Delays in autism diagnosis for U.S. Spanish-speaking families: The contribution of appointment availability.

Promoting equity in health services requires an understanding of the mechanisms that produce disparities. Utilizing a sequential, mixed-methods, explanatory study design, we analyzed child-, family-, and organizational-level factors and their association with wait times for an ASD diagnostic evaluation among 353 families scheduled for English and Spanish language appointments (27% Spanish language). A subset of parents and caregivers participated in English and Spanish language focus groups to provide their perspectives on the diagnostic process. Spanish language was associated with greater completion of, and time to evaluations than English language. The only variable found to mediate associations with time-to-evaluation was appointment availability - an organizational factor. Qualitative results elucidate potential explanations for greater Spanish language evaluation completion (e.g., fewer community-based diagnostic options). Results serve as a case study to support the utility and importance of analyzing the influence of organizational-level factors on delays and disparities for childhood health and mental health services. We discuss our findings in relation to strategies that can be widely applied to support equitable services access for childhood diagnostic and intervention services.

Student-teacher relationships of children with autism spectrum disorder: Distinct contributions of language domains.

BACKGROUND AND AIMS: High quality student-teacher relationships (STR) are important for children's academic and social development. We explore how individual child language domains (semantics, syntax, pragmatics), teacher years of experience, and classroom placement (general or special education) relate to STR quality for children with autism spectrum disorder (ASD) across the school year. METHODS AND PROCEDURES: 191 children with ASD (Mage = 5.6 years) completed a standardized language assessment and their teachers reported on STR quality twice during the school year. OUTCOME AND RESULTS: Pragmatics, but not semantics or syntax, had a direct effect on student-teacher closeness. The association between semantics and closeness was moderated by classroom type; for students with low semantics, teacher-reported closeness was lower in general versus special education. Teachers in special versus general education classrooms reported closer relationships. More experienced teachers reported closer and less conflictual relationships. None of the three language domains were associated with student-teacher conflict. CONCLUSIONS AND IMPLICATIONS: Pragmatic and semantic language skills were associated with closer relationships. Language-focused therapies may be effective in carrying over to impact STR quality. Given the stability in relationship quality, targeted interventions should be delivered to teachers at the beginning of the school year to support positive relationship development.

Developing Autism Screening Criteria for the Brief Infant Toddler Social Emotional Assessment (BITSEA).

There is a critical need for evidence-based, broadband behavioral, and ASD screening measures for use in pediatric and early educational settings to ensure that young children at risk for developing social-emotional disorders and/or ASD are provided with early intervention services to optimize long-term outcomes. The BITSEA is a 42-item screener designed to identify social-emotional/behavioral problems and delays/deficits in social-emotional competence among 11-48-month-olds; 19 items describe behaviors consistent with ASD. Secondary data analysis was employed to develop cut-scores for ASD subscales using Receiver Operating Curves, discriminating children with (n = 223) and without (n = 289) ASD. Cut-scores demonstrated moderate-to-high discriminative power, sensitivity, specificity, and PPV. Findings highlight feasibility of using a broadband social-emotional competence and behavior problem screener to improve early detection of ASD.

Student-Teacher Relationships for Young Children with Autism Spectrum Disorder: Risk and Protective Factors.

The quality of early student-teacher relationships (STRs) has been shown to predict children's school adjustment, and children with autism spectrum disorder (ASD) are at risk for poor quality STRs. The present study examined 162 children with ASD (ages 4-7) and their teachers to evaluate student, teacher, and classroom characteristics that predicted concurrent and prospective STR quality across one school year. Child oppositional behavior, autism severity and teacher degree predicted changes in student-teacher conflict over a 1-year period, while child social skills and IQ positively predicted change in student-teacher closeness. Teacher preparedness, trainings in ASD, and classroom setting were unrelated to STR quality. Implications for intervention are discussed.

Protocol for a multicentre randomised feasibility trial evaluating early Surgery Alone In LOw Rectal cancer (SAILOR).

