Rapid,Full-Scale Change to Virtual PCIT During the COVID-19 Pandemic: Implementation and Clinical Implications

Health agencies call for the immediate mobilization of existing interventions in response to numerous child and family mental health concerns that have arisen as result of the COVID-19 pandemic. Answering this call, this pilot study describes the rapid, full-scale change from a primarily clinic-based Parent–Child Interaction Therapy (PCIT) model to a virtual service model (i.e., I-PCIT) in an academic and community-based program in Miami, Florida. First, we describe the virtual service training model our program developed and its implementation with 17 therapists (M_Age?=?32.35, 88.2% female, 47.1% Hispanic) to enable our clinic to shift from providing virtual services to a small portion of the families served (29.1%) to all of the families served. Second, we examine the effect of I-PCIT on child and caregiver outcomes during the 2-month stay-at-home period between March 16, 2020, and May 16, 2020, in 86 families (M_ChildAge?=?4.75, 71% Hispanic). Due to the rapid nature of the current study, all active participants were transferred to virtual services, and therefore there was no comparison or control group, and outcomes represent the most recently available scores and not treatment completion. Results reveal that I-PCIT reduced child externalizing and internalizing problems and caregiver stress, and increased parenting skills and child compliance with medium to large effects even in the midst of the COVID-19 pandemic. Finally, the study examined components of our virtual service training model associated with the greatest improvements in child and caregiver outcomes. Preliminary findings revealed that locally and collaboratively developed strategies (e.g., online communities of practice, training videos and guides) had the strongest association with child and caregiver outcomes. Implications for virtual service delivery, implementation, and practice in the midst of the COVID-19 pandemic are discussed.

     

The association between muscular power from childhood to adulthood and adult measures of glucose homeostasis

This study aimed to assess whether the longitudinal association between childhood muscular fitness and adult measures of glucose homeostasis persist despite changes in muscular fitness across the life course. This prospective longitudinal study included 586 participants who had their muscular power (standing long jump distance), cardiorespiratory fitness (CRF), and waist circumference measured as children (aged 9, 12, 15 years) and again 20 years later as adults. In adulthood, these participants also provided a fasting blood sample which was tested for glucose and insulin. Glucose homeostasis measures including insulin resistance (HOMA2‐IR) and beta cell function (HOMA2‐β) were estimated. Child and adult muscular power levels were separated into thirds, and tracking groups (persistently low, decreasing, persistently moderate, increasing, and persistently high) were created. Sex‐stratified multivariable linear regression models were used to examine the association between muscular power tracking groups and adult measures of glucose homeostasis. Compared with males with persistently high muscular power, males with increasing and persistently low muscular power had higher fasting insulin (increasing: β = 1.12 mU/L, P = .04; persistently low: β = 2.12 mU/L, P = .001) and HOMA2‐β (increasing: β = 8.50%, P = .03; persistently low: β = 11.27%, P = .01) independent of CRF and males with persistently low muscular power had greater fasting insulin (β = 1.22 mU/L, P = .02) and HOMA2‐IR (β = 0.14, P = .02) independent of waist circumference. Non‐significant associations were present for females. For males, maintaining persistently high muscular power between childhood and adulthood could lead to a healthier adult glucose homeostasis profile.     

CT accuracy of percutaneous versus open pedicle screw techniques: a series of 1609 screws

Introduction

Traditional open exposure for posterior instrumentation requires significant soft tissue mobilization and causes significant blood loss and increased recovery time. Mal-placed screws can injure nerve roots, the spinal cord, viscera, vasculature and the cardiopulmonary system. Placement of pedicle screws using a minimally invasive technique can decrease bleeding risk, damage to soft tissues, and post-operative pain. The purpose of this study is to compare the radiographic accuracy of open free-hand versus percutaneous technique for pedicle screw placement.

Methods

Consecutive patients undergoing thoracolumbar surgery from September 2006 to October 2011 with post-operative CT imaging were included in this study. Three-dimensional screw positioning within the pedicle and the vertebral body was assessed on CT. The magnitude and location of violations were measured and recorded. Facet breaches at the cephalad and caudad ends of the construct were documented and graded.

