Anastomotic Leakage in Relation to Type of Mesorectal Excision and Defunctioning Stoma Use in Anterior Resection for Rectal Cancer.

BACKGROUND: Anastomotic leakage after anterior resection for rectal cancer is more common after total mesorectal excision compared to partial mesorectal excision but might be mitigated by a defunctioning stoma. OBJECTIVE: The aim is to assess how anastomotic leakage is affected by type of mesorectal excision and defunctioning stoma use. DESIGN: This is a retrospective multicenter cohort study evaluating anastomotic leakage after anterior resection. Multivariable Cox regression with HRs and 95% CIs was used to contrast mesorectal excision types and defunctioning stoma use with respect to anastomotic leakage, with adjustment for confounding. SETTINGS: This multicenter study included patients from 11 Swedish hospitals between 2014 and 2018. PATIENTS: Patients who underwent anterior resection for rectal cancer were included. MAIN OUTCOMES MEASURES: Anastomotic leakage rates within and after 30 days of surgery are described up to 1 year after surgery. RESULTS: Anastomotic leakage occurred in 24.2% and 9.0% of 1126 patients operated with total and partial mesorectal excision, respectively. Partial compared to total mesorectal excision was associated with a reduction in leakage, with an adjusted HR of 0.46 (95% CI, 0.29-0.74). Early leak rates within 30 days were 14.9% with and 12.5% without a stoma, whereas late leak rates after 30 days were 7.5% with and 1.9% without a stoma. After adjustment, defunctioning stoma was associated with a lower early leak rate (HR 0.47; 95% CI, 0.28-0.77). However, the late leak rate was nonsignificantly higher in patients with defunctioning stomas (HR 1.69; 95% CI, 0.59-4.85). LIMITATIONS: This study was limited by its retrospective observational study design. CONCLUSIONS: Anastomotic leakage is common up to 1 year after anterior resection for rectal cancer, where partial mesorectal excision is associated with a lower leak rate. Defunctioning stomas seem to decrease the occurrence of leakage, although partially by only delaying the diagnosis. See Video Abstract . FUGA ANASTOMTICA SEGN EL TIPO DE EXCISIN MESORRECTAL Y LA CONFECCIN DE OSTOMA DE PROTECCIN EN LA RESECCIN ANTERIOR POR CNCER DE RECTO: ANTECEDENTES:La fuga anastomótica después de una resección anterior por cáncer de recto es más frecuente después de la excisión total del mesorrecto comparada con la excisión parcial del mismo, pero podría mitigarse con la confección de ostomías de protección.OBJETIVO:El objetivo es evaluar cómo la fuga anastomótica se ve afectada según el tipo de excisión mesorrectal y la confección de una ostomía de protección.DISEÑO:Estudio de cohortes multicéntrico y retrospectivo que evalúa la fuga anastomótica después de la resección anterior. Se aplicó la regresión multivariada de Cox con los índices de riesgo (HR) y los intervalos de confianza (IC) al 95% para contrastar los tipos de excisión mesorrectal y el uso de otomías de protección con respecto a la fuga anastomótica, realizando ajustes respecto a las variables de confusión.AJUSTES:El presente estudio multicéntrico incluyó pacientes de 11 hospitales suecos entre 2014 y 2018.PACIENTES:Se incluyeron todos aquellos sometidos a resección anterior por cáncer de recto.PRINCIPALES MEDIDAS DE RESULTADOS:Las tasas de fuga anastomótica dentro y después de los 30 días de la cirugía fueron descritos hasta un año mas tarde al acto quirúrgico.RESULTADOS:La fuga anastomótica ocurrió en el 24,2% y el 9,0% de 1126 pacientes operados por excisión total y parcial del mesorrecto respectivamente.La excisión parcial del mesorrecto en comparación con la total se asoció con una reducción de la fuga, HR ajustado de 0,46 (IC del 95 %: 0,29 a 0,74). Las tasas de fuga temprana dentro de los 30 días fueron del 14,9 % con y el 12,5 % sin estoma, mientras que las tasas de fuga tardía después de 30 días fueron del 7,5 % con y el 1,9 % sin estoma.Después del ajuste de variables de confusión, las ostomías de protección se asociaron con una tasa de fuga temprana más baja (HR 0,47; IC 95 %: 0,28-0,77). Sin embargo, la tasa de fuga tardía no fue significativamente mayor en pacientes ostomizados (HR 1,69; IC 95%: 0,59-4,85).LIMITACIONES:Las limitaciones del presente estudio estuvieron vinculadas con el diseño de tipo observacional y retrospectivo.CONCLUSIONES:La fuga anastomótica es común hasta un año después de la resección anterior por cáncer de recto, donde la excisión parcial del mesorrecto se asocia con una menor tasa de fuga. La confección de ostomías de protección parece disminuir la aparición de fuga anastomótica, aunque en parte sólo retrasen el diagnóstico. (Traducción-Dr. Xavier Delgadillo ).

