A Novel Group Parenting Intervention for Emotional and Behavioral Difficulties in Young Autistic Children: Autism Spectrum Treatment and Resilience (ASTAR): A Randomized Controlled Trial.

OBJECTIVE: To examine the feasibility and preliminary efficacy of a group behavioral parenting intervention for emotional and behavioral problems (EBPs) in young autistic children. METHOD: This was a feasibility pilot randomized controlled trial comparing a 12-week group behavioral parenting intervention (Predictive Parenting) to an attention control (Psychoeducation). Parents of 62 autistic children 4 to 8 years of age were randomized to Predictive Parenting (n = 31) or Psychoeducation (n = 31). The primary outcome was a blinded observational measure of child behaviors that challenge. Secondary outcomes were observed child compliance and parenting behaviors; parent- and teacher-reported child EBPs; self-reported parenting practices, stress, self-efficacy, and well-being. Cost-effectiveness was also explored. RESULTS: Recruitment, retention, completion of measures, treatment fidelity, and parental satisfaction were high for both interventions. There was no group difference in primary outcome: mean log of rate 0.18 lower (d, 90% CI = -0.44 to 0.08) in Predictive Parenting. Differences in rates of child compliance (0.44, 90% CI = 0.11 to 0.77), facilitative parenting (0.63, 90% CI = 0.33 to 0.92) and parent-defined target symptom change (-0.59, 90% CI -0.17 to -1.00) favored Predictive Parenting. There were no differences on other measures. Predictive Parenting was more expensive than Psychoeducation, with a low probability of being more cost-effective. CONCLUSION: Feasibility was demonstrated. There was no evidence from this pilot trial that Predictive Parenting resulted in reductions in child EBPs beyond those seen following Psychoeducation; in addition, the effect size was small, and it was more expensive. However, it showed superiority for child compliance and facilitative parenting with moderate effect sizes. Future, definitive studies should evaluate whether augmented or extended intervention would lead to larger improvements. CLINICAL TRIAL REGISTRATION INFORMATION: Autism Spectrum Treatment and Resilience (ASTAR); https://www.isrctn.com/; 91411078.

The effect of saliva on the viscosity of thickened drinks.

Powdered thickeners are used to modify drink consistency in the clinical management of dysphagia. These thickeners are composed of primarily modified maize starch; some varieties also incorporate powdered gums. Amylase is a digestive enzyme found in saliva that initiates the breakdown of starch. To determine the significance of this process in dysphagia management, we measured the effects of human saliva on the viscosity of thickened drinks. Two thickeners were studied: one comprising modified maize starch alone and one that included additional gums. These were added to drinks with neutral and acidic pH: water and orange juice. Two clinical scenarios were simulated: (1) the effect of saliva on fluid as it is swallowed and (2) the effect when saliva enters a cup and contaminates a drink. Saliva was found to reduce the viscosity of water thickened with maize starch in both scenarios: (1) 90% reduction after 10 s and (2) almost 100% reduction in viscosity after 20 min. The thickener composed of gums and maize starch showed a significant reduction but retained a level of thickening. In contrast, thickened orange juice (pH 3.8) was not observed to undergo any measurable reduction in viscosity under the action of saliva.

Variation of the apparent viscosity of thickened drinks.

BACKGROUND: In dysphagia care, thickening powders are widely added to drinks to slow their flow speed by increasing their viscosity. Current practice relies on subjective evaluation of viscosity using verbal descriptors. Several brands of thickener are available, with differences in constituent ingredients and instructions for use. Some thickened fluids have previously been shown to exhibit time-varying non-Newtonian flow behaviour, which may complicate attempts at subjective viscosity judgement. AIMS: The aims were to quantify the apparent viscosity over time produced by thickeners having a range of constituent ingredients, and to relate the results to clinical practice. METHODS & PROCEDURES: A comparative evaluation of currently available thickener products, including two which have recently been reformulated, was performed. Their subjective compliance to the National Descriptors standards was assessed, and their apparent viscosity was measured using a rheometer at shear rates representative of situations from slow tipping in a beaker (0.1 s⁻¹) to a fast swallow (100 s⁻¹). Testing was performed repeatedly up to 3 h from mixing. OUTCOMES & RESULTS: When mixed with water, it was found that most products compared well with subjective National Descriptors at three thickness levels. The fluids were all highly non-Newtonian; their apparent viscosity was strongly dependent on the rate of testing, typically decreasing by a factor of almost 100 as shear rate increased. All fluids showed some change in viscosity with time from mixing; this varied between products from -34% to 37% in the tests. This magnitude was less than the difference between thickness levels specified by the National Descriptors. CONCLUSIONS & IMPLICATIONS: The apparent viscosity of thickened fluids depends strongly on the shear rate at which it is examined. This inherent behaviour is likely to hinder subjective evaluation of viscosity. If quantitative measures of viscosity are required (for example, for standardization purposes), they must therefore be qualified with information of the test conditions.

