An examination of referrals declined for chronic pain care: There is increasing mental health complexity within care-seeking patients with chronic pain over time.

Background: Chronic pain is a complex disease that requires interprofessional care for effective management. Despite the need for multidisciplinary care, disease and health care inequities can prevent individuals from attaining adequate treatment. Factors such as mental health, cost, and distance to a health care center can contribute to health care accessibility inequality. The aim of this study is to examine declined referrals at the Toronto Academic Pain Medicine Institute (TAPMI) to determine the reason for declining care and number of declined referrals. Methods: A retrospective chart review of all declined referrals at TAPMI in 2018 and 2022 was conducted. Referral documentation and the intake decision were extracted from the electronic medical charts by the research team and verified by the clinical intake team. Chi-square tests were conducted to determine whether the proportion of declined referrals changed between the years reviewed. Results: The number of declined referrals due to mental health complexities increased significantly from 51 (11%) in 2018 to 180 (18%) in 2022 (χ2 = 10.9, P = 0.0009). A significant rise in the number of declines due to mental health service requests was also observed (χ2 = 24.53, P < 0.00001). Other common reasons for declined referrals in 2018 and 2022 included duplicate service, no primary care provider, and health care service changes. Conclusion: Mental health complexities continue to be a significant barrier to health care service acquisition for individuals living with chronic pain. The increase in patient complexity from 2018 to 2022 highlights the need for integrated health care resources.

Contexte: La douleur chronique est une maladie complexe qui nécessite des soins interprofessionnels pour une prise en charge efficace. Malgré la nécessité de soins multidisciplinaires, les maladies et les iniquités en matière de soins de santé peuvent empêcher les individus d'obtenir un traitement adéquat. Des facteurs tels que la santé mentale, le coût et la distance d'un centre de soins de santé peuvent contribuer aux inégalités en matière d'accessibilité des soins de santé. Le but de cette étude est d'examiner les demandes de consultation refusées à l'Institut universitaire de médecine de la douleur de Toronto (TAPMI) afin de déterminer la raison du refus des soins et le nombre de demandes de consultation refusées.Méthodes: Un examen rétrospectif de toutes les demandes de consultation refusées au TAPMI en 2018 et 2022 a été effectué. La documentation relative à la demande de consultation et la décision d'admission ont été extraites du dossier médical électronique par l'équipe de recherche et vérifiées par l'équipe d'admission clinique. Des tests de chi-carré ont été effectués pour déterminer si la proportion de demandes de consultation refusées avait changé entre les années examinées.Résultats: Le nombre de demandes de consultation refusées en raison des complexités de la santé mentale a considérablement augmenté, passant de 51 (11 %) en 2018 à 180 (18%) en 2022 (χ2 = 10,9, P = 0,0009). Une augmentation significative du nombre de refus attribuables aux demandes de services de santé mentale a également été observée (χ2 = 24,53, P < 0,00001). Parmi les autres raisons courantes pour lesquelles les demandes de consultation ont été refusées en 2018 et 2022, on compte la duplication du service, l'absence de prestataire de soins primaires et les changements dans les services de soins de santé.Conclusion: Les complexités de la santé mentale continuent d'être un obstacle important à l'acquisition de services de soins de santé pour les personnes vivant avec une douleur chronique. L'augmentation de la complexité des patients de 2018 à 2022 souligne la nécessité de ressources de soins de santé intégrées.

Efficient System for Delimitation of Benign and Malignant Breast Masses.

In this study, a high-performing scheme is introduced to delimit benign and malignant masses in breast ultrasound images. The proposal is built upon by the Nonlocal Means filter for image quality improvement, an Intuitionistic Fuzzy C-Means local clustering algorithm for superpixel generation with high adherence to the edges, and the DBSCAN algorithm for the global clustering of those superpixels in order to delimit masses' regions. The empirical study was performed using two datasets, both with benign and malignant breast tumors. The quantitative results with respect to the BUSI dataset were JSC≥0.907, DM≥0.913, HD≥7.025, and MCR≤6.431 for benign masses and JSC≥0.897, DM≥0.900, HD≥8.666, and MCR≤8.016 for malignant ones, while the MID dataset resulted in JSC≥0.890, DM≥0.905, HD≥8.370, and MCR≤7.241 along with JSC≥0.881, DM≥0.898, HD≥8.865, and MCR≤7.808 for benign and malignant masses, respectively. These numerical results revealed that our proposal outperformed all the evaluated comparative state-of-the-art methods in mass delimitation. This is confirmed by the visual results since the segmented regions had a better edge delimitation.

Identification and Characterization of Families That Are Positively Deviant for Childhood Obesity in a Latino Population: A Case-Control Study.

