Multi-institutional evaluation of a Pareto navigation guided automated radiotherapy planning solution for prostate cancer.

BACKGROUND: Current automated planning solutions are calibrated using trial and error or machine learning on historical datasets. Neither method allows for the intuitive exploration of differing trade-off options during calibration, which may aid in ensuring automated solutions align with clinical preference. Pareto navigation provides this functionality and offers a potential calibration alternative. The purpose of this study was to validate an automated radiotherapy planning solution with a novel multi-dimensional Pareto navigation calibration interface across two external institutions for prostate cancer. METHODS: The implemented 'Pareto Guided Automated Planning' (PGAP) methodology was developed in RayStation using scripting and consisted of a Pareto navigation calibration interface built upon a 'Protocol Based Automatic Iterative Optimisation' planning framework. 30 previous patients were randomly selected by each institution (IA and IB), 10 for calibration and 20 for validation. Utilising the Pareto navigation interface automated protocols were calibrated to the institutions' clinical preferences. A single automated plan (VMATAuto) was generated for each validation patient with plan quality compared against the previously treated clinical plan (VMATClinical) both quantitatively, using a range of DVH metrics, and qualitatively through blind review at the external institution. RESULTS: PGAP led to marked improvements across the majority of rectal dose metrics, with Dmean reduced by 3.7 Gy and 1.8 Gy for IA and IB respectively (p < 0.001). For bladder, results were mixed with low and intermediate dose metrics reduced for IB but increased for IA. Differences, whilst statistically significant (p < 0.05) were small and not considered clinically relevant. The reduction in rectum dose was not at the expense of PTV coverage (D98% was generally improved with VMATAuto), but was somewhat detrimental to PTV conformality. The prioritisation of rectum over conformality was however aligned with preferences expressed during calibration and was a key driver in both institutions demonstrating a clear preference towards VMATAuto, with 31/40 considered superior to VMATClinical upon blind review. CONCLUSIONS: PGAP enabled intuitive adaptation of automated protocols to an institution's planning aims and yielded plans more congruent with the institution's clinical preference than the locally produced manual clinical plans.

Florida Doulas' Perspectives on Their Role in Reducing Maternal Morbidity and Health Disparities.

BACKGROUND: Maternal mortality rates continue to rise in the United States. Considerable racial disparities exist, as Black women face two to three times the risks of dying from pregnancy-related complications compared with white women. Doulas have been associated with improved maternal outcomes. This study aimed to 1) investigate Florida doulas' perspectives and influence on severe maternal morbidity/mortality and related inequities, as well as 2) identify opportunities for actionable change. The social ecological model, which acknowledges how individual, interpersonal, institutional, community, and public policy factors intersect, informed our analysis. METHODS: This qualitative study included seven online in-depth interviews and seven focus groups with doulas (N = 31) in Florida. Interview guides investigated how doulas perceive their role in the context of a) maternal morbidity and b) health disparities. RESULTS: Doulas associated maternal morbidity and health disparities with Black pregnant people, identifying racism as a major contributor. Doulas identified their role as one that most often intersects with the individual and interpersonal levels of the social ecological model. Doulas report providing positive social surveillance and emotional support, contributing education and resources, and championing for advocacy in health care settings. Actionable steps recommended by doulas to further mitigate health disparities include the integration of implicit bias training into doula certification programs, increasing public health funding to bolster a doula workforce that can serve racial and ethnic communities, establishing doula-hospital partnerships to improve relational communication, providing tailored resources for clients featuring representative messaging, and doulas' continued engagement in positive social surveillance of their clients. CONCLUSIONS: Doulas perceived their role as integral to mitigating maternal morbidity and health disparities, particularly in the context of supporting and advocating for birthing persons on all levels of the social ecological model. Equitable access to doulas for low-income and/or minoritized populations may be one key strategy to improve maternal health equity.

Handbooks and health interpreters: How men are assets for their pregnant partners in Senegal.

