If You Build It, Will They Come? Patient and Provider Use of a Novel Hybrid Telehealth Care Pathway for Low Back Pain

OBJECTIVE

The purpose of this study was to describe the referrals and use of a hybrid care model for low back pain that includes on-site care by physical therapists, physical activity training, and psychologically informed practice (PiP) delivered by telehealth in the Improving Veteran Access to Integrated Management of Low Back Pain (AIM-Back) trial.

METHODS

Data were collected from November 2020 through February 2023 from 5 Veteran Health Administration clinics participating in AIM-Back, a multisite, cluster-randomized embedded pragmatic trial. The authors extracted data from the Veteran Health Administration Corporate Data Warehouse to describe referral and enrollment metrics, telehealth use (eg, distribution of physical activity and PiP calls), and treatments used by physical therapists and telehealth providers.

RESULTS

Seven hundred one veterans were referred to the AIM-Back trial with 422 enrolling in the program (consult-to-enrollment rate = 60.2%). After travel restrictions were lifted, site visits resulted in a significant increase in referrals and a number of new referring providers. At initial evaluation by on-site physical therapists, 92.2% of veterans received pain modulation (eg, transcutaneous electrical nerve stimulation, manual therapy). Over 81% of enrollees completed at least 1 telehealth physical activity call, with a mean of 2.8 (SD = 2.0) calls out of 6. Of the 167 veterans who screened as medium to high risk of persistent disability, 74.9% completed at least 1 PiP call, with a mean of 2.5 (SD = 2.0) calls out of 6. Of those who completed at least 1 PiP call (n = 125), 100% received communication strategies, 97.6% received pain coping skills training, 89.6% received activity-based treatments, and 99.2% received education in a home program.

CONCLUSION

In implementing a hybrid care pathway for low back pain, the authors observed consistency in the delivery of core components (ie, pain modulation, use of physical activity training, and risk stratification to PiP), notable variability in telehealth calls, high use of PiP components, and increased referrals with tailored provider engagement.

IMPACT

These findings describe variability occurring within a hybrid care pathway and can inform future implementation efforts.

Adherence to Perioperative Behavioral Therapy With Pelvic Floor Muscle Training in Women Receiving Vaginal Reconstructive Surgery for Pelvic Organ Prolapse

OBJECTIVE

The objective of this study was to describe adherence to behavioral and pelvic floor muscle training in women undergoing vaginal reconstructive surgery for organ prolapse and to examine whether adherence was associated with 24-month outcomes.

METHODS

Participants were women ≥18 years of age, with vaginal bulge and stress urinary incontinence symptoms, planning to undergo vaginal reconstructive surgery for stages 2 to 4 vaginal or uterine prolapse. They were randomized to either sacrospinous ligament fixation or uterosacral ligament suspension and to perioperative behavioral and pelvic floor muscle training or usual care. Measurements included anatomic failure, pelvic floor muscle strength, participant-reported symptoms, and perceived improvement. Analyses compared women with lower versus higher adherence.

RESULTS

Forty-eight percent of women performed pelvic floor muscle exercises (PFMEs) daily at the 4- to 6-week visit. Only 33% performed the prescribed number of muscle contractions. At 8 weeks, 37% performed PFMEs daily, and 28% performed the prescribed number of contractions. No significant relationships were found between adherence and 24-month outcomes.

CONCLUSION

Adherence to a behavioral intervention was low following vaginal reconstructive surgery for pelvic organ prolapse. The degree of adherence to perioperative training did not appear to influence 24-month outcomes in women undergoing vaginal prolapse surgery.

IMPACT

This study contributes to the understanding of participant adherence to PFMEs and the impact that participant adherence has on outcomes at 2, 4 to 6, 8, and 12 weeks and 24 months postoperatively. It is important to educate women to follow up with their therapist or physician to report new or unresolved pelvic symptoms.

Naltrexone-Bupropion and Behavior Therapy, Alone and Combined, for Binge-Eating Disorder: Randomized Double-Blind Placebo-Controlled Trial

OBJECTIVE

Binge-eating disorder, the most prevalent eating disorder, is a serious public health problem associated with obesity, psychiatric and medical comorbidities, and functional impairments. Binge-eating disorder remains underrecognized and infrequently treated, and few evidence-based treatments exist. The authors tested the effectiveness of naltrexone-bupropion and behavioral weight loss therapy (BWL), alone and combined, for binge-eating disorder comorbid with obesity.

METHODS

In a randomized double-blind placebo-controlled trial conducted from February 2017 to February 2021, using a 2×2 balanced factorial design, 136 patients with binge-eating disorder (81.6% women; mean age, 46.5 years; mean BMI, 37.1) were randomized to one of four 16-week treatments: placebo (N=34), naltrexone-bupropion (N=32), BWL+placebo (N=35), or BWL+naltrexone-bupropion (N=35). Overall, 81.7% of participants completed independent posttreatment assessments.

