Anxiety and Depression in Pediatric Patients with Celiac Disease: A Large Cross-Sectional Study.

Mental health is a growing concern in pediatric celiac disease (CD). This study utilized the Revised Children's Anxiety and Depression Scale (RCADS) to investigate anxiety and depression symptom rates. Participants were children ages 8 to 17 years (M = 11.7, SD = 2.7; N = 175) with biopsy-proven CD (Median = 1.1 years post-diagnosis, IQR = 0-4) categorized into groups based on the child's age, caregiver or child respondent, presence or absence of comorbidities, and gluten-free diet duration. Self-reported RCADS scores showed 39% of children having clinically significant concerns for anxiety or depression ( P < 0.0001) but only 7% of caregiver-proxy RCADS scores indicated significant concerns for the child's anxiety and 14% for the child's depression. Rates of child-reported anxiety and depression symptoms were significantly higher for those without medical comorbidities than those with ( P = 0.04). Therefore, screening for mental health concerns, particularly anxiety and depression, should be routinely performed in pediatric patients with CD.

Family ties: the impact of celiac disease on children and caregivers.

PURPOSE: To evaluate the impact of celiac disease (CD) and the gluten-free diet (GFD) on the health-related quality of life (HRQoL) in children with CD in the United States using validated measures. We hypothesize that CD negatively impacts the child and caregivers' HRQoL. METHODS: Participants included children with a confirmed diagnosis of CD and their caregivers (n = 246) seen in a CD multidisciplinary clinic. Caregivers completed the Pediatric Quality of Life (PedsQL) parent-proxy scale to report on their child's HRQoL and the Family Impact Module (FIM), which assesses the impact of caring for a child with a chronic illness. Their children completed the age-appropriate PedsQL. PedsQL and FIM results were compared to published data for children with gastroenterological conditions and a healthy cohort using non-parametric tests. RESULTS: Children with CD reported significantly lower HRQoL than reports from healthy controls across all PedsQL domains (P < 0.001, Cohen d = 0.8), and lower compared to children with other organic gastrointestinal conditions in Social Functioning (P < 0.001, Cohen d = 0.5) and overall Psychosocial Functioning (P < 0.001, Cohen d = 0.3) domains. Results from the caregiver's report on their own HRQoL were significantly worse than that reported by historical controls in the domains of Communication (P < 0.001, Cohen d = 0.3) and Worry (P < 0.001, Cohen d = 0.8), yet similar on all other domains. CONCLUSIONS: In our population, CD is associated with low HRQoL scores for both children and their caregivers. Screening children and families for HRQoL can identify patients and families in need of additional support in this higher-risk population.

Considering the value of online support groups for colorectal conditions: perspectives from caregivers and adult patients.

PURPOSE: To evaluate the benefits of participating in an online support group for caregivers of children with a colorectal condition or adult patients with a similar condition. METHODS: An electronic survey was administered to members of an international online support group (18 items for caregivers; 15 for patients). Items included demographics, medical diagnosis, potential benefits, and overall experiences in the group. Quantitative results were summarized as descriptive trends, while qualitative responses were summarized thematically. RESULTS: Respondents (102 caregivers, 6 patients) were primarily female, 35-44 years old, Caucasian, and resided in the United States. Most respondents learned about the support group from medical providers or online search. Cited benefits included learning information, gaining support, forming connections through shared experience, and utilizing a unique resource. Being a member of the group was helpful to respondents, improved their mental health and access to health information, and they would recommend the group to others. CONCLUSION: Participation in online support groups offers educational and emotional benefits to patients/caregivers which complements the medical support from their colorectal teams. Thus, colorectal providers need to be aware of the availability and potential benefits of these groups, and encourage their patients/caregivers to be actively involved.

Long-term outcomes of adult patients following surgery for congenital colorectal conditions: analysis of psychosocial functioning.

