Behavioral Symptoms of Reported Abuse in Children and Adolescents with Autism Spectrum Disorder in Inpatient Settings.

The objective of this study was to examine how behavioral manifestations of trauma due to abuse are expressed in youth with autism spectrum disorder (ASD). Analysis of covariance (ANCOVA) compared outcomes between patients with a caregiver reported history of abuse and those without. Findings indicate that patients with ASD and reported abuse (i.e. physical, sexual, and/or emotional) have more intrusive thoughts, distressing memories, loss of interest, irritability, and lethargy than those without reported maltreatment. Those with clinical diagnoses of posttraumatic stress disorder (PTSD) had more severe and externalized symptoms than those with reported abuse not diagnosed with PTSD. Results emphasize the need for trauma screening measures to guide evidence-based treatments for children with ASD.

Biomarkers p16, Human Papillomavirus and p53 Predict Recurrence and Survival in Early Stage Squamous Cell Carcinoma of the Vulva.

OBJECTIVE: Vulvar squamous cell carcinoma (VSCC) develops through 2 distinct molecular pathways, one involving high-risk human papillomavirus (HPV) infection and the other through early p53 suppressor gene mutation. We sought to evaluate the influence of p53 mutation, HPV status, and p16 expression on local recurrence and disease-specific mortality in early stage VSCC. MATERIALS AND METHODS: We performed a retrospective chart review of all patients with stage I VSCC at the Maine Medical Center from 1998 to 2007 (n = 92). Tumor size, depth of invasion, lymphatic/vascular space invasion, and growth pattern were recorded. Paraffin-embedded tissue blocks were stained by immunohistochemistry for p16 and p53; high-risk HPV was detected by polymerase chain reaction assay. Margin distance was determined by a gynecologic pathologist. Survival analyses were conducted to examine predictors of VSCC recurrence and disease-specific mortality. RESULTS: Age, depth of invasion, lymphatic/vascular space invasion, growth pattern, and margin status were not significant predictors of recurrence or disease-specific mortality. Tumor size of greater than 4.0 cm indicated a 4-fold increase in disease-specific mortality but did not significantly increase recurrence. p16-Positive patients were less likely to recur and had no VSCC-related deaths. Human papillomavirus-positive patients were less likely to recur and had no VSCC-related deaths. p53-positive patients were 3 times more likely to recur and nearly 7 times more likely to die from vulvar cancer. CONCLUSIONS: Our findings suggest that HPV and the surrogate biomarker p16 indicate a less aggressive type of vulvar cancer. p53 positivity was associated with poor prognosis and significantly increased both recurrence and disease-specific mortality.

The autism inpatient collection: methods and preliminary sample description.

BACKGROUND: Individuals severely affected by autism spectrum disorder (ASD), including those with intellectual disability, expressive language impairment, and/or self-injurious behavior (SIB), are underrepresented in the ASD literature and extant collections of phenotypic and biological data. An understanding of ASD's etiology and subtypes can only be as complete as the studied samples are representative. METHODS: The Autism Inpatient Collection (AIC) is a multi-site study enrolling children and adolescents with ASD aged 4-20 years admitted to six specialized inpatient psychiatry units. Enrollment began March, 2014, and continues at a rate of over 400 children annually. Measures characterizing adaptive and cognitive functioning, communication, externalizing behaviors, emotion regulation, psychiatric co-morbidity, self-injurious behavior, parent stress, and parent self-efficacy are collected. ASD diagnosis is confirmed by the Autism Diagnostic Observation Schedule - 2 (ADOS-2) and extensive inpatient observation. Biological samples from probands and their biological parents are banked and processed for DNA extraction and creation of lymphoblastoid cell lines. RESULTS: Sixty-one percent of eligible subjects were enrolled. The first 147 subjects were an average of 12.6 years old (SD 3.42, range 4-20); 26.5 % female; 74.8 % Caucasian, and 81.6 % non-Hispanic/non-Latino. Mean non-verbal intelligence quotient IQ = 70.9 (SD 29.16, range 30-137) and mean adaptive behavior composite score = 55.6 (SD 12.9, range 27-96). A majority of subjects (52.4 %) were non- or minimally verbal. The average Aberrant Behavior Checklist - Irritability Subscale score was 28.6, well above the typical threshold for clinically concerning externalizing behaviors, and 26.5 % of the sample engaged in SIB. Females had more frequent and severe SIB than males. CONCLUSIONS: Preliminary data indicate that the AIC has a rich representation of the portion of the autism spectrum that is understudied and underrepresented in extant data collections. More than half of the sample is non- or minimally verbal, over 40 % have intellectual disability, and over one quarter exhibit SIB. The AIC is a substantial new resource for study of the full autism spectrum, which will augment existing data on higher-functioning cohorts and facilitate the identification of genetic subtypes and novel treatment targets. The AIC investigators welcome collaborations with other investigators, and access to the AIC phenotypic data and biosamples may be requested through the Simons Foundation (www.sfari.org).

