Paramedic Identification of Pediatric Seizures: A Prospective Cohort Study.

OBJECTIVE: Pediatric seizures commonly trigger emergency medical services (EMS) activation and account for approximately 5-15% of all pediatric 911-EMS calls. More than 50% of children with active seizure activity do not receive prehospital antiepileptic drugs, potentially because they are not recognized by EMS. The purpose of this study is to evaluate specificity and sensitivity of paramedic identification of pediatric seizures and to describe the characteristics of unrecognized seizures. METHODS: This is an 18-month prospective cohort study at a single, pediatric emergency department (ED). EMS patients ≤15 years old with a prehospital provider impression of seizure were included. Upon ED arrival, a data collection form, which included the EMS verbal report and patient's clinical status, was completed by the attending emergency physician. The primary outcome was sensitivity and specificity of paramedic identification of active seizure. Secondary outcomes included characteristics of missed seizures, ED interventions, and disposition. Descriptive statistics, sensitivity, and specificity were computed. Patient characteristics and clinical outcomes were compared. RESULTS: Surveys were completed for 349 patients (Median 3, IQR = 3.4). Fifty-two of the patients (15%) were actively seizing upon arrival at the ED. Sensitivity was 54% and specificity was 96% for paramedic identification of active seizure. Common features of missed cases were abnormal vital signs (75%), gaze deviation (50%) and clenched jaw (33%). Of these, 37% required intubation and 53% were admitted to the intensive care unit. CONCLUSION: Paramedics were highly specific, but not sensitive in identifying active seizures on ED arrival. Patients with unrecognized seizures presented most commonly with abnormal vital signs and gaze deviation.

Job satisfaction, work environment and successful ageing: Determinants of delaying retirement among acute care nurses.

AIM: To determine the relationships between job satisfaction, work environment and successful ageing and how these factors relate to Registered Nurses' intent to retire. BACKGROUND: Although little studied, retention of older nurses by delaying early retirement, before age 65, is an important topic for research. Qualitative and quantitative studies have indicated that job satisfaction work environment and successful ageing are key motivators in acute care Registered Nurses retention and/or delaying retirement. This study was designed to provide information to administrators and policy makers about retaining older, experienced RNs longer and more productively. DESIGN: This was a correlational, descriptive, cross-sectional study. METHODS: An online survey of acute care Registered Nurses (N = 2,789) aged 40 years or older working in Florida was conducted from September - October 2013. Participants completed items related to job satisfaction, work environment, successful ageing and individual characteristics. Hypotheses derived from the modified Ellenbecker's Job Retention Model were tested using regression analysis. RESULTS: Job satisfaction scores were high. Highest satisfaction was with scheduling issues and co-workers; lowest with advancement opportunities. Successful ageing scores were also high with 81% reporting excellent or good health. Work environment explained 55% of the variance in job satisfaction. Years to retirement were significantly associated with successful ageing (p < .001), age (p < .001) and income (p < .010). CONCLUSIONS: This study provides quantitative evidence that environment and successful ageing are important areas that have an impact on job satisfaction and delay of retirement in older nurses and further studies in these areas are warranted to expand on this knowledge.

A Randomized Controlled Trial of Team-Based Learning Versus Lectures with Break-Out Groups on Knowledge Retention.

