Novel Claims-Based Outcome Phenotypes in Survivors of Pediatric Traumatic Brain Injury.

OBJECTIVE: For children hospitalized with acute traumatic brain injury (TBI), to use postdischarge insurance claims to identify: (1) healthcare utilization patterns representative of functional outcome phenotypes and (2) patient and hospitalization characteristics that predict outcome phenotype. SETTING: Two pediatric trauma centers and a state-level insurance claim aggregator. PATIENTS: A total of 289 children, who survived a hospitalization after TBI between 2009 and 2014, were in the hospital trauma registry, and had postdischarge insurance eligibility. DESIGN: Retrospective cohort study. MAIN MEASURES: Unsupervised machine learning to identify phenotypes based on postdischarge insurance claims. Regression analyses to identify predictors of phenotype. RESULTS: Median age 5 years (interquartile range 2-12), 29% (84/289) female. TBI severity: 30% severe, 14% moderate, and 60% mild. We identified 4 functional outcome phenotypes. Phenotypes 3 and 4 were the highest utilizers of resources. Morbidity burden was highest during the first 4 postdischarge months and subsequently decreased in all domains except respiratory. Severity and mechanism of injury, intracranial pressure monitor placement, seizures, and hospital and intensive care unit lengths of stay were phenotype predictors. CONCLUSIONS: Unsupervised machine learning identified postdischarge phenotypes at high risk for morbidities. Most phenotype predictors are available early in the hospitalization and can be used for prognostic enrichment of clinical trials targeting mitigation or treatment of domain-specific morbidities.

Change in physical activity and quality of life in endometrial cancer survivors receiving a physical activity intervention.

BACKGROUND: Endometrial cancer survivors are at an increased risk of poor quality of life outcomes. Physical activity is positively associated with general quality of life in this population, however, little is known about how changes in physical activity may be associated with changes in specific aspects of quality of life. The aim of this secondary data analysis was to explore the relationships between change in physical activity and change in physical, mental, social, and other aspects of quality of life in endometrial cancer survivors receiving a physical activity intervention. METHODS: Endometrial cancer survivors (N = 100) participated in a telephone-based physical activity intervention for six months. At baseline and post-intervention we measured physical activity via accelerometry and ecological momentary assessment, and quality of life via the Short Form Health Survey (SF-36), the Quality of Life of Adult Cancer Survivors instrument, the Brief Symptom Inventory, the Pittsburgh Sleep Quality Index, and the Perceived Stress Scale. We conducted structural equation modeling path analyses to investigate how physical activity post-intervention was associated with the quality of life measures' subscales post-intervention, adjusting for baseline levels and potentially confounding covariates. RESULTS: Increasing physical activity was positively associated with improvements in general health (p = .044), role limitation due to physical health (p = .005), pain (p = .041), and somatic distress (p = .023). There was no evidence to indicate that change in physical activity was associated with change in other aspects of quality of life. CONCLUSIONS: Endometrial cancer survivors are at higher risk for suffering from challenges to physical quality of life, and findings from this study suggest that increasing physical activity may alleviate some of these problems. Further research is needed to determine whether other aspects of quality of life are linked to change in physical activity. TRIAL REGISTRATION: Trial registration number: NCT00501761 Name of registry: clinicaltrials.gov Date of registration: July 16, 2007. Date of enrollment: June 16, 2005.

The Association Between the Functional Status Scale and the Pediatric Functional Independence Measure in Children Who Survive Traumatic Brain Injury.

OBJECTIVES: To determine the association between the Functional Status Scale and Pediatric Functional Independence Measure scores during the rehabilitation stay in children who survive traumatic brain injury. DESIGN: Secondary analysis of a prospective observational cohort study. SETTING: Tertiary care children's hospital with a level 1 trauma center and inpatient rehabilitation service. PATIENTS: Sixty-five children less than 18 years old admitted to an ICU with acute traumatic brain injury and subsequently transferred to the inpatient rehabilitation service. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Functional Status Scale and Pediatric Functional Independence Measure at transfer to rehabilitation and Pediatric Functional Independence Measure at discharge from rehabilitation. The median age of the cohort was 7.1 years (interquartile range, 0.8-12.3 yr), and 29% were female. Nearly all of the children were healthy prior to the traumatic brain injury: six patients (9.2%) had a baseline Functional Status Scale score greater than 6. At the time of transfer to inpatient rehabilitation, total Functional Status Scale and Pediatric Functional Independence Measure scores had the expected negative correlation due to increasing disability resulting in lower scores in Pediatric Functional Independence Measure and higher scores in Functional Status Scale (r = -0.49; 95% CI, -0.62 to -0.35). Among subjects with less disability as measured by lower total Functional Status Scale scores, we found substantial variability in the total Pediatric Functional Independence Measure scores. In contrast, Pediatric Functional Independence Measure scores were consistently low among subjects with a wide range of higher total Functional Status Scale scores (more disability). CONCLUSIONS: Although proprietary and more time-intensive, the Pediatric Functional Independence Measure has advantages relative to the Functional Status Scale for less severely injured patients and task-specific measurements. The Functional Status Scale may have advantages relative to the Pediatric Functional Independence Measure for more severely injured patients. Further investigations are needed to characterize changes in the Functional Status Scale during the rehabilitation stay and after discharge.

