Enhancing Early Childhood Mental Health Primary Care Services: Evaluation of MA Project LAUNCH.

Objectives The purpose of this study was to evaluate the efficacy of an innovative early childhood mental health intervention, Massachusetts Project LAUNCH. Early childhood mental health clinicians and family partners (paraprofessionals with lived experience) were embedded within community pediatric medical homes. Methods A longitudinal study design was used to test the hypotheses that (1) children who received services would experience decreased social, emotional and behavioral problems over time and (2) caregivers' stress and depressive symptoms would decrease over time. Families who were enrolled in services and who consented to participate in the evaluation study were included in analyses (N = 225). Individual growth models were used to test longitudinal effects among MA LAUNCH participants (children and caregivers) over three time points using screening tools. Results Analyses showed that LAUNCH children who scored in age-specific clinically significant ranges of social, emotional and behavioral problems at Time 1 scored in the normal range on average by Time 3. Caregivers' stress and depressive symptoms also declined across the three time points. Results support hypotheses that the LAUNCH intervention improved social and emotional health for children and caregivers. Conclusions for Practice This study led to sustainability efforts, an expansion of the model to three additional communities across the state and development of an online toolkit for other communities interested in implementation.

Changes in HbA1c and Weight Following Transition to Continuous Subcutaneous Insulin Infusion Therapy in Adults With Type 1 Diabetes.

BACKGROUND: Historically, intensive insulin therapy for type 1 diabetes (T1D) has improved glycemic control at the risk of adverse weight gain. The impact of continuous subcutaneous insulin infusion therapy (CSII) on weight in the current era remains unknown. We assessed changes in hemoglobin A1c (HbA1c) and weight in adults with T1D transitioning to CSII at 2 diabetes centers in Denmark and the United States. METHODS: Patients with T1D, aged ≥18 years, managed with multiple daily injections (MDI) who transitioned to CSII between 2002 and 2013 were identified using electronic health record data from the Steno Diabetes Center (n = 600) and Joslin Diabetes Center (n = 658). Changes in HbA1c and weight after 1 year was assessed overall and by baseline HbA1c cut points. Multivariate regression assessed correlates of HbA1c reduction. RESULTS: In adults with T1D transitioning to CSII, clinically significant HbA1c reductions were found in patients with baseline HbA1c 8.0-8.9% (Steno, -0.7%; Joslin, -0.4%) and baseline HbA1c ≥9.0% (Steno, -1.1%; Joslin, -0.9%) ( P < .005 for all). Overall, there was no significant change in weight after 1 year at either center. Modest (<2%) weight gain was noted in patients with baseline HbA1c ≥9% at Steno (1.1 ± 0.3 kg, P < .0001) and Joslin (1.7 ± 1.1, P < .005). In multivariate models, HbA1c reduction was associated with higher HbA1c, older age, female sex at Steno ( R2 = .28, P < .005), but only higher baseline HbA1c at Joslin ( R2 = .19, P < .005). CONCLUSION: Adults with T1D with suboptimal glycemic control significantly improved HbA1c without a negative impact on weight 1 year after transitioning from MDI to CSII.

IMPROVEMENTS IN METABOLIC CONTROL IN ADULTS WITH TYPE 2 DIABETES FOLLOWING REFERRAL TO A DIABETES CENTER, 2005-2010.

OBJECTIVE: We aimed to compare metabolic control in adults with diabetes in the general population to those newly referred to a diabetes center and after 1 year of specialty care. METHODS: We performed a retrospective comparison of adults with diabetes aged ≥20 years data from the National Health and Nutrition Examination Survey (NHANES, n = 1,674) and a diabetes center (n = 3,128) from 2005-2010. NHANES participants represented the civilian, non-institutionalized U.S. POPULATION: Diabetes center referrals lived primarily around eastern Massachusetts. The proportion attaining targets for glycated hemoglobin A1c (A1c), blood pressure (BP), low-density lipoprotein (LDL) cholesterol, or all 3 (ABC control) and the proportion prescribed medications to lower A1c, BP, or cholesterol were evaluated. RESULTS: Compared to the general sample, a smaller proportion of new diabetes center referrals had A1c <7% (<53 mmol/mol, 24% vs. 53%, P<.001), BP <130/80 mm Hg (38% vs. 50%, P<.001), and ABC control (5.6% vs. 17%, P<.001) but not LDL<100 mg/dL (<2.6 mmol/L, 54% vs. 53%, P = .65). After 1 year, more diabetes center referrals attained targets for A1c (40%), BP (38%), LDL (67%), and ABC control (15%) (P<.001 for all versus baseline). ABC control was not different between the general sample and diabetes center referrals at 1 year (P = .16). After 1 year, a greater percentage of diabetes center referrals compared to the general sample were prescribed medications to lower glucose (95% vs. 72%), BP (79% vs. 64%), and cholesterol (77% vs. 54%)(all P<.001). CONCLUSION: Compared to the general population, glycemic control was significantly worse for adults newly referred to the diabetes center. Within 1 year of specialty care, ABC control increased 270% in the setting of significant therapy escalation. ABBREVIATIONS: A1c = glycated hemoglobin A1c ABC = composite of A1c, blood pressure, and cholesterol ACEi = angiotensin-converting enzyme inhibitor ARB = angiotensin receptor blocker BMI = body mass index BP = blood pressure EHR = electronic health record LDL = low-density lipoprotein NCHS = National Center for Health Statistics NHANES = National Health and Nutrition Examination Survey PCP = primary care provider.

