Investigating the Impact of Isolation During COVID-19 on Family Functioning - An Australian Snapshot.

This study explored possible changes in family functioning from the perspective of parents during the COVID-19 pandemic. Thirty-four parents/guardians of children under 18 years completed a semi-structured interview, average length 47 min. Interviews focussed on changes in different aspects of family functioning including family roles, routines, and rules; parenting practices; communication and relationships; and strengths, challenges, and tensions. Data were analysed using reflexive thematic analysis applied in an idiographic and inductive manner to reduce the loss of individual experiences and perspectives. Four superordinate themes were identified: shifting family roles and boundaries throughout the pandemic; impacts on routines and relationships; opportunities and resourcing; and, experiences of support and unity. Gender differences were evident across some themes, particularly changing roles, workload and work-home boundaries. Challenges and tensions were frequently highlighted, particularly by "vulnerable" family groups such as those with children with disabilities. Parents also described a renewed sense of family and community that underpinned adaptive coping responses. The results highlight the importance of family connectedness in times of need.

Barriers and facilitators of sport and physical activity for Aboriginal and Torres Strait Islander children and adolescents: a mixed studies systematic review.

BACKGROUND: Participation in sport and physical activity could minimise the inflated risk of poor physical health outcomes for Aboriginal and Torres Strait Islander children and adolescents. This review aimed to synthesise existing quantitative and qualitative literature regarding barriers and facilitators to physical activity and sports participation in Aboriginal and Torres Strait Islander children. METHODS: Literature was systematically searched to include studies reporting barriers or facilitators to physical activity and/or sports participation in Aboriginal and Torres Strait Islander children aged 0-18 years. Using a pre-established taxonomy based on the social-ecological model, a deductive analysis was performed. Quality appraisal was performed using the Mixed Methods Appraisal Tool. RESULTS: Of 3440 unique articles, nine studies were included with n = 10,061 total participants. Of the nine included studies one reported on participants from urban areas, two from regional and three from remote areas. Three were from representative samples of the Aboriginal and Torres Strait Islander population. Barriers were reported in all nine studies: 18 individual, 9 interpersonal, 27 community and 4 at the policy level (58 total); Facilitators were reported in five studies: 12 individual, 11 interpersonal, 11 community and 3 policy level (37 total). CONCLUSIONS: Research in this area is lacking with some states in Australia not represented and small samples. Strategies for improving participation in sport and physical activity by Aboriginal and Torres Strait Islander children and adolescents need to integrate a comprehensive identification of barriers and facilitators with a social-ecological understanding of how community and cultural factors can impact individual participation.

Adverse health events associated with clinical placement: A systematic review.

OBJECTIVE: Clinical placement is a fundamental aspect of student learning and skill development across healthcare disciplines. However, participation in clinical placements can also present significant risk to students. This systematic literature review sought to examine the range of risks and hazards encountered by students across healthcare disciplines during their clinical placements. DESIGN: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelines were utilised in conducting this exploratory systematic review. DATA SOURCES: The CINAHL Complete, Medline Complete, and PsycINFO databases were searched. Reference lists of eligible records obtained via database searching were screened, and a supplementary key author search was conducted. Research published between 2013 and 2018 and conducted in the context of comparative international healthcare systems was the focus of this study. REVIEW METHODS: Study titles and abstracts were screened, and the full text of potentially relevant records was perused. Records meeting key eligibility criteria by addressing risk posed to students in healthcare disciplines within a clinical placement context were included in the final synthesis. RESULTS: The search identified 46 eligible records. The literature highlighted the worrying trend that students, most notably in the nursing discipline, can be exposed to a wide range of risks and adverse health events during clinical placement. CONCLUSIONS: As risks in unpredictable clinical environments cannot be eradicated, this review demonstrated a critical need for educative action to enable students to competently and confidently manage risks, and to reduce occurrence of adverse health events.

Adverse events reported by anxious school refusing adolescents receiving cognitive behavioral therapy with and without fluoxetine.