Bowel Dysfunction After Colon Cancer Surgery: A Prospective, Longitudinal, Multicenter Study.

BACKGROUND: Longitudinal studies on functional outcomes after colon resection are limited. OBJECTIVE: To evaluate bowel dysfunction and related distress 1 and 3 years after colon resection using the low anterior resection syndrome score as well as specific validated items. DESIGN: This study presents the long-term results of bowel dysfunction and related distress based on the Quality of Life in Colon Cancer study, an observational, prospective multicenter study of patients with newly diagnosed colon cancer. SETTINGS: The study was conducted at 21 Swedish and Danish surgical centers between 2015 and 2019. PATIENTS: All patients who underwent right-sided or left-sided colon resection were considered eligible. Exclusion criteria were age younger than 18 years, cognitive impairment, or inability to understand Swedish/Danish. Patients completed extensive questionnaires at diagnosis and after 1 and 3 years. Clinical data were supplemented by national quality registries. MAIN OUTCOME MEASURES: The low anterior resection syndrome score, specific bowel symptoms, and patient-reported distress were assessed. RESULTS: Of 1221 patients (83% response rate), 17% reported major low anterior resection syndrome 1 year after either type of resection; this finding was consistent at 3 years (17% right, 16% left). In the long-term, the only significant difference between types of resections was a high occurrence of loose stools after right-sided resections. Overall, less than one-fifth of patients experienced distress, with women reporting more frequent symptoms and greater distress. In particular, incontinence and loose stools correlated strongly with distress. LIMITATIONS: Absence of prediagnosis bowel function data. CONCLUSIONS: Our study indicates that bowel function remains largely intact after colon resection, with only a minority reporting significant distress. Adverse outcomes were more common among women. The occurrence of loose stools after right-sided resection and the association between incontinence, loose stools, and distress highlights a need for postoperative evaluations and more thorough assessments beyond the low anterior resection syndrome score when evaluating patients with colon cancer. See the Video Abstract . DISFUNCIONAMIENTO INTESTINAL DESPUS DE LA CIRUGA POR CNCER DE COLON ESTUDIO PROSPECTIVO, LONGITUDINAL Y MULTICNTRICO: ANTECEDENTES:Los estudios longitudinales sobre el resultado funcional después de una resección cólica son limitados.OBJETIVO:Examinar la disfunción intestinal y el malestar relacionado uno y tres años después de la resección del colon utilizando la puntuación de referencia en el síndrome de resección anterior baja (LARS), así como otros ítems de validez específica.DISEÑO:Este estudio presenta los resultados a largo plazo de la disfunción intestinal y la angustia relacionada según el estudio QoLiCOL (Quality of Life in COLon cancer), un analisis observacional, prospectivo y multicéntrico de pacientes con cáncer de colon recién diagnosticado.AJUSTES:El presente estudio fué realizado en 21 centros quirúrgicos suecos y daneses entre 2015 y 2019.PACIENTES:Todos los pacientes sometidos a resección de colon, tanto del lado derecho como el izquierdo se consideraron elegibles. Los criterios de exclusión fueron tener menos de 18 años, deterioro cognitivo o incapacidad para entender sueco/danés. Los pacientes completaron extensos cuestionarios en el momento del diagnóstico y después de uno y tres años. Los datos clínicos se complementaron con los registros de calidad binacionales.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron los síntomas intestinales específicos, la puntuación LARS y la angustia manifestada por cada paciente.RESULTADOS:De 1221 pacientes (tasa de respuesta del 83%), el 17% informó LARS mayor un año después de cualquier tipo de resección, consistente a los tres años (17% derecha, 16% izquierda). A largo plazo, la única diferencia significativa entre los tipos de resección fue una alta incidencia de heces liquidas después de las resecciones del lado derecho. En general, menos de una quinta parte de los pacientes experimentaron angustia, y fué la poblacion femenina quién informó de síntomas más frecuentes y de mayor angustia. En particular, la incontinencia y las heces liquidas se correlacionaron fuertemente con la angustia.LIMITACIONES:Ausencia de datos de función intestinal previos al diagnóstico.CONCLUSIONES:Nuestro estudio indica que la función intestinal permanece en gran medida intacta después de la resección del colon, y sólo una minoría reporta malestar significativo. Los resultados adversos fueron más comunes en la población femenina. La aparición de heces liquidas después de la resección del lado derecho y la asociación entre incontinencia, heces liquidas y malestar resalta la necesidad de evaluaciones postoperatorias y valoraciones más exhaustivas más allá de la puntuación LARS al evaluar a los pacientes con cáncer de colon. (Traducción-Dr. Xavier Delgadillo ).

