Prediction model for major bleeding in anticoagulated patients with cancer-associated venous thromboembolism using machine learning and natural language processing.

PURPOSE: We developed a predictive model to assess the risk of major bleeding (MB) within 6 months of primary venous thromboembolism (VTE) in cancer patients receiving anticoagulant treatment. We also sought to describe the prevalence and incidence of VTE in cancer patients, and to describe clinical characteristics at baseline and bleeding events during follow-up in patients receiving anticoagulants. METHODS: This observational, retrospective, and multicenter study used natural language processing and machine learning (ML), to analyze unstructured clinical data from electronic health records from nine Spanish hospitals between 2014 and 2018. All adult cancer patients with VTE receiving anticoagulants were included. Both clinically- and ML-driven feature selection was performed to identify MB predictors. Logistic regression (LR), decision tree (DT), and random forest (RF) algorithms were used to train predictive models, which were validated in a hold-out dataset and compared to the previously developed CAT-BLEED score. RESULTS: Of the 2,893,108 cancer patients screened, in-hospital VTE prevalence was 5.8% and the annual incidence ranged from 2.7 to 3.9%. We identified 21,227 patients with active cancer and VTE receiving anticoagulants (53.9% men, median age of 70 years). MB events after VTE diagnosis occurred in 10.9% of patients within the first six months. MB predictors included: hemoglobin, metastasis, age, platelets, leukocytes, and serum creatinine. The LR, DT, and RF models had AUC-ROC (95% confidence interval) values of 0.60 (0.55, 0.65), 0.60 (0.55, 0.65), and 0.61 (0.56, 0.66), respectively. These models outperformed the CAT-BLEED score with values of 0.53 (0.48, 0.59). CONCLUSIONS: Our study shows encouraging results in identifying anticoagulated patients with cancer-associated VTE who are at high risk of MB.

Thrombosis in breast cancer patients on cyclin-dependent kinase inhibitors: Survival impact and predictive factors - A study by the cancer and thrombosis group of the spanish society of medical oncology (SEOM).

Thrombosis may be included in the profile of side effects associated with CDK4/6 inhibitors. Its significance might be greater than reported in randomized clinical trials. To investigate this, a retrospective, multicenter study was conducted. The primary objective was to calculate the incidence of thrombosis associated with CDK4/6 inhibitors. Secondary objectives included examining the impact of thrombosis on survival and identifying predictor variables for the development of venous thromboembolism (VTE) or arterial thrombosis (AT). A total of 986 patients were recruited. The incidence of VTE/AT associated with CDK4/6 inhibitor treatment during the follow-up period was 5.48 %. Survival analysis did not indicate that the development of VTE/AT during CDK4/6 inhibitor treatment significantly impacted patient survival (p = 0.133). In our analysis, two variables were found to be statistically significant (p < 0.05) as predictors of VTE/AT in breast cancer patients receiving CDK4/6 inhibitor therapy. These variables were the presence of central nervous system (CNS) metastasis with an odds ratio (OR) of 3.68 (95 % CI 1.18 - 11.49) and the use of abemaciclib with an OR of 2.3 (95 % CI 1.16 - 4.57).

Dynamic changes of hematological and hemostatic parameters in COVID-19 hospitalized patients: Potential role as severity biomarkers for the Chilean population.

Background: COVID-19 is still a global health issue, there is limited evidence in South America regarding laboratory biomarkers associated with severe disease. The objective of our study was to identify hematological and hemostatic changes associated with severe COVID-19. Methods: A total of 170 hospitalized patients with COVID19 were included in the study, defining their severity according to established criteria. Demographic, clinical, and laboratory (days 1, 3, 7, 15) data were obtained. We performed a statistical analysis, assuming significance with a value of p < 0.05. We analyzed the correlation between severity and biomarkers and established cut-off values for severe patients through ROC curves, estimating Odds Ratio associated with severe disease. Results: Day 1 was observed significant differences between moderate vs severe patients for leukocytes (WBC), Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and D-dimer, establishing cut-off points for each of them. The markers we found associated to risk of severe disease were WBC (OR=3.2396; p = 0.0003), NLR (OR=5.7084; p < 0.0001), PLR (OR=4.4094; p < 0.0001), Neutrophil (OR=4.1193; p < 0.0001), D-dimer (OR=2.7827; p = 0.0124). Conclusions: The results allow to establish basic laboratory biomarkers associated to severe disease, which could be used as prognostic markers.

