Economic evaluation of tele-resuscitation intervention on emergency department pediatric visits in the Niagara Region, Canada a pilot study

Introduction

The use of telemedicine in critical care is emerging, however, there is a paucity of information surrounding the costs relative to health gains in the pediatric population. This study aimed to estimate the cost-effectiveness of a pediatric tele-resuscitation (Peds-TECH) intervention compared to the usual care in five community hospital emergency departments (EDs). Using a decision tree analysis approach with secondary retrospective data from a 3-year time period, this cost-effectiveness analysis was completed.

Methods

A mixed methods quasi-experimental design was embedded in the economic evaluation of Peds-TECH intervention. Patients aged <18 years triaged as Canadian Triage and Acuity Scale 1 or 2 at EDs were eligible to receive the intervention. Qualitative interviews were conducted with parents/caregivers to explore the out-of-pocket (OOP) expenses. Patient-level health resource utilization was extracted from Niagara Health databases. The Peds-TECH budget calculated one-time technology and operational costs per patient. Base-case analyses determined the incremental cost per year of life lost (YLL) averted, and additional sensitivity analysis confirmed the robustness of the results.

Results

Odds ratio for mortality among cases was 0.498 (95% CI: 0.173, 1.43). The average cost of a patient receiving the Peds-TECH intervention was $2,032.73 compared to $317.45 in usual care. In total, 54 patients received the Peds-TECH intervention. Fewer children died in the intervention group resulting in 4.71 YLL. The probabilistic analysis revealed an incremental cost-effectiveness ratio of $64.61 per YLL averted.

Conclusion

Peds-TECH appears to be a cost-effective intervention for resuscitating infants/children in hospital emergency departments.

A Clinically Significant Difference on the COPM: A Review

Background. The Canadian Occupational Performance Measure (COPM) assists occupational therapists to identify occupational performance problems using a client-centred approach. Since its first publication in 1991, there has been abundant evidence of the ability of the COPM to detect a statistically significant difference as an outcome measure. There has also been a tacit understanding that a difference of 2 points from pre-test to post-test on either Performance or Satisfaction COPM score represents a clinically significant difference. There is however, some confusion about the origins of this claim. Purpose. To ascertain empirical evidence for the claim that a clinically significant difference is a change score ≥2 points. Method. We conducted a scoping review of peer-reviewed literature (1991-2020) for intervention studies using the COPM as an outcome measure and examined intervention type and change scores. Findings. One hundred studies were identified. The COPM was used to assess effectiveness of eight types of occupational therapy interventions. The common belief, however, was not empirically supported that clinical significance can be asserted on the basis of a two-point change in COPM scores. Implications. Further research is needed to test alternative approaches to asserting clinical significance or a minimal clinically important difference.

'Breast Cosmesis After Breast-Conserving Therapy' Who is the Judge, Patient or Surgeon?

INTRODUCTION

More than 80% of newly diagnosed breast cancers are managed with breast-conserving therapy (BCT). Preservation of cosmetically acceptable breasts is an inherent aim of all breast-conserving efforts-this can, however, be difficult to assess objectively. Compounding this is the difference in perception of breast cosmesis between patients and surgeons. This study compares the concordance of a new subscale-based cosmetic score (TCS) with the patient's perception.

METHOD

Eastern Health Breast and Cancer Centre conducted this study on patients who had completed their BCT and radiotherapy. Participation was voluntary and involved permitting an assessor (breast surgery fellow or consultant) to grade cosmetic outcomes to generate a Total Cosmesis Score (TCS). The patients blinded to this assessment were then asked to complete the postoperative segment of the BCT module of the Breast-Q questionnaire. TCS from surgeon assessment was compared against patient assessment (questions BQ1i and BQ1k specifically). Cohen's kappa was calculated to define the strength of the inter-rater agreement.

RESULTS

One hundred twelve patients with a mean age of 59 (range 27-89) participated in the study. TCS was low in 26% and high in 74% of participants. 76% and 69% of participants were satisfied when answering Breast-Q questions 'How your lumpectomy breast looks?' and 'How you look in the mirror unclothed?' respectively (Cohen's k = 0.464, 95% CI 0.337-0.591, p < 0.01). The agreement between the TCS and the patient assessment was poor (Cohen's k = 0.172, 95% CI - 0.020-2.093, p = 0.067).

CONCLUSION

Cosmetic outcomes scored using TCS by surgeons do not match patient's own assessment of the cosmetic result.

Lesion Volume in Relapsing Multiple Sclerosis is Associated with Perivascular Space Enlargement at the Level of the Basal Ganglia

BACKGROUND AND PURPOSE

Perivascular spaces surround the blood vessels of the brain and are involved in neuroimmune functions and clearance of metabolites via the glymphatic system of the brain. Enlarged perivascular spaces could be a marker of dysfunction in these processes and, therefore, are highly relevant to monitoring disease activity in MS. This study aimed to compare the number of enlarged perivascular spaces in people with relapsing MS with MR imaging markers of inflammation and brain atrophy.

MATERIALS AND METHODS

Fifty-nine patients (18 with clinically isolated syndrome, 22 with early and 19 with late relapsing-remitting MS) were scanned longitudinally (mean follow-up duration = 19.6 [SD, 0.5] months) using T2-weighted, T1-weighted, and FLAIR MR imaging. Two expert raters identified and counted enlarged perivascular spaces on T2-weighted MR images from 3 ROIs (the centrum semiovale, basal ganglia, and midbrain). Baseline and change with time in the number of enlarged perivascular spaces were correlated with demographics and lesion and brain volumes.

RESULTS

Late relapsing-remitting MS had a greater average number of enlarged perivascular spaces at baseline at the level of the basal ganglia (72.3) compared with early relapsing-remitting MS (60.5) and clinically isolated syndrome (54.7) (F = 3.4, P = .042), and this finding correlated with lesion volume (R = 0.44, P = .0004) but not brain atrophy (R = -0.16). Enlarged perivascular spaces increased in number with time in all regions, and the rate of increase did not differ among clinical groups.

