Velopharyngeal Insufficiency Following Furlow Versus Straight Line Repair With Intravelar Veloplasty: A Single-institution Experience.

BACKGROUND: Measurements of postoperative velopharyngeal dysfunction (VPD) can be used to determine the efficacy of a palatoplasty operation. Hypernasality and audible nasal air emission are typical manifestations of VPD during speech. We aimed to longitudinally compare VPD outcomes in postpalatoplasty patients who underwent Furlow repair versus straight line repair with intravelar veloplasty (IVVP). Additionally, we examined the relationship between VPD outcomes and select pre-existing patient characteristics. METHODS: Retrospective chart review was performed to identify primary palatoplasty patients treated from April 2012 to March 2021. Variables collected included gender, syndromic status, primary language, Veau cleft type, type of speech assessment, age at time of surgery, degree of hypernasality, presence of audible nasal air emission, and overall adequacy of velopharyngeal function. Pearson χ2 test and multivariable t tests were used to analyze variables. Logistic regression was used to control for statistically significant variables. RESULTS: Of the 118 patients included, 38 received a Furlow procedure and 80 received a straight line with IVVP procedure. Audible nasal air emission was present in 57.3% of straight line with IVVP patients and 42.9% of Furlow patients, with no statistically significant difference between groups. Clinically significant hypernasality was present in 42.1% of straight line with IVVP patients and 22.9% of Furlow patients (P=0.05). Velopharyngeal function was classified as adequate in 63.5% of straight line with IVVP patients and 83.3% of Furlow patients (P=0.03). However, after stratifying by syndromic versus nonsyndromic status, there was no statistically significant difference between straight line with IVVP and Furlow patients for postoperative hypernasality and velopharyngeal function. CONCLUSIONS: This study suggests that there are no statistically significant differences between straight line with IVVP and Furlow palatoplasty techniques regarding speech outcomes including hypernasality, audible nasal air emission, and overall VP function. Furthermore, select patient characteristics such as gender, primary language, syndromic status, age at repair, and Veau cleft type do not significantly impact postoperative speech outcomes.

American Medical Society of Sports Medicine Position Statement: Mononucleosis and Athletic Participation.

ABSTRACT: Infectious mononucleosis (IM) is a common illness in children and young adults caused primarily by the Epstein-Barr Virus (EBV). Transmission occurs primarily through sharing oral secretions, thus IM is known as the "kissing disease." Common clinical manifestations include fever, pharyngitis, posterior cervical lymphadenopathy, and splenomegaly. Atypical lymphocytosis and transaminase elevations are common, and the diagnosis of IM is confirmed with laboratory findings of a positive heterophile antibody ("Monospot"), polymerase chain reaction, or antibodies specific to EBV. Individuals with acute IM may be quite symptomatic and not feel well enough to participate in sports. Splenic enlargement is common, with rupture a relatively rare occurrence, typically occurring within a month of symptom onset, but this risk complicates sports participation, and is often the reason for restricting activity. The management of IM is primarily supportive, with no role for antivirals or corticosteroids. The variability of clinical presentation and the risk of splenic rupture in patients with IM present clinicians with challenging return to play/return to sport (RTS) decisions. This position statement updates the Evidence-Based Subject Review on Mononucleosis by the American Medical Society for Sports Medicine published in 2008 and reviews the epidemiology, clinical manifestations, laboratory assessment, and management including RTS for the athlete with IM. This statement also addresses complications, imaging, special considerations, diversity and equity considerations, and areas for future clinical research. Understanding the evidence regarding IM and sport is essential when communicating with athletes and their families and incorporating shared decision-making in the RTS decision.

Sports Medicine Curricular Recommendations for Undergraduate Medical Education.

ABSTRACT: Sports medicine is a unique field encompassing many specialties and aspects of medicine. While musculoskeletal medicine is a significant aspect of sports medicine, the breadth of sports medicine extends beyond the musculoskeletal system and includes the spectrum of care for the patient who is or desires to be physically active. This article provides recommendations for sports medicine education in undergraduate medical education. The framework highlighting these recommendations uses domains of competence. Entrustable professional activities, measures that are endorsed by the Association of American Medical Colleges, were matched to domains of competence to provide objective markers of achievement. In addition to recommended sports medicine educational content, there should be consideration of both methods of assessment and implementation catered to each individual institution's needs and resources. These recommendations may serve as a guide for medical educators and institutions pursing optimization of sports medicine education.

