Rewarding elementary schoolchildren for their use of safety belts.

This study reports on the application of reward procedures to elementary schoolchildren to increase their use of seat belts en route to two schools. Following strict rules for assessing buckle-up compliance, all passengers in a car had to be safely secured in order for the schoolchildren to receive rewards. Compliant children received paper slips as they arrived at schools, which were redeemable for stickers, bumper stickers, and coloring books. The slips were also used in weekly drawings for pizza dinners. The mean compliance rate for School 1 was 4.3% during baseline, 66.2% for the reward phase across 4 weeks, 60% for return to baseline, 17.2% for Follow-Up 1, and 8.5% for Follow-Up 2. For School 2, the mean percentage was 5.3% at baseline, 69.8% for the reward phase, 68.5% for return to baseline, 40.1% for Follow-Up 1, and 20% for Follow-Up 2. These results indicate that rewarding the schoolchildren increased their own seat-belt use as well as that of their adult drivers and other passengers. Decreases in usage were observed after the rewards were removed.

Pain assessment and treatment in children with cognitive impairment: a survey of nurses' and physicians' beliefs.

OBJECTIVE: To gather information about healthcare providers' beliefs regarding pain and its treatment in children with cognitive impairment. DESIGN: A survey consisting of two acute pain vignettes (a child undergoing surgery and a child undergoing an outpatient medical procedure) was completed by 440 nurses and 146 physicians at Arkansas Children's Hospital. Respondents completed one of four different surveys that systematically varied the child's level of cognitive impairment (none, mild, moderate, severe) in both vignettes. Questions addressed expected pain, pain assessment methods, pharmacologic regimens, and nonpharmacologic interventions. RESULTS: In general, provider discipline and level of cognitive impairment did not significantly influence responses about pain experience and treatment. Potent analgesia, regularly scheduled dosing, and nonpainful administration were selected most frequently. Self-report of pain, patient-controlled analgesia, and behavioral interventions requiring higher cognitive skills were selected less frequently for children with more severe cognitive impairment. CONCLUSIONS: The presence of cognitive impairment appeared to influence provider decisions regarding the appropriateness of specific pain assessment and treatment methods requiring skills on the part of the child. Overall, healthcare provider views regarding analgesia and sedation were similar for all children, regardless of impairment. Whether these beliefs are consistent with clinical practice is yet to be documented.

Children with cognitive impairment: parent report of pain and coping.

Information about pain in children with cognitive impairment is lacking. To gather pain-relevant information in this population, parents of 145 children with borderline to profound cognitive impairment were interviewed regarding their children's pain expression, experience, treatment, and coping behavior. Descriptions of pain expression and coping behavior were associated with the level of cognitive impairment. Children with mild to moderate cognitive impairment were more likely to be described as directly communicating their pain and exhibiting procedural coping strategies similar to those observed in children without cognitive impairments. More than half of the parents reported that their children experienced pain differently than did children without cognitive impairment, with the majority perceiving decreased pain sensitivity and greater pain tolerance. Finally, one third of parents felt that their children's pain was treated differently than that of other children. Half of these parents believed that health care providers had difficulties assessing and treating their children's pain. Results contribute to the developing foundation of information about pain in this special pediatric population.

Pain assessment in children with cognitive impairment. An exploration of self-report skills.

Prior to surgery, 47 children (ages 8 to 17) with borderline to profound cognitive impairment were administered tasks to evaluate their understanding of the concepts of magnitude and ordinal position and their abilities to use a 0 to 5 numerical scale to rate pain levels in schematic faces. Of the 111 children (ages 4 to 14) without cognitive impairment, were administered the same tasks. Nurses conducting preoperative evaluations predicted whether children would understand the numerical scale. Fifty percent (n = 3) of children with borderline and 35% (n = 7) of children with mild cognitive impairment (and all children 8 years and older nonimpaired) correctly used the scale. Half of the children with cognitive impairment demonstrated skills (magnitude and ordinal position) that may allow them to use simpler pain rating methods. Nurses overestimated the abilities of cognitively impaired children (and younger children without cognitive impairment) to use the rating scale.

The hypnotic dreams of healthy children and children with cancer: a quantitative and qualitative analysis.

In this study, the Stanford Hypnotic Clinical Scale for Children was administered to 52 healthy children and 47 children and adolescents with cancer. Responses to the dream item of this scale were analyzed for the type and detail of imagery. The hypnotizability scores of both groups were similar. However, children with cancer reported more pleasant than unpleasant fantasy in their hypnotic dreams, and their dream reports tended to contain less fantasy and detail overall. Rescoring the dream item based on extent of fantasy and detail resulted in a lower pass rate for that item, especially for children with cancer. Regardless of health status, older children experienced more self-involvement in their hypnotic dreams compared to younger children.

Efficacy and safety of the dipeptidyl peptidase-4 inhibitor, sitagliptin, in patients with type 2 diabetes mellitus inadequately controlled on glimepiride alone or on glimepiride and metformin.

