreated pain, yet sick, premature as well as healthy infants are continuing to be exposed to painful procedures with no effective treatment. There are however ongoing myths, misconceptions, and practical barriers to using the evidence as well as ongoing knowledge gaps. This paper will therefore highlight existing myths, misconceptions, barriers and current knowledge gaps to using the three key evidence-based pain management strategies of breastfeeding, skin-to-skin care and sweet solutions, in the hope that this will bring to light newborn infant pain treatment practices that can be improved.

Background Hospitalized children continue to experience procedural pain due to inconsistent implementation of readily available, evidence-based pain interventions. Aims To explore the prevalence of painful blood-testing procedures, pain management interventions, child-caregiver perceptions of effectiveness of, and satisfaction with, pain interventions, and adherence to best practice guidelines. Design A single-site cross-sectional study using a combination of child-caregiver interviews and chart reviews for hospitalized children, 0-18 years. Methods Interviews gathered information about the child's most recent blood test, procedural pain management intervention use, and participant perceptions of effectiveness of and satisfaction with these interventions. Concurrently, patient charts were reviewed for procedure documentation and pain management strategies used, including topical anesthetic and oral sucrose orders. Data were analyzed using descriptive statistics. Results Fifty children were included. At the time of data collection, 34 (68%) had experienced painful blood-testing procedures during their current admission. Pharmacologic pain interventions were documented for only 7 (21%) procedures and were often inconsistent with participant reports. Almost all interview respondents (n = 31, 91%) identified at least one pain intervention for the child's most recent painful blood-test. Twenty (59%) participants perceived pain interventions as effective and most were satisfied with utilized interventions (n = 27, 79%). Conclusions A multi-modal procedural pain management approach was infrequently used and documented, highlighting undertreatment based on recommended practices and guidelines. Perceived intervention effectiveness and satisfaction with pain management were however found to be relatively high.

BACKGROUND: Assessing pain in mechanically ventilated infants is challenging. The assessment of skin conductance (SC) is based on the sympathetic nervous system response to stress. This study purpose was to evaluate the validity of SC for assessing pain in mechanically ventilated infants. METHODS: A prospective cross-sectional observational design was used to study SC and its relation to: the category of procedure (i.e., painful or non-painful); the phase of procedure (i.e., before, during and after), and referent pain measurements (i.e., Premature Infant Pain Profile-Revised (PIPP-R) and Neonatal Facial Coding System (NFCS)). Eligible infants were those up to 12 months of age, in intensive care units, who were mechanically ventilated, and required painful and non-painful procedures. RESULTS: From October 2017 to November 2018, 130 eligible infants were identified, and 55 infants were studied. SC (number of waves per second) during painful procedures (median 0.27, interquartile range 0.2-0.4) was statistically significantly higher than those during non-painful procedures (0, 0-0.09). SC during painful procedures was statistically significantly higher than those before (0, 0-0.07) and after painful procedures (0, 0-0.07). SC showed moderate statistically significant positive correlations with PIPP-R (Spearman's rho = 0.4-0.62) and the four-item NFCS (Spearman's rho = 0.31-0.67) before, during and after painful or non-painful procedures respectively. SC had excellent performance (area under the receiver operator curve = 0.979) with excellent sensitivity (92.31%), specificity (95.42%) and negative predictive value (99.21%) but only sufficient positive predictive value (66.67%) when used to discriminate moderate-to-severe pain. CONCLUSIONS: SC showed good validity for assessing pain in critically ill infants requiring mechanical ventilation. SIGNIFICANCE OF THE STUDY: Pain assessment in mechanically ventilated infants is challenging. In this study, the validity of skin conductance (SC) for pain assessment is evaluated in the same population of infants during painful and nonpainful procedures. SC showed good validity for assessing acute pain in relation to category of procedure, phase of procedure, and referent pain measurements. SC is a promising method, especially with other pain assessment methods and other determinants of pain, in a multimodal pain assessment approach to understand the complexity of pain in mechanically ventilated infants.

