Effectiveness of a paediatric weight management intervention for rural youth (iAmHealthy): Primary outcomes of a cluster randomised control trial

BACKGROUND

Youth in rural areas are disproportionally affected by obesity. Given the unique barriers rural populations face, tailoring and increasing access to obesity interventions is necessary.

OBJECTIVE

This paper evaluates the effectiveness of iAmHealthy, a family-based paediatric obesity intervention delivered to rural children, compared to a Newsletter Control.

METHODS

Participating schools (n = 18) were randomly assigned to iAmHealthy or Newsletter Control. iAmHealthy consists of individual health coaching and group sessions delivered via televideo to a participant's home. The child and parent's body mass index (BMI), child physical activity and child dietary intake were assessed at baseline, post-treatment (8 months) and follow-up (20 months). Multilevel modeling estimated the effect of treatment at both time points.

RESULTS

Parent and child dyads were recruited (n = 148) and randomised to iAmHealthy (n = 64) or the Control group (n = 84). The Control group had significant increases in child BMIz from baseline to follow-up. iAmHealthy youth had no significant changes in BMIz from baseline to post or follow-up. Child dietary intake, physical activity and parent BMI results are also discussed.

CONCLUSIONS

This trial extends previous paediatric obesity work by simultaneously increasing convenience and dose of treatment. Results suggest iAmHealthy resulted in a change in BMIz trajectories and long-term health behaviour for youth.

Prevalence of Parent Mental Health Problems in an Interdisciplinary Feeding Clinic: Short Communication

Parents of children with pediatric feeding disorder (PFD) often experience high stress and may be at advanced risk for mental health conditions. We conducted a retrospective chart review of 413 parents who completed intake surveys at an interdisciplinary feeding clinic to determine the prevalence and types of mental health conditions among parents; 41.8% of parents reported a mental health diagnosis among the mother and/or father. Of the parents with mental health conditions, the most prevalent conditions reported were anxiety (71.1% for mothers, 50% for fathers) and mood disorders (62.7% for mothers, 40.9% for fathers). For mothers, 21.1% indicated their mental health disorder had a postpartum onset. Parents of children with birth complications were more likely to have a mental health condition (50.9%) than parents of children without a birth complication (38.7%), and parents reporting mental health conditions had children with significantly more co-occurring medical conditions. Since parent stress and mental health can influence parent-child interactions during mealtime, this study suggests the importance of addressing both parent mental health factors and child factors when treating children for PFD. Future studies are needed to develop novel interventions that support the specific mental health needs of parents of children with PFD.

Evaluation of Complex Mixture Toxicity in the Milwaukee Estuary (WI, USA) Using Whole-Mixture and Component-Based Evaluation Methods

Anthropogenic activities introduce complex mixtures into aquatic environments, necessitating mixture toxicity evaluation during risk assessment. There are many alternative approaches that can be used to complement traditional techniques for mixture assessment. Our study aimed to demonstrate how these approaches could be employed for mixture evaluation in a target watershed. Evaluations were carried out over 2 years (2017-2018) across 8-11 study sites in the Milwaukee Estuary (WI, USA). Whole mixtures were evaluated on a site-specific basis by deploying caged fathead minnows (Pimephales promelas) alongside composite samplers for 96 h and characterizing chemical composition, in vitro bioactivity of collected water samples, and in vivo effects in whole organisms. Chemicals were grouped based on structure/mode of action, bioactivity, and pharmacological activity. Priority chemicals and mixtures were identified based on their relative contributions to estimated mixture pressure (based on cumulative toxic units) and via predictive assessments (random forest regression). Whole mixture assessments identified target sites for further evaluation including two sites targeted for industrial/urban chemical mixture effects assessment; three target sites for pharmaceutical mixture effects assessment; three target sites for further mixture characterization; and three low-priority sites. Analyses identified 14 mixtures and 16 chemicals that significantly contributed to cumulative effects, representing high or medium priority targets for further ecotoxicological evaluation, monitoring, or regulatory assessment. Overall, our study represents an important complement to single-chemical prioritizations, providing a comprehensive evaluation of the cumulative effects of mixtures detected in a target watershed. Furthermore, it demonstrates how different tools and techniques can be used to identify diverse facets of mixture risk and highlights strategies that can be considered in future complex mixture assessments. Environ Toxicol Chem 2023;42:1229-1256. © 2023 SETAC.

Rationale and design of integrating a parents first obesity intervention with a pediatric weight management intervention for rural families - Evaluating the ripple effect

Rural families are disproportionately affected by obesity. Obesity often runs in families and is impacted by hereditary components, the shared home environment, and parent modeling/child observational learning. Moreover, parent changes in weight predict child changes in weight. Thus, targeting the family unit has the potential to enhance outcomes for adults and children simultaneously. Additionally, engaging rural nurses in medical clinics and schools may be important in determining whether rural telehealth programs are successfully implemented and sustained. This paper describes the rationale and design of a randomized control trial (RCT) evaluating the effectiveness of an integrated adult- and child-focused obesity treatment tailored for rural participants. Outcomes of this study include participant weight loss from baseline to 9-months, device-measured physical activity, and dietary intake. This project will additionally compare reach between clinic and school settings and evaluate the impact of nurse engagement. This study will include 240 participants from eight rural communities who will be randomized to either a Parent +Family-based group or a Newsletter +Family-based group. Parents in the Parent +Family-based group will receive a 3-month adult obesity treatment designed for adult behavior change as a first step. Then, parents and children together will enter the family-based program (iAmHealthy), allowing for potential enhancement of a theorized ripple effect. Parents in the Newsletter +Family-based group will receive 3 monthly newsletters and then participate in the 6-month family-based intervention designed for child behavior change. This study is the first RCT to examine the effectiveness of an integrated adult- and child-focused obesity treatment program. Registered with ClinicalTrials.gov NCT ID NCT05612971.

A Gamified Social Media-Based Head and Neck Radiology Education Initiative of the American Society of Head and Neck Radiology: Viewership and Engagement Trends at 3 Years

BACKGROUND AND PURPOSE

Social media has made inroads in medical education. We report the creation and 3-year (2018-2021) longitudinal assessment of the American Society of Head and Neck Radiology Case of the Week (#ASHNRCOTW), assessing viewership, engagement, and impact of the coronavirus disease 2019 (COVID-19) pandemic on this Twitter-based education initiative.

MATERIALS AND METHODS

Unknown cases were tweeted from the American Society of Head and Neck Radiology account weekly. Tweet impressions (number of times seen), engagements (number of interactions), and new followers were tabulated. A social media marketing platform identified worldwide distribution of Twitter followers. Summary and t test statistics were performed.

RESULTS

#ASHNRCOTW was highly visible with 2,082,280 impressions and 203,137 engagements. There were significantly greater mean case impressions (9917 versus 6346), mean case engagements (1305 versus 474), case engagement rates (13.06% versus 7.76%), mean answer impressions (8760 versus 5556), mean answer engagements (908 versus 436), answer engagement rates (10.38% versus 7.87%), mean total (case + answer) impressions (18,677 versus 11,912), mean total engagements (2214 versus 910), and total engagement rates (11.79% versus 7.69%) for cases published after the pandemic started (all P values < .001). There was a significant increase in monthly new followers after starting #ASHNRCOTW (mean, 134 versus 6; P < .001) and significantly increased monthly new followers after the pandemic started compared with prepandemic (mean, 178 versus 101; P = .003). The American Society of Head and Neck Radiology has 7564 Twitter followers throughout 130 countries (66% outside the United States).

