Post-discharge after surgery Virtual Care with Remote Automated Monitoring-1 (PVC-RAM-1) technology versus standard care: randomised controlled trial.

OBJECTIVE: To determine if virtual care with remote automated monitoring (RAM) technology versus standard care increases days alive at home among adults discharged after non-elective surgery during the covid-19 pandemic. DESIGN: Multicentre randomised controlled trial. SETTING: 8 acute care hospitals in Canada. PARTICIPANTS: 905 adults (≥40 years) who resided in areas with mobile phone coverage and were to be discharged from hospital after non-elective surgery were randomised either to virtual care and RAM (n=451) or to standard care (n=454). 903 participants (99.8%) completed the 31 day follow-up. INTERVENTION: Participants in the experimental group received a tablet computer and RAM technology that measured blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and body weight. For 30 days the participants took daily biophysical measurements and photographs of their wound and interacted with nurses virtually. Participants in the standard care group received post-hospital discharge management according to the centre's usual care. Patients, healthcare providers, and data collectors were aware of patients' group allocations. Outcome adjudicators were blinded to group allocation. MAIN OUTCOME MEASURES: The primary outcome was days alive at home during 31 days of follow-up. The 12 secondary outcomes included acute hospital care, detection and correction of drug errors, and pain at 7, 15, and 30 days after randomisation. RESULTS: All 905 participants (mean age 63.1 years) were analysed in the groups to which they were randomised. Days alive at home during 31 days of follow-up were 29.7 in the virtual care group and 29.5 in the standard care group: relative risk 1.01 (95% confidence interval 0.99 to 1.02); absolute difference 0.2% (95% confidence interval -0.5% to 0.9%). 99 participants (22.0%) in the virtual care group and 124 (27.3%) in the standard care group required acute hospital care: relative risk 0.80 (0.64 to 1.01); absolute difference 5.3% (-0.3% to 10.9%). More participants in the virtual care group than standard care group had a drug error detected (134 (29.7%) v 25 (5.5%); absolute difference 24.2%, 19.5% to 28.9%) and a drug error corrected (absolute difference 24.4%, 19.9% to 28.9%). Fewer participants in the virtual care group than standard care group reported pain at 7, 15, and 30 days after randomisation: absolute differences 13.9% (7.4% to 20.4%), 11.9% (5.1% to 18.7%), and 9.6% (2.9% to 16.3%), respectively. Beneficial effects proved substantially larger in centres with a higher rate of care escalation. CONCLUSION: Virtual care with RAM shows promise in improving outcomes important to patients and to optimal health system function. TRIAL REGISTRATION: ClinicalTrials.gov NCT04344665.

Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM): protocol for a randomized controlled trial.

BACKGROUND: After nonelective (i.e., semiurgent, urgent and emergent) surgeries, patients discharged from hospitals are at risk of readmissions, emergency department visits or death. During the coronavirus disease 2019 (COVID-19) pandemic, we are undertaking the Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM) trial to determine if virtual care with remote automated monitoring (RAM) compared with standard care will increase the number of days adult patients remain alive at home after being discharged following nonelective surgery. METHODS: We are conducting a randomized controlled trial in which 900 adults who are being discharged after nonelective surgery from 8 Canadian hospitals are randomly assigned to receive virtual care with RAM or standard care. Outcome adjudicators are masked to group allocations. Patients in the experimental group learn how to use the study's tablet computer and RAM technology, which will measure their vital signs. For 30 days, patients take daily biophysical measurements and complete a recovery survey. Patients interact with nurses via the cellular modem-enabled tablet, who escalate care to preassigned and available physicians if RAM measurements exceed predetermined thresholds, patients report symptoms, a medication error is identified or the nurses have concerns they cannot resolve. The primary outcome is number of days alive at home during the 30 days after randomization. INTERPRETATION: This trial will inform management of patients after discharge following surgery in the COVID-19 pandemic and offer insights for management of patients who undergo nonelective surgery in a nonpandemic setting. Knowledge dissemination will be supported through an online multimedia resource centre, policy briefs, presentations, peer-reviewed journal publications and media engagement. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT04344665.

Improving Access to Safe Anesthetic Care in Rural and Remote Communities in Affluent Countries.

