Youth and families who receive services in public mental health care (PMHC) often present with complex co-occurring concerns. These challenges might appear to necessitate spreading the foci of ...treatment across multiple targets during therapy, herein referred to as treatment focus diffusion (TFD). Higher TFD has recently been found to be related to poorer short-term clinical outcomes, but longer term clinical and system outcomes have not been examined. Utilizing routine clinical data from two PMHC-based intensive in-home service formats (implemented Multisystemic Therapy MST and standards-based services), this study examined whether TFD was associated with returning to the system for additional services at the same or more intensive/restrictive level and with treatment expenditures related to any service utilization following the treatment episode under study. When examined together and in separate models for MST and standards-based intensive in-home services, more TFD was significantly related to higher odds of returning to the system for additional services. Additionally, more TFD was significantly associated with higher treatment expenditure in the combined and MST-only models. These findings suggest that TFD could serve as a useful and measurable early treatment factor for predicting poorer outcomes. As such, monitoring TFD and using supervision and/or case reviews to adjust services where treatment focus diffuses would likely be beneficial in PMHC systems.
Highlights
More treatment focus diffusion (TFD; spreading treatment focus across multiple concerns) was related to worse long-term outcomes.
This relationship between TFD and poorer outcomes was particularly strong in the implemented Multisystemic Therapy service format.
TFD could be a useful tool for treatment monitoring and clinical decision-making in public mental health care systems.
This randomized trial comparing retropubic and transobturator slings for the treatment of stress urinary incontinence showed equivalent rates of treatment success according to objective criteria; the ...rates of treatment success in the two groups according to subjective criteria were similar but did not meet the criteria for equivalence. Complications differed in the two groups, with more voiding dysfunction requiring surgery in the retropubic-sling group and more neurologic symptoms in the transobturator-sling group.
In this randomized trial, two surgical approaches for the treatment of stress urinary incontinence had similar cure rates, although the complications differed by group.
Urinary incontinence affects up to 50% of women, resulting in substantial medical, social, and economic burdens.
1
,
2
Among U.S. women with urinary incontinence, 15 to 80% have a component of stress incontinence,
3
which results in leakage of urine during physical exertion, sneezing, and coughing.
4
Of these women, 4 to 10% undergo surgery.
5
In 1996, Ulmsten et al.
6
introduced a procedure that involved the placement of a retropubic midurethral mesh sling for the treatment of stress incontinence; this procedure was less invasive than the Burch colposuspension and the autologous rectus fascial sling procedures that were the reference standards at the time. . . .
Summary
Auxin produced by an active primary shoot apex is transported down the main stem and inhibits the growth of the axillary buds below it, contributing to apical dominance. Here we use ...Arabidopsis thaliana cytokinin (CK) biosynthetic and signalling mutants to probe the role of CK in this process. It is well established that bud outgrowth is promoted by CK, and that CK synthesis is inhibited by auxin, leading to the hypothesis that release from apical dominance relies on an increased supply of CK to buds. Our data confirm that decapitation induces the expression of at least one ISOPENTENYLTRANSFERASE (IPT) CK biosynthetic gene in the stem. We further show that transcript abundance of a clade of the CK‐responsive type‐A Arabidopsis response regulator (ARR) genes increases in buds following CK supply, and that, contrary to their typical action as inhibitors of CK signalling, these genes are required for CK‐mediated bud activation. However, analysis of the relevant arr and ipt multiple mutants demonstrates that defects in bud CK response do not affect auxin‐mediated bud inhibition, and increased IPT transcript levels are not needed for bud release following decapitation. Instead, our data suggest that CK acts to overcome auxin‐mediated bud inhibition, allowing buds to escape apical dominance under favourable conditions, such as high nitrate availability.
Significance Statement
It has been proposed that the release of buds from auxin‐mediated apical dominance following decapitation requires increased cytokinin biosynthesis and consequent increases in cytokinin supply to buds. Here we show that in Arabidopsis, increases in cytokinin appear to be unnecessary for the release of buds from apical dominance, but rather allow buds to escape the inhibitory effect of apical auxin, thereby promoting bud activation in favourable growth conditions.
Although the adaptive role of positive affect (PA) in childhood internalizing disorders is well-established, less is known about PA in children with Attention-Deficit/Hyperactivity Disorder (ADHD). ...In this cross-sectional study, we examined associations between child-reported PA and parent-reported emotional and behavioral problems in youth with ADHD using multiple hierarchical regression analyses. Participants included 848 ethnically diverse youth (253 youth with ADHD, 595 with other or no diagnoses; age range 6.12–19.65) referred for mental health assessments. Study measures included the Child Behavior Checklist (CBCL) and the Positive and Negative Affect Scale for Children (PANAS-C). Results indicated that higher levels of child-reported PA were associated with greater parental reports of total and internalizing problems among youth with ADHD but not in other clinic-referred youth. Specifically, child self-reports of PA were positively associated with parental reports of anxious/depressed and somatic problems in youth with ADHD. In addition, associations between child-reported PA and parent-reported problems differed by type of ADHD comorbidity. Findings suggest that at higher levels, PA in youth with ADHD might exert a paradoxical effect and be a subtle risk factor for or an indicator of parent-reported internalizing problems among youth with ADHD only and youth with ADHD and a comorbid externalizing disorder but not for youth with ADHD and a comorbid internalizing disorder or youth without ADHD. Discrepancies between child-reported PA and parent-reported problems may influence treatment planning and treatment response. Further clinical and theoretical implications for child therapists and parents are discussed.