INTRODUCTION: Global health researchers often approach fatherhood initiatives from a deficit-based perspective, assuming men need sensitization, education, or correction. Senegalese men, which some global health and development organizations have determined to be uninvolved, are part of a team of prenatal and postpartum support called the "entourage" and have a very specific role to play as ad hoc health interpreters. METHODS: The findings of this article come from 12 months of ethnographic research in Dakar, Senegal in 2018. In addition to participant-observation in three maternity wards across the city, semi-structured interviews were conducted with 32 pregnant women, 27 expectant fathers, and numerous family members, midwives, physicians, and governmental and nongovernmental organization employees. Data were coded and evaluated using thematic analysis. RESULTS: In Senegal, the Handbook of Mother and Child Health is distributed in state-funded maternity wards. The Handbook outlines what pregnant women should know about pregnancy and how to appropriately engage with clinical services. Male partners of pregnant women commonly read the book for and to their pregnant partners. Men are placed in the unique position of intermediary between pregnant women and the State and as such, they learn a lot about pregnancy and childbirth, as well as prenatal and postpartum care. CONCLUSIONS: Our ethnographic insights challenge global health rhetoric that frames men as uninvolved in women and children's health and this study demonstrates that future interventions should take an asset-based approach to men's involvement. Senegalese men are uniquely positioned by gendered expectations to act as health interpreters for their pregnant partners. We conclude with specific, actionable recommendations for the Senegalese case.

(Mis)measuring men's involvement in global health: the case of expectant fathers in Dakar, Senegal.

BACKGROUND: In 2018, USAID published a report based on Demographic and Health Surveys data on the relationship between men's involvement and women and children's health outcomes. Using a flawed operationalization of "men's involvement," USAID's analysis implies that Senegalese men are not involved in women and children's health. METHODS: The findings of this study come from 12 months of ethnographic research in Dakar, Senegal that examined the roles and responsibilities of expectant fathers. Research participants included 32 pregnant women and 27 expectant partners recruited from three maternity wards. Research methods included long-term, immersive participant observation and semi-structured interviews. RESULTS: Pregnant women in Senegal are surrounded by a kin-based network of care providers called the entourage who share responsibilities for support. Expectant fathers, as members of the entourage, are expected to provide financial and emotional support, while other members of the entourage are expected to undertake the responsibilities which USAID have designated as "men's involvement." Men typically do not undertake additional forms of care and support because they are considered "women's business," meaning that women actively discourage men from doing those things, in order to preserve women's autonomy. CONCLUSION: This research demonstrates that expectant fathers are involved in antenatal care in ways that USAID does not track through DHS. Further, I argue that USAID's heterosexist, monogamous, and nuclear operationalization of "men's involvement" aligns with a long history of Eurocentrism in development discourse which may be potentially harmful and obstructive to improving maternal and child health when the problem that is targeted is not a problem at all. This study is yet another case that demonstrates an urgent need of public and global health engagement with local stakeholders and ethnographic researchers.

Clinical implementation of a knowledge based planning tool for prostate VMAT.

BACKGROUND: A knowledge based planning tool has been developed and implemented for prostate VMAT radiotherapy plans providing a target average rectum dose value based on previously achievable values for similar rectum/PTV overlap. The purpose of this planning tool is to highlight sub-optimal clinical plans and to improve plan quality and consistency. METHODS: A historical cohort of 97 VMAT prostate plans was interrogated using a RayStation script and used to develop a local model for predicting optimum average rectum dose based on individual anatomy. A preliminary validation study was performed whereby historical plans identified as "optimal" and "sub-optimal" by the local model were replanned in a blinded study by four experienced planners and compared to the original clinical plan to assess whether any improvement in rectum dose was observed. The predictive model was then incorporated into a RayStation script and used as part of the clinical planning process. Planners were asked to use the script during planning to provide a patient specific prediction for optimum average rectum dose and to optimise the plan accordingly. RESULTS: Plans identified as "sub-optimal" in the validation study observed a statistically significant improvement in average rectum dose compared to the clinical plan when replanned whereas plans that were identified as "optimal" observed no improvement when replanned. This provided confidence that the local model can identify plans that were suboptimal in terms of rectal sparing. Clinical implementation of the knowledge based planning tool reduced the population-averaged mean rectum dose by 5.6Gy. There was a small but statistically significant increase in total MU and femoral head dose and a reduction in conformity index. These did not affect the clinical acceptability of the plans and no significant changes to other plan quality metrics were observed. CONCLUSIONS: The knowledge-based planning tool has enabled substantial reductions in population-averaged mean rectum dose for prostate VMAT patients. This suggests plans are improved when planners receive quantitative feedback on plan quality against historical data.