CONCLUSIONS

Enlarged perivascular spaces at the level of the basal ganglia are associated with greater neuroinflammatory burden, and the rate of enlargement appears constant in patients with relapsing-remitting disease phenotypes.

Characteristics of heterosexually-acquired compared to homosexually-acquired HIV and implications for clinical practice: results from the Australian HIV Observational Database

Heterosexuals living with HIV report feeling additional HIV stigma compared to homosexual men, which may affect clinical outcomes. Yet, beyond routinely collected surveillance data, little is known about the characteristics of individuals who acquire HIV heterosexually and clinical outcomes by mode of sexual acquisition have not been directly compared. Using data from the Australian HIV Observational Database, we compared clinical characteristics of those with heterosexually-acquired (Het-HIV) to homosexually-acquired HIV (Hom-HIV) to investigate any differences and their implications for clinical management. 513 Het-HIV and 1467 Hom-HIV patients were included and contributed 3,127 and 9,457 person-years of follow-up, respectively. Compared with Hom-HIV, Het-HIV were more often born outside Australia (62.5% vs 39.9%, p<0.001), less likely to have Hepatitis C (4.8% vs 7.8%, p=0.029) and had lower median CD4 counts at diagnosis (292 vs 450 cells/µL, p<0.001) and cART initiation (270 vs 340 cells/µL, p<0.001). Despite these lower CD4 counts, there were no significant differences between groups for time to the major clinical endpoints of cART initiation, viral suppression, virological failure or all-cause mortality. Het-HIV had a lower risk of loss-to-follow-up than Hom-HIV (aHR 0.78; 95% CI 0.64-0.95). Further studies examining factors associated with, and interventions to inform retention in care are required.

Virological failure and HIV drug resistance among adults living with HIV on second-line antiretroviral therapy in the Asia-Pacific

OBJECTIVES

To assess second-line antiretroviral therapy (ART) virological failure and HIV drug resistance-associated mutations (RAMs), in support of third-line regimen planning in Asia.

METHODS

Adults > 18 years of age on second-line ART for ≥ 6 months were eligible. Cross-sectional data on HIV viral load (VL) and genotypic resistance testing were collected or testing was conducted between July 2015 and May 2017 at 12 Asia-Pacific sites. Virological failure (VF) was defined as VL > 1000 copies/mL with a second VL > 1000 copies/mL within 3-6 months. FASTA files were submitted to Stanford University HIV Drug Resistance Database and RAMs were compared against the IAS-USA 2019 mutations list. VF risk factors were analysed using logistic regression.

RESULTS

Of 1378 patients, 74% were male and 70% acquired HIV through heterosexual exposure. At second-line switch, median [interquartile range (IQR)] age was 37 (32-42) years and median (IQR) CD4 count was 103 (43.5-229.5) cells/µL; 93% received regimens with boosted protease inhibitors (PIs). Median duration on second line was 3 years. Among 101 patients (7%) with VF, CD4 count > 200 cells/µL at switch [odds ratio (OR) = 0.36, 95% confidence interval (CI): 0.17-0.77 vs. CD4 ≤ 50) and HIV exposure through male-male sex (OR = 0.32, 95% CI: 0.17-0.64 vs. heterosexual) or injecting drug use (OR = 0.24, 95% CI: 0.12-0.49) were associated with reduced VF. Of 41 (41%) patients with resistance data, 80% had at least one RAM to nonnucleoside reverse transcriptase inhibitors (NNRTIs), 63% to NRTIs, and 35% to PIs. Of those with PI RAMs, 71% had two or more.

CONCLUSIONS

There were low proportions with VF and significant RAMs in our cohort, reflecting the durability of current second-line regimens.

Advanced ADC Histogram, Perfusion, and Permeability Metrics Show an Association with Survival and Pseudoprogression in Newly Diagnosed Diffuse Intrinsic Pontine Glioma: A Report from the Pediatric Brain Tumor Consortium

BACKGROUND AND PURPOSE

Diffuse intrinsic pontine glioma is a lethal childhood brain cancer with dismal prognosis and MR imaging is the primary methodology used for diagnosis and monitoring. Our aim was to determine whether advanced diffusion, perfusion, and permeability MR imaging metrics predict survival and pseudoprogression in children with newly diagnosed diffuse intrinsic pontine glioma.

MATERIALS AND METHODS

A clinical trial using the poly (adenosine diphosphate ribose) polymerase (PARP) inhibitor veliparib concurrently with radiation therapy, followed by maintenance therapy with veliparib + temozolomide, in children with diffuse intrinsic pontine glioma was conducted by the Pediatric Brain Tumor Consortium. Standard MR imaging, DWI, dynamic contrast-enhanced perfusion, and DSC perfusion were performed at baseline and approximately every 2 months throughout treatment. ADC histogram metrics of T2-weighted FLAIR and enhancing tumor volume, dynamic contrast-enhanced permeability metrics for enhancing tumors, and tumor relative CBV from DSC perfusion MR imaging were calculated. Baseline values, post-radiation therapy changes, and longitudinal trends for all metrics were evaluated for associations with survival and pseudoprogression.

RESULTS

Fifty children were evaluable for survival analyses. Higher baseline relative CBV was associated with shorter progression-free survival (P = .02, Q = 0.089) and overall survival (P = .006, Q = 0.055). Associations of higher baseline mean transfer constant from the blood plasma into the extravascular extracellular space with shorter progression-free survival (P = .03, Q = 0.105) and overall survival (P = .03, Q = 0.102) trended toward significance. An increase in relative CBV with time was associated with shorter progression-free survival (P < .001, Q < 0.001) and overall survival (P = .004, Q = 0.043). Associations of longitudinal mean extravascular extracellular volume fraction with progression-free survival (P = .03, Q = 0.104) and overall survival (P = .03, Q = 0.105) and maximum transfer constant from the blood plasma into the extravascular extracellular space with progression-free survival (P = .03, Q = 0.102) trended toward significance. Greater increases with time were associated with worse outcomes. True radiologic progression showed greater post-radiation therapy decreases in mode_ADC_FLAIR compared with pseudoprogression (means, -268.15 versus -26.11, P = .01.) CONCLUSIONS: ADC histogram, perfusion, and permeability MR imaging metrics in diffuse intrinsic pontine glioma are useful in predicting survival and pseudoprogression.

