Naloxone distribution programs in the emergency department: A scoping review of the literature.

This scoping review summarized the literature regarding naloxone distribution from emergency departments (EDs) without a prescription. Our intention was to examine various naloxone distribution programs, their methodologies, and the level of effectiveness of each. Understanding these key aspects of naloxone distribution could lead to improved standardized protocols, saving countless additional lives from opioid overdose. This review evaluated studies reporting naloxone distribution from EDs in the United States. The included studies were written in English and published between January 1, 2017, and December 31, 2022. Searches were performed using PubMed and Embase. A total of 129 studies were reviewed, with only 12 meeting the necessary criteria for analysis. Heterogeneity was found across naloxone distribution programs, including how patients were identified, how naloxone was dispensed to patients, and the specific naloxone products made available. The protocols included various methods, such as patient screening, where information used for this screening was sometimes obtained from health records or patient interviews. Some programs detailed only the distribution of naloxone, while others included additional interventions such as behavior counseling, peer support, and education. In four studies, patients received buprenorphine with naloxone kits. The various programs differed in their implementation but were generally successful in improving naloxone distribution. However, among the studies reviewed, the percentage of ED patients receiving naloxone varied from ∼30% to 70%, suggesting that certain program elements may be more impactful. Further research is needed to identify key elements of the most impactful programs in order to improve naloxone distribution and improve patient odds of surviving an opioid overdose.

Impact of axillary surgery on outcome of clinically node positive breast cancer treated with neoadjuvant chemotherapy.

PURPOSE: Axillary Lymph Node Dissection (ALND) is recommended for breast cancer patients who present with clinically node positive disease (cN1) especially if they have residual nodal disease (ypN+) following neoadjuvant therapy (NAT). It is unknown whether axillary dissection improves outcome for these patients. METHODS: A prospectively maintained database was used to identify all patients who were diagnosed with cTis-T4N1M0 breast cancer treated with NAT. RESULTS: In our study, of 292 cN1 breast cancer patients who received NAT, we compared ALND with targeted axillary surgery (TAS) in ypN+ patients. ALND was performed in 75% of the ypN+ subgroup, while 25% underwent TAS. Axillary recurrence occurred in four ALND patients, but no recurrence was observed in the TAS group (p = 0.21). Five-year axillary recurrence-free survival was 100% for TAS and 90% for ALND (p = 0.21). Overall survival at five years was 97% for TAS and 85% for ALND (p = 0.39). Disease-free survival rates at five years were 51% for TAS and 61% for ALND (p = 0.9). Clinicopathological variables were similar between the groups, although some differences were noted. ALND patients had smaller clinical tumor size, larger pathological tumor size, more lymph nodes retrieved, larger tumor deposits, higher rates of extranodal extension, and greater prevalence of macrometastatic nodal disease. Tumor subtype and size of lymph node tumor deposit independently predicted survival. CONCLUSION: Axillary recurrence is infrequent in cN1 patients treated with NAT. Our study found that ALND did not reduce the occurrence of axillary recurrence or enhance overall survival. It is currently uncertain which patients benefit from axillary dissection.

Adjuvant treatment decisions among adults aged 65 years and older with early-stage hormone receptor positive breast cancer seen in a simple multidisciplinary clinic versus standard consultation.