Background: Childhood obesity is a complex public health challenge that requires innovative, sustainable solutions. Positive deviance, inspired by the science of complexity, is an approach that examines what allows certain individuals to succeed despite being predicted to fail. This study is aimed at identifying and defining positive deviants for early childhood obesity. Methods: This case-control study used medical record data to identify Latino children aged 2-5 and classify them using their longitudinal weight change. Parents of children with trajectories toward a healthy weight from an obese weight (cases) and parents of children with stable obese weight trajectories over time (controls) were recruited. Mixed-methods analyses were used including a semistructured interview and quantitative surveys evaluating diet, physical activity, sleep, feeding practices, and self-efficacy. Qualitative description was applied to the qualitative data; quantitative data were analyzed using descriptive statistics and logistic regression modeling. Results: Of eligible Latino children identified from the overall data set (n=1,621), 257 (16%) had trajectories toward a healthy weight, and among these, 21 positively deviant cases completed the study with 23 matched controls. Positive deviant families were characterized by lower education, higher self-efficacy, and a more Mexican cultural orientation. Findings suggest that effective engagement of other caregivers and creating healthy food environments were important determinants of healthy weight outcomes. Conclusions: Positive deviants (cases) were distinct from controls in several parenting strategies such as creating healthy food environments and engaging caregivers. They had higher self-efficacy despite lower education. There were fewer differences in diet and physical activity than expected.

Parent Preferences for Shared Decision-making in Acute Versus Chronic Illness.

OBJECTIVES: The goal of this study was to examine preferences for shared decision-making (SDM) in parents of acutely ill versus chronically ill children in the inpatient setting. Additionally, we explored the effect of parental perception of illness severity and uncertainty in illness on decision-making preference. METHODS: In this cross-sectional study, we surveyed parents of children admitted to pediatric inpatient units at an academic, tertiary-care hospital. Surveys were administered in person and used validated tools to assess SDM preferences and uncertainty in illness. Descriptive statistics evaluated associations stratified by acute versus chronic illness, and multivariable analyses were performed. RESULTS: Of the 200 parents who participated, the majority were women (78%), Hispanic (81.5%), English speaking (73%), between 30 and 39 years old (37.5%), and had an education achievement of less than a college degree (77%). The mean age of hospitalized children was 8.1 years, and half reported a chronic illness. Most parents preferred an active (43%) or collaborative (40%) role in SDM. There was no association with SDM preference by demographics, number of previous hospitalizations, perception of illness severity, or uncertainty. However, parents of chronically ill children significantly preferred a passive role in SDM when they perceived a high level of uncertainty in illness. CONCLUSIONS: Most parents of hospitalized children prefer to take an active or collaborative role in SDM. However, parents of chronically ill children who perceive high levels of uncertainty surrounding their children's illness prefer a passive role, thus illustrating the complexity in decision-making among this parent population.

Trends and Disparities in the Prevalence of Childhood Obesity in South Texas between 2009 and 2015.

BACKGROUND: Recent reports have highlighted possible decreases over time in obesity, particularly among children aged 2-5 years. Hispanic children experience significantly higher obesity rates, and less is known about trends for Hispanic children. METHODS: A large healthcare system-based dataset from south Texas was used to analyze body mass index (BMI) values obtained clinically from 2009 through 2015. Age and race/ethnicity specific prevalence of overweight and obesity were calculated using CDC standards and trends were examined over time using regression analyses, and mapping software was used to identify geographic variation. RESULTS: Hispanic children in south Texas experience levels of obesity (25.3%, 95% CI: 25.1-25.6) significantly higher than their white (16.6%, 95% CI: 16.0-17.2) or black (18.2%, 95% CI: 17.3-19.1) peers. Obesity in Hispanic children aged 2-5 years decreased from 18.5%, 95% CI: 16.6-20.5, in 2009 to 15.1%, 95% CI: 14.3-15.9, in 2015. Obesity in Hispanic adolescents was stable at 30.4%, 95% CI: 28.5-32.4, in 2009 and 31.3, 95% CI: 30.3-32.2, in 2015. CONCLUSIONS: While obesity decreased in the youngest age group of Hispanic children, south Texas continues to experience high levels of obesity that exceed national averages with significant disparities.

Randomized Controlled Trial of DHA Supplementation during Pregnancy: Child Adiposity Outcomes.