Results

Two-hundred and twenty-three patients met the inclusion criteria for a total of 1609 pedicle screws. Seven-hundred and twenty-four screws were placed using a standard open free-hand technique and 885 were placed percutaneously. There was a significant difference in overall pedicle breach rates: 7.5 % for open and 4.7 % for percutaneous techniques. The magnitude of breach was greater for the percutaneous technique compared to the open technique: 5.4 versus 3.7 mm, respectively. The difference in vertebral body breaches was also significant: 11.3 % for open and 3.6 % for percutaneous. The rates of facet breach did not significantly differ.

Discussion and conclusion

This is the largest series comparing the accuracy of percutaneous to open pedicle screw placement. The rates of pedicle, vertebral body, and facets breaches in the percutaneous group were similar to the rates in the open technique group as well as rates reported in the literature. This demonstrates that the percutaneous technique described here is an accurate alternative to standard open free-hand technique.

     

Interrater and intrarater agreements of magnetic resonance imaging findings in the lumbar spine: significant variability across degenerative conditions

Background context

Magnetic resonance imaging (MRI) is frequently used in the evaluation of degenerative conditions in the lumbar spine. The relative interrater and intrarater agreements of MRI findings across different pathologic conditions are underexplored, as most studies are focused on specific findings.

Purpose

The purpose of this study was to characterize the interrater and intrarater agreements of MRI findings used to assess the degenerative lumbar spine.

Study design

A retrospective diagnostic study at a large academic medical center was undertaken with a panel of orthopedic surgeons and musculoskeletal radiologists to assess lumbar MRIs using standardized criteria.

Patient sample

Seventy-five subjects who underwent routine lumbar spine MRI at our institution were included.

Outcome measures

Each MRI study was assessed for 10 lumbar degenerative findings using standardized criteria. Lumbar vertebral levels were assessed independently, where applicable, for a total of 52 data points collected per study.

Methods

T2-weighted axial and sagittal MRI sequences were presented in random order to the four reviewers (two orthopedic spine surgeons and two musculoskeletal radiologists) independently to determine interrater agreement. The first 10 studies were reevaluated at the end to determine intrarater agreement. Images were assessed using standardized and pilot-tested criteria to assess disc degeneration, stenosis, and other degenerative changes. Interrater and intrarater absolute percent agreements were calculated. To highlight the most clinically important MRI disagreements, a modified agreement analysis was also performed (in which disagreements between the lowest two severity grades for applicable conditions were ignored). Fleiss kappa coefficients for interrater agreement were determined.

Results

The overall absolute and modified interrater agreements were 76.9% and 93.5%, respectively. The absolute and modified intrarater agreements were 81.3% and 92.7%, respectively. Average Fleiss kappa coefficient was 0.431, suggesting moderate overall agreement. However, when stratified by condition, absolute interrater agreement ranged from 65.1% to 92.0%. Disc hydration, disc space height, and bone marrow changes exhibited the lowest absolute interrater agreements. The absolute intrarater agreement had a narrower range, from 74.5% to 91.5%. Fleiss kappa coefficients ranged from fair-to-substantial agreement (0.282–0.618).

Conclusions

Even in a study using standardized evaluation criteria, there was significant variability in the interrater and intrarater agreements of MRI in assessing different degenerative conditions of the lumbar spine. Clinicians should be aware of the condition-specific diagnostic limitations of MRI interpretation.     

Testosterone and oxandrolone, a nonaromatizable androgen, specifically amplify the mass and rate of growth hormone (GH) secreted per burst without altering GH secretory burst duration or frequency or the GH half-life

We investigated the mechanisms by which androgens increase mean circulating GH concentrations in boys. We tested two hypotheses: 1) testosterone increases serum GH concentrations at least in part via an androgen receptor-mediated mechanism, rather than exclusively by way of aromatization to estrogen; 2) androgen augments one or more specific features to GH secretion (secretory burst number, amplitude, and/or duration) and/or prolongs the half-life of GH removal. To examine these hypotheses, prepubertal boys with constitutionally delayed development and/or growth were given injections of testosterone (100 mg monthly; n = 7) or treated with oral oxandrolone, a nonaromatizable androgen (1.25 mg twice daily; n = 5). Pulsatile GH release was studied before and during androgen administration by sampling blood at 20-min intervals for 24 h. The immunoreactive GH time series were subjected to a novel deconvolution technique, which revealed that 1) testosterone and oxandrolone each increased mean (24-h) serum GH concentrations significantly; 2) both androgens augmented the daily endogenous GH secretory rate significantly; 3) increased GH production resulted from a higher mass of GH secreted per burst and a higher maximal rate of GH secretion within each burst; and 4) androgens amplified the magnitude of the nyctohemeral rhythm in the mass (but not frequency) of GH secretory pulses. The observed effects of androgen were specific, since the number and duration of GH secretory bursts and the subject-specific GH half-life were unaltered by androgen treatment. We conclude that androgen acting apart from conversion to estrogen is capable of specifically activating the somatotropic axis via distinct neuroendocrine secretory mechanisms.     

