Problematic Behaviors and Predicting Online Risk Behaviors in High School Students.

Adolescent behavior now occurs offline and online. Frequently studied and treated independently, the relationship between offline problem behaviors and online risk taking is not well understood. This study asked whether there are any problematic behaviors predictive of online risk taking by high school students. Using a 2009 dataset of 2,077 high school students grades 9-12, five areas of offline problematic behaviors were examined: Academic problems, anxiety, behavioral wrongdoing, bullying, and social-emotional. Nine binary results were classified as online risk: Sexting, online harassment (perpetrating and experiencing), visiting sex sites, talking about sex, receiving sexual pictures, meeting offline, anything sexual happened, feeling nervous or uncomfortable. Behavioral wrongdoing (fighting, school suspension, trouble with police, theft), emerged as a significant predictor appearing in all nine models, followed by bullying experience (bully or victim) in six models. Identifying common problem behaviors that predict online risk taking are key components in developing strategies to promote adolescent health and well-being.

Transcutaneous carbon dioxide pattern and trend over time in preterm infants.

BACKGROUND: Chronic lung disease remains a burden for extremely preterm infants. The changes in ventilation over time and optimal ventilatory management remains unknown. Newer, non-invasive technologies provide insight into these patterns. METHODS: This single-center prospective cohort study enrolled infants ≤32 0/7 weeks. We obtained epochs of transcutaneous carbon dioxide (TcCO2) measurements twice each week to describe the pattern of hypercarbia throughout their hospitalization. RESULTS: Patterns of hypercarbia varied based on birth gestational age and post-menstrual age (PMA) (p = 0.03), regardless of respiratory support. Infants receiving the most respiratory support had values 16-21 mmHg higher than those on room air (p < 0.001). Infants born at the youngest gestational ages had the greatest total change but the rate of change was slower (p = 0.049) compared to infants born at later gestational ages. All infants had TcCO2 values stabilize by 31-33 weeks PMA, when values were not significantly different compared to discharge. No rebound was observed when infants weaned off invasive support. CONCLUSIONS: Hypercarbia improves as infants approached 31-33 weeks PMA. Hypercarbia was the highest in the most immature infants and improved with age and growth despite weaning respiratory support. IMPACT: This study describes the evolution of hypercarbia as very preterm infants grow and develop. The pattern of ventilation is significantly different depending on the gestational age at birth and post-menstrual age. Average transcutaneous carbon dioxide (TCO2) decreased over time as infants became more mature despite weaning respiratory support. This improvement was most significant in infants born at the lowest gestational ages.

The Ascendancy of Second-Generation Antipsychotics as Frontline Antimanic Agents.

INTRODUCTION: Knowledge of the factors affecting the adoption of new medications can enhance mental health care and guide quality improvement and policy development. Food and Drug Administration indications for treating bipolar disorder with several second-generation antipsychotics (SGAs) in the 2000s represent an opportunity to identify factors that impact the spread of a then-innovative treatment through a new population. METHODS: Analysis of Department of Veterans Affairs administrative data identified the population of 170,811 veterans diagnosed with bipolar disorder from 2003 to 2010. We analyzed time trends and predictors of antimanic choice (SGA vs other) among the 40,512 outpatients with bipolar disorder who initiated their first VA outpatient antimanic prescription, using multinomial logistic regression in month-by-month analyses. We conducted classwise analyses and investigated prespecified predictors among specific agents. RESULTS: In classwise analyses, SGAs supplanted lithium, valproate, and carbamazepine/oxcarbazepine as the most commonly initiated antimanics by 2007. Psychosis, but not other indices of severity, predicted SGA initiation. Demographic analyses did not identify substantial disparities in initiation of SGAs. Drug-specific analyses revealed some consideration of medical comorbidities in choosing among specific antimanic agents, although effect sizes were small. Most patients initiating an antimanic had received an antidepressant in the previous year. DISCUSSION: Second-generation antipsychotics quickly became the frontline antimanic treatment for bipolar disorder, although antidepressants most commonly predated antimanic prescriptions. Second-generation antipsychotics were used for a broad range of patients rather than being restricted to a severely ill subpopulation. The modest association of antimanic choice with relevant medical comorbidities suggests that continued attention to quality prescribing practices is warranted.

Patterns of initiation of second generation antipsychotics for bipolar disorder: a month-by-month analysis of provider behavior.