OBJECTIVE: This goal of this study was to evaluate the efficacy of team-based learning (TBL) on knowledge retention compared to traditional lectures with small break-out group discussion (teaching as usual (TAU)) using a randomized controlled trial. METHODS: This randomized controlled trial was conducted during a daylong conference for psychiatric educators on attention-deficit hyperactivity disorder and the research literacy topic of efficacy versus effectiveness trials. Learners (n = 115) were randomized with concealed allocation to either TBL or TAU. Knowledge was measured prior to the intervention, immediately afterward, and 2 months later via multiple-choice tests. Participants were necessarily unblinded. Data enterers, data analysts, and investigators were blinded to group assignment in data analysis. Per-protocol analyses of test scores were performed using change in knowledge from baseline. The primary endpoint was test scores at 2 months. RESULTS: At baseline, there were no statistically significant differences between groups in pre-test knowledge. At immediate post-test, both TBL and TAU groups showed improved knowledge scores compared with their baseline scores. The TBL group performed better statistically on the immediate post-test than the TAU group (Cohen's d = 0.73; p < 0.001), although the differences in knowledge scores were not educationally meaningful, averaging just one additional test question correct (out of 15). On the 2-month remote post-test, there were no group differences in knowledge retention among the 42 % of participants who returned the 2-month test. CONCLUSIONS: Both TBL and TAU learners acquired new knowledge at the end of the intervention and retained knowledge over 2 months. At the end of the intervention day and after 2 months, knowledge test scores were not meaningfully different between TBL and TAU completers. In conclusion, this study failed to demonstrate the superiority of TBL over TAU on the primary outcome of knowledge retention at 2 months post-intervention.

Short rest interval lengths between sets optimally enhance body composition and performance with 8 weeks of strength resistance training in older men.

PURPOSE: To determine if 8 weeks of periodized strength resistance training (RT) utilizing relatively short rest interval lengths (RI) in between sets (SS) would induce greater improvements in body composition and muscular performance, compared to the same RT program utilizing extended RI (SL). METHODS: 22 male volunteers (SS: n = 11, 65.6 ± 3.4 years; SL: n = 11, 70.3 ± 4.9 years) were assigned to one of two strength RT groups, following 4 weeks of periodized hypertrophic RT (PHRT): strength RT with 60-s RI (SS) or strength RT with 4-min RI (SL). Prior to randomization, all 22 study participants trained 3 days/week, for 4 weeks, targeting hypertrophy; from week 4 to week 12, SS and SL followed the same periodized strength RT program for 8 weeks, with RI the only difference in their RT prescription. RESULTS: Following PHRT, all study participants experienced increases in lean body mass (LBM) (p < 0.01), upper and lower body strength (p < 0.001), and dynamic power (p < 0.001), as well as decreases in percentage body fat (p < 0.05). Across the 8-week strength RT phase, SS experienced significantly greater increases in LBM (p = 0.001), flat machine bench press 1-RM (p < 0.001), bilateral leg press 1-RM (p < 0.001), narrow/neutral grip lat pulldown (p < 0.01), and Margaria stair-climbing power (p < 0.001), compared to SL. CONCLUSIONS: This study suggests 8 weeks of periodized high-intensity strength RT with shortened RI induces significantly greater enhancements in body composition, muscular performance, and functional performance, compared to the same RT prescription with extended RI, in older men. Applied professionals may optimize certain RT-induced adaptations, by incorporating shortened RI.

Neonatal Outcomes by Mode of Delivery in Preterm Birth.

OBJECTIVE: We set out to test the hypothesis that infants born vaginally at ≤ 30 weeks gestation have less respiratory distress syndrome (RDS) than those born by cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study of 652 infants born between 24 and 30 (6/7) weeks gestation from March 31, 1996 to May 31, 2014. Comparisons of neonatal outcomes by intended and actual mode of delivery were made using chi-square and t-tests (α = 0.05). Multiple logistic regression was performed to control for confounding variables. RESULTS: Neonates born by cesarean delivery were more likely to have RDS (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.10-2.90), require intubation (OR, 1.80; 95% CI, 1.12-2.88), and have longer neonatal intensive care unit stay (70.0 ± 37.1 vs. 57.3 ± 40.1 days, p = 0.02). CONCLUSION: Compared with cesarean delivery, vaginal delivery is associated with a significant reduction in RDS among infants born at ≤ 30 weeks gestation.

Feasibility of a sensory-adapted dental environment for children with autism.