CONCLUSIONS

Social media affords substantial visibility, engagement, and global outreach for radiology education. #ASHNRCOTW viewership and engagement increased significantly during the COVID-19 pandemic.

Validation of remote height and weight assessment in a rural randomized clinical trial

BACKGROUND

The purpose of this study is to describe and assess a remote height and weight protocol that was developed for an ongoing trial conducted during the SARS COV-2 pandemic.

METHODS

Thirty-eight rural families (children 8.3 ± 0.7 years; 68% female; and caregivers 38.2 ± 6.1 years) were provided detailed instructions on how to measure height and weight. Families obtained measures via remote data collection (caregiver weight, child height and weight) and also by trained staff. Differences between data collection methods were examined.

RESULTS

Per absolute mean difference analyses, slightly larger differences were found for child weight (0.21 ± 0.21 kg), child height (1.53 ± 1.29 cm), and caregiver weight (0.48 ± 0.42 kg) between school and home measurements. Both analyses indicate differences had only minor impact on child BMI percentile (- 0.12, 0.68) and parent BMI (0.05, 0.13). Intraclass coefficients ranged from 0.98 to 1.00 indicating that almost all of the variance was due to between person differences and not measurement differences within a person.

CONCLUSION

Results suggest that remote height and weight collection is feasible for caregivers and children and that there are minimal differences in the various measurement methods studied here when assessing group differences. These differences did not have clinically meaningful impacts on BMI. This is promising for the use of remote height and weight measurement in clinical trials, especially for hard-to reach-populations.

TRIAL REGISTRATION

Clinical. Registered in clinicaltrials.gov ( NCT03304249 ) on 06/10/2017.

Pre-deployment risk factors for PTSD in active-duty personnel deployed to Afghanistan: a machine-learning approach for analyzing multivariate predictors

Active-duty Army personnel can be exposed to traumatic warzone events and are at increased risk for developing post-traumatic stress disorder (PTSD) compared with the general population. PTSD is associated with high individual and societal costs, but identification of predictive markers to determine deployment readiness and risk mitigation strategies is not well understood. This prospective longitudinal naturalistic cohort study-the Fort Campbell Cohort study-examined the value of using a large multidimensional dataset collected from soldiers prior to deployment to Afghanistan for predicting post-deployment PTSD status. The dataset consisted of polygenic, epigenetic, metabolomic, endocrine, inflammatory and routine clinical lab markers, computerized neurocognitive testing, and symptom self-reports. The analysis was computed on active-duty Army personnel (N = 473) of the 101st Airborne at Fort Campbell, Kentucky. Machine-learning models predicted provisional PTSD diagnosis 90-180 days post deployment (random forest: AUC = 0.78, 95% CI = 0.67-0.89, sensitivity = 0.78, specificity = 0.71; SVM: AUC = 0.88, 95% CI = 0.78-0.98, sensitivity = 0.89, specificity = 0.79) and longitudinal PTSD symptom trajectories identified with latent growth mixture modeling (random forest: AUC = 0.85, 95% CI = 0.75-0.96, sensitivity = 0.88, specificity = 0.69; SVM: AUC = 0.87, 95% CI = 0.79-0.96, sensitivity = 0.80, specificity = 0.85). Among the highest-ranked predictive features were pre-deployment sleep quality, anxiety, depression, sustained attention, and cognitive flexibility. Blood-based biomarkers including metabolites, epigenomic, immune, inflammatory, and liver function markers complemented the most important predictors. The clinical prediction of post-deployment symptom trajectories and provisional PTSD diagnosis based on pre-deployment data achieved high discriminatory power. The predictive models may be used to determine deployment readiness and to determine novel pre-deployment interventions to mitigate the risk for deployment-related PTSD.

iKanEat: protocol for a randomized controlled trial of megestrol as a component of a pediatric tube weaning protocol

Background

Although tube feeding routinely saves the lives of children who do not eat by mouth, chronic tube feeding can be a burden to patients, caregivers, and families. Very few randomized trials exist regarding the best methods for weaning children from their feeding tubes.

Methods

The current paper describes a randomized controlled trial of an empirically supported outpatient treatment protocol for moving children from tube to oral eating called iKanEat. Specifically, we describe the methods of randomized double-blind, placebo-controlled trial which includes a 4-week course of megestrol, the only medication used in the iKanEat protocol, to determine whether the addition of megestrol results in improved child outcomes. The primary and secondary aims are to assess the safety and efficacy of megestrol as part of the iKanEat protocol. The third aim is to provide critical information about the impact of the transition from tube to oral feeding on parent stress and parent and child quality of life.

Discussion

This trial will provide data regarding whether megestrol is a safe and effective component of the iKanEat tube weaning protocol, as well as important data on how the tube weaning process impacts parent stress and parent and child quality of life.

Trial registration

ClinicalTrials.gov NCT#03815019. Registered on January 17, 2019

Automated High-Frequency Observations of Physical Activity Using Computer Vision

PURPOSE

To test the validity of the Ecological Video Identification of Physical Activity (EVIP) computer vision algorithms for automated video-based ecological assessment of physical activity in settings such as parks and schoolyards.

METHODS

Twenty-seven hours of video were collected from stationary overhead video cameras across 22 visits in nine sites capturing organized activities. Each person in the setting wore an accelerometer, and each second was classified as moderate-to-vigorous physical activity or sedentary/light activity. Data with 57,987 s were used to train and test computer vision algorithms for estimating the total number of people in the video and number of people active (in moderate-to-vigorous physical activity) each second. In the testing data set (38,658 s), video-based System for Observing Play and Recreation in Communities (SOPARC) observations were conducted every 5 min (130 observations). Concordance correlation coefficients (CCC) and mean absolute errors (MAE) assessed agreement between (1) EVIP and ground truth (people counts+accelerometry) and (2) SOPARC observation and ground truth. Site and scene-level correlates of error were investigated.

RESULTS

Agreement between EVIP and ground truth was high for number of people in the scene (CCC = 0.88; MAE = 2.70) and moderate for number of people active (CCC = 0.55; MAE = 2.57). The EVIP error was uncorrelated with camera placement, presence of obstructions or shadows, and setting type. For both number in scene and number active, EVIP outperformed SOPARC observations in estimating ground truth values (CCC were larger by 0.11-0.12 and MAE smaller by 41%-48%).

CONCLUSIONS

Computer vision algorithms are promising for automated assessment of setting-based physical activity. Such tools would require less manpower than human observation, produce more and potentially more accurate data, and allow for ongoing monitoring and feedback to inform interventions.

