Myopia in the Diagnosis of Marfan Syndrome: An Important Early Sign of a Systemic Condition.

Marfan syndrome is a genetic connective tissue disorder that is a frequent cause of aortic dissection in younger patients. We report a case of a patient with a history of ectopia lentis in his third decade and abdominal striae since adolescence, who presented with Stanford type A dissection at age 48.

Improving Delayed Antibiotic Prescribing for Acute Otitis Media.

OBJECTIVES: Acute otitis media (AOM) is the most-common indication for antibiotics in children. Delayed antibiotic prescribing for AOM can significantly reduce unnecessary antibiotic use and is recommended by the American Academy of Pediatrics for select children. We sought to improve delayed prescribing for AOM across 8 outpatient pediatric practices in Colorado. METHODS: Through a collaborative initiative with American Academy of Pediatrics and the Centers for Disease Control and Prevention, we implemented an economical 6-month antimicrobial stewardship intervention that included education, audit and feedback, online resources, and content expertise. Practices used The Model for Improvement and plan-do-study-act cycles to improve delayed antibiotic prescribing. Generalized estimating equations were used to generate relative risk ratios (RRRs) for outcomes at the intervention end and 3- and 6-months postintervention. Practice surveys were evaluated. RESULTS: In total, 69 clinicians at 8 practice sites implemented 27 plan-do-study-act cycles. Practices varied by size (range: 6-37 providers), payer type, and geographic setting. The rate of delayed antibiotic prescribing increased from 2% at baseline to 21% at intervention end (RRR: 8.96; 95% confidence interval [CI]: 4.68-17.17). Five practices submitted postintervention data. The rate of delayed prescribing at 3 months and 6 months postintervention remained significantly higher than baseline (3 months postintervention, RRR: 8.46; 95% CI: 4.18-17.11; 6 months postintervention, RRR: 6.69; 95% CI: 3.53-12.65) and did not differ from intervention end (3 months postintervention, RRR: 1.12; 95% CI: 0.62-2.05; 6-months postintervention, RRR: 0.89; 95% CI: 0.53-1.49). CONCLUSIONS: Baseline rate of delayed prescribing was low. A low-cost intervention resulted in a significant and sustained increase in delayed antibiotic prescribing across a diversity of settings.

A Learning Collaborative to Improve Antibiotic Prescribing in Primary Care Pediatric Practices.

An American Academy of Pediatrics State Chapter organized a 6-month, mostly online quality improvement learning collaborative to improve antibiotic prescribing and patient education for upper respiratory infection (URI) and acute otitis media (AOM). Practices submitted data on quality measures at baseline, monthly, and 4 months post-project. Fifty-three clinicians from 6 independent, private primary care pediatric practices participated. Use of first-line antibiotics for AOM increased from 63.5% at baseline to 80.4% 4 months post-project. Use of safety-net antibiotic prescriptions (SNAP) for AOM increased from 4.5% to 16.9%. Educating patients about management for URI increased from 66.1% to 88.0% and for AOM from 20.4% to 85.6%. Practices maintained high performance for not prescribing antibiotics for URI (94.4% to 96.2%). Leveraging local relationships and national resources, this replicable antibiotic stewardship project engaged independent private practices to improve patient education for URI and AOM and prescribing and use of SNAP for AOM.

Quantifying changes in size of arrhythmic photoplethysmography waveforms during a Valsalva maneuver for assessing cardiac filling pressure.

OBJECTIVE: We previously showed that the change in amplitude of a finger photoplethysmography waveform during the Valsalva maneuver reflects cardiac filling pressure. However, the automated determination of peaks and valleys to calculate amplitude is limited in significant arrhythmias such as atrial fibrillation and premature ventricular complexes, which are common in heart failure. The purpose of this study was to assess the change in size of the waveform by calculating the change in root mean square (RMS) of the signal, thereby utilizing the entire cardiac cycle, and to compare it to change in size of peak-to-valley amplitude. APPROACH: We compared the two approaches in signals obtained from participants of a prior study who were tested prior to a clinically indicated cardiac catheterization. Correlation between the two methods was assessed in cases without, and then with, significant arrhythmias including atrial fibrillation or premature ventricular complexes. MAIN RESULTS: Calculations from the two methods of peak-valley amplitude and RMS were highly correlated with each other in signals without (0.99, p < 0.0001, n = 252) and with significant arrhythmias (0.90, p < 0.0001, n = 34). SIGNIFICANCE: RMS analysis of photoplethysmography signal size during the Valsalva maneuver is highly correlated with the method of analyzing changes in peak-valley amplitude, but does not rely on identifying peaks and valleys. The RMS method may be a more robust automated method of assessing cardiac filling pressure in patients with significant arrhythmias.