High-fidelity simulation is used widely in the education of healthcare professionals; however, its effectiveness in teaching undergraduate nursing students clinical reasoning skills is not known. The objective of this systematic review is to synthesise findings from current literature about the effectiveness of high-fidelity simulation on the development of clinical reasoning-related skills in undergraduate nurses.A systematic review of the effectiveness of high-fidelity simulation was conducted, guided by the Joanna Briggs Institute methodology. Studies included were experimental and quasi-experimental study designs published in English between 2014 and 2020 that investigated clinical reasoning-related skills for undergraduate nursing students. Databases searched included Medline, CINAHL, Embase and the Joanna Briggs Institute of Evidence-based Practice database.A total of 1980 studies were identified and 15 studies met the inclusion criteria. Seven studies were randomised controlled trials, and eight studies were quasi-experimental. The 15 included studies reported 19 outcomes, as studies examined one or more outcomes of clinical reasoning-related skills. Statistically significant results favouring the simulation groups were reported in the following outcomes: clinical reasoning skills (three studies of three studies), critical thinking skills (four out of eight studies), problem-solving (two of four studies), decision-making skills (one of two studies), and clinical judgment skills (two of two studies).High-fidelity simulation was reported to be effective alone and in combination with traditional teaching or other simulation types in improving undergraduate nursing students' clinical reasoning-related skills acquisition. Limitations included cost and availability of high-fidelity simulation to large numbers of students, which have implications for practice. Further research is needed to determine the actual effect of high-fidelity simulation compared to other simulation types on undergraduate nursing students' clinical reasoning-related skills.

Dianne Crellin,1– 3 Denise Harrison,1,2,4 Nick Santamaria,1 Franz E Babl2,3,5 1Department of Nursing, The University of Melbourne, Melbourne, VIC, Australia; 2Murdoch Children’s Research Institute, Melbourne, VIC, Australia; 3Royal Children’s Hospital, Melbourne, VIC, Australia; 4Children’s Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada; 5Department of Paediatrics, The University of Melbourne, Melbourne, VIC, AustraliaCorrespondence: Dianne Crellinc/o Emergency Department, Royal Children’s Hospital, Flemington Road Parkville, Melbourne, VIC, 3052, AustraliaTel +61 39345 5331Fax +61 9345 5983Email dianne.crellin@rch.org.auPurpose: The purpose of this study was to compare the psychometric data and feasibility and clinical utility of the Face Legs, Activity, Cry and Consolability scale (FLACC), the Modified Behavioral Pain Scale (MBPS) and the Visual Analogue Scale for observers (VASobs) used to assess procedural pain in infants and young children.Patients and Methods: Twenty-six clinicians assessed videorecorded segments of 100 infants and young children who underwent a painful and/or distressing procedure in the emergency department using the FLACC scale, the MBPS and the VASobs pain and VASobs distress.Results: VASobs pain scores were lowest across all procedures and phases of procedures (p < 0.001). Inter-rater reliability was lowest for VASobs pain scores (ICC 0.55). Sensitivity and specificity were highest for FLACC scores (94.9% and 72.5%, respectively) at the lowest cut-off score (pain score two). Observers changed their MBPS scores more often than they changed FLACC or VASobs scores, but FLACC scores were more often incomplete. Reviewers did not consider any scale of use for procedural pain measurement.Conclusion: The reliability and sensitivity of the FLACC and MBPS were supported by study data but concerns about the capacity of these scales to distinguish between pain- and non-pain-related distress were raised. The VASobs cannot be recommended. Despite its limitations, the FLACC scale may be better suited than other scales for procedural pain measurement.Keywords: pain measurement, infants, validity, reliability

