Brief telephone-delivered cognitive behavioral therapy targeted to parents of children with functional abdominal pain: a randomized controlled trial.

Pediatric functional abdominal pain disorders (FAPDs) are associated with increased health care utilization, school absences, and poor quality of life (QoL). Cost-effective and accessible interventions are needed. This multisite study tested the effects of a 3-session cognitive behavioral intervention delivered to parents, in-person or remotely, on the primary outcome of pain severity and secondary outcomes (process measures) of parental solicitousness, pain beliefs, catastrophizing, and child-reported coping. Additional outcomes hypothesized a priori and assessed included functional disability, QoL, pain behavior, school absences, health care utilization, and gastrointestinal symptoms. The study was prospective and longitudinal (baseline and 3 and 6 months' follow-up) with 3 randomized conditions: social learning and cognitive behavioral therapy in-person (SLCBT) or by phone (SLCBT-R) and education and support condition by phone (ES-R). Participants were children aged 7 to 12 years with FAPD and their parents (N = 316 dyads). Although no significant treatment effect for pain severity was found, the SLCBT groups showed significantly greater improvements compared with controls on process measures of parental solicitousness, pain beliefs, and catastrophizing, and additional outcomes of parent-reported functional disability, pain behaviors, child health care visits for abdominal pain, and (remote condition only) QoL and missed school days. No effects were found for parent and child-reported gastrointestinal symptoms, or child-reported QoL or coping. These findings suggest that for children with FAPD, a brief phone SLCBT for parents can be similarly effective as in-person SLCBT in changing parent responses and improving outcomes, if not reported pain and symptom report, compared with a control condition.

Effects of a Cognitive Behavioral Therapy Intervention Trial to Improve Disease Outcomes in Children with Inflammatory Bowel Disease.

BACKGROUND: Studies testing the efficacy of behavioral interventions to modify psychosocial sequelae of inflammatory bowel disease in children are limited. This report presents outcomes through a 6-month follow-up from a large randomized controlled trial testing the efficacy of a cognitive behavioral intervention for children with inflammatory bowel disease and their parents. METHODS: One hundred eighty-five children aged 8 to 17 years with a diagnosis of Crohn's disease or ulcerative colitis and their parents were randomized to one of two 3-session conditions: (1) a social learning and cognitive behavioral therapy condition or (2) an education support condition designed to control for time and attention. RESULTS: There was a significant overall treatment effect for school absences due to Crohn's disease or ulcerative colitis (P < 0.05) at 6 months after treatment. There was also a significant overall effect after treatment for child-reported quality of life (P < 0.05), parent-reported increases in adaptive child coping (P < 0.001), and reductions in parents' maladaptive responses to children's symptoms (P < 0.05). Finally, exploratory analyses indicated that for children with a higher level of flares (2 or more) prebaseline, those in social learning and cognitive behavioral therapy condition experienced a greater reduction in flares after treatment. CONCLUSIONS: This trial suggests that a brief cognitive behavioral intervention for children with inflammatory bowel disease and their parents can result in improved child functioning and quality of life, and for some children may decrease disease activity.

BarTeL, a Genetically Versatile, Bioluminescent and Granule Neuron Precursor-Targeted Mouse Model for Medulloblastoma.

Medulloblastomas are the most common malignant pediatric brain tumor and have been divided into four major molecular subgroups. Animal models that mimic the principal molecular aberrations of these subgroups will be important tools for preclinical studies and allow greater understanding of medulloblastoma biology. We report a new transgenic model of medulloblastoma that possesses a unique combination of desirable characteristics including, among others, the ability to incorporate multiple and variable genes of choice and to produce bioluminescent tumors from a limited number of somatic cells within a normal cellular environment. This model, termed BarTeL, utilizes a Barhl1 homeobox gene promoter to target expression of a bicistronic transgene encoding both the avian retroviral receptor TVA and an eGFP-Luciferase fusion protein to neonatal cerebellar granule neuron precursor (cGNP) cells, which are cells of origin for the sonic hedgehog (SHH) subgroup of human medulloblastomas. The Barhl1 promoter-driven transgene is expressed strongly in mammalian cGNPs and weakly or not at all in mature granule neurons. We efficiently induced bioluminescent medulloblastomas expressing eGFP-luciferase in BarTeL mice by infection of a limited number of somatic cGNPs with avian retroviral vectors encoding the active N-terminal fragment of SHH and a stabilized MYCN mutant. Detection and quantification of the increasing bioluminescence of growing tumors in young BarTeL mice was facilitated by the declining bioluminescence of their uninfected maturing cGNPs. Inclusion of eGFP in the transgene allowed enriched sorting of cGNPs from neonatal cerebella. Use of a single bicistronic avian vector simultaneously expressing both Shh and Mycn oncogenes increased the medulloblastoma incidence and aggressiveness compared to mixed virus infections. Bioluminescent tumors could also be produced by ex vivo transduction of neonatal BarTeL cerebellar cells by avian retroviruses and subsequent implantation into nontransgenic cerebella. Thus, BarTeL mice provide a versatile model with opportunities for use in medulloblastoma biology and therapeutics.