OBJECTIVE: To provide an example of an occupational therapy feasibility study and evaluate the implementation of a randomized controlled pilot and feasibility trial examining the impact of a sensory-adapted dental environment (SADE) to enhance oral care for children with autism spectrum disorder (ASD). METHOD: Twenty-two children with ASD and 22 typically developing children, ages 6-12 yr, attended a dental clinic in an urban hospital. Participants completed two dental cleanings, 3-4 mo apart, one in a regular environment and one in a SADE. Feasibility outcome measures were recruitment, retention, accrual, dropout, and protocol adherence. Intervention outcome measures were physiological stress, behavioral distress, pain, and cost. RESULTS: We successfully recruited and retained participants. Parents expressed satisfaction with research study participation. Dentists stated that the intervention could be incorporated in normal practice. Intervention outcome measures favored the SADE condition. CONCLUSION: Preliminary positive benefit of SADE in children with ASD warrants moving forward with a large-scale clinical trial.

Effects of Group-delivered Stress-reduction Guided Imagery on Salivary Cortisol, Salivary Amylase, and Stress Mood in Urban, Predominantly Latino Adolescents.

OBJECTIVES: To determine acute effects of stress-reduction guided imagery delivered in group format on stress biomarkers salivary cortisol and salivary amylase, and on self-reported stress mood, in healthy, predominantly Latino adolescents. STUDY DESIGN: 111 adolescent participants (94% Latino), a subset from a large, randomized controlled lifestyle intervention to improve obesity-related health behaviors, received either 4 weekly lifestyle education sessions (Lifestyle group; LS) or the same weekly lifestyle education sessions plus an additional weekly stress-reduction guided imagery session delivered in group format (Guided imagery group; GI). Salivary cortisol, salivary amylase, and self-reported stress moods were assessed before and after sessions on intervention weeks 3 and 4. Statistics: Linear mixed effects models examined within- and between-session and group differences in pre- to post-session changes. RESULTS: Both groups showed decreases in salivary cortisol, 5% decrease in LS group and 32% in GI group (within-group differences all P < .05), with between-group difference in salivary cortisol of moderate size (P = .05; Cohen's d = .44). Within the GI group alone, salivary cortisol decrease was similar following either the lifestyle or GI sessions (P = .64). There were no statistically significant amylase changes within or between groups. All 5 individual stress moods declined by 27% to 46% in the GI group (all P < .05), while only 1 of the 5 declined in LS group. CONCLUSIONS: Group stress-reduction guided imagery reduces the stress biomarker salivary cortisol, as well as reducing subjective stress mood states, making it a viable modality for large scale stress-reduction interventions.

ICU Resource Limitations During Peak Seasonal Influenza: Results of a 2018 National Feasibility Study.

OBJECTIVES: Demonstrate the feasibility of weekly data collection and analysis of public health emergency (PHE) data. Assess fluctuations in, and challenges of, resource matching and potential effect on patient care for influenza in ICUs. DESIGN: Multicenter prospective noninterventional study testing effectiveness of leveraging the Discovery Critical Care Research Network Program for Resilience and Emergency Preparedness (Discovery-PREP) in performing PHE research. A 20-question internet survey was developed to prospectively assess ICU influenza-related resource stress. An informatics tool was designed to track responses; data were analyzed within 24 hours of weekly survey completion by the team biostatistician for timely reporting. PARTICIPANTS: Critical care and Emergency Medicine Discovery-PREP network investigators self-selected to participate in the voluntary query. SETTING: ICUs of 13 hospitals throughout the United States, 12 academic, and one community. INTERVENTIONS: ICU physicians were electronically surveyed weekly over 17 weeks during the influenza season (January 2018-April 2018). Responses were collected for 48 hours after each email query. MEASUREMENTS AND MAIN RESULTS: The average weekly response among the sites was 79% (range, 65-100%). Significant stress, defined as alterations in ICU staffing and/or resource allocation, occurred in up to 41% of sites during the national peak of influenza activity. These alterations included changes in staffing, not accepting external patient transfers, and canceling elective surgery. During this same period, up to 17% of the sites indicated that these changes might not have been sufficient to prevent potentially avoidable patient harm. CONCLUSIONS: This novel approach to querying ICU operational stress indicated that almost half of participating sites experienced critical care resource limitations during peak influenza season and required process and/or staffing changes to better balance resources with patient care demands. This weekly national reporting infrastructure could be adapted and expanded to better inform providers, hospital emergency management teams, and government leaders during PHEs.