Weight loss maintenance after a digital commercial behavior change program (Noom Weight): Observational cross-sectional survey study.

Background: Behavioral weight loss programs often lead to significant short-term weight loss, but long-term weight maintenance remains a challenge. Most weight maintenance data come from clinical trials, in-person programs, or general population surveys, but there is a need for better understanding of long-term weight maintenance in real-world digital programs. Methods: This observational survey study examined weight maintenance reported by individuals who had used Noom Weight, a digital commercial behavior change program, and identified factors associated with greater weight maintenance. The cross-sectional survey was completed by 840 individuals who had lost at least 10% of their body weight using Noom Weight 6-24 months prior. Results: The study found that 75% of individuals maintained at least 5% weight loss after 1 year, and 49% maintained 10% weight loss. On average, 65% of initial weight loss was maintained after 1 year and 57% after 2 years. Habitual behaviors, such as healthy snacking and exercise, were associated with greater weight maintenance, while demographic factors were not. Conclusion: This study provides real-world data on the long-term weight maintenance achieved using a fully digital behavioral program. The results suggest that Noom Weight is associated with successful weight maintenance in a substantial proportion of users. Future research will use a randomized controlled trial to track weight maintenance after random assignment and at a 2 year follow-up.

Acceptability and Efficacy of a Sexual Health Texting Intervention Designed to Support Adolescent Females.

OBJECTIVE: To evaluate the feasibility, acceptability, and initial efficacy of a pilot texting intervention ("t4she") in primary care designed to increase sexual health knowledge and promote dual protection strategies to reduce unintended pregnancies and sexually transmitted infections among adolescent females. METHODS: Participants were recruited from 2 federally qualified health centers. Eligibility included: being 13 to 18 years of age; assigned female at birth; English-speaking; not currently pregnant and/or intending to become pregnant; and having texting capabilities. A randomized controlled trial assessed between-group differences at 3 and 6 months on knowledge, Health Belief Model constructs, and sexual behaviors. Input on intervention acceptability was obtained at 3 months. RESULTS: Among 244 participants enrolled and randomized, the average age was 16 (±1.6), 80% were Hispanic/Latina, 53% had ever had vaginal sex, and 50% had used prescription birth control with 24% currently using a long-acting reversible method. Among those sexually active, 29% reported consistent condom use and 24% reported engaging in dual protection behaviors at last sex. Among participants with all follow-up data (N = 136), intervention participants had significant increases in sexual health knowledge and reported more prescription birth control use at follow-up than control participants. No significant outcome differences were found for condom use or dual protection behaviors. Intervention participants reported receiving messages, being introduced to new information, and reading and sharing the messages. CONCLUSIONS: The pilot t4she sexual health intervention significantly improved knowledge and use of short-acting prescription birth control among young females in primary care and was acceptable by youth and feasible to implement.

HPV Vaccination in Correctional Care: Knowledge, Attitudes, and Barriers Among Incarcerated Women.

Incarcerated women are at increased risk of developing cervical cancer and have high rates of human papillomavirus (HPV) infection, an important cause of cervical cancer. However, many correctional facilities do not offer HPV vaccination to female inmates. This pilot survey study, conducted with incarcerated women aged 18 to 26 at a facility that does not offer the vaccine, assessed attitudes and knowledge about HPV and the HPV vaccine, acceptability of and barriers to in-prison HPV vaccination, and self-reported HPV vaccination rates. Most participants reported that they had not received the HPV vaccine but had positive attitudes toward it and would be willing to get it in prison. Correctional facilities should consider offering this preventive service to this vulnerable population.

Students Seeking Mental Health Services at School-Based Health Centers: Characteristics and Utilization Patterns.

