A systematic mapping review of clinical guidelines for the management of fatigue in long-term physical health conditions.

PURPOSE: Despite a high prevalence of fatigue and its importance to patients, many people with long-term conditions do not receive fatigue management as part of their treatment. This review is aimed to identify clinical guidance for the management of fatigue in long-term physical health conditions. METHODS: A systematic mapping review was conducted in accordance with Social Care Institute for Excellence systematic review guidance. Bibliographic databases and guideline repositories were searched for clinical guidelines for long-term conditions, published between January 2008 and July 2018, with a search for updates conducted in May 2023. Data were extracted on the recommendations made for managing fatigue and, where cited, the underlying research evidence used to support these recommendations was also extracted. RESULTS: The review included 221 guidelines on 67 different long-term conditions. Only 30 (13.6%) of the guidelines contained recommendations for managing fatigue. These were categorised as clinical (e.g. conduct further investigations), pharmacological, behavioural (e.g. physical activity), psychological, nutritional, complementary, environmental, and multicomponent. The guidelines rated much of the evidence for fatigue management as fairly low quality, highlighting the need to develop and test fatigue-management strategies in high-quality trials. CONCLUSION: This review highlights that management of fatigue is a very important neglected area in the clinical guidelines for managing long-term conditions.

Fatigue is a common and debilitating symptom of many long-term physical health conditions; however, many people do not receive treatment for fatigue.This mapping review found that very few clinical guidelines contain recommendations for managing fatigue, even where published evidence exists.It is essential that developers of clinical guidelines address this important neglected area.

Perceived burdensomeness and thwarted belongingness as mediators of the relation between anxiety and suicidal ideation among adolescents.

INTRODUCTION: Anxiety and suicidal ideation have been shown to be positively related in adolescents. However, less is known about the strength of this association across different types of anxiety or the mechanisms through which this relation exists. Joiner's interpersonal theory of suicide suggests that thwarted belongingness (TB) and perceived burdensomeness (PB) lead to suicidal ideation; these constructs may explain a pathway through which anxiety and suicidal ideation are related. It was hypothesized that TB would mediate the relation between social anxiety disorder (SAD) symptoms and suicidal ideation, and PB would mediate the relation between generalized anxiety disorder (GAD) symptoms and suicidal ideation. METHODS: These longitudinal mediation models were assessed using data collected from 147 depressed adolescents, who were recently hospitalized for suicidal ideation or behavior, enrolled in a randomized controlled trial (RCT). RESULTS: Consistent with study hypotheses, PB mediated the relation between GAD symptoms and suicidal ideation severity. However, TB did not mediate the relation between SAD symptoms and suicidal ideation severity. CONCLUSION: These results suggest that screening for and addressing PB among youth with GAD may help reduce risk for suicidal behavior.

The IMPROVE trial: study protocol for a pragmatic cluster randomised controlled trial to assess the effectiveness of using lay health workers to improve uptake and completion of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease.

BACKGROUND: Pulmonary rehabilitation (PR) is a programme of exercise and education and the most effective treatment for the symptoms and disability associated with chronic obstructive pulmonary disease. However, the benefits of PR are limited by poor uptake and completion. This trial will determine whether using trained volunteer lay health workers, called "PR buddies," improves uptake and completion of PR and is cost-effective. This trial protocol outlines the methods for evaluating effectiveness, cost-effectiveness, and acceptability. METHODS: The IMPROVE trial is a pragmatic, open, cluster randomised controlled trial planned in 38 PR services across England and Wales. PR services will be randomised to either intervention arm-offering support from PR buddies to patients with chronic obstructive pulmonary disease-or to usual care as the control arm. PR staff in trial sites randomised to the intervention arm will receive training in recruiting and training PR buddies. They will deliver training to volunteers, recruited from among people who have recently completed PR in their service. The 3-day PR-buddy training programme covers communication skills, confidentiality, boundaries of the PR-buddy role and behaviour change techniques to help patients overcome obstacles to attending PR. An internal pilot will test the implementation of the trial in eight sites (four intervention sites and four in control arm). The primary outcome of the trial is the uptake and completion of PR. A process evaluation will investigate the acceptability of the intervention to patients, PR staff and the volunteer PR buddies, and intervention fidelity. We will also conduct a cost-effectiveness analysis. DISCUSSION: Improving outcomes for chronic obstructive pulmonary disease and access to PR are priorities for the UK National Health Service (NHS) in its long-term plan. The trial hypothesis is that volunteer PR buddies, who are recruited and trained by local PR teams, are an effective and cost-effective way to improve the uptake and completion rates of PR. The trial is pragmatic, since it will test whether the intervention can be incorporated into NHS PR services. Information obtained in this trial may be used to influence policy on the use of PR buddies in PR and other similar services in the NHS. TRIAL REGISTRATION: ISRCTN12658458. Registered on 23/01/2023.