RESULTS

Intention-to-treat binge-eating remission rates were 17.7% in the placebo group, 31.3% in the naltrexone-bupropion group, 37.1% in the BWL+placebo group, and 57.1% in the BWL+naltrexone-bupropion group. Logistic regression of binge-eating remission revealed that BWL was significantly superior to no BWL, and that naltrexone-bupropion was significantly superior to placebo, but there was no significant interaction between BWL and medication. Mixed models of complementary measures of binge-eating frequency also indicated that BWL was significantly superior to no BWL. The rates of participants attaining 5% weight loss were 11.8% in the placebo group, 18.8% in the naltrexone-bupropion group, 31.4% in the BWL+placebo group, and 38.2% in the BWL+naltrexone-bupropion group. Logistic regression of 5% weight loss and mixed models of percent weight loss both revealed that BWL was significantly superior to no BWL. Mixed models revealed significantly greater improvements for BWL than no BWL on secondary measures (eating disorder psychopathology, depression, eating behaviors, and cholesterol and HbA1c levels).

CONCLUSIONS

BWL and naltrexone-bupropion were associated with significant improvements in binge-eating disorder, with a consistent pattern of BWL being superior to no BWL.

Use of Behavior Change Techniques Alongside Exercise in the Management of Rotator Cuff-Related Shoulder Pain: A Scoping Review

OBJECTIVES

The aims of this scoping review were to: (1) determine the frequency and types of behavior change techniques (BCTs) and education utilized in trials investigating exercise interventions for rotator cuff related shoulder pain (RCRSP); (2) subcategorize the BCTs and education found in the trials to summarize all behavior change approaches reported by trials; and (3) compare the frequency, types, and subcategories of BCTs and education utilized in the clinical guidelines for managing RCRSP between the trials.

METHODS

Data sources included Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE, CINAHL Plus, Google Scholar and PubMed, which were searched from inception to June 2020. Trials assessing exercise interventions for RCRSP were included. Three authors independently determined eligibility and extracted data. The frequency and types of BCTs and education in the trials and clinical practice guidelines were reported and compared descriptively. Two authors assessed the content of the BCTs to develop subcategories.

RESULTS

Most trials reported including at least 1 type of BCT (89.2%), which was most commonly feedback and monitoring (78.5%). There were many different approaches to the BCTs and education; for example, feedback and monitoring was subcategorized into supervised exercise, exercise monitoring, and feedback through external aids, such as mirrors. Clinical guidelines recommend supervision, goal setting, activity modification, pain management recommendations, information about the condition, and exercise education.

CONCLUSION

Although over two-thirds of trials reported including a BCT alongside exercise interventions for RCRSP, the breadth of these interventions is limited (supervision is the only common one). Future trialists should consider using any type of BCT that may improve exercise adherence and outcomes.

IMPACT

The findings of this review have: (1) identified gaps in the literature; and (2) contributed to the design of future exercise interventions for RCRSP.

Training of Physical Therapists to Deliver Individualized Biopsychosocial Interventions to Treat Musculoskeletal Pain Conditions: A Scoping Review

OBJECTIVE

Current guidelines recommend management of musculoskeletal pain conditions from a biopsychosocial approach; however, biopsychosocial interventions delivered by physical therapists vary considerably in effectiveness. It is unknown whether the differences are explained by the intervention itself, the training and/or competency of physical therapists delivering the intervention, or fidelity of the intervention. The aim was to investigate and map the training, competency assessments, and fidelity checking of individualized biopsychosocial interventions delivered by physical therapists to treat musculoskeletal pain conditions.

METHODS

A scoping review methodology was employed, using Arksey and O'Malley's framework. Seven electronic databases were searched between January and March 2019, with a bridge search completed in January 2020. Full-text peer-reviewed articles, with an individualized biopsychosocial intervention were considered, and 35 studies were included.

RESULTS

Reporting overall was sparse and highly variable. There was a broad spectrum of training. More sophisticated training involved workshops combining didactic and experiential learning over longer durations with supervision and feedback. Less sophisticated training was brief, involving lectures or seminars, with no supervision or feedback. Competency assessments and fidelity testing were underperformed.

CONCLUSIONS

Training in some interventions might not have facilitated the implementation of skills or techniques to enable the paradigm shift and behavior change required for physical therapists to effectively deliver a biopsychosocial intervention. Lack of competency assessments and fidelity checking could have impacted the methodological quality of biopsychosocial interventions.

IMPACT

This study highlighted problematic reporting, training, assessment of competency, and fidelity checking of physical therapist-delivered individualized biopsychosocial interventions. Findings here highlight why previous interventions could have shown small effect sizes and point to areas for improvement in future interventions. These findings can help inform future research and facilitate more widespread implementation of physical therapist-delivered biopsychosocial interventions for people with musculoskeletal pain and thereby improve their quality of life.

