Contextualized, Multicomponent Language Instruction: From Theory to Randomized Controlled Trial.

PURPOSE: Clinicians address a wide range of oral language skills when working with school-age students with language and literacy difficulties (LLDs). Therefore, there is a critical need for carefully designed, rigorously tested, multicomponent contextualized language interventions (CLIs) that have a high likelihood of successful implementation and measurable academic impacts. This clinical focus article summarizes the development and testing of a CLI entitled Supporting Knowledge in Language and Literacy (SKILL), which is a supplementary narrative intervention program for elementary school-age children. Our aims are to (a) to review the foundational theoretical models that are the foundation of SKILL; (b) describe the iterative process used to develop the phases, lessons, procedures, materials, and progress monitoring tool; (c) summarize recent findings of the randomized controlled trial that was conducted to test its efficacy; and (d) discuss factors that may contribute to successful implementation of multicomponent language interventions. METHOD: A total of 357 students in Grades 1-4 with LLDs were randomized to a treatment group or to a business-as-usual control group. The treatment group received the SKILL curriculum in small groups during 30-min lessons by trained speech-language pathologists, teachers, and special educators. RESULTS: Students who received SKILL significantly outperformed those who did not on oral and written measures of storytelling and comprehension immediately after treatment and after 5-months at follow-up. Gains were similar among students with different levels of language ability (at-risk, language impaired) and language status (monolingual, bilingual) at pretest. CONCLUSIONS: There is growing support for the use of multicomponent CLIs to bring about educationally relevant outcomes for students with LLDs. The authors present this review of how SKILL was designed, manualized, and rigorously tested by a team of researchers and practitioners with the hope that this approach will serve as a springboard for the development of future multicomponent CLIs that may meaningfully improve communicative and educational outcomes for students with LLDs.

Malglycemia in the critical care setting. Part II: Relative and absolute hypoglycemia.

INTRODUCTION: The relationship between critical care mortality and hypoglycemia, both relative (>30% below average preadmission glycemia) and absolute (blood glucose (BG) <70 mg/dL (<10 mmol/L)) requires further definition. METHODS: We assessed the risk-adjusted relationship between hospital mortality with relative hypoglycemia using the Glycemic Ratio (GR), and with absolute hypoglycemia using BG in a retrospective cohort investigation (n = 4790). RESULTS: Relative hypoglycemia excursions below GR 0.7 with a of 24-h non-exposure period between excursions in those with HbA1c ≥ 8% were independently associated with mortality (n = 373, OR 2.49, 95% CI 1.54-4.04, p = 0.0002) but not those with HbA1c < 8% (n = 4417, OR 0.98 95% CI 0.89-1.08, p = 0.70). Hours below GR 0.7 (1.0037, 0.9995-1.0080, 0.0846) or minimum GR (0.0896, 0.0030-2.6600, 0.1632) were not independently associated with outcome. Absolute hypoglycemia occurred across the HbA1c spectrum in a U-shaped pattern. There was no difference in mortality associated with exposure to BG < 70 mg/dL for HbA1c ≥ 6.5% vs <6.5% (29.7% vs 24.3%, p = 0.77). Hours below 70 mg/dL demonstrated strongest association with outcome, while minimum BG, and excursions below 70 mg/dL were also independently associated. CONCLUSIONS: Relative hypoglycemia represented by excursions below GR 0.7 in those with HbA1c ≥ 8% occurred commonly and was independently associated with mortality. Absolute hypoglycemia had similar association with mortality regardless of HbA1c.

Malglycemia in the critical care setting. Part I: Defining hyperglycemia in the critical care setting using the glycemic ratio.

INTRODUCTION: Stress-induced hyperglycemia (SIH) is conventionally represented by Blood Glucose (BG) although recent evidence indicates the Glycemic Ratio (GR, quotient of mean BG and estimated preadmission BG) is a superior prognostic marker. We assessed the association between in-hospital mortality and SIH, using BG and GR in an adult medical-surgical ICU. METHODS: We included patients with hemoglobin A1c (HbA1c) and minimum four BGs in a retrospective cohort investigation (n = 4790). RESULTS: A critical SIH threshold of GR 1.1 was identified. Mortality increased with increasing exposure to GR ≥ 1.1 (r2 = 0.94, p = 0.0007). Duration of exposure to BG ≥ 180 mg/dL demonstrated a less robust association with mortality (r2 = 0.75, p = 0.059). In risk-adjusted analyses, hours GR ≥ 1.1 (OR 1.0014, 95%CI (1.0003-1.0026), p = 0.0161) and hours BG ≥ 180 mg/dL (OR 1.0080, 95%CI (1.0034-1.0126), p = 0.0006) were associated with mortality. In the cohort with no exposure to hypoglycemia however, only hours GR ≥ 1.1 was associated with mortality (OR 1.0027, 95%CI (1.0012-1.0043), p = 0.0007), not BG ≥ 180 mg/dL (OR 1.0031, 95%CI (0.9949-1.0114), p = 0.50) and this relationship remained intact for those who never experienced BG outside the 70-180 mg/dL range (n = 2494). CONCLUSIONS: Clinically significant SIH commenced above GR 1.1. Mortality was associated with hours of exposure to GR ≥ 1.1 which was a superior marker of SIH compared to BG.