Society of pediatric liver transplantation: Current registry status 2011-2018

BACKGROUND

SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies.

OBJECTIVE

To report the outcomes of the SPLIT registry from 2011 to 2018.

METHODS

This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period.

RESULTS

A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.

Early mortality after late initiation of antiretroviral therapy in the TREAT Asia HIV Observational Database (TAHOD) of the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Asia-Pacific

OBJECTIVES

Early mortality among those still initiating antiretroviral therapy (ART) with advanced stages of HIV infection in resource-limited settings remains high despite recommendations for universal HIV treatment. We investigated risk factors associated with early mortality in people living with HIV (PLHIV) starting ART at low CD4 levels in the Asia-Pacific.

METHODS

PLHIV enrolled in the Therapeutics, Research, Education and AIDS Training in Asia (TREAT Asia) HIV Observational Database (TAHOD) who initiated ART with a CD4 count < 100 cells/μL between 2003 and 2018 were included in the study. Early mortality was defined as death within 1 year of ART initiation. PLHIV in follow-up for > 1 year were censored at 12 months. Competing risk regression was used to analyse risk factors with loss to follow-up as a competing risk.

RESULTS

A total of 1813 PLHIV were included in the study, of whom 74% were male. With 73 (4%) deaths, the overall first-year mortality rate was 4.27 per 100 person-years (PY). Thirty-eight deaths (52%) were AIDS-related, 10 (14%) were immune reconstituted inflammatory syndrome (IRIS)-related, 13 (18%) were non-AIDS-related and 12 (16%) had an unknown cause. Risk factors included having a body mass index (BMI) < 18.5 [sub-hazard ratio (SHR) 2.91; 95% confidence interval (CI) 1.60-5.32] compared to BMI 18.5-24.9, and alanine aminotransferase (ALT) ≥ 5 times its upper limit of normal (ULN) (SHR 6.14; 95% CI 1.62-23.20) compared to ALT < 5 times its ULN. A higher CD4 count (51-100 cells/μL: SHR 0.28; 95% CI 0.14-0.55; and > 100 cells/μL: SHR 0.12; 95% CI 0.05-0.26) was associated with reduced hazard for mortality compared to CD4 count ≤ 25 cells/μL.

CONCLUSIONS

Fifty-two per cent of early deaths were AIDS-related. Efforts to initiate ART at CD4 counts > 50 cell/μL are associated with improved short-term survival rates, even in those with late stages of HIV disease.

Pathways and Resources for Engagement and Participation (PREP): Improving the Participation of Youth With Disabilities in Community-Based Occupations

Date Presented 04/04/19

This study demonstrates the effectiveness of a novel, client-centered OT intervention, named PREP, for improving the participation of youth with disabilities. By removing environmental barriers, OTs enabled 28 youth to successfully take part in the activities they identified, such as shopping with friends, riding a bike, and joining a glee club. These findings support a shift toward community-based ecological practices that occur in real-life situations.

Primary Author and Speaker: Dana Anaby

Additional Authors and Speakers: Rachel Teplicky, Laura Turner

Contributing Authors: Mary Law, Lisa Avery, Annette Majnemer, Debbie Feldman

Signal Hyperintensity on Unenhanced T1-Weighted Brain and Cervical Spinal Cord MR Images after Multiple Doses of Linear Gadolinium-Based Contrast Agent

BACKGROUND AND PURPOSE

The clinical implications of gadolinium deposition in the CNS are not fully understood, and it is still not known whether gadolinium tends to be retained more in the brain compared with the spinal cord. In this study, we assessed the effects of linear gadolinium-based contrast agents on the T1 signal intensity of 3 cerebral areas (dentate nucleus, globus pallidus, and the less studied substantia nigra) and the cervical spinal cord in a population of patients with MS.

MATERIALS AND METHODS

A single-center population of 100 patients with MS was analyzed. Patients underwent 2-16 contrast-enhanced MRIs. Fifty patients received ≤5 linear gadolinium injections, and 50 patients had ≥6 injections: Fifty-two patients had both Gd-DTPA and gadobenate dimeglumine injections, and 48 patients received only gadobenate dimeglumine. A quantitative analysis of signal intensity changes was independently performed by 2 readers on the first and last MR imaging scan. The globus pallidus-to-thalamus, substantia nigra-to-midbrain, dentate nucleus-to-middle cerebellar peduncle, and the cervical spinal cord-to-pons signal intensity ratios were calculated.

RESULTS

An increase of globus pallidus-to-thalamus (mean, +0.0251 ± 0.0432; P < .001), dentate nucleus-to-middle cerebellar peduncle (mean, +0.0266 ± 0.0841; P = .002), and substantia nigra-to-midbrain (mean, +0.0262 ± 0.0673; P < .001) signal intensity ratios after multiple administrations of linear gadolinium-based contrast agents was observed. These changes were significantly higher in patients who received ≥6 injections (P < .001) and positively correlated with the number of injections and the accumulated dose of contrast. No significant changes were detected in the spinal cord (mean, +0.0008 ± 0.0089; P = .400).

CONCLUSIONS

Patients with MS receiving ≥6 linear gadolinium-based contrast agent injections showed a significant increase in the signal intensity of the globus pallidus, dentate nucleus, and substantia nigra; no detectable changes were observed in the cervical spinal cord.