The effect of biofeedback on function in patients with heart failure.

Decreased HRV has been consistently associated with increased cardiac mortality and morbidity in HF patients. The aim of this study is to determine if a 6-week course of heart rate variability (HRV) biofeedback and breathing retraining could increase exercise tolerance, HRV, and quality of life in patients with New York Heart Association Class I-III heart failure (HF). Participants (N = 29) were randomly assigned to either the treatment group consisting of six sessions of breathing retraining, HRV biofeedback and daily practice, or the comparison group consisting of six sessions of quasi-false alpha-theta biofeedback and daily practice. Exercise tolerance, measured by the 6-min walk test (6MWT), HRV, measured by the standard deviation of normal of normal beats (SDNN), and quality of life, measured by the Minnesota Living with Congestive Heart Failure Questionnaire, were measured baseline (week 0), post (week 6), and follow-up (week 18). Cardiorespiratory biofeedback significantly increased exercise tolerance (p = .05) for the treatment group in the high (>or=31%) left ventricular ejection fraction (LVEF) category between baseline and follow-up. Neither a significant difference in SDNN (p = .09) nor quality of life (p = .08), was found between baseline and follow-up. A combination of HRV biofeedback and breathing retraining may improve exercise tolerance in patients with HF with an LVEF of 31% or higher. Because exercise tolerance is considered a strong prognostic indicator, cardiorespiratory biofeedback has the potential to improve cardiac mortality and morbidity in HF patients.

Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis.

BACKGROUND: Opioids can provide relief for people with chronic pain. However, a minority may develop aberrant drug behaviors. A critical issue is identifying "at-risk" patients. OBJECTIVE: To synthesize the evidence of published strategies for identifying at-risk patients to guide clinicians' decisions and practices for prescribing opioid treatment for chronic pain patients (CPP). DATA SOURCES: MEDLINE database search from 1966 to March 20, 2007, searching the bibliographies from all retrieved articles, and articles available in the authors' files. Studies were limited to human studies in the English language related to screening for predictors of aberrant drug behaviors in CPP who were prescribed long-term opioids. We included studies reviewing, developing measures, or investigating outcomes related to screening for aberrant opioid behaviors in CPP. RESULTS: We identified 6 published articles addressing clinician-based predictors of substance misuse of opioids and 9 published studies evaluating the predictive ability of clinical interviews and self-report measures for aberrant opioid behaviors in CPP. Several attempts have been made to develop procedures to identify at-risk patients including urine toxicology screening, structured interviews, observation, and self-report questionnaires. In general, the psychometric properties of the published questionnaires and interview protocols are weak; moreover, the samples included in the studies are often small and unrepresentative. Thus, none of them can be recommended for use with any confidence. CONCLUSION: Review of the published studies reveals that no one procedure or set of predictor variables is sufficient to identify CPP at-risk for opioid misuse or abuse. There is a scarcity of evidence regarding characteristics that predict aberrant behavior before beginning long-term opioids. Several predictors have been identified. Strong predictors include a personal history of illicit drug and alcohol abuse. Demographic factors have also been reported, but the results are not consistent. Prospective studies, especially ones with CPP who have not already been started on chronic opioid therapy, are needed.

Psychological approaches in the treatment of chronic pain patients--when pills, scalpels, and needles are not enough.

BACKGROUND: Chronic pain is a prevalent and costly problem that eludes adequate treatment. Persistent pain affects all domains of people's lives and in the absence of cure, success will greatly depend on adaptation to symptoms and self-management. METHOD: We reviewed the psychological models that have been used to conceptualize chronic pain-psychodynamic, behavioural (respondent and operant), and cognitive-behavioural. Treatments based on these models, including insight, external reinforcement, motivational interviewing, relaxation, meditation, biofeedback, guided imagery, and hypnosis are described. RESULTS: The cognitive-behavioural perspective has the greatest amount of research supports the effectiveness of this approach with chronic pain patients. Importantly, we differentiate the cognitive-behavioural perspective from cognitive and behavioural techniques and suggest that the perspective on the role of patients' beliefs, attitudes, and expectations in the maintenance and exacerbation of symptoms are more important than the specific techniques. The techniques are all geared to fostering self-control and self-management that will encourage a patient to replace their feelings of passivity, dependence, and hopelessness with activity, independence, and resourcefulness. CONCLUSIONS: Psychosocial and behavioural factors play a significant role in the experience, maintenance, and exacerbation of pain. Self-management is an important complement to biomedical approaches. Cognitive-behavioural therapy alone or within the context of an interdisciplinary pain rehabilitation program has the greatest empirical evidence for success. As none of the most commonly prescribed treatment regimens are sufficient to eliminate pain, a more realistic approach will likely combine pharmacological, physical, and psychological components tailored to each patient's needs.