Contribution of Sensory Processing to Chronic Constipation in Preschool Children.

OBJECTIVE: To assess differences in sensory processing patterns between children with chronic constipation compared with a matched normative sample as well as to examine the extent to which specific sensory processing patterns and modality scores predicted atypical toileting behaviors. STUDY DESIGN: We used a cross-sectional comparative design to evaluate differences between children age 3 and 5 years old with constipation (n = 66) and those in a matched control sample (n = 66). We also examined the contribution of sensory processing patterns to atypical toileting behavior in the clinical sample. RESULTS: Children with chronic constipation showed significantly higher sensory scores than a matched normative sample, specifically in oral processing (P < .001), visual processing (P < . 05), sensory avoiding (P < .001), and sensory sensitivity (P < .05). Sensory registration, avoidance, and oral processing significantly predicted toileting behavior over-responsiveness, and attentional difficulties contribute to toileting under-responsiveness. CONCLUSIONS: Our findings revealed that children with chronic constipation have underlying sensory characteristics that contribute to toileting behavioral difficulties. By identifying sensory processing patterns of children with chronic constipation, we can optimize behavioral interventions to complement laxative therapy for this population.

Mealtime Disruption and Caregiver Stress in Referrals to an Outpatient Feeding Clinic.

BACKGROUND: This investigation explores the feeding behaviors, comorbidities, and parenting stress in young children referred to an outpatient feeding clinic. MATERIALS AND METHODS: Eligible participants (n =72) were primary caretakers of children ages 2-6 years referred to an interdisciplinary outpatient feeding disorder clinic, subcategorized according to the absence (n = 18) or presence (n = 54) of caretaker-reported medical or developmental comorbidities. This group was compared with an equivalent control sample of caretakers of age-matched children (n = 72). Measures included the Children's Eating Behavior Inventory (CEBI) and the Parenting Stress Index-Short Form (PSI-SF). RESULTS: The CEBI and PSI scores were higher in the feeding disorder group than in the control group. PSI total was incrementally increased for control vs feeding disorder without comorbidity vs feeding disorder with comorbidity. CONCLUSION: Increased maladaptive behaviors and parenting stress were evident in children with feeding disorder regardless of the presence of comorbidity. Parenting stress was exacerbated by the presence of comorbidity.

Pediatric Outpatient Feeding Clinic: If You Build It, Who Will Come?

BACKGROUND: Feeding disorders occur commonly in the pediatric population and vary in severity from picky eating to extreme food selectivity. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, 10th Revision provide more inclusive diagnostic criteria for feeding disorders, but little is known about the actual referral population to an outpatient feeding clinic. In this investigation, the nutrition status, reason for referral, and related exploratory questions of outpatient referrals are detailed. MATERIALS AND METHODS: Children aged 1-18 years were eligible for enrollment. Survey data collected included demographics, prior diagnoses, parental/caretaker complaint, mealtime duration, referral source, and food repertoire. Exploratory questions examined the impact of the feeding disorder on immediate family. RESULTS: Ten percent of participants had a weight-for-height z score or body mass index score of ≤-2. The most common parental/caretaker chief complaint were poor nutrition, food refusals, and poor weight gain. The food repertoire included 15 or fewer items (7%), between 15 and 25 items (18%), or greater than 25 items (75%). The most positive responses to exploratory questions were mealtime frustration, lack of understanding by other family members, lack of access to appropriate treatment in a timely fashion, and inability to meet the child's feeding needs. CONCLUSION: Most referred infants and children were not undernourished. Despite this finding, most parents/caretakers were concerned about inadequate nutrition status and poor weight gain. Feeding disorders have an adverse effect on immediately family members. Revised diagnostic criteria should facilitate better identification of the broad spectrum of feeding disorders.

Force of infection is key to understanding the epidemiology of Plasmodium falciparum malaria in Papua New Guinean children.