Divergence in aerobic capacity impacts bile acid metabolism in young women

Liver adaptations may be critical for regular exercise and high aerobic capacity to protect against metabolic disease, but mechanisms remain unknown. Bile acids (BAs) synthesized in the liver are bioactive and can putatively modify energy metabolism. Regular exercise influences BA metabolism in rodents, but effects in humans are unknown. This study tested whether female subjects screened for high aerobic capacity (Hi-Fit, n = 19) [peak oxygen consumption (V̇o2peak) ≥45 mL·kg-1·min-1] have increased hepatic BA synthesis and different circulating BA composition compared with those matched for age and body mass with low aerobic capacity (Lo-Fit, n = 19) (V̇o2peak ≤35 mL·kg-1·min-1). Diet patterns, activity level, stool, and blood were collected at baseline before participants received a 1-wk standardized, eucaloric diet. After the 1-wk standardized diet, stool and blood were again collected and an oral glucose tolerance test (OGTT) was performed to assess insulin sensitivity and postprandial BA response. Contrary to our hypothesis, serum 7α-hydroxy-4-cholesten-3-one (C4), a surrogate of BA synthesis, was not different between groups, whereas Hi-Fit women had lower fecal BA concentrations compared with Lo-Fit women. However, Lo-Fit women had a higher and more sustained rise in circulating conjugated BAs during the OGTT. Hi-Fit women showed a significant post-OGTT elevation of the secondary BA, lithocholic acid (a potent TGR5 agonist), in contrast to Lo-Fit women where no response was observed. A 1-wk control diet eliminated most differences in circulating BA species between groups. Overall, the results emphasize the importance of using a standardized diet when evaluating BAs and indicate that regular exercise and aerobic capacity modulate BA metabolism under postprandial conditions.NEW & NOTEWORTHY Women with contrasting exercise and aerobic capacity levels show clear differences in bile acid (BA) metabolism. Women with low aerobic capacity (Lo-Fit) have increased circulating conjugated BAs post oral glucose tolerance test (OGTT), whereas women with high aerobic capacity (Hi-Fit) display a transient increase. Hi-Fit women show an increase in the secondary BA, lithocholic acid, during the OGTT not seen in Lo-Fit women. Differences in circulating BA species between Hi- and Lo-Fit women possibly contribute to differences in insulin sensitivity and energy regulation via different signaling mechanisms.

Metabolomic analysis of male combat veterans with post traumatic stress disorder

Posttraumatic stress disorder (PTSD) is associated with impaired major domains of psychology and behavior. Individuals with PTSD also have increased co-morbidity with several serious medical conditions, including autoimmune diseases, cardiovascular disease, and diabetes, raising the possibility that systemic pathology associated with PTSD might be identified by metabolomic analysis of blood. We sought to identify metabolites that are altered in male combat veterans with PTSD. In this case-control study, we compared metabolomic profiles from age-matched male combat trauma-exposed veterans from the Iraq and Afghanistan conflicts with PTSD (n = 52) and without PTSD (n = 51) (‘Discovery group’). An additional group of 31 PTSD-positive and 31 PTSD-negative male combat-exposed veterans was used for validation of these findings (‘Test group’). Plasma metabolite profiles were measured in all subjects using ultrahigh performance liquid chromatography/tandem mass spectrometry and gas chromatography/mass spectrometry. We identified key differences between PTSD subjects and controls in pathways related to glycolysis and fatty acid uptake and metabolism in the initial ‘Discovery group’, consistent with mitochondrial alterations or dysfunction, which were also confirmed in the ‘Test group’. Other pathways related to urea cycle and amino acid metabolism were different between PTSD subjects and controls in the ‘Discovery’ but not in the smaller ‘Test’ group. These metabolic differences were not explained by comorbid major depression, body mass index, blood glucose, hemoglobin A1c, smoking, or use of analgesics, antidepressants, statins, or anti-inflammatories. These data show replicable, wide-ranging changes in the metabolic profile of combat-exposed males with PTSD, with a suggestion of mitochondrial alterations or dysfunction, that may contribute to the behavioral and somatic phenotypes associated with this disease.

iAmHealthy: Rationale, design and application of a family-based mHealth pediatric obesity intervention for rural children

Children in rural areas are disproportionately affected by pediatric obesity. Poor access to healthcare providers, lack of nutrition education, lower socioeconomic status, and fewer opportunities to be physically active are all unique barriers that contribute to this growing health concern. There are very few pediatric obesity interventions that have been developed that target this unique population. iAmHealthy is a family-based behavioral, nutrition and physical activity intervention developed with input from rural children and families that capitalizes on the innovative use of mobile health applications (mHealth). iAmHealthy is a 25-contact hour multicomponent intervention delivered over an 8-month period targeting 2nd-4th grade school children and their families. This paper describes the rationale, design, participant/school enrollment, and planned implementation of a randomized controlled trial of the iAmHealthy intervention in comparison to a monthly newsletter delivered through rural elementary schools. Child Body Mass Index z-score (BMIz) is the primary outcome, along with child 24-hour dietary recall, and child accelerometer-determined physical activity and sedentary behavior as secondary outcomes. The study will include 18 schools (with 8 children each) resulting in a final planned sample size of 144 children. This project also has a strong focus on dissemination and implementation science, and thus includes many measures related to the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). Data collection is completed at baseline, end of intervention (8 months), and follow-up (20 months). This study is the first randomized controlled trial to deliver a rurally tailored, empirically supported, family-based behavioral intervention for pediatric obesity solely over mHealth. Registered with ClinicalTrials.gov NCT ID 03304249.

BC200 (BCYRN1) - The shortest, long, non-coding RNA associated with cancer

With the discovery that the level of RNA synthesis in human cells far exceeds what is required to express protein-coding genes, there has been a concerted scientific effort to identify, catalogue and uncover the biological functions of the non-coding transcriptome. Long, non-coding RNAs (lncRNAs) are a diverse group of RNAs with equally wide-ranging biological roles in the cell. An increasing number of studies have reported alterations in the expression of lncRNAs in various cancers, although unravelling how they contribute specifically to the disease is a bigger challenge. Originally described as a brain-specific, non-coding RNA, BC200 (BCYRN1) is a 200-nucleotide, predominantly cytoplasmic lncRNA that has been linked to neurodegenerative disease and several types of cancer. Here we summarise what is known about BC200, primarily from studies in neuronal systems, before turning to a review of recent work that aims to understand how this lncRNA contributes to cancer initiation, progression and metastasis, along with its possible clinical utility as a biomarker or therapeutic target.

Adherence With Multiple National Healthy Lifestyle Recommendations in a Large Pediatric Center Electronic Health Record and Reduced Risk of Obesity

OBJECTIVE

To evaluate the utility of a routine assessment of lifestyle behaviors incorporated into the electronic health record (EHR) to quantify lifestyle practices and obesity risk at a pediatric primary care center.

PATIENTS AND METHODS

Participants included 24,255 patients aged 2 to 18 years whose parent/caregiver completed a self-report lifestyle assessment during a well-child examination (January 1, 2013, through June 30, 2016). Cross-sectional analyses of age, race/ethnicity, body mass index, and lifestyle assessment responses were performed. Outcome measures included prevalence of patients meeting consensus recommendations for physical activity; screen time; and dairy, water, and fruit/vegetable consumption and the odds of obesity based on reported lifestyle behaviors.