Impact of COVID-19 in the incidence of venous thromboembolism (VTE) and clinical outcomes in cancer patients: a cohort study.

PURPOSE: To determine the incidence of VTE and clinical outcomes in a cohort of cancer patients and COVID-19 infection, and to establish possible predictive factors of VTE. METHODS/PATIENTS: A single-center retrospective cohort study was performed to determine the incidence of VTE and mortality in 118 cancer patients with SARS-CoV-2 infection from March to August 2020. We calculated individual Khorana Risk and CATS-MICA scores in order to evaluate their utility to identify risk of VTE or death. Continuous variables were compared using Wilcoxon or Student's T test, and categorical variables were compared using the Chi-Square or Fisher's exact text among patients with and without VTE. A Log-Rank test was performed to detect mortality differences between the groups. RESULTS: A total of 118 patients were included. VTE global incidence was 4.2% (n = 5), and mortality 25.4% (n = 30). Obesity (p = 0.05), recent chemotherapy (p = 0.049) and use of steroids (p = 0.006) were related to higher risk of VTE in the univariate analysis, although they were not confirmed in the multivariate analysis as independent risk factors. Statistically significant differences in all-cause, COVID-19-related and cancer-related mortality according to the Khorana risk score (KRS) were observed. CATS-MICA score (CMS) also showed statistically significant differences in mortality between low- and high-risk patients. Prediction of risk of VTE development with these scores showed a tendency towards significance. CONCLUSIONS: In this cohort, VTE incidence was similar to previously reported in the general population with SARS-CoV-2 infection. KRS was associated with overall and specific-cause mortality, and might be a useful prognostic tool in this setting.

Chronic neuropathic pain components in whiplash-associated disorders correlate with metabolite concentrations in the anterior cingulate and dorsolateral prefrontal cortex: a consensus-driven MRS re-examination.

Introduction: Whiplash injury (WHI) is characterised by a forced neck flexion/extension, which frequently occurs after motor vehicle collisions. Previous studies characterising differences in brain metabolite concentrations and correlations with neuropathic pain (NP) components with chronic whiplash-associated disorders (WAD) have been demonstrated in affective pain-processing areas such as the anterior cingulate cortex (ACC). However, the detection of a difference in metabolite concentrations within these cortical areas with chronic WAD pain has been elusive. In this study, single-voxel magnetic resonance spectroscopy (MRS), following the latest MRSinMRS consensus group guidelines, was performed in the anterior cingulate cortex (ACC), left dorsolateral prefrontal cortex (DLPFC), and occipital cortex (OCC) to quantify differences in metabolite concentrations in individuals with chronic WAD with or without neuropathic pain (NP) components. Materials and methods: Healthy individuals (n = 29) and participants with chronic WAD (n = 29) were screened with the Douleur Neuropathique 4 Questionnaire (DN4) and divided into groups without (WAD-noNP, n = 15) or with NP components (WAD-NP, n = 14). Metabolites were quantified with LCModel following a single session in a 3 T MRI scanner within the ACC, DLPFC, and OCC. Results: Participants with WAD-NP presented moderate pain intensity and interference compared with the WAD-noNP group. Single-voxel MRS analysis demonstrated a higher glutamate concentration in the ACC and lower total choline (tCho) in the DLPFC in the WAD-NP versus WAD-noNP group, with no intergroup metabolite difference detected in the OCC. Best fit and stepwise multiple regression revealed that the normalised ACC glutamate/total creatine (tCr) (p = 0.01), DLPFC n-acetyl-aspartate (NAA)/tCr (p = 0.001), and DLPFC tCho/tCr levels (p = 0.02) predicted NP components in the WAD-NP group (ACC r 2 = 0.26, α = 0.81; DLPFC r 2 = 0.62, α = 0.98). The normalised Glu/tCr concentration was higher in the healthy than the WAD-noNP group within the ACC (p < 0.05), but not in the DLPFC or OCC. Neither sex nor age affected key normalised metabolite concentrations related to WAD-NP components when compared to the WAD-noNP group. Discussion: This study demonstrates that elevated glutamate concentrations within the ACC are related to chronic WAD-NP components, while higher NAA and lower tCho metabolite levels suggest a role for increased neuronal-glial signalling and cell membrane dysfunction in individuals with chronic WAD-NP components.

Inferior vena CAVA and lung ultraSound-guided therapy in acute heart failure: A randomized pilot study (CAVAL US-AHF study).