Sexual Health Services in Schools: A Successful Community Collaborative.

School-based health centers (SBHCs) are an essential part of a comprehensive approach to address the health needs of youth. SBHCs that provide sexual health services (SHS) show promising results in improving reproductive health outcomes among youth. Despite the positive impact SBHCs can have, few school districts have SBHCs, and even fewer provide SHS. This article describes a successful 5-year project to provide SHS through SBHCs in a large county in the southeast United States. A community collaborative, including the schools, health department, community agencies and a local university, was created to address the project goals and objectives. Various steps were taken to plan for the SBHCs, including documenting community support for SHS offered through SBHCs, identifying school sites for SBHCs, and the process for offering pregnancy, STD (sexually transmitted disease), and HIV testing, treatment, and referrals. Protocols for clinic flow, testing, staffing, training, and student recruitment were developed. The staff at the SBHCs were successful in recruiting students to attend educational sessions and to receive testing and treatment. Student feedback was overwhelmingly positive. Lessons learned about the importance of the partnership's collaboration, using recommended clinic protocol, ensuring clear communication with school staff, and employing youth friendly recruitment and clinic practices are shared.

Cost-Effectiveness of a School-Based Chlamydia Screening Program, Duval County, FL.

During the 2015-2016 school year, the Florida Department of Health in Duval County hosted Teen Health Centers (TeenHC) at five high schools of Jacksonville providing HIV/STD screening and pregnancy testing. The purpose of this study was to assess the cost-effectiveness of the TeenHC chlamydia screening program and determine at what student participation level, the program can be cost-effective. We assessed the costs and effectiveness of the chlamydia screening program compared with "no TeenHC". Cost-effectiveness was measured as cost per quality-adjusted life years (QALY) gained. At a program cost of US$61,001 and 3% participation rate, the cost/QALY gained was $124,328 in the base-case analysis and $81,014-$264,271 in 95% of the simulation trials, all greater than the frequently citied $50,000/QALY benchmark. The cost/QALY gained could be <$50,000/QALY if student participation rate was >7%. The TeenHC chlamydia screening has the potential to be cost-effective. Future program efforts should focus on improving student participation.

Access to Multidisciplinary Care for Patients With 22q11.2 Deletion Syndrome: Identifying Breakdowns in the Screening Process.

The 22q11.2 deletion syndrome affects approximately 1 in 4000 live births and involves cardiac defects, immunodeficiency, and endocrine disruption. The complexity of diagnosis and multifaceted care often leads to fragmented management in the short and long term. With the purpose of developing an effective multidisciplinary program, the authors aimed to identify the deficiencies in current screening and referral processes among the teams required in the care for patients with 22q11.2 deletion syndrome. A retrospective chart review was conducted at our institution between 2001 and 2016. Patients with confirmed 22q11.2 deletion diagnoses between the ages of 0 and 28 were included. A list of 15 relevant specialties that should evaluate patients with 22q11.2 deletion syndrome was created according to established guidelines. Patient medical and demographic information were collected and analyzed. A total of 270 patients were included. Mean age at diagnosis was 3.3 years. On average, patients visited 6 of 15 departments (1-14). Only 8.8% of patients visited >10 specialties. The majority were seen by Cardiology, Allergy and Immunology, Genetics, and Speech (57.4-87.8%). A minority were seen by Hematology and Oncology, Sleep Therapy, and Physical Therapy (13.3-16.3%). Only 34.1% encountered plastic surgery. Negative correlation (-0.128; P = 0.035) was demonstrated between patients' age at diagnosis and number of specialty teams encountered. This study highlights the current underutilization of services required to manage patients with 22q11.2 deletion syndrome. While screening guidelines have been established, implementation can be challenging as it requires efficient care coordination between teams. Moving forward, the authors believe that a multidisciplinary clinical approach to streamline patient care is necessary.

