Commentary: Actionable Steps for Addressing Pediatric Pain in Rural and Underserved Communities: Disrupting Our Approach to Psychological Science and Care.

Although chronic pain is one of the most common health issues affecting children, disparities in access to behavioral healthcare limit its proper identification and management. There is a critical need to move beyond traditional care delivery approaches for chronic pain to reach those in communities that have limited access to care. We argue one means of doing so is to leverage our skills and expertise as psychologists to partner with and train professionals who have established relationships with youth in these communities. Drawing from a community-engaged dissemination and implementation science framework and our research implementing pain management strategies in rural and underserved communities, we review actionable strategies for disrupting traditional psychological methods to expand access to care for children with chronic pain.

Multistate Outbreak of Infection with SARS-CoV-2 Omicron Variant after Event in Chicago, Illinois, USA, 2021.

Bars and restaurants are high-risk settings for SARS-CoV-2 transmission. A multistate outbreak after a bar gathering in Chicago, Illinois, USA, highlights Omicron variant transmissibility, the value of local genomic surveillance and interstate coordination, vaccination value, and the potential for rapid transmission of a novel variant across multiple states after 1 event.

Chronic Pain in Young People With Cerebral Palsy: Activity Limitations and Coping Strategies.

PURPOSE: To describe the effect of chronic pain on the activities of children and adolescents with cerebral palsy, to describe coping strategies, and to examine associations between effect of pain on activities, coping strategies, and level of pain. METHODS: Using an online survey, 27, 8- to 18-year-olds with cerebral palsy and chronic pain or their parents reported pain intensity, distribution, activity limitations (using the Child Activity Limitations Interview-21), and coping strategies (using the Pediatric Pain Coping Inventory). RESULTS: Pain intensity ranged from 3 to 10, and 89% reported pain in multiple areas, principally the lower limbs. Individuals reporting higher pain intensity had more activity limitations and were more likely to use catastrophizing coping strategies. CONCLUSIONS: Coping strategies may be an important mediator between pain and its effect on activities in children with cerebral palsy. Individualized pain management should be based on routine pain assessment.

Characteristics of Persons Who Report Using Only Nicotine-Containing Products Among Interviewed Patients with E-cigarette, or Vaping, Product Use-Associated Lung Injury - Illinois, August-December 2019.

In 2019, the United States experienced an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) (1). Most EVALI patients have reported using tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products obtained from informal sources (2,3), and vitamin E acetate in these products has been closely linked with EVALI (4,5). However, some EVALI patients report using only nicotine-containing products. This study compared demographic, product use, and clinical characteristics of EVALI patients in Illinois who reported using only nicotine-containing e-cigarette, or vaping, products with those of patients who reported using any THC-containing products. Among 121 interviewed Illinois EVALI patients, 17 (14%) reported using only nicotine-containing products, including nine (7%) patients who had no indication of any THC use, based on self-report or toxicology testing. Compared with patients who used any THC-containing products, these nine patients were significantly more likely to be older and female and were less likely to experience constitutional symptoms or to have leukocytosis on initial evaluation. Although vitamin E acetate has been strongly linked with EVALI, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC- or non-THC-containing products, in some reported EVALI cases. The contributing cause or causes of EVALI for patients reporting use of only nicotine-containing products warrants further investigation.

Interobserver reliability of the Australian Spasticity Assessment Scale (ASAS).