INTRODUCTION: Randomized studies support de-escalation of adjuvant therapy for a target population of older adults ≥65 years with stage I, estrogen-receptor (ER) positive breast cancer after breast conserving surgery. We sought to evaluate the impact of a simplified multidisciplinary clinic (s-MDC) in this population by comparing treatment patterns and patient perceptions of adjuvant radiation therapy (RT) and hormone therapy (HT) between patients seen in s-MDC vs. standard consultations. MATERIALS AND METHODS: Medical records were retrospectively reviewed for patients in the above target population who underwent surgery between August 2020 and May 2022 at our institution. Two cohorts were included: (1) patients seen in s-MDC, and (2) patients seen in standard clinic separately by medical and radiation oncology (non-s-MDC cohort). The non-s-MDC patients declined, could not attend, and/or were not referred to the s-MDC. Patients in the s-MDC cohort were prospectively administered validated questionnaires to evaluate patient reported data including the Decision Autonomy Preference Scale (DAPS), e-Prognosis, and Medical Maximizing-Minimizing Scale (MMS). Chi square, t-tests, and non-parametric equivalents compared demographics, and logistic regression evaluated RT and HT use and survey score outcomes between cohorts. RESULTS: A total of 127 patients met inclusion criteria, with 33 s-MDC and 94 non-s-MDC patients. There was no difference between the cohorts in age, margin status, histology, grade, or focality. In the s-MDC cohort there were significantly more patients without sentinel lymph node biopsy (71.3% vs 42.4%, p = 0.003) and mean tumor size was smaller (0.69 vs. 0.96 cm, p < 0.003), and Charlson comborbidity index (CCI) was higher (5.21 vs 4.96, p = 0.038). There was no significant difference in receipt of RT (65% s-MDC vs 77% standard; odds ratio [OR] = 0.55, p = 0.189), HT (78% ss-MDC vs 72% standard; OR = 1.36, p = 0.513), or both (50% s-MDC vs 59% standard; OR = 0.7, p = 0.429). The s-MDC cohort was significantly more likely to undergo accelerated (vs. standard hypofractionated) RT (70% vs 39%; OR = 3.59, p = 0.020). In s-MDC patients with completed questionnaires (n = 33), all whose selected "mostly patient (n=6)" based decision making by DAPS chose RT while all "mostly doctor (n=1)" chose no RT. Based on e-Prognosis, there were lower odds of RT for increasing Schonberg score/ higher 10 yr mortality risk (OR 0.600, p = 0.048). MMS score ≥ 40 ("maximizer") was strongly linked with the use of RT (OR 18.57, p = 0.011). DISCUSSION: For adults ≥65 years with early stage, ER positive breast cancer, s-MDC participation was not significantly associated with lower use of adjuvant RT or HT versus standard consultation but was significantly associated with shorter RT courses. DAPS and MMS results indicate that patient treatment preference may be predictable, highlighting an opportunity to tailor consultation discussions and recommendations based on intrinsic patient preferences and individual goals.

Pediatric tele-coaching fidelity evaluation: Feasibility, perceived satisfaction and usefulness of a new measure.

Background: To promote and ensure coaches' fidelity in delivering an online health coaching program to parents of children with suspected developmental delay, we developed and implemented a novel coaching fidelity rating tool, CO-FIDEL (COaches Fidelity in Intervention DELivery). We aimed to (1) Demonstrate CO-FIDEL's feasibility in evaluating coaches' fidelity and its change over time; and (2) Explore coaches' satisfaction with and usefulness of the tool. Methods: In an observational study design, coaches (n = 4) were assessed using the CO-FIDEL following each coaching session (n = 13-14 sessions/parent-participant) during the pilot phase of a large randomized clinical trial involving eleven (n = 11) parent-participants. Outcome measures included subsections' fidelity measures, overall coaching fidelity, and coaching fidelity changes over time analyzed using descriptive and non-parametric statistics. In addition, using a four-point Likert Scale and open-ended questions, coaches were surveyed on their satisfaction and preference levels, as well as facilitators, barriers, and impacts related to the use of CO-FIDEL. These were analyzed using descriptive statistics and content analysis. Results: One hundred and thirty-nine (n = 139) coaching sessions were evaluated with the CO-FIDEL. On average, overall fidelity was high (88.0 ± 6.3 to 99.5 ± 0.8%). Four coaching sessions were needed to achieve and maintain a ≥ 85.0% fidelity in all four sections of the tool. Two coaches showed significant improvements in their coaching skills over time in some of the CO-FIDEL sections (Coach B/Section 1/between parent-participant B1 and B3: 89.9 ± 4.6 vs. 98.5 ± 2.6, Z = -2.74, p = 0.00596; Coach C/Section 4/between parent-participant C1 and C2: 82.4 ± 7.5 vs. 89.1 ± 4.1, Z = -2.66; p = 0.00758), and in overall fidelity (Coach C, between parent-participant C1 and C2: 88.67 ± 6.32 vs. 94.53 ± 1.23, Z = -2.66; p = 0. 00758). Coaches mainly reported moderate-high satisfaction with and usefulness of the tool, and pointed out areas of improvement (e.g., ceiling effect, missing elements). Conclusions: A new tool ascertaining coaches' fidelity was developed, applied, and shown to be feasible. Future research should address the identified challenges and examine the psychometric properties of the CO-FIDEL.

Telerehabilitation for Children and Youth with Developmental Disabilities and Their Families: A Systematic Review.

