Implementation of the Mind Youth Questionnaire (MY-Q) for routine health-related quality of life screening of adolescents with type 1 diabetes in a large tertiary care center.

OBJECTIVES: Prevalence of diabetes distress and mental health comorbidities among adolescents with type 1 diabetes (T1D) is high. Despite recommendations for routine psychosocial risk assessment, there is little guidance for their implementation. This study aims to describe the implementation and baseline outcomes of the Mind Youth Questionnaire (MY-Q), a validated psychosocial screening tool for health-related quality of life (QoL) including mood, among adolescents living with T1D. METHODS: Adolescents aged 13-18 years completed the MY-Q from October 1, 2019-April 1, 2023. Baseline characteristics, MY-Q results including categories flagged positive (noting possible areas of concern), debrief duration, and frequency of social work or mental health referral were collected and analyzed using descriptive statistics. RESULTS: A total of 343 adolescents (mean age 15.3 years; 52 % female) completed a baseline MY-Q. Median overall MY-Q debrief time (IQR) was 10.0 min (6.0, 20.0). About 290 (84.5 %) adolescents had at least one of seven categories flagged, most commonly "Family" (61 %). About 30 % of adolescents had "Mood" flagged, and 2.9 % of adolescents were referred to mental health following debrief. CONCLUSIONS: Without the need for additional resources, implementation of the MY-Q in a pediatric tertiary care diabetes clinic successfully identified QoL issues and mental health concerns among adolescents with T1D.

Variation in the Management of Hospitalized Children With Orbital Cellulitis Over 10 Years.

OBJECTIVES: No previous study has examined the management of hospitalized children with orbital cellulitis at both children's and community hospitals across multiple sites in Canada. We describe variation and trends over time in diagnostic testing and imaging, adjunctive agents, empiric antibiotics, and surgical intervention in children hospitalized with orbital cellulitis. PATIENTS AND METHODS: Multicenter cohort study of 1579 children aged 2 months to 18 years with orbital cellulitis infections admitted to 10 hospitals from 2009 to 2018. We assessed hospital-level variation in the use of diagnostic tests, imaging, antibiotics, adjunctive agents, surgical intervention, and clinical outcomes using X2, Mann-Whitney U, and Kruskal-Wallis tests. The association between clinical management and length of stay was evaluated with median regression analysis with hospital as a fixed effect. RESULTS: There were significant differences between children's hospitals in usage of C-reactive protein tests (P < .001), computed tomography scans (P = .004), MRI scans (P = .003), intranasal decongestants (P < .001), intranasal corticosteroids (P < .001), intranasal saline spray (P < .001), and systemic corticosteroids (P < .001). Children's hospital patients had significantly longer length of hospital stay compared with community hospitals (P = .001). After adjustment, diagnostic testing, imaging, and subspecialty consults were associated with longer median length of hospital stay at children's hospitals. From 2009 to 2018, C-reactive protein test usage increased from 28.8% to 73.5% (P < .001), whereas erythrocyte sedimentation rate decreased from 31.5% to 14.1% (P < .001). CONCLUSIONS: There was significant variation in diagnostic test usage and treatments, and increases in test usage and medical intervention rates over time despite minimal changes in surgical interventions and length of stay.

Does age play a role in fever and neutropenia events and complications: A comparison of adolescents versus younger children with cancer at a tertiary care pediatric hospital, a pilot project.