AIM: The aim of this paper is to present the Australian Spasticity Assessment Scale (ASAS) and to report studies of its interrater reliability. The ASAS identifies the presence of spasticity by confirming a velocity-dependent increased response to rapid passive movement and quantifies it using an ordinal scale. METHOD: The rationale and procedure for the ASAS is described. Twenty-two participants with spastic CP (16 males; age range 1y 11mo-15y 3mo) who had not had botulinum neurotoxin-A within 4 months, or bony or soft tissue surgery within 12 months, were recruited from the spasticity management clinic of a tertiary paediatric teaching hospital. Fourteen muscles in each child were assessed by each of three experienced independent raters. ASAS was recorded for all muscles. Interrater reliability was calculated using the weighted kappa statistic (quadratic weighting; κqw) for individual muscles, for upper limbs, for lower limbs, and between raters. RESULTS: The weighted kappa ranged between 0.75 and 0.92 for individual muscle groups and was 0.87 between raters. INTERPRETATION: The ASAS complies with the definition of spasticity and is clinically feasible in paediatric settings. Our estimates of interrater reliability for the ASAS exceed that of the most commonly used spasticity scoring systems.

Exercise interventions improve postural control in children with cerebral palsy: a systematic review.

AIM: The aim of this study was to evaluate the efficacy and effectiveness of exercise interventions that may improve postural control in children with cerebral palsy (CP). METHOD: A systematic review was performed using American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Six databases were searched using the following keywords: ('cerebral palsy' OR 'brain injury'); AND ('postur*' OR 'balance' OR 'postural balance' [MeSH]); AND ('intervention' OR 'therapy' OR 'exercise' OR 'treatment'). Articles were evaluated based on their level of evidence and conduct. RESULTS: Searches yielded 45 studies reporting 13 exercise interventions with postural control outcomes for children with CP. Five interventions were supported by a moderate level of evidence: gross motor task training, hippotherapy, treadmill training with no body weight support (no-BWS), trunk-targeted training, and reactive balance training. Six of the interventions had weak or conflicting evidence: functional electrical stimulation (FES), hippotherapy simulators, neurodevelopmental therapy (NDT), treadmill training with body weight support, virtual reality, and visual biofeedback. Progressive resistance exercise was an ineffective intervention, and upper limb interventions lacked high-level evidence. INTERPRETATION: The use of exercise-based treatments to improve postural control in children with CP has increased significantly in the last decade. Improved study design provides more clarity regarding broad treatment efficacy. Research is required to establish links between postural control impairments, treatment options, and outcome measures. Low-burden, low-cost, child-engaging, and mainstream interventions also need to be explored.

Australian hip surveillance guidelines for children with cerebral palsy: 5-year review.

AIM: To ensure hip surveillance guidelines reflect current evidence of factors influencing hip displacement in children with cerebral palsy (CP). METHOD: A three-step review process was undertaken: (1) systematic literature review, (2) analysis of hip surveillance databases, and (3) national survey of orthopaedic surgeons managing hip displacement in children with CP. RESULTS: Fifteen articles were included in the systematic review. Quantitative analysis was not possible. Qualitative review indicated hip surveillance programmes have decreased the incidence of hip dislocation in populations with CP. The Gross Motor Function Classification System was confirmed as the best indicator of risk for displacement, and evidence was found of hip displacement occurring at younger ages and in young adulthood. Femoral geometry, pelvic obliquity, and scoliosis were linked to progression of hip displacement. A combined data pool of 3366 children from Australian hip surveillance databases supported the effectiveness of the 2008 Consensus Statement to identify hip displacement early. The survey of orthopaedic surgeons supported findings of the systematic review and database analyses. INTERPRETATION: This review rationalized changes to the revised and renamed Australian Hip Surveillance Guidelines for Children with Cerebral Palsy 2014, informing frequency of radiographic examination in lower risk groups and continuation of surveillance into adulthood for adolescents with identified risk factors.

Improving Chronic Pain Management in a Family Medicine Residency.