Diabetes, mortality and glucose monitoring rates in the TREAT Asia HIV Observational Database Low Intensity Transfer (TAHOD-LITE) study

OBJECTIVES

Diabetes is a growing cause of morbidity and mortality in people living with HIV (PLHIV) receiving antiretroviral therapy (ART). We investigated the association between fasting plasma glucose (FPG) levels and mortality, and factors associated with FPG monitoring rates in Asia.

METHODS

Patients from the Therapeutics Research, Education, and AIDS Training in Asia (TREAT Asia) HIV Observational Database Low Intensity Transfer (TAHOD-LITE) cohort were included in the present study if they had initiated ART. Competing risk and Poisson regression were used to analyse the association between FPG and mortality, and assess risk factors for FPG monitoring rates, respectively. FPG was categorized as diabetes (FPG ≥ 7.0 mmol/L), prediabetes (FPG 5.6-6.9 mmol/L) and normal FPG (FPG < 5.6 mmol/L).

RESULTS

In total, 33 232 patients were included in the analysis. Throughout follow-up, 59% had no FPG test available. The incidence rate for diabetes was 13.7 per 1000 person-years in the 4649 patients with normal FPG at ART initiation. Prediabetes [sub-hazard ratio (sHR) 1.32; 95% confidence interval (CI) 1.07-1.64] and diabetes (sHR 1.90; 95% CI 1.52-2.38) were associated with mortality compared to those with normal FPG. FPG monitoring increased from 0.34 to 0.78 tests per person-year from 2012 to 2016 (P < 0.001). Male sex [incidence rate ratio (IRR) 1.08; 95% CI 1.03-1.12], age > 50 years (IRR 1.14; 95% CI 1.09-1.19) compared to ≤ 40 years, and CD4 count ≥ 500 cells/μL (IRR 1.04; 95% CI 1.00-1.09) compared to < 200 cells/μL were associated with increased FPG monitoring.

CONCLUSIONS

Diabetes and prediabetes were associated with mortality. FPG monitoring increased over time; however, less than half of our cohort had been tested. Greater resources should be allocated to FPG monitoring for early diabetic treatment and intervention and to optimize survival.

Personal, environmental, and family factors of participation among young children

OBJECTIVE

The purpose of this study is to assess the influences of environment, population characteristics, and service utilization on participation frequency and involvement in the home setting among children 0 to 5 years.

METHOD

Data were collected from parents of 236 children (mean age 3 years and 5 months, SD = 1.30, girls = 152 and boys = 84) using a children's treatment centre in Ontario through an online survey. Two path models measuring home frequency and home involvement were assessed using structural equation modelling. The exogenous factors in the models included child's age, child's sex, child's complexity, number of environmental barriers, income, mother's participation, and service utilization. In addition to participation as the primary outcome, each model explored predictors of service utilization and mother's participation.

RESULTS

The involvement model (R²  = 0.46) explained more variance than the frequency model (R²  = 0.33). Age (0.35, P < 0.001) and barriers (0.07, P = 0.001) predicted participation frequency in the home, χ² (9) = 8.51, P < 0.4, root mean square error of approximation (RMSEA) = 0.00, comparative fit index (CFI) = 1.00. The home involvement model, χ² (6) = 9.79, P < 0.13, RMSEA = 0.06, CFI = 0.97, showed that increasing age (0.09, P < 0.001), lower complexity (0.13, P = 0.001), and higher mother's participation (0.057, P = 0.001) were significantly related to higher participation. An increase in child's age or complexity significantly influenced service utilization across both models. Complexity reduced mother's participation in both the frequency and involvement models.

CONCLUSIONS

This study is one of the first in Canada to examine participation of young children. The aggregation of each unit factor, particularly barriers and complexity, can accrue a large impact on the child's and mother's participation. The potential to mediate this impact by removing environmental barriers and promoting mother's participation merits further study.

Long-term loss to follow-up in the TREAT Asia HIV Observational Database (TAHOD)

OBJECTIVES

With earlier antiretroviral therapy (ART) initiation, time spent in HIV care is expected to increase. We aimed to investigate loss to follow-up (LTFU) in Asian patients who remained in care 5 years after ART initiation.

METHODS

Long-term LTFU was defined as LTFU occurring after 5 years on ART. LTFU was defined as (1) patients not seen in the previous 12 months; and (2) patients not seen in the previous 6 months. Factors associated with LTFU were analysed using competing risk regression.

RESULTS

Under the 12-month definition, the LTFU rate was 2.0 per 100 person-years (PY) [95% confidence interval (CI) 1.8-2.2 among 4889 patients included in the study. LTFU was associated with age > 50 years [sub-hazard ratio (SHR) 1.64; 95% CI 1.17-2.31] compared with 31-40 years, viral load ≥ 1000 copies/mL (SHR 1.86; 95% CI 1.16-2.97) compared with viral load < 1000 copies/mL, and hepatitis C coinfection (SHR 1.48; 95% CI 1.06-2.05). LTFU was less likely to occur in females, in individuals with higher CD4 counts, in those with self-reported adherence ≥ 95%, and in those living in high-income countries. The 6-month LTFU definition produced an incidence rate of 3.2 per 100 PY (95% CI 2.9-3.4 and had similar associations but with greater risks of LTFU for ART initiation in later years (2006-2009: SHR 2.38; 95% CI 1.93-2.94; and 2010-2011: SHR 4.26; 95% CI 3.17-5.73) compared with 2003-2005.

CONCLUSIONS

The long-term LTFU rate in our cohort was low, with older age being associated with LTFU. The increased risk of LTFU with later years of ART initiation in the 6-month analysis, but not the 12-month analysis, implies that there was a possible move towards longer HIV clinic scheduling in Asia.

Socio-economic status and risk of tuberculosis: a case-control study of HIV-infected patients in Asia

SETTING

Tuberculosis (TB) is the most common human immunodeficiency virus (HIV) related opportunistic infection and cause of acquired immune-deficiency syndrome related death. TB often affects those from a low socio-economic background.

OBJECTIVE

To assess the socio-economic determinants of TB in HIV-infected patients in Asia.