Real-time adjudication: collecting copayments and balances before the patient sees the doctor.

Doctors need to become better businesspeople, which means making sure that they collect all the monies that they deserve for all the services they provide to their patients. One method to achieve this is to use real-time adjudication. This article will describe real-time adjudication and how it can improve your collections by 7% to 10%.

A portable self-sensing rheometer for investigation and therapy of swallowing disorders.

Dysphagia is a medical condition in which the safety or efficiency of eating and drinking is compromised. Thin, watery fluids flow too quickly through the oral anatomy during an abnormal swallow, pre-empting airway protective mechanisms, and potentially resulting in fluid entry into the lung. Dysphagia therapy consists of reducing flow speed during swallowing by increasing fluid viscosity using thickeners. Bolus viscosity must be specified and presented to the patient within a well-defined range for effective therapy. Thickeners produce non-Newtonian fluids, rendering current subjective methods for fluid assessment unreliable. Widespread quantification of fluid viscosity is presently impractical as rheometers are costly and complicated to use. Alternative techniques also have disadvantages such as operation at shear rates inappropriate to fluid use. A simple and inexpensive rheometer has been constructed to remedy this situation using a self-sensing electromagnetic actuator. This avoids the need for separate force and displacement sensors, with benefits for simplicity and robustness. The actuator and fluid interface were designed for viscosities consistent with those used for dysphagia therapy. The self-sensing rheometer was found to be able to resolve the different dynamic viscosities obtained from three commonly used therapeutic fluid consistency levels in close agreement with results from a reference laboratory rheometer. Widespread use of the rheometer could remove the subjectivity of fluid assessment, increasing accuracy of fluid specification and therapy across all consistencies and fluid types.

Viscosity and non-Newtonian features of thickened fluids used for dysphagia therapy.

Thickening agents based primarily on granulated maize starch are widely used in the care of patients with swallowing difficulties, increasing viscosity of consumed fluids. This slows bolus flow during swallowing, allowing airway protection to be more properly engaged. Thickened fluids have been shown to exhibit time-varying behavior and are non-Newtonian, complicating assessment of fluid thickness, potentially compromising efficacy of therapy. This work aimed to quantify the flow properties of fluids produced with commercial thickeners at shear rates representative of slow tipping in a beaker to fast swallowing. Results were presented as indices calculated using a power-law model representing apparent viscosity (consistency index) and non-Newtonian nature of flow (flow behavior index). Immediately following mixing, 3 fluid thicknesses showed distinct consistency indices and decreasing flow behavior index with increasing thickener concentration. An increase in consistency index over 30 min was observed, but only for samples that were repeatedly sheared during acquisition. Three-hour measurements showed changes in consistency index across fluids with the largest being a 25% rise from initial value. This may have implications for efficacy of treatment, as fluids are not always consumed immediately upon mixing. Flow behavior indices were comparable across thickeners exhibiting similar rises over time. The indices were a more complete method of quantifying flow properties compared with single viscosity measurements, allowing an increased depth of analysis. The non-Newtonian nature of fluids perhaps renders them particularly suitable for use as dysphagia therapies, and such analysis may allow the possibility of altering these properties to optimize therapeutic efficacy to be explored. Practical Application: Effective treatment of swallowing disorders relies upon the appropriate choice and subsequent reproduction of drinks thickened to one of a number of predetermined levels. Currently there are no agreed methods of measuring the thickness of these drinks in use and the specifications are subjective, relying on descriptions such as "syrup" thick. This research aims to further understanding of the flow properties of thickened drinks and bring a quantified measure of thickness closer to being a practical reality.

Force modeling for needle insertion into soft tissue.

The modeling of forces during needle insertion into soft tissue is important for accurate surgical simulation, preoperative planning, and intelligent robotic assistance for percutaneous therapies. We present a force model for needle insertion and experimental procedures for acquiring data from ex vivo tissue to populate that model. Data were collected from bovine livers using a one-degree-of-freedom robot equipped with a load cell and needle attachment. computed tomography imaging was used to segment the needle insertion process into phases identifying different relative velocities between the needle and tissue. The data were measured and modeled in three parts: 1) capsule stiffness, a nonlinear spring model; 2) friction, a modified Karnopp model; and 3) cutting, a constant for a given tissue. In addition, we characterized the effects of needle diameter and tip type on insertion force using a silicone rubber phantom. In comparison to triangular and diamond tips, a bevel tip causes more needle bending and is more easily affected by tissue density variations. Forces for larger diameter needles are higher due to increased cutting and friction forces.