Pediatric Professional Medical Associations and Industry Guideline Compliance.

BACKGROUND AND OBJECTIVES: There has been an increasing focus on the relationship between pediatric prescribers and the biomedical industry. There is a lack of research, however, on the biomedical industry's relationship with the professional medical associations (PMAs) of pediatric prescribers. We developed a systematic method to assess this relationship by evaluating PMA transparency and compliance with a set of 2009 best practice guidelines (BPGs). METHODS: Nine PMAs rated as having the greatest influence on pediatric prescribers were examined. Two researchers independently coded publicly accessible information from the PMAs' Web sites for transparency and compliance with 36 BPG recommendations. Using the coded data, an industry relationship index (IRI) score was developed to systematize comparisons across PMAs. RESULTS: The PMAs demonstrated transparency and compliance with less than one-half of the 2009 BPGs (mean ± SD: 30.2 ± 15.6; range: 8-51 on the 66-point IRI scale). Two PMAs clustered in the high IRI (more transparent and compliant) group, 3 in the medium group, and 4 in the low group. There was no significant association of IRI group status and the PMAs' number of members or age. PMAs were least compliant with recommendations that prohibit or limit financial relationships with industry. CONCLUSIONS: PMAs with influence on pediatric prescribers have achieved only limited transparency and compliance with a set of 2009 BPGs, particularly with respect to financial separation from industry. Use of quantifiable standards of conduct facilitates comparisons between organizations and may enhance public trust in PMAs, preserving their ability to achieve organizational goals.

Effects of personalized colorectal cancer risk information on laypersons' interest in colorectal cancer screening: The importance of individual differences.

OBJECTIVE: To evaluate how personalized quantitative colorectal cancer (CRC) risk information affects laypersons' interest in CRC screening, and to explore factors influencing these effects. METHODS: An online pre-post experiment was conducted in which a convenience sample (N=578) of laypersons, aged >50, were provided quantitative personalized estimates of lifetime CRC risk, calculated by the National Cancer Institute Colorectal Cancer Risk Assessment Tool (CCRAT). Self-reported interest in CRC screening was measured immediately before and after CCRAT use; sociodemographic characteristics and prior CRC screening history were also assessed. Multivariable analyses assessed participants' change in interest in screening, and subgroup differences in this change. RESULTS: Personalized CRC risk information had no overall effect on CRC screening interest, but significant subgroup differences were observed. Change in screening interest was greater among individuals with recent screening (p=.015), higher model-estimated cancer risk (p=.0002), and lower baseline interest (p<.0001), with individuals at highest baseline interest demonstrating negative (not neutral) change in interest. CONCLUSION: Effects of quantitative personalized CRC risk information on laypersons' interest in CRC screening differ among individuals depending on prior screening history, estimated cancer risk, and baseline screening interest. PRACTICE IMPLICATIONS: Personalized cancer risk information has personalized effects-increasing and decreasing screening interest in different individuals.

Current Orthopaedic Surgeon Practices for Nonarthroplasty Treatment of Osteoarthritis of Adult Hip and Knee.

Evidence-based guidelines have recently been published for the nonarthroplasty treatment of osteoarthritis of the hip and knee and are becoming an expected part of comprehensive patient care. To understand how current treatment practices correlate with these guidelines, a survey was administered to 50 consecutive hip replacement and 50 consecutive knee replacement patients immediately before arthroplasty for osteoarthritis in one group practice. This article is a compilation of patients' usage of the modalities suggested in two such exemplary guidelines and demonstrates that patient and surgeon preferences, as well as factors such as preoperative Oxford score, body mass index, age, and joint involved, affect usage of one or more of the commonly employed preoperative modalities. This information provides orthopaedic surgeons and administrators with a compilation of responses that reflects surgeon and patient preferences for treatment before surgery.

Evaluation of anesthetic technique on surgical site infections (SSIs) at a single institution.