BACKGROUND: Adolescents and young adults with cancer (AYA) are a complex group of patients. The development of fever and neutropenia (FN) is a potentially lethal complication of chemotherapy. Risk stratification of patients with FN has become increasingly valuable allowing for early intervention and to guide treatment type and duration appropriately. There are risk stratification guidelines that exist, but most are validated in young children with cancer (YCWC). AYA are frequently shown to have more numerous and severe side effects from chemotherapy. AIMS: This study aimed to identify whether age contributes to the incidence and severity of FN. METHODS AND RESULTS: Patients diagnosed with a malignancy in a 5-year period at our institution were included from ages 0-18 years. We reviewed details of their FN events, including duration of hospital admission, source (bacterial/fungal), PICU admission and duration, positive blood cultures and mortality. Adolescents with cancer (AWC) had a trend of being 1.56 times more likely to have FN events (CI 95% 0.936-2.622, p = 0.087). Assessment of the duration of PICU stay showed that AWC were 4.9 times more likely to have longer admissions (CI 95% 0.998-24.067, p = 0.050). There was no significant difference between the two groups in the rate of PICU admission, positive cultures, identification of a bacterial or fungal source, hospital admission duration or mortality from FN. CONCLUSION: This study demonstrated a trend towards AWC being more likely to develop FN events. When such events occur in this group, the severity of them may be heightened as evidenced by longer duration of PICU admission.

Factors Associated with Surgery and Imaging Characteristics in Severe Orbital Infections.

OBJECTIVES: To evaluate risk factors associated with surgical intervention and subperiosteal/orbital abscess in hospitalized children with severe orbital infections. STUDY DESIGN: We conducted a multicenter cohort study of children 2 months to 18 years hospitalized with periorbital or orbital cellulitis from 2009 to 2018 at 10 hospitals in Canada. Clinical details were extracted, and patients were categorized as undergoing surgical or medical-only management. Primary outcome was surgical intervention and the main secondary outcome was clinically important imaging. Logistic regression was used to identify predictors. RESULTS: Of 1579 patients entered, median age was 5.4 years, 409 (25.9%) had an orbital/subperiosteal abscess, and 189 (12.0%) underwent surgery. In the adjusted analysis, the risk of surgical intervention was associated with older age (age 9 to <14: aOR 3.9, 95% CI 2.3-6.6; and age 14 to ≤18 years: aOR 7.0, 95% CI 3.4-14.1), elevated C-reactive protein >120 mg/L (aOR 2.8, 95% CI 1.3-5.9), elevated white blood cell count of 12-20 000/µL (aOR 1.7, 95% CI 1.1-2.6), proptosis (aOR 2.6, 95% CI 1.7-4.0), and subperiosteal/orbital abscess (aOR 5.3, 95% CI 3.6-7.9). There was no association with antibiotic use before hospital admission, sex, presence of a chronic disease, temperature greater than 38.0°C, and eye swollen shut. Complications were identified in 4.7% of patients, including vision loss (0.6%), intracranial extension (1.6%), and meningitis (0.8%). CONCLUSIONS: In children hospitalized with severe orbital infections, older age, elevated C-reactive protein, elevated white blood cell count, proptosis, and subperiosteal/orbital abscess were predictors of surgical intervention.

Cortico-Striatal Control over Adaptive Goal-Directed Responding Elicited by Cues Signaling Sucrose Reward or Punishment.