Can Transabdominal Cervical Length Measurement Exclude Short Cervix?

OBJECTIVE: This study aims to determine if transabdominal (TA) cervical length may be used to rule out a short cervix on transvaginal (TV) ultrasound. STUDY DESIGN: We conducted a prospective cohort study of women undergoing routine anatomic survey at 17 to 23 weeks gestation. TA and TV cervical length measurements were obtained in each patient. A short cervix was defined as TV cervical length < 30 mm. Predictive characteristics were calculated for different cutoff values of TA cervical length. RESULTS: There were 404 patients enrolled, a TA cervical length could not be obtained in 83 women (20.6%) and 318 women had both TA and TV measurements. Of those, 14 (4.4%) had a TV cervical length < 30 mm. TA cervical length measurement ≥ 35 mm excluded the possibility of TV cervical length < 30 mm (negative predictive value, 99.5%; 95% confidence interval [CI], 97.4; 100%). In our cohort, 67.6% (95% CI, 62.2; 72.7%) of TV ultrasounds could have been avoided using a TA cervical length cutoff of ≥ 5 mm. CONCLUSION: ATA cervical length of at least 35 mm excludes a short cervix of < 30 mm. While TA cervical length screening may not be feasible in 1 in 5 women, it may be used to decrease the burden of universal TV cervical length screening.

Obsessive-Compulsive Personality Traits in Youth with Obsessive-Compulsive Disorder.

While interest in the relationship between obsessive-compulsive disorder (OCD) and obsessive compulsive personality disorder has increased, there are currently no studies that have examined the presence of obsessive compulsive personality traits (OCPTs) in youth. The current study sought to determine the latent factors and psychometric properties of a modified version of the Childhood Retrospective Perfectionism Questionnaire (CHIRP) and examine the correlates of specific OCPTs (e.g., rigidity, perfectionism) in youth with OCD. Participants included 96 treatment-seeking youth diagnosed with primary OCD (and a parent). Parents and youth completed measures of OCPTs, OCD severity, depression, and disability. A confirmatory factor analysis of the modified CHIRP resulted in a two-factor model: perfectionism and preoccupation with details. The CHIRP and its subscales demonstrated acceptable internal consistency and preliminary evidence for convergent and divergent validity. Obsessive compulsive traits in youth were also found to be associated with the checking, symmetry and contamination symptom dimensions.

