Screening for eating disorders in adolescents with chronic pain: the Eating Attitudes Test-16-Chronic Pain.

BACKGROUND: Few measures have been validated to screen for eating disorders (ED) in youth with chronic pain. We conducted confirmatory (CFA) of two established factor structures of the Eating Attitudes Test-26 (EAT-26) in a sample of youth with chronic pain attending an intensive interdisciplinary pain treatment (IIPT) program and examined the validity of the best-fitting model in predicting ED diagnoses in this sample. METHODS: Participants were 880 adolescents (M age = 16.1, SD = 2.1) consecutively admitted into an IIPT program who completed the EAT-26 upon admission. CFA was conducted and in the case of inadequate fit, EFA was planned to identify alternative models. Factors of the best-fitting model were included in a logistic regression analysis to predict ED diagnoses. RESULTS: The TLIs (0.70; 0.90), RMSEAs (0.09; 0.07) and CFIs (0.73; 0.92) suggested poor fit of one model and adequate of the second model. Goodness of fit indices from EFA (TLI:0.85, RMSEA:0.06) did not outperform the fit of the second CFA. As such, the second model was retained with the exception of one factor. The items loaded onto a 16-item, five factor model: Fear of Getting Fat, Social Pressure to Gain Weight, Eating-Related Control, Eating-Related Guilt and Food Preoccupation. Based on chart review, 19.1% of the participants were diagnosed with an eating disorder. Logistic regression analyses indicated the new 16-item measure and Fear of Getting Fat, significantly predicted an ED diagnosis that did not include avoidant restrictive food intake disorder (ARFID) and Social Pressure to Gain Weight significantly predicted a diagnosis of ARFID. CONCLUSIONS: An alternative 16-item, 5-factor structure of the EAT-26 should be considered in screening for EDs with youth with chronic pain.

Characteristics and outcomes of youth with functional seizures attending intensive interdisciplinary pain treatment.

Functional seizures (FS) can be debilitating and negatively impact quality of life. Yet intervention research for FS is limited, especially for youth. This study examined clinical characteristics and outcomes of youth with FS (13-23 years) presenting to a pediatric intensive interdisciplinary pain treatment (IIPT) program in the midwestern United States. Sixty youth (mean age = 16.5 years; 83.3 % female) met inclusion criteria. At intake, comorbid chronic pain, somatic symptoms, autonomic dysfunction, eating and weight disturbances, and mental health concerns were common. Despite this high symptom burden, youth with FS reported significant improvements in functioning measured with the Functional Disability Inventory, t(53) = 9.80, p <.001, d = 1.32; depression measured with the Center for Epidemiological Studies - Depression Scale for Children, t(53) = 6.76, p <.001, d = 0.91; anxiety measured with the Spence Children's Anxiety Scale, t(53) = 3.97, p < .001, d = 0.53; and catastrophizing measured with the Pain Catastrophizing Scale for Children, t(53) = 6.44, p <.001, d = 0.86, following completion of the program, suggesting that IIPT may be an effective treatment option for highly disabled and emotionally distressed youth with FS. Future research is needed to continue to refine best practices for youth with FS to reduce suffering and improve outcomes.

Gender Diversity Among Youth Attending an Intensive Interdisciplinary Pain Treatment Program.

Transgender and gender diverse (TGD) youth with chronic pain may be at unique risk for psychological distress and associated functional impairment, yet research on the intersection of chronic pain and gender identity is lacking. In a retrospective chart review of 491 participants admitted to a pediatric intensive interdisciplinary pain treatment (IIPT) program in the midwestern United States over an approximately 4-year period, 6.11% were TGD. TGD participants who completed the IIPT program reported significant and large improvements in anxiety, depression, pain catastrophizing, and functional ability. At baseline, TGD participants presented as more emotionally distressed and functionally impaired compared to age-matched, cisgender peers. When accounting for baseline scores, TGD participants who completed the IIPT program reported similar scores to cisgender peers at discharge, yet TGD youth were significantly less likely than cisgender peers to complete the IIPT program. Future directions and implications for clinical practice are discussed.