Telehealth and rural-urban differences in receipt of pain care in the Veterans Health Administration

OBJECTIVE

Examine changes in specialty pain utilization in the Veterans Health Administration (VHA) after establishing a virtual interdisciplinary pain team (TelePain).

DESIGN

Retrospective cohort study.

SETTING

A single VHA healthcare system, 2015-2019.

SUBJECTS

33,169 patients with chronic pain-related diagnoses.

METHODS

We measured specialty pain utilization (in-person and telehealth) among patients with moderate to severe chronic pain. We used generalized estimating equations to test the association of time (pre- or post-TelePain) and rurality on receipt of specialty pain care.

RESULTS

Among patients with moderate to severe chronic pain, the reach of specialty pain care increased from 11.1% to 16.2% in the pre- to post-TelePain periods (aOR: 1.37, 95% CI: 1.26-1.49). This was true of both urban patients (aOR: 1.62, 95% CI: 1.53-1.71) and rural patients (aOR: 1.16, 95% CI: 0.99-1.36), although the difference for rural patients was not statistically significant. Among rural patients who received specialty pain care, a high percentage of the visits were delivered by telehealth (nearly 12% in the post-TelePain period), much higher than among urban patients (3%).

CONCLUSIONS

We observed increased use of specialty pain services among all patients with chronic pain. Although rural patients did not achieve the same degree of access and utilization overall as urban patients, their use of pain telehealth increased substantially and may have substituted for in-person visits. Targeted implementation efforts may be needed to further increase the reach of services to patients living in areas with limited specialty pain care options.

An ounce of prevention is worth a pound of cure: considerations for pharmacists delivering the National Diabetes Prevention Program

Prediabetes is highly prevalent in the United States affecting over 88 million adults. In 2010, the Centers for Disease Control and Prevention (CDC) established the National Diabetes Prevention Program (NDPP), an intensive lifestyle program consisting of a 16-lesson curriculum focused on diet, exercise, and behavior modification, with the ultimate goal to reduce progression from prediabetes to diabetes. Despite tens of millions of adults potentially qualifying to participate in the program, the uptake of the NDPP has been exceedingly low. As a result, the CDC has focused its efforts on engaging with local health departments and community partners, including community pharmacies, across the United States to scale-up enrollment in the NDPP. In this commentary we discuss factors affecting implementation of the NDPP in community pharmacies and other settings where pharmacists practice, including training, space, personnel, recruitment and enrollment, retention, and sustainability.

Perceptions of Kinesiophobia in Relation to Physical Activity and Exercise After Myocardial Infarction: A Qualitative Study

OBJECTIVE

Physical activity and exercise are central components in rehabilitation after a myocardial infarction. Kinesiophobia (fear of movement) is a well-known barrier for a good rehabilitation outcome in these patients; however, there is a lack of studies focusing on the patient perspective. The aim of this study was to explore patients' perceptions of kinesiophobia in relation to physical activity and exercise 2 to 3 months after an acute myocardial infarction.

METHODS

This qualitative study design used individual semi-structured interviews. Face-to-face interviews were conducted with 21 patients post-myocardial infarction who were screened for kinesiophobia (≥32 on the Tampa Scale for Kinesiophobia Heart). The interviews were transcribed and analyzed according to an inductive content analysis.

RESULTS

An overarching theme was defined as "coping with fear of movement after a myocardial infarction-a dynamic process over time" comprising 2 subthemes and explaining how coping with kinesiophobia runs in parallel processes integrating the patient's internal process and a contextual external process. The 2 processes are described in a total of 8 categories. The internal process was an iterative process governed by a combination of factors: ambivalence, hypervigilance, insecurity about progression, and avoidance behavior. The external process contains the categories of relatives' anxiety, prerequisites for feeling safe, information, and the exercise-based cardiac rehabilitation program.

CONCLUSION

Coping with fear of movement after a myocardial infarction is a dynamic process that requires internal and external support. To further improve cardiac rehabilitation programs, person-centered strategies that support the process of each person-as well as new treatment strategies to reduce kinesiophobia-need to be elaborated.

IMPACT

Patients with a myocardial infarction were found to be ambivalent about how they expressed their fear of movement; therefore, it is crucial for physical therapists to acknowledge signs of fear by listening carefully to the patient's full story in addition to using adequate self-reports and tests of physical fitness. These results will inform the design, development, and evaluation of new treatment strategies, with the overall aim of reducing kinesiophobia and increasing physical activity and participation in exercise-based cardiac rehabilitation.

Rural Family Medicine Clinicians' Motivations to Participate in a Pragmatic Obesity Trial

PURPOSE

To understand the motivations of rural-practicing primary care clinicians who participate in an intensive multiyear pragmatic randomized behavioral obesity intervention trial, Rural Engagement in Primary Care for Optimizing Weight Reduction (RE-POWER).