Relations between discrimination, rejection sensitivity, negative affect, and decrements in problem-solving ability following social rejection: An experimental investigation.

INTRODUCTION: While negative affect and problem-solving deficits have been consistently linked to suicidal thoughts and behaviors, the latter are often conceptualized and studied as time- and/or context-invariant. Though requiring additional empirical support, theory suggests that discrimination may strengthen the relation between rejection sensitivity and increases in negative affect as well as declines in problem-solving abilities following rejection. The aim of the current study was to test this claim using a social rejection paradigm (i.e., Cyberball) with young adults experiencing past-month suicidal ideation. METHODS: The sample consisted of 50 participants. Lifetime discrimination and rejection sensitivity were assessed prior to Cyberball. Negative affect and problem-solving abilities were assessed pre- and post-Cyberball. SPSS and the PROCESS macro were used to test relations among variables of interest. RESULTS: Rejection sensitivity predicted greater problem-solving decrements, but not negative affect, following rejection among individuals who had experienced higher (vs. lower) levels of lifetime discrimination. CONCLUSION: Addressing rejection sensitivity and sources of discrimination within the context of treatment may reduce the impact of social rejection on problem-solving abilities among young adults at risk for suicide.

Pediatric Medical Subspecialist Use in Outpatient Settings.

Importance: A first step toward understanding whether pediatric medical subspecialists are meeting the needs of the nation's children is describing rates of use and trends over time. Objectives: To quantify rates of outpatient pediatric medical subspecialty use. Design, Setting, and Participants: This repeated cross-sectional study of annual subspecialist use examined 3 complementary data sources: electronic health records from PEDSnet (8 large academic medical centers [January 1, 2010, to December 31, 2021]); administrative data from the Healthcare Integrated Research Database (HIRD) (14 commercial health plans [January 1, 2011, to December 31, 2021]); and administrative data from the Transformed Medicaid Statistical Information System (T-MSIS) (44 state Medicaid programs [January 1, 2016, to December 31, 2019]). Annual denominators included 493 628 to 858 551 patients younger than 21 years with a general pediatric visit in PEDSnet; 5 million beneficiaries younger than 21 years enrolled for at least 6 months in HIRD; and 35 million Medicaid or Children's Health Insurance Program beneficiaries younger than 19 years enrolled for any amount of time in T-MSIS. Exposure: Calendar year and type of medical subspecialty. Main Outcomes and Measures: Annual number of children with at least 1 completed visit to any pediatric medical subspecialist in an outpatient setting per population. Use rates excluded visits in emergency department or inpatient settings. Results: Among the study population, the proportion of girls was 51.0% for PEDSnet, 51.1% for HIRD, and 49.3% for T-MSIS; the proportion of boys was 49.0% for PEDSnet, 48.9% for HIRD, and 50.7% for T-MSIS. The proportion of visits among children younger than 5 years was 37.4% for PEDSnet, 20.9% for HIRD, and 26.2% for T-MSIS; most patients were non-Hispanic Black (29.7% for PEDSnet and 26.1% for T-MSIS) or non-Hispanic White (44.9% for PEDSnet and 43.2% for T-MSIS). Annual rates for PEDSnet ranged from 18.0% to 21.3%, which were higher than rates for HIRD (range, 7.9%-10.4%) and T-MSIS (range, 7.6%-8.6%). Subspecialist use increased in the HIRD commercial health plans (annual relative increase of 2.4% [95% CI, 1.6%-3.1%]), but rates were essentially flat in the other data sources (PEDSnet, -0.2% [95% CI, -1.1% to 0.7%]; T-MSIS, -0.7% [95% CI, -6.5% to 5.5%]). The flat PEDSnet growth reflects a balance between annual use increases among those with commercial insurance (1.2% [95% CI, 0.3%-2.1%]) and decreases in use among those with Medicaid (-0.9% [95% CI, -1.6% to -0.2%]). Conclusions and Relevance: The findings of this cross-sectional study suggest that among children, 8.6% of Medicaid beneficiaries, 10.4% of those with commercial insurance, and 21.3% of those whose primary care is received in academic health systems use pediatric medical subspecialty care each year. There was a small increase in rates of subspecialty use among children with commercial but not Medicaid insurance. These data may help launch innovations in the primary-specialty care interface.