BACKGROUND: Investigating adverse events associated with antidepressant treatments in adolescents is important given the concerns about increased risk of suicidal ideation and behavior in this age group. The aim of this study is to investigate adverse and serious adverse events associated with the treatment of anxiety (cognitive behavioral therapy (CBT)-only, CBT-plus-placebo, and CBT-plus-fluoxetine) in anxious school-refusing adolescents. METHODS: A side-effect symptom checklist was completed by participants prior to commencing treatment and during treatment (weekly/fortnightly). RESULTS: CBT-plus-fluoxetine was well tolerated and not associated with higher levels of adverse events than the other treatments. Adverse events in all groups decreased over time, and the only adverse event distinct to fluoxetine was nausea. Baseline anxiety predicted higher levels of adverse events. There was one suicide attempt in the CBT-plus-placebo group but no statistically significant difference in suicide attempts between groups. Participants with a comorbid depressive disorder were more likely to report self-injury ideation but not suicidal ideation compared with those who did not have comorbid depressive disorder. Frequency of suicidal ideation and non-suicidal self-injury was significantly lower in the CBT-plus-fluoxetine group compared with the CBT-only group. Frequency of self-injury ideation was significantly lower in the CBT-plus-fluoxetine group compared with both other groups. CONCLUSIONS: Overall, the treatments were well tolerated and fluoxetine plus CBT appeared to be protective against suicidal ideation, non-suicidal self-injury, and self-injury ideation in this sample.

Biomarker of extracellular matrix remodelling C1M and proinflammatory cytokine interleukin 6 are related to synovitis and pain in end-stage knee osteoarthritis patients.

Little is known about local and systemic biomarkers in relation to synovitis and pain in end-stage osteoarthritis (OA) patients. We investigated the associations between the novel extracellular matrix biomarker, C1M, and local and systemic interleukin 6 (IL-6) with synovitis and pain. Serum C1M, plasma, and synovial fluid IL-6 (p-IL-6, sf-IL-6) were measured in 104 end-stage knee OA patients. Contrast-enhanced magnetic resonance imaging was used to semiquantitatively assess an 11-point synovitis score; pain was assessed by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Neuropathic Pain Questionnaire (NPQ). Linear regression was used to investigate associations between biomarkers and synovitis, and biomarkers and pain while controlling for age, sex, and body mass index. We also tested whether associations between biomarkers and pain were confounded by synovitis. We found sf-IL-6 was associated with synovitis in the parapatellar subregion (B = 0.006; 95% confidence interval [CI] 0.003-0.010), and no association between p-IL-6 and synovitis. We also observed an association between C1M and synovitis in the periligamentous subregion (B = 0.013; 95% CI 0.003-0.023). Furthermore, sf-IL-6, but not p-IL-6, was significantly associated with pain, WOMAC (B = 0.022; 95% CI 0.004-0.040), and NPQ (B = 0.043; 95% CI 0.005-0.082). There was no association between C1M and WOMAC pain, but we did find an association between C1M and NPQ (B = 0.229; 95% CI 0.036-0.422). Lastly, synovitis explained both biomarker-NPQ associations, but not the biomarker-WOMAC association. These results suggest that C1M and IL-6 are associated with synovitis and pain, and synovitis is an important confounding variable when studying biomarkers and neuropathic features in OA patients.

Augmenting Cognitive Behavior Therapy for School Refusal with Fluoxetine: A Randomized Controlled Trial.

This study investigates whether the augmentation of cognitive behavior therapy (CBT) with fluoxetine improves outcomes in anxious school refusing adolescents (11-16.5 years). Sixty-two participants were randomly allocated to CBT alone, CBT + fluoxetine or CBT + placebo. All treatments were well tolerated; with one suicide-attempt in the CBT + placebo group. All groups improved significantly on primary (school attendance) and secondary outcome measures (anxiety, depression, self-efficacy and clinician-rated global functioning); with gains largely maintained at 6-months and 1-year. Few participants were anxiety disorder free after acute treatment. During the follow-up period anxiety and depressive disorders continued to decline whilst school attendance remained stable, at around 54 %. The only significant between-group difference was greater adolescent-reported treatment satisfaction in the CBT + fluoxetine group than the CBT alone group. These results indicate the chronicity of school refusal, and the need for future research into how to best improve school attendance rates.

What happens to depressed adolescents? A follow-up study into early adulthood.