AIM: To determine the level of evidence for the effectiveness of telerehabilitation against comparison interventions in improving child- and parent-related outcomes in children and youth with developmental disabilities. METHOD: A systematic approach, comprised of a comprehensive search; transparent study selection, data extraction, quality assessment by independent reviewers; and synthesis of sufficiently similar data (per diagnostic group, health profession, and overall level of evidence for each outcome) was undertaken. RESULTS: Fifty-five studies (29 randomized trials) were included across six diagnostic groups and ten health professions. Common telerehabilitation targets varied across diagnostic groups and included motor function, behavior, language, and parental self-efficacy. Telerehabilitation was found to be either more effective or as effective versus comparison intervention in improving 46.9% or 53.1% of outcomes, respectively. It was never found to be detrimental or less effective. Strong to moderate, limited, and insufficient levels of evidence were found for 36.5%, 24.5%, and 38.6% of the outcomes, respectively. CONCLUSION: There is sufficient evidence suggesting that telerehabilitation is a promising alternative when face-to-face care is limited. It is comparable to usual care and is more effective than no treatment. Blending in-person and telerehabilitation approaches could be beneficial for the post-pandemic future of rehabilitation in pediatric care.

Integrating Immunotherapy in Early-Stage Triple-Negative Breast Cancer: Practical Evidence-Based Considerations.

The KEYNOTE-522 study is a practice-changing phase III randomized study that demonstrated that the addition of pembrolizumab to polychemotherapy improves outcomes in patients with high-risk early-stage triple-negative breast cancer (TNBC). This regimen is highly efficacious with unprecedented pathologic complete response (pCR) rates, and clinically meaningful improvements in event-free survival (EFS). However, the combination is also associated with significant high-grade treatment-related toxicity. The backbone regimen deviated from common practice, including the addition of carboplatin, lack of dose dense anthracyclines, and adjuvant capecitabine for residual disease, thus brining important questions regarding real-world translation of these results. This brief report practically addresses some of the most relevant questions physicians and patients face in optimizing care using the best available evidence.

Development of the Tiers of Service framework to support system and operational planning for children's healthcare services.

BACKGROUND: Providing access to pediatric healthcare services in British Columbia, Canada, presents unique challenges given low population densities spread across large geographic distances combined with a lack of availability of specialist providers in remote areas, leading to quality of care shortcomings and inequalities in care delivery. The study objective was to develop a framework that provides a common language and methodology for defining and planning child and youth healthcare services across the province. METHODS: The framework was developed in two phases. In Phase 1, a literature and jurisdictional review was completed using the following inclusion criteria: (i) description of a framework focusing on organizing service delivery systems (ii) that supports health service planning, (iii) includes specialty or subspecialty services and (iv) has been published since 2008. In Phase 2, a series of meetings with key provincial stakeholders were held to receive feedback on the developed Tiers of Service framework versions that were based on the literature and jurisdictional review and adjusted to the British Columbian health care context. The final version was endorsed by the Child Health BC Steering Committee. RESULTS: Ten medical articles and thirteen jurisdictional papers met the established selection criteria and were included in this study. Most frameworks were developed by the Australian national or state jurisdictions and published in jurisdictional papers (n = 8). Frameworks identified in the medical literature were mainly developed in Canada (n = 3) and the US (n = 3) and focused on maternity, neonatal, critical care and oncology services. Based on feedback received from the expert group, the framework was expanded to include community-based services, prevention and health determinants. The final version of the Tiers of Service framework describes the specific services to be delivered at each tier, which are categorized as Tier 1 (community services) through Tier 6 (sub-specialized services). Two consecutive steps were identified to effectively use the framework for operational and system planning: (i) development of a 'module' outlining the responsibilities and requirements to be delivered at each tier; and (ii) assessment of services provided at the health care facility against those described in the module, alignment to a specific tier, identification of gaps at the local, regional and provincial level, and implementation of quality improvement initiatives to effectively address the gaps. CONCLUSIONS: The benefits of the Tiers of Service framework and accompanying modules for health service planning are being increasingly recognized. Planning and coordinating pediatric health services across the province will help to optimize flow and improve access to high-quality services for children living in British Columbia.

Participación de los pacientes en una intervención de coaching en línea para padres de niños con retraso en el desarrollo.