RESULTS

Prevalence of meeting recommendations for lifestyle behaviors was highest for physical activity (84%), followed by screen time (61%) and consumption of water (51%), dairy (27%), and fruits/vegetables (10%). Insufficient physical activity was the strongest predictor of obesity (odds ratio [OR], 1.65; 95% CI, 1.51-1.79), followed by excess screen time (OR, 1.36; 95% CI, 1.27-1.45). Disparities existed across ages, races/ethnicities, and sexes for multiple lifestyle habits. Youth who met 0 or 1 lifestyle recommendation were 1.45 to 1.71 times more likely to have obesity than those meeting all 5 recommendations.

CONCLUSION

Healthy behaviors vary in prevalence, as does their association with obesity. This variation is partially explained by age, sex, and race/ethnicity. Meeting national recommendations for specific behaviors is negatively associated with obesity in a dose-dependent manner. These findings support the assessment of lifestyle behaviors in primary care as one component of multilevel initiatives to prevent childhood obesity.

Clinical-Community Collaboration: A Strategy to Improve Retention and Outcomes in Low-Income Minority Youth in Family-Based Obesity Treatment

BACKGROUND

Clinical-community collaboration is a promising strategy for pediatric obesity treatment, but current research is limited. This study examined the effect of a family-based treatment program embedded in a primary care clinic on retention and changes in child weight status at 1 year.

METHODS

Children (2-16 years, BMI ≥85th percentile, 87.0% Hispanic) and their parents were recruited from a single pediatric clinic for Healthy Hawks Primary Plus (HHP+). Children were referred by physicians and enrolled by a bilingual clinic-based recruitment coordinator. Participants received 12 weekly 2-hour sessions focused on lifestyle modification and health behavior change and then received bimonthly follow-up visits with their clinic-based physician through 1-year follow-up. Child body mass index (BMI) percentage of the 95th percentile (%BMI_p95) was measured as the primary outcome at baseline, postintervention, and 1-year follow-up. Random effect multilevel models assessed changes in child weight status over time accounting for clustering by family. To further evaluate the impact, HHP+ retention and changes in child weight status were compared to a standard 12-week treatment program only.

RESULTS

HHP+ participants had significantly better retention at 1 year (73.9%, p ≤ 0.001) compared to the standard treatment program (38.3%). In HHP+, physician visit attendance was significantly correlated with retention at 1 year (r = 0.69, p ≤ 0.001), and HHP+ completers had significant reductions in %BMI_p95 between baseline and 1-year follow-up (p = 0.03).

CONCLUSION

Clinical-community partnerships might be a promising strategy to improve retention and reduce child weight status in populations currently underrepresented in obesity treatment.

Technology Components as Adjuncts to Family-Based Pediatric Obesity Treatment in Low-Income Minority Youth

BACKGROUND

Strategies to treat pediatric obesity are needed, especially among high-need populations. Technology is an innovative approach; however, data on technology as adjuncts to in-person treatment programs are limited.

METHODS

A total of 64 children [body mass index (BMI) ≥85th percentile, mean age = 9.6 ± 3.1 years, 32.8% female, 84.4% Hispanic] were recruited to participate in one of three cohorts of a family-based behavioral group (FBBG) treatment program: FBBG only, TECH1, and TECH2. Rolling, nonrandomized recruitment was used to enroll participants into three cohorts from May 2014 to February 2015. FBBG began in May 2014 and received the standard, in-person 12-week treatment only (n = 21); TECH1 began in September 2014 and received FBBG plus a digital tablet equipped with a fitness app (FITNET) (n = 20); TECH2 began in February 2015 and received FBBG and FITNET, plus five individually tailored TeleMed health-coaching sessions delivered via Skype (n = 23). Child BMI z-score (BMI-z) was assessed at baseline and postintervention. Secondary aims examined weekly FBBG attendance, feasibility/acceptability of FITNET and Skype, and the effect of technology engagement on BMI-z.

RESULTS

FBBG and TECH1 participants did not show significant reductions in BMI-z postintervention [FBBG: β = -0.05(0.04), p = 0.25; TECH1: β = -0.006(0.06), p = 0.92], but TECH2 participants did [β = -0.09(0.02), p < 0.001] and TeleMed session participation was significantly associated with BMI-z reduction [β = -0.04(0.01), p = 0.01]. FITNET use and FBBG attendance were not associated with BMI-z in any cohort. Overall, participants rated the technology as highly acceptable.

CONCLUSIONS

Technology adjuncts are feasible, used by hard-to-reach participants, and show promise for improving child weight status in obesity treatment programs.

Pervasive influence of maternal and paternal criminal offending on early childhood development: a population data linkage study

BACKGROUND

Parental criminal offending is an established risk factor for offending among offspring, but little evidence is available indicating the impact of offending on early childhood functioning. We used data from a large Australian population cohort to determine associations between exposure to parental offending and a range of developmental outcomes at age 5 years.

METHOD

Multi-generation data in 66 477 children and their parents from the New South Wales Child Development Study were combined using data linkage. Logistic and multinomial regressions tested associations between any and violent offending histories of parents (fathers, mothers, or both parents) obtained from official records, and multiple measures of early childhood developmental functioning (social, emotional-behavioural, cognitive, communication and physical domains) obtained from the teacher-reported 2009 Australian Early Development Census.

RESULTS

Parental offending conferred significantly increased risk of vulnerability on all domains, particularly the cognitive domain. Greater risk magnitudes were observed for offending by both parents and by mothers than by fathers, and for violent than for any offending. For all parental offending exposures, vulnerability on multiple domains (where medium to large effects were observed) was more likely than on a single domain (small to medium effects). Relationships remained significant and of comparable magnitude following adjustment for sociodemographic covariates.

CONCLUSIONS

The effect of parental offending on early childhood developmental outcomes is pervasive, with the strongest effects on functioning apparent when both parents engage in violent offending. Supporting affected families in early childhood might mitigate both early developmental vulnerability and the propensity for later delinquency among these offspring.

Splenic Abscess

We reviewed the imaging findings of 14 splenic abscesses in 13 patients. All patients underwent chest radiography, 12 ultrasonography (US), 9 CT, 4 plain abdominal radiography, 2 99mTc-HMPAO leukocyte scan and 2 99mTc-HIG scan. Three patients were treated with percutaneous catheter drainage, and 5 with diagnostic or therapeutic fine-needle aspiration (FNA). At US the abscess was hypoechoic (n = 9), anechoic (n = 2), or anechoic with gasbubbles (n = 1), or the entire spleen was inhomogeneous with gasbubbles (n = 1). At CT the abscesses appeared as low density (18–30 HU) lesions with (n = 2) or without (n = 7) gas. In 2 cases 99mTc-HMPAO leukocyte scan, and in one case 99mTc-HIG scan showed an intrasplenic defect, and in one case 99mTc-HIG scan was considered normal. At plain abdominal radiography extraintestinal gas was suggested in 2 patients, and the findings were normal in 2. US-guided FNA confirmed infectious etiology of the lesion in 4 patients, and a necrotic specimen suggested infection in one. One patient was cured with repeated aspirations. Catheter drainage was successful in all 3 patients who underwent the procedure. We conclude that US and CT are accurate in detecting splenic abscesses. Our results in splenic interventions advocate wider use of the procedures.

