A Nationwide Survey of the Management of Unintentional—Low Dose Tricyclic Antidepressant Ingestions Involving Asymptomatic Children: Implications for the Development Of an Evidence-Based Clinical Guideline

Background: The triage of unintentional tricyclic and cyclic antidepressant ingestions involving children <6 years seems based on single cases or small studies. Walsh, in describing 2 cases involving 15–20 mg/kg ingestions, recommended hospitalizing all children ingesting tricyclic and cyclic antidepressants. Objective: To evaluate the patterns of triage for pediatric tricyclic and cyclic antidepressants practiced by regional poison control centers nationwide, and to determine the amount ingested (mg/kg) that resulted in referral to the emergency department, including the recommended duration of observation time for asymptomatic children. Second, to analyze the cost implications, as well as the need for a practice guideline based on severity stratification. Methods: We sent a survey to 44 major regional poison control centers. We reviewed Health Care Financing Administration's tricyclic and cyclic antidepressants management related costs. Results: Thirty centers responded (68%). Eighty-seven percent of all centers send children, regardless of dose ingested, to the emergency department. Four out of the 30 recommended observation based on dose in mg/kg ingested (range >1.5–5). Recommended observation times in the emergency department varied between 6–24 hours. Twenty-seven (90%) Poison Control Centers recommended 6 hours (although one recommended doing so only after administering activated charcoal). One recommended 6–12 hours of observation and 2 Poison Control Centers recommended 24-hour observation. Only 1 center recommended obtaining tricyclic and cyclic antidepressant plasma levels. Discussion: In our review of the literature, the lowest toxic dose reported was 6.7 mg/kg. This is consistent with our Poison Control Center data over the past 5 years where no child was toxic at doses <5 mg/kg. While only 13% of the centers surveyed utilize a stratification strategy to triage pediatric tricyclic and cyclic antidepressant ingestions, the current referral patterns support evaluation based on pharmacokinetics, not worst case incidents. Conclusion: This survey demonstrates that most children with tricyclic and cyclic antidepressant ingestions will be sent to the emergency department, regardless of the amount ingested. A prospective study is needed to determine the probable dose of tricyclic and cyclic antidepressant ingestions that requires observation at a health care facility.     

Evaluating a Bereavement Follow-Up Intervention for Grieving Fathers and Their Experiences of Support After the Death of a Child—A Pilot Study

This article describes a study designed to evaluate the effectiveness of an intervention program for bereaved fathers and their experiences of it in a sample of intervention (n = 62) and control (n = 41) fathers. Data were collected by 3 scales: the Hogan Grief Reactions Checklist, a scale for measuring received social support, and a scale for measuring fathers' experiences of the intervention program. Assessment at 6 months after leaving the hospital showed that intervention fathers reported lower grief reaction scores and stronger personal growth. Intervention fathers reported the most emotional support from both health care personnel and peer supporters. The support received was perceived as helpful in coping, and fathers rated the intervention favorably. The findings support the continuation of the intervention.     

Empirical Validation of the Information–Motivation–Behavioral Skills Model of Diabetes Medication Adherence: A Framework for Intervention

OBJECTIVE

Suboptimal adherence to diabetes medications is prevalent and associated with unfavorable health outcomes, but it remains unclear what intervention content is necessary to effectively promote medication adherence in diabetes. In other disease contexts, the Information–Motivation–Behavioral skills (IMB) model has effectively explained and promoted medication adherence and thus may have utility in explaining and promoting adherence to diabetes medications. We tested the IMB model’s hypotheses in a sample of adults with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Participants (N = 314) completed an interviewer-administered survey and A1C test. Structural equation models tested the effects of diabetes medication adherence-related information, motivation, and behavioral skills on medication adherence and the effect of medication adherence on A1C.

RESULTS

The IMB elements explained 41% of the variance in adherence, and adherence explained 9% of the variance in A1C. As predicted, behavioral skills had a direct effect on adherence (β = 0.59; P < 0.001) and mediated the effects of information (indirect effect 0.08 [0.01–0.15]) and motivation (indirect effect 0.12 [0.05–0.20]) on adherence. Medication adherence significantly predicted glycemic control (β = −0.30; P < 0.001). Neither insulin status nor regimen complexity was associated with adherence, and neither moderated associations between the IMB constructs and adherence.

CONCLUSIONS

The results support the IMB model’s predictions and identify modifiable and intervenable determinants of diabetes medication adherence. Medication adherence promotion interventions may benefit from content targeting patients’ medication adherence-related information, motivation, and behavioral skills and assessing the degree to which change in these determinants leads to changes in medication adherence behavior.     