An Evaluation of the Structure of Attention in Adolescence.

This study evaluated the factor structure of attention, considering internal and external attention, and juxtaposed alongside processing speed (PS) and working memory (WM). We expected the hypothesized model to fit better than unitary or method factors. We included 27 measures with 212 Hispanic middle schoolers from Spanish-speaking backgrounds, where a substantial proportion were at risk for learning difficulties. Confirmatory factor analytic models separated factors of PS and WM, but the final model did not align with theoretical predictions; rather only measurement factors emerged. Findings extend and refine our understanding of the structure of attention in adolescents.

The concept of holism applied in recent palliative care practice: A scoping review.

BACKGROUND: Whilst there is a sense of holism existing within palliative care practice, what is not clear is the extent to which holism, as applied in recent palliative care practice, has been adequately researched. Currently, no reviews on this topic were identified through systematic and scoping review registries. AIM: To identify and describe the available published evidence on the key features of holism and the core domains underpinning the application of holism in relation to recent palliative care practice. DESIGN: Scoping review using the Johanna Briggs Institute design. DATA SOURCES: MEDLINE, EMCARE, and CINAHL (Ovid), PsycINFO, SocINDEX, SCOPUS and Web of Science. (International, peer-reviewed, published papers in the English language from January 2010to December 2020). RESULTS: Five studies met inclusion criteria. Two studies used qualitative methods, one used mixed-methods, and two were randomised controlled trials. The research investigated (1) frameworks for holistic care and (2) assessment tools applied in palliative care settings. CONCLUSIONS: The results from the review led to identifying key features of palliative care that were presented as interconnected aspects of holistic care domains in both assessments and interventions. The literature revealed a focus on curative and biomedical approaches to disease management with holistic aspects acknowledged, but not in the forefront of core service delivery. Holism was generally conceptualised as an overarching theoretical framework to palliative care service provision and positioned as an adjunct to palliative models of care. These findings point to a gap in research that links the concept of holism to applied palliative care practices.

The Glycemic Ratio Is Strongly and Independently Associated With Mortality in the Critically Ill.

BACKGROUND: Interventional studies investigating blood glucose (BG) management in intensive care units (ICU) have been inconclusive. New insights are needed. We assessed the ability of a new metric, the Glycemic Ratio (GR), to determine the relationship of ICU glucose control relative to preadmission glycemia and mortality. METHODS: Retrospective cohort investigation (n = 4790) in an adult medical-surgical ICU included patients with minimum four BGs, hemoglobin (Hgb), and hemoglobin A1c (HbA1c). The GR is the quotient of mean ICU BGs (mBG) and estimated preadmission BG, derived from HbA1c. RESULTS: Mortality displayed a J-shaped curve with GR (nadir GR 0.9), independent of background glycemia, consistent for HbA1c <6.5% vs >6.5%, and Hgb >10 g/dL vs <10 g/dL and medical versus surgical. An optimal range of GR 0.80 to 0.99 was associated with decreased mortality compared with GR above and below this range. The mBG displayed a linear relationship with mortality at lower HbA1c but diminished for HbA1c >6.5%, and dependent on preadmission glycemia. In adjusted analysis, GR remained associated with mortality (odds ratio = 2.61, 95% confidence interval = 1.48-4.62, P = .0012), but mBG did not (1.004, 1.000-1.009, .059). A single value on admission was not independently associated with mortality. CONCLUSIONS: The GR provided new insight into malglycemia that was not apparent using mBG, or an admission value. Mortality was associated with acute change from preadmission glycemia (GR). Further assessment of the impact of GR deviations from the nadir in mortality at GR 0.80 to 0.99, as both relative hypo- and hyperglycemia, and as duration of exposure and intensity, may further define the multifaceted nature of malglycemia.