Neuropsychological performance across symptom dimensions in pediatric obsessive compulsive disorder.

BACKGROUND: Few studies have examined neuropsychological functioning among youth with obsessive compulsive disorder (OCD), with inconclusive results. Although methodological differences may contribute to inconsistent findings, clinical factors may also account for differential performance. Symptom dimensions are associated with specific patterns of genetic transmission, comorbidity, and treatment outcome, and may also be uniquely associated with neuropsychological performance. This study examined differences in cognitive sequelae and neurocognitive impairment across symptom dimensions among youth with OCD. METHOD: Participants included 93 treatment-seeking youth diagnosed with OCD. A trained clinician administered the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) to parents and children together. Afterward, youth completed a battery of neuropsychological tests that assessed nonverbal memory and fluency, verbal memory, verbal fluency, verbal learning, processing speed, and inhibition/switching. RESULTS: Across five symptom dimensions, youth exhibiting Hoarding symptoms (χ(2) = 5.21, P = .02) and Symmetry/Ordering symptoms had a greater occurrence of cognitive sequelae (χ(2) = 4.86, P = .03). Additionally, youth with Symmetry/Ordering symptoms had a greater magnitude of cognitive impairment (Mann-Whitney U = 442.50, Z = -2.49, P < .02), with specific deficits identified on nonverbal fluency (P < .01), processing speed (P < .01), and inhibition and switching (P < .02). CONCLUSIONS: Neuropsychological deficits identified in youth with Hoarding and Symmetry/Ordering symptoms may suggest that these symptoms have characteristics specific to neurocognitive impairment. Alternatively, symptoms associated with these dimensions may impede youth's performance during testing. Findings advise neuropsychological testing for youth with symptoms on either of these dimensions when concerns about neuropsychological and/or academic impairment are present.

Cervical cerclage: one stitch or two?

OBJECTIVE: We sought to determine whether routine placement of a second stitch at the time of cervical cerclage improves its efficacy. STUDY DESIGN: This is a retrospective cohort study of patients who had cervical cerclage placement at a single institution. Operative reports, ultrasound images, and delivery records were reviewed. Pregnancy outcomes of patients receiving a two-stitch cerclage were compared with those who received a one-stitch cerclage, with a primary outcome of spontaneous preterm delivery at <35 weeks' gestation. Univariable, multivariable, and Kaplan-Meier survival analyses were performed. RESULTS: Of 146 patients, 63 had two stitches and 83 had one. Baseline characteristics and indications for cerclage were similar except for differences in history of prior cerclage and multiple gestations. The two-stitch approach was associated with a greater median cerclage height (20 mm versus 17 mm, p = 0.008), but there was no difference in spontaneous preterm delivery at <35 weeks' gestation (47.6% versus 41.0%, adjusted odds ratio 1.22, p = 0.630). CONCLUSION: A two-stitch approach to cervical cerclage increases cerclage height, but may not improve efficacy.

Evidence-based assessment of compulsive skin picking, chronic tic disorders and trichotillomania in children.

Body-focused repetitive behavior (BFRB) is an umbrella term for debilitating, repetitive behaviors that target one or more body regions. Despite regularly occurring in youth, there has been limited investigation of BFRBs in pediatric populations. One reason for this may be that there are few reliable and valid assessments available to evaluate the presence, severity and impairment of BFRBs in youth. Given the shift toward evidence-based assessment in mental health, the development and utilization of evidence-based measures of BFRBs warrants increasing attention. This paper examines the available evidence-base for assessments in youth across three BFRB-related disorders: compulsive skin picking, chronic tic disorders and trichotillomania. Based upon present empirical support in samples of youth, recommendations are made for an evidence-based assessment of each condition.