Protecting Youth Against the Adverse Effects of Peer Victimization: Why Do Parents Matter?

Exposure to peer victimization is associated with a variety of adverse outcomes but there is individual variability in its effects, suggesting the need to identify why some youth are resilient in the face of victimization. This research examined whether (a) high-quality parent-child relationships protect youth against the effects of peer victimization on psychopathology (antisocial behavior and depressive symptoms); and (b) mitigation of social risks (deviant peer group affiliation and social helplessness) accounts for the protective effects of high-quality parent-child relationships. Youths (N = 636; 338 girls, 298 boys; Mage in 5th grade = 10.94; SD = 0.36) and their teachers completed survey measures at three annual waves across the transition to middle school (5th - 7th grade). Path analyses indicated that high-quality parent-child relationships attenuated the effects of pre-transition victimization on post-transition antisocial behavior, depressive symptoms, and social risks, with some effects differing by gender. As predicted, results suggested that the protective effect against antisocial behavior may operate through mitigated deviant peer group affiliation. This research identifies one key protective factor that contributes to resilience among victimized youth and suggests the importance of incorporating parental support into prevention programs for victimized youth.

Adolescents and Young Adults Living with Congenital Heart Disease: Coping, Stress Reactivity, and Emotional Functioning.

Living with congenital heart disease (CHD) presents survivors with numerous stressors, which may contribute to emotional problems. This study examined (a) whether coping with CHD-related stress predicts symptoms of depression and anxiety, and (b) whether associations between coping and emotional distress are moderated by involuntary stress reactivity. Adolescents and young adults diagnosed with CHD (Mage = 26.4) were recruited from pediatric and adult outpatient cardiology clinics. Participants (N = 168) completed online self-report measures. Hierarchical multiple regression analyses revealed that secondary control coping (e.g., cognitive restructuring, positive thinking) predicted lower depression and anxiety. Primary control coping (e.g., problem-solving) and stress reactivity (e.g., rumination, emotional numbing) interacted to predict depression and anxiety: the higher individuals were in involuntary stress reactivity, the stronger was the association between primary control coping and lower depression and anxiety. These results can inform clinical efforts to prevent or reduce emotional distress among CHD survivors.

Executive Function and Internalizing Symptoms in Adolescents and Young Adults With Congenital Heart Disease: The Role of Coping.

Objective: Executive functioning deficits have been documented among congenital heart disease (CHD) survivors and may contribute to emotional distress. Little research has investigated the role of coping in this association. This study examined the role of coping in accounting for the association between self-reported executive function problems and internalizing symptoms among adolescents and emerging adults (AEAs), as well as young adults (YAs) with CHD. Methods: Participants included 74 AEA (Mage = 19.32 ± 3.47 years, range 15-25 years) and 98 YA CHD survivors (Mage = 32.00 ± 3.69 years, range 26-39 years), recruited from pediatric and adult outpatient cardiology clinics. Participants completed self-report measures of executive function problems, coping (primary control, secondary control, and disengagement coping), and internalizing symptoms. Lesion severity classification and functional impairment due to symptoms of heart failure were determined from medical chart review. Results: Significant problems in executive function were reported by 5% of AEA and 13% of YA. Coping was not associated with executive function problems or internalizing symptoms for AEA. However, among YA, less use of adaptive coping strategies and more maladaptive coping responses was associated with both more executive function problems and internalizing symptoms. An indirect effect of executive function problems on internalizing symptoms via secondary control coping emerged for YA. Conclusions: Executive function problems may disrupt the ability to use important adaptive coping skills, such as cognitive reappraisal, positive thinking, and acceptance, thereby resulting in greater emotional distress among YA CHD survivors.

Stress Reactivity as a Pathway from Attentional Control Deficits in Everyday Life to Depressive Symptoms in Adolescent Girls.