METHODS

Structured interviews were conducted with 21 family medicine clinicians who were study leads at participating rural practices. Themes emerged through an analysis of transcripts and interview notes by using the constant comparative method.

RESULTS

The analysis revealed 3 main themes. First, primary care clinicians participated in RE-POWER because it provided a concrete plan to address their recurring clinical care need for effective obesity treatment and management. Second, participation offered help to frustrated physicians who felt a deep professional duty to care for all their patients' problems but were dissatisfied with current obesity management. Third, participation was also attractive to rural primary care clinicians because it provided a visible and sustainable way to demonstrate their commitment to improving the health of patients and the broader community.

CONCLUSIONS

Our findings show that clinicians are motivated to try solutions for a clinical problem-in this case obesity-when that clinical problem is also closely connected to a particularly frustrating area of clinical care that challenges their professional identity. Our data suggest that a motivation to close the gap between ideal and real practice can become such a high priority that clinicians are sometimes willing to try potential solutions, such as engagement in research, that they otherwise would not consider.

Association between enuresis and obesity in children with primary monosymptomatic nocturnal enuresis

Objective

The purpose of this study was to determine whether the presence of obesity was related with symptoms of nocturnal enuresis (NE) and the efficacy of behavioral intervention in the treatment of NE.

Materials and Method

The patients diagnosed with primary monosymptomatic nocturnal enuresis (PMNE) were studied retrospectively. NE severity was classified as mild, moderate, and severe according to the frequency of enuresis. The children were divided into three groups, namely normal weight (5th-84th percentile), overweight (85th-94th percentile), and obesity (≥95th percentile), according to their Body Mass Index (BMI) percentage. The relationship between obesity level and enuresis severity was analyzed. After three months of behavioral therapy, the efficacy of treatment among normal, overweight, and obese groups were evaluated. Moreover, the predictive risk factors for treatment failure were investigated.

Results

The rates of severe enuresis in patients with normal weight, overweight, and obesity were 63.9%, 77.5%, and 78.6%, respectively. Obese children depicted higher odds of having severe enuresis compared with normal-weight children (OR: 1.571; 95% confidence interval [CI]: 1.196-2.065; P=0.001). The odds of presenting with severe enuresis were 1.99 times higher in children who are obese or overweight compared to children with normal weight (OR: 1.994; 95% CI: 1.349-2.946; P=0.001). The complete response of the normal group was higher than those of the overweight and obese groups (26.8% vs. 14.0%, P=0.010; 26.8% vs. 0.0%, P=0.000). Overweight children showed higher complete response than obese ones (14.0% vs. 0.0%, P=0.009). Logistic regression analysis revealed that obesity level and enuresis frequency were significantly related to the treatment failure of behavioral intervention.

Conclusions

Obesity is associated with severe enuresis and low efficacy of behavioral therapy in children with nocturnal enuresis.

A Cluster Randomized Trial Comparing Strategies for Translating Self-Management Support into Primary Care Practices

INTRODUCTION

Self-management support (SMS) is a key factor in diabetes care, but true SMS has not been widely adopted by primary care practices. Interactive behavior-change technology (IBCT) can provide efficient methods for adoption of SMS in primary care. Practice facilitation has been effective in assisting practices in implementing complex evidence-based interventions, such as SMS. This study was designed to study the incremental impact of practice education, the Connection to Health (CTH) IBCT tool, and practice facilitation as approaches to enhance the translation of SMS for patients with diabetes in primary care practices.

METHODS

A cluster-randomized trial compared the effectiveness of 3 implementation strategies for enhancing SMS for patients with diabetes in 36 primary care practices: 1) SMS education (SMS-ED); 2) SMS-ED plus CTH availability (CTH); and 3) SMS-ED, CTH availability, plus brief practice facilitation (CTH + PF). Outcomes including hemoglobin A1c (HbA1c) levels and SMS activities were assessed at 18 months post study initiation in a random sample of patients through medical record reviews.

RESULTS

A total of 488 patients enrolled in the CTH system (141 CTH, 347 CTH + PF). In the intent-to-treat analysis of patients with medical record reviews, HbA1c slopes did not differ between study arms (CTH vs SMS-ED: P = .2243, CTH + PF vs SMS-ED: P = .8601). However, patients from practices in the CTH + PF arm who used CTH showed significantly improved HbA1c trajectories over time compared with patients from SMS-ED practices (P = .0422). SMS activities were significantly increased in CTH and CTH + PF study arms compared with SMS-ED (CTH vs SMS-ED: P = .0223, CTH + PF vs SMS-ED: P = .0013). The impact of CTH on SMS activities was a significant mediator of the impact of the CTH and CTH + PF interventions on HbA1c.

CONCLUSION

An interactive behavior change technology tool such as CTH can increase primary care practice SMS activities and improve patient HbA1c levels. Even brief practice facilitation assists practices in implementing SMS.