Disparities in Medical Assessment Practices for Adolescents at Risk for Eating Disorders.

PURPOSE: The United States Preventative Services Task Force found insufficient evidence to support universal screening for eating disorders (EDs) but did recommend assessing high-risk adolescents through laboratory tests, close follow-up, and referrals to other specialties. Yet, it is unclear whether youth at high risk for EDs receive such assessment and whether patient characteristics influence such practices. METHODS: Using the Rochester Epidemiological Project, we identified adolescents (13-18 years) at risk for EDs (i.e., weight loss, underweight, or loss of appetite not explained by a medical condition) who presented for a medical appointment between January 1, 2005 to December 31, 2017 (n = 662; M age = 15.8 years; 66% female; 76% white). Patient and visit characteristics, assessment practices (i.e., tests, referrals, and follow-up), and ED diagnoses within 5 years following index visit were extracted. RESULTS: Adolescents who received referrals to other providers were 4 times more likely to be diagnosed with a future ED (p < .001) and were diagnosed 137.8 days sooner (Est = -137.8, p = .04) compared to those who did not receive referrals. Compared to males, females were 2.2 times more likely to receive referrals (p < .001). Compared to those presenting at a lower body mass index, adolescents with a higher body mass index were more likely to receive medical tests (HR = 1.0, p < .01) and less likely to receive recommendations to improve eating/weight (HR = 0.99, p < .01) or follow up visits (HR = 0.99, p < .01). DISCUSSION: Disparities in assessment practices for adolescents at high-risk for EDs underscore the need for improved tools to enhance early detection and treatment.

Weight Suppression and Risk for Childhood Psychiatric Disorders.

Weight suppression, defined as the discrepancy between an individual's highest historical weight and their current weight, has been implicated in the development and maintenance of eating disorders. Although weight suppression has also been found to impact mood, anxiety and suicidal behavior in patients with and without disordered eating, it has not been examined as a transdiagnostic risk factor for general psychopathology. The current study examined growth records of 281 children and adolescents (ages 7 to 17) newly diagnosed with psychiatric disorders to determine whether these children were more likely to be weight suppressed as compared to an age- and gender-matched control group. Findings suggest that weight suppression is related to an increased risk for anxiety disorders and externalizing disorders for males. These results underscore the need for psychiatric and behavioral health providers to review pediatric growth charts as a routine part of psychiatric evaluation. As weight restoration is a necessary precondition for eating disorder recovery, more research is necessary to determine if weight restoration can enhance treatments for psychiatric symptoms occurring in the context of weight suppression.

Lifetime Prevalence of Psychiatric Disorders in Adolescents with Unexplained Weight Loss, Underweight, or Poor Appetite.

BACKGROUND: When adolescents present with symptoms of unexplained weight loss, underweight, or poor appetite, eating disorders (EDs) are commonly on the list of differential diagnoses. However, the relationship of these symptoms to other psychiatric disorders is often less clear. METHODS: Using the Rochester Epidemiology Project database, a retrospective cohort study of adolescents (13-18 years) with billing diagnoses of weight loss, underweight, or loss of appetite was conducted between January 2005 and December 2017. Patients who presented with conditions commonly associated with weight loss, underweight, or poor appetite (e.g., cancer) were excluded. This study sought to examine the proportion of patients who received ED and psychiatric diagnoses within 5 years of the index visit and patient characteristics associated with these diagnoses. RESULTS: Of 884 patients diagnosed with symptoms of unexplained weight loss, underweight, or poor appetite, 662 patients ( M age = 15.8; SD = 1.6; 66.0% female) met study criteria. Within 5 years of the index visit, the lifetime prevalence of all psychiatric disorders was 70% (n = 461) and of EDs was 21% (n = 141). For both psychiatric disorders and EDs, sex and race were significantly associated with receiving a diagnosis within 5 years. Decrease in body mass index (BMI) percentile was associated with receiving an ED diagnosis, whereas the highest historical BMI percentile was associated with receiving a psychiatric diagnosis. CONCLUSION: Patients presenting with symptoms of unexplained weight loss, underweight, or poor appetite are at risk not only for EDs but also for other psychiatric disorders that may require further assessment and follow-up.

