Telesimulation for Training in Infant Feeding: A Randomized Controlled Trial.

Simulation is an education modality known to support clinical skill development. Unfortunately, access to simulation has been challenging, both prior to and during the pandemic. Simulation via telepractice, i.e., "telesimulation", has emerged, but little is known about whether outcomes are comparable to in-person simulation. This study compared in-person versus telesimulation learner outcomes in an infant feeding scenario. The secondary aim was to compare outcomes between novice and experienced participants.This pragmatic randomized controlled trial included speech pathologists who could attend if randomized to the in-person modality. Block randomization matched participants with < 6 months' infant feeding experience to those with > 6 months experience (2:1 ratio) into telesimulation or in-person simulation. Measures of clinical reasoning, confidence/anxiety, and satisfaction were collected, pre-, post-, and 4-weeks post-simulation.Overall, 39 clinicians completed either in-person simulation (n = 17) or telesimulation training (n = 22), including 16 experienced and 23 novice learners. Both in-person and telesimulation groups achieved significant improvements across time in clinical reasoning, self-reported confidence, and anxiety. The extent of change in clinical reasoning, confidence and anxiety was comparable between the telesimulation and in-person simulation groups. Comparing by experience, novice-level participants reported significantly greater changes in confidence and anxiety than experienced participants. Satisfaction levels were high regardless of simulation modality or experience.Participants in telesimulation and in-person simulation achieved similar improvements in the primary outcome measure of clinical reasoning, had comparable improvements in self-perceived confidence and anxiety, and demonstrated high satisfaction levels. Telesimulation is a promising means to improve clinician access to simulation training in infant feeding.

Examining the Outcomes of Project ECHO® as an Interprofessional Community of Practice for Pediatric Feeding Clinicians.

Project ECHO® is a virtual, interprofessional, cased-based peer-learning model. To date, no studies have explored ECHO as a model for pediatric feeding education. This study examined the outcomes of establishing a pediatric feeding ECHO network. Using a prospective, mixed-methods design, two cohorts of allied health professionals were recruited. Each cohort participated in eight, 90-min videoconference sessions incorporating a didactic presentation and clinical case presentation. The case was presented by a participant, with questions and recommendations provided by the ECHO network. Participants completed: (1) a learning needs analysis before the ECHO series, (2) a self-reported confidence questionnaire pre, post, and 3-month post, (3) a satisfaction questionnaire after each session, and (4) an overall satisfaction questionnaire post-ECHO series. Time spent by hospital allied health clinicians providing impromptu phone/email feeding support to external clinicians was recorded for 8 weeks prior to and 8 weeks during the ECHO series. Forty-seven participants were included in the study, attending an average of 5.8 sessions. Significant improvements in self-reported confidence were observed across the three time points (p < 0.01) with less experienced participants demonstrating greater improvements. Participants reported high satisfaction with ECHO, with 93% (40/43) wanting continued access to ECHO in future. The multidisciplinary format, interactivity, structure, and case-based nature of ECHO were considered beneficial. A 75% reduction in requests for support from clinicians in the same catchment area was noted during the ECHO series. Results demonstrated that Project ECHO is a viable model for pediatric feeding education for clinicians working in the field. Further research is needed to investigate the long-term effects and impacts on clinical care.

Testing and Development of Slightly Thick Infant Formula Recipes for Dysphagia Management: An Australian Perspective.