Speech Outcomes After LeFort I Advancement Among Cleft Lip and Palate Patients.

BACKGROUND: Velopharyngeal insufficiency (VPI) results from incomplete closure of the velopharyngeal (VP) sphincter with oral pressure consonants during speech. Maxillary hypoplasia is common among cleft children and often requires LeFort I advancement. This results in anterior movement of the soft palate with the bony maxillary segment. Consequently, the size of the VP sphincter is increased and may result postoperative VPI or worsening of prior VPI. To better counsel our patients and their families of the risk of VPI after LeFort I advancement, we chose to evaluate our own cohort. METHODS: We conducted an institutional review board-approved prospective review of all cleft children presenting to Texas Children's Hospital who underwent LeFort I advancement after previous palatoplasty between 2013 and 2016 in a three-surgeon, consecutive patient series. Data collected included age, sex, ethnicity, cleft type, prior secondary speech surgery, presence of preoperative fistula, planned distance of advancement, orthognathic surgery performed, and any concurrent procedures performed. Primary outcomes measured included preoperative and postoperative VP function and hypernasality as measured by a certified speech pathologist. RESULTS: Velopharyngeal function was unchanged in 67% of our cohort after LeFort I advancement. Of those patients, 83% had evidence of VPI preoperatively, and 17% had normal speech preoperatively. Twenty-two percent of the patients displayed worsening VP function after surgery, and 6% displayed evidence of improvement. Velopharyngeal function was unable to be assessed in 6% of patients. Nasality ratings worsened in 39% of patients, were unchanged in 39%, and improved in 22%. Of the patients with incompetent VP function after surgery, 50% already received or are currently scheduled for secondary speech surgery, 25% declined secondary surgery, and 25% are pending scheduling. CONCLUSIONS: Although VP function remains unchanged in a majority of patients after LeFort I advancement, VPI should be carefully screened for after surgery. If detected, secondary operations to correct speech should be strongly considered.

Action and inaction in multi-behaviour recommendations: a meta-analysis of lifestyle interventions.

This meta-analysis examined theoretical predictions about the effects of different combinations of action (e.g., start an exercise regime) and of inaction (e.g., reduce screen time, rest in between weight lifting series) recommendations in smoking, diet, and physical activity multiple-domain interventions. The synthesis included 150 research reports of interventions promoting multiple behaviour domain change and measuring change at the most immediate follow-up. The main outcome measure was an indicator of overall change that combined behavioural and clinical effects. There were two main findings. First, as predicted, interventions produced the highest level of change when they included a predominance of recommendations along one behavioural dimension (i.e., predominantly inaction or predominantly action). Unexpectedly, within interventions with predominant action or inaction recommendations, those including predominantly inaction recommendations had greater efficacy than those including predominantly action recommendations. This effect, however, was limited to interventions in the diet and exercise domains, but reversed (greater efficacy for interventions with predominant action vs. inaction recommendations) in the smoking domain. These findings provide important insights on how to best combine recommendations when interventions target clusters of health behaviours.

A meta-intervention to increase completion of an HIV-prevention intervention: Results from a randomized controlled trial in the state of Florida.

OBJECTIVE: A randomized control trial with 722 eligible clients from a health department in the State of Florida was conducted to identify a simple, effective meta-intervention to increase completion of an HIV-prevention counseling program. METHOD: The overall design involved 2 factors representing an empowering and instrumental message, as well as an additional factor indicating presence or absence of expectations about the counseling. Completion of the 3-session counseling was determined by recording attendance. RESULTS: A logistic regression analysis with the 3 factors of empowering message, instrumental message, and presence of mediator measures, as well as all interactions, revealed significant interactions between instrumental and empowering messages and between instrumental messages and presence of mediator measures. Results indicated that (a) the instrumental message alone produced most completion than any other message, and (b) when mediators were not measured, including the instrumental message led to greater completion. CONCLUSIONS: The overall gains in completion as a result of the instrumental message were 16%, implying success in the intended facilitation of counseling completion. The measures of mediators did not detect any experimental effects, probably because the effects were happening without much conscious awareness. (PsycINFO Database Record

Support for Offering Sexual Health Services Through School-Based Health Clinics.