Young Adult Pain Rehabilitation: Interdisciplinary Development and Preliminary Outcomes of a Novel Treatment Program.

BACKGROUND: Young adults with chronic pain and symptoms experience disruptions to their social, emotional, physical, and vocational functioning. Interdisciplinary pain rehabilitation programs for pediatric and adult populations are not designed specifically to address the developmental needs of young adults. METHODS: This article describes the development of a novel intensive interdisciplinary outpatient rehabilitation program tailored to the unique needs of young adults with chronic pain and symptoms. Tailored content included vocational assessment and consultation, financial literacy education, and sexual health education. RESULTS: Outcome data demonstrate treatment gains, with reductions in pain interference, pain severity, pain catastrophizing, and depressive symptoms, as well as improvements in mental and physical quality of life, perceived performance, perceived satisfaction with performance, and objective measures of physical functioning. CONCLUSIONS: The article concludes with clinical recommendations for the management of chronic pain and symptoms in young adults, applicable across multiple treatment settings.

Feasibility of wearable activity tracking devices to measure physical activity and sleep change among adolescents with chronic pain-a pilot nonrandomized treatment study.

Purpose: Personal informatics devices are being used to measure engagement in health behaviors in adults with chronic pain and may be appropriate for adolescent use. The aim of this study was to evaluate the utilization of a wearable activity tracking device to measure physical activity and sleep among adolescents attending a three-week, intensive interdisciplinary pain treatment (IIPT) program. We also assessed changes in physical activity and sleep from baseline to the treatment phase. Methods: Participants (57.1% female, average age 15.88, SD = 1.27) wore an activity tracking device three weeks prior to starting and during the treatment program. Results: Of 129 participants contacted, 47 (36.4%) agreed to participate. However, only 30 (64%) complied with the instructions for using the device prior to programming and during program participation. Preliminary analyses comparing averages from 3-weeks pre-treatment to 3-weeks during treatment indicated increases in daily overall activity minutes, daily step counts, and minutes of moderate to vigorous physical activity (by 353%), as well as a corresponding decrease in sedentary minutes. There was more missing data for sleep than anticipated. Conclusions: Wearable activity tracking devices can be successfully used to measure adolescent physical activity in-person, with more difficulty obtaining this information remotely. Adolescents with chronic pain experience improvements in objective measurements of physical activity over the course of a 3-week IIPT program. Future studies may want to spend more time working with pediatric patients on their understanding of how to use trackers for sleep and physical activity.

The Goals and Outcomes of Adolescent and Young Adults with POTS Attending an Intensive Interdisciplinary Treatment Program.

Postural Orthostatic Tachycardia Syndrome (POTS) affects approximately 1% of adolescents, however, little research has been done in this area. This retrospective chart review describes the treatment goals and perceived progress as measured by the Canadian Occupational Performance Measure (COPM) of 111 adolescents and young adults (AYAs) aged 12-22 (M = 15.8, SD = 1.8) diagnosed with POTS who were admitted to an interdisciplinary intensive pain treatment program (IIPT). This study also examined the change in progress and satisfaction in goals over a 3-week intensive pain treatment program, as well as the utility and validity of the COPM as an outcome measure for AYAs attending an IIPT. Results indicated adolescents and young adults endorsed treatment goals focused on self-care, school, and leisure and found that performance and satisfaction scores significantly improved from admission to discharge. The findings also suggest that the COPM is a useful and valid outcome measure for this population.

Physical Symptoms, Distress, and Functional Disability in Youth With Chronic Orthostatic Intolerance.