Comparison of lipopolysaccharides and soluble CD14 measurement between clinically endotoxaemic and nonendotoxaemic horses

REASONS FOR PERFORMING STUDY

Clinically useful biomarkers are needed for early identification of endotoxaemic horses. Soluble CD14 (sCD14) is amplified early in response to inflammatory signals, including bacterial lipopolysaccharide (LPS), and may prove a useful biomarker for clinical endotoxaemia.

OBJECTIVES

The aim of this study was to determine if sCD14 could serve as a more reliable biomarker of the clinical signs of endotoxaemia, compared to measuring LPS alone.

STUDY DESIGN

Prospective observational study in horses at a veterinary teaching hospital.

METHODS

Plasma samples were collected from 20 healthy horses and 35 horses presenting for emergency evaluation. Horses were classified as clinically endotoxaemic, using previously established criteria, if they had a heart rate >70 beats/min, packed cell volume >45% and/or a lesion likely to result in endotoxaemia. Soluble CD14 was measured using a cytometric bead-based assay and LPS was measured using a Limulus amoebocyte lysate (LAL) assay.

RESULTS

Soluble CD14 was higher in horses classified as clinically endotoxaemic (median 1102 ng/ml, interquartile range 439 ng/ml), compared to clinically nonendotoxaemic (median 692 ng/ml, interquartile range 455 ng/ml, P = 0.03. There was no difference in LPS concentrations between clinically nonendotoxaemic (median 5.4 endotoxin units [EU]/ml, interquartile range 5 EU/ml) and endotoxaemic horses (median 7.2 EU/ml, interquartile range 17 EU/ml, P = 0.2). There was no correlation between sCD14 and LPS values in paired serum samples. LPS and sCD14 values were used to generate a receiver operating characteristic curve. The area under the curve for LPS and sCD14 was <0.7, suggesting that sCD14 and LPS were poor predictors of clinical endotoxaemia for the horses in this study.

CONCLUSIONS

Further investigation is warranted to assess the utility of sCD14 measurement as a clinically useful biomarker to identify endotoxaemia in horses.

A Randomized Controlled Trial of an Outpatient Protocol for Transitioning Children from Tube to Oral Feeding: No Need for Amitriptyline

OBJECTIVE

To assess the role of amitriptyline in the effectiveness of an outpatient protocol for weaning medically complicated children from tube to oral feeding.

STUDY DESIGN

Twenty-one children seen in multidisciplinary outpatient feeding teams across 4 sites were recruited to a randomized placebo-controlled trial of a 6-month outpatient treatment protocol with behavioral, oral-motor, nutrition, and medication components.

RESULTS

All of the children who completed the 6-month program (73%) were weaned to receive only oral feeding, regardless of group assignment. The transition from tube to oral feeding resulted in decreases in body mass index percentile and pain, some improvements in quality of life, and no statistically significant changes in cost.

CONCLUSIONS

Amitriptyline is not a key component of this otherwise effective outpatient, interdisciplinary protocol for weaning children from tube to oral feeding.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01206478.

Post-illness-onset risk of offending across the full spectrum of psychiatric disorders

BACKGROUND

The link between psychotic disorders and violent offending is well established; knowledge about risk of post-illness-onset offending across the full spectrum of psychiatric disorders is lacking. We aimed to compare rates of any offending and violent offending committed after the onset of illness, according to diagnostic group, with population controls.

METHOD

A 25% random sample of the Danish population (n = 521 340) was followed from their 15th birthday until offending occurred. Mental health status was considered as a time-varying exposure in a Poisson regression model used to examine the duration from service contact to the offence.

RESULTS

Males with any psychiatric contact had an incidence rate ratio (IRR) of 2.91 [95% confidence interval (CI) 2.80-3.02] for any offending; 4.18 (95% CI 3.99-4.38) for violent offending. Associations were stronger for women (IRR 4.17, 95% CI 3.95-4.40 for any offending; 8.02, 95% CI 7.20-8.94 for violent offending). Risk was similar across diagnostic groups for any offending in males, while variation between diagnostic groups was seen for male violent and female offending, both any and violent.

CONCLUSIONS

Risk of offending, particularly violent offending, was elevated across a range of mental disorders following first contact with mental health services. The extent of variation in strength of effect across diagnoses differed by gender.

Treating rural paediatric obesity through telemedicine vs. telephone: Outcomes from a cluster randomized controlled trial

OBJECTIVE

The objective of the current study was to examine the feasibility of telemedicine vs. telephone for the delivery of a multidisciplinary weekly family-based behavioural group intervention to treat paediatric obesity delivered to families living in rural areas using a randomized controlled trial methodology.

METHODS

103 rural children and their families were recruited. Feasibility measures included participant satisfaction, session attendance and retention. Treatment outcome measures included child Body Mass Index z-score (BMIz), parent BMI, 24-hour dietary recalls, accelerometer data, the child behavior checklist and the behavioral pediatrics feeding assessment scale.

RESULTS

Participants were highly satisfied with the intervention both via telemedicine and via telephone. Completion rates were much higher than for other paediatric obesity intervention programmes, and both methodologies were highly feasible. There were no differences in telemedicine and telephone groups on primary outcomes.

CONCLUSION

Both telemedicine and telephone intervention appear to be feasible and acceptable methods of delivering paediatric obesity treatment to rural children.

Violent and non-violent crime against adults with severe mental illness

BACKGROUND

Little is known about the relative extent of crime against people with severe mental illness (SMI).

AIMS

To assess the prevalence and impact of crime among people with SMI compared with the general population.

METHOD

A total of 361 psychiatric patients were interviewed using the national crime survey questionnaire, and findings compared with those from 3138 general population controls participating in the contemporaneous national crime survey.

RESULTS

Past-year crime was experienced by 40% of patients v. 14% of controls (adjusted odds ratio (OR) = 2.8, 95% CI 2.0-3.8); and violent assaults by 19% of patients v. 3% of controls (adjusted OR = 5.3, 95% CI 3.1-8.8). Women with SMI had four-, ten- and four-fold increases in the odds of experiencing domestic, community and sexual violence, respectively. Victims with SMI were more likely to report psychosocial morbidity following violence than victims from the general population.

CONCLUSIONS

People with SMI are at greatly increased risk of crime and associated morbidity. Violence prevention policies should be particularly focused on people with SMI.

Caring for Tube-Fed Children: A Review of Management, Tube Weaning, and Emotional Considerations

Enteral nutrition is the practice of delivering nutrition to the gut either orally or through a tube or other device. Many children are reliant on enteral feedings to either supplement their nutrition or as a complete source of their nutrition. Managing children on tube feedings requires a team of providers to work through such dilemmas as feeding schedules, weaning from tube feeding, sensory implications of tube feeding, treatment of pain or nausea associated with eating, oral-motor issues, and behavioral issues in the child and family. The purpose of the current review is to summarize the multidisciplinary aspects of enteral feeding. The multidisciplinary team consists of a variable combination of an occupational therapist, speech-language pathologist, gastroenterologist, psychologist, nurse, pharmacist, and dietitian. Children who have minimal oral feeding experience and are fed via a nasogastric or gastrostomy tube often develop oral aversions. Limited data support that children with feeding disorders are more likely to have sensory impairment and that early life pain experiences contribute to feeding refusal. There are inpatient and outpatient programs for weaning patients from tube feeding to eating. The parent-child interaction is an important part of the assessment and treatment of the tube-fed child. This review also points out many information gaps, including data on feeding schedules, blenderized tube feedings, the best methods for weaning children off enteral feedings, the efficacy of chronic pain medications with tube-fed children, and, finally, the necessity of the assessment of parental stress among all parents of children who are tube fed.