PURPOSE: This study aimed to obtain information about the psychosocial functioning of adults with various congenital colorectal conditions (e.g., anorectal malformation, Hirschsprung disease). METHODS: A research registry of adult patients with colorectal conditions was developed. Items included demographics, medical diagnosis/treatment, and measures of anxiety and depression. Descriptive and inferential statistical approaches were applied to summarize data and determine significant differences in the average scores for depression and anxiety between various groupings of diagnoses, gender, race, and the use of psychotropic medication. RESULTS: Study measures were completed by 131 adults. Depression and anxiety scores were significantly higher for women than men and those self-identified as non-binary (p = 0.012, < 0.001, respectively). No significant differences in depression and anxiety scores were found due to colorectal diagnosis (p > 0.05). Participants who identified as Asian had significantly higher depression scores than participants of other races (p = 0.002); but no significant difference was noted for anxiety scores (p = 0.065). CONCLUSIONS: Results suggest that depression and anxiety scores were significantly influenced by gender and race. However, colorectal diagnosis was not a predictor of depression or anxiety. It is important for colorectal providers to be aware of the psychosocial implications of congenital colorectal conditions and consider how to provide adequate support to address patients' psychosocial needs.

Analysis of patients' and caregivers' psychosocial functioning in colorectal conditions: comparison of diagnosis, gender, and developmental functioning.

PURPOSE: To evaluate the psychosocial functioning of caregivers and patients with anorectal malformation (ARM), Hirschsprung disease (HD), spinal conditions, and idiopathic constipation (IC) during the beginning of participation in bowel management program (BMP). METHODS: In this retrospective study, Parent Stress Scale (PSS, parent-report) and Strengths and Difficulties Questionnaire (SDQ, parent-proxy; SDQ-S, self-report for 11 years and older) were used to evaluate parental stress levels and behavioral functioning, respectively. Descriptive and comparative statistical approaches were applied to summarize the data and to determine differences in scores between diagnoses, gender, and developmental functioning. RESULTS: Two hundred patients and caregivers participated in BMP during the study period. PSS scores were significantly higher for caregivers of patients with IC than ARM. Statistical differences in SDQ were found for patients with IC versus those with ARM, male versus female patients, and patients with developmental delays versus those without delays. No significant differences were found in SDQ-S scores between these groups. CONCLUSION: Key findings suggest that level of parental stress and behavioral concerns were significantly influenced by diagnoses, and partly by gender and presence of developmental delay. Thus, psychosocial support may need to be tailored based on these findings to provide optimum quality of care for patients and families.

Mental illness on Instagram: a mixed method study to characterize public content, sentiments, and trends of antidepressant use.

BACKGROUND: Individuals with mental illness use social media to share treatment experiences and anecdotal information. Despite the significant impact of social media on individuals with mental illness, posts related to antidepressants have not been studied systematically. AIMS: This study evaluates public sentiments and content posted on Instagram regarding the use of antidepressants. METHODS: Instagram posts from July 2010 to June 30, 2018 containing hashtags of commonly prescribed antidepressants and anxiety/depression-related terms were gathered (n = 13,096). Approximately 1,000 posts were randomly selected and evaluated for photo content, anecdotal experiences, sentiments towards antidepressants, and mentions of psychotherapy, comorbidities, polypharmacy, or adverse effects. RESULTS: Instagram posts describing antidepressant use have increased exponentially from 2010, and 43% provided anecdotal experiences. Among these posts, 58% expressed negative sentiments towards antidepressant usage, citing adverse effects and lack of improvement. Posts that also mentioned psychotherapy, comorbidities, or polypharmacy differed in their collective sentiments. Misinformation was present in analyzed posts, and none mentioned recovery-oriented materials (i.e., mental health facility, hotline, etc.). CONCLUSIONS: Instagram is a useful resource for exploring public sentiments related to antidepressant use. Mental health professionals should be cognizant of these sentiments/perceptions in order to tailor communication with patients and should consider increasing their social media presence.

Providers' perspectives on substance use among solid organ transplant candidates in a pediatric hospital.