Proof of Concept for an Adaptive Treatment Strategy to Prevent Failures in Internet-Delivered CBT: A Single-Blind Randomized Clinical Trial With Insomnia Patients

OBJECTIVE

This study aimed to demonstrate proof of concept for an adaptive treatment strategy in Internet-delivered cognitive-behavioral therapy (ICBT), where risk of treatment failure is assessed early in treatment and treatment for at-risk patients is adapted to prevent treatment failure.

METHODS

A semiautomated algorithm assessed risk of treatment failure early in treatment in 251 patients undergoing ICBT for insomnia with therapist guidance. At-risk patients were randomly assigned to continue standard ICBT or to receive adapted ICBT. The primary outcome was self-rated insomnia symptoms using the Insomnia Severity Index in a linear mixed-effects model. The main secondary outcome was treatment failure (having neither responded nor remitted at the posttreatment assessment).

RESULTS

A total of 102 patients were classified as at risk and randomly assigned to receive adapted ICBT (N=51) or standard ICBT (N=51); 149 patients were classified as not at risk. Patients not at risk had significantly greater score reductions on the Insomnia Severity Index than at-risk patients given standard ICBT. Adapted ICBT for at-risk patients was significantly more successful in reducing symptoms compared with standard ICBT, and it decreased the risk of failing treatment (odds ratio=0.33). At-risk patients receiving adapted ICBT were not more likely to experience treatment failure than those not at risk (odds ratio=0.51), though they were less likely to experience remission. Adapted treatment required, on average, 14 more minutes of therapist-patient time per remaining week.

CONCLUSIONS

An adaptive treatment strategy can increase treatment effects for at-risk patients and reduce the number of failed treatments. Future studies should improve accuracy in classification algorithms and identify key factors that boost the effect of adapted treatments.

Doubly Randomized Preference Trial of Prolonged Exposure Versus Sertraline for Treatment of PTSD

OBJECTIVE

The authors examined the effect of patient treatment preference on the differential effectiveness of prolonged exposure and sertraline for the treatment of posttraumatic stress disorder (PTSD).

METHOD

In a doubly randomized preference trial, 200 patients with PTSD viewed standardized treatment rationales prior to randomization. Patients were first randomized to choice of treatment or no choice. Those assigned to no choice were then randomized to prolonged exposure or sertraline. Acute treatment was 10 weeks, with 24-month follow-up. Interviewer-rated PTSD symptom severity was the main outcome measure, and depression, anxiety, and functioning were assessed as additional outcomes.

RESULTS

Patients preferred prolonged exposure over sertraline (number needed to benefit [NNTB]=4.5). Using intent-to-treat analyses (N=200), both prolonged exposure and sertraline showed large gains that were maintained over 24 months. Although no differential effect was observed on interviewer-rated PTSD severity, there was a significant benefit of prolonged exposure over sertraline on interview-rated loss of PTSD diagnosis (NNTB=7.0), responder status (NNTB=5.7), and self-reported PTSD, depression, and anxiety symptoms and functioning (effect sizes, 0.35-0.44). Patients who received their preferred treatment were more likely to be adherent, lose their PTSD diagnosis (NNTB=3.4), achieve responder status (NNTB=3.4), and have lower self-reported PTSD, depression, and anxiety symptoms (effect sizes, 0.40-0.72).

CONCLUSIONS

Prolonged exposure and sertraline confer significant benefits for PTSD, with some evidence of an advantage for prolonged exposure. Giving patients with PTSD their preferred treatment also confers important benefits, including enhancing adherence.

Randomized Clinical Trial of Computerized and Clinician-Delivered CBT in Comparison With Standard Outpatient Treatment for Substance Use Disorders: Primary Within-Treatment and Follow-Up Outcomes

OBJECTIVE

Previous trials have demonstrated the efficacy and durability of computer-based cognitive-behavioral therapy (CBT4CBT) as an add-on to standard outpatient care in a range of treatment-seeking populations. In this study, the authors evaluated the efficacy and safety of CBT4CBT as a virtual stand-alone treatment, delivered with minimal clinical monitoring, and clinician-delivered cognitive-behavioral therapy (CBT) compared with treatment as usual in a heterogeneous sample of treatment-seeking outpatients with substance use disorders.

METHOD

This was a randomized clinical trial in which 137 individuals who met DSM-IV-TR criteria for current substance abuse or dependence were randomly assigned to receive treatment as usual, weekly individual CBT, or CBT4CBT with brief weekly monitoring.

RESULTS

Rates of treatment exposure differed by group, with the best retention in the CBT4CBT group and the poorest in the individual CBT group. Participants who received CBT or CBT4CBT reduced their frequency of substance use significantly more than those who received treatment as usual. Six-month follow-up outcomes indicated continuing benefit of CBT4CBT (plus monitoring) over treatment as usual, but not for clinician-delivered CBT over treatment as usual. Analysis of secondary outcomes indicated that participants in the CBT4CBT group demonstrated the best learning of cognitive and behavioral concepts, as well as the highest satisfaction with treatment.