Genotyping Plasmodium falciparum parasites in longitudinal studies provides a robust approach to estimating force of infection (FOI) in the presence of superinfections. The molecular parameter (mol)FOI, defined as the number of new P. falciparum clones acquired over time, describes basic malaria epidemiology and is suitable for measuring outcomes of interventions. This study was designed to test whether (mol)FOI influenced the risk of clinical malaria episodes and how far (mol)FOI reflected environmental determinants of transmission, such as seasonality and small-scale geographical variation or effects of insecticide-treated nets (ITNs). Two hundred sixty-four children 1-3 y of age from Papua New Guinea were followed over 16 mo. Individual parasite clones were tracked longitudinally by genotyping. On average, children acquired 5.9 (SD 9.6) new P. falciparum infections per child per y. (mol)FOI showed a pronounced seasonality, was strongly reduced in children using ITNs (incidence rate ratio, 0.49; 95% confidence interval, [0.38, 0.61]), increased with age, and significantly varied within villages (P = 0.001). The acquisition of new parasite clones was the major factor determining the risk of clinical illness (incidence rate ratio, 2.12; 95% confidence interval, [1.93, 2.31]). Adjusting for individual differences in (mol)FOI completely explained spatial variation, age trends, and the effect of ITN use. This study highlights the suitability of (mol)FOI as a measure of individual exposure and its central role in malaria epidemiology. It has substantial advantages over entomological measures in studies of transmission patterns, and could be used in analyses of host variation in susceptibility, in field efficacy trials of novel interventions or vaccines, and for evaluating intervention effects.

Variation in pain medication use in end-of-life care.

BACKGROUND: Pain is a common and distressing symptom at the end of life that medications can help relieve. We sought to explore variation in approaches to pharmaceutical management of pain among hospice-eligible patients and to determine if variation was explained by patient or site of care characteristics. Variation in medication use may suggest areas for best practices or quality improvement in medication use in end-of-life care. METHODS: We conducted a secondary analysis of randomized trial data, examining use of five medication classes: opiates, nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvant pain medications (tricyclics and antiseizure), stimulants, and antianxiety medications in 16 study sites nationwide. Descriptive statistics were generated for patient-level data and by site. Unadjusted and adjusted odds ratios were calculated to compare patient and location of care characteristics with each medication class use by site. RESULTS: We found variation in medication use was not predicted by most patient characteristics or location of care (home versus facility). Use of all types of pain medications decreased with age (odds ratio [OR] 0.75 [0.63-0.90]). Medication use varied between sites: a range of 14%-83% of patients were on different types of opiates, 0%-40% on NSAIDS, 20%-69% on benzodiazepines, 0%-25% on adjuvant medications, and 0%-23% were on acetaminophen at any time during the data collection period. CONCLUSIONS: Pain and adjuvant medication use differs widely by site of care. Further research is needed to determine the extent to which provider and patient choice contribute to prescribing variation, and to explore associations between patient symptoms, medication variation, and patient care quality.

Adolescent immunization delivery in school-based health centers: a national survey.

PURPOSE: Vaccinating adolescents in a variety of settings may be needed to achieve high vaccination coverage. School-based health centers (SBHCs) provide a wide range of health services, but little is known about immunization delivery in SBHCs. The objective of this investigation was to assess, in a national random sample of SBHCs, adolescent immunization practices and perceived barriers to vaccination. METHODS: One thousand SBHCs were randomly selected from a national database. Surveys were conducted between November 2007 and March 2008 by Internet and standard mail. RESULTS: Of 815 survey-eligible SBHCs, 521 (64%) responded. Of the SBHCs, 84% reported vaccinating adolescents, with most offering tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and human papillomavirus vaccines. Among SBHCs that vaccinated adolescents, 96% vaccinated Medicaid-insured and 98% vaccinated uninsured students. Although 93% of vaccinating SBHCs participated in the Vaccines for Children program, only 39% billed private insurance for vaccines given. A total of 69% used an electronic database or registry to track vaccines given, and 83% sent reminders to adolescents and/or their parents if immunizations were needed. For SBHCs that did not offer vaccines, difficulty billing private insurance was the most frequently cited barrier to vaccination. CONCLUSIONS: Most SBHCs appear to be fully involved in immunization delivery to adolescents, offering newly recommended vaccines and performing interventions such as reminder/recall to improve immunization rates. Although the number of SBHCs is relatively small, with roughly 2000 nationally, SBHCs appear to be an important vaccination resource, particularly for low income and uninsured adolescents who may have more limited access to vaccination elsewhere.