The Management of Pediatric Asthma Using Telehealth: An Integrative Review.

Introduction: Asthma is one of the most chronic noncommunicable diseases of childhood, affecting 1 in 12 children in the United States. The use of telemedicine for the management of pediatric asthma has shown improved health outcomes; however, it is important to understand what can impact its acceptance. The purpose of this review was to identify the facilitators and barriers to pediatric asthma management, as viewed by stakeholders. Methods: An electronic literature search was performed using PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature Complete. Articles included in the review contained perceptions of the use of telemedicine for the management of pediatric asthma, as viewed by stakeholders. The socioecological model was used as the theoretical framework to extract data based on its five levels. Results: After reviewing full texts of 143 articles, 118 were excluded, leaving 25 articles included in this review. A majority of included articles focused on mobile health (m-Health) studies for the management of pediatric asthma, with the remaining articles studying synchronous telemedicine or a combination of modalities. Common themes were identified; however, most were focused on the use of m-Health and few studies contained the viewpoints of the caregiver, children, or providers regarding synchronous telemedicine. Discussion: This integrative review identified a number of facilitators and barriers for the management of asthma using telemedicine. However, more qualitative studies are needed to evaluate the perceptions of caregivers, patients, and primary providers regarding synchronous telehealth. It was also recognized that telemedicine may increase instead of reduce health care disparities.

Discovery and Clinical Proof-of-Concept of RLY-2608, a First-in-Class Mutant-Selective Allosteric PI3Kα Inhibitor That Decouples Antitumor Activity from Hyperinsulinemia.

PIK3CA (PI3Kα) is a lipid kinase commonly mutated in cancer, including ∼40% of hormone receptor-positive breast cancer. The most frequently observed mutants occur in the kinase and helical domains. Orthosteric PI3Kα inhibitors suffer from poor selectivity leading to undesirable side effects, most prominently hyperglycemia due to inhibition of wild-type (WT) PI3Kα. Here, we used molecular dynamics simulations and cryo-electron microscopy to identify an allosteric network that provides an explanation for how mutations favor PI3Kα activation. A DNA-encoded library screen leveraging electron microscopy-optimized constructs, differential enrichment, and an orthosteric-blocking compound led to the identification of RLY-2608, a first-in-class allosteric mutant-selective inhibitor of PI3Kα. RLY-2608 inhibited tumor growth in PIK3CA-mutant xenograft models with minimal impact on insulin, a marker of dysregulated glucose homeostasis. RLY-2608 elicited objective tumor responses in two patients diagnosed with advanced hormone receptor-positive breast cancer with kinase or helical domain PIK3CA mutations, with no observed WT PI3Kα-related toxicities. SIGNIFICANCE: Treatments for PIK3CA-mutant cancers are limited by toxicities associated with the inhibition of WT PI3Kα. Molecular dynamics, cryo-electron microscopy, and DNA-encoded libraries were used to develop RLY-2608, a first-in-class inhibitor that demonstrates mutant selectivity in patients. This marks the advance of clinical mutant-selective inhibition that overcomes limitations of orthosteric PI3Kα inhibitors. See related commentary by Gong and Vanhaesebroeck, p. 204 . See related article by Varkaris et al., p. 227 . This article is featured in Selected Articles from This Issue, p. 201.

Capacity assessment and spatial analysis of cervical cancer services in The Gambia.