The goal of this research was to expand theoretical models of adolescent depression to determine whether individual differences in cognitive processing-specifically attentional control deficits-help to explain increased risk for depression during adolescence. We also examined whether this pathway was stronger in girls than in boys. A longitudinal design was used to examine whether poor attentional control in everyday life (i.e., difficulties shifting between ideas, tasks, and activities) contributes to depression over time by fostering higher levels of stress reactivity. Youth (298 boys, 338 girls) completed questionnaires assessing stress reactivity (6th and 7th grades) and depressive symptoms (6th, 7th and, 8th grades); teachers completed the shifting subscale of the Behavior Rating Scale of Executive Function (Gioia et al. 2000a) to assess attentional control (6th and 7th grades). Structural equation modeling analyses provided support for the predicted pathway in girls but not boys, yielding a significant indirect effect from 6th grade shifting deficits to 8th grade depressive symptoms via 7th grade stress reactivity. These results suggest that attentional control deficits in early adolescence heighten girls' sensitivity to stress and consequent depressive symptoms, providing a critical direction for efforts to decrease adolescent girls' risk for depression.

Maternal and Paternal Influences on Children's Coping with Cancer-Related Stress.

Childhood cancer is a significant source of stress for children and families, and children's coping with cancer-related stress is a key predictor of emotional adjustment. To extend understanding of the determinants of children's coping with cancer-related stress, this study examined whether mothers' and fathers' functioning after their child's diagnosis-including coping and depressive symptoms-is predictive of children's coping over time. Participants included 166 children (Mage = 13.47, SD = 2.47, 51.2% female), 161 mothers, and 83 fathers. Approximately two months post-diagnosis (T1), parents reported on their coping and depressive symptoms. At T1 and approximately 12 months later (T2), children reported on their coping. Results indicated that mothers' coping and depressive symptoms were correlated with children's coping at T1; fathers' coping and depressive symptoms were generally not associated with children's coping at T1. Hierarchical regression analyses revealed that fathers' secondary control coping (i.e., coping aimed at adapting to cancer-related stress) predicted higher levels of secondary control coping in children over time. Mothers' depressive symptoms predicted lower levels of secondary control coping over time in girls, and fathers' depressive symptoms predicted lower levels of secondary control coping over time across sex. Parents' functioning after their child's cancer diagnosis may shape how children cope with cancer-related stress. Parents' coping and depressive symptoms may be important targets for interventions aiming to promote positive adjustment in children with cancer.

Cognition-emotion interaction as a predictor of adolescent depressive symptoms.

Given the sharp increase in rates of depression during adolescence, especially in girls, it is important to identify which youth are at greatest risk across this critical developmental transition. During the present research, we examined whether (a) individual differences in cognition-emotion interaction, as reflected in cognitive control (CC) deficits and trait negative emotionality (NE), predict depression levels across a 1-year period (sixth-seventh grades); and (b) these temperamental traits create a particularly strong risk in girls. Youth (338 girls, 298 boys; M age in 6th grade = 11.96, SD = .37) reported on their trait NE and depressive symptoms; teachers reported on CC deficits. As hypothesized, compromised CC predicted subsequent depressive symptoms in girls with high, but not average or low, trait NE. This research informs efforts to identify which adolescents are at heightened risk for depression during the adolescent transition and points to possible candidates for early intervention. (PsycINFO Database Record

Rumination about Social Stress Mediates the Association between Peer Victimization and Depressive Symptoms during Middle Childhood.

Although prior research has established a link between exposure to peer victimization and depressive symptoms, relatively little is known about the processes underlying this association. This study examined whether maladaptive responses to a novel social stressor - specifically, lower levels of problem solving or higher levels of rumination - mediate this association. Data were gathered from 130 children (64 boys, 66 girls; M age = 9.46, SD = .33) who participated in a laboratory social stressor task with an unfamiliar peer. Results indicated that prior exposure to peer victimization in the school context was associated with ruminative responses to the novel stressor, which mediated the association between victimization and depressive symptoms. These results indicate that ruminative responses to social stress outside of the victimization context may serve as one process explaining the association between victimization and heightened depressive symptoms.

Maternal depression and trajectories of adolescent depression: The role of stress responses in youth risk and resilience.

This study examined the independent and interactive contributions of maternal depression and youth stress responses to trajectories of youth depression in adolescence. Youths (n = 165, M age = 12.43, SD = 1.18) and their maternal caregivers participated in a 4-year longitudinal study. Mothers and youths were administered diagnostic interviews assessing depression, and youths provided reports of their responses to peer stress. Consistent with an interactive model, adaptive responses to stress (high effortful engagement and low involuntary disengagement) buffered the effect of maternal depression on initial levels and trajectories of youth depression, with gender differences emerging. Consistent with a dual-risk model, maternal depression and maladaptive responses to stress (high effortful disengagement and involuntary engagement) contributed additive risks such that youths displayed the highest levels of depression when they were exposed to maternal depression and showed maladaptive stress responses. This research provides novel evidence that responses to stress contribute to individual differences in depression among offspring of depressed mothers, and suggests that responses to stress are an important target for efforts to promote resilience in at-risk youth.