BACKGROUND: Several second generation antipsychotics (SGAs) received FDA approval for bipolar disorder in the 2000s. Although efficacious, they have been costly and may cause significant side effects. Little is known about the factors associated with prescribers' decisions to initiate SGA prescriptions for this condition. METHODS: We gathered administrative data from the Department of Veterans Affairs on 170,713 patients with bipolar disorder between fiscal years 2003-2010. Patients without a prior history of taking SGAs were considered eligible for SGA initiation during the study (n =126,556). Generalized estimating equations identified demographic, clinical, and comorbidity variables associated with initiation of an SGA prescription on a month-by-month basis. RESULTS: While the number of patients with bipolar disorder using SGAs nearly doubled between 2003 and 2010, analyses controlling for patient characteristics and the rise in the bipolar population revealed a 1.2% annual decline in SGA initiation during this period. Most medical comorbidities were only modestly associated with overall SGA initiation, although significant differences emerged among individual SGAs. Several markers of patient severity predicted SGA initiation, including previous hospitalizations, psychotic features, and a history of other antimanic prescriptions; these severity markers became less firmly linked to SGA initiation over time. Providers in the South were somewhat more likely to initiate SGA treatment. CONCLUSIONS: The number of veterans with bipolar disorder prescribed SGAs is rising steadily, but this increase appears primarily driven by a corresponding increase in the bipolar population. Month-by-month analyses revealed that higher illness severity predicted SGA initiation, but that this association may be weakening over time.

Prediabetes: Adherence to Nutrition Visits Decreases HbA1c in Children and Adolescents.

Background: Prediabetes, the precursor of type 2 diabetes (T2D), is on the rise in the US, but the determinants of its progression are poorly characterized in youth. Objective: To determine the impact of nutrition visits, as a surrogate marker of lifestyle modification, on the trajectory of prediabetes over a 4-year period. Hypothesis: Adherence to nutrition visits could reduce BMI and lower HbA1c. Methods: A 4-year retrospective study of 108 youth with prediabetes who were recommended to receive medical nutrition therapy every 3 months following their diagnosis. Subjects were divided into 2 groups: the non-adherent group who had ≤1 nutrition visit/year, and the adherent group with ≥2 nutrition visits/year. Results: There were 46 male subjects, mean age 12.4 ± 3.6y; and 62 female subjects, mean age, 13.3 ± 3.0y, p=0.2. The adherent group (n=44, 41.5%) had higher BMI z-scores, but similar values for HbA1c, metformin use, and racial/ethnic composition compared to the non-adherent group. Overall, 18(17.0%) subjects progressed to T2D in 4y and consisted of 14(22.6%) of the 62 non-adherent subjects and 4(9.1%) of the 44 adherent subjects. The non-adherent subjects progressed to T2D at a mean duration of 25.8 ± 12.6 months while the adherent subjects progressed at a mean duration of 34.9 ± 11.8 months. The hazard ratio of progression from prediabetes to T2D for the non-adherent versus adherent group was 3.88 (95%CI 1.26-11.98, p=0.02). The results remained significant after adjusting for age, sex, race/ethnicity, BMI, and metformin use. Conclusion: Adherence to nutrition visits was associated with a 4-fold reduction in the likelihood to progress from prediabetes to T2D in US youth.

Impact of a targeted volume-increase nutrition guideline on growth and body mass index in premature infants: A retrospective review.

BACKGROUND: The negative impact of disproportionate growth in premature infants is well documented, but optimal nutrition practices needed to prevent an unhealthy body mass index (BMI) remain unclear. METHODS: An evidence-based, volume-increase guideline that advanced feeding volumes from 150-160 to 170-180 ml/kg/day between the postmenstrual age (PMA) of 31 0/7 and 34 0/7 weeks was implemented in October 2017 for infants born at ≤32 0/7 weeks' gestational age. Data were collected on 262 infants' weight and length at birth and at discharge for 20 months before and 21 months after guideline implementation, and retrospective analysis was conducted to determine disproportionate growth by comparing BMIs (in g/cm2 ) at birth and at discharge. Changes in infants' body habitus were determined through bivariate analysis of weight and length z-scores from the Fenton growth curve. RESULTS: Implementation of a targeted volume nutrition guideline resulted in fewer infants with growth failure, defined as weight <10th percentile (19.5% vs 11.2%; P = .06) at discharge. Infants who received treatment according to the targeted nutrition guideline had a statistically significant reduction in disproportionately low BMI (8.6% vs 2.5%; P = .0380) and an increase in disproportionately high BMIs (4.3% vs 12.3%; P = .025). There was minor change in the percentage of disproportionately large infants who received the guidelines from birth to discharge (11.5% vs 12.3%). CONCLUSIONS: A targeted volume-increase nutrition guideline may prevent growth failure, with some effects on disproportionate growth in preterm infants born at ≤32 0/7 weeks' gestational age.