BACKGROUND: Cervical cancer is the most common cancer and the leading cause of cancer-related death in Gambian women. The Gambian Ministry of Health is striving to improve access to screening, diagnostic, and treatment services for cervical cancer, but comprehensive data on currently available services is limited making it challenging to appropriately prioritize the ideal next steps for expanding care. This study aims to describe the current services available for the prevention, screening, and treatment of cervical cancer in The Gambia and provide suggestions for expanding geographic access to care. METHODS: A survey aimed at assessing the availability of key cervical cancer-related services was developed and then administered in person by research assistants to all secondary and tertiary health facilities (HFs) in The Gambia. ArcGIS Pro Software and 2020 LandScan population density raster were used to visualize and quantify geographic access to care. Survey results were compared with published targets outlined by the Gambian Ministry of Health in the "Strategic Plan for the Prevention and Control of Cervical Cancer in The Gambia: 2016-2020." RESULTS: One hundred and two HFs were surveyed including 12 hospitals, 3 major health centers, 56 minor health centers, and 31 medical centers/clinics. Seventy-eight of these HFs provided some form of cervical cancer-related service. HPV vaccination was available in all health regions. Two-thirds of the population lived within 10 km of a HF that offered screening for cervical cancer and half lived within 10 km of a HF that offered treatment for precancerous lesions. Ten HFs offered hysterectomy, but nine were located in the same region. Two HFs offered limited chemotherapy. Radiotherapy was not available. If all major health centers and hospitals started offering visual inspection with acetic acid and cryotherapy, 86.1% of the population would live within 25 km of a HF with both services. CONCLUSIONS: Geographic access to cervical cancer screening, and precancer treatment is relatively widespread across The Gambia, but targeted expansion in line with the country's "Strategic Plan" would improve access for central and eastern Gambia. The availability of treatment services for invasive cancer is limited, and establishing radiotherapy in the country should continue to be prioritized.

General and subspecialist pediatrician perspectives on barriers and strategies for referral: a latent profile analysis.

BACKGROUND: Children in need of pediatric subspecialty care may encounter multiple barriers, and multiple strategies have been suggested to improve access. The purpose of this study was to describe the perceptions of general and subspecialty pediatric physicians regarding barriers to subspecialty care and the value of strategies to improve subspecialty access. METHODS: We surveyed a national sample of 1680 general pediatricians and pediatric subspecialists in May and June 2020 regarding 11 barriers to subspecialty care and 9 strategies to improve access to subspecialty care, selected from recent literature. Using latent profile analysis, respondents were grouped according to the degree to which they believed each of the barriers impacted access to subspecialty care. Using chi-squared tests, we compared the profiles based on respondent characteristics and perspectives on strategies to improve access. RESULTS: The response rate was 17%. In 263 responses completed and eligible for inclusion, the barriers most frequently described as "major problems" were wait times (57%), lack of subspecialists (45%) and difficulty scheduling (41%). Respondents were classified into 4 profiles: "Broad concerns," "Subspecialist availability concerns," "Clinician communication concerns," and "Few concerns." These profiles varied significantly by respondent specialty (p < .001, with medical subspecialists overrepresented in the "Clinician communication" profile, psychiatrists in the "subspecialist availability" profile, and surgeons in the "few concerns" profile); and by respondents' typical wait time for appointments (p < .001, with physicians with the longest wait times overrepresented in the "subspecialist availability" profile). CONCLUSIONS: We found specific profiles in clinician views regarding barriers to subspecialty care which were associated with perspectives on strategies aimed at overcoming these barriers. These results suggest that health systems aiming to improve subspecialty access should first identify the barriers and preferences specific to local clinicians.

Facets of social problem-solving as moderators of the real-time relation between social rejection and negative affect in an at-risk sample.

Social rejection predicts negative affect, and theoretical work suggests that problem-solving deficits strengthen this relation in real-time. Nevertheless, few studies have explicitly tested this relation, particularly in samples at risk for suicide. This may be particularly important as social rejection and negative affect are significant predictors of suicide. The aim of the current study was to examine whether cognitive (i.e., perceiving problems as threats) and behavioral (i.e., avoidance) facets of problem-solving deficits moderated the real-time relation between social rejection and negative affect. The sample consisted of 49 young adults with past-month suicidal ideation. Demographic information, social problem-solving deficits, as well as depressive/anxiety symptoms and stress levels were assessed at baseline. Social rejection and negative affect were assessed using ecological momentary assessment over the following 28 days. Dynamic structural equation modeling was used to assess relations among study variables. After accounting for depressive/anxiety symptoms, stress levels, sex, and age, only avoidance of problems bolstered the real-time positive relation between social rejection severity and negative affect (b = 0.04, 95% credibility interval [0.003, 0.072]). Individuals with suicidal ideation who possess an avoidant problem-solving style may be particularly likely to experience heightened negative affect following social rejection and may benefit from instruction in problem-solving skills.