The medial prefrontal cortex (mPFC) and nucleus accumbens (NAc) have been associated with the expression of adaptive and maladaptive behavior elicited by fear-related and drug-associated cues. However, reported effects of mPFC manipulations on cue-elicited natural reward-seeking and inhibition thereof have been varied, with few studies examining cortico-striatal contributions in tasks that require adaptive responding to cues signaling reward and punishment within the same session. The current study aimed to better elucidate the role of mPFC and NAc subdivisions, and their functional connectivity in cue-elicited adaptive responding using a novel discriminative cue responding task. Male Long-Evans rats learned to lever-press on a VR5 schedule for a discriminative cue signaling reward, and to avoid pressing the same lever in the presence of another cue signaling punishment. Postacquisition, prelimbic (PL) and infralimbic (IL) areas of the mPFC, NAc core, shell, PL-core, or IL-shell circuits were pharmacologically or chemogenetically inhibited while animals performed under (1) nonreinforced (extinction) conditions, where the appetitive and aversive cues were presented in alternating trials alone or as a compound stimulus; and (2) reinforced conditions, whereby cued responding was accompanied by associated outcomes. PL and IL inactivation attenuated nonreinforced and reinforced goal-directed cue responding, whereas NAc core and shell inactivation impaired nonreinforced responding for the appetitive, but not aversive cue. Furthermore, PL-core and IL-shell inhibition disinhibited nonreinforced but not reinforced cue responding. Our findings implicate the mPFC as a site of confluence of motivationally significant cues and outcomes, and in the regulation of nonreinforced cue responding via downstream NAc targets.SIGNIFICANCE STATEMENT The ability to discriminate and respond appropriately to environmental cues that signal availability of reward or punishment is essential for survival. The medial prefrontal cortex (mPFC) and nucleus accumbens (NAc) have been implicated in adaptive and maladaptive behavior elicited by fear-related and drug-associated cues. However, less is known about the role they play in orchestrating adaptive responses to natural reward and punishment cues within the same behavioral task. Here, using a novel discriminative cue responding task combined with pharmacological or chemogenetic inhibition of mPFC, NAc and mPFC-NAc circuits, we report that mPFC is critically involved in responding to changing cued response-outcomes, both when the responses are reinforced, and nonreinforced. Furthermore, the mPFC coordinates nonreinforced discriminative cue responding by suppressing inappropriate responding via downstream NAc targets.

SLEAP SMART (Sleep Apnea Screening Using Mobile Ambulatory Recorders After TIA/Stroke): A Randomized Controlled Trial.

BACKGROUND AND PURPOSE: Poststroke/transient ischemic attack obstructive sleep apnea (OSA) is prevalent, linked with numerous unfavorable health consequences, but remains underdiagnosed. Reasons include patient inconvenience and costs associated with use of in-laboratory polysomnography (iPSG), the current standard tool. Fortunately, home sleep apnea testing (HSAT) can accurately diagnose OSA and is potentially more convenient and cost-effective compared with iPSG. Our objective was to assess whether screening for OSA in patients with stroke/transient ischemic attack using HSAT, compared with standard of care using iPSG, increased diagnosis and treatment of OSA, improved clinical outcomes and patient experiences with sleep testing, and was a cost-effective approach. METHODS: We consecutively recruited 250 patients who had sustained a stroke/transient ischemic attack within the past 6 months. Patients were randomized (1:1) to use of (1) HSAT versus (2) iPSG. Patients completed assessments and questionnaires at baseline and 6-month follow-up appointments. Patients diagnosed with OSA were offered continuous positive airway pressure. The primary outcome was compared between study arms via an intention-to-treat analysis. RESULTS: At 6 months, 94 patients completed HSAT and 71 patients completed iPSG. A significantly greater proportion of patients in the HSAT arm were diagnosed with OSA (48.8% versus 35.2%, P=0.04) compared with the iPSG arm. Furthermore, patients assigned to HSAT, compared with iPSG, were more likely to be prescribed continuous positive airway pressure (40.0% versus 27.2%), report significantly reduced sleepiness, and a greater ability to perform daily activities. Moreover, a significantly greater proportion of patients reported a positive experience with sleep testing in the HSAT arm compared with the iPSG arm (89.4% versus 31.1%). Finally, a cost-effectiveness analysis revealed that HSAT was economically attractive for the detection of OSA compared with iPSG. CONCLUSIONS: In patients with stroke/transient ischemic attack, use of HSAT compared with iPSG increases the rate of OSA diagnosis and treatment, reduces daytime sleepiness, improves functional outcomes and experiences with sleep testing, and could be an economically attractive approach. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02454023.

Educating Stroke/TIA Patients about Obstructive Sleep Apnea after Stroke: A Randomized Feasibility Study.

