Examination of multiple birth as a predictor of autism symptom severity and developmental functioning in an early intervention sample.

Multiple birth is one of several perinatal factors associated with increased risk for autism spectrum disorder (ASD); however, complexity in its relationship to ASD symptoms and developmental functioning remains. The present study investigated perinatal risk factors for ASD, primarily focusing on birth status, within a large early intervention sample. In particular, the relationship between ASD, perinatal factors, and the effect of birth status on developmental functioning and ASD symptom severity were examined in youth with and without ASD classification who were born singly or were the product of a multiple birth. Overall, the presence of other perinatal risk factors, including prematurity, low birth weight, and advanced parental age, was primarily related to birth status and not to ASD classification, while severity of ASD symptoms and developmental impairments were primarily related to ASD classification and not to birth status. Study findings and implications for early screening of children with developmental delays are discussed.

Enhancing suicide prevention outreach via mobile-enabled website design.

Online outreach campaigns are a potential public health method for reaching service members at risk for suicide. The Real Warriors Campaign website underwent a full redesign in 2019 to enhance its ability to provide crisis resources and increase engagement by adopting a mobile-first strategy and implementing a responsive framework, meaning the site renders properly on all devices, including desktop, tablets, and mobile. Usability testing with end-user service members led to several innovations on the website, including a one-click banner that directly linked users on their mobile phones to crisis resources, the redesign of menus and content to better display on mobile devices, and promoting use of website resources through gateway topics. Comparing the 6 months before and after the mobile redesign showed significant increases in new mobile users, pages viewed on mobile devices, and new users coming to the site through social media. There was also a significant increase in specific help-seeking actions by users, including use of referral links and live chat, as well as 200 individuals accessing crisis phone lines through new one-click dialing banners. Suicide prevention campaigns should continue to optimize their online presence to reach groups at risk. This study of the website redesign from the Real Warriors Campaign illustrates several best practices in digital outreach as applied to suicide prevention, including leveraging usability testing, synching outreach material with social media, and ensuring mobile compatibility.

Factors Associated with Restricted, Repetitive Behaviors and Interests and Diagnostic Severity Level Ratings in Young Children with Autism Spectrum Disorder.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by restricted, repetitive patterns of behavior and interests (RRBIs). With the latest update to the Diagnostic and Statistical Manual of Mental Disorders, a severity level rating is assigned to the two core features of ASD (American Psychiatric Association in Diagnostic and statistical manual of mental disorders 5 American Psychiatric Association Washington, D.C., 2013). Previous studies have identified factors associated with RRBI severity; however, the relationship among RRBIs, adaptive functioning, and diagnostic severity level remains unclear. The present study investigated whether adaptive functioning and parent-reported ASD symptoms predict RRBI severity in young children with ASD. Additionally, a fine-grained analysis was conducted to examine the factors associated with diagnostic severity level ratings. Several significant associations were found. Study findings and implications for assessment and treatment of RRBIs are discussed.

An Evaluation of a Mobile Application Designed to Teach Receptive Language Skills to Children with Autism Spectrum Disorder.

The current study evaluated the effectiveness of a mobile application, Camp Discovery, designed to teach receptive language skills to children with autism spectrum disorder based on the principles of applied behavior analysis. Participants (N = 28) were randomly assigned to an immediate-treatment or a delayed-treatment control group. The treatment group made significant gains, p < .001, M = 58.1, SE = 7.54, following 4 weeks of interaction with the application as compared to the control group, M = 8.4, SE = 2.13. Secondary analyses revealed significant gains in the control group after using the application and maintenance of acquired skills in the treatment group after application usage was discontinued. Findings suggest that the application effectively teaches the targeted skills.

Gender Differences and Similarities: Autism Symptomatology and Developmental Functioning in Young Children.