Different structural correlates for verbal memory impairment in temporal lobe epilepsy with and without mesial temporal lobe sclerosis.

OBJECTIVES: Memory impairment is one of the most prominent cognitive deficits in temporal lobe epilepsy (TLE). The overall goal of this study was to explore the contribution of cortical and hippocampal (subfield) damage to impairment of auditory immediate recall (AIMrecall), auditory delayed recall (ADMrecall), and auditory delayed recognition (ADMrecog) of the Wechsler Memory Scale III (WMS-III) in TLE with (TLE-MTS) and without hippocampal sclerosis (TLE-no). It was hypothesized that volume loss in different subfields determines memory impairment in TLE-MTS and temporal neocortical thinning in TLE-no. METHODS: T1 whole brain and T2-weighted hippocampal magnetic resonance imaging and WMS-III were acquired in 22 controls, 18 TLE-MTS, and 25 TLE-no. Hippocampal subfields were determined on the T2 image. Free surfer was used to obtain cortical thickness averages of temporal, frontal, and parietal cortical regions of interest (ROI). MANOVA and stepwise regression analysis were used to identify hippocampal subfields and cortical ROI significantly contributing to AIMrecall, ADMrecall, and ADMrecog. RESULTS: In TLE-MTS, AIMrecall was associated with cornu ammonis 3 (CA3) and dentate (CA3&DG) and pars opercularis, ADMrecall with CA1 and pars triangularis, and ADMrecog with CA1. In TLE-no, AIMrecall was associated with CA3&DG and fusiform gyrus (FUSI), and ADMrecall and ADMrecog were associated with FUSI. CONCLUSION: The study provided the evidence for different structural correlates of the verbal memory impairment in TLE-MTS and TLE-no. In TLE-MTS, the memory impairment was mainly associated by subfield-specific hippocampal and inferior frontal cortical damage. In TLE-no, the impairment was associated by mesial-temporal cortical and to a lesser degree hippocampal damage.

Treatment of symptomatic focal nodular hyperplasia with percutaneous radiofrequency ablation.

The authors report a case of a 21-year-old woman taking oral contraceptives for severe dysmenorrhea who presented with a hepatic mass and worsening right upper quadrant pain. The oral contraceptives could not be discontinued because of her pelvic symptoms, necessitating treatment of the liver lesion for symptomatic relief. Computed tomography and percutaneous biopsy demonstrated the mass to be focal nodular hyperplasia. The patient opted for radiofrequency ablation rather than surgical enucleation for symptomatic relief. The ablation proved to be a safe and effective alternative to surgery to treat the benign tumor, and permitted more aggressive therapy of the dysmenorrhea.

Examining patterns of change in the critical thinking skills of graduate nursing students.

Although critical thinking in undergraduate nursing education has been explored in depth, little is known about the critical thinking skills of graduate nursing students. Prior research on change in critical thinking scores is based primarily on pretest and posttest assessments that provide minimal information about change. This study used individual growth modeling to investigate how critical thinking skills change during a 2-year graduate nurse program. Scores from the evaluation, inference, and analysis subscales of the California Critical Thinking Skills Test comprised the empirical growth record. Change in the three critical thinking skills was more dynamic than that reported in previous studies. Patterns of change differed by critical thinking skill and in relation to students' initial critical thinking skill levels at program entry.

The pathway from musculoskeletal pain to mobility difficulty in older disabled women.