DESIGN

This was a matched case-control study. HIV-positive, TB-positive cases were matched to HIV-positive, TB-negative controls according to age, sex and CD4 cell count. A socio-economic questionnaire comprising 23 questions, including education level, employment, housing and substance use, was distributed. Socio-economic risk factors for TB were analysed using conditional logistic regression analysis.

RESULTS

A total of 340 patients (170 matched pairs) were recruited, with 262 (77.1%) matched for all three criteria. Pulmonary TB was the predominant type (n = 115, 67.6%). The main risk factor for TB was not having a university level education (OR 4.45, 95%CI 1.50-13.17, P = 0.007). Burning wood or coal regularly inside the house and living in the same place of origin were weakly associated with TB diagnosis.

CONCLUSIONS

These data suggest that lower socio-economic status is associated with an increased risk of TB in Asia. Integrating clinical and socio-economic factors into HIV treatment may help in the prevention of opportunistic infections and disease progression.

Relationships between Adaptive Behaviours, Personal Factors, and Participation of Young Children

AIM

To examine the extent to which personal factors (age, socioeconomic grouping, and preterm birth) and adaptive behaviour explain the participation patterns of young children.

METHODS

65 Children 2-5 years old with and without a history of preterm birth and no physical or intellectual disability were selected by convenience sampling from Galway University Hospital, Ireland. Interviews with parents were conducted using the Adaptive Behaviour Assessment System, Second Edition (ABAS-II) and the Assessment of Preschool Children's Participation (APCP). Linear regression models were used to identify associations between the ABAS-II scores, personal factors, and APCP scores for intensity and diversity of participation.

RESULTS

Adaptive behaviour explained 21% of variance in intensity of play, 18% in intensity of Skill Development, 7% in intensity of Active Physical Recreation, and 6% in intensity of Social Activities controlling for age, preterm birth, and socioeconomic grouping. Age explained between 1% and 11% of variance in intensity of participation scores. Adapted behaviour (13%), Age (17%), and socioeconomic grouping (5%) explained a significant percentage of variance in diversity of participation controlling for the other variables.

CONCLUSIONS

Adaptive behaviour had a unique contribution to children's intensity and diversity of participation, suggesting its importance.

Psychometric Evaluation of the Young Children's Participation and Environment Measure (YC-PEM) for use in Singapore

AIMS

To estimate the psychometric properties of a culturally adapted version of the Young Children's Participation and Environment Measure (YC-PEM) for use among Singaporean families.

METHODS

This is a prospective cohort study. Caregivers of 151 Singaporean children with (n = 83) and without (n = 68) developmental disabilities, between 0 and 7 years, completed the YC-PEM (Singapore) questionnaire with 3 participation scales (frequency, involvement, and change desired) and 1 environment scale for three settings: home, childcare/preschool, and community. Setting-specific estimates of internal consistency, test-retest reliability, and construct validity were obtained.

RESULTS

Internal consistency estimates varied from .59 to .92 for the participation scales and .73 to .79 for the environment scale. Test-retest reliability estimates from the YC-PEM conducted on two occasions, 2-3 weeks apart, varied from .39 to .89 for the participation scales and from .65 to .80 for the environment scale. Moderate to large differences were found in participation and perceived environmental support between children with and without a disability.

CONCLUSIONS

YC-PEM (Singapore) scales have adequate psychometric properties except for low internal consistency for the childcare/preschool participation frequency scale and low test-retest reliability for home participation frequency scale. The YC-PEM (Singapore) may be used for population-level studies involving young children with and without developmental disabilities.

Abstract 447: A novel proteotoxic combination therapy for EGFR+ and HER2+ cancers

EGFR and/or HER2 are frequently overexpressed oncoproteins in HER2+ breast cancer, Triple Negative Breast Cancer (TNBC), and Inflammatory Breast Cancer (IBC). However, EGFR and/or HER2 targeting agents have failed to make major advances in improving survival for these cancer patients, largely because these cancers frequently develop resistance to these drugs. The identification of novel treatment strategies is critically needed. Overexpression of EGFR and/or HER2 presents a severe burden to the secretary pathway, as HER-family proteins EGFR, HER2, HER3 share conserved extracellular cysteine-rich and proline-rich repeats that form numerous disulfide bonds and control cis-trans isomerization in the protein folding processes. We demonstrated that the disulfide bond disrupting Agents (DDAs) selectively killed EGFR+ and/or HER2+ breast cancer cells in vitro and decreased tumor growth of HER2+ cancer in a xenograft mouse model. DDA-dependent anti-cancer actions resulted from downregulation of EGFR/HER2/HER3, induction of AKT dephosphorylation, and activation of Endoplasmic Reticulum (ER) stress. We also investigated a novel proteotoxic combination therapy employing DDAs and Proline Isomerase Inhibitors (PIIs) in treating breast cancers. PIIs potentiated the efficacy of DDAs in downregulating EGFR/HER2/HER3 levels and initiating ER stress, and the combination was highly synergistic in reducing EGFR+ and/or HER2+ breast cancer cell viability. Importantly, the combination of DDAs and PIIs overcame single drug resistance, significantly decreased tumor volumes and increased the survival of xenograft mice. Evidence that the drug combination was effective against metastatic breast cancer cells is also provided.