CONCLUSIONS

This first trial of computerized CBT as a virtual stand-alone intervention delivered in a clinical setting to a diverse sample of patients with current substance use disorders indicated that it was safe, effective, and durable relative to standard treatment approaches and was well-liked by participants. Clinician-delivered individual CBT, while efficacious within the treatment period, was unexpectedly associated with a higher dropout rate and lower effects at follow-up.

Changes in Glomerular Filtration Rate and Impact on Long-Term Survival among Adults after Hematopoietic Cell Transplantation: A Prospective Cohort Study

BACKGROUND AND OBJECTIVES

Kidney injury is a significant complication for patients undergoing hematopoietic cell transplantation (HCT), but few studies have prospectively examined changes in GFR in long-term survivors of HCT. We described the association between changes in GFR and all-cause mortality in patients up to 10 years after HCT.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a prospective, observational cohort study of adult patients undergoing HCT at the Fred Hutchinson Cancer Center in Seattle, Washington from 2003 to 2015. Patients were followed from baseline, before conditioning therapy, until a maximum of 10 years after transplant. We used Cox proportional hazard models to examine the association between creatinine eGFR and all-cause mortality. We used time-dependent generalized estimating equations to examine risk factors for decreases in eGFR.

RESULTS

A total of 434 patients (median age, 52 years; range, 18-76 years; 64% were men; 87% were white) were followed for a median 5.3 years after HCT. The largest decreases in eGFR occurred within the first year post-transplant, with the eGFR decreasing from a median of 98 ml/min per 1.73 m2 at baseline to 78 ml/min per 1.73 m2 by 1 year post-HCT. Two thirds of patients had an eGFR<90 ml/min per 1.73 m2 at 1 year after transplant. When modeled as a continuous variable, as eGFR declined from approximately 60 ml/min per 1.73 m2, the hazard of mortality progressively increased relative to a normal eGFR of 90 ml/min per 1.73 m2 (P<0.001). For example, when compared with an eGFR of 90 ml/min per 1.73 m2, the hazard ratios for eGFR of 60, 50, and 40 ml/min per 1.73 m2 are 1.15 (95% confidence interval, 0.87 to 1.53), 1.68 (95% confidence interval, 1.26 to 2.24), and 2.67 (95% confidence interval, 1.99 to 3.60), respectively. Diabetes, hypertension, acute graft versus host disease, and cytomegalovirus infection were independently associated with a decline in GFR, whereas calcineurin inhibitor levels, chronic graft versus host disease, and albuminuria were not.

CONCLUSIONS

Adult HCT recipients have a high risk of decreased eGFR by 1 year after HCT. Although eGFR remains fairly stable thereafter, a decreased eGFR is significantly associated with higher risk of mortality, with a progressively increased risk as eGFR declines.

Impact of the Early Start Denver Model on the cognitive level of children with autism spectrum disorder: study protocol for a randomised controlled trial using a two-stage Zelen design

INTRODUCTION

Early intervention for autism spectrum disorder (ASD) in the European French-speaking countries is heterogeneous and poorly evaluated to date. Early intervention units applying the Early Start Denver Model (ESDM) for toddlers and young children with ASD have been created in France and Belgium to improve this situation. It is essential to evaluate this intervention for the political decision-making process regarding ASD interventions in European French-speaking countries. We will evaluate the effectiveness of 12 hours per week ESDM intervention on the cognitive level of children with ASD, over a 2-year period.

METHODS AND ANALYSIS

The study will be a multicentre, randomised controlled trial, using a two-stage Zelen design. Children aged 15-36 months, diagnosed with ASD and with a developmental quotient (DQ) of 30 or above on the Mullen Scale of Early Learning (MSEL) will be included. We will use a stratified minimisation randomisation at a ratio 1:2 in favour of the control group. The sample size required is 180 children (120 in the control and 60 in the intervention group). The experimental group will receive 12 hours per week ESDM by trained therapists 10 hours per week in the centre and 2 hours in the toddlers' natural environment (alternatively by the therapist and the parent). The control group will receive care available in the community. The primary outcome will be the change in cognitive level measured with the DQ of the MSEL scored at 2 years. Secondary outcomes will include change in autism symptoms, behavioural adaptation, communicative and productive language level, sensory profile and parents' quality of life. The primary analysis will use the intention-to-treat principle. An economic evaluation will be performed.

DISSEMINATION

Findings from the study will be disseminated through peer reviewed publications and meetings.

TRIAL REGISTRATION NUMBER

NCT02608333 (clinicaltrials.gov); Pre-results.

Prediabetes Screening and Treatment in Diabetes Prevention: The Impact of Physician Attitudes

PURPOSE

Detection and treatment of prediabetes is an effective strategy in diabetes prevention. However, most patients with prediabetes are not identified. Our objective was to evaluate the relationship between attitudes toward prediabetes as a clinical construct and screening/treatment behaviors for diabetes prevention among US family physicians.