Development and Psychometric Evaluation of the HPV Clinical Trial Survey for Parents (CTSP‐HPV) Using Traditional Survey Development Methods and Community Engagement Principles

Objective

This study describes the development and psychometric evaluation of HPV Clinical Trial Survey for Parents with Children Aged 9 to 15 (CTSP‐HPV) using traditional instrument development methods and community engagement principles.

Methods

An expert panel and parental input informed survey content and parents recommended study design changes (e.g., flyer wording). A convenience sample of 256 parents completed the final survey measuring parental willingness to consent to HPV clinical trial (CT) participation and other factors hypothesized to influence willingness (e.g., HPV vaccine benefits). Cronbach''s a, Spearman correlations, and multiple linear regression were used to estimate internal consistency, convergent and discriminant validity, and predictively validity, respectively.

Results

Internal reliability was confirmed for all scales (a ≥ 0.70.). Parental willingness was positively associated (p < 0.05) with trust in medical researchers, adolescent CT knowledge, HPV vaccine benefits, advantages of adolescent CTs (r range 0.33–0.42), supporting convergent validity. Moderate discriminant construct validity was also demonstrated. Regression results indicate reasonable predictive validity with the six scales accounting for 31% of the variance in parents’ willingness.

Conclusions

This instrument can inform interventions based on factors that influence parental willingness, which may lead to the eventual increase in trial participation. Further psychometric testing is warranted.     

Predictors of Treatment Outcome in Contextual Cognitive and Behavioral Therapies for Chronic Pain: A Systematic Review

There is increasing evidence that contextual forms of cognitive-behavioral therapy (CBT) are effective in the management of chronic pain, yet little is understood about the factors that moderate or predict outcomes in these treatments. This systematic review aimed to identify pretreatment participant characteristics associated with positive treatment responses in contextual CBT for chronic pain. Medline, EMBASE, PsychINFO, and CENTRAL were searched to identify eligible studies. Studies were included if the participants were adults with chronic pain, designs were longitudinal, treatments focused on psychological flexibility or mindfulness, and reported results allowed for examination of moderators or predictors of standard treatment outcomes. Of 991 records initially identified, 20 were eligible for inclusion in the review. Some evidence suggested that baseline emotional functioning predicts treatment response, but the direction of this association varied between studies. Substantive findings were inconsistent and inconclusive, however, methodological limitations were consistent. These included treatment heterogeneity, and a lack of theoretical, a priori guidance in examining potential predictors. Future research should adopt a theoretically based approach to examining moderators in relation to specific treatment methods and therapeutic processes. Considering moderation without first considering mediation is probably a limited strategy.

How to Measure the International Development of Palliative Care? A Critique and Discussion of Current Approaches

ContextA number of research projects have been conducted that aim to gather data on the international development of palliative care. These data are important for policy makers and palliative care advocates.ObjectivesThe aim of this article was to provide a critical comparative analysis of methodological approaches used to assess the development and status of palliative care services and infrastructure at an international level.MethodsA selective literature review that focused on the methodological features of eight identified reports was undertaken.ResultsReviewed reports were found to differ in adopted methodologies and provided uneven amounts of methodological information. Five major methodological limitations were identified (lack of theory, use of experts as source of information, grey literature, difficulties in ranking, and the problematic nature of data on service provision). A set of recommendations on how to deal with these issues in future research is provided.ConclusionMeasuring the international development of palliative care is a difficult and challenging task. The results of this study could be used to improve the validity of future research in this field.     

Validity evidence for a modified version of the Orthotics and Prosthetics Users’ Survey

Purpose: To evaluate the validity of a modified version of the Orthotics and Prosthetics Users’ Survey (OPUS) with persons using different prosthetic and orthotic (P&O) devices.Method: Two-hundred-and-eighty-two adults using prosthesis, orthosis, shoe insoles or orthopaedic shoes completed OPUS. OPUS comprises five modules - Lower and Upper Extremity Functional Status, respectively (LEFS and UEFS), Client Satisfaction with Device and Services, respectively (CSD and CSS), and, Health-Related Quality of Life (HRQoL). Eight new items were added to LEFS and six to UEFS. Rasch analysis was used for data analyses.Results: Rating scales functioned satisfactory after some modifications. All modules demonstrated a ceiling effect. Unidimensionality was satisfactory after deleting some items and dividing HRQoL into two subscales, although somewhat weak on CSD and CSS. Item reliability was excellent for all modules and person reliability good for all but CSD and CSS. Some items demonstrated differential item functioning related to sex and age, but the impact on person measures was small.Conclusions: This study supports the validity of a modified version of OPUS for persons using different P&O devices, but also reveals limitations to be addressed in future studies. OPUS could be useful in clinical rehabilitation and research to evaluate P&O outcomes.