Management of epilepsy during pregnancy and lactation.

Epilepsy is a group of neurological diseases characterized by susceptibility to recurrent seizures. Antiseizure medications (ASMs) are the mainstay of treatment, but many antiseizure medications with variable safety profiles have been approved for use. For women with epilepsy in their childbearing years, the safety profile is important for them and their unborn children, because treatment is often required to protect them from seizures during pregnancy and lactation. Since no large randomized controlled trials have investigated safety in this subgroup of people with epilepsy, pregnancy registries, cohort and case-control studies from population registries, and a few large prospective cohort studies have played an important role. Valproate, in monotherapy and polytherapy, has been associated with elevated risk of major congenital malformations and neurodevelopmental disorders in children born to mothers who took it. Topiramate and phenobarbital are also associated with elevated risks of congenital malformations and neurodevelopmental disorders, though the risks are lower than those of valproate. Lamotrigine and levetiracetam are relatively safe. Insufficient data exist to reach strong conclusions about the newest antiseizure medications such as eslicarbazepine, perampanel, brivaracetam, cannabidiol, and cenobamate. Besides antiseizure medications, other treatments such as vagal nerve stimulation, responsive neurostimulation, and deep brain stimulation are likely safe. In general, breastfeeding does not appear to add any additional long term risks to the child. Creative ways of optimizing registry enrollment and data collection are needed to enhance patient safety.

Interpersonal stress and proinflammatory activity in emerging adults with a history of suicide risk: A pilot study.

Interpersonal stress during adolescence and young adulthood can threaten healthy developmental trajectories. A "primed" proinflammatory response to acute stress may serve as an underlying process that results in negative outcomes for youth. The present pilot study examined the relation between interpersonal stress and two proinflammatory cytokines in a sample of 42 university-recruited emerging adults with recent suicidal thoughts and behaviors. Participants completed self-report measures of mood, suicidal thoughts and behaviors, recent peer-related stressors, and interpersonal sensitivity. They also participated in an acute laboratory social stress task and provided three saliva samples to measure their proinflammatory responses (IL-6 and TNF-α) to the stressor. Participants reported significant increases in sadness and exclusion, and significant decreases in inclusion, following task participation. Importantly, no participants reported an increase in or onset of suicidal thoughts. No significant associations between interpersonal stress and proinflammatory cytokines were found. Changes in affect during the task coupled with lack of increased suicidal thoughts indicate it is acceptable to use this exclusion and rejection paradigm with this population, with proper debriefing and positive mood induction procedures. Given all other nonsignificant associations, future research considerations are discussed, including impact of COVID-19 on task potency and incorporation of multiple stress response systems.

Patterns in Medication Use for Treatment of Depression in Autistic Spectrum Disorder.

INTRODUCTION: Depression impacts many individuals with autism spectrum disorder (ASD), carrying increased risk of functional impairment, hospitalization, and suicide. Prescribing medication to target depression in patients with ASD occurs despite limited available systematic data describing medication management of depression in this population. PURPOSE: The purpose of this study is to discover prescribing patterns for individuals with MDD and ASD during this time period (2004-2012) to inform current and future prescribing practices with historical data. METHOD: Drawing from a large clinical database describing the prescribing practices in patients with ASD, we identified 166 individuals with ASD (mean age 14.5 ± 8.3 years old) who received medication targeting symptoms of depression. We report prescribing rates for specific drugs, drug treatment duration, and reasons for drug discontinuation when applicable. RESULTS: Sertraline, mirtazapine, and fluoxetine were the three most commonly prescribed medications to treat comorbid depression for this patient population. Among 241 drug starts, 123 (49%) drug treatments were continued at the final reviewed follow-up visit (average treatment duration of ± 0.72 years). The most common reason for discontinuation across all medications prescribed was loss of or lack of effectiveness. CONCLUSION: This study raises concern that standard of care pharmacological treatments for depression in individuals with ASD may be less effective than in neurotypical populations. There remains a need to develop effective interventions for depression specifically tailored to the needs of individuals with ASD.