METHODS

An electronic survey of a national sample of academic family physicians (n 1248) was conducted in 2016. Attitude toward prediabetes was calculated using a summated scale assessing agreement with statements regarding prediabetes as a clinical construct. Perceived barriers to diabetes prevention, current strategies for diabetes prevention, and perceptions of peers were also examined.

RESULTS

Physicians who have a positive attitude toward prediabetes as a clinical construct are more likely to follow national guidelines for screening (58.4% vs 44.4; P < .0001) and recommend metformin to their patients for prediabetes (36.4% vs 20.9%; P < .0001). Physicians perceived a number of barriers to treatment, including a patient's economic resources (71.9%), sustaining patient motivation (83.2%), a patient's ability to modify his or her lifestyle (75.3%), and time to educate patient (75.3%) as barriers to diabetes prevention.

CONCLUSIONS

How physicians view prediabetes varies significantly, and this variation is related to treatment/screening behaviors for diabetes prevention.

The Fit Family Challenge: A Primary Care Childhood Obesity Pilot Intervention

BACKGROUND

Childhood obesity has increased dramatically over several decades, and the American Academy of Pediatrics has recommended primary care practices as ideal sites for the identification, education, and implementation of therapeutic interventions. The objective of this study was to describe the implementation and results for the Fit Family Challenge (FFC), a primary care-based childhood obesity intervention.

METHODS

A single-intervention pilot project that trains primary care practices on childhood obesity guidelines and implementation of a family-focused behavior modification curriculum. A total of 29 family medicine and pediatric community practices in Colorado participated. Participants included 290 patients, aged 6 to 12 years, with a body mass index (BMI) above the 85th percentile. The main outcome measure included the feasibility of implementation of a childhood obesity program in primary care; secondary outcomes were changes in BMI percentile, BMI z-scores, blood pressure, and changes in lifestyle factors related to childhood obesity.

RESULTS

Implementation of FFC is feasible, statically significant changes were seen for decreases in BMI percentile and BMI z-scores for participants who completed 9 to 15 months of follow-up; lifestyle factors related to childhood obesity in proved Spanish-speaking families and food insecurity were associated with less follow-up time (P < .01).

CONCLUSIONS

A primary care-based childhood obesity intervention may result in significant clinical and lifestyle changes.

Automated Behavioral Text Messaging and Face-to-Face Intervention for Parents of Overweight or Obese Preschool Children: Results From a Pilot Study

Background

Children are 5 times more likely to be overweight at the age of 12 years if they are overweight during the preschool period.

Objective

The purpose of this study was to establish the feasibility, acceptability, and preliminary effects of a cognitive behavioral intervention (TEXT2COPE) synergized with tailored mobile technology (mHealth) on the healthy lifestyle behaviors of parents of overweight and obese preschoolers delivered in a primary care setting.

Methods

Fifteen preschooler-parent dyads recruited through primary care clinics completed a manualized 7-week cognitive behavioral skills building intervention. Beck’s Cognitive Theory guided the TEXT2COPE intervention content and Fogg’s Behavior Model guided the implementation. The intervention employed a combination of face-to-face clinic visits and ecological momentary interventions using text messaging (short message service, SMS). To enhance the intervention’s relevance to the family’s needs, parents dictated the wording of the text messages and also were able to adapt the frequency and timing of delivery throughout program implementation.

Results

Self-reported findings indicate that the program is feasible and acceptable in this population. The intervention showed preliminary effects with significant improvements on parental knowledge about nutrition (P=.001) and physical activity (P=.012) for their children, parental beliefs (P=.001) toward healthy lifestyles, and parental behaviors (P=.040) toward engaging in healthy lifestyle choices for their children. Effect sizes were medium to large for all variables. The timing, frequency, and wording of the text messages were tailored to the individual families, with 69% of parents (9/13) increasing the frequency of the tailored SMS from being sent once weekly to as many as 5 times a week.

Conclusions

Utilizing a cognitive behavioral skills intervention with SMS has great potential for supporting clinical care of overweight and obese preschool children and their families. Further exploration of the potential effects on health and behavioral outcomes is warranted.

Reinforcement Behavior Therapy by Kindergarten Teachers on Preschool Children's Aggression: A Randomized Controlled Trial

BACKGROUND

Aggression is a kind of behavior that causes damage or harm to others. The prevalence of aggression is 8-20% in 3-6 years old children. The present study aimed to assess the effect of training kindergarten teachers regarding reinforcement behavior therapy on preschoolers' aggression.

