Development of a Telehealth Intervention to Improve Access to Live Donor Kidney Transplantation.

BACKGROUND: Live donor kidney transplantation (LDKT) is underutilized by patients with end-stage kidney disease due to knowledge, communication, and logistical barriers. MATERIAL AND METHODS: The Talking About Live Kidney Donation Social Worker Intervention (TALK-SWI) is a previously validated intervention demonstrated to improve patients' access to and pursuit of LDKT through in-person delivery of education and social support. To help overcome logistical barriers to LDKT, we adapted TALK-SWI into a telehealth intervention employing digital (ie, tablet, smartphone) and telephone technologies. We studied the usability and acceptability of both the mobile device and telephone counseling portions of the intervention among people with kidney disease. For the digital portion, we assessed critical (ie, inability to complete a task) and non-critical (ie, ability to complete a task utilizing an alternative method) errors participants encountered when using the program and their preferences regarding digital materials. Simultaneously, we assessed participants' satisfaction with telephone-adapted counseling compared to the original, in-person counseling. RESULTS: The 15 participants testing the digital technology made 25 critical errors and 29 non-critical errors, while they easily completed 156 tasks (out of 210). A majority of participants (73%) preferred the tablet/smart phone education application over traditional materials, and most (80%) indicated they would be more likely to utilize the mobile platform over traditional materials. Participants testing the telephone-adapted (n = 45) and in-person (n = 125) social worker counseling all reported high satisfaction with the intervention. CONCLUSION: We successfully adapted a validated educational and behavioral intervention to improve access to LDKT into a usable and acceptable telehealth intervention.

Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial.

Care for patients transitioning from chronic kidney disease to kidney failure often falls short of meeting patients' needs. The PREPARE NOW study is a cluster randomized controlled trial studying the effectiveness of a pragmatic health system intervention, 'Patient Centered Kidney Transition Care,' a multi-component health system intervention designed to improve patients' preparation for kidney failure treatment. Patient-Centered Kidney Transition Care provides a suite of new electronic health information tools (including a disease registry and risk prediction tools) to help providers recognize patients in need of Kidney Transitions Care and focus their attention on patients' values and treatment preferences. Patient-Centered Kidney Transition Care also adds a 'Kidney Transitions Specialist' to the nephrology health care team to facilitate patients' self-management empowerment, shared-decision making, psychosocial support, care navigation, and health care team communication. The PREPARE NOW study is conducted among eight [8] outpatient nephrology clinics at Geisinger, a large integrated health system in rural Pennsylvania. Four randomly selected nephrology clinics employ the Patient Centered Kidney Transitions Care intervention while four clinics employ usual nephrology care. To assess intervention effectiveness, patient reported, biomedical, and health system outcomes are collected annually over a period of 36 months via telephone questionnaires and electronic health records. The PREPARE NOW Study may provide needed evidence on the effectiveness of patient-centered health system interventions to improve nephrology patients' experiences, capabilities, and clinical outcomes, and it will guide the implementation of similar interventions elsewhere. TRIAL REGISTRATION: NCT02722382.

Autonomic reactivity and psychopathology in middle childhood.

BACKGROUND: Better indicators are needed for identifying children with early signs of developmental psychopathology. AIMS: To identify measures of autonomic nervous system reactivity that discriminate children with internalising and externalising behavioural symptoms. METHOD: A cross-sectional study of 122 children aged 6--7 years examined sympathetic and parasympathetic reactivity to standardised field-laboratory stressors as predictors of parent- and teacher-reported mental health symptoms. RESULTS: Measures of autonomic reactivity discriminated between children with internalising behaviour problems, externalising behaviour problems and neither. Internalisers showed high reactivity relative to low-symptom children, principally in the parasympathetic branch, while externalisers showed low reactivity, in both autonomic branches. CONCLUSIONS: School-age children with mental health symptoms showed a pattern of autonomic dimorphism in their reactivity to standardised challenges. This observation may be of use in early identification of children with presyndromal psychopathology.

A violence-prevention and evaluation project with ethnically diverse populations.

The purpose of this paper is to describe some of the challenges encountered and lessons learned while providing and evaluating a violence-prevention program for and with ethnically diverse populations in child care settings. The paper discusses Safe Start, a violence prevention education program for child care staff and parents, and the evaluation of the program. Safe Start was designed to include culturally relevant content to increase cultural awareness for child care staff and parents from diverse ethnic backgrounds. The evaluation project enrolled child care centers with families representing the ethnically diverse communities in which they were located. Violence prevention research involving children from diverse ethnic backgrounds presents new methodologic challenges, but also provides new opportunities for creative, novel methods. This paper describes some of the challenges encountered with curriculum development, staff recruitment, instrument selection, and data collection procedures.