OBJETIVO: Evaluar los procesos de participación de los pacientes en el desarrollo de una nueva intervención de coaching de salud para padres de niños con problemas de desarrollo emergentes. MÉTODO: Se utilizó un diseño de estudio transversal de método mixto. Los investigadores (n=18) y los padres-asesores (n=9) fueron encuestados utilizando la Herramienta de Evaluación del Compromiso Público y del Paciente (PPEET) en áreas de comunicación/apoyos para la participación, compartiendo puntos de vista/perspectivas, impactos/influencia de la iniciativa de compromiso, y pensamientos finales/satisfacción. Se utilizaron estadísticas descriptivas y resúmenes temáticos para analizar los datos. RESULTADOS: Para ambos grupos de estudio, en las cuatro secciones de la PPEET se observó un alto grado de acuerdo, con respuestas que variaban en gran medida entre 'estoy de acuerdo' y 'estoy muy de acuerdo'. Los informes cualitativos reflejaban que la participación de los pacientes era importante, significativa y tenía un impacto significativo en la calidad del proyecto y en el desarrollo profesional de los investigadores en su comprensión y uso de la metodología orientada al paciente. Los padres-asesores señalaron los problemas relacionados con la fijación de plazos realistas para proporcionar la retroalimentación y la falta de una representación más amplia entre los miembros. INTERPRETACIÓN: Se destacaron los beneficios y desafíos de aplicar estrategias orientadas al paciente a un ensayo multicéntrico. Estos se utilizarán para mejorar nuestros procesos de participación.

Patient engagement in an online coaching intervention for parents of children with suspected developmental delays.

AIM: To evaluate patient engagement processes in the development of a new health coaching intervention for parents of children with suspected developmental delays. METHOD: A cross-sectional mixed-method study design was used. Researchers (n=18) and patient-partners (n=9) were surveyed using the Public and Patient Engagement Evaluation Tool (PPEET) in areas of: (1) communication/supports for participation; (2) sharing views/perspectives; (3) impacts/influence of engagement initiative; and (4) final thoughts/satisfaction. Descriptive statistics and an inductive thematic-based approach were used to analyse the data. RESULTS: For both study groups, high agreement, with responses largely ranging between 'agree' to 'strongly agree', was noted on all four sections of the PPEET. Qualitative reports reflected that patient engagement was important, meaningful, and had a significant impact on the quality of the project and on the professional development of researchers in their understanding and use of patient-oriented methodology. Patient-partners noted challenges related to having realistic deadlines in providing feedback and a lack of a broader range of representation among members. INTERPRETATION: The benefits and challenges of applying patient-oriented strategies to a multicentre trial were highlighted. These will be used to enhance our engagement processes.

Fathers Matter: Enhancing Healthcare Experiences Among Fathers of Children With Developmental Disabilities.

Background: Being a parent of a child with a developmental disability (DD; e. g., cerebral palsy, autism) comes with great challenges and apprehensions. Mothers and fathers of children with DD are experiencing heightened levels of psychological distress, physical health problems, financial difficulties, social isolation, and struggles with respect to traditional parenting roles. In relation to the latter, the involvement of fathers in caregiving in today's society is increasing and is highlighted by its importance and positive contribution to the development of their children. However, fathers of children with DD report feeling excluded and marginalized by healthcare providers (HCPs) when arranging for and getting involved in healthcare services for their children. Currently, there is limited evidence as to what factors influence those experiences. We aimed to explore barriers to and facilitators of positive and empowering healthcare experiences, from the perspectives of fathers of children with DD and HCPs. Methods: A mixed-method approach, such as quantitative (survey) and qualitative (semi-structured interview) strategies, was used. Participants were fathers of children with DD and HCPs working in childhood disability. Data analysis consisted of using descriptive statistics and an inductive-thematic analysis of emergent themes. Results: Fathers (n = 7) and HCPs (n = 13, 6 disciplines) participated. The fathers indicated that while they were moderate to very much satisfied with their interactions with HCPs, they reported that HCPs were only sometimes attentive to them during interactions. Fathers also revealed that positive interactions with HCPs in relation to their children had multiple benefits. Several themes related to barriers and facilitators of optimal interactions and parent-professional relationships emerged. These included session factors (time, attention), personal factors (knowledge of the condition, child and healthcare system, acceptance vs. denial, previous experiences, culture, stereotypes, pre-existing beliefs, stress levels, working schedule), and family dynamics. The participants offered several insights into the different strategies that can be implemented to promote optimal interactions between fathers and HCPs. Conclusion: We identified several barriers, facilitators, and improvement strategies for optimal interactions and enhanced parent-professional relationships from the perspectives of fathers and HCPs. These can be integrated by existing clinical settings in efforts to enhance current clinical practices and improve child- and parent-related outcomes.

Physical Therapists Are Key to Hip Surveillance for Children with Cerebral Palsy: Evaluating the Effectiveness of Knowledge Translation to Support Program Implementation.