Investigating safe and effective interventions in pregnancy that lower offspring adiposity is important given the burden of obesity and subsequent metabolic derangements. Our objective was to determine if docosahexaenoic acid (DHA) given during pregnancy to obese mothers results in lower offspring adiposity. This study was a long-term follow-up of a randomized trial of mothers with gestational diabetes or obesity who were randomized to receive DHA supplementation at 800 mg/day or placebo (corn/soy oil) starting at 25-29 weeks gestation. Anthropometric measures were collected at birth and maternal erythrocyte DHA and arachidonic (AA) levels were measured at 26 and 36 weeks gestation. At two- and four-year follow-up time points, offspring adiposity measures along with a diet recall were assessed. A significant increase in erythrocyte DHA levels was observed at 36 weeks gestation in the supplemented group (p < 0.001). While no significant differences by measures of adiposity were noted at birth, two or four years by randomization group, duration of breastfeeding (p < 0.001), and DHA level at 36 weeks (p = 0.002) were associated with body mass index z-score. Our data suggest that DHA supplementation during pregnancy in obese mothers may have long-lasting effects on offspring measures of adiposity.

A Pilot Study of Parent Mentors for Early Childhood Obesity.

Objective. To assess the feasibility of a parent mentor model of intervention for early childhood obesity using positive deviance-based methods to inform the intervention. Methods. In this pilot, randomized clinical trial, parent-child dyads (age: 2-5) with children whose body mass index (BMI) was ≥95th percentile were randomized to parent mentor intervention or community health worker comparison. The child's height and weight were measured at baseline, after the six-month intervention, and six months after the intervention. Feasibility outcomes were recruitment, participation, and retention. The primary clinical outcome was BMI z-score change. Results. Sixty participants were enrolled, and forty-eight completed the six-month intervention. At baseline, the BMI z-score in the parent mentor group was 2.63 (SD = 0.65) and in the community health worker group it was 2.61 (SD = 0.89). For change in BMI z-score over time, there was no difference by randomization group at the end of the intervention: -0.02 (95% CI: -0.26, 0.22). At the end of the intervention, the BMI z-score for the parent mentor group was 2.48 (SD = 0.58) and for the community health worker group it was 2.45 (SD = 0.91), both reduced from baseline, p < 0.001. Conclusion. The model of a parent mentor clinical trial is feasible, and both randomized groups experienced small, sustained effects on adiposity in an obese, Hispanic population.

A randomized clinical trial of the effects of parent mentors on early childhood obesity: Study design and baseline data.

BACKGROUND: Few effective community-based interventions exist for early childhood obesity. Parent mentors have been successful as an intervention for other conditions, but have not been used in childhood obesity. We designed an intervention for early childhood obesity using parent mentors and a positive outlier approach to assess potential efficacy, feasibility, and acceptability. METHODS: This trial enrolled obese (≥ 95th BMI percentile for age and gender) 2-5-year-old children in a Head Start program and their parents, with allocation to either parent mentors trained in positively deviant behaviors regarding childhood obesity, or community health workers delivering health education on obesity-related behaviors. The primary outcome is body mass index z-score change at the six-month follow-up assessment. Secondary outcomes include feeding behaviors and practices, health-related quality of life, dietary intake, and participation levels. RESULTS: We enrolled three parent mentors and 60 parent-child dyads. The population is 100% Hispanic; 44% of parents speak Spanish as their primary language and 45% were not high-school graduates. Children had a reported median vegetable and fruit intake of 0.3 and 1.1 cups per day, respectively, at baseline, and a median daily screen time of three hours. There was no intergroup difference in quality-of-life scores at baseline. Retention has been high, at 90% in three months. CONCLUSIONS: In this randomized trial of the effects of parent mentors on early childhood obesity, parent-child dyads from an underserved, Hispanic population were successfully enrolled through a partnership with a Head Start organization, with a high retention rate.

Odontología Basada en Evidencia: Las 82 Revistas de Mayor Impacto / Evidence Based Dentistry: The 82 Highest Impact Journals

La Odontología Basada en Evidencia es la aplicación clínica de las mejores evidencias científicas basadas en la experiencia del operador y en las expectativas del paciente. Estas evidencias científicas se presentan día a día en revistas indexadas alrededor del mundo con una actualización constante. El objetivo de la presente revisión es presentar y describir las características de las revistas de mayor impacto científico en el área de Odontología sirviendo como base para la mejor toma de decisiones clínicas en nuestros pacientes. La búsqueda de la información se realizó según el Indice de factor de impacto del ISI Web of Science 2014.

Evidence-Based Dentistry is the clinical application of the best scientific evidence based on operator experience and patient expectations. This everyday scientific evidence presented in indexed journals around the world with constantly updated. The aim of this review is to present and describe the characteristics of the scientific impact of journals in the field of Dentistry serving as a basis for better clinical decision making in our patients. The search for information was made according to index impact factor ISI Web of Science 2014.