Outcomes from a community speech and language therapy service treatment waiting list: The natural history of 525 children with identified speech and language needs.

BACKGROUND: Understanding the natural history of developmental speech and language impairments can support the selection of children whose difficulties are persistent rather than transitory. It can also provide information against which the effectiveness of intervention can be evaluated. However, natural history data are difficult to collect ethically. Furthermore, as soon as an impairment is identified, the behaviour of those around changes, thus creating some level of intervention. Longitudinal cohort studies, where intervention is minimal, or the control arm of randomized trials have provided the best evidence. However, occasional opportunities arise where service waiting lists can provide data about the progress of children who have not received intervention. This natural history study arose within an ethnically diverse, community paediatric speech and language therapy service in the UK where levels of social disadvantage are high. AIMS: To identify (1) the characteristics of the children who attended initial assessment and were selected for treatment; (2) the differences between children who did and did not attend reassessment; and (3) the factors associated with outcomes. METHODS & PROCEDURES: A cohort of 545 children were referred and assessed as in need of therapy. Due to resource constraints, intervention was not available for an average of 12 months. Children were invited to attend for a reassessment of need. Initial and follow-up assessments were conducted by experienced clinicians using service guidelines and the Therapy Outcomes Measures Impairment Scale (TOM-I). Descriptive and multivariate regression analyses examined child outcomes for changes in communication impairment, demographic factors and length of wait. OUTCOMES & RESULTS: At initial assessment, 55% of children presented with severe and profound communication impairments. Children offered appointments at clinics in areas of high social disadvantage were less likely to attend reassessment. By reassessment, 54% of children showed spontaneous improvement (mean TOM-I rating change = 0.58). However, 83% were still judged to require therapy. Approximately 20% of children changed their diagnostic category. Age and impairment severity at initial assessment were the best predictors of continuing requirement for input. CONCLUSIONS & IMPLICATIONS: Although children do make spontaneous progress post-assessment and without intervention, it is likely that the majority will continue to be assigned case status by a Speech and Language Therapist. However, when evaluating the effectiveness of interventions, clinicians need to factor in the progress that a proportion of the caseload will make spontaneously. Services should be mindful that a lengthy wait may disproportionately impact children who already face health and educational inequalities. WHAT THIS PAPER ADDS: What is already known on the subject Data from longitudinal cohorts (where intervention has been minimal) and the no treatment control arms of randomized controlled trials have provided the best evidence of the natural progression of speech and language impairments in children. These studies provide a varied rate of resolution and progress depending on the case definitions and measurements used. What this study adds to existing knowledge Uniquely, this study has evaluated the natural history of a large cohort of children who had been waiting for treatment for up to 18 months. Data showed that, over a period of waiting for intervention, the majority of those identified as a case by a Speech and Language Therapist remained a case. Using the TOM, on average children in the cohort made just over half a rating point progress during their waiting period. What are the potential or actual clinical implications of this work? The maintenance of treatment waiting lists is probably an unhelpful service strategy for two reasons: first, the case status of the majority of the children is unlikely to change whilst they await intervention and thus children and their families are subjected to further limbo waiting time; second, the dropout from the waiting list may disproportionately affect children who are offered appointments in clinics where there are higher levels of social disadvantage, thus exacerbating inequalities in the system. Currently, a suggested reasonable outcome of intervention is a 0.5 rating change in one domain of TOMs. Study findings suggest this is insufficiently stringent for a paediatric community clinic caseload. There is a need to evaluate spontaneous improvement which may occur in other TOM domains (i.e., Activity, Participation and Wellbeing) and to agree an appropriate change metric for a community paediatric caseload.

Degree of Cancer Spread at Presentation and Survival Among Adolescents and Young Adults in New South Wales, Australia.

Purpose: Five-year relative cancer survival increased from 80% to 89% among adolescent and young adult (AYA) Australians between 1985-1989 and 2011-2015. New South Wales (NSW), with a third of the Australian population, has long recorded degree of spread (localized, regional, or distant) at diagnosis. This study complements national data by investigating survival increases after adjusting for differences in degree of spread, cancer type, and sociodemographic characteristics. Methods: Population-based NSW Cancer Registry data, for malignant solid cancers where degree of spread was applicable, were analyzed for ages 15-24 years in 1980-2015. Subhazard ratios (SHRs) from competing risk regression indicated risk of death from the primary cancer as opposed to other causes. Multiple logistic regression was used to model odds ratios for more extensive compared with localized spread at diagnosis. Results: Approximately 72% of cancers had a localized degree of spread. Adjusted SHRs for cancer-specific mortality decreased from 1980-1989 to 2010-2015 (SHR: 0.73, 95% confidence interval: 0.55-0.95). Adjusted odds ratios (aORs) for more advanced versus localized spread were lowest for melanoma and lip, oral cavity, and pharyngeal carcinoma, and highest for breast carcinoma, Ewing tumor, and colorectal carcinoma. The aOR for more advanced versus localized cancer was higher for men than women. Conclusions: Cancer survival increased to a statistically significantly in AYAs during 1980-2015, after adjusting for degree of spread, cancer type, and sociodemographic characteristics. We attribute this mostly to treatment gains. Linked data should be used to explore treatment contributions.

Glycolytic metabolism confers resistance to combined all-trans retinoic acid and arsenic trioxide-induced apoptosis in HL60rho0 cells.

Glycolytic cancers are resistant to many forms of chemotherapy and some respond poorly to differentiation therapies. Here, we investigate the effects of exposure to all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) on differentiation and cell survival in the human leukemia cell line, HL60 and its mitochondrial gene knockout mutant, HL60rho0. Glycolytic HL60rho0 cells exposed to single and combined treatments expressed less CD15, in most cases, but produced a stronger respiratory burst than parental HL60 cells. HL60rho0 cells were also significantly more resistant to apoptosis after combined ATO+ATRA treatment compared with HL60 cells, and this was associated with failure to upregulate Fas expression.

Mycoplasma pneumoniae infection complicated by pneumomediastinum and severe mucositis.

We report an 8-year-old boy with Mycoplasma pneumoniae respiratory infection complicated by pneumomediastinum and severe oral and conjunctival mucositis. M. pneumoniae-associated mucositis is distinct from the Stevens-Johnson syndrome. There are no skin lesions and it improves promptly with antibiotics. Spontaneous pneumomediastinum usually only requires rest, analgesia and management of the underlying condition.