We sought to inform decision-making for children and families by describing what is known and remains unknown about the impact of childhood critical illness and injury on families. This report also ...was designed as a tool for research planning and design so that meaningful studies are performed and duplication is avoided.
After a national scholarship competition and the identification of 3 medical student summer scholars, a literature search was conducted by using the National Library of Medicine and a PubMed keyword search system at the National Institutes of Health.
A total of 115 reports were reviewed and assigned to the 5 following categories characterizing the impact of pediatric critical illness/injury on families: stressors, needs, specific domains (psychological, physical, social), coping, and interventions. The reports reviewed indicate that pediatric critical illness and injury is stressful for the entire family. The effects on parents, siblings, and marital cohesion were variably described. Needs of family members (eg, rest, nutrition, communication) were identified as being unmet in many studies. Permanent impact on siblings and marital relationships has been considered detrimental, but these conclusions are not adequately quantified in presently available studies. Reviewed reports minimally investigated cultural diversity, effects on fathers versus mothers, siblings, socioeconomic status, and financial burden. Studies were often anecdotal and included small sample sizes. Methodologic limitations were numerous and varied and seriously narrowed the significance of the studies we reviewed. The reports that we evaluated were largely limited to those of English-speaking families, white people, and married mothers.
Future research should use more rigorous methods in the measurement of impact of childhood critical illness and injury on families. Families of critically ill and injured children would benefit from the practitioners of pediatric critical care acquiring enhanced knowledge and sensitivity about family communication and dynamics.
Contrary to received scholarly wisdom, this article argues that the Frankish conquest of Saxony under Charlemagne in the late eighth and early ninth centuries was driven in no small part by the ...pursuit of material wealth. Specifically, most scholars have viewed pre‐conquest Saxony as too materially impoverished for economic incentives to have played a significant role in Frankish expansion into the lands between the Rhine and the Elbe. However, a thorough review of the written and archaeological evidence suggests that Saxony had much to offer its Carolingian conquerors in the form of plunder and tribute, land and mineral resources, revenue from royal and ecclesiastical renders and taxation, and access to and control of trade routes.
Depression is a common condition associated with significant morbidity in adolescents. Few depressed adolescents receive effective treatment for depression in primary care settings.
To evaluate the ...effectiveness of a quality improvement intervention aimed at increasing access to evidence-based treatments for depression (particularly cognitive-behavior therapy and antidepressant medication), relative to usual care, among adolescents in primary care practices.
Randomized controlled trial conducted between 1999 and 2003 enrolling 418 primary care patients with current depressive symptoms, aged 13 through 21 years, from 5 health care organizations purposively selected to include managed care, public sector, and academic medical center clinics in the United States.
Usual care (n = 207) or 6-month quality improvement intervention (n = 211) including expert leader teams at each site, care managers who supported primary care clinicians in evaluating and managing patients' depression, training for care managers in manualized cognitive-behavior therapy for depression, and patient and clinician choice regarding treatment modality. Participating clinicians also received education regarding depression evaluation, management, and pharmacological and psychosocial treatment.
Depressive symptoms assessed by Center for Epidemiological Studies-Depression Scale (CES-D) score. Secondary outcomes were mental health-related quality of life assessed by Mental Health Summary Score (MCS-12) and satisfaction with mental health care assessed using a 5-point scale.
Six months after baseline assessments, intervention patients, compared with usual care patients, reported significantly fewer depressive symptoms (mean SD CES-D scores, 19.0 11.9 vs 21.4 13.1; P = .02), higher mental health-related quality of life (mean SD MCS-12 scores, 44.6 11.3 vs 42.8 12.9; P = .03), and greater satisfaction with mental health care (mean SD scores, 3.8 0.9 vs 3.5 1.0; P = .004). Intervention patients also reported significantly higher rates of mental health care (32.1% vs 17.2%, P<.001) and psychotherapy or counseling (32.0% vs 21.2%, P = .007).
A 6-month quality improvement intervention aimed at improving access to evidence-based depression treatments through primary care was significantly more effective than usual care for depressed adolescents from diverse primary care practices. The greater uptake of counseling vs medication under the intervention reinforces the importance of practice interventions that include resources to enable evidence-based psychotherapy for depressed adolescents.
Quality improvement programs for depressed youths in primary care settings have been shown to improve 6-month clinical outcomes, but longer-term outcomes are unknown. The authors examined 6-, 12-, ...and 18-month outcomes of a primary care quality improvement intervention.
Primary care patients 13-21 years of age with current depressive symptoms were randomly assigned to a 6-month quality improvement intervention (N=211) or to treatment as usual enhanced with provider training (N=207). The quality improvement intervention featured expert leader teams to oversee implementation of the intervention; clinical care managers trained in cognitive-behavioral therapy for depression to support patient evaluation and treatment; and support for patient and provider choice of treatments.