STUDY OBJECTIVE: To determine whether the previously published relationship between anesthetic technique and rate of surgical site infections (SSIs) was influenced by institution specific effects. DESIGN: Retrospective Review of Quality Assurance and Hospital Epidemiology databases. SETTING: Metropolitan medical center. MEASUREMENTS: The records of 7,751 patients who underwent knee or hip joint replacement from 2004 to 2010 were analyzed. Data regarding anesthetic technique, age, ASA status, gender, postoperative temperature, duration of anesthesia and type of surgery were from the department of anesthesiology quality assurance database and SSI cases were identified from the department of epidemiology database. The impact of anesthetic technique and other variables was assessed using bivariate and multivariate techniques. MAIN RESULTS: There was no association of anesthetic technique on the rate of SSI. Duration of anesthesia and ASA status were associated with effects on the rate of SSI. CONCLUSIONS: The impact of anesthetic technique on SSI following hip and knee replacement surgery may be site specific and using locally gathered quality data may assist in assessing specific institutional impact.

Developing, evaluating and validating a scoring rubric for written case reports.

OBJECTIVE: The purpose of this study was to evaluate Family Medicine Clerkship students' writing skills using an anchored scoring rubric. In this study, we report on the assessment of a current scoring rubric (SR) used to grade written case description papers (CDP) for medical students, describe the development of a revised SR with examination of scoring consistency among faculty raters, and report on feedback from students regarding SR revisions and written CDP. METHODS: Five faculty members scored a total of eighty-three written CDP using both the Original SR (OSR) and the Revised SR1 (RSR1) during the 2009-2010 academic years. RESULTS: Overall increased faculty inter-rater reliability was obtained using the RSR1. Additionally, this subset analysis revealed that the five faculty using the Revised SR2 (RSR2) had a high measure of inter-rater reliability on their scoring of this subset of papers (as measured by intra-class correlation (ICC) with ICC = 0.93, p = 0.001. CONCLUSIONS: Findings from this research have implications for medical education, by highlighting the importance of the assessment and development of reliable evaluation tools for medical student writing projects.

Preliminary investigation of lithium for mood disorder symptoms in children and adolescents with autism spectrum disorder.

OBJECTIVE: Children with autism spectrum disorder (ASD) have higher rates of comorbid psychiatric disorders, including mood disorders, than the general child population. Although children with ASD may experience irritability (aggression, self-injury, and tantrums), a portion also experience symptoms that are typical of a mood disorder, such as euphoria/elevated mood, mania, hypersexuality, paranoia, or decreased need for sleep. Despite lithium's established efficacy in controlling mood disorder symptoms in the neurotypical population, lithium has been rarely studied in children with ASD. METHODS: We performed a retrospective chart review of 30 children and adolescents diagnosed with ASD by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) criteria who were prescribed lithium in order to assess target symptoms, safety, and tolerability. Clinical Global Impressions - Improvement (CGI-I) ratings were performed by two board-certified child psychiatrists with expertise in ASD. CGI-I scores were dichotomized into "improved" (CGI-I score of 1 or 2) or "not improved" (CGI-I score ≥3). RESULTS: Forty-three percent of patients who received lithium were rated as "improved" on the CGI-I. Seventy-one percent of patients who had two or more pretreatment mood disorder symptoms were rated as "improved." The presence of mania (p=0.033) or euphoria/elevated mood (p=0.041) were the pretreatment symptoms significantly associated with an "improved" rating. The mean lithium blood level was 0.70 mEq/L (SD=0.26), and the average length of lithium treatment was 29.7 days (SD=23.9). Forty-seven percent of patients were reported to have at least one side effect, most commonly vomiting (13%), tremor (10%), fatigue (10%), irritability (7%), and enuresis (7%). CONCLUSIONS: This preliminary assessment of lithium in children and adolescents with ASD suggests that lithium may be a medication of interest for those who exhibit two or more mood disorder symptoms, particularly mania or euphoria/elevated mood. A relatively high side effect rate merits caution, and these results are limited by the retrospective, uncontrolled study design. Future study of lithium in a prospective trial with treatment-sensitive outcome measures may be indicated.

Specialized inpatient psychiatry for serious behavioral disturbance in autism and intellectual disability.

Psychiatric hospitalization of children with autism spectrum disorder and/or intellectual disability is common, however, the effectiveness of this intervention is largely unknown. Thirty-eight clinically-referred children 8-19 years old admitted to a specialized inpatient psychiatry unit were assessed by a consistent caregiver on the Aberrant Behavior Checklist-Irritability (ABC-I) subscale at admission, discharge and 2 months post discharge. There was a decrease in the mean ABC-I score from admission (27.3, SD 7.4) to discharge (11.9, SD 8.8), which was sustained at 2 months post discharge (14.8, SD 9.3) (p < 0.001). Seventy-eight percent of the subjects were rated as "Improved" on the clinician Clinical Global Impressions Improvement scale at discharge. The study is limited by lack of a control group, but offers preliminary evidence for specialized inpatient psychiatry as an intervention for serious behavioral disturbance in this population.