Citation Format: Mengxiong Wang, Renan Ferreira, Mary Law, Elham Yaaghubi, Coy Heldermon, Ronald Castellano, Brian Law. A novel proteotoxic combination therapy for EGFR+ and HER2+ cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 447.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

Complications of Radiotherapy and Radiosurgery in the Brain and Spine

Radiation therapy is an integral part of the standard of care for many patients with brain and spine tumors. Stereotactic radiation surgery is increasingly being used as an adjuvant therapy as well as a sole treatment. However, despite newer and more focused techniques, radiation therapy still causes significant neurotoxicity. In this article, we reviewed the scientific literature, presented cases of patients who had developed different complications related to conventional radiation therapy or radiosurgery (gamma knife), demonstrated the imaging findings, and discussed the relevant clinical information for the correct diagnoses. Radiation therapy can cause injury in different ways: directly damaging the structures included in the radiation portal, indirectly affecting the blood vessels, and increasing the chance of tumor development. We also divided radiation complications according to the time of occurrence: acute (0 to 4 weeks), early delayed (4 weeks to months), and late delayed (months to years). With the increasing application of radiation therapy for the treatment of CNS tumors, it is important for the neuroradiologist to recognize the many possible complications of radiation therapy. Although this may cause significant diagnostic challenges, understanding the pathophysiology, time course of onset, and imaging features may help institute early therapy and prevent possible deleterious outcomes.

Learning Objectives

To recognize the main complications of radiation therapy and stereotactic radiosurgery in the brain and spine, and to highlight the imaging findings to improve the diagnostic process and treatment planning.

The effectiveness of the Pathways and Resources for Engagement and Participation (PREP) intervention: improving participation of adolescents with physical disabilities

AIM

This study examined the effectiveness of the Pathways and Resources for Engagement and Participation (PREP) intervention in improving the participation of adolescents in community-based activities.

METHOD

Twenty-eight adolescents (14 males, 14 females), aged 12 to 18 years (mean 14y 6mo, SD 21.6mo) with moderate physical disabilities participated in a 12-week PREP intervention. An interrupted time series design with multiple baselines was employed, replicating the intervention effect across three chosen activities and all participants. An occupational therapist worked individually with adolescents and parents to identify and implement strategies to remove environmental barriers that impede participation in selected activities. Activity performance was repeatedly measured using the Canadian Occupational Performance Measure (COPM) at baseline, intervention, and follow-up (20wks). For each activity, the trajectory representing change in performance was analyzed descriptively. Segmented regression combined with a mixed-effects modeling approach was used to statistically estimate the overall effectiveness of the intervention within and across 79 activities.

RESULTS

A statistically significant improvement (B=2.08, p<0.001) was observed across all activities, 59 per cent of which also indicated a clinically significant change of more than 2 points on the COPM scale. Levels of performance were maintained during follow-up with an additional increase of 0.66 points on the COPM scale (t=3.04, p=0.004). Intervention was most effective for males and those with a higher number of functional issues.

INTERPRETATION

Findings illustrate that participation can be improved by changing the environment only. Such evidence further supports emerging therapeutic approaches that are activity-based, goal-oriented, and ecological in nature.

WHAT THIS PAPER ADDS

Environment-based intervention strategies, guided by the Pathways and Resources for Engagement and Participation, are effective in improving and maintaining adolescent participation. Intervention was most effective for males and those with a higher number of functional issues. The study design serves as an example for future pragmatic studies accounting for individual-based changes and contexts.

Abstract P2-11-16: The safety and pathological impact of neoadjuvant radiotherapy for local advanced breast cancer undergoing mastectomy and autologous reconstruction

Introduction

Delayed breast reconstructions are preferred if post mastectomy radiotherapy is indicated due to lower complication rates compared to immediate permanent implant or autologous reconstructions (AR) but cosmetic outcomes are inferior. Radiotherapy has a deleterious effect on implants and autologous tissue and often an interim tissue expander is place which has inherent pain and complications.

However, neoadjuvant radiotherapy (NART) prior to surgery allows for definitive oncological surgery to be performed with an immediate AR in a single operation and the avoidance of a temporary expander. The aim of this study is to assess the safety and downstaging impact of NART.

Methods

This is a prospective review of patients who underwent NART at GenesisCare Victoria, the Austin and the Alfred hospital. 59 LABC patients (median age 49.2 years) were divided into two groups; clinically staged and pathologically staged for reporting. There were 15 pathologically staged patients (pStage 2A-3C) and 43 clinically staged patients (cStage 2A-3B). All patients initially underwent NACT, followed by NART (median dose 50.4Gy in 28 fractions) to the breast, supraclavicular fossa and level 3 axilla with or without coverage of their Level 1 and 2 axilla, and/or internal mammary nodes. Approximately 6 weeks after completing NART, patients underwent definitive surgery and AR.

Results

All patients completed their NART with minimal toxicity and no break in treatment. 55 patients had a skin-sparing mastectomy (SSM) and 3 patients had a modified radical mastectomy. All clinically staged patients underwent an AD. ARs with a DIEP flap were performed in the majority of patients (51). The average length of hospitalisation was 6.2 days.

The Miller Payne (MP) scoring index was used to record pathological responses in clinically staged patients. Overall 36 patients achieved significant downstaging of their disease, with MP scores of 5/5 for 20 and 4/5 for 16. Only 1 patient failed to achieve any downstaging with a MP score of 1/5. All 12 Her2 positive patients, 3/5 Triple negative patients and 5/26 Luminal A/B patients achieved a MP score of 5/5. All patients achieved R0 resection margins. This included 6 patients who had initial cT4 disease (cT4a X2, cT4b X1 and cT4d X3). 15 patients had initial cN2/3 disease and all successfully underwent their axillary dissections with R0 resections achieved. 10/15 had no involved axillary nodes with significant scarring seen in 6. 5/15 had residual involved nodes with significant scarring seen in 3 patients.

Post surgical toxicities were graded using Clavien-Dindo classification. 8 significant grade 3 toxicities were seen in 6 patients, with no grade 4 or 5 toxicities. No patients developed DVT or PE. No flap losses were seen.

Median follow up is 23 months. Cosmesis was rated as good to excellent in all cases. 1 patient developed simultaneous loco-regional and distant recurrence with another 3 patients developing distant metastases only.

Conclusion

This review demonstrated that NART is a safe technique, which has not lead to an increase in surgical complication rates or resulted in a detriment in cosmetic outcome. NART can achieve a shorter, simpler reconstructive journey for patients.