The quality improvement intervention, relative to enhanced treatment as usual, lowered the likelihood of severe depression (Center for Epidemiological Studies Depression Scale score > or =24) at 6 months; a similar trend at 18 months was not statistically significant. Path analyses revealed a significant indirect intervention effect on long-term depression due to the initial intervention improvement at 6 months.
In this randomized effectiveness trial of a primary care quality improvement intervention for depressed youths, the main effect of the intervention on outcomes was to decrease the likelihood of severe depression at the 6-month outcome assessment. These early intervention-related improvements conferred additional long-term protection through a favorable shift in illness course through 12 and 18 months.
California uses a unique method to screen newborns for cystic fibrosis (CF) that includes gene scanning and DNA sequencing after only one California-40 cystic fibrosis transmembrane conductance ...regulator ( CFTR ) panel mutation has been identified in hypertrypsinogenemic specimens. Newborns found by sequencing to have one or more additional mutations or variants (including novel variants) in the CFTR gene are systematically followed, allowing for prospective assessment of the pathogenic potential of these variants. During the first 3 years of screening, 55 novel variants were identified. Six of these novel variants were discovered in five screen-negative participants and three were identified in multiple unrelated participants. Ten novel variants (c.2554_2555insT, p.F1107L, c.-152G>C, p.L323P, p.L32M, c.2883_2886dupGTCA, c.2349_2350insT, p.K114del, c.-602A>T, and c.2822delT) were associated with a CF phenotype (42% of participants were diagnosed at 4 to 25 months of age), whereas 26 were associated with CFTR-related metabolic syndrome to date. Associations with the remaining novel variants were confounded by the presence of other diseases or other mutations in cis or by inadequate follow-up. These findings have implications for how CF newborn screening and follow-up is conducted and will help guide which genotypes should, and which should not, be considered screen positive for CF in California and elsewhere.
This thesis reconsiders longstanding questions regarding the economic and ideological forces that drove Frankish expansion into Saxony in the late eighth and early ninth centuries, Frankish ...strategies of rule in the newly conquered region, and the effects of conquest and cultural disposession on the Saxons themselves. Specifically, the dissertation seeks to present a new interpretation of this critical historical episode as a process of colonization. After an introduction that briefly outlines various conceptions and definitions of colonization and how these apply to the early medieval period, chapter one provides an overview of the main Latin and Old Saxon sources regarding Saxony and the Saxons in the Carolingian period from the coronation of Pippin III to the suppression of the Saxon Stellinga uprising in 842. The chapter emphasizes the tendentious nature of these sources and the ways in which they reflect the perspective of the colonizer while obscuring the experiences of the colonized. Chapter two looks at the ideological justifications for the conquest advanced in the Frankish primary sources, arguing that the Franks’ forcible Christianization of the Saxons was driven in part by the Carolingian dynasty’s increasingly close ties with the papacy and by ancient imperial prerogatives regarding the extension of the faith. Chapter three, in contrast, examines the economic forces driving Frankish expansion into Saxony, demonstrating that the region possessed more material wealth than is generally assumed. Finally, chapter four turns to the effects of conquest and colonization on the Saxons themselves, analyzing the ways in which imperial ideologies and practices of rule were presented to a newly converted Saxon audience in the Old Saxon Gospel harmony known as the Heliand.
This study examined racial-ethnic differences in the impact of the Youth Partners in Care quality improvement intervention. The intervention was designed to improve access to evidence-based ...depression care, primarily cognitive-behavioral therapy and medication, through primary care. Previous analyses have shown that the quality improvement intervention was associated with improved depression and quality-of-life outcomes at the end of the six-month intervention period.
A randomized controlled trial comparing quality improvement and usual care for youths from diverse racial-ethnic groups from five health care organizations, including managed care, the public sector, and academic center clinics, was conducted. Depressed youths (N=325), who self-identified as black (N=59), Latino (N=224), and white (N=42), aged 13-21 years, were included in these analyses. To evaluate intervention effects within racial-ethnic groups, regression models were constructed, which adjusted for baseline and study site variation in depression symptoms, mental health status, satisfaction with mental health care, and mental health service utilization.
Differential intervention effects were found across racial-ethnic groups. Black youths in the intervention group experienced significant reductions in depression symptoms and had higher rates of use of specialty mental health care at the six-month follow-up. Among Latino youths, the intervention was associated with significantly greater satisfaction with care. Intervention effects were weak among white youths.
Quality improvement interventions may help to reduce disparities in mental health care for youths from racial-ethnic minority groups. (
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