Ergocalciferol in New-onset Type 1 Diabetes: A Randomized Controlled Trial.

CONTEXT: The effect of the anti-inflammatory and immunomodulatory actions of vitamin D on the duration of partial clinical remission (PR) in youth with type 1 diabetes (T1D) is unclear. OBJECTIVE: This work aimed to determine the effect of adjunctive ergocalciferol on residual ß-cell function (RBCF) and PR in youth with newly diagnosed T1D who were maintained on a standardized insulin treatment protocol. The hypothesis was that ergocalciferol supplementation increases RBCF and prolongs PR. METHODS: A 12-month, randomized, double-blind, placebo-controlled trial was conducted of 50 000 IU of ergocalciferol per week for 2 months, and then once every 2 weeks for 10 months, vs placebo in 36 individuals aged 10 to 21 years, with T1D of less than 3 months and a stimulated C-peptide (SCP) level greater than or equal to 0.2 nmol/L (≥ 0.6 ng/mL). The ergocalciferol group had 18 randomly assigned participants (10 male/8 female), mean age 13.3 ±â€…2.8 years, while the control group had 18 participants (14 male/4 female), aged 14.3 ±â€…2.9 years. RESULTS: The ergocalciferol treatment group had statistically significantly higher serum 25-hydroxyvitamin D at 6 months (P = .01) and 9 months (P = .02) than the placebo group. At 12 months, the ergocalciferol group had a statistically significantly lower serum tumor necrosis factor α (TNF-α) concentration (P = .03). There were no statistically significant differences between the groups at each time point from baseline to 12 months for SCP concentration (P = .08), glycated hemoglobin A1c (HbA1c) (P = .09), insulin dose-adjusted A1c (IDAA1c), or total daily dose of insulin. Temporal trends for rising HbA1c (P = .04) and IDAA1c (P = .02) were statistically significantly blunted in the ergocalciferol group. CONCLUSION: Ergocalciferol statistically significantly reduced serum TNF-α concentration and the rates of increase both in A1c and IDAA1c, suggesting a protection of RBCF and PR in youth with newly diagnosed T1D.

Variation in Pediatric Anesthesiologist Sedation Practices for Pediatric Gastrointestinal Endoscopy.

Background: Despite a worldwide shift toward anesthesiologist-administered sedation for gastrointestinal endoscopy in children, ideal sedation regimens remain unclear and best practices undefined. Aim: The aim of our study was to document variation in anesthesiologist-administered sedation for pediatric endoscopy. Outcomes of interest included coefficients of variation, procedural efficiency, as well as adverse events. Methods: IRB approval was obtained to review electronic health records of children undergoing routine endoscopy at our medical center during a recent calendar year. Descriptive and multivariate analyses were used to examine predictors of sedation practices. Results: 258 healthy children [2-21 years (median 15, (Q1-Q3 = 10-17)] underwent either upper and/or lower endoscopies with sedation administered by anesthesiologists (n = 21), using different sedation regimens (29) that ranged from a single drug administered to 6 sedatives in combination. Most patients did not undergo endotracheal tube intubation for the procedure (208, 81%), and received propofol (255, 89%) either alone or in combination with other sedatives. A total of 10 (3.8%) adverse events (9 sedation related) were documented to occur. The coefficient of variation (CV) for sedation times was high at 64.2%, with regression analysis suggesting 8% was unexplained by procedure time. Multivariable model suggested that longer procedure time (p < 0.0001), younger age (p < 0.0001), and use of endotracheal tube intubation (p = 0.02) were associated with longer sedation time. Discussion: We found great variation in anesthesiologist administered regimens for pediatric endoscopy at our institution that may be unwarranted, presenting may opportunities for minimizing patient risk, as well as for optimizing procedural efficiency.