BACKGROUND AND OBJECTIVE: Although the opioid epidemic continues to affect millions of Americans, many family physicians feel underprepared to perform chronic pain management (CPM) and treat opioid use disorder (OUD). To address this gap, we created organizational policy changes and implemented a didactic curriculum to help improve patient care, including medication-assisted treatment (MAT) into our residency. We investigated whether the educational program improved the comfort and ability of family physicians to prescribe opioids and utilize MAT. METHOD: Clinic policies and protocols were updated to align with the 2016 Centers for Disease Control and Prevention Guidelines for Prescribing Opioids. A didactic curriculum was created to improve resident and faculty comfort with CPM and introduce MAT. An online survey was completed pre- and postintervention between December 2019 and February 2020, utilizing paired sample t test and percentage effective (z test) to assess for change in provider comfort with opioid prescribing. Assessments were made using clinical metrics to monitor compliance with the new policy. RESULTS: Following the interventions, providers reported improved comfort with CPM (P=.001) and perception of MAT (P<.0001). Within the clinical setting there was significant improvement in the number of CPM patients who had a pain management agreement on file (P<.001) and completed a urine drug screen within the past year (P<.001). CONCLUSION: Provider comfort with CPM and OUD increased over the course of the intervention. We were also able to introduce MAT, adding a tool to the toolbox to help our residents and graduates treat OUD.

Childhood Sexual Abuse and Coping as Young Adults: The Roles of Attachment and Mattering.

This study examined whether a history of childhood sexual abuse (CSA), attachment to mother, father, and friends, and mattering were related to the coping behaviors of 171 male and 85 female, ethnically diverse, low-income, young adults. The 74 survivors of CSA reported lower attachment to father and less mattering to parents than did the 97 who reported no abuse. Compared to male survivors, female survivors reported greater use of problem-focused coping and also perceived their abuse experience, particularly the use of force, as having a more negative impact on them. Stronger attachment to mother and to friends predicted more positive problem-focused coping. Mattering to friends moderated the relation between CSA history and problem-focused coping, with the CSA survivors who reported the highest mattering to friends also using the most problem-focused coping strategies. The role of attachment and mattering in problem-focused coping among young adults, especially those with a CSA history, is discussed.

Child-Focused Cognitive Behavioral Therapy for Pediatric Abdominal Pain Disorders Reduces Caregiver Anxiety in Randomized Clinical Trial.

Pediatric functional abdominal pain disorders (FAPD) are associated with elevated anxiety in youth and their caregivers, both contributing to an adverse impact on functioning in youth with FAPD. While a CBT approach (ie, Aim to Decrease Anxiety and Pain Treatment [ADAPT]) is known to improve health outcomes for youth, it is unknown if child-focused treatment improves caregiver anxiety. This secondary analysis of a larger randomized clinical trial examined if child-focused CBT (ADAPT) for pain and anxiety also impacts caregiver anxiety and explored the relation between caregiver anxiety and child symptoms (ie, pain, disability, anxiety) after treatment. A total of 79 caregiver-child dyads were randomized to ADAPT plus treatment as usual (TAU) or TAU only. Caregiver anxiety and child outcomes (pain, disability, anxiety) were assessed at baseline and approximately 8 weeks later. Caregivers of children who completed ADAPT+TAU demonstrated lower anxiety compared to those who only received TAU. Moreover, regardless of treatment assignment, caregivers with greater anxiety had children who reported more pain and anxiety, but not functional disability at post-assessment. Results suggest a brief, child-focused intervention targeting pain and anxiety may also improve caregiver anxiety. As such, suggestions to improve future treatments are offered. PERSPECTIVE: Caregiver anxiety symptoms diminished after their child with functional abdominal pain completed a course of child-focused CBT targeting pain and anxiety. Further, caregiver anxiety was related to child-reported symptoms (pain and anxiety) after treatment. Therefore, improved caregiver mental health via a child-focused CBT may also improve pediatric outcomes.

Australian hip surveillance guidelines at 10 years: New evidence and implementation.