Surgical outcomes in American Indian veterans: a closer look.

BACKGROUND: American Indian/Alaska Native (AI/ANs) male veterans have considerably higher postoperative mortality rates than their Caucasian counterparts, but similar postoperative morbidity rates even after adjusting for major preoperative risk factors. This study seeks to explain the discrepancy in morbidity and mortality. STUDY DESIGN: We obtained data from the Veterans Affairs National Surgical Quality Improvement Program on major, noncardiac, surgical procedures performed from 1991 to 2002 for all AI/AN men (n = 2,155), and a random sample of Caucasian men (n = 2,264), matched by site. We compared the number and types of postoperative complications and mortality rates for those patients in whom complications developed. We also examined complication and mortality rates by whether they occurred after hospital discharge, or by specific type of surgical procedure. Preoperative risk factors were assessed in patients who died. Chi-square or Fisher's exact tests were used for all comparisons. RESULTS: AI/ANs and Caucasians did not differ by number of complications but Caucasian patients had considerably higher rates for three specific complications. There was no difference in deaths after discharge or in mortality rates after specific surgical procedures. The groups differed considerably in the types of procedures performed. Among patients who died, three preoperative risk factors, ie, hemiplegia, diabetes, and wound infection, occurred more frequently among AI/AN than Caucasian veterans. CONCLUSIONS: We cannot fully explain higher postoperative mortality rates experienced by AI/AN relative to Caucasian veterans after examining complications, types of procedures, and other relevant factors. AI/ANs with certain preoperative risk factors can be vulnerable to 30-day postoperative mortality and benefit from closer postoperative surveillance.

Drug users seeking emergency care for soft tissue infection at high risk for subsequent hospitalization and death.

OBJECTIVE: Although soft tissue infections are common among injection drug users (IDUs), little is known about the health outcomes among those who seek care for these infections. Emergency department visits are an important point-of-health-care contact for IDUs. In this prospective cohort study, we aimed to determine the hospitalization and mortality rates and factors associated with hospitalization or death among IDUs seeking emergency care for soft tissue infection. METHOD: Participants were English-speaking IDUs, 18 years of age and older, who sought initial care for soft tissue infection in an urban emergency department. We conducted semistructured interviews, identified hospitalizations from hospital records, and identified deaths using the National Death Index. Cox proportional hazards regression was used to investigate associations between baseline characteristics and hospitalizations or death. RESULTS: Of 211 eligible patients, 156 (74%) participated (mean age = 42 years). There were 255 subsequent hospitalizations over a mean of 3.9 years follow-up. The hospitalization rate was 42 hospitalizations per 100 person-years (95% confidence interval [CI]: 38-48). The mortality rate was 2.0 per 100 person-years (95% CI: 1.1-3.7). Factors associated with increased risk for hospitalization or death included living on the street or in a shelter (adjusted odds ratio [AOR] = 1.75, 95% CI: 1.10-2.79), being recently incarcerated (AOR = 1.90, 95% CI: 1.05-3.44), and having insurance (AOR: 1.98, 95% CI: 1.22-3.23). CONCLUSIONS: IDUs who sought care in the emergency department for soft tissue infections were at high risk for subsequent hospitalization and death. Visits for soft tissue infections represent missed opportunities for preventive care.

Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer: a randomized trial.