A growing body of research suggests that symptoms of autism spectrum disorder (ASD) may present differently in males and females. This study examined gender differences in ASD symptoms and developmental functioning, using the Baby and Infant Screen for Children with aUtism Traits, Part 1 (BISCUIT-Part 1) and the Battelle Developmental Inventory, 2nd Edition (BDI-2), amongst children aged 17-37 months meeting ASD diagnostic criteria (n = 1317). No gender differences were found in regards to overall symptom severity or symptom domains on the BISCUIT-Part 1 when gender groups were matched by cognitive ability. Females with ASD had greater motor deficits and less communication impairment compared to their male counterparts as measured by the BDI-2. Secondary analyses examining item endorsement patterns were also conducted. Implications of the findings are discussed.

Gangrenous cholecystitis: innovative laparoscopic techniques to facilitate subtotal fenestrating cholecystectomy when a critical view of safety cannot be achieved.

BACKGROUND: Gangrenous cholecystitis is associated with a higher conversion rate of conversion from laparoscopic to open than acute non-gangrenous cholecystitis. New strategies and techniques are needed to decrease conversion rates and improve outcomes. METHODS: In this article, we provide a richly detailed, illustrated description of a modified fundus-first technique that we have developed over the last 15 years and now use routinely with rare conversions. We also compared outcomes of laparoscopic (LC) and open (OC) approaches for pathologically confirmed gangrenous cholecystitis in 146 patients during 1995-2005, the first 10 years during which these two approaches were performed contemporaneously at our institution on comparable patients. RESULTS: Among the 142 patients that met the inclusion criteria, laparoscopic procedures were started in 112 (79%) of these patients, with successful completion in 72 resulting in an overall conversion rate of 36%. During the last 5 years, however, in cases where the described laparoscopic technique was used, no patient has required conversion. The laparoscopic LC group had shorter average ICU stay (p < 0.05) and overall length of stay (2 vs 6 days, p < 0.001). Intraoperative cholangiography was completed in 37 of 72 LC patients (52%) versus 6 of 30 OC (20%). In five of the LC patients, a filling defect was seen on the cholangiogram and laparoscopic transcystic common bile duct stones, thereby avoiding a second anesthetic and endoscopic procedure. CONCLUSIONS: In the setting of severe inflammation, a number of procedural modifications can be incorporated to allow the surgeon to approach dissection of the gangrenous gallbladder using a flexible operative plan designed to optimize safe completion of this challenging procedure, with the expected improvement in surgical outcomes.

Association Between Pediatric Psoriasis and Waist-to-Height Ratio in the Absence of Obesity: A Multicenter Australian Study.

Importance: Increasing evidence suggests that psoriasis poses a cardiometabolic risk in children, as in adults. The best way to screen for this has not yet been established. Waist-to-height ratio (WtHR) can easily identify children with increased central adiposity and is a simpler alternative to body mass index (BMI) that does not require growth charts or percentiles. Having a WtHR of 0.5 or greater is associated with future cardiovascular risk. Objective: To determine whether children with psoriasis are more likely to have increased WtHR, obesity, and metabolic syndrome relative to children without psoriasis. Design, Setting, and Participants: This multicenter cross-sectional prospective case-control study was conducted from February 7, 2014, to July 15, 2015, in a tertiary referral center pediatric dermatology clinic and in 2 private consultant rooms of specialist dermatologists, all located in Sydney and Gosford, New South Wales, Australia. Participants were children (110 girls and 98 boys) aged from 5 to 16 years, 135 children with psoriasis and 73 controls with noninflammatory skin conditions. Main Outcomes and Measures: Increased central adiposity indicated by WtHR of 0.5 or higher, metabolic syndrome, and increased BMI. Results: Of the 208 children evaluated (110 girls and 98 boys) aged from 5 to 16 years (mean age, 8.9 years), 135 had psoriasis and 73 were controls with noninflammatory skin conditions. Children with psoriasis were more likely to have increased central adiposity, with WtHR of 0.5 or greater (29% [n = 39] vs 11% [n = 8]; P = .002). Four of 53 children older than 10 years with psoriasis were found to have metabolic syndrome compared with none of 29 in the control group (8% vs 0%; P = .29). Three of 15 children with moderate to severe psoriasis had metabolic syndrome compared with 1 of 38 children with mild psoriasis (20% vs 3%; P = .06). Children with moderate to severe psoriasis had a higher mean WtHR than children with mild psoriasis (0.48 vs 0.46; P = .04). Overweight and obesity according to BMI did not vary significantly between children with psoriasis and controls (17% [n = 23] vs 16% [n = 12]; P = .91). Conclusions and Relevance: In this Australian cohort of children with psoriasis, elevated WtHR was significantly more common in patients with psoriasis than in controls, while proportions of participants with metabolic syndrome or BMI-determined obesity were not significantly different between the 2 groups.