When Treatment Adherence Matters: Interactions Among Treatment Adherence, Instructional Quality, and Student Characteristics on Reading Outcomes.

In this study, we examined the extent to which teachers' treatment adherence, instructional quality, and the interaction of these variables influenced eighth-grade students' content knowledge and reading comprehension. We examined treatment fidelity for students (n = 775) in classes randomly assigned to receive an evidence-based content area reading program called Promoting Adolescents' Comprehension of Text. Results indicate that teachers' instructional quality was a statistically significant, positive predictor of student content knowledge and reading comprehension performance, whereas teachers' treatment adherence was not. Statistically significant interactions between treatment adherence and instructional quality were present, such that teachers' treatment adherence had a stronger impact on student learning outcomes when their overall instructional quality was low. Moderator analyses also revealed that students' pretest performance and English learner status influenced the effects of treatment adherence and instructional quality on student outcomes. These findings help elucidate the conditions under which Promoting Adolescents' Comprehension of Text leads to improved outcomes, and more broadly, underscore the importance of carefully examining dimensions of treatment fidelity when testing the effects of treatment programs.

Online Administration of the Test of Narrative Language-Second Edition: Psychometrics and Considerations for Remote Assessment.

PURPOSE: Our aim was to evaluate the psychometric properties of the online administered format of the Test of Narrative Language-Second Edition (TNL-2; Gillam & Pearson, 2017), given the importance of assessing children's narrative ability and considerable absence of psychometric studies of spoken language assessments administered online. METHOD: The TNL-2 was administered to 357 school-age children at risk for language and literacy difficulties as part of a randomized controlled trial, across three annual cohorts, at three time points (pretest, posttest, and 5-month follow-up). Cohort 3 students were tested using an online format at posttest and at follow-up. We compared the Cronbach's alpha internal consistency reliability of the TNL-2 online testing scores with in-person scores from TNL-2 normative data and Cohort 3 in-person testing at pretest, and interrater reliability for Cohort 3 across test points. In addition, we examined measurement invariance across test occasions and the criterion validity of the TNL-2, the latter based on its correlations with narrative sample measures (Mean Length of Utterance in words and the Monitoring Indicators of Scholarly Language rubric). RESULTS: Internal consistency reliability, interrater reliability, and measurement invariance analyses of the online and in-person administration of the TNL-2 yielded similar outcomes. The criterion validity of the TNL-2 was found to be good. CONCLUSIONS: TNL-2 psychometric properties from online administration were generally in the good range and were not significantly different from in-person testing. When administered online using standardized procedures, the TNL-2 is valid and reliable for use in assessing narrative language proficiency in school-age children at risk for language and learning difficulties.

Applying an Individual Word-Problem Intervention to a Small-Group Setting: A Pilot Study's Evidence of Improved Word-Problem Performance for Students Experiencing Mathematics Difficulty.

The purpose of this pilot study was to determine whether positive results from a word-problem intervention implemented one-to-one contributed to similar outcomes when implemented in small groups of three to four students. Third-grade students experiencing mathematics difficulty (N = 76) were randomly assigned to word-problem intervention (n = 56) or business-as-usual comparison (n = 20). Intervention occurred for 13 weeks, 3 times per week, 30 min per session. Multilevel models revealed the intervention condition significantly outperformed the BaU on a proximal word-problem outcome, corroborating results from our prior individual intervention. When comparing student performance in the individual versus small-group intervention, findings suggest students received added benefit from the individual intervention. The word-problem intervention successfully translated to a small-group setting, which holds important implications for educators working with students in supplemental, targeted, or Tier 2 mathematics intervention settings.

Visual attention and reading: A test of their relation across paradigms.

Relations of visual attention to reading have long been hypothesized; however, findings in this literature are quite mixed. These relations have been investigated using several different visual attention paradigms and with variable controls for other competing reading-related processes. We extended current knowledge by evaluating four of the key visual attention paradigms used in this research-visual attention span, attention blink, visual search, and visuospatial attention-in a single study. We tested the relations of these to reading in 90 middle schoolers at high risk for reading difficulties while considering their effect in the context of known language predictors. Performance on visual-spatial, visual search, and attentional blink paradigms showed weak nonsignificant relations to reading. Visual attention span tasks showed robust relations to reading even when controlling for language, but only when stimuli were alphanumeric. Although further exploration of visual attention in relation to reading may be warranted, the robustness of this relationship appears to be questionable, particularly beyond methodological factors associated with the measurement of visual attention. Findings extend and refine our understanding of the contribution of attention to reading skill and raise questions about the mechanism by which visual attention is purported to affect reading.