Verification and clarification of patterns of sensory integrative dysfunction.

Building on established relationships between the constructs of sensory integration in typical and special needs populations, in this retrospective study we examined patterns of sensory integrative dysfunction in 273 children ages 4-9 who had received occupational therapy evaluations in two private practice settings. Test results on the Sensory Integration and Praxis Tests, portions of the Sensory Processing Measure representing tactile overresponsiveness, and parent report of attention and activity level were included in the analyses. Exploratory factor analysis identified patterns similar to those found in early studies by Ayres (1965, 1966a, 1966b, 1969, 1972b, 1977, & 1989), namely Visuodyspraxia and Somatodyspraxia, Vestibular and Proprioceptive Bilateral Integration and Sequencing, Tactile and Visual Discrimination, and Tactile Defensiveness and Attention. Findings reinforce associations between constructs of sensory integration and assist with understanding sensory integration disorders that may affect childhood occupation. Limitations include the potential for subjective interpretation in factor analysis and inability to adjust measures available in charts in a retrospective research.

An exploratory study of predictors of cognition in two low-income samples of infants across the first year of life.

OBJECTIVE: In this exploratory longitudinal study we assessed cognitive development in a community sample of infants born into predominantly low-income families from two different urban sites, to identify family and community factors that may associate with outcomes by 1 year of age. METHOD: Infant-mother dyads (n = 109) were recruited in Boston and Los Angeles community pediatric practices. Infant cognition was measured using the Mullen Scales of Early Learning when the infant was aged 2, 6, 9, and 12 months. Longitudinal linear mixed effects modeling and linear regression models explored potential predictors of cognitive outcomes. RESULTS: Cognitive scores were lower than the reference population mean at both 6 and 12 months. There were site differences in demographics and cognitive performance. Maternal education predicted expressive language in Boston, and speaking Spanish and lower rates of community poverty were associated with greater increases in overall cognition in Los Angeles. CONCLUSION: This exploratory study identified a number of drivers of child development that are both shared across cohorts and unique to specific community samples. Factors influencing heterogeneity within and across populations both may be important contributors to prevention and intervention in supporting healthy development among children.

Creating a Culture of Health for Perinatal Women with Mental Illness: A Community-Engaged Policy and Research Initiative.

BACKGROUND: Maternal mental health disorders (MMHDs) affect 35% to 40% of low-income, minority, perinatal women and negatively impact these women, their newborns, families, and communities. However, MMHDs are overlooked or stigmatized by medical systems, families, and women themselves. OBJECTIVES: We sought to answer the following research questions: 1) What lessons can we learn about maternal mental health in our local neighborhoods by creating and engaging with a community advisory board (CAB)? 2) What policy recommendations can we formulate with the CAB to address MMHDs among a low-income Latino population? METHODS: We conducted a qualitative research study guided by a community-based participatory research (CBPR) approach. We built on long-term relationships as well as newly identified organizations to develop a CAB of community service providers. We also drew from the perspective of two focus groups of women in the community who had experienced a MMHD. We engaged in an 18-month, iterative process focused on mutual sharing to learn about community perspectives on maternal mental health care barriers and solutions. Researchers and the CAB then created a community policy brief. RESULTS: We developed a CAB and facilitated two focus groups. Together we gleaned a stronger understanding of the importance of education, culture, the patient-provider relationship, and community-based resources. We built on these findings to create specific policy recommendations. CONCLUSIONS: Engaging the CAB and facilitating focus groups informed our understanding of MMHDs from a community perspective, grounding our results and policy in culturally sensitive ways. We developed partnerships between researchers and community providers that can continue to reduce barriers and create solutions to maternal mental health care in our community.