BACKGROUND: Small studies of variable quality suggest that massage therapy may relieve pain and other symptoms. OBJECTIVE: To evaluate the efficacy of massage for decreasing pain and symptom distress and improving quality of life among persons with advanced cancer. DESIGN: Multisite, randomized clinical trial. SETTING: Population-based Palliative Care Research Network. PATIENTS: 380 adults with advanced cancer who were experiencing moderate-to-severe pain; 90% were enrolled in hospice. INTERVENTION: Six 30-minute massage or simple-touch sessions over 2 weeks. MEASUREMENTS: Primary outcomes were immediate (Memorial Pain Assessment Card, 0- to 10-point scale) and sustained (Brief Pain Inventory [BPI], 0- to 10-point scale) change in pain. Secondary outcomes were immediate change in mood (Memorial Pain Assessment Card) and 60-second heart and respiratory rates and sustained change in quality of life (McGill Quality of Life Questionnaire, 0- to 10-point scale), symptom distress (Memorial Symptom Assessment Scale, 0- to 4-point scale), and analgesic medication use (parenteral morphine equivalents [mg/d]). Immediate outcomes were obtained just before and after each treatment session. Sustained outcomes were obtained at baseline and weekly for 3 weeks. RESULTS: 298 persons were included in the immediate outcome analysis and 348 in the sustained outcome analysis. A total of 82 persons did not receive any allocated study treatments (37 massage patients, 45 control participants). Both groups demonstrated immediate improvement in pain (massage, -1.87 points [95% CI, -2.07 to -1.67 points]; control, -0.97 point [CI, -1.18 to -0.76 points]) and mood (massage, 1.58 points [CI, 1.40 to 1.76 points]; control, 0.97 point [CI, 0.78 to 1.16 points]). Massage was superior for both immediate pain and mood (mean difference, 0.90 and 0.61 points, respectively; P < 0.001). No between-group mean differences occurred over time in sustained pain (BPI mean pain, 0.07 point [CI, -0.23 to 0.37 points]; BPI worst pain, -0.14 point [CI, -0.59 to 0.31 points]), quality of life (McGill Quality of Life Questionnaire overall, 0.08 point [CI, -0.37 to 0.53 points]), symptom distress (Memorial Symptom Assessment Scale global distress index, -0.002 point [CI, -0.12 to 0.12 points]), or analgesic medication use (parenteral morphine equivalents, -0.10 mg/d [CI, -0.25 to 0.05 mg/d]). LIMITATIONS: The immediate outcome measures were obtained by unblinded study therapists, possibly leading to reporting bias and the overestimation of a beneficial effect. The generalizability to all patients with advanced cancer is uncertain. The differential beneficial effect of massage therapy over simple touch is not conclusive without a usual care control group. CONCLUSION: Massage may have immediately beneficial effects on pain and mood among patients with advanced cancer. Given the lack of sustained effects and the observed improvements in both study groups, the potential benefits of attention and simple touch should also be considered in this patient population.

POWER for reproductive health: results from a social marketing campaign promoting female and male condoms.

PURPOSE: To evaluate effects of a 6-month social marketing campaign on awareness of, attitudes toward and use of female as well as male condoms for 15-25 year-old-women. METHODS: Using a time-space sampling methodology, we conducted a cross-sectional survey of 3407 women at pre-campaign in 12 western U.S. neighborhoods on female and male condom awareness, attitudes, and use. Six of the 12 study neighborhoods were randomly selected to receive the POWER social marketing campaign designed to impact condom knowledge, attitudes, and use. The campaign was followed with another cross-sectional survey of 3,003 women in all 12 study neighborhoods on condom knowledge, attitudes, use and awareness of POWER materials. We compared pre-and post-campaign surveys to determine the efficacy of POWER and conducted post hoc analyses on post-campaign data to determine if exposure to POWER was related to higher levels of positive condom attitudes and norms and condom use. RESULTS: We found no differences between neighborhoods with and without the POWER campaign with regard to our primary outcomes. To diagnose reasons for this null effect, we examined outcomes post hoc examining the influence of POWER exposure. Post hoc analyses show some evidence that exposure to POWER was associated with condom use. In the context of the nested trial, this raises concerns that post test only evaluations are limited. CONCLUSIONS: Establishing the efficacy of a social marketing campaign is challenging. This group randomized trial showed a null effect. Social marketing campaigns may need to have more media channels and saturation before they can show behavioral effects. Using a nested design with randomization at the community level and probability sampling introduces rigor not commonly seen in evaluations of social marketing campaigns.