Usefulness of a Noninvasive Device to Identify Elevated Left Ventricular Filling Pressure Using Finger Photoplethysmography During a Valsalva Maneuver.

The high rate of re-hospitalization for heart failure might be reduced by improving noninvasive techniques for identifying elevated left ventricular (LV) filling pressure. We previously showed that changes in a finger photoplethysmography (PPG) waveform during the Valsalva maneuver (VM) reflect invasively measured LV end-diastolic pressure (LVEDP). We have since developed a hand-held device that analyzes PPG while guiding the expiratory effort of a VM. Here we assessed the sensitivity and specificity of this device for identifying elevated LVEDP in patients. We tested 82 participants (28 women), aged 40 to 85 years, before a clinically indicated left heart catheterization. Each performed a VM between 18 and 25 mm Hg for 10 seconds into a pressure transducer. PPG was recorded continuously before and during the VM. LVEDP was measured during the catheterization. An equation for calculating LVEDP was derived using (1) ratio of signal amplitudes: minimum during VM to average at baseline, (2) ratio of peak-to-peak time intervals: minimum during VM to average at baseline, and (3) mean blood pressure. Calculated and measured LVEDP were compared. The range of measured LVEDP was 4 to 35 mm Hg. Calculated LVEDP correlated with measured LVEDP (p <0.0001, r = 0.56). A calculated LVEDP >20 mm Hg had a 70% sensitivity and 86% specificity for identifying measured LVEDP >20 mm Hg (area under receiver-operating characteristic curve 0.83). In conclusion, a hand-held device for assessing LV filling pressure had high specificity and good sensitivity for identifying LVEDP >20 mm Hg, a clinically meaningful threshold in heart failure.

A finger photoplethysmography waveform during the valsalva maneuver detects changes in left heart filling pressure after hemodialysis.

BACKGROUND: A noninvasive system for determining left ventricular (LV) filling pressure may help to improve personalized fluid removal goals in hemodialysis patients. We previously showed that the change in photoplethysmography (PPG) pulse amplitude measured by finger PPG during a Valsalva maneuver correlates with invasively measured left ventricular end-diastolic pressure (LVEDP). This key PPG change, the ratio of finger PPG pulse amplitude at end-Valsalva to baseline, is known as the Pulse Amplitude Ratio, PAR. The objective of this study was to determine how PAR changes after fluid removal in hemodialysis. METHODS: We tested subjects with end-stage renal disease, before and after hemodialysis. Each subject performed a Valsalva maneuver with an effort of 20 mmHg for 10 s, guided by the device display. Finger PPG was recorded continuously before and during the maneuver. PAR was calculated automatically. RESULTS: Twenty-seven subjects (21 Males) ages 25-75 years were tested. Access sites were AV-fistulas of the arm predominantly. Weight decreased from 99.7 ± 36.9 kg to 97.0 ± 6.0 kg (p < 0.0003) with an average fluid removal of 3.07 ± 1.08 l. Correspondingly, PAR decreased from 0.74 ± 0.24 to 0.62 ± 0.23 (p = 0.003). The change in PAR was correlated with baseline PAR (r = 0.48, p = 0.01). CONCLUSION: An index of left heart filling pressure obtained noninvasively using finger photoplethysmography during the Valsalva maneuver is sensitive enough to detect reductions in filling pressure after fluid removal with hemodialysis. Further studies are warranted to determine if this method can be used to guide fluid removal during hemodialysis.

Moving against and away from the world: the adolescent legacy of peer victimization.