Partial Clinical Remission Reduces Lipid-Based Cardiovascular Risk in Adult Patients With Type 1 Diabetes.

Importance: Risk factors for atherosclerotic cardiovascular disease (ASCVD) are well established in type 2 diabetes (T2D), but not in type 1 diabetes (T1D). The impact of partial clinical remission (PR) on short-term ASCVD risk in T1D is unclear. Aim: To investigate the impact of PR on the earliest ASCVD risk phenotype in adult T1D using factor analysis to compare the lipid phenotypes of T1D, T2D and controls after stratifying the T1D cohort into remitters and non-remitters. Subjects and Methods: A study of 203 adults subjects consisting of 86 T2D subjects, and 77 T1D subjects stratified into remitters (n=49), and non-remitters (n=28). PR was defined as insulin-dose adjusted HbA1c of ≤9, and obesity as a BMI ≥30 kg/m2. Factor analysis was used to stratify the groups by ASCVD risk by factorizing seven lipid parameters (TC, LDL, HDL, non-HDL, TC/HDL, TG, TG/HDL) into 2 orthogonal factors (factor 1: TC*LDL; factor 2: HDL*TG) that explained 90% of the variance in the original seven parameters. Results: The analysis of individual lipid parameters showed that TC/HDL was similar between the controls and remitters (p=NS) but was significantly higher in the non-remitters compared to the remitters (p=0.026). TG/HDL was equally similar between the controls and remitters (p=NS) but was lower in the remitters compared to the non-remitters (p=0.007). TG was significantly lower in the remitters compared to T2D subjects (p<0.0001) but was similar between T2D subjects and non-remitters (p=NS). Non-HDL was significantly lower in the controls versus non-remitters (p=0.0003) but was similar between the controls and remitters (p=NS). Factor analysis showed that the means of factor 1 and factor 2 composite scores for dyslipidemia increased linearly from the controls, remitters, non-remitters to T2D, p value 0.0042 for factor 1, and <0.0001 for factor 2, with remitters having similar lipid phenotype as controls, while non-remitters were similar to T2D. Conclusions: Partial clinical remission of T1D is associated with a favorable early lipid phenotype which could translate to reduced long-term CVD risk in adults.

Long-term GH Therapy Does Not Advance Skeletal Maturation in Children and Adolescents.

CONTEXT: There is no consensus on the effect of recombinant human GH (rhGH) therapy on skeletal maturation in children despite the current practice of annual monitoring of skeletal maturation with bone age in children on rhGH therapy. AIMS: To investigate the effects of long-term rhGH therapy on skeletal age in children and explore the accuracy of bone age-predicted adult height (BAPAH) at different ages based on 13 years of longitudinal data. METHODS: A retrospective longitudinal study of 71 subjects aged 2 to 16 years, mean 9.9 ±â€…3.8 years, treated with rhGH for nonsyndromic short stature for a duration of 2 to 14 years, mean, 5.5 ±â€…2.6 years. Subjects with syndromic short stature and systemic illnesses such as renal failure were excluded. RESULTS: Bone age minus chronological age (BA-CA) did not differ significantly between baseline and the end of rhGH therapy (-1.05 ±â€…1.42 vs -0.69 ±â€…1.63, P = 0.09). Piecewise regression, however, showed a quantifiable catch-up phenomenon in BA of 1.5 months per year of rhGH therapy in the first 6.5 years (P = 0.017) that plateaued thereafter (P = 0.88). BAPAH overestimated near-adult height in younger subjects but became more accurate in older subjects (P < 0.0001). IGF-I levels correlated significantly with increases in child's height and BA-CA. CONCLUSION: Long-term rhGH therapy demonstrated an initial catch-up phenomenon in skeletal maturation in the first 6.5 years that plateaued thereafter with no overall significant advancement in bone age. These findings are reassuring and support strategic, but not the insurance company mandated reflexive annual monitoring of skeletal maturation with bone age in children receiving rhGH therapy.

Contracture Severity at Hospital Discharge in Children: A Burn Model System Database Study.