Thickened feeds may be useful in supporting improved suck-swallow-breath coordination and airway protection in infants with dysphagia. Unfortunately, the stability of thickened feeds for infant formulas is unpredictable, which makes use of this strategy challenging. This study aimed to propose a set of Level 1 (slightly thick) recipes for Australian infant formulas/thickeners. A secondary aim was to test whether formula could be batch prepared. A set of powdered, ready-to-feed, and specialized formulas were mixed with two thickening products (Aptamil Feed Thickener® and Supercol®) and tested at 5-, 10-, 15-, 20-, 25-, 30-, and 45-min intervals using the International Dysphagia Diet Standardization Initiative (IDDSI) Flow Test. Formula/thickener samples were mixed following manufacturer instructions, but recipes were adapted to determine an ideal recipe for Level 1 (slightly thick) consistency that would be maintained over a feed. Samples were refrigerated, reheated after 12 h, and retested. Each combination was tested six times. Overall, 1,353 IDDSI Flow Tests were conducted using 14 formula/thickener combinations. In all combinations, recipe alterations were made using metric spoon measurements as opposed to the manufacturer-provided scoop. All samples were most variable at the 5-min timepoint. Formulas thickened with Supercol® generally reached a more stable consistency by 10 min, whereas formulas thickened with Aptamil Feed Thickener® were more stable by 15 min. Samples tested after 12 h were more variable with Aptamil Feed Thickener®. This study provides practical recommendations for clinicians working with infants requiring thickened feeds for dysphagia management. Further study under controlled laboratory conditions is required.

Oral feeding for infants and children receiving nasal continuous positive airway pressure and high flow nasal cannula: a systematic review.

BACKGROUND: The aim of this systematic review was to determine whether introduction of oral feeding for infants and children receiving nasal continuous positive airway pressure (nCPAP) or high flow nasal cannula (HFNC) respiratory support facilitates achievement of full oral feeding without adverse effects, compared to no oral feeding (NPO; nil per oral) on CPAP or HFNC. METHODS: A protocol was lodged with the PROSPERO International Prospective Register of Systematic Reviews. We searched Medline, Embase, CINAHL, CENTRAL and AustHealth from database inception to 10th June 2020. Study population included children (preterm to < 18 years) on nCPAP or HFNC who were orally feeding. Primary outcomes included full or partial oral feeding and oropharyngeal aspiration. Secondary outcomes examined adverse events including clinical signs of aspiration, aspiration pneumonia and deterioration in respiratory status. RESULTS: The search retrieved 1684 studies following duplicate removal. Title and abstract screening identified 70 studies for full text screening and of these, 16 were included in the review for data extraction. Methods of non-invasive ventilation (NIV) included nCPAP (n = 6), nCPAP and HFNC (n = 5) and HFNC (n = 5). A metanalysis was not possible as respiratory modes and cohorts were not comparable. Eleven studies reported on adverse events. Oral feeding safety was predominantly based on retrospective data from chart entries and clinical signs, with only one study using an instrumental swallow evaluation (VFSS) to determine aspiration status. CONCLUSIONS: Findings are insufficient to conclude whether commencing oral feeding whilst on nCPAP or HFNC facilitates transition to full oral feeding without adverse effects, including oropharyngeal aspiration. Further research is required to determine the safety and efficacy of oral feeding on CPAP and HFNC for infants and children. TRIAL REGISTRATION: PROSPERO registration number:  CRD42016039325 .

Psychoeducation for Children with Chronic Conditions: A Systematic Review and Meta-analysis.

OBJECTIVE: This systematic review and meta-analysis evaluated the effectiveness of psychoeducational interventions in improving quality of life (QoL) for children with chronic conditions. METHODS: We identified 25 randomized controlled trials of psychoeducational interventions for children with chronic conditions that reported a QoL outcome and were published 1980-2018. Due to small numbers of interventions in other chronic conditions, comparisons between chronic conditions were limited to 17 studies addressing interventions for asthma and diabetes. RESULTS: Psychoeducational interventions were associated with a small, statistically significant improvement in QoL (standardized mean difference = 0.14; 95% confidence interval: 0.06-0.23). The effect was significantly larger for asthma interventions compared to diabetes interventions, and in interventions delivered to younger (under 12 years) rather than older children (12 years and over). CONCLUSIONS: These results suggest that currently evaluated psychoeducational interventions improve QoL for children with asthma but not for children with diabetes. Children with diabetes may require tailored interventions with additional components alongside psychoeducation. Further intervention studies are needed to generalize to other conditions and to draw conclusions about which settings and modes of delivery are most effective in improving QoL.