Citation Format: Baker C, Chao MW, Jassal S, Neoh D, Bevington E, Hyett A, Grinsell D, Loh SW, Zantuck N, Stoney D, Foley C, Law M, Chew G, Yu V, Cheng M, Guerrieri M, Taylor K, Chipman M, Cokelek M, Lim Joon D, Foroudi F. The safety and pathological impact of neoadjuvant radiotherapy for local advanced breast cancer undergoing mastectomy and autologous reconstruction [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-11-16.

Measuring Participation of Children and Environmental Factors at Home, School, and in Community: Construct Validation of the Korean PEM-CY

AIMS

To determine construct validity of the Korean Participation and Environment Measure for Children and Youth (KPEM-CY) in South Korea.

METHODS

A total of 184 parents of children with (n = 80) and without disabilities (n = 104) aged 5 to 13 years completed the KPEM-CY. Construct validity was analyzed by assessing differences in the participation and environment scores for children with and without disabilities across age and gender.

RESULTS

Validity of the KPEM-CY was supported by significant differences in participation and environmental factors for subgroups (p < .05). Children with disabilities participated less in typical activities and had more environmental barriers than those without disabilities across all settings. Parents of children with disabilities reported a higher level of desire to change their children's participation patterns. Similar participation patterns and environmental factors, which were influenced by interaction effects between disability and age, were confirmed at home and in the community.

CONCLUSIONS

KPEM-CY is a valid measure to assess participation and environmental factors in home, school, and community settings for Korean children, aged 5-13 years, with and without disabilities.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Smoking and projected cardiovascular risk in an HIV-positive Asian regional cohort

OBJECTIVES

The aim of the study was to assess the prevalence and characteristics associated with current smoking in an Asian HIV-positive cohort, to calculate the predictive risks of cardiovascular disease (CVD), coronary heart disease (CHD) and myocardial infarction (MI), and to identify the impact that simulated interventions may have.

METHODS

Logistic regression analysis was used to distinguish associated current smoking characteristics. Five-year predictive risks of CVD, CHD and MI and the impact of simulated interventions were calculated utilizing the Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D) algorithm.

RESULTS

Smoking status data were collected from 4274 participants and 1496 of these had sufficient data for simulated intervention calculations. Current smoking prevalence in these two groups was similar (23.2% vs. 19.9%, respectively). Characteristics associated with current smoking included age > 50 years compared with 30-39 years [odds ratio (OR) 0.65; 95% confidence interval (CI) 0.51-0.83], HIV exposure through injecting drug use compared with heterosexual exposure (OR 3.03; 95% CI 2.25-4.07), and receiving antiretroviral therapy (ART) at study sites in Singapore, South Korea, Malaysia, Japan and Vietnam in comparison to Thailand (all OR > 2). Women were less likely to smoke than men (OR 0.11; 95% CI 0.08-0.14). In simulated interventions, smoking cessation demonstrated the greatest impact in reducing CVD and CHD risk and closely approximated the impact of switching from abacavir to an alternate antiretroviral in the reduction of 5-year MI risk.

CONCLUSIONS

Multiple interventions could reduce CVD, CHD and MI risk in Asian HIV-positive patients, with smoking cessation potentially being the most influential.

Misspecification of at-risk periods and distributional assumptions in estimating COPD exacerbation rates: The resultant bias in treatment effect estimation

In trials comparing the rate of chronic obstructive pulmonary disease exacerbation between treatment arms, the rate is typically calculated on the basis of the whole of each patient's follow-up period. However, the true time a patient is at risk should exclude periods in which an exacerbation episode is occurring, because a patient cannot be at risk of another exacerbation episode until recovered. We used data from two chronic obstructive pulmonary disease randomized controlled trials and compared treatment effect estimates and confidence intervals when using two different definitions of the at-risk period. Using a simulation study we examined the bias in the estimated treatment effect and the coverage of the confidence interval, using these two definitions of the at-risk period. We investigated how the sample size required for a given power changes on the basis of the definition of at-risk period used. Our results showed that treatment efficacy is underestimated when the at-risk period does not take account of exacerbation duration, and the power to detect a statistically significant result is slightly diminished. Correspondingly, using the correct at-risk period, some modest savings in required sample size can be achieved. Using the proposed at-risk period that excludes recovery times requires formal definitions of the beginning and end of an exacerbation episode, and we recommend these be always predefined in a trial protocol.

Leisure participation-preference congruence of children with cerebral palsy: a Children's Assessment of Participation and Enjoyment International Network descriptive study

AIM

To examine participation-preference congruence, regional differences in participation-preference congruence, and predictors of whether children with cerebral palsy participate in preferred activities.

METHOD

The sample (n=236) included 148 males and 88 females aged 10 to 13 years, living in Victoria, Australia (n=110), Ontario (n=80), or Quebec (n=46), Canada. Ninety-nine (41.9%) were classed at Gross Motor Function Classification System (GMFCS) level I; 89 (37.7%) at GMFCS level II/III; and 48 (20.3%) at GMFCS level IV/V. Participants completed the Children's Assessment of Participation and Enjoyment and Preferences for Activity of Children questionnaires. Regional comparisons were performed using one-way analyses of variance and factors influencing participation-preference congruence were explored using multiple linear regression.

RESULTS

The proportion of children doing non-preferred activities in each activity type was generally low (2-17%), with only one regional difference. Higher proportions were not doing preferred active physical (range 23.2-29.1% across regions), skill-based (range 21.7-27.9% across regions), and social activities (range 12.8-14.5% across regions). GMFCS level was the most important predictor associated with not doing preferred activities.

INTERPRETATION

Children with cerebral palsy did not always participate in preferred active physical and skill-based activities. Understanding discrepancies between preferences and actual involvement may allow families and rehabilitation professionals to address participation barriers.

Current Rehabilitation Practices for Children with Cerebral Palsy: Focus and Gaps

AIMS

To describe the focus of therapy practices in occupational and physical therapy for school-aged children with cerebral palsy, and better understand whether it is congruent with recommended practices.