BACKGROUND: Obstructive sleep apnea (OSA) occurs in about 70% of stroke and transient ischemic attack (TIA) patients and is associated with poor function and recurrent vascular events. Continuous Positive Airway Pressure (CPAP) has been shown to improve poststroke/TIA outcomes but adherence is generally poor. This study aimed to develop and conduct a preliminary assessment of educational materials for poststroke/TIA OSA. METHODS: This blinded pilot study involved the randomization of stroke/TIA patients to either an intervention group (who viewed an educational pamphlet and slideshow) or a control group (standard of care). Patient ratings were used to evaluate the educational materials. Changes in knowledge, daytime sleepiness, functional outcomes of sleep, and CPAP use were assessed at baseline and 6 months. RESULTS: Total 93% of eligible patients consented to participate. Forty-eight participants were randomized to the control group (n = 23) or intervention group (n = 25). In the intervention group, all patients agreed or strongly agreed that the information in the educational materials was useful and that the wording was easy to understand. There were no significant changes in knowledge, daytime sleepiness, and functional outcomes of sleep between both groups at 6 months. In those who used CPAP, there was no significant difference in mean hours of CPAP use at the 6-month follow-up. CONCLUSIONS: The educational program was feasible and easy to understand amongst stroke/TIA patients but did not lead to a significant change in outcomes or CPAP use. The lessons learned can be used to facilitate future development of educational materials and plan an adequately-powered trial.

Actigraphic detection of periodic limb movements: development and validation of a potential device-independent algorithm. A proof of concept study.

STUDY OBJECTIVES: We propose a unique device-independent approach to analyze long-term actigraphy signals that can accurately quantify the severity of periodic limb movements in sleep (PLMS). METHODS: We analyzed 6-8 hr of bilateral ankle actigraphy data for 166 consecutively consenting patients who simultaneously underwent routine clinical polysomnography. Using the proposed algorithm, we extracted 14 time and frequency features to identify PLMS. These features were then used to train a Naïve-Bayes learning tool which permitted classification of mild vs. severe PLMS (i.e. periodic limb movements [PLM] index less than vs. greater than 15 per hr), as well as classification for four PLM severities (i.e. PLM index < 15, between 15 and 29.9, between 30 and 49.9, and ≥50 movements per hour). RESULTS: Using the proposed signal analysis technique, coupled with a leave-one-out cross-validation method, we obtained a classification accuracy of 89.6%, a sensitivity of 87.9%, and a specificity of 94.1% when classifying a PLM index less than vs. greater than 15 per hr. For the multiclass classification for the four PLM severities, we obtained a classification accuracy of 85.8%, with a sensitivity of 97.6%, and a specificity of 84.8%. CONCLUSIONS: Our approach to analyzing long-term actigraphy data provides a method that can be used as a screening tool to detect PLMS using actigraphy devices from various manufacturers and will facilitate detection of PLMS in an ambulatory setting.

Integrated Signal Encoding and Analysis System for Actigraphy-based Long-term Monitoring of Periodic Limb Movements in Sleep.

There has been a boom in the development of wearable devices for wellness and healthcare applications. Numerous studies have been conducted on the utility of employing wearable devices for the long-term monitoring of biosignals. Despite their efficacy, the potential for practical implementation faces many hurdles such as memory usage, power consumption, denoising, and efficient data transmission. Of the many wearables being used, the actigraph has been a popular choice amongst experts for identifying motion abnormalities such as periodic leg movements (PLMs) in sleep and the activities of patients suffering from various medical illnesses. In this paper, we present an efficient pulse code modulation based, 3-bit, signal encoding technique, which when applied to long-term (6-8 hours), 16-bit sleep actigraphy signals, generates 3-bit encoded, accelerometry data with an average compression ratio of 92%, an average increase in the signal-to-noise (SNR) ratio by 20 dB and an average reduction of memory usage by 92%. The proposed technique also eliminates the need to apply filters for denoising, by retaining only characteristic signal information in the quantized version. The proposed technique, in general, could be applied to accelerometer-based wearables and has the potential to provide efficient memory and power usage in long-term monitoring applications.