OBJECTIVE: Youth with chronic orthostatic intolerance (OI) can experience significant physical, social, and academic functional debilitation. Previous studies have indicated associations among symptom severity, psychosocial factors, and functional disability. However, empirically tested models explaining how different medical and psychosocial factors may contribute to functional disability are lacking. The current cross-sectional study aimed to evaluate mediation, moderation, and additive models of the effect of physical symptoms and psychological distress on functional disability. METHODS: One hundred and sixty-five youth (13-22 years old) undergoing medical evaluation of chronic OI symptoms completed measures of autonomic dysfunction symptom severity, depressive and anxiety symptoms, and functional disability. Models were evaluated using tests of indirect effects and linear and logistic regression analyses. RESULTS: Results supported the mediation and additive effects models for depressive symptoms. Mediation, moderation, and additive models for hypothesized effects of anxiety symptoms were not supported. CONCLUSIONS: Results provide preliminary support for models in which OI symptoms affect functional debility via their effects on mood and in which depressive symptoms have unique and additive effects on functioning. Findings lay the foundation for longitudinal and experimental evaluation of biopsychosocial models of functional disability in youth with chronic OI and related conditions. Implications include the importance of a biopsychosocial conceptualization of OI symptoms and debility as a complex interplay of factors rather than as a purely physiological or psychological process.

Seeing Makes the Difference: Augmented Reality in the OR.

Although many surgeries, including spinal procedures, have been much improved with robotics in recent years, the additional technology has created associated issues with its use in the space constraints of the operating room (OR). This is especially true with monitors and their small screen sizes, which make it difficult for surgeons to see details during procedures. Solving such problems and finding the optimal position for viewing as well as ensuring integration with current technology were primary objectives in the development of iSight, a wireless augmented reality (AR) system designed by Dr. Chetan K. Patel, MD, in collaboration with startup Altair Innovations [1]. Patel is an orthopedic spine surgeon and executive medical director for spine surgery at AdventHealth Neuroscience Institute (Figure 1).

What about parents? A systematic review of paediatric intensive interdisciplinary pain treatment on parent outcomes.

BACKGROUND AND OBJECTIVE: Intensive interdisciplinary pain treatment (IIPT) for youth with high impact chronic pain has been found to be effective in improving child symptoms and functioning. However, it remains unclear how these interventions impact the parents' own well-being, as well as cognitions and behaviours which are known to influence child pain and functioning. Thus, the current study sought to determine the effect of IIPT on parent mental health, cognitions and behaviours in parents of youth attending IIPT with their child. DATABASES AND DATA TREATMENT: A search of the electronic databases CINAHL, Ovid EBM Reviews, Embase, Medline, APA PsychINFO, Scopus and web of Science was conducted. Studies were included if they comprised at least 10 parents of patients aged 9-22 with nonmalignant chronic pain attending an IIPT and were written in English. RESULTS: A random-effects model was used to pool the standardized mean change (SMC) across seven prepost studies. At discharge, IIPT participation was associated with small to moderate improvements in direct parental outcomes (general mental health, anxiety, depression and parenting stress), a moderate improvement in pain catastrophizing and large improvements in psychological flexibility and parenting behaviours. Most improvements were maintained at follow-up. The risk of bias of all studies was rated as serious and the certainty of the evidence as low, suggesting limited confidence in the estimates. CONCLUSIONS: Although parents appear to benefit from attending an IIPT with their child, RCTs are needed to substantiate the effect of these interventions on important aspects of parent well-being and functioning.

Excessive Postural Tachycardia and Postural Orthostatic Tachycardia Syndrome in Youth: Associations With Distress, Impairment, Health Behaviors, and Medication Recommendations.