BACKGROUND: School-based health centers (SBHC) can address unmet mental health needs. Little is known about how students seek care from different providers at SBHCs. We describe and compare how students' SBHC visits differ for students seen by mental health providers (MH group) relative to students seen only by primary care providers (PC group). METHODS: Using administrative data with ICD-9 codes from 9 SBHCs in Denver, Colorado serving youth 10-19 years old during the 2014-2015 school year, we analyzed predictors of SBHC clinic visits via negative binomial regression and ICD-9 codes for first visit to MH providers. RESULTS: Mental health users (N = 516) had an average of 14.2 ± 12.9 SBHC visits and PC users (N = 4026) had an average of 2.6 ± 2.4 SBHC visits annually. Students in the MH group, those with public insurance, and females had a higher incidence rate ratio for SBHC clinic visits than PC group students, those with private insurance, and males respectively. Depression was the most common primary diagnosis for the first MH visit. CONCLUSIONS: Students accessing MH services at SBHC return for follow up visits at higher rates than students only seeing PC providers. SBHCs represent a valuable opportunity to enhance integrated mental health services.

Food Insecurity and Healthy Behavior Counseling in Primary Care.

OBJECTIVE: While food insecurity (FI) has been associated with obesity in some studies, few have examined the relationship between FI and health attitudes and behaviors. We hypothesized that families who experienced FI would report lower importance of discussing health-related behavior change, report lower physical activity (PA) and have children who were more likely to be obese. DESIGN/METHODS: We conducted a cross-sectional analysis of data collected from 2012 - 2015 from three clinics serving primarily low-income, Latino patients. Parents of 6 to 12 year old children presenting for well child care were surveyed about their experience of food insecurity, the importance of discussing behavior change with a health care provider and their children's physical activity. We calculated children's BMI z scores from the height and weight measured at that visit. We used path analysis to test our hypotheses. RESULTS: Among 1048 families in the study sample, 610 reported experiencing FI (56%). Experiencing FI was positively related to importance of discussing health behavior (p < 0.001) and negatively related to PA (p=0.008). The relationship between FI and BMI was not significant. CONCLUSION: We found FI was associated with greater perceived importance of discussing health related behavior change, but lower amounts of PA, indicating contrasting attitudes and behaviors. Families facing food insecurity are likely experiencing financial and other barriers to PA, as evidenced by lower reported PA. Providers counseling low-income populations should not presume that food insecure families are unwilling to discuss weight related health behavior changes.

Oxandrolone Treatment Results in an Increased Risk of Gonadarche in Prepubertal Boys With Klinefelter Syndrome.

Context: Klinefelter syndrome (KS) is a common genetic condition in which males have an extra X chromosome. KS is associated with testosterone deficiency, neurodevelopmental delays, and cardiometabolic disorders. There has been recent interest in prepubertal androgen treatment; however, the effects on puberty and gonadal function are unknown. Objective: To compare onset of puberty and testicular function in prepubertal boys treated with 2 years of oxandrolone (Ox) vs placebo (Pl). Design: Double-blind, randomized, controlled trial. Setting: Single tertiary care referral center. Participants: Eighty prepubertal boys with KS; mean age: 8.0 ± 2.2 years (range: 4 to 12). Interventions: Ox 0.05 mg/kg vs identical-appearing Pl capsule given for 2 years. Outcome Measures: Onset of gonadarche (testicular volume ≥4 mL) and onset of pubarche (Tanner 2 pubic hair); change in testicular hormone concentrations. Results: Ox-treated group had 20.5 times higher odds of reaching gonadarche (OR 95% CI: 6.5, 77.8) and 28.1 times higher odds of reaching pubarche (OR 95% CI: 8.8, 110.4) during the 2-year study period after adjusting for baseline age. Gonadarche and pubarche both occurred at a younger age in the Ox group (gonadarche: 9.8 ± 1.5 vs 12.1 ± 1.0 years, P < 0.001; pubarche: 10.2 ± 1.1 vs 11.6 ± 1.3 years, P = 0.02). Serum concentrations of testicular hormones and gonadotropins were not different between groups. Conclusions: Two years of Ox treatment in prepubertal boys with KS results in an increased risk of early gonadarche, on average 2 years earlier than in Pl-treated boys. Ox did not affect serum concentrations of testicular hormones.

Effects of Oxandrolone on Cardiometabolic Health in Boys With Klinefelter Syndrome: A Randomized Controlled Trial.