INTRODUCTION: Substance use is prevalent among youth and often leads to impairment in multiple domains. Additionally, substance use may pose adverse health issues post-transplant. Yet, practices related to substance use among pediatric patients who require organ transplant remain inconsistent. In this study, providers were surveyed for their perspectives on substance use among solid organ transplant candidates within a pediatric hospital. METHODS: An online survey was administered to providers on the heart, kidney, and liver transplant teams at one tertiary pediatric care center located in the intermountain region of the United States (N = 50, 42% response rate). Providers answered questions about the need for a hospital-wide policy across heart, liver, and kidney transplant teams within this transplant center, timing of substance use evaluation, types of substances eliciting concerns based on organ, and recommended interventions. Data were analyzed using descriptive statistics. RESULTS: Providers felt strongly about the need for a policy to guide recommendations for substance use among transplant candidates. Providers wanted a hospital-wide substance use policy (84%) and a standardized measure for assessing substance use (98%). Respondents (98%) indicated that substance use should be assessed during the pretransplant evaluation. Respondents expressed varied concerns based on substance and organ type, and recommended interventions for patients to cease substance use prior to transplant listing. CONCLUSIONS: This study highlights the need for a clear, directive, hospital-wide policy and standardized procedure for evaluating substance use among adolescent solid organ transplant candidates nationally across pediatric transplant centers.

Evaluating Health-Related Quality of Life and School Attendance in a Multidisciplinary School Program for Youth with Significant Medical Needs.

Many youth with significant medical needs have difficulty attending traditional schools due to academic, physical, and psychosocial challenges. To meet the needs of these youth and prepare them for a successful transition to a traditional school, a multidisciplinary school program (MSP) provides support in these three domains. The aims of this program evaluation are to describe the operation of the novel MSP, characterize participants, and determine the impact of participation as related to school attendance and health-related quality of life (HRQoL). Attendance in the MSP was significantly higher than school attendance estimates provided by caregivers prior to participation in the program. Youth reported significant improvement in physical functioning and total HRQoL. Caregivers reported significant improvement in academic functioning and total HRQoL of youth. The MSP represents a unique educational model for youth with significant medical issues that also provides physical and psychosocial support. Initial findings highlight the potential positive impact of this model for this population of youth.

A survey of adults with anorectal malformations: perspectives on educational, vocational, and psychosocial experiences.

PURPOSE: Despite medical advances, individuals with anorectal malformations (ARM) experience significant medical and psychosocial challenges due to their complex conditions. This study aimed to obtain the perspectives of adults with ARM throughout their lifetime regarding their medical, school/vocational, and psychosocial functioning. METHODS: A 40-item survey was administered electronically to members of an international ARM Facebook group (56% response rate; n = 125). Survey items included demographics, medical diagnosis/treatment, school/workplace accommodations, mental health diagnosis/treatment, and life perspectives. RESULTS: Majority of respondents were female (73%), aged 25-34 years (31%), Caucasian (92%), US residents (60%), and attended public school (86%). 53% of respondents are currently employed. 32% of respondents received school-based accommodations and 24% at work. 58% of respondents had a mental health diagnosis, with depression (82%) and anxiety (81%) being the most common. CONCLUSIONS: Results suggest that adults with ARM experience ongoing difficulties related to schooling, employment, and mental health, in addition to medical complications. It is becoming increasingly clear that improving patients' physical well-being is not enough; psychosocial concerns must also be addressed directly. Thus, it is important for clinicians to be aware of and partner with psychosocial providers to support these challenges associated with ARM, to maximize patients' overall health and well-being.

Preliminary evaluation of behavior technician burnout when working with boarded and traditional psychiatric inpatients diagnosed with developmental disabilities.

PROBLEM: The COVID-19 pandemic has led to a youth mental health crisis, with research demonstrating an increased prevalence of depression, anxiety, and disruptive behavior in youth compared to pre-pandemic years. Consequently, the insurgence of emergency psychiatric evaluations has increased the demands for extended inpatient stay (or patient boarding) at various licensed treatment facilities. Questions remain about the extent of burnout being experienced by behavior technicians who are caring for these patients. METHODS: The Shirom-Melamed Burnout Measure was used to evaluate symptoms of burnout of behavior technicians practicing at a specialized psychiatric inpatient unit. Comparisons were made for instances of caring for boarded (meeting criteria for discharge but unable to be discharged due to disposition) and traditional patients (short-term treatment). FINDINGS: Behavior technicians caring for boarded patients reported significantly higher scores in overall stress, physical exhaustion, cognitive fatigue, and emotional exhaustion than those managing patients getting traditional care. CONCLUSIONS: Extensive burnout can have adverse impacts at both the personal level (staff well-being, individual staff-patient interactions) and clinic level (daily operations and service, general quality of care). Efforts need to be made to address this issue to prevent staff turnover.