BACKGROUND: Numerous studies document support for sexuality education in the schools. However, there is a dearth of research assessing support for sexual health services offered through school-based health clinics (SBHCs). The purpose of this study was to assess voter support for offering 3 sexual health services (STI/HIV testing, STI/HIV treatment, condom distribution) through SBHCs. METHODS: The survey was developed after review of existing surveys on support for sexuality education and sexual health services. The university's Public Opinion Research Laboratory used random-digit-dialing to administer the survey to participants (N = 311) including residential and cell phone numbers. RESULTS: Most participants were supportive of offering sexual health services at both middle schools (MS) and high schools (HS): testing for STIs/HIV (61% MS, 76% HS), treatment for STIs/HIV (60% MS, 75% HS), and provision of condoms (44% MS, 63% HS). Analyses showed significant differences in support for sexual health services by a few demographic variables, opinions about sexuality education, and the percentage of students perceived to have had sexual intercourse. CONCLUSIONS: Results document support for offering sexual health services through SBHCs. These findings may benefit other communities looking to implement similar clinics. Such services have great potential for positively impacting the sexual health of youth.

The Americleft Speech Project: A Training and Reliability Study.

OBJECTIVE: To describe the results of two reliability studies and to assess the effect of training on interrater reliability scores. DESIGN: The first study (1) examined interrater and intrarater reliability scores (weighted and unweighted kappas) and (2) compared interrater reliability scores before and after training on the use of the Cleft Audit Protocol for Speech-Augmented (CAPS-A) with British English-speaking children. The second study examined interrater and intrarater reliability on a modified version of the CAPS-A (CAPS-A Americleft Modification) with American and Canadian English-speaking children. Finally, comparisons were made between the interrater and intrarater reliability scores obtained for Study 1 and Study 2. PARTICIPANTS: The participants were speech-language pathologists from the Americleft Speech Project. RESULTS: In Study 1, interrater reliability scores improved for 6 of the 13 parameters following training on the CAPS-A protocol. Comparison of the reliability results for the two studies indicated lower scores for Study 2 compared with Study 1. However, this appeared to be an artifact of the kappa statistic that occurred due to insufficient variability in the reliability samples for Study 2. When percent agreement scores were also calculated, the ratings appeared similar across Study 1 and Study 2. CONCLUSION: The findings of this study suggested that improvements in interrater reliability could be obtained following a program of systematic training. However, improvements were not uniform across all parameters. Acceptable levels of reliability were achieved for those parameters most important for evaluation of velopharyngeal function.

Appealing to fear: A meta-analysis of fear appeal effectiveness and theories.

Fear appeals are a polarizing issue, with proponents confident in their efficacy and opponents confident that they backfire. We present the results of a comprehensive meta-analysis investigating fear appeals' effectiveness for influencing attitudes, intentions, and behaviors. We tested predictions from a large number of theories, the majority of which have never been tested meta-analytically until now. Studies were included if they contained a treatment group exposed to a fear appeal, a valid comparison group, a manipulation of depicted fear, a measure of attitudes, intentions, or behaviors concerning the targeted risk or recommended solution, and adequate statistics to calculate effect sizes. The meta-analysis included 127 articles (9% unpublished) yielding 248 independent samples (NTotal = 27,372) collected from diverse populations. Results showed a positive effect of fear appeals on attitudes, intentions, and behaviors, with the average effect on a composite index being random-effects d = 0.29. Moderation analyses based on prominent fear appeal theories showed that the effectiveness of fear appeals increased when the message included efficacy statements, depicted high susceptibility and severity, recommended one-time only (vs. repeated) behaviors, and targeted audiences that included a larger percentage of female message recipients. Overall, we conclude that (a) fear appeals are effective at positively influencing attitude, intentions, and behaviors; (b) there are very few circumstances under which they are not effective; and (c) there are no identified circumstances under which they backfire and lead to undesirable outcomes.