METHODS

A Canada-wide Web-based survey was completed by 62 occupational and 61 physical therapists to identify problems, assessments, and treatment interventions for two case-based scenarios. Data were coded using the International Classification of Functioning, Disability and Health (ICF) definitions for "body functions and structure," "activity and participation," and "environment."

RESULTS

Physical therapists, in comparison to occupational therapists, were more likely to select interventions classed in the "body functions and structure" category (34-42% and 18-20%, respectively). Both professions focused on "activity and participation" (34-61%) when identifying problems, assessing, and intervening; attention, however, was mainly directed towards task-oriented activities such as activities of daily living and mobility. Participation in leisure or community-based activities received less attention (2-15%). The environment received limited attention for problems and assessments (4-25%), though it was an important focus of intervention (19-37%).

CONCLUSIONS

While body functions and structure are well-addressed, other ICF elements, specifically participation, are poorly integrated into practice. The emerging focus on the environment in therapy intervention, by modifying the context rather than changing aspects of the child, is consistent with current approaches and evidence. Knowledge translation implementation initiatives are recommended to bridge identified gaps.

CT Angiography of the Head in Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation is an artificial cardiopulmonary bypass technique used to support patients with severe pulmonary failure or both pulmonary and cardiac failure. The hemodynamic changes produced by extracorporeal membrane oxygenation affect the appearance of CTA of the head images, often confounding interpretation if the correct history and understanding of extracorporeal membrane oxygenation are not known. This technical report describes the principles of extracorporeal membrane oxygenation, techniques to optimize intracranial CTA imaging, and pitfalls.

Establishing the Cultural Equivalence of the Young Children's Participation and Environment Measure (YC-PEM) for Use in Singapore

AIMS

Establishing the cultural equivalence of clinical assessments is critical to ensuring culturally competent care. Developed in North America, the Young Children's Participation and Environment Measure (YC-PEM) is a caregiver questionnaire of participation in home, preschool, and community activities and perceptions of environmental impact on participation. The purpose of this study is to establish the cultural equivalence of YC-PEM content for use in Singapore.

METHODS

We conducted semi-structured interviews with ten early childhood and healthcare providers and cognitive interviews with ten parents in Singapore to examine the relevance of original YC-PEM content (activities, environmental factors, item wording). Interviews were transcribed, summarized, and categorized according to item, semantic, conceptual, and operational dimensions of the Applied Cultural Framework that served as a decision-making guide to keep, modify, or delete the items.

RESULTS

Providers and parents agreed on conceptual, item and semantic changes but less on operational changes. Significant changes were made to improve comprehension of the YC-PEM.

CONCLUSIONS

Despite using the same language, the majority of the YC-PEM items needed modification to be relevant to the Singapore culture. Cultural adaptation of the YC-PEM is important because there are cultural differences in children's participation and their environments, as well as the way people understand words.

Knowledge Translation from Research to Clinical Practice: Measuring Participation of Children with Disabilities

This knowledge translation project was conducted to increase occupational therapy practitioners' awareness of the importance of measuring participation of children with disabilities. The Knowledge to Action process framework (KTA framework) guided knowledge translation via a web-based seminar (webinar) to practitioners working with children and educators teaching in occupational therapy programs in South Korea. Two hundred and seventy six views of the webinar were recorded within a month and 15 practitioners and 13 educators completed the online evaluation survey. The participants indicated that the webinar helped them understand the participation concept and its associated measures and raised awareness of practitioners' current use of measurement and intervention that do not focus on participation of children with disabilities. This project led practitioners and educators to realize the importance of measuring participation of children with disabilities and contributes to inform the importance of knowledge translation science to facilitate the evidence-based practice.

Developing a classification system of social communication functioning of preschool children with autism spectrum disorder

AIM

Impairments in social communication are the hallmark of autism spectrum disorder (ASD). Operationalizing 'severity' in ASD has been challenging; thus, stratifying by functioning has not been possible. The purpose of this study is to describe the development of the Autism Classification System of Functioning: Social Communication (ACSF:SC) and to evaluate its consistency within and between parent and professional ratings.

METHOD

(1) ACSF:SC development based on focus groups and surveys involving parents, educators, and clinicians familiar with preschoolers with ASD; and (2) evaluation of the intra- and interrater agreement of the ACSF:SC using weighted kappa (кw ).

RESULTS

Seventy-six participants were involved in the development process. Core characteristics of social communication were ascertained: communicative intent; communicative skills and reciprocity; and impact of environment. Five ACSF:SC levels were created and content-validated across participants. Best capacity and typical performance agreement ratings varied as follows: intrarater agreement on 41 children was кw =0.61 to 0.69 for parents, and кw =0.71 to 0.95 for professionals; interrater agreement between professionals was кw =0.47 to 0.61, and between parents and professionals was кw =0.33 to 0.53.

INTERPRETATION

Perspectives from parents and professionals informed ACSF:SC development, providing common descriptions of the levels of everyday communicative abilities of children with ASD to complement the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Rater agreement demonstrates that the ACSF:SC can be used with acceptable consistency compared with other functional classification systems.

The Effect of a Sensory Integration Program on Academic Achievement, Motor Performance, and Self-Esteem in Children Identified as Learning Disabled: Results of a Clinical Trial

A multicenter clinical trial was conducted to evaluate the effect of sensory integration therapy on the academic achievement, motor performance, and self-esteem of learning disabled children who have sensory integrative dysfunction. A sample of 67 children was randomized into one of two groups: sensory integrative (SI) and perceptual-motor therapy (PM). The Woodcock-Johnson Psychoeducational Battery, the Bruininks-Oseretsky Test of Motor Proficiency, the Behavioral Academic Self-Esteem Rating Scale, and the Personality Inventory for Children were administered before therapy, after 6 months of therapy, and 3 months following cessation of therapy. Both the SI and PM groups improved on academic and motor measures. No group differences were detected on any measure. The implications of the findings and possible interpretations are discussed and future studies suggested.