Factors affecting eyelid crease formation before and after silicone frontalis suspension for adult-onset myogenic ptosis.

PURPOSE: To evaluate factors that affect eyelid crease formation before and after frontalis suspension. DESIGN: Nonrandomized, comparative, interventional case series. METHODS: Sixty-three patients (125 eyes) with myogenic ptosis were included. Data collected included age, gender, previous surgeries, follow up, as well as pre- and postoperative margin reflex distance, palpebral fissure height, and levator function. Intraoperative maneuvers of incorporation of the levator aponeurosis into the skin closure, conservative fat excision, and conservative skin excision were recorded. Pre- and postoperative eyelid creases were graded by 2 masked, independent observers as "good," "fair," or "poor." RESULTS: The weighted κ coefficient between the graders was 0.68 (95% CI, 0.58-0.79) preoperatively and 0.70 (95% CI, 0.61-0.79) postoperatively. Evaluating preoperative eyelid crease grades, there was no significant difference with regard to age or gender (p = 0.83 or 0.69, respectively). Eyelid crease grade correlated with margin reflex distance (p = 0.0004) and palpebral fissure height (p = 0.002). There was no significant correlation of eyelid crease with levator function (p = 0.104). After frontalis sling, intraoperative maneuvers of incorporation of the levator aponeurosis into the incision, skin preservation, and fat preservation correlated with postoperative eyelid crease (p = 0.0004, 0.059, and 0.033, respectively). CONCLUSIONS: Preoperative levator function in patients with adult onset myogenic ptosis may be an inaccurate measure of true levator palpebrae strength. Reliance on levator function alone in decision making for surgical intervention in these patients may be misguided. The inclusion of the intraoperative maneuvers of incorporation of the levator aponeurosis into the skin incision and preservation of fat and skin results in a stronger eyelid crease after frontalis sling surgery.

Vulvovaginal candidiasis as a chronic disease: diagnostic criteria and definition.

OBJECTIVE: Although recurrent vulvovaginal candidiasis is defined as 4 or more discrete attacks of vulvovaginal candidiasis per year, there is no diagnostic nomenclature or definition for the many women who are chronically symptomatic. This study aims to establish and propose a definition and a set of diagnostic criteria, which would enable clinicians to promptly identify and treat women with chronic vulvovaginal candidiasis (CVVC). DESIGN: Prospective cohort study. SETTING: Public and private vulvar dermatology outpatient clinics in Sydney, Australia. PARTICIPANTS: Data were obtained prospectively from 50 women with presumptive CVVC and 42 controls. Historical and clinical features of CVVC identified by expert consensus were compared between the 2 groups. Diagnostic criteria were then prospectively applied to a further 163 patients to verify their accuracy. OUTCOME MEASURES: Signs and symptoms diagnostic of CVVC. RESULTS: The following characteristics were found to be significantly more common in women with CVVC compared to controls (p ≤ .001): a history of positive vaginal Candida swab, discharge, dyspareunia, soreness, swelling, cyclicity, and exacerbation of symptoms with antibiotics. CONCLUSIONS: We propose that CVVC can be confidently diagnosed using the major criteria of a chronic nonspecific and nonerosive vulvovaginitis that includes at least 5 or more properties from the following criteria: soreness, dyspareunia, positive vaginal swab either at presentation or in the past, previous response to antifungal medication, exacerbation with antibiotics, cyclicity, swelling, and discharge. This condition responds reliably to oral antifungal medication.