Optimum management of hip displacement in children with cerebral palsy (CP) is facilitated by an approach that focuses on anticipatory and preventive measures. Hip surveillance programs for children with CP were developed at the beginning of the new millennium, with the purpose of identifying hip displacement sufficiently early to permit a choice of effective management options. In the early years, hip surveillance was guided by epidemiological analysis of population-based studies of prevalence. In Australia, a National Hip Surveillance in CP Working Group was first convened in 2005. This resulted in a 2008 Consensus Statement of recommendations published and endorsed by Australasian Academy of Cerebral Palsy and Developmental Medicine (AusACPDM). The group undertook that the recommendations should be reviewed every 5 years to ensure currency and congruency with the emerging evidence base. As new evidence became available, hip surveillance guidelines developed, with the most recent 2020 Australian Hip Surveillance Guidelines endorsed by the AusACPDM. Implementing comprehensive hip surveillance programs has now been shown to improve the natural history of hip dislocations and improve quality of life. Standardised hip surveillance programs can also facilitate planning for multicentre research through harmonisation of data collection. This, in turn, can help with the identification of robust new evidence that is based on large cohort or population studies. Here a review of evidence informing the updated 2020 Hip Surveillance Guidelines is presented.

The Influence of Caregiver Distress and Child Anxiety in Predicting Child Somatization in Youth with Functional Abdominal Pain Disorders.

Pediatric functional abdominal pain disorders (FAPD) are associated with adverse outcomes including increased somatization (e.g., heightened physiological sensations that include gastroenterological and non-gastroenterological symptoms) and increased functional disability. Caregiver distress and child anxiety are separately associated with the adverse outcomes of pediatric FAPD. However, the cumulative role of caregiver (i.e., stress, anxiety, and depression) and child psychological functioning (anxiety) in relation to adverse outcomes associated with FAPD, and particularly somatization, is unclear. Thus, the present investigation sought to examine the role of caregiver distress and child anxiety in relation to pain-related functioning (i.e., somatization, pain intensity, functional disability) in youth with FAPD. Data were gathered as part of a larger study examining a psychological treatment for youth with FAPD. Participants (ages 9-14) with FAPD completed measures of child anxiety, pain, and pain-related functioning. Caregivers completed a measure of caregiver distress (e.g., stress, anxiety, depressive symptoms). Pearson correlations revealed significant positive associations between child anxiety and child functional disability. Additionally, caregiver anxiety, child anxiety, and child somatization were all significantly and positively correlated with one another. Therefore, we assessed whether child anxiety may potentially mediate the relationship between caregiver anxiety and child somatization in this cross-sectional study. The indirect association between caregiver anxiety and child somatization via child anxiety was not significant. Future research including longitudinal designs to further understand the relationship between caregiver anxiety, child anxiety, and child pain-related functioning, would enhance understanding of how these potentially modifiable psychological factors may impact adverse outcomes of FAPD.

Botulinum toxin A in the management of focal muscle overactivity in children with cerebral palsy.

Cerebral palsy comprises a heterogenous group of neurological disorders representing a continuum of pathologies and clinical phenotypes. Although cerebral palsy is not a focal disorder, it is appropriate to treat identified focal problems as long as the intervention is goal directed. This paper reviews principles of managing muscle imbalance in the growing, changing child using a range of complementary, carefully timed intervention options. Over the past two decades these options have increasingly included intramuscular injection of botulinum toxin-A to manage focal spasticity and dystonia. The predictable movement patterns and postures characteristic of spasticity enable a systematic clinical rationale to be developed to determine the role of botulinum toxin-A to manage the spasticity and subsequently improve function. The management of dystonia with botulinum toxin-A is more complex, particularly when spasticity and dystonia are present in combination. An active therapy programme remains central to the management of movement problems in the child with cerebral palsy, including task-specific motor training, maintenance of muscle lengths, and improved muscle strength, aiming to achieve carry over improvements that persist beyond the pharmacological effects of the botulinum toxin-A. A series of case examples are presented to highlight the role of botulinum toxin-A in the overall management of the child with focal muscle hyperactivity.

The Role of the World Health Organization's International Classification of Functioning, Health and Disability in Models of Infant Cochlear Implant Management.