AIMS: Physical and occupational therapists play a key role in the implementation of hip surveillance for children with cerebral palsy (CP) in British Columbia, Canada. We aimed to develop and assess a knowledge translation strategy to support the implementation of a provincial hip surveillance program. METHODS: Pediatric therapists were invited to participate in an anonymous survey assessing hip surveillance knowledge and learning needs. Based on these results, educational materials were developed. Two years later, one year following the launch of the hip surveillance program, the survey was repeated to assess learning, knowledge use, and barriers to enrollment. RESULTS: The initial survey was completed by 102 therapists; 74 therapists completed the second survey. Multifaceted educational strategies, including web-based learning, in-person education, email notifications, and print materials that targeted knowledge gaps were developed. Upon re-evaluation, knowledge increased on all questions. At follow-up, 45 therapists had enrolled a child, indicating knowledge use. Barriers to enrollment included lack of a CP diagnosis, parents or physicians not agreeing to enrollment, time requirements, and lack of space to complete the clinical exam. CONCLUSIONS: Targeted knowledge translation strategies were successful in meeting the educational requirements of a large group of therapists in a vast geographic area.

Developing a province-wide hip surveillance program for children with cerebral palsy: from evidence to consensus to program implementation: a mini-review.

Hip displacement is a common orthopedic problem in children with cerebral palsy (CP) that can result in significant morbidity. Hip surveillance has been shown to reduce the incidence of hip dislocations in children with CP and to reduce the need for salvage hip surgeries. Guidelines for hip surveillance have been developed and can be adapted to meet local needs. Implementation of surveillance guidelines for a population of children is complex and highly dependent upon the region, province/state, or country's system of care for children with CP. Recognizing that implementation of the evidence on hip surveillance was necessary in British Columbia, a Canadian province spanning 1 million square kilometers, a comprehensive, coordinated approach to hip surveillance was developed collaboratively by provincial stakeholders. Surveillance guidelines and a desired implementation plan were established based on the best available research evidence, current international practice, and service delivery in British Columbia. Staged implementation preceded full provincial roll out. Implementation was supported by detailed communication, knowledge translation, and evaluation plans. This province-wide hip surveillance program is the first of its kind in North America.

Implementation study of a 5-component pediatric early warning system (PEWS) in an emergency department in British Columbia, Canada, to inform provincial scale up.

BACKGROUND: The rapid identification of deterioration in the pediatric population is complex, particularly in the emergency department (ED). A comprehensive multi-faceted Pediatric Early Warning System (PEWS) might maximize early recognition of clinical deterioration and provide a structured process for the reassessment and escalation of care. The objective of the study was to evaluate the implementation fidelity, effectiveness, and utility of a 5-component PEWS implemented in the ED of an urban public general hospital in British Columbia, Canada, and to guide provincial scale up. METHODS: We used a before-and-after design to evaluate the implementation fidelity, effectiveness, and utility of a 5-component PEWS (pediatric assessment flowsheet, PEWS score, situational awareness, escalation aid, and communication framework). Sources of data included patient medical records, surveys of direct care staff, and key-informant interviews. Data were analyzed using mixed-methods approaches. RESULTS: The majority of medical records had documented PEWS scores at triage (80%) and first bedside assessment (81%), indicating that the intervention was implemented with high fidelity. The intervention was effective in increasing vital signs documentation, both at first beside assessment (84% increase) and throughout the ED stay (> 100% increase), in improving staff's self-perceived knowledge and confidence in providing pediatric care, and self-reported communication between staff. Satisfaction levels were high with the PEWS scoring system, flowsheet, escalation aid, and to a lesser extent with the situational awareness tool and communication framework. Reasons for dissatisfaction included increased paperwork and incidence of false-positives. Overall, the majority of providers indicated that implementation of PEWS and completing a PEWS score at triage alongside the Canadian Triage and Acuity Scale (CTAS) added value to pediatric care in the ED. Results also suggest that the intervention is aligned with current practice in the ED. CONCLUSION: Our study shows that high-fidelity implementation of PEWS in the ED is feasible. We also show that a multi-component PEWS can be effective in improving pediatric care and be well-accepted by staff. Results and lessons learned from this pilot study are being used to scale up implementation of PEWS in ED settings across the province of British Columbia.