Among adolescents with fatigue and postural dizziness, it is unclear how health behaviors and emotional distress relate to the presence of excessive postural tachycardia. We prospectively evaluated adolescents aged 13-22 years presenting with symptoms suggestive of autonomic dysfunction between September 2017 and December 2018. Patients underwent standard 10-minute, 70-degree head-up tilt testing. Clinician diagnoses and recommendations were recorded from the medical record. Patients completed validated self-report measures of lifestyle factors, autonomic symptoms, depression, anxiety, and functional disability. Of 179 patients, 58 were diagnosed with postural orthostatic tachycardia syndrome and 59 had excessive postural tachycardia, with 90.5% concordance between the 2 groups. Presence of excessive postural tachycardia was associated with greater baseline fluid intake and likelihood of medication prescription in their treatment plan. Medication findings were replicated for postural orthostatic tachycardia syndrome diagnosis. Presence of excessive postural tachycardia or postural orthostatic tachycardia syndrome did not differentiate patients on perceived symptom severity, emotional distress, disability, or health behaviors but did appear to determine treatment recommendations.

Intensive interdisciplinary pain treatment for children and adolescents with chronic noncancer pain: a preregistered systematic review and individual patient data meta-analysis.

ABSTRACT: Chronic noncancer pain in children and adolescents can be impairing and results in substantial health care costs. Intensive interdisciplinary pain treatment (IIPT), an inpatient or day hospital treatment delivered by a team of 3 or more health professionals, may be an effective intervention for these children and adolescents. Based on previous reviews and meta-analyses, we updated findings regarding the description of available treatments and estimated the effectiveness of IIPT, overcoming methodological shortcomings of previous work by requesting and analyzing individual participant data. On June 26, 2021, we searched 5 literature databases (PubMed, PsycINFO, Web of Science, Cochrane Library, and PubPsych) for studies examining the effectiveness of IIPT. Included studies used a pre-post design, assessed patients younger than 22 years, and presented their results in English, German, French, or Spanish. We used standard methodological procedures expected by Cochrane to pool treatment effects and assess risk of bias. We identified 13 different treatment sites with similar treatment inclusion criteria and treatment components, but the descriptions of those treatments varied widely. Regarding treatment effectiveness, IIPT may result in large improvements in the mean pain intensity ( g = -1.28), disability ( g = -1.91), and number of missed school days at the 12-month follow-up ( g = -0.99), as well as moderate improvements in anxiety ( g = -0.77) and depression ( g = -0.76). The certainty of the evidence, however, was graded from very low to low. We recommend that future researchers use more scientific rigor to increase the certainty of the evidence for IIPT and standardize treatment outcomes for children and adolescents with chronic pain.

Working Toward Diversity and Inclusion in Neural Engineering.

How do we begin to consider ways to broaden the reach of our field, both to engage younger students and also those from different ethnicities, classes, and socio-economic backgrounds? Where are the opportunities to make our research, our laboratory, our surrounding community more open, inclusive, and diverse? By what means can we increase outreach in our communities, providing avenues for diverse students to explore STEM topics and engage in research?

Harnessing Another Tool for Treating Brain Cancer.

In the United States alone, an estimated 700,000 people have been diagnosed and are living with a brain tumor, and it is estimated that approximately 84,000 people will receive a tumor diagnosis in 2021 [1]. Fortunately, the majority of these tumors will be benign; on average only 30% of all brain tumors are malignant. For patients with malignant tumors, the current five-year survival rate is 36% with an average 31% ten-year survival rate [2] but for those diagnosed with glioblastoma (GBM)-one of the most deadly and treatment-resistant cancers-the patient survival rate falls to a low 7.2% and the median life-span after diagnosis is only eight months. GBM is the most common primary malignant brain tumor, even as an increasing numbers of cancer patients are diagnosed with brain metastases (secondary brain tumors), where the cancer has traveled to the brain from another part of the body.

The RADxSM Tech Process: Accelerating Innovation for COVID-19 Testing.

In the wake of the COVID-19 pandemic, the need for rapid and accurate diagnostic testing across populations quickly became evident. In response, the National Institutes of Health (NIH) was determined not only to invest heavily in this area but to change the process by which grant proposals were reviewed and funded in order to spur faster development of viable technologies. The Rapid Acceleration of Diagnostics (RADx) initiative was designed to speed innovation, commercialization, and implementation of potential COVID-19 diagnostic technology. As part of this effort, the RADx Tech initiative focuses on the development, validation, and commercialization of innovative point-of-care, home-based, and clinical lab-based tests that can detect SARS-CoV-2. This effort was enabled through the NIH's National Institute of Biomedical Imaging and Bioengineering (NIBIB) Point-of-Care Technology Research Network (POCTRN).