Newborn hearing screening has led to the early diagnosis of hearing loss in neonates and early device fitting is common, based primarily on electrophysiologic and radiologic information, with some supplementary behavioral measures. Such early fitting of hearing devices, in particular cochlear implants (CIs), has been beneficial to the majority of children implanted under the age of 12 months who meet the cochlear implant candidacy criteria. Comorbidities are common in children with hearing loss, although they may not be evident in neonates and may not emerge until later in infants. Evidence suggests that the child's outcomes are strongly influenced by a range of environmental factors including emotional and social support from the immediate and extended family. Consequently, such factors are important in service planning and service delivery for babies and children receiving CIs. The World Health Organization's International Classification of Functioning, Health and Disability (ICF) can provide a framework to facilitate the holistic management of pediatric cochlear implant recipients. The ICF also can be used to map the progress of recipients over time to highlight emerging issues that require intervention. This article will discuss our preliminary use of the ICF to establish clinical practice; develop advocacy skills among clients and their families; identify eligibility for services such as support in educational settings; enable access to modes of service delivery such as telepractice; provide a conceptual framework for policy and program development for pediatric cochlear implant recipients (i.e., in both disability and health services); and, most importantly, establish a clear pathway for the longitudinal management of the cochlear implant in a child's future. It is anticipated that this model will be applied to other populations receiving cochlear implants through our program.

Early Application of High Cut-Off Haemodialysis for de-Novo Myeloma Nephropathy is Associated with Long-Term Dialysis-Independency and Renal Recovery.

BACKGROUND: Multiple myeloma (MM) is a haematological malignancy associated with kidney injury resulting from cast nephropathy, which can be caused by monoclonal free light chains (FLC). It has been demonstrated that early reduction of FLC can lead to a higher proportion of patients recovering renal function with a better outcome, especially if high cut-off haemodialysis (HCO-HD) combined with chemotherapy is used. PATIENTS AND METHODS: In this study, four cases with MM nephropathy were treated with HCO-HD and chemotherapy at a single institution during the period from August 2009 to August 2011. All of the patients presented with acute renal failure and high serum FLC. All patients underwent a bone marrow biopsy to confirm the diagnosis of MM, according to the WHO criteria. Three patients had de novo MM and one patient had relapsed light chain myeloma disease. All patients underwent HCO-HD concomitantly with specific myeloma therapy once the diagnosis or relapse of MM was established. RESULTS: After a medial follow up of 26 months, (range, 13-36) our data showed that all patients had a significant decrease in serum FLC through HCO-HD, proving the effectiveness of HCO-HD in managing MM. De-novo MM patients restored their renal function and achieved low-level FLC early in the treatment and became dialysis-independent. One patient with relapsed myeloma remained dialysis-dependent. CONCLUSION: In summary, our study suggests that in myeloma nephropathy associated with light-chain MM, HCO-HD should be initiated as early as possible. At the same time a specific MM treatment should be initiated to gain control of the disease and salvage the kidneys in order to achieve dialysis-independency. Further randomized trials to confirm our results are warranted.

Hip displacement in spastic cerebral palsy: repeatability of radiologic measurement.

Radiologic measures of migration percentage (MP) and acetabular index (AI) taken from plain radiographs of the pelvis are the most commonly used tools for determining hip displacement and management options in children with cerebral palsy and spastic hip disease. This study determined interrater and intrarater reliability of MP and AI on pelvic radiographs chosen to represent a wide range of age (11 months to 8 years 5 months), MP (0%-56%), and AI (9 degrees -33 degrees ). The study demonstrated that an experienced rater would be expected to measure MP on a single radiograph to within +/-5.8% of the true value and a change in MP between two radiographs taken at different times to within +/-8.3% of the true value. Similarly for AI, the measurement error for a typical rater would be within +/-2.6 degrees on a single reading and +/-3.7 degrees if recording change between two occasions. The authors believe that the results indicating true change are acceptable in clinical practice, provided treatment decisions are based on a series of radiographs taken at 6-month intervals, methods and training are standardized, and consistent raters are used.