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.

A new look at the psychometrics of the parenting scale through the lens of item response theory.

The psychometrics of the Parenting Scale's Overreactivity and Laxness subscales were evaluated using item response theory (IRT) techniques. The IRT analyses were based on 2 community samples of cohabiting parents of 3- to 8-year-old children, combined to yield a total sample size of 852 families. The results supported the utility of the Overreactivity and Laxness subscales, particularly in discriminating among parents in the mid to upper reaches of each construct. The original versions of the Overreactivity and Laxness subscales were more reliable than alternative, shorter versions identified in replicated factor analyses from previously published research and in IRT analyses in the present research. Moreover, in several cases, the original versions of these subscales, in comparison with the shortened versions, exhibited greater 6-month stabilities and correlations with child externalizing behavior and couple relationship satisfaction. Reliability was greater for the Laxness than for the Overreactivity subscale. Item performance on each subscale was highly variable. Together, the present findings are generally supportive of the psychometrics of the Parenting Scale, particularly for clinical research and practice. They also suggest areas for further development.

An initial evaluation of the role of emotion and impulsivity in explaining racial/ethnic differences in the use of corporal punishment.

The authors sought to provide an initial evaluation of the hypothesis that corporal punishment is less strongly associated with parental emotion and impulsivity among African American ("Black") in contrast to European American ("White") parents. White-Latino and Black-Latino differences in corporal punishment, emotion, and impulsivity were explored, given the lack of existing theory predicting group differences. Couples with 3- to 7-year-old children were recruited via random digit dialing, and the parents completed questionnaires and an analog parent-child conflict task in the laboratory. Group differences were tested pooling mothers and fathers via dyadic data analyses. Black parents (N = 57) had more positive attitudes toward and used more corporal punishment than White parents (N = 730). Latino American parents' (N = 78) views and use of corporal punishment were similar to those of White parents. By and large, associations of corporal punishment with parents' impulsivity and emotion did not significantly vary by race/ethnicity. The present findings, although preliminary, do not support the emotion-impulsivity hypothesis of racial differences in the use of corporal punishment suggested by K. Deater-Deckard, K. A. Dodge, J. E. Bates, and G. S. Pettit (1996).

Distinguishing risk profiles among parent-only, partner-only, and dually perpetrating physical aggressors.

This study addressed whether and how men and women who are not physically aggressive, physically aggressive toward only their children or their partners, or aggressive toward both children and their partners differ in their risk profiles. Risk factors unrelated to the partner or parenting role (e.g., impulsivity) and specific to one of these roles (e.g., negative parenting attributions or negative partner attributions) were examined using profile analysis. Dually aggressive men and women had the highest overall risk across all types of risk factors; nonaggressive men and women had consistently low risk. Individuals who were aggressive toward only their partners or their children had distinct risk profiles, with highest levels of risk on the role-specific variable sets. With the exception of parent-aggressive-only men, singly aggressive individuals' risk levels were significantly lower on role-independent and unrelated role-specific risk factors than they were on role-related risk factors. These results suggest theories of partner and parent aggression might gain precision if co-occurrence status were specifically taken into account.

Affective and physiological factors predicting maternal response to infant crying.

This study evaluated physiological, affective, and perceptual factors hypothesized to predict how quickly 45 primiparous mothers of 7-9-month-old infants would respond to non-distressed infant crying. Aversiveness ratings of the non-distressed cries of one's "own" infant and physiological reactivity to one's "own" infant crying accounted for a significant amount of the variance in a Cox proportional hazards regression analysis of speed of response. These findings suggest that mothers who have strong affective and physiological responses to non-distressed infant cries may be more likely to respond indiscriminately to attention-seeking infant behaviors.

Understanding preemptive parenting: relations with toddlers' misbehavior, overreactive and lax discipline, and praise.

The relations among preemptive parenting (i.e., a hypothetical set of strategies parents can use prior to child misbehavior that serves to prevent or avoid undesirable child behaviors), dysfunctional discipline, and praise were examined. Forty mother-toddler (M age = 26.15 months, SD = 5.60) dyads interacted in a standard laboratory task designed to elicit misbehavior and discipline. Observational data indicated that preemptive parenting contributed to the prediction of child misbehavior above and beyond the prediction from dysfunctional discipline and praise but did not contribute uniquely to the prediction of mother-reported externalizing behavior problems. Further analyses indicated that child misbehavior mediated the relation between preemptive parenting and overreactive, but not lax, discipline.