AIM: To assess the efficacy and safety of a 24-week treatment with sitagliptin, a highly selective once-daily oral dipeptidyl peptidase-4 (DPP-4) inhibitor, in patients with type 2 diabetes who had inadequate glycaemic control [glycosylated haemoglobin (HbA(1c)) >or=7.5% and or=4 mg/day) monotherapy and 229 were on glimepiride (>or=4 mg/day) plus metformin (>or=1,500 mg/day) combination therapy. Patients exceeding pre-specified glycaemic thresholds during the double-blind treatment period were provided open-label rescue therapy (pioglitazone) until study end. The primary efficacy analysis evaluated the change in HbA(1c) from baseline to Week 24. Secondary efficacy endpoints included fasting plasma glucose (FPG), 2-h post-meal glucose and lipid measurements. RESULTS: Mean baseline HbA(1c) was 8.34% in the sitagliptin and placebo groups. After 24 weeks, sitagliptin reduced HbA(1c) by 0.74% (p < 0.001) relative to placebo. In the subset of patients on glimepiride plus metformin, sitagliptin reduced HbA(1c) by 0.89% relative to placebo, compared with a reduction of 0.57% in the subset of patients on glimepiride alone. The addition of sitagliptin reduced FPG by 20.1 mg/dl (p < 0.001) and increased homeostasis model assessment-beta, a marker of beta-cell function, by 12% (p < 0.05) relative to placebo. In patients who underwent a meal tolerance test (n = 134), sitagliptin decreased 2-h post-prandial glucose (PPG) by 36.1 mg/dl (p < 0.001) relative to placebo. The addition of sitagliptin was generally well tolerated, although there was a higher incidence of overall (60 vs. 47%) and drug-related adverse experiences (AEs) (15 vs. 7%) in the sitagliptin group than in the placebo group. This was largely because of a higher incidence of hypoglycaemia AEs (12 vs. 2%, respectively) in the sitagliptin group compared with the placebo group. Body weight modestly increased with sitagliptin relative to placebo (+0.8 vs. -0.4 kg; p < 0.001). CONCLUSIONS: Sitagliptin 100 mg once daily significantly improved glycaemic control and beta-cell function in patients with type 2 diabetes who had inadequate glycaemic control with glimepiride or glimepiride plus metformin therapy. The addition of sitagliptin was generally well tolerated, with a modest increase in hypoglycaemia and body weight, consistent with glimepiride therapy and the observed degree of glycaemic improvement.

A community program to reward children's use of seat belts.

This paper reports on a community-wide effort to increase elementary school children's use of seat belts. Twenty-five schools serving over 9,000 children participated in a program of rewards (stickers, bumper strips, and chances on pizza dinners) administered by parent-teacher organization volunteers. Comprehensive observations were made at three representative schools. Categorization of compliance with safety rules required all passengers to be buckled into safety devices before the children received the rewards. The rewards, on average across schools, increased compliance from baseline of 18.1% to 62.4% during the interventions. Withdrawal of the rewards resulted in a decrease to 49% compliance, but this rate remained above baseline. The involvement of community groups and institutions in this safety program is highlighted.

Parenting the Chronically Ill Adolescent.

This chapter describes the role of the primary care physician in helping parents of chronically ill adolescents. The primary care practitioner can help parents (1) to become advocates for adolescents by helping them to understand the workings of the tertiary care system; (2) to be cognizant of important issues concerning the effect of the adolescent's illness on family functioning; and (3) to coordinate multidisciplinary treatment so that the care of the adolescent does not become fragmented.

The role of parent stress and coping and family functioning in parent and child adjustment to Duchenne muscular dystrophy.

This study found 57% of parents of 35 children with Duchenne Muscular Dystrophy (4 to 14 years of age) to have self-reported poor psychological adjustment. The hypothesized mediational variables of parent appraisal of stress, relative use of palliative coping methods, and level of family conflict accounted for 58% of the variance in general distress, 50% in depressive symptoms, and 31% in anxiety symptoms. In terms of parent-reported child adjustment, 89% of the children were classified by parent report as having a behavior problem pattern. The internalizing profile pattern was most frequent (37%). The parent mediational variables accounted for 26% of the variance in parent-reported internalizing behavior problems and 29% in externalizing behavior problems.

Efficacy of parental application of eutectic mixture of local anesthetics for intravenous insertion.

OBJECTIVE: To demonstrate that parent application of eutectic mixture of local anesthetics (EMLA) results in equal reduction of the pain of intravenous (IV) placement compared with clinician application of EMLA, and to assess potential difficulties with parental application. STUDY DESIGN: A 2 x 2 randomized block design was used, with 41 children divided into two age groups (5-12 years vs 13-18 years) and randomized to one of two experimental groups (parent-applied EMLA vs clinician-applied EMLA). METHODS: All children were scheduled to have outpatient gastrointestinal endoscopies with IV sedation. EMLA was placed at least 60 minutes before IV insertion either by the parent or a clinician, depending on the experimental group assignment. Outcome measures were child pain ratings and observed behavioral distress ratings. Parents and children were interviewed to determine parent and child anxiety levels in anticipation of the IV insertion, previous needle stick experience, and previous difficulty coping. Feasibility outcomes included technical difficulty with application of EMLA and appearance of the EMLA cream and occlusive covering. RESULTS: Pain ratings and behavioral distress ratings in the low to moderate range for all groups and ws and were consistent w previous empiric reports of EMLA outcome. There were no significant differences in pain or distress ratings for either the age or the experimental groups. Parent ratings of their child's previous difficulty coping was related to the level of behavioral distress exhibited before (r =.50), during (r =.32) and after (r =.44) the IV insertion. In addition, children's anxiety ratings about IV insertion seemed to differ among groups (although not statistically significant for post hoc comparisons), with the most anxiety reported by the younger children when clinicians applied the EMLA and by older children when parents applied the EMLA. CONCLUSION: Parent application of EMLA appears to be as effective as clinician application in reducing children's pain and distress associated with IV insertion. Permitting parents to apply the EMLA at home can allow children who are having procedures on an outpatient basis to benefit from topical anesthesia without having to arrive early to the clinic or hospital. Additionally, application by parents may result in less anticipatory anxiety for younger children.