Urban general practice and medical education: Academic outcomes from a unique urban, longitudinal integrated community-based program.

BACKGROUND: In 2009, Flinders University established an urban, community-based, longitudinal integrated program providing medical students extended placements that offered continuities of patient care, clinical supervision and peer group. OBJECTIVE: The aim of this research was to analyse academic outcomes of the new placement program. METHODS: The results of all students undertaking Year 3 exams from 2011 to 2014 were collected and analysed. The Years 1 and 2 exam results for students in the new program were also analysed. RESULTS: Students in the new placement program achieved significantly higher grades than those who undertook the traditional rotations program, with aver-age scores of 69.05, compared with 66.45 (P = 0.03). Analysis of average class ranking for students who undertook the new program showed a statistically significant improvement from 59th in class to 48th in class (P = 0.03). DISCUSSION: This evaluation shows that an urban, community-based, longitudinal integrated clerkship centred in general practice provides at least academically equivalent outcomes to traditional rotations-based programs.

Appearance concerns and psychosocial adjustment following head and neck cancer: A cross-sectional study and nine-month follow-up.

Psychosocial difficulties have been reported in head and neck cancer (HNC) patients, yet only few studies have assessed the impact of altered appearance following HNC treatment using theoretically selected measures of appearance-related distress. This study investigated appearance-related adjustment following HNC, and demographic and socio-cognitive predictors of adjustment. HNC patients (n=49) completed baseline questionnaires and a nine-month postal follow-up (n=20). Participants showed considerable variation in appearance-related adjustment, with females reporting higher levels of appearance-related distress (derriford appearance scale [DAS-24]) than females in the general population and male HNC survivors. Depression scores on the hospital anxiety and depression scale were higher than UK norms whilst anxiety was similar to UK norms. There were no significant differences between baseline and follow-up data. Fear of negative evaluation (a central feature of social anxiety) was a significant predictor of appearance-related adjustment at baseline, whilst dispositional optimism was a significant predictor of appearance-related adjustment at baseline and follow-up. Qualitative responses showed themes of appearance and disability, and coping strategies. Findings suggest that appearance-related adjustment post-HNC varies considerably and psychosocial services working with HNC patients should consider this broad pattern of response. Future research to examine the role of socio-cognitive predictors of appearance-related adjustment could progress development of effective psychological interventions.

Experiences of Allied Health Clinicians Accessing a Pilot Project ECHO® Program to Support Learning in Pediatric Feeding.

INTRODUCTION: Pediatric feeding disorder is increasing in prevalence, yet low clinician confidence regarding its management is a barrier to care. Targeted clinician training is needed as traditional didactic training programs are limited in both their accessibility and capacity to provide opportunities for the application of theory-based learning. METHODS: This study examined the experiences of a group of clinicians involved in a multidisciplinary PedFeed ECHO® network, a virtual community of practice established to support speech pathologists, occupational therapists, dieticians, and psychologists in Queensland, Australia, working with children with pediatric feeding disorder. Sixteen clinicians (34% of the total PedFeed ECHO network) from different professional backgrounds, clinical settings, and locations participated in semistructured interviews three months post completion of eight ECHO sessions. RESULTS: Inductive thematic analysis revealed three themes: (1) broad-ranging outcomes of PedFeed ECHO, (2) participant experiences of PedFeed ECHO, and (3) facilitators for future success. PedFeed ECHO was viewed very positively and provided participants with a valuable opportunity for information sharing and collaboration as a multidisciplinary team. Participants described impacts on their professional practice, knowledge, confidence, and professional isolation, as well as service and patient-level impacts. Several facilitators for the success of future PedFeed ECHO cohorts were provided. DISCUSSION: Insights from participants will serve to improve the design and delivery of ECHO training for future cohorts. Monitoring clinical skill development over a longer period of time and exploring clinician perceptions regarding direct impact on patient care are needed to further validate the impact of ECHO.