Contractures can complicate burn recovery. There are limited studies examining the prevalence of contractures following burns in pediatrics. This study investigates contracture outcomes by location, injury, severity, length of stay, and developmental stage. Data were obtained from the Burn Model System between 1994 and 2003. All patients younger than the age of 18 with at least one joint contracture at hospital discharge were included. Sixteen areas of impaired movement from the shoulder, elbow, wrist, hand, hip, knee, and ankle joints were examined. Analysis of variance was used to assess the association between contracture severity, burn size, and length of stay. Age groupings were evaluated for developmental patterns. A P value of less than .05 was considered statistically significant. Data from 225 patients yielded 1597 contractures (758 in the hand) with a mean of 7.1 contractures (median 4) per patient. Mean contracture severity ranged from 17% (elbow extension) to 41% (ankle plantarflexion) loss of movement. Statistically significant associations were found between active range of motion loss and burn size, length of stay, and age groupings. The data illustrate quantitative assessment of burn contractures in pediatric patients at discharge in a multicenter database. Size of injury correlates with range of motion loss for many joint motions, reflecting the anticipated morbidity of contracture for pediatric burn survivors. These results serve as a potential reference for range of motion outcomes in the pediatric burn population, which could serve as a comparison for local practices, quality improvement measures, and future research.

Assessing risk of sexually abusive behavior among youth in a child welfare sample.

Statutory management of juvenile sexual offenders demands reliable, valid methods for assessing the risk posed by these youth. This study examined the predictive validity of the J-SOAP-II using samples of adolescent and pre-adolescent boys who were wards of the Massachusetts Department of Social Services. The base rate for sexual recidivism among the adolescents (14-16%) is generally in line with what has been reported. The equivalent base rate for the pre-adolescents (25-28%), however, was notably higher. Although the J-SOAP-II was developed for adolescents, the scale also worked with the pre-adolescents in predicting sexual recidivism over 7 years, with AUC values of 0.77, 0.74, 0.77, and 0.80 for Scales 1, 3, 4, and Total among the pre-adolescents and AUC values of 0.80, 0.82, and 0.83 for Scales 1, 4, and Total among the adolescents. Discussion focuses on extant J-SOAP research and sample dependent variability, as well as social policy implications.

Effect of Ergocalciferol on ß-Cell Function in New-Onset Type 1 Diabetes: A Secondary Analysis of a Randomized Clinical Trial.

This secondary analysis of a randomized clinical trial evaluates the effectiveness of ergocalciferol vs placebo in youths with newly diagnosed type 1 diabetes.

Burn survivors injured as children exhibit resilience in long-term community integration outcomes: A life impact burn recovery evaluation (LIBRE) study.

INTRODUCTION: There is limited understanding of how burn injuries at different ages are associated with normal growth and development as well as the burn recovery process. This study provides new useful insights by comparing social participation outcomes among burn survivors injured in childhood compared with injuries sustained in middle age, and older adulthood. METHODS: Items from the development of the LIBRE profile were administered to 601 adult burn survivors with ≥5% TBSA burned or burns to critical areas (hands, feet, face, or genitals). Each item was answered on a 5-point Likert scale with higher scores denoting better outcomes. Mean scores for the 6 LIBRE profile scales (sexual relationships, family and friends, social interactions, social activities, work and employment, and romantic relationships) were compared between those burned as children (<18years) and those burned as adults (≥18years). Regression analyses were used to assess differences between groups with adjustment for demographic and clinical characteristics. RESULTS: Of the 597 burn survivors having complete data on age at injury, 165 (27.6%) sustained burn injuries as a child. Those burned as children were more frequently female than those burned as adults (57% vs 47%) and were also more frequently white non-Hispanic (89% vs 77%). Marital status and education level were similar in the two groups. Those who were burned as children had slightly higher scores on the social activities, work and employment and romantic relationships scales. However, these differences did not persist in adjusted regression analyses. CONCLUSIONS: Burn survivors who sustained injuries as a child fared at least as well as those burned as adults in a broad range of long-term social participation outcomes. The impact on long-term social participation outcomes of burn survivors was not significantly different between individuals with burns sustained during important developmental stages at young ages and those injured later in life.

The Use of a Brief Measure to Assess Longitudinal Changes in Appearance Concerns for Youth Recovering From Burn Injuries.