This study examined whether psychological treatment for youth with comorbid externalizing and internalizing disorders targets externalizing rather than internalizing pathology. Therapist-reported ...treatment targets for youth (N = 679) with (a) only internalizing diagnoses (n = 195); (b) only externalizing diagnoses (n = 314); (c) a primary internalizing diagnosis and at least 1 additional externalizing diagnosis (n = 75); and (d) a primary externalizing diagnosis and at least 1 additional internalizing diagnosis (n = 95) receiving treatment-as-usual in a public mental health system of care were examined. Treatment targets that appeared significantly more often in the externalizing-only and internalizing-only diagnostic groups were empirically determined, and a derived proportional measure of these targets was analyzed across all 4 diagnostic groups, controlling for effects of additional client and treatment characteristics. As required by the target selection method, the proportion of externalizing targets selected in treatment was greatest for youth with externalizing-only diagnoses and least for youth with internalizing-only diagnoses. Importantly, the co-occurrence of a secondary externalizing disorder with a primary internalizing disorder resulted in a large increase in the proportion of externalizing targets endorsed, whereas the co-occurrence of an internalizing disorder with a primary externalizing disorder resulted in a comparatively small decrease in the proportion of externalizing targets endorsed. Results persisted despite several covariates also predicting increased focus on externalizing targets, including male gender and younger age. These findings suggest that community therapists tend to prioritize externalizing over internalizing problems during treatment for such comorbid youth. Implications for practice, research and dissemination/implementation efforts are discussed.
The current study examined the extent to which the Ohio Scales, Short Form, Problem Severity domain was able to perform as a reliable and valid measure within a large community mental health sample ...of multiethnic youth and families in Hawaiʻi. Using a sample of 1,125 youth participants, who were 59.1% male (
n
= 665), with a mean age of 12.96 (
SD
= 3.4), confirmatory factor analyses pointed to four factors (Externalizing, Delinquency, Anxiety, Depression), with subscale internal reliabilities varying slightly. The majority of convergence patterns between Problem Severity domain and related Child and Adolescent Functional Assessment Scale subscales were significantly correlated in the expected directions. Problem Severity subscale scores were mostly able to discriminate between youth with and without pertinent mental health diagnoses. Youth- and caregiver-report Problem Severity domain subscale and total scores were significantly correlated in the predicted directions. Finally, significant youth improvement was evident at 3-month follow-up, and Problem Severity intake and 3-month follow-up scores were significantly and positively related to one another. Implications and suggestions for future research are discussed.
•Traumatic stress was undertreated in this community treatment foster care program.•Therapists underutilized evidence-based practices for youth trauma treatment.•Few youth made substantial progress ...on trauma-related concerns early in services.•Additional studies of trauma treatment in treatment foster care programs are needed.
Many youth in treatment foster care (TFC) have been exposed to traumatic life events that are associated with negative health outcomes, yet few studies have examined how TFC programs are addressing the needs of trauma-exposed youth. This study used clinical data from 542 youth enrolled in TFC services within a statewide publicly funded mental health system from 2008 to 2018 to explore (a) how many youth receive trauma treatment, including youth diagnosed with PTSD, (b) to what extent common elements for youth trauma treatment are among the interventions employed during months when trauma was included as a treatment focus, and (c) clinician-reported trauma treatment progress. Only 34% of all youth in TFC, and 56% of youth diagnosed with PTSD, received treatment with any focus on trauma during the first six months of TFC. Therapists used a variety of therapeutic strategies during months when trauma was treated, some of which were consistent with the evidence-base for youth traumatic stress. Therapists reported 36% of youth with some trauma treatment focus made, at most, minimal improvement on trauma concerns during this time. Considerations for research and clinical practice in trauma-focused treatment foster care services are discussed.
Assess outcomes of a clinical cohort of patients with endometrioid endometrial cancer (EEC) harboring somatic POLE exonuclease domain mutations (EDMs).
Patients were consented to a protocol of ...tumor-normal massively parallel sequencing of 410–468 cancer related genes. EECs subjected to sequencing from 2014 to 2018 were reviewed. Tumors with somatic POLE EDMs were identified. EECs were assessed for microsatellite instability (MSI) using MSIsensor and immunohistochemical analysis for mismatch repair (MMR) proteins.