Implications for Rehabilitation

• The rehabilitation of individuals with musculoskeletal dysfunction often includes prosthetic or orthotic devices.

• There is a need for validated instruments to assess the outcomes of prosthetic and orthotic (P&O) interventions.

• This study provides validity evidence in support of using the Orthotics and Prosthetics Users’ Survey (OPUS) as an outcome measure for P&O interventions.

     

A Cross-cultural Test of the Cognitive Theory of Obsessions and Compulsions: A Comparison of Greek, Italian, and American Individuals—a Preliminary Study

A widely-held theory is that obsessions arise from the misinterpretation of normal intrusive thoughts (e.g., misinterpreting unwanted harm-related thoughts as a sign that one is going to act on them). This leads the person to perform compulsions such as repeated checking. Misinterpretations are said to arise from various types of beliefs (e.g., the belief that thoughts inevitably give rise to actions). In support of this theory, some studies have shown that such beliefs are correlated with obsessive-compulsive (OC) symptoms. We investigated whether the theory can be extended to conditions in which cultural differences are taken in consideration. Measures of OC beliefs and symptoms were completed by participants in Greece (n = 46) and Italy (n = 348) and, for comparison purposes, the US (n = 73). Beliefs were correlated with symptoms in all three groups. There were significant, albeit modest, cross-cultural effects. In particular, the relation between beliefs and cleaning and checking compulsions tended to be low in Greek participants, compared to Italian and US counterparts. Although the results generally support the cognitive model, some culture-specific modifications may be required, possibly by including variables that moderate or attenuate the correlations between OC symptoms and putatively related beliefs.

Transcutaneous Electrical Nerve Stimulation for the Treatment of Pain in Physiotherapy Practices in Hong Kong and the United Kingdom—A Survey of Usage and Perceived Effectiveness Compared With Other Pain Relieving Modalities

This study compared the use and perceived effectiveness of transcutaneous electrical nerve stimulation (TENS) with other electrophysical modalities for pain management by physiotherapists (PTs) in Hong Kong (HK) and the United Kingdom (UK). Two random samples (n = 600 each) of HK and UK PTs were mailed questionnaires. Four hundred and sixteen out of 1,200 respondents (34.7%) returned fully completed questionnaires (HK,34.2%; UK, 35.2%). A significant difference was found in the type of electrodes used (p < 0.001); self-adhesive electrodes were used more commonly in the UK (UK, 73.0%; HK, 18.4%), compared with carbon rubber electrodes and gel in HK (HK, 75.6%; UK, 15.7%). A significantly higher percentage of HK PTs reported receiving an undergraduate education in TENS (84.4% vs. 43.1%; p < 0.001). Acupuncture was used more in the UK (67.7%) than in HK (48.8%; p < 0.001), but it was rated equally effective, especially for chronic pain. There were significant differences in perceived effectiveness of TENS for chronic pain (p < 0.001); TENS was rated second most effective for the management of chronic pain by UK PTs and fourth by HK PTs. This survey has highlighted differences in the patterns of use and perceived effectiveness of TENS and other modalities in the UK and HK.     

What Are the Determinants of Dental Care Expenditures in Institutions for Adults With Disabilities? Findings From a National Survey

Objective

To analyze the determinants of dental care expenditures in institutions for adults with disabilities.

Is Mindfulness Associated With Lower Pain Reactivity and Connectivity of the Default Mode Network? A Replication and Extension Study in Healthy and Episodic Migraine Participants

Formal training in mindfulness-based practices promotes reduced experimental and clinical pain, which may be driven by reduced emotional pain reactivity and undergirded by alterations in the default mode network, implicated in mind-wandering and self-referential processing. Recent results published in this journal suggest that mindfulness, defined here as the day-to-day tendency to maintain a non-reactive mental state in the absence of training, associates with lower pain reactivity, greater heat-pain thresholds, and resting-state default mode network functional connectivity in healthy adults in a similar manner to trained mindfulness. The extent to which these findings extend to chronic pain samples and replicate in healthy samples is unknown. Using data from healthy adults (n = 36) and episodic migraine patients (n = 98) and replicating previously published methods, we observed no significant association between mindfulness and heat-pain threshold, pain intensity or unpleasantness, or pain catastrophizing in healthy controls, or between mindfulness and headache frequency, severity, impactor pain catastrophizing in patients. There was no association between default mode network connectivity and mindfulness in either sample when probed via seed-based functional connectivity analyses. In post-hoc whole brain exploratory analyses, a meta-analytically derived default mode network node (ie, posterior cingulate cortex) showed connectivity with regions unassociated with pain processing as a function of mindfulness, such that healthy adults higher in mindfulness showed greater functional connectivity between the posterior cingulate cortex-and cerebellum. Collectively, these findings suggest that the relationship between mindfulness and default mode network functional connectivity may be nuanced or non-robust, and encourage further investigation of how mindfulness relates to pain.PerspectiveThis study found few significant associations between dispositional mindfulness and pain, pain reactivity and default mode connectivity in healthy adults and migraine patients. The relationship between mindfulness and default mode network connectivity may be nuanced or non-robust.     