BACKGROUND: This study describes the mental illness and psychosocial outcomes of adolescents who experienced a depressive disorder and identifies predictors of full remission and recurrence. METHODS: 140 adolescents with major depressive disorder, dysthymic disorder, or depressive disorder NOS were offered psychosocial and/or antidepressant treatment across two clinical trials. Three to nine years later (mean 5.7 years), 111 adolescents and young adults completed self-, parent- and clinician-reported measures of psychopathology and psychosocial functioning in a naturalistic follow-up study. The Structured Clinical Interview for DSM-IV Axis 1 Disorders was used to determine the presence or absence of depressive disorder as well as other Axis 1 Disorders. RESULTS: By the follow-up assessment, most adolescents made a full remission from their index depressive disorder (92.6%). Recurrence of depressive disorder (52.4%) during the follow-up period was common, as was the experience of other disorders including anxiety, substance abuse and eating disorders. Time to full remission and recurrence did not vary between baseline types of depressive disorder. Self-reported depressive symptoms and anxiety disorder were associated with failure to achieve full remission while socio-economic status, self-reported self-efficacy and depressive symptoms were associated with recurrence of depressive disorder. LIMITATIONS: Due to different treatment starting times, the length of the follow up period varied by up to 5.2 years. CONCLUSIONS: Adolescents who experience depressive disorder are at high risk of ongoing mental illness and psychosocial impairment. Predictors of the course of depressive disorder may be of use in determining which adolescents may require more intensive intervention.

Biologics: the next generation of analgesic drugs?

For many decades, there have been few novel therapies for pain, and the number of promising targets that have been genuinely validated in the clinic is small. Discovery and development of biologic therapies for analgesia provides a better opportunity to test such targets, potentially providing new and effective therapies. Biologics have revolutionised the treatment of many diseases, with the greatest advances seen in oncology and inflammatory disorders. Across a broad spectrum of severe, chronic pain disorders - including inflammatory pain, neuropathic pain and cancer pain - biologics could offer patients safer and more-effective alternatives to currently available treatments. As such, progression of large-molecule therapies is becoming a strategic priority for companies as they look to advance their portfolios.

Perceived discrimination and hypertension among African Americans in the Jackson Heart Study.

OBJECTIVES: Using Jackson Heart Study data, we examined whether perceived discrimination was associated with prevalent hypertension in African Americans. METHODS: Everyday discrimination, lifetime discrimination, burden of discrimination, and stress from discrimination were examined among 4939 participants aged 35 to 84 years (women = 3123; men = 1816). We estimated prevalence ratios of hypertension by discrimination, and adjusted for age, gender, socioeconomic status, and risk factors. RESULTS: The prevalence of hypertension was 64.0% in women and 59.7% in men. After adjustment for age, gender, and socioeconomic status, lifetime discrimination and burden of discrimination were associated with greater hypertension prevalence (prevalence ratios for highest vs lowest quartile were 1.08 [95% confidence interval (CI) = 1.02, 1.15] and 1.09 [95% CI = 1.02,1.16] for lifetime discrimination and burden of discrimination, respectively). Associations were slightly weakened after adjustment for body mass index and behavioral factors. No associations were observed for everyday discrimination. CONCLUSIONS: Further understanding the role of perceived discrimination in the etiology of hypertension may be beneficial in eliminating hypertension disparities.

Influence of albuminuria and glomerular filtration rate on blood pressure response to antihypertensive drug therapy.

BACKGROUND: Albuminuria and glomerular filtration rate (GFR), two factors linked to kidney and vascular function, may influence longitudinal blood pressure (BP) responses to complex antihypertensive drug regimens. METHODS: We reviewed the clinic records of 459 patients with hypertension in an urban, academic practice. RESULTS: Mean patient age was 57-years, 89% of patients were African American, and 69% were women. Mean patient systolic/diastolic BP (SBP/DBP) at baseline was 171/98 mmHg while taking an average of 3.3 antihypertensive medications. At baseline, 27% of patients had estimated (e)GFR <60 ml/min/1.73(2), 28% had micro-albuminuria (30-300 mg/g) and 16% had macro-albuminuria (>300 mg/g). The average longitudinal BP decline over the observation period (mean 7.2 visits) was 25/12 mmHg. In adjusted regression models, macro-albuminuria predicted a 10.3 mmHg lesser longitudinal SBP reduction (p < 0.001) and a 7.9 mmHg lesser longitudinal DBP reduction (p < 0.001); similarly eGFR <60 ml/min/1.73(2) predicted an 8.4 mmHg lesser longitudinal SBP reduction (p < 0.001) and a 4.5 lesser longitudinal DBP reduction (p < 0.001). Presence of either micro- or macro-albuminuria, or lower eGFR, also significantly delayed the time to attainment of goal BP. CONCLUSIONS: These data suggest that an attenuated decline in BP in drug-treated hypertensives, resulting in higher average BP levels over the long-term, may mediate a portion of the increased risk of cardiovascular-renal disease linked to elevated urinary albumin excretion and reduced eGFR.

