Abstract
Objective
To assess developmental trajectories of decision-making involvement (DMI), defined as the ways in which parents and children engage each other in decision-making about illness ...management, in youth with type 1 diabetes (T1D) and examine the effects of DMI on levels of and changes in adherence with age.
Methods
Participants included 117 youth with T1D, enrolled at ages 8–16 years and assessed five times over 2 years. The cohort sequential design allowed for the approximation of the longitudinal curve from age 8 to 19 from overlapping cohort segments. Children and parents completed the Decision-Making Involvement Scale, which yields subscales for different aspects of DMI, and a self-report adherence questionnaire. Mixed-effects growth curve modeling was used for analysis, with longitudinal measures nested within participant and participants nested within cohort.
Results
Most aspects of DMI (Parent Express, Parent Seek, Child Express, and Joint) increased with child age; scores on some child report subscales (Parent Express, Child Seek, and Joint) decreased after age 12–14 years. After accounting for age, Child Seek, Child Express, and Joint were associated with overall higher levels of adherence in both child (estimates = 0.08–0.13, p < .001) and parent (estimates = 0.07– 0.13, p < .01) report models, but they did not predict changes in adherence with age.
Conclusion
These data suggest that helping children to be more proactive in T1D discussions, by encouraging them to express their opinions, share information, and solicit guidance from parents, is a potential target for interventions to enhance effective self-management.
The efficacy of influenza vaccination in patients treated with rituximab is a clinically important question. Rheumatology clinics are populated with patients receiving rituximab for a broad array of ...disorders. Although several studies have explored the efficacy of other vaccines in rituximab-treated populations, results have been conflicting. We wished to define influenza vaccine efficacy in a rituximab-treated cohort. We examined 17 evaluable subjects treated with rituximab for rheumatologic conditions. T cell subsets, B cells subsets, T cell function, and B cell function were evaluated at specific time points along with hemagglutinination inhibition titers after receiving the standard inactivated influenza vaccine. T cell subset counts were significantly different than controls but did not change with rituximab. B cells depleted in all patients but were in various stages of recovery at the time of vaccination. Influenza vaccine responsiveness was poor overall, with only 16 % of subjects having a four-fold increase in titer. Pre-existing titers were retained throughout the study, however. The ability to respond to the influenza vaccine appeared to be related to the degree of B cell recovery at the time of vaccination. This study emphasizes that antibody responses to vaccine are impaired in subjects treated with rituximab and supports the concept that B cell recovery influences influenza vaccine responsiveness.
Aim
To compare the effect of iMOVE (Intensive Mobility training with Variability and Error) therapy with dose‐matched conventional therapy on gross motor development and secondary outcomes in young ...children with cerebral palsy.
Method
This single‐blind, randomized controlled trial included repeated assessments of gross motor function (using the Gross Motor Function Measure) and secondary outcomes during a 12‐ to 24‐week intervention phase and at three follow‐up points after treatment. Treatment was delivered three times per week in both groups. Forty‐two children aged 12 to 36 months were stratified by age and motor function to ensure equivalence between groups at baseline.
Results
Thirty‐six children completed treatment and follow‐up phases. Treatment fidelity was high and adherence was equivalent between groups (77.3% conventional therapy, 76.2% iMOVE). There were no group differences on the primary (gross motor function after 12 weeks p = 0.18; after 24 weeks p = 0.94) or any secondary (postural control p = 0.88, caregiver satisfaction p = 0.52, child engagement p = 0.98) measure after treatment or at the follow‐up points. However, one‐third of total participants exceeded predicted change after 12 weeks and 77% exceeded predicted change after 24 weeks of treatment.
Interpretation
Our observations indicate a potential dose–response effect of rehabilitation therapy. We further demonstrated that individual therapeutic ingredients can be manipulated. When delivered consistently, both iMOVE and conventional therapy interventions might both be more effective than standard care.
What this paper adds
Those receiving iMOVE therapy demonstrated more independent practice time, error, and child‐initiation than those receiving the dose‐matched control.
iMOVE therapy was not superior to the control (conventional physical) therapy.
Most participants exceeded predicted change after 24 weeks of treatment.