Dissociations between psychobiologic reactivity and emotional expression in children.

Although there are general assumptions that physiological and behavioral indices of emotion are interrelated, empirical research has revealed inconsistent findings with regard to their degree of association, particularly in children. Two studies were conducted to examine the relations between cardiovascular reactivity and emotional behavior. In the first study, 3- to 6-year-olds completed challenging tasks during which measures of their physiological responses and facial expressions were obtained. With age, children's heart rate decreased, vagal tone increased, and facial expressions became slightly more exaggerated. However, children's physiologic reactions were unrelated to their concurrent facial expression when all children were considered, when only boys were considered, and when children extreme in their physiologic reactions were considered. Only among girls was physiologic reactivity moderately associated with concurrent negative expressiveness. In the second study, 4- and 5-year-olds' physiologic reactivity was examined as a predictor of later overt emotional reaction to venipuncture episodes. Children's overt emotional reactions were consistent across repeated venipunctures, and girls were more visibly distressed than boys. As in the first study, physiologic reactivity was generally unrelated to children's behavioral responses. Findings have implications for assumptions about the degree of coupling between biological and behavioral emotional systems in childhood.

Injuries in child care centers: gender-environment interactions.

OBJECTIVES: To examine child characteristics (age, gender) and child care center environments (socioemotional quality, physical safety) that jointly predict injuries for preschool children. METHODS: A two year prospective study of 360 preschool children, ages 2-6 years, was conducted in four urban child care centers. Composite scores for center quality and physical safety were derived from on-site observations, and injury rates were based on teacher reports. Poisson regression analyses examined age, gender, center quality, center safety, and the interactions of gender with quality and safety as predictors of injury incidence over one child year. RESULTS: Age was significantly associated with injury rates, with younger children sustaining higher rates. An interaction between gender and center quality also significantly predicted injury incidence: girls in low quality centers experienced more injuries, while girls in high quality centers sustained fewer injuries than their male peers. Finally, an interaction between gender and center safety showed that girls in high safety centers sustained more injuries than boys, while girls in low safety centers sustained fewer injuries. CONCLUSIONS: Injuries occur even in relatively safe environments, suggesting that in child care settings, the socioemotional context may contribute, along with physical safety, to the incidence of injury events. Further, gender specific differences in susceptibility to environmental influences may also affect children's vulnerability and risks of injuries. The prevention of injuries among preschool children may thus require attention to and modifications of both the physical and socioemotional environments of child care.

The epidemiology of injuries in 4 child care centers.

OBJECTIVES: (1) To describe the pattern of injury in preschool-aged children in 4 child care centers as compared with the results of other studies; (2) to compare injury rates by sex, age, and child care center; and (3) to examine environmental and child factors contributing to injury severity. DESIGN: A 2-year cohort study of 362 preschool-aged children attending 4 urban child care centers. Teachers completed standardized injury forms on the type of injury, body location, site of injury, and contributing factors. RESULTS: During the 2 years of the study, 1886 injuries were reported. The mean and median child injury rate was 6 and 4 injuries per 2000 exposure hours (equivalent to 1 full-time child care year), respectively. The majority of injuries (87%) were minor, occurred during free play (81%) and on the playground (74%), and were precipitated by child-related factors (59%), such as being pushed. Boys had significantly higher median injury rates than girls. Age-adjusted injury rates for each child care center were significantly different by center (F3 = 61, P<.001). While moderate to severe injuries were more often precipitated by combinations of child and environmental factors (chi2(4) = 20, P<.001), minor injuries were usually precipitated by child-related factors. CONCLUSIONS: Injury data from child care centers are important for identifying common risk factors for frequent or severe injury events and for designing injury prevention programs. More research is needed to identify factors contributing to injuries, such as children's behavior and the child care centers' physical and socioemotional environments.

Health assessment in child care centers: parent and staff perceptions.

PURPOSE: The purpose of this study was to identify preschool children's health needs in child care centers, as perceived by parents and staff. METHOD: A Health Care Services Assessment was completed by 55 parents and 13 staff in four urban child care centers to identify the health services needed and children's common health problems. FINDINGS: The majority (69%) of the parents and staff reported that onsite health services were needed at least once a week. Helpful health services were identified as screening exams for respiratory illnesses (88%), other illnesses (87%), developmental problems (51%), and children with special needs (50%). The most commonly identified child health problems were colds (93%) and ear infections (75%). CONCLUSION: These findings indicate that efforts to protect the health of preschool children in child care centers might best begin with health services focused on prevention, such as screening children for illnesses and providing information on infection control.