Investigation of consumer satisfaction with cognitive-behaviour therapy and sertraline in the treatment of adolescent depression.

OBJECTIVE: A new instrument, the Adolescent Depression Treatment Satisfaction Questionnaire (ADTSQ) was devised to measure the consumer satisfaction of depressed adolescents and their parents. The objectives of the paper were to present the psychometric properties of the ADTSQ and to investigate the relative consumer satisfaction with cognitive-behavioural therapy (CBT), sertraline (SRT) and a combined treatment of CBT and SRT (COMBINED) for the treatment of adolescent depression. In addition, participants were asked to rank their most preferred treatment from the following approaches: medication, individual counselling, group program and family therapy. METHOD: Thirty-eight adolescents with a unipolar depressive disorder and 37 parents who participated in a randomized clinical trial of CBT versus SRT versus COMBINED completed the ADTSQ following the completion of acute treatment. RESULTS: The ADTSQ was found to have high internal consistency and exploratory factor analysis detected three underlying factors. High levels of consumer satisfaction were reported by both adolescents and parents in all three treatments. Those treated with CBT treatments reported higher levels of skill acquisition than those treated with SRT. Of the four treatment approaches, most parents and adolescents rated individual counselling as their first preference. CONCLUSIONS: The ADTSQ is a useful measure of consumer satisfaction for depressed adolescents and their parents. CBT, SRT and COMBINED were shown to have high consumer satisfaction with CBT's higher skills training content reflected in the participants' reports. Individual counselling was perceived as the most favourable choice of treatment for adolescent depression. Although limitations associated with the measurement of consumer satisfaction and of the study are acknowledged, it is recommended that the inclusion of consumer satisfaction measures be considered in clinical trials that examine treatment efficacy.

Determinants of blood pressure response to quinapril in black and white hypertensive patients: the Quinapril Titration Interval Management Evaluation trial.

Race has been considered an important factor in determining blood pressure response to treatment and selection of antihypertensive drug therapy. Data collected during a clinical trial that evaluated rapidity of medication up-titration with blood pressure response to monotherapy with the angiotensin-converting enzyme (ACE) inhibitor quinapril were used to characterize response in 533 black and 2046 white participants. Our objectives were to examine the influence of race and other factors on blood pressure response and to assess the degree to which nonrace factors account for apparent racial differences in response. Average systolic and diastolic blood pressure responses (baseline minus follow-up) to treatment were assessed with treatment groups combined. Crude systolic and diastolic blood pressure responses averaged 4.7 and 2.4 mm Hg less, respectively, in black compared with white participants; however, the response distributions largely overlapped. In multivariate linear regression models adjusted for study design variables and measured participant characteristics, the racial difference in systolic response was reduced by 51% to 2.3 mm Hg, and diastolic response by 21% to 1.9 mm Hg. In these models, participant characteristics, including age, gender, body size, and pretreatment blood pressure severity, significantly predicted either attenuated or enhanced blood pressure response to treatment. Our findings demonstrate that a large source of variability of blood pressure response to treatment is within, not between, racial groups, and that factors that vary at the level of the individual contribute to apparent racial differences in response to treatment.

Disease-free survival difference between African Americans and whites after radical prostatectomy for local prostate cancer: a multivariable analysis.

OBJECTIVES: Age-adjusted mortality rates (per 100,000) for men with prostate cancer from 1991 through 1997 reported by the Surveillance, Epidemiology, and End Results national registry have consistently demonstrated that African-American men (AAM) have twice the death rate of white men (WM). However, there has been considerable controversy as to how this relates to progression-free survival among these men. In an attempt to address this controversy of localized prostate cancer, we report on a multivariable analysis of survival data of a large number of AAM and WM who underwent radical prostatectomy. METHODS: The study cohort was composed of 791 men whose only prostate cancer treatment was radical prostatectomy performed between July 1990 and December 1999. The variables analyzed were age, preoperative prostate-specific antigen level, pathologic grade and stage, and race/ethnicity. Pathologic examination of all specimens was performed in a uniform manner according to an established protocol. Multivariable analysis based on Cox's proportional hazards regression model was performed to assess whether a significant difference in progression-free survival time between AAM and WM persisted after controlling for the main effects of other prognostic factors. RESULTS: The study cohort consisted of 229 AAM and 562 WM. Our results indicated that all variables, except age, had highly significant effects on progression-free survival, even in the presence of other predictors. CONCLUSIONS: The effects of age, preoperative serum prostate-specific antigen level, and pathologic grade and stage did not account for the racial disparity in progression-free survival among men diagnosed with clinically localized prostate cancer and treated with radical prostatectomy.