METHODS

In this cluster randomized control trial, 14 out of 35 kindergarten and preschool centers of Mohr city, Iran, were chosen using random cluster sampling and then randomly assigned to an intervention and a control group. All 370 kindergarten and preschool children in 14 kindergarten were assessed by preschoolers' aggression questionnaire and 60 children who obtained a minimum aggression score of 117.48 for girls and 125.77 for boys were randomly selected. The teachers in the intervention group participated in 4 educational sessions on behavior therapy and then practiced this technique under the supervision of the researcher for two months. Preschoolers' aggression questionnaire was computed in both intervention and control groups before and after a two-month period.

RESULTS

The results demonstrated a significant statistical difference in the total aggression score (P=0.01), verbal (P=0.02) and physical (P=0.01) aggression subscales scores in the intervention group in comparison to the control group after the intervention. But the scores of relational aggression (P=0.09) and impulsive anger (P=0.08) subscales were not statistically different in the intervention group compared to the controls.

CONCLUSION

This study highlighted the importance of teaching reinforcement behavior therapy by kindergarten teachers in decreasing verbal and physical aggression in preschoolers.

TRIAL REGISTRATION NUMBER

IRCT2014042617436N1.

Behavioral Therapies for Management of Premature Ejaculation: A Systematic Review

INTRODUCTION

Premature ejaculation (PE) is defined by short ejaculatory latency and inability to delay ejaculation causing distress. Management may involve behavioral and/or pharmacological approaches.

AIM

To systematically review the randomized controlled trial (RCT) evidence for behavioral therapies in the management of PE.

METHODS

Nine databases including MEDLINE were searched up to August 2014. Included RCTs compared behavioral therapy against waitlist control or another therapy, or behavioral plus drug therapy against drug treatment alone. [Correction added on 10 September 2015, after first online publication: Search period has been amended from August 2013 to August 2014.].

MAIN OUTCOME MEASURE

Intravaginal ejaculatory latency time (IELT), sexual satisfaction, ejaculatory control, and anxiety and adverse effects.

RESULTS

Ten RCTs (521 participants) were included. Overall risk of bias was unclear. All studies assessed physical techniques, including squeeze and stop-start, sensate focus, stimulation device, and pelvic floor rehabilitation. Only one RCT included a psychotherapeutic approach (combined with stop-start and drug treatment). Four trials compared behavioral therapies against waitlist control, of which two (involving squeeze, stop-start, and sensate focus) reported IELT differences of 7-9 minutes, whereas two (web-based sensate focus, stimulation device) reported no difference in ejaculatory latency posttreatment. For other outcomes (sexual satisfaction, desire, and self-confidence), some waitlist comparisons significantly favored behavioral therapy, whereas others were not significant. Three trials favored combined behavioral and drug treatment over drug treatment alone, with small but significant differences in IELT (0.5-1 minute) and significantly better results on other outcomes (sexual satisfaction, ejaculatory control, and anxiety). Direct comparisons of behavioral therapy vs. drug treatment gave mixed results, mostly either favoring drug treatment or showing no significant difference. No adverse effects were reported, though safety data were limited.

CONCLUSIONS

There is limited evidence that physical behavioral techniques for PE improve IELT and other outcomes over waitlist and that behavioral therapies combined with drug treatments give better outcomes than drug treatments alone. Further RCTs are required to assess psychotherapeutic approaches to PE.

Effect of combined systematized behavioral modification education program with desmopressin in patients with nocturia: a prospective, multicenter, randomized, and parallel study

Purpose

The aims of this study were to investigate the efficacy of combining the systematized behavioral modification program (SBMP) with desmopressin therapy and to compare this with desmopressin monotherapy in the treatment of nocturnal polyuria (NPU).

Methods

Patients were randomized at 8 centers to receive desmopressin monotherapy (group A) or combination therapy, comprising desmopressin and the SBMP (group B). Nocturia was defined as an average of 2 or more nightly voids. The primary endpoint was a change in the mean number of nocturnal voids from baseline during the 3-month treatment period. The secondary endpoints were changes in the bladder diary parameters and questionnaires scores, and improvements in self-perception for nocturia.

Results

A total of 200 patients were screened and 76 were excluded from the study, because they failed the screening process. A total of 124 patients were randomized to receive treatment, with group A comprising 68 patients and group B comprising 56 patients. The patients' characteristics were similar between the groups. Nocturnal voids showed a greater decline in group B (-1.5) compared with group A (-1.2), a difference that was not statistically significant. Significant differences were observed between groups A and B with respect to the NPU index (0.37 vs. 0.29, P=0.028), the change in the maximal bladder capacity (-41.3 mL vs. 13.3 mL, P<0.001), and the rate of patients lost to follow up (10.3% [7/68] vs. 0% [0/56], P=0.016). Self-perception for nocturia significantly improved in both groups.

Conclusions

Combination treatment did not have any additional benefits in relation to reducing nocturnal voids in patients with NPU; however, combination therapy is helpful because it increases the maximal bladder capacity and decreases the NPI. Furthermore, combination therapy increased the persistence of desmopressin in patients with NPU.