Sensory integration and praxis patterns in children with autism.

OBJECTIVE: We sought to characterize sensory integration (SI) and praxis patterns of children with autism spectrum disorder (ASD) and discern whether these patterns relate to social participation. METHOD: We extracted Sensory Integration and Praxis Tests (SIPT) and Sensory Processing Measure (SPM) scores from clinical records of children with ASD ages 4-11 yr (N=89) and used SIPT and SPM standard scores to describe SI and praxis patterns. Correlation coefficients were generated to discern relationships among SI and praxis scores and these scores' associations with SPM Social Participation scores. RESULTS: Children with ASD showed relative strengths in visual praxis. Marked difficulties were evident in imitation praxis, vestibular bilateral integration, somatosensory perception, and sensory reactivity. SPM Social Participation scores were inversely associated with areas of deficit on SIPT measures. CONCLUSION: Children with ASD characteristically display strengths in visuopraxis and difficulties with somatopraxis and vestibular functions, which appear to greatly affect participation.

Enrichment of elevated plasma F2t-isoprostane levels in individuals with autism who are stratified by presence of gastrointestinal dysfunction.

Etiology is unknown in the majority of individuals with autism spectrum disorder (ASD). One strategy to investigate pathogenesis is to stratify this heterogeneous disorder based on a prominent phenotypic feature that enriches for homogeneity within population strata. Co-occurring gastrointestinal dysfunction (GID) characterizes a subset of children with ASD. Our current objective was to investigate a potential pathophysiological measure to test the hypothesis that children with both ASD and GID have a more severe metabolic dysfunction than children with ASD-only, given that the highly metabolically active brain and gastrointestinal system may additively contribute measurable impairment. Plasma levels of F2t-Isoprostanes (F2-IsoPs), a gold standard biomarker of oxidative stress, were measured in 87 children in four groups: ASD-GID, ASD-only, GID-only and Unaffected. F2-IsoP levels were elevated in all 3 clinical groups compared to the Unaffected group, with the ASD-GID group significantly elevated above the ASD-only group (mean, SD in pg/mg: ASD-GID 53.6, 24.4; ASD-only 36.5, 13.3; p = 0.007). Adjusting for age, sex, and triglyceride levels, F2-IsoP levels remained significantly different between study groups, with a moderate effect size of η(p)(2) = 0.187 (p = 0.001). Elevation in peripheral oxidative stress is consistent with, and may contribute to, the more severe functional impairments in the ASD-GID group. With unique medical, metabolic, and behavioral features in children with ASD-GID, the present findings serve as a compelling rationale for both individualized approaches to clinical care and integrated studies of biomarker enrichment in ASD subgroups that may better address the complex etiology of ASD.

Acute effects of stress-reduction Interactive Guided Imagery(SM) on salivary cortisol in overweight Latino adolescents.

OBJECTIVES: Chronic stress with relative hypercortisolism has been associated with metabolic disease risk. Stress-reduction interventions may therefore hold promise for reducing such chronic disease risk in obese youth. The purpose of this study was to conduct a 4-week pilot intervention to determine whether stress-reduction Interactive Guided Imagery(SM) (IGI) could serve as an acceptable and effective stress-reduction modality in overweight Latino adolescents. DESIGN: Subjects (6 male/6 female, ages 14-17, body-mass index >95th percentile) were randomly assigned to the experimental guided imagery group (IGI, n = 6), or the nonintervention control group (C, n = 6). IGI subjects received four weekly 45-minute stress-reduction IGI sessions. Salivary cortisol was assessed immediately before and after each session. Acceptability was assessed by compliance and qualitative interviews. RESULTS: Subjects attended all sessions and expressed acceptance of the IGI intervention. There were significant within-group reductions in salivary cortisol in the IGI group in three of the four sessions, and no reductions in cortisol in the control group. For all four sessions combined, there was a significant between-group effect for the change in salivary cortisol in IGI versus C (p = 0.007). Effect sizes of cortisol change in IGI group were moderate to very high in the four sessions. CONCLUSIONS: We conclude that IGI may be feasible and effective in acutely reducing salivary cortisol levels in overweight Latino adolescents. Future studies will need to determine whether stress-reduction IGI can result in longer-term reductions in chronic stress and measures of HPA activity.