Early childhood trichotillomania: Initial considerations on phenomenology, treatment, and future directions.

Historically, trichotillomania (TTM) in young children (0-3 years old) generally has been considered to be a benign habit that is clinically distinct from the TTM seen in older children and adults. However, early childhood TTM can be an impairing pathological disorder that merits formal intervention. The present article reviews the extant literature on TTM in young children, highlighting the limited available phenomenological data. We discuss a behavioral approach to conceptualization and treatment, highlighting core intervention strategies in three early childhood TTM cases seen in our clinic. We conclude by discussing areas in need of further empirical attention.

Profiling Behavioral and Psychological Symptoms in Children Undergoing Treatment for Spondyloarthritis and Polyarthritis.

OBJECTIVE: Few studies examine psychopathology in different juvenile idiopathic arthritis (JIA) subtypes and disease activity states. We aimed to (1) evaluate emotional and behavioral symptoms in children with juvenile spondyloarthritis (SpA) and polyarticular arthritis (PolyA) as compared to a national normative population using the Child Behavior Checklist (CBCL), and (2) evaluate the relationship between CBCL scores and disease activity. METHODS: Patients with JIA aged 6-17 years with SpA or PolyA were recruited from our pediatric rheumatology clinic from April 2018 to April 2019 and the CBCL and clinical Juvenile Arthritis Disease Activity Score in 10 joints (cJADAS10) were completed. Primary outcome measures were CBCL total competence, internalizing, externalizing, and total problems raw scores. We compared outcomes from each group to national CBCL normative data. To investigate the relationship between CBCL scores and disease activity, we ran a generalized linear regression model for all patients with arthritis with cJADAS10 as the main predictor. RESULTS: There were 111 patients and 1753 healthy controls (HCs). Compared to HCs, patients with SpA or PolyA had worse total competence and internalizing scores. Higher cJADAS10 scores were associated with worse total competence, worse internalizing, and higher total problems scores. Most of these differences reached statistical significance (P < 0.01). Self-harm/suicidality was almost 4-fold higher in patients with PolyA than HCs (OR 3.6, 95% CI 1.3-9.6, P = 0.011). CONCLUSION: Our study shows that patients with SpA and PolyA with more active disease have worse psychological functioning in activities, school, and social arenas, and more internalized emotional disturbances, suggesting the need for regular mental health screening by rheumatologists.

Compulsive hoarding in children.

This article discusses the nature and treatment of compulsive hoarding among children. We summarize the phenomenology of compulsive hoarding, including its clinical presentation, comorbidity with varied mental disorders, and associated impairment. The limited data on treatment outcome are presented along with a behavioral framework that we utilized to treat youth who hoard. Our approach is highlighted in the context of a case illustration of an 11-year-old girl suffering from compulsive hoarding and several comorbid mental health disorders. We conclude with recommendations for clinical work with this challenging and neglected population.

Measuring the suicidal mind: implicit cognition predicts suicidal behavior.

Suicide is difficult to predict and prevent because people who consider killing themselves often are unwilling or unable to report their intentions. Advances in the measurement of implicit cognition provide an opportunity to test whether automatic associations of self with death can provide a behavioral marker for suicide risk. We measured implicit associations about death/suicide in 157 people seeking treatment at a psychiatric emergency department. Results confirmed that people who have attempted suicide hold a significantly stronger implicit association between death/suicide and self than do psychiatrically distressed individuals who have not attempted suicide. Moreover, the implicit association of death/suicide with self was associated with an approximately 6-fold increase in the odds of making a suicide attempt in the next 6 months, exceeding the predictive validity of known risk factors (e.g., depression, suicide-attempt history) and both patients' and clinicians' predictions. These results provide the first evidence of a behavioral marker for suicidal behavior and suggest that measures of implicit cognition may be useful for detecting and predicting sensitive clinical behaviors that are unlikely to be reported.