Examining the Effects of Integrating Anxiety Management Instruction Within a Reading Intervention for Upper Elementary Students With Reading Difficulties.

We present findings from the first cohort of third- and fourth-grade students with reading difficulties (128 students from 31 classrooms) who participated in a 2-year intervention examining the effects of a reading intervention with and without anxiety management. Using a randomized controlled trial, students were assigned to one of three conditions: (a) small-group reading intervention with anxiety management instruction (RANX), (b) small-group reading intervention with math fact practice (RMATH), and (c) business-as-usual (BAU) comparison condition (no researcher provided treatment). Personnel from the research team provided participants in the RANX and RMATH the same reading intervention with the variation in the two treatments being whether the same amount of time per lesson was allocated to anxiety management (RANX) or practicing math facts (RMATH). Students in the RANX significantly outperformed students in the BAU on reading comprehension (effect size [ES] = 1.22) and students in the RMATH outperformed BAU on reading comprehension (ES = 0.77). Groups did not differ significantly on other reading outcomes. Reading anxiety moderated the main effect of the RANX intervention on the Test of Word Reading Efficiency (TOWRE) word reading when contrasted against the BAU group, indicating a significant difference favoring RANX where treatment's effect decreased by 0.94 units (about 1 point on the outcome) on word reading for each additional point increase in reading anxiety.

Sustained attention and behavioral ratings of attention in struggling readers.

Attention is correlated with reading, but the extent to which behavioral ratings and sustained attention relate to reading skills is unclear. We assessed 245 4th and 5th grade struggling readers (mean age = 10.3 years) on behavioral ratings of attention, sustained attention, and reading over a school year. Contributions of behavioral ratings and sustained attention were considered cross-sectionally and longitudinally in the context of other important predictors of reading. Results suggest that sustained measures and behavioral ratings assess distinct, yet overlapping, aspects of attention. Both types of attention accounted for unique variance in comprehension, but not word reading accuracy or fluency, when evaluated cross-sectionally. Results also support the role of behavioral ratings of attention in fluency and in comprehension growth. Findings suggest that multidimensional assessment of attention is useful when considering its relation to reading, and highlights the need to integrate conceptualizations of attention that arise from different theoretical approaches.

Problem Behaviors and Response to Reading Intervention for Upper Elementary Students With Reading Difficulties.

This study investigated the extent to which problem behaviors were factors associated with response to a year-long multicomponent reading intervention for fourth- and fifth-grade students with reading difficulties. Students scoring ≤85 standard score on the Test of Silent Reading Efficiency and Comprehension (n = 108), a reading fluency and comprehension screener measure, were randomized to the researcher-provided treatment condition (n = 55) or the business-as-usual comparison condition (n = 53). Results indicated that problem behaviors were associated with lower reading comprehension outcomes. Findings also suggested that students with higher levels of overall problem behaviors and externalizing behaviors in the treatment condition outperformed similar students in the comparison condition on the Gates-MacGinitie Reading Test (p < .05). Future research is needed on how to best identify, develop, and adapt effective interventions for students with reading difficulties and problem behaviors within school-wide response to intervention frameworks.

Hospital admission as a deprescribing triage point for patients discharged to Residential Aged Care Facilities.

BACKGROUND: Deprescribing may benefit older frail patients experiencing polypharmacy. We investigated the scope for deprescribing in acutely hospitalised patients and the long-term implications of continuation of medications that could potentially be deprescribed. METHODS: Acutely hospitalised patients (n = 170) discharged to Residential Aged Care Facilities, ≥75 years and receiving ≥5 regular medications were assessed during admission to determine eligibility for deprescribing of key drug classes, along with the actual incidence of deprescribing. The impact of continuation of nominated drug classes (anticoagulants, antidiabetics, antiplatelets, antipsychotics, benzodiazepines, proton pump inhibitors (PPIs), statins) on a combined endpoint (death/readmission) was determined. RESULTS: Hyperpolypharmacy (>10 regular medications) was common (49.4%) at admission. Varying rates of deprescribing occurred during hospitalisation for the nominated drug classes (8-53%), with considerable potential for further deprescribing (34-90%). PPI use was prevalent (56%) and 89.5% of these had no clear indication. Of the drug classes studied, only continued PPI use at discharge was associated with increased mortality/readmission at 1 year (hazard ratio 1.54, 95% confidence interval (1.06-2.26), P = 0.025), driven largely by readmission. CONCLUSION: There is considerable scope for acute hospitalisation to act as a triage point for deprescribing in older patients. PPIs in particular appeared overprescribed in this susceptible patient group, and this was associated with earlier readmission. Polypharmacy in older hospitalised patients should be targeted for possible deprescribing during hospitalisation, especially PPIs.