Little is known about the pathway from musculoskeletal pain to mobility difficulty among older persons. We examined potential physical and psychological mediators of the pain-disability relationship in the Women's Health and Aging Study (WHAS), a cohort of women aged 65 who had at least mild disability at baseline. Pain was classified according to location and severity (widespread pain; lower extremity pain; other pain; none or mild pain in only one site). Among women without a lot of difficulty in stair climbing (n=676) or walking (n=510) at baseline, those who reported widespread pain were more likely than those with none or mild pain to develop a lot of difficulty with mobility during the 3 year follow-up. The likelihood for mobility difficulty was unchanged after adjusting for physical impairments and symptoms of depression and anxiety (walking aOR=1.85, 95%CI, 1.08-3.17; stair climbing, aOR=2.68, 95%CI, 1.56-4.62). Lower extremity pain was associated with increased likelihood for difficulty with climbing stairs but not with walking. However, this association was attenuated after adjusting for physical impairments and psychological symptoms (aOR=1.66, 95%CI, 0.99-2.77). Pain was not associated with increased risk for becoming unable to walk or climb stairs. The findings suggest that pain is a unique domain as a cause of disablement, independent of the usual pathway to disability via physical impairments. Research is needed to better understand the development of pain-related disability in order to determine optimum approaches to prevent and treat mobility disability in older persons with persistent pain.

Sex differences in musculoskeletal pain in older adults.

Little is known about sex differences in musculoskeletal pain in older persons. There were 682 women and 380 men aged 72 years and older who participated in the 22nd biennial exam of the Framingham Study (1992-1993). Participants were asked to identify pain locations on a homunculus showing all regions of the body. Pain was categorized according to number of regions, with the most disseminated pain classified as widespread pain (back pain and upper and lower extremity pain with bilaterality). Among the women, 63% reported pain in one or more regions, compared to 52% of men. Widespread pain was more prevalent among women than men (15 versus 5%, respectively). In both men and women, pain was associated with fair or poor self-rated health, history of back pain before age 65, and disability. Factors associated with pain only in women included body mass index, systolic blood pressure, and depressive symptoms. In men but not women, pain was associated with polyarticular radiographic osteoarthritis. In conclusion, musculoskeletal pain was more prevalent and more widespread in older women than older men. Men and women differ in the factors associated with musculoskeletal pain in older ages. Further research is needed to understand sex differences in musculoskeletal pain the older population.

Patterns of service utilization by adults with a developmental disability: type of service makes a difference.

Patterns and correlates of service utilization by adults with a developmental disability were examined using data from 831 mothers of an adult child with a developmental disability. A modified Andersen model of health services was used to examine service utilization in seven domains. Multinomial logistic regression revealed that predictors of services received as well as predictors of unmet need for services varied by service. Findings emphasize the importance of considering predisposing characteristics, enabling resources, and need as well as service in order to understand patterns of service utilization.

Advancing the taxonomy of disability in older adults.

BACKGROUND: Refinement of the traditional task-based classification of disability is needed to advance the field of disability research and to inform clinical practice. We propose an enhancement of the taxonomy of disability that incorporates information about symptoms and impairments that directly contribute to disability. In the first step of this new development, we present evidence to support five categories of disability related to pain, balance, weakness, endurance, and other symptoms. METHODS: The Women's Health and Aging Study, begun in 1992, was a population-based study of older disabled women living in the Eastern region of Baltimore and surrounds. In-home examinations were conducted every 6 months for 3 years. During the second examination, the 879 participants were asked the main symptom cause of their disability for each activity with which they had difficulty. Symptom causes of disability in activities of daily living were grouped into five nonmutually exclusive categories as stated above. Descriptive analyses were used to compare groups according to sociodemographic, health, disease, and physical performance information. RESULTS: Women with pain-related disability were younger, more obese, and had high prevalence of widespread pain and symptomatic osteoarthritis. Balance-related disability was related to having an age of 85 years or older, being Caucasian, and poor performance in tests of standing balance and gait. Women with weakness-related disability were older, more often African American and sedentary, had high prevalence of stroke and diabetes, and performed poorly in chair-stands and knee strength tests. Endurance-related disability was associated with low self-rated energy, depressive symptoms, smoking history, and lung and cardiovascular diseases. CONCLUSIONS: The proposed refinement of the taxonomy of disability describes a set of empirically derived symptom and impairment-related disability groupings that have criterion and face validity. Further research about symptom and impairment-related disability in other populations of older persons is warranted.