The Burden of Caring for a Child or Adolescent With Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): An Observational Longitudinal Study.

OBJECTIVE: To describe the longitudinal association between disease severity, time established in clinical treatment, and caregiver burden in a community-based patient population diagnosed with pediatric acute-onset neuropsychiatric syndrome (PANS). METHODS: The study included an observational longitudinal cohort design, with Caregiver Burden Inventories (CBIs) collected between April 2013 and November 2016 at the Stanford PANS multidisciplinary clinic. Inclusion criteria for this study were as follows: pediatric patients meeting strict PANS/pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) diagnostic criteria (n = 187), having a caregiver fill out at least 1 complete CBI during a disease flare (n = 114); and having family who lives locally (n = 97). For longitudinal analyses, only patients whose caregiver had filled out 2 or more CBIs (n = 94 with 892 CBIs) were included. In the study sample, most primary caregivers were mothers (69 [71.1%] of 97), the majority of PANS patients were male (58 [59.8%] of 97), and mean age at PANS onset was 8.8 years. RESULTS: In a patient's first flare tracked by the clinic, 50% of caregivers exceeded the caregiver burden score threshold used to determine respite need in care receiver adult populations. Longitudinally, flares, compared with quiescence, predicted increases in mean CBI score (6.6 points; 95% CI, 5.1 to 8.0). Each year established in clinic predicted decreased CBI score (-3.5 points per year; 95% CI, -2.3 to -4.6). Also, shorter time between PANS onset and entry into the multidisciplinary clinic predicted greater improvement in mean CBI score over time (0.7 points per year squared; 95% CI, 0.1 to 1.3). Time between PANS onset and treatment with antibiotics or immunomodulation did not moderate the relationship between CBI score and time in clinic. CONCLUSIONS: PANS caregivers suffer high caregiver burden. Neuropsychiatric disease severity predicts increased caregiver burden. Caregiver burden tends to decrease over time in a group of patients undergoing clinical treatment at a specialty PANS clinic. This decrease could be independent of clinical treatment.

Hoarding in Children With ADHD.

OBJECTIVE: Although evidence suggests that hoarding may be associated with symptoms of ADHD, no study has examined this relationship in children. METHOD: Participants included 99 youth diagnosed with ADHD (and a parent) seen in a general outpatient psychiatry clinic. Children completed the Obsessive-Compulsive Inventory-Child Version, the Revised Child Anxiety and Depression Scale, and the Rosenberg Self-Esteem Scale. Parents completed the Children's Saving Inventory and Vanderbilt ADHD Diagnostic Rating Scale-Parent Version. RESULTS: Inattentive and hyperactive/impulsive symptoms were the only indicator that differentiated those with and without clinically significant hoarding. Symptoms of ADHD, but not nonhoarding obsessive-compulsive symptoms, significantly predicted hoarding. Inattention and hyperactivity/impulsivity were uniquely associated with individual hoarding features. Hoarding symptoms mediated the relationship between ADHD and oppositionality. CONCLUSION: These findings contribute to the growing literature about the association between hoarding and ADHD.

ADHD and executive functioning deficits in OCD youths who hoard.