What this paper adds
Those receiving iMOVE therapy demonstrated more independent practice time, error, and child‐initiation than those receiving the dose‐matched control.
iMOVE therapy was not superior to the control (conventional physical) therapy.
Most participants exceeded predicted change after 24 weeks of treatment.
This original article is commented on by Maitre on pages 145–146 of this issue.
Little is known about the effectiveness and cost-effectiveness of train-the-trainer implementation strategies in supporting mental health evidence-based practices in schools, and about the optimal ...level of support needed for TT strategies.
The current study is part of a larger type 2 hybrid cluster randomized controlled trial. It compares two train-the-trainer strategies, Train-the-Trainer (TT) and Train-the-Trainer plus ongoing consultation for trainers (TT +) on the delivery of a group cognitive behavioral treatment protocol for anxiety disorders. Participants were 33 therapists, 29 supervisors, and 125 students who were at risk for anxiety disorders from 22 urban schools. Implementation outcomes were implementation fidelity and treatment dosage. Student outcomes were child- and parent-reported symptoms of anxiety, child-reported symptoms of depression, and teacher-reported academic engagement. We estimated the cost of implementing the intervention in each condition and examined the probability that a support strategy for supervisors (TT vs TT +) is a good value for varying values of willingness to pay.
Therapists in the TT and TT + conditions obtained similarly high implementation fidelity and students in the conditions received similar treatment dosages. A mixed effects modeling approach for student outcomes revealed time effects for symptoms of anxiety and depression reported by students, and emotional disaffection reported by teachers. There were no condition or condition × times effects. For both conditions, the time effects indicated an improvement from pre-treatment to post-treatment in symptoms of anxiety and depression and academic emotional engagement. The average cost of therapist, supervisor, and consultant time required to implement the intervention in each condition was $1002 for TT and $1431 for TT + (p = 0.01). There was a greater than 80% chance that TT was a good value compared to TT + for all values of willingness to pay per one-point improvement in anxiety scores.
A TT implementation approach consisting of a thorough initial training workshop for therapists and supervisors as well as ongoing supervision for therapists resulted in adequate levels of fidelity and student outcomes but at a lower cost, compared to the TT + condition that also included ongoing external expert consultation for supervisors.
ClinicalTrials.gov identifier: NCT02651402.
BACKGROUND:The purpose of this study was to evaluate the long-term outcomes following modified Furlow palatoplasty over a 30-year experience at a single institution.
METHODS:A retrospective review ...was performed of all nonsyndromic patients undergoing primary modified Furlow palatoplasty at The Children’s Hospital of Philadelphia between 1980 and 2011. Surgical success was evaluated by the rate of postoperative oronasal fistula, speech outcomes assessed at a minimum of age 5 years, and the need for secondary surgery for velopharyngeal dysfunction. Results were analyzed by surgeon, Veau cleft type, age at repair, and over time.
RESULTS:Eight hundred sixty-nine patients who underwent modified Furlow repair were included in this study. The mean age at palatoplasty was 1.1 years, and the mean length of follow-up was 6.7 years. Repairs were performed by 11 surgeons, with 44.3 percent performed by a single surgeon. The overall oronasal fistula rate was 5.2 percent, and this improved significantly over the 30-year period (p = 0.003). Speech results at age 5 or older were available for 559 patients. Of these 559 patients, 72.4 percent had a competent velopharyngeal mechanism, and 21.5 percent had a borderline mechanism consistent with socially acceptable speech. Secondary pharyngeal surgery was indicated in 8.1 percent of patients. Speech results were stable (p = 0.10), and rates of secondary surgery for velopharyngeal dysfunction declined significantly over the study period (p = 0.005).
CONCLUSIONS:The authors’ 30-year experience with the modified Furlow palatoplasty shows stable speech results, decreasing rates of secondary surgery, and an acceptable rate of postoperative oronasal fistula.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.
The neuroanatomic basis for cognitive impairment in chronic kidney disease (CKD) is incompletely characterized. We performed advanced quantitative structural magnetic resonance imaging (MRI) to ...determine whether CKD affects brain structure and whether poorer neurocognitive performance in CKD is associated with structural brain differences.
Cross-sectional.