A comparative study of childhood psoriasis and atopic dermatitis and greater understanding of the overlapping condition, psoriasis-dermatitis.

BACKGROUND AND OBJECTIVES: Psoriasis (Pso) in children may be confused clinically with atopic dermatitis (AD) and, indeed, the two conditions may co-exist. The aim of this study was to determine historical and clinical features that are different in paediatric Pso and AD and to describe children who have features of both: psoriasis-dermatitis overlap (PD). METHODS: Children with features of psoriasis or eczema, or both, who were referred to paediatric outpatients and/or private rooms were evaluated. Data were collected from 170 consecutive children aged less than 12 years between July 2011 and November 2011. Participants were classified by described criteria as having Pso (n = 64), AD (n = 62) or PD (n = 44). RESULTS: Only 9.4% of children with Pso were correctly diagnosed by the referring doctor. Children with Pso relative to AD were more likely to have had a history of scaly scalp and nappy rash in infancy, a family history of psoriasis, current scalp and periauricular rashes, defined, patchy plaque morphology and papulosquamous rashes not typical of adult psoriasis on extensor elbows and knees. Children with PD had features of both but presented most often as typical paediatric psoriasis combined with flexural eczema. Children with Pso and PD responded well to specific treatment strategies for psoriasis, including potent topical corticosteroids (TCS), calcipotriol and phototherapy. Both Pso and PD tended to require more potent TCS than AD to achieve disease suppression. CONCLUSION: We found that Pso and PD in children both differ clinically from AD and have identified historical and clinical features that characterise childhood Pso.

Incipient retinal vein occlusion following immunotherapy of periorbital basal cell carcinoma.

We report a case of retinal vein occlusion in a 54-year-old woman following treatment with topical imiquimod for a superficial basal cell carcinoma of the temple. Signs and symptoms resolved rapidly upon ceasing treatment. Although they are uncommon, it is important to recognise and promptly manage ophthalmic complications related to treatment with imiquimod in order to prevent serious sequelae such as macular oedema and neovascularization.

Propranolol for recalcitrant ulcerated hemangioma of infancy.

Hemangioma of infancy (HOI) is a common, self-resolving, benign tumor that frequently requires no intervention. Ulceration is one of the main complications of HOI, and active treatment is usually required to manage pain, potential scarring, and occasionally bleeding and infection. Since the discovery that oral propranolol is an effective treatment for complicated HOI, it has been replacing systemic corticosteroids as first-line therapy, and early recommendations for treatment protocols have been devised. We report the successful treatment of six children with recalcitrant ulcerated HOI using propranolol. In all cases, complete, rapid healing occurred. Two children experienced recurrence of ulceration after ceasing propranolol, but this was rapidly controlled by restarting treatment. No adverse effects were encountered. We propose that ulceration in HOI is an indication for propranolol treatment if more conservative therapies have failed.

Ocular myeloid sarcoma in a 10-year-old child.

A 10-year-old girl presented with a 2-week history of an elevated, red conjunctival mass. She was in remission from acute myeloid leukemia (AML) and had two recurrences. Biopsy revealed a conjunctival myeloid sarcoma, an extramedullary lesion composed of cells of myeloid lineage that may present in children and adults, most commonly in the lymph nodes, skin, and subcutaneous tissues; it is less likely in ocular tissue. In patients with a history of AML, a new myeloid sarcoma is considered a relapse. To the best of our knowledge, this is the first case of a conjunctival myeloid sarcoma heralding a recurrence of an aggressive form of AML in a child.

Evaluation of the atrophogenic potential of topical corticosteroids in pediatric dermatology patients.