Burns are among the most common injuries to children, and, although survival rates have improved, many burn survivors are left with scars and/or other visible differences, which may be associated with anxiety, depression, and/or low self-esteem. A better understanding of the prevalence and persistence of these problems in child and adolescent burn survivors might lead to an expanded paradigm of care and possibly to better outcomes. The present study provides longitudinal prevalence data for the Appearance Concerns (AC) subscale of the parent-reported Burn Outcomes Questionnaire (BOQ) for 5- to 18-year-old children and identifies patient characteristics associated with higher risk for appearance concerns. Subjects were 799 pediatric burn survivors who were assessed prospectively using the parent-reported BOQ5-18, which was administered soon after their discharge from acute care and again every 3 to 6 months for up to 4 years. Approximately 20% of all youth were reported to have appearance concerns over the first 2 years, after which the rate declined gradually, falling to around 10% after 3 years. This study showed that such concerns were prevalent and persistent years after burn injuries and suggested that larger burns, facial burns, and country of origin outside of the United States were all associated with higher scores on the AC subscale. These findings highlight the importance of assessing appearance concerns in the long-term care of young burn survivors and suggest that the BOQ5-18 AC subscale could be used to identify individuals with heightened appearance concerns and to measure their response to interventions.

A Comparison of Contracture Severity at Acute Discharge in Patients With and Without Heterotopic Ossification: A Burn Model System National Database Study.

This study assesses the association between heterotopic ossification and upper extremity contracture by comparing goniometric measured active range of motion outcomes of patients with and without heterotopic ossification. Data were obtained from the Burn Model System National Database between 1994 and 2003 for patients more than 18 years with elbow contracture at acute discharge. Absolute losses in elbow range of motion were compared for those with and without radiologic evidence of heterotopic ossification (location undefined) and were further examined by burn size subgroups using Wilcoxon rank-sum test. Differences in elbow range of motion were estimated using regression models, adjusted for demographic and clinical variables. Loss of range of motion of shoulder, wrist, forearm, and hand were also compared. From 407 instances of elbow contracture, the subjects with heterotopic ossification were found to have greater median absolute loss of elbow flexion among all survivors (median 50° [IQR 45°] vs 20° [30°], P < .0001), for the 20 to 40% total body surface area burn subgroup (70° [20°] vs 20° [30°], P = .0008) and for the >40% subgroup (50° [45°] vs 30° [32°], P = .03). The adjusted estimate of the mean difference in the absolute loss of elbow flexion between groups was 23.5° (SE ±7.2°, P = .0013). This study adds to our understanding of the potential effect of heterotopic ossification on upper extremity joint range of motion, demonstrating a significant association between the presence of heterotopic ossification and elbow flexion contracture severity. Further study is needed to determine the functional implications of heterotopic ossification and develop treatment protocols.

Usefulness of a Novel System for Feedback of Patient-Reported Outcome Measures in Children Recovering From Burns.

The Burn Outcomes Questionnaire for children ages 5-18 years (BOQ5-18) is a widely used, reliable, and valid parent-reported outcome measure designed to assess children's recovery from burn injuries in 12 physical and psychosocial domains. This study evaluated the feasibility, acceptability, and usefulness of a feedback system that delivered BOQ and Pediatric Symptom Checklist (PSC-17; a widely used measure of psychosocial functioning) results to burn care clinicians prior to an outpatient appointment or a postoperative surgical encounter. The BOQ and the PSC-17 were administered to the parents of 147 children receiving outpatient or surgical care in two pediatric burn hospitals. Clinician and parent perceptions of the feedback system were evaluated using debriefing questionnaires. Over half of all patients were at-risk on at least one BOQ subscale, and risk on three or more BOQ domains was significantly associated with a higher likelihood of poor psychological scores on the PSC-17 (P < .001). Significant differences in BOQ scores were found between the two hospital sites on four BOQ subscales, three related to physical ability and one to psychosocial well-being. Parent ratings of the feedback system were positive, with 90% of parents in both settings agreeing that the BOQ tablet experience was easy and helpful. Clinician attitudes differed across the two settings with more positive clinician ratings of the system in the outpatient setting (P < .001). Clinician interviews revealed that the data was especially useful in bringing to light psychosocial aspects of functioning relevant to long-term recovery from burn injuries.

Building Bridges Using the Shriners Hospitals for Children/American Burn Association Burn Outcome Questionnaires to Follow Teenagers and Young Adults Across the Age Spans.