Opioids for the Management of Dyspnea in Cancer Patients: Evidence of the Last 15 Years—A Systematic Review

The objective of this study was to review the evidence on the use of opioids for treatment of the dyspnea in adult cancer patients. A systematic literature review was conducted in the databases MEDLINE, CINAHL (EBSCO), ScienceDirect, and Cochrane Library of trials testing the effect of opioids in relieving dyspnea in cancer patients. Fourteen trials met the criteria for inclusion in the review. Eight randomized trials and six nonrandomized trials. All randomized clinical trials analyzed present risks of bias. Morphine has been the most studied strong opioid showing efficacy in alleviating dyspnea when administered, either orally or subcutaneously, in cancer patients. The potential benefit of the strong opioids in the alleviation of dyspnea in cancer patients is modest and limited to some opioids. More studies are needed to sufficiently support the role of opioids in dyspnea at rest, at exertion, and for breakthrough dyspnea and to clarify the safety issues.     

End-of-Life Care in Italian Hospitals: Quality of and Satisfaction With Care From the Caregivers' Point of View—Results from the Italian Survey of the Dying of Cancer

ContextA number of studies have highlighted the poor quality of end-of-life (EOL) care provided in hospital settings, leading to a reduction in the quality of EOL care and increase in patient and caregiver dissatisfaction levels.ObjectivesThe aims of this study were the evaluation of the prevalence of major symptoms, treatment, outcomes, information, and care provided to dying cancer patients in Italian hospitals; and an analysis of clinical and socio-demographic factors associated with caregiver satisfaction with the health care provided.MethodsThis is a mortality follow-back survey of 2,000 cancer deaths representative of the country. Caregivers were interviewed about patients' experiences by using a tailored version of the View of Informal Carers—Evaluation of Services questionnaire.ResultsValid interviews were obtained for 84% (n = 364) of the cancer patients who died in hospital. Most Italian cancer patients dying in hospital suffered from a number of untreated or poorly treated symptoms, and only a few reported an acceptable control over physical suffering. Moreover, only two-thirds of patients and one-third of caregivers received basic information on therapies and care. About one-third of the caregivers expressed dissatisfaction with the health care received. The probability of being satisfied was more likely for caregivers of patients living in the north of Italy; caregivers of patients who had not experienced or were only slightly distressed by fatigue; and caregivers who were generally satisfied with hospital facilities and when the health care professionals had provided appropriate information to both patients and caregivers.ConclusionThis study revealed poor quality of EOL care in Italian hospitals, with almost one-third of the caregivers expressing their clear dissatisfaction. A national policy is, therefore, urgently called for to improve the quality of EOL care in Italian hospitals.     

A comparison of the Acapella and a threshold inspiratory muscle trainer for sputum clearance in bronchiectasis—A pilot study

Background: Inspiratory muscle training is used to specifically strengthen the respiratory muscles. Controversy exists regarding the use of inspiratory muscle training as a method of facilitating airways clearance. Acapella is already known to be effective in airway clearance. Objective: The objective of the study was to compare the effects of the Acapella and a threshold inspiratory muscle trainer as a method of airway clearance in subjects with bronchiectasis and to determine patient preference between the two techniques. Methods: Thirty patients (10 males, 20 females) mean age of 50.67±6.37 (mean±SD) with a history of expectoration of more than 30?ml sputum per day were recruited. The sequence of therapy was allocated by block randomization. Assessment and familiarization session was perfomed on day 1. Treatments employing the Acapella and inspiratory muscle trainer were done on days 2 and 3. Treatment order and allocation was determined by block randomization. Sputum volume was measured during and 2 hours after the treatment and patient treatment preference was recorded. Results: A statistically significant difference was found in the sputum volume expectorated after treatment with the Acapella (7.16±1.12?ml) compared with the threshold inspiratory muscle trainer (6.46±1.08?ml). Patients preferred Acapella in terms of usefulness of clearing secretions. Conclusion: The present study demonstrated increased sputum clearance following the use of the Acapella when compared to the threshold inspiratory muscle trainer. In addition, the Acapella was preferred by patients who judged that it was more useful in clearing secretions.