We conducted a cross-sectional observational study to determine the atrophogenic potential of TCS in children with dermatitis requiring long-term TCS suppression. Children who were able to achieve good disease control, with a maximum Eczema Area and Severity Index score of 1.0, using TCS were examined for adverse effects of treatment. Cutaneous atrophy was assessed using a validated dermoscopic technique. Cutaneous sites exposed to TCS were compared with nonexposed sites in all patients. There was no significant atrophy in 70 TCS-exposed and 22 TCS-naïve children. Mild grade 1 telangiectasia of the cubital fossa was observed in 3.3% of the test group and 3.1% of the control group (p > 0.99). We conclude that routine, appropriate, long-term use of TCS in children with dermatitis does not cause skin atrophy. These data do not support the widely held belief that routine use of TCS will "thin the skin." Parents, pharmacists, and health practitioners should be confident about the safety of using this treatment.

Corticosteroid phobia and other confounders in the treatment of childhood atopic dermatitis explored using parent focus groups.

BACKGROUND/OBJECTIVES: Anxieties associated with corticosteroid treatment and preference for 'safer natural therapy' are common in parents of children with atopic dermatitis. We used focus groups to explore the source of these attitudes. METHODS: The study involved 16 parents. Parents expressed difficulties with living with and treating atopic dermatitis which were categorized into themes using qualitative data analysis software. RESULTS: Themes identified include: emotional impact of atopic dermatitis; difficulty in accepting 'control' verses 'cure'; topical corticosteroid negative perceptions; anxiety and confusion with treatment; preference for 'natural' therapy; and attitude-changing positive experiences. CONCLUSIONS: Our findings illustrate the emotional impact of atopic dermatitis and the frustration with the lack of potential cure. 'Corticosteroid phobia' was universal among parents in our cohort and is a fear generated by doctors, pharmacists, close acquaintances and information from the internet. Participants expressed high levels of parental guilt linked to a desire for an eradicable 'cause' for atopic dermatitis, despite intellectually understanding this is a genetically determined condition. Parents were willing to change attitudes with accurate information from perceived reliable sources, positive hospitalization experiences and a relationship with a trusted dermatologist. Parents' suggestions to improve confidence included the provision of readily available information and better access to doctor- and nurse-led paediatric dermatology services.

Childhood ocular rosacea: considerations for diagnosis and treatment.

Rosacea in children is not as well described as it is in adults. Ocular signs may be a dominant feature and some children with what has previously been called periorificial dermatitis may in fact have rosacea. We report three cases of paediatric ocular rosacea responding to prolonged treatment with oral erythromycin. Our cases demonstrate the close association of periorificial dermatitis with childhood rosacea, and highlight the importance of eye signs in its diagnostic criteria.

Albinism in Africa as a public health issue.

BACKGROUND: Oculocutaneous albinism (OCA) is a genetically inherited autosomal recessive condition and OCA2, tyrosine-positive albinism, is the most prevalent type found throughout Africa. Due to the lack of melanin, people with albinism are more susceptible to the harmful effects of ultraviolet radiation exposure. This population must deal with issues such as photophobia, decreased visual acuity, extreme sun sensitivity and skin cancer. People with albinism also face social discrimination as a result of their difference in appearance. The World Health Organization is currently investigating the issues concerning this vulnerable population. METHODS: Systematic electronic search of articles in PubMed concerning albinism in Africa. Furthermore, a World Health Organization (WHO) pilot survey of albinism was drafted in English, French and Portuguese, and distributed to African countries through WHO African Regional Offices (AFRO) in an attempt to gather further information on albinism. RESULTS: Epidemiologic data on albinism, such as prevalence, were available for South Africa, Zimbabwe, Tanzania and Nigeria. Prevalences as high as 1 in 1,000 were reported for selected populations in Zimbabwe and other specific ethnic groups in Southern Africa. An overall estimate of albinism prevalences ranges from 1/5,000-1/15,000. In addition, both the literature review and the survey underscored the medical and social issues facing people with albinism. CONCLUSION: The estimated prevalence of albinism suggests the existence of tens of thousands of people living with albinism in Africa. This finding reiterates the need for increased awareness of and public health interventions for albinism in order to better address the medical, psychological and social needs of this vulnerable population.