Context: Klinefelter syndrome (KS) is a common condition in males, resulting in androgen deficiency and cardiometabolic diseases. These interrelated conditions may be present in prepubertal boys with KS. Objective: To determine whether supplemental low-dose androgen has a beneficial effect on body composition in prepubertal boys with KS. Design, Setting, and Participants: We conducted a secondary analysis of a randomized, double-blind, placebo-controlled clinical trial in 93 boys with KS aged 4 to 12 years. Interventions: Oral oxandrolone (Ox) 0.06 mg/kg/d or placebo for 2 years. Outcome Measures: The primary outcome was percent body fat standard deviation score (%BF SDS) at 2 years. Secondary outcomes included additional measures of cardiometabolic health and safety. Results: The %BF SDS at 2 years was significantly lower in the treatment (0.29 ± 0.76 SDS) compared with placebo group (0.81 ± 0.72 SDS) after adjusting for age and baseline %BF SDS (95% confidence interval for the difference between means -0.86 to -0.19 SDS, P = 0.009). Ox resulted in lower triglycerides (P = 0.043), but also lower high-density lipoprotein (HDL) cholesterol (P < 0.001) and a more rapid advancement in bone age (P = 0.011). Conclusions: Ox has positive effects on measures of cardiometabolic health in prepubertal boys with KS; however, it does lower HDL cholesterol and advance bone age.

Chronic School Absenteeism and the Role of Adverse Childhood Experiences.

OBJECTIVE: To examine the association between chronic school absenteeism and adverse childhood experiences (ACEs) among school-age children. METHODS: We conducted a secondary analysis of data from the 2011-2012 National Survey of Children's Health including children 6 to 17 years old. The primary outcome variable was chronic school absenteeism (≥15 days absent in the past year). We examined the association between chronic school absenteeism and ACEs by logistic regression with weighting for individual ACEs, summed ACE score, and latent class analysis of ACEs. RESULTS: Among the 58,765 school-age children in the study sample, 2416 (4.1%) experienced chronic school absenteeism. Witnessing or experiencing neighborhood violence was the only individual ACE significantly associated with chronic absenteeism (adjusted odds ratio [aOR] 1.55, 95% confidence interval [CI] 1.20-2.01). Having 1 or more ACE was significantly associated with chronic absenteeism: 1 ACE (aOR 1.35, 95% CI 1.02-1.79), 2 to 3 ACEs (aOR 1.81, 95% CI 1.39-2.36), and ≥4 ACEs (aOR 1.79, 95% CI 1.32-2.43). Three of the latent classes were also associated with chronic absenteeism, and children in these classes had a high probability of endorsing neighborhood violence, family substance use, or having multiple ACEs. CONCLUSIONS: ACE exposure was associated with chronic school absenteeism in school-age children. To improve school attendance, along with future graduation rates and long-term health, these findings highlight the need for an interdisciplinary approach to address child adversity that involves pediatricians, mental health providers, schools, and public health partners.

Self-reported and automatic cognitions are associated with exercise behavior in cancer survivors.

OBJECTIVE: Physical activity is beneficial for cancer survivors, but exercise participation is low in this population. It is therefore important to understand the psychological factors underlying exercise uptake so that more effective interventions can be developed. Social-cognitive theory constructs such as outcome expectancies predict exercise behavior, but self-report measures have several limitations. We examined the associations between implicit (automatic) cognitions and exercise behavior and self-efficacy in endometrial cancer survivors. METHOD: This was a longitudinal study to examine predictors of exercise behavior in female endometrial cancer survivors who all received an exercise intervention. Participants (N = 100, mean age of 57.0) completed questionnaires to assess self-report exercise-related measures (outcome expectancy and attitudes about and identification with exercise) and reaction time (RT) tasks to assess implicit exercise cognitions (expectancy accessibility, implicit attitudes about exercise, and implicit self-identification with exercise) at baseline and at 2, 4, and 6 months at follow-up. Exercise behavior was measured using accelerometers and self-report. Data were analyzed using linear mixed models. RESULTS: Expectancy accessibility was associated with exercise duration independent of the corresponding self-report measure. Exercise implicit attitudes and self-identification were prospectively associated with exercise self-efficacy only after adjustment for the corresponding self-report measures and baseline self-efficacy. Self-report measures were also associated with study outcomes. CONCLUSIONS: Both self-reported cognitions and implicit cognitions may be useful to identify individuals at risk of failing to exercise. Individuals so identified might be provided with a different or more intensive intervention. The data also suggest cognitive targets for intervention. (PsycINFO Database Record