85 individuals with CKD stages 2 to 5 and 63 healthy controls, aged 8 to 25 years
CKD versus control, estimated glomerular filtration rate (eGFR), and kidney transplant status were analyzed as predictors of MRI findings. MRI volumes in 19 prespecified regions of gray matter (GM), white matter (WM), and cerebrospinal fluid were analyzed as predictors of neurocognitive performance (median z scores) in 7 prespecified domains.
19 prespecified brain regions of interest (ROIs) in 7 prespecified domains. Neurocognitive performance in 7 prespecified domains.
ROI volumes were compared in CKD versus controls using unadjusted t tests and analysis of covariance (ANCOVA). Associations of ROI volumes with eGFR and kidney transplant status in participants with CKD were analyzed using ANCOVA and linear regression. Associations of neurocognitive performance and ROI volumes were analyzed by linear regression.
Participants with CKD had lower whole-brain, cortical, and left parietal GM volumes than controls in unadjusted analyses, but no differences were found in adjusted analysis. In participants with CKD, lower eGFR was associated with higher WM volume in whole-brain (P=0.05) and frontal (P=0.04) ROIs, but differences were not significant after multiple comparisons correction. Kidney transplant recipients had lower GM volumes in whole-brain (P=0.01; Q=0.06), frontal (P=0.02; Q=0.08), and left and right parietal (P=0.01; Q=0.06; and P=0.03; Q=0.1) ROIs and higher whole-brain WM volume (P=0.04; Q=0.1). Neurocognitive performance in the CKD group was not associated with ROI volumes.
Unable to assess changes in brain structure and kidney function over time; analysis limited to prespecified ROIs and neurocognitive domains.
CKD in children and young adults may be associated with lower GM and higher WM volumes in some ROIs. Differences were relatively subtle in the CKD group as a whole, but were more prominent in recipients of a kidney transplant. However, neurocognitive performance was not explained by differences in brain ROI volumes, suggesting a functional rather than structural basis for neurocognitive impairment in CKD.
Ibuprofen used in postoperative management of pain after tonsillectomy has not been shown to increase the overall risk for posttonsillectomy hemorrhage (PTH). The severity of bleeding is difficult to ...quantify but may be a more important outcome to measure.
To evaluate the association between ibuprofen use and severity of PTH using transfusion events as a marker of severity.
This retrospective cohort study identified 8868 patients who underwent tonsillectomy from January 20, 2011, through June 30, 2014, at the tertiary academic Children's Hospital of Philadelphia. Of these patients, 6710 met the inclusion criteria. Data were collected using electronic database acquisition and query.
Multivariate analysis was performed to identify independent prognostic factors for PTH and receipt of transfusion.
Of the 6710 patients who met criteria for analysis (3454 male 51.5% and 3256 female 48.5%; median age, 5.4 years interquartile range, 3.7-8.2 years), 222 (3.3%) presented with PTH that required surgical control (sPTH). A total of 15 of the 8868 patients required transfusion for an overall risk for transfusion after tonsillectomy of 0.2%. Fifteen of 222 patients undergoing sPTH (6.8%) received transfusions. No significant independent increased risk for sPTH was associated with use of ibuprofen (adjusted odds ratio OR, 0.90; 95% CI, 0.68-1.19). A significant independent association was found in the risk for sPTH in patients 12 years or older (adjusted OR, 2.74; 95% CI, 1.99-3.76) and in patients with a history of recurrent tonsillitis (adjusted OR, 1.52; 95% CI, 1.12-2.06). When using transfusion rates as a surrogate for severity of sPTH, transfusion increased by more than 3-fold among ibuprofen users compared with nonusers (adjusted OR, 3.16; 95% CI, 1.01-9.91), and the upper limit of the 95% CI suggests the difference could be nearly 10 times greater.
The risk for sPTH is not increased with use of postoperative ibuprofen but is increased in patients 12 years or older and patients undergoing tonsillectomy with a history of recurrent tonsillitis. Hemorrhage severity is significantly increased with ibuprofen use when using transfusion rate as a surrogate marker for severity.
Brain lesions, especially white matter lesions (WMLs), are associated with cardiac and vascular disease, but also with normal aging. Quantitative analysis of WML in large clinical trials is becoming ...more and more important.