Improving value and access to specialty medical care for families: a pediatric surgery telehealth program

Background: In Canada, access to subspecialty surgical services for children imposes inconvenience and financial hardship on geographically remote families. The purpose of this study was to evaluate a recently implemented pediatric surgical telehealth pilot program from the family and provider perspectives. Methods: Enabled by an existing telehealth infrastructure for pediatric subspecialty medicine and mental health, a pilot telehealth program for surgical consultation was established by a single surgeon in British Columbia. Following establishment of eligibility criteria, patients from remote communities requiring new consultation or clinical follow-up were offered a telehealth alternative. At the end of the encounter, both the parent and patient (if appropriate) provided feedback via a questionnaire. Provider satisfaction was also assessed via a questionnaire. We estimated costs avoided and analyzed data on pediatric surgery consultation wait time. Results: Between September 2014 and November 2017, 80 patients were seen in 19 remote telehealth centres, 23 as new referrals and 57 in follow-up consultation. Among new referrals, the commonest diagnosis was chest wall deformity. The average travel distance avoided was 705 km, with an estimated direct cost avoidance of $585. Sixty-four families (80%) completed the questionnaire. Almost all (63 [98%]) indicated high overall satisfaction with the telehealth experience. Provider satisfaction was similarly high, in terms of both the technology user interface and clinical effectiveness. Overall pediatric surgical consultation wait times were unaffected. Conclusion: Implementation of telehealth technology in a pediatric surgical practice offered high value to patients/families and, from the provider's perspective, yielded an acceptable alternative to in-person assessment.

Contexte: Au Canada, l'accès aux services chirurgicaux surspécialisés pour enfants est source d'inconvénients et de difficultés financières pour les familles vivant en région éloignée. L'objectif de cette étude était d'évaluer le point de vue des familles et des fournisseurs de services sur un programme pilote de télésanté pédiatrique récemment mis en oeuvre. Méthodes: Ce programme pilote de consultation chirurgicale à distance a été mis sur pied par un chirurgien de Colombie-Britannique, qui s'est servi d'une infrastructure de télésanté préexistante permettant la prestation de services surspécialisés de médecine et de santé mentale pour enfants. Une fois leur admissibilité établie, les patients vivant en région éloignée et ayant besoin d'une consultation ou d'un suivi clinique se sont vu offrir des services de télésanté. Après la consultation, les parents et le patient (lorsque c'était approprié) ont rempli un formulaire de rétroaction. La satisfaction des fournisseurs de soins a été également évaluée au moyen d'un questionnaire. Nous avons estimé les coûts évités et analysé les données sur le temps d'attente pour une consultation en chirurgie pédiatrique. Résultats: Entre septembre 2014 et novembre 2017, 80 patients ont consulté 19 centres de télésanté : 23 pour une nouvelle consultation et 57 pour un suivi. Parmi les nouveaux cas, le diagnostic le plus fréquent était une malformation de la paroi thoracique. En moyenne, 705 km de déplacements ont été évités, ce qui représente un coût estimé de 585 $. Soixante-quatre familles (80 %) ont rempli le questionnaire, et presque toutes (63 [98 %]) se sont dites globalement satisfaites de leur expérience de télésanté. La satisfaction des fournisseurs de soins était également élevée, tant en ce qui a trait à l'interface utilisateur des outils technologiques qu'à l'efficacité clinique. Le programme n'a eu aucun effet sur le temps d'attente général pour une consultation en chirurgie pédiatrique. Conclusion: L'utilisation de services de télésanté en chirurgie pédiatrique a été d'une grande valeur pour les patients et leur famille. Du point de vue des fournisseurs de soins, elle a constitué une solution de rechange acceptable aux consultations en personne.

BRIGHT Coaching: A Randomized Controlled Trial on the Effectiveness of a Developmental Coach System to Empower Families of Children With Emerging Developmental Delay.