Evaluation of Patient Satisfaction Surveys in Pediatric Orthopaedics.

BACKGROUND: Patient satisfaction survey scores are increasingly being tied to incentive compensation, impact how we practice medicine, influence decisions on where patients seek care, and in the future may be required for accreditation. The goal of this study is to compare the results of an internal distribution of patient satisfaction surveys at the point of care to responses received by mail in a hospital-based, high-volume pediatric orthopaedic practice. METHODS: A pediatric outpatient survey is used at our institution to evaluate patient satisfaction. Surveys are randomly mailed out to families seen in our clinic by the survey vendor, and the results are determined on a quarterly basis. We distributed the same survey in a similar manner in our clinic. The results of the surveys, external/mailed (EXM) versus internal/point of care (INP) over the same 3-month time period (second quarter 2013) were compared. The survey questions are dichotomized from an ordinal scale into either excellent (9 to 10) or not excellent (0 to 8) commonly used in patient satisfaction methodology. We evaluated the raw data from the INP surveys for the question on provider rating by evaluating the mean score, the standard excellent response (9 to 10), and an expanded excellent response (8 to 10). RESULTS: Response rate was 72/469 (15.4%) for EXM, and 231/333 (69.4%) for INP. An excellent response for the "rating your provider" question was 72.2% (EXM) versus 84.8% (INP) (P=0.015). Our analysis of the raw data (INP) has a mean rating of 9.42. The expanded scale (8 to 10) for an excellent response increased the provider rating to 94.4% (P=0.001). Waiting time response within 15 minutes was the only item that correlated with rating of provider (P=0.02). For the majority of the items, the INP responses were consistently higher than the EXM responses, including 6/7 responses that were statistically significant (P<0.05). CONCLUSIONS: As mandated by the Centers for Medicare and Medicaid Services, patient satisfaction surveys will be important in determining health care outcomes. Properly designed and administered surveys provide robust measures of quality. Our study reinforces methodological concerns about patient satisfaction surveys distributed in a high-volume pediatric subspecialty practice. Further research is needed to evaluate the patients' health care experience and true quality of care in pediatric subspecialty ambulatory settings.

When it comes to lifestyle recommendations, more is sometimes less: a meta-analysis of theoretical assumptions underlying the effectiveness of interventions promoting multiple behavior domain change.

A meta-analysis of 150 research reports summarizing the results of multiple behavior domain interventions examined theoretical predictions about the effects of the included number of recommendations on behavioral and clinical change in the domains of smoking, diet, and physical activity. The meta-analysis yielded 3 main conclusions. First, there is a curvilinear relation between the number of behavioral recommendations and improvements in behavioral and clinical measures, with a moderate number of recommendations producing the highest level of change. A moderate number of recommendations is likely to be associated with stronger effects because the intervention ensures the necessary level of motivation to implement the recommended changes, thereby increasing compliance with the goals set by the intervention, without making the intervention excessively demanding. Second, this curve was more pronounced when samples were likely to have low motivation to change, such as when interventions were delivered to nonpatient (vs. patient) populations, were implemented in nonclinic (vs. clinic) settings, used lay community (vs. expert) facilitators, and involved group (vs. individual) delivery formats. Finally, change in behavioral outcomes mediated the effects of number of recommended behaviors on clinical change. These findings provide important insights that can help guide the design of effective multiple behavior domain interventions.

Barriers to accessing HIV-prevention in clinic settings: Higher alcohol use and more sex partners predict decreased exposure to HIV-prevention counseling.

Understanding barriers to accepting HIV-prevention counseling among vulnerable populations is of critical importance, as prevention efforts can only have a public health impact if high-risk populations are willing to enroll. A correlational field study was conducted in a health care setting with a high-risk community sample (N = 350) to determine if number of sex partners and alcohol consumption predict acceptance of an invitation to take part in HIV-prevention counseling. Findings indicated that participants engaging in the least risky behavior (i.e. individuals reporting no alcohol consumption and few sex partners) were more likely to accept an offer to receive HIV-prevention counseling. Moreover, heavy drinking was associated with decreased exposure to HIV-prevention counseling, regardless of the number of sex partners reported (b = .12, p > .05). Given associations between heavy drinking and sexual risk taking, finding ways to increase exposure to HIV-prevention counseling programs among heavy drinkers could serve a vital public health function.