A prospective study of the associations between 25‐hydroxy‐vitamin D,sarcopenia progression and physical activity in older adults

Objective Low 25‐hydroxyvitamin D (25OHD) levels may be associated with both sarcopenia (the age‐related decline in muscle mass and function) and low physical activity (PA). Our objective was to describe prospective associations between 25OHD, muscle parameters, and PA in community‐dwelling older adults. Design Prospective, population‐based study with a mean follow‐up of 2·6 ± 0·4 years. Patients Six hundred and eighty‐six community‐dwelling older adults (49% women; mean ± SD 62 ± 7 years old). Measurements Appendicular lean mass percentage (%ALM) and body fat assessed by Dual‐energy X‐ray Absorptiometry, leg strength by dynamometer, leg muscle quality (LMQ), PA assessed by pedometer, self‐reported sun exposure by questionnaire, and serum 25OHD measured by radioimmunoassay. Results Participants with 25OHD ≤50 nm had lower mean %ALM, leg strength, LMQ and PA (all P < 0·05). As a continuous function, baseline 25OHD was a positive independent predictor of change in leg strength (β = 5·74 kg, 95% CI 0·65, 10·82) and LMQ (β = 0·49 kg/kg, 95% CI 0·17, 0·82). Also, change in 25OHD was positively predicted by baseline %ALM (β = 2·03 pm /p.a., 95% CI 0·44, 3·62) leg strength (β = 0·30 pm /p.a., 95% CI 0·06, 0·53), LMQ (β = 4·48 pm /p.a., 95% CI 0·36, 8·61) and PA (β = 2·63 pm /p.a., 95% CI 0·35, 4·92) after adjustment for sun exposure and body fat. Conclusions 25OHD may be important for the maintenance of muscle function, and higher skeletal muscle mass and function as well as general PA levels may also be beneficial for 25OHD status, in community‐dwelling older adults.     

Brain cancer incidence,mortality and case survival: Observations from two australian cancer registries

Data from 2 Australian cancer registries covering a population of 1.7 million people were combined for the purposes of analysing brain cancer incidence, mortality and survival patterns for the time period 1978 through 1992. A total of 1,752 cases of primary brain cancer were registered, representing age-standardised incidence rates of 6.7 per 100,000 in men and 4.6 in women. Histological confirmation was available for 94% of cases. The incidence rate among persons aged 75 or over was higher during 1986–1992 than during 1978–1985, the rate for men increasing from 16.3 to 26.2 and that for women increasing from 9.7 to 18.0. The largest increases in this age group occurred for cases of glioblastoma multiforme. During the study period, 1,411 brain cancer deaths were notified to the 2 registries at age-standardised rates of 5.3 in men and 3.4 in women. Mortality rates among persons aged 75 years or older were higher during 1986–1992 than 1978–1985, increasing from 15.7 to 28.4 in men and from 10.1 to 15.3 in women. Only among men aged 15–49 years was a decline in mortality rates observed, from 3.3 to 2.4. Survival analyses indicated that age and histological type were the most powerful prognostic indicators. There was no improvement in 5-year survival for any of the age groups or histological types. An improvement in 36-month survival was noted for the 15–49 year age group diagnosed with gliomas other than glioblastoma multiforme.     