Reduction in risk factors for type 2 diabetes mellitus in response to a low-sugar, high-fiber dietary intervention in overweight Latino adolescents.

OBJECTIVE: To examine if reductions in added sugar intake or increases in fiber intake in response to a 16-week intervention were related to improvements in metabolic outcomes related to type 2 diabetes mellitus risk. DESIGN: Secondary analysis of a randomized control trial. SETTING: Intervention classes at a lifestyle laboratory and metabolic measures at the General Clinical Research Center. PARTICIPANTS: Fifty-four overweight Latino adolescents (mean [SD] age, 15.5 [1] years). Intervention Sixteen-week study with 3 groups: control, nutrition, or nutrition plus strength training. MAIN OUTCOME MEASURES: Body composition by dual-energy x-ray absorptiometry; visceral adipose tissue by magnetic resonance imaging; glucose and insulin incremental area under the curve by oral glucose tolerance test; insulin sensitivity, acute insulin response, and disposition index by intravenous glucose tolerance test; and dietary intake by 3-day records. RESULTS: Fifty-five percent of all participants decreased added sugar intake (mean decrease, 47 g/d) and 59% increased fiber intake (mean increase, 5 g/d), and percentages were similar in all intervention groups, including controls. Those who decreased added sugar intake had an improvement in glucose incremental area under the curve (-15% vs +3%; P = .049) and insulin incremental area under the curve (-33% vs -9%; P = .02). Those who increased fiber intake had an improvement in body mass index (-2% vs +2%; P = .01) and visceral adipose tissue (-10% vs no change; P = .03). CONCLUSIONS: Individuals who reduced added sugar intake by the equivalent of 1 can of soda per day or increased fiber intake by the equivalent of a cup of beans showed improvements in key risk factors for type 2 diabetes, specifically in insulin secretion and visceral fat. Improvements occurred independent of group assignment and were equally likely to occur in control group participants.

A high-sugar/low-fiber meal compared with a low-sugar/high-fiber meal leads to higher leptin and physical activity levels in overweight Latina females.

Acute effects of high-sugar/low-fiber meals vs low-sugar/high-fiber meals on hormones and behavior were studied in 10 overweight Latina females, age 11 to 12 years, using a crossover design. In this exploratory pilot study, participants arrived fasted at an observation laboratory on two occasions and randomly received either a high-sugar/low-fiber meal or a low-sugar/high-fiber meal at each visit. Glucose, insulin, and leptin were assayed from serum drawn at 0, 15, 30, 60, 90, and 120 minutes. Ad libitum snacks were provided at 120 minutes. Physical activity was measured using an observational system that provides data on time spent lying down, sitting, standing, walking, and in vigorous activity. Data were collected between March 2005 and July 2006. In the high-sugar/low-fiber condition, glucose and leptin levels decreased more slowly, glucose levels were higher at 60 minutes (111.2 mg/dL vs 95.4 mg/dL, P=0.03), and leptin levels were higher at 90 minutes (49.3 ng/mL vs 46.7 ng/mL, P=0.017) than in the low-sugar/high-fiber condition. Meals did not affect insulin or ad libitum dietary intake. Sitting, standing, lying down, and vigorous activity differed by condition, but not walking. Participants were significantly more active in the first 30 to 60 minutes after the high-sugar/low-fiber meal, but after 60 minutes there was a trend for activity to be lower after the high-sugar/low-fiber meal vs the low-sugar/high-fiber meal. High-sugar meals sustain glucose and leptin levels longer, which may play an important role in modulating levels of physical activity in this group at high risk for obesity-related disease.