Multivariate models of men's and women's partner aggression.

This exploratory study was designed to address how multiple factors drawn from varying focal models and ecological levels of influence might operate relative to each other to predict partner aggression, using data from 453 representatively sampled couples. The resulting cross-validated models predicted approximately 50% of the variance in men's and women's partner aggression. The 3 strongest direct predictors of partner aggression for men and women were dominance/jealousy, marital adjustment, and partner responsibility attributions. Three additional direct paths to aggression for men were exposure to family-of-origin aggression, anger expression, and perceived social support. The 1 additional direct path for women was a history of their own aggression as a child or teenager. Implications for more integrative theories and intervention are discussed.

Multivariate models of mothers' and fathers' aggression toward their children.

Multivariate, biopsychosocial, explanatory models of mothers' and fathers' psychological and physical aggression toward their 3- to 7-year-old children were fitted and cross-validated in 453 representatively sampled families. Models explaining mothers' and fathers' aggression were substantially similar. Surprisingly, many variables identified as risk factors in the parental aggression and physical child abuse literatures, such as income, unrealistic expectations, and alcohol problems, although correlated with aggression bivariately, did not contribute uniquely to the models. In contrast, a small number of variables (i.e., child responsible attributions, overreactive discipline style, anger expression, and attitudes approving of aggression) appeared to be important pathways to parent aggression, mediating the effects of more distal risk factors. Models accounted for a moderate proportion of the variance in aggression.

Factor structure and validity of the parenting scale.

Confirmatory factor analyses based on the scoring derived from 5 prior studies of the Parenting Scale were conducted using a representatively recruited sample of 453 couples parenting 3-to 7-year-old children. Comparative analyses favored the Reitman et al. (2001) 2-factor scoring system as well as a 3-factor solution, including Lax, Overreactive, and Hostile discipline. This 3-factor solution demonstrated good fit across parent gender and child age and gender. Mothers rated themselves as more overreactive than fathers. The factor scores correlated significantly with several validity measures, including child behavior problems. The Hostile factor contributed significantly to the prediction of child behavior problems after controlling for Lax and Overreactive discipline. Both parents reported using more dysfunctional discipline than they thought they should.

Using random telephone sampling to recruit generalizable samples for family violence studies.

Convenience sampling methods predominate in recruiting for laboratory-based studies within clinical and family psychology. The authors used random digit dialing (RDD) to determine whether they could feasibly recruit generalizable samples for 2 studies (a parenting study and an intimate partner violence study). RDD screen response rate was 42-45%; demographics matched those in the 2000 U.S. Census, with small- to medium-sized differences on race, age, and income variables. RDD respondents who qualified for, but did not participate in, the laboratory study of parents showed small differences on income, couple conflicts, and corporal punishment. Time and cost are detailed, suggesting that RDD may be a feasible, effective method by which to recruit more generalizable samples for in-laboratory studies of family violence when those studies have sufficient resources.

Precipitants of partner aggression.

Self-reported precipitants of psychological and physical partner aggression were examined in a community sample of 453 cohabiting couples with 3- to 7-year-old children. Partners precipitated most partner aggression. Men, but not maritally discordant men, were more likely than women to cite physical partner aggression as the precipitant of their own aggression. Women, including maritally discordant women, were more likely to endorse partner verbal than partner physical aggression as a precipitant for their own mild physical aggression, which is consistent with women's aggression escalation. Nonaggressive partner precipitants were common and deserve future research attention.

Antecedents of toddler aggression: dysfunctional parenting in mother-toddler dyads.

Aggression is stable as early as 2 years of age and predicts many negative adult outcomes. Although longitudinal predictors of child aggression have been identified, information is lacking regarding the proximal precursors of toddlers' aggression. During a 30-min interaction, 54 mother-toddler dyads were observed. Toddlers were categorized as aggressive or nonaggressive based on whether they exhibited aggression toward their mothers within the interaction. Most toddlers in both groups escalated from mild to more severe forms of misbehavior. Mothers of aggressive toddlers displayed more lax and over-reactive discipline when addressing misbehaviors that preceded aggression than did mothers of nonaggressive toddlers. Mothers of aggressive toddlers either ignored or attended neutrally or positively to the aggression. Implications for parenting interventions are discussed.