Background: In preschool-aged children with, or at elevated risk for, developmental disabilities, challenges and needs arise from vulnerabilities linked to critical and newly emerging cognitive, speech, motor, behavioral, and social skills. For families, this can be a stressful period as they witness the gradual unfolding of their child's differences and await to receive care. Nationally and internationally, service delivery models during this critical period are not standardized nor are they nimble or sufficient enough, leading to long wait times, service gaps and duplications. Given these struggles, there is a need to examine whether "health coaching", a structured educational program that is deliverable by different and more accessible means, can be effective in empowering families, by delivering information, providing social supports, and decreasing the demands on the overwhelmed health and developmental services. The primary objective is to evaluate the feasibility and the effectiveness of a coaching intervention (in comparison to usual and locally available care), for parents of children with emerging developmental delays. Method/Design: A multi-centered pragmatic randomized controlled trial design will be used. Families will be recruited from a representative sample of those awaiting publicly-funded regional child health services for children with developmental delays in four Canadian provinces. The target sample size is 392 families with children aged 1.5 to 4.5 years at recruitment date. Families will be randomly assigned to receive either the BRIGHT Coaching intervention (coach supported, hardcopy and online self-managed educational resources: 14 sessions, 2 sessions every 4 weeks for 6-9 months) or usual care that is locally available. In addition to the feasibility and acceptability measures, outcomes related to family empowerment, parental satisfaction and efficacy with caregiver competency will be evaluated at baseline, post-treatment (8 months), and follow-up (12 months). Discussion: This manuscript presents the background information, design, description of the interventions and of the protocol for the randomized controlled trial on the effectiveness of BRIGHT Coaching intervention for families of children with emerging developmental delays. Trial Registration: ClinicalTrials.gov, U.S. National Library of Medicine, National Institutes of Health #NCT03880383, 03/15/2019. Retrospectively registered.

Health coaching for parents of children with developmental disabilities: a systematic review.

AIM: To determine the level of evidence on the effectiveness of health coaching for parents of children with disabilities. METHOD: A systematic review approach, comprised of a comprehensive, librarian-guided literature search; transparent study selection and data extraction; quality assessment; and synthesis of sufficiently similar data (per population, intervention nature, and overall level of evidence for each outcome using standard definitions) was undertaken. RESULTS: Twenty-eight studies (13 randomized clinical trials) were included. Three health coaching approaches were identified: child-targeted (most commonly applied), parent-targeted, and a mixed approach. Overall, there is an insufficient-to-limited level of evidence regarding the effectiveness of these approaches. INTERPRETATION: High-quality clinical trials using the parent-targeted coaching approach are warranted. WHAT THIS PAPER ADDS: Health coaching parents of children with disabilities is an emergent practice. Child-targeted, parent-targeted, or mixed health coaching approaches exist. The child-targeted health coaching approach is currently most applied. Parents of children with autism spectrum disorder are the most common recipients.

ENTRENAMIENTO EN SALUD PARA PADRES DE NIÑOS CON TRASTORNOS DEL DESARROLLO: UNA REVISIÓN SISTEMÁTICA: OBJETIVO: Determinar el nivel de evidencia sobre la efectividad del entrenamiento en salud "health coaching" para padres de niños con discapacidades. MÉTODO: Se llevó a cabo una revisión sistemática, usando una búsqueda bibliográfica exhaustiva guiada por bibliotecarios; con selección transparente de estudios y extracción de datos; evaluación de la calidad; y se realizó una síntesis, combinando los datos de estudio suficientemente similares (por población, naturaleza de intervención y nivel general de evidencia para cada resultado, utilizando definiciones estándar). RESULTADOS: Se incluyeron 28 estudios (13 ensayos clínicos aleatorios). Se identificaron tres enfoques de orientación de salud: orientado a los niños (más comúnmente aplicado), orientado a los padres y un enfoque mixto. En general, el nivel de evidencia que existe con respecto a la efectividad de estos enfoques es insuficiente a limitado. INTERPRETACIÓN: Son necesarios ensayos clínicos de alta calidad orientados a padres que utilizen el enfoque de entrenamiento en salud.

ORIENTAÇÃO EM SAÚDE PARA PAIS DE CRIANÇAS COM DEFICIÊNCIAS DO DESENVOLVIMENTO: UMA REVISÃO SISTEMÁTICA: OBJETIVO: Determinar o nível de evidência da efetividade da orientação em saúde para pais de crianças com deficiências. MÉTODO: Uma abordagem de revisão sistemática, contendo uma compreensiva busca literária com auxílio de bibliotecário; seleção de estudos e extração dados transparentes; avaliação de qualidade; e síntese de dados suficientemente similares (por população, natureza da intervenção, e nível geral de evidência para cada resultado usando definições padronizadas) foi realizada. RESULTADOS: Vinte e oito estudos (13 ensaios clínicos randomizados) foram incluídos. Três abordagens de orientação em saúde foram identificadas: voltadas para a criança (mais comumente aplicada), voltada para os pais, e abordagem mista. No geral, o nível de evidência é de insuficiente a limitado com relação à efetividade destas abordagens. INTERPRETAÇÃO: Ensaios clínicos de alta qualidade usando abordagens de orientação voltadas para os pais são necessários.