Of the 451 EECs sequenced, 23 had a POLE EDM (5%): 20 primary and 3 recurrent tumors sequenced. Nineteen cases (83%) were stage I/II and 4 (17%) were stages III/IV. Thirteen EECs (57%) were of FIGO grades 1/2, 10 (43%) grade 3. All patients were treated with surgery and 17 (89%) received adjuvant therapy. Five (22%) demonstrated loss of DNA MMR protein expression, none were due to Lynch syndrome. MSIsensor scores were conclusive for 21 samples: 19 were microsatellite stable and 2 MSI-high. After median follow-up of 30 months, 4/23 (17%) developed recurrences: 3 with initial grade 3 stage I and 1 with grade 1 stage III disease. One patient with grade 2 stage IV EEC had progressive disease after treatment.
Patients with POLE EDM EEC have been shown to have a favorable prognosis. In this real-world cohort of patients, de novo metastatic disease and recurrences in initially uterine-confined cases were observed. Further research is warranted before incorporating the presence of POLE EDM into decision-making regarding adjuvant therapy.
•In this prospective cohort, 5% of endometrioid endometrial carcinoma have POLE EDM.•17% of POLE-mutant cases developed recurrences.•Recurrences were observed in uterine-confined G3 disease after adjuvant RT.•De novo metastatic disease was observed.•Further research is warranted before changes in treatment/management are considered.
We sought to determine whether sequencing analysis of circulating cell-free DNA (cfDNA) in patients with prospectively accrued endometrial cancer captures the mutational repertoire of the primary ...lesion and allows for disease monitoring.
Peripheral blood was prospectively collected from 44 newly diagnosed patients with endometrial cancer over a 24-month period (i.e., baseline, postsurgery, every 6 months after). DNA from the primary endometrial cancers was subjected to targeted next-generation sequencing (NGS) of 468 cancer-related genes, and cfDNA to a high-depth NGS assay of 129 genes with molecular barcoding. Sequencing data were analyzed using validated bioinformatics methods.
cfDNA levels correlated with surgical stage in endometrial cancers, with higher levels of cfDNA being present in advanced-stage disease. Mutations in cfDNA at baseline were detected preoperatively in 8 of 36 (22%) patients with sequencing data, all of whom were diagnosed with advanced-stage disease, high tumor volume, and/or aggressive histologic type. Of the 38 somatic mutations identified in the primary tumors also present in the cfDNA assay, 35 (92%) and 38 (100%) were detected at baseline and follow-up, respectively. In 6 patients with recurrent disease, changes in circulating tumor DNA (ctDNA) fraction/variant allele fractions in cfDNA during follow-up closely mirrored disease progression and therapy response, with a lead time over clinically detected recurrence in two cases. The presence of ctDNA at baseline (P < 0.001) or postsurgery (P = 0.014) was significantly associated with reduced progression-free survival.
cfDNA sequencing analysis in patients with endometrial cancer at diagnosis has prognostic value, and serial postsurgery cfDNA analysis enables disease and treatment response monitoring. See related commentary by Grant et al., p. 305.
Identifying the mechanistic drivers of migration can be crucial in shaping conservation and management policies. The cownose ray (Rhinoptera bonasus) is a relatively poorly understood elasmobranch ...species that occurs along the U.S. Atlantic coast and undergoes large‐scale seasonal migrations. To better understand the drivers and timing of cownose ray seasonal migration in order to inform potential management measures, we analyzed telemetry detections of 51 mature cownose rays (38 female, 13 male) tagged with acoustic transmitters in the Maryland and Virginia portions of Chesapeake Bay. Detections within their summer habitat in Chesapeake Bay and winter habitat in the vicinity of Cape Canaveral, Florida, were matched with publicly available sea surface temperature (SST) data recorded by data buoys near the areas of tag detections and with local photoperiod and day of year. These variables were used in boosted regression tree models of ray presence (all rays combined, females only, and males only) in each seasonal habitat. Models were developed for presence during the entire summer and winter season, and for the time periods of arrival and departure from both summer and winter habitats. Seasonal presence in both summer and winter habitats was associated with distinct temperature, photoperiod, and date ranges, with temperature as the most influential variable in seasonal models. In models of arrival and departure periods, southward migration (departure from Chesapeake Bay and arrival off Cape Canaveral) was strongly associated with SST for all rays and arrival in the Chesapeake Bay region after northward migration was most strongly associated with day of year. The most influential variable during the period of northward departure from Cape Canaveral differed between males (day of year) and females (SST). This suggests that mature female northward migration may be driven by temperature while male northward migration may be driven by endogenous cues. These findings provide detailed information on the timing of cownose ray arrival at, presence in, and departure from seasonal habitats and provide potential justification for including the species in cross‐taxa comparative studies on migratory behavior.
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