"Take It One Dilation at a Time": Caregiver Perspectives of Postoperative Anal Dilations in Pediatric Patients with Colorectal Conditions.

BACKGROUND: Postoperative anal dilations (PAD) are the standard of care for patients after a posterior sagittal anorectoplasty (PSARP) for anorectal malformation (ARM) or a transanal pull-through (TP) procedure for Hirschsprung disease (HD). This study assessed the psychosocial impact of PAD among caregivers of children with ARM or HD, which may inform postoperative care strategies. METHODS: Caregivers of patients with ARM and HD who underwent PSARP or TP within five years participated in the online survey. Questions included demographics, patient and caregiver experiences with PAD, and baseline psychosocial functioning. Quantitative results were reported descriptively, while qualitative responses were summarized as major themes. RESULTS: The survey indicated a response rate of 26% caregivers, with most being female (91%) and biological mothers (85%). Patients were mostly male (65%), born with ARM (74%), and were five months old on average when PAD began. Caregivers reported that during PAD, children experienced distress (56%), pain (44%), and fear (41%), while a third noted no negative reactions. Over time, their child's ability to cope with PAD got easier (38%) or stayed the same (41%). Caregivers reported worry/anxiety (88%), guilt (71%), stress (62%), and frustration (35%), noting that additional coping strategies to manage the emotional and logistical challenges of daily PAD would be helpful. CONCLUSION: Although PAD is necessary, it can be highly stressful for the patients and their caregivers. Key findings emphasized the need for additional coping strategies and highlighted the importance of integrating psychosocial support into the postoperative care regimen.

#KidsAnxiety and the Digital World.

This article discusses child onset anxiety disorders in conjunction with the risks and benefits of the rapidly changing digital world including screen time, social media, and potential treatment platforms. A section includes the impact of pandemic stressors including social distancing, quarantining, the association of the pandemic and youth mental health, and prolonged screen time.

The Utility of Pharmacogenetic-Guided Psychotropic Medication Selection for Pediatric Patients: A Retrospective Study.

BACKGROUND: To describe trends and clinical experiences in applying commercial pharmacogenetic testing among pediatric patients with neuropsychiatric disorders. METHODS: Demographic and clinical data of patients receiving GeneSight® testing from January 2015 to November 2016 at an urban pediatric hospital were retrospectively extracted from medical charts. Outcome data included pharmacogenetic test results and medication prescriptions before and after the test. RESULTS: A total of 450 patients (12.1 ± 4.3 years) diagnosed with anxiety disorder, attention deficit hyperactivity disorder, developmental disorders including autism, and/or a mood disorder received testing, and 435 of them were prescribed medications. Comparing data before and after testing, the total number of psychotropic prescriptions were reduced by 27.2% and the number of prescribed medications with severe gene-drug interactions decreased from 165 to 95 (11.4% to 8.9% of total medications prescribed). Approximately 40% of actionable genetic annotation were related to CYP2CD6 and CYP2C19. Patients of Asian descent had significantly higher likelihood than other races of being classified as poor to intermediate metabolizers of antidepressants, mood stabilizers, and antipsychotics (p = 0.008, 0.007, and 0.001, respectively). Diagnoses, including autism spectrum disorder, were not associated with increased risks of severe gene-drug interactions. CONCLUSIONS: Pharmacogenetic testing in child and adolescent psychiatry is currently based on few clinically actionable genes validated by CPIC and/or FDA. Although this approach can be moderately utilized to guide psychotropic medication prescribing for pediatric patients with psychiatric disorders, clinicians should cautiously interpret test results while still relying on clinical experience and judgment to direct the final selection of medication.

Comparison of DNA extraction kits for PCR-DGGE analysis of human intestinal microbial communities from fecal specimens.