The Shriners Hospitals for Children/American Burn Association Burn Outcomes Questionnaires (BOQ) are well-established, reliable, and valid outcome measures. The adolescent (BOQ11-18 years) and young adult version (YABOQ 18-30 years) have similar overlapping domains, but the scores are not comparable. This study objective was to build bridges across these forms. Datasets were from the Multi-Center Benchmarking Study Group. The comparable subscales from the BOQ11-18 and the YABOQ were bridged using item response theory cocalibration. The item response theory scale scores were then transformed into an expected raw score on the alternative form, from which normative scores are available. A sensitivity analysis using up to three time points, as opposed to one randomly selected occasion, was also conducted to ensure robust results. Data were available on 353 unique adolescents and 148 young adults. The comparable subscales were successfully bridged across forms (adolescent reliability from 0.67 to 0.85; young adult from 0.69 to 0.88). Compared with adolescents, young adults on average reported more pain and itch, less symptom and role satisfaction, and poorer work/school reintegration (Cohen's d = 0.39-0.77; P < .05). Physical functioning, appearance, and family/parental concern were comparable across ages (d = -0.01 to 0.09; P > .05). Family functioning was better for young adults than adolescents (d = -0.25; P = .006). BOQ11-18 scores can be mapped from adolescence into young adulthood. Physical and psychosocial outcomes change across the lifespan. Bridges provide a highly useful approach to track changes across this part of the lifespan.

Space-Time Cluster Analysis to Detect Innovative Clinical Practices: A Case Study of Aripiprazole in the Department of Veterans Affairs.

OBJECTIVE: To identify space-time clusters of changes in prescribing aripiprazole for bipolar disorder among providers in the VA. DATA SOURCES: VA administrative data from 2002 to 2010 were used to identify prescriptions of aripiprazole for bipolar disorder. Prescriber characteristics were obtained using the Personnel and Accounting Integrated Database. STUDY DESIGN: We conducted a retrospective space-time cluster analysis using the space-time permutation statistic. DATA EXTRACTION METHODS: All VA service users with a diagnosis of bipolar disorder were included in the patient population. Individuals with any schizophrenia spectrum diagnoses were excluded. We also identified all clinicians who wrote a prescription for any bipolar disorder medication. PRINCIPAL FINDINGS: The study population included 32,630 prescribers. Of these, 8,643 wrote qualifying prescriptions. We identified three clusters of aripiprazole prescribing centered in Massachusetts, Ohio, and the Pacific Northwest. Clusters were associated with prescribing by VA-employed (vs. contracted) prescribers. Nurses with prescribing privileges were more likely to make a prescription for aripiprazole in cluster locations compared with psychiatrists. Primary care physicians were less likely. CONCLUSIONS: Early prescribing of aripiprazole for bipolar disorder clustered geographically and was associated with prescriber subgroups. These methods support prospective surveillance of practice changes and identification of associated health system characteristics.

The Development and Validity of the Adult Burn Outcome Questionnaire Short Form.

Patient Reported Outcome Measures (PROMs) are useful for understanding the health needs and outcomes of the general public. We aim to develop a burn-specific metric-Adult Burn Outcome Questionnaire (ABOQ)-that is brief and can be administered electronically to all burn survivors over the age of 18. The 14-item ABOQ was developed from the already validated Young Adult Burn Outcome Questionnaire (YABOQ) long form. The ABOQ questionnaire, along with Patient-Reported Outcomes Measurement System-10 (PROMIS-10), was administered to 120 outpatient burn survivors at three hospitals. Clinical validity of the ABOQ was measured by testing associations between ABOQ items and burn size, the PROMIS-10 generic items and composite scales using correlational analysis including multivariate canonical analysis. Nine out of 14 ABOQ items were significantly correlated with burn size (correlations ranging from -0.25 to -0.46, P < .01). The canonical correlation between ABOQ and burn size was 0.68 (P = .0002). The overall canonical correlation between two instruments was also significant (P < .0001). At the item level, at least 25% of the variation in each of the five ABOQ items could be explained by PROMIS-10 items and composite scores, while six other items could only be accounted for by less than 15% of the variation. ABOQ short form assessment can be used to efficiently measure burn outcomes across a range of relevant clinical domains with credible validity. A large proportion of the variation in ABOQ scores was not accounted for by PROMIS-10, suggesting that ABOQ provided additional health-related information specifically for the burn population beyond the generic instrument.