Nicki Crick initiated a generative line of theory and research aimed at exploring the implications of exposure to overt and relational aggression for youth development. The present study aimed to continue and expand this research by examining whether early (second grade) and increasing (second-sixth grade) levels of victimization during elementary school contributed to youths' tendencies to move against, away from, or toward the world of peers following the transition to middle school. Youth (M age in second grade = 7.96 years, SD = 0.35; 338 girls, 298 boys) reported on their exposure to victimization and their social goals (performance-approach, performance-avoidance, or mastery). Teachers reported on youths' exposure to victimization and their engagement in antisocial, socially helpless, and prosocial behavior. Latent growth curve analyses revealed that early and increasing levels of both overt and relational victimization uniquely contributed to multifinality in adverse developmental outcomes, predicting all three social orientations (high conflictual engagement, high disengagement, and low positive engagement). The pattern of effects was robust across sex and after adjusting for youths' early social motivation. These findings confirm that both forms of victimization leave an enduring legacy on youths' social health in adolescence. Given that profiles of moving against and away from the world can contribute to subsequent psychopathology, understanding and preventing this legacy is pivotal for developing effective intervention programs aimed at minimizing the effects of peer adversity.

Emotional awareness as a pathway linking adult attachment to subsequent depression.

Although research links insecure adult attachment with depression, the emotional processes accounting for this association over time remain relatively unexplored. To address this gap, this study investigated whether deficits in emotional awareness serve as one explanatory process. Adult female caregivers (N = 417, Mage = 37.83) completed questionnaires annually for 3 years. As anticipated, attachment avoidance exerted an indirect effect on depression via emotional awareness. Attachment anxiety directly predicted subsequent depression, but the indirect effect through emotional awareness was nonsignificant. These results suggest that an avoidant attachment style interferes with the effective processing of emotions, thereby placing women at risk for depression. This research implicates emotional awareness as a potential target for interventions aimed at reducing depressive symptoms in mothers with avoidant attachment styles.

Contributions of Socialization of Coping to Physiological Responses to Stress.

The messages mothers communicate to their children about coping may play an important role in children's emotional development by shaping children's responses to stress. Building on prior research demonstrating associations between maternal socialization of coping (SOC) and children's self-reported coping and emotional functioning (Abaied & Rudolph, 2010; 2011), we examined the contribution of SOC to children's physiological responses to stress. Mothers completed a measure of SOC with peer victimization. Children (N = 118; M age = 9.46 years, SD = 0.33) completed a measure of peer victimization and participated in a laboratory social challenge task. Saliva samples were collected prior to and following the task and were assayed for alpha-amylase (sAA), a marker of autonomic nervous system (ANS) activation. Hierarchical linear modeling analyses revealed that SOC contributed to sAA reactivity. Peer victimization predicted greater sAA reactivity when mothers made few engagement suggestions (orienting toward stress and associated emotions and cognitions) but not when mothers made many engagement suggestions. Mothers' distress responses predicted greater sAA reactivity. These findings provide novel evidence that the messages parents communicate about coping have implications for children's physiological reactivity to stress during middle childhood.

Contributions of maternal emotional functioning to socialization of coping.

This study examined whether maternal emotional functioning-emotional awareness and depression-guides the coping suggestions mothers make to their children in the context of a common childhood stressor (peer victimization). Across two waves of a longitudinal study, 330 mothers and their second graders (mean age (M) = 7.95 years, SD = .33; 158 boys and 172 girls) completed questionnaires. Emotional awareness predicted more primary control engagement suggestions (directly addressing stress or emotions). Depression predicted fewer cognitive restructuring suggestions (thinking positively) and more cognitive avoidance suggestions (orienting thoughts away from stress). Interactive effects between maternal emotional functioning and child sex also emerged. This study elucidates the impact of mothers' emotional functioning on how they teach their children to cope with stress.

Frontiers of therapy for patients with heart failure.

This review broadly covers advances in heart failure, which is responsible for significant morbidity, mortality, and cost in the United States. It is a heterogeneous condition, and accurate classification helps ensure appropriate application of evidence-based therapies. Hemodynamics are important in acute heart failure syndromes and may help tailor therapy. Neurohormonal modulation forms the cornerstone of chronic systolic heart failure treatment but does not affect outcomes in diastolic heart failure where management goals emphasize optimization of central volume, blood pressure, and atrial rhythm, as well as the treatment of comorbidities. Frontiers of heart failure therapy range from advances in pharmacology (novel inotropic agents and neurohormonal modulators), to cell biology (nucleic acid-based drugs and cell therapy) to biomedical engineering (devices such as ultrafiltration, biventricular pacemakers, implantable cardiac defibrillators, remote monitoring systems, and left ventricular assist devices), and to health systems (risk stratification and integrated care of comorbidities). The ultimate frontier will be to integrate these data effectively to ensure that patients with heart failure consistently receive the best evidenced-based care possible.