New salt-sensitivity metrics: variability-adjusted blood pressure change and the urinary sodium-to-creatinine ratio.

DESIGN: We report the results of a 24-week, placebo-controlled, two-period, crossover trial of sodium supplementation in 112 normotensive African Americans, aged 25 to 64 years, with average blood pressure (BP) of 105/70 mm Hg. Estimated 24-hour urinary sodium excretion was 133.6 mmol; the average urinary sodium-to-creatinine ratio was 0.74. METHODS: Variability-adjusted BP change was the difference in BP level after the respective treatment periods, divided by the intra-person standard deviation of the average BP obtained at 3 consecutive screening visits during a 4-week period. RESULTS: The urinary sodium-to-creatinine ratio and the total urine sodium content were 37.8% and 26.5% higher, respectively, at the end of the sodium treatment period. Twenty-four hour ambulatory BP change (mm Hg) (95% CI) was systolic 1.2 (0, 2.4), and diastolic 0.7 (-0.3, 1.8); cuff BP change was systolic 0.9 (-1, 2.9), and diastolic 1.4 (0.1, 2.7). Variability-adjusted BP change was systolic 0.2 (-0.4, 0.8) and diastolic 0.4 (-0.1, 0.9). Though variability-adjusted and unadjusted SBP change correlated highly (r = 0.941, P<.001), only the former correlated with body mass index (r = 0.224, P<.05), a known correlate of salt sensitivity. While total urinary sodium content in timed urine collections and urinary sodium-to-creatinine ratio correlated (r = 0.727, P<.001), neither correlated with cuff BP changes. Change in urinary sodium-to-creatinine ratios of 3 consecutive pooled overnight 8-hour urine collections correlated with changes in 24-hour ambulatory SBP (r = 0.294, P<.001) and DBP (r = 0.193, P<.05); however, change in total urinary sodium content was uncorrelated. Total urinary sodium content of these pooled collections (P = .001), but not the urinary sodium-to-creatinine ratio, was positively related to urinary creatinine excretion per kilogram of body weight, the latter being an indicator of urine collection duration. CONCLUSIONS: The lack of effect of the duration of urine collection on the urinary sodium-to-creatinine ratio is advantageous in individuals who may report inaccurately the duration of their urine collection. Sequential regression analyses demonstrated that the urinary sodium-to-creatinine ratio conveyed all of the changes in urinary sodium excretion information contained in aggregate urinary sodium excretion-and more. Variability-adjusted BP change was the more sensitive metric of BP response to dietary sodium manipulations, than unadjusted BP change. Thus, variability-adjusted BP change and the urinary sodium-to-creatinine ratio appear to be incrementally better metrics of salt sensitivity than those traditionally used.

Effects of telmisartan on arterial stiffness in Type 2 diabetes patients with essential hypertension.

Arterial wall stiffness, an important independent risk factor for cardiovascular disease in patients with hypertension, is worsened by the coexistence of diabetes mellitus. This randomised, prospective, double-blind, crossover trial assessed the effects of telmisartan on arterial stiffness in patients with Type 2 diabetes with essential hypertension. After a two-week placebo wash out period, 28 ambulatory patients received telmisartan (40 mg) or placebo for three weeks. Following a second two-week placebo wash out period, patients received the alternate treatment for a further three weeks. Augmentation index and central blood pressure (BP) were determined using the SphygmoCor device and pulse wave velocity (PWV) was measured using an automatic device, the Complior trade mark, at the beginning and the end of each period. Telmisartan significantly reduced the carotid femoral PWV compared with placebo (mean adjusted treatment difference 0.95 m/s; 95% CI: 1.67, 0.23 m/s; p=0.013). Peripheral and central diastolic, systolic and pulse pressures were also significantly reduced with telmisartan compared with placebo. In conclusion, telmisartan reduces arterial stiffness and peripheral and central BPs as assessed by PWV and pulse contour analysis in hypertensive patients with Type 2 diabetes. These properties of telmisartan suggest that it may improve cardiovascular outcome in this patient population.