BACKGROUND: The influence of diet on intestinal microflora has been investigated mainly using conventional microbiological approaches. Although these studies have advanced knowledge on human intestinal microflora, it is imperative that new methods are applied to facilitate scientific progress. Culture-independent molecular fingerprinting method of Polymerase Chain Reaction and Denaturing Gradient Gel Electrophoresis (PCR-DGGE) has been used to study microbial communities in a variety of environmental samples. However, these protocols must be optimized prior to their application in order to enhance the quality and accuracy of downstream analyses. In this study, the relative efficacy of four commercial DNA extraction kits (Mobio Ultra Clean(R) Fecal DNA Isolation Kit, M; QIAamp DNA Stool Mini Kit, Q; FastDNA SPIN Kit, FSp; FastDNA SPIN Kit for Soil, FSo) were evaluated. Further, PCR-DGGE technique was also assessed for its feasibility in detecting differences in human intestinal bacterial fingerprint profiles. METHOD: Total DNA was extracted from varying weights of human fecal specimens using four different kits, followed by PCR amplification of bacterial 16S rRNA genes, and DGGE separation of the amplicons. RESULTS: Regardless of kit, maximum DNA yield was obtained using 10 to 50 mg (wet wt) of fecal specimens and similar DGGE profiles were obtained. However, kits FSp and FSo extracted significantly larger amounts of DNA per g dry fecal specimens and produced more bands on their DGGE profiles than kits M and Q due to their use of bead-containing lysing matrix and vigorous shaking step. DGGE of 16S rRNA gene PCR products was suitable for capturing the profiles of human intestinal microbial community and enabled rapid comparative assessment of inter- and intra-subject differences. CONCLUSION: We conclude that extraction kits that incorporated bead-containing lysing matrix and vigorous shaking produced high quality DNA from human fecal specimens (10 to 50 mg, wet wt) that can be resolved as bacterial community fingerprints using PCR-DGGE technique. Subsequently, PCR-DGGE technique can be applied for studying variations in human intestinal microbial communities.

Parent experience with volunteers and support groups in a multidisciplinary DSD clinic.

OBJECTIVE: Despite recommendations that clinics for children with a difference of sex development (DSD) should include peer support, information on how to provide this support is lacking. We utilized a mixed-methods program evaluation to evaluate family satisfaction with our clinic-based volunteers (who either have DSD themselves or are a parent of a child with DSD) and to understand the experience of these volunteers. METHODS: Parents (n=29) of a child with DSD completed an electronic survey. Interviews were conducted with three clinic volunteers. RESULTS: Most participants (72%) met with a clinic volunteer and majority (81%) rated their interaction as helpful. Most common topics discussed between parents and volunteers included: connecting to support groups (81%), their child's future (62%), and learning about their child's diagnosis (48%). Half of parents (48%) attended an after-clinic support group lunch, and 43% of these attendees rated the lunch session as helpful. Parents who attended a lunch liked the experience because they met other families with a child with a similar medical condition (100%), met volunteers with a similar medical condition (64%), and it helped them think more positively about their child's future (64%). Those who did not attend a lunch cited logistical reasons for not attending. CONCLUSIONS: Incorporating clinic volunteers into a multidisciplinary DSD clinic is associated with high reported rates of satisfaction by families and volunteers.

Relations between patient and staff member characteristics and staff member injury on a psychiatric inpatient unit for children with intellectual or developmental disabilities.

PROBLEM: Staff member injuries are a pervasive and long-standing problem for psychiatric inpatient units. METHOD: The current study analyzed the prevalence of staff member injury and characteristics of patients that injured staff on a specialized psychiatric unit for children with intellectual or developmental disabilities. We evaluated staffing patterns as well as characteristics of patients (e.g., diagnoses, body mass index) between 2016 and 2018. This time period was selected because it represented an approximately equal period before and after the introduction of a new clinical model that incorporated applied behavior analysis (ABA) and other safety-related practices (e.g., personal protective equipment). FINDINGS: During this study period, there were 110 cases of staff injuries caused by 42 patients. Injuries were most likely to occur during physical management of a patient engaging in aggressive behavior, but less so when strategies requiring less physical contact were implemented. The frequency of staff injury was also significantly related to patients' diagnoses, particularly those exhibiting aggressive behavior and diagnosed with moderate-to-severe intellectual disability and/or autism spectrum disorder. CONCLUSIONS: Robust staff training incorporating the principles of ABA and the provision of other safety-related resources can be integrated to clinical guidelines to promote the safety of staff practicing in psychiatric inpatient units.

The Use of N-acetylcysteine Supplementation to Decrease Irritability in Four Youths With Autism Spectrum Disorders.