BACKGROUND: The optimal assessment of systemic and lung decongestion during acute heart failure is not clearly defined. We evaluated whether inferior vena cava (IVC) and pulmonary ultrasound (CAVAL US) guided therapy is superior to standard care in reducing subclinical congestion at discharge in patients with AHF. METHODS: CAVAL US-AHF was an investigator-initiated, single-center, single-blind, randomized controlled trial. A daily quantitative ultrasound protocol using the 8-zone method was used and treatment was adjusted according to an algorithm. The primary endpoint was the presence of more than 5 B-lines and/or an increase in IVC diameter and collapsibility at discharge. And secondary endpoint exploratory outcome was the composite of readmission for HF, unplanned visit for worsening HF or death at 90 days RESULTS: Sixty patients were randomized to CAVAL US (n = 30) or control (n = 30). The primary endpoint was achieved in 4 patients (13.3%) in the CAVAL US group and 20 patients (66.6%) in the control group (P < .001). A significant reduction in HF readmission, unplanned visit for worsening HF or death at 90 days was seen in the CAVAL US group (13.3% vs 36.7%; log rank P = .038). Other endpoints such as NT-proBNP reduction at discharge showed a nonstatistically significant reduction in the CAVAL US group (48% IQR 27-67 vs 37% -3-59; P = .09). Safety outcomes were similar in both groups. CONCLUSION: IVC and lung ultrasound-guided therapy in AHF patients significantly reduced subclinical congestion at discharge. CAVAL US-AHF provides preliminary evidence for the potential use of a simple technique to guide decongestive therapy during hospitalization for AHF, which may reduce the composite outcome at 90 days.

Protocol for fluorescent live-cell staining of tardigrades.

Tardigrades are microscopic organisms with exceptional resilience to environmental extremes. Most protocols to visualize the internal anatomy of tardigrades rely on fixation, hampering our understanding of dynamic changes to organelles and other subcellular components. Here, we provide protocols for staining live tardigrade adults and other postembryonic stages, facilitating real-time visualization of structures including lipid droplets, mitochondria, lysosomes, and DNA.

Leveraging technology to improve access to medical education in anatomy and physiology in resource-limited settings: A mixed methods study.

This study assesses the acceptability, appropriateness, feasibility, and efficacy of a novel asynchronous video-based intervention for teaching respiratory physiology and anatomy to medical students in resource-limited settings. A series of short video lectures on pleural anatomy, pulmonary physiology, and pathophysiology was created using Lightboard and screen capture technology. These were uploaded to YouTube and Google Drive and made available to 1st-3rd year medical students at two Latin American universities for 1 week. Employing a parallel-convergent mixed methods design, we conducted surveys, focus groups, interviews, and pre/post testing for qualitative and quantitative data. Thematic Analysis was used to analyze qualitative data and McNemar's test for quantitative analysis. Seventy-six students participated. The videos' short format, interactivity, and Lightboard style were highly valued for their flexibility, time efficiency, and educational impact. Students recognized their clinical relevance and trusted their content, suggesting potential applicability in similar settings. Despite infrastructure and connectivity challenges, the use of flexible streaming and downloadable options facilitated learning. Survey results indicated high levels of feasibility (99%), appropriateness (95%), and acceptability (95%), with significant knowledge gains observed (37% correct pre-test answers vs. 56% post-test, p < 0.0001). Our findings demonstrate high acceptability, appropriateness, feasibility, and efficacy of a targeted asynchronous education centered on short-format videos in resource-limited settings, enabling robust learning despite local barriers. Flexible access is key for overcoming localized barriers. Taking an adaptive, learner-centered approach to content creation and delivery to address constraints was pivotal to success. Our modular videos could serve as versatile models for flexible education in resource-constrained settings.

Epidemiology of traumatic spinal cord injury in Spain: A ten-year analysis of trend of clinical and demographic characteristics.