Constraints to implementing guidelines for the identification, assessment, and management of childhood obesity in the clinical care setting: Prevention and treatment framework.

The "Pathway for the Identification, Assessment and Management of Overweight and Obese Children & Youth" was developed to support healthcare providers in identifying and treating childhood obesity in British Columbia (Canada). PURPOSE: The study aimed to determine the feasibility and effectiveness of using the Pathway in clinical settings. METHODS: 13 healthcare providers (7 family physicians, 2 pediatricians, 2 registered dietitians, and 2 nurse practitioners) assessed the Pathway and participated in semi-structured interviews in 2015. A direct constant comparative analysis guided the coding of the interviews in the NVivo 9 software. RESULTS: The interviews uncovered the complexity of factors that influenced practices of healthcare providers. Three broad issues were identified as required if the "Pathway" were to be used and fully implemented in practices. First, the "Pathway" needs to be modified in terms of how it is presented and explained and be supplemented with appropriate documentation and resources for its implementation, Second, the constraints that limit implementation need to be addressed and should include a focus on both individual (i.e., the healthcare providers themselves) and environmental (i.e., factors within and outside of providers' organizations) factors. Lastly, there is a need to establish processes and/or infrastructure for adapting the "Pathway" to the local context as resources and supports vary by organizations and regions. CONCLUSION: Healthcare providers should be involved in screening and managing childhood obesity. Addressing the challenges found in this study will enable healthcare providers to take a more active role in addressing childhood obesity in their day to day practices.

Dose-dependent effect of mammographic breast density on the risk of contralateral breast cancer.

PURPOSE: Increased mammographic breast density is a significant risk factor for breast cancer. It is not clear if it is also a risk factor for the development of contralateral breast cancer. METHODS: The data were obtained from Breast Cancer Surveillance Consortium and included women diagnosed with invasive breast cancer or ductal carcinoma in situ between ages 18 and 88 and years 1995 and 2009. Each case of contralateral breast cancer was matched with three controls based on year of first breast cancer diagnosis, race, and length of follow-up. A total of 847 cases and 2541 controls were included. The risk factors included in the study were mammographic breast density, age of first breast cancer diagnosis, family history of breast cancer, anti-estrogen treatment, hormone replacement therapy, menopausal status, and estrogen receptor status, all from the time of first breast cancer diagnosis. Both univariate analysis and multivariate conditional logistic regression analysis were performed. RESULTS: In the final multivariate model, breast density, family history of breast cancer, and anti-estrogen treatment remained significant with p values less than 0.01. Increasing breast density had a dose-dependent effect on the risk of contralateral breast cancer. Relative to 'almost entirely fat' category of breast density, the adjusted odds ratios (and p values) in the multivariate analysis for 'scattered density,' 'heterogeneously dense,' and 'extremely dense' categories were 1.65 (0.036), 2.10 (0.002), and 2.32 (0.001), respectively. CONCLUSION: Breast density is an independent and significant risk factor for development of contralateral breast cancer. This risk factor should contribute to clinical decision making.

Prevention of hip displacement in children with cerebral palsy: a systematic review.

AIM: To conduct a systematic review and evaluate the quality of evidence for interventions to prevent hip displacement in children with cerebral palsy (CP). METHOD: A systematic review was performed using American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Searches were completed in seven electronic databases. Studies were included if participants had CP and the effectiveness of the intervention was reported using a radiological measure. Results of orthopaedic surgical interventions were excluded. RESULTS: Twenty-four studies fulfilled the inclusion criteria (4 botulinum neurotoxin A; 2 botulinum neurotoxin A and bracing; 1 complementary and alternative medicine; 1 intrathecal baclofen; 1 obturator nerve block; 8 positioning; 7 selective dorsal rhizotomy). There was significant variability in treatment dosages, participant characteristics, and duration of follow-up among the studies. Overall, the level of evidence was low. No intervention in this review demonstrated a large treatment effect on hip displacement. INTERPRETATION: The level and quality of evidence for all interventions aimed at slowing or preventing hip displacement is low. There is currently insufficient evidence to support or refute the use of the identified interventions to prevent hip displacement or dislocation in children and young people with CP. WHAT THIS PAPER ADDS: High-quality evidence on prevention of hip displacement is lacking. No recommendations can be made for preventing hip displacement in children with cerebral palsy because of poor-quality evidence. High-quality, prospective, longitudinal studies investigating the impact of interventions on hip displacement are required.