Strategy for Generating Blinded Evidence for Single-Arm Trials with External Controls Using Expert Review of Home Video.

INTRODUCTION: Neurodegenerative diseases cause developmental delays and loss of milestones in infants and children. However, scalable outcome measures that quantify features meaningful to parents/caregivers (P/CGs) and have regulatory precedence are lacking for assessing the effectiveness of treatments in clinical trials of neurodegenerative disorders. To address this gap, we developed an innovative, blinded strategy for single-arm trials with external controls using expert panel review of home video. METHOD: We identified meaningful, observable, and objective developmental milestones from iterative interviews with P/CGs and clinical experts. Subsequently, we standardized video recording procedures and instructions to ensure consistency in how P/CGs solicited each activity. In practice, videos would be graded by an expert panel blinded to treatment. To ensure blinding and quality control, video recordings from interim time points would be randomly interspersed. We conducted a pilot study and a pretest of grading to test feasibility and improve the final strategy. RESULTS: The five P/CGs participating in the pilot study found the instructions clear, selected activities important and reflective of their children's abilities, and recordings at-home preferrable to in-clinic assessments. The three grading experts found the videos easy to grade and the milestones clinically meaningful. CONCLUSION: Our standardized strategy enables expert panel grading of developmental milestone achievements using at-home recordings, blinded to treatment and post-baseline time points. This rigorous and objective scoring system has broad applicability in various disease contexts, with or without external controls. Moreover, our strategy facilitates flexible, continued data collection and the videos can be archived for future analyses.

Trajectories of adolescent suicidal ideation and depressive symptoms during partial hospitalization: Clinical and demographic characteristics as predictors of change.

Partial hospital programs (PHPs) are a vital mental health service for youth at risk for suicide. Yet, few studies have examined trajectories of suicidal ideation and depressive symptoms, two important risk factors for suicidal behavior, over the course of care. Moreover, little is known about factors that may impact these trajectories among youth in PHPs. The present study examined trajectories of suicidal ideation and depressive symptoms, as well as clinical and demographic predictors of these changes, among youth enrolled in two PHPs. A sample of 253 youth (Mage = 15.3; SD = 1.4; range = 12-18; 68.8% female; 63.2% White; 75.1% non-Hispanic/Latino/a/x) completed repeated measures of suicidal ideation severity and depressive symptoms during treatment. Trajectories of these outcomes were examined using two separate latent growth models. Recent history of self-injurious behaviors and demographics were tested as predictors of trajectories using a taxonomic approach. Overall, suicidal ideation and depressive symptoms declined over the course of care. Sex, history of self-injury, and sexual identity were associated with variability in one or both trajectories of change. Results suggest individual variability in the rate of change among youth in PHPs. Such information may be used to aid in treatment planning and quality improvement efforts within PHPs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Examination of proinflammatory activity as a moderator of the relation between momentary interpersonal stress and suicidal ideation.

INTRODUCTION: Peer-related interpersonal stress can increase risk for suicidal thoughts among adolescents and young adults. However, not all individuals who undergo peer-related interpersonal stressors experience suicidal thoughts. Heightened proinflammatory activity is one factor that may amplify the relation between interpersonal stress and suicidal thinking. METHODS: This pilot study examined the relation between interpersonal stress and suicidal ideation in real time, as well as whether proinflammatory cytokine (IL-6 and TNF-α) activity across a laboratory social stressor moderated this association in a sample of 42 emerging adults with recent suicidal ideation. Participants completed 28 days of 6×/daily ecological momentary assessment that assessed for suicidal ideation (presence vs. absence, ideation intensity), occurrence of negative peer events, and feelings of exclusion. RESULTS: There was a trend for within-person increases in feelings of exclusion to be associated with increases in concurrent suicidal ideation intensity. Additionally, within-person increases in negative peer events were associated with increased odds of subsequent suicidal ideation among individuals with very low IL-6 activity. However, this finding is considered preliminary. CONCLUSION: Interventions targeting perceptions of exclusion and increasing social support may be of benefit. However, findings require replication in larger samples, and thus must be interpreted with caution.

A scoping review of workplace health promotion interventions for chronic diseases in Australia.