In this article, we present a computer-assisted WML segmentation method, based on local features extracted from multiparametric magnetic resonance imaging (MRI) sequences (ie, T1-weighted, T2-weighted, proton density-weighted, and fluid attenuation inversion recovery MRI scans). A support vector machine classifier is first trained on expert-defined WMLs, and is then used to classify new scans.
Postprocessing analysis further reduces false positives by using anatomic knowledge and measures of distance from the training set.
Cross-validation on a population of 35 patients from three different imaging sites with WMLs of varying sizes, shapes, and locations tests the robustness and accuracy of the proposed segmentation method, compared with the manual segmentation results from two experienced neuroradiologists.
Purpose To investigate the pathophysiologic effects of chronic kidney disease (CKD) on brain function in children with CKD by correlating cerebral blood flow (CBF) with clinical and behavioral ...indexes. Materials and Methods In this prospective study, 73 pediatric patients with CKD (mean age, 15.80 years ± 3.63; range, 9-25 years) and 57 control subjects (mean age, 15.65 years ± 3.76; range, 9-25 years) were recruited. CBF measurements were acquired with an MRI arterial spin labeling scheme. Neurocognitive measurements were performed with traditional and computerized neurocognitive batteries. Clinical data were also collected. Group-level global and regional CBF differences between patients with CKD and control subjects were assessed. Regression analyses were conducted to evaluate the associations among regional CBF, clinical variables, and cognitive performance. Results Patients with CKD showed higher global CBF compared with control subjects that was attributable to reduced hematocrit level (mean, 60.2 mL/100 g/min ± 9.0 vs 56.5 mL/100 g/min ± 8.0, respectively). White matter CBF showed correlation with blood pressure (r = 0.244, P = .039), a finding suggestive of altered cerebrovascular autoregulation. Regional CBF differences between patients and control subjects included regions in the "default mode" network. In patients with CKD, positive extrema in the precuneus showed a strong correlation with executive function (ρ = 0.608, P = .001). Conclusion Systemic effects of estimated glomerular filtration rate, hematocrit level, and blood pressure on CBF and alterations in regional CBF may reflect impaired brain function underlying neurocognitive symptoms in CKD. These findings further characterize the nature of alterations in brain physiologic features in children, adolescents, and young adults with CKD.
Cognitive behavioral therapy (CBT) for pediatric anxiety is efficacious for reducing anxiety symptoms and improving functioning, but many children are unable to access CBT for anxiety in community ...settings. Schools are an important setting in which children access mental health care, including therapy for anxiety. In this setting, therapy is usually delivered by Masters-level therapists.
Friends for Life (FRIENDS), a 12-session, manualized, group CBT program for anxiety has demonstrated effectiveness when implemented in schools. However, prior research has also found challenges regarding feasibility and cultural fit when delivering FRIENDS in the urban school context. To address these challenges, we adapted FRIENDS for implementation in the school setting so that it might be more feasible and culturally appropriate for low-income, urban schools in the United States, while maintaining the core components of treatment. The current study uses a mixed-method approach to compare the effectiveness, cost-effectiveness, and perceived appropriateness of FRIENDS and CATS when delivered by Masters-level therapists with train-the-trainer support.
First, we compared change scores for student outcomes (i.e., child-report MASC-2 total score, parent-report MASC-2 total score, teacher-report Engagement and Disaffection subscale scores) from pre- to post- treatment between students receiving FRIENDS and students receiving CATS to assess whether the two conditions resulted in equivalent outcomes. Second, we compared the cost and cost-effectiveness between the groups. Finally, we used an applied thematic analysis to compare appropriateness of the interventions as perceived by therapists and supervisors.
The mean change score for the child-reported MASC-2 was 1.9 (SE = 1.72) points in the FRIENDS condition and 2.9 (SE = 1.73) points in the CATS condition; results indicated that the conditions were similar in their treatment effects, and symptom reductions were small in both groups. The modified protocol, CATS, was shown to cost significantly less to implement compared to FRIENDS and showed greater cost-effectiveness. Finally, compared to therapists and supervisors in the CATS condition, therapists and supervisors in the FRIENDS condition more strongly described aspects of the intervention that were not appropriate for their context and in need of more extensive adaptations.
Relatively brief, group CBT for anxiety, with adaptations to improve cultural fit, is a promising approach to treat youth anxiety symptom when delivered by school-based therapists with train-the-trainer implementation support.
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