Resilience and vulnerability among preschool children: family functioning, temperament, and behavior problems.

OBJECTIVE: To examine the effects of child temperament and stressful family functioning on child behavior problems among preschool children. METHOD: One hundred forty-five preschool children, aged 2 to 5 years, were evaluated by teachers, mothers, and independent observers. Teachers reported on child temperament; from these ratings, two dimensions of temperament were derived: difficult/easy and approachability. Mothers reported on two dimensions of family functioning: conflict and expressiveness. Both teachers and independent observers rated child behavior problems. RESULTS: Children with more difficult temperaments who were in high-conflict families had the most internalizing and externalizing behavior problems, while children with easy temperaments had fewer such problems, regardless of levels of family conflict. Difficult children whose families were highly expressive engaged in the most observed aggression. CONCLUSIONS: Results suggest that temperament is involved in both protective and vulnerability processes. A difficult temperament operates as a vulnerability factor for internalizing and externalizing behavior problems and observed aggression, while an easy temperament functions as a protective mechanism for these outcomes.

Psychobiologic reactivity to stress and childhood respiratory illnesses: results of two prospective studies.

Psychological stress is thought to undermine host resistance to infection through neuroendocrine-mediated changes in immune competence. Associations between stress and infection have been modest in magnitude, however, suggesting individual variability in stress response. We therefore studied environmental stressors, psychobiologic reactivity to stress, and respiratory illness incidence in two studies of 236 preschool children. In Study 1, 137 3- to 5-year-old children from four childcare centers underwent a laboratory-based assessment of cardiovascular reactivity (changes in heart rate and mean arterial pressure) during a series of developmentally challenging tasks. Environmental stress was evaluated with two measures of stressors in the childcare setting. The incidence of respiratory illnesses was ascertained over 6 months using weekly respiratory tract examinations by a nurse. In Study 2, 99 5-year-old children were assessed for immune reactivity (changes in CD4+, CD8+, and CD19+ cell numbers, lymphocyte mitogenesis, and antibody response to pneumococcal vaccine) during the normative stressor of entering school. Blood for immune measures was sampled 1 week before and after kindergarten entry. Environmental stress was indexed with parent reports of family stressors, and a 12-week respiratory illness incidence was measured with biweekly, parent-completed symptom checklists. The two studies produced remarkably similar findings. Although environmental stress was not independently associated with respiratory illnesses in either study, the incidence of illness was related to an interaction between child care stress and mean arterial pressure reactivity (beta = .35, p < .05) in Study 1 and to an interaction between stressful life events and CD19+ reactivity (beta = .51, p < .05) in Study 2.(ABSTRACT TRUNCATED AT 250 WORDS)

Dimensions of psychobiologic reactivity: Cardiovascular responses to laboratory stressors in preschool children.

Individual differences in children's physiologic responses to environmental stressors may be responsible for significant, but modest, associations found in past studies between stress and various morbidities. Because no standardized approach currently exists for eliciting and measuring cardiovascular reactivity (CVR) to laboratory stressors in preschool children, we developed a laboratory-based reactivity protocol that derives three dimensions of CVR-intensity, variability, and attenuation-and collected reliability data for each. A sample of 137 children between the ages of three and five years completed a series of seven devel-opmentally challenging tasks, comprising interpersonal, cognitive, and fine motor problems. Pulse rate (PR), diastolic blood pressure (DBP), systolic blood pressure (SBP), and mean arterial blood pressure (MAP) were measured at twelve standardized points using a Dinamap oscillometric blood pressure monitor. CVR scores were calculated for each of the four cardiovascular measures using: (a) a difference score; (b) a standardized residual score; and (c) three scores characterizing the dimensions of intensity, variability, and attenuation. Four to six weeks following initial testing, the protocol was readministered to ascertain temporal stability of reactivity measures.All four cardiovascular measures were responsive to the presented tasks (p>.001), and extensive variability was found in the character of cardiovascular responses. Subjects less than four years of age showed higher task PRs and lower DBPs, SBPs, and MAPs compared to older peers, but no gender differences were found. Difference scores were highly correlated with standardized residual scores (r's=.94 and .79,p>.001 for PR and MAP, respectively), but the three reactivity dimension scores showed a lack of intercorrelation and were independent of both difference and residual scores. Only the intensity and variability dimension scores showed modest and significant test-retest reliability (r's=.25 to .50,P>.01). Although previous CVR research has generally utilized difference or residual scores, dimensional scores reflecting the intensity and variability of CVR may achieve greater reliability in preschool childen.