Motivational barriers to retention of at-risk young adults in HIV-prevention interventions: perceived pressure and efficacy.

Multi-session HIV-prevention interventions are efficacious but depend on the retention of clients over time. In a sample of at-risk young adults (N = 386), we investigated three potential motivational barriers that might affect the likelihood of retention. Perceived pressure, perceived efficacy and fear and anxiety during the initial session were measured, along with demographic characteristics, partner characteristics, and HIV-related health knowledge. Logistic regressions demonstrated that (1) in general, perceived ineffectiveness was negatively associated with retention; (2) perceived pressure or coercion was negatively associated with retention but only for younger clients; (3) experienced fear and anxiety had no significant association with retention. Implications for theory and counseling practices to reduce motivational barriers and effectively tailor interventions are discussed.

When is Retention in Health Promotion Interventions Intentional? Predicting Return to Health Promotion Interventions as a Function of Busyness / ¿Cuándo es la adherencia en las intervenciones de promoción de salud intencional? Predicción de regreso a las intervenciones de promoción de la salud en función de la ocupación

To test when intentional decisions enhance retention in health-promotion interventions, we analyzed the rate of return of 278 clients of HIV-prevention counseling at a state health department in Florida. Specifically, the role of intentions as a facilitator of returns was analyzed as a function of busyness (more children and work hours), while demographic and health factors that also influenced returns were controlled for. Consistent with the notion that actions depend on ability, intentions predicted the behavior of the less busy participants but failed to facilitate retention when participants were occupied with children and work. These findings suggest the efficacy of different retention strategies -one emphasizing explicit intention formation, and the other either attracting clients to counseling on the spot or using more ubiquitous technologies.

Para poner a prueba cuándo las decisiones intencionales promueven la retención dentro de las intervenciones de promoción de salud, se analizó la proporción en que 278 usuarios de consejería de prevención de VIH regresaban al departamendo de salud estatal de Florida. Específicamente, el rol de las intenciones como facilitador de los retornos fue analizado como una función de trabajo (más hijos y más horas laborales), mientras que los factores demográficos y de salud que también tenían influencia fueron controlados. Consistente con la noción de que las acciones dependen de la habilidad, las intenciones predijeron la conducta de los usuarios menos ocupados y no predijeron en los casos de usuarios con mayor carga de trabajo e hijos. Estos hallazgos sugieren la eficancia de diferentes estrategias de retención -una enfatizando la formación explícita de intenciones, y otra ya sea atrayendo clientes a consejería sobre la marcha, o utilizando tecnología más ubicuas.

Etiology and incidence of pediatric gallbladder disease.

PURPOSE: The spectrum of pediatric biliary tract disease is changing. The goal of this study was to examine the causes and comorbidities of pediatric gallbladder disease at our institution. METHODS: We performed a retrospective chart review on consecutive patient at Kosair Children's Hospital who underwent cholecystectomy over a 9-year time period ending in 2012. RESULTS: Among the 453 patients in the study group, the average age was 13.3 years and 67.2% were female. Indications for cholecystectomy were gallstones in 285 (63%) and biliary dyskinesia in 140 (33%). Of the patients with gallstones, 68 children (15%) had hemolytic disease. Although the number of cholecystectomies for hemolytic disease was relatively stable throughout our study, the number for biliary dyskinesia and non-hemolytic (cholesterol) cholelithiasis rose by 63% and 216%, respectively. Average body mass index (BMI) for patients with non-hemolytic (cholesterol) stones and biliary dyskinesia were significantly greater than the average BMI for patients with hemolytic stones (P < .0001). In addition, the average BMI for children with non-hemolytic (cholesterol) stones was greater than the average BMI with biliary dyskinesia (P < .0001). CONCLUSION: Symptomatic gallbladder disease increased over the study period. Biliary dyskinesia and children with non-hemolytic disease are responsible for this increase.