The effectiveness of psychosocial interventions designed to improve health-related quality of life (HRQOL) amongst asthmatic children and their families: a systematic review.

PURPOSE: Asthmatic children are at risk of compromised health-related quality of life (HRQOL) compared with their healthy peers. This systematic review reports the range and effectiveness of psychosocial interventions designed to improve HRQOL amongst asthmatic children, adolescents, and their families. METHOD: Data sources included The Cochrane Airways Group Trials Register of trials, PubMed database, and reference lists from review articles. RESULTS: Eighteen studies of psychosocial interventions were identified. Interventions were designed to improve HRQOL amongst a range of psychosocial, health care, school-related and clinical outcomes, and were delivered in numerous settings and formats. Four studies reported that interventions were effective for significant improvements in child overall HRQOL scores. These include asthma education (n = 2), asthma education plus problem solving (n = 1), and art therapy (n = 1). CONCLUSIONS: Most interventions focussed on the delivery of asthma education to children, with the purpose of improving knowledge about asthma and disease management. There is limited evidence to suggest that interventions currently available are effective for significantly improving HRQOL amongst asthmatic children, adolescents, and their families. Most interventions lacked a theoretical basis and did not focus on family functioning variables. Multi-component interventions that incorporate asthma education along with strategies to assist families with implementing behaviour change towards improved asthma management are required. Future interventions should also attempt to address the wider context of family functioning likely to contribute to the family's ability to engage in successful asthma management in order to improve HRQOL.

The development of a self-help intervention to build social confidence in people living with visible skin conditions or scars: a think-aloud study.

INTRODUCTION: People with a visible difference, such as scarring or a skin condition, can experience anxiety and intrusive reactions from others when in social situations. The use of products to conceal marks on the skin is provided in a number of different hospital services and by charities. However, there are relatively few psychosocial interventions available for these individuals. OBJECTIVES: To examine the views of skin camouflage users and practitioners on the acceptability, usability and need for a specifically developed cognitive behavioural therapy (CBT) self-help booklet. METHODS: A think-aloud protocol and descriptive form of thematic analysis were used to ascertain participants' views of this novel psychosocial intervention. Nine participants took part in think-aloud interviews that were analysed using thematic analysis. Six skin camouflage users and three skin camouflage practitioners participated in the study. RESULTS: Support for the relevance, acceptability and usability of the booklet was found from both participants who used camouflage and those who provided it. However, some participants reported that they would envisage that some people would need additional support so as to be able to use the techniques described within the booklet. CONCLUSIONS: This study represents an important step towards developing a brief self-help intervention for people with living with visible skin conditions or scars and demonstrates the importance of seeking feedback from experts by experience on theoretically informed psychological interventions for this patient group.

Mothers' explanations of communicating past health and future risks to survivors of childhood cancer.

Mothers of survivors of Retinoblastoma (Rb) experience unique challenges communicating with their child about the condition. Children are mostly diagnosed within their first year but the consequences continue into young adult life. Here 39 mothers of Rb survivors (23 males, mean age = 10.26 years) were interviewed about their experiences. Mothers were asked about communication with their children about Rb, and future health risks. Interviews were analysed using thematic analysis. Mothers reported that they had informed children about past diagnosis and treatment but had spoken less about genetic risk or risk of secondary cancer. The child's age and information-seeking behaviour were associated with mothers' disclosure, along with mothers' perceptions that information would facilitate child coping. Findings suggest that mothers may need more guidance during follow-up care in communicating about the disease and its consequences for future health. Medical staff should also take extra care to ensure that mothers are aware of genetic counselling services and how to access them before the child is discharged from specialist care.

Health behaviours in childhood cancer survivors: a systematic review.