Hoarding is common among youth with obsessive compulsive disorder (OCD), with up to 26% of OCD youth exhibiting hoarding symptoms. Recent evidence from adult hoarding and OCD cohorts suggests that hoarding symptoms are associated with executive functioning deficits similar to those observed in subjects with attention deficit hyperactivity disorder (ADHD). However, while hoarding behavior often onsets during childhood, there is little information about executive function deficits and ADHD in affected children and adolescents. The study sample included 431 youths (ages 6-17 years) diagnosed with OCD who participated in the OCD Collaborative Genetics Study and the OCD Collaborative Genetics Association Study and completed a series of clinician-administered and parent report assessments, including diagnostic interviews and measures of executive functioning (Behavior Rating Inventory of Executive Functioning; BRIEF) and hoarding severity (Hoarding Rating Scale-Interview; HRS-I). 113 youths (26%) had clinically significant levels of hoarding compulsions. Youths with and without hoarding differed significantly on most executive functioning subdomains and composite indices as measured by the parent-rated BRIEF. Groups did not differ in the frequency of full DSM-IV ADHD diagnoses; however, the hoarding group had significantly greater number of inattention and hyperactivity symptoms compared to the non-hoarding group. In multivariate models, we found that overall BRIEF scores were related to hoarding severity, adjusting for age, gender and ADHD symptoms. These findings suggest an association between hoarding and executive functioning deficits in youths with OCD, and assessing executive functioning may be important for investigating the etiology and treatment of children and adolescents with hoarding and OCD.

Living with tics: reduced impairment and improved quality of life for youth with chronic tic disorders.

Pharmacological and behavioral interventions have focused on reducing tic severity to alleviate tic-related impairment for youth with chronic tic disorders (CTDs), with no existing intervention focused on the adverse psychosocial consequences of tics. This study examined the preliminary efficacy of a modularized cognitive behavioral intervention ("Living with Tics", LWT) in reducing tic-related impairment and improving quality of life relative to a waitlist control of equal duration. Twenty-four youth (ages 7-17 years) with Tourette Disorder or Chronic Motor Tic Disorder and psychosocial impairment participated. A treatment-blind evaluator conducted all pre- and post-treatment clinician-rated measures. Youth were randomly assigned to receive the LWT intervention (n=12) or a 10-week waitlist (n=12). The LWT intervention consisted of up to 10 weekly sessions targeted at reducing tic-related impairment and developing skills to manage psychosocial consequences of tics. Youth in the LWT condition experienced significantly reduced clinician-rated tic-impairment, and improved child-rated quality of life. Ten youth (83%) in the LWT group were classified as treatment responders compared to four youth in the waitlist condition (33%). Treatment gains were maintained at one-month follow-up. Findings provide preliminary data that the LWT intervention reduces tic-related impairment and improves quality of life for youth with CTDs.

Child disability and mothers' tubal sterilization.

CONTEXT: The needs of children with disability can be substantial, leading some parents to consider contraceptive sterilization to prevent additional births. METHODS: Matched records from the 1993 National Health Interview Survey and the 1995 National Survey of Family Growth were used to investigate the relationship between child disability and mothers' sterilization. Data included the birth records of 8,711 children, information on older children in the household, and the mothers' background and reproductive characteristics. Logistic and Cox regression models were used to estimate the effect of the birth of a child with a disability on the risk of mothers' sterilization. RESULTS: The birth of a child with disability has no effect on the likelihood that a mother will undergo sterilization within the next month; however, women who have an older child with severe disability are more likely than those whose older children are nondisabled to undergo sterilization within a month after the birth of another child (odds ratio, 2.6). Severe disability in a newborn significantly increases the risk of sterilization 1-36 months after birth (risk ratio, 1.7); severe disability among older children also appears to increase the risk of sterilization 1-36 months after birth (1.5), although this result was only marginally significant. CONCLUSIONS: Women often respond to the birth of children with disabilities by changing their fertility plans, although usually not immediately unless they have older children with severe disability. These findings are consistent with parents'desire to have a nondisabled child and with their need to care for an exceptional child by forgoing additional births.

Novel approaches in treatment of pediatric anxiety.