CONTEXT: The study of epidemiological changes of traumatic spinal cord injury (TSCI) is needed due to its highly variable incidence. OBJECTIVE: To determine the incidence of TSCI in Spain and to describe the trend of clinical and demographic characteristics according to age group during a 10-year period. METHODS: A prospective cohort study was conducted. A multidisciplinary team evaluated all individuals with new TSCI. The data were recorded according to the International Spinal Cord Injury Core Data Sets. RESULTS: In a 10-year period, 933 new patients with TSCI were admitted to the hospital. The annual incidence of TSCI was 6.2 per million. The leading causes of injury were traffic accidents (38.5%), low-level falls (20.6%), and high-level falls (19.1%). Males, age group of 31-45 years, and cervical level of injury were the most common profiles of TSCI. In patients over 60 years,71.5% were injured following a fall, particularly low-level falls (47.2%). In patients under 60 years old, the leading cause of SCI was traffic accidents (46%). The proportion of tetraplegia in patients above 60 years was 68.3%, compared to 43.7% in patients under 60 years of age. Patients in the age group above 60 years were hospitalized with a shorter duration of rehabilitation compared to younger age group. CONCLUSIONS: Compared with globally estimated data reported in previous studies, this research demonstrated a low incidence of TSCI in Spain, suggesting a decrease in the last years. Falls and traffic accidents were the most common causes of TSCI in elderly and youth, respectively. Prevention programs should focus on these issues.

[Surface roughness of two composite resins after immersion in soda drinks: in vitro study]. / Rugosidad superficial de dos resinas compuestas después de la inmersión en bebidas gaseosas: estudio in vitro.

Objective: Compare the surface roughness of two composite resins after immersion in carbonated beverages. Materials and methods: 160 resin discs (6 x 2 mm) were divided into 8 groups (n=20 per group) according to type of resin (Filtek™ Z350 XT® and Palfique LX5®) and type of immersion in beverages (distilled water, Coca Cola®, Inca Kola® and Kola Escocesa®. The immersions were carried out under a structured cycle: 4 immersions a day for 5 days, intermediate storage in distilled water and overnight incubation for 8 h at 37°C. The measurements with the roughness meter were evaluated in three times: baseline, 7 and 14 days. The three-way Anova test was used at P<0.05. Results: Roughness showed differences only for the individual factors of time (P<0.000) and resin (P=0.000), and for the interaction time*drink (P=0.000) and resin*drink (P=0.003). Roughness was higher with Filtek Z350 XT® immersed with Inca Kola® (0.85 ± 0.37) than 14 days compared to other times (P=0.035) and with Palfique LX5 immersed in Coca Cola® at 7 days (1.61 ± 0.42) and in Inca Kola® at 14 days (1.66 ± 0.56) compared to distilled water (P<0,05). Conclusion: Surface roughness was affected by the type of resin, the type of soft drink and the immersion time. The roughness was greater with the Palfique LX5® nanohybrid resin, the Inca Kola® drink and after 14 days of immersion.

[Compressive stress in three types of finishing lines with lithium disilicate crowns in permanent teeth: finite element analysis]. / Tensión compresiva en tres tipos de líneas de terminación con coronas de disilicato de litio en dientes permanentes: análisis de elemento finito.

Introduction: In oral rehabilitation, the use of ceramic restorations is widely accepted due to its aesthetic capacity to mimic the naturalness of the dental tissue, provide longevity of the material, and present a greater marginal fit compared to crowns with a metal structure. Termination lines are biological preparations whose function is to minimize the cervical opening of the marginal seal. Consequently, analyzing the behavior of restorative materials under compressive forces decreases the risk of fracture and increases the success of the treatment. Objective: To compare the compressive stresses of lithium disilicate crowns with three different finishing lines. Methodology: In silico study of the simulation of a dental preparation on a lower right first molar with chamfer (0.6 mm), shoulder (0.5 mm) and deep chamfer (0.5 mm) finish lines. Using the SolidWorks®ï¸ version 2017 software, the maximum stresses, minimum stresses, and location of the compressive force were collected on the Megapascal (Mpa) measurement scale. Results: The chamfer type termination line (0.6mm) obtained a lower compressive stress compared to the other two shoulder type termination lines (0.5mm) and deep chamfer (0.5mm). Conclusions: It was shown that the chamfer type finishing line (0.6mm) presented a better force distribution, determining greater reliability in the selection of this finishing line with the use of a lithium disilicate crown in a unitary manner.

Self-stigma mediates the relationships between childhood maltreatment and symptom levels of PTSD, depression, and anxiety.