AIM: To review (1) prevalence and predictors of risk behaviours especially smoking and (2) values of interventions to reduce risk behaviours in childhood cancer survivors. METHOD: A systematic search of four databases (OVID Medline (1966 to May week 2, 2006), CINAHL, EMBASE, and Pubmed (US Library of Medicine and National Institute of Health)) for articles published between January 1990 and May 2006. RESULTS: Twenty-three eligible articles. Incidence of risk behaviours are comparable with, or lower than the general population and controls. Socio-demographic (age, socio-economic status, diagnosis, ethnic group) and psychological variables (perceived vulnerability) predict risk behaviour. Improved knowledge and awareness of vulnerability have been found after interventions, but no changes in health behaviours. CONCLUSION: This review illustrates an optimistic picture of low participation in substance use amongst survivors, although based mainly on smoking. However, smoking might not be the major problem for survivors and attention must also be directed to other health behaviours including exercise and healthy diet.

Social support: gender differences in cancer patients in the United Kingdom.

Social support is an important aspect of psychological functioning during diagnosis and treatment of cancer. Gender has been found to influence support preferences, and previous research suggests that women are more likely to seek and utilize support by comparison to men. This qualitative study explores how patients perceive the support they receive. It also examines patient preferences and satisfaction with information and emotional support provided by staff. Eleven melanoma patients (6 men and 5 women) and 5 breast cancer patients participated in a semistructured interview. Thematic analysis suggests that gender is central to patients' satisfaction and preference for support. Whereas women expected staff to provide information and emotional support, men felt that emotional support from staff was inappropriate and perceived information as supportive in helping them deal with their emotions. Men were also more satisfied with support generally, and women perceived staff to have less time to provide support. Breast cancer patients were more satisfied with access to and the nature of support available to them. Findings suggest that female melanoma patients would benefit from similar services. Meeting the support needs of men appears less clear. If support were available as part of a structured care plan, it is possible that men would also utilize support. Future research is required to gain greater understanding of men's support needs.

The measurement of health-related quality of life (QOL) in paediatric clinical trials: a systematic review.

BACKGROUND: The goal of much care in chronic childhood illness is to improve quality of life (QOL). However, surveys suggest QOL measures are not routinely included. In addition, there is little consensus about the quality of many QOL measures. OBJECTIVES: To determine the extent to which quality of life (QOL) measures are used in paediatric clinical trials and evaluate the quality of measures used. DESIGN: Systematic literature review. REVIEW METHODS: Included paediatric trials published in English between 1994 and 2003 involving children and adolescents up to the age of 20 years, and use of a standardised QOL measure. Data Sources included MEDLINE, CINAHL, EMB Reviews, AMED, BNI, PSYCHINFO, the Cochrane library, Internet, and reference lists from review articles. RESULTS: We identified 18 trials including assessment of QOL (4 Asthma, 4 Rhinitis, 2 Dermatitis, and single studies of Eczema, Cystic fibrosis, Otis media, Amblyopia, Diabetes, Obesity associated with a brain tumour, Idiopathic short stature, and Congenital agranulocytosis). In three trials, parents rated their own QOL but not their child's. Fourteen different QOL measures were used but only two fulfilled our minimal defined criteria for quality. CONCLUSIONS: This review confirms previous reports of limited use of QOL measures in paediatric clinical trials. Our review provides information about availability and quality of measures which will be of especial value to trial developers.

Redundancy in the immune system restricts the spread of HSV-1 in the central nervous system (CNS) of C57BL/6 mice.

Resistance to lethal encephalitis in mice infected with HSV-1 via the oral mucosa is mouse strain dependent. In susceptible BALB/c, HSV-1 spreads throughout the CNS but in resistant BL/6 mice, virus is restricted to the brainstem. To examine the contribution of cellular immunity in restricting viral spread, we used a combination of antibody depleted and KO mice. Individually, NK/NKT, iNKT, CD4(+), CD8(+), and gammadelta T-cells do not restrict HSV-1 spread. In contrast, virus spreads throughout the CNS of BL/6 CL I KO mice and BL/6 mice treated with either anti-asialoGM1 Ab or both anti-CD8 and anti-NK1.1 mAbs. The results highlight the importance of redundancy in the immune system in restricting viral spread in the CNS, argue for a role of NK/NKT and CD8(+) T-cells in mediating the restriction, and provide a hierarchical order of the individual elements in controlling virus in BL/6 mice infected with HSV-1 via the oral mucosa.