INTRODUCTION: There are 11 500 rectal cancers diagnosed annually in the UK. Although surgery remains the primary treatment, there is evidence that preoperative radiotherapy (RT) improves local recurrence rates. High-quality surgery in rectal cancer is equally important in minimising local recurrence. Advances in MRI-guided prediction of resection margin status and improvements in abdominoperineal excision of the rectum (APER) technique supports a reassessment of the contribution of preoperative RT. A more selective approach to RT may be appropriate given the associated toxicity. METHODS AND ANALYSIS: This trial will explore the feasibility of a definitive trial evaluating the omission of RT in resectable low rectal cancer requiring APER. It will test the feasibility of randomising patients to (1) standard care (neoadjuvant long course RT±chemotherapy and APER, or (2) APER surgery alone for cT2/T3ab N0/1 low rectal cancer with clear predicted resection margins on MRI. RT schedule will be 45 Gy over 5 weeks as current standard, with restaging and surgery after 8-12 weeks. Recruitment will be for 24 months with a minimum 12-month follow-up. OBJECTIVES: Objectives include testing the ability to recruit, consent and retain patients, to quantify the number of patients eligible for a definitive trial and to test feasibility of outcomes measures. These include locoregional recurrence rates, distance to circumferential resection margin, toxicity and surgical complications including perineal wound healing, quality of life and economic analysis. The quality of MRI staging, RT delivery and surgical specimen quality will be closely monitored. ETHICS AND DISSEMINATION: The trial is approved by the Regional Ethics Committee and Health Research Authority (HRA) or equivalent. Written informed consent will be obtained. Serious adverse events will be reported to Swansea Trials Unit (STU), the ethics committee and trial sites. Trial results will be submitted for peer review publication and to trial participants. TRIAL REGISTRATION NUMBER: ISRCTN02406823.

An evaluation of operative training lists for senior house officers in a district general hospital.

INTRODUCTION: To address concerns about reduced opportunities for operative training, a programme of training operating lists for senior house officers was established. The entire patient pathway was used as a learning resource so that training was offered in a range of areas including development of knowledge, communication skills and attitudes as well as operative technique. PATIENTS AND METHODS: The programme was evaluated using a stakeholder approach, considering the impact on patients, the trainees and the host institution, including costs. Forty-two operations were performed during the 6-month evaluation period and the patients were compared with control patients undergoing the same procedure during a consultant-run operating list within 4 weeks. RESULTS: There was no difference in the patients' experience or overall satisfaction when comparing the trainees' patients with controls. Senior house officers performed only six other supervised operations on routine lists during the period; the programme increased their experience by 700%. Costs were increased by 12% per patient. CONCLUSIONS: There is an imperative to find new, efficient ways to train surgeons. Dedicated training operating lists with an appropriately controlled case-mix can both address a service need and provide a high intensity learning experience.

Patterns of hearing loss following retrosigmoid excision of unilateral vestibular schwannoma.

Objectives To determine the pattern of auditory responses, time-course of hearing deterioration, and possible site of lesion following retrosigmoid excision of unilateral vestibular schwannomas. Design Prospective, nonrandomized, observational pilot study. Setting Tertiary referral medical center. Main outcome measures Preoperative and postoperative pure-tone and speech audiometry, auditory brainstem response testing, and distortion product otoacoustic emissions were performed in 20 patients. Testing was conducted every 24 hours for the duration of hospitalization. Transtympanic electrocochleography was performed if delayed deterioration of auditory responses was documented. Results Of the 20 patients, 7 had no discernible cochlear nerve at the end of the procedure. Of the 13 patients with an intact nerve, 6 retained hearing, 3 with evidence of reduced neural function. Of the 7 who lost hearing despite an intact nerve, 5 lost at least cochlear and possibly also neural function, and 1 had reduced neural function but retained cochlear function. There were two examples of delayed deterioration of cochlear nerve responses. Conclusions Hearing loss following retrosigmoid removal of vestibular schwannomas most often involves loss of at least cochlear function, possibly in addition to neural damage. In a smaller number of cases anacusis or hearing deterioration can be attributed to purely neural trauma.

Improving the efficiency of the emergency general surgical service.

OBJECTIVE: To improve the quality and efficiency of our emergency surgical service. METHODS: Until 2007, the surgical on-call in our unit was run on a 'consultant of the day' model with triage in a 10-bed surgical receiving unit (SRU) before admission to the wards. The reduction in junior doctors' hours meant little continuity and delays in care.In July 2007, the SRU was expanded and a daily on-ward ultrasound session was established. The consultant rota was changed to a split-week model with twice-daily SRU ward rounds, allowing unstable patients regular senior assessment. RESULTS: As a result of the change, our acute length of stay reduced from 4.4 to 3.8 days and our actual versus expected length of stay was the best figure country-wide. CONCLUSION: Early consultant review and swift ultrasound assessment reduce admissions and patient stay. We have combined these factors in our emergency service and have delivered significant cost savings and improved care.