Domestic and sexual violence against patients with severe mental illness

BACKGROUND

Domestic and sexual violence are significant public health problems but little is known about the extent to which men and women with severe mental illness (SMI) are at risk compared with the general population. We aimed to compare the prevalence and impact of violence against SMI patients and the general population.

METHOD

Three hundred and three randomly recruited psychiatric patients, in contact with community services for ⩾ 1 year, were interviewed using the British Crime Survey domestic/sexual violence questionnaire. Prevalence and correlates of violence in this sample were compared with those from 22 606 general population controls participating in the contemporaneous 2011/12 national crime survey.

RESULTS

Past-year domestic violence was reported by 27% v. 9% of SMI and control women, respectively [odds ratio (OR) adjusted for socio-demographics, aOR 2.7, 95% confidence interval (CI) 1.7-4.0], and by 13% v. 5% of SMI and control men, respectively (aOR 1.6, 95% CI 1.0-2.8). Past-year sexual violence was reported by 10% v. 2.0% of SMI and control women respectively (aOR 2.9, 95% CI 1.4-5.8). Family (non-partner) violence comprised a greater proportion of overall domestic violence among SMI than control victims (63% v. 35%, p < 0.01). Adulthood serious sexual assault led to attempted suicide more often among SMI than control female victims (53% v. 3.4%, p < 0.001).

CONCLUSIONS

Compared to the general population, patients with SMI are at substantially increased risk of domestic and sexual violence, with a relative excess of family violence and adverse health impact following victimization. Psychiatric services, and public health and criminal justice policies, need to address domestic and sexual violence in this at-risk group.

Outcomes from an urban pediatric obesity program targeting minority youth: the Healthy Hawks program

BACKGROUND

The aim of this study was to describe the outcomes of a family-based behavioral group treatment program with a group of urban, minority, low-income families.

METHODS

Two hundred and ten families enrolled in a 12-week family-based behavioral group treatment program for pediatric obesity. The program was offered in English and in Spanish and targeted the enrollment of low-income highly diverse youth and families. Primary outcome measures included child BMI z-score (zBMI), maternal BMI, 3-day diet record, and accelerometer.

RESULTS

Seventy-one percent of enrolled families completed the 12-week program. Significant 12-week outcomes were achieved for child zBMI (p<0.001) and for maternal BMI (p<0.001), as well as for child kcals (p<0.001), sugar-sweetened beverages (p=0.017), and red foods (p<0.001). Only change in child zBMI remained significant at 1 year (p<0.05). Physical activity outcomes were not significant and not in the expected direction. There were no differences in outcome by race/ethnicity, but by age, younger children had higher zBMI at baseline and were also more likely to decrease zBMI during the intervention.

CONCLUSIONS

It is possible to enroll and maintain urban, minority, low-income families in a family-based behavioral group treatment program for pediatric obesity. Outcome data indicate that these families achieve significant outcomes on zBMI, and that children who remain available for assessment maintain this at 1 year, which is an improvement over previous research using other intervention methodologies with this population.

Improving Melt Strength of Polylactic Acid

Melt strength of polylactic acid (PLA) was improved through various modifications including grafting, crosslinking, chain extension, blending, plasticizing and nucleation. The results showed that melt strength was increased, to varying degrees, by crosslinking, chain extension and blending. In addition, melt strain (detected by velocity) was increased by chain extension, blending with elastomer, and plasticizing, but was decreased by crosslinking. The molecular weights, thermal properties and viscosity of the modified PLAs were also studied to investigate the causes of the observed variations in melt strength. Viscosity results generally corresponded with that of melt strength, but not with that of melt strain. With the exception of plasticizing and nucleation, the modifications had no significant effect on the thermal properties of PLA. The molecular weight (in particular the extremely large molecules representing by Mz) and the polydispersity of PLA were significantly increased after crosslinking and chain extension, which accounts for the observed increase in melt strength.

Insurer and employer views on pediatric obesity treatment: a qualitative study

OBJECTIVE

The effectiveness of group-based comprehensive, multidisciplinary (stage 3) pediatric weight management programs is backed by a growing body of literature, yet insurance coverage of these programs is scarce to nonexistent, limiting their reach and long-term survival. The objective of this study was to better understand the perspectives of insurers and large employers on the issue of group-based treatment coverage.

DESIGN AND METHODS

The authors performed a qualitative study utilizing structured interviews with these stakeholders, following accepted techniques.

RESULTS

Six major themes emerged: cost, program effectiveness, corporate social responsibility, secondary parental (employee) benefits, coverage options and new benefit determination.

CONCLUSION

Future efforts to secure payment for group-based pediatric weight management programs should address these key themes.

Effect of Compatibilizer Distribution on Thermal and Rheological Properties of Gelatinized Starch/Biodegradable Polyesters Blends

Thermal and rheological properties of various blends of gelatinized starch and biodegradable polyester, polycaprolactone (PCL) or poly(butylene succinate adipate) (PBSA), were studied by DSC, TGA and rheometry. Methylenediphenyl diisocyanate (MDI) was used as a compatibilizer and was distributed in different phases through controlled processing. The addition of MDI showed a stronger effect on thermal and rheological properties when it was mainly distributed in the polyester phase prior to blending. Starch was shown to increase the shear viscosity of both types of polyesters. The two blends, starch/PCL and starch/PBSA, showed a similar pattern of a power law dependence of viscosity on shear rate. MDI was shown to enhance the effect of starch on the melting and decomposition temperatures, especially when distributed in the polyester phase.

Offending prior to first psychiatric contact: a population-based register study

BACKGROUND

There is a well-established association between psychotic disorders and subsequent offending but the extent to which those who develop psychosis might have a prior history of offending is less clear. Little is known about whether the association between illness and offending exists in non-psychotic disorders. The aim of this study was to determine whether the association between mental disorder and offending is present prior to illness onset in psychotic and non-psychotic disorders.

METHOD

In a nested case-control study, cases (n=101,890) with a first psychiatric contact during the period 1995 to 2006 were identified and matched by age and gender to population-based controls (n=2,236,195). Exposure was defined as prior criminal and violent offending.

RESULTS

Males with one offence had an incidence rate ratio (IRR) of 2.32 [95% confidence interval (CI) 2.26-2.40] for psychiatric admission whereas two or more convictions yielded an IRR of 4.97 (95% CI 4.83-5.11). For violent offending the associations were stronger and IRRs of 3.97 (95% CI 3.81-4.12) and 6.18 (95% CI 5.85-6.52) were found for one and several offences respectively. Estimates for females were of a similar magnitude. The pattern was consistent across most diagnostic subgroups, although some variability in effect sizes was seen, and persisted after adjustment for substance misuse and socio-economic status (SES).

CONCLUSIONS

A prior history of offending is present in almost one in five patients presenting to mental health services, which makes it an important issue for clinicians to consider when assessing current and future risks and vulnerabilities.