Acceleration of growth rate in growth hormone-deficient children treated with human growth hormone-releasing hormone

Twenty-four growth hormone-deficient children were treated with growth hormone releasing hormone-40 (GHRH) for 6 months or longer. GHRH (1 to 4 micrograms/kg of body weight per dose) was administered subcutaneously every 3 h (n = 10); or every 3 h overnight only (n = 10); or by twice daily injections (n = 4). Twenty-one children had an increase in growth rate during GHRH treatment. The growth velocities (mean +/- SD; cm/yr) before and during treatment were, respectively: every 3 h 3.5 +/- 1.4 versus 10.0 +/- 2.2, p = 0.0001; overnight only 3.4 +/- 1.0 versus 6.2 +/- 2.1, p = 0.008; twice daily injections 3.2 +/- 1.8 versus 7.9 +/- 2.4, p = 0.06. Using these three modes of GHRH administration, different total daily amounts of GHRH were administered. Regression analysis of average daily dose versus growth velocity revealed a correlation coefficient (r) value of 0.57, p = 0.004. Sixteen children received extended treatment for periods varying from 9 to 30 months. Of these, seven children were treated continuously for 9 months with pump overnight only and 5 for 12 months with pump every 3 h. Their growth velocities were sustained at a similar rate as those observed at 6 months. Six children received both twice daily and three hourly treatments consecutively. The growth velocities were similar during both treatments. Eleven children developed circulating antibodies to GHRH during treatment, however, all 11 had accelerated growth rates during GHRH therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cytochrome P450 3A4-mediated bioactivation of raloxifene: irreversible enzyme inhibition and thiol adduct formation

Raloxifene is a selective estrogen receptor modulator which is effective in the treatment of osteoporosis in postmenopausal women. We report herein that cytochrome P450 (P450)3A4 is inhibited by raloxifene in human liver microsomal incubations. The nature of the inhibition was irreversible and was NADPH- and preincubation time-dependent, with K(I) and k(inact) values estimated at 9.9 microM and 0.16 min(-1), respectively. The observed loss of P450 3A4 activity was attenuated partially by glutathione (GSH), implying the involvement of a reactive metabolite(s) in the inactivation process. Subsequently, GSH adducts of raloxifene were identified in incubations with human liver microsomes; substitution with GSH occurred at the 5- or 7-position of the benzothiophene moiety or at the 3'-position of the phenol ring, with the 7-glutathionyl derivative being most abundant based on LC/MS and NMR analyses. These adducts are postulated to derive from addition of GSH to raloxifene arene oxides followed by dehydration and aromatization. Alternatively, raloxifene may be oxidized to an extended quinone intermediate, which then is trapped by GSH conjugation. The bioactivation of raloxifene most likely is catalyzed by P450 3A4, since the formation of GSH adducts was almost abolished when liver microsomes were pretreated with ketoconazole or with an inhibitory anti-P450 3A4 IgG. The GSH adducts also were detected in incubations of raloxifene with rat or human hepatocytes, while the corresponding N-acetylcysteine adducts were identified in the bile and urine from rats treated orally with the drug at 5 mg/kg. Taken together, these data indicate that P450 3A4-mediated bioactivation of raloxifene in vitro is accompanied by loss of enzyme activity. The significance of these findings with respect to the clinical use of raloxifene remains to be determined.     

Validity and reliability of adult recall of past sun exposure in a case-control study of multiple sclerosis.

BACKGROUND: Measurement of past sun exposure through recall by adults has the potential for measurement error. We aimed to investigate aspects of validity and reliability of self-reported past sun exposure. METHODS: A population-based case-control study was conducted in Tasmania on 136 cases with multiple sclerosis and 272 age- and sex-matched community controls. Repeat interviews on 52 cases and 52 controls were done on average 11 weeks after the initial interview. Sun exposure was assessed by questionnaire and lifetime calendar. Other measurements included serum 25-hydroxyvitamin D, actinic damage, and skin phenotype. RESULTS: There was an association between recent sun exposure and serum vitamin D (time in the sun: r = 0.22, P < 0.01; activities outside: r = 0.31, P < 0.01 for controls) and between lifetime sun exposure and actinic damage [correlation between 0.34 (P < 0.01) and 0.17 (P = 0.01) for controls]. The test-retest weighted kappa statistic of self-reported sun exposure ranged from 0.43 to 0.74. Recall of childhood/adolescent sun exposure by standardized questioning was no less reproducible than recall of recent adult sun exposure and no less reliable when made with the calendar method. Comparing the questionnaire and calendar method, the measures of childhood/adolescent sun exposure had a similar predictive validity for multiple sclerosis. CONCLUSIONS: The results of this study provide further evidence that adults are able to recall past sun exposure with shown validity and reliability and present information about the possible reasons for the good reliability of recalled sun exposure measures.