Background Practices to support the transition of a young person from the pediatric to the adult health care setting have been examined for many chronic illness populations. However, specific transition practices to support young people with chronic pain have not been examined. Aim The aim of this study was to describe the current nursing practices used in the pediatric and the adult health care to support transition of young people with chronic pain in Canada. Methods An online survey of pediatric and adult chronic pain nurses’ self-reported transition practices was conducted. Results Twenty-two nurses completed the survey, 10 (45.5%) from the pediatric chronic pain setting and 12 (54.4%) from the adult chronic pain setting. Of the pediatric nurses surveyed none reported using a psychometrically valid tool to assess a young person’s readiness of general transition skills; however, one reported using a tool to assess understanding of chronic pain. Most health care facilities in which these pediatric nurses worked offered a general transition clinic, but only one of these facilities also had a chronic pain transition clinic. Nurses in both settings perceived that young people experience increased levels of distress during transition yet most did not report using formal transition practices in their care. Conclusion Nursing practices and clinic resources to support the transition of young people with chronic pain may not meet the needs of this population. Practices may benefit from the use of psychometrically validated tools to assess general transition preparedness. Research is needed to adapt tools and determine best transition practices for the chronic pain population.

Increased patient advocacy has resulted in a shift toward more active patient engagement in the research. A scoping review was conducted to explore the literature on healthcare research priority settings wherein children, youths, or their families were involved in the priority-setting process. Six databases including MEDLINE, CINAHL, PsycINFO, Embase, Web of Science, and Global Health and the James Lind Alliance website were searched up until September 2019. All primary studies involving children (

Stakeholders are coming together to develop a vision for increasing access to family planning (FP) by 2030. Of the 923 million women in the developing world who wish to avoid a pregnancy, 218 million women are not using a modern contraceptive (Guttmacher Institute, 2020). In 2016, over 3.4 billion people were using the internet (https://ourworldindata.org/internet 2016). Moreover, internet users in the developing world use social media more frequently than Internet users in the U.S. and Europe. Of the many proposed actions to accelerate progress in family planning, the use of Twitter should be a key component. In this commentary, we describe the use of Twitter in a select group of low-and-middle-income countries that have made commitments to the family planning 2020 initiative (FP2020 countries, and have the potential to leverage Twitter with current and potential family planning users. We examine Twitter feeds in eight key FP2020 countries, and we look at the content of Tweets issued by the ministries of health in most of these same countries. Our view is that it is feasible and easy to access Twitter feeds in low and middle income countries. We base our view on the types of reproductive health and family planning terms discussed in a public forum such as Twitter by current and potential users and their partners and ministries of health. We highlight two broad considerations that merit discussion among interested stakeholders, including policy makers, program designers, and health advocates. The first relates to the use of Twitter within family planning programs, and the second relates to themes that require more significant research. Data coupled with analytical capacity will help policy makers and program designers to effectively leverage Twitter for expanding the reach of family planning services and influencing social media policy. Our aim is to not only to contribute to the body of knowledge but also to spur greater engagement by program personnel, researchers, health advocates and contraceptive users.

Stakeholders are coming together to develop a vision for increasing access to family planning (FP) by 2030. Of the 923 million women in the developing world who wish to avoid a pregnancy, 218 million women are not using a modern contraceptive (Guttmacher Institute, 2020). In 2016, over 3.4 billion people were using the internet (https://ourworldindata.org/internet 2016). Moreover, internet users in the developing world use social media more frequently than Internet users in the U.S. and Europe. Of the many proposed actions to accelerate progress in family planning, the use of Twitter should be a key component. In this commentary, we describe the use of Twitter in a select group of low-and-middle-income countries that have made commitments to the family planning 2020 initiative (FP2020 countries and have the potential to leverage Twitter with current and potential family planning users. We examine Twitter feeds in eight key FP2020 countries, and we look at the content of Tweets issued by the ministries of health in most of these same countries. Our view is that it is feasible and easy to access Twitter feeds in low-and -middle income countries. We base our view on the types of reproductive health and family planning terms discussed in a public forum such as Twitter by current and potential users and their partners and ministries of health. We highlight two broad considerations that merit discussion among interested stakeholders, including policy makers, program designers, and health advocates. The first relates to the use of Twitter within family planning programs, and the second relates to themes that require more significant research. Data coupled with analytical capacity will help policy makers and program designers to effectively leverage Twitter for expanding the reach of family planning services and influencing social media policy. Our aim is to not only to contribute to the body of knowledge but also to spur greater engagement by program personnel, researchers, health advocates and contraceptive users.