Can adolescents with eating disorders be treated in primary care? A retrospective clinical cohort study.

BACKGROUND: Family-Based Treatment (FBT) is considered the first-line intervention for adolescent anorexia nervosa. However, access to this treatment is limited. Treatment programs for other pediatric mental health conditions have successfully overcome barriers to accessing evidence-based intervention by integrating mental health services into primary care. This study evaluated the proof-of-concept of a novel modification of FBT, Family-Based Treatment for Primary Care (FBT-PC) for adolescent restrictive eating disorders designed for delivery by primary care providers in their practices. METHODS: This retrospective clinical cohort study evaluated 15 adolescents with restrictive eating disorders receiving FBT-PC and 15 adolescents receiving standard FBT. We examined improvement in BMI percentile, reduction in weight suppression, and clinical benchmarks of eating disorder recovery including weight restoration to > 95% of expected body weight (EBW) and resolution of DSM-5 criteria for eating disorders. RESULTS: In both groups, effect sizes for increased BMI percentile exceeded Cohen's convention for a large effect (FBT-PC: d = .94; standard FBT: d = 1.15) as did effect sizes for reduction in weight suppression (FBT-PC: d = 1.83; standard FBT: d = 1.21). At the end of treatment, 80% of the FBT-PC cohort and 87% in the standard FBT group achieved > 95%EBW and 67% in the FBT-PC group and 60% in the standard FBT group no longer met DSM-5 criteria for an eating disorder. There were no cohort differences in the number of treatment drop-outs or referrals to a more intensive level of eating disorder treatment. CONCLUSIONS: Findings suggest that primary care providers have potential to improve weight and clinical status in adolescents with restrictive eating disorders. Based on these results, more rigorous testing of the FBT-PC model is warranted.

Family-Based Treatment (FBT) is considered the first-choice intervention for adolescent anorexia nervosa. However, finding a qualified provider in this modality is difficult. Treatment programs for other pediatric mental health conditions have successfully overcome barriers to accessing quality treatment by integrating mental health services into primary care. This study evaluated the proof-of-concept of a novel modification of FBT, Family-Based Treatment for Primary Care (FBT-PC) for adolescent restrictive eating disorders designed for delivery by primary care providers in their practices. This study examined weight gain in 15 adolescents with restrictive eating disorders receiving FBT-PC and 15 adolescents receiving standard FBT. At the end of treatment, both groups showed large improvements in BMI percentile and large decreases in weight suppression. Each group had the same number of drop-outs and referrals to more intensive eating disorder treatment. Findings suggest that primary care providers have potential to improve weight and clinical status in adolescents with restrictive eating disorders. Based on these preliminary results, more rigorous testing of the FBT-PC model is indicated.

Solving Unmet Needs With Innovative Pediatric Medical Devices.

In the last decade, only 24% of class III life-saving devices approved by the U.S. Food and Drug Administration (FDA) were for pediatric use-and most of those were for children over 12. Of these, less than 4% were labeled for pediatric patients ages 0-2 years old and the number of approved devices is even lower for neonatal patients. For these young patients, adult medical devices are often manipulated by pediatric specialists in order to provide stop-gap solutions. However, these repurposed devices are not always able to fulfill the unique needs of children's biology and growth patterns.

A Life Well Lived: In Memory of Máximo E. Valentinuzzi.

Throughout his career, Dr. Máximo (Max) E. Valentinuzzi worked long and hard for the development of the BME profession locally, regionally, and internationally. His accomplishments were numerous and valuable, including his editorship of the IEEE Pulse special column known as "Retrospectroscope" for more than ten years. A highlight and strength of the magazine over the past decade, this special column was built largely on the efforts and contributions from Dr. Valentinuzzi (Figure 1).