Examining the Reading and Cognitive Profiles of Students With Significant Reading Comprehension Difficulties.

This study investigated the word reading and listening comprehension difficulties of fourth-grade students with significant reading comprehension deficits and the cognitive difficulties that underlie these weaknesses. Latent profile analysis was used to classify a sample of fourth-grade students (n = 446) who scored below the 16th percentile on a measure of reading comprehension into subgroups based on their performance in word reading (WR) and listening comprehension (LC). Three latent profiles emerged: (a) moderate deficits in both WR and LC of similar severity (91%), (b) severe deficit in WR paired with moderate LC deficit (5%), and (c) severe deficit in LC with moderate WR difficulties (4%). Analyses examining the associations between cognitive attributes and group membership indicated students with lower performance on cognitive predictors were more likely to be in a severe subgroup. Implications for educators targeting improved reading performance for upper elementary students with significant reading difficulties were discussed.

Multitiered Systems of Support, Adaptive Interventions, and SMART Designs.

This article introduces the special section on adaptive interventions and sequential multiple-assignment randomized trial (SMART) research designs. In addition to describing the two accompanying articles, we discuss features of adaptive interventions (AIs) and describe the use of SMART design to optimize AIs in the context of multitiered systems of support (MTSS) and integrated MTSS. AI is a treatment delivery model that explicitly specifies how information about individuals should be used to decide which treatment to provide in practice. Principles that apply to the design of AIs may help to more clearly operationalize MTSS-based programs, improve their implementation in school settings, and increase their efficacy when used according to evidence-based decision rules. A SMART is a research design for developing and optimizing MTSS-based programs. We provide a running example of a SMART design to optimize an MTSS-aligned AI that integrates academic and behavioral interventions.

Improving the Mathematics Performance of Second-Grade Students with Mathematics Difficulties through an Early Numeracy Intervention.

The purpose of this study was to determine the effects of an early numeracy Tier 2 intervention on the mathematics performance of second-grade students with persistent mathematics difficulties. Whole number content and instructional design features were used to boost performance in second-grade early numeracy concepts and skills. Researchers employed a pretest-posttest control group design with randomized assignment of 83 students to the treatment condition and 38 students to the comparison condition. The research team's mathematics interventionists delivered instruction four days per week for 20 weeks to small groups of second-grade students who were identified with persistent mathematics difficulties. Proximal and distal measures were used to determine the effects of the intervention. Findings showed that students in the treatment group outperformed students in the comparison group on the proximal measure of mathematics performance. There were no differences between groups on the problem-solving measures.

Examining Factors Affecting Reading and Math Growth and Achievement Gaps in Grades 1-5: A Cohort-Sequential Longitudinal Approach.

Despite focused efforts, achievement gaps remain a problem in the America's education system, especially those between students from higher and lower income families. Continued work on reducing these gaps benefits from an understanding of students' reading and math growth from typical school instruction and how growth differs based on initial proficiency, grade, and demographic characteristics. Data from 5,900 students in Grades 1-5 tested in math and reading at six points across two years were analyzed using cohort-sequential latent growth curve models to determine longitudinal growth patterns. Results indicated that students with low initial proficiency grew more quickly than students with higher proficiency. However, after two school years their achievement remained below average and well below that of students with higher initial proficiency. Demographic characteristics had small but significant effects on initial score and growth rates.

Do the Processes Engaged During Mathematical Word-Problem Solving Differ Along the Distribution of Word-Problem Competence?

Conventional research methods for understanding sources of individual differences in word-problem solving (WPS) only permit estimation of average relations between component processes and outcomes. The purpose of the present study was instead to examine whether and if so how the component processes engaged in WPS differ along the spectrum of WPS performance. Second graders (N = 1,130) from 126 classrooms in 17 schools were assessed on component processes (reasoning, in-class attentive behavior, working memory, language comprehension, calculation fluency, word reading) and WPS. Multilevel, unconditional quantile multiple regression indicated that 3 component processes, calculation fluency, language comprehension, and working memory, are engaged in WPS differentially depending on students' overall word-problem skill. The role of calculation fluency and language comprehension was stronger with more competent word-problem solving ability. By contrast, the role of working memory was stronger with intermediate-level than for strong problem solving. Results deepen insight into the role of these processes in WPS and provide the basis for hypothesizing how instructional strategies may be differentiated depending on students' overall level of WPS competence.