Parental communication and children's behaviour following diagnosis of childhood leukaemia.

Many parents find decisions about what to tell their child with cancer difficult. Open communication is generally considered the best policy and most health care professionals encourage parents to talk openly and honestly about the illness. However, parents differ in their views about what to tell the child. In this study 55 parents of children (36 boys and 19 girls, mean age = 7.33 years) newly diagnosed with acute lymphoblastic leukaemia (ALL) were interviewed about (i) the child's reactions and behaviour following diagnosis, (ii) their views about what to tell their child and (iii) factors influencing parents' communication with the child. Interviews were analysed using thematic analysis. Most children showed behavioural and mood difficulties after diagnosis. Older children were given more information. In addition, parents' perceptions of childhood cancer affect the way they communicate with their child. These findings may be used to inform training packages in order to facilitate improved communication amongst health professionals.

Latent infection with herpes simplex virus is associated with ongoing CD8+ T-cell stimulation by parenchymal cells within sensory ganglia.

CD8+ T-cell persistence can be seen in ganglia harboring latent herpes simplex virus (HSV) infection. While there is some evidence that these cells suppress virus reactivation, this view remains controversial. Given that maintenance of latency by CD8+ T cells would necessitate ongoing exposure to antigen within this site, we sought evidence for such chronic stimulation. Initial experiments showed infiltration by activated but not naïve CD8+ T cells into ganglia harboring latent HSV infection. While such infiltration was independent of T-cell specificity, once recruited, only virus-specific T cells expressed high levels of preformed granzyme B, a marker of ongoing activation. Moreover, bone marrow replacement chimeras showed that these elevated granzyme levels were totally dependent on presentation by parenchymal cells within the ganglia. Overall, this study argues that activated CD8+ T cells are nonspecifically recruited into latently infected ganglia, and in this site they are exposed to ongoing antigen stimulation, most likely by infected neuronal cells.

Reliable use of the ServoMed Evaporimeter EP-2 to assess transepidermal water loss in the canine.

Transepidermal water loss (TEWL) describes the total amount of water lost through the skin, a loss that occurs constantly by passive diffusion through the epidermis. Although TEWL is a normal physiological phenomenon, if it rises too high, the skin can become dehydrated, disrupting form and function and potentially leading to infection or transepidermal passage of deleterious agents. We have validated the use of the Evaporimeter EP-2 for the accurate assessment of TEWL in the canine. We have identified a requirement for the subject to be completely still during measurements, a requirement that can be fulfilled by training. It was found that, following training of the subject, the mean TEWL value dropped, on average, 47% compared to that of untrained animals. A significant effect on TEWL of shaving the coat from the area to be measured was identified. Using the refined protocol we observed that TEWL tended to be higher in adult (2-7 y) than senior (8-11 y) dogs, suggesting that aging processes may be occurring in canine skin that impact barrier function. The implications of poorer barrier function with age could be increased susceptibility to certain skin conditions. The overall poorer skin and coat condition seen for many older dogs may also be related to an increased TEWL.

Homeostasis and anergy of CD4(+)CD25(+) suppressor T cells in vivo.

CD4(+)CD25(+) suppressor T (TS) cells play a critical role in the maintenance of peripheral tolerance. We examined here proliferative and functional responses as well as differential gene expression in T(S) cells. We found that T(S) cells were hyporesponsive to antigenic stimuli in vivo and unable to flux Ca(2+) upon T cell receptor (TCR) engagement. However, T(S) cells were not impaired in their proliferative response to lymphopenia, which was dependent on major histocompatibility complex class II expression. Homeostatic proliferation did not abolish T(S) cell anergy; rather, it substantially augmented T(S) cell function. DNA array analyses identified genes that may inhibit responsiveness at a number of levels in multiple signaling cascades in T(S) cells, as well as several anti-apoptotic genes that may mediate their survival.