Abundant published evidence demonstrates the pain-reducing effects of sweet solutions in human infants and animals. Analgesic effects persist up to around 1 year of age in human infants, though there is less research to support analgesic effects in older infants and, for the existing research, effects are more moderate than seen in the neonatal period. Though the exact mechanisms are unclear, analgesic effects are believed to be due to the relationship between sweet taste and the endogenous opiate system. Based on the extensive evidence to support sweet solutions, their use can be recommended prior to commonly performed short-lasting minor painful procedures in newborn and young infants. Despite extensive research, knowledge gaps and controversies remain relating to the mechanisms of analgesia; the effectiveness and safety of sweet solutions when given over prolonged periods to preterm and sick infants; the effectiveness in sick infants receiving concomitant analgesics; and the effectiveness in children older than 12 months of age.

Objective To map research based pain management interventions used in the paediatric intensive care unit. Methodology A scoping review of research literature has been conducted. Five databases were searched from their inception to end 2015 (CINAHL, EMBASE, MEDLINE, PsychINFO, and ProQuest Dissertations & Theses Global). Reference lists from the screened full text articles were reviewed. Results 7046 articles were identified, 100 underwent full text screening and 27 were included in the scoping review. Seventeen (63%) were non-experimental, and 10 (37%) were experimental, of which 8 (30%) were randomised controlled trials. The majority of the articles focused on pharmacological interventions (n = 21, 78%), one on physical, and one on psychological interventions. Four studies included more than one category of interventions. The majority of the studies focused on post-operative pain management (n = 18, 67%), three (11%) on analgesia and sedation management and six (22%) on other pain management for different conditions. Discussion Most studies included in this scoping review focused on medications and post-operative pain management and most were non clinical trials. More research, including clinical trials, is warranted to determine the effectiveness of pharmacological and non-pharmacological interventions for pain management in the paediatric intensive care unit.

ObjectivesHead and neck cancers (HNCs) may be among the health consequences of involvement in the World Trade Center (WTC) response on and after 11 September 2001. We conducted a nested case–control study of WTC Health Program (WTCHP) general responders to examine the effects of WTC exposures and behavioural risk factors on HNC.MethodsWe enrolled 64 cases and 136 controls, matched on age, sex and race/ethnicity within risk sets. We assessed tobacco and alcohol use, sexual activity, and occupational exposures prior to, during and after WTC exposure until case diagnosis via questionnaire. We obtained WTC exposure information (duration (first to last day), total days and location of work) from the WTCHP General Responder Data Center. We assessed associations with HNC, and interaction among exposures, using conditional logistic regression.ResultsResponders in protective services versus other occupations had increased odds (OR: 2.51, 95% CI 1.09 to 5.82) of HNC. Among those in non-protective services occupations, arriving to the WTC effort on versus after 11 September 2001 was significantly associated with HNC (OR: 3.77, 95% CI 1.00 to 14.11). Duration of work was not significantly associated with HNC. Lifetime and post-WTC years of cigarette smoking and post-WTC number of sex partners were positively and significantly associated with HNC, while alcohol consumption was not.ConclusionsThese findings suggest opportunities for HNC risk factor mitigation (eg, smoking cessation, human papillomavirus vaccination) and contribute to a risk factor profile which may assist WTCHP clinicians with identifying high-risk responders and improve detection and treatment outcomes in this population.