Criminal offending before and after the onset of psychosis: examination of an offender typology

OBJECTIVE

Clinicians often consider whether or not offenders with psychosis have a history of offending pre-dating the onset of their illness. The typology of offenders based on age at first offence, developed in the field of criminology, has been recently extended to mentally disordered groups, but this ignores the potential role of illness onset.

METHOD

Using a large UK cohort of individuals with both psychosis and offending histories (n=331), we compared those with a history of offending pre-dating their illness (pre-morbid offenders) to those who commenced offending after becoming unwell (post-morbid offenders). We compared the demographic, clinical and offending pattern characteristics of the two groups.

RESULTS

198 (60%) had offended before the onset of psychosis. These pre-morbid offenders were more likely to be male, have a lower pre-morbid IQ and have had a history of neurological abnormality. Pre-morbid offenders also committed more crime overall, but this was due to an excess of acquisitive, drug and minor offending, rather than violent offending, which was comparable to the post-morbid offending group.

CONCLUSION

Currently, standardised clinical risk assessment tools view offenders with mental illness as a homogenous group with respect to life-course patterns of offending in relation to illness. Taking account of an individual's pathway to offending may improve risk assessment and management.

Violent behaviour in U.K. military personnel returning home after deployment

BACKGROUND

There is growing concern about an alleged rise in violent behaviour amongst military personnel returning from deployment to Iraq and Afghanistan. The aims of this study were to determine the prevalence of violence in a sample of U.K. military personnel following homecoming from deployment in Iraq and to examine the impact of deployment-related experiences, such as combat trauma, on violence, and the role of sociodemographics and pre-enlistment antisocial behaviour.

METHOD

This study used baseline data from a cohort study of a large randomly selected sample of U.K. Armed Forces personnel in service at the time of the Iraq war (2003). Regular personnel (n=4928) who had been deployed to Iraq were included. Data, collected by questionnaire, included information on deployment experiences, sociodemographic and military characteristics, pre-enlistment antisocial behaviour, post-deployment health outcomes and a self-report measure of physical violence in the weeks following return from deployment.

RESULTS

Prevalence of violence was 12.6%. This was strongly associated with pre-enlistment antisocial behaviour [adjusted odds ratio (aOR) 3.6, 95% confidence interval (CI) 2.9-4.4]. After controlling for pre-enlistment antisocial behaviour, sociodemographics and military factors, violence was still strongly associated with holding a combat role (aOR 2.0, 95% CI 1.6-2.5) and having experienced multiple traumatic events on deployment (aOR for four or more traumatic events 3.7, 95% CI 2.5-5.5). Violence on homecoming was also associated with mental health problems such as post-traumatic stress disorder (aOR 4.8, 95% CI 3.2-7.2) and alcohol misuse (aOR 3.1, 95% CI 2.5-3.9).

CONCLUSIONS

Experiences of combat and trauma during deployment were significantly associated with violent behaviour following homecoming in U.K. military personnel. Post-deployment mental health problems and alcohol misuse are also associated with increased violence.

Criminal conviction among offspring with parental history of mental disorder

BACKGROUND

Offspring of parents with mental disorder are at risk of a range of adverse outcomes. We sought to establish whether such risks extend to offending by examining rates of criminal conviction, including conviction for violent and sexual offences, among offspring of parents with mental disorder compared to offspring without parental disorder.

METHOD

From a random sample of the Danish population, a cohort aged ≤15 years (n=412,117) was followed for the occurrence of conviction between January 1981 and December 2006. Incidence rate ratios (IRRs) and cumulative incidences for offspring conviction by parental mental disorder status were calculated using a Cox regression model. Analyses were repeated for conviction for a serious first offence.

RESULTS

Offspring with history of parental mental disorder had higher rates of conviction than those without parental disorder; rates were highest for those with two affected parents [IRR 3.39, 95% confidence interval (CI) 3.08-3.73]. The association persisted when parental gender, offspring gender and the nature of parental disorder were considered. Absolute rates were lower but relative rates higher for female offspring (IRR 3.26 for males with two affected parents, 4.52 for females). Similar patterns were seen for conviction for serious offences. Associations were attenuated after adjustment was made for family socio-economic position (SEP) and parental criminality.

CONCLUSIONS

Offspring of parents with mental disorder represent a group at elevated risk of criminality. This raises the possibility of shared familial vulnerability for mental disorder and criminal behaviour, and highlights the need to consider early identification and intervention in this group.

A multi-site randomized controlled trial of a cognitive skills programme for male mentally disordered offenders: social-cognitive outcomes

BACKGROUND

Cognitive skills programmes have been associated with improvements on psychometric measures and reductions in antisocial behaviour in mentally disordered offenders (MDOs). However, to date there have been no randomized controlled trials (RCTs) of such programmes with this population. In the first RCT of a cognitive skills programme with MDOs we aimed to determine if participation in the Reasoning and Rehabilitation (R&R) programme was associated with improvements in social-cognitive skills and thinking styles.

METHOD

A total of 84 men with a primary diagnosis of psychotic disorder and a history of violence were recruited from medium-secure forensic units and allocated to receive R&R (n=44) or treatment as usual (TAU; n=40). At baseline and post-treatment interviews, participants completed questionnaires to assess social problem-solving, criminal attitudes, anger experience, blame externalizing and perspective-taking. Researchers were not blind to group status.

RESULTS

The R&R group demonstrated significant improvements on measures of social problem-solving relative to the TAU group, some of which were maintained at 12 months post-treatment. Only half of those allocated to receive R&R completed the full programme. In post-hoc analyses programme completers showed improvements in social problem-solving at the end of treatment and changes in criminal attitudes at 12 months post-treatment.

CONCLUSIONS

Among male MDOs, R&R participation was associated with improvements in social-cognitive skills, some of which were maintained for up to 12 months post-treatment. Our finding that programme completers do better may reflect pre-treatment patient characteristics. This study establishes that multi-site RCTs can be conducted in medium-secure forensic units.

Mental health and health service use among post-national service veterans: results from the 2007 Adult Psychiatric Morbidity Survey of England

BACKGROUND

There is concern surrounding the psychological health and uptake of treatment services among veterans of the UK Armed Forces.

METHOD

Data from a cross-sectional, nationally representative sample were used to compare health outcomes and treatment seeking among 257 post-national service veterans aged 16-64 years and 504 age and sex frequency-matched non-veterans living in the community in England. Early leavers (<4 years service) were compared with longer serving veterans.

RESULTS

Male veterans reported more childhood adversity and were more likely to have experienced a major trauma in adulthood than non-veterans. There was no association between any measure of mental health and veteran status in males, except reporting more violent behaviours [adjusted odds ratio (aOR) 1.44, 95% confidence interval (CI) 1.01-2.06]. In females, a significant association was found between veteran status and ever having suicidal thoughts (aOR 2.82, 95% CI 1.13-7.03). No differences in treatment-seeking behaviour were identified between veterans and non-veterans with any mental disorder. Early service leavers were more likely to be heavy drinkers (aOR 4.16, 95% CI 1.08-16.00), to have had suicidal thoughts (aOR 2.37, 95% CI 1.21-4.66) and to have self-harmed (aOR 12.36, 95% CI 1.61-94.68) than longer serving veterans.