Children and adolescents with autism spectrum disorder (ASD) often experience high levels of irritability, which adversely affects their functioning and behaviors. N-acetylcysteine (NAC), an antioxidant precursor to glutathione, has recently been studied for a variety of neuropsychiatric disorders. There is growing evidence to support its use to decrease irritability and self-injurious behaviors in youth with ASD. However, previous studies were limited to outpatient youth with mild symptoms of irritability, maintained on stable medication regimens, who do not meet criteria for higher levels of care. We describe the use of NAC among 4 youths (14-17 years) with ASD who had Aberrant Behavior Checklist-Irritability (ABC-I) scores of ≥ 20 and other psychotropic medication trials prior to treatment with NAC. In all of the cases, NAC appeared to be well tolerated. There was a reduction of symptoms of irritability and/or antipsychotic medication dosages in these cases; despite this, the authors cannot know whether use of NAC or other medication or behavioral strategies were responsible for such changes because this study was not a controlled trial.

Acute and chronic effects of honey and its carbohydrate constituents on calcium absorption in rats.

The effects of honey and its carbohydrate constituents (glucose, fructose, and raffinose) on calcium absorption in rats were investigated in acute and chronic feeding studies. In the acute study, rats ( n = 120) were gavaged with an oral solution consisting of (a) 10 microCi (45)Ca, (b) 25 mg of calcium as calcium acetate, and (c) one of the following: 0 mg of honey (control), or 200, 500, or 800 mg of honey, a glucose-fructose mixture, 10.75 mg of raffinose, or 200 mg of raffinose. Another group received (45)Ca intraperitoneally. Femurs were collected 2 days later and analyzed for (45)Ca content. Rats given 500 and 800 mg of honey showed 25.5 and 33.6% increases in calcium absorption ( P<0.05), respectively, over the control group. Groups given the glucose-fructose mixture or 200 mg of raffinose had a significantly higher increase in calcium absorption than the control group (17.1 and 25.6%, respectively). In the chronic study, rats (n=96) were fed for 8 weeks with either 0% honey (control), 5% honey, 10% honey, or a glucose-fructose-raffinose (GFR) mixture. Femurs of GFR-fed rats had significantly lower calcium content, (45)Ca absorption, width, and BMD (at distal region) than control rats. Groups fed honey did not show the negative effects of GFR on bone, but had no advantage over the control group. No significant differences were observed in femur length, density, strength, or BMC among any treatment group compared to the control group. These results indicate that although a positive dose-response effect of honey and its carbohydrate constituents on calcium absorption was observed in the acute study, this effect disappeared upon long-term feeding in rats, implying adaptation had occurred.

Pulse Oximetry Values in Newborns with Critical Congenital Heart Disease upon ICU Admission at Altitude.

Pulse oximetry screening for critical congenital heart disease (CCHD) has been recommended by the American Academy of Pediatrics (AAP). The objectives of this study are to describe saturation data, and to evaluate the effectiveness of AAP-recommended pulse oximetry screening guidelines applied retrospectively to a cohort of newborns with known CCHD at moderate altitude (5557 feet, Aurora, Colorado). Data related to seven critical congenital heart disease diagnoses were extracted from electronic health records (pulse oximetry, prostaglandin administration, and oxygen supplementation). Descriptive epidemiologic data were calculated. 158 subjects were included in this analysis; the AAP pulse oximetry screening protocol was applied to 149 subjects. Mean pre-ductal and post-ductal pulse oximetry values of the infants known to have CCHD at 24 h of life were 87.1% ± 7.2 and 87.8% ± 6.3, respectively. Infants treated with prostaglandins and oxygen had lower oximetry readings. The screening algorithm would have identified 80.5% of infants with known CCHDs (120/149 subjects). Additionally, sequential pulse oximetry screening based on the AAP-recommended protocol was able to identify a true positive screen capture rate of 80.5% at moderate altitude.

Chocolate and cardiovascular health: is it too good to be true?

Recent findings indicate that cocoa and chocolate, when processed appropriately, may contain relatively large amounts of flavonoids, particularly catechin and epicatechin. We review the benefits of these flavonoids, specifically with regard to cardiovascular health, and raise several unresolved issues that suggest the need for additional research and product development in this area.