Feasibility of bispectral index monitoring to guide early post-resuscitation cardiac arrest triage.

INTRODUCTION: Triage after resuscitation from cardiac arrest is hindered by reliable early estimation of brain injury. We evaluated the performance of a triage model based on early bispectral index (BIS) findings and cardiac risk classes. METHODS: Retrospective evaluation of serial patients resuscitated from cardiac arrest, unable to follow commands, and undergoing hypothermia. Patients were assigned to a cardiac risk group: STEMI, VT/VF shock, VT/VF no shock, or PEA/asystole, and to a neurological dysfunction group, based on the BIS score following first neuromuscular blockade (BISi), and classified as BISi>20, BISi 10-20, or BISi<10. Cause of death was described as neurological or circulatory. RESULTS: BISi in 171 patients was measured at 267(±177)min after resuscitation and 35(±1.7)°C. BISi<10 suffered 82% neurological-cause and 91% overall mortality, BISi 10-20 35% neurological and 55% overall mortality, and BISi>20 12% neurological and 36% overall mortality. 33 patients presented with STEMI, 15 VT/VF-shock, 41 VT/VF-no shock, and 80 PEA/asystole. Among BISi>20 patients, 75% with STEMI underwent urgent cardiac catheterization (cath) and 94% had good outcome. When BISi>20 with VT/VF and shock, urgent cath was infrequent (33%), and 4 deaths (44%) were uniformly of circulatory etiology. Of 56 VT/VF patients without STEMI, 24 were BISi>20 but did not undergo urgent cath - 5(20.8%) of these had circulatory-etiology death. Circulatory-etiology death also occurred in 26.5% BIS>20 patients with PEA/asystole. When BISi<10, a neurological etiology death dominated independent of cardiac risk group. CONCLUSIONS: Neurocardiac triage based on very early processed EEG (BIS) is feasible, and may identify patients appropriate for individualized post-resuscitation care. This and other triage models warrant further study.

Telephone administration of the aberrant behavior checklist: a pilot study of feasibility in children with intellectual disability and autism.

To advance clinical care and research in children with intellectual disability and autism there is a growing need for efficient means to measure behavioral severity and response to treatment. The objective of this study was to assess the feasibility of telephone administration of the Aberrant Behavior Checklist-Irritability Subscale (ABC-I). The ABC-I was administered by telephone to the primary caregivers of 39 subjects with intellectual disability and/or autism. The same primary caregiver of each subject was also mailed a written copy of the ABC-I with a self-addressed, stamped envelope. Scores obtained by telephone and written administration were highly correlated (r = 0.827, p < 0.001). Telephone administration of the ABC-I may be a feasible and efficient means of determining response to treatment in children with intellectual disability and/or autism, though these pilot findings need to be replicated in a larger sample.

Mobilization of ventilated older adults.

BACKGROUND: Recent studies of ventilated, critically ill patients have shown early mobilization to be safe and resulting in better functional outcomes at discharge but have not focused on older adults. OBJECTIVES: The objectives of this pilot study were to examine the feasibility of and to describe functional outcomes associated with providing early mobilization to critically ill, older adult patients. METHODS: This is a prospective cohort study that took place in the medical and surgical intensive care units of a tertiary, academic medical center. Participants were aged 65 years or older, were on mechanical ventilation for 72 or more hours, and had a preadmission Barthel Index score of 70 or greater. Patients with an open ventriculostomy, continuous hemodialysis, or hospitalization of 7 or more days prior to intubation were excluded. A standardized early mobilization protocol was applied by a trained physical and occupational therapist to eligible participants according to previously published guidelines. Demographic information, hospitalization data, RAND 36-Item Short Form Health Survey (SF-36), and Barthel Index scores from preadmission, hospital discharge, and 30-day follow-up were collected. RESULTS: Patients who survived to hospital discharge compared with nonsurvivors were similar in their admission and hospital stay demographics. Survivors reported significantly higher functioning than nonsurvivors on preadmission functional status on both the physical functioning and general health RAND SF-36 subscales. Nonsurvivors reported significantly lower physical functioning, general health, vitality, and mental health on preadmission function when compared with the published normative RAND SF-36 data for patients aged 75 years and older. Patients who did survive hospitalization reported significantly more bodily pain at 30-day follow-up than the published normative data. Patients met criteria for therapy 92% of planned interventions, 99% of those sessions were completed, and adverse events occurred in less than 1% of interventions. CONCLUSION: Overall results indicate the feasibility and safety of implementing an early mobilization program to critically ill older adult patients.