Identifying Youth Problem Profiles and Predicting Remission Following Mental Health Treatment

This study utilized latent profile analysis to categorize youth served by a public mental health setting into homogenous classes. Then, associations between class membership and meeting clinical criteria by the latest assessment were examined. Caregiver responses to the Ohio Scales, Short Form, Problem Severity Scale for 1090 youth completed at entry into this public mental health system were subjected to latent profile analysis. This method classifies youth into categories based on mental health problem profiles, in order to determine the degree to which these groupings are related to later mental health outcomes. The classification of youth cases that emerged was then used to predict clinical remission at or nearest end of treatment, including final Ohio Scales Problem Severity scores and a measure of day-to-day functioning, the Child and Adolescent Functional Assessment Scale (CAFAS). A four-class model was identified as best representing the data, reflecting a relatively low-risk class (63.3% of the sample), an internalizing class (23.2%), a delinquency class (8.8%), and a high-risk class (4.7%). Individuals in the internalizing and high-risk classes had lower likelihoods of achieving problem remission than those in the low-risk and delinquency classes at the time of their last completed Ohio Scales. Additionally, youth assigned to the delinquency and high-risk classes had lower likelihoods of reaching functional impairment remission than those in the internalizing and low-risk classes. Youth membership in a class based on initial problem scores can be utilized to predict clinical remission over the course of treatment in public mental health care. Such class-based predictions support other methods of predicting outcomes and can be used by clinicians to develop more informed treatment plans and to adjust treatment based on such classifications.

     

Treatment of scedosporiosis with voriconazole: clinical experience with 107 patients

The efficacy of voriconazole in 107 patients with scedosporiosis was analyzed. Principal infection sites were the lungs/sinuses (24%), central nervous system (CNS) (20%), and bone (18%), while 21% of patients had disseminated infection. Solid organ transplantation (22%), hematological malignancy (21%), and surgery/trauma (15%) were the predominant underlying conditions. A successful therapeutic response was achieved in 57% of patients (median, 103 therapy days), with > 98% of those responding receiving > or = 28 days of therapy. Patients receiving primary therapy showed a 61% response versus 56% for the others. The best therapeutic responses were seen for skin/subcutaneous (91%) or bone (79%) infections, and the lowest for CNS infections (43%). Patients without major immune suppression (72%) or those with solid organ transplantation (63%) or various hematological conditions (60%) showed the best responses by underlying condition. Median known survival time was 133 days (therapy successes, 252 days; failures, 21 days). In all, 43 (40%) patients died, 73% due to scedosporiosis. Patients with Scedosporium prolificans infection had significantly reduced survival times (P = 0.0259) and were more likely to die from fungal infection (P = 0.002) than were Scedosporium apiospermum-infected patients. In a subset of 43 patients where voriconazole baseline MICs were available, response to voriconazole was higher for S. apiospermum-infected patients (54% response; MIC(50), 0.25 microg/ml) than for S. prolificans-infected patients (40% response; MIC(50), 4.0 microg/ml). Voriconazole demonstrated clinically useful activity in the treatment of both S. apiospermum and S. prolificans infections and was well tolerated.     

Planning for the evaluation of a pediatric end-of-life curriculum

BACKGROUND: Decision making at the end of life can be complex and emotionally challenging for healthcare providers, particularly in pediatrics. Unfortunately, few undergraduate and graduate medical education curricula adequately address these issues. In this article, we describe the plan and progress to date of the design, implementation, and evaluation of an end-of- life curriculum for pediatric residents. NEEDS ASSESSMENT: Prior to the development of a formal end-of-life curriculum, a survey was given to a single cohort of residents four times over the course of their training to assess their attitudes toward end-of-life issues and their experience with the informal curriculum in residency. Entering pediatric residents felt relatively uncomfortable dealing with death and dying, but by the end of training, residents felt more comfortable dealing with these issues. Residents were relatively ambivalent about the degree to which their education helped them to deal with end-of-life issues. CURRICULUM DEVELOPMENT AND EVALUATION PLAN: A number of curricular interventions were developed including a noon conference series, grand rounds presentations, a 3-hour seminar on giving bad news, and written information for the housestaff manual. The curriculum was implemented in the fall of 1999. The impact of the curriculum will be assessed using a single interventional group with historical control study design. The evaluation instruments will include the previously used survey and an objective written examination. The 3-hour seminar will be assessed with a pre-test post-test crossover design using standardized patients. DISCUSSION: This rigorous, feasible, and cost-effective approach to curriculum development is intended to serve as a model for end-of-life education in pediatric residencies.     

Ganciclovir sensitivity of cytomegalovirus at diagnosis and during treatment of cytomegalovirus pneumonia in marrow transplant recipients.

Cytomegalovirus (CMV) often persists in the lungs of marrow transplant patients with CMV pneumonia, despite ganciclovir (GCV) treatment. To determine whether GCV resistance contributes to viral persistence, the susceptibilities of CMV isolates from diagnostic bronchoalveolar lavage samples and CMV isolates obtained during treatment or from autopsy lung tissue from 12 patients were compared by DNA hybridization. Resistance (50% effective dose, > 12 microM) was detected in an isolate from only one patient who had also received several courses of GCV. GCV resistance did not explain the persistence of CMV in the lung.     

Ocular manifestations of Mycoplasma pneumoniae infection.

Ocular manifestations of Mycoplasma pneumoniae infection, other than conjunctivitis, are uncommon. Optic disk swelling, optic nerve atrophy, retinal exudates and hemorrhages, and cranial nerve palsies have been infrequently reported. We describe a 15-year-old patient who developed bilateral optic disk edema and iritis during an acute infection with M. pneumoniae and review the world literature on findings associated with ocular manifestations of infection with this pathogen. Although our patient experienced complete resolution of iritis and optic disk edema after 6 weeks, several patients described in the literature have experienced permanent sequelae as a result of optic neuropathy.