Mediated paths to over-reactive discipline: mothers' experienced emotion, appraisals, and physiological responses.

The present investigation was designed to evaluate whether mothers' emotion experience, autonomic reactivity, and negatively biased appraisals of their toddlers' behavior and toddlers' rates of misbehavior predicted over-reactive discipline in a mediated fashion. Ninety-three community mother-toddler dyads were observed in a laboratory interaction, after which mothers' emotion experience and appraisals of their toddler's behavior were measured via a video-recall procedure. Autonomic physiology and over-reactive discipline were measured during the interactions. Mothers' negatively biased appraisals mediated the relation between emotion experience and over-reactive discipline. Heart rate reactivity predicted discipline independent of this mediation. Toddler misbehavior appeared to be an entry point into the above process. Interventions that more actively target physiological and experiential components of mothers' emotion may further reduce their over-reactive discipline.

Marital adjustment, child-rearing disagreements, and overreactive parenting: predicting child behavior problems.

Using structural equation modeling, the authors evaluated the hypothesis that the relation between marital adjustment and children's behavior problems is mediated by child-rearing disagreements, whose effects are mediated by parents' overreactive discipline. In a community sample, fully or partially mediated models of internalizing and externalizing behavior problems of 3- to 7-year-old boys (N = 99) and girls (N = 104) were supported for mothers and fathers in 7 of 8 cases. Child-rearing disagreements always mediated the relation of marital adjustment and child behavior problems, and overreactive discipline was a final mediator in 3 cases. More variance was accounted for in mothers' than fathers' ratings. For mothers' ratings, the most variance was accounted for in boys' externalizing and girls' internalizing behavior problems.

Parent and partner violence in families with young children: rates, patterns, and connections.

In this study, the authors assessed men's and women's partner and parent physical aggression among 453 representatively sampled families with young children. The prevalences of partner aggression and of severe parent aggression were higher than previously reported. Substantial rates of co-occurrence were found. Risk ratios and regression analyses indicated that connections between (a) husbands' and wives' partner aggression and (b) mothers' and fathers' parent aggression were especially strong. Patterns of co-occurrence pointed to the probable relative importance of family-level, in comparison with individual, predictors of aggression. Patterns of co-occurring violence are described in light of the theoretical literature. Implications for studying family violence in community samples are discussed.

Mothers' overreactive discipline and their encoding and appraisals of toddler behavior.

The relations of observed overreactive discipline with mothers' tendencies to notice negative, relative to positive, child behavior (preferential negative encoding), and mothers' negative appraisals of neutral and positive child behavior (negative appraisal bias), were examined in mothers of toddlers. The mothers rated both their own children's and unfamiliar children's behavior. Negative appraisal bias with respect to mothers' own (but not unfamiliar) children was related to mothers' overreactivity, independent of child misbehavior. Overreactivity was not related to mothers' preferential negative encoding either of their own or of unfamiliar children's behavior. However, in the case of mothers' own children, preferential negative encoding moderated the relation between negative appraisal bias and overreactive discipline, such that the negative appraisal bias-overreactivity relation was significant only in the context of high preferential negative encoding.

Father involvement and self-reported parenting of children with attention deficit-hyperactivity disorder.

This study examined the moderating effects of 4 variables on the relation between father involvement (FI) and self-reported parenting practices of 71 couples who have children with attention deficit-hyperactivity disorder (ADHD). The variables were parents' love for their spouses, similarity in child-rearing views, traditional role identification, and paternal ADHD symptoms. These variables interacted with FI in predicting parenting practices. FI was associated with fathers' use of more effective discipline when fathers had no ADHD symptoms and reported more love for their wives but was associated with fathers' use of less effective discipline when fathers reported having ADHD symptoms, when they reported less love for their wives, and when they identified highly with traditional roles. For mothers, FI was associated with less effective discipline practices when couples' child-rearing views were dissimilar.