Background: Childhood maltreatment is a risk factor for developing multiple forms of psychopathology, including depression, posttraumatic stress disorder (PTSD), and anxiety. Yet, the mechanisms linking childhood maltreatment and these psychopathologies remain less clear.Objective: Here we examined whether self-stigma, the internalization of negative stereotypes about one's experiences, mediates the relationship between childhood maltreatment and symptom severity of depression, PTSD, and anxiety.Methods: Childhood trauma survivors (N = 685, Mage = 36.8) were assessed for childhood maltreatment, self-stigma, and symptoms of depression, PTSD, and anxiety. We used mediation analyses with childhood maltreatment as the independent variable. We then repeated these mediation models separately for childhood abuse and neglect, as well as the different subtypes of childhood maltreatment.Results: Self-stigma significantly mediated the relationship between childhood maltreatment and depression, PTSD, and anxiety symptoms. For sexual abuse - but not physical or emotional abuse - a significant mediation effect of self-stigma emerged on all symptom types. For childhood neglect, self-stigma significantly mediated the relationship between both emotional and physical neglect and all symptom types.Conclusion: Our cross-sectional study suggests that different types of childhood maltreatment experiences may relate to distinct mental health problems, potentially linked to increased self-stigma. Self-stigma may serve as an important treatment target for survivors of childhood abuse and neglect.

Childhood maltreatment is linked to depression, PTSD, and anxiety symptoms.Self-stigma, or internalizing negative stereotypes, plays a significant role in mediating this relationship.Different types of maltreatment are linked to varying levels of self-stigma and symptom severity.

Immune checkpoint inhibitors-associated thrombosis in patients with head and neck cancer: a study of the Spanish society of medical oncology (SEOM) thrombosis and cancer group.

PURPOSE: Both venous and arterial thrombotic events (VTE/AT) can be associated with Immune Checkpoint Inhibitors (ICI). However, there is a paucity of information apropos patients in routine clinical practice. METHODS: /Patients. This retrospective, multicenter study was promoted by the Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM). Individuals with head and neck cancer who initiated ICI between 01/01/2015 and 31/12/2021 were recruited. Minimum follow-up was 6 months (except in cases of demise). The primary objective was to calculate the incidence of ICI-associated VTE/AT, with secondary objectives including the analysis of their impact on survival and the identification of variables predictive of VTE/AT. RESULTS: A total of 143 patients with head and neck cancer were enrolled. The incidence of VTE/AT during follow-up (median 8.6 months) was 2.8%. Survival analysis showed no significant differences (p = 0.644) between the group that developed VTE/AT (median 7.13 months, 95% CI 0-22.9) and the group that did not (median 9.86 months, 95% CI 6.3-13.4). The presence of liver metastases was predictive of VTE/AT (p < 0.05). CONCLUSIONS: Thromboembolic disease associated with immunotherapy in patients with head and neck neoplasia does not significantly impact survival. The presence of liver metastases can predict these events.

Leveraging Instagram to Engage Adolescents With Depression: The Use of Evidence-Based Brief Video Interventions.

Recent research underscores the vital role social media can play in enhancing mental health awareness and encouraging help-seeking behaviors among youth. Nevertheless, the inherent risks of social media highlight the need for the careful creation of safe, effective content. This editorial outlines our strategy of using crowdsourcing platforms to develop and refine video interventions before launching a targeted Instagram campaign featuring these evidence-based videos. This process ensures the content is both beneficial and secure prior to public exposure. We emphasize the necessity of such meticulous preparation in leveraging social media to foster a supportive environment for adolescents seeking mental health help. Our approach and ongoing adjustments offer guidance for future initiatives aimed at promoting the well-being of young digital users.

Chronological pattern of venous thromboembolism (VTE) occurrence impacts in survival of pancreatic ductal adenocarcinoma (PDAC).

BACKGROUND: Limited data exist on the prognostic significance of the chronology of VTE in patients with PDAC. METHODS: Medical data and survival characteristics of patients treated for PDAC from 2019 to 2021 were retrospectively reviewed. Early VTE was defined as occurring within the three months of PDAC diagnosis. RESULTS: 197 patients were included, 54 (27.4%) developed a VTE. Early appearance of VTE was associated with worse prognosis: median overall survival (mOS) VTE < 3 months 8.5 months (HR 1.65, 95% CI 1.11-2.46; p = 0.014), mOS VTE > 3 months 12.8 months (HR 0.78, 95% CI 0.39-1.54; p = 0.5) and mOS patients without VTE 11.4 months (95% CI 10.1-15.4). There was no significant association between the patient's VTE risk according to the Khorana risk score (KRS) (chi2 test p-value = 0.9). CONCLUSION: Early VTE is a prognostic factor in PDAC, which may identify a more aggressive subtype.

When Play Reveals the Ache: Introducing Co-constructive Patient Simulation for Narrative Practitioners in Medical Education.