OBJECTIVE: The aim of this study is to systematically chart and summarize the literature pertaining to workplace health promotion (WHP) interventions targeting the five main modifiable lifestyle risk factors for chronic disease, including smoking, nutrition, alcohol, physical activity, overweight/obesity (SNAPO) in Australian workers. METHODS: A scoping review was performed using the framework of Arksey and O'Malley. MEDLINE, EMBASE, CINAHL, and SCOPUS were searched to identify peer-reviewed publications that evaluated primary or secondary WHP interventions which targeted one or more modifiable risk factor (SNAPO). RESULTS: A total of fifty-six articles were included in the review. The findings revealed a heterogeneous nature of WHP intervention design and evaluation. The majority of the interventions focussed on physical activity, with fewer targeting the other four main modifiable risk factors. Health care and white-collar workers were most frequently targeted, with less attention paid to other worker groups. The review also found that many interventions had a duration of three months or less. CONCLUSIONS: Significant gaps have been identified in relation to the occupational role, risk factors targeted, and intervention length. This review also highlights the need for further research to be conducted to determine the efficacy of interventions to facilitate the development of a framework for WHP interventions to reduce the risk and prevalence of chronic disease.

Profiles of Early Childhood Adversity in an Urban Pediatric Clinic: Implications for Pediatric Primary Care.

Pediatricians are well-positioned to screen for early childhood adversities, but effective responses to positive screens require an understanding of which adversities typically co-occur, and to what extent they are associated with other risk or protective factors. Among children seen at an urban academic pediatric practice, this study aimed to (1) examine the prevalence of different types of early adversity and protective experiences reported by primary caregivers, and (2) define latent classes of co-occurring adversities. Of 1434 children whose parents completed the Safe Environment for Every Kid (SEEK) at well-child visits during November 2019-January 2021, three classes of adverse experiences emerged, including those reporting low adversity (L; 73%), caregiver stress (CS; 17%), and both caregiver stress and depression (CSD; 10%). Among those who also completed the Adverse Childhood Experiences Questionnaire (ACE-Q, n = 1373) and the Protective and Compensatory Experiences Scale (PACES, n = 1377), belonging to the L class was associated with lower ACE-Q and higher PACES scores. For parent-respondents only, ACE-Q scores were significantly greater for the CSD class compared to the CS and L classes. Pediatricians should attend to the needs of caregivers reporting both stress and depression, as these families may face especially high levels of adversity and low levels of protective factors.

Telehealth Policy and the Advanced Practice Nurse.

Telehealth is an efficient and effective method of care delivery used by advance practice registered nurses (APRNs) nationally, especially in the wake of the coronavirus disease 2019 pandemic. With the ever-changing rules and regulations governing telehealth practice, the APRN may struggle to keep abreast. Telehealth is governed by legislation and regulation in addition to telehealth-specific laws. APRNs delivering care through telehealth must be informed about the crucial aspects of telehealth policy and how their practice is affected. Telehealth-related policy is complex and evolving and varies by state. This article provides APRNs with essential knowledge about telehealth-related policy to support legal and regulatory compliance.

A Comprehensive Multilevel Analysis of the Bucharest Early Intervention Project: Causal Effects on Recovery From Early Severe Deprivation.

OBJECTIVE: The Bucharest Early Intervention Project is the first randomized controlled trial of foster care as an alternative to institutional care. The authors synthesized data from nearly 20 years of assessments of the trial to determine the overall intervention effect size across time points and developmental domains. The goal was to quantify the overall effect of the foster care intervention on children's outcomes and examine sources of variation in this effect, including domain, age, and sex assigned at birth. METHODS: An intent-to-treat approach was used to examine the causal effects of the randomized controlled trial for 136 children residing in institutions in Bucharest, Romania (baseline age, 6-31 months) who were randomly assigned to either foster care (N=68) or care as usual (N=68). At ages 30, 42, and 54 months and 8, 12, and 16-18 years, children were assessed for IQ, physical growth, brain electrical activity (EEG), and symptoms of five types of psychopathology. RESULTS: Participants provided 7,088 observations across follow-up waves. Children assigned to foster care had better cognitive and physical outcomes and less severe psychopathology than did those who received care as usual. The magnitude of these effect sizes remained stable across development. The foster care intervention most influenced IQ and disorders of attachment/social relatedness. CONCLUSIONS: Young children benefit from placement in families after institutional care. The benefits of foster care for previously institutionalized children were remarkably stable across development.