CONCLUSIONS

The findings of this study do not suggest that being a veteran is associated with adversity in terms of mental health, social disadvantage or reluctance to seek treatment compared with the general population. Some evidence implies that early service leavers may experience more mental health problems than longer-serving veterans.

Combining dimensional and categorical representation of psychosis: the way forward for DSM-V and ICD-11?

BACKGROUND

There is good evidence that psychotic symptoms segregate into symptom dimensions. However, it is still unclear how these dimensions are associated with risk indicators and other clinical variables, and whether they have advantages over categorical diagnosis in clinical practice. We investigated symptom dimensions in a first-onset psychosis sample and examined their associations with risk indicators and clinical variables. We then examined the relationship of categorical diagnoses to the same variables.

METHOD

We recruited 536 patients as part of a population-based, incidence study of psychosis. Psychopathology was assessed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). A principal axis factor analysis was performed on symptom scores. The relationship of dimension scores with risk indicators and with clinical variables was then examined employing regression analyses. Finally, regression models were compared to assess the contribution of dimensions versus diagnosis in explaining these variables.

RESULTS

Factor analysis gave rise to a five-factor solution of manic, reality distortion, negative, depressive and disorganization symptom dimensions. The scores of identified dimensions were differentially associated with specific variables. The manic dimension had the highest number of significant associations; strong correlations were observed with shorter duration of untreated psychosis, acute mode of onset and compulsory admission. Adding dimensional scores to diagnostic categories significantly increased the amount of variability explained in predicting these variables; the reverse was also true but to a lesser extent.

CONCLUSIONS

Categorical and dimensional representations of psychosis are complementary. Using both appears to be a promising strategy in conceptualising psychotic illnesses.

Effect of clinical audits of radiation use in one hospital district in Finland

BACKGROUND

A clinical audit is a systematic, independent, and documented process to improve the quality of radiological processes and radiation safety for patients.

PURPOSE

To evaluate the effect of an audit process by comparing the results of two consecutive audits at the same units.

MATERIAL AND METHODS

Audits were carried out twice at each imaging unit in the southwest hospital district of Finland: first, at the end of 2003, and again in November 2007. Both evaluations were carried out in a similar way: by interviewing personnel and examining documents, independent experts from other hospital districts ensured that diagnostic medical imaging processes at each unit were carried out according to generally accepted standards for good medical radiological procedures. The results of the consecutive audits were compared in order to analyze the effects of the clinical audits.

RESULTS

The use of radiation was in accordance with the requirements and standards of good medical procedures at every audited unit during both evaluations. The list of audit criteria was fulfilled satisfactorily on both occasions at all of the audited units, and clearly better during the second run. In the first audit, the auditors made 80 recommendations for improving diagnostic procedures and, in the second audit, 53 recommendations. During the first audit, most of the recommendations (22/80) concerned instructions in the fundamental practice of examining a patient. During the second audit, most recommendations were in the category of radiation doses.

CONCLUSION

The clinical audit had a positive impact on the practice of work procedures in radiological departments. Most of the recommendations made after the first audit had been taken into consideration by the time of the second audit.

Minor physical anomalies in patients with first-episode psychosis: their frequency and diagnostic specificity

BACKGROUND

An increased prevalence of minor physical anomalies (MPAs) has been extensively documented in schizophrenia but their specificity for the disorder remains unclear. We investigated the prevalence and the predictive power of MPAs in a large sample of first-episode psychotic patients across a range of diagnoses.

METHOD

MPAs were examined in 242 subjects with first-episode psychosis (50% schizophrenia, 45% affective psychosis and 5% substance-induced psychosis) and 158 healthy controls. Categorical principal components analysis and analysis of variance were undertaken, and individual items with the highest loading were tested using the chi2 test.

RESULTS

Overall facial asymmetry, assymetry of the orbital landmarks, and frankfurt horizontal significantly differentiated patients with schizophrenia and affective psychosis from controls, as did a 'V-shaped' palate, reduced palatal ridges, abnormality of the left ear surface and the shape of the left and right ears. Patients with affective psychosis had significantly lowered eye fissures compared with control subjects.

CONCLUSIONS

MPAs are not specific to schizophrenia, suggesting a common developmental pathway for non-affective and affective psychoses. The topographical distribution of MPAs in this study is suggestive of an insult occurring during organogenesis in the first trimester of pregnancy.

Predictors of violent victimization amongst those with psychosis

OBJECTIVE

The aim of this study was to establish the prevalence and predictors of violent victimization amongst a community-dwelling sample of individuals with psychosis.

METHOD

The 2-year prevalence of self-reported violent victimization was estimated for a sample of 708 individuals with chronic psychosis living in the community in four urban UK centres. Baseline socio-demographic and clinical factors were examined as possible risk factors for victimization over the 2-year follow-up period.

RESULTS

The 2-year prevalence of violent victimization in the sample was 23%. Four factors were found to be independently predictive of victimization - history of victimization, less than daily family contact, young age at illness onset and the presence of co-morbid Cluster B personality disorder.

CONCLUSION

Those with psychotic illnesses are at elevated risk of being assaulted. Given the likely adverse health implications, clinicians should routinely enquire about victimization in their assessments of those with psychotic disorders particularly amongst those who are socially isolated, with a younger age of illness onset and in those with co-morbid personality disorder.

A comparison of symptoms and family history in schizophrenia with and without prior cannabis use: implications for the concept of cannabis psychosis

BACKGROUND

There is considerable interest in cannabis use in psychosis. It has been suggested that the chronic psychosis associated with cannabis use, is symptomatically distinct from idiopathic schizophrenia. Several studies have reported differences in psychopathology and family history in people with schizophrenia according to whether or not they were cannabis users. We set out to test the hypotheses arising from these studies that cannabis use is associated with more bizarre behaviour, more thought disorder, fewer negative symptoms including blunted affect, more delusions of reference, more paranoid delusions and a stronger family history of schizophrenia.

METHOD

We used a case register that contained 757 cases of first onset schizophrenia, 182 (24%) of whom had used cannabis in the year prior to first presentation, 552 (73%) had not and 3% had missing data. We completed the OPCRIT checklist on all patients and investigated differences in the proportion of people with distractibility, bizarre behaviour, positive formal thought disorder, delusions of reference, well organised delusions, any first rank symptom, persecutory delusions, abusive/accusatory hallucinations, blunted affect, negative thought disorder, any negative symptoms (catatonia, blunted affect, negative thought disorder, or deterioration), lack of insight, suicidal ideation and a positive family history of schizophrenia, using chi square tests. Logistic regression modelling was then used to determine whether prior cannabis use affected the presence of the characteristics after controlling for age, sex and ethnicity.

RESULTS

There was no statistically significant effect of cannabis use on the presence of any of the above. There remained however a non-significant trend towards more insight (OR 0.65 p=0.055 for "loss of insight") and a finding of fewer abusive or accusatory hallucinations (OR 0.65 p=0.049) of borderline significance amongst the cannabis users. These were in the hypothesised direction. There was no evidence of fewer negative symptoms or greater family history amongst cannabis users.

CONCLUSION

We found few appreciable differences in symptomatology between schizophrenic patients who were or were not cannabis users. There were no differences in the proportion of people with a positive family history of schizophrenia between cannabis users and non-users. This argues against a distinct schizophrenia-like psychosis caused by cannabis.