Despite the ubiquity of healthcare simulation and the humanities in medical education, the two domains of learning remain unintegrated. The stories suffused within healthcare simulation have thus remained unshaped by the developments of narrative medicine and the health humanities. Healthcare simulation, in turn, has yet to utilize concepts like co-construction and narrative competence to enrich learners' understanding of patient experience alongside their clinical competencies. To create a conceptual bridge between these two fields (including narrative-based inquiry more broadly), we redescribe narrative competence via Ronald Heifetz's distinction of "technical" and "adaptive" challenges outlined in his adaptive leadership model. Heifetz, we argue, enriches learners' self-understanding of the unique demands of cultivating narrative competence, which can be both elucidated on the page and tested within the charged yet supportive simulation environment. We introduce Co-constructive Patient Simulation (CCPS) to demonstrate how working with simulated patients can support narrative work by drawing on the clinical vicissitudes of learners in the formulation and enactment of case studies. The three movements of CCPS-resensing, retelling, and retooling-told through learner experiences, describe the affinities and divergences between narrative medicine's sequence of attention, representation, and affiliation; Montello's three forms of narrative competence (departure, performance, change), and Heifetz's three steps (observe, interpret, and intervene) of adaptive leadership.

Pathways and identity: toward qualitative research careers in child and adolescent psychiatry.

OBJECTIVE: Qualitative research methods are based on the analysis of words rather than numbers; they encourage self-reflection on the investigator's part; they are attuned to social interaction and nuance; and they incorporate their subjects' thoughts and feelings as primary sources. Despite appearing well suited for research in child and adolescent psychiatry (CAP), qualitative methods have had relatively minor uptake in the discipline. We conducted a qualitative study of CAPs involved in qualitative research to learn about these investigators' lived experiences, and to identify modifiable factors to promote qualitative methods within the field of youth mental health. METHODS: We conducted individual, semi-structured 1-h long interviews through Zoom. Using purposive sample, we selected 23 participants drawn from the US (n = 12) and from France (n = 11), and equally divided in each country across seniority level. All participants were current or aspiring CAPs and had published at least one peer-reviewed qualitative article. Ten participants were women (44%). We recorded all interviews digitally and transcribed them for analysis. We coded the transcripts according to the principles of thematic analysis and approached data analysis, interpretation, and conceptualization informed by an interpersonal phenomenological analysis (IPA) framework. RESULTS: Through iterative thematic analysis we developed a conceptual model consisting of three domains: (1) Becoming a qualitativist: embracing a different way of knowing (in turn divided into the three themes of priming factors/personal fit; discovering qualitative research; and transitioning in); (2) Being a qualitativist: immersing oneself in a different kind of research (in turn divided into quality: doing qualitative research well; and community: mentors, mentees, and teams); and (3) Nurturing: toward a higher quality future in CAP (in turn divided into current state of qualitative methods in CAP; and advocating for qualitative methods in CAP). For each domain, we go on to propose specific strategies to enhance entry into qualitative careers and research in CAP: (1) Becoming: personalizing the investigator's research focus; balancing inward and outward views; and leveraging practical advantages; (2) Being: seeking epistemological flexibility; moving beyond bibliometrics; and the potential and risks of mixing methods; and (3) Nurturing: invigorating a quality pipeline; and building communities. CONCLUSIONS: We have identified factors that can support or impede entry into qualitative research among CAPs. Based on these modifiable findings, we propose possible solutions to enhance entry into qualitative methods in CAP (pathways), and to foster longer-term commitment to this type of research (identity).

Trajectories of school refusal: sequence analysis using retrospective parent reports.

School refusal (SR) is a form of school attendance problem (SAP) that requires specific mental health care. Despite improvements in the definition of SAPs, the course of SR is not well characterized. To explore three-year patterns of SR course in children, as reported by their parents, we deployed an anonymous web-based survey. We defined SR onset as the absence of ≥ 2 school weeks during one academic year, combined with emotional distress. We defined standard SR trajectories using sequence analysis of parents' recollection of three consecutive years of school attendance. We obtained 1970 responses, 1328 (67%) completed by a parent and meeting the definition of SR. Of these, 729 (55%) responses included three years of school attendance recollection. We identified five prototypical trajectories of SR: two profiles for children: beaded absences (n = 272), and rapid recovery (n = 132); and three for adolescents: prolonged recovery (n = 93), gradual decline (n = 89), and rapid decline (n = 143). We found five distinct trajectories of retrospective recall of SR course. Through pattern recognition, this typology could help with timely identification of SR and implementation of evidence-based interventions to optimize outcomes. Prospective replication of these findings and their field application is warranted.