Pediatric anxiety disorders have high prevalence rates and morbidity and are associated with considerable functional impairment and distress. They may be predictors for the development of other psychiatric disorders and, without intervention, are more likely to persist into adulthood. While evidence-based pharmacological and behavioral interventions are currently available, there remains a sizable subset of youth who remain only partially treatment-responsive and therefore symptomatic following treatment. Novel methods of treatment, pharmacologic and non-pharmacologic, including acceptance and commitment therapy (ACT), attention bias modification (ABM), d-cycloserine (DCS) augmentation of cognitive behavioral treatment (CBT), and glutamatergic agents such as riluzole, are briefly introduced and discussed.

Adult offspring perspectives on parental hoarding behaviors.

Hoarding disorder (HD) is characterized by difficulty discarding unneeded items and the accumulation of items within living spaces and is associated with significant functional impairment and distress. Along with the negative impact of hoarding on the individual, HD is substantially impairing for family members, and linked to disruptions in family functioning. The present study utilized a path model analysis to examine the associations between an array of hoarding variables hypothesized to impact family functioning and parent-offspring relationships in 150 adult-aged children of hoarders who responded to online requests to participate in a research study. It was hypothesized that increased hoarding severity, decreased insight, and increased family accommodation (i.e., act of family members facilitating or assisting in hoarding behaviors) would be associated with decreased family functioning, decreased quality of parent-offspring relationships, and increased offspring impairment. Results from the path model revealed that family functioning mediated the relationship between hoarding severity and parent-offspring relationship. Diminished insight in the hoarding parent (as reported by the offspring) was associated with increased familial conflict and family functioning partially mediated the relationship between insight and quality of parent-offspring relationship. Increased family accommodation was significantly associated with increased impairment (work, social, and family domains) in offspring of hoarders.

Neuropsychological functioning in youth with obsessive compulsive disorder: an examination of executive function and memory impairment.

Preliminary research suggests neuropsychological deficits in youth with obsessive-compulsive disorder (OCD) similar to those in adults; however, small samples and methodological confounds limit interpretation. We aimed to examine the rates and clinical correlates of cognitive sequelae in youth with OCD, focusing on executive functioning and memory abilities. Youth ages 7-17 years with OCD (N=96) completed a hypothesis-driven neuropsychological battery (including the Rey-Osterreith Complex Figure, California Verbal Learning Test, and subtests of the Delis-Kaplan Executive Function System and Wide Range Assessment of Memory and Learning) that primarily assessed executive functioning, memory and processing speed. Cognitive sequelae were identified in 65% of youth (37% using a more stringent definition of impairment). Magnitude of cognitive sequelae was not associated with OCD severity or age; however, greater neuropsychological impairments were found amongst youth prescribed atypical neuroleptics and those diagnosed with comorbid tic disorders. Comorbidity burden was associated with presence of neuropsychological impairment, but was not specific to any single test. Findings suggest that the presence of cognitive sequelae is prevalent amongst treatment-seeking youth with OCD. Deficits were found in executive functioning and non-verbal memory performance but these impairments were not associated with OCD severity.

Does d-Cycloserine Augmentation of CBT Improve Therapeutic Homework Compliance for Pediatric Obsessive-Compulsive Disorder?

Clinical studies in adults and children with obsessive-compulsive disorder (OCD) have shown that d-cycloserine (DCS) can improve treatment response by enhancing fear extinction learning during exposure-based psychotherapy. Some have hypothesized that improved treatment response is a function of increased compliance and engagement in therapeutic homework tasks, a core component of behavioral treatment. The present study examined the relationship between DCS augmented cognitive-behavioral therapy (CBT) and homework compliance in a double-blind, placebo controlled trial with 30 youth with OCD. All children received 10 CBT sessions, the last seven of which included exposure and response prevention paired with DCS or placebo dosed 1 h before the session started. Results suggested that DCS augmented CBT did not predict improved homework compliance over the course of treatment, relative to the placebo augmented CBT group. However, when groups were collapsed, homework compliance was directly associated with treatment outcome. These findings suggest that while DCS may not increase homework compliance over time, more generally, homework compliance is an integral part of pediatric OCD treatment outcome.